When it comes to managing an acute injury many of you will have heard of RICE and some will have seen it progress to PRICE. For those that missed it, it stands for Protect Rest Ice Compression Elevation.
But a recent study by Bleakley, Glasgow and MacAuley 2012 in the British Journal of Sports Medicine has suggested this needs updating and in their words we “call the POLICE”. Aside from the obvious fact that the acronym now spells a word that can be used in mildly amusing blog titles (and awesome songs) it does make sense. So POLICE would be Protect Optimal Loading Ice Compression Elevation.
So why replace rest with “optimal loading”?
- While rest may be helpful in the very short term, continued rest may lead to deconditioning of the tissues – joint stiffness, muscle weakness and tightness and reduced proprioception (control and balance)
- Optimal loading will stimulate the healing process as bone, tendon, ligament and muscle all require some loading to stimulate healing.
- The right amount of activity can help manage swelling. For example in the ankle, contraction of the calf muscles helps to move swelling up the body against gravity. Complete rest would the prevent this.
The key word here is optimal.
In some cases optimal loading may be no loading. Unstable fractures, complete tendon ruptures etc are unlikely to benefit from loading and may require casting, bracing or surgical repair. There is no recipe for this, each situation needs to be managed based on the person and their injury and usually under the guidance of a health professional.
Like so many things in health and injury it's about balance. I'm not suggesting you ditch your crutches and run off down the street! When it comes to managing acute injuries I recommend you seek medical advice, especially if there is noticeable swelling or any restriction in joint range of movement or a sensation of giving way. Bony tenderness or difficulty weightbearing are also signs that you should get checked out.
With acute injuries I see I tend to adopt a policy of weightbearing as tolerated. Meaning do as much as you feel comfortable to do and don't push through pain. This usually fits within the idea of optimal loading but as ever comes with the caveat, if in doubt, get it checked out. This also includes exercises, and I encourage people to gently move the joints around the affected area, again listening to the body and not pushing through pain. It's usually better to do this little and often to prevent stiffness rather than a lot at one sitting which is more likely to cause pain. Offload taping can also be very useful to support an area when you load it, for example the Achilles taping demonstrated in my tendonopathy post. For more on the affects of loading and exercise see this excellent (though quite technical) study by Khan and Scott 2009.
You might be surprised to hear that the research behind the use of ice is far from conclusive. There is a real lack of high quality evidence and very little guidance in terms of how ice should be used. Despite this we all tend to reach for the ice pack when nursing an injury and I think we are right to continue to do so.
Although the research may not be conclusive most of us have seen from personal experience that ice can reduce pain and swelling post injury and aid a quicker return to sport.
There area a few of safety points with ice;
- Don't ice over a numb area or open wound. If the skin is numb you won't notice if you're developing an ice burn and ice on an open wound would risk a infection
- Be wary of ice burns – don't apply ice directly to the skin, wrap an ice pack in a clean, damp tea towel before applying. Avoid prolonged exposure to ice, 10-20 minutes in usually adequate and also be careful applying the ice with too much pressure (e.g. Resting your leg on the ice bag).
- If you use frozen peas don't eat them after!
Practical details in the use of ice
Having read several reviews of the use of ice in the literature it's very hard to make an evidence based recommendation for use of ice in terms of how long to apply it and how frequently. There is some evidence that as little as 10 minutes can be effective to create tissue cooling and that, although fairly rare, ice burn can occur after just 20-30 minutes. Baring that in mind, and in the spirit of getting the most benefit with the smallest risk of harm I'd recommend the following very general guide;
Apply ice wrapped in a damp towel for 10-20 minutes 2-3 times per day for the first 5-7 days post injury.
Stop applying ice if there are any negative effects such as increase in pain or swelling or skin soreness.
I'll continue to look into the research for ice and cryotherapy and will update the post if i find any more specific recommendations. If you have a different method and it works for you, stick with it! Also worth noting is that cooling can be achieved using cooling gels if you prefer.
Similar to ice the research behind compression is far from conclusive. From personal experience I find compression very useful in managing swelling and it can be used in both the acute and more chronic stages. A simple tubigrip bandage can be used, especially good for ankles and knees and I tend to use 2 layers. The area should feel compressed but not uncomfortable or painful. Ensure there is good circulation distal to the bandage (I.e. in the toes if the ankle is compressed). I usually recommend patients to remove the bandage at night for comfort when sleeping and also because swelling is usually fairly well controlled when we are lying down.
Elevation can be very effective in reducing swelling and pain. You can combine it with gentle exercises that aid circulation such as moving the ankle up and down or tightening the thigh muscles to straighten the knee. Obviously this will depend on your injury and the guidance you get from your health professional.
Hang on a mo….who's taken the P?
Yep I've forgotten to cover P for protection. Protection is part of optimal loading and involves the use of crutches, casts, braces etc to help protect the area as it heals. Think of it as a tool to prevent excessive loading in the early stages and it's especially useful if you are struggling to weightbear and need some extra help (in which case you need to make sure you've had your injury checked out).