I was fortunate enough to be interviewed by Jen Murphy, a health & fitness reporter for the Wall Street Journal. She did a story on how to prevent common injuries that can happen as a result of more people staying home to exercise… particularly those who may be used to working out in a gym and now find themselves without the space and equipment they are used to. And they are trying online exercise programs that might not have supervision to perform the exercises correctly. Here are some tips from myself and other physical therapists around the country to safely work out at home! Read the full text here.

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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

And if you’re interested in more from me on this topic, see my post on MikeReinold.com…and check out the comments afterward!

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

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 […]

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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

January 19, 2019

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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