Chill out…

I’m hearing more and more physios and other healthcare professionals discussing and promoting the negative, detrimental, and so-called harmful effects of using ice for the treatment of injuries or soreness after exercise, with some claiming that it should be abandoned completely. Well, I think this is just crazy talk and I think some people just need to chill out about ice!

Even in 2019, there is still a lot of confusion and misunderstanding about the simple process of using of ice after an injury or exercise, sometimes called ‘cryotherapy’ to make it sound more scientific and sexy. Some say it’s the best thing ever and should be used all the time, others say it’s the worst thing ever and never to do it. So the aim of this blog is to see who is more right, or less wrong and decide if using ice is good, bad, or somewhere in-between.

Now there are many ways to use cryotherapy from the application of a simple bag of frozen peas, to immersion in buckets of cold water, to pumped cold water circulation devices, even full body cryo-chambers that use liquid nitrogen at temperatures below -100*C! However one of the daftest applications I’ve ever seen has to be to the freeze gun below… especially when given down the shorts of a soccer player.

 

Time to stop icing?

Icing or cryotherapy after an injury or exercise has been around for as long as I can remember, and I’m sure it’s been around a lot longer than that. However you choose to do it, most methods are simple, safe and effective for many things that hurt, ache, or niggle. However, as I mentioned more and more healthcare professionals are calling for a ‘cease and desist’ to using cryotherapy because of some possible detrimental effects it can have on our natural healing processes.

This even includes Dr Gabe Mirkin who first came up with the well-known acronym R.I.C.E for acute injury management, standing for Rest, Ice, Compression, Elevation back in 1978 (ref). The main argument made by Dr Mirkin and many others is that using cryotherapy after an injury or intense exercise causes blood vessels to close, called vasoconstriction which delays normal inflammatory healing processes (ref).

When tissues are damaged there is a period of inflammation and increased blood flow as blood vessels vasodilate. This increases the transportation of many inflammatory cells and nutrients that help tissue healing, including macrophages that release a hormone called Insulin-like Growth Factor Number 1 (IGF-1) which is a key factor in tissue repair.

Inflammation isn’t bad!

Now I do think many people, both patients and healthcare professionals alike still see inflammation as a bad, negative, and harmful process rather than good, positive, helpful one. So I support the position that the ‘anti icers’ take here that inflammation after any injury or exercise is something that should be encouraged and not impeded or got in the way of.

It amazes me when I hear a doctor or physio say that they need to reduce or stop inflammation as if its some kind of pathology or disease! Inflammation is a normal, natural, and amazing process. It is the first stage of repairing and remodelling damaged tissue. Without inflammation, you cannot have tissue adaption.

However, cryotherapy is thought to be detrimental to tissue healing and adaption due to it interfering with inflammation by causing vasoconstriction of blood vessels that then reduces blood flow and transportation of cell like macrophages to the damaged tissues, even possibly causing tissue necrosis (death) and neuropathy (nerve damage) (ref). However, before we all panic and lose our minds lets put these concerns into some perspective.

It doesn’t reduce inflammation that much!

Cryotherapy as a method of reducing inflammation is kind of weak, in fact, it’s kind of pathetic in comparison to other anti-inflammatory treatments such as cortico-steroid injections or even Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) that have well documented strong and long-lasting anti-inflammatory effects (ref, ref).

Comparing cryotherapy’s anti-inflammatory effects to things is like NSAIDs or cortico-steroids is like comparing, and I am not over exaggerating here, the effects of a water pistol to a thermonuclear warhead.

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Using some ice, or a bucket of cold water for 10-20 minutes may indeed create a temporary reduction in blood flow and therefore a temporary reduction of inflammation, but when it comes to impeding or affecting the natural inflammatory processes its simply insignificant in the grand scheme of things, and plenty of research supports this (ref, ref, ref).

It doesn’t change temperature that much!

Another thing to consider is that the application of cold or hot things to our bodies often doesn’t significantly affect the temperature of our tissues that much. Our bodies are very very good at maintaining a steady constant temperature of 38.7 +/- 1*C. This is called thermoregulation and is a vital process that keeps us happy and healthy. If our tisues temperature were easily altered then a whole host of catastrophic events would soon occur.

Most studies that have looked at the temperature changes with either topical hot or cold application only tends to find significant effects in the skin and very superficial tissues, anything below 1cm in depth is just not affected that much (ref, ref, ref)

Now, this is not to say that no significant temperature changes occur in any relevant tissues as there are some areas and some people that are affected by heating or cooling more than others. Adipose tissue, more simply called body fat, is a bloody good insulator and so body parts and individuals that are covered with more or less of it, will be more or less susceptible to temperature changes from things like cryotherapy (ref).

Therefore the thinner the individual or the less fat there is around a body part the more likely it will be affected by topical heating or cooling, with some studies finding temperature changes in some knee joints of up to 9*C which is very significant (ref, ref). However, the thing to consider is that as soon as the hot or cold source is removed from the tissues the rewarming or recooling process occurs very quickly, usually within a few minutes especially if the patients move around a bit (ref).

It doesn’t help or harm performance that much!

The next thing to discuss is the effects of cryotherapy on performance as again some are claiming that it should be abandoned completely as they think it’s more harmful than helpful. Now sitting in ice baths after marathons or rugby games is something that many do, myself included in the past, in a belief that it helps reduce the soreness after, or improves recovery, and there are some studies that support this a little (ref).

However, other studies have found that cryotherapy after strenuous exercise doesn’t significantly affect post-exercise soreness, and may actually impede the inflammatory process again and may have a detrimental effect on the tissues repair and adaption, even reducing muscle strength and power (ref, ref, ref).

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Recent systematic reviews, however, are less clear (ref, ref). They find cryotherapy after sport appears to not significantly affect performance or recovery either positively or negatively, but it may be beneficial for athletes perceptions of recovery. It may be that cryotherapy works more via psychological effects such as expectations, rituals, beliefs and of course good old placebo effects rather than any true physiological effects.

Therefore my approach to any athlete (or potential athlete) who wants to do post-exercise cryotherapy is just that, if you want to do it because you think it will help, it most likely will. I don’t think it’s essential or necessary and so wont recommend it, but unless an athlete is using it all the time, for crazy long durations I don’t think it will have any significant detrimental effects if they do use it.

So if you want to jump in that ice bath for a few minutes and get ya Wim Hof on, or use that crazy expensive cryo-chamber after a really tough game or run now and then, crack on, I won’t stop you! But FYI I don’t do ice baths anymore now that I’ve read what I’ve read… I find it’s hard to get the same psychological or placebo effects when you are better informed.

It does reduce pain!

However, the thing that cryotherapy can do is reduce pain. Don’t get me wrong its not the strongest pain killer, again comparing it to the effects of something like morphine or cortico-steriods is just silly. And it won’t dramatically imporve outcomes if it is or isn’t used (ref), and it appears to be better at reducing some pains more than others such as post operative knee and shoulder pain more than muscular back pain (ref, ref, ref, ref)

But applying an ice pack to something that hurts is a simple, cheap and more importantly safe method of analgesia, and for that, it should be promoted and used more than it is. I am always amazed at the number of patients I see who want a steroid injection for some recent annoying mild pain without even trying something like an ice pack or even paracetamol first. And I think the anti-ice brigade are not helping things here by harping on about the possible small transient negative effects cryotherapy may have but overlooking the small transient POSITIVE effects it also has.

Again this doesn’t mean I think ice or any other cryotherapy has to be used for pain, as I’ve said many times before I think we, and I mean society as a whole here, look to remove or reduce pain way too soon way too often for many things that just niggle, ache, annoy, or frustrate us for a period of time. Rather I think more of us need to learn to tolerate pain a little more, for a little longer, but if you have to find something to help reduce pain why wouldn’t you first use something that is simple and safe like ice.

Summary

Of all the things physios and other healthcare professionals clinicians need to think about reducing, removing, or abandoning in their treatment and management of things that hurt, ice and cryotherapy comes waaaaaay down the list.

How about more physios and other clinicians first think about reducing, removing and abandoning the more expensive, time consuming, dubious, and infinitely more stupid treatments for pain like dry needling, cupping, spinal manipulations, and machines that go bing.

How about physios and other clinicians first think about reducing, removing, or abandoning the more dangerous and potentially life-threatening treatments like steroid injections, opioid medications, and unnecessary surgeries before worrying too much about telling people to stop using a bit of ice now and then.

As always thanks for reading.

Adam

7 thoughts on “Chill out…

  1. Ok Adam you had a great point until you suggested abandoning a lot of things like needling modalities manual therapy etc which have level 1 evidence for them upon which our profession has been founded – don’t throw the baby out with the bath water you just discredited the hell out of yourself –
    From at physio with 25 years of practice and 3 post grad disciplines 6 published research studies and 5 Olympic Games as physio for athletes under her belt –

  2. Interesting and thought provoking.

    Assess properly – and each case on it s merit.

    N K FORD ( RPT )

  3. I agree with most of your comment (ice is not for inflammation) but would like to bring another argument in favor or cooling as a therapeutic modality. One way cooling may be beneficial is to prevent secondary injury in the acute phase (Knight & Draper, 2013). Using a cooling agent (e.g., cold packs, crushed ice) over an injured area (e.g.,bruise, sprains) very early after the initial trauma will contribute to reduce metabolic demands locally (e.g. icing is used to preserve organs for transplant), thereby limiting edema and spreading of secondary injury. Reducing total injury in the immediate phase could speed up recovery (i.e., less damage to repair). So keep “icing”, especially when dealing injuries in the acute phase.

  4. Reading your post was refreshing, as it mirrors exactly what I preach to patients every single day. It’s nice to see I am not the only one who informs patients that inflammation is a GOOD thing. It’s the beginning phase of healing. I tend to tell patients that icing 10 to 20 minutes is like peeing on a campfire that has jumped out of the fire ring. It will never put the fire out, but if you catch it early, it can certainly be effective. NSAIDS are like bringing out the garden hose to the same fire and over time, you will put out the fire. Coritcosteriods are like calling the fire department, it certainly will put out the fire but may be over kill.

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