On My Nerves: Moving away from recommending ice for bondage-related nerve injuries

I’ve recommended ice after bondage-related nerve injuries for years. I no longer think it’s optimal, and if I was injured, I personally would not choose to apply ice. Partly this is because I fucking hate cold… but it’s also because icing isn’t good evidence based practice.

Use of ice to treat of acute injuries is controversial and current thinking (especially in sports medicine) is moving away from it. Many experts recommend MEAT (Movement, Exercise, Analgesia, and Therapy) rather than the old stand-by RICE (Rest, Ice, Compress, Elevate) for optimal recovery after an injury.1 In fact, even the doctor who coined the acronym RICE now recommends against routine icing: “applying ice to reduce swelling actually delays healing.”2 IMG_5919

RICE was poorly studied in the first place: “[there is] insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy.”3 Studies on use of ice after an acute injury are scarce and poor-quality (for one thing, it is basically impossible to do a double-blind study where the patient does not know whether they are receiving ice therapy or not), and mostly focus on relief of acute pain rather than enhancing recovery. Most studies conclude the same thing- ice may temporarily decrease pain, but doesn’t have much (if any) effect on healing: “Application of ice appears to be effective in reducing pain, but there is no credible evidence that it accelerates healing.”4 “There is insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries.”5 “Cryotherapy or icing… could actually delay recovery and increase muscle scarring following significant muscle damage.”6

Keep in mind that almost all the studies on this subject (including the ones cited above) are looking at injuries like sprained ankles. I could not find any studies on acute compression nerve injuries, which is most directly relevant to bondage injuries. However, multiple articles suggested that ice would have more potential to help an injury of more vascular tissue (muscle), and more potential to be harmful to an injury of less well-vascularized tissue (ligaments or nerves). As these tissues have minimal perfusion to begin with, and perfusion is crucial to healing, further decreasing perfusion by applying ice is unlikely to be helpful and may even be harmful.1 All of that is IF the cooling effect from ice even penetrates down to the muscles/nerves, which studies suggest it probably doesn’t.6 It’s worth noting that there is solid evidence that a cold environment increases the likelihood of acute nerve compression injuries,9 which strongly suggests that cold is unlikely to be helpful in healing such an injury.

To some extent, I’m going against “conventional wisdom” here, but it’s worth noting that there are many acute injuries where it is NOT “conventional wisdom” to recommend ice (traumatic lacerations, for example). The rationale behind ice centers on decreasing swelling. Ice is not routinely recommended for injuries that do not have significant swelling. Bondage nerve compression injuries, in my experience, do not generally have much (if any) notable swelling, and they are closer to a cut finger than a sprained ankle in this way. There is also a component of ischemic injury to bondage related nerve damage, and ischemic injuries are another situation where ice would not be recommended.

There are a few outlier cases, for example if there is a large bruise (hematoma) forming, where reduction of swelling becomes important and ice may be indicated. Injuries of this sort are quite unlikely in a bondage context, and should prompt an immediate visit to the closest ER.

Ice may reduce pain, and likely doesn’t have much effect on healing, therefore I wouldn’t be one to say “no one ever should use ice after a bondage nerve injury.” If it was my nerves, I wouldn’t do it, but you should make your own judgements. If you DO choose to apply ice after a bondage-related nerve injury, do so conservatively (applying a padded ice pack for 10 minutes every hour, only for the first day). Remember that the location of the injury may not be immediately intuitive or apparent. If there is a radial nerve injury from a box tie, mostly likely the origin is the upper arm (wherever the rope was compressing) rather than the wrist (the main place symptoms manifest). If ice was to be used in this case, it should be applied to the upper arm, not the wrist.

Some general guidelines for bondage nerve injury first aid (and I think these are far more important than icing or not): Don’t stretch or compress the injured area (remember that both stretch and compression likely contributed to getting the injury in the first place), consider taking an anti-inflammatory like ibuprofen8 (if not contraindicated for other reasons- and noting that this is controversial as well, with some experts believing that these medications also delay healing), consider splinting of the affected limb to prevent further injury (for example, a wrist splint for wrist drop), mobilize early to prevent joint stiffness,7 and see an MD (a neurologist if possible) within a few days if symptoms persist. “Conservative treatment is generally the rule for patients with a one-time compression injury to the radial nerve. Physical therapy, wrist splinting (to maintain function), and pain management are most important. Prognosis for full recovery is generally good.”8 I’ve written in a lot more detail about first aid for nerve damage – that can be found here.

As a final note – it’s important to keep in mind that there’s no quick fix for nerve damage and it can be cumulative and cause significant pain/disability. That’s why PREVENTION is key!

 

About the author:

This article was written by me (Shay)- I’m an ER nurse and ACLS (Advanced Cardiac Life Support) instructor who has spent WAYYY too much time geeking out over bondage safety. I also got input on the ideas in this post from several other kinky medical professionals (including FrozenMeursault). However, I would note that nurses (and doctors!) can and do say idiotic/incorrect things, so using your own judgement no matter how “qualified” the source is always a good thing.
References:

[1] http://www.caringmedical.com/sports-injuries/rice-why-we-do-not-recommend-it/

[2] http://drmirkin.com/fitness/why-ice-delays-recovery.html

[3] J Athl Train. 2012 Jul-Aug;47(4):435-43. doi: 10.4085/1062-6050-47.4.14. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? van den Bekerom MP1, Struijs PA, Blankevoort L, Welling L, van Dijk CN, Kerkhoffs GM.

[4] General Principles of Orthopedic Injuries Joel M. Geidermanand Dan Katz, Rosen’s Emergency Medicine, Chapter 49, 511-533.e2

[5] Emerg Med J. 2008 Feb;25(2):65-8. doi: 10.1136/emj.2007.051664. Is ice right? Does cryotherapy improve outcome for acute soft tissue injury? Collins NC1.

[6] Curr Rev Musculoskelet Med. 2015 Jun;8(2):162-7. doi: 10.1007/s12178-015-9261-3. Alternative treatments for muscle injury: massage, cryotherapy, and hyperbaric oxygen. Tiidus PM1.

[7] Compressive neuropathy in the upper limb. Mukund R. Thatte and Khushnuma A. Mansukhani

[8] Prognosis of acute compressive radial neuropathy. AUArnold WD, Krishna VR, Freimer M, Kissel JT, Elsheikh BSOMuscle Nerve. 2012 Jun;45(6):893-5.

[9] Winfree C, Kline D. (2005) Intraoperative positioning nerve injuries. Surgical Neurology. 63: 5-18