Saturday, April 3, 2010
Ice or Cold Therapy helps in Injury Rehabilitation
Golden Rule of Foot: When in doubt to heat or ice, use ice.
The goal of ice or cold water is to control inflammation, minimizing the swelling which occurs following an injury, or an aggravation of a previous injury. Why is this swelling so bad? Actually, swelling does get a bad name. With this increased blood flow to an injured area, the body brings in the building blocks for healing that injury. Very important!!! However, the body normally over does it, opening the flood gates to excessive swelling that can get in the way of healing. A simple ankle sprain can be swollen for weeks and weeks. It is the excessive swelling that slows the healing process by cutting off the micro-circulation to the area. Chronic swelling in the achilles tendon for example has been known to completely stop the healing process. This excessive swelling also adds excessive stiffness, adds instability by floating joint surfaces, and interfers with normal motion. It is the excessive swelling that must be minimized by immediate treatment of acute injuries or sudden aggravations of previous injuries.
There will soon be a post of R.I.C.E. therapy for acute injuries that everyone learns in high school/college, but somehow most forget. The I. stands for Ice. As soon after an injury you can put ice on, the faster it will heal!! All athletes know that by controlling the swelling, injuries heal so much faster.
The basic sciences teach us that the inflammatory phase of an acute injury lasts around 4 days. Heat in any form is considered the enemy during this time. Therefore, most teach ice for 72 to 96 hours after an injury or aggravation, then switch to heat only. This, however, does not take into account that symptoms will go up and down based on gradually getting back to full activity. Therefore, ice can be used in some form or another for months. I commonly recommend an ice pack or soak after strenuous activity during the return to activity period for 2 weeks longer than anyone (doctor, therapist, or patient) thinks necessary. It is that important.
Ice gets a bad name since it minimizes blood flow after those initial 4 days. Some believe ice should never be used after the first 4 days. But patients continue to push the limits as they rehab, needing ice sometimes for up to a year after strenuous activities. We all want normal to better blood flow after an injury. But excessive blood flow from utilizing too much heat at the wrong time (following aggravation) can slow the healing way down.
The best way of applying ice is soaking with ice water getting the temperature around 55 degrees. The patient in the photo above is ice soaking for 20 minutes following a cortisone shot to the heel. This is usually attained by cold tap water and 1/2 tray of ice cubes in a 3/4 filled basin. However, if you have cold sensitivities, poor circulation, or are experiencing nerve pain, please consult your doctor/therapist before using this cold environment. Soaking in cold water is normally for 20 minutes, and the foot remains stiff for approximately 1 and 1/2 hours after this. No physical activities are allowed in this time period. The stiffnes could lead to other muscle pulls, etc.
Ice can be applied sometimes easier, and less painfully, with cold packs. These may or may not be reusuable. Never use a reusuable ice pack that is stiff; it should be soft and malleable when applied to your skin. Normally, these can go directly onto your skin, but many prefer a moist towel between the ice pack and the skin. Some skin surfaces are too sensitive for direct ice secondary to nerves or bony prominences. The towel must be moist with cold water to allow the full effect of the cold to penetrate your skin. Patients have used frozen peas as ice packs for years successfully. Supposedly, frozen corn or mixed vegetables hold in the cold better due to the denser material and last longer. Definitely mark the packages "Do Not Eat." You can use ice packs 20 minutes every 2 hours to quickly calm an inflammed area as long as you pay attention to the circulation. Unless you have to ice pack the bottom of your foot, most patients can perform ambulatory multi-tasking with ice packs somehow secured to enable them to get around. Ice soaking does not allow ambulatory multi-tasking.
When you have a small inflammed area, like a bunion, you can use ice massage effectively. Take an ice cube in a towel, and using circular motions, gradually massage the area for 5 minutes. As the minutes pass, massage deeper and deeper into the tissue. The massage helps push out the fluid, while the ice calms down the inflammation. Ice and massage is a powerful way of eliminating inflammation. Many will freeze water in a dixie cup, peel away the top of the cup, and then massage. The frozen sport bottle routine for plantar fasciitis is another example of ice massage commonly utilized. Fill a plastic bottle 1/2 with water and freeze it standing up (not you the bottle). The water expands during the freezing process. Place a towel on the floor and then the bottle. While you are sitting or standing, gradually with more pressure roll the sore area over the bottle for 5 minutes. You get the most effective self-treatment ever by mixing anti-inflammation, massage, and stretching of the injured tissue. After a 5 minute ice massage, the area remains tight for 30 minutes, so avoid strenuous activity during this time. For example, do not run right after ice massage.
The final form of ice used commonly is Contrast Bathing. Please see the post entitled "Secrets of Contrast Bathing" for a full discussion. This slowly introduces heat into the rehabilitation.
Soaking in warm water after the first 4 days of an injury or aggravation in a mild injury is very soothing. The injured area normally feels great with this for 1 or 2 hours, but then the negative effect of the heat may surface causing overall more swelling and stiffness. As you start to use heat, be willing to listen to what your body is saying. Generalizations may say one thing, but your body the other. Only if you understand the basic principles, can you experiment successfully with these very powerful tools of rehabilitation: Heat and Cold. I hope at least some of the basic principles are now clear.