Tag Archives: swelling

Why Ice and Anti-inflammatory Medication is NOT the Answer

This is a reprint from Stone Athletic Medicine:

 

In July I posted a blog discussing The Overuse of Cryotherapy. The controversy surrounding the topic made it one of the most popular blogs I’ve written. What is surprising to me is that a controversy exists at all. Why, where, and when did this notion of anti-inflammation start? Ice, compression, elevation and NSAIDs are so commonplace that suggesting otherwise is laughable to most. Enter an Athletic Training Room or Physical Therapy Clinic nearly all clients are receiving some type of anti-inflammatory treatment (ice, compression, massage, NSAIDs, biophysical modalities, etc). I evaluated a client the other day and asked what are you doing currently – “Well, I am taking anti-inflammatories and icing.” Why do you want to get rid of inflammation and swelling? I ask this question for both chronic and acute injury!

The Stigma of Inflammation:

Editor in Chief of The Physician and Sports Medicine Journal (Dr. Nick DiNubile) once posed this question: “Seriously, do you honestly believe that your body’s natural inflammatory response is a mistake?” Much like a fever increases body temperature to kill off foreign invaders; inflammation is the first physiological process to the repair and remodeling of tissue. Inflammation, repair, and remodel. You cannot have tissue repair or remodeling without inflammation.  In a healthy healing process, a proliferative phase consisting of a mixture of inflammatory cells and fibroblasts naturally follows the inflammatory phase (1). Researchers headed by Lan Zhou, MD, PhD, at the Cleveland Clinic, found that in response to acute muscle injury, inflammatory cells within the damaged muscle conduct phagocytosis, contribute to accumulation of intramuscular macrophages, and produce a high-level of Insulin-like growth factor 1, (IGF-1) which is required for muscle regeneration (3). IGF-1 is a primary mediator of the effects of growth hormone and a stimulator of cell growth and proliferation, and a potent inhibitor of programmed cell death. Similarly, in 2010, Cottrell and O’Conner stated “overwhelmingly, NSAIDs inhibit or delay fracture healing” (2). And you want to stop this critical process of healing by applying ice, because inflammation is “bad”?

The Anecdotal Rationale for Ice:

Somewhere along the line the concept that ice facilitates healing became conventional wisdom. Sorry, that wisdom is wrong. I had someone tell me the other day, “We need to ice, because we need to get the swelling out.” Really? Does ice facilitate movement of fluid out of the injured area? No, it does not. The lymphatic system removes swelling. The Textbook of Medical Physiology says it best: “The lymphatic system is a ‘scavenger’ system that removes excess fluid, protein molecules, debris, and other matter from the tissue spaces. When fluid enters the terminal lymphatic capillaries, any motion in the tissues that intermittently compresses the lymphatic capillaries propels the lymph forward through the lymphatic system, eventually emptying the lymph back into the circulation.”  Lymphatic drainage is facilitated by contraction of surrounding muscle and changes in compressive forces that push the fluid back to the cardiovascular system. This is why ankle pumps work so well at removing swelling.

Inflammation is a necessary component in the first phase of phase of the healing process. Swelling is controlled by the body’s internal systems to attain homeostasis. If swelling is accumulated it is not because there is excessive swelling, rather it is because lymphatic drainage is slowed. The thought that ice application increases lymphatic flow to remove debris makes no sense. Gary Reinl, author of “Iced! The Illusionary Treatment option gave me a good analogy. Take two tubes of toothpaste, one is under ice for 20 minutes, the other is warmed to 99 degrees. In which tube will the toothpaste flow fastest?  It does not take an advanced physics degree to know that answer.

What might surprise you is that ice actually reverses lymphatic drainage and pushes fluid back to interstitial space. A study published in 1986 (yes, 1986, is old, but this is a foundational study) found when ice is applied to a body part for a prolonged period of time; lymphatic vessels begin to dramatically increase permeability. As lymphatic permeability increases fluid will pour from the lymphatics into the injured area, increasing the amount of local swelling (5). Ice can increase swelling and retard debris removal!

The Acronym RICE is Bogus:

The acronym RICE is bogus in my opinion. First, Rest is not the answer. Rest does not stimulate tissue repair. In fact rest causes tissue to waste and can cause abnormal gene transcription of collagen tissue. Evidence has shown that tissue loading through exercise or other mechanical means stimulates gene transcription, proteogenesis, and formation of type I collagen fibers (See studies by Karim Khan, Durieux, Mick Joseph, and Craig Denegar). Our body has all types of cells. When a cell is born it has no clue what type of cell it will eventually become. This infancy cell – for lack of a better term – is called a progenitor cell. Progenitor cells can be changed to a specific cell type. Load in tendon tells our body to turn a progenitor cell in to a tenocyte. Load in bone tells a progenitor cell to become an osteocyte. Ever wonder why myositis ossificans (calcification or bone growth in muscle) develops? The direct, repeated trauma turns progenitor cell currently living within muscle to an osteocyte. Subsequently, we develop bone growth within muscle.

The other reason RICE is bogus is obvious; Ice. Ice does nothing to facilitate collagen formation. Ice will not influence progenitor cell development. Ice does not regenerate tissue. Ice does not facilitate healing – it inhibits natural healing process from occurring. Ice does not remove swelling; it increases swelling and lymphatic backflow.

Closing thoughts:

Bottom line, ice and NSAIDs are over utilized. I am not saying never, but I am saying ice is not a magical cure all that fixes everything and is required for healing. It is not the gold standard that it has come to be. My goal with this blog is to get individuals to stop and think before immediately turning to ice and NSAIDs. Is it really the best option? Is it necessary for this injury at this stage? I understand it is not the only form of treatment clinicians use, but ice certainly is the most heavily used. Go ahead, I will wait while you look at your treatment logs.

My goal is to get this trend reversed one clinician and one patient at a time. Have you seen the video discussion between Kelly Starrett, DPT and Gary Reinl? If not I recommend you watch it. It’s fascinating. I am glad to have expert minds like Kelly and Gary in this fight with me.

I ask health care professionals to do one thing, just try it. Pick one client with chronic musculoskeletal pain, skip the ice, skip the NSAIDs and try to use light exercise as a repair stimulus. Then, try skipping the ice on a client with an acute mild injury. The outcomes might surprise you.

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Cold Laser for All Animals and People

Cold laser therapy offers a wide range of options for tissue therapy, wound healing, pain management, and improved circulation. Cold laser therapy is a game changer for many pets suffering from painful injuries. This technology allows us to successfully treat many injuries including tissue damage, inflammation, wounds, and even scars with minimal invasion.

The technology has been used in Europe since 1970 to promote healing, but has only been approved by the FDA for use in the U.S. since 2002. It is only recently, though, that U.S. veterinarians have begun using it to treat many different conditions that affect pets today, such as fractures, ligament and tendon injuries, post-surgical incisions, arthritis, nerve injuries, sprains, muscle strains, abrasions, lesions, and more.

Cold laser therapy is non-invasive and makes use of light in order to stimulate activity or regeneration in cells in addition to increasing blood circulation. Unlike hot laser treatments that target tissue deep beneath the skin’s surface, cold laser therapy treats injuries or damage on or near the surface – without the risk of cutting or burning from the lasers. Most conditions require between three and eight treatments, though I have seen great improvement after the first laser session. Most animals enjoy their seession: many fall asleep or thoroughly relax. th

 

Whole Body Treatment

The usual approach to treating sore muscles is to use liniment for a relaxing rubdown, or use a high tech blanket, or maybe do some leg stretches.  And if none of those techniques work, what is next?  Trigger points, or muscle knots, are small patches of contracted muscle fibers that cause aching and stiffness. When activated through strain or injury, they cause pain either at the site itself, or refer it somewhere else in the body.

Thousands of muscle fibers contract to create movement. Sometimes muscle fibers can tear, leading to tension, swelling, and heat. What may begin as a small numbers of fibers, barely noticeable, can become a progressive problem as the micro trauma spreads to adjacent muscle fibers.

Conscientious riders will be aware of the smallest change in movement or behavior and take action before the problem becomes a major injury.

When muscle fibers are injured, the surrounding area becomes shortened and tight. This uneven stress can be transferred through the fascia and cause additional pain and restrictions in other parts of the body as trigger points or stress points.  My job is to apply gentle pressure until the restriction is released, and free movement and balance are restored. Muscle tension, pain, postural imbalances, and improved circulation are all benefits of stress and trigger point therapy. As Jack Meagher always said, “That is called putting your finger on the problem!”

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New Applications for Cold Laser Therapy

Almost every day, there are new and exciting announcements on ways that low level laser therapy can help keep us and our animals healthy.  The following is from Valerie C. Coffey, Science Writer:

It started with mouse hairs. In 1967, Dr. Endre Mester of Semmelweis Medical University in Budapest, Hungary, recognized that a low-power ruby laser could stimulate faster hair regrowth in mice. Since then, lasers have increasingly become an important instrument in the physician’s toolbox. 

Today, research is advancing toward the use of lasers to diagnose and treat a plethora of conditions. Recent rapid technological developments in lasers have contributed to their safe and effective use in surgical settings, aesthetic treatments, ophthalmology, oncology, cardiology and many other biomedical applications, including veterinary settings. 

Lasers’ efficiency, safety and precision are the drivers behind this growth. In surgical applications, medical lasers are more precise than conventional surgical scalpels, and therefore cause less damage to surrounding tissue. Although systems are expensive and operators of medical lasers require special training, the advantages of reduced pain, bleeding, swelling and scarring are compelling enough to justify their widespread adoption. 

Much current cutting-edge research is focused on biophysical and physiological studies at the molecular and cellular level, and on lasers’ effects on whole organisms. A group at the University of Texas at Arlington, led by assistant professor of physics Dr. Samarendra Mohanty, has used low-power near-IR lasers and crystalline magnetic carbon nanoparticles (CNPs) to perform photothermal delivery of impermeable dyes and plasmids (self-replicating DNA molecules) into live human prostate cancer (PC3) cells (Scientific Reports, doi: 10.1038/srep05106). The noninvasive technique involves directing a CW Ti:sapphire laser at 800 nm toward the cancer cells in the presence of plasmids and CNPs measuring 5-10 nm. The heat causes the CNPs to stretch the cell membranes and increase fluid flow to allow exogenous substances (plasmids, for example, or an agent that kills the cancer) to be delivered.

Laser therapy is one of several emerging medical and veterinary techniques using high-intensity light to stimulate cellular function in tissue, or to shrink and destroy tumors and precancerous growths. Doctors can direct laser therapy on the surface of a body, or use it to reach where conventional surgical techniques can’t, via a flexible fiber optic endoscope inserted through the mouth, nose, colon or vagina.

Photodynamic therapy is another laser therapy approach that activates an applied photosensitive agent that kills only the cancer cells.

Recent medical research theorizes that the mechanism of low-level laser therapy is primarily via the absorption of light within mitochondria, the numerous “power plants” within cells that convert the oxygen and pyruvate from food into cellular energy via adenosine triphosphate (ATP). As it happens, cytochrome C oxidase, a critical protein involved in the regulation of mitochondrial activity, is a photoacceptor of light in the near- to far-IR. At the cellular level, LLLT displaces nitric oxide from the respiratory chain to increase levels of ATP and reactive oxygen species. The deep-tissue application of laser or LED devices in LLLT techniques may work via this mitochondrial mechanism to promote tissue repair, reduce inflammation and induce analgesia, according to James Carroll, medical researcher, and founder and CEO of Thor Photomedicine in Chesham, England

In 2012, researchers at the Institute of Ophthalmology at University College London applied LLLT to eye disease. Researcher Dr. Rana Begum and colleagues found that when the retinas of aged mice were exposed to five 90-s exposures of 670-nm light over 35 hours, key inflammatory markers in the mitochondrial membrane were significantly reduced (Neurobiology of Aging).  The hope is that, someday, the noninvasive approach may help to slow the progression of dry age-related macular degeneration, according to founder and CEO Clark Tedford.

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The Cold, or Soft, Laser

Many types of injuries, as well as chronic conditions, can be effectively treated with the cold laser.

Low Level Laser Therapy  is the use of therapeutic (or cold) laser light to provide relief from pain, eliminate inflammation or swelling, or to repair damaged tissues. The cold, or soft laser,  is entirely noninvasive and has a wide range of applications, from neural muscular-skeletal conditions to wound healing to acupuncture treatments. Rather than destroying tissue, as with surgical (or hot) lasers, LLLT uses low intensity laser light energy to stimulate cells through a number of known cellular pathways in order to encourage tissue healing.

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Pain Relief Without Drugs

The cold laser I use is different from the lasers used to perform surgery. The lower frequency of light of the therapeutic laser used at horse shows by me and other practitioners does not cut or cauterize tissue.

You might want to try the soothing effects of the laser on your own aches and pains, so you know what your horse, dog, or cat is experiencing. Laser light takes the soreness out of painful tissue and enhances the delivery of blood, oxygen and nutrients to the injury site. This increase in circulation allows the tissues to expel lactic acids or other metabolic wastes along with inflammatory substances that contribute to local pain and swelling.

You can experience natural pain relief without the risks associated with pain medications. Most studies conclude that much faster healing takes place from injury when cold laser therapy is included in the recovery treatment.

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Cold Laser Case Study

I was called to a barn yesterday to work on a horse with a swollen leg. He had been playing in turnout and caught his leg on a wire. There was a shallow puncture on the fetlock of his right front leg. The leg was pretty big ( I apologize for not providing before and after photos. Sometimes, when I’m in the middle of assessing a problem, and I’m concerned about the horse being in pain, I forget that my phone, with camera, is right there in  my pocket!). I used the cold laser, with three different settings, on the swelling, for about an hour. Both the owner, the horse, and I were thrilled that the leg was almost normal at the end of the treatment. Unless you looked carefully, it was hard to find the remaining swollen area. Today I’ll be going back, and I will report on Day 2 of treatment.

Cold lasers or low level lasers are very effective at treating soft tissue injuries and eliminating the excess fluid and swelling.” Dr.Schnee,D.C. of Fort Worth Texas

When Not to Massage

I love doing bodywork and writing about it, but there are times when massage is not appropriate:

The first 24-48 hours after an injury is a time for veterinary care.

The first couple of days of an illness, especially when fever is present, is not a time for bodywork.

If heat or swelling are present, do not treat those areas with massage (though cold laser is very helpful ).

If there is head bobbing lameness, call the vet.

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