By Sonia Rafferty, Co- founder Safe in Dance International
The debate on whether icing an injury is help or hindrance to the healing process continues.
At the International Association for Dance Medicine and Science (IADMS) Annual Meeting in Houston, Texas in October 2017, a “duel”, entitled “Cryotherapy: Help or harm” was organised to try to persuade or dissuade therapists and dancers regarding the use of icing as a technique to manage injury.
Two physical therapists, Valerie Williams (PhD) and Rosie Canizares (DPT) were charged with putting forward evidence both for and against respectively. Arguments on both sides drew on research studies to support the different viewpoints.
The case FOR icing from Valerie Williams:
- A decrease in pain, swelling and inflammation following injury is a positive thing
- Swelling prevents the negative by-products of the injury leaving the site of the injury
- There is less restriction caused by the increased and accumulated fluid in the injured joint
- Intermittent application sustained over a few weeks (for example 6 weeks for an ankle sprain) decreases the speed of nerve conduction which increases tolerance to pain
- Ice application decreases swelling over this 6-week period.
So her advice is:
- An ice pack, crushed ice or an ice massage has benefits but….
- The time and dose of cooling application can vary
- 10 to 20 minutes is enough to reduce pain and swelling AND monitor the outcome.
The case AGAINST icing from Rosie Canizares:
- Studies on the application of cryotherapy have been inconsistent, often based on anecdotal evidence, using small sample sizes and frequently done with animals – even the human subjects used have been healthy
- There are many cryotherapy interventions but with so many unknowns, can it really be safe?
- Ice should not be used on everyone, such as people with allergies, for example those who can suffer from cold uticaria (a mild or severe skin rash in reaction to cold), or individuals who suffer from Raynaud’s disease (a condition that causes reduced blood flow to certain parts of the body in response to cold or stress)
- Ice can mask injury due to loss of pain sensitivity
- Ice could actually increase swelling rather than reduce it due to increased permeability of tissues when damaged
- Studies have shown that icing has a negative effect on strength, endurance and performance outcomes, such as reduced jump height
- If people are icing on their own, do they really understand what they are doing?
So her advice is:
- Dancers should be educated in the protocols before administering ice themselves
- Consider more carefully when ice could be applied rather than simply using it as standard solution to any injury
- Use re-warming periods after ice application
The question persists – can we continue to use ice safely or is cryotherapy counterproductive to the body’s natural processes?
Many studies supporting a detrimental effect on the body tissues are basing their findings on studies that involve cooling periods of 20 minutes or more. Systematic reviews of these studies on the effects of topical cooling (cold application directly to the injury) are directing that, until definitive evidence is available, short cooling applications with a progressive re-warming period are advised (Bleakly et al, 2012).
In sports, fitness and therapy articles and blogs, much has been made of the fact that the originator of the RICE (Rest, Ice, Compression, Elevation) procedure, Dr Gabriel Mirkin, has now recognised that both ice and complete rest may delay, instead of assisting, healing (Mirkin, 2016).
While he agrees that there are now pertinent questions raised regarding the efficacy of ice application following injury, a personal appraisal of the recent studies has led Dr Mirkin to make the following recommendations:
- Since applying ice to an injury has been shown to reduce pain, it is acceptable to cool an injured part for short periods soon after the injury occurs
- Apply the ice for up to 10 minutes, remove it for 20 minutes, and repeat the 10-minute application once or twice
- There is no reason to apply ice more than six hours after you have injured yourself (Mirkin, 2016).
Until studies show definitely one way or the other, SiDI’s advice is similar to that offered the previous 2016 blog:
- Use ice with caution and question WHY, HOW and HOW OFTEN you are applying it
- Follow recommendations more carefully rather than simply grabbing an ice pack and using it as a quick fix “solution” when something hurts
- Apply ice for up to 10 minutes immediately following an injury to initially slow down the blood flow to the area to limit swelling and reduce pain Remove the ice for 20 minutes so that the blood flow can return to the area and the body’s natural healing response can take over to remove waste and excess fluid
- Repeat the whole procedure (10 minutes on, 20 minutes off) once more
- Progressive re-warming of the body part is advised but….
- Remember, don’t return to dancing immediately following application of ice or use ice to numb pain so that you can continue working!
- Take advice from your therapist as to how the application of ice will affect your specific type of injury in the short and long term. This implies that you have followed the PRICED recommendations and taken action to get a Diagnosis, something that, for several reasons, dancers are often reluctant to do!
- If ice is freely supplied in your school or studio for injury management purposes, ensure that everyone who has access to it understands and can put into practice these recommendations.
Bleakly, C.M, Costello, J.T & Glasgow, P.D. (2012). Should athletes return to sport after applying ice? A systematic review of the effect of local cooling on functional performance. Sports Med, Jan 1:42 (1), 69-87.
Mirkin, G. (2016). Why Ice Delays Recovery. Retrieved from http://www.drmirkin.com/fitness/why-ice-delays-recovery.html
Williams, V. & Canizares, R. IADMS “DUELS”: Cryotherapy: help or harm? IADMS Annual Meeting, Houston, TX, USA, October 2017.