Chill Out!

More and more physios are now discussing the so-called negative, detrimental, and harmful effects of using ice for the treatment of acute or sports injuries or even for soreness felt after exercise. Some even claim that icing everything should be abandoned completely. I think this is utterly crazy and of all the stupid, ridiculous, and ineffective things physios should stop doing, using some ice now and then is NOT one of them!

There is still a lot of confusion and misunderstanding around the long-standing and simple process of icing after an injury or exercise. This treatment is sometimes called ‘cryotherapy’ by some to make it sound more sexy and scientific, with some saying it’s the best thing ever, others saying it’s the worst thing ever.

So the aim of this short 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 apply cryotherapy from the application of a bag of ice or frozen peas to the immersion of a body part into buckets of cold water. There are even fancy pumped cold water compression devices and even full-body cryo-chambers that use liquid nitrogen at temperatures below -100*C! And you will see physios running around sports grounds and arenas with buckets of ice water, bags of ice, and even freeze guns. 

Time to stop icing?

Icing after an injury or strenuous exercise has been around for as long as I can remember, and a lot longer than that. However you choose to do it, most cryotherapy methods are simple, safe, and effective for many things that ache or niggle. However, 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 includes Dr Gabe Mirkin who came up with the well-known acronym R.I.C.E standing for Rest, Ice, Compression, Elevation back in 1978 (ref). The main argument made by him and many others is that using cryotherapy after an injury or intense exercise causes blood vessels to reduce or close, reducing blood flow, which may delay normal tissue inflammatory healing processes (ref).

When any tissue is damaged there is an inflammatory response which starts with blood vessels opening, called vasodilation. This increases the transportation of inflammatory cells and other things that help tissue healing such macrophages that release a hormone called Insulin-like Growth Factor Number 1 (IGF-1) which is a key in any tissue repair.

Inflammation isn’t bad!

To this day, many people, both patients, and healthcare professionals alike still see inflammation as a bad, negative, and harmful process rather than good, positive, and helpful one.

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

So inflammation after an acute injury or exercise is something that should in fact be encouraged, not interfered, impeded, or got in the way of. This is where cryotherapy is thought to be detrimental by causing vasoconstriction of blood vessels, reducing blood flow and transportation of cells like macrophages and hormones like IGF-1 to the damaged tissues.

However, before we all panic, lose our minds, and throw out all our ice trays let’s put these concerns into some perspective.

Ice doesn’t reduce inflammation much!

Cryotherapy as a method of reducing inflammation is kind of pathetic. In fact, it’s really pathetic, especially in comparison to other anti-inflammatory treatments such as Cortico-Steroids or 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 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.

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

Ice doesn’t change tissue temperature 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. 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 tissue temperature were easily altered by a bag of ice or a bucket of cold water then a host of harmful catastrophic events would occur.

Most studies that have looked at the temperature changes with either topical hot or cold application only tend to find significant temperature change 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 deeper 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 re-warming or re-cooling process occurs very quickly, usually within a few minutes especially if the patients move around a bit (ref).

Ice doesn’t help or harm performance much!

The effects of cryotherapy on performance are also small, but yet again some are claiming that it should be abandoned completely. Now sitting in ice baths after marathons or rugby games is something that many people do, myself included in the past, in a belief that it helps reduce soreness or improve recovery, and there are some studies that support this a little (ref).

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

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

Therefore my approach to any athlete at any level who wants to ice after exercise is crack on. If an athlete wants to ice because they think it helps, it most likely will. I don’t think it’s necessary and so won’t recommend it if they don’t and certainly won’t force it on anyone. 

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 tough game or run, crack on. Personally, I don’t do ice baths anymore now that I know what I know… I find it’s very hard to get placebo effects when you’re better informed.

Ice does reduce pain!

However, the one thing that cryotherapy can do is reduce pain. Don’t get me wrong it’s not the best or strongest pain killer, and again comparing it to the effects of something like morphine or cortico-steroids is just silly, and it won’t dramatically improve outcomes if it is or isn’t used (ref). But ice 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)

Applying an ice pack to something that’s sore or 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 mild pain without even trying something like an ice pack or paracetamol first. And I think the anti-ice brigade is 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 us as a society here, look to remove or reduce pain way too soon, way too often, for way too 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 as simple and safe like ice.

Summary

As I said at the start, of all the things physios need to think about reducing, removing, or abandoning in their treatment of things that hurt, ice and cryotherapy comes waaaaaay down the list.

How about more physios and other clinicians think about 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 think about removing and abandoning the more dangerous and risky treatments like steroid injections, opioids, 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