To Ice or Not to Ice: That is the question

by Dr. Phil on December 3, 2019

This is an article I wrote for the Cramer First Aider in 2018…and I still stand by it today!

https://www.cramersportsmed.com/first-aider/to-ice-or-not-to-ice-that-is-the-question.html

Ice has gotten a bad rap recently. Anti-ice proponents have stated that “icing doesn’t work,” and ice has “never been proven effective.” Such statements are biased, inaccurate, and just plain wrong. Unfortunately, these claims have done nothing but create confusion and even anger. It’s easy to make these statements by looking at a few selected studies that support the anti-ice position while ignoring the hundreds of other studies on the benefits of cryotherapy.

The good thing about the anti-ice movement is that it makes us take a step back and re-evaluate the clinical decisions we make—and why we make them. Are they based on “tradition” or evidence? This article will help you understand the facts about ice to help YOU make the decision whether to use ice or not.

In a survey of Cramer First Aider readers, 97% (nearly 450 individuals) stated that they believe in applying ice to acute injuries. So, despite the negative press and false accusations, proponents of ice are still doing the right thing. Yes, icing immediately after an acute injury is correct and has lots of evidence to support it. But how do you defend your decision against the nay-sayers?

It is important to note that while the scientific literature on cryotherapy is quite vast, it remains plagued with poor quality clinical studies and few studies on injured populations; in addition, the heterogeneity among ice application in terms of time and type limits generalizability. Much of what we know about the physiological effects of ice on the healing process is based on animal studies, where extraneous variables are easier to control and obviously subjects are easier to recruit.

The most confusing anti-ice claim is that ice impedes the healing process, particularly the inflammatory phase, potentially leading to an increase in swelling. Some claim ice delays healing because it does not allow the body to go through the textbook phases of healing: injury, inflammation, repair, and remodeling. And in doing so, they claim this delay causes a buildup of metabolic waste and fluid (edema).

Interestingly, the same argument was addressed in 1975 by the ice-research guru, Dr. Ken Knight [1]. While inflammation is a natural and necessary phase of the healing process, the inflammatory mediators can sometimes do more harm than good. Remember that acute trauma, such as an ankle sprain, is relatively isolated to one or two ligaments; however, the inflammatory response may consume a much broader area, filling the entire lateral compartment. The inflammatory mediators may be necessary to heal the ligaments, but they can cause harm to uninjured tissues in the area.

Dr. Knight noted that ice essentially “dampens” the negative effects of inflammation on associated tissues by reducing the “secondary injury.” He did not identify ice as an ‘anti-inflammatory’ per say; rather, ice slows down tissue metabolism and circulation, delaying and reducing the inflammatory response to reduce the amount of residual injury. Through hypothermia and vasoconstriction, ice actually decreases the amount of waste material that must be removed from the injury site [1].

Other researchers have supported Dr. Knight’s position on reducing secondary injury with ice [2, 3]. In addition, a recent animal study [4]confirmed that while inflammation is reduced or delayed, ice does not affect the healing process. Furthermore, no studies have shown that ice actually increases swelling; in fact, a systematic review of animal studies [5]confirmed that cryotherapy significantly reduces edema after acute trauma.

While the physiologic research behind cryotherapy mechanisms provide convincing evidence, several systematic reviews of randomized controlled trials evaluating cryotherapy after injury have concluded “insufficient evidence” due to the low quality of available studies [5-9]. In addition, most studies use swelling or other surrogate measures as the main outcome variable, which may not be the best outcomes to determine “effectiveness” of ice, as opposed to a functional outcome such as ‘return to activity.’

There is no direct evidence that ice impedes healing after acute trauma or return to activity. A systematic review [10]concluded that cryotherapy may have a positive effect on return-to-sport. One found that early cryotherapy (<36 hours) after injury was associated with significantly faster return to activity compared to delayed cryotherapy or heat[11]. With ice, timing may be everything. Bleakley and colleagues [6]noted, “The sooner after injury cryotherapy is initiated, the more beneficial this reduction in metabolism will be.” Therefore, the conclusion that ice is not effective is egregiously false.

While there is no direct evidence that ice is harmful to the healing process, its use as a recovery tool is questionable, particularly after intensive eccentric exercise (such as pitching). This may be because the recovery process is different from the healing process. It is unwise to equate recovery to healing from a physiological perspective until scientists can identify specific mechanisms associated with recovery such as delayed onset muscle soreness (DOMS).

Aside from acute trauma (<48 hours after injury), ice probably does not help beyond pain reduction. Ice alone doesn’t directly reduce swelling, which has been confirmed in several studies [12, 13]. However, ice’s ability to reduce pain makes it an effective and safe alternative in pain management. It’s been well established that pain and swelling can inhibit muscle strength; therefore, it would be wise for practitioners to address pain with safer cryotherapy alternatives to initiate movement as soon as possible. That’s where therapeutic exercise and muscle activation comes in. “Cryokinetics,” or the use of cold to facilitate exercise, can play a key role in a rehabilitation program [14].

Yes, sometimes ice is over-used and sometimes claimed to do things it probably doesn’t do. While there are some circumstances where ice may not be appropriate or helpful, blanket statements like, “Ice is wrong” is both inaccurate and unfair. The science supports ice in some situations, but the research is often insufficient to make a definitive conclusion on when to use ice or not. Until ice is directly proven harmful to healing (which is unlikely), it remains a gold standard of treatment in acute injuries.

REFERENCES

1. Knight, K.L., The Effects of Hypothermia on Inflammation and Swelling. Athletic Training.Athletic Training, 1975. 11(1): p. 7-10.

2. Ho, S.S., et al., The effects of ice on blood flow and bone metabolism in knees.Am J Sports Med, 1994. 22(4): p. 537-40.

3. Merrick, M.A., et al., A preliminary examination of cryotherapy and secondary injury in skeletal muscle.Med Sci Sports Exerc, 1999. 31(11): p. 1516-21.

4. Vieira Ramos, G., et al., Cryotherapy Reduces Inflammatory Response Without Altering Muscle Regeneration Process and Extracellular Matrix Remodeling of Rat Muscle.Sci Rep, 2016. 6: p. 18525.

5. Collins, N.C., Is ice right? Does cryotherapy improve outcome for acute soft tissue injury?Emerg Med J, 2008. 25(2): p. 65-8.

6. Bleakley, C., S. McDonough, and D. MacAuley, The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials.Am J Sports Med, 2004. 32(1): p. 251-61.

7. Yerhot, P.S., T.; Wienkers, B.; Durall, C., The efficacy of cryotherapy for imrpoving functional outcomes following lateral ankle sprains.Ann Sports Med Res, 2015. 2(2): p. 1015.

8. van den Bekerom, M.P., et al., What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?J Athl Train, 2012. 47(4): p. 435-43.

9. Malanga, G.A., N. Yan, and J. Stark, Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury.Postgrad Med, 2015. 127(1): p. 57-65.

10. Hubbard, T.J., S.L. Aronson, and C.R. Denegar, Does Cryotherapy Hasten Return to Participation? A Systematic Review.J Athl Train, 2004. 39(1): p. 88-94.

11. Hocutt, J.E., Jr., et al., Cryotherapy in ankle sprains.Am J Sports Med, 1982. 10(5): p. 316-9.

12. Song, M., et al., Compressive cryotherapy versus cryotherapy alone in patients undergoing knee surgery: a meta-analysis.Springerplus, 2016. 5(1): p. 1074.

13. Cote, D.J., et al., Comparison of three treatment procedures for minimizing ankle sprain swelling.Phys Ther, 1988.68(7): p. 1072-6.

14. Knight, K.L., Cryotherapy in Sport Injury Management. 1995, Champaign, IL: Human Kinetics.

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Kinesiology Tape Myths and Mythbusters

by Dr. Phil on September 4, 2019

By Phil Page, PhD, PT, ATC, CSCS, FACSM

NOTE: I wrote this article 2 years ago. It was removed from the original site I wrote it for because it made some people uncomfortable, but I’m pulling it out of the laptop. I’m disappointed that the media and even ‘healthcare professionals’ continue to propagate myths and untruths about kinesiology tape. That’s not doing anyone good! Kinesiology tape DOES work in some patients, so let’s not throw the baby out with the bathwater! If you’re interested in more science behind my article, listen to my free webinar about Kinesiology Taping Myths here.

A recent blog post that tried to clear up misconceptions about kinesiology tape unfortunately perpetuated them. While the mechanisms in the article sound ‘scientific,’ the scientific proof is what’s lacking in the article, and it’s all the same stuff we’ve heard for years. (Interestingly, while the article was touting ‘science’, there were no scientific references!)

Unfortunately, everything you’ve been taught about kinesiology taping is probably wrong. Why?

Pseudoscience.

It’s not all your fault, though. There are several reasons why these kinesiology taping myths continue to linger; mainly because the ‘mechanisms’ behind kinesiology taping were essentially fabricated to substantiate the need to provide materials for training and certification—made to look more technical than it really is.

It’s easy to claim something using scientific logic or ‘biologic plausibility,’ simply waiting until good science proves otherwise (ie “pseudoscience”).  It’s easy to simply quote some guru or textbook without thinking twice, or even worse, simply believe a manufacturer’s claims. In today’s era of “information overload,” we generally believe what we’re told. (Bonjour!)

On the flip side, it’s hard to keep up with the literature…10 to 15 new articles on kinesiology tape continue to be published every month! And then it’s hard to interpret the literature. There are over 600 published studies on kinesiology taping (I didn’t say they were all good, though!). So, what’s a hard-working well-intended clinician supposed to do?

The issue is compounded by the fact that published studies are generally done on healthy populations with many different techniques and brands of tape. There’s a big gap in the literature on patient populations, specific techniques, and the mechanisms behind kinesiology tape.

We’ve been following the Pied Piper.

What’s worse, clinicians are attending these training and ‘certification’ courses (because they’ve been conned into thinking they need to be certified to slap some tape on someone) …without any basis of evidence.

I recently saw an online course for kinesiology taping. I looked at the references. What did I see? Not one journal article. Texts and presentation references often hide the scientific truth. It seems they even are cherry-picking secondary sources of evidence!

Years ago, I asked kinesiology taping instructors for a reason why they thought the direction the tape application would facilitate or inhibit a muscle. The reply from the instructors generally was, “That’s what Kenzo Kase said.” (he’s the guy who started the Kinesio Taping fad).

Blindly following without questioning the evidence.

By the way, we still don’t have good proof that direction of the tape can facilitate or inhibit muscle activation, particularly since the dozen or so studies looking at the influence of kinesiology tape direction use different techniques on healthy subjects.

It’s time we stop judging the effectiveness of kinesiology tape by using studies on healthy subjects! Kinesiology tape benefits those with deficits, whereas healthy subjects have no room to improve. That’s called a “ceiling effect” in research.

Despite a lack of hard evidence, clinicians and patients will swear by kinesiology tape. Let’s face it. It works (in some people). There’s got to be something to it, even if it is just placebo effect (that’s a whole other story). But it’s time to cut the bull about using ‘science’ to explain how it works.

What really grinds my gears is when people bastardize true science with ‘pseudoscience’ to try and sell you something. I prefer to see the evidence myself and then make an informed decision.

So, let’s really get you up to speed with the current state of science behind kinesiology taping.

It’s not mechanical.

We don’t know exactly how it works (and some will argue that we don’t know if it actually works!), but science is slowly catching up and may change the way you look at kinesiology taping. Unfortunately, these myths are still taught today despite evidence to the contrary.

The main mechanism claimed in its efficacy is the ‘lifting of the skin’ from convolutions in the tape, which subsequently increases blood flow and relieves pressure on underlying tissues. I’ll show you that convolutions have nothing to do with outcomes, and thus nothing to do with the mechanism of action, in 3 swings of the bat.

First of all, there is no evidence (at least in English) that kinesiology tape ‘mechanically lifts’ or ‘compresses’ the skin; nor is there proof of “decompressing the tissues beneath where the tape is applied.” In fact, a study showed that kinesiology tape doesn’t lift the skin or increase the area under the skin (Lyman et al. 2017) (Strike 1).

So, lifting the skin likely isn’t the ‘mechanism’ behind increased circulation, particularly since one study shows that skin microcirculation increases with kinesiology tape regardless of tension or convolutions (Craighead et al. 2017). The mechanism behind the increased skin blood flow is not clear.

Notice that this study found circulation is increased in the skin. We don’t know about circulation under the skin. That’s where the theoretical changes in circulation are thought to take place that facilitate lymphatic flow. Despite claims that kinesiology tape increase blood flow to the tissues, no studies have confirmed this.

And those fancy patterns you see with the ‘fan’ taping after bruising? Kinesiology tape must be reducing swelling, right? Those “dramatic changes in inflammation and bruising”?

Not so fast my friend.

While we have seen those cool pictures, it’s not all black and blue. Vercelli and colleagues found no better resolution of hematomas with kinesiology tape, regardless of tension or the presence of convolutions. (Strike 2)

It’s likely that the patterns you see where the tape was applied to the skin had an effect by facilitating skin blood flow, quickly moving the chemicals that cause the discoloration out of the skin. But resolving the ecchymosis doesn’t mean the swelling is reduced below the skin.

In fact, another study on acute ankle sprains found no difference in swelling reduction with or without kinesiology tape applied after injury (Nunes et al. 2015). And the jury is still out on its efficacy on chronic swelling like lymphedema; the few studies out there are mixed on the results, and use different techniques.

Don’t be deceived into believing something from a photo…

In fact, I think pictures helped us get into this mess. Photos of athletes wearing kinesiology tape at the Olympics. (Can’t wait to see how ‘cupping’ works out for everyone now!) I certainly didn’t learn some of those patterns when I became a “certified kinesiotape practitioner”.

And by the way, many of those athletes wearing the tape are PAID to do it. It’s not helping their performance or pain.

The only real outcome of kinesiology taping that’s well-supported in the literature is short-term pain reduction (up to 5-7 days) in chronic (> 4 weeks) musculoskeletal pain (Lim & Tay, 2016). However, the mechanism of pain relief is still unclear. It’s probably mediated by the “Gate Control Theory” (which in itself is still a theory!). It’s likely related to activation of afferent receptors in the skin; not from ‘reducing mechanical pressure on free nerve endings” through the skin convolutions.

In fact, it’s been shown that convolutions don’t really matter when it comes to pain reduction. Parreira and colleagues (2014) showed that low back pain patients had similar outcomes whether or not the tape was applied with convolutions. (Strike 3).

Simply placing your hand over an area that hurts somehow makes it feel better. Kinesiology tape’s pain relief is likely the same mechanism, but the tape is constantly there instead of your hand.

Bottom line: When we really look at the science, convolutions are not the mechanism. In this case, neurology trumps mechanical (same we see with “myofascial rolling,” by the way).

So that leads to more questions: Do we need to ‘elongate’ tissues before taping them to create these convolutions? Are the patterns and positions that are taught really the right ones? The more we learn about the tape, the better we can utilize it—and avoid using it in ways that don’t help our patients.

It’s time for everyone (including the manufacturers, instructors and even researchers) who continue to perpetuate pseudoscience and misinformation to update their articles and presentations, and stop making false claims that aren’t backed up with science.

Oh, and please stop using the word “science” or “research” to explain or market techniques or products as a cover-up.

Look, I’m a fan of kinesiology taping like many others, but I’m a skeptic by nature. I’ve seen it help reduce pain in lots of people. There is science out there, but everyone has a responsibility to accurately report it. And clinicians have a responsibility to identify pseudoscience and make evidence-informed decisions in patient care rather than rely on ‘gurus’ and slick marketing.

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Journal Club Lesson: Never rely on the abstract

April 11, 2019

Dear Editor*: I was happy to see a meta-analysis by Silvia Lopes et al. (DOI: 10.1177/2050312119831116) comparing elastic resistance with ‘conventional’ resistance on muscle strength. In general, I believe the analysis was adequate; however, I noted several serious errors in the manuscript that must be addressed. It appears that the legends of Figures 2 and […]

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How to use research to guide your clinical decision making

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Today’s approach to “evidence-based practice” (EBP) should be a process rather than an end-point. In this article published in the Journal of Performance Health, I recommend a 6-step process for a pragmatic approach to EBP….beginning with asking the question and ending with analyzing the results: AAAAAA. The AAAAA’s of Pragmatic EBP Want some help to […]

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5 Important Pieces of Advice for the New Physical Therapists

February 15, 2018

Congratulations, you made it through the hard part— school, licensing, job; check, check, and check. You’re in this field because you understand the importance of preparation and you have a passion for helping others, but now you’re ready to excel in clinical practice. It’s important to seek wise counsel when mapping out a strategy to […]

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108 More Research Studies That You Need to Read… Now

December 6, 2017

If you missed the first 55 research studies and second 93 research studies published this year, catch up! Just because we’re getting into the swing of the holiday season doesn’t mean the research is stopping anytime soon. This quarter, there were 86 new original research articles added to the Academy database and 22 abstracts from the annual […]

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Evidence-Based Musculoskeletal Pain Relief is a Spray Away

November 22, 2017

As you’re reading this sentence, millions of people are struggling with some form of musculoskeletal pain. This notion isn’t new to you, though; you treat these patients day in and day out in your clinic. Thankfully, more clinicians are wising up to the detriments of opioid prescriptions to treat musculoskeletal pain, and these pain sufferers […]

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Dynamic vs. Isometric Resistance Training for Knee Osteoarthritis

November 15, 2017

Osteoarthritis is a progressive condition that can significantly hinder a person’s ability to get around and negatively impacts their overall quality of life. Osteoarthritis is the most common joint disorder in the US and the second most common disability in older adults. When osteoarthritis impacts the knee, it’s especially limiting and can eventually prevent the affected […]

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Don’t Rely on Your Ankle Brace in The Off-Season

November 8, 2017

Ankle braces are great for preventing injuries in athletes who participate in sports with high risk of ankle injury. The question remains; should athletes wear ankle braces even during the off-season? A study recently released by the Journal of Performance Health suggests that performing neuromuscular ankle training during the off-season without wearing an ankle brace […]

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Can Kinesiology Tape Reduce Pain Post-Chiropractic Adjustment?

November 1, 2017

Annually, 30-50% of adults will experience some form of debilitating neck pain. That’s a lot of people, a lot of pain and, potentially, a lot of pills. However, we all know better than that (right?!). There are a whole host of treatment options that can actually reduce neck pain instead of just masking it: one […]

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