To ice or not ice?

  • 21st November 2018
  • Pain, Tips

The “to ice or not to ice” debate is one of our favourites in clinic and championed by SPEAR physiotherapist, Isla. We asked Isla to write a blog for us on the subject, sharing some findings and her views on icing an injury to reduce swelling.

“Managing an injury in the acute stage entails trying to promote the bodies’ own healing mechanisms as effectively as possible. The Acronym; Rest, Ice. Compression and Elevation. (R.I.C.E) and its more recent evolution into; Protect, Optimally Load, Ice, Compress and Elevate. (P.O.L.I.C.E) have been used for many years as part of early management for injuries and is widely used today.

National Institute Clinical Evidence (NICE) currently supports that POLICE management is based upon expect opinion as there is insufficient evidence to support it for the management of acute sprains and strains (NICE 2016). And yet it is common practice. Ice is usually used with the intensions of reducing pain and swelling from an injury, but is lacking the evidence to support it.

Ice can be used to reduce pain when applied to the injury site. This is effective when the tissues are cooled below 15 degrees centigrade resulting in decreased speed of noiceceptive nerve signals (feeling of pain), effectively numbing the area. (Algafly and George 2007, Chesterton, Foster and Ross 2002, Nadler, Weingand and Kruse 2004).There is some evidence to support this in acute soft tissue injuries and in post-operative management (Adie, Naylor and Harris 2009., Hubbard and Denegar 2004), but with poor outcomes and further evidence required.

A Randomised Control Trial by Bleakley, McDonough and MacAuley 2004, concluded that there is some evidence available to show that icing and exercise are beneficial to acute soft tissue injuries and post -operative management, but that icing in addition to compression had little significant effect upon swelling and range of motion compared to the effects of compression alone. There is minimal evidence to show that icing alone has an effect on swelling, but the lack of clinical evidence means we rely upon expert opinion.

Gabe Mirkin, M.D, sports Dr who formed RICE in his ‘The Sportsmedicine Book’ 1987, has recently voiced new thoughts on icing. He now believes that icing should not be used as a measure to reduce swelling, and in addition, that it should not be used at all. He discusses that icing does not prevent inflammation and swelling, rather that it delays it. He goes on to say that because of this effect icing could delay heeling times and return to sport but can be used to temporarily reduce pain if the consequences are taken into account. Gary Reinl, Dr. Kelly Starrett and Gabe Mirkin M.D. released a book “Iced!: The Illusionary Treatment Option” in 2013 detailing why they believe, and evidence to support, why not to use ice.

Curently based on the minimal clinical evidence available, icing can be used to reduce pain at the site of injury. Whether this helps reduce swelling due to increased muscle activity because of reduced pain is purely speculation. Only with further strong randomised controlled trials will we know if ice should be used within acute management and rehabilitation of soft tissue injuries and post-operative management.”

Adie, S., Naylor, J. and Harris, I., 2009. Cryotherapy following total knee replacement. Cochrane Database Syst Rev, 9.
Algafly, A.A. and George, K.P., 2007. The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. British journal of sports medicine, 41(6), pp.365-369.
Bleakley, C., McDonough, S. and MacAuley, D., 2004. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. The American journal of sports medicine, 32(1), pp.251-261.
Chesterton, L.S., Foster, N.E. and Ross, L., 2002. Skin temperature response to cryotherapy. Archives of physical medicine and rehabilitation, 83(4), pp.543-549.
Gabe Mirkin, M.D., 2015. Why Ice Delays Recovery. Dr. Mirkin.
Hubbard, T.J. and Denegar, C.R., 2004. Does cryotherapy improve outcomes with soft tissue injury?. Journal of athletic training, 39(3), p.278.
Nadler, S.F., Weingand, K. and Kruse, R.J., 2004. The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. Pain physician, 7(3), pp.395-400.
National Institute for Health and Clinical Excellence (2016). Clinical Knowledge summaries: Sprains and Strains. Evidence Service CKS