Are Ice and NSAIDs Beneficial for Recovery?

Take Home Points on Are Ice and NSAIDs Beneficial for Recovery?
  • Ice helps decrease pain, but does increase muscle damage.
  • NSAIDs restore function, but improve bone, but not soft tissue healing.
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!

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):

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

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.

Inflammation in Sports

Inflammation in sports is a baffling subject. Some view inflammation as beneficial, while others consider it detrimental. This subject is confusing as inflammation occurs in seemingly two different scenarios. For example, how can inflammation after exercise be beneficial, where inflammation about injury is harmful if both are the same process?

This article tackles the difference between inflammation after injury and exercise while providing a practice approach for using common anti-inflammatory medication.

Spotting Inflammation
There are five attributes to inflammation in sports:
  • Redness, swelling, heat, pain, loss of function
Moreover, pain all the time (not only during movement) and pain in the morning are typical signs of inflammation. Increased joint fluid increases pressure on pain receptors (nocioceptors), causing pain all the time. If pain is worse in the morning, it is likely inflammation surrounds the joint, as muscle contractions did not pump the fluid away from the joint during sleep. This increased fluid increases the pressure on pain receptors increasing pain during the morning.

Exercise Induced Inflammation
Many feel inflammation in sports help long-term strength gains as inflammation repairs damaged muscle fibers following exertion. Mishra in 1995, determined supplementing a strength training group with anti-inflammatory medication had an acute increase in strength, compared to the control group. This increase persisted at 7 days, but at 28 days the medication group experienced a step back, as their maximal muscle tension dropped by about 1/3 of their maximum tension.

It appears anti-inflammatory medication resolves acute exercise induced inflammation resulting in increased strength, as it would allow them to recover and be stronger, as they less sore from the muscle fibers being destructed during the exercise.

However, the mechanism which NSAIDs improve acute performance has not been justified:
“anti-inflammatory doses of ibuprofen reduced CK activity but not the neutrophil response or other indirect markers of muscle injury during recovery from eccentric arm exercise (Pizza 1999).”

After training Gulick performed an analysis of many types of treatment and concluded:

“none of the treatments were effective in abating the signs and symptoms of DOMS. In fact, the NSAID and A. montana treatments appeared to impede recovery of muscle function (Gulick 1996).”

Therefore, it seems NSAIDs improve acute strength with NSAID, but it seems to prevent overall recovery of muscle and strength gains.

This is perhaps from NSAIDs masking the amount of damage during exercise, allowing the body to do more damage without allowing proper recovery time. Don't beat yourself while you're down!

No study has directly studied NSAIDs on in-water strength, but one could guess NSAIDs would impair in-water strength development. This loss of strength impairs swimming progress as in water strength (especially of the upper body) correlates with speed (Hsu 2000).

Injury Induced Inflammation
After any musculoskeletal injury inflammation occurs. This process increases the volume of fluid in an unwanted area. When too much fluid is in a confined area, the amount of mechanical pressure increases. This mechanical pressure presses on nocioceptors and causes pain. Pain inhibits strength and athletic performance, therefore resolving this mechanical pressure is mandatory to move the injury from inflammation to remodeling.

The best method to improve this is with homeopathic and over-the counter medication. Combining Ginsenosides and Large volumes of NSAIDs helps inflammation by helping the medication reach 'titer level' or the minimum effective level (Read more about tips to improve shoulder inflammation) (note: take with food and watch stomach irritation).
Once the inflammation subsides, discontinuing the anti-inflammatories is essential for improving strength (see below).

If you are looking for short-term improvement whether you are at a competition or injured, NSAIDs acutely improve strength. However, if you’re seeking long-term strength gains, do not use NSAIDs to trick the body into working harder or not letting inflammation to aide full repair and remodeling, essentials for muscle strength.

Last Point
Lastly, the chronic use NSAIDs appears damaging to tendons.

In rats, Dimmen 2009 determined:
“We found a significantly lower tensile strength in rats given both parecoxib and indomethacin (anti-inflammatory medications) compared to the control group. Stiffness in the healing tendons was significantly lower in the parecoxib group compared to both the placebo and the indomethacin groups. The transverse and sagittal diameters of the tendons were reduced in both the parecoxib and indomethacin groups. Both parecoxib and indomethacin impaired tendon healing; the negative effect was most pronounced with parecoxib (Dimmen 2009).”

This has not been proven in humans, but is worrisome nonetheless.
Summary
Make sure you are not abusing NSAIDs and use them properly, as overuse is damaging and reckless. Follow these simple guidelines:
  • Only take NSAIDs after an acute musculoskeletal injury
  • Discontinue intake after inflammation resolves
  • Do not take NSAIDs after exercise unless at a competition, where performance not strength gains are most important
References:
  1. Pizza FX, Cavender D, Stockard A, Baylies H, Beighle A. Anti-inflammatory doses of ibuprofen: effect on neutrophils and exercise-induced muscle injury. Int J Sports Med. 1999 Feb;20(2):98-102.
  2. Gulick DT, Kimura IF, Sitler M, Paolone A, Kelly JD. Various treatment techniques on signs and symptoms of delayed onset muscle soreness. J Athl Train. 1996 Apr;31(2):145-52.
  3. Dimmen S, Engebretsen L, Nordsletten L, Madsen JE. Negative effects of parecoxib and indomethacin on tendon healing: an experimental study in rats. Knee Surg Sports Traumatol Arthrosc. 2009 Jul;17(7):835-9. Epub 2009 Mar 19.
  4. Hsu, K. M., & Tsu, T. G. The relationships among shoulder isokinetic strength, swimming speed, and propulsive power in front crawl swimming. Medicine and Science in Sports and Exercise. 2000 32(5).
  5. Defreitas JM, Beck TW, Stock MS, Dillon MA, Kasishke PR 2nd.An examination of the time course of training-induced skeletal muscle hypertrophy. Eur J Appl Physiol. 2011 Mar 16.
By G. John Mullen founder of the Center of Optimal Restoration, head strength coach at Santa Clara Swim Club, creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.