Baby it’s cold outside — it should be.
Of late, cold has been taking the heat, not just from the local populace but in the medical arena, too. Evidence that cold treatments are not beneficial after exercise (e.g. to a shoulder or elbow after throwing) has been added to the theory that cold impedes the inflammatory process after an injury.
What is wrong with impeding inflammation? Inflammation means pain and swelling, doesn’t it? So why not apply ice?
Let’s get back to the original question. Inflammation is actually beneficial. It may cause pain but, without it, there is no healing. Inflammation in the wake of injury starts the healing process. Not surprisingly, then, there has been ample research lately showing that non-steroidal anti-inflammatory medications (aspirin, ibuprofen, and naproxen sodium are in this class of drugs), particularly at higher doses, significantly slow healing.
Consequently, the British Journal of Sports Medicine — in a recent editorial — joined a growing chorus of expert resources recommending that NSAIDs no longer be prescribed for soft tissue injuries such as bruises, sprains, and strains.
However, citing the same concerns regarding interference with the necessary inflammatory process, the editorial also “question(ed) the use of cryotherapy.” As further justification for the skepticism, the editorial asserted, “There is no high-quality evidence on the efficacy of ice for treating soft tissue injuries.” In other words, ice and other forms of cold therapy, if not harmful to the healing process, very well may do nothing to aid it.
I am sorry, as much as I respect the British Journal of Sports Medicine, that assertion is entirely inaccurate.
Much of that high quality research may have been done many years ago but it was still done and its author was Indiana State University athletic training professor Ken Knight, PhD, ATC — now retired. His athletic training text, “Cryotherapy in Sport Injury Management” was published in 1995 but remains a trusted sports medicine reference.
More recently, there has been ample academic investigation to confirm Knight’s work.
One attribute of cold therapy is not in dispute, its ability to relieve pain. Its numbing effect makes post-injury and post-surgical pain far more tolerable.
However, does it reduce swelling and speed recovery?
A Dutch literature review published just last year, also in the British Journal of Sports Medicine, looked at prevention and treatment of ankle sprains. Among its conclusions:
• The combination of cryotherapy and exercise result in significant improvements in ankle function in the short term, allowing patients to increase weight-bearing sooner when compared to exercise alone.
• Relative rest, ice, compression, and elevation (RICE), when combined, provide pain reduction, improve ankle function, and reduce swelling.
• However, the components of RICE are of little use when applied individually.
A Chinese literature review published in 2016 looked at post-operative knee patients. The surgeries were varied: ACL reconstructions, joint replacements, and relatively simple arthroscopies. The authors concluded that “compressive cryotherapy is beneficial to patients undergoing knee surgery at the early rehabilitation stage. At the last stage, the effectiveness of compressive cryotherapy and cryotherapy alone were found to be similar.”
Also in 2016, a study was published in Nature that looked at muscle healing in rats at the cellular level. The research found that cryotherapy did reduce the inflammatory response — without eliminating it — but had no adverse effect on speed or thoroughness of healing, laying aside the concerns expressed in the BJSM editorial.
Other than Knight’s extensive work, the landmark study on the effectiveness of ice was published in the American Journal of Sports Medicine in 1982. Looking specifically at severe ankle sprains, the researchers found that initiating cryotherapy — as compared to applying heat or doing nothing — within 36 hours of the injury, shortened the average recovery time from 30 days to 13.
Consequently, despite the opinion of the British Journal of Sports Medicine, the 97% of athletic trainers who, according to a recent survey, still apply ice to new injuries are correct to do so. The other three percent should thaw their opposition to the practice.
John Doherty is a licensed athletic trainer and physical therapist. This column reflects solely his opinion. Reach him at email@example.com. Follow him on Twitter @JDohertyATCPT.