May 9, 2019

Putting R.I.C.E to rest

Mark Callanen, PT, DPT, OCS

Clinicians are faced with treating inflammation on a daily basis. When treating muscle strains, sound knowledge of the mechanisms involved with tissue healing — and knowing which evidence-based therapies effectively reduce pain and inflammation — are paramount to restoring function as quickly as possible.

There are several options to treat pain and inflammation, but which choice is best?

ICE

In 1978 Gabe Mirkin, M.D., came up with the familiar acronym “R.I.C.E.” (Rest, Ice, Compression, and Elevation) regarding how to address inflammation. While commonly used, several studies have been published that question its effectiveness regarding inflammation.

The British Journal of Sports Medicine retrospectively investigated 22 separate studies and concluded that “ice is commonly used after acute muscle strains, but there are no clinical studies of its effectiveness.” A report in the Journal of Strength and the Conditioning Research went a step further by stating that not only does icing fail to help injuries heal, it may well delay recovery from injury.

A 2013 study in the Journal of Applied Physiology showed that cryotherapy had null to mild impact on pro-inflammatory markers on post-exercise induced muscle damage. Ice apparently plays more of an analgesic role post injury than it does in reducing inflammation.

Dr. Mirkin himself was recently quoted that he now openly rejects at least half of R.I.C.E. (Rest and Ice). In a foreword to the second edition of Iced!, Dr. Mirkin says most athletes are far more concerned with long-term healing than transient pain relief. “And research,” he writes, “now shows that both ice and prolonged rest actually delay recovery.”¹

NSAIDS

Although commonly recommended, there is rising evidence that dampening acute inflammation via NSAIDS impairs muscle growth and regeneration in animal and human models.² While decreasing swelling, NSAIDs have been shown to negatively impact tissue repair by diminishing proliferation, differentiation, and fusion of satellite cells in muscle tissue which can lead to impaired skeletal muscle repair, growth, and increased fibrosis. This can result in poorer scar formation and increased re-injury rates.²

When advising patients on the topic of chronic inflammation, clinicians should be aware that NSAIDS have been found to be ineffective in reducing diffuse, systemic inflammation.³ Steroids (SAIDs) such as prednisone have been found to be a better alternative in restoring the balance of the inflammatory process for chronic inflammation and repeat “asynchronous” injuries to muscle tissue, such as repeated muscle strain to the same tissue.^4,5 It should be noted the positive effects of SAIDS is limited to the window of months to years, as long term muscle wasting can outweigh short term anti-inflammatory benefits.^6,7

LASER

For those individuals that are beginning to cool on the idea of icing and are weary of the detrimental impact of NSAIDS, laser therapy may be the next approach to consider.

Promoting active recovery is becoming a much more accepted concept. Gary Reinl, veteran athletic trainer and author of the book Iced! The Illusionary Treatment Option believes the answer lies in a new acronym: A.R.I.T.A. — Active Recovery Is The Answer. Instead of being still and shutting down blood blow, try to get things moving and circulating as soon as possible.¹

Laser therapy, correctly referred to as Photobiomodulation (PBM), promotes this concept. PBM describes the mechanism by which photons elicit (primarily) photochemical changes in tissues that positively influence the inflammatory process and enhance tissue healing.

Unlike NSAIDS which block the inflammatory cascade at the COX-2 level, and ice which delays the inflammatory process by restricting blood flow for a period of time, laser metabolically influences the injured tissue at the mitochondrial level; accelerating the healing process. Laser research that investigates the mechanisms involved with reducing inflammation, at a glance, look similar to pharmacological studies because they impact the inflammatory cascade at similar points.^9,10,11,12

However, they are fundamentally different. PBM reduces inflammation organically from intrinsic, anti-inflammatory signaling at the source of the inflammation. PBM’s impact on metabolism, improved micro-circulation, and increased fibroblastic activity significantly impacts muscle healing.¹³

For those clinicians that can’t bear the thought of stepping away from their ice machines, there have been two recent studies that have compared: ice, ice combined with laser, and laser therapy used independently to treat quadriceps muscles after maximum volitional contractions (MVC). Parameters that were measured included oxidative damage, MVC, and DOMS after MVC.^14,15

They concluded that the laser group had significantly higher MVC on retest and less oxidative stress compared to the placebo group. They also found that when cryotherapy was combined with the laser it lowered the efficacy of the laser treatment done independently.

While change is often painful for clinicians, moving away from ice and NSAIDS may be better for patients.

For more information, please visit www.lightforcelasers.com.

References

1. Reinl, G. Iced!: The Illusionary Treatment Option Paperback – October 1, 2014.
2. Duchesne E, Dufresne S, Dumont N. Impact of Inflammation and Anti-inflammatory Modalities on Skeletal Muscle Healing: From Fundamental Research to the Clinic. Physical Therapy [serial online]. August 2017;97(8):807-817.
3. Sin DD, Reid WD. Is inflammation good, bad or irrelevant for skeletal muscles in COPD? Thorax . 2007;63:95–96.
4. Arnold L, Henry A, Poron F et al Inflammatory monocytes recruited after skeletal muscle injury switch into antiinflammatory macrophages to support myogenesis. J Exp Med . 2007;204:1057–1069.
5. Dadgar S, Wang Z, Johnston H et al Asynchronous remodeling is a driver of failed regeneration in Duchenne muscular dystrophy. J Cell Biol . 2014;207:139–158.
6. Sali A, Guerron AD, Gordish-Dressman H et al Glucocorticoid-treated mice are an inappropriate positive control for long-term preclinical studies in the mdx mouse. PLoS One . 2012;7:e34204.
7. Manzur AY, Kuntzer T, Pike M, Swan A. Glucocorticoid corticosteroids for Duchenne muscular dystrophy. Cochrane Database Syst Rev . 2008;(1):CD003725.
8. Anders JJ, Lanzafame RJ, Arany PR. Low-level light/laser therapy versus photobiomodulation therapy. Photomed Laser Surg 2015;33:183–184.
9. Prianti, A.C.G. et al. (2014) Low-level PBMT (LLLT) reduces the COX-2 mRNA expression in both subplantar and total brain tissues in the model of peripheral inflammation induced by administration of carrageenan. Lasers Med Sci. 29(4):1397-1403.
10. Jimbo, K. et al. (1998) Suppressive effects of low-power laser irradiation on bradykinin evoked action potentials in cultured murine dorsal root ganglion cells. Neurosci Lett. 240(2):93-96.
11. Lopes-Martins, R.A. et al. (2005)Spontaneious effects of low-level PBMT (650 nm) in acute inflammatory mouse pleurisy induced by carrageenan. Photomed Laser Surg. 23(4):377-381.
12. Mizutani, K. et al. (2004) A clinical study on serum prostaglandin E2 with low-level PBMT. Photomed Laser Surg. 22(6)537-539.
13. Alves, AN. et al. Effects of Low-Level Laser Therapy on Skeletal Muscle Repair. Am J Phys Med Rehabil 2014;00-00.
14. De Marchi, T. et al. (2017) Does photobiomodulation therapy is better than cryotherapy in muscle recovery after a high-intensity exercise? A randomized, double-blind, placebo-controlled clinical trial. Lasers Med Sci. DOI 10.1007/s10103-016-2139-9.
15. De Paiva, P. et al. Photobiomodulation therapy (PBMT) and/or cryotherapy in skeletal muscle restitution, what is better? A randomized, double-blinded, placebo-controlled clinical trial. Lasers Med Sci (2016) 31:1925–1933.