When working in an acute rehabilitation setting, treating injuries and post surgical patients, we often manage varying degrees of swelling around the involved body part. The consequences of this swelling can have a negative impact on living an active life and participating in sport. These consequences include pain, immobilisation, and muscle atrophy (wasting). Ice has traditionally been used as one of the key therapies for acute swelling. The physiological benefits of ice include vasoconstriction, antiinflammation and pain relief.
In the post surgical setting, swelling can increase with early mobilisation, such as gait retraining, hydrotherapy and exercise. It can also increase when traveling by Airplane. We have commonly recommended elevation and ice, three to four times a day, to reduce this swelling. Interestingly, it is very slow to work or does not work at all. If it works, is it the ice or the elevation or a reduction in activity which causes this reduction in swelling? When swelling does reduce we can see it return when the operated joint is mobilised again. Why is ice not always as effective as we would like it to be?
We decided to investigate the literature and check online for information on icing and injury. It is clear there is a lack of current and high quality research to support the use of ice in treating acute injuries. Various online authors suggest ice is in fact detrimental to the healing process, and impairs the lymphatic system from reducing swelling.
The key argument against ice therapy is it’s antiinflammatory effect. The inflammation process must start and complete its natural course. This permits macrophages (cells which clean up the site of injury) and growth factors (control the repair process) to do their job. If ice has an antiinflammatory effect, the healing process cannot continue its natural course.
It has also been suggested, ice causes congestion of deoxygenated blood, by impairing muscular contraction, necessary for lymphatic drainage back towards the heart and against gravity (reducing swelling). The pooling of deoxygentated blood is proposed to be the main reason we feel pain.
On the other hand, a positive effect of icing appears to be pain reduction. Using it in short bursts (10 minutes) with at least 30 minutes between applications may help with comfort levels after acute swelling. Note, muscle function can be impaired for up to 30 minutes after ice application. Short bursts of icing allows skin temperature to return to normal, but muscle temperature to remain low.
So if we do not use ice to reduce swelling what should we do?
The possible alternative is to use compression and muscle contraction to help the lymphatic system reduce swelling. The lymphatic system is a passive system, and requires muscular contraction to move fluid away from the site of swelling. Compression also supports this system. Sometimes, the operated joint has a movement restriction and it is difficult to produce good muscular contractions. In this instance, a muscle stimulator could be used. Watch this video for an insightful discussion https://youtu.be/0UmJVgEWZu4
Interestingly, elevation may make drainage of swelling easier, but it’s effect is small. Compression and muscle contraction is the current alternative some therapists replace for ice. At the current time, more high quality research is required to support this concept. However, there is some sense in the argument, and the test will be, does it work for you.
We will be investigating different forms of compression therapy and electrical muscle stimulation. If you would like to find out more please contact us.
Please note, there are different phases of healing. Consult your health professional for advice on managing your injury appropriately through each phase.
References
Chris Bleakley, BSC (hons), MCSP, Suzanne McDonough, Phd, MCSP, Domhnall MacAuley, Md, FISM. The use of ice in the treatment of acute soft-tissue injury. The Am J of Sports Medicine 2004; Jan; 32(1): 251-261.
(Summary: Systematic review; ice had no additional benefit to compression. More high quality trials are needed.)
Karemer WJ, Bush JA, Wickham RB, Denegar CR, Gomez AL, Gotshalk LA, Duncan ND, Volek JS, Putukian M, Sebastianell WJ. Influence of compression therapy on symptoms following soft tissue injury from maximal eccentric exercise. J Orthop Sports Phys Ther 2001; Jun; 31(6):282-90.
(Summary: Positive benefits of compression on DOM’s, maintaining motion, reducing pain and swelling, and promoting recovery of force production.)
Kannus P. Immobilisation or early moblisation after an acute soft-tissue injury? Phys Sportsmed 2000; Mar; 28(3): 55-63.
(Summary: Early controlled mobilisation is superior to immobilisation for primary treatment of acute musculoskeletal soft-tissue injuries and post operative management. Protection, rest, ice, compression, elevation, and support are recommended in early stages of recovery in this article.)
Mac Auley DC. Ice Therapy: how good is the evidence. Int J Sports Med. 2001; Jul; 22(5): 379-84.
(Summary: Ice used intermittently for 10mins can cool muscle and not cause skin damage. Reflex muscle activity and motor function impaired with icing and prone to injury for 30mins after ice application.)
Michel P.J van den Bekerom, MD, Peter A.A Struijs, MD, Phd, Leendert Blankevoort, Phd, Lieke Welling, MD, Phd, C. Niek van Dijk, MD, Phd, and Gino M.M.J Kerkhoffs, MD,Phd. What is the evidence for Rest, Ice, Compression, and Elevation Therapy in the treatment of ankle sprains in adults. J Athl Train 2012; Aug; 47(4): 435-443.
(Summary: RCT systematic review; Insufficient evidence to support the use of RICE therapy for acute ankle sprains in adults.)
Rohner-Spengler M, Frotzler A, Honigmann P, Babst R. Effective treatment of Posttraumatic and Postoperative edema in patients with ankle and hindfoot fractures: a reandomised controlled trial comparing multilayer cmpression therapy and intermittant impulse compression with the standard treatment with ice. J Bone Joint Surg Am. 2014; Aug 6; 96(15): 1263-1271.
(Summary: Multilayer compression compression therapy alternative to icing for reducing oedema.)
Schmid S, Moffat M, Gutierrez G. Effect of knee joint cooling on the electromyographic activity of lower limb extremity muscles during a plyometric exercise. Physiotherapy 2011; 97: eS1110-eS1111.
(Summary: Reduced average EMG activity post 20mins icing with plyometric exercises.)
Online articles
https://www.howardluksmd.com/orthopedic-social-media/ice-ice/
https://www.running-physio.com/ice2/
https://www.myphysioperth.com.au/patient-education/ice-injury-not-ice/