The Ice age is Melting

Why we should stop teaching RICE

Before the early 1960’s ice simply wasn’t used in medicine, or first aid. Then on the 23 May 1962, an event occurred that would change medicine for ever. 

A 12 yr old boy, Eddie Knowles, tried to jump onto a moving train in Somerville, MA , and in doing so severed his arm from his body.  The young boy was taken to Massachusetts General Hospital (MGH) where Dr. Ronald A. Malt, a young medic, tried to save Eddie’s amputated limb by cooling it with ice. Despite the fact that there had never been a successful reattachment of a major limb recorded in medical literature, Dr. Malt and a team of twelve doctors successfully performed the first limb reattachment in history.

In the following months the story became a global phenomenon. However, as is often the case with medical news, the details of the operation to reattach the arm were complicated, medical, and considered ‘boring’ for the general public.  So, instead of focusing on the surgical details that actually saved the arm, reporters focused on the aspects of the story that would be intriguing to the public.  Doctors were interviewed and asked “what’s the best way to transport a severed arm to hospital?” Put in a plastic bag on ice, was the answer, and this became the focus of news stories. (1)(2)

This is still the first aid advice today, and rightly it should be. When dealing with severed body parts we want to stop cells dying, so that the amputated part remains viable and can be reattached.

The use of ice to treat injuries was never part of medical protocols before to the events of May 23, 1962. However the idea of using ice for tissue preservation was quickly re-published by newspapers around the globe.  However, as the story was retold, facts began to change. Eventually, we reached a point where ice became a panacea for all injuries, with no differentiation between whether the body part was still attached to the body or not.

In 1978, Dr Gabe Mirkin and Marshall Hoffman proposed the mnemonic RICE (Rest, Ice, Compression and Elevation) in their book “The Sports Medicine Book”. It was quickly and widely accepted as a simple, easy to apply, method for dealing with soft tissue injuries. Its use became ‘standard practice’ in academic curricula and in the recommendations of all major first aid training and sports medicine bodies.  

However in 2013, the RICE procedure was challenged by Gary Reinl in his book “Iced! The Illusionary Treatment Option.”  (3). Reinl quotes numerous studies and anatomical resources in support of the idea that resting an injury, while wrapping it tightly (compression) with ice, is ineffective in accelerating the recovery process and could also result in further damage to the affected tissues. Following the release of this book, Dr Gabe Mirkin publicly recanted his original position on the RICE protocol in a 2015 publication on his personal website (4)

Dr Mirkin even wrote the foreword to Reinl’s second edition of “Iced! The Illusionary Treatment Option”, and offered his revised opinion on the protocol he created;

Subsequent research shows that rest and ice can actually delay recovery.    Mild  movement helps tissue to heal faster, and the application of cold suppresses the immune responses that start and hasten recovery. Icing does help suppress pain, but athletes are usually far more interested in returning as quickly as possible to the playing field. So, today, RICE is not the preferred treatment for an acute athletic injury  (5)

Reinl, G. (2019, February) The cold hard facts: Weighing the evidence. Retrieved from http://garyreinl.com/articles/The-Cold-Hard-Facts.pdf

After nearly 30 years of research there is very little evidence to support icing injuries but it is still being taught and administered. 

I am not only a director of Marlin Training, but also advise the First Aid Industry Body (FAIB) on standards, as the chair of the advisory board. I also represent FAIB at meetings of the First Aid Quality Partnership, set up by the HSE to encourage the industry to work together. In 2018 I presented the medical evidence on removing ice from first aid treatment. I have reviewed a huge range of papers on the subjects and it is clear to me (and the vast majority of the scientific community) that ice reduces inflammation and thus delays healing. It may also result in local nerve damage.

A summary of 22 scientific articles found almost no evidence that ice and compression hastened healing over the use of compression alone, although ice plus exercise may marginally help to heal ankle sprains (6)

The current UK NICE guidelines state that there is “insufficient evidence to determine the relative effectiveness of PRICE “ However, from my own investigations it is clear that whilst there is little evidence for PRICE (or RICE), there is clear and overwhelming evidence against it’s use.  I have written to NICE on this issue.

My concern is that almost every first aid course teaches the use of ICE and that we are needlessly delaying healing by using a practice that was born out of ‘accepted practice’ rather than any definitive scientific evidence.

I refer to some key papers:

Scialoia, D & Swartzendruber, A. The R.I.C.E Protocol is a MYTH: A Review and Recommendations. The Sport Journal. Oct 2020 (https://thesportjournal.org/article/the-r-i-c-e-protocol-is-a-myth-a-review-and-recommendations/). Most of the key papers on ICE are referenced at the end of this review.

Takagi, R, et al (7) undertook a key study on the effect of ice on muscle tissue. In their study, the researchers crushed the muscle belly of the extensor digitorum longus of anaesthetised rats for 30 seconds using forceps, to which a weight (500g) was attached. Immediately after the injury the rats were randomly divided into two groups, the no icing group and icing group where they lightly placed fine crushed ice in a tiny polyethylene bag on their injured hind leg for 20 minutes.

The final summary sentence from this study state:

“Judging from these findings, it might be better to avoid icing, although it has been widely used in sports medicine.”

Takagi, R, et al. Influence of Icing on Muscle Regeneration After Crush Injury to Skeletal Muscles in Rats. J of App Phys. 2011 vol. 110 (2) 382-388

However, it could be argued that this is just one study. In an analysis of 11 trials involving 868 patients, Van den Bekerom et al (2012) conclude that there is insufficient evidence from randomised controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains. In a systematic review  based on 35 clinical trials (Bleakley et al 2012) suggests that athletes may in fact be at a performance disadvantage if they return to their athletic activity immediately after 20 minutes of icing.

In another systematic review (Bleakley et al 2004) based on 22 clinical trials concluded that the effect of cryotherapy on acute injuries such as muscle strains and contusions has not yet been shown. They state, “There was little evidence to suggest that the addition of ice to compression had any significant effect”.

“There was little evidence to suggest that the addition of ice to compression had any significant effect”.

(Bleakley et al 2004)

Icing of sore muscles after a hard athletic workout is commonly thought to help recovery and promote earlier return to activity. This experimental study in fact demonstrated the opposite to occur (Tseng et al 2013). After performing 6 sets of heavy eccentric triceps workout, half the athletes were randomly allocated to receive either 15 minutes of cooling ice pack or a sham pack. After 2 and 3 days the icing group had significantly greater creatine kinase and myoglobin (signs of muscle overload) and the athletes subjectively reported of having more triceps fatigue than the sham ice group.

There are also many other journal articles and reviews quoted in: Iced!: The Illusionary Treatment Option Paperback. Reini, G (2014). This book also has a forward by Dr Gabe Mirkin, the inventor of the ‘RICE’ procedure. I would encourage all first aid trainers too read this book!

So where does this leave us. I spent several years working as a research scientist. I understand how to read medical papers and interpret them. It is clear to me that the use of Ice on injuries is delaying inflammation. Further,  inflammation is not something that should be stopped, it is instead a process that our bodies have evolved in order to deal with injury. Inflammation is the first step of a series of events that lead to healing. When a muscle is damaged, inflammatory cells, called macrophages, within the damaged muscle itself produce a protein called IGF-1. This protein is required for muscle regeneration. Ice therefore stops this inflammatory process, delays the release of ICF-1 and delays healing.

“ Do you really think your body’s natural inflammatory process is a mistake?

Gary Renini, (ICED, 2015)

Following my own research I would ask the proponents of ICE and RICE:

“Show me the evidence that Icing reduces swelling?”

Show me the evidence that icing improves recovery?”

If you do your own research (which I suggest you do), you won’t find anything. What you will find is a mass of evidence showing the opposite!

So, I throw the challenge out there to the proponents of ICE (and RICE) inn the first aid world:

“Show me the evidence for teaching ICE (and RICE) to our students?

Challenge from Stuart Marshall to other first aid organisations, Feb 2021

1. Knebel, F. (2013, January). The right arm of Eddy Knowles. MEDICAL MIRACLES. Retrieved from medicaltreats.wordpress.com/2013/01/27/the-right-arm-of-eddy-knowles/.

2. Nagourney, Eric. (2002, October). “Ronald A. Malt, 70, is dead; Innovator in reattaching limb.” The New York Times, Section A, Page 32.

3. Reinl, G. (2013). Iced! The Illusionary Treatment Option, 2nd ed. United States of America: G. Reinl

4. Mirkin, G. (2015, September). Why ice delays recovery. Dr Gabe Mirkin on Health. Retrieved from www.drmirkin.com/fitness/why-ice-delays-recovery.html.

5. Reinl, G. (2019, February) The cold hard facts: Weighing the evidence. Retrieved from http://garyreinl.com/articles/The-Cold-Hard-Facts.pdf

6. The American Journal of Sports Medicine, January, 2004;32(1):251-261.

7. Takagi, R, et al. Influence of Icing on Muscle Regeneration After Crush Injury to Skeletal Muscles in Rats. J of App Phys. 2011 vol. 110 (2) 382-388