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[Physio Explained] To ice or not to ice? Unpacking acute injury treatment with Jean-Francois Esculier

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In this episode with JF Esculier, we explore the new acronym of “PEACE and LOVE” in acute musculoskeletal injuries. We discuss:

  • What each of the letters in the acronym means and the evidence behind them being used in an acute setting
  • The evidence behind icing in acute injuries
  • Ice vs heat in acute injuries
  • The inflammatory response in acute musculoskeletal injuries

Jean-Francois (JF) Esculier PT PhD is a Canadian physiotherapist and clinician-researcher. His main research interests include knee pain, treatments for common musculoskeletal injuries, and running biomechanics and footwear. JF leads the Research & Development division at The Running Clinic, is a Clinical Associate Professor at the University of British Columbia and practices at his clinic, MoveMed Physiotherapy.

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Our host is @James_Armstrong_Physio

SPEAKER_00:

If you actually read the research on the use of ice after an ankle sprain, you will not find any evidence that it's superior in terms of reducing pain or improving function than if you don't use ice after an ankle sprain. So there's currently no evidence to suggest that we should be using it.

SPEAKER_02:

Should we still be icing? If so, when? And if not, why not? Today we're joined by Dr. Jean-François Escolier as we dive into the topic of ice and acute injury management. You may be surprised by some of the answers JF gives us today. We also couldn't miss the opportunity to talk to JF about the acronyms, all of them, such as RICE, POLICE, and the most up-to-date one, PEACE AND LOVE, especially as he was one of the authors of the paper that introduced PEACE AND LOVE to us. J.F. does a great job of breaking down this topic and he does it in a way that means you will finish listening today with much greater confidence when recommending how patients should manage injuries in the acute stages. You'll also have a much better understanding of the use of ice. J.F. was joint author of the paper Soft Tissue Injuries Simply Need Peace and Love, published in the British Journal of Sports Medicine. He's also currently a clinician, teacher and researcher. He holds clinical assistant professor position at the University of British Columbia, teaches through the running clinic and works clinically at MoveMed Physiotherapy. I absolutely love chatting Jeff on this topic and I ask a lot of questions that I'm sure you will find really useful in giving some clarity to this widely debated topic. So without delay, let's get on with the episode. I'm James Armstrong and this is Physio Explained. JF, thank you so much for coming on to the podcast. I'm really excited by this and it's great to finally put a face to the name. Thanks,

SPEAKER_00:

James. I'm happy to be on and yeah, thanks for the invite.

SPEAKER_02:

Brilliant. So we're going to be talking about an interesting subject that I think is relevant to pretty much every single MSK clinician listening, and that's all about ice. and the use of ICE. So we're going to kick straight off with, I think, probably a relevant question, and that is the acronyms. We've got loads of them. Listeners will have probably heard of the RICE, the PRICE, the POLICE, and maybe even up to date with PEACE and LOVE. And I thought it'd be a really good way of kickstarting the podcast in terms of giving us a bit of background and where we're at currently in our thinking around this acute injury management.

SPEAKER_00:

So the old RICE acronym coming from like the 1970s, right? So what do you do after an acute soft tissue injury? R for rest, I for ice, C for compress, and E for elevate. And still nowadays, it's being used a lot. And we don't really question that too often. We just assume that's how we should be doing things. And then the first update to that was the PRICE acronym, where we added the PROTECT before the rest of the RICE acronym. And then in 2012, there was a paper published that was called Should We Call the Police? Because Rice and Price are outdated. So basically, they replaced rest with optimal loading. So that was already a step in the right direction. Basically, don't just sit there and wait for your injury to get better, right? So what my colleague Blaise Dubois and I did in 2019 is we created this updated acronym called the Peace and Love acronym. And it's way better. Obviously, I'm biased because I'm one of the co-creators of it, but I'll tell you why it's good because it's just an update based on all the relevant research that we have right now. So first of all, it's separated into two main parts because the old acronyms are like, okay, what do you do now? How do you address this soft tissue injury? But the Peace and Love acronym is, okay, what do you do now is peace and later on is love. So I'll just cover briefly each one of those letters so that listeners can have a better idea. So peace, we kept the P for protection. So just make sure you don't overload the tissue. It's recently injured, so you don't want to just make it worse, right? So that's pretty obvious. We kept the E for elevation because it's not strong evidence about it, but it can still be useful to help reduce a bit of the swelling. And then the A, that's the one where we got a lot of comments on. So A is for avoid anti-inflammatories and ice. So why do we want to avoid the anti-inflammatories? Well, it's pretty obvious based on current research that they delay the healing process in the tissues after an injury. So now more and more, we realize that if you take NSAIDs, so non-steroidal anti-inflammatory drugs, after say a muscle tear or after a ligament injury, you recover slower than if you don't take those. So It seemed obvious to us to just push people in thinking, you know, like, just don't take these pills because they're available off the counter. Like everyone will just take them without a prescription because they think they should. But there's no benefit of it. And it's actually maybe harm for it. And ice, which we'll cover a bit after a bit more, is basically potentially associated with also a bit of a delay in the healing process. So that's why we have it in there. And then comes the C for compression, also present in the previous acronyms. And the second E of peace is for education. So education stands for avoid, basically avoiding the over-medicalization, the over-treatment, just telling people, you know, it's normal that it will take a bit of time. Like it's normal, you have a new injury, it will take probably two weeks, maybe four weeks, maybe a bit more, six weeks, eight weeks in some cases. And you should expect that timeline and not try to speed things up as your main priority. So that's why we have the E in there. And that's usually for the first 24 to 48 hours that would do the piece. And then we'd be moving on to the love, which comes after. So usually 48, 72 hours after the injury. And L is for load. So after protecting, you want to reload. And then O is optimism, which is kind of funny. But if you look at the research on even ankle sprains, looking at how your state of mind, your optimism level can affect your recovery, is associated with your pain and disability level maybe more than the grade of the actual ankle sprain. So that's quite interesting. So I always like to tell people, you know, just stay positive. It will get better. It will need some time. But that's a key part. The V of love is for vascularization. So basically, aerobic exercise, cross-training, try to keep your body active. Try to speed things up in terms of the healing process by staying active. So something that doesn't hurt can be on the bike, can be in the pool, whatever, but staying active is key. And then the E, the last E of the acronym is for exercises. And I think I won't need to convince the listeners about the benefits of exercise, but it's just to emphasize, especially for patients, that strengthening, range of motion, proprioception, and all those things are necessary in the process of rehabbing. So that's basically what the peace and love acronym stands for.

SPEAKER_02:

Acronyms are great, aren't they? They're useful. They give us something just to kind of trigger our minds. But this is a really big step forward actually as well from a lot of the thinking that's maybe still out there, but certainly was rife amongst the sort of acute injury management. Now you mentioned ice. So we put that at the top of the podcast, didn't we? And we said we're going to talk about it. So what about ice in terms of pain after an acute soft tissue injury? Does it have a place? Where are we at

SPEAKER_00:

with that? That's the question I get all the time. It's interesting because we didn't really get any pushbacks on the avoid anti-inflammatory drugs. Everyone seems to agree with that. But the ice, it seems like we're very attached to it. I don't know if it's just as a profession or as part of the culture, but if you actually read the research on the use of ice after an ankle sprain, you will not find any evidence that it's superior in terms of reducing pain or improving function than if you don't use ice after an ankle sprain. So there's currently no evidence to suggest that we should be using it. Which was kind of interesting to me initially because I did like a full literature review on the topic and trying to see what's out there. There's nothing. You won't find anything. Even in the clinical practice guidelines, you won't find ice in there. But we're so attached to it that we want to use it. And we're working with teams on the field. Like someone springs their ankle, what's our first reaction? We bring the ice back, right? That's the classic. So there's no research out there. Same for muscle injuries. As far as I know, there's nothing there that says, hey, you will reduce your pain levels. It will be better. Now, we can also wonder is what's the purpose of reducing pain after an injury like that? I personally tell people I want to know what is hurting, right? So when you're moving, like we know if you're overloading or if you should take it easier. So pain is actually a useful signal. We want to know about that. Now, if you say I can't sleep, And ice is helping me to sleep and it's helping my recovery. And obviously, it's a good idea to use it. The only place really in the literature right now where you can see that ice helps with pain is in the post-surgical setting. For example, you're getting a total knee replacement surgery, you're getting an ACL reconstruction surgery. There is interesting evidence that using ice, applying ice in the first 24 to 48 hours will help decrease the use of opioids and pain medication. So that's a benefit for sure. But it's pretty much the only one that we can find out there in the literature. There's nothing else. And I would be happy if someone sent me an article, an RCT somewhere that I haven't read yet that says applying ice will help with pain for an acute ankle sprain. It does not exist.

SPEAKER_01:

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SPEAKER_02:

It's fascinating, isn't it? To be fair, Joe, this isn't the first time on this podcast I've had someone on saying actually something that we routinely do, there is no evidence to really give us any backing to say we should be. I think it's astonishing, but it's not uncommon. Do you think sometimes we're forced to, from a I'm particularly thinking in sport. I know from working in rugby, people will often ask for the ice. They'll expect it. It's part of that routine. And to me, in some respects, there's an element of placebo there. It will help me. I need it. Therefore, I use it. It does. But we're saying that the evidence doesn't really support that.

SPEAKER_00:

It's such a great question because it's definitely part of the culture. And when I'm asked about it, usually I say, well, okay, what are the risks, right? Like if I do give an ice pack to this player who just got injured, am I compromising something? Am I ruining the whole healing process? And the answer is not really, right? The potential risks are really low. Therefore, if someone says, can I get ice? I know it helps me, then I'm going to be, yeah, for sure, let's have this bag of ice and it's great. But if I'm working with those people, just working with them on the rehab process and whatnot afterwards, then I'll try to educate them and say, you might want to use it initially, that's okay, but you don't need to use it consistently. If you feel like it's helping you, that's great, but it's not going to help you heal any faster. And there's not a lot of evidence right now on how it impacts the healing process in humans. We have a few small studies in rats that would say, okay, we injure these rats and then we apply a pack of ice versus a hot pack immediately after the injury. And you look at how the muscles and the tendons repair. And actually, there's a bit of a delay in the migration of some neutrophils, macrophages in the injured tissue up to about a week after and maybe a bit more. So it seems to impair a little bit the speed of the healing, but maybe it's just catching up just fine later on. Like we don't really have some sort of longer term evidence that says it's detrimental, right? So if it's only for that small potential risk there of slowing the healing, but the person feels better and they sleep better and it psychologically helps them, then I think it's worth it. So we have to weigh the pros and the cons of that.

SPEAKER_02:

Definitely. It's interesting, isn't it? Because you look at it in a lot of ways. I mean, one of the things I talk to patients about is I quite often rightly or wrongly will say to them, which they'll often ask me about, should I ice it or should I heat it? And I usually say, which feels better? And I kind of go with that because as far as my head goes, there's no massive risk or benefit to either therefore just go with what feels good. Is that right to say that?

SPEAKER_00:

I think so, yeah. That's the same thing that I tell my patients too. If they ask me and they say, which one do you think is better? I usually ask them, have you tried them? Which one feels better for you? They say, no, I would say try heat. It's quite interesting because you were mentioning the cultural aspect earlier and I've worked with patients coming from everywhere around the world and some people come from countries where they would play football and they would sprain their ankle and They don't have access to ice right there. And I've heard some people say that culturally they would use heat immediately after an injury and it would help them. You know, I like to question what we do and ask myself, do you think people living in the Great North are healing faster after an injury versus people living in Africa? And I don't think that's the case. I feel like the human body has evolved for how many years to... designed that amazing inflammatory response that actually brings blood flow in the area to start the healing process. And we think we're smarter than our own evolution by saying, hey, let's put ice on this to constrict the vessels so it doesn't swell up. I'm very skeptical about that practice personally.

SPEAKER_02:

And it's this demonization of inflammation as well. The word inflammation, I think for a lot of people, is something that should be stopped, hindered, and is bad. But actually, is essential for that early phase of healing. So moving through, we talked about risks of using ice. Is there anything more you want to add on that one, Jeff?

SPEAKER_00:

I mean, in terms of the risks, like I said, we need more studies. As far as I know, there is one study in humans that looked at eccentric exercise and creating muscle damage. And they still had a bit of a delay in the migration of these molecules coming in the injured tissue. So basically, when people ask me, what are the recommendations? Like, what do you do with that? If someone asks you, like for clinicians. So my take on that personally is we probably don't have enough evidence right now to say we should be recommending that. I mean, I would need some RCTs on that because we do it all the time. There are RCTs that have been done on using ICE and show no benefits. Unless someone says, hey, we got this new RCT and it helps a lot, then I'd be like, okay. But at this stage, I don't think we have enough evidence to say we should implement the use of ICE for everyone all the time. when they have an acute soft tissue injury. I hope the listeners will just think about this for a bit and ask the question to themselves. And it's about education if you're working with teams and whatnot, but I don't think we have enough evidence for that. Now, do we have enough evidence to say, stop using it completely and never ever use ice on anyone? I don't think so. If someone says, it helps me, I feel better, it helps me to sleep better, then go ahead and use it, right? The risks, if any, are pretty low. But I don't think we have enough evidence to say we should be using it and recommend it as a standard care for acute soft tissue injury. Even Dr. Merkin, who created the RICE acronym, backed off and said, I don't think we should be using ICE anymore. But yeah, we still use it because it's part of the culture.

SPEAKER_02:

Yeah, I think that's it. And I think it's like lots of things. It's really important to question all the time and reflect on the practice that we practice. carry out and say, is it still appropriate? Have we moved on? Is there an alternative? And just have that bit of self-scepticism as well in our own practice and what we're doing. And hopefully listeners have sort of taken that from this podcast today and just thought, actually, yeah, maybe I do jump to it a bit too quickly without full understanding. I'm not going to stop all the time, but I'm not necessarily going to push it as much as I have done. And that might be the bit of a takeaway from today's podcast.

SPEAKER_00:

Absolutely. I still cover events and I do bring ice. I just bring way less and I hide it so people have to ask for it for me to give it to them. And I have this nice peace and love flyer that's printed in there and I just give it to people so they actually learn about it.

SPEAKER_02:

Brilliant. Jeff, thank you so much. It's been a short, snappy, but really useful episode today. So thank you so much for your time. I would love to carry on this conversation. And I think to do that, we're definitely going to need to get you back on the podcast if that's all right at some point.

SPEAKER_00:

Absolutely. Thanks, James, for having me. And I hope listeners will find this useful. Wonderful.

SPEAKER_02:

All right, Jeff. Well, enjoy the rest of your day. And again, thanks again.

SPEAKER_00:

Thank you. Bye-bye.