Is RICE the best option?

– The METH alternative – 

RICE (Rest, Ice, Compression, Elevation) is a term that is synonymous with treating athletic injuries. Ice has been the gold standard for injuries and sore muscles since Dr. Mirkin coined it in 1978 from his sports medicine book. 

Everyone from Trainers to Grandma’s prescribes ice for those injuries because it relieves the pain from the injured tissue.

What if I told you that there isn’t much scientific support to whether ice will help your injury or not?

You’d probably look at me like I told you Santa is alive, sorry for the dreams I just crushed. In the National Athletic Trainers’ Association position statement, they found that ice therapy had a “C” level of evidence, this means little to poor evidence exists for it. In an interview, the author of that article said: “I wish I could say that what we found is what is really being done in a clinical setting…. Maybe our European colleagues know something we don’t…there is very little icing over there.” In the 1970’s we knew very little to what we know now about the healing process.  We didn’t know that inflammation is actually an important part of the overall healing process. 

Dr. Mirkin has since changed his mind on RICE, he believes that ice and complete rest may delay healing and not help it.

We are going to talk about a few things today:

• What is RICE and What is METH
• What is inflammation and healing
• What is the Lymphatic System
• The problems with RICE and a possible solution
• Quick tips
• FAQ
 
The inflammatory phase and healing
 

Let’s talk about what I mean by “inflammation”. I’m talking the inflammatory process, the Pro-inflammatory and anti-inflammatory processes. The inflammation phase is an inevitable biological process following acute soft tissue injuries. It’s the body’s way of protecting itself by removing the damaged stimulus and begins the healing process.

There came a point in time where this became second nature to stop or limit this process. It’s the inflammatory response that increases blood and lymphatic flow to and from the injured tissues. This brings the healing nutrients and inflammatory mediators to the injury site and removes the damaged refuse. 

The best analogy to think is  “Groceries in, Garbage out”. 

It starts with the release of the inflammatory mediators that cause a vasodilation (rush or opening of blood vessels) at the injury site. This allows more leukocytes and macrophages (Groceries aka White blood cells) to clean up the site and moderate the inflammation.

The more fluid at the site means swelling (edema) and this will increase the sensitivity to pain. Once the fluid is filled up with waste products (Garbage), it needs to be drained. This is where one of the lesser-known systems comes in handy, the Lymphatic system. The lymphatic system removes all the waste products and excess fluid build-ups caused by the inflammatory process.

 
Signs and Symptom’s of inflammation:
 
• Swelling 
• Redness
• Heat
• Loss of function
 
The Lymphatic System
 
The lymphatic system works in a one-way valve system. The circulatory system is a valve system also but your heart pushes the blood through with every contraction. The lymphatic system isn’t so lucky; it needs the muscles around to push it through. It works like an old fashion bike pump, the one that you stand on and push down to get air to go through the tire.
 
Healing requires inflammation
 
When you damage your tissues through a traumatic event or develop exercise induced muscle soreness (DOMS), you’re healed by inflammation and other processes. When you hurt yourself, your body sends inflammatory cells to the newly damaged tissue in order to promote healing. The inflammatory cells are called macrophages that 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.

What is RICE? (According to WebMD)

Rest
Rest and protect the injured or sore area. Stop, change, or take a break from any activity that may be causing your pain or soreness.
 
Ice 
Cold will reduce pain and swelling. Apply an ice or cold pack right away to prevent or minimize swelling. Apply the ice or cold pack for 10 to 20 minutes, 3 or more times a day. After 48 to 72 hours, if swelling is gone, apply heat to the area that hurts. Do not apply ice or heat directly to the skin. Place a towel over the cold or heat pack before applying it to the skin.
 
Compression
Compression, or wrapping the injured or sore area with an elastic bandage (such as an Ace wrap), will help decrease swelling. Don’t wrap it too tightly, because this can cause more swelling below the affected area. Loosen the bandage if it gets too tight. Signs that the bandage is too tight include numbness, tingling, increased pain, coolness, or swelling in the area below the bandage. Talk to your doctor if you think you need to use a wrap for longer than 48 to 72 hours; a more serious problem may be present.
 
Elevation
Elevate the injured or sore area on pillows while applying ice and anytime you are sitting or lying down. Try to keep the area at or above the level of your heart to help minimize swelling.

What is METH?

Movement
Controlled movement of the affected limb can stimulate blood flow, reduce the formation of inappropriately aligned collagen fibers (aka scar tissue) and effectively improve recovery.
 
Elevation
Place the injury site above the heart to assist the movement and allow gravity to assist you in removing the swelling. This will reduce pain from the pressure of the swollen tissue.
 
Traction
Traction is the new compression. Traction helps to take pressure off the injury by promoting movement of fluid.
 
Heat
Incorporating heat instead of ice will be the most scrutinized aspect of this new method. Those who support the use of heat suggest that inflammation is the bodies’ natural response to injury and bringing more blood to the area will help speed the process and instead of halt/delay it with ice.

The problem with RICE

Rest
Rest does not stimulate tissue repair. Rest causes tissue to waste and can cause abnormal gene transcription of collagen (scar) tissue. When we get hurt, scar tissue is laid down in a random formation (think wet spaghetti when pulling out of the water). This can cause some problems and make it harder/prolong to rehab. When the cells are being laid down as tissue, they don’t know what they are going to be (muscle/ tendon/ ligament/bone) but with movement you can stimulate which ones and proper alignment (think handful dry spaghetti). This is why cross-friction massage works well and how myositis ossificans can form. Myositis ossificans is an uncommon condition that may occur following a bruise (typically the thigh) and is characterized by bone formation in the muscle belly at the site of the bruise.
Complete rest does to facilitate the processes of mechanotherapy (exercise prescription to specifically treat injuries) and cellular signalling. This takes the progenitor cells (baby cells that don’t know what they are going to be) and makes them into rebuilding cells like myocytes (muscle cells), osteocytes (bones cells), tenocytes (tendon cells), chondrocytes (cartilage), and so on. You need to some type of controlled movement (aka therapeutic exercise) to stimulate this, that doesn’t mean if you sprain you ankle you can go run a marathon.
 
Ice
You’d be surprised that there isn’t much scientific proof that Ice works, I know I was. Ice limits/delays the body from releasing IGF-1. Macrophages (white blood cells) release the hormone Insulin-Like Growth Factor (IGF-1) into the damaged tissues, which helps muscles and other injured parts heal.
Ice has been shown to actually reverses lymphatic drainage and pushes the fluid back into the interstitial space! A study from 1986 (yes it’s old but it’s a foundational study) found when ice is applied to a body part for a prolonged period of time; it increases the permeability of the lymphatic vessels. So when these vessels become more permeable, the fluid goes back into the injured area increasing the swelling. Ice slows down debris removal and increases swelling. Ice impedes the cellular signalling and inhibits the proper development of new cells. There was a study in June of 2013 in the American Journal of Sports Medicine that had the athletes exercise intensely that they developed DOMS (delayed onset muscle soreness). It showed that the cooling delayed the swelling, but it didn’t speed healing along.
 
Compression
 
Compression isn’t all that bad; it just depends when you use it. It has been shown to help limit swelling.
 
Elevation
Elevation is great; you can use it in conjunction with massage, muscle pumping, and compression.

The possible solution with METH

We all know that we aren’t going to die or lose a limb if we put ice on an ankle sprain. Heck, it can be quite relieving. What if there’s a faster way?
 
This is where METH  – Movement, Elevation, Traction, and Heat is intriguing.
 
It’s a pretty new concept and a brand new one for many people. Let’s think of it from a logical process and take a step back.
 

The breakdown

Movement
We know that when mechanical stimulation can stimulate cell transcription in a positive way. We need that “baby cell” to turn into the proper cell and to be laid down in a fashion that is conducive to healing. We want that scar tissue laid down as dry spaghetti instead of random wet noodle it wants to.
 
Elevation
We want to get rid of the swelling because the increased pressure will cause pain. Remember the lymphatic system works on a one-way valve system, to make it easier on the body, we can elevate the limb and use the muscles to get rid of the excess edema.
 
Traction
Athletic Therapists and Physiotherapists use traction as a treatment to decrease pain and muscle spasm. It can reduce the compression, pressure, and allow fluid to move flush in.
 
Heat
Your first thought is, if I heat it – it will swell more. You’re right, increasing the temperature will inevitably increase the fluid to the area. I don’t think that’s necessarily a bad thing; the major problem is can we remove that excess fluid before it becomes problematic. Inflammation is a necessary part of the first phase of healing, without inflammation there is not healing. Inflammation is controlled by the body’s response to maintain homeostasis. If too much swelling has accumulated, it’s not that your body has produced too much, but the drainage system isn’t fast enough to get rid of it. Gary Reinl, the author of “ Iced! The illusionary treatment” may have the best analogy. Take two tubes of toothpaste, put 1 under ice for 20 minutes, the other one warmed to 99 degrees. If you can’t figure out which one flows better, well I can’t help you friend.

Quick Tips

  • Inflammation is not a bad thing. Healing requires inflammation. You can’t have tissue repair without inflammation. Ice impedes the necessary inflammatory cells to reach the tissues.
  • Inflammatory cells are designed to release the IGF-1 ( insulin-like growth factor). This is a primary mediator of the effects of growth hormone and stimulator of cell growth/proliferation, and a potent inhibitor of cell death. Ice inhibits the release of IGF-1
  • Complete Rest causes muscles cause muscles to waste away.  The body needs mechanical loading (exercises) to promote structural change.
  • Ice impedes cellular signalling and inhibits the proper development of new cells.
  • Your body doesn’t release “ swelling cells”, it’s a by product of the inflammation process. The best way to remove swelling is to facilitate the lymphatic system. Effectively remove swelling = remove pain. Think about this, you buy groceries and then eat them. You have left over garbage from it, you don’t wait until the garbage is over flowing and going onto the ground. No you don’t, you get rid of it before it becomes a problem.
  • Gabe Mirkin, the physician who termed “RICE”, has said he was wrong. “ Coaches have used my “ RICE” guideline for decades, but now it appears that both Ice and complete rest may delay healing, instead of helping”
  • How can you effectively get rid of swelling? Massage, muscle pumping, compression, and elevation are effective ways to remove swelling.
  • Don’t ever use ice and then immediately return to your sport. Ice has been shown to decrease strength, speed, power, and agility-based running.

Final Thoughts…

Ice will control the pain from injury, that relief only lasts between 20-30 minutes. There are many other things that we can do to control pain and not impede the healing process. The research is now saying that if you delay or inhibit inflammation, you will also delay your healing.
We now know more about the role inflammation in healing than we did when RICE was coined. Healing requires many different chemical reactions, proteins, and new cells to repair the damage. Ice will lead to a decrease in blood flow, this blood flow brings with it 
 
• white blood cells
• potent chemicals
• new cells needed for repair
 
So keep in mind… anything that reduces inflammation, may also be reducing your chance at rapidly healing from an injury. There’s a question that has been asked, ” Do you really believe that your body’s natural inflammatory response is wrong?”. Our bodies have evolved over million of years, when did inflammation after an injury become this deadly disease that needs to be eliminated?

Let the Ice debate heat up...

FAQ

Most frequent questions and answers
Swelling is a by-product of the inflammatory process; swelling is not inflammation. Ice doesn’t facilitate the lymphatic system to remove the swelling. Ice will inhibit the drainage and in some cases cause an increase swelling. Ice will also delay the potent components for healing while elevation will remove the by-product of inflammation aka swelling.Elevation uses gravity to give the lymphatic system a break, fluid is easier to move if it’s going downhill.
What might surprise you is that ice actually reverses lymphatic drainage and pushes fluid back to interstitial space. A study published in 1986 (yes, 1986, is old, but this is a foundational study) found when ice is applied to a body part for a prolonged period of time; lymphatic vessels begin to dramatically increase permeability. As lymphatic permeability increases fluid will pour from the lymphatic vessels into the injured area, increasing the amount of local swelling. Ice can increase swelling and retard debris removal!
Ice will control the pain from injury, but the relief only lasts anywhere between 20-30 minutes. There are many other things that we can do to control pain and not impede the healing process.
The evidence seems to support use for ice in this instance. We do want inflammation to initiate the healing process and to rebuild muscle that has been broken down during exercise. The end process of inflammation is painful though, the fluid and acidity in the muscle during the inflammatory stage inhibits enzymatic activity required for force production. If I were a trainer for a team that had back-to-back games or multi-day events, icing after activity would be beneficial. Be smart however; if time permits and an injury is a concern, Ice would not be beneficial.
References
 
Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sport Med. 2004; 32:251–261.
 
Bleakley, CM and Davidson, GW. Cryotherapy and inflammation: evidence beyond the cardinal signs. Physical Therapy Reviews. Volume 15, Number 6, December 2010 , pp. 430-435(6).
Bleakley CM1, Costello JT, Glasgow PD. Should athletes return to sport after applying ice? A systematic review of the effect of local cooling on functional performance. Sports Med. 2012 Jan 1;42(1):69-87.
 
Buckwalter, JA, and  Grodzinsky, AJ.  Loading of Healing  one, Fibrous Tissue, and Muscle: Implications for Orthopedic Practice. Journal of American Academy of Orthopedic Surgeons, Vol 7, No 5, 1999.
 
Cottrell, and O’Connor, P. Effect of Non-Steroidal Anti-Inflammatory Drugs on Bone Healing. Pharmaceuticals, Vol 3, No 5, 2010.
 
French SD1, Cameron M, Walker BF, Reggars JW, Esterman AJ. A Cochrane review of superficial heat or cold for low back pain. Spine (Phila Pa 1976). 2006 Apr 20;31(9):998-1006.
 
Haiyan Lu, Danping Huang, Noah Saederup, Israel F. Charo, Richard M. Ransohoff and Lan Zhou. Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury. The FASEB Journal. Vol. 25 no. 1 January 2011. 358-369.
 
Hubbard, TJ, Denegar, CR. Does Cryotherapy Improve Outcomes with Soft Tissue Injury? J Athl Train. 2004 Jan-Mar; 39(1): 88–94.
 
Meeusen, R. The use of Cryotherapy in Sports Injuries. Sports Medicine.  Vol. 3. pp. 398-414, 1986.
 
Meeusen R, Lievens P. The use of cryotherapy in sports injuries. Sports Med. 1986 Nov-Dec;3(6):398-414.
 
Starrette K, MobilityWod video: http://www.mobilitywod.com/2012/08/people-weve-got-to-stop-icing-we-were-wrong-sooo-wrong/

Takagi, R, et al. Influence of Icing on Muscle Regeneration After Crush Injury to Skeletal Muscles in Rats. J of App Phys. February 1, 2011 vol. 110 no. 2 382-388
 
Tseng CY1, Lee JP, Tsai YS, Lee SD, Kao CL, Liu TC, Lai C, Harris MB, Kuo CH. Topical cooling (icing) delays recovery from eccentric exercise-induced muscle damage. J Strength Cond Res. 2013 May;27(5):1354-61.
 
Van den Bekerom MP1, Struijs PA, Blankevoort L, Welling L, van Dijk CN, Kerkhoffs GM. What is the evidence for rest, ice, compression, and elevation therapy Train. 2012 Jul-Aug;47(4):435-4
 
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