Updated: Apr 19, 2022
To ice or not to ice - a sprained ankle, a painful knee or a sore muscle?
According to general knowledge and common opinions amongst doctors the protocol would be to put an ice pack over a sore muscle or a painful back; and surely you have reached for that ice pack in the freezer at least once in your life?! It is believed to reduce swelling and speed up the healing process.
The procedure for injury management followed by most doctors, physical therapists and athletic trainers hasn’t changed since 1978, when Harvard physician Dr. Gabe Mirkin coined the term 'the RICE protocol.' The acronym, which stands for 'rest, ice, compression and elevation'. Mirkin was reporting the anecdotal evidence of doctors who saw a temporary decrease in swelling and pain from immobilization, ice and compression. The RICE protocol is listed on the National Institute of Health website as the top treatment for both acute and chronic sports injuries and many doctors and physical therapists still swear by it.
Mirkin himself, however, now aged 86, seems to have reconsidered his approach in the forward to Gary Reinl’s 2013 self-published book, Iced! The Illusionary Treatment Option, which has become the bible of the growing anti-ice movement. 'If your muscles are sore,' says Mirkin, 'you can relieve that pain with ice. But the inflammation causing that soreness is actually bringing healing to the body; by icing, you “dampen that immune response". You think you’re recovering faster, but science has shown you’re not.' In 1978 inflammation wasn't even in research literature.
One of the first thing I was taught during my Bowen Technique training was to discourage clients, especially after a treatment, to use cold (or heat, but this is for another article!) on the affected area, because it slows the natural healing process of the body.
What happens when there is injury and inflammation in the body?
Ice might be the cheapest, most readily available way to alleviate pain. But be warned: the pain will return once the tissue rewarms and the inflammatory response resumes. This is because the inflammatory response needs to happen. The three stages of healing for soft tissue injuries are now universally accepted by the medical community: inflammation, repair and remodeling. And you can’t reach the repair and remodeling phases until you’ve gone through Phase One.
When tissue is damaged, the immune system initiates that inflammatory response. The body deploys its repair and cleanup crew, the white blood cells, which engulf and digest cellular debris but also produce the protein insulin-like growth factor 1, which is required for muscle repair and regeneration. According to a recent study (published in 2010 in Federation of American Societies for Experimental Biology Journal), blocking inflammation delays healing by preventing the release of this protein.
Whilst inflammation is actually good, swelling isn't. Inflammation is a process the body uses to heal tissue, while swelling is a byproduct of that process. With inflammation comes fluid. This is because chemicals are produced from your body's white blood cells that enter your blood or tissues to protect your body from invaders. This raises the blood flow to the area of injury or infection. It can cause redness and warmth. Some of the chemicals cause fluid to leak into your tissues, resulting in swelling (webmd.com).
Whilst your body is producing the right amount of fluid in the area, what might happen is that the evacuation process of this fluid isn't working as it should. Debris and waste in the body are mostly expelled through the lymphatic system. The lymphatics though, are a passive system, fully reliant on muscle activation; movement is necessary to propel fluid through the vessels. Sitting still with an ice pack creates the exact opposite effect! The only way to do that is through movement.
Of course we may not want to push too strongly an acute injury but keep moving that sprained ankle or sore knee by 'loading the damaged tissue - that is, applying force to it, accelerates healing of bone and muscle tissue, while inactivity promotes aberrant tissue repair." (Journal of the American Academy of Orthopedic Surgeons)
If an injury is too painful or the area is too fragile for any type of voluntary movement, consider using Bowen Therapy, with its light-pressure and rolling moves which squeeze fluid out of the tissues, very much like a sponge releases water when squeezed, it promotes waste evacuation. The new fluid, that is sucked back in from the adjacent environment is full of nutrients and oxygen, helping in the regenerative and remodelling process.
You might want to also consider a neuromuscular electrical stimulation device. Such devices (and there are more and more of them on the market) create non-fatiguing muscle contractions, allowing waste and congestion to be removed by your lymphatic system, which is driven by muscle contraction. I would not recommend using these straight after a Bowen Technique treatment.
We need PEACE and LOVE not RICE
In April 2019, two British physical therapists proposed a different acronym in the British Journal of Sports Medicine: PEACE — Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate — & LOVE — Load, Optimism, Vascularization, Exercise. All these ideas want you prioritizing movement over decreasing inflammation.
P = Protect
unload or restrict movement for 1 - 3 days
minimise rest. Prolonged rest compromises tissue strength and quality
let pain guide removal of protection and gradual reloading
E = Elevate
elevate the injured limb higher than the heart. This promotes interstitial fluid flow out of the injured tissue. However, there is no scientific evidence for this.
A = Avoid anti-inflammatory modalities
anti-inflammatory medications may negatively affect long-term tissue healing
optimal soft tissue regeneration is supported by the various phases of the inflammatory process
making use of medications to inhibit the inflammatory process could impair the healing process. Sometimes the pain is too intense and debilitating and we do need to use medication.
C = Compress.
compression such as taping or bandages helps to reduce swelling
E = Educate
Movement education to promote healthier movement and self-help techniques
If a manual-therapist nurture a patient's "need to be fixed" it may create dependence to them and actually contribute to persistent symptoms
Patients need to be better educated on their condition
It is critical for manual therapists to educate their patients and set realistic expectations about recovery times.
L = Load
Patients with musculoskeletal disorders benefit from an active approach with movement and exercises
Normal activities should continue as soon as symptoms allow for it
Optimal loading without increasing pain. It promotes repair and remodeling;
O = Optimism
The brain plays a significant part in rehabilitation interventions
Barriers of recovery include psychological factors such as: catastrophisation, depression and fear
Pessimistic patient expectations influence outcomes and prognosis of an injury
Stay realistic, but encourage optimism to improve the chances of an optimal recovery
V = Vascularisation
Musculoskeletal injury management needs to include cardiovascular physical activit
E = Exercise
Benefits of exercise: restores mobility, strength and proprioception, early after an injury.
Use pain as a guide to progress exercises gradually to increased levels of difficulty
I absolutely love this new acronyms! In my practice I have a strong interest and I am developing an application of preventive movement education and rehabilitation post-injury. I also apply principles of pain science to reframe how we feel about pain by literally rewiring our brain and thinking process in a more optimistic way.