R.I.C.E. does it work and should we do it?

10 Apr 2020

 

R.I.C.E. (Rest, Ice, Compression, Elevation)

Mirkin and Hoffman (1978) came up with the idea of RICE for the treatment of strains and sprains, this has been the standard treatment method ever since.  R.I.C.E. is widely used by coaches and therapists and other medical professionals as the early stage treatment of sprains and strains.  There is conflicting evidence on efficacy of this treatment. A study by Bleakley et al. (2010), found that patients with ankle inversion sprains who incorporated therapeutic exercises during the first week had improved mobility in the short term.  This suggests that complete rest in the first week will slow the healing process.

Recently Dr Mirkin reversed his original thinking (Dr Gabe Mirkin, 2015) on the back of studies which determined that rest and ice can delay healing.

RICE is not a four stage protocol where one step follows the other, often two or three or all four are used simultaneously.

Rest.  This is supposedly a key element in injury recovery, giving the body time to heal without putting further strain on the injured tissues.  But as we have just see there is now evidence to suggest complete rest is not always ideal (Bleakley et al., 2010).

Ice.  Used for the reduction of inflammation as well as pain relief.  The British Medical Association (BMA, 2019) suggests applying ice for 10 minutes every 2 hours for the first 3 days, this would appear to be both impractical and excessive if followed to the letter.  Mirkin (2015) tells us that applying ice more than six hours after the injury occurs is unnecessary.  His advice is to use ice only for pain relief and to apply for up to 10 minutes, remove it for 20 minutes, then repeat up to two more times.  A major consideration with the application of ice to acute muscle injuries is the depth of the injured site.  Most studies have been performed on small mammals such as rats and based on crush injuries, as highlighted by Bleakley, Glasgow and Webb (2012).  They go on to point out that the depth of injuries on human study participants is not specified, with the lowest recorded intramuscular temperature being 21°C at a depth of 1cm.  This suggests that icing intervention is likely ineffective with dealing with inflammation of deep muscle tissue.  Ice therefore, may be more suitably used for pain mediation and maintenance of function (Lewindon & Lee, 2016)

Compression.  This involves the use of bandaging to provide support, limit swelling and reduce blood flow to the injured site.  There is little study evidence for this, and therefore, scant evidence regarding the true effect of compression around acute muscle injuries.  Due to the nature of compression it is not possible to apply a placebo effect.  Most research has been conducted with regard to compression socks in recovery following training or competition.  Brophy-Williams et al. (2015) attempted to study the effect of compression socks on recovery, they found that those who believed they would have a positive effect were more likely to benefit from wearing them post exercise.

Elevation.  According to the American Academy of Orthopaedic Surgeons (2015) Elevating the injury above the level of the heart will help reduce swelling and pain.  It is most commonly used in conjunction with compression bandaging.  As with compression there is little scientific research evidence to suggest this is truly effective in injury recovery compared with not elevating.

 

More to recovery than just RICE.

The R.I.C.E. acronym has been expanded and adapted to create new versions based on updated thinking over the years.  

P.R.I.C.E. adds Protection to the same protocol, and certainly there will be instances in more serious sprains where this would be justified.  This would particularly benefit athletes with a history of sprains, who should consider the use of braces.  

P.O.L.I.C.E also advocates Protection but adds Optimal Loading over Rest, similarly, Bleakley, Glasgow and MacAuley (2012) promote the idea of early activity via a well balanced rehabilitation programme to promote early recovery.

M.I.C.E. Swaps Rest for Movement.  Khan and Scott (2009) discuss mechanotransduction as “the process by which the body converts mechanical loading into cellular responses”, in other words, movement stimulates tissue healing.

 

Summary

Bekerom et al. (2012), examined the evidence for and against the use of the RICE studying 11 trials, they concluded that there was insufficient evidence to determine how effective RICE was on the treatment of ankle sprains.  They also cited 57 other articles in their report, however only 18 of those reports were published after 2000 highlighting that much of the evidence for the use of ice is based on old, and often anecdotal study data.  Despite this and Mirkin’s (2015) reversal of the original RICE model for the acute phase of injury rehabilitation and other evidence to support this, the BMA (2019) still promotes the RICE protocol for treatment of muscle, tendon and ligament injuries.  

References

Alonso, J., Edouard, P., Fischetto, G., Adams, B., Depiesse, F. & Mountjoy, M. (2014). Determination of future prevention strategies in elite track and field: analysis of Daegu 2011 IAAF Championships injuries and illnesses surveillance. British Journal of Sports Medicine 46(7): 505-514

 

Alonso, J., Junge, A., Renstrom, P, Engebretsen, L, Mountjoy, M. & Dvorak, J. (2009).  Sports Injuries Surveillance During the 2007 IAAF World Athletics Championships.  Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine 19(1): 26-32

 

American Academy of Orthopaedic Surgeons (2015). Sprains, Strains and Other Soft Tissue Injuries. Retrieved from https://orthoinfo.aaos.org/en/diseases--conditions/sprains-strains-and-other-soft-tissue-injuries/

 

British Medical Association, (2019).  Guide to Sports Injuries (2nd ed). London: Penguin Random House.  

 

Bekerom, M., Struijs, P., Blankevoort, L., Welling., L., van Dijk, C & Kerkhoffs, G. (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

 

Bleakley, C., Glasgow, P. & MacAuley, D. (2012). PRICE Needs Updating, Should we Call the POLICE? British Journal of Sports Medicine 46: 220-221.

 

Bleakley, C., Glasgow, P. & Webb, M. (2012).  Cooling an acute muscle injury: can basic scientific theory translate into the clinical setting? British Journal of Sports Medicine 46(4): 296-298.

 

Bleakley, C., O’Connor, S., Tully, M., Rocke, L., MacAuley, D., Bradbury, I., Keegan, S. & McDonough, S (2010). Effect of Accelerated Rehabilitation on Function After Ankle Sprain: Randomised Controlled Trial. British Medical Journal (online) 340:c1964

 

British Medical Association, (2019).  Guide to Sports Injuries (2nd ed). London: Penguin Random House.  

 

Khan, K. & Scott, A. (2009).  Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair.  British Journal of Sports Medicine 43: 247-251.

 

Lewindon, D. & Lee, J. (2016). Muscle Injuries In D. Joyce & D. Lewindon (eds.) Sports Injury Prevention and Rehabilitation, Integrating Medicine and Science for Performance Solutions (pp. 181-198). Abingdon: Routledge.

 

Mirkin, G, & Hoffman, M. (1978) The Sportsmedicine Book. Boston, MA: Little Brown and Co.

 

Mirkin, G. (2015). Why Ice Delays Recovery.  Retrieved from https://www.drmirkin.com/fitness/why-ice-delays-recovery.html

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