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RICE no more?

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Kristi Brown

on 30 June 2014

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Transcript of RICE no more?

. . . time for the meltdown
R.I.C.E. No More?!
Is Ice no longer recommended as treatment for Injury?

While immobility is detrimental to soft tissue healing, movement improves blood flow and removes debris!

Natural analgesics, such as proteolytics enzymes, aid by reducing viscosity of ECF! (e.g bromelain, trypsin, chymotrypsin and papain) –> they do not stop natural inflammation.
NSAIDS are equally as bad as ice!

New Recommendations:
Rest & Ice are out!!



*emphasized for ligament and tendon injuries -
(since their blood supply is more limited than muscle!)
Current information shows that inflammation is the body’s first physical response to repairing tissue, and without it healing does not happen!!

To quote Dr. Nick DiNubile, Editor in Chief of The Physician And Sports Medicine Journal,

Seriously, do you honestly believe that your body’s natural inflammatory response is a mistake?”

Wait . . . doesn't ice prevent this?
effects of vasoconstriction stays for hours after the ice is taken off!
The Controversy

Two months ago Dr. Mirkin retracted his recommendation to include ice in the protocol due to lack of evidence for cryotherapy benefits and said,

"'now it appears that both Ice and complete rest may delay healing instead of helping."'

To analyze (RICE) therapy within 72 hours after trauma for patients in the initial period after ankle sprain.

Assessed outcomes: pain, swelling, ankle mobility or range of motion, return to sports, return to work, complications, and patient satisfaction.

Inclusion of 11 trials involving 868 patients - with at least one comparison

Early mobilization with or without physiotherapy offered the most rapid return to activity - pts immobilized required more days missed from work and more visits to clinic for follow up
Evidence from RCTs to support the use of ice in the treatment of acute ankle sprains is limited.
Treatment decisions must be made on an individual basis, carefully weighing the relative benefits and risks of options.

Since R.I.C.E. was coined ice became the standard for injury treatment.

Ice is used to:
Reduce acute pain
Decrease inflammation/swelling (
Thought to boost recovery after exercise

Why Ice?
Answer: In 1978!

Gabe Mirkin, MD coined the term RICE (Rest, Ice, Compression, Elevation) for the treatment of athletic injuries in his best-selling
Sportsmedicine Book

Health care practitioners & laypersons were quick to recognize RICE as the ‘gold standard’ treatment option following injury.
RCT -11 males - performed 6 sets of elbow extension at 85% maximum voluntary load.
(Cold packs were applied to exercised muscle for 15 minutes at 0, 3, 24, 48, and 72 hours after exercise)

Subjective fatigue feeling was greater at 72 hours after topical cooling compared with controls.

Removal of the cold pack also led to a protracted rebound in muscle hemoglobin concentration compared with controls.
How long have we bee using RICE?
Objectives . . .
The Science . . .
Tseng CY, 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;27(5):1354-61.

Van den Bekerom M, Struijs P, Blankevoort L, Welling L, Van Dijk C, Kerkhoffs G. 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):435-443.

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

Prins JC, Stubbe JH, van Meeteren NL, et al. Feasibility and preliminary effectiveness of ice therapy in patients with an acute tear in the gastrocnemius muscle: a pilot randomized controlled trial. Clin Rehabil 2011;25:433–41.

Khan KM, Scott A. Mechanotherapy: how physical therapists' prescription of exercise promotes tissue repair. Br J Sports Med 2009;43:247–52

The use of Cryotherapy in Sports Injuries,’ Sports Medicine, Vol. 3. pp. 398-414, 1986


Influence of icing on muscle regeneration after crush injury to skeletal muscles in rats
(Takagi et all) 2011
The influence of icing on muscle regeneration after crush injury was examined in the rat extensor digitorum longus.

Due to the icing:
Degeneration of the necrotic muscle fibers and differentiation of satellite cells at early stages of regeneration were retarded by -1 day.
Cross-sectional area of the muscle fibers at 28 days was evidently smaller
Ratio of collagen fibers at 14 and 28 days after the injury was higher.
Chronological changes in the number of macrophages and expression of (TGF)-β1 and IGF-I were also retarded by 1 to 2 days.

Conclusion: Icing applied soon after the injury not only considerably retarded muscle regeneration but also induced impairment of muscle regeneration along with excessive collagen deposition.
Feasibility and preliminary effectiveness of ice therapy in patients with an acute tear in the gastrocnemius muscle: a pilot randomized controlled trial
(Prins et al 2011)
19 patients with an acute tear in gastroc
Tested measures:
Functional capacity
Reconvalescence time
Work absenteeism
Pain relief
No significant differences between the intervention and control group were found.

The Limited-sized trial indicates that the use of ice is not beneficial for people who receive ice therapy.

. . . or M.C.E.
Move safely when you can - what you can.
: Compress lymphatics and soft tissues (use bands, muscle contraction, clothing, normatec, etc.)
Elevate when you can.
By: Kristi Brown
Why we use ice . . .

Find out what the argument against ice is all about

What's the latest research say
Inflammatory signals sent from damaged tissues
Damaged cells are eliminated by
phagocytosis of macrophages!!
Macrophages release insulin-like growth factor (IGF-1)<--
ice delays this!!

The response can last for a week along with increased levels of CK-MB and Myoglobin levels during regeneration.
Ice also increases the permeability of the lymphatic vessels -
in the wrong direction!
What is the evidence for Rest, Ice, Compression and Elevation therapy in the Treatment of Ankle Sprains in Adults

(Beckerom et al) 2012
When do you use ice?
. . . but seriously
If you need to make something numb, ice is great! -
but watch out for nerve damage

Apply ice for pain relief immediately after the injury occurs, but for
short periods only!!

Research suggests icing for 10 minutes, removing the ice for 20 minutes, and repeating the process once or twice, but stresses that there is
no reason to continue icing more than six hours after injury.
. . . in your drink!
Emphasis on:

Compression! -
using distal extremity massage or movement to return debris in passive vessels!!
Importance of how cell sense and respond to mechanical loads -
how exercise promotes tissue healing!
Topical cooling (icing) delays recovery from eccentric exercise induced muscle damage.
Tseng et al 2013
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