The way we approach treatment of injuries and post-surgical patients is constantly changing as we continue to learn and understand how the body works.
Over the years, ice has been a part of traditional first line treatment of acute injury management, but is this modality supported with the latest research?
The History
Clinicians, coaches, and athletic trainers have traditionally used R.I.C.E. (rest, ice, compression, elevation) for acute injuries based on Dr. Gabe Mirkin’s 1978 concept. However, recent research suggests that, contrary to previous belief, applying ice to injuries may actually hinder the healing process. In fact, in 2015, Dr. Mirkin changed his stance on the appropriateness of using ice to treat acute injuries.
Over the years, the R.I.C.E. (rest, ice, compression, elevation) protocol evolved to include protection (PRICE), then POLICE (protection, optimal loading, ice, compression elevation). Finally, in 2019, the protocol PEACE & LOVE (protection, elevation, avoid anti-inflammatory drugs, compression, and education & load, optimism, vascularization, and exercise) completely removing ice from the treatment guideline.
The Healing Process
The inflammatory stage is the first phase the body goes through to heal an acute injury. When injured, the body naturally triggers inflammation as a defense mechanism to start the healing process. Inflammation includes several crucial processes within the body. Initially, blood vessels near the injury expand to enhance blood flow. This increased blood flow transports essential cells to the injury site, such as white blood cells, which assist in combating potential infections, and cells designed to remove damaged tissue.
Next, the affected area may exhibit redness, swelling, and warmth. This occurs as the blood vessels in the area become more permeable, enabling fluid and immune cells to escape into the nearby tissues. The swelling acts as a natural cushion, safeguarding the injured area. At this point, there may also be some pain or discomfort. This discomfort serves as a warning, prompting the patient to shield and attend to the injured area. In cases of acute injury, inflammation is a regular and crucial part of the healing journey.
The Effects of Icing
With the progressing research over the years, it is now suggested to think twice about ice. With justification, ice should only be considered to aid in the reduction of swelling if that is the limiting factor or when injuries are severe.
When ice is applied, it does not affect the underlying muscles because their temperature remains constant. Cryotherapy has been shown to reduce inflammation by decreasing certain immune cells and limiting their infiltration after soft tissue injuries. While applying cold to the surface of an injury can help manage pain and swelling, it may slow down the recovery process. This is because when we get injured, our body signals inflammatory cells (macrophages) to release insulin-like growth factor (IGF-1) to aid healing. However, applying ice externally causes vasoconstriction, blocking the transport of these healing agents to the injured area. This interference with the body’s natural healing process can delay recovery.
However, there are cases in which topical ice should be considered. Excessive edema exerts unnecessary pressure on tissues, limits movement, can elevate pain levels, and reduces muscle function. This is commonly observed in severe joint sprains, like ankle sprains, where swelling is substantial enough to impede range of motion. Another instance is the arthrogenic muscle inhibition of the quadriceps post ACL surgery. In these types of cases, using ice may be a suitable approach. The aim is not necessarily to prevent all swelling but to control excessive swelling. When applying ice as part of the initial treatment for these injuries, recent studies recommend using ice for around 5 minutes at a time. This approach helps alleviate pain without hindering the body’s natural inflammatory response responsible for healing. By shortening the icing duration, we support the body’s natural inflammatory process while still offering some relief.
The Current Protocol for Treating Acute Injuries:
PEACE
Protect: The first step is to protect the injured area from further damage or injury. This may include immobilization (i.e. braces, splints, crutches, or slings) and activity modifications to prevent exacerbation of the injury.
Elevate: Elevating the injured area above heart level helps reduce swelling and promote fluid drainage.
Avoid Anti-inflammatory Modalities: In the initial stages of the injury, it is recommended to avoid anti-inflammatory treatments like non-steroidal anti-inflammatory drugs (NSAIDs) or ice therapy. At first this may seem counterintuitive; however, inflammation is a natural part of the healing process. By inhibiting inflammation too early, it may interfere with the body’s natural recovery mechanisms.
NOTE: Consult with your healthcare professional before making any decisions regarding medication.
Compress: Applying compression to the injured area helps control swelling as well as provide support to compromised soft tissues. Compression can be achieved using bandages, elastic wraps, and compression garments.
NOTE: Make sure compression is not tight enough to restrict blood flow.
Educate: Understanding the injury is a crucial component of the recovery process. Knowledge regarding the injury, expected healing timeline, and how to actively participate in recovery will empower individuals during the recovery process, with following appropriate rehabilitation protocols, and in making informed decisions regarding injury management.
LOVE:
Load: Gradually reintroducing appropriate levels of loading and stress to the injured tissues is a key component of the rehabilitation process. This involves progressive exercises and activities tailored to each individual’s injury and stage of recovery. Controlled loading helps promote tissue healing, rebuild strength, and restore function.
Optimism: Having a positive mindset and an optimistic outlook are crucial during the recovery journey. By fostering positivity, supporting self-belief in the recovery process, and promoting motivation, individuals can experience enhanced well-being and improved outcomes.
Vascularization: This point underscores the significance of improving blood flow and circulation to the affected area. Sufficient blood circulation is crucial for transporting oxygen, nutrients, and healing elements to the damaged tissues. Techniques like gentle movements, massages, and targeted exercises can boost vascularization and aid in the recovery process.
Exercise: Integrating injury-specific therapeutic exercises gradually is vital for rehabilitation. These exercises aim to enhance strength, flexibility, mobility, and proprioception, facilitating individuals in recovering full functionality and reducing the risk of future injuries.
Conclusion
The traditional RICE protocol involving the use of ice is no longer recommended based on current research and clinical findings for treating acute injuries. The understanding of the inflammatory phase in the healing process has emphasized the significance of inflammation in natural recovery. Ice treatment, once assumed to decrease swelling, may impede healing by constricting blood vessels and limiting the body’s natural inflammatory response. An evidence-based approach to injury management, known as the PEACE and LOVE protocol, has gained prominence. This method advocates for a comprehensive and patient-centric strategy to facilitate optimal recovery and functional return. The PEACE element focuses on safeguarding the injured area, elevating it to reduce swelling, avoiding early anti-inflammatory interventions, and applying suitable compression. Complimentary, the LOVE aspect underscores the gradual reintroduction of loading, maintaining a positive mindset, encouraging vascularization, and engaging in tailored exercises.
Specific injuries may require individualized variations of this approach, and it’s always recommended to consult with your medical team for an accurate diagnosis and guidance toward a personalized treatment plan.
LET OUR TEAM GUIDE YOU
Seeking guidance from healthcare professionals such as our team here at Physical Therapy Innovations is recommended for accurate diagnosis and individualized treatment plans. By embracing this approach, individuals can empower themselves with knowledge, actively participate in their recovery process, and optimize their overall well-being and outcomes.
