REST. ICE. COMPRESSION. ELEVATION

RICE – How to Deal with Inflammation

The New Thinking on Rest . Ice . Compression . Elevation

You come back from a run and you feel a little “tight”, as if you have strained your knee and hamstring. You see a little inflammation (defined as a form of physical congestion or a localized physical condition in which part of the body becomes reddened, swollen, sometimes hot, and many times painful) especially as a reaction to a strain, injury, or infection. What’s the next step? Ibuprofen, RICE, or movement.

It’s time for the world of physical therapy and personal training to shift their thinking from the idea of anti-inflammatory drugs, RICE (rest, ice compression and elevation) to the POLICE principle (protection, optimal load, ice compress, elevate) for injury recovery and tissue healing. Understanding the systematic course that the body takes and the variability in healing times based on tissue type will help you reassess whether you apply RICE or shift to POLICE.

WHY DO WE USE THE RICE PRINCIPLE?

In order to understand the theory of why the RICE principle is used, we’re going to have to take a deep dive into the basic physiology of acute musculoskeletal injury. The initial reaction is a complex immune response with the goal to “attack.” 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 critical to note that both these inflammatory responses are necessary for the process of healing to occur.

Factoid: Originally, the RICE principle was developed and utilized by Dr. Malt in 1962 to reattach a 12year old boy’s arm. Then in 1970 coined by Dr. Mirkin in his best seller The Sportsmedicine Book, he promoted the thought to decrease the congestion and inflammation, RICE must applied.

Let’s take an ankle sprain as our primary example. Ankle sprains are the most common low body injury and can occur in any sport or recreational physical activity. In order to restore your ankle stability and ideally build up its capacity you need to assess what stressed it in the first place.

The question asked, is RICE still best practice? The truth be told is …No. Inflammation isn’t bad and as mentioned it is a necessary part of the healing process. Even Dr. Mirkin reassessed this concept on RICE and said, “Coaches have used my ‘RICE’ guideline for decades, but now it appears that both ice and complete rest may delay healing instead of helping.”

Factoid: When you get an injury, inflammatory cells and proteins rush to the affected site and start the healing process. These cells are called macrophages and release a hormone which helps your muscles recover.

Mirkin came to the realization when you apply ice to your body, it constricts the blood flow to that area. By reducing the blood flow to your injury, you’re minimizing the amount of healing cells that can get there. Once you’ve iced your injury, the blood vessels may not open again for many hours later, which can result in permanent nerve damage and can cause the surrounding tissue to die.

He also claims that anything that reduces the inflammation in your injury can also prolong the healing process. This could include cortisone drugs, pain relief medication like ibuprofen and even immune suppressants (which are used to treat a number of conditions, such as arthritis).

Factoid: If absolutely necessary, ice should only be applied for up to 10 minutes. However, be aware that using ice could potentially prolong the healing process and cause even further damage.

Dr Mirkin also recommends moving your injured body part the next day, so long as you can do so without pain or discomfort; that way you can get back to your healthy self in less time! Yet if you do find yourself with a serious muscular or soft tissue injury, it’s quite possible you could need expert advice and rehabilitation from a physiotherapist or chiropractor.

Now let’s dive a little deeper. I believe Dubois and Esculier’s theory on soft tissue injuries has created the perfect balance referred to as PEACE & LOVE (protect, elevate, avoid anti-inflammatories, compress, educate, load, optimism, vascularization, exercise.)

The focus is to decongest the congested area. In order for this to happen we need to utilize the lymphatic system. The lymphatic system is a collection of vessels and organs that relies mostly on extrinsic pumping of skeletal muscle and breathing to rid the bodies of waste, toxins, and extra fluid.

COMPRESSION

Compression is another method utilized to reduce swelling, yet muscle contraction is more beneficial due to pressure differences. Compression devices are available in five levels, offering pressure that ranges from:

. Mild Compression – ranging between 8-15 mmHg – designed to help sore and aching joints while providing mild circulatory stimulation.

. Medium Compression – ranging from 15 to 20 mmHg – designed for relief from severe aches and pains either in muscles or joints. Ideal for long distance travel to improve circulation and relieve stiffness.

. Firm Compression – ranging from 20-30 mmHg, typically used to promote the circulation of blood or Lymphatic fluids. Frequently used in postoperative setting, wherein circulation may be decreases, or for medical conditions.

. Extra Firm Compression – ranging from 30 – 40 mmHg, is used to relieve many of the same conditions used with firm compression, just providing more pressure for larger patients or more severe symptoms. Extra firm can be used to promote circulation, relieve hypertension, and treat severe edema.

. Medical Compression – ranging from 40 to 50 mmHg and is only used in medical treatment and rehabilitation. Used mostly for post-surgical conditions to prevent the pooling of the blood or other circulation problems.

Factoid: Most compression garments have a pressure of approximately 30-40 mmHg, whereas contractions of the calf causes approximately 200 mmHg of pressure on the local veins. This is why absolute rest is not likely the best practice after injury.

Muscular contraction and breathing are required to decongest the area. Movement stimulates healing through mechanotransduction, the physiological process where cells sense and respond to mechanical load used therapeutically to stimulate tissue repair and remodeling in tendon, muscle, cartilage and bone.

I want to reinforce the fact that we want inflammation to occur as it is necessary to begin the healing process. Anti-inflammatory medications deserve equal caution. Professor James McCormack confirms there is no evidence non-steroidal anti-inflammatories (NSAID) improve the outcome of acute sports injuries or reduce swelling (listen to the podcast). Steroidal anti-inflammatories, such as cortisone, inhibit the production of collagen and granulation tissue.

A Baseball Story

Ice is commonly used in baseball after pitching. Currently, 10/30 Major League Baseball teams no longer ice their pitchers after an outing. Researcher’s found signs of muscle damage after applying topical cooling. The benefit of ice likely lies in the fact that most people believe that it is going to make them feel better. A placebo effect so to speak. Yet, it is highly unlikely that an ice pack is going to reach depths to truly make a physiological change at the injury site. It is probable the superficial treatment of ice causes a change in our nervous system sensitivity leading to the perception of the injured area feel better.

TAKEAWAY

Movement, not rest

Recovery after injury is improved with movement, not rest, was published in1996, by Dr. Jim and Phil Wharton in The Wharton’s Stretch Book. They suggested the acronym MICE to replace RICE, where Rest is replaced with Movement. The Whartons advocated that once fracture or catastrophic injury is excluded: movement is best, not rest, to treat an injury. They encourage immediate but gentle restoration of active range of motion with gradual introduction of functional activities. They note that inactivity shuts the muscle down restricting blood flow to the injury and tissue atrophy. In contrast, activity improves blood flow, which brings oxygen and removes metabolic waste.

That movement also directly stimulates tissue healing was clarified by Dr. Khan (Editor of the British Journal of Sports Medicine) and Dr. Scott (Director of Vancouver Hospital’s Tendon Laboratory). Called mechanotransduction, the actual physical deformation of tissue by mechanical load of movement leads to release of chemical growth factors from cells. These enhance synthesis of protein and structural scaffolds, which maintain, repair and strengthen bone, cartilage, tendon and muscle. Even Dr. Gabe Mirkin, who coined the acronym RICE, now agrees rest may delay healing.

For your wellness appointment contact coachmikeconner@gmail.com or call 404-358-3250