Why you should STOP icing for performance-related pain.
Over the past few months I've heard many stories from musicians experiencing performance-related pain that use icing as a primary method for addressing their symptoms. In this article we won't look at icing when it is combined with other interventions, such as heat, compression, or elevation, but rather focus on what happens if you use ice as the only intervention. Although icing is said to have short-term benefits, all of these stories have led to more serious conditions. With that said, I wanted to provide an alternative perspective.
Icing is a method that has been recommended by medical professionals to help alleviate pain and reduce inflammation since the 1970s. Today, it is commonly used by musicians after long concerts or rigorous practice schedules, or it is used as a form of daily pain management.
Icing involves using a cold compress or ice pack on a strained, tender, or painful muscle in an attempt to decrease inflammation and numb the affected area to reduce pain. Research suggests that icing can be effective at reducing pain and swelling in the affected area due to the constriction of blood vessels and decreased circulation.
But is it time to look at other alternatives?
Icing was introduced by Dr. Gabe Mirkin in his publication of “The Sports Medicine Book” in 1978. He introduced icing as part of his RICE protocol – rest, ice, compress, and elevate. The RICE protocol was mainly geared towards athletic injuries and quickly became the industry standard to relieve pain for acute injury.
We will get into this later in the article, but as of 2015, Dr. Gabe Mirkin actually recanted the benefits of his RICE protocol, specifically, icing.
A journal article published in 2015 suggests that the application of ice not only delays recovery, but also damages tissue in the process. The evidence presented in this study also suggests that the application of ice is only necessary if pain reduction is the desired outcome, which brings me into the first point of a much a deeper conversation.
Ice delays the healing response
As mentioned earlier, icing is mainly used to reduce inflammation and the perception of pain. Inflammation is often viewed in the music community as something bothersome and problematic. Musicians often use icing, anti-inflammatories, or other self-medicating methods to reduce inflammation as fast as possible. After all, the sooner the inflammation is gone, the quicker we can heal and return to practicing, performing, and feeling better again, right?
Unfortunately, not so much.
It's important to appreciate that inflammation is a three-phase biological response of the immune system in an attempt to heal itself. This process acts by removing potentially harmful stimuli and initiating the healing process. Therefore, "inflammation is a defense mechanism that is vital to health."
According to Dr. Gabe Mirkin, anything that reduces inflammation also delays healing, including icing, cortisone-type drugs, most pain-relieving medicines, non-steroidal anti-inflammatory drugs (like ibuprofen), or immune suppressants, to name a few. When ice is applied to an affected area, the cold environment causes the area to constrict blood flow, stalling the essential transportation of oxygen and various inflammatory chemicals to the affected site.
Another study found that prolonged icing applied to an affected area can also increase lymphatic permeability.
This can be a complex topic, so bear with me. Let’s think of the lymphatic system as the body’s “sewage system.” Its main responsibilities are to protect your body from illness, maintain body fluid levels, absorb digestive tract fats, and remove cellular waste. “When lymphatic permeability in enhanced by periods of prolonged icing, large amounts of fluid begin to pour from the lymphatics in the wrong direction, increasing the amount of local swelling and pressure, and potentially contributing to greater pain."
To simplify, we want blood flowing in and toxins flowing out, but if prolonged icing has increased lymphatic permeability and constricted blood circulation, you have a limited amount blood flowing in AND toxins flowing back into the same area, often causing more inflammation, local swelling, or pressure. You could see how this could delay healing and potentially cause more problems.
So in summation, current research suggests that ONLY icing can:
Prevent healing cells from entering injured tissue
Stall the natural healing process by reducing inflammation
Prolong recovery time
And as stated above, as of 2015, Dr. Gabe Mirkin publicly announced on his website that “it appears both Ice and complete rest may delay healing, instead of helping." Bravo to Dr. Gabe Mirkin for recanting his protocol that has been an industry standard for over 30 years. This isn't what this article is about, but what a great example on someone who is willing to put his ego aside and change his perspective - a quality that every great leader possesses. Anyways, let's get back to what you can do instead of icing!
So what do I do if I am in pain?
Please note that all information on this site is not medical advice and is for educational purposes only.
As a guiding principle, I want to serve and benefit the musician community as best I can. I am often upset with how other business owners often provide a problem, but don't offer any steps or solutions to that problem. This is why on most of my blogs posts you will always find a "what do I do" section to help provide some clarity around what steps you might want to take.
Check in with yourself and evaluate your situation. Some questions might include:
Was this pain caused by an instant event like a car crash, broken bone, or ligament? (If so please seek medical attention immediately). Or was this a gradual onset of a variety of different factors, like sleep, hydration, lack of movement, external load on the body, etc.
Do I need to see a doctor or medical professional, or do I feel my situation can be addressed through self-management?
What are some factors that contributed to the pain?
Has this pain happened before? If so, when was the last time this happened? Do any simliar factors stick out to you?
What factors where in my control?
What factors where out of my control?
What can I do next time, or what habit can I set up when I am in this type of environment to help prevent my body from becoming inflamed again?
What goal(s) do I want to accomplish with my approach? Do I have time to take a step back and focus on putting my body in a state of healing, or do I have to push through due to academic, professional, or other obligations?
These questions are important to ask, as they can steer you towards what self-management tool best fits your situation. If you are in pain, but need to address the pain as quickly as possible, there are passive options. If you want to a more longterm holistic approach, there are active approaches. Depending on your situation, you may want to use a combination of the two.
A passive approach to pain management does not require any active participation. This can temporarily help with pain, but ultimately only provides short term benefits.
An example of a passive approach might include icing, cortisol shots, pain-medication, muscle relaxers, massage therapy, dry needling, acupuncture, chiropractic manipulation, or surgery, or certain types of physical therapists trained in passive pain-management techniques (not all PTs are passive!).
An active approach to pain management involves active participation of the person.
Examples of active options incorporate body movements such as active breathing, self-myofacial release, meditation, targeted strengthening, mobility, cardiovascular activities, stretching, or stability exercises.
As stated above, you can have a combination of different approaches to create something that works for you, but ultimately, research suggests that a purely passive approach rarely has a significant impact on pain or improving daily functioning.
An example of an active approach during an inflammation stage
Based on my experience, certifications, and work as an injury coach, I have found that prioritizing lifestyle habits (hydration, sleep, and nutrition) and pain-free movements through a full range of motion, while gradually progressing intensity and complexity overtime, to be an effective long-term strategy.
But again - what is your goal? Is your goal to manage your symptoms or address the root cause? If you have a double rehearsal day with a short break and cannot take a relaxed breath, or if you feel extremely tense due to your pain, maybe a short-term ibuprofen fits well. Just recognize that ultimately you are addressing the symptoms at that point, and whatever caused your playing-related pain is likely to keep happening.
Prioritize high quality and quantity of sleep (more than you usually would during this stage)
Prioritize hydration - 50-60% of your weight in ounces. For example, I weigh 175, so I would want to aim for 87.5 - 105 ounces of water per day. This number will fluctuate based on your activity level and humidity of environment.
Targeted movement going through pain-free ranges of motions, incorporated with active breathing strategies - 15 minutes.
Daily walk or light jog - 20-30 minutes
Targeted light strengthening exercises (with supervision - form and approach is crucial) of the affected area to help decongest the area of toxins (strengthening the area in and around the affected area helps activate the lymphatic system).
This may seem like a lot to do, but ultimately recovery and prevention have more similarities than differences. If you want to be a musician that lives and performs without pain over the course of y
our life, integrating habits that support your lifestyle and performance is an important step to take.
As always, if you have any questions, need any support, or would like to get in touch for whatever reason, feel free to reach out! I am happy to see how I can be a resource for you.