Is R.I.C.E. outdated for Injuries?
Have you ever experienced a sprain or strain and remember that simple acronym R.I.C.E. meaning Rest, Ice, Compress, and Elevate? Most likely, you have. If not, let me provide an example. Let’s say you sprain your ankle trying to learn a kickflip at the local skatepark (definitely not talking about myself), it is not uncommon that I would head to the kitchen and reach for a frozen bag of peas to place on my aching and swollen ankle immediately afterwards. Believe it or not, this approach is not ancient, and its origin starts in the late 1980’s when Dr. Gabe Mirkin published a book titled “Sports Medicine Book” where the acronym R.I.C.E. was born in efforts to expedite the recovery process and reduce inflammation following an acute injury. However, recent research challenges this approach as it appears that both ice and complete rest may actually delay healing. In light of recent research, Dr. Gabe Mirkin himself has stepped back a bit on his original stance and promotes a more active movement approach, with much smaller emphasis on long term ice application and rest.
“ …ice and complete rest may actually delay healing.”
To understand why ice may delay healing, we must understand the role of inflammation. inflammation is not the devil. You can’t heal the body without inflammation. When you experience any trauma involving soft tissues like muscle or joint structures, you heal yourself using your immune system the same way you fight things like a flu virus… This is called inflammation. Inflammatory cells will rush to the injured tissue to get the healing process underway. Certain approaches like applying ice following a soft tissue injury causes blood vessels near the area to constrict and shut off blood flow that disrupts the “healing cells” from getting to the injured site. Anything that reduces inflammation also delays healing. Other ways inflammation is cut off are the use of non-steroidal anti-inflammatory (NSAID) drugs like ibuprofen or cortisone-type drugs.
“Anything that reduces inflammation also delays healing.”
So overall, R.I.C.E. isn’t as effective as once believed, so now what?
Introducing a more evidenced-based approach, also in acronym form… PEACE and LOVE.
The following information is most applicable to soft tissue injuries. As a general rule of thumb, PEACE is to be used during the first 1-3 days following injury. LOVE is to be used immediately following the initial healing phase. Okay, let’s break it down.
“Immediately following injury, do no harm and let PEACE be your guide”
P = Protection
* Pain signals should guide the cessation of protecting the affected area. Avoid prolonged rest.
E = Elevate
* Elevate the limb higher than the heart to promote interstitial fluid flow out of tissues. The evidence behind this is weak but offers a low-cost, low risk-to-benefit ratio way of having an option to possibly reduce swelling.
A = Avoid anti-inflammatories
* Inhibiting inflammation using medications may negatively affect long-term tissue healing, especially when higher doses are used.
C = Compress
* Despite conflicting studies, compression does seem to help reduce swelling and improve quality of life. Like elevation, this option is typically a low risk-to-benefit ratio.
E = Education
* An active approach to recovery including tolerable movement is generally more effective than a passive approach which includes things like manual therapy, acupuncture, and electrotherapy to mention a few. Creating realistic expectations with recovery as opposed to finding a miracle cure or a “need to be fixed” will increase long term recovery, and decrease therapy-dependent behavior. This might be the most important aspect of PEACE.
“After the first days have passed, soft tissues need LOVE”
L = Load
* Mechanical stress, or load, including running/jogging, carrying groceries, completing general exercise, or weight lifting should be added early, and normal activities should be resumed as soon as symptoms allow. This will help promote repair, remodeling, and build tissue tolerance of the injured tissue.
O = Optimism
* Being optimistic about your recovery goes a long way and improves chances of having a successful outcome. Poor coping strategies including catastrophization and fear-avoidance can represent a significant barrier to recovery. This is easier said than done, and there are tools to help manage your expectations and emotions which may include but are limited to meditation, daily nature walks, hanging out with supportive friends, and/or participating in meaningful activities to help stay optimistic and improve injury outlook.
V = Vascularization
* Starting pain-free aerobic exercise as soon as possible is a no-brainer and offers the chance to increase blood flow and remain active. This may require you to get creative temporarily. For example, if you sprained your ankle, walking/running for aerobic exercise may not be appropriate if it’s too symptomatic, and you may benefit more from activities such as swimming with a focus on using your arms to propel in the water.
E = Exercise
* The level of evidence supporting the use of exercise for treatment of acute injuries like sprains and strains is STRONG. Exercise can help you return to your meaningful activities with confidence, and oftentimes, a gradual loading exercise program will leave you feeling stronger than you did before the initial injury. Remember, we want to avoid exacerbating symptoms but at the same time perform exercise at a level where pain is tolerable.
Is PEACE and LOVE better than RICE? In short, yes, and admittedly, evidence regarding some of the tools are weak including compression and elevation during the early stages, but overall they can be helpful and are worth attempting if swelling is more than mild. Remember, the swelling that accompanies injuries is part of the inflammation process that promotes tissue healing, but any swelling that is beyond mild may profit from some reduction measures. The promotion of active movement, exercise, and education accompanying PEACE and LOVE is where the cake is, and where you will have more long term success with rehabilitating strains and sprains.
Getting injured sucks, but getting injured is also part of being human and it can happen for a variety of reasons that are beyond the scope of this post. Additionally, getting injured is very very difficult to prevent, and what I hope this information can provide for you is an evidenced based tool set to manage injuries when they occur by listening to your body and removing unhelpful beliefs and fears to move or load your strains and sprains. The key message is to load the injury as soon as possible without exacerbating symptoms, which takes discipline. Stay positive about your outcomes and keep moving.
Peace...and LOVE YOUR LIFE!
- Austin Henke, PT, DPT
FYZICAL of South Oak Park
References
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Bleakley CM, O’Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: Randomised controlled trial. BMJ 2010;340: c1964.
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Van Den Bekerom, Michel PJ, et al. "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 (2012): 435-443.
https://www.drmirkin.com/fitness/why-ice-delays-recovery.html
https://bjsm.bmj.com/content/bjsports/54/2/72.full.pdf