I got riiiice cookin' in the microwave...
...got a three day beard I don't plan to shave..
Lighten up, would ya? I will. That last one was a bit touchy, I'd say. Vaccines are murky water. This one won't be as challenging to get through.
How often do you question things you've been told your whole life?
You will get a cold from being outside in the cold.
Sprite and chicken noodle soup cures a lot of things.
Drinking a bunch of cranberry juice will cure your bladder infection.
If you have green snot you have a sinus infection and you need a ZPack.
How often do you tell people "good luck!" when they don't need luck at all, and if you consider what "good luck!" means in terms of their upcoming circumstance...it could even be offensive... "Good luck with your open heart surgery tomorrow!" "Good luck with your marriage!" What???
Y'all know how to cook fluffy rice in a pot on the stove? Highly recommend....
You twist your ankle, your knee, your hip.
You bump your head. Hyperextend your finger.
First thing mom does? Ice pack. Frozen peas.
There, all better now. Pink or blue band-aid?!
How often do you question the things you've been told your whole life that you have always just accepted as being true?
RICE. Rest. Ice. Compression. Elevation.
Some of you, a lot. Some, not a lot. Well thank goodness for your old approachable NP, huh? I'm here to really challenge some major world problems.
Like - is icing an injury even helpful or right? Big stuff here.
There's a lot of people out there that say - nope. Those people now say, that not only is icing an acute injury not proven to be helpful, but it could delay or completely impair healing. So, I decided to attempt to find out who's right! Just for y'all.
The person who is credited with coining the term R.I.C.E. is Dr. Gabe Mirkin (a medical
doctor, an MD). Everybody say Hi. "He is one of a very few doctors board-certified in four specialties: Sports Medicine, Allergy and Immunology, Pediatrics and Pediatric Immunology." (1)
This tells me 2 things: this dude likes studying, tests and school. And he understands athletes and inflammation.
His youngest board certification is in sports medicine, back in '91. Ahh the 90's, when Zack Morris and Kelly Kapowski and The Fresh Prince and Carl Winslow were the dream team. IIIIIINNNNN WEST Philadelphia BORN and RAISED....
[Literature: All the available written reports about actual scientific research studies.
Review: Researchers identify eligible/relevant studies in a super complicated way. An inclusion/exclusion/analysis process called...the Research process..and conduct a meta-analysis of the literature...]
...One such literature review is posted on the NIH site, and they define: "Ice [as] the most common means by which cooling is achieved. We use the term ice to represent the application of cryotherapy in general, with the different means by which this can be achieved being considered in more detail later." (2)
I always write these blogs in 2 mindsets. 1. A mindset of being funny, upbeat, and informative - while being minimally bitter. I spent half of my nurse life in an emergency room, so sorry guys, not sure I'll ever be totally cured of bitter. And, 2. A mindset that people are going to criticize these blogs, and pick them apart about all the little details and nuances I leave out. I'm putting myself out there - I can handle it. But, please be reminded - I am intentionally leaving things out of every single episode. Because like shit is too complicated LOL. And - people generally don't care to know about any of these topics in such detail. That's OUR job as healthcare professionals, not the people's job.
SO on this note, I mentioned I was an ER nurse ... I am so fully aware of the utility of CRYO in circumstances of cardiac arrest with ROSC, TBI, hyperthermia... Or in flare-ups of chronic inflammatory states such as Rheumatoid Arthritis. I've used the Artic Sun with my very own eyeballs and fingers and brain. Never did we ever put ice packs on an acute fracture and never was the trauma room ever cooler than 82 degrees.
Soft tissues in your body are your fat, tendons, ligaments, mucous membranes, muscles, and so on. One of the most common musculoskeletal injuries in the world is an ankle sprain. The same NIH article says: An ankle sprain is a "condition representing a diversity of pathologic conditions, ranging from overstretching of the ligament to complete rupture with gross
instability of the joint." I'm choosing this specific injury as a point of discussion because nearly all of us should be familiar with it. Let's think about ligaments and tendons being like Airheads. The candy. The strips of gummy sugar.
Ligament = bone to bone
Tendon = bone to muscle
sPrain = injury to ligament
sTrain = injury to tendon
We sPrain our ankles and sTrain our backs, right? Right.
We have ligaments and tendons all over our bodies. Do an internet search of "image of human ligaments" and you'll get a good visual.
While we all know fractures occur in sports like football, soccer, basketball, gymnastics.. more often, sprains and strains occur. Sprains and Strains are both graded by determining their severity after performing an assessment. Considering how the injury occurred, if there is swelling with or without bruising and if there is abnormal (excessive) movement of the affected joint.
Grades for sprains and strains are from I-III.
The descriptions for ligament sprain grades are very similar to muscle strain grades.
So what happens right after we strain or sprain ourselves? If you've been reading my previous blogs.. you can definitely make an educated guess on this one....
If you said "inflammatory response".. YOU'RE GOING to the BONUS ROUND!
In previous episodes, we've learned about the inflammation response, and why it's necessary for healing. We've learned before that when you see swelling or redness at the site of an injury or bug bite, you are watching your immune system perform an inflammation response in real time. When you sprain or strain a body part, you will have some degree of appropriate inflammatory response. Dr. Mirkin is not nearly the only anti-icer. Gary Reinl is a physical therapist (Dr. Reinl with a PhD) who has written and spoken extensively about the detrimental effect of early icing. Gary Reinl writes "I want to make note here of the critical point that the only way to organically decrease swelling in and around a damaged site is via the passive lymphatic system, which is nearly fully reliant on muscle activation around those lymphatic vessels to move the waste (and cryotherapy depresses that process)." (5)
The supply of oxygen and nutrients to tissues is performed by the blood system, and involves a net leakage of fluid outward at the capillary level. One of the principal functions of the lymphatic system is to gather this fluid and return it to the blood system to maintain overall fluid balance. (3)
Dr. Jennifer Robinson is another sports medicine MD in agreement that RICE is outdated. She is not in support of the I in RICE.. or the R. She (is one of many) believes in early mobilization of an acute injury (except in cases of grade III tears or fractures of course). She also adds on to the anti-ice discussion by including anti-inflammatory medications as being counter-intuitive. Steroids & NSAIDS. (4) What are your anti-inflammatories? Advil (Ibuprofen), Aleve (Naproxen), Mobic (Meloxicam), Toradol (Ketorolac), Diclofenac (Voltaren) and so on. What else have we talked about that is anti-inflammatory in previous blogs?? Steroids. Steroid pills or shots are certainly a no-go during acute injury. The new thought wave is to allow the inflammation response to happen early on for Grade I-II's and instead of using ice or NSAIDs to reduce pain and swelling... let's do compression, elevation, early mobilization, and perhaps Acetaminophen. I know I gave Tylenol a hard time in the last one, but I'm redeeming it here!
Sooooo, what are we supposed to do?
The literature says things like:
"Insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults."(2)
"There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft-tissue injury, and there was no evidence of an optimal mode or duration of treatment."(8)
"The exact effect of cryotherapy on more frequently treated acute injuries (eg, muscle strains and contusions) has not been fully elucidated. Additionally, the low methodologic quality of the available evidence is of concern. Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy."(9)
Should I keep going?
My point is, when we get better information, or we start to question what we've always accepted to be true, and we find there's a gap in the research...that's how we optimize healthcare!
Studies are being done, and we just need more time, attention and reporting on what's best. Here's one example from a study published in 2019 that focused on protecting the affected ankle ligament and early mobilization.
An issue other than blocking the inflammation response at the injury site with applying ice or taking NSAIDS is the clamping down of your tiniest blood vessels. If you didn't know this already, our blood vessels open wider and close tighter in response to cold, heat, stress, alcohol, nicotine, blood pressure medications, stimulants, etc. etc. You've probably noticed that your veins look fatter and are more visible when you're hot or out in the heat, and they're "harder to find" when you're cold. "Harder to find", means clamped down (trying to conserve heat), and the medical term for it is vasoconstriction. Vaso = vessel, constriction = clamping down.
The concern with icing a fresh sprain is cryotherapy-induced vasoconstriction that persists long after the ice is removed from the skin. What needs more research (because so far, the studies have used a small number of participants, and they haven't all been carried out stringently) is what is called a nonfreezing cold injury "(NFCI)" associated with cryotherapy.
"An important aspect of cryotherapy that is not widely documented and acknowledged is the strong effect of lowered skin temperature on reducing local tissue perfusion and mechanisms by which this phenomenon may lead to the occurrence of NFCI." In the experiments that were performed (yes, critics, they were not randomized or double-blinded and they had small sample sizes) after ice application for 15 minutes or 60 minutes, the amount of detectable blood flow to the skin was still not back to baseline after 120 minutes! This occurred in a few studies using a few different cooling methods and time frames for cooling and rewarming. (10)
And that is a big part of the argument against icing acute injuries. Injuries or sick tissues NEED blood flow in order to heal! Fluid (swelling) NEEDS to move out the area and into the lymph system, not remain stagnant.
The bottom line - if you're a trainer, a coach, an athlete, a parent - click the links below, and let Google take you for a ride! If your injury protocols include applying ice, you may want to consider sticking to an early visit to your healthcare provider to assess the injury, grade it, then use compression, elevation, tylenol, and early/easy/light mobilization. See your favorite physical therapist or search for sprain/strain rehab exercises online.
If you choose ice with compression, limit ice application to 10 minutes at a time, just a few times a day! Use elastic bandage wraps or socks for compression, and do rehabilitative light exercises, early. It can make the difference by days or weeks, especially for your prime athletes.
Pass you some Vicksalve for good luck.