Has RICE finally been laid to rest?
Friday, February 23, 2018
RICE is the injury protocol everyone remembers: rest, ice, compression and elevation. It's been used since the late '70s to remind us all what to do when we suffer a soft-tissue injury such as a sprained ankle or pulled hamstring.
But medical experts are now strongly vocalizing their doubt over the protocol, thanks to research and theories that question its use. So why should we be abandoning the age-old RICE technique, and what should we be doing instead?
The latest stance
While a period of rest is often necessary and certainly so if a fracture or major soft-tissue rupture is suspected, rest may actually be counterproductive to healing.
A lack of motion after injury restricts blood flow, minimizes vascular drainage (of metabolic waste) and causes tissues to atrophy (waste) more rapidly. On top of that, the term mechanotherapy is used to explain how movement encourages cell repair. The physical loading of tissues leads to the release of chemical growth factors, which help to repair and strengthen bone, cartilage, tendon and muscle.
The aim of applying ice when RICE was first established was principally to reduce pain, bleeding and inflammation. However, the vasoconstriction that occurs as a result of cooling an area also reduces tissue oxygenation, which is counterproductive to recovery.
Icing an injury also delays healing by inhibiting the inflammatory response that is required for the process to begin. The release of inflammatory markers from injured tissues serves to increase blood flow, bringing with it fibrinogen and platelets to stop bleeding; white blood cells to clear up damaged tissue, foreign bodies and potential infections; and fibroblasts for tissue repair via collagen synthesis. By attempting to prevent or reduce inflammation with ice (and anti-inflammatory medications), we are limiting the body's natural healing response.
Dr. Karim Khan believes ice can play a role in recovery post-surgery, but for most chronic soft tissue injuries it won't make a difference to recovery.
Compression and Elevation
There is little evidence to support the use of either compression or elevation in the treatment of musculoskeletal injuries. The design of good, quality studies poses many challenges for researchers, most notably the placebo effect that is thought to play a large part in reported benefits.
Much of the rationale for the use of compression actually comes from research into DVT and lymphoedema management. The purpose behind elevation was to reduce bleeding and swelling (and therefore blood flow) to the injured area and so could have the same negative effect on healing as ice.
So, what now?
MOVE! Many top sports injury professionals are calling for this new acronym to replace the use of RICE.
Once fractures, spinal cord injuries and the like are ruled out, movement is encouraged. This can start with gentle, range-of-motion exercises — simple movements like ankle circles for a sprained ankle, bending and straightening the knee for knee injuries, and pendulum exercises for the shoulder.
Early movement should be within the patient's pain threshold, i.e. taking it to the point of pain then backing off. As pain levels decrease, activity level can increase to include weight-bearing as soon as possible. Weight-bearing exercise helps with the orientation of the newly-laid-down tissues, along the lines of strain, resulting in a stronger muscle (tendon/ligament) in the long run.
Look at the options available for cross-training. Find alternative ways of exercising that will maintain strength and fitness without overstressing the injury. For example, cycling for runners or water-based exercises to reduce weight-bearing load and impact.
Find ways of allowing people to continue with their daily lives as much as possible. This may include the temporary use of supports/braces and walking aids, for example. While many therapists are against the use of such items, if they allow someone to bear weight bear sooner, then that can only be a good thing. They should, of course, be phased out as soon as possible.
Rehabilitation should be varied to include strength, balance and agility work. In many cases, these can start before exercises for the injured area.
For example, in many knee pain cases, a weak core and malfunctioning glutes are a causative factor. Exercises to develop these areas can be incorporated much sooner than some more specific knee-loading exercises. For rotator cuff injuries, work on stabilizing the scapula can often start early in the rehab process, before strengthening the cuff itself.
Simple balance exercises for both upper and lower body injuries are also a great tool to start early as the weight-bearing (through the foot or hand) will help with developing the strength in the newly laid tissue.
Easing back to activity
A return to activity can begin a lot earlier than many people would anticipate by limiting the time and intensity of the early sessions. For runners, cyclists and rowers, indoor gym equipment such as treadmills, bikes and ergos are great for this purpose as short sessions are feasible and can be stopped at any point. For example, someone returning to running after an Achilles injury may start with only a 5-minute run.
For sports, individual components of the sport can be introduced first in an order that starts with the least stressful for the injury and gradually progresses to more intense and complex movements. For example, after a shoulder injury in a badminton player, a return to sport may start with underhand shots such as net play and serving, before progressing to overhead shots.
For athletes and even weekend warriors, returning to some form of sporting activity as early as possible can be really beneficial to their emotional health. It helps to see a light at the end of the tunnel in their rehabilitation journey and to maintain some involvement and connection to the sport or activity they love.
It’s easy to see why rest and ice have been the prescription for soft tissue injuries for so long. Before so much was known about tissue healing, the theories behind it made sense.
In addition, it was always viewed as "safe" to prescribe rest to an injured patient. There is no risk of them doing further damage and, as Khan states, a therapist can't be sued for advising an injured athlete to rest.
As research has advanced, we now know that movement helps the body to heal, and loading tissues as early as possible improves the long-term outcomes in injury recovery. We also now know that icing and trying to eradicate the inflammatory process is also counterproductive to the body's built-in healing and repair processes.
The best summary here is to say, "Let the body do what it does best." It is a natural healer that is built for movement. Let it do what it needs to do!
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