Ice & Cold: Essential when we get hurt?
Whether you play sport occasionally or intensively, there’s a high likelihood that you’ve experienced pain or got injured at some point in your life. Sprain, strain, overload or stress injury… If you’re too careless, you can run into a variety of obstacles to your physical well-being.
Faced with that, a common habit is to apply cold to the site of pain. In itself, this is not surprising, since it’s also something that you can see on TV when an athlete get hurt. The desired effects are simple: reduced pain and diminished local inflammation.
And yet, if we look at the latest scientific data, the use of cold is not the most interesting option in many contexts. Sometimes, it can even be counterproductive. This article is intended to shed some light on the subject.
Various protocols over the years
To understand the use of ice and cold, we need to go back several decades: in 1978, the RICE protocol (Rest, Ice, Compression & Elevation) was introduced. Based on this, there was 4 essential aspects to treat an injury: rest, application of cold/ice, compression and elevation of the affected limb. Then, in the early 1990s, the element of protection was added to give the acronym PRICE (Protection, Rest, Ice, Compression & Elevation).
Initially, cold therapy was seen as crucial for reducing the inflammatory response to trauma, reducing oedema, bruise formation and pain, reducing muscle spasm, decreasing tissue metabolism and reducing enzyme activity in the damaged area.
Then, in the mid-2000s, in response to scientific advances at the time, the PRICE protocol was replaced by POLICE (protection, optimal loading, ice, compression & elevation). The idea of mobilization was added, as the researchers realized that too much rest could delay the recovery of function in the affected area.
Finally, the PEACE & LOVE protocol (protection, elevation, avoid anti-inflammatory drugs, compression, and education & load, optimism, vascularization, and exercise) emerged in 2019, and corresponds to the optimal way of treating an injury according to the latest research.
To go into a little more detail:
PROTECTION = unloading or restricting movement in the affected area for 1 to 3 days. This may involve crutches for a leg injury, or a sling for an arm. The goal is to avoid further damage or aggravation of the injury.
ELEVATION = elevate the injured area above heart level to reduce swelling.
AVOID ANTI-INFLAMMATORY DRUGS = in the early stages of injury, anti-inflammatory drugs can inhibit tissue repair. Simple analgesics such as paracetamol can be used for pain relief.
COMPRESSION = external mechanical compression (such as with a brace or bandage) can reduce local swelling and prevent further bleeding into injured tissue.
EDUCATION = talk to a healthcare professional about the injury and get a recovery guideline on top of a therapy plan. Set recovery goals and expectations. Understand that load restriction on the injured area is only a protective measure for the first few days.
LOAD = an active approach, with movement and exercise, benefits most injuries. Loading or « stressing » the joint or muscle (i.e. making it work) while respecting and not exceeding the pain threshold promotes healing and stimulates tissue repair.
OPTIMISM = science shows that depression and fear linked to injury and recovery can lead to poorer results and less favorable forecasts. Staying realistic and positive is important, as the brain plays a key role in recovery.
VASCULARIZATION = seek to improve blood flow to the area, as better blood flow means more oxygen and nutrients, ensuring good tissue healing. Moving and exercising the joint or muscle helps that.
EXERCISE = controlled exercise, within pain limits, is important at the start of recovery. Restoring mobility and building strength aid to speed recovery and limit the risk of re-injury.
What about the cold?
Today, we have lot of evidence that should make us cautious about the systematic use of cold/ice when we get hurt:
– Cold acts as a vasoconstrictor (i.e., it slows down blood circulation), which hinders the transport of certain elements including macrophages, whose role it is to eliminate damaged tissue when there’s an injury (in order to replace it later with healthy cells),
– Excessive use of cold can reduce blood flow around the impacted area (delaying the healing process), cause further damage (to tissue and nerves in extreme cases) and negatively impact neuromuscular function (meaning reduced strength and mobility),
– Cold is particularly useful in cases of severe injury (particularly sprains) involving significant swelling, as it can itself be the limiting factor in healing and recovery. Excessive swelling can place pressure on tissues, restrict movement, exacerbate pain and reduce muscle function.
The first 2 factors lead to poorer blood circulation, and therefore less oxygen reaching the damaged site. The objective is therefore to limit swelling, not prevent it altogether, as it’s inherent to the inflammatory process.
Conversely, in cases of muscle injury where swelling is relatively low, cold and ice aren’t really that useful and may even be detrimental.
– In the instances of severe pain, ice can also be used to reduce subjective sensations in a short-term way. But it’s essential to remember that anything that reduces inflammation also delays healing (by slowing down the inflammatory process).
Train to recover
On the other hand, if you want to regain full capacity quickly, activity and mobilization of the damaged joint or muscle seem crucial. Adequate mechanical loading promotes cell regeneration, limits swelling, reduces joint stiffness and prevents muscle atrophy.
When an injury occurs, we should hence try to mobilize the affected area as soon as possible in a safe manner, i.e. without « overloading » the injury and while making sure not to exacerbate the pain (which should always decline gradually over time).
Even after a training session (whether sports or lifting), cold isn’t necessarily the best option: as with injuries, training induces an inflammatory process (including an increase in the rate of muscle protein synthesis), which cold decreases – potentially limiting the desired adaptations.
Thus, the use of cold should depend on the context. When you want to maximize training-related gains, it’s best to avoid tools that limit inflammation. If you’re looking to perform optimally after an intense workout, then this type of tool becomes useful.
| PERSONAL NOTE For me, when I get hurt, I adopt a proactive attitude very quickly. First, I’m lucky enough not to have any « big » injuries (only minor sprains and strains). Second, I know several kinesiology and neurology techniques that are highly effective in reducing pain and eliminating potential blockages in my nervous system. As a result, on the rare occasions when something happens to me, I often find myself able to perform exercises at my best in just a few days (sometimes even hours). |
In any case, when you get hurt, first seek the advice of a competent health professional and follow what he/she tells you. However, if he/she systematically advises you to ice the area for several days, without ever mentioning mobilizing it, then don’t hesitate to seek the advice of another health professional.
REFERENCES
- ‘’Is it time to put traditional cold therapy in rehabilitation of soft-tissue injuries out to pasture?’’, Wang & Ni (2021)
- ‘’The cold truth: the role of cryotherapy in the treatment of injury and recovery from exercise’’, Kwiecien & McHugh (2021)
- ‘’Postexercise cooling impairs muscle protein synthesis rates in recreational athletes’’, Fuchs & al. (2019)
- How to Properly Ice an Injury (2022), website verywellhealth.com
- To Ice or not to ice an injury? (2020), website physio-network.com
- The ICE Debate – Is Icing your injury still the right thing to do? (2020), website grandslamphysio.com
- Ice should no longer be applied to injuries, and here’s why (2023), website rehabhub.co.uk
- Why you Shouldn’t Ice an Injury, website trainedphysioperth.com.au
- PJF Podcast, episode 26 & 41