Changing from RICE to Peace & Love

The more I learn, the more I feel like a toddler that is always asking "why?" Playing in numerous sports throughout my life it seemed the response to injury was pretty similar. After classic comments from the coach like "you okay, Nancy?", "rub some dirt on it", or "the ankle is a long way from your heart", the next step was icing the area. The past three years I've had the opportunity to provide sideline coverage as a sports physical therapist ranging from youth up to professional sports. Part of this job description is carrying an ice chest from the parking lot to the fields/stadium that typically seem to be uphill and miles away. During this walk, including multiple breaks (the ice chest gets heavy!), I've asked the following: why do we rest, ice, compress, and elevate after injury? Where did this originate? Is this still best practice? Why did my coach call me Nancy? In this post we will answer at least three of the above questions. 

Where did the RICE principle originate?

Story time! The year is 1962 and a freckled-faced 12-year-old boy hops onto a freight car in Somerville, Massachusetts. Why? He's a 12-year-old boy and it's a dangerous game. The train rolls under a bridge and the boy, Everett Knowles, doesn't hug the ladder rail tight enough. This results in his arm being almost completely severed from his body. He is rushed to the hospital where, for the first time in history, Dr. Ronald Malt decides to surgically reattach the arm. In the process of assembling the dream team for the surgery, he orders the arm to be preserved by placing it in ice. The surgery takes about 15 hours and is a success. Following this success, Dr. Malt and his team travel around the world explaining the surgery. In a press conference a reporter asks "if we encounter a person with a severed arm, what should we do?" He replies, "Don't panic, place the limb on ice, stop the bleeding by using a tourniquet, and elevate it above the heart." This then becomes known respectively as rest, ice, compress, elevate. The term is coined and introduced into sports medicine by Dr. Robert Mirkin in his best selling The Sportsmedicine book in 1978. From 1978 to present day, RICE is the mostly widely used principle for acute/initial injuries.

Why do we use the RICE principle? 

In order to understand the proposed theory of why this principle is used, we're going to have to take a field trip with Ms. Frizzle into the basic physiology of acute musculoskeletal injury. The initial response is a complex immune response with the goal to "attack." For a very, very, very detailed description of this process please see Tidball's 2017 paper. In this phase, vasoconstriction occurs to stop bleeding and various white blood cells go to the area to eliminate the invader. During the process, secondary damage is likely done to the area. The second part of the initial inflammatory phase is characterized by vasodilation to bring blood to the area and "rebuild" or "regenerate". It is important to note that both of these inflammatory responses are necessary for healing to occur. The effects of the inflammatory phase result in redness, swelling/edema, hypersensitivity, and nociception. We are just going to call this "congestion." The RICE principle is thought to decrease the congestion and decrease inflammation to help recover from an injury. 

Is this still best practice? 

...No. Inflammation isn't the bad guy and is NEEDED for healing to occur. Remember Dr. Mirkin? He coined the term RICE in 1978, but recently he has written, "Coaches have used my 'RICE' guideline for decades, but now it appears that both ice and complete rest may delay healing, instead of helping." I applaud his ability to change his perspective based on the best available evidence in the present time. Let's dive into this topic a bit deeper. 

When acute injury musculoskeletal occurs we want to first rule out any fractures, dislocations, or anything else that would require referral for emergency medicine. Next, we want to decongest the congested area. In order for this to happen we have to utilize the lymphatic system. This system is a collective of vessels and organs that relies mostly on extrinsic pumping of skeletal muscle and breathing to rid our bodies of waste, toxins, and extra fluid. Compression may help to reduce swelling but muscle contraction is more beneficial due to pressure differences. For example, most compression garments have the pressure of approximately 30-40 mmHg, whereas contraction of the calf causes approximately 200 mmHg of pressure on the local veins. This is also why absolute rest is not likely the best practice after injury. Muscular contraction and breathing is needed to decongest the area; maybe the classic "walk it off" coaching comment wasn't the worst advice! Movement stimulates healing through the process of mechanotransduction. Elevation may also still be done, however this is supported by weak evidence and is more recommended due to low risk-benefit ratio. That covers the R, C, and E of RICE, but I want to know if I need to keep carrying this heavy ice chest to games!

Ice was recommended to be used for proposed anti-inflammatory benefits. This is very true for ibuprofen, which is significantly overused by our youth athletes. As stated above, we want inflammation to occur as it is necessary to begin the healing process. Recent research has shown anti-inflammatory medications and ice may be detrimental for long-term tissue healing. Ice is commonly used in baseball after pitching. Currently, 10/30 MLB teams no longer ice their pitchers after an outing. Research done by Tseng et al. 2013 found signs of muscle damage after applying topical cooling following eccentric exercise compared to a sham application. Furthermore, a randomized controlled trial by Prins et al. 2011 tested the effectiveness of ice therapy in the initial phases of a calf muscle tear. They compared two groups, active ice group vs control group, and looked at functional capacity, time to return to work, and pain relief. They concluded, "the use of ice is not beneficial for people receiving ice therapy." It is important to point out that the research on ice/cryotherapy has its methodological flaws (you either know it's ice or it isn't...), so we don't conclude anything with full certainty.

Why, then, can ice still seem to help with pain? The benefits of ice likely lie in the fact that most people believe that it is going to make them feel better. It is unlikely that an ice pack is reaching depths to truly make a physiological change at the injury site. Bleakley and Hopkins 2013 stated "Based on healthy human models, it is difficult to induce large decreases in intramuscular or joint temperature, particularly in circumstances of deep tissue injury or areas of higher levels of body fat. The lowest reported superficial muscle temperature (1 cm sub-adipose) after cryotherapy is 21°C, in a lean athletic population. Reaching currently accepted threshold temperatures for metabolic reduction (5–15°C) seems unlikely." It is likely that the superficial treatment of ice causes a change in our nervous system sensitivity leading to the perception of the injured area feeling better.

Currently, what is best practice for acute musculoskeletal injury?

The RICE principle has transitioned from RICE to PRICE to POLICE to now PEACE & LOVE, (see graphic at top of this post.) I will outline what we now use for athletes of all ages when acute injury occurs: 

1. Rule out any condition requiring referral to the hospital. If no referral is needed, let the athlete know this information to create safety and decrease fear or uncertainty. 
2. Assess immediate tolerance to load and identify optimal load. Optimal load is dependent on symptom response. Can they lightly move the injured area without weight being put onto it? If yes, then how much weight can be put through the injured area? Can the athlete walk, limp, or are they not accepting any load through the area?  
3. Do they have hopes to return to play within the same day? If yes, then I'm not going to use ice. Research has shown application of ice for greater than five minutes decreases strength, power, and performance in the short-term. If ice is used, then a period of rewarming is needed before the athlete proceeds into higher level movements. Instead, we will use optimal load and progress this load until the athlete feels confident with a quick screen on the sideline of sport-specific demands (running, jumping, absorbing contact, etc) 
4. If the athlete communicates that they do not want to return to play within the same day, we move to pain free exercise followed by compression, elevation, education, avoiding anti-inflammatory medications, and ice (if they REALLY want it).

Our goal is to introduce safe movements to our youth athletes after their first injury experience, allowing them to learn that movement and perspective made them better- not ice. In the future we hope to only use ice for cases of heat exhaustion. Therefore, we conclude that the effectiveness of ice for acute musculoskeletal injury is due to the belief it will help, changes in sensory nerve conduction, and the ability for ice to melt and become water to hydrate the athlete.

Why did my coaches call me Nancy when an injury occurred? 

I still have no idea. 

Stay Connected, Stay Curious, Stay Strong (insert flexing emoji)

Dr. Dillon Caswell, PT, DPT

Get out of the injury cycle Series 


References:

1. Mine and Dr. Jason Tuori's thoughts
2. Available at: http://www.thesomervilletimes.com/archives/36886
3. Available at: https://www.drmirkin.com/fitness/why-ice-delays-recovery.html
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