ICE therapy IS still good!  – Especially for my patients!!


Public Commentary by Dr. Makani Lew, BSc, DC on ICE and how it can be ESSENTIAL in patient healing to use ice.

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Last edited 5/11/2014

~In health to all, Dr. Lew, DC~


This is in response to several blogs and an article saying we approached the end of the RICE era:  (from the man who created “RICE” in acute care)

In a nutshell, the articles question the use of ice because it appears to reduce the normal metabolic effects of the healing properties of inflammation.


This Ice-hating is a subject that I've been planning to address officially through various written journals. In the meantime, here is what I have so far.


I've been very disturbed about the jump on the bandwagon against ICE movement. As a person who has been studying ice and its effects since 1991, I feel I come to the table with a degree of authority. Furthermore, it seems in most of these studies there is no accounting for the amount of NSAIDs or SAIDs taken for pain. 


Here are my current thoughts:

1) The first question is what is the goal?

a) Decrease pain and/or

b) Decrease swelling

c) Hasten healing (Does it? this is the one that is in question- based on a Bleakley 2004 systematic review of in-hospital injury care. Bleakley C, McDonough S, and MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports Med January 2004 32 251-261. HOWEVER, has anyone seen the ice pack appropriately applied in the hospital recently?? I have not. It is usually draped over the area that is in a stabilizer brace. And the cold cannot penetrate the cast material.)


2) The second question is: who is the patient?

Here is what I think the basic formula for patient type is. (Combinations of these, of course, exist):

a) A fit athlete performing a strenuous athletic endeavor?

b) A person attempting new fitness activities?

c) An average person who was injured by a rapid trauma?

d) An average person who was injured by a repetitive use or repetitive posture trauma


3) I believe that reducing pain and swelling in the first 24 hours is key to the outcome of the injury.

a) Ice is known to reduce interstitial swelling ONLY in the first 24-48 hours

b) Reduction of the initial swelling will reduce secondary tissue damage due to tissue distension

c) Reduction in swelling is dramatically increased with compression

d) Remember: heat transfers from hot to cold and not vice versa. Therefore Application of a cold object will in effect draw the blood flow and “heat” of inflammation out to the surface. This is why a bigger body part or more several injury (eg quads contusion) takes longer to get “numb”. Pulling the blood out will cause the internal swelling to be reduced (superficial venous drainage).

e) Cooling of the tissues will reduce the NCV (nerve conduction velocity), thereby reducing the sensation of pain


4) What about the analgesic properties of ice? Why provide “pain relief”?

a) Decreasing pain naturally is my primary goal- so if I can take a person from writhing in pain and going into adrenal overload (and therefore sympathetically induced muscle tightness “spasms” and anxiety), I feel the metabolism issues are less vital.

b) A few minutes of pain relief can provide a bridge to sleep, muscle relaxation, more open-mind for mindfulness healing and so much more. 


5) Are pharmaceutical anti-inflammatories the answer? If the argument against ice is that it messes with normal inflammation and tissue metabolism, then we should avoid the following as well

a) NSAIDs (The risk of serious gastro-intestinal ulcer complications is about 2.5-4.5 higher in NSAID users than in non-NSAID-users. Zhang, W. (2007) NSAIDs and Pain Management in Sports, in Evidence-based Sports Medicine, Second Edition (eds D. MacAuley and T. M. Best), Blackwell Publishing, Malden, Massachusetts, USA.)

b) SAIDs


6) What about using heat on the acute injury?

a) A well-done study showed that heat or ice on a swollen sprained ankle in the first few days showed same 6-month outcomes in terms of "back on the field" abilities.

b) However, use of heat will increase the swelling and thereby the secondary tissue damage


7) What other types of modalities help? (appear to decrease initial inflammation overload?) * means there appears to be supportive evidence, x means there appears to be evidence that the modality doesn't do as we once thought, - means that evidence is either lacking or being gathered at present.

a) Cold-laser (3b) *

b) Pulsed ultrasound x

c) Microcurrent -

d) IASTM (Instrument-Assisted Soft Tissue Massage) -

(Graston, FAKTR (Functional and Kinetic Treatment with Rehab), Tecnica Gavilan, etc)

e) Kinesiotape/Rocktape/etc edema strips (RockTape, Kinesiotape, KT Tape, Spider Tech) -

f) Voodoo flossing -

g) Careful low range of movement of an mild to moderately injured body part *

Bleakley C. Effect of accelerated rehabilitation on function after ankle sprain: RCT 2010

h) Epsom salts soaks (mostly athlete and grandmother anecdotal evidence on this) -

i) ??? (there must be more out there!)


8) If I do still decide to ice, what ice set up is best?

a) It is patient dependent- size of limb/body part, patient gender, patient fitness level, patient preference

b) NEVER Ice longer than the first indication of numbness

c) Bags of ice are the safest

d) Wet ice is better- add a wet towel between the ice bag and the skin

e) Addition of compression is essential in controlling swelling (not too tight/not too loose)

f) Couple the cryotherapy with other supportive modalities (listed above)


So, I conclude: as a drug-free practitioner, are we not always seeking ways to reduce pain and the anxiety of pain? I believe that ice still plays a key role especially in the first 2 days. Period.




I am sorry I haven’t included in this commentary all the reference links to each of the above statements (yet). I recently did a research platform presentation on findings from a study conducted on the Palmer College of Chiropractic West Campus titled Time to numbness in response to 5 different cryotherapy applications.

Here is a link to my platform abstract:  

(To request a handout from my ACC-RAC 2014 platform presentation, send an email to: (Be put in the email subject:  “requesting copy of Ice handout” and provide an explanation of your request in the email text body.)


Here is my Platform Presentation Reference list.

(This is, of course, not a complete list of references that I turn to regarding the subject of ice)


Agafly A and George K. The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. Br J Sports Med 2007;41:365-9.


Belanger A. Chapter 8: Cryotherapy in Therapeutic Electrophysical Agents: Evidence Behind Practice. Lippincott Williams and Wilkins, Philadelphia, 2010.


Belitsky R, Odam S, and Hubley-Kozey C. Evaluation of effectiveness of wet ice, dry ice, and cryogen packs in reducing skin temperature. Phys Ther 1987;67(7):1080-1084.


Bleakley C and Hopkins J. Is it possible to achieve optimal levels of tissue cooling in cryotherapy? Phys Ther Rev 2010;15(4):344-50


Bleakley C and MacAuley D. Chapter 11: What is the role of ice in soft-tissue injury management? In MacAuley D and Best T. Evidence-Based Sports Medicine. Evidence-Based Sports Medicine, 2nd

ed. BMJ Books London. 2007.


Bleakley C, McDonough S, and MacAuley D. Cryotherapy for acute ankle sprains: a randomized controlled study of two different icing protocols. Br J Sports Med 2006;40:700-5.


Bleakley C, McDonough S, Gardner E, Baxter GD, Hopkins JTy, and Davison GW. Cold-immersion for preventing and treating muscle soreness after exercise. Cochrane Database Syst Rev 2012 Feb 15;2:CD008262.


Cameron M. Chapter 8: Superficial Cold and Heat in Physical Agents in Rehabilitation: From Research to Practice, 4th ed., Saunders, Philadelphia, 2013.


Denegar C. Chapter 8: Cold and Superficial Heat in Therapeutic Modalities for Musculoskeletal Injuries, 3rd ed., Human Kinetics Publishers, Champaign, 2010.


Dykstra J, Hill H, Miller M, Cheatham C, Michael T, and Baker R. Comparisons of cubed ice, crushed ice, and wetted ice on intramuscular and surface temperature changes. J Athl Train 2009;44(2):136–41.


Enwemeka C, Allen C, Avila P, Bina J, Konrade J, and Munns S. Soft tissue thermodynamics before, during and after cold pack therapy. Med Sci Sports Exerc 2001;34(1):45-50.


Frute S. in Michlovitz S, Bellow J, and Nolan T. Chapter 2: Cold Therapy in Modalities for Therapeutic Intervention, 5th Ed., FA Davis, Philadelphia, 2012.


Graham C and Stevenson J. Frozen chips: an unusual cause of severe frostbite. Br J Sports Med 2000;34:382-4.


Herrera E, Sandoval M, Camargo D, and Salvini T. Motor and sensory nerve conductions are affected differently by ice pack, ice massage, and cold water immersion. Phys Ther 2010;90(4):581-91.


Hocutt J, Jaffe R, Rylander R, Beebe K. Cryotherapy in ankle sprains. Am J Sports Med 1982;10(5):316-9.


Hopkins JT, Knee joint effusion and cryotherapy alter lower chain kinetics and muscle activity. J Athl Train 2006;41(2):177-84.


Hubbard T, Aronson S, and Denegar C. Does cryotherapy hasten to participation? A systematic review. J Athl Train 2004;39(1):88-9.


Jutte L, Hawkins J, Miller K, Long B, and Knight K. Skinfold thickness at 8 common cryotherapy sites in various athletic populations. J Athl Train 2012;47(2):170-7.


Jutte L, Merrick M, Ingersoll C, and Edwards J. The relationship between intramuscular temperature, skin temperature, and adipose thickness during cryotherapy and rewarming. Arch Phys Med Rehabil 2001;82:845-50.


Kanlayanaphotporn R and Janwantanakul P. Comparison of skin surface temperature during the application of various cryotherapy modalities. Arch Phys Med Rehabil 2005;86:1411-5.


Knight K and Draper D. Chapter 13: Cryotherapy, Beyond Immediate Care in Therapeutic Modalities, the Art and Science, 2nd ed., Lippincott Williams and Wilkins, 2012.


Knight K and Draper D. Chapter 5: Immediate care in acute orthopedic injuries in Therapeutic Modalities, the Art and Science, 2nd ed., Lippincott Williams and Wilkins, 2012.


Knight K. Cryotherapy: Theory, Technique and Physiology, 1st ed., Human Kinetics Publishers, Champaign, 1985.


MacAuley D. Chapter 4: What is the role of ice in soft tissue injury management?  In MacAuley D and Best T. Evidence-Based Sports Medicine. Evidence-Based Sports Medicine, 2nd ed. BMJ Books London. 2002.


MacAuley D. Do textbooks agree on their advice on ice? Clin J Sport Med 2001;11(2):67-72.


Merrick M, Knight K, Ingersoll C, and Potteiger J. The effects of ice and compressive wraps on intramuscular temperatures at various depths. J Athl Train 1993;28(3):236-245.


Merrick M. Chapter 8: Therapeutic Modalities as an Adjunct to Rehabilitation in Andrews J, Harrelson G, and Wilk K. Physical Rehabilitation of the Injured Athlete, 4th ed., Elsevier Saunders, Philadephia, PA, 2012.


Myrer J, Measom G, and Fellingham G. Temperature Changes in the Human Leg During and After Two Methods of Cryotherapy. J Athl Train 1998;33(1):25-9.


Nadler S, Prybicien M, Malanga G, and Sicher D. Complications from therapeutic modalities: results of a national survey of athletic trainers. Arch Phys Med Rehabil 2003;84:849-53.


Otte J, Merrick M, Ingersoll C, and Cordova M. Subcutaneous adipose tissue thickness alters cooling time during cryotherapy. Arch Phys Med Rehabil 2002;83:1501-5.


Park G, Kim C, Park S, Kim M, and Jang S. Reliability and usefulness of the pressure pain threshold measurement in patients with myofascial pain. Ann Rehabil Med 2011; 35: 412-7.


Rupp K, Herman D, Hertel J, and Saliba S. Intramuscular temperature changes during and after two different cryotherapy interventions in healthy individuals. J Orthop Sports Phys Ther 2012;42(8):731-7.


Starkey C. Chapter 5: Thermal Modalities in Therapeutic Modalities, 4th ed. FA Davis, Philadelphia, PA, 2013.


Tegeder I, Adolph J, Schmidt H, Woolf C. Geisslinger G, and Lotsch J. Reduced hyperalgesia in homozygous carriers of a GTP cyclohydrolase 1 haplotype. Eur J Pain 12 (2008) 1069-77.


Tomchuk D, Rubley M, Holcomb W. Guadagnoli M, and Tarno J. The magnitude of tissue cooling during cryotherapy with varied types of compression. J Athl Train 2010;45(3):230-7.


Ungar E and Stroud K. A new approach to defining human touch temperature standards. NASA, Johnson Space Center, Houston, TX Conference Proceedings, 2010


Zemke J, Andersen J, Guion WK, McMillan J, and Joyner B. Intramuscular temperature responses in the human leg to two forms of cryotherapy: ice massage and ice bag. J Ortho Sports Phys Ther 1998;27(4):301-7.


Here is a link to my PubMed list of refs- it is constantly updated and growing:

Also, if the text is housed on PubMed, it can’t be linked to this list. So some excellent resources aren’t on my list.


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page last modified 5/11/2014