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RICE protocol for healing injuries refuted

Old 01-01-17, 05:18 PM
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RICE protocol for healing injuries refuted

After 30 years of packing ice on strained muscles the famous Rest Ice Compression Elevation technique has been discredited, and by none other than the man who first thought of it, Gabe Mirkin, MD. He wrote the book on sports medicine but now declares ICE is the worst think you can do for an injury as it slows the healing process.

It's interesting that in the comments on the link people in the industry have a hard time believing this, even when it came from the mouth of the man who invented it. I guess some don't want to part with all those expensive gel ice packs they invested in


RICE: The End of an Ice Age | Stone Athletic Medicine
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Old 01-01-17, 05:36 PM
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Cool article Not too surprising there's resistance to it.

RICE has been standard treatment rec for decades. You learn something fundamental like that in basic first aid forever ago...it is very odd to apply skepticism to it. Especially when we live in an era of "junk science" pre-digested news-blurbs where studies purported to be claiming opposite things about the same idea seem (1 wine glass a day will make you live longer: the same ZOMG will KILL YOU!) to make the news every day of every week.


Near as I've read, compression and elevation are still goo things...inactivity (rest) and ice are not necessarily good.
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Old 01-01-17, 05:41 PM
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makes sense that reducing blood flow (with ice or drugs) inhibits healing
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Old 01-01-17, 05:48 PM
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One thing I noticed---the doctor said "... elevate the injured part to use gravity to help minimize swelling."

However, earlier in his post he claims that swelling happens "When muscles and other tissues are damaged, your immunity sends the same inflammatory cells to the damaged tissue to promote healing."

Why would elevating a limb reduce swelling?

I had learned that at least in part, swelling was caused when broken cell membranes clogged capillaries, blocking the cell fluid from being sucked away via the circulatory system, which then prevented the body from delivering healing nutrients and white blood cells which should eat the damaged cells and carry them away.

Elevating an injured limb prevented some of this fluid build-up as gravity would pull the fluid away from the injured area.

If, however, swelling is caused by "inflammatory cells" then why would elevating the injured area help, or even make a difference?

I'd say ... the science is still not clear. Mice injected with poison versus my broken body parts? Hmmmm ....

I had always heard that ice killed pain (useful ... I find I heal best when I am not writhing, and when I can actually rest and relax, even faster.) I had also heard ice slowed all processes in the damaged area ... yes, it might slow healing, but the damage down by swelling was ongoing ... as the swelling increased, more cells would be crushed and die, clogging more capillaries, while the pressure would also block blood flow.

Ice was not a cure, but a trade-off treatment, to stop swelling so that eventually the injured area could be heated, to break down dead tissue and stimulate blood flow, and thus healing ... in fact, many suggested a middle period of alternating heat and cold, to keep the swelling from reaching damaging proportions while not completely stopping blood flow and thus healing.

Also, the doctor here talks about a loss of strength after cooling, which lasts ... until the athlete warms up (Duh.) Thing here is ... most of us are not NFL linemen trying to get back into the game ... we are amateur athletes who, once inured, want to heal quickly so we can resume our daily lives, which include some exercise.

This guy can come along and say "I was totally wrong and have a new theory." My response is, "Why should I then believe Either of your theories?" If he got it all wrong last time, maybe he got it all wrong again?

Look at his points:

Healing Requires Inflammation

This is unproven and just bad science. “Post hoc ergo propter hoc” doesn’t hold up. The fact that the body tries to heal the site of an inflammation is fine, but what about a cut with no swelling? The body rushes healing cells to that site too. The body responds to damage, not just inflammation.

Ice Keeps Healing Cells from Entering Injured Tissue

Absolutely true and well understood. It doesn’t actually Block cells ... it slows metabolism, blood flow, all bodily function .. . including decay. it prevents some inflammation (but not all---I am sure we all have experience with this.) The use of ice is a trade-off, as I mentioned above.

Anything That Reduces Inflammation Also Delays Healing

By this logic, healing delays healing.

The science on this is Not settled. This is an interesting theory, but so far, it is all based on a few tests with genetically altered mice. It also supposes that there is only a single healing mechanism, all based on the immune system.

I am really glad you posted this. it is interesting and worth following as it is (hopefully) further tested. But right now, I am not about to totally change my views just because this guy told me he didn’t know what he was talking about .. but now he does.

By the way ... no gel-paks here. I have always been a bag-of-frozen-peas guy ... corn also works.
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Old 01-01-17, 05:50 PM
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Originally Posted by Flip Flop Rider View Post
makes sense that reducing blood flow (with ice or drugs) inhibits healing
Not surprising.

But, one should also realize that not all injuries are the same.

There have been several articles that NSAIDS can inhibit the healing of tendons (sprains).

But, they are also very important in treating some types of inflammatory diseases such as rheumatoid arthritis.

Is there a point where too much swelling is bad? Uncomfortable?

Oh, also some moderate exercise is also helpful... not HARD... very mild. I.E. moderate weight bearing for bones. And movement to prevent clotting.
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Old 01-01-17, 06:17 PM
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Originally Posted by CliffordK View Post
Oh, also some moderate exercise is also helpful... not HARD... very mild. I.E. moderate weight bearing for bones. And movement to prevent clotting.
Agree. Having had my share of ankle sprains, I learned that gentle exercise is an effective treatment.
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Old 01-01-17, 06:29 PM
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Originally Posted by practical View Post
Agree. Having had my share of ankle sprains, I learned that gentle exercise is an effective treatment.
gentle exercise is good treatment in general ... it promotes blood flow to the injured area and envigorates the whole body, which accelerates healing.

But ... it has to wait until after sufficient rest that the body will not be injured by the exercise.

I just broke my clavicle ... and rebroke it twice because i wouldn't let i heal sufficiently before exercising. I did a similar thing when I separated my other shoulder.

Ice is first-aid. Heat is second, after a couple hours of ice. Motion takes over after two or three days--and stays gentle (ideally.)

Has worked for me for most of my life.

I think that has to be emphasized---Ice is Not a "treatment" for an injury. it is used to slow swelling and lessen pain. Swelling can cause more damage, and rest is a great treatment but it is hard to rest when one is in great pain.

For the same reason i wouldn't hesitate to take Ibuprofen if I was injured (I had already heard about how Ibuprofen is bad after deliberate exercise-induced soreness ... muscles grow by being torn down and rebuilding.) But in those first few hours after a serious injury, being able to rest and relax seems as important as anything else. (Anyone who has been up all day and night in pain, trying to but unable to sleep, will appreciate this.)

I still see ice as a sensible trade-off---it slows Immediate healing but also provides Immediate benefits.

Waiting on the rest of the science---or the next theory from the guy whose credibility rests on his admitting he spent decades preaching the wrong stuff.
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Old 01-01-17, 06:35 PM
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Originally Posted by CliffordK View Post
Not surprising.

But, one should also realize that not all injuries are the same.

There have been several articles that NSAIDS can inhibit the healing of tendons (sprains).

But, they are also very important in treating some types of inflammatory diseases such as rheumatoid arthritis.

Is there a point where too much swelling is bad? Uncomfortable?

Oh, also some moderate exercise is also helpful... not HARD... very mild. I.E. moderate weight bearing for bones. And movement to prevent clotting.

This is 100% correct and we need to be careful here.

Inflammation is not the same as tear or break. If something is ripped or broken then immobilizing it and rest might be exactly what's needed. You have to know what is going on under the skin and until you do you are only guessing at the proper treatment.

This is why evaluation of an injury by a trained professional is so important.
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Old 01-01-17, 06:53 PM
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Hmmm . . . with regard to ice, in particular, I certainly wouldn't rule out its benefits. About 4 years ago I was racing in a crit here in northern California. A gaggle of us went down all of a sudden (I'll never know exactly what caused the crash) and the back of my neck wound up on somebody's chainring, and as I twisted my body around , a small, crimson version of Old Faithful started to gush skyward. Well, after I got sewn up (with luck, the race was held near a hospital), the Doc told me to put ice packs on my neck if I suffered any inflammation, which I did. If nothing else, it really soothed my injury and served to numb the pain. I'd say this was of some value. The Doc also told me that, in time, my scar would become just an almost imperceptible white line, which it has not!
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Old 01-01-17, 07:43 PM
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Originally Posted by Maelochs View Post
Why would elevating a limb reduce swelling?

I had learned that at least in part, swelling was caused when broken cell membranes clogged capillaries, blocking the cell fluid from being sucked away via the circulatory system, which then prevented the body from delivering healing nutrients and white blood cells which should eat the damaged cells and carry them away.

Elevating an injured limb prevented some of this fluid build-up as gravity would pull the fluid away from the injured area.

If, however, swelling is caused by "inflammatory cells" then why would elevating the injured area help, or even make a difference?
The inflammatory response, among other things, makes cell membranes and blood vessels more permeable. This allow fluid to leave the cells and circulatory system and enter the intercellular space. This causes localized swelling, but since the fluid is not completely contained inside cell membranes or vessels, gravity can help it drain away.
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Old 01-02-17, 12:04 AM
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Originally Posted by JohnDThompson View Post
The inflammatory response, among other things, makes cell membranes and blood vessels more permeable. This allow fluid to leave the cells and circulatory system and enter the intercellular space. This causes localized swelling, but since the fluid is not completely contained inside cell membranes or vessels, gravity can help it drain away.
Indeed, sir or madam. (Whoops, sir I guess ... I didn't look at the name before responding.) In fact, I mentioned that in my post. My point is, in inflammation is good, and if inflammation is what Dr. Mirkin suggests is essential for healing, why would one want to stop it?

And further, the cell fluid will just be carried away by the circulatory system if it is just fluid leakage --- unless, of course, the dead cell membranes clog the capillaries. By the way, you say the inflammatory response makes capillaries more permeable---then how are nutrients to get delivered to the cells for repair?

And if the inflammatory chemicals Cause inflammation, and you don't Want inflammation---why the big insistence on doing nothing to impede the inflammatory chemicals?

The premise seems to be that without these inflammatory agents the body won't heal. I am not convinced that one test injecting boron or whatever into genetically altered mice bears this out.

I am not a doctor. maybe you are, are simply more educated in the field than I. Good. Still, my understanding of physiology leads me to think that icing some injuries is a good idea, and I don't see anything in this article which makes me change that view.

As I said, in my opinion the science is not yet done. I will wait until more research has been done, and more doctors have weighed in.

In any case ... every severe injury I have ever had has swollen, ice or no ... and has healed, swelling or no. What this means, I don't know.
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Old 01-02-17, 10:32 AM
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When considering what to do about the painful and debilitating pes anserine bursitis/tendonitis or other soft tissue inflammatory condition and looking for alternatives to RICE (Rest, Ice, Compression, Elevation) because of this new research, you may also want to read:


Why Most Published Research Findings Are False, John P. A. Ioannidis (2005)


Abstract

Summary

There is increasing concern that most current published research findings are false. The probability that a research claim is true may depend on study power and bias, the number of other studies on the same question, and, importantly, the ratio of true to no relationships among the relationships probed in each scientific field. In this framework, a research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser preselection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance. Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias. In this essay, I discuss the implications of these problems for the conduct and interpretation of research.
Why Most Published Research Findings Are False
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Old 01-02-17, 01:11 PM
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Originally Posted by Maelochs View Post
By the way, you say the inflammatory response makes capillaries more permeable---then how are nutrients to get delivered to the cells for repair?
Another aspect of the inflammatory response is dilation of blood vessels, which brings more blood (and thus nutrients) to the region. This also accounts for the redness associated with the inflammatory response.

I am not a doctor. maybe you are, are simply more educated in the field than I. Good. Still, my understanding of physiology leads me to think that icing some injuries is a good idea, and I don't see anything in this article which makes me change that view.

As I said, in my opinion the science is not yet done. I will wait until more research has been done, and more doctors have weighed in.

In any case ... every severe injury I have ever had has swollen, ice or no ... and has healed, swelling or no. What this means, I don't know.
I'm not a doctor, but I am a Registered Nurse with over 25 years experience in acute health care. On reading the article, I don't see that the RICE protocol has been clearly demonstrated to be harmful, only that it does not appear to confer any consistent measurable benefit. So, go ahead and ice injuries if you wish, and conversely, don't feel bad if, for whatever reason, you do not ice/compress/elevate an injury. The outcome is likely to be the same either way.

And keep in mind that RICE was intended to treat acute injuries. If you have a chronic inflammatory problem like arthritis, RICE was never meant to be used as a treatment.

Last edited by JohnDThompson; 01-02-17 at 01:16 PM.
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Old 01-03-17, 08:18 AM
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Well........I will bring up another question.
Has anyone looked at applying heat instead of ice in the scenario of an acute injury
Causes vasodilation which accelerates removal of blood and other cellular products and toxins, increase fluid absorption with elevation of the extremity( gravity),
Enhances the arrival of antiinflammatory and other cells ( platelets etc).
Not an expert but always thought it was more logical to increase blood flow to an injury than decrease it. Only benefit would be to decrease initial swelling which may compress vessels and limit blood flow.
Maybe cold for a few hours and then heat for a few days?
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Old 01-03-17, 09:56 AM
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As other folks have noted, for acute injuries cold and compression are very effective at minimizing soft tissue swelling from impact type and similar traumatic motion injuries. That's why end-swell type devices have become the standard among boxing cornermen. The combination has proven to be more effective than ice or compression alone. (Example: Mike Tyson's cornermen failed to be properly prepared with end-swell devices in his bout against Buster Douglas, which may have contributed to Tyson's loss due to partially impaired vision from swelling. They had only rubber gloves filled with ice water.)

For relief of chronic pain, particularly in my neck (permanently splintered C2 from car wreck), I'll keep alternating between cold and hot compresses because it feels good and works better for me than either alone. Same with my frequent sinus headaches, cluster headaches and trigeminal neuralgia. I don't care what some new research supposedly proves. I'll do what feels good for me. I'll try something new, but I won't discontinue something that works.

As another poster here mentioned, bags of frozen food work as well as gel packs. Frozen peas, corn, etc., work just fine. Anything that conforms to the affected area. Those microwavable bags of veggies can work too, but only once and great care need to be taken to avoid scalding -- let 'em cool a bit before applying. Gel packs are better overall.

Last edited by canklecat; 01-03-17 at 10:00 AM.
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Old 01-03-17, 06:13 PM
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Originally Posted by Rstyle View Post
Not an expert but always thought it was more logical to increase blood flow to an injury than decrease it. Only benefit would be to decrease initial swelling which may compress vessels and limit blood flow.
Maybe cold for a few hours and then heat for a few days?
I had heard that cold for the start did more to limit swelling which limited further damage----if the area swelled too much it killed more cells with the pressure, which added to the swelling and the congestion of the capillaries ... so controlling swelling did more to speed overall recovery than immediate heat.

As I understand it, cold slows things down and heat speeds them up---plus heat apparently helps the dead cell membranes to decay (stimulates the bacteria or blood cells or weakens bonds or whatever.) So, after a couple hours of cold (which is also good for pain mitigation) then swap to cold and heat alternatively for a while, then just heat to maximize healing.

I don't Know any of this. And I would guess that the amount of swelling differs per person and per injury, so how much ice is helpful or harmful would vary.

But as I see it ... all this is first aid and home aid for injuries not sufficient to warrant a trip to the ER. So ... it isn't science and doesn't need to be. If someone is a competitive athlete, then this stuff would Really matter ... but also, then a real doctor would probably be involved, and pain meds and whatever other equipment or procedures which would get the athlete back into competition swiftly (though sometimes at a cost to long-term health ... another big difference between me and the pros. I will take longer to heal if it means not having permanent or recurring issues after a few years.)
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Old 01-03-17, 06:22 PM
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I have sin e read other articles by the doctor in question. Ice does reduce pain by reducing swelling he proports, but it slows the release of specific healing enzymes or somesuch and inhibits the flow of blood for healing. So it's a trade off, no pain, no gain. Personally if I get a bad burn I place it in a bucket of icy water for as long as I can. An hour even. It takes all the pain away and often prevents that big blister from forming so no one will ever convince me to avoid ice for that purpose. As for sprains etc I wouldn't bother now.
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Old 01-03-17, 09:30 PM
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Originally Posted by Maelochs View Post
I had heard that cold for the start did more to limit swelling which limited further damage----if the area swelled too much it killed more cells with the pressure, which added to the swelling and the congestion of the capillaries ... so controlling swelling did more to speed overall recovery than immediate heat.

As I understand it, cold slows things down and heat speeds them up---plus heat apparently helps the dead cell membranes to decay (stimulates the bacteria or blood cells or weakens bonds or whatever.) So, after a couple hours of cold (which is also good for pain mitigation) then swap to cold and heat alternatively for a while, then just heat to maximize healing.

I don't Know any of this. And I would guess that the amount of swelling differs per person and per injury, so how much ice is helpful or harmful would vary.

But as I see it ... all this is first aid and home aid for injuries not sufficient to warrant a trip to the ER. So ... it isn't science and doesn't need to be. If someone is a competitive athlete, then this stuff would Really matter ... but also, then a real doctor would probably be involved, and pain meds and whatever other equipment or procedures which would get the athlete back into competition swiftly (though sometimes at a cost to long-term health ... another big difference between me and the pros. I will take longer to heal if it means not having permanent or recurring issues after a few years.)
My theory is that swelling and pain inhibit most people from doing what's necessary to heal properly and quickly. I've seen this in my own family and among friends, at both extremes, where some would follow medical directions and heal quickly while others resisted, complained about pain, and never recovered properly.

So even if cold inhibits some measurable factors in healing, the reduction of pain may be more beneficial if it encourages people to cooperate with physical therapy. That may offset the temporary *theoretical* drawbacks to using cold early in the process.

In the same way prescription pain relievers are tricky to use well. They can encourage some people to be more active and recover more quickly because the lack of pain makes it more comfortable to cooperate with physical therapy. And some folks may enjoy the sensation of the opioids too much and not make constructive use of the lack of pain to do anything more than sit around or get high.
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Old 01-03-17, 09:38 PM
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Corsi e ricorsi, as they say...
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Old 01-03-17, 11:02 PM
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Originally Posted by canklecat View Post

In the same way prescription pain relievers are tricky to use well. They can encourage some people to be more active and recover more quickly because the lack of pain makes it more comfortable to cooperate with physical therapy. And some folks may enjoy the sensation of the opioids too much and not make constructive use of the lack of pain to do anything more than sit around or get high.

I know two blokes who have chronic back problems and both went on opioids for pain relief. With no pain to speak of they went about business as usual, lifting heavy objects, working around the yard when they really should have been resting. Since then both have had to undergo laminectomy surgery and are basically rooted, they will never be able to perform normal tasks again. I had a lot of back trouble once or twice and never even thought of painkillers, even though I was basically confined to bed with a throbbing lower back. In the end I found a good chiropractor, recovered fully and with appropriate care can perform any task.

There are times to take strong painkillers and times not to. But try to tell that to the tens of millions of people addicted to prescribed opioids. A drug addict is a drug addict.
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