The Healthy Swimmer
Ice, Ice, Maybe (Not)
Sergey Mikhaylov/BigStock
O
n a Tuesday morning
three summers ago, I
was dragging our
weekly garbage bags to the
curb for pickup. Thanks to a
semi-taper, my body felt less
rickety than usual, a fair omen
for an upcoming long course
meters meet that weekend.
Chronologically still 59, I had
nevertheless “aged up” to 60 in
FINA years and hoped to capitalize on my status as youngpup-in-old-dog division. I
reached over to hoist a bloated
Hefty, realizing too late that my
wife had filled it with bustedup fragments of concrete.
A taser to the sacroiliac could
not have been more incapacitating. It took 10 minutes to crawl/
slither back inside our house,
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hoist myself up to the freezer,
and grab my best hope for relief:
an oversized ice bag I kept everready. Shoulders, elbows, hips,
knees, ankles—injuries to any of
these bring unique torments, but
there’s nothing like a massive
back sprain to make you feel ancient in an instant. As I lay on
ice, I texted the meet director
hoping for a refunded entry fee.
Or, barring that, permission to
swim in the 120–124 age group.
When it comes to self-help
treatments, I’ve backed the
wrong horse many times, from
forcing down fluids before exercising in the heat (a recipe for
hyponatremia) to popping antioxidants to boost training effects (such supplements now appear to undercut physiological
adaptation). Thanks to these
and other reversals in the medical literature, I’ve become skeptical of much conventional wisdom. But one pearl I never
thought would lose its luster
was RICE, especially its famous
“I” component.
RICE stands for Rest, Ice,
Compression, and Elevation,
and it’s one of the few medical
acronyms with household-name
status. RICE was coined by physician Gabe Mirkin in his bestseller, “The Sportsmedicine
Book” (Little, Brown, 1978).
Over the following decades, athletic victims of sprains and
strains have reflexively grabbed
for the ice pack (or, in a pinch, a
bag of frozen vegetables) at the
first hint of orthopedic trauma.
Especially when applied within
the first “Golden Hour” of injury, the healing powers of ice
were considered, by patients
and practitioners alike, akin to
a trip to Lourdes.
But faith in miracles does not
necessarily make them so. Ice
does relieve pain by reducing the
sensitivity of pain-sensing receptors, called nociceptors, plus the
nerve fibers that transmit pain
signals to the brain. But as for
expediting actual healing, a big
chill does not accomplish what
we’ve long been led to believe.
Veteran sports trainer Gary
Reinl first became skeptical after searching the medical literature for the best ways to ice different injuries. What he discovered shocked him. In 2012, the
British Journal of Sports
Medicine published a review of
22 earlier studies on cryotherapy and concluded that “ice is
commonly used after acute
muscle strains, but there are no
clinical studies of its effectiveness.” A 2013 study in the
Journal of Strength and Conditioning Research reported
that icing not only doesn’t
help, it may well delay recovery
from injury. Research completed at the University of Pittsburgh Medical Center argues
that icing sore muscles may be
detrimental to recovery.
“Icing just doesn’t work—it
actually screws things up,” says
Reinl, whose book “ICED! The
Illusionary Treatment Option,”
is dedicated to—in his words—
encouraging doctors and athletes alike to move “out of the
Ice Age” and toward a new approach, which he calls ARITA
(More on this in a moment.)
Reinl has gained a growing
cadre of academic and athletic
boosters, including one particularly high-profile doctor: Mirkin
himself, who now openly rejects
the RICE advice that helped
make him famous. “I do not believe in cooling anymore,” Mirkin wrote in an email.
Nor does he believe in the
“R” component of his famous
prescription either. In a foreword to the second edition of
“ICED!” Mirkin acknowledges
that ice can temporarily suppress pain, but that most athletes are far more concerned
with long-term healing than
transient palliation. “And research,” he writes, “now shows
that rest and ice actually delay
recovery.” Mirkin credits researchers at the Cleveland Clinic for discovering one particularly deleterious impact of ice: it
delays the release of IGF-1 (Insulin-like Growth Factor-1), a
key hormone released by immune cells in order to repair
damaged tissues.
So if ice doesn’t do what we
think it does, how exactly did it
become so entrenched in both
popular and medical cultures?
Reinl credits a freak accident in
1962 with launching the mythology. A 12-year-old boy
named Everett Knowles attempted to hop a freight train in
Somerville, Mass. He miscalculated his trajectory and his arm
was severed from his body. The
boy picked it up and flagged
down help. A police ambulance
rushed him to Massachusetts
General Hospital.
There, a team of Harvard
physicians led by Ronald Malt
managed to reattach his arm—a
first-of-its-kind operation that
garnered headlines worldwide.
The key, Malt told reporters,
was their decision to “put it on
ice” to prevent further damage
until they were ready to surgically reattach it.
“The decision to use ice,”
says Reinl, “did keep the boy’s
arm from deteriorating any
further. But it had absolutely
nothing to do with regenerating damaged tissue, nothing.
It only prevented the arm
from rotting.”
Alas, this wasn’t the message
the general public heard. If ice
could save a severed limb, surely it could keep a sore shoulder,
tweaked knee, or sprained lower back from erupting into an
escalating inflammatory nightmare of pain, swelling, and
protracted disability.
“Nearly everyone who ices
today,” says Reinl, “believes
they’re doing it to prevent inflammation, reduce swelling,
and control pain. But here’s the
problem: Icing doesn’t prevent
inflammation or swelling, it
only delays it. Once tissues rewarm, the inflammatory process resumes and your body’s innate intelligence sends the correct amount of fluid to the damage site. Although icing can provide temporary pain relief,
numbing just shuts off protective
signals that alert you to harmful
movement. And the Journal of
Athletic Medicine Research recently showed that icing actually
kills muscle cells.” Inflammation used to be a
widely demonized bogeyman,
but investigators now know it’s
a highly evolved, exquisitely calibrated system for repairing injuries. The moment after an
acute trauma, the immune system seals off damaged blood
vessels by forming clots within
them. Healthy blood vessels automatically dilate, perfusing the
affected area with additional
blood flow and a cascade of
healing factors, from macrophages to myokines. Rather
than a symptom of malfunction,
swelling is evidence the system is
working as intended. Damaged
cells and other debris are gobbled up and diverted to the lymphatic system for removal. The
temporary increase in pain signals serve as powerful warnings
against movements that can
cause more damage.
“The human body is absolutely remarkable, and most of
the time it knows what it’s doing,” says Nicholas DiNubile,
an orthopedic surgeon and former team physician for the Philadelphia 76ers. “I still believe
there’s an occasional place in the
medical bag for ice—for athletes
in acute pain, for instance, I’d
rather they use ice than Percocet
or Vicodin. But you really have
to be mindful of what you’re
trying to accomplish before you
throw in the ice pack.”
Reinl agrees that ice can
sometimes make sense for temporary analgesia—provided
you don’t use numbness as an
excuse to cause further injury.
But if optimal healing is your
goal, he says, forget the ice and
concentrate instead on active
movement instead. “We don’t
understand everything about
this yet,” Reinl concedes, “but
we do know that stillness is the
enemy. If you remain still, everything shrinks and atrophies—your muscles, bones,
ligaments, everything.”
Careful muscle activation, by
contrast, brings a host of benefits. Contractions around lymphatic vessels remove waste
from the system while increasing
blood circulation to damaged tissues. Such enhanced blood flow
expedites both the immediate deposition of replacement collagen
and the crucial “remodeling”
process that pulls apart scar tissue and makes it functional.
All of which brings us back to
ARITA—Active Recovery Is
The Answer—Reinl’s new acronym for those of us who love
our sports despite the inevitable
pains they sometimes bring.
ARITA may not appeal to
everyone, but it’s absolutely
worked for me. A half hour after icing the small of my back,
I forced myself off the couch
and hobbled around the block.
For the rest of the day, I repeated this every hour on the
hour. By Wednesday, I was
back in the pool. Though I
needed a pull buoy to keep my
sciatic legs from sinking, I still
“crawled” 1000 yards using
open turns. The Saturday the
meet began was the first time I
tried a flip turn.
But when the starter horn
blasted, something else kicked
in courtesy of the human body’s
innate healing prowess—endorphins, maybe, or some other
compound for battlefield analgesia. It was a small LCM meet,
granted, but I still won all my
events—both in the 120-124
age group and my own new
one, too. That night, I threw
away my ice bag in favor of a
new approach. To the extent my
body allows me to move, I’ve resolved to do so. Arriba ARITA!
— Jim Thornton
The information in “The
Healthy Swimmer” is not intended to be a substitute for
professional or medical advice
on personal health matters.
For personal medical advice,
or if you are concerned about
a medical condition or injury,
see your healthcare provider
for evaluation and care.
may-june 2015
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