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.

****************************************************

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.

*****************************

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.

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

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  5. Douglas Ruegger

    As a coach of all different levels and part time team trainer I do admit that I am a proponent for the “RICE” steps to recovery. Now that I have read this article I am determined to do some more research. I do like the ice for the pain for the athlete, if its not actually working directly on the point of injury it’s working mentally for the athlete that is injured. It’s one thing to change the process for the trainers but the we also need to make the athletes smarter in the processes as well. If you think about it, when we put ice on the injured area all we are doing is creating the bodies reaction of vasoconstriction which is closing up the blood vessels and beginning the initial stages of frostbite. Hence the “20 minute” time limit.

    Thank you for the great article and with great controversy comes great discovery!

    Respectfully,
    Doug Ruegger
    Retired U.S. Navy

    Reply
    1. Marti

      Dear Douglas. Fortunately we have great harmless alternatives to RICE protocol. You need to update your training if you do not want to keep causing damages to your athletes. There are potent and truly therapeutic ice-free and drug-free methodologies to solve common sports injuries. After Dr. Gabe Mirkin’s retraction you have no sound basis to keep doing the same thing, unless you want to incur in a legal battle, if your patients feel that you caused them damages. The proponent and promoter of RICE has retracted since 2014. If you want you can authorize Joshua to forward your email address and we get in touch. Since 1980, just 2 years after Dr. Mirkin wrote his “Sportsmedicine Book, independent scientists, faced with adverse side effects, have done scientific studies that show that cryotherapy is a risk. I have been able to rescue athletes who were victims of cryotherapy and harmful synthetic drugs, in a very short period of time, using an ice-free and drug-free methodology. They were able to recover from “severe” sports injuries, which were threatening to end their career. If I might, I would just point to you 2 famous cases I attended, one of a professional English footballer (UK) and another of a professional 10km runner from Ethiopia (Athens 2004 Olympic Games). I would be very pleased to share with you many more cases of athletes who were suffering from “incurable” sports injuries, after unsuccessful and harmful use of both cryotherapy and synthetic drugs, but are now all back on track, with enough information to prevent further common sports injuries. None of them are now using cryotherapy or synthetic drug therapies.

      In injuries of Level IV, with great perfusion, one could use some icing, but with much care, and right after the injuries, for a short time. But most of sports injuries are not of level IV. Saying that icing an injured part of the body is good because it takes the pain away is falling, ignoring all the implications, into a huge trap, prepared by those who promote “Social Pchycoscotoma” (social mental blindness) in order to impose falsehood and collect financial gains, because they will be eternally busy treating recurring injuries. I may say that some will do that out of ignorance and not out of greed or malice. If you are using cryotherapy to hide pain, you would better use anaesthetic drugs, without interfering with body temperature. The only would-be good thing about cryotherapy for common sports injuries of level 1-3 is to numb the area and prevent nerve function as not to let you know that you are injured. It does not reduce or prevent the swelling. If you remember physiology, you will recall that the interstitial fluids that may cause swelling are collected by lymph capillaries with the help of muscle contraction. If the capillaries are broken because of injuries, they do not collect the interstitial fluids and we have swelling. How does icing heal the capillaries so they can collect the fluids? It doesn’t make sense.

      What happens is that we have several lymphatic adjacent territories in the body, which helps to remove some of the excess fluids in the injured areas. So, whether you use ice or not, after a while some swelling will be reduced from the injured areas. You may recall that even after using ice, some swelling will remain. That is why. If it was true that ice prevents swelling, the whole of the excess fluid would be removed from the injured areas. Got me? Please compare “Regarding the use of ice, it has been shown that the early use of cryotherapy is associated with a significantly smaller hematoma between the ruptured myofiber stumps, less inflammation, and somewhat accelerated early regeneration” (http://ajs.sagepub.com/content/33/5/745.abstract). “Less inflammation” equals less healing. “…accelerated early regeneration” equals false statement. Please bear in mind that Dr. Gabe Mirkin, the man behind the RICE thing, has retracted and admitted that he was wrong (http://drmirkin.com/fitness/why-ice-delays-recovery.html). He admitted that icing depresses the level of IGF-1 and so affects negatively the healing process. “Depression of…growth hormone/IGF-I levels may exacerbate the adverse lipid and body compositional changes, reduce exercise tolerance, and have deleterious effects on quality of life” (http://europepmc.org/abstract/med/10680161). This is very serious. “It needs to be stressed that there is not a single, randomized clinical trial to prove the
      effectiveness of the RICE principle in the treatment of soft tissue injury” (http://ajs.sagepub.com/content/33/5/745.abstract). Please compare with studies which have proved that cryotherapy is deleterious for common sports injuries (http://www.caringmedical.com/sports-injuries/rice-why-we-do-not-recommend-it/).

      Reply
      1. Nathan

        I just fell off my bike yesterday injuring my shoulder. Having read from so many sources that RICE is under a lot of criticism with good reason, I chose not to ice my shoulder. I was able to move my arm to some small degree but with pain. Today it’s way worse and sleeping was quite difficult last night given the pain. I also chose not to take any NSAIDs since that also may be counterproductive for the same reason. I don’t know what to do now. I have an appointment with the Orthopedic surgeon at the Rothman Institute tomorrow so I can get it examined and possibly get an MRI, just to know what happened, but I have no idea what to do in the meantime.

        Reply
        1. Marti

          Dear Nathan, I trust that by now you have found some comfort. From what I have read about Joshua, I believe that he will be able to sort you out, if he is not too far away from where you live. There are many reflex points around your body, which will correspond to particular muscles. You may have noticed that the muscles involved in injuries will become particularly tense as a compensation and protection mechanism. A well trained practitioner will be able to find those points, work on them, relieve the congested areas around your injuries and reduce the pain to a manageable level, until the healing takes place and the inflammation is dispersed. Then the rest of pain will vanish naturally, as the brain will stop sending you signals about the injury. I do understand what you were saying. Now that it is so clear that both cryotherapy and NSAIDs can be so damaging, what to do with injuries? Surgery may not be the answer either (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1065571/pdf/hsresearch00085-0066.pdf). All this could have been avoided altogether, had the medical establishment listened to honest and independent scientists, who have worked relentlessly to provide us with sound science, but it is not clear that the real intention behind this allopathic version of medicine is to help us solve our health problems. Otherwise, we would have, by now, enough practitioners, everywhere, ready to come to our rescue and save us from unnecessary pain, without causing us more damages. The knowledge has been out there for quite a long time, but their holders are often treated, by conventional practitioners (who say they have the duty to protect people), as those of lower class, con artists, curious and charlatans, who have to be persecuted, harassed and taken out of business, in the name of “science”. And now that it is crystal clear that pseudo-science has replaced the real science, for centuries, we don’t seem to have enough practitioners ready to step in and help those in need. Now we have to do what we can (slowly, because we don’t have enough well trained practitioners) and train more people able to help solve the problems, without causing further harm. I can imagine how bad are those good-hearted physicians are feeling, after finding out they were being deceived for so long, manipulated and used to sell harmful substances and methodologies, causing thus harm to their very loved ones. See what an outstanding scientist (among many others) has been made to endure, just because he left his comfort zone and decided to get out there and warn people about the risks they are facing, when faced with the vested interests of some medical mercenaries, who managed to infiltrate our otherwise great and needed Medical System (https://www.youtube.com/watch?v=Ra0QtTUuFIc). You can see how paramount it is to change the medical paradigm and to allow for the proper training of helpful practitioners. Do all you can to avoid your injury becoming chronic, as that could make you dependent on palliative care. I commute between London (UK) and Praia (Cape Verde), assisting people with chronic conditions which no longer respond to conventional approaches and so would not be easily handy, but if Joshua or other good practitioners you certainly have in the States are not available, keep trying. Good luck and take care.

          Reply
  6. Christos

    Recently I sprained my ankle pretty badly.
    It was Friday night, went to the hospital, there was no fracture so I went home.
    RICE was the recommendation and I already had iced it and taken NSAIDs before hand.
    Monday night I went to my physiotherapist, I was walking on crutches.
    He saw a slight separation between the tibia and fibula bone on the x-ray.
    He told me RICE was obsolete and immediately had me slowly walking on the leg and doing exercises when I thought I couldn’t even touch the ground with it.
    I left there walking on my own.
    I have not taken any NSAIDs any more or applied any ice after that and it’s been going well.
    I know that orthopedic surgeons do not prescribe NSAIDs after surgery in order to allow healing,I’m a pharmacist myself so I get a lot of post surgery prescriptions and they usually involve just strong pain killers such as codeine.
    Also I do a lot of weight training and have always felt that I should not take anything after exercise to reduce inflammation if I couldn’t sleep because inflammation is actually desirable and the normal response of the body to muscle tissue damage.
    I feel that after injury one should try to stabilize the injured member and then gradually apply stress to keep the blood flowing without feeling any pain or serious discomfort from the effort, avoid NSAIDs and ice and generally do not baby the injury any more than is necessary.

    Reply
  7. Gerald Mirabal

    As a personal trainer for over 26 years I have always done research on the way to speed up recoveries from injuries, my self as a prime example had a major ankle sprain very ssevear I personal I did not use RICE , warm water with Epson salt and then compress then rehab after seeing 2 Dr’s and having 2 X-rays was to;s 6 to 8 weeks recovery, well wishing 2 days I was walking, the more I walk the better it felt only when I rested then it was painful to walk but it got better the more I walk I have pic and video to prove that the system I use work anyone interested I will send them pictures and video.

    Reply
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  9. Jason

    I can say that in my case, sprained ankles were absolutely helped by RICE. I was a sponsored skateboarder and sprained my ankle’s many many times over a 15 year period. As soon as I forced myself to diligently RICE, my recovery times literally halved. I went from 3-4 weeks down to 1.5-2 before I could start working my way back up to full activity, with the use of an ankle brace. Before, I would have a ton of swelling and it would take a really long time for that all go away but after RICE, The swelling was maybe 1/3 as much and I recovered so much faster it’s unbelievable. Perhaps it was just the compression that helped and not the ice, I don’t know, but I know for sure that strictly following RICE very dramatically improve my recovery times and I had done enough of both to get a really good handle on what worked and what didn’t. I did RICE for the first 48 hours, then relaxed for a day, then started walking around and trying to get back on my leg. Not a chance on earth that I would ever go back to eliminating the whole procedure.
    These days I have a lower back issue. I’m actually icing it right now after a bone scan. If I don’t I sit for 12 minutes with an extremely cold pack right after I work out or otherwise stress it ( laying on my back for the bone scan stressed it) my back is sore for the next couple days. I’ve had times where I had to keep going and didn’t have time to ice because of obligations and my back pays the price every time. I have never iced a sore muscle because I want maximum blood flow to go there, but for an injury, I will definitely continue to ice initially.

    Reply
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  11. Rob

    Josh – incredible post.

    I broke my toe playing soccer last weekend. My physician recommended 1) buddy taping, and 2) RICE.

    At a cellular level, RICE has never made sense to me. At an injury site, our tissues activate signaling proteins to send pro-inflammatory cytokines — many of which are carried through the blood — to begin the healing process. The degree of swelling = the degree of signaling proteins needed to heal an injury site. And once the damaged tissues are either repaired or metabolized, anti-inflammatory signaling proteins take over which then begin to reduce the swelling.

    Paradoxically, the RICE model does everything it can to minimize blood flow / pooling to a damaged area – thereby lowering the number of signaling proteins required to heal the injury.

    I’ve never seen a single study demonstrating that RICE is more effective for healing injuries versus safe movement / use of the injury site versus a control group.

    So when my doctor told me, “One more thing: don’t take ibuprofen. Studies show it reduces inflammation by inhibiting certain proteins that help tell your body to make more bone cells,” I asked her, “If that’s the case, what’s the scientific basis for recommending RICE? Doesn’t RICE do the same thing, albeit through a different mechanism?”

    She said yes, and that she’d never thought of that before. And then she told me that she’d also never seen a study demonstrating RICE’s superiority over other healing models. The only reason she recommends it is from a clinical perspective, it helps reduce pain.

    That seems a little short-sighted.

    Bottom line: until RICE is clinically proven as a more effective healing model for minor acute injuries versus no RICE, physicians should stop blindly recommending it.

    Reply

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