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Should we be utilizing cryotherapy following injury?

3/18/2013

3 Comments

 
One of the first things we are taught in modalities classes is the importance of utilizing the RICE acronym following acute injuries. R=rest, I=ice, C=compression, E=elevation. The purpose is to decrease the inflammatory response, and thus pain, following injury. Perhaps we should reconsider the importance of inflammation to the healing process. Our bodies are incredibly functional in self-healing. By blocking the pro-inflammatory cells from getting to the injured area, are we altering the tissue healing for the better or worse? A similar argument has been made before with utilizing NSAIDs after injury, especially in cases of tendinopathy.
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Kelly Starrett from Mobility Wod brought this issue to the light with a post last year. His findings showed that, yes, cryotherapy can be effective in reducing pain following injury, but it was inconclusive as to whether or not it improved clinical outcomes. Again, this modality can be useful in preventing the body from healing its natural way, but do we really want to do that? You might ask then about other methods of limiting pain and swelling in the area. Starrett suggests utilization of compression  to limit the swelling, along with elevation at times. Another method to decrease swelling is muscle activation. Mobility (when safe) is an incredibly useful method to a) maintain strength, b) evacuate swelling through muscle pumping, and c) help to restore collagen alignment. Now we're not suggesting ice should suddenly be abandoned in physical therapy altogether, but it should be given a more serious consideration as to its appropriateness. In fact, an interesting response by Nick Heudecker was brought up to this post, questioning the analysis of the literature cited and the method of the studies as well. 

Perhaps it is time to consider a shift from the traditional RICE theory to a MEAT theory, as discussed by The Sports Physiotherapist. We have actually seen the MEAT protocol in practice with impressive effectiveness for returning injured athletes to play. M=movement, E=exercise, A=analgesics (non-NSAID), T=treatment.  What are your thoughts on the RICE vs MEAT debate? Should we choose one or the other? Or is there a middle-ground that is more desirable?
3 Comments
Jasmine Pang link
3/18/2013 01:47:44 am

I guess this is something 'fresh' other than the RICE management. MEAT could work its way out. It is somewhat debatable but if there are researches done comparing these two, then we should know which is more appropriate then for patients :)

Reply
hiphopanonymous
3/18/2013 09:46:40 am

It's kind of hard to argue with the points Heudecker brought up with respect to Starrett's analysis of the literature. The idea that we are interfering with the natural healing process with icing and that in itself is a bad thing also seems a bit disingenuous. The "natural" inflammation process is what causes all that edema and pain in the first place!

Where I do think this has some merit though is making us question why we do what we do (in this case, cryotherapy). In cases where there actually is inflammation (i.e. acute injuries, not something like tendonopathy), ice can help with pain control and perhaps swelling if applied correctly. But, as Starrett helps point out there are other interventions that may help in conjunction (such as compression, pain-free movement, etc.). A more middle of the road approach with a case-by-case need based analysis seems to be appropriate in this debate.

Maybe starrett should just stick to creative self-mobilization/mwm techniques? All criticism aside he's got some cool ideas that I've used with certain patients who are appropriate.

Reply
Chris link
3/22/2013 12:22:00 pm

"Inflammation serves a vital role in the healing process. Inflammation has both protective and curative features. Every step serves a specific purpose and is necessary as the body responds to tissue injury or damage. The ultimate goal of the inflammatory process is to replace injured tissue with healthy regenerated tissue, a fibrous scar, or both" (Goodman & Fuller, 2009).

I would not be so quick to dismiss the important effects of inflammation. It is during this early phase of healing that polymorphonuclear leukocytes and macrophages destroy bacteria, release elastase and collagenase, along with secrete growth factors. During this phase, the various cells are responsible for initiating mechanical support for tissue regeneration. Now I recognize that pain and edema are the reason we use ice with patients, but pain arises from edema compressing the nearby peripheral nerves. This edema can also be managed with compression and elevation. The addition of mobility can also aid in improving blood flow in the injured area that can increase the healing effects of inflammation. Now, I do recognize that inflammation can have some side effects as well such as tissue destruction of nearby healthy structures, but if you can improve the time spent in the inflammatory phase, is that not beneficial as well? I am not saying for sure that we should eliminate cryotherapy from our tool set, but I wouldn't be so quick to dismiss the idea of RICE's negative effects. This is an excellent opportunity for further research! Thanks for the comment!

Goodman, Catherine C & Fuller, Kinda. (2009). Pathology: Implications for the Physical Therapist. (3rd ed., pp. 215-217). St. Louis: Saunders Elsevier.

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