Why Ice is Not Always Nice (Part 1 of 2)
Thursday, December 4, 2016
Written by: Cora Tomowich
“Oh, you have a sprained ankle? Just put some ice on it for a half an hour or so”
“Oh, you tweaked your shoulder? Just put some ice on it until it goes away”
“Oh, you’re fresh out of surgery? Just use ice to keep the swelling down”
How many of you out there have heard sentences like these? If I could see you, I would likely see many hands in the air. Why is it that we are always told to put ice on our acute injuries? Where did that even come from?
During my time in physio school, I was engrained with the idea that we must always prescribe ice to our patients for acute injuries and inflammation. We must use “the RICE (rest, ice, compression, elevation) principle” to heal from an injury but there were only vague reasons as to why. What I also found interesting was that the recommended dosage of ice differed greatly across the board, again without a clear reason as to why. Some practitioners would say to ice for 10 minutes and keep off for 20 minutes, or ice for 20 minutes and keep off for 30 minutes, and so on and so on. It got to be a bit confusing. So what is this ice business really all about?
In May of 2014, I came across a fascinating evidence-based piece by Bleakley et al (2010), which opened my eyes to the idea that maybe ice is overused in the clinical setting and maybe, just maybe, it’s not quite as helpful as we once thought it to be. Another interesting paper by Bleakley, Glasgow, and MacAuley (2012) suggested that perhaps we should alter our beloved ice prescriptions to address pain instead of inflammation because our current uses for it have not always been a good idea.
In the case of an acute injury, the body’s natural blood flow is designed to carry all kinds of specialized cells that are heavily involved in the healing process. Some of these cells promote immediate swelling to protect the injury site, some of these cells clean up the damaged tissue, and some of these cells lay down new tissue in order to repair that which was injured.
It is important to know that there are three main phases to the healing process of an injury. Phase one is the inflammatory phase and usually lasts a short time and is often the more uncomfortable phase – I mean really, who loves feeling all swollen and puffy? The second phase is the repair phase and can last for a few weeks depending on the individual. The third phase is the remodeling phase and can actually last for a couple years as all the underlying tissues around the injury site develop into strong, healthy, and tensile tissues once again.
Since ice is a vasoconstrictor, meaning that it narrows blood vessels and slows down blood flow to an injury site, it serves to delay the natural healing process by limiting or inhibiting one of the most important phases of healing: the inflammatory phase! This means that we could end up with seriously altered tissue health as the body moves into the subsequent phases of healing, which often means delayed tissue repair or a repeat injury. So the question begs: is that something we really want to do?
As inconvenient as inflammation might be it is perfectly natural and normal and should be allowed to occur in the initial phase of healing from an acute injury. Why would we want to mess with nature? Instead, as the experts say, let’s focus on using ice as a pain management tool. Some studies have shown that using small doses of ice post-operatively are very helpful to reducing pain. Maybe ice can even be used to decrease the amount of painkillers we take after surgery… what an intriguing thought!
In my own practice, I often prescribe ice to patients if pain is rated high (8-10/10) or if there are difficulties getting to sleep because of pain. I will usually suggest a dose of 10 minutes of ice, once per day if the patient feels it is needed. I also provide a comprehensive, customized home-exercise program designed to gradually load the injured tissues in a way that optimizes their eventual repair and remodeling.
Clinically, I have found huge success with this strategy! Firstly, I see patients relying less and less on painkillers or NSAIDs (non-steroidal anti-inflammatory drugs), which means fewer side effects and happier gastrointestinal systems. Secondly, with gentle mobility exercises, I see swelling diminish gradually without any compromise to the end-result tissue. And thirdly, since they allowed their bodies to recover the way they were designed to recover, I see patients returning to their normal activities of daily living as if better than before!
In all of this, I would ask that you remember one thing: don’t be so quick to throw ice onto an acute injury for hours on end. Simply use it to manage your pain and then come see your friendly neighbourhood physio for some simple exercises to help you on your way. In my next piece, I will take a closer look at the RICE principle and offer suggestions on what to do in case an acute injury becomes chronic.
Raynor MC1, Pietrobon R, Guller U, Higgins LD. Cryotherapy after ACL reconstruction: a meta-analysis. J Knee Surg. 2005 Apr;18(2):123-9.
Adie S1, Naylor JM, Harris IA. Cryotherapy after total knee arthroplasty a systematic review and meta-analysis of randomized controlled trials. J Arthroplasty. 2010 Aug;25(5):709-15.
Adie S1, Kwan A, Naylor JM, Harris IA, Mittal R. Cryotherapy following total knee replacement. Cochrane Database Syst Rev. 2012 Sep 12;9
Bleakley CM et al Effect of accelerated rehabilitation on function after ankle sprain: randomized control trial. BMJ. 2010 May 10;340:c1964
Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE? Br J Sports Med. 2012 Mar;46(4):220-1