We are often asked in clinic when ice or when heat is appropriate to use. Some clients get so confused from conflicting web-based searches that they opt to use neither option.

There is current research both for and against ice treatments. We are here to help with these common, confusing questions, and to discuss the current literature on the evidence for ice treatment. This blog will discuss the use of ice and the current literature on ice treatment. In our next blog we will further discuss heat therapy. Read on to learn more about ice/cryotherapy!

In early years of research (1980’s-2000’s), ice was proposed to promote the healing process, decrease swelling and pain in acute and chronic injuries.

Are any of these claims supported in the newer research?

What does the more current research on ice suggest?

It is important to note that although there are many studies on ice/cryotherapy, most of them are poor quality clinical studies and few studies are on injured populations. According to Page (2018), the research on ice application in terms of time and type of ice to use limits generalizability because much of what we know about the physiological effects of ice on the healing process is based on animal studies rather than human. These animal studies may or may not be transferrable to humans.

A meta-analysis on the effectiveness of ice treatment performed by Bleakley et. al (2004) identified 55 articles for review, of which 22 were eligible randomized, controlled clinical trials, many of which were poor quality studies. They found icing, to be most effective in decreasing pain. Their analysis reported that cold seemed to be more effective in limiting swelling and decreasing pain in the short term (immediately after application to 1-week post-injury). However, the long-term effects of icing and the effect on the tissue repair are not known. Whether cryotherapy facilitates return to participation is still unclear. Ice does not seem to be more effective than compression after surgery.

What about ice baths post activity for muscle and joint recovery? According to a randomized control trial on the effectiveness of ice baths by Higgens, et. al (2011) ice baths appear to have a wide use in sport but the results of their study would indicate that their use is not warranted or recommended.

Can ice cause harm?

It should not come as a surprise that prolonged application at very low temperatures should be avoided as this may cause serious side-effects, such as frost-bite and nerve injuries (Swenson, et. al, 1996).

Ice has also received some bad press in the past several years with newer research saying that their previous claims for decreasing swelling and promoting healing are actually false.  Reinl (2014), Mirkin (2016) and other authors have agreed with their research that ice shows delays in recovery time. The scientific reasoning to this (only if you are interested) according to Robinson (2017) is that:

the resulting vasoconstriction from cooling, not only reduces tissue oxygenation with necrosis [(tissue death)] if extreme, but inhibits the inflammatory response needed to initiate healing. The release of kinins and cytokines from damaged tissue is meant to increase vascular influx, which brings fibrinogen and platelets for hemostatis, leukocytes and monocytes to phagocytose necrotic debris, and fibroblasts for collagen and protein synthesis.

The whole idea here is that your body needs its natural inflammation in order to effectively heal. NSAID (Nonsteroidal anti-inflammatory drugs) such as Advil, Naproxen or Aleve have been scrutinized worse than ice for removing our natural swelling and in turn delaying rather than supporting healing. Remember, similar to the research above most of these studies are based on animal testing and some are not of great quality. The debate is still out on whether or not this is the absolute truth, but this conflicting research is very interesting nonetheless!

What does this research mean?

Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury (Bleakley, et al., 2004). Cold appears to be effective for pain control, with few complications or side-effects when used appropriately.

According to Page (2018), the science supports ice in some situations, but the research is often insufficient to make a definitive conclusion on when to use ice or not. Until ice is directly and fully proven harmful to healing with convincing, irrefutable evidence, it remains a good option of treatment in acute injuries. Aside from acute trauma (<48 hours after injury), ice probably does not help beyond pain reduction. Ice alone does not directly reduce swelling, and this has been confirmed in several studies.

Here is what we currently recommend for parameters of ice use:

In light of both sides of the research for and against ice, we believe that ice should be used sparingly as a more natural pain controlling method (analgesic). We know based on the available studies that the most powerful therapeutic effect of ice is pain control, not swelling control, nor promoting tissue healing. Ice, like any modality if used properly, can have benefits. 

Remember, moderation is always important! Too much of a good thing is never good. Always protect your skin by using a towel between the icing agent. Ice may be an ice pack, cubes, crushed ice, frozen vegetables or cryocuff machine. Ensure that you have good sensation to the area you are icing. If you have decreased blood flow and or a neuropathy/decreased sensation in the area, do not use ice. A good time to use ice is when an injury is new/acute, and or whenever your level of pain is high.  

Please note that as new evidence changes so will our viewpoint accordingly. If you have a differing viewpoint and or you have heard of new, compelling evidence for or against the use of ice, please let us know. As practitioners, we are always learning and growing and would love to hear and learn more on your educated opinions! We will continue to advise our clients in an evidence-based manner as we learn every day in this ever-evolving profession!

If you have any questions in regard to this blog, please reach out to our amazing Zen team on our contacts page!

References:

Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sport Med. 2004; 32:251–261.

Higgins, T., Heazlewood, T., Climstein, M. (2011). A Random Control Trial of Contrast Baths and Ice Baths for Recovery during Competition in U/20 Rugby Union. Journal of Strength and Conditioning Research, 25 (4), 1046-1051. 

Hubbard TJ, Aronson SL, Denegar CR. Does cryotherapy hasten return to participation? A systematic review. (2004). Journal of Athletic Training, 39:88–94

Hubbard, T., Denegar, C. Journal of Athletic Training (2004). Does Cryotherapy Improve Outcomes With Soft Tissue Injury?, 39(3): 278–279.

Knight, K.L., Cryotherapy in Sport Injury Management. 1995, Champaign, IL: Human Kinetics.

Mirkin, G. (2016). Why Ice Delays Recovery. Dr. Gabe Mirkin on Health, Fitness and Nutrition blog.

Speer, K., Warren, R., Horowitz, L. The efficacy of cryotherapy in the postoperative shoulder.  J. Shoulder Elbow Surg. 5 (1), 61-68.

Swenson. C., Sward. L., & Karlsson. J., (1996), Cryotherapy in sports medicine. Scand J Med Sci Sports,6(4):193-200.

Page, P. (2018). To Ice or Not to Ice: That is the question.

Retrieved October 6, 2020 from: https://www.cramersportsmed.com/first-aider/to-ice-or-not-to-ice-that-is-the-question.html

Reinl, G. (2014). Iced! The Illusionary Treatment Option, 2^nd edition.

Robinson, J. (2017). MOVE an injury not RICE. Retrieved October 28, 2020 from:  https://thischangedmypractice.com/move-an-injury-not-rice/#:~:text=healing%20(7).-,Dr.,response%20needed%20to%20initiate%20healing.