Rest, Ice, Compression & Elevation (RICE) is a term and form of treatment/management for acute soft tissue injuries that has been the ‘standard’ of care the world over for the last 30 years. The RICE concept was first introduced by Dr Gabe Mirkin (MD) in his pivotal book titled “The Sports Medicine Book” published in 1978. It was in this book that Dr Gabe Mirkin presented his ideas at the time which included the use of ice on soft tissue injuries. It was thought that ice would benefit and assist in the healing process as well as minimise pain.
Interesting to note that in 2014 Dr Gabe Mirkin wrote a blog stating that ice does not assist in the healing process of soft tissue injuries and actually hinders said process. In his blog post he highlighted that a systemic review conducted in 2013 and published in “The American Journal of Sports Medicine” found that ice did delay swelling, however it did not hasten the healing process.
I find it extremely interesting that Chinese Medicine has stated for the last 2000 years that ‘ice’ or ‘cold’ is not conducive to physiology, healing or repair. I also find it interesting that we needed a systemic review of published literature to bring us to the point of questioning the use of ice in the treatment of soft tissue injuries. Thus my intention with this blog post is to present some basic physiology of what occurs in the inflammatory process. My hope is with this basic information we can together see how counter intuitive it really is to put ice on soft tissue injuries, regardless of what the general consensus is.
As I am a fan of logic, let’s begin with questioning why the tissue/area becomes inflamed due to a soft tissue injury. Let us use the example of an individual who came to my acupuncture practice 2 weeks ago with a severely swollen knee due to another MMA fighter striking him there. Now, inflammation in this case is initiated due to cellular damage which resulted in the knee joint swelling, pain, and limited range of motion due to the swelling & pain. Thus, the body is telling this individual “I don’t want you to move this joint” which is very logical as the healing process is underway and the tissues/joint needs rest to repair. If the swelling would not be there, repair of the tissues cannot occur. If the pain & resulting limited range of motion was not there, the individual would use the joint and possibly cause further damage. Hence your body is talking to you and telling you to take it easy, rest & repair!
Let’s together delve a little deeper into what occurs in the inflammatory process. So, a muscle has been injured and thus there is cellular damage which initiates the inflammatory response. The main aims of the inflammatory response is to bring immune cells to the area & to begin repair. It is important to note that the steps that follow do not occur one by one in a linear fashion. However, for the purpose of description let us begin with the mast cells which are present in the damaged area. These mast cells subsequently release histamine which causes vasodilation and increased vascular permeability. What this means is that imagine you have a blood vessel that is ‘feeding’ the damaged area of tissue. The endothelial cells that make up the wall of the blood vessel contract and allow for spaces to open up in said blood vessel wall, as well as the blood vessel itself dilates (expand/get bigger). So essentially you end up with a bigger blood vessel that has little spaces/holes in it, thanks to histamine. This results in more blood flow/plasma/proteins to the injured area, resulting in swelling.
OK, so we have established that ‘swelling’ is due to the release of histamine by mast cells in response to tissue damage, which causes vasodilation and vascular permeability and results in increased blood flow to the damaged area. However this effect is strengthened by macrophage cells that secrete cytokines (inflammatory mediators) which have the effect of increasing the processes discussed above as well as triggering tissue repair. Furthermore, these cytokines also cause immigration of neutrophil cells & monocytes to the area via the discussed ‘increased blood flow’ which further assist in tissue repair indirectly.
The above description is why Dr Gabe Mirkin also stated in his blog post that “blood flow is needed for tissue repair”, he also goes on to mention that studies show Insulin Like Growth Factor-1 (IGF-1) is also needed for tissue repair. As IGF-1 is a protein that travels via the blood and has a similar structure to the hormone insulin, it goes without saying that if you apply ice to an injured area and decrease blood flow to said area, IGF-1 will not be able to initiate growth and repair of the damaged cells.
Acupuncture philosophy has stated that ‘ice’ or ‘cold’ is not conducive to health or tissue repair for the last two millennia. As we can see form the paragraphs above, common sense and basic physiology also agrees with this. My question is now why is RICE still being taught and promoted? I was at a first aid course some months ago and RICE was still being taught there as form of therapy that can decrease pain and hasten recovery. Granted, it can decrease pain by essentially ‘freezing’ and numbing the nerve endings, however the pain will dissipate on its own in due time regardless.
My recommendation has always been to those who seek treatment at my acupuncture practice to simply rest & listen to your body. Acupuncture can assist in the healing process by regulating the meridians and strengthening the constitution of the individual. However, the most important thing one can do is Rest! & give the body time to heal…
As always feel free to contact me with any questions you may have.
Warm Regards,
Giancarlo Nerini - Licensed Acupuncturist
Interesting to note that in 2014 Dr Gabe Mirkin wrote a blog stating that ice does not assist in the healing process of soft tissue injuries and actually hinders said process. In his blog post he highlighted that a systemic review conducted in 2013 and published in “The American Journal of Sports Medicine” found that ice did delay swelling, however it did not hasten the healing process.
I find it extremely interesting that Chinese Medicine has stated for the last 2000 years that ‘ice’ or ‘cold’ is not conducive to physiology, healing or repair. I also find it interesting that we needed a systemic review of published literature to bring us to the point of questioning the use of ice in the treatment of soft tissue injuries. Thus my intention with this blog post is to present some basic physiology of what occurs in the inflammatory process. My hope is with this basic information we can together see how counter intuitive it really is to put ice on soft tissue injuries, regardless of what the general consensus is.
As I am a fan of logic, let’s begin with questioning why the tissue/area becomes inflamed due to a soft tissue injury. Let us use the example of an individual who came to my acupuncture practice 2 weeks ago with a severely swollen knee due to another MMA fighter striking him there. Now, inflammation in this case is initiated due to cellular damage which resulted in the knee joint swelling, pain, and limited range of motion due to the swelling & pain. Thus, the body is telling this individual “I don’t want you to move this joint” which is very logical as the healing process is underway and the tissues/joint needs rest to repair. If the swelling would not be there, repair of the tissues cannot occur. If the pain & resulting limited range of motion was not there, the individual would use the joint and possibly cause further damage. Hence your body is talking to you and telling you to take it easy, rest & repair!
Let’s together delve a little deeper into what occurs in the inflammatory process. So, a muscle has been injured and thus there is cellular damage which initiates the inflammatory response. The main aims of the inflammatory response is to bring immune cells to the area & to begin repair. It is important to note that the steps that follow do not occur one by one in a linear fashion. However, for the purpose of description let us begin with the mast cells which are present in the damaged area. These mast cells subsequently release histamine which causes vasodilation and increased vascular permeability. What this means is that imagine you have a blood vessel that is ‘feeding’ the damaged area of tissue. The endothelial cells that make up the wall of the blood vessel contract and allow for spaces to open up in said blood vessel wall, as well as the blood vessel itself dilates (expand/get bigger). So essentially you end up with a bigger blood vessel that has little spaces/holes in it, thanks to histamine. This results in more blood flow/plasma/proteins to the injured area, resulting in swelling.
OK, so we have established that ‘swelling’ is due to the release of histamine by mast cells in response to tissue damage, which causes vasodilation and vascular permeability and results in increased blood flow to the damaged area. However this effect is strengthened by macrophage cells that secrete cytokines (inflammatory mediators) which have the effect of increasing the processes discussed above as well as triggering tissue repair. Furthermore, these cytokines also cause immigration of neutrophil cells & monocytes to the area via the discussed ‘increased blood flow’ which further assist in tissue repair indirectly.
The above description is why Dr Gabe Mirkin also stated in his blog post that “blood flow is needed for tissue repair”, he also goes on to mention that studies show Insulin Like Growth Factor-1 (IGF-1) is also needed for tissue repair. As IGF-1 is a protein that travels via the blood and has a similar structure to the hormone insulin, it goes without saying that if you apply ice to an injured area and decrease blood flow to said area, IGF-1 will not be able to initiate growth and repair of the damaged cells.
Acupuncture philosophy has stated that ‘ice’ or ‘cold’ is not conducive to health or tissue repair for the last two millennia. As we can see form the paragraphs above, common sense and basic physiology also agrees with this. My question is now why is RICE still being taught and promoted? I was at a first aid course some months ago and RICE was still being taught there as form of therapy that can decrease pain and hasten recovery. Granted, it can decrease pain by essentially ‘freezing’ and numbing the nerve endings, however the pain will dissipate on its own in due time regardless.
My recommendation has always been to those who seek treatment at my acupuncture practice to simply rest & listen to your body. Acupuncture can assist in the healing process by regulating the meridians and strengthening the constitution of the individual. However, the most important thing one can do is Rest! & give the body time to heal…
As always feel free to contact me with any questions you may have.
Warm Regards,
Giancarlo Nerini - Licensed Acupuncturist
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