RICE: Slowing the Healing Process
Melissa E. MacDonald DC ICIS CCSP® NREMT ART® FAKTR
(Guest writer for the Minnesota Chiropractic Association January 2021 Newsletter)
Research is always changing, and our understanding is growing each day. Research has caused changes to “proven trusted” methods of care. When patients come in and ask which should they use ice and rest or movement or heat? What to tell them? Is pain type considered? Acute? Chronic? Area of the body? What is the correct answer?
History of Our Attempt to Heal the Musculoskeletal System
In 1978 Dr. Gabe Mirkin coined the acronym RICE for the treatment of musculoskeletal injuries. The biggest concerns that were being managed were symptoms – pain and swelling. Understanding how we heal came later and caused changes, but when it initially came out, the question of whether it made the healing time shorter was never asked (1).
R – Rest
I – Ice
C – Compress
E – Elevate
Rest was utilized to offload the injured joint and theoretically prevent further injury. If a patient has a broken or shattered leg, it is important not to walk and further displace the fracture. If it is a sprained joint, is the same true? Ice was used for pain management and inflammation control. This all sounds good, but what is inflammation? Our bodies are brilliant and will try to do the best thing for themselves. Inflammation is our body's response to an injury or an illness. Signs of inflammation are redness, swelling, pain, stiffness, and loss of function in the joint. Inflammation is caused by chemicals in our white blood cells, B and T type lymphocytes. The substances are released to increase blood flow and create pain as a protective measure to prevent movement. Two types of inflammation are essential to understand – acute and chronic. Acute inflammation occurs within minutes and is generally short-lived. Chronic inflammation is a long-standing disease process that is typically associated with an issue with the immune system. These two types of inflammation are essential to consider when deciding on care. Another way to manage inflammation is compression. An ace wrap can be used to provide gentle compression to prevent too much swelling. However, be careful; too much compression can cut off blood supply, accidentally creating a tourniquet. The last step is to elevate, which is to use gravity to help with the swelling. Furthermore, there is no research supporting this makes in a difference in recovery (2).
Now, things have started to change, initially with the addition of “P,” resulting in the acronym PRICE. The “P” stood for protection. Protection, such as bracing, was utilized to prevent further injury and potentially allow for returning to activity before complete healing. This can be important if there is a need to return to work.
The next change was in 2010 when the “R” was dropped for “OL,” making the mnemonic POLICE. The shift from “rest” to “optimal loading” came with the understanding that our body heals better with controlled stress. With too long of a rest period, there is a loss of range of motion and function; also, fear-avoidance to activity can set in.
The most recent change is the largest and was developed based on the need to load the tissue to heal. The new mnemonic is PEACE & LOVE.
P – Protect
Used for 1 to 3 days to minimize bleeding, prevent further tearing of the injured tissue, and reduce the risk of more significant injury.
E – Elevate
Utilizes natural gravity to help reduce swelling of the tissue. Must be above the heart.
A – Avoid anti-inflammatory modalities
The research has determined that their use can have a long-term effect on tissue healing. Each part of the inflammatory process is essential, and ice and over the counter medication impede different steps and increase healing time. Ice has no evidence of benefit other than reported pain relief while numb.
C – Compress
Use of taping and bandages to help limit inter-joint swelling and tissue bleeding.
E – Educate
Teaching individuals that the best way to heal is to move. Research has shown some passive care options such as muscle stim, massage, or manual therapy can be counterproductive long term when not combined with rehabilitative exercise.
L – Load
Research has shown that movement and exercise is the best way to recover from an injury. Loading the injury to pain tolerance instead of only loading while remaining pain-free has led to quicker recovery times.
O – Optimism
With all injuries, there is a psychological factor in how we see the damage. Catastrophisation, depression, and fear can create barriers to recovery. Pessimistic thoughts can create suboptimal outcomes and a worse prognosis. Meaning keeping a positive outlook will create a more optimal recovery.
V – Vascularization
Pain-free cardio training is a cornerstone of recovery. The exact dosage has not been researched, but early mobilization increases blood flow and improves motivation. Determining the dose will be patient-specific and injury-specific, so in-office instruction and tracking will be necessary.
E – Exercise
The final step, if it is not clear yet, is to get back to movement. Improving mobility, strength, and proprioception (awareness in space) creates the best environment for recovery.
We have now covered the history of how we have changed our treatment recommendations. Now let us talk about when to use ice and heat.
When should ICE, HEAT be used
Ice has been moved to the emergency medicine realm of pain management and extreme acute care. It is truly one of the best pain managers. Using ice days after an injury is not a great option unless used to reduce pain to do rehab exercises. Quite a few musculoskeletal conditions can be caused by the spasming of the muscles. Adding ice may make them feel better for a short period, but it will further tighten the muscles. Heat can be a better option for managing pain because it will help to loosen the tight muscles. (3)
This is a shift in care, but using the best evidence for care is how injury and disability times are shortened, and the patient can get back to their best life.
References:
Mirkin, G., MD. (2015, September 16). Why Ice Delays Recovery [Web log post]. Retrieved December 24, 2020, from https://www.drmirkin.com/fitness/why-ice-delays-recovery.html
Bekerom, M. P., Struijs, P. A., Blankevoort, L., Welling, L., Dijk, C. N., & Kerkhoffs, G. M. (2012). What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults? Journal of Athletic Training, 47(4), 435-443. doi:10.4085/1062-6050-47.4.14
Yerht, P., Stensrud, T., Wienkers, B., & Durall, C. (2015). The Efficacy of Cryotherapy for Improving Functional Outcomes Following Lateral Ankle Sprains. Annals of Sport Medicine and Research, 2(2).