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Ice or heat for injuries?
A question I am often asked in clinic is “Should I use ice or heat on this injury?”.
The icing controversy
The conventional viewpoint is that it’s best to ice an injury in the first few hours and to apply heat to a chronic (long-lasting) injury. Ice, along with rest, compression and elevation (R-I-C-E), is seen to limit swelling and inflammation for the first 24-48 hours following an injury. However, the use of ice has recently been questioned by some in Western medicine, and has never been advocated in Traditional Chinese Medicine. In clinic, what we tend to see is that people continue to ice injuries long after this initial period, and that this can lead to problems.
This is particularly true for tendons and ligaments, as these structures naturally have less blood supply than muscles. So ligament and tendon injuries are particularly likely to become longstanding if we interfere with the already low blood flow.
So among some sections of the sports injuries world, for tendon and ligament injuries, RICE has been superseded by M-E-A-T (movement – exercise – analgesia (pain relief) – treatments (that promote blood flow).
Conventionally, ice application is recommended immediately after an injury under the premise that it helps the coagulation process, limiting bleeding from damaged blood vessels. The second reason put forward for icing an injury is that ice can ease inflammation. Thirdly, it has a numbing effect so can help relieve pain.
So let’s look at these aspects in turn.
Stopping bleeding immediately after an injury certainly makes sense. But how long is the window of opportunity for this? One animal study suggests that critical period for preventing secondary injury (from swelling due to bleeding around the injury) may be much shorter than we originally thought – somewhere from 30 minutes to 5 hours, with the first 30 minutes being the most critical.
It’s generally accepted that too much inflammation is a bad thing. But some animal research shows that interfering with inflammation after trauma may be detrimental. It could actually slow down healing. Researchers have found that injured cells produce the inflammatory hormone IGF-1 (insulin-like growth factor-1), which significantly increases the rate of muscle repair. In mice bred to not produce IGF-1, healing after an injury was slower than in normal mice.
How about pain relief? In 2004, researchers looked at all the available studies to try to determine the effectiveness of ice after injuries and surgery. As part of this, they looked into pain relief. They found that while ice helped to reduce pain, the majority of studies showed that compression alone was just as effective. They also noted that there wasn’t much good-quality research into this area.
How Traditional Chinese Medicine sees cold
In Chinese Medical theory, too much cold is not a good thing. In fact it is seen as the root of many problems, with the cold becoming lodged in the tissues, leading to ongoing stiffness and pain.
Of course, in ancient China there were no freezers. Only those who lived in cold or mountainous regions would even have had access to ice. So people needed other ways to treat injuries. Traditional Chinese Medicine has a whole toolkit of techniques to help heal injuries. For acute injuries, a form of massage incorporating acupressure points (tui na), as well as acupuncture and moxibustion (a herbal heat treatment on specific points) can help relieve pain and reduce swelling. For chronic injuries that are slow to heal, as well as the above therapies, techniques such as Tai Chi can be very useful in gently promoting movement and freeing up the area. These forms of treatment correspond much better to the MEAT viewpoint than the ICE protocol – Tai Chi for movement and exercise, acupuncture for analgesia (pain relief), and acupuncture/massage and moxibustion for treatments that promote blood flow, thereby promoting rather than hindering the body’s natural healing mechanisms.
How does heat help after an injury?
Heat is certainly useful in the chronic phase of an injury, as it relaxes the area, promotes blood flow and relieves pain. I generally recommend patients apply warm packs after any swelling has gone down. Another approach is to use ginger soaks or compresses, which also have a warming action. [Link to ginger poultice article]
When used correctly, heat is also very useful in the acute phase of an injury. If you come to see me in the first couple of days after minor trauma, I will perform a full assessment of the injury. Then I will usually burn small cones of moxa, derived from the leaf of the mugwort plant, to apply heat to specific points around the site. I can also teach you how to use this technique at home between clinic visits, to maximise the rate of healing. When used in this way, moxa actually has a slight cooling effect (by encouraging local sweating), but is much gentler than ice. It encourages local blood flow and reduces pain, allowing you to gradually get back to the activities you enjoy. Other moxibustion techniques are useful once the inflammation has started to subside and we are concentrating on regaining range of motion.
Gentle acupuncture using very fine needles at specific points is also helpful in triggering the body’s healing mechanisms.
Heat or cold for injuries – summary.
- See if you can avoid ice if possible, especially for injuries likely to involve ligaments and tendons rather than muscles – in other words the sinewy parts of the body: ankles, knees, wrists/hands. If you are going to use ice, restrict it to the first 24-48 hours. Make sure any cold compress / ice pack is well wrapped in a towel to avoid injuring the skin from excessive cold. Use for no longer than 20 min at a time.
- Heat is more useful after this stage, along with gentle mobilisation, depending on the extent of the injury. Be guided by your body and stop any movements that make the pain worse.
- If you can get in to see an acupuncturist in the first day or so after the injury, this is very useful and may allow you to avoid using ice and speed up recovery.
Sleep peacefully with Oriental Medicine
How did you sleep last night? Could have been better? If you are rubbing your eyes while reading this and trying to counteract the effects of insomnia with coffee, you are not alone. Almost one in four of us has trouble sleeping on a regular basis.
Much has been said about modern life eating into our sleep. In Victorian times, before the electric light bulb, adults generally slept 9-10 hours per night. Ancient Chinese texts describe the idea of the body being governed by a 24-hour clock, with each of the 12 main meridians responsible for a 2-hour segment of the clock. For the body to function at its best, with all meridian pathways and associated organs working smoothly, it is advised to be in deep sleep by 11pm, so to go to bed between 9 and 10pm, and to rise between 5 and 7am. But with today’s long and irregular working hours and access to electronic devices that stimulate the brain instead of winding us down, many of us would struggle to follow these guidelines.
We now know that chronic (long-term) sleep deprivation has a host of health consequences. It plays havoc with your hormonal and metabolic regulation, contributing to weight gain, elevated stress hormones, and raised blood pressure. If you aren’t sleeping well, you are also more likely to struggle to concentrate, have accidents at work or while driving, and to suffer from depression.
If insomnia has been a long-term issue for you, you will probably have tried a lot of the self-help strategies recommended. Even so, it’s worth reading through the list at the end of this article to see if there are ways you could tweak your lifestyle to help promote sleep.
Various medications are available for insomnia, but most have side-effects you’d probably rather be without, like feeling groggy in the day. And for some classes of these drugs, long-term dependence is a real issue. So the ideal approach (in combination with lifestyle changes, of course) is one that’s natural and doesn’t have troublesome side effects.
That’s where Oriental medicine (the combination of acupuncture and Chinese herbal medicine) come in. This has a long history of use for insomnia. There are several Oriental medicine patterns associated with insomnia, and we work out which is responsible by taking a detailed history of your sleep issues and other aspects of your health, examining your pulse, tongue and abdomen and putting all the information together.
Treatments focus on calming the mind, using a combination of points throughout the body. I use the gentle Japanese style of needling, which inserts very fine needles very shallowly, so is suitable for even the most needle-phobic. Generally, 4-6 weekly sessions will give us a good idea of your response to treatment. After a few sessions, herbal support is often introduced as the frequency of acupuncture treatments is dropped.
There has been quite a bit of research done on acupuncture and sleep, although the quality of the research could be better.
One recent research trial looked at the effect of acupuncture on insomnia, focussing on quality of sleep. This trial was small (180 patients) but had a great design, comparing true acupuncture (points selected to treat insomnia) with sham acupuncture (points that don’t actually treat insomnia) and a commonly used sedative as control measures. This was done to make sure that any effect of the acupuncture treatment was not just due to being paid attention by the practitioner, or relaxing in the treatment room, or some other aspect of the treatment not actually related to needling specific acupuncture points.
After 6 weeks of treatment, those in the true acupuncture group rated their sleep quality as better than those in the sham acupuncture or sedative groups. They also reported less drowsiness and more energy in the daytime (in contrast to those on the sedative, who felt worse during the day even though their sleep improved). These improvements were maintained 2 months after the end of the treatment period.
Another couple of small trials looked at how acupuncture (or in one case, acupressure) works to help you sleep. They found that acupuncture or acupressure tended to normalise the levels of melatonin, a hormone produced by the pineal gland in the brain that regulates the sleep-wake cycle. This is very intriguing; and hopefully larger studies will explore this area in the future to verify the results.
The bottom line? Acupuncture can be a long-lasting remedy for insomnia, giving you better sleep quality without that hung-over feeling from sedatives.
Some tips to help you sleep.
- Avoid caffeine after 4pm, or noon if you are sensitive to it. Remember that chocolate and green tea also contain small amounts of caffeine that can be too stimulating for some people. Many “energy drinks” contain a lot of caffeine too.
- Try to get up at around the same time each day and go to bed at the same time each night. This gets your body into a regular pattern, so that the sleep hormone, melatonin, is being produced right when it’s needed.
- Aim for a short walk in sunlight (about 20 mins without sunglasses if you can tolerate it) first thing in the morning. A surge in melatonin (which promotes sleepiness) happens about 12 hours after this first exposure to sunlight, so this is another measure that can help reset your sleep clock.
- For at least an hour before bed, limit your use of TV, internet, mobile phones and other electronic devices, which tend to stimulate the brain. For some people who are sensitive, 2 hours may be better.
- If you can’t sleep after 30 mins, go and do something that’s not very interesting for 10-20 mins in low light, then try again. Avoid TV etc, for the reasons given above.
- Acupressure (applying pressure to acupuncture points) can help. Run your fingers outwards from the back of the neck at the base of the skull, till you reach a sore point behind the ear (but still under the skull). This is the An Mian (peaceful sleep point). Massage this area with firm pressure. The other point to apply pressure to is Kidney 1, which is on the sole of the foot, about 1/3 of the way down from where the toes join the sole of the foot. When you bend your foot downwards, you can feel a depression here, which may also feel quite tender.