What do you do when you’re out for a run, and you step on a rock and twist your ankle? Or say you’re in the gym lifting weights, and you feel a twinge of pain in your shoulder than lingers? What about if you go to pick up your sock from the floor and feel some pain in your lower back? Conventional wisdom for the past several decades would say the best thing to do is – RICE it! That is, Rest, Ice, Compress, and Elevate it. I’m guessing most of you reading this have tried this at some point for some injury, and you’ve likely recovered from the injury just fine, but is RICE the BEST paradigm for management of acute injuries? Recent advancements in research on the topic would tell us that is probably not the case.
Rest, Ice, Elevation, Compression have been staples of acute injury management for decades, since Dr. Gabe Mirkin coined the term in 1978. The initial thought behind this protocol was to reduce inflammation, in hopes that this would speed up healing. About 20 years after RICE came out, P was added to the process, for “Protection” – hence PRICE management. This constitutes a small tweak to RICE, but apparently enough to garner a whole new letter in the acronym. In 2012, Bleakley, Glasgow, and Webb in the BJSM proposed POLICE – Protection, Optimal Loading, Ice, Compression, Elevation – the biggest change was changing advice from rest, to optimal loading, which was an addition made due to research that showed cell regeneration is induced by light mechanical loading in early stages of recovery from an injury.
Since that time, even more has changed – in 2014, Dr. Mirkin, the original RICE proponent, acknowledged that there is new research that shows that ice, along with complete rest, may be harmful in the healing process. It turns out that the inflammatory process is actually essential for optimal healing. One aspect of particular importance is the release of Insulin-like Growth Factor (IGF-1). This hormone is released by inflammatory cells called macrophages, and IGF-1 plays a vital role in stimulating healing in injured muscles and other tissues.
Largely in response to this new research, yet another new acronym and new guidelines for acute injury management have been proposed. In 2019, Blaise and Esculier in the BJSM proposed the acronym PEACE & LOVE. Protection, Elevation, Avoid Anti Inflammatories, Compression, Education & Load, Optimism, Vascularization, Exercise. This is by far the most comprehensive (and longest) acronym yet for acute injury management.
Protection is still appropriate for the initial days immediately following an acute injury – these authors suggest 1-3 days as the timeframe for which limited movement may be appropriate, and they suggest pain level as the guiding principle for when the protection phase can be ended. Elevation is also permissible in this protection phase, although the authors admit that the evidence for its effectiveness is limited. The thought is that it can promote the flow of interstitial fluid from the tissues, and there is no significant evidence that elevation would slow the healing process. Further advice in this phase is to Avoid Anti Inflammatory modalities – this one is probably the biggest surprise of the bunch so far as it would include anti inflammatory medication, as well as modalities including ice. The reason for this change is that these modalities may help to reduce pain, but they are also slowing the inflammatory response, which may reduce pain, but also delays healing. Compression is still a recommendation because it will help to limit tissue hemorrhage and will also help to limit intra-articular edema. Finally, Education – this one is geared more towards a health professional who is helping a patient or client to manage an acute injury. The patient should be educated on the benefits of actively managing their symptoms.
Once the initial pain from an acute injury has subsided, it’s time to move into the more active stage of managing the injury to facilitate your return to full activity. Load is the first part of the acronym. Almost universally, tissues respond to appropriate stress levels by growing/healing. The key word here is appropriate. Depending on the severity of the injury, the proper load may simply be isometrics, or if you are nearing readiness for return to full sport or activity, you probably need to be doing high intensity exercise. Optimism is the next part of the recommendation. Psychological factors are huge contributors to someone’s recovery from an injury. For numerous conditions, those who are more kinesiophobic (afraid of movement) and those who catastrophize their pain tend to recover much more slowly. The opposite is also true, those who have better expectations tend to have better outcomes. The mind is so incredibly powerful! Next is Vascularization. This means it is important for people to be able to still perform cardiovascular exercise without compromising the healing tissues. For someone with an ankle sprain, maybe this means they use an arm bike for some cardio, and someone with a shoulder strain would probably benefit from performing high intensity cardio exercise on a bike. This uses the body’s natural systems to generate improved blood flow, as well as a release of endogenous endorphins that can often significantly reduce pain. Finally, Exercise should be progressed to restore full ROM, strength, proprioception, and control at whichever muscle/joint is involved.
Blood Flow Restriction
We also wanted to take a minute to highlight one more thing that we like to do with acute injuries – Blood Flow Restriction Training! There are two main reasons we like to use BFR in these scenarios. First, BFR allows you to continue to get strength and hypertrophy gains with a much lighter load than is required with traditional strength training, so the injury doesn’t necessarily have to slow your gains. Second, the body’s hormonal response to BFR (as we discussed here) is such that healing of tendons and muscles is optimized. If you want to start working BFR training into your program, we can help with that too! Check out this website to get a discount on SAGA fitness BFR cuffs.
Perhaps the most important takeaway from the whole thing is that the evidence is clearly pointing rehab professionals towards a more ACTIVE management of acute injuries. Movement is medicine people! Don’t let these nagging injuries keep you down. As always, if you need our help managing some of these types of injuries, please reach out!
- Dubois B, Esculier JSoft-tissue injuries simply need PEACE and LOVEBritish Journal of Sports Medicine 2020;54:72-73.
- Mirkin, G. (2014, March 16). Why Ice Delays Recovery. https://www.drmirkin.com/fitness/why-ice-delays-recovery.html