Cooperation: The Unicorn We Are All Hunting For

By: Michael Falk, ATC-L, CSCS, SPT

Inter-disciplinary Cooperation.

I have been thinking a lot recently about cooperation between health care and related disciplines, and I have touched on this subject previously on the Professional Football Athletic Trainers Society website. On the surface, this idea doesn’t sound that difficult; professionals should share facts and agree on what is best for the athlete. Yet, time and time again, I hear clinicians talking about how the athletic training staff, coaching staff, medical staff, performance staff or you fill in the blank staff cannot get on the same page. I have been fortunate to experience interdepartmental co-operation and the benefits it can have. However, much more commonly I have witnessed and heard about turf wars between departments who cannot get along or who view athlete wellness through different lenses and you probably have too. The bottom line is – this kind of thing is bad for athletes and for our professions in general. We need to inspire confidence in our athletes that our recommended actions are the best thing for them, not cause them to question everything by getting different advice from different departments.

For example, I read a blog post several months ago written by a strength coach that discussed the strength coach’s role on a team including rehabilitating athletes, preparing them to perform, preventing injuries, being a team “psychologist”, motivating the team, being a team nutrition counselor, etc. Several weeks ago, I talked to a colleague who is a performance coach at a collegiate institution and she commented on the difficulties she has had communicating with the athletic training staff over preseason screening and return-to-play protocols. The athletic trainer didn’t see the value of this activity and did not want to help support the performance staff in these screens and protocols. The athletes are left wondering who is correct and what they really need.

Last week, I listened to Brian Gallagher, an Associate Athletic Director and Athletic Trainer for football at Stanford University, talk about how Stanford has organized an interdisciplinary team around a common goal – athlete wellness. Performance coaches, physicians, nutritionists, athletic trainers, physical therapists, pilates instructors, etc. all cooperate and work together to maximize their athletes’ wellness. Again, this concept seems like common sense, yet it has become like a unicorn in competitive athletics. Some people say unicorns exist, but they rarely seen.

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As clinicians, it is time to swallow our egos and respect the expertise of other clinicians and professions. Rather than try to be the person that has to have all the answers and do everything for your team, why not take advantage of the expertise of other staff members and departments?

Here are some ideas to improve this inter-departmental co-operation:

  • Start by agreeing on a common goal. For example, athlete wellness, athlete availability, setting records for performance, setting records with athlete durability, etc.
  • Listen, really listen to the ideas of others. Ask why the idea would not work before dismissing it.
  • Share your ideas and check to make sure others understand. Ask why the idea would not work to understand objections.
  • Model an attitude of respect and cooperation. Expect to be treated that way by others. Give constructive feedback in situations where you are not.
  • Look for areas of overlap between professions. The athletes will see the staff working together and will buy in to the overall program. As an athletic trainer, be present in the weight room or at conditioning sessions. Understand what the athlete is going through in the weight room. As a strength coach, ask questions about an athlete’s rehab. protocol, be conscious of previous injury history and communicate with the sports medicine staff if you can modify that athlete’s program so they get more out of it.
  • Have a common message and language. Get on the same page with how you teach exercises. Don’t teach the squat one way in rehab., only to have the performance staff use different cues and teach a different technique when the athlete is released back into the weight room.
  • As an athletic trainer managing a rehabilitating athlete, consult the performance staff on volume of work and reconditioning. Try to get that athlete as close to the volume, conditioning and intensity that his or her teammates are getting while remaining safe within the stages of tissue healing.

Sports performance and sports medicine staffs should have much more in common than they have differences. They are experts on movement and proper movement patterns. They have sound physiology backgrounds. And they should have the same interests, maximizing on-field performance and durability of athletes. If we can find a way to maximize our similarities and trivialize our differences, the athletes, our customers, will be the winners.

Do you have a story of a great relationship with another interdisciplinary staff member? Or, a bad relationship? What things have you tried to do to build a relationship? Feel free to share in the comments section – I am always looking for new ideas!

Six Things I Learned While Teaching a College Course

By: Michael Falk ATC-L, CSCS, SPT

Last fall, I had the opportunity to teach the therapeutic exercise class in the athletic training education program at Marquette University. As an alumni of the program, I was honored and excited to be a part of an educational program where I built my foundation as a professional.

A few months before the semester started, I jumped in head first to prepare the course materials. So, if you want to know what I did on my summer vacation last year, course prep would be it! I have a whole new appreciation for college professors and how difficult it is to put complex material into the limited time available for lecture and lab.

Here are the top six things that I learned from my experience teaching:

1) More is not always better

I quickly learned I could not teach everything I know about a subject in the time available. I couldn’t possibly include every variable, injury, exercise or manual technique. I needed to focus on the basics and help the students build a strong foundation to grow from.

2) Students like to ask why

After the first day of class, I realized the students really wanted to know the why of things. They did not accept answers simply because I told them my perspective; they also wanted to know the reasoning behind the answer. I was encouraged by this attitude as I design my rehab programs with the intention of explaining the purpose for every exercise. Their questions challenged me to dig deep into what I was teaching them and make sure that I could explain the rationale behind everything I included in the course.

3) Case studies (stories) are remembered

About halfway into the semester, I gave the students a brief survey about what they found valuable in the course and what else I could do to help them. Nearly 90 percent of the class said they wanted more case studies. I was able to use pictures and examples of athletes I had worked with to provide the students an opportunity to apply the concepts they had just learned about and synthesize the information to develop a plan of care. This turned out to be extremely valuable as it encouraged class participation and helped connect complex material in a tangible way. People remember stories much more readily than a list of facts or figures.

As a new teacher, I struggled with surrendering class time that I could be “teaching” new information. However, I soon realized that allowing students to immediately apply the information truly allowed them to learn the information. Just like in any well designed exercise program, I surrendered quantity of information for quality of learning.

4) Mentors are important

I was lucky enough to lean on my current professors in the physical therapy program as well as former professors and administration in the athletic training program for advice on everything from class policies, writing a syllabus, organizing lectures, how to simplify complex material, and writing tests or practical exams. It is really easy to forget how important mentors are, and it is even easier to forget to thank these people and let them know what impact they had on you. Those that go before you pave the way for you most of the time.

5) How to bring evidence into the classroom

The current emphasis of clinical practice and education is on evidence-based practice. I struggled with how to incorporate new research into the classroom and help the students connect. Research is often presented with a citation and an overview of the study. I wanted to show the students how to use research to guide care, while still educating them about therapeutic exercise. The greatest success I had was incorporating EMG studies into the lectures. After reviewing what EMG was, and how it could impact exercise selection, I would put charts from articles up and pose a question to the students. Which exercise would you pick if you had a patient with a spondylosisthesis? If you determined an athlete had an over-active TFL during your examination, which exercise would you choose? Questions like this created great discussion and helped show the students how to approach research in a clinically meaningful way.

6) To bring it everyday

Having only taught in a limited lab setting or given lectures at a state or national meeting, I realized what a big step up it is to lecture for 2 hours each week and teach a weekly two-hour lab. No matter how busy my schedule was, or how much I didn’t like a particular topic, I needed to bring energy and focus to try and create the best learning environment. Teaching every week was a great experience and a new challenge for me as well. For example, I couldn’t just glaze over the wrist and hand and only teach what I was interested in and passionate about. I had to force myself to get comfortable with material I was uncomfortable with.

Overall, I learned as much during the semester as the students learned from me. I loved working with the kids during lab, the challenge of preparing lectures, and I was energized by the students and their desire to learn.   I have also been blessed with great mentors and teachers throughout my career, and it was an honor to be able to try and return the favor to another generation of students.

One of my mentors, Dave Leigh, always told us that if you wanted to be in this profession, you have to be an educator because you must teach athletes, coaches, parents and students. I jumped at this opportunity and grew as much from it as the effort that I put into it.

Is Ice Right? Following Soft Tissue Injuries

By: Michael Falk, ATC-L, CSCS, SPT

This is my final blog in a 3 part series about the use of ice to treat soft tissue injuries (read Part 1 and Part 2 here). This subject has been the hardest post to both research and write. Frankly, there is a lack of high quality studies on the benefits of using ice following injury. Systematic reviews since as early as 2004 have been calling for studies with improved methodology in order to gain concrete evidence on how we should be using cryotherapy in our practice. In many of the systematic reviews I read, the average PEDro score was around 2 to 3 out of 10 (a scale used to rate the quality of evidence; the closer to a 10, the better the quality of evidence in the paper).

I believe the challenges with the research are multi-fold. First, it is difficult (nearly impossible) to blind a study participant as to whether they are receiving ice or not. Second, it is a difficult study to design, as I mentioned in previous posts. Very few researchers want to be on call 24 hours a day, 7 days a week in order to enroll participants in an acute injury study. Third, the use of ice has become so common, it would be very hard to maintain a control group (most people immediately start icing on their own after injury). Finally, there is no well-established protocol for the application of cryotherapy. Some authors perform ice with compression, some use ice packs, some use a cold-water immersion, and the list goes on. In the literature, there appears to be no set time period or dosage for cryotherapy; some clinicians apply ice for ten minutes and I saw one study that applied it for 6 hours. This much variability makes it very difficult to draw true conclusions from the research.

This lack of a standard for cryotherapy should raise serious questions about the efficacy of its use. If you go to a physician, do they say take this medicine, somewhere between 1-6 pills, maybe as often as 4-5 times a day, but it just depends on how you’re feeling? No. They prescribe a set dosage that has been researched and is appropriate for different body weights, age, medical conditions, etc.

Furthermore, what do we measure with cryotherapy research? Is it all about return to play? Ice is not the only factor that contributes to return to play. Do we measure swelling? Treatments outside of ice such as exercise, compression, elevation, etc. can also affect recovery. Do we measure pain? Do we measure inflammatory mediators? (As I mentioned in the first blog, I don’t think we want to decrease these processes, as they are an important first step in the healing cycle).

Finally, the rationale behind using ice can change as the injury develops. Within the first several hours after injury, we justify the use of ice for reducing secondary cell death. Then we justify its use by helping control the inflammation and swelling (again, I am not sure this goal is worthy). Then we talk about using ice after rehab exercises to control pain or damage that may have occurred while exercising that day. With the wide array of potential applications for ice, designing a study is very difficult. So, with that uplifting preamble, I offer you some of the articles that I found most interesting and provide you with some ways that these articles could be applied to your clinical practice.

A Couple of Systematic Reviews

Essentially, the research on using ice is inconclusive and of poor quality to the extent that drawing conclusions from it is difficult. For example, in 2004 Hubbard et al. reported four different studies on cryotherapy following ankle sprains and the effect on return to play. The authors found two studies that showed no difference and two studies that did show an improvement in the cryotherapy treatment group. So, score 2 for ice and 2 for no ice – a perfect tie. However, one of these studies compared using ice to using heat, so it was not a true control. And I don’t think any current practitioner would recommend heating an acute injury.

In 2012, van den Bekerem et al. performed a systematic review of the R.I.C.E. principle (rest, ice, compression, elevation) in ankle sprains. They attempted to look at each of these different variables in the literature. To stay on topic, I will only discuss the findings about ice.

Again, the results were mixed. Multiple studies found no difference between the ice group and the control group on swelling, ROM, pain, or ability to weight bear. Two studies found that cryotherapy resulted in faster return to play or decreased swelling compared to using heat (again, not a true control). One study also found that using a cooling gel under an ace wrap caused faster reduction in edema and increased return of ROM compared to compression alone. The authors’ conclusion was there is insufficient evidence to support the use of ice, but we need higher quality studies to truly make a judgment.

Things That Are Definitely True

If you have an ankle sprain, early controlled mobilization and exercise is better than ice alone. Bleakly et al. showed that early exercise increased the patient’s ability to walk and the number of steps that they took at 1 and 2 weeks after injury compared to a group who only used ice. No effect was noted on pain or swelling.

Ice does temporarily control pain. This doesn’t require fancy research. If something hurts and you ice it, that body part will become numb and you won’t feel it as much. However, we have other modalities that can be used to control pain temporarily that will not negatively impact the important inflammatory process and potentially affect the overall healing cycle. Additionally, research has found that exercise has been shown to have an analgesic effect.

What About In Rats?

While animal studies have their limitations (namely, humans are different then rats), good quality animal studies may at least be able to lead us in a direction and help guide further human studies on the use of cryotherapy. Schaser et al. had an interesting article (although it involved way more vascular physiology than I understand). The authors induced muscle damage in rats and studied what happened with prolonged (6 hour) treatment with ice. They found that ice significantly reduced macrophages, adhering leukocytes and granulocytes. I found it interesting that, despite the decrease in inflammatory cells, they found no differences in edema in the rats’ muscles. So, there were equal amounts of swelling, but less of the inflammatory cells necessary for normal healing.

Now, the authors felt that cryotherapy was still helpful because the cryotherapy group was able to maintain the capillary network and venule cross sectional area. This effect would, in theory, help maintain oxygenation and delivery of nutrients to the injured area. So, in rat studies, looking at the detailed vascular physiology, there may be some evidence that ice could be helpful.

If You Still Want to Use Ice

If reading these posts or doing your own research has led you to still use ice following injuries, then let me direct you to another article by Bleakly et al. He compared two different icing protocols: prolonged continuous application (20 minutes every 2 hours) and intermittent application (10 minutes of ice, 10 minute break, and 10 more minutes of ice repeated every 2 hours). The intermittent ice group showed decreased pain with activity compared to the continuous application. There was no difference in swelling, function or pain at rest.

However, I will note that even with the decreased pain, participants of both groups had difficulty running and cutting at 6 weeks.

In Conclusion

The evidence is not clear at this point about what ice does do and what ice does not do to help recover from injury. Is the use of ice neutral (does no harm), does it offer some benefits that are just hard to measure or does it actually inhibit recovery? I am surprised that cryotherapy has become such a common treatment without any clinical support. The use of ice is commonplace and is often prescribed without a second thought. Your athlete gets hurt – you give them a bag of ice – we’ve all done it. I have routinely prescribed cryotherapy of 20 minutes on every two hours with no consideration of the body size of the person or the subcutaneous fat thickness that may affect the cooling delivered.

I would love to see a high quality study get funded to look at the effect of ice in treating acute injuries and help clinicians to develop better guidelines on whether ice should be used or not, and, if it should be used, what the best treatment parameters are.

Until then, in my practice, I plan to limit the use of ice and decide whether to use it on a case-by-case basis. I believe that controlled exercise and early mobilization (where appropriate) are alternates to using ice that will be more effective. The main indication I would use ice for is to control pain. However, there are other electrophysical agents to control pain that do not have the potential drawbacks of ice. If I do use ice for pain, I would no longer prescribe it for 20 minutes every two hours. I would use ice until the pain decreases (go for the numb) and only as needed.

I hope this series of posts was thought provoking about a commonly used practice. I would love to hear your thoughts on this post or on the series of posts.

I also hope if you work in a facility that has the ability to research, or if you know someone in academia, that you would try to convince them to look into this area of research and get some answers that are clinically applicable.

References

  1. Bleakley, Chris M., Suzanne M. McDonough, and Domhnall C. MacAuley. “Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols.” British journal of sports medicine8 (2006): 700-705.
  2. Bleakley, Chris M., et al. “Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial.” BMJ 340 (2010).
  3. Bleakley, Chris, Suzanne McDonough, and Domhnall MacAuley. “The use of ice in the treatment of acute soft-tissue injury a systematic review of randomized controlled trials.” The American journal of sports medicine1 (2004): 251-261.
  4. Hubbard, Tricia J., and Craig R. Denegar. “Does cryotherapy improve outcomes with soft tissue injury?.” Journal of athletic training3 (2004): 278.
  5. Hubbard, Tricia J., Stephanie L. Aronson, and Craig R. Denegar. “Does cryotherapy hasten return to participation? A systematic review.” Journal of athletic training1 (2004): 88.
  6. Schaser, Klaus-Dieter, et al. “Prolonged superficial local cryotherapy attenuates microcirculatory impairment, regional inflammation, and muscle necrosis after closed soft tissue injury in rats.” The American journal of sports medicine1 (2007): 93-102.
  7. van den Bekerom, Michel PJ, et al. “What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?.” Journal of athletic training4 (2012): 435-443.

Is Ice Right? As a Recovery Modality

By: Michael Falk, ATC-L, CSCS, SPT

In my first blog of this series (Is Ice Right? Part 1), I posed some theoretical, physiological questions that are being raised about whether cryotherapy is an appropriate treatment post injury or as a recovery method.

In this article, I have summarized the current evidence in the literature on the topic of cryotherapy as a recovery modality and will attempt to draw some conclusions that you may be able to incorporate into your practice. In the third and final part of this blog series, I will address ice for use after injuries and post-surgically.

Cold Water Immersion or Topical Cooling for Recovery

Around athletics and training, recovery is the newest hot topic. There are recovery pumps, recovery machines, massages, more self-myofascial release tools than you can count, cold whirlpools, contrast baths, cryosaunas, and the list goes on and on.

With regard to cryotherapy, recovery has been well researched because it is a fairly easy research design. Two main research designs are typically used:

1) Eccentrically-induced muscle damage followed by an ice group or a control group and then tracking various markers of muscle damage, sleep, performance markers or subjective feelings of recovery.

2) Simulated or live practice or game followed by a cryotherapy group and a control group and then tracking performance markers or subjective feelings of recovery.

This area of research is convoluted with numerous studies showing varying results.  Just to be clear, this is blog should not be mistaken for a fully-researched systematic review, but I did my best to find a variety of clinically-relevant articles related to this topic. An additional challenge with this research is the sheer number of different cryotherapy modalities to choose from. In this blog post, I will address studies that used either cold-water immersion or topical cooling (ice bag).

After reading a number of articles on this subject, some research shows cryotherapy helps recovery, and some studies say it makes no difference. I could cite 10 articles either in support of or against using ice, but the research wasn’t of very high quality and there were no overwhelmingly clear results. One of the big flaws of these studies is that the cryotherapy group is often compared to a control that is doing nothing. Clinically, if you are not using a cold bath for recovery, you will be using some other recovery tool during that time to try and maximize your effect on the athlete.

In 2014, this research was summarized in a systematic review by Diong et al. in the British Journal of Sports Medicine. In 17 studies, cold water immersion led to small to moderate effects of less subjective soreness when compared to passive recovery. This review also concluded that cold water immersion was superior to contrast baths (alternating hot and cold) in 5 different studies. However, the authors cautioned the effects may not be clinically significant and noted that there was a high amount of bias in the studies that were reviewed. So, ice maybe superior to doing nothing, but it is not conclusive.

The next question is, does using cryotherapy as a recovery modality cause any harm?

Tseng et al. researched eccentric muscle damage of the elbow flexors in collegiate baseball players. Each player served as his own control doing eccentric exercise followed by an ice bag application, then a 4-week break, and then eccentric exercise followed by a sham treatment. The study tracked muscle damage markers, pro-inflammatory cytokines, isometric strength, subjective reports of soreness and fatigue and blood flow following cryotherapy application. The results of the study found some cellular changes in cytokines that may negatively impact the healing process; and they found what the authors considered to be potentially damaging reactive hyperemia following the cryotherapy treatment. The study found no changes in isometric strength at 72 hours after exercise and found subjectively more fatigue in the ice group then in the control group. So, using ice actually inhibited recovery goals during this study.

Perhaps the most interesting and thought provoking article was recently published in 2015 in the Journal of Physiology. Roberts et al. tracked cellular hypertrophy markers, isometric strength and muscle cross-sectional area after resistance training. The study had one group use cold water immersion after training for recovery and a control group that did not use the immersion. One of the highlights of this study is that it compares the cold water immersion group to a group that completed an active recovery program. The study found that both groups increased their strength and muscle cross-sectional area, but the cold water immersion group had less strength gains, less cross-sectional area and less cellular hypertrophy markers all at statistically significant levels. The authors propose that cold water immersion after resistance training may decrease the hypertrophy effects of the training and over time may blunt the training effect.  So, using cryotherapy may inhibit the goals of training.

My opinion about using cryotherapy as a recovery tool is mixed and is based on the time of year and the goals for recovery. I listened to Mike Robertson’s Physical Preparation Podcast with Keith D’Amelio recently. Keith talked about the fact that recovery has a large psychological component. His example was, if someone can’t swim and hates the water, no matter how good it may be for them, a pool workout is not going to be a good recovery tool for that person. Their sympathetic nervous system will be working in overdrive and they will have no shot at relaxing and recovering.

In season or during a competition period, I apply this thinking to a decision to use cryotherapy in recovery. If an athlete has been using the cold tub since high school and believes it is a key part of his or her recovery, he or she will probably get a benefit from the treatment. The flip side of this argument is the athlete that HATES the cold tub. For these situations, I choose not to fight this battle and convince them to spend 5-10 minutes in the tub. The evidence just is not there to support this recovery modality as superior to any other recovery modality.

However, during the off-season, based on the results of Roberts et al. I try to educate my athletes and encourage them to use other recovery methods. The off-season is the time when we are trying to build strength and muscle mass and there is no need to use cryotherapy. Athletes don’t have games to prepare for, and they should not be bruised and battered from competition. As a clinician, since cryotherapy may limit the training effect that I am working to program and develop, why would I risk blunting that effect? Instead, I will teach my athletes to participate in an active recovery program following their training sessions and on their days off in their off-season training program.

So, bottom line, like many things in our profession, it depends, and the recovery modality used needs to be specific to that client or athlete. If ice works for the athlete in season, put them in the cold plunge. If they aren’t programmed for ice or if they are in the off-season, use other recovery therapies.

What do you think? Do you use or prescribe ice for recovery? What are some alternative recovery modalities you use?

 

References:

  1. Al Haddad, Hani, Jonathan Parouty, and Martin Buchheit. “Effect of daily cold water immersion on heart rate variability and subjective ratings of well-being in highly trained swimmers.” Int J Sports Physiol Perform1 (2012): 33-8.
  2. Bleakley C, McDonough S, et al. Cold-water immersion (cryotherapy) for preventing and treating muscle soreness after exercise. Cochrane Database Syst Rev 2012;2: CD008262.
  3. Burgess, Theresa L., and Michael I. Lambert. “The efficacy of cryotherapy on recovery following exercise-induced muscle damage: invited review article.” International SportMed Journal2 (2010): 258-277.
  4. Glasgow, Philip D., Roisin Ferris, and Chris M. Bleakley. “Cold water immersion in the management of delayed-onset muscle soreness: Is dose important? A randomised controlled trial.” Physical Therapy in Sport4 (2014): 228-233.
  5. Ingram, Jeremy, et al. “Effect of water immersion methods on post-exercise recovery from simulated team sport exercise.” Journal of Science and Medicine in Sport3 (2009): 417-421.
  6. Roberts, Llion A., et al. “Post‐exercise cold water immersion attenuates acute anabolic signalling and long‐term adaptations in muscle to strength training.” The Journal of physiology18 (2015): 4285-4301.
  7. Sellwood, Kylie Louise, et al. “Ice-water immersion and delayed-onset muscle soreness: a randomised controlled trial.” British journal of sports medicine6 (2007): 392-397.
  8. Takeda, Masaki, et al. “The Effects of Cold Water Immersion after Rugby Training on Muscle Power and Biochemical Markers.” Journal of sports science & medicine3 (2014): 616.
  9. Tseng, Ching-Yu, et al. “Topical Cooling (Icing) Delays Recovery From Eccentric Exercise–Induced Muscle Damage.” The Journal of Strength & Conditioning Research5 (2013): 1354-1361.

Is Ice Right? Part 1

By: Michael Falk, ATC-L, CSCS, SPT

Ice has been the de facto accepted treatment for any sprain, strain, bruise, tendonitis, muscle soreness, etc. Across the country, kids get hurt playing soccer and parents put ice on the injured area. Athletic Trainers always have ice with them at every event coverage.   Jumping in an ice bath after a hard practice or game to recover is an extremely common practice for athletes in many sports.

Several years ago, I began to hear rumblings that maybe ice wasn’t as beneficial as we have been taught. Maybe we are over-using it, or possibly using it inappropriately. I heard about an interview that Gary Reinl did on Kelly Starett’s blog, and a book that Reinl wrote about why you shouldn’t ice. I didn’t think much about it until I started noticing that MLB pitchers are no longer icing after they throw.

This summer, I finally got around to reading Reinl’s book, Iced: The Illusionary Treatment Option. While the book has solid physiologic reasoning, it is lacking evidential support. In my opinion, to make a case to stop using a treatment that has become the norm, you need evidence to show that it does not help or could delay healing. (Conversely, I assumed there had to be research showing improved outcomes with such a commonly used treatment)

The biggest eye catcher in Reinl’s book for me was a forward by Dr. Gabe Mirkin, M.D. who was the first doctor to develop the R.I.C.E principle in the The Sportsmedicine Book in 1978. In the forward he says, “Subsequent research shows that rest and ice can actually delay recovery… So, today, RICE is not the preferred treatment for an acute athletic injury.”

Recently, our evidence-based practice class had a project to research a treatment strategy, so my group decided to take on the subject of using ice as a treatment for musculoskeletal soft tissue injuries. I ended up going a little bit over the top and could not include all the research we found in our project, so I decided to blog about this subject instead.

Warning: PHYSIOLOGY AHEAD

In order to look at the effects of cryotherapy, we first need to review the inflammatory process. The inflammatory process is the first step in healing. It is responsible for destroying damaged cells, flushing out any foreign substances or debris and preparing the injured site for the proliferation and remodeling phase of the healing process.

Initially, the inflammatory response causes a rapid vasoconstriction that lasts for 5-10 minutes, caused by norepinephrine being released by sympathetic stimulation. This reaction is the body’s response to prevent bleeding out.

Next, vasodilation and increased vascular permeability occurs. This reaction is mediated by histamine, bradykinin, and prostaglandin and brings increased blood flow to allow extravasation, or the migration of neutrophils and macrophages into the damaged area. This increase in fluid brings in more of the key inflammatory mediators and the volume of fluid helps wash out any debris. The neutrophils and macrophages are the cells that are able to phagocytose and clean up all debris and damaged tissue. Additionally, macrophages are crucial to the healing process because they attract fibroblasts to the area. Fibroblasts are the key cells that begin laying down collagen and form the initial scar of connective tissue.

The increase in vasodilation and vascular permeability only lasts for about an hour.   Hageman factor begins to activate when it comes in contact with damaged tissues. This then promotes vasoconstriction (still allows for increased vascular permeability) and also begins to activate the clotting cascade.   Platelets also help to activate the clotting cascade and seal off all the damaged vessels. Additionally, platelets are key factors that attract fibroblasts.

Why does it hurt?

Our tissues contain nociceptors (pain sensors) that sense mechanical, chemical or thermal stimuli. The nociceptors transmit pain to the dorsal horn of the spinal cord via A-delta and C-fibers. T-neurons then transmit the pain signal to the brain.

The prostaglandins from inflammation sensitize these nociceptors and cause the pain signal to be sent. Additionally, the mechanical stress caused by the increased fluid volume in a tissue can cause these nociceptors to send pain signals to the brain. Once the pain signal reaches the brain, it is interpreted and the relevance is determined.

Why Ice?

Here is the theory that has been taught for years on why we should use ice:

Ice causes a superficial vasoconstriction of the vessels through a sympathetic response, which leads to a reflex vasoconstriction of the deeper vessels (deeper than the cooling area of ice). The cooling effect of the ice also increases blood viscosity which will decrease the flow of blood. These two things (vasoconstriction and decreased blood flow) combine to decrease edema and fluid leakage.

Additionally, there is a phenomena called secondary cellular injury caused by relative ischemia of the tissues surrounding an injury site. The theory of using ice to treat injury is that it will decrease the metabolism of these cells, which decreases their oxygen demand. By lowering their metabolism, you will diminish secondary cell death due to ischemia.

Finally, ice affects pain in two different ways. First, it slows down nerve conduction velocity (both sensory and motor), which decreases the rate that the pain signal can be transmitted. Second, ice controls pain through the gate control theory, which states that touch and temperature are carried on A-beta fibers. These different stimuli effectively inhibit (blocks) the pain signal transmission to the brain at the T-neuron.

Critically Thinking about Ice

Now that we have reviewed the physiology and the theory behind ice usage, we need to examine if this therapy makes sense.

If inflammation is the first step in the healing process, do we really want to inhibit it? If we reduce the natural debridement and macrophage activity, do we get as many fibroblasts that form a strong scar? Many treatments (Soft Tissue Mobilization (STM), Instrument Assisted Soft Tissue Mobilization (IASTM), eccentric exercise) are actually about restarting the healing process or causing a controlled inflammatory response to improve healing. Ice is a contraindication after many of these techniques because they are trying to take advantage of the benefits of the inflammatory process.

Is there a difference between inflammation and swelling? If inflammation represents increased blood flow and neutrophils, prostaglandins, macrophages, etc., then the lymphatic system should be able to function to carry that extra fluid out of an area. Swelling is really just trapped inflammation. When we ice, we are increasing viscosity and decreasing blood flow. Could this potentially inhibit flow out via the lymphatic system due to increasing the viscosity of the fluid?

How many things that we want to heal do we restrict blood flow, oxygen and nutrient delivery to? I understand that a prolonged or excessive inflammatory phase can delay healing or be damaging. But can we avoid this by helping the body move fluid more effectively, rather than by trying to decrease the flow in?

If ice reduces metabolic rate, will that reduce the healing rate? If it slows everything down, won’t that slow down the healing process as well? Take a fever for example, while a fever is not ideal, it serves a physiologic purpose of helping the body fight the infection. I view the inflammatory process in the same way, while it is not ideal (it hurts, increased fluid decreases function) it helps the body heal and it serves a physiologic function.

These are some of the questions that came to mind when I was examining the physiology. The next post in this blog will examine the current evidence in the literature and see what conclusions we can draw from that. I have tried to find articles examining the variety of ways that ice is used, post-operatively, post-injury, with chronic arthritis and recovering from a game or exercise (i.e. ice baths).

In the meantime, I would love to start a discussion on this blog on your experience and thoughts on using ice to treat injuries.

References

  • Reinl, Gary. Iced! The Illusionary Treatment Option – Second Edition. United States of America, 2014.
  • Cameron, Michelle H. Physical Agents in Rehabilitation: From Research to Practice, Fourth Edition. Saunders, 2012. Pg 13-40.

What Does Going Back To PT School and Justin Timberlake Have in Common?

By: Lauren Falk MS, ATC-L, CSCS, SPT

I was an Athletic Trainer in Division I athletics for 9 years. I was very driven. I loved learning new things, taking my practice to the next level, taking on new challenges, and helping my athletes receive the best care they possibly could. I had grown enough that people were telling me it was time to move on, move to another level, that I needed a new challenge. I was willing to do whatever it took to be successful. But what was success? I received a job offer from an MLS team, but it didn’t fulfill what I was looking for. I needed something more than a better job title or to have an “exciting” job in professional sports. I needed to learn, I needed to be taken out of my comfort zone and forced to grow.

I could not have been more correct. Don’t get more wrong I would have learned a lot by taking a more challenging job. But, I have learned and experienced things this year that I don’t know if I would have ever had the ability to do if I had just taken another job. I have had the opportunity to dissect a cadaver, and let me tell you – there are no pictures in any textbook that will do that justice! I have been taught by Don Neumann and learned things about the mechanics of the shoulder that are truly fascinating (if you don’t know who that is you should look him up – he is practically the godfather of Kinesiology). For better or for worse I have improved my documentation skills. And I have been challenged to learn how to work with patients outside of the population that I have become comfortable with over all of these years. This year has reminded me of how important it is to continue to better yourself through all of the different forms of education and life experience.

I would be lying if I told you that PT school was all sunshine and rainbows. It has been an interesting experience learning how to be a student again. It is a challenge moving from role that I had success in, to a new environment where I had to learn how to learn again, sometimes struggling to remember facts, take tests, and balance studying with having a normal life. It has been a process of embracing the changes, the challenges, and learning how to grow from them. I am so fortunate to be able to be in school with my husband and to share this journey with him. We have spent a lot of time discussing these things as we have shared the ups and downs of this new challenge, which has helped me to grow educationally, professionally, and personally.

One night Michael and I were watching Oprah’s Master Class, this one happened to be about Justin Timberlake. (You may laugh but it is a great show about well known people, their experiences in life, what drives them, what has made them successful – well worth the watch!) As you all know Justin has become a very successful business mogul and he was explaining his theory on what he thinks it takes to “be a master” at something – and it really hit home. He said:

“To be a master at something – it takes a long time at a high level. And for me the way to do that is to always be a beginner. If I’m not learning from something that I’m doing, then that means I’ve done it before. Do something different. . .To always be the novice – that’s what’s exciting to me. To continue to learn. To be lucky enough to have done all the things I have been able to do and learn, and to be thankful for it. “

And in that moment it all made sense. Sometimes while you are in the thick of things, it’s easy to forget what has brought you to this point. I had forgotten how much in my career I loved being a beginner and challenging myself. It was important for me to remember all of the things I have accomplished, and all of the things I still want to accomplish. And that by going back to school – that was what I needed most to accomplish the next step. It made me appreciative of the challenges that I face in school. Because if it was easy, then that means I already knew it – and if I already knew all of these things, then going back to school didn’t serve it’s purpose!

So I received healthy dose of reality, I needed to remember and internalize that it’s ok to be a beginner. That actually it’s great to be a beginner – because that is the one thing that is going to continue to make me better! And to always be thankful for it!

Well said JT . . . well said!

When Does Rehab End and Performance Enhancement Begin?

By: Michael Falk, ATC-L, CSCS, SPT

I was asked the other day “When does rehab. end and performance enhancement begin?” by a fellow student last week, and the answer was more complicated then I had the time to give. So I decided to write about it.

This is a question that has been debated by many professionals working around the sports world either as a strength coach or those rehabilitating athletes. Obviously, when athletes are injured it is commonly seen as a negative, the goal is for every player to make it through every season healthy. However, if we can combine rehabilitation and performance enhancement the time lost to injury does not have to be wasted time.

The answer should should be – DAY ONE.

Why can’t we rehabilitate people, correct movement dysfunction and improve their performance? Why can’t a period away from competition due to injury be an opportunity to attack the rehabilitation process, their strength training and nutrition, and come back bigger, faster, and stronger.

More commonly we are seeing professional teams integrating their rehabilitation and performance programs. Many NBA teams have dual credentialed strength coaches that are also physical therapists or athletic trainers that hold the title of Director of Performance or Director of Athlete Wellness. You see off-season training centers that advertise and promote their integration of rehabilitation and performance enhancement. There was a wave of athletic trainers getting certified through NASM as Performance Enhancement Specialists. Clearly, the trend is spreading. But where is the line drawn?

I propose that their is no line, it is a continuation of a process. The goal should be what is best for the athlete. I think that physical therapists and athletic trainers who are rehabilitating athletes should learn about performance coaching and/or strength training, as well as build a strong relationship with a strength coach.

From the time that rehabilitation begins, there needs to be a mapped out plan that returns the athlete to play. You can never undue the physiologic damage that was done to a joint, tendon, etc. But you can work to correct movement impairments, muscle imbalances, and faulty motor patterns to decrease stress and strain on the affected tissues. We need to not simply settle for return to function, but rather set goals for improving from their baseline. The athlete was injured, that means there is room to improve, and things to correct.

There is no reason that rehabilitation cannot smoothly transition into a performance program. Squats can get heavier, which can progress to single leg, which can foster a progression to running, cutting and jumping. Shoulder exercises can progress past the theoretical wall in physical therapy clinics of 5 lbs. There is no reason that with progressive overload and proper technique that people cannot get stronger in a traditional “rehabilitation exercise.” There is also no reason that a traditional strength training exercise cannot be regressed and incorporated into a rehabilitation program.

Charlie Weingroff,PT, DPT, CSCS is one of the leaders in this area. His DVD series Training = Rehab, Rehab = Training discusses this issue in detail. His main concept surrounding this is to never stop training. All you need to do is lateralize and/or regress an exercise to a level that the athlete can safely handle. This is where the skill of the rehabilitation staff and a strong partnership with a strength coach can make all the difference .

Building strength is critical for people to recover from injury. Often weakness, or muscle imbalances are blamed as the “cause” of an injury. Why wouldn’t we try to get people as functionally strong as possible during their rehab program? Again, the rehabilitation staff needs to use their skill to keep the athlete at appropriate levels of activity as they recover and to identify and correct imbalances or dysfunctional movement.

There is also no reason that physical therapists or athletic trainers without the training and expertise in performance enhancement cannot devise ways to keep athletes involved in a training program. This requires trust and a relationship between a strength coach and the rehabilitation team. However, you must remember – trust, much like communication is a two-way street. The mark of a great professional is someone that knows what they don’t know, who stays within their area of expertise, and reaches out to others for theirs. As a physical therapist or athletic trainer, if you are not comfortable with the performance enhancement aspect of a rehabilitation program, integrate yourself with a strength coach. Develop strong lines of communication so that the athletes under a rehab protocol still get the maximal advantage out of their training. The flip side of that relationship is that as a strength coach, it is valuable to reach out to a physical therapist or athletic trainer when an athlete is demonstrating a dysfunctional movement pattern, pain or difficulty with a lift. This way both sides of the equation are always working together to keep the athlete functioning at their highest potential.

Everyday that we hold an athlete out of training is a day that their teammates or competition move ahead of them. Mentally, it can become very draining for an athlete. They are already missing time in their sport, holding them out of training is taking another medium for them to interact with their teammates, participate in their normal routine and feel like an athlete.

The easy way to keep someone safe is to do nothing, keep them in a bubble and they will not get hurt. But is this what is best for the athlete? It is harder to think critically, understand the biomechanics and kinesiology of their injury, and modify lifts and activities to allow them to improve and remain safe. It is crucial to build a relationship with the performance staff and allow them to help the athletes train effectively and safely.

I hope to encourage everyone to challenge your athletes, don’t be limited to the 5 lb dumbbells when the athlete is capable of 20 lbs. Don’t eliminate training because they may get hurt – find ways to modify it so they can safely participate. Allow them to benefit from their time away from competition. Challenge them, make them work, and return them to the field bigger, faster and stronger then when they left.