Take Home Points on Are Ice and NSAIDs Beneficial for Recovery?
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The use of non-steroid anti-inflammatory drugs (NSAIDs) and
ice are common staples in
sports medicine. Yet, the use of these modalities has
recently received resistance from some online experts (Kelly Starrett, Dr. Gabe Mirkin). Despite this criticism,
these modalities are still frequently used, sometimes ad libium. Now, before I make a notion on these modalities, it is important
to understand the injury process, below is an exert from the COR Swimmer's Shoulder System.
Everyone is familiar with
inflammation. The inflammatory process occurs within seconds of every injury,
but can linger for weeks or months with bad injuries or poor management.
Inflammation is stemmed by the
infiltration of cells, entitled neutrophils, during the first 6-24 hours; they
are replaced by other cells (monocytes) in 24-48 hours. These cells will try to
attack the inflammation and remove injurious agents. Phagocytosis is involved
in the process of engulfing foreign particles and releasing the enzymes of
neutrophils and macrophages which are responsible for eliminating the injurious
agents. These are two major benefits derived by the accumulation of leukocytes
at the inflammatory site.
Chronic inflammation is a
different warrior. The key player is another type of cell, the macrophage.
Macrophages are large cells that can remain for weeks to months, perpetuating
injuries.
The classic signs and
symptoms of inflammation are swelling, redness, throbbing, radiating heat, and
constant pain. These pains especially occur when you wake up in the morning and
last between thirty and sixty minutes. Also, just because you had the initial
injury four months ago doesn’t mean inflammation has resolved or hasn’t
returned, so pay closer attention to the signs and symptoms as opposed to the
duration.
Once again, the inflammtory process initiates every injury.
This process is beneficial in restoring the body, but does decrease strength.
This decrease in strength is why many seek improvement [well and the pain].
This has resulted in the use of the two most common modalities NSAIDs and ice.
Unfortunately, these two modalities may prevent the normal physiological
reaction of an injury. This impairment is thought to alter long-term
improvement. However, many people take NSAIDs and ice for short-term gains. If
someone needs improvement, for a quick return to the pool, then NSAIDs and ice
are beneficial. However, the use of these modalities likely decreases long-term
recovery, perhaps increasing the risk of re-injury. Unfortunately, most of this
research is based on rodents, not humans and as I've mentioned before, rodents
have different inflammatory processes! This makes the research nontransferable to humans ... oh well! Nonetheless, lets look at the research we have!
No humans studies have been done on humans assessing the interaction between NSAIDS and soft tissue healing. Of the studies reviewed, there is a controversy between the administration of selective and non-selective NSAIDS after surgery, as many studies suggest detrimental effects on bone and soft tissue healing. However, the literature on this subject in humans is minimal.
NSAIDs on Healing
The authors reviewed the effectiveness of NSAIDS and selective (COX-2 inhibitors) NSAIDS on soft tissue and bone healing. A total of 44 articles reviewed (9 on soft tissue and 35 on bone healing). Thirty-nine of these articles were on animals and 5 on humans.
No humans studies have been done on humans assessing the interaction between NSAIDS and soft tissue healing. Of the studies reviewed, there is a controversy between the administration of selective and non-selective NSAIDS after surgery, as many studies suggest detrimental effects on bone and soft tissue healing. However, the literature on this subject in humans is minimal.
It appears inflammation mediated by prostaglandins is necessary to improve bone healing. However, in soft tissue injury, growth factors are more important and prostaglandins less involved. This suggest NAIDS are likely beneficial in soft tissue, but potentially not bone healing.
Improving inflammation is necessary to decrease symptoms, however the use of NAIDS during bone repair may impair recovery, therefore only use NSAIDs in soft tissue injuries. However, more human clinical trials are necessary before a definitive answer is possible.
NSAIDs on Gut Bacteria
One potential hazardous result of NSAID consumption is the potential loss of integrity of bacteria, making the gut permeable to harmful substance.
Nine male trained cyclists underwent small intestine lining permeability in four different conditions (Van Wijck 2012):
Nine male trained cyclists underwent small intestine lining permeability in four different conditions (Van Wijck 2012):
1) during and after cycling after intake of ibuprofen
2) during and after cycling without ibuprofen
3) rest with prior intake of ibuprofen
4) rest with prior ibuprofen intake
The small intestinal lining was evaluated by providing the
subjects a sugary drink, then assessing the amount of human intestinal fatty
acid binding protein (I-FABP).
The ibuprofen conditions took 400 mg of ibuprofen the night
before and 1-hour prior to cycling on a fasted stomach. The cyclist performed
roughly 90 minutes of cycling at moderate/hard cycling.
In both exercise conditions, the I-FABP levels gradually
increased with cycling. However, cycling with ibuprofen ingestion resulted in
even high levels of I-FABP.
These results show cycling alone increases both gastroduodenal and
small intestinal permeability. This difference increased with ibuprofen intake.
This is thought to be from splanchic hypoperfusion, reducing the blood to the
gut and including injury to the enterocytes. One of the major pathways
suspected for GI damage is:
“to be involved is the inhibition of COX isotypes 1 and 2, resulting
in local inflammation and vascular dysregulation, ultimately reducing perfusion
and promoting mucosal integrity loss within the splanchnic area (Van Wijck
2012)”.
Unless ergogenic benefits from NSAIDs exists, swimmers should not use these medications prior to exercise. Moreover, inflammation may
yield greater results in endurance sports. One flaw with the study is the fact
the athletes were fasted while taking NSAIDs. However, one note is the athletes
were fasted during this test, this may have increased the intestinal lining to
susceptibility.
For rehabilitation, NSAIDs may still be beneficial, but at
this time it is not certain if the benefits outweigh the risks.
Ice and Muscle Damage Healing
Eleven male college baseball players underwent two trials: sham application and topical cooling. Each trial was used five sessions of 15-min cold pack application to the exercised muscles 0 hours, 3 hours, 24 hours, 48 hours, and 72 hours after eccentric exercise training.
The eccentric training protocol consisted of 6 sets of 5 eccentric contractions with 2 min rest between sets at 85% of their maximal strength. Muscle hemodynamics (hemoglobin most notably), inflammatory cytokines (multiple interleukins), muscle damage markers (Creatine kinase), visual analog scale (VAS), and muscle isometric strength.
After topical cooling, rapid and sustained elevations in total hemoglobin and tissue oxygen saturation were noted. Also, creatine kinase was noted in both trials, but was elevated after topical cooling. Inflammatory markers were not changed following cooling. VAS was not different between groups, however topical cooling significantly increased rating of fatigue post-exercise. No significant differences were noted in strength between groups.
Increased muscle damage, most notably the creatine kinase increase, was apparent in the topical cooling group. This is thought to occur from the rapid deviation in blood supply to the muscle.
Using ice after practice improves muscular soreness, but appears to increase muscle damage due to rapid changes in ischemia. Therefore, unless injured topical cooling should be avoided.
Ice and Blood Flow
Nineteen subjects participated in this single-blinded, where
the clinician was blinded. There was no history of lower extremity injuries for
the past 6 injuries. Each participant visited the laboratory four separate
times where baselines were measured at the first two visits, then the next two
visits a trial of ice (750-g of crushed ice placed on the medial gastrocnemius)
and a control trial.
“There was a significant correlation (r = 0.49) between
subcutaneous tissue thickness and change in intramuscular temperature
immediately after treatment (P = 0.05) for the cryotherapy condition.
Significant correlations were also found for change in temperature during the
rewarming period and change in blood volume at rewarming (r = 0.53, P = 0.033)
and change in blood flow at rewarming (r = 0.56, P = 0.025) for cryotherapy
(Selkow 2012)”.
Microvascular perfusion of the gastrocnemius did not decrease
from baseline with cyrotherapy was applied, despite the decrease in
subcutaneous temperature. The result was different than past studies, as many
think cryotherapy decreases blood flow. This may be from no alterations noted
in the microvascular.
In the healthy population, cryotherapy appears not to alter
blood-flow. Therefore, benefits and risks associated with cryotherapy
application for inflammation may be negligible. However, next research must
look at inflammation specifically. Until then, the effects of ice for injuries
seem purely for slowing nerve conduction to gate pain.
NSAIDs or Corticosteroids for Recovery
Zheng (2014) performed a systematic review of all the high-quality studies comparing NSAIDs and corticosteroid injections, a total of ten full articles. Overall, 267 patients were analyzed and of the six studies two focuses on rotator cuff tendonitis patients, two on shoulder impingement syndrome, one studied frozen shoulder of diabetes and the other investigated shoulder pain.
Of these studies, NSAIDs and corticosteroids did not have a significant difference in pain improvement. Corticosteroids were significantly better for remission of symptoms. Five of the studies reported range of active shoulder abduction and note NSAIDs did not significantly improve the active shoulder abduction compared to corticosteroids. The studies assessed were 4 – 6 weeks in length.
Compared to NSAIDs, corticosteroid injections provide faster relief. However, comparisons of other therapies and conjunctions of therapy are needed, as well as longer study periods and follow-ups.
My Recommendations
If you are injured, stop exercising. If the pain is non-stop, see a rehabilitation specialist like a physical therapist. At this time, apply ice, as it does reduce pain and doesn't seem to alter blood flow. However, apply the ice for a short period, as it may increase muscular damage. I suggest applying the ice for up to 10 minutes and remove it for 20 minutes. Only ice immediately after the injury, ~6 hours after the injury. If you are competing at a meet and must perform, NSAIDs can help decrease pain and restore function. However, if you are not in a rush for return, try not to ice and consider compression instead. Compression helps naturally clear the fluid from the joint, facilitating recovery. When you are able to move comfortably without pain, do so. Movement also helps move fluid out of the joint and restore function. However, do not move into pain, as this can alter movement patterns and impair function.
Try and prevent using NSAIDs, unless unrelenting pain exists and the injury appears muscular. If recovering from an injury, a corticosteroid injection is likely better than just NSAIDs, but remember other rehabilitation is needed.
We have much more research needed on the subject, but it isn't clear that ice and NSAIDs are a “no brainer”. Until more research is performed, I'll continue the suggestions I've made for years, if you're in no rush, let the inflammation naturally make it's way throughout the body, giving yourself rest and compression for improvement. Once you're able to move naturally do so! However, if you are in a rush, like at a big competition and need to get in the pool, NSAIDs and ice can help!
References
- VAN Wijck K, Lenaerts K, VAN Bijnen AA, Boonen B, VAN Loon LJ, Dejong CH, Buurman WA. Aggravation of exercise-induced intestinal injury by Ibuprofen in athletes. Med Sci Sports Exerc. 2012 Dec;44(12):2257-62. doi: 10.1249/MSS.0b013e318265dd3d.
- hen MR, Dragoo JL. The effect of nonsteroidal anti-inflammatory drugs on tissue healing. Knee Surg Sports Traumatol Arthrosc. 2012 Jun 29. [Epub ahead of print]
- Selkow NM, Day C, Liu Z, Hart JM, Hertel J, Saliba SA.Microvascular perfusion and intramuscular temperature of the calf during cooling. Med Sci Sports Exerc. 2012 May;44(5):850-6.
- Tseng CY, Lee JP, Tsai YS, Lee SD, Kao CL, Liu TC, Lai CS, Harris MB, Kuo CH.Topical Cooling (Icing) Delays Recovery from Eccentric Exercise-Induced Muscle Damage. J Strength Cond Res. 2012 Jul 18. [Epub ahead of print]
- Zheng XQ, Li K, Wei YD, Tie HT, Yi XY, Huang W. Non-steroidal anti-inflammatory drugs versus corticosteroid for treatment of shoulder pain: A systematic review and meta-analysis. Arch Phys Med Rehabil. 2014 May 16. pii: S0003-9993(14)00345-1. doi: 10.1016/j.apmr.2014.04.024. [Epub ahead of print] Review
By Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University where he swam collegiately. He is the owner of COR, Strength Coach Consultant, Creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.
