24 HEALTHCARE CAREERS | 2018 | www.advanceweb.com For chronic local conditions, NSAIDs help via pain relief, but are not good for reducing chronic inflammation. SAID use is warranted for chronic, local inflammation, however; prolonged use can lead to protein breakdown and promote mus- cle wasting. They should be used judiciously. ICE What about ice? People have been using it for decades to manage inflammation, so it must be a good choice. Or is it? In 1978 an ortho- pedic surgeon, Gabe Mirkin, M.D. came up with the familiar acronym “R.I.C.E.” (Rest, Ice, Compression, and Elevation) regarding how to address inflammation. Its simplicity and general adoption has been the gold standard for addressing inflamed tissue in the medi- cal community for almost 40 years. The tide currently appears to be changing. Dr. Mirkin himself was recently quoted in an article pub- lished on the Spartan website (www.life.spar- tan.com) that he now openly rejects at least half of R.I.C.E. “I do not believe in cooling anymore,” he explained via email. Nor does he believe in the “R” component of his famous prescrip- tion either. In a foreword to the second edition of Iced!, Dr. Mirkin says most athletes are far more concerned with long-term healing than transient pain relief. “And research,” he writes, “now shows that both ice and prolonged rest actually delay recovery.” The research he may be referring to includes astudyintheBritishJournalofSportsMedicine that retrospectively investigated 22 separate studies and concluded that “ice is commonly usedafteracutemusclestrains,butthereareno clinicalstudiesofitseffectiveness.”Moredamn- ingwasthereportintheJournalofStrengthand the Conditioning Research, which stated that not only does icing fail to help injuries heal, it may well delay recovery from injury.20 Ice apparently plays more of an analgesic role post injury more than it does in reducing inflammation. A 2013 study in the Journal of Applied Physiology showed that cryotherapy had null to mild impact on pro-inflamma- tory markers on post-exercise induced muscle damage.21 Research from the Cleveland Clinic has gone a step further showing that icing an injury delays the release of IGF-1 (insulin-like growth factor-1), a hormone involved in the inflammatory cascade that helps repair dam- aged tissues.22 These findings should at least start to bring into question the effectiveness of cryotherapy. LASER So if R.I.C.E. is no longer the answer, and NSAIDs are detrimental to the tissue healing process for acute injuries and ineffective for chronic inflammation, what’s a better strategy for managing inflammation and expediting tissue repair? Promoting active recovery is becoming much more accepted as the preferred plan of care. Gary Reinl, veteran athletic trainer and author of the book Iced! The Illusionary Treatment Option believes the answer lies in a new acronym: A.R.I.T.A.—Active Recovery Is The Answer. Instead of being still and shutting down blood flow, try to get things moving and circulating as soon as possible. In line with this concept, laser ther- apy is starting to gain traction in more forward-thinking training rooms and reha- bilitation centers that have acquired this technology. The laser is instrumental in cre- ating photobiomodulation (PBM), which is the mechanism by which photons elicit pho- tophysical and photochemical events in tis- sues leading to physiological changes and therapeutic effects. This process helps has- ten the inflammatory process, which leads to improved tissue healing. Unlike NSAIDs, which block the inflamma- tory cascade at the COX-2 level, and ice, which delays the inflammatory process by restrict- ing blood flow for a period of time, laser met- abolically influences the injured tissue at the mitochondrial level, accelerating the heal- ing process. PBM has both a direct photo- chemical influence on the mitochondria via Cytochrome C Oxidase23, 24 and indirect modu- lation on the inflammatory cascade via enzy- matic changes.25 Both of these effects decrease the length of time needed for tissue repair. Laser research that investigates the mech- anisms involved with reducing inflammation, at a glance, look similar to pharmacological studies because they impact the inflamma- tory cascade at similar points. These include reduced COX-2 levels26 , reduced Bradykinin levels27 , reduction in IL-1 levels28 , and reduc- tion in PGE-2.29 It is important to understand that these reductions are fundamentally dif- ferent with PBM in that they take place from intrinsic, anti-inflammatory signaling gener- ated by better cell metabolism and improved micro-circulation. There have been two recent studies that have compared ice, ice combined with laser, and laser therapy used independently to treat quadriceps muscles after maximum voli- tional contractions (MVC). They concluded that the laser had significantly higher MVC on retest and less oxidative stress compared to the placebo group. They also found that when cryotherapy was combined with the laser, it lowered the efficacy of laser treatment done independently.30 A second study looked at similar groupings but looked at delayed onset muscle soreness (DOMS), MVC, and oxidative damage. They found that laser used as a single treatment (not performed in conjunction with ice) is “the best modality for enhancement of post-exercise restitution, leading to complete recovery to baseline levels from 24 hours after high-inten- sity eccentric contractions.”31 These findings generally support the idea of active recovery. Specifically, they support the use of PBM to help with muscle recovery after exercise. These studies in conjunction with other emerging research are clearly bringing the use of cryotherapy and NSAIDs into ques- tion as the ideal choices for managing injured muscle tissue. It is never easy to change the way clinicians practice,butresearchisstartingtosuggestthat the ideal way to address pain and inflamma- tion will require a departure from past norms. Avoiding ice and NSAIDs in the early stages of the inflammatory process and introducing pro-metabolic modalities like laser therapy could become the new standard for evidence based practice. Clinicians might need to start wrapping their heads around the A.R.I.T.A. philosophy and put R.I.C.E. to REST. n References: References are available online at http://nursing. advanceweb.com/references-nsaids/ Mark joined the LightForce team in early 2017 as Director of Clinical Development. He has treatedorthopedicpatientsfor18yearsandhas been board certified as an Orthopedic Clinical Specialist(OCS)bytheAPTAsince2003. Mark graduated with his doctorate in physical ther- apy in 2007 from Marymount University. NSAIDS  |  HEALTHCARE CAREERS 2018