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use of cold in acute injuries

I have read that some people argue that cold is not beneficial to use in acute injuries because it causes alterations in the recovery of injured tissues. This is true?

myriam maya

5 months ago

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Prof Alison Hoens
Prof Alison Hoens

Good morning. Yes, this is a 'hot' topic. I was interviewed recently with a number of colleagues regarding this topic (Sports Medicine Experts Move On with Evidence-Based Advice. http://vancouversun.com/news/local-news/sports-medicine-experts-move-on-with-evidence-based-advice). Take home message: it isn't about NOT icing - it is about icing at the right dose at the right time for the right reason. Icing has been shown to reduce pain ( Algalfy & George, 2007, Herrera et al, 2010) but not to assist with clotting (managed by platelets) and not to reduce 'swelling' that already exists. It is best used early in the inflammatory cycle (first 48 hours) to reduce the metabolism of the cells (Merrick, 1999) which have not been damaged so that they are not secondarily damaged from the 'toxic debris' of the cells that were injured in the initial injury. More importantly, it reduces the activity of neutrophils which also exacerbate inflammation (Puntel et al, 2013). Bottom line: Too much ice is bad but too much inflammation is also bad. Here are some refs: Decreased cellular metabolism Merrick et al 1999, Osterman et al, 1984, Sapega et al 1988; Altered white cell activity within the vasculature Sapega et al 1988, Lee et al 2005, Schaser et al 2006, Schaser et al 2007, Westermann et al 1999; Reduced muscle necrosis Schaser et al, 2007; Reduced apoptosis Westermann et al 1999; Prolonged cryotherapy – effects after soft tissue injury (Schaser et al, 2007); Is Ice Right? (Collins, 2007) I hope this helps.

Prof Alison Hoens
Prof Alison Hoens

Good morning. Yes, this is a 'hot' topic. I was interviewed recently with a number of colleagues regarding this topic (Sports Medicine Experts Move On with Evidence-Based Advice. http://vancouversun.com/news/local-news/sports-medicine-experts-move-on-with-evidence-based-advice). Take home message: it isn't about NOT icing - it is about icing at the right dose at the right time for the right reason. Icing has been shown to reduce pain ( Algalfy & George, 2007, Herrera et al, 2010) but not to assist with clotting (managed by platelets) and not to reduce 'swelling' that already exists. It is best used early in the inflammatory cycle (first 48 hours) to reduce the metabolism of the cells (Merrick, 1999) which have not been damaged so that they are not secondarily damaged from the 'toxic debris' of the cells that were injured in the initial injury. More importantly, it reduces the activity of neutrophils which also exacerbate inflammation (Puntel et al, 2013). Bottom line: Too much ice is bad but too much inflammation is also bad. Here are some refs: Decreased cellular metabolism Merrick et al 1999, Osterman et al, 1984, Sapega et al 1988; Altered white cell activity within the vasculature Sapega et al 1988, Lee et al 2005, Schaser et al 2006, Schaser et al 2007, Westermann et al 1999; Reduced muscle necrosis Schaser et al, 2007; Reduced apoptosis Westermann et al 1999; Prolonged cryotherapy – effects after soft tissue injury (Schaser et al, 2007); Is Ice Right? (Collins, 2007) I hope this helps.

L.Laakso335
L.Laakso335

Hi Myriam. Yes, it’s contentious and the response will depend on who you talk to and what evidence they’ve accessed. First principles first: The physiotherapist’s role is to optimise the environment in which healing and repair is taking place, and to limit the deleterious effects of excessive bleeding and oedema as a first aid response. As I’m sitting on a train right now I can only give you a brief response to your question about cooling without references; and some of the advice is predicated on the fact that Research in to the effects of ice in humans has been done mostly in “normals”:

  • it depends on a number of factors including length of time of application, place of (anatomical) application, how deep injury is and how soon after injury the ice is applied;
  • most would agree that early application asap after injury is desirable (to reduce bleeding and oedema via vasoconstriction);
  • know that the body’s Hunting Response will result in reflex vasodilation (which is undesirable in acute injury) after initial vasoconstriction if ice is applied for lengthy periods or on areas of body susceptible to this effect (such as face).

As I recall, the latest evidence suggests that ice is best applied for probably 20-30 minutes at a time and only during the first few hours after injury with the main aim being to reduce excessive reactive bleeding and swelling which might limit the “normal” inflammatory reaction. If you think about it, after the initial few hours after injury, the body will have sent its own cellular and molecular cavalry in to commence tissue healing and initiate the repair processes related to vascular injury and to stop bleeding. If the normal inflammatory response is occurring, healing should progress normally thereafter. So from a Clinical reasoning perspective, it’s about understanding what is happening as part of the inflammatory reaction, what underlying co-morbidities might be interfering with that response in any given individual, and what we know about the physiological effects of applying ice. Not that simple really, is it! I’m sure others will be keen to comment.

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