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Aug 02, 2023

ICE - The Why, The When and The Who. Understanding the use of Ice in therapy and performance.

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Dr. Yoni Rosenblatt: And here we go. We're gonna talk a whole bunch about Icing because I've gotten a ton of questions about what we do with ice. What do we do with ice at True Sports Physical Therapy, what's current best practice? What do we think is best? What do we know is best about ice? What the hell does the word ice even mean? Tons of DMs about, if I could cover a little bit about this topic. And so that's what I set out to do. I want to talk about the way we use cryotherapy by and large, and, we're gonna get into exactly what I mean by cryotherapy, but let me just lay it out, the way I want to address this. So the first thing we're gonna do is we're gonna define a few terms. We're gonna go into exactly what the literature seems to mean when it says ice.

Dr. Yoni Rosenblatt: What does it mean when it says cold compression? What is intermittent cold compression? Doesn't matter. We'll talk about all those things. I also want to get into what are we 99% sure about, as it pertains to ice? What does the literature really convince us currently that we know about ice? Then I wanna break it down. Pathology specific approaches. So what types of pathologies do we know ice really helps or hinders? What are we not really sure of? Then I want to slide into the performance world. How do we utilize this idea of messing with our body temperature, both systemically or, very specifically or region specifically. How can we tinker with that or biohack that to enhance performance? Or what do we need to be leery of? And finally, like I said before, what do I at least currently do?

Dr. Yoni Rosenblatt: I try to approach this very humbly, just like we do with all of our interventions at True Sports Physical Therapy, knowing that what we do today, maybe tomorrow we look back and be like, what the hell were we doing? But just trying to put our best foot forward and get the very best interventions that we can and outcomes that we can for our athletes, so that they begin to trust us, trying to be as transparent as possible, saying, "Hey, this is our best effort." So, that's what I want to cover in today's podcast about all things ice. So, bear with me. It's gonna be a lot of my voice 'cause I don't have a guest today and God knows I've heard a ton of my own voice today. It was a... It's a special day with In true Sports Physical Therapy. First Tuesday of every month, we get all of the leaders together. We set up individual meetings with the regional directors.

Dr. Yoni Rosenblatt: So I've been talking all day, and this is just another edition of some of what we covered in those meetings, 'cause some of that is clinical. So without further ado, here is some of my thoughts on cryotherapy. So let's define the terms. So ice, the way it's really operationalized is usually referring to ice packs. So that means, when you'll see either like the branded packs or the packs that you'll see placed like in pillowcases or just putting a fine layer of protection in between. Usually a mushy type substance that has been frozen. Usually there's some type of alcohol base to prevent pure clumping. And usually that is what it means when they say, "Hey, we're gonna use a cold compress, or we're gonna run a study or look at ice by and large.

Dr. Yoni Rosenblatt: The other... Another term that is used commonly is cold compression. So cold compression usually is static compression, where you're keeping a constant pressure as well as inter... As well as applying, or introducing a colder substance in an effort to bring down surface temperature. And hopefully that temperature bring... Comes all the way down also at a deeper level. And then finally what you'll hear or read a lot is intermittent cold compression. And so that kind of mimics your muscle pump, which is one of the ways in which we push fluid back into circulation, into the circulatory system. And so it'll squeeze you, it will also get cold. Usually that's by way of pumped water so that it's a constant cold compression and the temperature remains constant, although the compression, sorry, is not constant. It's intermittent. So it's squeezing you, releasing, but staying cold. And the idea there is that you're getting the best of both worlds. You're getting both that muscle pump and compression and also we're playing, with the circulation. Now remember, when you apply any type of lower level temperature to the surface, it causes vasoconstriction. Now what's interesting is, so you're envisioning your venous system kind of puckering up or tightening up, and so it's gonna decrease blood flow to that area.

Dr. Yoni Rosenblatt: Remember, the body automatically reverses the response that vasoconstriction and becomes vasodilation, after a given amount of time. Studies are kind of out as to when that transpires. We know after about 20 minutes that the body reverses its response totally. And so becomes vasodilated for sure. And so blood flow will then increase in an effort. The body's making an effort to warm itself, back up naturally. So initially, kind of the original thought was simply placing that ice on it will cause vasoconstriction and maybe push fluid out. Then we began to think, Hey, maybe this is actually creating a natural pumping mechanism of the venous system in which you'll cause vasoconstriction and then followed by a vasodilation regardless.

Dr. Yoni Rosenblatt: It seems to be that the body does reverse its initial response after about 20 minutes. So that's why I used to be a proponent of putting ice on for only 18 minutes, although I've moved away from that, since that point, as newer evidence kind of came out. But whether you're looking at simple, ice, whether you're looking at a cold compress or you're looking at cold compression, or you're looking at intermittent cold compression, there is so much goddamn conflicting evidence on all of this, almost all of it. In almost every venue, you can bring up a study that will totally support, Hey, you gotta ice immediately, versus one that will show, you should never ice. And ice should be not even in the room, as it pertains to a different injury. So we'll try to parse that out.

Dr. Yoni Rosenblatt: I'll try to give you some of the best guidance that we now currently see or that we now currently utilize. Some of it is totally anecdotal, like, Hey, what's worked for our patients? What's worked for my patients? And what's the preference? And sometimes I'll simply look the patient in the eye when they say, Hey, should I ice this? Should I heat this? Say like, whatever you think makes you feel better. Because I think placebo is stronger than all. Certainly any cold compress it seems to be that whatever the patient thinks will make them feel better is gonna be the most worthwhile. So, okay, let's dive into the next phase of this, now that we've defined some of those terms is what do we... What are we fairly certain of as it pertains to cryotherapy? And by that I mean really the garbage term of just introducing, some type of temperature change or temperature lowering.

Dr. Yoni Rosenblatt: So it does seem that decreasing tissue temperature decreases pain, period. I've seen studies that show while it's on it decreases pain, and this is patient reported pain. I've seen studies that will last for a matter of an hour after you take that ice pack off. But really since the '80s and '90s from a lot of the literature that I pulled, we know that the patient will report, I feel less pain when I'm utilizing an icing protocol. There is a huge amount of neural component here. We know that you are decreasing firing patterns peripherally when you add ice to an intervention or when you lower someone's body temperature. And most likely that is decreasing how rapidly those pain sensations are traveling up your nervous system. And that's a lot of why we're decreasing pain. That's why when you go to touch a surface after it has been iced, it is numb.

Dr. Yoni Rosenblatt: And that is just because it is taking forever or the nervous system is blocked from transmitting those painful stimuli kind of up towards your brain where you're gonna feel as if you're in pain. It's also interesting to note that while we've known for years and years and really decades, that ice does decrease patient reported pain. Dr. Dinar, who's a fabulous shoulder surgeon, in Pacific Northwest, he ran a study and he looked at their good effects with ice as good effects with just icing ice and as you have with constant ice compression. So, and that's looking at what we used to call an iceman. They were like the biggest player in the field where you're pumping constant cold water through a pad with a little bit of compression, that seems to be equally as good as an ice pack.

Dr. Yoni Rosenblatt: So that was Dinar and that was in the early 2000s, who showed that? But again, you're gonna see studies kind of back and forth, but we know that ice decreases pain. Furthermore, we know that cold submersion with all of the very best evidence seems to have outstanding cardiovascular health benefits. There is tremendous dopamine release. There is an amazing decrease in perceived soreness. And doms there is awesome power and endurance beneficial efforts 24 hours after completing cold submersion. And that's when you put your entire body in a body of water up to the neck. And they usually define cold as 50 degrees and below there's a lot of literature that has come out recently looking at duration needed in that temperature. It seems that the colder it is, the less time you actually need to spend in that, water.

Dr. Yoni Rosenblatt: So as you get down into the '40s and '30s, a lot of patients and athletes are spending anywhere from three to five minutes and seeing the same benefit as if they were staying in that cold bath from 12 to 15 minutes with the water a little, a little bit warmer, but again, should be below 50 degrees seemingly to have all of those positive effects. There's just a plethora of literature and evidence from massive universities that say cold submersion can have those specific effects. And so just keep that in mind as we keep kind of talking about things that I think are our current best evidence and best intervention and stuff that really creeps up and that you'll see, in our clinic or part of home exercise programs that we prescribe. Okay. So a big piece of the questions that I'm receiving is, okay, when do you want to use this stuff? 

Dr. Yoni Rosenblatt: When do you not want to use it? And how much of it do you want to do in the clinic? And so in full transparency, just as like, kind of giving away some of the answers, I think when I first started True Sports in 2014, my first big purchase was a freezer and ice packs. And at the time, this is when we used to have like rehab reps, who would like find out you opened the clinic and be like, Hey, I can sell you this, this, this, this, this, this. The guy pitched me on these big ice packs, which were like 50 bucks or 60 bucks.

Dr. Yoni Rosenblatt: That I would keep in the freezer. And I remember putting them on my balance sheet because I'm like, how am I gonna afford the 50 bucks for the ice pack? Also, the freezer, what's the cheapest freezer I can get? So there is a freezer in our first clinic with ice packs in it. That freezer probably has not been opened, in a matter of months or years. And that's because I've simply moved away from it. So we do not by and large do ice in our sports outpatient setting. I just think it is something that like goes against my nature, which is I don't wanna do things in the clinic that you can do on your own time. You're paying us X amount of dollars or your insurance is paying us X amount of dollars to provide you the very best.

Dr. Yoni Rosenblatt: I am still very much of mind and the literature says as such, I think... That your time is going to be far better spent with me, either with my hands on you, or I think now even more recently in my career with me coaching you on exercise and movement and proper therapeutic exercise, proper loading principles more so than these passive interventions and modalities like ice, like heat. And I think insurance companies are actually kind of finally picked up on that and they don't even reimburse for it. So when I first came out of school, it was like, here was the rule. Patient walks in, you set a timer for 20 minutes, you put heat on them, you come in, you do a little bit of man manual therapy, you do a couple exercises, you set the timer for 20 minutes again, and you put ice on them. And that's the way we did it. And it's about time. This profession has come a long way in that we're beginning to pick these things apart and say, why the hell do we do this? Why do we do three sets of 10? Why do we do, plyometric training? Why do we do running before jumping or jumping before running when you're doing a rehab, progression with an ACL? 

Dr. Yoni Rosenblatt: All these things should have a reason and should be thought out. Now, as you can tell from this pod, which is somewhat scatterbrained, but the literature is so scattered as to how to do certain things. So you're not gonna have concrete answers necessarily, but I'm just encouraging everyone who's listening to this that when you choose an intervention, it is, it has been thought through process and that you can defend it, that it is the absolute best use of time. Your brain power, the patient's efforts to the best evidence that we currently have. And whether that be anecdotal evidence or whether that be, meticulously, scientifically proven evidence, you just gotta have some type of thought process from it.

Dr. Yoni Rosenblatt: So that's why I'm just kind of starting to pick away, and pick apart this ice stuff. So let's dive into, a study that I found, which was super granular. So it ties in nicely with that last rant, which is 2009, I found a study that looked at what ice intervention provides, the lowest temperature to the surface to which it's applied. And so they looked at wet ice, which I just loved 'cause it reminded me of Rookie of the year and heating up the ice. But you have wet ice versus cubed ice versus crushed up ice. So the wet ice is they simply, took ice cubes, put it in a Ziploc bag with water, and created like a slushie and used that versus, cubed ice, just the cubes versus crushed kind of like we would call them Baltimore, like a snowball crushed ice. And they compared all of those. And that wet ice, decreased tissue temperature, far greater than cubed and far greater than crushed.

Dr. Yoni Rosenblatt: And so I, that's pretty good support that if you're going to ice, the best intervention is most likely one of those ice packs that is that kind of amalgamation of both water that has been frozen as well as an alcohol that will keep it moist. That seems to be, the best conveyor of colder temperature. So at least you're getting the best bang for your buck, next this cold with compression. They compared again, what's getting colder, they compared just ice, cubed ice, then they compared ice and compression. So that's with an ACE bandage or a pneumatic compression, but it was a consistent compression. And then they compared that also to ice and Flexi wrap. Flexi wrap is like the thick plastic that you'll see athletic trainers like holding on a, looks like a Popsicle stick and they'll just wrap it around the ice.

Dr. Yoni Rosenblatt: Shout out to Israel Lacrosse, which is where I first learned how to use one of those flexi wrap things 'cause they never taught me that in grad school. And they compared all of those. And what gets colder? Is it the ice, is it the icing compression or is it the ice and flexi wrap and ice with compression seems to decrease that temperature greater than just ice with the flexi wrap, which doesn't give you as much of a squeeze versus just the ice. So that compression is a huge player. And I think, again, that study came out in 2010, so I think that's when you really started to see these efforts to include compression at all costs. So much so that, they ran a study comparing, mobility as, so functional mobility, which is how the patient rated their ability to move around. They looked at... Patient reported pain levels and they did that just comparing, ice versus ice and compression and the ice and compression was far greater.

Dr. Yoni Rosenblatt: So it really goes to kind of show you that hey, maybe compression is a bigger predictor of positive outcomes after immediate pathology. That was with an ankle sprain, than it is the ice. And I think we kind of just got on this bandwagon of ice. It does seem that in terms of lowering temperature, that ice with compression is the absolute best bang for your buck. But it could be that functionally speaking, it's all about compression and not so much ice. So when in doubt to cover your bases, you really want to kind of look at how do I get some type of consistent compression on the injured tissue. Especially if it's acute as soon as possible to I think prevent that swelling. We do far better at preventing swelling, as a profession than we do at clearing swelling. And we'll get into that in a second. Okay.

Dr. Yoni Rosenblatt: So now that we've kind of cleared up, what's the best way to lower a tissue temperature? What is some of the functional kind of. Pearls or the rehab pearls, which is to include some type of compression? Let's get a little bit into pathology specific utilization of cold. So a lot of times patients will come in, you give them the diagnosis and based on that diagnosis, you can start to think, how do I want to use the tools at my disposal? So how do I want to use cold in this instance, if someone walks in and they underwent a contusion, they simply blunt force trauma. And so this was a really interesting study that I found 2017, this is out of Frontiers of Physiology. And so they looked at one bout of icing immediately following a blunt force trauma. And they did, this is a rat based study, but it was, it's just interesting, bear with me. Like the level to which they were able to dissect this and the outcomes. And I think there's some pearls here that you can kind of pull out and say, "Hey, I wanna apply this, to my thought process. I know it just recently affected an ankle eval that I did yesterday." So...

Dr. Yoni Rosenblatt: They provide the blunt force trauma to the rat, right? Then they do... They ice the rat's limb for 20 minutes once, they kill one section of those rats on that day. And they slice that leg open and they look and they compare. One group of rats was iced for 20 minutes. We just kill those. [chuckle] One group of rats was not iced. We just kill those. And we're looking at both of those groups and comparing them. Ice group versus sham group. At day one of post-injury. And so on day one, post-injury, the sham group had significantly less necrosis, had far more macrophages, which clear out disease tissue in that limb that just underwent the blunt force trauma, then did their iced counterparts. So why is that so interesting to me? It's interesting because it seems to be imperative, and you'll see through the rest of this study what transpires immediately following that trauma. And if you try to slow down, if you try to impede or totally prevent the body's own healing response, and that's by encouraging, you want macrophages in there so it can clean out the disease tissue. You wanna fight the necrosis that will transpire. That seems to be what happened when you just let that rat go through its healing process versus us trying to add icing to the mix because when we added icing to the mix, they weren't able to begin to heal themselves. They don't have the macrophages, they have far more necrosis.

Dr. Yoni Rosenblatt: And that's just immediately in day one following that trauma. What's interesting is they did the same thing at day three, day seven and day 28. And so days three and day seven, the sham intervention, so the rats that were not iced, they had more regenerating muscle fibers than the icing group. So the rat's body is healing itself and laying down clean, healthy muscle fibers to which the iced rats hadn't recovered. And you're talking three days, seven days, which is far longer in human years, if you're gonna extrapolate and make a correlation. But it's so interesting to me that they're not able to... Once you retard that healing process, it's almost like the body never gets over it. Or at least the rat's body. And then finally at 28 days, again iced versus sham, they had a far larger number of immature muscle fibers in the iced group. So it really just seems that blunting, that healing response so early, they never caught up. You're talking 28 days later that that group that had iced only one time immediately post-trauma, they never caught up. Now, I totally understand that we're a different species, but there's so much more... There's so much that we can glean from this. And so when I had that very recently, this acute ankle sprain, he had been to his orthopedist. He'd been sitting in a booth, all he'd been doing is icing it.

Dr. Yoni Rosenblatt: He had been just totally trying to protect and limit this grade one ankle sprain, which the orthopedist simply kind of didn't even recommend therapy and just put him in the booth. I'm looking at that thing and I'm like "How many days, how much time has this athlete lost by preventing his body from beginning that healing process that now we're gonna have to try to make up responsibly, obviously," but I just immediately thought of this, this blunt force trauma where injury has ensued, muscles begin to shut down, and then we're gonna continue to encourage and blunt that response. It's really just gave me a new look. So again, that's a 2017 study. Take it for what you will. Maybe there's some gems there, but worth thinking about. Next is, is ACLs. And some of this is how do we apply this to our post-op world? 'Cause I think that's one of the few populations where I strongly encourage ice early post-op. And I think there's a major difference between those levels of trauma that are transpiring, which I just had a great dinner with an orthopedist. We were talking about what it's like to go in as a physical therapist and observe surgeries. I highly recommend it. Anyone who's listening here, find a doctor who gives a damn about their patients get in that OR because it's eye-opening to remind yourself the physical therapist, what it is that these patients go through on the OR table and how traumatic it really is when you look at a BTB ripped out of the front of that knee.

Dr. Yoni Rosenblatt: I actually think I just talked about this on a pod when we were talking about different graft choices, but it is huge amounts of trauma. They are cutting bone, they're cutting tendon. That totally makes sense how much anterior knee pain is specifically with that BTB. But even you're looking at cuff repairs or just talking to shoulder surgeons and talking about remplissage and talking about labral repairs and the amount of trauma that's transpiring just from that scope going in and banging around. It's pretty incredible. So get your ass in an OR and kind of make sure you're watching some surgery, but what's the deal with icing post-op and how effective is it? So interesting study in 2012, looking at the effectiveness of cryotherapy after ACL ligament reconstruction. And so acute post-op ACL, they had a group that included icing post therapy and then they had a group that wouldn't ice post therapy. Everyone's doing the same range of motion exercises. Hopefully amazing quad sets, hopefully with heel pops. Hopefully getting terminal knee extension like everyone knows, has to happen immediately post-op ACL. One group, they iced 20 minutes a day. One group they didn't.

Dr. Yoni Rosenblatt: The group that they were icing 20 minutes a day showed decreased pain. Like I said, that's one of the things we can really hang our hat on. But two increased ranges of motion, both flexion and extension in the group that was icing 20 minutes a day. That's a pretty decent study by Dan Bros et al in 2012, which I encourage you to go through and is really convincing to say when you get that patient post-op, making ice a part of their game... And I would strongly encourage making ice and compression as a part of that game, we'll get into some of the worthwhile compression companies at the end of the pod, I think. But making that a piece seems to really increase their ranges of motion post-op. It's not as much about pain as it is ranges of motion. It looks like you're getting great bang for your buck by including icing at a 20 minute clip at a minimum to encourage those outcomes.

Dr. Yoni Rosenblatt: So that's kind of like my thought, or one quick study on post-op knees, we also... There are some good literature on just overall knee scopes, so they were excluding ACLs from that and just talked... They just talked about meniscectomies. I think it was meniscectomies debridements. If people are still doing that and... What was the third, I can't think off the top of my mind, but I'll throw it in the show notes. Also looking at ranges and pain far better in the ice group than in the non-ice group, so that is a piece of what I encourage that ice in post-op knee scopes knee surgeries by and large, okay. And then there is a great study by athletic trainers, God, if you're an athletic trainer and listening to this, thank you for what you do because there are some awesome athletic trainers out there, I'm looking at you, Collin Francis, and just some of... Some of the research that ATCs are putting together is worthwhile, there's a massive study of systematic review of randomized control studies that came out all the way in '04, American Journal of sports med, but led by ATCs and looked at icing alone seemed to be more effective than applying no form of cryotherapy after minor knee surgery in terms of pain, so definitely again, helped with the pain.

Dr. Yoni Rosenblatt: What's interesting is ice and compression is far better than just ice. So again, two groups, one's get ice and compression, one's just get ice in terms of ranges of motion out of minor knee surgery, that's what this... That's what this is talking about. So range of motion and pain levels, better ice and compression than just ice, so find yourself a company that provides some compression, please. Okay, what's the other hot topic that people are always talking about, ice do I ice do I not, would be tendinopathy, and there's so much literature on tendinopathy on tendinitis, when to ice, whether to ice, whether to run from ice, somebody talking about heat, I think that'll be another pod I just wanna separate heat all the way out, 'cause I could talk for hours just on that, so maybe we'll get there. But not today.

Dr. Yoni Rosenblatt: So looking at ice for tendinopathies specifically with lateral epicondylitis, had the exact same outcomes with physical therapy, so same exercise regimen, same manual intervention, one was with ice, one was without ice, they had the exact same outcomes, and so that was British journal sports medicine 2006, specifically looking at lateral epicondylitis, the reason I love this study is because it highlights what is the biggest bang for our buck in the clinic.

Dr. Yoni Rosenblatt: I just have to believe that it is not the use of me going to the freezer, grabbing some ice and putting it on a patient, and I think is... It just has become so the norm and we need to get out of that, we know that we can have far better intervention with loading, with some type of manual intervention, than we can with just applying these passive modalities. The study in '06 certainly supports that when that patient comes in with lateral epicondylitis, you should be doing really just the following, number one, identify why the hell you think they have the tendinitis with the epicondylitis. Or the tendinosis. Why is it there? Are they missing extension? Are they missing supination or pronation? Is it simply a matter of volume control, what is their C5 doing, what's their C5 intervention looking like around elbow flexion, around risk extension, do we need to shore that up. There are so many things to hit, what's their scapular mechanics looks like, let me spend time there than just throwing passive modalities on people.

Dr. Yoni Rosenblatt: That's where you're gonna get biggest bang for your buck. I always come back to a study looking at shoulder tendinitis and shoulder tendinopathy, and this isn't an ice thing, they looked at outpatient care, same exercise routines and interventions, same manual routines and interventions.

Dr. Yoni Rosenblatt: The only difference was one group got ultrasounds and one group did not. And the group that did better, did not get ultrasound, and what the authors discussed was, was there just simply more use of time on whether it be education or whether it be progression or whatever it is, instead of just wasting time rubbing a wand and gel on people, I feel the same way at times about ice, think about that as you're planning out a given session, another one, and hopefully you guys heard the pod that I did with David Gray, if not, check it out it's one of our most popular podcasts, just getting his feel for achilles tendinopathy, lower extremity strength, foot and ankle strength mobility and biomechanics, he did a great job of explaining it. And so I highly encourage that, I think it was like two or three pods ago, but looking at achilles tendinopathy and how ice relates to that or how we're gonna use ice for that, it really seems that it does have a positive effect, short-term introducing cryo to achilles tendinopathy or chronic tendonitis, but only short-term, long-term there seems to be zero effect, at least according to a study in '08 journal of sports medicine, so give that a look.

Dr. Yoni Rosenblatt: It is worthwhile to think, again, what is my use of time, but if there is a pain-limiting factor that is totally precluding a patient from either coming in or kinda getting through their exercises, how can I hack the system to use some type of Cryotherapy to move them through their exercise, there is some literature on achilles tendinopathy, and just introducing that coal plunge we spoke about previously, I believe they did a study on introducing the three-minute version, and so that was with the water at 40 degrees or below, and a decrease in reported pain in achilles tendinopathy, which is fascinating, again, the authors in that study looked at or postulated, perhaps it was just an overall decrease of pain, systemic pain or increased tolerance, I guess the pain that allow them to get through their therapeutic exercise to see the benefit there in. So again, just kind of reverse engineering how we can use what can be an awesome intervention of Cryotherapy or lowering one's body temperature for positive effects. So think about how you can put that in. Okay, let's talk about some symptoms.

Dr. Yoni Rosenblatt: The number one reason you're going to usually go to ice is either to decrease pain or decrease edema. So it's that swollen knee. And one study that I thought was really fascinating, specifically around edema was 2019, Sari et al reported that pneumatic compression with standard PT is far better than ice packs and PT for decreasing knee joint edema. Now, the literature's all over the place in terms of ice and its ability to decrease specific edema. There's some really good studies looking at circumferential measurements immediately following ice intervention and that was without compression and it having zero effect. It seems like the only way to really change your circumferential measurement is with compression. And it has been shown that pneumatic compression, so intermittent pneumatic compression where it's squeezing the crap out of you and then easing off regardless of the pattern in which it's doing that, is far better than just consistent compression.

Dr. Yoni Rosenblatt: And then obviously far better than not having compression. Again, just introducing ice on top of that may help with pain. It will not help fairly convincingly with circumferential measurements and ice. I'm working with a football athlete now and his biggest complaint was pre-op and now post-op was simply joint effusion. And he's working with some of the best trainers in the league and there's a tremendous amount of reliance on passive modalities and yet still that knee will not calm the hell down. And so not until we really started to look at what is causing the need to swell, will help us address that biomechanically. And that is far more advantageous to try to do that, incorporate it within movement, than it is simply laying on a table, so when in doubt try to parse through those biomechanics and figure out what's causing the edema, how do I step in there as opposed to just fighting the edema 'cause too often, it's just gonna come back.

Dr. Yoni Rosenblatt: Okay, let's talk about performance. And so as it pertains to performance, I wanna look at the body's ability to produce force, the body's ability to produce force over time or endurance, and what that looks like immediately, following ice and how different that can really be. So, a couple of literature points here that came out of, of this lit review was looking at the body's ability to create max isometric force through the quadriceps following icing of anterior knee versus following icing of posterior knee for 20 minutes time. What was interesting, I figured that there would be decreased max output there following icing, but it was equal amounts of decreased output, whether you ice anterior knee or posterior knee. And so what that's kind of telling me is you're not just getting a response directly localized to where you're putting that ice.

Dr. Yoni Rosenblatt: I would bet that that temperature is dropping enough that the limb is being inhibited or shut down, that you're no longer able to contract those quads appropriately. So, this is a conversation that I had to have actually recently with a football player who was rehabbing elsewhere, in which they would start this session with ice on the knee in an effort to decrease pain, but then immediately went into strength training. You got to think, does that make amazing sense? Like does it make sense to, yes, I might inhibit some of that pain with the ice, but I know based upon that study that I just quoted, it's also gonna decrease your output. And so, now you're not training to your optimum, probably not the best use of ice or not the best timing of icing, but that definitely kind of came out of that study where that kinda made really good sense.

Dr. Yoni Rosenblatt: And then also looking at hypertrophy, following... When followed by icing. We know that muscle growth is severely inhibited when applying ice. And you can look at a study by Zach looking at muscle growth with ice versus heat. And again, I'll link to that in the show notes, but when they ran biopsies of muscle tissue following a lifting session, one group was iced, one group was heated, there was significant increased growth factor in the heated group compared to the iced. And so, you'll hear performance coaches or scientists talk about cold plunging following a strength effort, a bout of strength training in the gym and how that seems to be negate the effects or the positive effects of a strength session.

Dr. Yoni Rosenblatt: Let's think about that from a rehab perspective. So, often you'll go through your squats, your lunges, you're going through some type of strengthening protocol or progressions, and then we're gonna have them sit on ice. So, okay, you're decreasing the pain. We know you're not really decreasing the edema that may have been caused by the session. I don't think it's thought through thoroughly enough what is happening from a hormonal perspective and are we blunting the strengthening effect of the session that we just had.

Dr. Yoni Rosenblatt: For sure that patient or athlete should not be dunking in a cold plunge. Huge amounts of studies there. But just based upon the Zach study and looking at the growth factors that were released, both systemically as well as concretely or specifically in the loaded muscle that they were less. Or sorry, they were higher with the heat and less with the ice. Let's be careful that when we're icing patients have that front of mind, let them ice a few hours later if they're in a bit of pain. But we want as much of those human growth factors to be released and to really soak through the system, so that they can get the best bang for your buck.

Dr. Yoni Rosenblatt: And maybe this is why we will see athletes have a tremendous amount of trouble, putting size and mass on a leg after an ACL, especially BTB. 'Cause they have the decreased inhibition of the quadriceps. They're not activating all of those muscle tissues. Maybe their nutrition isn't all the way up to par, but also are they just icing the crap out of their knee following these strength sessions? Something to consider. I put that both in the rehab as well as the performance side. Now, this next piece of performance is fascinating. Had a great conversation with one of the smarter football players. I know a guy named Chance Campbell.

Dr. Yoni Rosenblatt: Chance Campbell was telling me all about this awesome research on palmar cooling, which is when you simply hold, it could be a cold water bottle or they have very specific tools that live at about 50 degrees Fahrenheit and you simply hold it for 30 seconds to three minutes. And what it does is it decreases your core body temperature significantly. And what we know countless studies, I encourage you guys to Google this palmar cooling. There's a tremendous amount of studies that support the body's ability to then maintain force over a far longer duration, following a bout of palmar cooling, then without, and then compare it to a palmar heating.

Dr. Yoni Rosenblatt: So, the ideal temperature they think is about 50 degrees Fahrenheit there. And so, the first study they did was on dips. And the amount of dips that the guy was able to complete with palmar cooling compared to non palmar cooling, they said it was far more effective than anabolic steroid use. I think, I know that was in Stanford, I know that was in San Francisco. And I say that because I think it was a San Francisco tight end, that was the N-of-1 there. That was a study there, but it kind of blew up. And you'll hear it on Huberman podcasts or Huberman Lab podcasts like crazy 'cause he's a Stanford guy. So, he's always talking about it.

Dr. Yoni Rosenblatt: But this... Sorry, back to Chance. Chance is one who will keep his palms cool on the sidelines as he's competing. Not only that when I was lucky enough to work with the Israeli National Baseball Team in the Olympics in the Tokyo Olympics recently. I started to encourage a lot of use of palmar cooling in the dugout. First of all, it's hot as hell. So it is a far more effective way to decrease your core temperature by cooling your palms than it is putting an ice pack or a cold towel on your head or on your neck like you'll see, or even in the armpits. It's far more effective on the palms or on the bottoms of your feet if you're not wearing cleats.

Dr. Yoni Rosenblatt: And so, as I was talking about some of this stuff with the guys, one of the pitchers, a guy named Jeremy Blechle, who I think is director of pitching for the Pirates now, shout out to Jeremy. Jeremy's already in the corner holding ice in his hand 'cause he's about to pitch. I'm like, "How the hell do you know about that?" He's like, "Oh, we always used to do it at Stanford." I'm like, "Of course you used to do it at Stanford." So, this is an awesome tool that can be used for max effect, and I would encourage people to start kind of toying with this in the rehab world, can I get more out of my patients? Can I get more reps? Can I get higher weights? Can I have them go for longer by utilizing some of this biohacking? 

Dr. Yoni Rosenblatt: Again, they have very expensive tools that can really dial in and give you the exact temperature of how your palmar cooling. Just so everyone knows there have been studies that have come out that have attempted to debunk this or do not support it as heavily or cleanly as I'm pontificating. But something to think about, something to kind of look into for sure. Okay, so takeaways. Here, I just kind of put together a couple bullet points as to the way I currently approach this. You've heard me say this a few times already in the pod, but I figured I would just kinda dial it down, dial it all the way in.

Dr. Yoni Rosenblatt: I do not do things in my private outpatient world that I think can be done at home. And that's because I want to do things in PT, in rehab that require my supervision, our facility. Maybe you don't have access to something like that, or that you just simply haven't done yet and will require coaching, gain of confidence, etcetera. That's what I want our session to be based on. Anything you can do at home, because I want you to have the best use of your time. You do it at home, I'll educate the hell out of you about it. But that's why I don't ice in the clinic, at least not consistently.

Dr. Yoni Rosenblatt: I do a lot of educating on icing protocols, on cold plunging, on this palmar cooling, on just anything, that I'm kind of tinkering with that I think is worthwhile. And educate the patient, don't forget your transmission of your education as the physical therapist. That's why the patient's there. You don't have to do everything for them, but you can teach them so that they can kind of do it forever. It's like teach a man to fish. So, you want to educate them on icing principles, but I do try to insist to include some type of compression because of the billions of studies that I just quoted to you.

Dr. Yoni Rosenblatt: I love a company called Preventice. They do a great job of both compressing, providing cooling. They also give you the option to compress and provide heat. You can set it so it goes back and forth, look into them if you haven't already. But at the very least, I want that patient wrapping with an ACE bandage or using a NormaTec if that's what they have access to. Any compression is better than no compression for sure.

Dr. Yoni Rosenblatt: Acute muscle trauma, my go-to is compression. If you're gonna ice, great, but you have to compress it. And then I would encourage an ice plunge, like I'm thinking ankle sprains here. If you're going to try to use ice and try to mess with the temperature, the surface level temperature. If you get into an ice plunge and you're moving that foot around that ankle around, now we're getting the movement that I want. It might make it easier for you to move 'cause it's gonna numb it up a little bit, or at the very least, putting it in an ice bucket but moving it. Don't just let it in there and freeze to death, because I'm just thinking of that rat study previously quoted. But put it in the bucket, put it in the ice plunge, move it around. Go through your alphabet, get that ankle moving, best bang for your buck.

Dr. Yoni Rosenblatt: And finally, chronic tendinopathy. I actually like the use of heat. Again, we'll get into that in another pod. But for me, tendinopathy is maybe some heat, get them on a valium control. So understanding their usage and how do we play with that? How do we overload the tissue appropriately and how do we progress that? A loading of the tissue, but also understanding the mechanical deficiencies that may have led to this overload. That's the way I approach tendinopathy. Stop icing your tendinopathies is what I would say today. Maybe I'll change that. And then you want to use that next day to gauge the effect of the intervention.

Dr. Yoni Rosenblatt: I can't tell you how many athletes I've had come in, Rip-Roaring achilles tendinopathies. We go through a session, maybe it gets a little bit better in the session. They're a little bit sore coming out of that session and I see it and they'll voice it like, "Jesus, I think I'm worse coming in or walking out than I was coming in." But that is not the test as to how they handle the session, it's the next morning and throughout the next day have them journal that, that's the way you begin to load appropriately and understand, hey, here's how I'm gonna beat that chronic tendinopathy as they persist.

Dr. Yoni Rosenblatt: So, that's hopefully a whole bunch of useful information. Thank you so much for listening. I encourage your comments and your feedback. Again, my mouth's been running all day, so, hopefully this was easy enough to get through and to listen to. And any feedback, always welcome. Please do us a favor here at True Sports Physical Therapy. We would love for you to, number one, learn from this.

Dr. Yoni Rosenblatt: Number two, I want you to share this, and number three, let us know what you think. Because we're creating this for you, we're creating this product for you, and we got a lot more products coming. We just wrapped up shooting our awesome ACL course. So, I've been teasing that for a little bit, but that's forthcoming in the next month or two. And that's really gonna dive into at True Sports rubber meets the road, how do you actually rehab an ACL? And there are a lot of ACL courses out there, don't get me wrong. And a lot of them are pretty good.

Dr. Yoni Rosenblatt: This one really shows you step by step how to teach the appropriate exercises, why we're teaching the appropriate exercises. Giving you how do you progress? How do you scale those exercises, what are some of the tidbits that you have to hit as your athlete is making their way back to the field. And interestingly enough, it's going to have one of the area's absolute best surgeons talking about the way he approaches the surgery. He's gonna talk about the way he harvest grafts and why he chooses different grafts, great learning opportunity. So, look for the True Sports Physical Therapy, ACL course coming your way.

Dr. Yoni Rosenblatt: And other than that, we got a lot of just awesome opportunities. We got a Rip-Roaring new clinic in Delaware and we're always looking to add to our team of sports physical therapists. We have clinics throughout the state of Maryland. We have two clinics now in Pennsylvania, now we have two in Delaware. And we just love helping athletes. So, if you wanna be a part of our True Sports family, shoot me a DM, Truesportspt on Instagram. Just let me know that you're interested. We've already gotten a number of physical therapists that have just been awesome additions to the team just by way of the podcast. So keep them coming. Let me know what you want to hear of more. Let me know what you want to hear about less. Let me know what you love. Let me know what you hated. Can't wait to hear from you. Thanks so much for listening guys.


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