Ah yes, a question as old as time. The general thought for a long time has been that as soon as possible following an injury, such as a knee tweak or ankle sprain, you can relieve pain and swelling and even promote faster healing and improved flexibility with RICE.
No not the food!
RICE – Rest, Ice, Compression and Elevation. Dr. Gabe Mirkin coined this term in 1978 and this guideline has been in use for decades since. In recent years, Dr. Mirkin has altered course as evidence shows that both Ice and Rest may delay healing rather than helping.
But ‘RICE is Nice’, right? Evidence would point to contrary.
Going into this discussion you have to ask yourself this question first: What’s my goal of using ice? What am I trying to accomplish with taking Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?
If your goal is simply to control pain, then ice is the answer. It does a wonderful job of controlling pain.
But consider this, our body is a wonderful healing machine so the use of ice as a means of IMPROVING the healing process is just flat out wrong. It’s incorrect. It goes against how the physiology is designed.
To further explain, the healing process consists of 3 very distinct and slightly overlapping phases.
Inflammation: 4-6 days
Proliferation: 4-24 days
Remodeling: 21 days -2 years
Inflammation is the FIRST step to healing. Without it, the other phases cannot occur, which ultimately halts healing in its tracks. When you damage tissue, your immune system is responsible for your recovery. The same mechanisms that are used to fight off/kill germs start the healing process. Specialized cells and proteins are shuttled into the affected area (infection or injury) via the inflammatory process, and they go to work.
To be overly technical for a moment, the specialized cells are called macrophages and they are responsible for releasing a hormone called Insulin-like Growth Factor (IGF-1) into the affected area and tissues, this helps drive the healing process. These macrophages use powerful corrosives to remove dead and dying tissues while IGF-1 is a hormone that influences the action of Growth Hormone in muscle, bone, cartilage, nerves, skin, kidneys, lungs and liver.
So, to put is simply, the macrophages are the cleaning crew and IGF-1 mediates how everything gets put back together.
Icing causes localized blood vessels near the injury to constrict which slows or even shuts down blood flow to the affected tissue. This lack of ample blood flow prevents the cells and proteins featured in the inflammatory process from accessing the damaged tissue which can result in unnecessary tissue death from decreased blood flow.
This sounds horrible. Dead tissue. Permanent tissue damaged. Horrible.
This is a worst-case scenario. The tissue death part, that is. The part about hindering the delivery of inflammatory cells and proteins to the damaged tissue, absolutely 100% accurate.
Not only does icing hinder the inflammatory/healing process it congests the system and inhibits the body's ability to shuttle waste and healing byproducts away from the damaged area which further limits the extent of healing.
The shuttling of swelling-related byproducts occurs via the lymphatic system which runs from head to toe featuring long channels in the limbs and complimented by large concentrations of lymph nodes at major joints. The lymphatic system is designed to move - or rather it is meant to be used in conjunction with movement of the muscles and joints. As you use muscles and move joints, the contractions squeeze and essentially "milk" the fluid away from the injured area. Swelling is the end of the inflammatory cycle and when you apply ice the lymphatic system cannot operate effectively. Coupled with the addition of rest/immobilization of the affected area, the result is a stagnation of swelling in the injured area. If there is no movement, the pumps do not work. If the pumps do not work, the area will stay swollen until you return to moving.
If you were presented with a choice for your hypothetical sprained ankle, would you choose ice or NSAIDs?
The issue with NSAIDs is that they're actually much worse on the healing process than ice. NSAIDs stop the healing process altogether. Remember the macrophages from earlier? They don't even get released, so the IGF-1 they release doesn't even have a chance to mediate how things are put back together. No macrophages. No IGF-1. No healing.
Chronic use of NSAIDS can actually accelerate the progression of osteoarthritis because inflammation is present, but the repair work is never able to be completed
There can be inflammation without healing but there cannot be healing without inflammation.
So, what can we do instead of RICE and NSAIDs?
PEACE and LOVE
Not that kind of peace and love. This kind -
Protection
Avoid movements, positions and activities that increase pain during the first days after injury.
Elevate
Elevate the injured limb higher than the heart as frequently as possible.
Avoid anti-inflammatories
Avoid taking anti-inflammatory medications, they can slow down or stop the healing process.
Compress
Utilize an ACE bandage, compression sock or taping to reduce localized swelling.
Educate
Help from a Physical Therapist will accelerate the healing process and get you back faster.
Love
Gradually loaded tissue will heal better than tissue that was rested completely.
Optimism
Your body will heal and recover better if you are confident and positive about the healing process.
Vascularisation
Work with your Physical Therapist to choose appropriate activities to improve blood flow to healing tissues.
Exercise
Work with your Physical Therapist to restore, mobility, strength and stability through an active approach to recovery.
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