RICE: The End of an Ice Age

Coaches have used my “RICE” guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping.” – Gabe Mirkin, MD, March 2014


ice-for-injuriesIn 1978, Gabe Mirkin, MD coined the term RICE. Health care practitioners to laypersons are quick to recognize RICE as the ‘gold standard’ treatment option following injury. Followers of my blog know my stance against ice and now there is support from the physician who coined the term. Yes, the very same physician, Dr. Gabe Mirkin, who coined RICE, is now taking a step back. I reached out to Dr. Mirkin and asked for permission to share his story. As you will read below in Dr. Mirkin’s full post, the lack of evidence for cryotherapy is something we must listen to.

This is a controversial topic. My blog Why Ice and Anti-inflammatory Medication is NOT the Answer sparked a lot of debate. I had nearly 30,000 page hits per day for several weeks. I recently received a tweet from a peer (@AlanMRussell) who attended a presentation by Cindy Trowbridge from the University of Texas-Arlington refuting many of my comments. The debate continues, but given the evidence – or lack thereof – I stand by my thoughts that ice does not facilitate tissue healing.

I recently had the pleasure of connecting with Nichan “Nick” Zourikian a physiotherapist and researcher at Sainte-Justine University Hospital Center in Quebec. Nick published a study with Angela Forsyth, DPT (Rush University Medical Center) that led to a unique, in-journal debate among experts. The original review article published in Haemophilia, challenged the effectiveness of ice (1). This led to a “Letter to the Editor” rebuttal published one year later (2), which led to a rebuttal to the rebuttal published in the same journal (3). Why is this such a hot topic? Nick summed it up perfectly in an email:

There clearly exists a dogmatic polarization on the use of ice in our physiotherapist/athletic therapist communities! Old habits die hard. Many colleagues (even in our hemophilia community) still insist on using ice…despite the current scientific evidence available.”  Nick is spot on, RICE is an old habit that is dying hard.

I have long said modalities are overused and exercise is under used. Ice: The Overused Modality was my first post to make this point. I have added several posts that demonstrate the need for exercise and the positive effect mechanical load has on tissue healing and repair. See my posts on MechanotransductionAchilles Tendinopathy and reversibility as these explain more.

The NATA’s position statement in August 2013 on management of ankle sprains would support my anti-ice case. The researchers for the NATA position statements take years to critically appraising data to make conclusions. They comb over all the data and rate evidence from best “A” to worst “C”. In this particular position statement cryotherapy was overall a C rating for evidence (4). The article says “Strong clinical evidence for advocating cryotherapy is limited”. The evidence that had the better ratings: functional rehabilitation, proprioception, balance, and range of motion (note: these are all tissue loading exercises) (4). What’s interesting is many of the readers to my blog are athletic trainers, physical therapists, and physiotherapists. Yet, they are the ones who think I am nuts. Your own organization has a comprehensive position statement that supports my thoughts. Am I that crazy?

I read a piece on Medscape the lead author of the NATA position statement, Thomas W. Kaminski, PhD, ATC, said that he believes that many practitioners are still following the prescription too closely (5). The article goes on to quote Dr. Kaminski: “I wish I could say that what we found is what is really being done in a clinical setting.” There is another quote: “Maybe our European colleagues know something we don’t”…”there is very little icing over there.” (5)

Despite the lack of evidence advocating the use of ice the debate continues. Peers continually challenge me and would like to see me hung, drawn, and quartered for suggesting no ice. ‘My gosh, you mean I shouldn’t take 30 ice bags out to the baseball field wrap shoulder and elbows? You’re insane!’ A shift in paradigmatic treatment is on the horizon. Exercise is heating up and ice is melting down. Below is the full article from Dr. Mirkin’s website, which will only fuel the end of the ice age.

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Why Ice Delays Recovery

March 20, 2014

by Gabe Mirkin, MD

When I wrote my best-selling Sportsmedicine Book in 1978, I coined the term RICE (Rest, Ice, Compression,Elevation) for the treatment of athletic injuries (Little Brown and Co., page 94). Ice has been a standard treatment for injuries and sore muscles because it helps to relieve pain caused by injured tissue. Coaches have used my “RICE” guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping.

In a recent study, athletes were told to exercise so intensely that they developed severe muscle damage that caused extensive muscle soreness. Although cooling delayed swelling, it did not hasten recovery from this muscle damage (The American Journal of Sports Medicine, June 2013). A summary of 22 scientific articles found almost no evidence that ice and compression hastened healing over the use of compression alone, although ice plus exercise may marginally help to heal ankle sprains (The American Journal of Sports Medicine, January, 2004;32(1):251-261).

Healing Requires Inflammation
When you damage tissue through trauma or develop muscle soreness by exercising very intensely, you heal by using your immunity, the same biological mechanisms that you use to kill germs. This is called inflammation. When germs get into your body, your immunity sends cells and proteins into the infected area to kill the germs. When muscles and other tissues are damaged, your immunity sends the same inflammatory cells to the damaged tissue to promote healing. The response to both infection and tissue damage is the same. Inflammatory cells rush to injured tissue to start the healing process (Journal of American Academy of Orthopedic Surgeons, Vol 7, No 5, 1999). The inflammatory cells called macrophages release a hormone called Insulin-like growth Factor (IGF-1) into the damaged tissues, which helps muscles and other injured parts to heal. However, applying ice to reduce swelling actually delays healing by preventing the body from releasing IGF-1.

The authors of one study used two groups of mice, with one group genetically altered so they could not form the normally expected inflammatory response to injury. The other group was able to respond normally. The scientists then injected barium chloride into muscles to damage them. The muscles of the mice that could not form the expected immune response to injury did not heal, while mice with normal immunities healed quickly. The mice that healed had very large amounts of IGF-1 in their damaged muscles, while the mice that could not heal had almost no IGF-1. (Federation of American Societies for Experimental Biology, November 2010).

Ice Keeps Healing Cells from Entering Injured Tissue
Applying ice to injured tissue causes blood vessels near the injury to constrict and shut off the blood flow that brings in the healing cells of inflammation (Knee Surg Sports Traumatol Arthrosc, published online Feb 23, 2014). The blood vessels do not open again for many hours after the ice was applied. This decreased blood flow can cause the tissue to die from decreased blood flow and can even cause permanent nerve damage.

Anything That Reduces Inflammation Also Delays Healing
Anything that reduces your immune response will also delay muscle healing. Thus, healing is delayed by:

  • cortisone-type drugs,
  • almost all pain-relieving medicines, such as non-steroidal anti-inflammatory drugs like ibuprofen (Pharmaceuticals, 2010;3(5)),
  • immune suppressants that are often used to treat arthritis, cancer or psoriasis,
  • applying cold packs or ice, and
  • anything else that blocks the immune response to injury.

Ice Also Reduces Strength, Speed, Endurance and Coordination
Ice is often used as short-term treatment to help injured athletes get back into a game. The cooling may help to decrease pain, but it interferes with the athlete’s strength, speed, endurance and coordination (Sports Med, Nov 28, 2011). In this review, a search of the medical literature found 35 studies on the effects of cooling . Most of the studies used cooling for more than 20 minutes, and most reported that immediately after cooling, there was a decrease in strength, speed, power and agility-based running. A short re-warming period returned the strength, speed and coordination. The authors recommend that if cooling is done at all to limit swelling, it should be done for less than five minutes, followed by progressive warming prior to returning to play.

My Recommendations
If you are injured, stop exercising immediately. If the pain is severe, if you are unable to move or if you are confused or lose even momentary consciousness, you should be checked to see if you require emergency medical attention. Open wounds should be cleaned and checked. If possible, elevate the injured part to use gravity to help minimize swelling. A person experienced in treating sports injuries should determine that no bones are broken and that movement will not increase damage. If the injury is limited to muscles or other soft tissue, a doctor, trainer or coach may apply a compression bandage. Since applying ice to an injury has been shown to reduce pain, it is acceptable to cool an injured part for short periods soon after the injury occurs. You could apply the ice for up to 10 minutes, remove it for 20 minutes, and repeat the 10 minute application once or twice. There is no reason to apply ice more than six hours after you have injured yourself.

If the injury is severe, follow your doctor’s advice on rehabilitation. With minor injuries, you can usually begin rehabilitation the next day. You can move and use the injured part as long as the movement does not increase the pain and discomfort. Get back to your sport as soon as you can do so without pain.

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I want to thank Dr. Mirkin for allowing me to share his article. I really appreciate his continued contributions to health and wellness.

 

Until next time –

Josh

 

References:

  1. Forsyth, A. L., Zourikian, N., Valentino, L. A. and Rivard, G. E. (2012), The effect of cooling on coagulation and haemostasis: Should “Ice” be part of treatment of acute haemarthrosis in haemophilia?. Haemophilia, 18: 843–850. doi: 10.1111/j.1365-2516.2012.02918.x
  2. Rajamanickam, M., Michael, R., Sampath, V., John, J. A., Viswabandya, A. and Srivastava, A. (2013), Should ice be used in the treatment of acute haemarthrosis in haemophilia?. Haemophilia, 19: e267–e268. doi: 10.1111/hae.12163
  3. Forsyth, A. L., Zourikian, N., Rivard, G.-E. and Valentino, L. A. (2013), An ‘ice age’ concept? The use of ice in the treatment of acute haemarthrosis in haemophilia. Haemophilia, 19: e393–e396. doi: 10.1111/hae.12265
  4. Kaminski TW, Hertel J, Amendola N, et al. National Athletic Trainers’ Association position statement: conservative management and preventing of ankle sprains in athletes. J Athl Train. 2013;48:528-545
  5. http://www.medscape.com/viewarticle/823217_1 – accessed April 9, 2014.

100 thoughts on “RICE: The End of an Ice Age

  1. alikat

    So why not hot/ cold contrasts? Inflammation brings with it pain as established, and significant swelling that decreases ROM, so in order for cleansing of damage tissue and cells, i would think its beneficial now ending with heat than before as I was taught to end with cold. what’s your consensus? it makes more sense in the locker room vs. field, with heat use.

    Reply
  2. J. Gore

    As usual the pendulum swings too far the other way. While exercise IS the thing that produces the progress, ice in the form of pain relief and improved motion that the excessive swelling can hinder, improve compliance and performance of those activities. Reliance on either too much ice and rest or too much activity without managing the painful and often restrictive swelling is not a good idea. The answer is good judgement in the use of both somewhere in the middle. Just read Jeff Kelly’s comments before hitting the done button and he has said it all very well.

    Reply
  3. mark

    All points taken in consideration.
    Which is why not everyone is qualified to treat solely based on knowledge of the action of any modality or treatment procedure.
    One must be aware of the purpose why a certain treatment is DEEMED NECESSARY.
    There is a saying. “More than one approach to any situation” I’ll add to this saying. …and knowing what NEEDS TO BE ADDRESSED FIRST at that critical moment will HELP determine what action best suits the need.
    I’m sad to say…most people attend a couple of seminars / watch some documentary shows and start rolling out what they felt as practice. It shouldn’t be the case. Seminar givers should always give verbal caution on whatever they introduce.
    Certificate of attendance is different from completion.
    I’ved attended seminars showing exercises and manipulations and I was a bit concerned. Introduction is one different thing from Education and Practice.
    Please be careful. Do No Harm even when intentions are good. Though Patch Adams may also have a say on this. :)

    Now that’s why medical professionals spend a couple of years in boring and mind numbing pre med before practicing and learning how to use the knife. We can’t reverse engineer this like a digital appliance.

    Now is ice obsolete…Depends on what management a specific case requires. Nothing is obsolete.
    Nothing is written in stone.

    Reply
  4. Hillary Matthews

    Active (pneumatic) Compression is great because it simply helps reabsorb edema and increase circulation to the injury site. We (RecoveryPump) work with many athletes on daily recovery protocol as well as post-op or post injury treatment and the healing time is incredible.

    Reply
  5. Paul

    Great info Josh. Do you have any advice for ice after surgery such as total joint replacement or other joint surgeries? I am an ortho nurse and we use ice for these patients whose stay is usually 2-3 days and the ice is on continuously.Thanks

    Reply
  6. Muffin

    What about icing (ice cube massage) for longer term injuries?
    Shin splints, turf toe, plantar fascitis, hip abductor strains, IT band tightness, etc.
    Especially in low blood flow areas, where healing is slow regardless, can ice jump-start the healing process again?

    Reply
  7. Sean

    The medical profession has a long history of “raping and pillaging” anyone who dares to buck conventional wisdom (Google Joseph Lister). However, to deem ice as now utterly irrelevant is silly. While ice MAY delay healing, it does, in fact, significantly reduce pain that can at times be disabling; I have the surgical scars (13) on my knees and shoulders to prove it . . . and on those few occasions where I applied ice inadequately, I paid the price in severe pain; one occasion necessitated a trip to the ER to receive a shot of Demerol. Also, having not applied any ice to a severely sprained ankle left me virtually immobile for over a week, while subsequent sprained ankles that received applications of ice minimized the pain and swelling, and allowed me to walk within a couple of days. Still, walking with a limp is NOT the same as being fully healed, so the debate about ice, and attendant clinical trials, should continue . . . without resulting in the personal attacks for which the medical establishment has become so well-known.

    Reply
  8. AshevilleChicken

    I’m not an sports athlete, but a yoga practitioner. Did I loose you already? The yoga I practice is hot and intense and might be considered somewhat extreme. Anywho, I can’t imagine total rest being the cure for any injury. It just seems like on multiple fronts that wouldn’t be helpful: stiffness caused from immobilization of the injured area, because you’re laid up you have all the time in the world to think about how much it sucks that you can’t move your knee, shoulder, neck…etc. But, I take issue with the idea that slowing the inflamatory response 100% of the stone will slow healing. Our immune systems aren’t perfect. They over respond, from time to time. An extreme example is juvenile artritis

    Reply
  9. Jordan

    CONTRADICTORY ARTICLE
    “elevate the injured part to use gravity to help minimize swelling”
    Yet before that it says:
    “Anything That Reduces Inflammation Also Delays Healing”

    Is inflammation and swelling 2 different things? I am confused, please clarify for me.

    Reply
    1. Joshua Stone Post author

      Sorry for the delayed response on this.

      Yes, they are in fact two very different things. Swelling is a byproduct of inflammation. We want to swelling out. Swelling is what causes hypoxic injury. Swelling leads to pain. Swelling inhibits tissue growth. Swelling can inhibit muscle function.

      Use this analogy: A road is in need of major construction. The pavement must be torn up and replaced. Think of inflammation as the road crew they are digging up and repairing. When you dig up the old pavement that left over debris is swelling. To repair a road, you must dig up the old, smooth, and repair or patch. The old debris must be taken away. However, image this team doing this work if all the old pavement and debris that was dug up was not removed. It would be near impossible.

      Massage, muscle pumping, compression, and elevation will work to remove the swelling. Ice will also minimize swelling, but it will not remove swelling. Ice will also impede inflammation.

      Reply
  10. Toni

    How does this go for shoulder injuries where impingement syndrome gets in a circle of inflammation and swelling, producing harder impingement and there for inflammation again. Any thoughts on that with the RICE theory?

    Reply
    1. Joshua Stone Post author

      I’ve had good success not icing impingement syndromes. Typically there is an underlying cause to the impingement syndrome. Inflammation just didn’t show up, something brought about the inflammation. I would address scapulothoracic mechanics as well as scapulohumeral mechanics. Load and proper motion!

      Reply
  11. Claudiu Szenasi

    I’m sure telling a competitive athlete to lay off immediately will work out just fine. We do what we need to do in order to keep going. Reduction in inflamation is typically a reduction in pain and therefore allows me to jump back on the horse again right away. I can only imagine walking into my gym and telling the fighters if they are sore they need to stop training immediately and take time off to heal properly! Hahaha! See how quickly you get laughed out of the place… Ideally, sure… but realistically, that would be an impossibility. A competitive athlete would never be able to keep up technically with the rest of the field by training that way… They would actually be looked at as a slacker and be categorized as lazy. So the bottom line is… It doesn’t matter if your studies are correct… The application of your physical training philosophy would never survive in the competitive arena. In order to be great, sacrifices must be made… Destroying our bodies is simply a part of the deal. I’m sure it’s difficult to understand for many, but it is the price a warrior pays to be at their very best.

    Reply
    1. Joshua Stone Post author

      Rarely would I recommend taking time off or resting. I think there are other things we can do to fix it. Icing is not one of those things.
      I’ve worked with many MMA athletes for both performance training and injury rehabilitation. Some are a rare breed of toughness. Then there are others who are not. I know a some high school female gymnasts who are mentally tougher than any athlete I’ve ever met. My point is that no competitive athlete wants to be held out. They persevere. It is these athletes that deserve attention to fix the problem.

      Reply
  12. Richard Harmon

    Oh my! This is an example of how a little knowledge can be worse than none. “Immunity” involves several distinct cell types. Immediate inflammation does NOT involve classic immunity, mediated by T cells, B cells and antigen presenting cells. Healing requires macrophages, and, yes, their migration to injured tissues will be slowed by ice. But granulocytes, neutrophils, etc.? They do immediate DAMAGE in injured tissues that will BECOME inflamed, and release of the damaging chemokines, etc. is inhibited by ICE.

    Wow. You do much more harm than good by floating this $%^&.

    Reply
    1. Joshua Stone Post author

      Oh yes, the neutrophil. You’re are correct; they are highly toxic and do immediate damage. Our body is really screwed up. These highly volatile and dangerous cells are also the most abundant (by a large margin) leukocyte. We are a walking time bomb with these evil doers in our system! What is our body thinking having so many on guard. When they burst, they release reactive enzymes creating a hyperoxide environment which eventually becomes a hydrogen peroxide environment that kills tissue!
      I will remember this next time I need to immediately deep cleanse a wound from an athlete who suffers an open compound fracture on a muddy soccer field. I’d much rather let that bacteria sit and fester than use hydrogen peroxide. We wouldn’t want to kill the tissue.
      That small window immediately after injury, when neutrophils are most active, is also a required trigger for the rest of healing to occur. It’s like a 3 alarm fire an apartment complex. We call 911, fire crews and emergency dispatch arrive at the scene and then we say, STOP! let the fire burn! We don’t want to stop this fire. We don’t want other crews to come clean up debris. We don’t want laborers to come rebuild that apartment.

      Reply
  13. James Leavitt

    I agree that RICE shouldn’t be the immediate treatment for all injuries. With that being said, the use of ice and other cryotherapy modalities for something like ankle sprains and chronic inflammatory issues is still very beneficial. Ice has been shown to decrease inflammation and pain. Cryotherapy causes vasoconstriction and assists in decreasing the pooling of blood so health tissue can still get oxygenated blood. Too much inflammation can block the flow of blood to healthy tissue and can lead to a secondary hypoxic injury. This will further damage the tissue around the injury site resulting in a longer recovery. In addition to decreasing inflammation, the use of ice also allows practitioners to perform ligament tests and other special tests to the athlete without causing them significant pain and minimizes muscle guarding. If the muscle is guarding to much you can’t get valid results from the special tests. So I will not be giving up on the RICE treatment model just yet. It really seems like there should be more studies on the beneficial uses of cryotherapy.

    Reply
  14. Scott Harres

    Claudui is completely missing the point! What we’re saying is that not icing will help you heal faster, make you less sore, less swollen, etc. etc. Icing is SLOWING THE RECOVERY. This isn’t rocket science. It’s basic human biology. If you want your athletes to recover more slowly and underperform, by all means, ice the crap out them. If you want a supple, healing human machine, move, compress, heat, elevate.

    Reply

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