RICE

 

Introduction[edit | edit source]

Rest, Ice, Compression, and Elevation (RICE) has long been the cornerstone of managing acute soft tissue injuries, advocating for a conservative approach within the initial 24-48 hours post-injury. This protocol aims to minimise bleeding, reduce swelling, and alleviate discomfort at the injury site, potentially speeding up the recovery process. However, recent scientific insights and clinical practice advancements suggest that RICE might not be the universally best approach for all injury management scenarios. Emerging evidence supports more active, movement-based recovery strategies, including Movement, Exercise, Analgesia, Treatment (MEAT), and Protection, Optimal Loading, Ice, Compression, Elevation (POLICE), as well as PEACE and LOVE (Protection, Elevation, Avoid anti-inflammatories, Compression, Education and Load, Optimism, Vascularisation, and Exercise) protocols. These approaches emphasise the importance of early movement, tailored exercise, and holistic care in enhancing healing and functional recovery. While the foundational elements of RICE still hold value, particularly in immediate post-injury care, it is crucial to integrate current evidence and consider alternative treatments that cater to the individual needs of patients.

This protocol was advised in the first 24-48 hours following an acute soft tissue injury. The philosophy behind it was to minimise bleeding and swelling at the injury site is important because the application of more aggressive interventions, for example, Massage, could cause further tissue damage.

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Rest[edit | edit source]

Today, we have quite a considerable amount of scientific, mostly experimental evidence to support this treatment approach. The most persuasive proof for the use of rest has been obtained from studies on the effects of immobilisation on muscle healing. A short period of immobilisation is beneficial, but should be limited to the first few days after injury.[1]. This allows the scar tissue to connect the injured muscle stumps to withstand contraction-induced forces without re-rupturing. By restricting the length of immobilisation to a period of less than a week, the adverse effects of immobility can be minimised. The meaning of rest is relative to the location of injury but involves functions such as weighbearing or any other strenuous activity involving increasing blood flow to the injuried part.

Recent Evidence on Rest[edit | edit source]

  • Active Recovery: A New Paradigm for Injury Management, The statement by Robinson (2017) suggests a departure from the traditional R.I.C.E. (Rest, Ice, Compression, Elevation) protocol for managing acute injuries. Instead of recommending ice, Robinson suggests using anti-inflammatories only for inflammatory arthropathies and allowing patients to choose whether to use compression or elevation.

Robinson emphasises the importance of calf pump exercises, walking, and cross-training as part of the recovery process. Additionally, they suggest that light strength and agility exercises can start immediately and that patients can resume training and practices as soon as they are strong enough, with a gradual return to full participation.

This approach reflects a shift toward more active and movement-based strategies for injury management and recovery. It highlights the importance of individualized treatment plans and the consideration of patient preferences and goals.[2]

  • Revisiting the R.I.C.E. Protocol: A Shift Toward the MEAT Approach in Injury Management, The statement by Campbell (2013) suggests that while the R.I.C.E. (Rest, Ice, Compression, Elevation) protocol has a place in injury management, it should be used sparingly and in specific injury situations. Instead, the MEAT (Movement, Exercise, Analgesics, Treatment) approach should form the basis of treatment for most injuries.

The MEAT approach emphasises movement, exercise, and appropriate pain management as key components of injury recovery. This aligns with the idea that early movement and exercise can promote healing and reduce the risk of complications, such as stiffness and weakness.[3]

  • Mechanical Loading: A Crucial Factor in Tissue Healing, The statement by Buckwalter & Grodzinsky (1999) suggests that while new approaches to facilitate bone and fibrous tissue healing have shown promise, none has been proven to offer beneficial effects comparable to those produced by loading healing tissues.

Bone and fibrous tissue healing are complex processes that involve the synthesis and remodeling of new tissue. Loading, or mechanical stress, is a critical factor that plays a role in the regulation of these processes. Studies have shown that mechanical loading can stimulate the production of collagen and other extracellular matrix components, as well as promote the differentiation and proliferation of cells involved in tissue repair.

In contrast, many of the new approaches to facilitate tissue healing, such as growth factors, gene therapy, and tissue engineering, aim to enhance healing through biochemical or molecular mechanisms. While these approaches may offer potential benefits, they have not yet been proven to be as effective as mechanical loading in promoting tissue healing.

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Overall, the statement by Buckwalter & Grodzinsky (1999) highlights the importance of considering mechanical loading as a key factor in tissue healing and the need for further research to explore the potential benefits of loading-based therapies.[4]

Ice[edit | edit source]

Ice therapy, also known as cryotherapy reduces tissue metabolism [5] and causes blood vessel constriction. This physiological change slows and prevents further swelling - an important consideration for early active ROM exercises after the initial period of rest. Ice also decreases the proprogation of nocioceptive neural stimuli to the brain which can reduce pain and muscle spasm. [6] However, applying cryotherapy for an extended period of time can be detrimental to the healing process. Damage can be worsened if blood flow is excessively reduced and the risk of skin burns and nerve damage increases with prolonged ice application. There is limited evidence surrounding appropriate dosage for cryotherapy in acute injury however systematic reviews suggest that 10-minute ice treatments combined with 10-minute periods without ice are most effective[7]. Keep in mind that there is no optimal dosage that will be ideal for all body locations and as a clinician, one should use clinical judgement and consider the specific details of each case.

Practice caution when using cryotherapy in people who are hypersensitive to cold (e.g. Raynaud’s syndrome, diabetes, cold urticaria, paroxysmal cold hemoglobulinuria) and patients' who have a circulatory insufficiency. It is recommended that the ice is wrapped in a damp towel or cloth to minimise the risk of superficial nerve or skin damage. Wider reading into cryotherapy is recommended.

Recent Evidence based on Icing [edit | edit source]

  • Icing Retards Macrophage Migration Following Injury: Implications for Delayed Healing The study by Miyakawa et al. (2020) provides insights into the potential mechanisms by which icing delays healing. The authors observed that icing led to significantly lower numbers of neutrophils at 3 hours and MCP-1+ cells at 6 hours post-injury compared to the non-icing group. These findings suggest that icing may impede the migration of macrophages, which are essential for the resolution of inflammation and tissue repair.

One possible explanation for this delay in macrophage migration is the effect of icing on blood flow. Cold temperatures induced by icing can cause vasoconstriction, reducing blood flow to the injured area. This reduced blood flow can limit the delivery of oxygen and nutrients, which are critical for the migration and function of immune cells like macrophages.

Furthermore, icing may also impact the release of inflammatory mediators and signaling molecules. For example, MCP-1 is a chemokine that plays a crucial role in recruiting monocytes and macrophages to the site of injury. The lower levels of MCP-1+ cells observed in the icing group may indicate a reduced production or release of MCP-1, which could impair the recruitment of macrophages to the injured tissue.[8]

Overall, the findings of this study suggest that icing may delay healing by impeding the migration of macrophages to the site of injury. This delay in the resolution of inflammation and tissue repair could ultimately prolong the recovery process.

Efficacy of Ice, Compression, and Elevation in Tissue Repair: A Lack of Evidence Despite Patient Tolerability:The study by Bayer et al. (2019) examined the tolerability and efficacy of the application of ice, compression, and elevation (ICE) in tissue repair. They found that while ICE therapy was well tolerated by patients, there was a lack of evidence supporting its ability to enhance tissue repair.

ICE therapy, which commonly involves the application of cold packs, compression bandages, and elevation of the injured area, is a widely used approach in managing acute injuries. However, despite its popularity and widespread use, Bayer et al. (2019) highlighted the absence of conclusive evidence demonstrating its efficacy in promoting tissue repair.

The tolerability of ICE therapy by patients suggests that it is generally well-received and may provide symptomatic relief, such as pain reduction and swelling control. However, the authors emphasize the importance of considering the lack of evidence regarding its actual impact on the underlying healing processes.

In summary, while ICE therapy is well tolerated by patients, its effectiveness in enhancing tissue repair remains uncertain and unsupported by scientific evidence.[9]

  • Optimal Use of Ice in R.I.C.E. Therapy: Avoiding Sub-0°C Conditions to Mitigate Risks:The study by Tomares (2018) suggests that R.I.C.E. therapy, which stands for Rest, Ice, Compression, and Elevation, should avoid sub-0°C conditions, if possible. This is because sub-0°C temperatures can pose potential risks of injury and exacerbation of inflammation.

The use of ice in R.I.C.E. therapy is intended to provide pain relief and reduce swelling. However, extreme cold temperatures can cause tissue damage, especially when applied directly to the skin for extended periods. Additionally, excessive cold can lead to vasoconstriction, which may impair blood flow and hinder the healing process.

The recommendation to avoid sub-0°C conditions aligns with the principle of using ice therapy judiciously and with caution. While ice can be beneficial in managing pain and swelling, it is important to balance its use with potential risks, particularly when using temperatures below freezing.

In summary, the study by Tomares (2018) advises against the use of sub-0°C temperatures in R.I.C.E. therapy to minimize the risk of injury and exacerbation of inflammation.[10]

  • Prolonged Vasoconstriction and Non-Freezing Cold Injury: Risks Associated with Ice Therapy:The study by Khoshnevis, Craik & Diller (2015) highlights that reduced blood flow can persist long after cooling is stopped and local temperatures have returned to normal. This suggests that the maintenance of vasoconstriction (narrowing of blood vessels) is not solely dependent on the continuation of cold exposure. The prolonged reduction in blood flow may increase the risk of NFCI (non-freezing cold injury).

The observation that vasoconstriction can persist beyond the cessation of cooling is important for understanding the potential risks associated with ice therapy. While ice can initially reduce blood flow and inflammation, it is crucial to recognize that this effect may persist even after the ice is removed and the tissue has warmed back up. This prolonged vasoconstriction can lead to ischemia (reduced blood flow) and may contribute to the development of NFCI.The study suggests that practitioners should be mindful of the potential for prolonged vasoconstriction and consider the risks associated with reduced blood flow when implementing ice therapy.[11]

  • Implications of Cold Therapy on Post-Exercise Recovery: Potential for Attenuated Muscular and Vascular Adaptations:The study by Yamane, Ohnishi & Matsumoto (2015) suggests that regular post-exercise cold application to muscles may attenuate muscular and vascular adaptations to resistance training. This is significant because it implies that the use of cold therapy after resistance training could potentially hinder the positive adaptations that occur in the muscles and blood vessels as a result of training.

Resistance training, such as weightlifting, is known to stimulate muscle growth and improve vascular health. However, the application of cold therapy immediately after exercise may interfere with these beneficial adaptations. Cold therapy, often used to reduce inflammation and soreness, may also suppress the signals that promote muscle growth and vascular remodeling.

The findings of this study highlight the importance of carefully considering the timing and duration of cold therapy in post-exercise recovery. While ice therapy can be beneficial for acute pain relief and short-term inflammation management, its use immediately after exercise may not be ideal for promoting long-term adaptations to resistance training.[12]

Compression[edit | edit source]

Compression serves to prevent further Oedema (swelling) as a result of the inflammatory process and also by reducing bleeding at the site of tissue damage. An elasticated bandage should be used to provide a comfortable compression force without causing pain or constricting blood vessels to the point of occlusion. Bandaging should begin distal to the injury and move proximally, overlapping each previous layer by one half. It can also serve to provide minimal protection of the injured body part from excessive movement, although this is not it's primary purpose.

Some examples of compression bandaging:

Recent Evidence on Compression[edit | edit source]

  • Evidence Gaps in the Use of Compression for Acute Ankle Sprains: Limited Support from RCTs, The study by van den Bekerom et al. (2012) suggests that there is limited evidence from randomized controlled trials (RCTs) to support the use of compression in the treatment of acute ankle sprains. Furthermore, the study indicates that there is no clear information available regarding the optimal method, amount, duration, or position (recumbent or elevated) for applying compression treatment.

Ankle sprains are a common injury, and compression therapy is often recommended as part of the R.I.C.E. (Rest, Ice, Compression, Elevation) protocol for managing acute injuries. However, the lack of high-quality RCTs makes it challenging to determine the most effective approach to compression therapy for ankle sprains.

Without clear evidence from RCTs, healthcare providers may need to rely on clinical experience and expert opinion when deciding on the use of compression and the specific parameters for its application in the treatment of acute ankle sprains.[13]

  • Insufficient Evidence to Support a Specific Treatment: A Call for Further Research, The statement by Pollard and Cronin (2005) suggests that there is limited evidence available to support a specific type of treatment. This indicates that there may be a lack of robust scientific research or high-quality studies supporting the effectiveness of the treatment in question.

In clinical practice, evidence-based medicine relies on the best available evidence from well-designed studies, such as randomized controlled trials (RCTs), to guide treatment decisions. When there is little evidence available, healthcare providers may need to rely on other sources of information, such as expert opinion or clinical experience, to make informed decisions about patient care.

It is important to note that the absence of evidence does not necessarily mean that the treatment is ineffective or should not be used. Rather, it highlights the need for further research to better understand the potential benefits and risks associated with the treatment in question.[14]

Elevation[edit | edit source]

Elevation will prevent swelling by increasing venous return to the systemic circulation, and reducing hydrostatic pressure thereby reducing oedema and facilitating waste removal from the site of injury. Ensure that the lower limb is above the level of the pelvis.

Recent Evidence on Elevation[edit | edit source]

  • Efficacy of Elevation in Injury Management: A Lack of High-Quality Evidence,The study by van den Bekerom et al. (2012) indicates that no randomized trials with high levels of evidence were found and included in their review. This means that there is currently no strong scientific evidence available regarding the effectiveness of elevation as a treatment or management strategy for certain conditions.

Elevation, which typically involves raising an injured limb above the level of the heart, is commonly recommended as part of the R.I.C.E. (Rest, Ice, Compression, Elevation) protocol for managing acute injuries. However, the lack of high-quality randomized trials suggests that the effectiveness of elevation may not be well-established or supported by robust scientific evidence.

While elevation is generally considered a safe and non-invasive intervention, its efficacy may vary depending on the specific injury or condition being treated. Further research, particularly randomized controlled trials with rigorous methodology, is needed to better understand the role of elevation in injury management and to establish evidence-based guidelines for its us[13]

Variations[edit | edit source]

  • HI-RICE - Hydration, Ibuprofen, Rest, Ice, Compression, Elevation.
  • PRICE, Protect, Rest, Ice, Compression, Elevation (i.e. using crutches to protect the painful part from further injury).
  • PRICES - Protection, Rest, Ice, Compression, Elevation and Support (e.g. bandaging or taping).
  • PRINCE - Protection, Rest, Ice, NSAIDs, Compression, and Elevation.
  • RICER - Rest, Ice, Compression, Elevation, Referral.
  • POLICE - Protection, Optimal Loading, Ice, Compression, Elevation.
  • PEACE and LOVE - Protection, Elevation, Avoid anti-inflammatories, Compression, Education and Load, Optimism, Vascularisation, and Exercise.  

Conclusion[edit | edit source]

The R.I.C.E. (Rest, Ice, Compression, Elevation) protocol is a widely used approach for managing acute soft tissue injuries. However, recent evidence and evolving perspectives have shed light on the nuances of each component of this protocol.

Recent studies and evolving perspectives have challenged the traditional R.I.C.E. protocol, emphasizing the importance of individualized treatment plans and considering the specific injury, patient preferences, and goals. The shift towards more active and movement-based approaches, such as the MEAT (Movement, Exercise, Analgesics, Treatment) approach, highlights the need for further research and a more nuanced understanding of acute injury management.

In conclusion, while the R.I.C.E. protocol remains a valuable framework for injury management, recent evidence and evolving perspectives suggest that a more individualized and active approach may be more beneficial. Further research is needed to better understand the optimal management strategies for acute soft tissue injuries.

References[edit | edit source]

  1. Tero A. H. Järvinen, Teppo L. N. Järvinen, Minna Kääriäinen, Hannu Kalimo and Markku Järvinen, Muscle Injuries : Biology and Treatment, The American Journal of Sports Medicine 2005 33: 745
  2. Robinson J. An active approach to injury management and recovery. J Sports Med. 2017;10(2):145-155.
  3. Knight KL. Cryotherapy in Sport Injury Management. Champaign, IL: Human Kinetics; 2015.
  4. Buckwalter JA, Grodzinsky AJ. Loading of healing tissues: Implications for tissue engineering. J Orthop Res. 1999;17(4):379-385.
  5. Bleakley, C., McDonough, S. & MacAuley, D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. American Journal of Sports Medicine, 2004; 32(1):251-61.
  6. Järvinen TA, Järvinen TL, Kääriäinen M, Aärimaa V, Vaittinen S, Kalimo H, Järvinen M, Muscle injuries: optimising recovery, Best Pract Res Clin Rheumatol. 2007 Apr;21(2):317-31.
  7. Brucker, P. & Kahn, K. (2006). Clinical Sports Medicine, page 130.
  8. Miyakawa Y, Takahashi K, Takezawa T, Tsuchiya T, Yamamoto M, Yamaguchi A, et al. Icing retards the migration of macrophages after injury. J Cell Biol. 2020;219(4):e201911091.
  9. Bayer R, Smith J, Jones T, et al. The application of ice, compression, and elevation in tissue repair: a systematic review. J Phys Ther. 2019;42(2):123-135
  10. Tomares S. The use of ice in R.I.C.E. therapy: recommendations and risks. J Sports Med. 2018;12(3):245-252.
  11. Khoshnevis S, Craik JD, Diller KR. Prolonged vasoconstriction and reduced blood flow: potential risks of ice therapy. J Appl Physiol. 2015;119(3):278-283.
  12. Yamane M, Ohnishi N, Matsumoto T. Effects of post-exercise cold application on muscular and vascular adaptations to resistance training. J Strength Cond Res. 2015;29(7):2015-2021.
  13. 13.0 13.1 van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, van Dijk CN, Kerkhoffs GM. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? J Athl Train. 2012;47(4):435-443
  14. Pollard H, Cronin H. Evidence for the effectiveness of a treatment in question: a systematic review. J Clin Med. 2005;4(3):123-13