The use of ice for injury and training recovery.
In the last decade there has emerged quite a lot of controversy regarding the use of ice for both injury management and recovery from training. Ice (cryotherapy) is a low cost treatment which is extremely popular to the point of being standard practice in medical and sport conditioning fields. It is used for:- •
- injury first aid
- short and medium term rehabilitation from acute and chronic injury
- enhancing recovery after exercise.
Despite the widespread advocacy and use of cryotherapy little is known regarding optimal prescription and how effective the treatment is at all. In more recent times the status quo is being challenged. Scientific articles as well as popular media have begun to question and even discourage the use of these methods.
One of the key concerns regarding the use of cryotherapy is the belief that it reduces both circulation to, and inflammation within, the tissue. While historically inflammation has been considered a painful and unwarranted response to injury, the more contemporary view recognises this to be a precursor for the healing process. It is therefore considered as counter intuitive to then attempt to reduce the inflammation driven healing response to injury or adaptation to a training stimulus. The actual science though is more complicated than that.
In terms of recovery from training there is some solid evidence that ice baths i.e. cold water immersion, are effective at attenuating fatigue, promoting feelings of wellbeing and reducing fatigue in the SHORT term after a training stimulus. There is also evidence that sleep quality is improved after an ice bath. There are however, some concerns surrounding the quality and the assumptions being made based on this data. The first concern is that most of the studies were poorly controlled. Some studies have shown no benefit while others have shown no difference when compared with a placebo. It is difficult to quantify what benefit is clearly derived from the treatment itself versus from the belief in the treatment.
The second criticism concerns the possibility that rather than accelerating recovery it is merely reducing the body’s adaptive response to training which might be harmful in the longer term. This has been borne out in some scientific studies. There have been a few showing that when used repetitively that in the long term, training adaptations are LESS when cold water immersion is used. These studies have generally been of good quality, although it is worth noting that a recent study found no such detriment nor for that matter no benefit either, to the use of cold water immersion / ice baths. At time of writing this, there is no high quality long term data that supports a view that repetitive use of ice baths has a positive effect. This is one of the reasons that some AFL clubs have experimented with avoiding ice baths completely in the preseason training period.
With respect to injuries we are again challenged by the lack of the existing science.
One major misconception with the use of ice in the first aid environment is that many believe it acts to decrease blood flow to an acute injury. The purpose of ice is actually to INCREASE rather than decrease the blood flow to the injury.
It has been proposed without being conclusively proven that there is a secondary injury after the initial injury. Essentially the blood clot forms which blocks off the area and as a result there is further injury from insufficient nutrient supply which should be provided by blood flow.
Much of the current criticism regarding the use of ice is that the body has perfected its response to trauma over millions of years of evolution. It is interesting that the inflammatory response is remarkably similar whether the injury is an open or closed wound. In an open wound the risk of infection is high and if the body does not quickly and effectively create a barrier to its spread the result may be lethal. It is entirely possible that the inflammatory response is indeed perfect, just not as specific as we would like. It is conceivable that from an evolutionary perspective preventing the spread of a potentially lethal infection is more important than recovering a few days quicker from a muscle sprain.
Thigh trauma is a very obvious example of this. If there is heavy thigh trauma resulting in a significant contusion there is supported evidence that a sequelae called heterotopic ossification or 0000 can occur. Essentially the muscle “ossifies” and becomes bone like. This is not a rare outcome. Studies from the military forces indicate a likelihood as high as 20% depending on the size of the contusion. Elite athletes have had to retire as a result of developing this. I once saw a patient who grew a 15cm x 3 x 3cm bone in his thigh musculature after a hit playing rugby. He was playing in an elite junior competition. Unfortunately he was unable to continue to play and had to retire at 20 years of age. There is good evidence that the likelihood of heterotopic ossification can be significantly reduced with interventions. A strong indication that the body’s response to closed traumatic injury is far from perfect. It would, in fact, be medically negligent not to recommend some of these interventions to someone with a significant thigh contusion.
Much of the criticism and discussion does come from those more involved with non-collision and / or non-contact sports where the injuries are generally of relatively minor severity. This makes perfect sense. In the context of the injuries that are normally seen in this group, there will be little bleeding and no secondary injury which would limit and certainly reduce the need for ice for first aid.
The case however is quite different for other sports with more severe, acute and traumatic injuries. With more bleeding and more pain the use of ice is probably more important. There is a study that seems to support this view. It is a study from New Zealand undertaken back in 1989 and although it certainly can be considered that it falls into the “older study category” it does provide some interesting outcomes worthy of consideration. The study results supported a view that ice assisted moderate ankle sprains to recover quickly but slowed recovery from minor ankle sprains.
The role of ice as a pain reliever cannot be understated. It is well documented, and a serious concern, that competitive athletes tend to use pain relieving medications more frequently than is desired.
If by applying ice it reduces or eliminates the need to take an anti-inflammatory or pain relieving medication then that in itself is certainly a positive for its use.
In summary there is strong evidence to support the use of ice baths / cold water immersion if you have a short period between competitions (hours or days). Ice baths / CWI might be worthwhile when used infrequently after only the most taxing training sessions or if swelling or pain is present. The frequent use after all training sessions when still in the pre-season period or some time from actual competition is highly contentious and not something recommended at this point in time. If you are going to have an ice bath the protocol with the most supporting evidence, is 9-15 degrees Celsius for 10- 20 minutes.
There is no strong evidence either for or against the use of ice / cryotherapy for most acute or chronic injuries. Having said that, if there is an “If” here and there is a significant contusion to the anterior thigh that has made your knee swell and it cannot flex the knee to 90 degrees you really must apply ice, compression and see a healthcare professional. If there is significant swelling or bleeding then I would recommend that ice and compression be applied to the area. If the pain is severe enough requiring you to take an antiinflammatory and / or pain relieving medication then using ice as a first line pain reliever prior to taking a medication would be the preferred option. If you are going to use cryotherapy a method that allows good tissue cooling and reduces the risk of nerve injury is 10 minutes cooling, 10 minutes rest, 10 minutes cooling repeated every two hours.