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Ice to treat soft-tissue injuries contraindicated by creator of protocol (wikipedia.org)
62 points by stank345 9 months ago | hide | past | favorite | 64 comments



This is a weird article / statement. RICE, afaik (former doctor here), was never about prolonged use for healing. The intent is to mitigate the harms of the initial excessive inflammation/swelling response (which threatens to compromise tissue at the peak of the injury event), by dampening this response via cooling / constriction of blood vessels.

But, absolutely, after this has settled a bit, you're supposed to apply warmth, not heat, to encourage increased perfusion to the area and promote healing.

So, apples/oranges. There's nothing in the statement above to say that RICE is contraindicated as an initial management, and the implication that RICE was meant to be applied past initial management simply isn't true in the first place (afaik).

I could be wrong as to how others used it, however. I wouldn't put it past a hospital to mindlessly make it a protocol that would then be followed blindly, I guess...


As a patient, in the past I've absolutely been directed to ice injuries for weeks. (Not so much in the last ~10 years, as the world caught up to the fact that this was a bad idea.) Sources like the Red Cross or WebMD article on RICE[0] _still_ recommend it for at least 48 hours after a minor injury, even though this has been debunked.

So I think it's good that the Wikipedia article emphasizes that the protocol is outdated.

[0] https://www.webmd.com/first-aid/rice-method-injuries


Last time I had anything like that (tooth removal) they said two hours tops, after that it won't make much of a difference for the swelling anymore.


I had a knee injury just this February and I was instructed to cool my knee with ice for weeks (I don't think they meant it constantly - but at least from time to time).


Aside from tissue necrosis or nerve damage due to extreme compression, (which seem to be situations where you'd be at an ER or urgent care anyway due to the severity that entails) what other harms need mitigation? It seems that ice is recommended for every minor or moderate injury handled purely at home.


Well, I don't know; an educated guess is that it's not just blood vessels that could be compromised by excessive swelling, however localised.

Having said that, the RICE acronym is often extended to PRICE, to indicate that the typical treatment also involves a "Plaster of Paris". So in the presence of a plaster, the confinement is even more strict, so you would want to control the swelling response inside the tightly-fitting plaster anyway.

But, again, disclaimer, haven't practiced in years, and even then I was not specifically an orthopedic doctor. :)


RICE is widely recommended to athletes to heal injuries by doctors, PTs, etc.


Ice is also widely recommended to aid recovery for athletes, despite it having a negative effect on post-exercise adaptation. People widely recommend incorrect stuff to athletes all the time.


Ice is good for muscle recovery immediately after strenuous activity. Within minutes is best, up to an hour or so is still effective. After that you need warmth.

Strenuous here means lifting your one rep max, running 20 miles, breaking a personal best sprint time, that sort of thing.

I can attest from personal experience that ice bath right after exercise works in these cases. I’ve even tested it by icing just one leg and not the other. There is a marked difference in recovery by next day.

Ideally you ice the muscles right after workout then put them in a compression clothing so they’re extra warm for the next several hours.


I think the idea is that you performed the exercise to create stress that you want your body to respond to by getting stronger / more aerobically fit etc in some way. So by icing, yes, you recover better, but by reducing the stress you reduce the adaptations.

Imagine you could perfectly recover with some intervention. Then weight lifting no longer works!

For examples like the ones you listed, peak performances where you’re not concerned about gainz and maybe even have to perform again soon after, it makes a lot of sense to do anything to recover quickly.


I find I need two different modes:

- hypertrophy to actually gain strength and muscle (ie. longer recovery time)

- maximum recovery to heal from a strenuous exercise and be ready for more the next day (ie. shortest possible recovery time)

In the second scenario, I don't care about gaining strength at all, and the recovery is the only important aspect.


Yep, this is exactly the point I was getting to.

The stress response is literally the point of working out, you won’t get adaptation without stress.

Sometimes that’s undesirable, ie if you’re in the middle of a competitive league and need to reduce stress post-game. In which case, ice away.


> and maybe even have to perform again soon after, it makes a lot of sense to do anything to recover quickly

For running specifically I’m not trying to make my legs stronger, I’m improving cardio. I need the legs to be in good shape for tomorrow’s hard run :)


In running specifically you need the stress to drive adaptation in the muscle such as capillarisation.

If you’re icing after you run you’re missing out on the benefits of the run.


The article's kind of confusingly written (not exactly unusual for articles on any wiki), but it does indicate in the 2nd paragraph that RICE is no longer indicated for the promotion of healing. It does cite several articles suggesting that, while it can reduce pain and swelling, this is not associated with faster healing.

I'm no physician, but as a child I did spend many Saturday afternoons watching Dad prepare lecture materials for the med school classes he occasionally taught, so I think that I am probably as qualified as a non-physician can be to massively overestimate my own competence. And I certainly don't know anything about soft tissue injury and inflammation beyond what my physical therapist has told me. But in the classes on research methods that I took in grad school, we loved to pick on the mid-to-late 20th century medical literature and standards of care, and one of the common themes that cropped up was a tendency to over-extrapolate.[1] That might be part of what happened with RICE? A strong acute histamine response might be associated with some secondary cellular damage at the injury site, but that's not necessarily a bad thing for long-term outcomes.

[1]: This tendency was deliciously satirized in https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001541/


Who’s to say the initial inflammation is excessive though?

Isn’t it possible that promotes healing? The body should know how to heal.


When people talk about ice bath recovery, is that strictly for immediately post-exercise then? As in, within 10 minutes?

How does this all relate to sauna to ice bath hot-cold style treatment? Is that a totally different kettle of fish?


Does that mean that alternating hot and cold is no longer recommended for long term healing?


He's saying it never was


It's not mentioned here, but at some point there were studies suggesting that alternating heat and cold gave improved recovery over cold (ofc now we know that cold is debunked, the question is whether heat and cold improves recovery over doing nothing or adding heat)


How is the initial swelling dangerous / compromising?


It's been years since I've practiced, so take my understanding with a grain of salt, but, the idea is that the swelling will be excessive, and because the space to accommodate it is limited, this can end up constricting the blood vessels and compromise blood perfusion, despite the fact that the inflammatory response is trying to 'open' them.

Therefore by artificially causing them to open slightly less, you control the swelling, and stop it from pooling so much that it then blocks blood flow completely.

The extreme scenario of this is called compartment syndrome, where the blood flow is completely blocked, leading to necrosis of the affected area; this is an orthopedic emergency, where 'fasciectomy' needs to be performed; effectively slicing open the compartments to allow the expansion to occur without compromising blood flow.


Off topic, why did you stop being a doctor?


Since people here are arguing about things that the article doesn't state, or mistating things it does state, here is the actual relevant text

The current research supports the role of ice in temporary pain relief, but there is little evidence supporting the use of ice to aid in healing, or even swelling reduction.[7] Further research is needed to further understand how ice should be applied. At this time, due to the lack of evidence, there is no consensus on the ideal temperature ranges, time frames, application methods, or patient populations when using ice on a soft tissue injury.[16] Most studies use icing protocols of intermittent 10-20 minute applications, several times a day for the first few days following an injury.[7]

and

Currently, the RICE protocol is no longer recommended and has given way to other protocols for treating soft tissue injuries. Most recently, in 2019 the mnemonic "PEACE & LOVE" was coined by Blaise Dubois. The PEACE component stands for protection, elevation, avoid anti-inflammatories, compression, and education. It guides the treatment of acute soft tissue injuries. The LOVE component stands for load, optimism, vascularization, and exercise. It guides the treatment for the sub-chronic and chronic management of soft tissue injuries.


Tangentially related, the article mentioned the first re-attachment of a limb from a 12-year old boy whose limb was preserved with ice prior to surgery at MGH. That jogged my memory, as my AP Chemistry teacher told us that story one day in class. Turns out he grew up in Somerville and knew the kid from the neighborhood, and all the kids used to hop the freight trains to catch a lift to various places around Somerville and the surrounding areas. He may have even said that he was there when it happened. He said that the kid was fairly new to hopping the trains like that, as you learn to pull yourself in between cars or very close to the train so that you don't hit a wall and, well, lose an arm. [1]

[1] https://en.wikipedia.org/wiki/Ronald_A._Malt#First_Successfu...


I suppose it's related, that for athletes, ice baths after exercising are to be avoided because they hinder hypertrophy.


I'm not sure there is a consensus on ice baths at this stage? Some athletes swear by it, some say it's useless, and last I looked at it the science was ambivalent (somewhere between small to no effect, either positive or negative).


There was a meta study published in February.

https://onlinelibrary.wiley.com/doi/10.1002/ejsc.12074


Hypertrophy is often not the goal.


Surprising that this fact is being often overlooked in this thread. If you're in a multi-day golf tournament for example, an ice bath for immediate recovery and lack of hypertrophy is exactly what you want.


I think it hinders recovery too though, inflammation has a function, which is why we don't just systematically administer high dose anti-inflammatories for every infection, only when it's too risky to leave the natural process handle it, or when the inflammatory response is pathological (e.g. COVID cytokine storm).


And why do golfers not want hypertrophy exactly?


They do sometimes - like when they're trying to gain strength. At other times, recovery is more important than growing stronger (like during a tournament).


Are there any athletes who want hypertrophy? Bodybuilders aside.


Hypertrophy improves performance in any sport which demands speed and power, up to a point. Anyone playing basketball or gridiron football or hockey at an elite level tends to be pretty heavily musceled.


one wonders how it ever even seemed like common sense to disrupt the body's evolved immune response to acute, traumatic soft-tissue injury, never mind good conventional medical advice.

ice to preserve a detached structure? sure. quelling the inflammation of organs or the brain? yeah, those types of inflammation can turn into a cascading collection of responses, often (but not always) having distinct non-traumatic root causes.

but disrupting increased (life)blood flow to the site of acute, traumatic soft-tissue injury? seems like some otherwise logical lines crossed there, not to mention just a bad idea on its face.


That's because the body's initial response is often way out of proportion. I get the flu and my body decides to turn up the heat. There's pollen in the air and my nose goes into lockdown for weeks.

I've dislocated my kneecap a few times and the near-immediate swelling was much worse than the actual injury. Recovery took a few weeks anyway so easing my discomfort for a couple of hours made no difference.


From what I remember, turning up the heat is an attempt by your body to kill off the virus. This is a natural response, not a genetic mistake.

Our sinuses have shrunk and or airways collapsed far too quickly for evolution to adapt, leaving us highly susceptible to allergies and inflammation. This makes the likelihood of catching a cold or flu much worse. It also makes the healing process longer.

I very much recommend you read Breath by James Nestor if you suffer from allergies. Or at the very least, let chafgpt summarize it for you.


This is likely because you are deficient in vitamin D.


my comment is limited to "acute, traumatic soft-tissue injury", the scope of which excludes viral infection, allergic reaction, and strict joint injury.


> my comment is limited to "acute, traumatic soft-tissue injury", the scope of which excludes viral infection, allergic reaction, and strict joint injury.

The point is that evolved responses don't always properly account for nuance or proportion. If inflammation evolved for large traumatic injury, it may still be triggered for limited soft tissue injuries but then the response could be disproportionate.


Those examples were more about the body's tendency to overdo its response.

(But aren't joint injuries usually soft-tissue as well? It's the ligaments that get the short shaft.)


And here I thought the ice was intended to be a pain reliever, not a way to induce healing.


Mostly a way to reduce inflammation, ice bath isn't exactly a "painless" experience


> Ice has been used for injuries since at least the 1960s, in a case where a 12-year-old boy needed to have a limb reattached. The limb was preserved before surgery by using ice

Of course, for detached limbs, ice is really good to conserve them until they can be reattached. But that's not the majority of injuries fortunately. Also, compression is really good for wounds that are bleeding profusely. For soft tissue injuries, maybe not so much?


It's amazing how much medical knowledge we have to unlearn (and sometimes relearn) as time passes. Some of it from experts; much of it folk wisdom. And how much of that knowledge was based on overzealous extrapolation (as appears to be the case here).

Heat vs Ice for injuries

Fats vs Sugars vs Proteins (and everything else diet-related)

Leeches went out of favor, but now see limited use again (for very specific things, not blanket "release the bad humours!" quackery.


What exactly do we need to unlearn about Fats vs Sugars vs Proteins?


https://pubmed.ncbi.nlm.nih.gov/18296750:

> This article examines how faith in science led physicians and patients to embrace the low-fat diet for heart disease prevention and weight loss. Scientific studies dating from the late 1940s showed a correlation between high-fat diets and high-cholesterol levels, suggesting that a low-fat diet might prevent heart disease in high-risk patients. By the 1960s, the low-fat diet began to be touted not just for high-risk heart patients, but as good for the whole nation. After 1980, the low-fat approach became an overarching ideology, promoted by physicians, the federal government, the food industry, and the popular health media. Many Americans subscribed to the ideology of low fat, even though there was no clear evidence that it prevented heart disease or promoted weight loss. Ironically, in the same decades that the low-fat approach assumed ideological status, Americans in the aggregate were getting fatter, leading to what many called an obesity epidemic. Nevertheless, the low-fat ideology had such a hold on Americans that skeptics were dismissed. Only recently has evidence of a paradigm shift begun to surface, first with the challenge of the low-carbohydrate diet and then, with a more moderate approach, reflecting recent scientific knowledge about fats.


The obesity rate was 30% in 2000, when sugar consumption peaked and the low-carb movement became mainstream. Now the obesity rate is over 40%:

https://cdn.statcdn.com/Infographic/images/normal/11497.jpeg

> Many Americans subscribed to the ideology of low fat

The "low-fat guidelines made people fat" nonsense would carry more weight if people actually followed the guidelines, but they didn't.


Thanks for the link. My understanding is that fats are more energy dense than simple carbs, and therefore eating high-fat diets is more likely to cause weight gain. The article is interesting, but it seems to take for granted that this isn't true. Are there any evidence-based studies you can link?


The reason I posted that article is because it summarizes how there has been a huge shift in thinking since the low-fat craze. I don't think it takes anything for granted, and I wasn't looking to argue for a particular point of view. I'm sure you can find studies about a specific topic as easily as I can.

Re caloric density: it's true that fat has more cal/g than carbs or protein. But, people do not eat a fixed mass of food per day -- the satiety of the food they consume influences this. Insulin response also affects weight gain and satiety.


Ancedotally. Growing up, there was a huge push towards "fat-free" and "low fat" foods that is extremely ingrained in my parents generation.

I can only summarize it as an ingrained feeling of "Fat is what fat people have". It meant they avoided it like the plague while completely overdoing it on other bad stuff.


Then, just like now, unscrupulous product marketing and media mistates medical consensus or ascribes consensus where there there is none. Just look at Snackwells. The product marketing term "Doctor recommended" does not mean all doctors, or even specialists in the relevant area.

Unless you are talking to a physician or reading a medical journal, anyone should assume that someone claiming to talk about what the medical community believes is probably wrong and possibly lying.

In the context of the current conversation, reducing saturated fats and bad cholesteral was a reactions to this epidemic https://pubmed.ncbi.nlm.nih.gov/24811552/

After peaking in the mid-1960s, the number of heart disease deaths began a marked decline that has persisted to the present. The increase in heart disease deaths from the early 20th century until the 1960s was due to an increase in the prevalence of coronary atherosclerosis with resultant coronary heart disease, as documented by autopsy studies. This increase was associated with an increase in smoking and dietary changes leading to an increase in serum cholesterol levels


When I was growing up there was a big emphasis on eating lots of grains which basically equates to lots of carbs. It was also widely believed that fats were bad and contributed to weight gain.

Both of those ideas may not necessarily have been 100% abandoned but are at the very least now viewed with a lot more nuance.


In my life, eggs have been both bad and good. Butter vs margarine. Atkins vs paleo vs whatever else. Calorie restriction vs more exercise.

Lots of junk science. Lots of marketing fluff. But, also lots of recommendations that were assumed correct but didn't stand up to deeper scrutiny.

Note, I'm not saying any of this is bad, or that scientists are stupid and wrong all the time. Just always amazed about how much our understanding of the human body has changed in the last ~50 years.


Thanks. All of those examples aren't about macronutrients though, which I thought were fairly well understood. (Though I'm sure various myths about them have been spread: such as another commenter suggesting "you can't get fat if you don't eat fat.")

Nutrition is definitely a minefield, I'm with you there!


I'm assuming you never saw folks like Susan Powter making claims of how you can't get fat if you don't eat fat.



Funny that anyone would point to icing a detached limb as a solution for the ones still attached.


It is contraindicated from the parameter of speed of recovery/healing.

While that's important in order for someone to get back to work or a sport, the most important parameter should be quality of recovery, in my opinion.


I'm not prepared to provide citations, but my understanding is that the evidence indicates that attempting to inhibit inflammation also reduces that. For example, the use of NSAIDs to treat sports injuries is associated with an increased risk of things like chronic pain and lasting reductions in strength and mobility. This part of why the A in PEACE & LOVE stands for "avoid anti-inflammatories".


The usual recommendation regarding ice is that it's only supposed to be used for a short while, immediately after the injury. Like minutes to hours. If used on the second day at all, the protocol is to alternate it heat. Pills may end up used for days. Some of them have long half-lives; e.g. 17 hours for naproxen.


Declared unsuitable in 2014 after 30+ years, and I'm just now finding out.

I feel a bit like Woody Allen in Sleeper...


(2014)?




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