Ice or Heat

Confusing Question ever....

ICE OR HEAT

Injuries... most of us want to avoid this.... but when it does, many are confused about what steps you need to follow, the first question which strike the mind is ....

Ice Or Heat

Let's get into the detailed information on this subject and know what works
The BEST,,,

Ice.. has been widely accepted and widely practice of application in the recent POLICE protocol on acute injuries for its clinical significance and outcomes.

"YES ! PRICE protocol is outdated now, stay updated..

"Put ice on it" is the most famous quote doctor, trainer, coaches and first aid specialist use considering its acute response to any injured tissue.

Cryotherapy (Ice Therapy) is the use of application of ice in the acute stage of any inflammation following a contact or non-contact injury.

Ice is most preferred mode of treatment modality for its ability to

·      Reduce Tissue metabolism,

·      Reduce pain and swelling.

·      Reduce Arthrogenic muscle response

·      Increase Joint function.

Reducing Pain...

All cryotherapy modalities applied topically, helps in reducing the temperature of Skin and Subcutaneous tissue to give analgesic effect.

An adequate (5 – 15 degree C) is required to show its effect. Reduction in tissue temperature happens by heat abstraction.

As skin temperature reaches 15 degree C, more vasoconstriction occurred in cutaneous vessel.

Gyton AC- medical physiology,ed chapter 27, 72 philadelphia, SB Saunders Co. 1981.

Vasoconstriction: cutaneous vasoconstriction is predominantly an important autonomic response to cold exposure, norepinephrine is released from sympathetic nerve ending and induces constriction through Alpha Receptors. Skin contains Alpha 2 receptors.

When exposed to cold, increase sympathetic output to adrenal medulla induces it to release more epinephrine into the bloodstream.

Vasodilatation occurred below 15 degree C via B receptors, as a result of paralysis of musculature, which provides vasoconstriction or a conduction block of sympathetic nervous system.

(k. gallowat PT, Dsc, ECS, in orthopaedic physical therapy secrets (third edition), 2017.

EUS J.W. Van Someren in Handbook of biology of aging (Seventh Edition) 2011.

"Reducing skin temp reduce the nerve conduction velocity of sensory afferent"

(Every 0 degree C = 0.4m sec reduction)

Ice increase threshold levels in the free nerve endings and at synapses and by increasing nerve conduction latency to promote analgesia. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396304/)

Reduction to 10 Degree C = 33 %reduction in NCV.

Reduction to 12.5 degree C is responsible for lower metabolic enzyme activity by 50%.

(Ref: http://dx.doi.org/10.1053/apmr.2002.30926)

Ice Application Method..

crushed Ice with External pressure can reduce the temp up to 10 degree.

 melting Ice water applied through wet towel for repeated period can reduce to 10 Degree.

Intermittent Application than sustained help in maintaining the reduction in skin temp.

Application with green peas shows sustained maintenance of temp compared to frozen gel packs.

Reducing Tissue Metabolism...

In acute phase (36 – 72 hrs.) Ice helps in reducing Inflammation by reducing macrophage infiltration and accumulation of TNF – Alpha, NF, TGF beta, MMP-9 and Macrophage Percentage.

·      Increasing the Neutrophils activation to promote Healing

·      Increase the fibroblast cell activity to promote collagen synthesis.

·      Increase myoblast activity to reduce scar formation or hematoma.

Reducing the Tone in Muscles...

Ice Influence the Intrafusal FIBER (Muscle Spindle and Golgi tendon Organ-GTO) to
Decrease the Tone by

1.     Reducing rate of firing of muscle spindle afferent signal of 1A and IIb towards dorsal horn of the spinal cord and reducing the gamma efferent activity reducing the tone.

2.     Reducing stretch reflex responses.

3.     Inhibit release of chemical acetylcholine thereby reducing muscle guarding (spasm) and reducing pain.

4.      In sore muscles, ice help in reducing the creatine kinase activity, a predictor of muscle damage.

(Ref: Eston R, et al. J Sports Sci. 1999. : effect of cold water immersion on the symptoms of exercise – induced muscle damage)

To reduce Swelling....

Swelling is reduced by increasing the interstitial space pressure which causes ancillary filament attached to lymphatic capillaries to contract and allow space of interstitial fluid to channelize in the lymphatic duct.

conclusion : Ice is only beneficial for reducing inflammation not in accelerating healing and can only work effectively in initial acute phase.

Depending on size, type and depth of the tissue involved

Ice application results are dependent on

1.     Duration of each individual treatment session

2.     Frequency

3.     Time

4.     Modes of application

Prolonged application of ice increases capillaries permeability of lymphatic vessels causing large amount of fluid to enter from lymphatic vessel into the injured area increasing swelling and pressure leading to pain.

(http://marcpro.com/wp-content/uploads/2017/04/Icing-Whitepaper.pdf)

Repeated application rather than continuous helps to sustain reduced muscle temperature without compromising the skin and allow the superficial skin temp to return to normal

Ice application should be applied in repeated application in 10 minutes to be most effective, to avoid side effect and prevent possible further injury (sensation, reflex activity and motor function are impaired)

ref: Int J Sports Medicine, 2001 July ;22(%): 379- 84.

Effect of ice on muscles...

Maximum reduction in intramuscular temp is just up to 10 degrees.

If crushed ice is applied for 20 min with Compression we can achieve the Muscle temp to drop by 21 degree.

Penetration is maximum 2 – 3cms skin depth, greater the depth of tissue injuries, less intramuscular reduction in temp occurred.

Ice Bag Application with External Compression with elastic Wrap

https://www.ncbi.nlm.nih.gov/m/pubmed/20446835/?i=2&from=/28872444/related#fft

Many of the studies shows that IMT response depends on Mode. Temp. Area, blood flow, local metabolic rate, depth, sympathetic, integrity, duration, mass to be cooled.

Ice Influence Intrafusal fiber (Muscle Spindle and GTO) to reduce tone by altering muscle-firing rate, reducing muscle strength.

In acute cases, in warm temp application of ice prior exercise tends to increase muscle endurance.

Motor output on muscle – cold show initial decreased in strength followed by steady increase in strength.

grose JE: Depression of muscle fatigue curves by heat and cold, res Q 29(1); 19- 31. 1958.)

Johnson DJ, Leider FE: influence of cold bath on maximum handgrip strength, percept Mot Skills 44:323-326,1977

LIND AR, SamaueloffM: Influence of local temperature on successive sustained contraction. Processing of the physiological society, 19Jan 1957,12p- 13p.

Joints...

Ice applied on joint causes vasoconstriction causing reduction in intra articular temperature

·       (Cobbold AF, Lweis OJ: Blood Flow to knee joint of dog: effect of heating, cooling and adrenaline. J physiol 132: 379 – 383,1856)

·       Am J Sports Med. 1994 Jul-Aug;22(4):537-40.

The temp decreased from 1.9 to 3.2 degree C while skin temp fell from 15 – 27 degree C. however it’s more achieved with heat rather than cold application

(Broken N. Bierman W: temperature changes produced by spraing elthyl chloride. Arcg phys med rehabili 3: 288 – 290. 1955)

Ice in the form of ice chips or nitrogen air is more preferred over heat in inflammatory condition in knee as increased temperature causes activity of destructive enzyme increase causing breakdown of articular cartilage

(http://onlinelibrary.wiley.com/store/10.1002/art.1780350204/asset/1803502014_ftp.pdf?v=1&t=jbuw1o8x

Tendons...

Ice applied during loading phase (stretched position) increase the length in tendon due to reorganization of tissue during healing phase.

(lehmann Jf, masock AJ, Warren Cg, Koblanski JN: effect of therapeutic temp in tenson extensibility)



Conclusion : Ice is more Superior Application in case of Acute Injuries (0 hrs - 72 hrs) 

Chronic Injuries and Bony Joints aches - Apply HEAT !!!!.