#40: Can you avoid injury and what to do when it occurs?

Take ibuprofen , what actually works ? Let's see where the evidence takes us . Hi , I'm Dr Bobby DuBois and welcome to Live Long and Well , a podcast where we will talk about what you can do to live as long as possible and with as much energy and figure that you wish . Together , we will explore what practical and evidence-supported steps you can take .

Come join me on this very important journey and I hope that you feel empowered along the way . I'm a physician , ironman , triathlete and have published several hundred scientific studies . I'm honored to be your guide . Welcome , my dear listeners , to now episode 40 , how to avoid injuries and what to do when they occur .

Well , an injury is typically something sudden , accidental , and commonly is a sprain or a strain or a bruise . Well , what should we do when an injury occurs ? Well , should you ice it or not ? Is ibuprofen or naproxen a good idea or not ? Should you rest or remain active ? And how might we prevent injuries from occurring ? Will stretching help ?

Is it better to do dynamic stretches versus static stretches ? And we hear so many people tell us what we should do . Is that based upon credible evidence ? Social media and health experts are each proposing their own special approach , which might include ice . It might include this .

It might include that they might be suggesting oh , you need to do cryotherapy or red light therapy , or you must do acupuncture or massage , or a supplement or a topical treatment or an ointment .

Too often , what's recommended is not evidence-based medicine , but what some call eminence-based medicine , meaning a supposedly knowledgeable person says this is what you need to do , whether it's about injuries or injury prevention or almost any other aspect of healthcare and longevity .

Often it's really loudness-based medicine or confidence-based medicine , the person who says , oh , this is the way it's done . I've done this with all of my patients and they all do great , you need to do this . Or it's frequency-based medicine , meaning I've read about icing forever . It must be correct , because you just run across it all the time .

Well , what really works ? And is there any rigorous evidence to support one particular way to treat an injury versus another , and it's perhaps remarkable that we actually don't fully know . Now . There are a lot of studies . Most of them are small , most are not very rigorous and most don't apply to you , my listeners .

There might have been a study in high school athletes . I doubt I have too many of you listening . Some of these studies are done in military recruits , young people with a particular type of exercise they're doing . Also may or may not apply to most of us .

Let me just point out that today I'm not talking about an injury that involves a broken bone and I'm not talking about chronic injuries . I'm really focusing on what happens so often to us . We pull a muscle in our calf or our hamstring or our back goes out . These are strains , sprains and bruises , and that's what I want to focus on .

Well , as always , why now ? Well , I had coffee about a week or so ago with Tim and I began at the beginning sharing his pickleball story . He skips his warmup , he injures a calf muscle and was it avoidable ? And now that he's got the injury , what should he do ? I'm an Ironman triathlete and I've had my share of minor injuries .

I sprain my ankle all the time . Sometimes I pull a muscle in my kind of hip back area and I've obviously had to try all sorts of approaches both to treat them and to avoid them impossible . So yesterday I had a triathlon and fortunately I felt good . This morning I'm not feeling injured . Was I just lucky ? Did I do something that caused it to happen ?

Is it based upon evidence ? Well , let's see . Well , when I was in my early medical training , there was a formative study that was published on back pain . Now , at the time the recommendation was you should go to bed for about a week and during that time inflammation will go away and you'll feel much better .

And Richard Dale , the investigator , said I don't know if that's a good idea or not being in bed for a week . So he did a study , a randomized control trial , where he compared a very brief period of rest with the full week in bed , and what he found was the prolonged rest actually made things worse .

And this was very formative to me during my training that what we hear isn't necessarily always true and that we need good studies to help us sort that out . I'm also reminded of the French philosopher Voltaire , and I love this quote and I've used it in prior episodes the art of medicine consists of amusing the patient while nature cures the disease .

What this means is so many things are going to get better on their own , no matter what we do or what we don't do . Own no matter what we do or what we don't do . So if we have to be cautious when people say , oh , I did this , I got better , well , it may or may not have had anything to do with what they are proposing .

Well , before we dive into the full episode , I want to thank you for those that referred me to other people on my podcast , for my podcast to be a little more known . Many people have joined since my last podcast and thank you . Thank you so much for referring people and telling them about it . If you have done so , please continue . It worked .

I'll keep posted on what happens in the future . If you have done so , please continue . It worked . I'll keep posted on what happens in the future . If you haven't had a chance yet , please . If you enjoy my podcast , I suspect others might enjoy it too , and I will be very happy when I see more people that might be benefited from it . So thanks .

Okay , let's dive in . You've been injured Again . You haven't broken a bone . This isn't a chronic injury . This is something acute like , happens to almost all

of us very regularly . So you're injured , now what Ice ? So let's talk about ice Now . Ice and cooling the area that's injured goes back thousands of years .

2500 BC , the ancient Egyptians used cold compresses to treat injuries and the famous Hippocrates , the sort of father of of medicine , in the 4th century BC , they used to use snow and ice to reduce pain and bleeding in wounded soldiers . And then in the 60s and 70s we heard about rice Rest for the R . I was ice , c is compression and E is elevation .

No matter what the injury was , rice was what you should do Rest , ice , compression and elevation of that limb . Well , the ice belief and the rice belief has changed over the years . So ice became rice . But then people said wait , a second rice approach isn't right .

We now need peace , and peace is protect E , elevate A , avoid ibuprofen , c compression and E elevation . So PEACE approach removes ice and says don't do non-steroidal anti -inflammatories like ibuprofen . But not to stop there , there's also the MEAT approach movement , you should continue to move and exercise , analics and various types of other treatments .

Well , the peace approach became the peace and love approach , where love means load , optimism , vascular and exercise . Now , how can all the right thing keep changing from ice to rice , to peace , to peace and love to meat ? It's mind-boggling , and when you think you know what you're supposed to do to treat an injury , we still don't know . How is that possible ?

Well , for those of you who've listened to my podcast for a while , this is a common theme of not knowing and thinking we know and then being told later oops , we had it wrong . Eggs used to be bad . Now eggs are good Peanuts . Oh , avoid those in the very young kiddos . Well , that turned out not to be a good idea .

In this area of treating an injury and avoiding injuries , there's a lot of studies , but they're not very convincing , and in a few minutes I'm going to tell you Dr Bobby's law of many studies . So this is a teaser . I'll answer this in a few minutes .

You've probably heard the law of large numbers , where if you study a large enough group of people , you kind of get the right answer . Well , you're going to get a variation called Dr Bobby's Law of Many Studies . So we're now injured . What do we want to accomplish ? We would like to relieve pain . Of course , nobody wants to be in pain .

We think we want to reduce swelling and inflammation . Well , as we'll see in a few minutes , maybe that's a good idea , Maybe it's not such a good idea , and of course , we want to return to function . Definitely we want to do that and obviously as quickly as possible .

Well , from my beginning discussion , you can see that three elements seem to be diametrically opposed about whether it's a good idea or a bad idea Ice , yes or no , ibuprofen yes or no , rest or movement which is best ? So let's walk through each of these and I'll share the evidence that I found or didn't find . So let's begin with ice

Now . Ice really does work for pain control . So when you put ice on an area that hurts , it works . There was a randomized control trial of 105 folks with ankle injuries . As you're going to see , a lot of the studies in this area are done with ankle injuries . Well , what did they find ?

They found that , in terms of pain control , ice worked , and the feeling is that the ice slows down the nerve conduction in that part of your body , that it numbs things . So it appears and this has been for thousands of years that ice helps pain . Okay , but what about inflammation and returning to full use ? Where does ice fit in here ?

Well , the theory is , if we put ice on a limb or anywhere else , it will cause the blood vessels to constrict , reducing blood flow into that area . And the theory is that by so doing , you'll get less swelling , and swelling can't be good . Swelling hurts , swelling looks bad . Swelling definitely is something let's avoid . So ice seems like a good idea .

But if you're reducing the blood flow into that area , maybe there's cells or reparative parts of our body that are trying to get there to solve the problem , and now we've reduced the ability to get there . Also , there may be bad things that are formed in the injured areas .

You'd like to get them out of there , and when you constrict the blood vessels , that can't happen . So what seems like a good idea let's get rid of the swelling may or may not be Okay . Well , that's theory . What about evidence ? There was a study that looked at compressing the area with ice , or just compressing it and no ice , and this was ankle sprains .

It was a randomized , controlled trial and there was no difference . So adding the ice to the regimen didn't make a difference . Well , what about more broadly , not just ankle injuries ? So they had a publication of a summary , a meta-analysis of 22 randomized control trials , where again , they tried ice in addition to compression of the area .

Again , it didn't make a difference . The ice didn't seem to solve the problem . Didn't seem to solve the problem . Well , what about RICE , which , as we've said , is not just ice , it also includes R , which is rest , c compression and E elevation . There were 11 randomized control trials , almost 900 people , and what did they find ?

Well , it wasn't clear whether rice , this approach that included the ice , helped or not . Now , the studies that were in this were not all that well designed and we really couldn't fully answer the question . So , all of these studies , what's going on ? Why isn't it clear ? Well , I have three theories , and again we're talking about ice right now .

Ice may reduce pain . Clearly , that seems to work , and it may reduce inflammation . But that may or may not be a good idea . Maybe the inflammation , the swelling , is our body's way of helping you , and by stopping it you're not helping yourself . So that's one theory that the ice actually doesn't work . In fact , it might make things worse .

The second theory as to what's going on Well , maybe we just don't know . Because the studies are poor and you do a bunch of poor studies , you're really not necessarily going to know and you do a bunch of poor studies , you're really not necessarily going to know .

Third theory is when people tout that ice is the way to go , it could be our famous placebo effect . If you want to learn more about that , listen to episode 28 . And now , as I alluded to earlier , I want to bring you to Dr Bobby's law of large number of studies . Okay , so this is what the law is , or the theory is , or the hypothesis .

If there are a large number of studies examining a treatment or an approach to taking care of something , and at the end of all these studies , if we look at them and we scratch our head and say I still don't know whether it works or not , my law , my hypothesis , is that it likely doesn't work . And , yes , the studies were poor .

But because there are a lot of studies and they never show a clear , clear benefit , I'm guessing it doesn't work . Or if it does work , the actual benefit is probably really small . So that's my law . When you see lots of studies and you don't know , at the end of it all , I'm guessing if there's any benefit , it's not huge .

So what do I take from the literature and evidence

on ice . There's no need to rush to get ice . It might help the discomfort , but we don't know in the long run whether that reduction of inflammation is a good idea or not . And let me also re-point out that all of these studies not all , but most all of these studies on ice were done with people who either had an ankle injury or just had surgical repair .

So again , we don't really know about routine muscle injuries like a calf strain or pulling a hamstring , but nothing that's clearly saying ice works All right . The second area that we think might help how about ibuprofen or naproxen or a non-steroidal anti-inflammatory Very commonly recommended ?

Well , there was an important review of the evidence , the Cochrane Collaboration , which are groups around the world that summarize evidence in very rigorous ways . They found 20 studies looking at this topic in over 3,300 people . And what do they find ?

That there was no difference between the patients who took ibuprofen or a non-steroidal and those that took an alternative drug called paracetamol , which is like Tylenol . It's like an acetaminophen , and they looked at whether pain was better at one to two hours , two to three days , changes in swelling and basically they found no difference .

So if you are in pain , by all means do something . But Tylenol is probably just as good . Why not take the ibuprofen ? Well , ibuprofen reduces inflammation , and just like ice . Well , ibuprofen reduces inflammation , and just like ice , reducing the inflammation may or may not be a good idea .

Unfortunately , the studies haven't really been done well enough to say whether ibuprofen will help you return to exercise and function . It just didn't fully answer that , so we don't know . Okay , so ice doesn't seem to be a great idea . Ibuprofen doesn't seem to be a great idea . Now , should you rest ? You've injured that muscle . You've injured your ankle .

Should you rest or not ? Now , before we get too far in this , I did not find any studies that compared rest versus gentle

exercise for the typical leg muscle strain . So what am I going to do ? I'm going to now tell you more about that low back pain set of studies , because a low back pain episode is kind of like pulling a muscle . You are feeling good , you move some furniture , you pull a muscle in your back and you are in pain .

So I don't have an example on rest or not for some of these other parts of our body , but I do have some data on low back , and I did mention that study that looked at

two days of rest versus seven days of bed rest . And again there were no differences . And there were no differences in getting back to work sooner , except that the people who were in bed longer , of course , didn't get back to work very soon at all , that the people who were in bed longer , of course , didn't get back to work very soon at all .

Then in 1995 , there was a randomized trial that compared two days of bed rest , back exercises or just continue your normal activities . And then they looked at people who had hurt their back Again an acute injury , not a chronic problem . They looked to see at three weeks and 12 weeks who did best .

Well , it turns out it wasn't the people who had two days of bed rest , it wasn't the people who did the back exercises . The people who did best were the ones that continued their normal activity . The duration of pain was less , the intensity of the pain was less and their ability to work was better .

And in fact the people who went to bed for a couple of days actually had the slowest injury resolution . So this was fascinating . Again , it's not in some of the other areas of your body it doesn't tell us necessarily for my buddy tim with his calf muscle .

But in the area of back pain it looks like if you have an acute injury you really just want to continue normal activities . Obviously you don't want to do anything that's making it cause severe pain . But resting the other things didn't do better than just continuing normal activity , and in fact normal activity did even better .

So well , what about other things you might do ? Acupuncture or massage . Well , another day I may drill into those . I don't think there's great data for an acute injury to your hamstring for that , but we'll dive into it . And if any of you out there in listener land have some good studies , by all means send them my way .

And if you're interested in where does red light therapy fit into all this , you can listen again to episode 31 of my podcast . Okay , so the obvious things people tell you to do don't seem to make a difference to get the injury to go away . But how about preventing an injury ? That seems

really important . How about stretching ? Does it work ? And what type of stretching ? You might have heard of static stretching or dynamic stretching . When should you do the stretching ? Before exercise , in the middle of exercise or after ? Well , I went to a set of guidelines by the American Academy of Orthopedic Surgeons .

This is a very well-recognized group of physicians and surgeons and I asked the question in their guidelines , do they say anything about ways to prevent sports injuries ? And they basically say , well , stretching is the way to go to help reduce injury . Well , I looked at the evidence and I wanted to figure out is that true ?

Well , there was an article that reviewed four randomized control trials and they looked at static stretching . Now , what is static stretching ? That's the kind of typical stretching you usually think about . You know touching your toes , you know twisting your back a little bit to make it , you know , stretch certain muscles .

So these are the types of stretching that's called static . And what these four studies found was there was really no significant difference between the people who did the static stretching or didn't to prevent injury .

And if there is some suggestion that maybe there's a tiny bit of benefit and we're going to come back to what a tiny bit of benefit means in just a little bit Well , there was another study . They looked at 5,000 papers , 5,000 published articles , and it turns out of the 5,000 articles , only four of those articles qualified for review .

Meaning all of these studies were really poorly done , except for the four , and those four were kind of atypical , meaning three of them were in military recruits , who do get injured regularly , and one was in soccer players .

Now , what they tested was a pretty significant regimen of stretching , so 20 seconds at a time , one to two sets for each of the key muscle areas , and they followed up at 12 weeks to see whether stretching before vigorous activity and obviously military recruits are doing vigorous activity and also the soccer players . What did they find ?

The stretching did not prevent tendon injuries . Now , it did seem to reduce muscle injuries and in fact they had what's called an odds ratio of 0.37 , meaning that it reduced the rate of muscle injuries by two-thirds . That sounds fantastic , but , as Mark Twain said well over a century ago , there are lies , damn lies and statistics .

So in these studies of 1,300 people the people who did nothing , no stretching only 65 muscle injuries . In the people who did the static stretching , there were fewer muscle injuries . There were about 33 . So the rate of injury went from about 5% to 2.6 or 7% . Now , what does this mean ?

It seems like it made a difference , but 95% of the people had no injuries whatsoever . So a whole lot of people were stretching to reduce the number of injuries by a very small number , and there's something called the number needed to treat and basically it would take 33 people stretching for 12 weeks to prevent one injury .

Now , this isn't one person dying or having a heart attack you're trying to avoid . It's just a muscle sprain or strain . So even if you think the data are compelling , the impact isn't huge at all . And these studies were in young people , you know , military recruits and such .

What does it tell us about stretching for people who are 40 or 50 year olds more like my listeners ? We just don't know . Okay , what about dynamic stretching ? Dynamic stretching has been something that's gotten a lot of attention . Now , what is dynamic stretching ?

Dynamic stretching is things like , you know , shoulder rotation or trunk rotation or hip flexion or lifting your knees up high , so it's basically stretching while you're moving the joint , as opposed to just holding a stretch for a significant period of time . Now , there weren't many studies . They were small , they weren't well done . But what about dynamic stretching ?

There's conflicting evidence Now . Stretching may increase your range of motion , it might make you feel better , it might even improve performance . So if you can move your muscles in your leg better , maybe you'll run faster . But that isn't the question on the table .

The question on the table is not whether it feels better , not whether you'll run a little bit faster , but does it prevent injury ? Turns out , not much evidence to support it . Okay , I talked with you earlier about the law Dr Bobby's law of the large number of studies . You know , when something works , it's often quite clear and not all prevention efforts fail .

Now this is a less sexy area and might not apply to you , but the reason I want to explain this to you is that when something works , it can be pretty clear and pretty obvious . So old people fall . About a third of people will fall each year who are older than 65 . And people who fall leads to disability and death .

So we want to help our elderly folks avoid falls . Less sexy area . If you're in your 30s and 40s , you want to know what helps for you . The reason I'm sharing this was there was a meta-analysis of 66 clinical trials , 47,000 people who are about 77 years old . So they did strength training .

Would strength training and balance-oriented core muscles would that reduce falls ? Well , it turned out . It was pretty obvious 20 to 30% reduction in falls in thousands of people observed . When something works , it's pretty clear and it's reproducible . So again , dr Bobby's law of a large number of studies .

When it works , it's usually not that hard to show , and if you can't find evidence , probably if there's any benefit , it's pretty small . All right , let's wrap things up . Injuries are common . We're all going to get them . Too

many experts , even real experts , tell you you need to do this approach , or that it's what I call eminence-based medicine . They're promoting their approaches and usually there's not evidence to support it , not just in the injury space but more generally .

Ice ibuprofen definitely can help your pain , but there's no real evidence it will get you back to your activities any sooner . Rest Well , strict rest of that area of your body probably isn't a good idea . Gentle return to activities seems like a good idea . But again , the only real data is on low back pain .

Well , dr Bobby , shouldn't I just do one of the famous N of 1 studies and see what works for me ? Maybe by stretching I can avoid problems ? Here's the difficulty . You don't have an injury that often , so it might be once a year and you might do your stretching .

And to be statistically significant , you know , you might have to try stretching for years and years to see whether it works and then if you stop stretching , you might have to wait years and years to see if the problems come back . So a little hard to do the N of one here come back . So a little hard to do the N of 1 here .

I wish there were a magical approach , but sadly there is no magical approach to avoid injuries . There are some approaches that seem to work or don't , when you have some discomfort from an injury , but again , no magic approach . I hope you all can live long and well and be as active as much of the time as possible . Take care Until next time .

Thanks so much for listening to Live Long and Well with Dr Bobby . If you like this episode , please provide a review on Apple or Spotify or wherever you listen . If you want to continue this journey or want to receive my newsletter on practical and scientific ways to improve your health and longevity , please visit me at that's drbobblivelongandwellcom .

That's doctor , as in D-R Bobby livelongandwellcom .