The Case Against Ice

Ice has gotten a bad rap as a therapeutic option of late, and that’s uncool.
I honestly find it can be a real treat. As did a recent patient, returning for her second visit, to relay that “I didn’t think I’d say this, but icing your neck, ahh, it’s reeeeally nice!”
And of course, cold application on necks is not something for everyone, but it’s also not the first time I’d had this specific feedback, following my suggestion to give it a try.
Could it be worth a try for you?

A lot has been made of the abandonment of R.I.C.E. as the injury management of choice used by health professionals, due very much to the fact that the originator of the method, Dr Gabe Merkin, decided that after 30 years of advocating R.I.C.E., he didn't back the protocol any longer. Research coming out at the time didn't support aspects of it any more.

That all happened about a decade ago now.
Since then the research waters on this subject and on cold therapy particularly, have become even murkier, and clouded the understanding of appropriate clinical applications of ice.
In my opinion, this is a particularly sad variety of being so open minded, your brain falls out.

Looking at R.I.C.E.
In terms of injury care, personally I agree that complete rest is not great management very often The over-prescription of bed rest was one of a number of factors that lead to the old ACC ads and posters suggesting we "don't take back pain lying down."
Taking a broader view, if you consider rest as a relative thing, and keep active doing what you can, without pushing an injury unnecessarily, maybe reducing certain movements, healing will generally progress more quickly. How active that really works out to be is such a case-by-case, person-by-person, injury-by-injury scenario it's hard to say what it incudes and excludes in any specific terms.
Obviously, rest can take other forms too, nobody is going to argue that a cast isn't the best thing to rest a broken leg. There are times where immobilisation can be the quickest way forward. 
For persistent pain, rest is often actually problematic, hence the ACC ads, because in too many cases people who end up in pain, end up doing less, becoming less capable, doing less, and become less and less capable, the result is often even worse pain, and less and less ability. Not the direction you want to go in.
Rest in itself is clearly a complex issue, then, if much is dependent on the meaning and whether the same specific meaning is understood by both the prescriber and the patient.

As for the remainder of R.I.C.E.
Largely, there is agreement that Compression and Elevation are helpful for acute injuries. Indeed, athletes will use compression garments, to aid recovery from heavier training loads, being in some respects a manner of ‘controlled injury’ and that healing required, is useful as a means to gain ability.
For longer term pain and longer term injuries, it’s a little more complex. Outside of vascular and lymphatic issues, generally there aren’t reasons compression or elevation would be necessary

So, out of R.I.C.E.
It does somehow seem like it’s specifically just using Ice, which has largely been put on ice.
(Couldn’t miss that pun, sorry)

Often, ice is ignored, in favour of heat. 
Often, unfortunately, a recommendation to try heat is accompanied by advice that ice is BAD.
Which it isn’t inherently, though you can certainly use ice ineffectively, and even badly, if you have bad advice.

Quite frankly, I think this is an utter freaking travesty. 
As do the many, many, many patients I have suggested try using ice. And whom all, almost categorically, find it useful in relieving pain and returning to fuller function more quickly. 
I had to smile as I read a email a patient sent me, following a conversation we’d had while working on an issue she was experiencing, and having considered the various factors, we decided cold was worth a try:
”Just want to give you a huge thanks for helping me get on top of my injury pain, and also encouraging me to use ice. Not sure why there is such a big movement out there to get away from icing injuries. Fake news.”

This is a common experience.
Frequently, I suggest patients try using ice, and find they can relieve pain in a meaningful way when they have been experiencing pain for years.
Persistent pain is largely what I see in clinic. Being as booked up as I am, I don’t have the availability to see many acute patients nowadays, and that’s unfortunate because I like acute care and I’m pretty good at it.
What’s interesting is that while cold is mostly thought of as something that -if, heaven forbid, you might use cold at all- you would apply once immediately after an injury, and then move on to using heat for anything else, what I see in practice has been that cold is often so effective on persistent pain, too.
More often than not, people with persistent pain find ice will relieve pain that they have been putting heat on, and putting heat on, and putting heat on, having achieved nothing more than temporary relief. 

Why is it that I would regularly suggest something that, seemingly, most people think the research doesn't support? 

Well, it seems that I have such regular success with it, and improvement in both persistent pain as well as acute pain, across probably 95%+ of cases where I suggest it. Yeah, if I can help people that effectively by getting them to help themselves with something as simple as an ice pack, then why wouldn't I?

So, something seems to be wrong here.
If the man behind the plan to get everyone RICEing, and basically everyone else also says ice is bad.....
Either, I'm wrong, or the research is wrong, right? 

Wrong. 
I'm right, and the research is right. 
Or to be more correct, the research is....... as right as it can be.

It's really hard to design good studies, and the possibilities that trip them up are numerous. Mostly, studies are very good at reaching the conclusion that "we were able to determine only to a reasonably low statistical certainly that the effect was significant or attributable to the factor we were studying and more research is required to gather better data before we can ascertain with any better certainty whether X is better than Y"

That's where even very well designed studies will often end up. 

Studying pain is really tricky. This is partly where I think ice has really run afoul of the way studies are constructed, not least of all because complex, multi-factorial things, like pain, don’t fit into the construct of a randomised, double blinded, controlled study.

It's very hard to come up with a study design to look at knee pain and whether it improves with ice, because there are so many causes of knee pain. You can't just get a hundred people with knee pain to use ice and see them all make good progress. 
It's very hard to come up with a study to look at shoulder whether it improves with ice, because there are so many causes of shoulder pain. You can't just get a hundred people with shoulder pain to use ice and see them all make good progress.
It's very hard to come up with a study to look at lower back pain and whether it improves with ice, because there are so many causes of lower back pain. You can't just.... you get my drift.

The same is actually true of heat. Research shows it’s also not really that great. You can't just put heat on lower backs or knees or whatever, and expect improvement across more than the period until things cool down again. That's just not how bodies work. And it's not how studies that show anything worth showing actually work, either. 

This, I believe, is one of the reasons why there is a discrepancy between what the research seems to be unable to show as effective, and what I do clinically, in recommending using cold as often as I do. The research itself is problematic. Because, guess what, I recommend heat too, and see good results. In specific cases.
I tend not to do that with the same frequency as I recommend cold, most probably due to the fact everybody has tried heat already, because their physio or whoever said, and well, if that had worked they wouldn’t now be talking to me.
There are other reasons, and while some reading this might find the physiological basis to the arguments for and against using cold really fascinating, nobody is going to get through a blog post three times this long!

So while I’d love to get into the practical, in-your-body science, that I love discussing in practice on a daily basis, I’m going to avoid that. For now, anyway.
Let's just focus on the research. And on applying the research, because without clinical reasoning, and relevance, research is just words on paper.

What I do works because I'm not just throwing ice at things willy nilly, it is considered, and therefore effective, advice. Where, as I mentioned, it's probably more than a 95% success rate.
In the handful of other cases, hey, we tried it and it wasn't as helpful as hoped, let's keep trying other angles. Because the answer to your pain is out there.

“Oh, you see, it's because you're telling people it's going to be helpful, it’s the placebo effect, that's why it's helpful,” some might say.
Sure, that is indeed an important part of placebo, but all I'm actually doing is explaining the physiological basis for why I think it'll help. I certainly think, and you may well agree, that having the support of a health practitioner in doing something, is going to have some effect on how helpful it is. That is also part of how this works. Not much point paying for my advice on what's helpful unless there’s progress hey, and progress most often relies on more than placebo alone!

Of course, those same patients who see good changes with using cold, they also wanted to believe their physio or massage therapist or PT or osteo or GP or whoever when they said putting some heat on it would help. And yet the pain endures, it just reduces temporarily and never really goes, or if it does go, it keeps returning.
So if placebo really were that big a part of things helping, then the heat, along with the advice to use heat, would have fixed it.

Most often I'm not reinforcing people's ideas of 'what feels right' because generally people don't like using ice. What they like using is heat. Because it feels nice.
Until they find out how helpful ice it is, and then it's something they do like. 
OK....... let's be honest, while I’m laying it all out in this blog post here, it's still not exactly fun to use ice, saying people ‘like’ it is a relative thing. Even once you have used it frequently, people don’t get to the point of liking it like they like icecream, but it gets a little easier when, from previous experiences, you know the outcome has been positive.
I’m not at all claiming that ice is some miracle answer, although sometimes changes do seem that way, there are definitely pain complaints that I do not recommend putting ice on, and those are often problems where I think putting ice or heat on isn’t going to do any good. that’s where we come to reasoning and rationale.

I actually think advising people to put heat on things as often as practitioner seem to, is what I would call empty headed.
And I'm being unkind about that advice, because it does actually rub me up the wrong way in a professional sense.
It seems if people aren't being actively discouraged from using cold (because studies say it's bad remember, when really what studies say is that it’s hard to show it works using those specific parameters) then the advice will often be "Well what the studies show is that it doesn't really matter if you use heat or ice so just do whatever feels right for you"

Wrong. 
I meet tooooo many people who have had this advice, from physios mostly, I find.

How did we end up here?
If that was what studies showed, how would I have the success I do? 
What it shows is that practitioners either aren't actually reading the research for themselves, and are being swayed by the perspectives of others who may sound like they know what they're on about yet seem to miss the mark somehow. Or that they are reading it but can't actually assess the research in relation to their clinical practice and apply it appropriately.

Overall, it is this failure to interpret the research which I am dismayed by, as well as the resultant thought that by telling people what the research doesn't show, you're doing a good job, without really considering how the research might be best used, to help the patient in front of you.

Suggesting people put heat on painful areas without any proper assessment (looking at you, GPs that never even put your hands on the problem) is poor practice, often driven by time constraints.
Telling everybody to just use whatever they like is not patient-centred, it’s lazy.
Telling people that advice is based on the research? That is what needs to go on ice.

If you’ve got pain, and particularly if you’ve got pain that’s been there for a while, and especially if you’ve been putting heat on it regularly, maybe try some cold.
If it’s not helping after a few days use, hey, it was worth a try, cos while it can feel pretty intense putting ice on things, in all probability it’s not going to do you any harm.
Follow guidelines on how to safely apply it, shorter applications are probably better than longer. If it feels worse, stop.

Obviously this doesn’t constitute clinical advice, I can’t say it’s the answer I’d suggest for you personally, without some sort of assessment, but:
If you know you have no underlying health concerns about cold use
Give it a go, you might be surprised.
It could be just the treat your body is looking for.