Apr 5, 2011

Ice/E-stim/Ultrasound: Age old therapies that may not be so therapeutic

By: Chris Ecklund, MA, CSCS
For: SB Independent
For years we’ve heard it from the medical community—
    Roll an ankle?  Ice it.
    Pull a muscle? Ice it.
    Jam a finger?  Ice it.

Those who have been involved in athletics or fitness are all too familiar with this advice.  Adhering to it may be another issue altogether, but suffice it to say we have been instructed to do it.  The question is…should we?

Research over the past couple decades has brought the therapeutic effects of R.I.C.E (rest, ice, compress, elevate) for soft tissue injury into question.  Does it actually help?  Is it worth the time and discomfort?  Are there other therapies (i.e. e-stim or ultrasound) that are more appropriate or better yet, more efficacious in bringing about the tissue healing process for acute soft tissue trauma?  Some studies have even gone so far as to say that cryotherapy has a negative impact on tissue healing and can actually slow or negate some of the body’s natural healing processes for recovery.

The truth, not surprisingly, lies somewhere in the middle. 

Local Physical Therapist, Tom Walters, DPT, CSCS notes that “for acute musculoskeletal trauma (due to surgery or injury), the practice of R.I.C.E. still holds value. Numerous studies are available that show the positive effects of RICE, particularly with regard to ice and compression during the inflammatory phase of healing (first 24-72 hours after injury).”  Further, he describes that the exact application technique, total icing/compression time and number of applications per day does vary depending on the size and severity of the aforementioned injury.  As a rule, however, 15-20 minutes of application (particularly that of crushed ice) several times daily with at least an hour between applications are still sound advice.

Where does the confusion lie, then?  Why are some arguing against it?  Primarily in the research evaluating cryotherapy effects past the inflammatory phase.  Here the information is equivocal at best.  Certainly there are enough studies to suggest (and most likely add credibility) to the theory that icing beyond this initial phase of 24-72 hours may actually limit the body’s natural healing response.  However, Walters points out “one must remember that if [he/she does] not rest the injured area, the inflammatory process may be lengthened beyond 72 hours.”  In this situation, further icing therapy may be warranted. 

Okay then, what about E-stim (electrical stimulation) and Ultrasound? Interestingly, while both of these practices have been fairly common practices in therapy regimens in various clinics (physical therapy, chiropractics, athletic training, etc.), the research appears equivocal at this point.  Walters suggests that while there is a need for more research, currently uses are primarily for pain relief (both) and increasing muscle strength (E-stim) but have limited support for tissue healing and repair. 

In short, E-stim and Ultrasound appear to offer very little, if any, additional benefit to tissue repair and the healing process.

Where does that leave us?  R.I.C.E.  Still good advice according to the literature…at least for the first 72 hours.

One stone remains unturned, however: how long is it going to take the tissue to heal beyond the 72 hours and what should we do until then? 

We find many of the clients in our performance center struggle to simply allow tissue repair to take place and often reengage in activities beyond tissue capacity far too soon thinking, “it doesn’t hurt anymore so it must be healed.”  Understanding that injuries are unique and blanket statements can’t be made about healing processes, I asked Walters to offer a general time line and plan of action for a typical ankle sprain based on the latest research.  Here’s what he suggests:

Phase 1: Inflammatory Phase (24-72 hours)1.  If unable to bear weight or have point tenderness along the malleoli (ankle bones), see physician to rule out fracture.
2.  Begin RICE ASAP (assuming no fracture) and continue for 24-72 hours (depending on severity).
3.  Keep ankle as inactive as possible to avoid re-injury.

Phase 2:  Fibroblastic Healing Phase (approximately 4 weeks)
4.  Increase Range of Motion, Strength and Proprioception (balance and neuromuscular control) using pain as guide (if pushed into pain, the tissue will regress into the Inflammatory Phase again).
Grade I sprains (least severe) may be healed and allow regular sports participation between 2 weeks - 2 months.
Grade II usually require between 3-6 months to be pain-free with all activities.
Grade III sprains (most severe) may require >6 months to heal and may ultimately require surgery if instability remains.

Walter’s Works Cited:
1. Does Cryotherapy Improve Outcomes With Soft Tissue Injury? Hubbaard TJ, Denegar CR. J Athl Train. 2004 Sep; 39 (3):278-279
2. Cooling Efficiency of 4 Common Cryotherapeutic Agents. Kennet, Jane; Hardaker, Natalie; Hobbs, Sarah; Selfe, James. J Athl Train. 2007 Jul; 42 (3):343
3. The role of physical agents in modulating pain. Fedorczyk J. J Hand Ther 10: 110-121, 1997.
4. Effectiveness of Interferential Current Therapy in the Management of Musculoskeletal Pain: A Systematic Review and Meta-Analysis. Fuentes J, Olivo S, Magee D and Gross D. Physical Therapy. 2010 Sept; 90; 1219-1238.
5. Thermal Agents in Rehabilitation, 2nd ed. Michlovitz SL. Philadelphia. 1990. FA Davis.
6. The effect of cryotherapy on intraarticular temperature and postoperative care after anterior cruciate ligament reconstruction. Okoshi Y. Am J Sports Med 27:357-362, 1999.


dbdunlap60 said...

Great article Chris. Too often, modalities are used as "blanket therapies", rather than on a therapeutic case by case basis. Keep up the great work.

Chris Ecklund, MA, CSCS said...


Thanks for the comment. Frankly I was surprised to find the research backing was that limited, but my conversations with Physical Therapists over the past 5 years have been almost 100% in line with this perspective. Apparently RICE, manual therapy and corrective exercise (i.e. work!) are still the best route, huh?