Iced: The Illusionary Treatment Option: A Book Review

Image Google “benefits of cryotherapy” and it will yield a plethora of results, ranging from faster recovery to decreased soreness to decreased tissue damage.  If you were to ask a medical doctor, personal trainer, athletic trainer, or even your mom then you would likely get the same answer from each one regarding the benefits of ice – it reduces pain and prevents excess inflammation. But do we want to prevent inflammation?  And what constitutes excessive?

The answer has been accepted by athletes, non-athletes, and medical professionals everywhere.  The rolled ankle of a child playing soccer during recess, to the collegiate tennis player that strained her hamstring chasing down a drop shot, to the professional baseball pitcher that routinely deals with a sore shoulder after 7 intense innings pitched.

Cryotherapy is thought to be the perfect home-remedy because of its ease of access. Over time, physiotherapy companies spawned interest in commercializing ice such that products have been invented to harness and dispense the power of ice to the extreme.   Surely the discovery of ice as a natural healing aid would have went under peer review and standard research protocols before its widespread implementation into sports medicine. Well, the author argues that this is not the case.

Gary Reinl, author of Iced: The Illusionary Treatment Option, adamantly believes that ice’s pervasive use by athletes and injured people everywhere is based on a fallacy.  Gary’s background is in personal training, strength and conditioning, and as a distance runner.  His knowledge of the history, physiology, and practical applications for healing and recovery of the athlete are among the most I’ve ever come across.  We met at the USPTA Tennis World Conference in Orlando in September 2013 where I was a speaking on Kinesiology Taping for Performance and Injury Prevention as the Tennis Director for RockTape.  I recognized him from the video below, which is when my curiosity for understanding ice as a clinical treatment option was set on fire.

We’ve got to stop icing people.  We were wrong. Soooo wrong. Image

Author Bio

Gary consults with the athletic training staff for every team in the MLB, NBA, NFL, and NHL.  His influence has reached Olympic athletes, their trainers, and collegiate training rooms.  While his network is quite prestigious – it’s a small, tight-knit group.  He wrote this book because he figured that it was about time that his message should heard by the weekend warriors of the world, the non-athletes, and the non-medical professionals.

Lay people often take the word of their doctors because it is logical to defer to an expert’s opinion; however, most doctors make recommendations to ice after an acute injury or to help with pain or swelling without even knowing the physiological effects that ice has on the body.  Gary believed that dropping a knowledge bomb on the world would help people make a more informed decision regarding ice application.

Book Synopsis

Without completely stealing the book’s thunder, I want to highlight some key pieces of the book that should spark your curiosity enough to make you want to pick it up for yourself.   It’s less than 200 pages and has plenty of stories to entertain you while your mind is blown by the reviews of current scientific literature and digestible explanations of human physiology.

History of Icing

In the late 60s, there was a young boy who somehow managed to sever his arm on a railroad track.  He arrived at an emergency room with his dismembered limb.  Never before had a re-attachment surgery been performed.  With the tissues of his arm rapidly decaying, the doctors thought to put the limb on ice to preserve it.  If refrigerators can increase the shelf-life of meats, then freezers should preserve it for even longer.  Their logic was sound, and is still used to this day.  If you cut off a finger, put it in a bag of ice to slow down coagulation and scarring of the torn blood vessels – you want them to be open so the doctors can surgically reattach it.

The surgery for the boy was a complete success.  He eventually regained functionality in the use of his limb.  Amazing!  The story made national news but the story was too garbled up with technical jargon concerning the tissue reattachment surgery.  So the reporters choice a piece that people could grasp – the bottom line was that if you ever sever a limb, put it in an ice bag.

Over time, a logical leap was made, where if you simply got injured, you were recommended to put ice on it.  No research, no peer-review.  In fact, Gary argues that if ice was a controlled substance like any pharmacologic drug on the market today, it would not be able to satisfy requirements for FDA approval.  No research showing it’s effectiveness, no clear treatment guidelines for treatment times depending on varying tissue thickness, and lack of safety (frostbite/delayed healing response time/delayed nutrient delivery).

Try Pubmed or other publication databases and see what you can find – I searched and came up short on finding relevant articles showing the benefits of ice for acute soft-tissue injuries.  If they exist I would love to read them so that I can incorporate ice into clinical treatments effectively.

Contemporary Research

“Topical cooling (icing) delays recovery from eccentric exercise-induced muscle damage.”

–  Journal of Strength and Conditioning Research (2013)

This study found that after exercise people who were given ice compared to not showed increased levels of creatine kinase, an indicator of soft-tissue damage.  Subjects also reported a higher level of fatigue 72 hours post exercise of the iced tissues compared to the non-ice controls.  The findings make sense when you assume that an injured tissue, delayed in it’s recovery from ice, would feel more fatigued than those that were not subjected to the freeze.

Gary sites research in the book that showed icing actually increases the amount of fluid build-up in the damaged area by creating a backflow from the lymphatic vessels. Lymph vessels work as a negative pressure system.  Imagine a balloon filled with air.  If you open the end of a full balloon, then air will rush out.  It’s operating on a pressure gradient – the air moves from high to low.  When fluid is built up in the body, like after an acute ankle sprain, it is a high pressure area.  The fluid is pushed through the lymphatic vessels by compression, either from an outside force (massage, compression sleeves, Graston tools) or from intrinsic muscle contraction.

The lymph vessels are split into small chambers.  As a chamber is filled with fluid, the gates open to the next chamber, which pushes it along the pressure gradient. Icing has been shown to open the gates of the lymph vessels, which can allow for the fluid to back-up, moving towards the injured area versus being pushed away from the injury site, towards the heart where it can be detoxed through the liver/kidney/spleen.  It’s like a salmon swimming upstream instead of traveling with the current.  Ultimately, the time it takes for the fluid to clear if the gates are open and there is a backflow of fluid is increased (obviously not good).

Basic Physiology of Inflammation

“Icing does not prevent the inflammatory cascade, it merely delays it.”

Inflammation is phase one of a three step process of tissue healing.

1) Inflammation (3-5 days) – clean up crew and emergency response team assesses damage, moves debris, and fights potential invaders

2) Repair (4-6 weeks) – collagen cross-linkages are delivered to reconnect torn tissues

3) Remodel (up to 6 months and likely on-going for forever) – Tissues require loading and adaptation through corrective exercises/stretching to regain peak function. We already covered the fact that ice can help delay the effects of inflammation when applied to a severed limb.

The exact reason why you want to ice the pinky finger you chopped off trying to mince onions is why you don’t want to ice a tissue still attached to your body.  It needs inflammation to initiate healing!  You (fortunately) cannot stop this process.  Since you cannot leave the bag of peas on forever, once you take it off your body will continue on with its job of healing you through the inflammatory cascade.  The temporary benefit of nerve sedation so that you feel less pain does not outweigh the cost that ice has on the delayed healing process and increased lymphedema.

Acute soft-tissue injury is a unique situation where our body vitally needs to undergo the inflammatory response.  There can be inflammation without healing but there cannot be healing without inflammation.  Swelling and inflammation are not synonymous.  The former is necessary and vital for healing and latter is a deleterious effect of an injury.

Do you actually think that the body’s innate response to acute injury would be incorrect or faulty such that extreme changes in temperature are needed to regulate the process better?  Sedating nerves to feel less pain can even be dangerous when you consider the fact that the brain is communicating with you when you perceive pain.  It’s telling you to stop putting pressure or moving the injured tissue as vigorously as you normally would – the tissue can’t handle the stress.  You’re going to make it worse if you push it.  Listen to your senses and stop aggravating the injured tissue while it heals!

Injuries need time to heal, and if you progress through the following rehab protocols under a doctor’s supervision, you will likely recover well.

1) Attain joint alignment/improved joint motion (Get adjusted by a Chiropractor or placed in a cast in the case of a fracture under the care of an Orthopedist) –>

2) Increase soft tissue mobility/range of motion (Get myofasical release like ART, Graston Technique, VooDoo Floss and complement with self-myofascial release daily with a foam roller, lacrosse ball, golf ball, RockBallz, or the Stick, and dynamically stretch immediately afterwards –>

3) Stabilize/activate muscles surrounding the affected joint (corrective, postural, and/or balance/proprioceptive exercises)

This should help you achieve the fastest return to activity possible.  Don’t skip steps – Earn your progression!


Alternative to Ice:  Movement and The Marc Pro

Dr. Kelly Starett has popularized the revamping of the RICE protocol into the MCE protocol.  Rest and ice have not been found to be important factors for improving recovery times from injury.  They have been replaced by Movement/Muscle Activation.  Sometimes movement is painful, so only small, pain-free ranges of movements should be performed.  If drawing ankle circles is too difficult, then start by wiggling your toes.  That’s still better than nothing when it comes to regaining function to an injured tissue.

When you literally can’t move yourself, like when you’re stuck in a the confined space of a car or plane, or you are just so sore after an intense game/competition/work-out, you still need your muscles to squeeze around your lymph vessels to pump all the metabolic waste products (garbage) out of your system.

The Marc Pro is designed to rid the body of the metabolic waste that lingers in our interstitial spaces.  Letting it linger would be like letting the exhaust of our car emit directly into the car where it would stay trapped if the windows were closed.  Waste needs to get cleared.  Open the windows = shuttle the waste products back towards the heart via the vein/lymph vessels.

In no way is the Marc Pro actually “treating” an injury – it’s simply creating a pump by passively contracting muscles in order to shuttle the fluid build-up out of it’s current location. To use the device, hook yourself up to the electrodes like a regular e-stim unit. Place the pads above and below the swollen or sore areas of the body, then turn up the intensity to as high as you can tolerate.  Leave it on for a minimum of 30 minutes.   The longer you leave it on, the more dramatic of an effect it will have (up to ~8 hours at a time is doable, but 30-60 minutes is the typical therapeutic dose).  The longer the time treated, the more pump effect you get.

Movement in general and utilizing the Marc Pro are likely the most effective ways to activate muscles to physically force lingering metabolic waste products (swelling/edema) through lymphatic vessels.  The pain that was due to pressure on the nerves from the swelling should go away once the fluid has cleared.  Assuming you have good plumbing (working circulatory system) it should be a rather simple solution.

Practical Application Take Away Message: Image

Gary recommends that we all stop using ice for post-injury treatment and soreness.  Inflammation is your friend post-injury and needs to happen.  You can’t stop it, it can only be delayed.  If you are experiencing pain after an injury, consider applying a topical analgesic like Rock Sauce to numb your sensory nerve endings.  Follow the MCE protocol instead of RICE.  If you don’t know how to treat and manage an injury, visit a Sports Chiropractor, Doctor of Physical Therapy, or Sports Medicine Physician that has experience helping people just like you.

Ice still has practical uses, which include: chilling beverages, slowing the metabolic rate during open-heart surgery, and preventing healing of a severed appendage so that the neurovascular bundles will still be viable when they are surgically reattached.

Paradigms change.  Don’t be afraid to challenge antiquated assumptions of sports medicine under the supervision of an experienced medical expert.  A no-ice regimen might just get you back in action faster than you would have otherwise.

Read Some Research:

Topical cooling (icing) delays recovery from eccentric exercise-induced muscle damage.

Cooling an acute muscle injury: can basic scientific theory translate into the clinical setting?

Is ice right? Does cryotherapy improve outcome for acute soft tissue injury?

Watch Some Videos:

We’ve Got to Stop Icing People.  We Were Wrong. Soooo Wrong.

People, We’ve Got To Stop Icing – A Year Later

Demonstration of the Marc Pro

More Articles to Check Out

Stillness is the Enemy

Ice Delays Recovery From Injuries

Stanford Researchers’ Cooling Glove ‘Better Than Steroids’ – and Helps Solve Physiological Mystery

@DrChrisBakerDC | Sports Chiropractor
ART/Graston/PTR Certified
RockTape Tennis Director

Premiere Spine & Sport
4982 Cherry Ave. San Jose, CA 95118
(408) 448-4445 (office) | (408) 448-4447 (fax)

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