[00:00:03] Nick: Inflammatory processes is productive. You need it. So do we want to mitigate that? Not significantly. Could we curb it a little bit? Maybe. But, do we want to stop it? No, we do not. So in that context, ice is not the best.
[00:00:29] PODCAST INTRO: Welcome to “In The RACK” podcast, where we provide you with the practical framework for breaking PRs in all facets of health and wellness. We are just a couple of bros giving you the simple house in a world of complex wants. No filters, no scripts, no rules, just straight talk, talk tune. Now, let's get into the rack with your hosts, Dr. Chad and Dr. Nick.
[00:00:55] Chad: Alright, everyone. Welcome to Episode 09, “In The RACK” podcast. I'm your host, Chad. And with me is my co-host and fellow physical therapist, Nick. Today, we're going to continue on with those PT misconceptions. It wasn't the last episode but the episode before that, I believe we did talk a little bit about arthritis and tendonitis and all that kind of debunked a little bit of the stuff going on there. And now we're going to talk about that great old debate of ice. Is ice good or is it bad? That's the big question mark. Seems like we are still pretty mixed on the question of whether or not we should be icing after our injuries. So we're here to kind of bust that today and see if we can kind of put some closure on this. Let's talk about the facts that can allow you to decide how you feel about the ice and the role that plays in our healing. I've been practicing for 10 to 12 years, and I've seen this change so many times. But now I feel like I'm on the right side of the ball. So Nick, is it good advice that ice following an injury?
[00:02:05] Nick: I wish I could give just a “Yes” or “No” answer here. It is probably not as good as we once thought. And we'll get more into that. But basically, we've probably overdone it a little bit with ice. So are there situations that don't need ice? Yeah, we probably don't need to ice immediately after an injury like we think we do. Are there other situations where you get ice and it's gonna provide you some benefit later on. And then there's other situations where it's really not going to provide anything, it just might make you think you're hoping. But anyway, the whole ice thing we mentioned a couple episodes ago, where with the RICE method gave marking develop that couple of decades ago, and that was not the first time in history that we had seen ice be used for injuries and inflammation and things like that there's periods of time throughout history where they have evidence that it was used for things and maybe that has to do with the fact that when something is swollen and join or part of the body is swollen, it doesn't look good. It just looks like what we need to fix that. But what we're going to talk about a little bit today is that inflammation is actually really important to not only healing but recovering your body from certain things that it undergoes throughout days, weeks months. And in inflammatory processes is a protective mechanism. We need it. So do we want to mitigate that? Not significantly. Could we curb it a little bit? Maybe. But, do we want to stop it? No, we do not. So in that context, ice is not the best. But there are other things that we'll talk about that ice can be super helpful for. One of which is reducing pain and discomfort that comes along with an injury or pain. So there's plenty of research to show us that that ice can decrease pain. It just numbs the area. That's essentially what it does. And because of the way we've been conditioned to think that ice is helpful, there's usually very high compliance rates with ice. So it's easy for a practitioner to say, “Oh, just throw some ice on this because people will do it”. And it can help with the pain but if it's a situation where now it's helping with the pain, but it's also decreasing the inflammatory process. We're actually going to delay healing. And Gabe Mirkin actually came out and said, “My method that I developed a couple of decades ago was not right, because it actually delays healing”. So when the person who develops the method says I was wrong, because we're actually causing more harm than good. We should probably listen to him. So in that situation, acute injuries, injuries that just happened recently. We probably don't want to be using ice. We'll talk about more chronic situations later on. But overall, the ice for the injury that happened today, yesterday, couple days ago postoperatively those types of things, probably not the best.
[00:05:12] Chad: And just too kind of go back on the whole RICE thing, because I know that that's a pretty popular acronym. But even if we did take out the rest and the ice, because in a previous podcast, we did talk about the importance of movement as another acronym, an acronym in and I think that's still important. We're left with CE which is compression and elevation. And I think those are both still important concepts to an end and treatment practices. But I'm also going to add that there's no evidence that ice and compression didn't improve healing over just the use of compression alone. So that goes to show you that there really is no additional benefit of adding the ice with reducing inflammation if that's your goal. Now, do we recommend the compression elevation of acute injuries after sustaining a low to moderate injury? I don't know. I would say that it's still important that we should apply a little bit of elevation, if you want to use the compression, I think it's helpful. But the research is now showing that the ice is probably not the best bet in terms of that. In the clinic, we do use forms of compression. And we will say that, we've done a lots of something that's called flossing. So flossing is the use of a band that we actually wrapped around a limb, whether it's an ankle or an elbow, or whatever. And we're basically using that compression to improve certain movement patterns. So we're actually improving mobility with the use of movement patterns with the compression, because not only does it give that sense of stability, but it also probably has an analgesic effect as well. So that's the importance that we use the compression in the clinic, as well as with movements. So again, ice is not probably the best solution following an injury, there are definitely other things you can be doing for sure.
[00:06:56] Nick: And it really, like I said before, comes down to the inflammatory process, so the ice is going to slow that inflammatory process down. And when we do that, we slow down that protective response. What the inflammation is doing, essentially, just to simplify it, it's sending healing factors and other good things inside the body to the area. So those things can now get rid of the bad stuff that was caused by the injury. So if you get injured, say you have damaged tissue, we need to get that stuff out. So that's what the body does the inflammatory process is sends all this good stuff, the healing factors to get rid of the bad stuff. And that's in a simplified way, just inflammation. And if you put ice on something, it's going to slow down the mobilization of those, those healing factors and not let them get into the area as quickly as they could. So now we've just delayed the healing process. One of those factors is what's called insulin like growth factor. And that has been shown to be decreased substantially in studies when we ice after an injury. And when we have less of that insulin growth factor, the rebuilding process of the cells and the tissues cannot occur. So there's actually, I think, one study that was done, it was done on mice. But they somehow they did this study, so they removed all of the insulin like growth factor from one group of mice. And they actually didn't heal at all from the injury that they had. So without any insulin, like growth factor, can't heal. If we decrease it to the area, it's not gonna heal. So we're just delaying that process. So think about something postoperatively. We want healing to happen right away, as soon as whatever's done in the OR is done, we need to initiate that healing process right away. And if we're told we leave and we're told that ice 15, 20, 30 whatever it is, and then off for 15, 20, 30 minutes, we're just in this constant battle of the body trying to get this stuff in, then it can't, then it tries to get this stuff in, and then it can't. So we're fighting ourselves. So in those situations, probably best to use some gentle movement, maybe a little light compression to curb any excessive inflammation. Because excessive inflammation probably isn't ideal, because now you start to press on nerves, other blood vessels, that kind of stuff, so not the best. But what really, I think needs to happen is we need to look at this whole ice and inflammation issue on both a macro and a micro level. So normally we just look at say, “You sprained your ankle”. You look at the ankle, and you say “Oh my gosh, that's a balloon. We got to fix that. That doesn't look good.” So you're just thinking of that on the macro level. But don't forget what's happening on the micro level inside in the cells. That swelling up like a balloon because we're getting all that good stuff into the area to help with the healing. So we have to let that occur, at least to some extent. We can't just try to mitigate it altogether. We need to work with it, keep that joint moving. So we can help flush some of that fluid out. And if it looks excessive, then let's try maybe a little compression first, maybe some elevation so we can curb that. But ice isn't the first thing to turn to. Because it's really just going to constrict those blood vessels and keep that stuff from getting in there.
[00:10:22] Chad: And, like Nick said, I mean just to kind of recap on the IGF-1 that's vital for injured parts to heal, whether it's muscle tissue, whether it's tendons, whether it's fractures, we all need to release this IGF-1 in order to create this healing process in the body. Now, going a step further, for all of you people out there that are familiar with what IGF-1 is, you're like, “Well, that's what people use to make gains in the gym.” Like, that's what we're looking for at the end of our workout that's exactly right. So, as most bodybuilders know the gains come after the workout or anybody in general, it's just an athlete. So why is this so important in in our recovery process? Well, it's important because if you're applying ice, let's say you have a shoulder that sore, and you just worked out and you start throwing ice all over your body mainly the shoulder. Now, all of a sudden, you're reducing the release of this IGF-1 which means that now you're not going to get this great repair this damage muscle tissue that you just spent so hard damaging to get these gains. So you're actually kind of wasting your time in terms of that respect. Now to go a step further, anything that's going to reduce your immune response i.e. inflammation is also going to delay the muscle healing. Now this could be cortisone. NSAIDs like ibuprofen, Aleve, whatever you're taking as well as arthritis medication Celebrex, whatever's in your, your kitchen cabinet? So make sure that if you are going to take that don't take it before after your workout, this includes the ice as well, because now all you're doing is affecting the release of that IGF-1, which means that you're not going to get the most benefit out of the free workout that you had.
[00:12:11] Nick: And realistically, when that stuff happens, I don't know, I feel like we are so deterred from feeling any kind of discomfort that we just turned to that stuff right away. So we always have to be our own investigator there and see is this hurting because I just did some hard work with it. The tissues just turning over, there was some micro damage, and now the body is sending a small inflammatory process to the area to now build that back up. We need to kind of take a step back and see is this just something that's not going to last very long, it's just a couple minutes, couple hours, whatever the case is, I can get through this as opposed to as soon as you feel the onset of discomfort just reaching in that medicine cabinet for the medicine or the freezer for the ice.
[00:12:58] Chad: Or even permitted. So people that are like, “Oh man, I'm gonna take this ibuprofen right now. Because I know, that bother me today's day or whatever”.
[00:13:06] Nick: It's so true. And that's some of it's a cultural thing. Like, we need to fight that that free conception that preconceived notion that, “Oh man, this is hurting. I need to do this, because this is what I've been taught, or this is how I've always done it”. So it's actually could be hurting you using something like ice after an incident like that. Or even like, Chad, was saying some of those medications, were just physical therapists, we're not saying don't take these medications, we're just saying, think about the time you're using it. So think about everything as a whole, the big picture, not just “Oh, this hurts. I need to take this or this is swollen, I need to take this”. So basically, if you look at a summary of all the evidence, there's really not much research to support that ace will help heal your injury. Contrary to what we may have been taught, or the way we tend to think about injuries, it's actually going to hurt it's going to slow it down that vasoconstriction that I mentioned, that constricting of blood vessels has actually been shown to last, not only hours after the use of ice in some people that can actually last up to a day or two. So if you use ice say for 20, 30 minutes after an injury or even a workout, it can actually impact the healing or the gains the growth from that up to 24 to 48 hours afterwards. We don't want that, that's no good. So and that's not to say that, if you use ice, it's going to your injury is going to linger that much longer. No, it just has the potential to so we don't want to do anything that's going to impede the progress. We just we want the body to do what the body wants to do. The other thing that you mentioned about the gains, so ISS are also been shown to impair strength, speed coordination and cardiovascular endurance in the short term. That is, again a variety of differences among people. But that basically speaks to, “Let's probably not use ice around either a sporting event, a training session”. If you use a say, after a game practice anything like that, if you're an athlete to say that's just your norm, that's your ritual, so to speak. If you do that, for sore joints, something like that, probably not the best isn't going to impede you that that much, probably not. But maybe rethink about when you're using the ice, maybe if you're sore, say in the morning, because you're in the heat of your season. Maybe use the ice in the morning practices in the afternoon, you have plenty of time for the body to decrease that pain in the morning, decrease that soreness, you can get moving, get the blood flow and all that good stuff after practice, probably not the optimal time. If you do it, and you've always done it, keep doing it. You're okay, you’re not going to destroy anything, and you’re not going to hinder anything. But rethink, maybe just take a step back and think why am I doing this? What's my goal here? And if my goal is to decrease pain, it does do that. But if your goal is something else, if you think it's helping you with healing, just take a step back, rethink that process, rethink why you're doing everything, what your goals are and maybe that's not the best time for you to use it. And towards the end of this episode, we're going to talk a little bit more about cold exposure, so that cold touch cryotherapy, that kind of stuff. But we'll save that for the end, we'll get into a few other things we want to talk to about chronic injuries, because we've been mentioning mostly acute injuries. So injuries that just occurred recently, whether it was today, yesterday, a couple days ago, postoperatively, that kind of stuff. So more with chronic injuries, save and dealing with pain for an extended period of time, that is a situation that now the ice becomes more reasonable, because now your chronic pain likely isn't associated with any kind of tissue damage. So we're not curving that. And in a lot of these chronic injuries, where we think there's inflammation, a lot of times there's actually not. There might be cellular changes going on but they're not necessarily indicative of inflammation. So you're not curving that issue. And there needs to be more research on this, just like anything else. But if you're using ice for more chronic pain, it's more okay I would say, because now you are using it to curb that discomfort in the pain more so than delaying the healing. So that is a situation where it's more okay. If you've been doing that, and it works really well for you? Go for it. If you have chronic pain that you've never tried ice before, do you need it? No, not at all. It's not going to be the thing that helps you over the hump necessarily. But if you've been doing it, don't worry, don't stress out about it. It's not curving the inflammation nearly as much as it would if you were to have an acute injury earlier today.
[00:18:02] Chad: And I want people to understand that there's a difference between reducing inflammation and analgesic effect or that decrease in pain that you're feeling with the use of ice, just because you're feeling less pain doesn't actually mean the inflammation is going down just means that you're creating the stimulus on the surface. So I want people to understand that, if you are done with playing a sport and you jump in an ice cold bath, your odds are your whole body's just so much of a stimulus right now, because you're just applying this cold exposure we're gonna be talking about soon, but that not necessarily decreasing inflammation, it's just this body going through this stimulus of cold. And now you're just getting this like full body analgesic effect. So I just want people to understand that there is a difference for sure. So what's the main recommendation, so people listen to this are like, “Alright, now what do I do?” What's your recommendation here in terms of applying ice?
[00:19:00] Nick: So I would say that, if you have an injury that just occurred, or let's just call them the everyday injuries, you sprained an ankle, you stub a toe or something like that, these everyday injuries that just occurred recently, you could probably go without ice, and it's probably for the better based on the research we've seen and based on even our experiences working with people dealing with injuries, pain and stuff like that. So the ice will just delay your healing from that injury that has just occurred. So it's probably best to go without the ice leaving in the freezer for these types of instances unless you were to have a significant injury. The inflammation so severe, and these will be situations like fractures or car accidents, blunt force trauma, those types of things. And those are typically situations where you're going to end up under someone's medical supervision anyway in a hospital, or some kind of a setting like that. So those are situations where we might need to verbally inflammation because it is so severe. But the vast majority of instances, you probably get to go without ice. And then just like we mentioned before with chronic injuries, it's your preference. If you want to use ice, because it feels good, it feels better afterward. Cool, go for it. Just be mindful that if there is any swelling or inflammation there, you might be limiting or impairing your healing capacity to some extent.
[00:20:24] Chad: And so the question that we kind of started off with is, is ice bad? And the answer is “No”, with everything we just talked about. So go back to the old podcast, and let's do it. Now, we just want to be clear that everything that we were referring to was regarding that localized ice to treat injuries. Now, there is a lot of science to back up the use of cryotherapy. It's very real. And it has been shown to be beneficial in improving our immune system. What is that called? It's called cold exposure. We just talked about this earlier. Actually, in our last episode, we did talk about our Wim Hof experience that we had last year, which was cool. And we talked about our experience with that, and how we felt afterwards, and so forth. So let's keep in mind that these tools should be used either hours before or after activity, whether it's a workout, or training or whatever you're doing, because this affects the muscle healing. Now, let's address cold exposure. Because we don't want people to think that they can avoid ice altogether because they're missing out on all the other benefits. So what are the benefits of cold exposure, Nick?
[00:21:27] Nick: So cold exposure is awesome. I say that, I'm biased because I implemented in my life. I take cold showers at least twice a week, sometimes more all year round. So obviously right now it's the summer it's a little bit easier to embrace a cold shower. But during the winter, I actually this past winter did it for 45 days straight just to see how it would go through February, March. And it was tough, but you get a ton of benefits from it. And the best way I can describe cold exposure is just as you would lift weights or strength train to increase your musculoskeletal capacity. You would run, cycle, swim, do something like that to increase your cardiovascular capacity. Cold exposure is like training your biology. So you train your muscles through lifting weights, you train your heart through running for extended periods of time, or cycling. You train your biology, your immune system, all that kind of stuff your nervous system, through exposing it to cold, you can also do the same with heat exposure like saunas, but cold is really, really cool, because you can do it at home, turn your shower as cold as it'll go and embrace it. And with cold exposure, like Chad mentioned, you're getting that increased immune response, you're getting an increased efficiency in the way your central nervous system functions. And the central nervous system drives all other functions. So it drives all these other systems, that digestive system, so you get an increase in response in pretty much all these systems. But in terms of the research we've seen, like I said, increased immune response. So decreased likelihood of getting sick from cold viruses, things like that, which is huge right now. We're still in this pandemic. So increase immune response, you get an increased burning of fat, actually, when you do cold exposure. Again, because it makes those systems those energy systems a little bit more efficient. So basically, what's happening when you go into the cold, is you are trying to calm yourself down in that cold environment. So when you go and you get a cold stimulus, it's very sympathetic. So it's your fight or flight system, your fight or flight nervous system, what you try to do is you try to calm your body down, get yourself to a point where your breathing is more under control. And that triggers on that parasympathetic. So that rest or digest system. And your body is constantly fluctuating in and out of these systems throughout the day based on what stimulating the body. So if you're going about your day, no minimal stresses, that kind of stuff, you're a little bit more on that parasympathetic side. But if you're going through and you've got all this high stress, you're probably a little bit more sympathetic, more that fight or flight. And it's never fully necessarily wants to submit the other, it's this gentle balance between the two, really. But in today's world, we are probably all sympathetically driven, because of technology, lights, noises, all that kind of stuff. So our bodies in this state of on. It's on guard a little bit. So if we can do something like exposing ourselves to cold, it's a very natural way to stimulate parasympathetic activity and parasympathetic control. So we can have that better balance of the two nervous systems. So that's in essence what exposing yourself to cold does and like, Chad, mentioned before, do hours before after your weightlifting, you're running your Those types of things because the cold like a cold tub has been shown to limit the gains made from a strength training session. It's been shown to limit like I said before, strength, power, and all that kind of stuff so it can impact it. But if you look at it as a separate training session, because now I'm training my biology, they are on me training my musculoskeletal system, we don't want to train all these things at once we want to train them separately. So we can focus put our focus towards them. That's kind of what we're doing with cold exposure. And that's why we wanted to bring this up, because people may hear us talk about ice and be like, “Oh, cool. I don't have to do this cold tub like someone said”. And all these people around here talking about jumping in the ocean in the winter. I don't need to do that, that's stupid. They're being stupid. Not really, because they're doing it for a different purpose. It's all depends what the goals are and why we're doing something.
[00:25:50] Chad: And the benefits of cold exposure are, they're great. And I will say Nick's a little bit more on the aggressive side with this than I am. I have been introducing more cold showers into my day, am I going to jump in a cold ocean? Hell, no, I'm all set with that. I did my time. But I did feel like a million dollars afterwards. And it's not something that I would do every day, but I do believe that it is something that you should do frequently.
[00:26:15] Nick: And if you're going to try a cold shower, I always have a few recommendations for people. Don't try to get into the cold water, your body just won't let you. Get in the shower, and turn on cold. That's if you're going all out and just saying I'm going to do this whole thing cold. If you really want to start with this, take your normal shower. Do however you do it, hot, warm, however you like shower, and then gradually shift it to cold towards the end. And increase the amount of time you can do that. While you're doing that, try to calm the breathing down and try to breathe in and out of your nose. So all nasal breathing and see if you can just get that breathing to slow down, calm down. So you're in control, don't let the temperature of the water be in control, they're you being control. If you do go full on colds like I do, get in and turn it on yourself, it's much easier than stepping into it. And then if you are still struggling with that, try a big exhale as the water is about to hit you. So big inhale through your nose. And a big exhale as the water is about to hit you when it's cold, it won't be quite as cold on the exhale, because an exhale will stimulate your parasympathetic nervous system, then you will shift into sympathetic once the cold hits you, but you'll be in a better place.
[00:27:31] Chad: That's exactly right.
[00:27:32] Nick: So that's a good try. And then the ocean especially where we live here where we are in this area right on the coast, you have access to the water pretty much all year round. Some people can walk, some people gotta drive, and that’s okay. But the water, the ocean is a great way to expose yourself to cold, it's still pretty cold right now it really doesn't get too warm up here. But if you go in the winter months, or even in the spring, the spring is a good time because the water is freezing, but the air is not as bad. So that's a good way to try to. Same thing if you go in try to control your breathing before you get out, don't just go into panic mode and then be panicked when you get out. You'll be shivering for a while.
[00:28:11] Chad: And I think that the key there is the breathing for sure the breathing does make a huge difference. And for all of you that aren't familiar with Wim Hof, you should check it out, because that'll kind of cue you into the importance of the breathing. I felt that firsthand and it's pretty remarkable. It's wild. Let's kind of conclude this. So let's kind of sum everything up here and just say that if you're using ice post injury, I would say that you should probably stop. Unless it's severe inflammation where it's like restricting blood flow to your limbs, and causing compression to your nerves that sort of thing like Nick talked about earlier. If it's just a regular ankle sprain or whatever it may be that's not severe, then I would say movement is probably your best key there. If you're using ice water to stimulate the nervous system and the immune system, I say it's all good.
[00:29:00] Nick: Absolutely.
[00:29:01] Chad: You can decide how aggressive you want to get with that. I do warm water and I slowly make it to cold. That's what I do. But either way, I think that's a great benefit for you.
[00:29:09] Nick: To piggyback off that too. And when Chad said they're the best thing you can do there is move, that's exactly it. So if you have an injury and there's no fractures, there's nothing like that, nothing severe, gentle movement is going to help mobilize those human factors. So that's going to help flush out the cellular debris and get things healing a little bit quicker. The other two things you can really do that will help the healing process are going to be breathe through your nose, so in and out of your nose. Because next time you get hurt, pay attention to how you're breathing, you're probably breathing in your mouth, and that is going to drive up sympathetic activity. The other thing that brings you nose does is it increases nitric oxide, which will dilate your blood vessels. So now you're going to get more of those healing factors in faster. And then the other thing to do, don't panic. Because when you’re panic, stress is going to increase your sympathetic and that's fight or flight, you're not going to heal as well there. You want to stay calm. As long as you know nothing significant or severe is happening, stay as calm as possible. That'll increase your parasympathetic activity, which will then allow you to heal a little bit quicker as well.
[00:30:14] Chad: Perfect. All right, so what do we got going on for next episode, Nick?
[00:30:17] Nick: We got our next stories episode.
[00:30:19] Chad: Story time again, we had a great response on the last story time. So we're gonna hit it again, we got some good stories coming up. We're gonna do a couple each. So it's not too long. We're trying to keep this a little bit on the shorter side. But we really love the fact that you guys can find yourself in a similar situation as some of these stories. So if you guys feel that you're in the same situation as some of these people that we're talking about, then you should give it a good listen. It'll be a good one for you. So what's the moral story? So should I spell on an injury for all of you that have kids or are into Disney, take it from elsewhere from frozen and let it go. In other words, build a snowman.
[00:31:13] PODCAST OUTRO: Thank you for joining us “In The RACK” this week. Make sure to subscribe so you don't miss out on any future episodes. You can also find us online at proformptma.com, or on social media at ProForm PTMA. And remember;
“If you train inside the rack, you better be thinking outside the rack”.
