Dr. Gabe Mirkin coined the term RICE — for rest, ice, compression and elevation — in his best-selling book The Sportsmedicine Book a in 1978. The practice of icing anything that hurts, feels tight, or seems “injured” has gained widespread acceptance among practitioners of all types – sports medicine, PTs, athletic trainers, coaches, personal trainers and more. As a clinical bodyworker who mostly sees clients with fairly severe pain complaints, I can say that virtually every one of them has been told to ice, and most did until they began working with me.
Unfortunately, the practice of icing was based upon questionable science — which has since been conclusively debunked. Dr. Mirkin retracted the protocol that made him famous in an article that he wrote in June, 2013, Ice Delays Recovery from Injuries. In that article, he cites a study by the Cleveland Clinic showing that ice delays healing by reducing the body’s production of IGF-1, or insulin-like growth factor – a compound that is present in the fluid that surrounds inflamed tissues. Dr. Mirkin later expanded upon that article with another post in March, 2014, Why Ice Delays Recovery.
Healing is delayed by cortisone-type drugs, nonsteroidal anti inflammatory drugs such as ibuprofen, applying cold packs or ice, and anything else that blocks the immune response to injury – Dr. Gabe Mirkin, originator of the RICE protocol.
Athletes are subjected to icing at every turn, and I’ve recently heard of teams that are routinely immersing their young players in ice baths following strenuous workouts. Studies have shown that immediately after cooling, there was a decrease in strength, speed, power and agility-based running. Icing is not good for athletes. It delays recovery from hard workouts, because the body needs inflammation to heal and recover.
Icing over the last few decades has become trendy among baseball pitchers, whose arms and shoulders are subject to huge mechanical stress. But some very prominent opposing views are emerging as the coaching catches up with the science. In Why Icing the Pitching Arm is Harmful, Coach Mills of pitching.com interviews Gary Reinl, author of the book ICED! The Illusionary Treatment Option. Reinl advocates active recovery, in which no ice is used, but the joint is intentionally mobilized after pitching to keep fluid moving and metabolic exchange happening. In his research, ice actually increases swelling and causes further damage.
Josh Stone is an athletic trainer who caused a firestorm in the sports medicine community by strongly espousing the deletion of icing as a protocol for athletes recovering from physical stress or injury, using tissue loading and exercise instead. His article, Ice – The Overused Modality provides a compelling and informed case for rehabilitation via movement.
…active recovery is how you regenerate tissue… Stillness is the enemy. Ice is stillness to the extreme. You stop the process and worse, you’ve caused additional damage. — Gary Reinl, author of ICED! The Illusionary Treatment Option
It’s Probably Not an Injury — and Icing Will Make It Worse
Icing is attractive in that it provides a dramatic, immediate, illusory and temporary benefit, because it has a numbing and distractive effect on pain. I had a client recently who complained of severe low back pain, and when he arrived moved haltingly and was barely able to walk. When I started working on his hips, his skin felt like it had been in a freezer for hours. Ice and NSAIDs were his only tools for reducing his pain, which I discovered was caused by trigger points in his gluteus medius and maximus muscles among others. Little did he know that the extreme icing he was doing, while it temporarily reduced his sensation, was making his condition much worse by further embedding trigger points in muscles that referred to his low back.
The use of ice for injuries is a belief that is dying a hard and controversial death in the physical therapy and sports medicine communities, in spite of the conclusive science that has emerged. Unfortunately, there is a major voice missing from this debate which makes the argument against ice even more compelling. The trigger point literature has provided ample evidence that the great majority of pain complaints have no basis in injury, but rather are due to myofascial trigger points.
Trigger points originate at a microscopic level due to chronic or acute muscle fiber overload. Inflammatory chemicals develop near the motor endplate zones of muscles, causing local hypoxia, edema and blocked capillary function, as well as nociceptive signals to be sent along the neurological feedback pathways to the central nervous system. These signals are misinterpreted as pain referral via a mechanism that is still a subject of research but is thought to be due to up regulation of neurons.
The use of ice on tissues that already have trigger points and compromised capillary function causes further stagnation and vasoconstriction – the last thing those tissues need.
To take a typical example, when someone experiences pain in the front of their shoulder, it is highly likely that it will be diagnosed as an injury of some kind – a supraspinatus tear, or at least an inflammatory state such as bursitis. However, as in all pain, most shoulder pain is due to taut fibers and trigger points in muscles that have adapted to stress and posture. 13 different muscles directly refer pain to the anterior shoulder. I see patients with serious shoulder pain often in my practice, and in very few cases has a Clinical Thai Bodywork treatment failed to resolve their issue (one was due to an actual injury following a motorcycle accident, and needed surgical repair).
So there are two problems here: the general assumption that the pain is due to injury, which most of the time it isn’t; and the use of ice to treat the “injury”, which even in the case of acute injury has now been shown to impede healing. However, given that pain most likely originates in trigger points, the ice treatment is far more damaging – cold is the last thing they need. Ice puts already taut, stagnant muscle areas in the deep freeze, further stagnating the local metabolism. Trigger points need metabolic exchange in order to be cleared – a restoration of capillary function and movement in the area, not stasis, which is the inevitable result of ice treatment.
Heat, on the other hand, causes vasodilation, enhances local metabolism and is efficiently distributed by the body due to enhanced capillary action. Ice vasodilates capillaries, and according to Travell & Simons, penetrates quickly to deep tissues as layer upon layer of tissues go into stagnation. According to Gary Reinl, the icing craze took off after a news story about a surgeon who performed the first procedure to reattach a boy’s severed limb – using ice to preserve the tissues of the arm prior to the surgery. Somehow that got inappropriately applied to damaged or stressed tissues. Ice is great for shutting tissues down and preventing decay, not so much encouraging healing and recovery. Cooling muscles deeply is a major perpetuator of trigger points, and ultimately pain.
Travell & Simons cite muscle cooling as one of the most insidious perpetuators of trigger points b. Anyone who wakes up with a stiff neck due to cold air on their neck at night causing trapezius and levator scapulae trigger points knows the potentially damaging effects of cold on muscle. Icing an athlete’s muscles after or during a workout or icing a sore shoulder shuts down the capillaries and increases the likelihood that microscopic stagnation fostering trigger points and pain will develop. When a cold distraction spray is used in trigger point therapy (for the purpose of neurological distraction, not cooling), it is very important to apply heat to the area immediately after to reverse the negative effects of muscle cooling.
Latent TrPs in a fatigued muscle, especially in the calf or neck and shoulders, may be activated by direct cooling of the overlying skin, as by a cold draft from air conditioning or an open car window. — Travell & Simons, The Trigger Point Manual
The Clinical Thai Bodywork Perspective – Movement is Health
I was trained in Traditional Thai Massage, but my work later evolved into what I teach and practice today, Clinical Thai Bodywork. The concept of treating pain with cold is completely foreign to asian medicine. Pain, in both Traditional Chinese Medicine and Traditional Thai Medicine is equated with stagnation. The body in health should be in a constant process of physical and energetic movement, or flow. Herbs, bodywork, acupuncture and heat may all be employed to facilitate the flow. Cold stagnates and impedes flow.
This correlates in an interesting way with the principles of trigger point therapy, which was developed by western doctors independent of any asian influence. Trigger points are a phenomenon of stagnation at a cellular level. When trigger points develop, the sarcomeres at the center of the fiber bundle contract and stay stuck, making the fiber feel hard, taut and static. The only way to eliminate the referred pain caused by the trigger point is to disrupt the contracture in some manner and allow the sarcomeres to move normally again.
My approach to working with pain is to try and understand the body’s logic. For example, over a period of time during which trigger points are producing a steady flow of referred pain in the area of a joint (very common) and noxious input to the central nervous system, the body goes into a self-protective splinting action, creating taut fibers in additional muscles to immobilize the joint. In a sense our goal is to help the body understand that nothing is injured and things need to move again. We are facilitators who provide the body with a conscious experience of movement without pain.
Heat, compression and movement are some of our best tools as clinical bodyworkers dealing with pain. The Thai Herbal Compress (Luk Pra Kob) is a wonderful tool that combines moist heat with compression and the topical application of medicinal herbs such as turmeric, various varieties of ginger, eucalyptus, lemongrass and others. The herbs are wrapped in a cotton ball with a stem that provides an excellent form factor as a tool for compression in bodywork.
In CTB treatments, the Luk Pra Kob is used as a compressive tool on muscle lines that are being shortened and lengthened. The moist heat and herbal oils are highly effective in relieving stagnation and stimulating flow in the tissues. Neurological distraction also plays an important part. The heat, pleasant smells and rolling pressure all serve to disrupt the pain response triggered by stretching taut fibers, making it easier for the fibers to let go and the trigger point encapsulations dissolve.
I would encourage you not to blindly follow the advice of the people who haven’t gotten the memo yet about icing. Unfortunately, it would seem that many health practitioners would rather unquestioningly keep doing what they’ve always done rather than do the research and go against the grain. If you have an injury or have worked your muscles very hard, your body’s inflammatory response isn’t a mistake, it’s the first step toward healing and should not be suppressed. If you have pain, chances are that it’s not an injury unless you have other indications that would indicate so. You can make the pain go away if you understand what muscles could be causing it and encourage their movement and metabolic vitality — and you won’t need drugs, surgery or ice.