In last week’s blog post we discussed that icing and following the RICE (rest, ice, elevation, and compression) protocol, while wildly popular, is not the best way to treat the pain and inflammation of an acute injury. Icing or following RICE is very effective at providing pain relief; however, it is likely delaying your recovery.

So, what should you do?

To recover the fastest from acute injuries, it turns out an active recovery is the answer.

So out with RICE and in with the MEAT! (Sorry vegetarians and vegans.)

MEAT stands for Movement, Exercise, Analgesia, and Treatment. It has been proposed as the optimal approach for managing acute injuries. 1

So, lets break MEAT down like a low and slow smoked brisket…

Movement:

There’s a couple saying from the NOI group—“movement is medicine” and “motion is lotion”. Instead of resting an injury, moving the damaged area through a full range of motion that is pain free. First gentle movement generates a muscle contraction, this a propulsive force necessary to move lymph (swelling) throughout the body. The lymphatic system largely mirrors the circulatory system; however, it does not have an active pump (the heart) to move fluid. It is passive and relies on contraction of the muscles or “muscle pumps” to function normally. When you’re fully resting an area there’s no muscle pump and swelling more readily accumulates. Another benefit to movement, the pain-free movement (and later exercise) does some interesting things with the nervous system which decreases pain and the perceived threat surround the injury. Basically, the more you move it in a pain-free manner the better you’re going to feel, and the more you expect it to feel better… which makes you feel better. It’s a nice positive feed back loop!

Exercise:

Gentle exercises should be the next progress. It increases circulation to the area. More blood equals more oxygen and nutrients to the injured tissue. That equates to faster recovery. Additionally, movement and exercises introduce a gentle amount of stress into the injured tissues. That stress or load, helps trigger new tissue grow and ensure the new tissues are formed in an organized manner, increasing their strength along the direction of tension. That equates to a better recovery. A recent study on amateur athletes with severe muscle injuries found that those who started early therapeutic exercises (2 days after injury) recovered on average 3 weeks faster than those who vs delayed exercise (9 days after injury). 2

Analgesia:

Analgesia is a fancy word for pain relief. Pain limits one’s ability to efficiently move an injured area through a full range of motion or engage in exercise, so addressing pain to allow as much movement as possible is key. Pharmacologically, NSAIDs (nonsteroidal anti-inflammatory drugs) like Ibuprofen, Aleve or Advil, are commonly taken for pain management. But NSAIDS alone do not expedite recovery and could be delaying it as they—by name-- disrupt the inflammation which is part of the body’s natural healing process. Tylenol is also commonly used. Tylenol is not an NSAID and will not disrupt prostaglandin synthesis; however, Tylenol and the liver do not play nice with one another. Additionally, both Tylenol and NSAIDS can cause gastrointestinal issues even if taken as recommended. Therefore, it is always a good idea to discuss medication use with your physician! But pain relief comes in many other forms. Topical analgesics like biofreeze, Ben Gay, Tiger Balm, etc), massage therapy, and the application of heat are other good options for temporarily decreasing pain to allow you to better move an injured area and participation in exercise.

Treatment. This is a broad category that consists of treating the individual injury using a variety of therapeutic approaches—e.g. physical therapy. Specific prescribed therapeutic exercise and activities are the cornerstones of treatment for acute injury. And there’s a myriad of complementary therapeutic interventions which relieve the pain of acute injuries, augment the therapeutic exercises, and expedite recovery: soft tissue mobilization, joint mobilization or manipulation, dry needling, electrical stimulation, H-Wave NMES, and blood flow restriction rehabilitation.

We’ll talk more about those in the coming weeks! But if you’d like to know more just give me a call at 231-881-9770!

So MEAT in summary is: do what you can to decrease the pain (but not ice), so you can begin moving the injured area as much as possible without causing pain, then begin exercises and therapy ASAP!

References:

1. Campbell, Ryan. (2013, December) Goodmed Direct Primary Care. Retrieved from https://goodmedclinic.com.

2. (PDF) Early versus Delayed Rehabilitation after Acute Muscle Injury (researchgate.net)

A recent trip from a family member to the doctor’s office and being told to rest, ice, compress and elevate the injury prompted this blog post…

Should I Ice It?

It is one of the most frequently asked questions I’m asked at Optimum DPT. A summertime hot take…

No.

But that’s heresy you charlatan! When I tweak something, I ice it. Like my father before me and his father before him!

Roll an ankle: Ice it.

Tweak your back: Ice it.

Pull a hammy: Ice it.

Yes, we’re icing folk round these parts and you’re kind isn’t welcome round here!

Hey, I get it. Icing a new injury was still gospel when I was in undergrad studying to be an athletic trainer and later physical therapy school (1999-2007). (Geez time flies.) And, if you or someone you know has played sports in the past 60 years, you’ve likely heard from every physician, therapist, trainer, and coach that icing all injuries is the way to go. You may have even heard of the acronym RICE--Rest, Ice, Compression, Elevation-- is the best thing you can do for your injury.

But why is that?

Well studies from early 1940’s describe that surgeons would use ice to help control pain, lower infection rates, decrease the rate of dying on the operating table.1 This is because ice slows down cellular metabolism, and this allows surgeons to keep as much tissue alive as possible. While ice was intended to preserve lost limbs and decrease surgical complications, it would eventually sneak its way into being used for all injuries.

The key moment for this happened in 1962 when a 12-year-old boy was playing on some train tracks. (That never ends well.) He zigged when he should have zagged, and he lost an arm. But then, for the first time in history, surgeons successfully reattach a whole limb. To preserve the boy’s arm a lot of ice was used.2

This a was major medical milestone, and news story of the successful operation spread. People had lots of questions. Medical jargon answers are hard to remember, but that doctors “iced” the boy’s injured tissue was easy to recall. Public’s take away: any injury needs a good icing. Seems legit. That logic combined with the fact that icing does provide significant pain relief was the foundation for our “ice every injury” mentality.

Fast forward a little more than a decade to 1978. Harvard physician Dr. Gabe Mirkin published the “Sportsmedicine Book” and in created the acronym “RICE” (Rest, Ice, Compression, and Elevation) which was considered the gold standard initial four activities for treating the pain and inflammation of an acute trauma. RICE cemented the concept that icing is THE WAY to go to treat the pain and swelling of a new injury.3

As I said in 2007 icing and RICE was still considered the gold standard… but is it today?

No, we’ve cooled on icing injures (but not on bad puns). And, more come to accept that inflammation isn’t necessarily bad.4

In 2013, Gary Reinl published “Iced! The Illusionary Treatment Option.” In which refuted the RICE protocol, citing numerous research that icing-- while it feels good-- is certainly not beneficial and likely detrimental to a person’s recovery. “It’s actually the worst thing you can do.”

Evidence suggests that icing will:

Prevent the natural flow of oxygen and nutrients via blood circulation.
Trap metabolic waste in and around the injured area.
Potentially cause additional damage to tissues and nerves.
May delay recovery

For most people in pain, anything that takes away the pain (even temporarily) can feel like it’s helping. Since icing can very effectively numb pain, many may think that it too is helping. But in reality, it’s just putting a band-aid on the pain, it’s not actually fixing anything.” 5

Reinl’s argument and supporting evidence was so strong that in 2015 Dr. Mirkin recanted his position and advised people to abandon the RICE protocol he coined.

“Subsequent research shows that rest and ice can actually delay recovery. … the application of cold suppresses the immune responses that start and hasten recovery. Icing does help suppress pain, but athletes are usually far more interested in returning as quickly as possible to the playing field. So, today, RICE is not the preferred treatment for an acute athletic injury.” Reinl, G. (2013). Iced! The Illusionary Treatment Option, 2nd ed. United States of America: G. Reinl

Well, shoot. Now what?

Find out in the next post!

References

1. Massie FM. Refrigeration anesthesia for amputation. Annals of Surgery. 1946;123(5):937-947

2. May 23, 1962: Give That Kid a Hand! | WIRED

3. The R.I.C.E Protocol is a MYTH: A Review and Recommendations – The Sport Journal

4. The Use of Ice For Inflammation: A Prehistoric Approach That Should Be Discontinued

5. An Interview with Dr. Kelly Starrett and Gary Reinl