The old adage of the profession of athletic training is “ice er’ down”. This comment is both simple and can seem to the patients/parents/coaches that you are not doing enough. However I am here to tell you that hypothermic treatment (ice) is EXTREMELY beneficial for just about every* injury we see for the basic principle of; slowing the metabolic response to injury.
When there is an insult to the body the immediate response is a metabolic reaction – in other terms the body uses chemical and mechanical pathways to repair/fix itself. Although the reason for the metabolic response is thought to be for “repair” the body response is usually not limited to what is needed – the more is better philosophy. I can bore you and make you click away real fast by giving you all the physiology of a metabolic response, so I won’t, but if you would like to read about it T.S. Walsh wrote a chapter in a book called “Principals of Surgical Care”.
Subsequent medical research has shown that attenuating the metabolic response has; decreased pain, shunted swelling, and improved outcomes, especially in a very narrow window after injury. The least invasive and easiest way to accomplish this is via hypothermia (see heat related illness). Cooling the body, even locally, can attenuate the metabolic response and the negative effects it has on recovery. That is why you will hear athletic trainers tell you ad nausea to “ice ‘er down”. The reason is simple we are helping you AND YOUR BODY recover faster.
*Don’t use ice if you have the following conditions: rheumatoid arthritis, Raynaud’s Syndrome, cold allergic conditions, paralysis, or areas of impaired sensation.
Logic would then tell you that because during a concussion there is a metabolic response (cascade), perhaps cooling will help with not only recovery but the attenuation of symptoms related to the brain insult. In my humble opinion there is no “perhaps”, it does; not only have I seen this empirically with concussions I treat, but research suggests this with TBI’s;
Therapeutic hypothermia is a promising treatment for patients with severe traumatic brain injury (TBI). We present here the results of a study in which noninvasive selective brain cooling (SBC) was achieved using a head cap and neckband. Ninety patients with severe TBI were divided into a normothermia control group (n=45) and a SBC group (n=45), whose brain temperature was maintained at 33-35 degrees C for 3 days using a combination of head and neck cooling. At 24, 48 and 72h after injury, the mean intracranial pressure (ICP) values of the patients who underwent SBC were lower than those of the normothermia controls (19.14+/-2.33, 19.72+/-1.73 and 17.29+/-2.07 mmHg, versus 23.41+/-2.51, 20.97+/-1.86, and 20.13+/-1.87 mmHg, respectively, P<0.01). There was a significant difference in the neurological recovery of the two groups at the 6-month follow-up after TBI. Good neurological outcome (Glasgow Outcome Scale score of 4 to 5) rates 6 months after injury were 68.9% for the SBC group, and 46.7% for the control group (P<0.05). There were no complications resulting in severe sequelae. In conclusion, the noninvasive SBC described here is a safe method of administering therapeutic hypothermia, which can reduce ICP and improve prognosis without severe complications in patients with severe TBI.
There are other articles out there for various conditions and the usage of hypothermia that show the same results: better outcomes, 1072 articles in this search alone.
UPDATE: To continue with logic, the area of icing should not only encompass the head, but over the vessels that supply the brain with blood, carotid artery; thus the anterior/lateral parts of the neck.
Not only should we be applying ice to the head/neck of a possibly concussed athlete, we should be doing it yesterday – as in immediately upon revelation of the injury. This is not only my opinion but also the opinion of Dr. Huan Wang who was awarded a grant to research the issue/feasibility of getting cool quick. That study is being performed in my back yard and began in June, I will be anxiously awaiting the results.
Employing this technique should not be an issue, but what can be an issue is how you do it. Traditionally we have used the simple bag of ice (or bags) to accomplish the goals; it still works and seems to be the “gold standard” on the sidelines. However technology and research may be catching up to develop a process by which a cool temperature is more sustainable for a longer time and delivered even more rapidly.
Thermopraxis thinks they may have a solution and seem to be on the same page;
Research has elucidated two distinct windows of opportunity for clinical use of hypothermia, a multimodal treatment. In the early intra-ischemic window, hypothermia modulates the downstream necrotic and inflammatory pathways, abnormal electrical brain activity, cellular free radical production, poor calcium management and poor pH management. In the more delayed post-reperfusion window, hypothermia modulates the downstream apoptotic – delayed cell death – and inflammatory pathways. The mechanisms of protection – including reduction of cellular metabolism, maintenance of levels of ATP, reduction of enzymatic reaction rates, reduction of patterns of gene expression and protein production, improved ion management, and improved pH management support the concept that the efficacy depends on the time between ischemia/trauma onset and hypothermia induction.
Therapeutic hypothermia is not only a major field of investigation, it is an important development in the practice of emergency medicine.
In a recent phone interview with Thermopraxis President, Tony Finley, his passion for the advent of this technology is clear and “makes no sense as to why nothing has been accepted to this point.” Their technology, which is gaining funding for a prototype seems to make sense. Of course there are the practical hurdles of placing them in helmets: the accessibility of the delivery device, any possible compounding effects from pressure, etc., however Mr. Finley would like to “at least generate discussion on this topic.”
I suggest we do two things after my conversation with Mr. Finley: 1. start applying ice to the concussed, IMMEDIATELY (paying attention to any contraindications) and 2. discuss this technology.
I will be interested to see if the professional sports start doing this, make note…