TO ICE OR NOT TO ICE?
The "to ice or not to ice" debate is one of our favourites in clinic and championed by SPEAR physiotherapist, Isla. We asked Isla to write a blog for us on the subject, sharing some findings and her views on icing an injury to reduce swelling.
"Managing an injury in the acute stage entails trying to promote the bodies’ own healing mechanisms as effectively as possible. The Acronym; Rest, Ice. Compression and Elevation. (R.I.C.E) and its more recent evolution into; Protect, Optimally Load, Ice, Compress and Elevate. (P.O.L.I.C.E) have been used for many years as part of early management for injuries and is widely used today.
National Institute Clinical Evidence (NICE) currently supports that POLICE management is based upon expect opinion as there is insufficient evidence to support it for the management of acute sprains and strains (NICE 2016). And yet it is common practice. Ice is usually used with the intensions of reducing pain and swelling from an injury, but is lacking the evidence to support it.
Ice can be used to reduce pain when applied to the injury site. This is effective when the tissues are cooled below 15 degrees centigrade resulting in decreased speed of noiceceptive nerve signals (feeling of pain), effectively numbing the area. (Algafly and George 2007, Chesterton, Foster and Ross 2002, Nadler, Weingand and Kruse 2004).There is some evidence to support this in acute soft tissue injuries and in post-operative management (Adie, Naylor and Harris 2009., Hubbard and Denegar 2004), but with poor outcomes and further evidence required.
A Randomised Control Trial by Bleakley, McDonough and MacAuley 2004, concluded that there is some evidence available to show that icing and exercise are beneficial to acute soft tissue injuries and post -operative management, but that icing in addition to compression had little significant effect upon swelling and range of motion compared to the effects of compression alone. There is minimal evidence to show that icing alone has an effect on swelling, but the lack of clinical evidence means we rely upon expert opinion.
Gabe Mirkin, M.D, sports Dr who formed RICE in his ‘The Sportsmedicine Book’ 1987, has recently voiced new thoughts on icing. He now believes that icing should not be used as a measure to reduce swelling, and in addition, that it should not be used at all. He discusses that icing does not prevent inflammation and swelling, rather that it delays it. He goes on to say that because of this effect icing could delay heeling times and return to sport but can be used to temporarily reduce pain if the consequences are taken into account. Gary Reinl, Dr. Kelly Starrett and Gabe Mirkin M.D. released a book “Iced!: The Illusionary Treatment Option” in 2013 detailing why they believe, and evidence to support, why not to use ice.
Curently based on the minimal clinical evidence available, icing can be used to reduce pain at the site of injury. Whether this helps reduce swelling due to increased muscle activity because of reduced pain is purely speculation. Only with further strong randomised controlled trials will we know if ice should be used within acute management and rehabilitation of soft tissue injuries and post-operative management."
Adie, S., Naylor, J. and Harris, I., 2009. Cryotherapy following total knee replacement. Cochrane Database Syst Rev, 9.
Algafly, A.A. and George, K.P., 2007. The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. British journal of sports medicine, 41(6), pp.365-369.
Bleakley, C., McDonough, S. and MacAuley, D., 2004. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. The American journal of sports medicine, 32(1), pp.251-261.
Chesterton, L.S., Foster, N.E. and Ross, L., 2002. Skin temperature response to cryotherapy. Archives of physical medicine and rehabilitation, 83(4), pp.543-549.
Gabe Mirkin, M.D., 2015. Why Ice Delays Recovery. http://www.drmirkin.com/fitness/why-ice-delays-recovery.html: Dr. Mirkin.
Hubbard, T.J. and Denegar, C.R., 2004. Does cryotherapy improve outcomes with soft tissue injury?. Journal of athletic training, 39(3), p.278.
Nadler, S.F., Weingand, K. and Kruse, R.J., 2004. The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. Pain physician, 7(3), pp.395-400.
National Institute for Health and Clinical Excellence (2016). Clinical Knowledge summaries: Sprains and Strains. Evidence Service CKS
HYDROTHERAPRY AND WHY IT WORKS
At SPEAR Sports Injury and Physiotherapy we specialise in sports injuries and neurological rehabilitation and have a small team of dedicated and highly specialised experienced physiotherapists who treat and rehabilitate people with neurological conditions.
One of the rehabilitation techniques used at SPEAR physiotherapy is Hydrotherapy - which is literally physiotherapy treatment in water.
We are lucky at SPEAR physiotherapy to have access to the pool at Village gym in Kingswells and Aberdeen Aquatics Centre in the Aberdeen Sports Village. The pool at the Village gym has a slightly warmer temperature than regular swimming pools, has steps to access the pool rather than a ladder and there is also hoisting equipment which can be used when required.
For some of our patients after injury or a neurological diagnosis, rehabilitation in water is the key to leading the highest quality of life and in a rehabilitation / recovery capacity too.
But why is that?
Primarily due to water’s unique properties:
- The fear of falling evaporates in the water for most people, which makes walking and moving in this environment much easier.
- Water buoyancy means that when you are submerged you feel much lighter than when on land, this makes movement less effortful which can result normalising muscle tone.
- Water provides resistance which helps improve strength and core stability and all of that is achieved with a much lower perceived physical exertion when in water.
SPEAR Neurological Physiotherapist, Lesley Kay says:” one of the highlights of using hydrotherapy with a patient was when I was working with a patient who was seven years post stroke and struggled with confidence to walk outdoors. Our goal was to be able to walk around a supermarket and find a hobby she could do to help fill her week! She had enjoyed swimming before her stroke so we tried hydrotherapy at Village gym; for the first few sessions we practised walking in the water and gradually increased fitness levels.”
Lesley continues: “The time spent in the water was enjoyable and beneficial; and it was so rewarding when she was then able to go into the pool with her husband and start enjoying moving in water without a physiotherapist being there! Six months after hydrotherapy started, our patient was able to complete her own shopping at the supermarket without being totally exhausted afterwards, she also went on holiday for the first time and was able to go into the resort swimming pool in the sunshine with her husband - both confident knowing that she was able to safely do! A smile moment for all of us.”
As with any form of physiotherapy and rehabilitation, hydrotherapy doesn't help everyone. A good indicator for this is whether you enjoyed being in water and were comfortable in that environment pre-diagnosis; if yes, there is a good chance it will be of benefit to you! Before going into the water, physiotherapists would always complete a risk assessment and go through all past medical history to check it’s safe option for you.
For more information, please contact us here or email email@example.com #teamSPEAR
PHYSIO BIKEFIT STRETCHING RECOMMENDATIONS
A warm up and cool down is beneficial when doing any form of exercise and cycling is no exception, but having spoken to many of my cyclist patients about this, is seems it is overlooked by many! Even though their chosen hobby/sport means regularly being in one position for long periods of time.
There are many benefits of a warm up, these include:
- Increasing muscle temperature which in turn helps to enhance muscle contraction
- Preparing the body mentally- giving you time to prepare for the session ahead
- Increases the core temperature which increases the speed of nerve impulses in turn increasing reaction time
- Reduces injury risk by releasing adrenaline which helps to increase muscle elasticity
I’d recommend dynamic warm ups as opposed to static stretches before a cycle and for a cyclists this means the best option for a warm up is to do it on the bike! The first 10-15 minutes of your cycle should involve working up through the gears and increasing your cadence, this will help to increase the heart rate and get your legs turning.
Why should you cool down?
- It helps return the body to its pre-exercise state, by aiding in recovery and muscle adaptations
- Helps to prepare the body for the next session, whether that be tomorrow or next week
- Reduces the heart rate gradually while blood continues to circulate the body, which helps to remove waste products from the muscles while bringing oxygen and nutrients to them
- Your body will become stiff after being on the bike in one position for hours, stretching will help to return to normal range of movement
Ideally your cool down would involve 5-10 minutes of stretching as soon as you come off your bike, however we live in Scotland and this isn’t always practical - particularly if you’re coming off the bike cold and wet! In these circumstances, I would advise that once you’re home you have a warm shower and get on dry clothes before you stretch.
The cool down differs from the warm up in that the stretches should be static with holds for each stretch being 20-30 seconds - never into pain just to the point of tension. The main muscles that would benefit from a stretch post-cycle include:
- Thoracic spine
- Lumbar spine
- Hip flexors
The Benefits of Move-Ment
This year, SPEAR Sports Injury and Physiotherapy helped you Move-More in November! It is a common goal for our physiotherapists across all the SPEAR services as we aim to keep you moving and facilitate move(ment) in recovery and rehabilitation. We spoke to SPEAR physiotherapist, James who runs our SPEAR:Run, on the benefits of movement and choosing to move-more.
“Men and women alike can embrace the Move-More-in-November idea (or any month) by merely being active. It’s what we like to call Move. For example, set a distance goal at the start of the month (week / year…), and walk, run, cycle, swim or row your way to achieving it. The benefits of movement are both physical and psychological and in this blog I want to highlight the benefits of running.
- 1 hour of Running = 7 Extra Hours of Life
In a recent study in the Progress in Cardiovascular Diseases they summarised that in general, runners have a 25%-40% reduced risk of premature mortality and live approximately 3 years longer than non-runners.
- 1 Minute of Running a Day to Strengthen your Bones
This remarkable claim looked too good to be true in the recent study in the International Journal of Epidemiology.
Testing indicated that, with this set-up, running at 12:00 per mile pace gives you a jolt equivalent to about 75 percent of the force of gravity, while running at 9:36 mile pace is about 100 percent the force of gravity. These findings aren't too surprising as to stimulate bone growth you need to load through the bone. Running is fantastic for loading and increases bone growth with every step. Controlled loading is important to ensure the bone load is not over its capacity.
- Running IMPROVES joint care
A report in 2013 looked at the common myth that running increases damage to the joint. Where in fact the study showed that runners have 20% lower risk of osteoarthritis and hip replacement than walkers. Furthermore averaging 15-23 miles per week is further beneficial than 8 miles weekly.
- Running reduces stress, Stress reduces regeneration.
Its well known that exercise releases a good hormone in the body called endorphins. These are what relates to the "runners high" that comes after a long run. In a recent interview with Mel Edwards, running legend, he was quoted as saying: "the best I felt in a day was after a session." Furthermore, there is research looking at factors that can slow healing/regeneration after a run and stress contributes to this. It is very important to have a balance between the load and the capacity of the body to accept load, in avoiding injuries - the bodies capacity is therefore reduced by stress. “Doing nature-based physical activity could lower stress and anxiety, while boosting mental well-being” according to research by Edge Hill University, maximising the existing mood-improving qualities of exercise.
These are just four benefits that running has on the body. Running also can be great for a social interaction (JogScotland, Parkrun, Fit Like Joggers, Metro Running Club to name a few Aberdeen local running clubs...). Running in a group or having accountability to another individual increases adherence to a new habit! It's as easy as putting one foot in front.... so what are you waiting for...."
How to start:
1. Pick a number of steps to complete this week (9000 - 10000 steps a day)
2. Download Strava app join the SPEAR:Run Strava group to share your achievement. #teamSPEAR
SPEAR:Run and some of your favourite running apps
With the modernisation of running, there certainly are a lot of apps out there that can help with your training! An app not only helps monitor distance or pace but some of them can map your run, help with motivation, monitor load and over training, build up a network of running buddies or help you venture into the unknown. SPEAR:Run physiotherapist, James took to social media recently and asked the question “what running app do you use”. Here’s a list of the top 10 and a few extras thrown in too!
This app is easily at the top of the list! It’s like Facebook for runners, cyclists, paddle boarders…the list goes on. A great feature of this app is that it keeps a total of your load week on week; you can even set a target distance to hit for the week.
Some other great features from Strava is the ability to monitor the shoe usage (knowing roughly how many miles each shoe has completed), a map view of your run and the segment feature. Over the course of your run there will be segments that are timed and every time you run a route your segment will be compared to your previous runs on the same route; and to others who run the same route! If you have the fastest time, you get a crown – total #runfasterinspo there. Starve also links with most GPS watches, helps with monitoring your runs and also keeps an online diary of your achievements…add James if you wish (James Cruickshank). This gets a full thumbs up from the SPEAR team.
This one is a relatively new discovery from James, it links with your Strava account and gives you a fly by of your run over Google maps. If you take pictures on your run it also embeds the pictures and where you took them onto the map… great if you trail run, run whilst abroad, do a lot of fancy runs…or just normal running!
This app is great for trail running, it is based on the ordnance survey maps that are already out there. You can buy segments of the map, which allow you to plot routes and plan adventures! There are alternative map apps, but this one has pre-loaded runs or hill walks with expected times and guided routes…. it also links well with Google maps and gives spoken directions if required.
In this app you can use it to predict performance in races based on previous race performances taking into account age, fatigue, etc. The accuracy is reduced, similar to taking your 5km time and predicting your marathon time, I believe this has to relate to training ability, training phase and also previous running experience. For those of you that have completed marathons, you will know that the last 6 miles feels like half way… If anything though it does give a good indicator towards a goal time, which of course your training can be linked to!
5. Running Hero’s
With this app you can run your way to free gear or heavily discounted brand names. Again, it links with your Strava account and the more you run the more awards / draw-entering occurs. You can earn anything from 30% off Nike goods, to a complementary Avocado on toast, 40% off SIS gels, 20% off of ADIDAS to name a few.
6. Map My Run
This is another map-based app for planning and running routes. It’s very easy to use and works off the GPS of your phone. A great app for tracking distance and pace of your run!
7. Couch to 5km Runner
This is a go to for anyone that dreams of running but doesn’t know how to catch that dream! The idea is to get you from couch to 5 km in 8 weeks at a sensible and controlled level. There is over 4.2 million success stories off the back of this app – getting healthy, getting fit, basically saving your own life! A great tool, spoken information, information updates and progression which helps you get your goal and there is a 5km to 10km follow-on app too.
Strictly not an app but these are very helpful for achieving the long runs at slow pace for the marathon-runners out there! There is a podcast for everyone, comedy, spoken books, physiotherapy, latest TED talks…the list is endless. A personal favourite for SPEAR physiotherapist, James is the Magic Sponge – a football talk programme sharing stories from the 90’s 00’s (disclaimer: the language is very choice so don’t download if easily offended).
9. Map – o – Meter
This map app shows satellite and hybrid settings to plan your run. It’s great for planning specific distance runs so you can complete training plans without having to run around the block a few times to make up the mileage! Is a little tricky to map out the dots but gives a good distance between plots in either km, mile or feet.
This final app in the list, combines music adjusted to the tempo of the run. It keeps with the speed of your run so your pace doesn’t drop when you get lost in the music. A good feature of the app is the “running story” where an audio book is combined with music to maintain pace and speed whilst listening to a story lasting 30-35mins long (i.e on average, long enough to get between a 5-7 km run.)
The list is definitely not exhaustive and we are always hearing about new apps, if you have a favourite app and it’s not mentioned above, let us know and some of the SPEAR team can download it and try it out.
Side note – since James put out this question out there, other popular apps have come to light such as, Zombie run – an app which goes along with a story line where you get chased by zombies and Run Smash – an app for data for logging runs and everything else data-driven!