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Adam J. Gabe Mirkin. These guidelines have been used by coaches and healthcare providers for over four decades with the intent of expediting the recovery process and reducing inflammation. Although popular, the implementation of this protocol to attenuate the recovery process is unsubstantiated. There is, however, an abundance of research that collectively supports the notion that ice and rest does not enhance the recovery process, but instead delays recovery, and may result in further damage to the tissue.

Research in regard to compression and elevation is inconclusive, diluted and largely anecdotal. Definitive guidelines for their application have yet to be purported. As a result of the subsequent research that examined the validity of the protocol, Dr. Mirkin recanted his original position on the protocol in The objective of this article is to analyze the available evidence within the research literature to elucidate why the RICE protocol is not a credible method for enhancing the recovery process of acute musculoskeletal injuries.

In addition, evidence- based alternatives to the protocol will be examined. These findings are important to consider and should be utilized by any healthcare professional; specifically, those who specialize in the facilitation of optimal recovery, as well as those who teach in health-related disciplines in higher education. Disclaimer: The following information is intended for educational purposes only and not as medical advice.

On May 23, , twelve- year- old Everett Eddie Knowles jumped on to a freight train in Somerville, MA resulting in his arm being completely severed from his body.

Ronald A. Despite the fact that there had never been a successful reattachment of a major limb recorded in medical literature, Dr. Malt and a team of twelve doctors performed the first successful limb reattachment in history.

Newscasters swarmed the team of doctors to obtain essential facts about the miracle limb reattachment touted as one of the most monumental operations in medical history. However, the essential facts about the surgery were rather complicated and would not be understood by the general public.

Instead, reporters focused on the aspects of the story that would be intriguing to the reader. As a result, the application of ice to preserve the severed tissue became the main focus of the story. The use of ice to treat injuries was never part of medical protocol prior to the events of May 23, and the notion to utilize ice for tissue preservation was quickly published by newspapers around the globe.

Subsequently, as the story was continuously retold by individuals not directly involved in the surgery, facts began to change. Eventually, the general public was quickly accepting the notion that any injury should be treated with the application of ice, regardless of its severity or how it occurred In , Dr.

The RICE protocol has been ingrained in academic curriculum as well as in public perception for over four decades. The Illusionary Treatment Option. Subsequent research shows that rest and ice can actually delay recovery. Mild movement helps tissue to heal faster, and the application of cold suppresses the immune responses that start and hasten recovery. Icing does help suppress pain, but athletes are usually far more interested in returning as quickly as possible to the playing field.

So, today, RICE is not the preferred treatment for an acute athletic injury Based upon the available evidence, the only plausible conclusion is that the use of the RICE technique to accelerate the recovery process is unequivocally a myth.

Its validity was unequivocally compromised in when Dr. Mirkin publicly recanted his original position from There is an abundance of scientific evidence purporting proven methods to accelerate the healing of muscle, ligament, and tendon injuries that do not include extended periods of rest used in conjunction with ice, compression, and elevation. To debunk the RICE myth, it is prudent to explore the physiological responses to injury and the effect ice, compression, elevation and inactivity have on those processes.

The ultimate conclusion is that there are more optimal techniques to accelerate the recovery process that do not include a period of inactivity in which compression and topical cooling ice is simultaneously applied to the affected area.

Additionally, each phase of the repair process must successfully occur to allow for the initiation of the next phase When disruptions form in tissues, the body responds with three sequenced phases of recovery: 1 inflammation, 2 repair, and 3 remodeling 2. This sequence means that the process of inflammation must successfully occur in order for the body to shift its focus to the repair phase which must also be completed before proceeding to the remodeling phase.

The magnitude of the inflammatory response is dependent upon the severity of the trauma, as well as the degree of vascularization of the tissue Inflammation is commonly misunderstood and generally believed to be synonymous with swelling. However, the two are entirely different. Inflammation is not an undesired outcome that needs to be reduced or delayed, but rather an instantaneous defense mechanism with the primary objective of controlling the extent of cell injury and preparing the tissue for the process of repair The rapid process of inflammation is caused by necrosis, or accidental cell death 34 , and begins with a brief period of vasoconstriction and hemostasis which restricts blood flow and allows for a blood clot to form 7.

The formation of the blood clot prevents substantial blood loss. Immediately after this transitory period of vasoconstriction, damaged tissue mast cells degranulate, releasing inflammatory chemicals such as histamine, which cause local vasodilation and an increased permeability of the lining of the blood vessels Local vasodilation is the process in which the blood vessels in the immediate area begin to widen in an effort to enhance blood flow.

This increase in vascular permeability and vasodilation allow neutrophils, which are white blood cells that have been attracted to the area of trauma by the inflammatory chemicals, to enter the interstitial space where they can optimally interact with damaged tissues Macrophages, which are cells that are essential for tissue development and repair, simultaneously enter the interstitial space to clear debris and produce growth factors Specifically, macrophages are responsible for the release of insulin-like growth factor IGF-1 , which is an essential hormone required for muscle regeneration As the waste products produced by macrophages and neutrophils begin to accumulate around the damaged site in the form of fluid, the body relies on the lymphatic system to drain the area The inadequate functioning of the lymphatic system is the primary contributor to the accumulation of waste products, excess swelling, and the inability to allow for the optimal recovery of damaged tissues When the body is able to successfully clear the damaged site of excess fluid via the lymphatic system, the process of repair is enabled phase two of the recovery process.

An essential aspect of this phase includes angiogenesis, the division of endothelial cells that add blood vessels to portions of tissues that did not previously have them 1. Another key aspect of the repair phase is the construction of a temporary extracellular matrix, which is accomplished by fibroblasts.

Fibroblast are collagen producing cells, which create weak granulation tissue composed of collagen and fibronectin that will provide the framework for the development of new tissue Immediately after the body reestablishes a vascular network and produces the framework for tissue reconstruction, the process of remodeling is initiated phase three of the recovery process.

The granulation tissue that was laid down during the repair phase is gradually remodeled into stronger tissue and the recovery process is completed. The general premise of applying ice to damaged tissues is reducing inflammation. However, it is important to note that anything that reduces inflammation also delays healing 31 because the process of inflammation is an essential aspect of recovery. When topical cooling ice is applied to damaged tissues, it acts as a vasoconstrictor the narrowing of local blood vessels This physiological response impedes the transport of inflammatory chemicals and neutrophils to the site of trauma.

As a result of the reduced blood flow, the tissue is subjected to a hypoxic low oxygen environment, which can result in tissue death and permanent nerve damage Although ice seems like a beneficial option to reduce swelling according to decades of assumptions about the R. According to Meeusen and Lievens When ice is applied to a body part for a prolonged period, nearby lymphatic vessels begin to dramatically increase their permeability. As lymphatic permeability is enhanced, large amounts of fluid begin to pour from the lymphatics in the wrong direction, increasing the amount of local swelling and pressure and potentially contributing to greater pain.

Not only has topical cooling ice been proven to be an ineffective method for recovery of tissues, it has also been proven to delay the healing process and produce additional damage. Tseng et al. Consequently, participants experienced an increased perception of pain and fatigue, as well as no change in their elevated levels of muscle damage markers, even after ice was applied to the site of trauma Icing also prevents the release of IGF-1 from macrophages during the process of inflammation.

Lu 25 examined this phenomenon in mice. One group of lab mice were genetically altered and unable to carry out the normal inflammatory process. The second group, which was not subjected to the genetic alterations, possessed the ability to carry out the normal process of inflammation. Both groups of mice were injected in their right quadriceps muscle with microliters of barium chloride in order to produce an acute skeletal muscle injury.

The mice who were genetically unable to produce the inflammatory response experienced a reduction in the amounts of IGF-1 present in their tissues and did not successfully recover On the other hand, the control group of mice had very large amounts of IGF-1 present in their tissues after being subjected to trauma.

These findings suggest that the inflammatory process is essential for tissue regeneration since it produces IGF Further, the results of this study suggest that the use of ice, which has been proven to delay the inflammatory process 9, 27, 49 , will directly suppress the production of IGF-1 from macrophages and may result in suboptimal tissue regeneration.

A more recent study explored this phenomenon as well. Miyakawa et. There are several studies that suggest the cyclical application of ice is beneficial with the pain management of soft tissue injuries 3, 8, 16, 19, The authors of these studies have merely supported the notion that ice therapy may be beneficial in pain management, but not one could definitively prove that ice decreased swelling or attenuated the recovery process. In some cases, the authors suggested that evidence in support of icing is insufficient and more studies are warranted 8, 16, There is no evidence in the available literature that definitively supports the notion that ice belongs in a rehabilitation protocol for an acute musculoskeletal injury, unless pain reduction is the only desired outcome.

Compression is commonly used with the objective of stopping hemorrhage and reducing swelling Although popular, research on the validity of compression for recovery enhancement is limited 4, 35, 51 and most support for its application is anecdotal.

Pollard and Cronin 35 concluded there is little evidence available that supports compression for all soft tissue ankle injuries. The authors could not suggest a definitive recommendation regarding the level and type of compression. No information can be provided about the best way, amount, and duration of compression or the position in which the compression treatment is given.

There is also a lack of definitive evidence that supports compression used in conjunction with ice therapy when treating an acute musculoskeletal injury. Elevation is commonly used in an effort to reduce swelling in the extremities by increasing venous return Bayer et al.

It is difficult to assert that compression and elevation are always advantageous when utilized in a recovery protocol, as clinical research has not yet provided definitive guidelines on their usage. However, besides the possibility of applying too much pressure to the limbs and reducing circulation, there are no adverse side effects associated with applying compression. Consequently, if the application of compression or elevation creates a placebo effect and makes the athlete, patient, or client feel better during the recovery process then it may be justified to continue their use.

However, prioritizing the application of compression or elevation over another therapeutic approach is unsubstantiated. Periods of rest following an acute musculoskeletal injury does not enhance the recovery process.


– Clarifying the R.I.C.E. Method for Minor Injuries


Most support the idea of resting, or immobilizing, an injured body part immediately after an injury. Yet, some studies have shown that deliberate, guided movements can be helpful as recovery progresses.

Some physical therapists take a dim view of applying ice and other efforts to prevent inflammation. Injuries are common. Between and , people in the U. Luckily, not all were serious. Approximately half required a visit to a doctor or clinician, but not emergency treatment. The RICE method is best able to treat mild or moderate injuries, such as sprains, strains, and bruises. If a person has tried the RICE method but experiences no improvement, or if they are unable to put any weight on the injured area, they should seek medical attention.

This is also a good idea when an injured area is numb or misshapen. Hip flexor strain can occur when the hip flexor muscles are overstretched or injured. Learn more about surgery and prevention. When a muscle or soft tissue bruises, the signs can be clear to see. But a bone deep within the soft tissues can also bruise and be less visible…. A look at lateral foot pain or pain along the outer side of the foot.

In fact, R. E treatment is a mainstay for sports trainers and other athletic health experts. Experts recommend 24 to 48 hours of no weight-bearing activities. Continued use of a moderate or severely sprained ankle can delay healing, increase pain, or even worsen the injury.

With a mild sprain , activity is generally tolerated after 24 to 48 hours of rest. To help reduce pain and swelling during the first 48 hours after injury, ice the area 20 minutes at a time every 4 hours, using an ice pack covered in a towel. Try not to ice the injury for more than 20 minutes at a time, as it may actually cause further tissue damage. Using an elastic medical bandage, wrap the area to help decrease swelling and internal bleeding if present. Studies have shown that ice not only cools the areas around the injury, but can also have a cooling effect on the inside of the muscle as well.

Compression — By compressing the injured area, you can reduce the swelling that may occur. Compression also provides structure and stability to the injured area. Many people who have sustained an injury will continue to use compression for quite a while as a source of strength and support. Elevation — This can be an important step, especially when injury occurs in the lower parts of the body. By raising the injured area, it will decrease swelling that automatically occurs in an injured area.

Gravity will work to your advantage in reducing swelling. With less swelling fluid there is less pressure on the nearby nerves sending pain signals and joint mobility and range of motion are improved. For this reason, compression is especially useful during the rehab and strengthening portions of post-injury recovery to ease the transition returning to activity.

NSAIDs block the synthesis of prostaglandins, which initiate inflammation, and thus can be effective in temporarily reducing inflammation as well as symptoms of pain and swelling.

NSAIDs can also inhibit the formation of bone callus during healing fractures and inhibit proper healing of tendons after tears. Acetaminophen Tylenol works slightly differently and can help to reduce pain and fever without necessarily interfering with the inflammatory process as much. And yet masking pain signals can have its own downsides as well. By blocking pain, we take away this awareness and ultimately run the risk of further injury.

Ice can be useful immediately following an injury to help temporarily numb the pain and slow down any potential excess bleeding into the surrounding tissues, but for many injuries, the actual bleeding stops within minutes to hours after the initial injury. Starting within hours after most injuries, heat alone or intermittent cold alternating with heat applications minutes at a time can be used to help reduce the potential for stagnation and congestion while encouraging adequate healthy blood flow.

For some, heat can also be just as effective in temporarily relieving pain as ice. The E of HEAT, Exercise, represents initial gentle movements and activity as tolerated , starting with static range-of-motion and isometric strengthening exercises. As the injury heals, it becomes more important to progress to dynamic movement exercises and actively strengthen the muscles surrounding the injured area.

This helps us return to full function and prevent future recurrences of the injury. The stronger and healthier muscles are, the less stress is put on ligaments, bones, joints, and other structures. Analgesia and Topicals can be one-in-the-same, both working to alleviate pain.

Topicals with menthol, camphor, and capsaicin can help to reduce pain and promote more exercise. Topicals work great on the feet and ankles because most structures we are trying to reach are very superficial , just below the surface of the skin. PEACE represents a thoughtful approach for immediately following an acute injury and stands for Protect, Elevate, Avoid anti-inflammatory modalities, Compress, and Educate.

Patient education is essential for long-term success.


What is the r.i.c.e. method – what is the r.i.c.e. method:. R.I.C.E. Treatment for Acute Musculoskeletal Injury


Continued use of a moderate or severely sprained ankle can delay healing, increase pain, or even worsen the injury. With a mild sprain , activity is generally tolerated after 24 to 48 hours of rest. To help reduce pain and swelling during the first 48 hours after injury, ice the area 20 minutes at a time every 4 hours, using an ice pack covered in a towel.

Try not to ice the injury for more than 20 minutes at a time, as it may actually cause further tissue damage. Using an elastic medical bandage, wrap the area to help decrease swelling and internal bleeding if present.

The wrap should be snug, but make sure you have proper circulation. Some signs that the bandage is too tight include numbness, tingling, increased pain, coolness, or swelling. If you think you need to use the wrap for more than 48 to 72 hours, you may have a more serious issue that requires prompt medical attention.

Serious injuries may require more intensive treatment and possibly surgery. With an acute injury, it’s important to bring pain, swelling, and inflammation under control as soon as possible. The R. You may want to include an ice pack and an ACE bandage in your first-aid kit in case you need it at some point. If you are still experiencing pain and swelling after 48 hours of R.

Traditionally, ice is recommended for the first 48 hours or so, because it reduces inflammation and swelling due to increased blood flow to the area , and pain. However, some researchers discourage ice, arguing that the extra blood flow could allow the body to heal itself more quickly. You can try ice or no ice, depending on what seems to work for your recovery, but never use heat on a new acute injury.

Compression means wrapping an injured area of the body with an elastic bandage to reduce swelling. You need to wrap it in a way that provides light pressure. A compression wrap should only be needed for the first 48 to 72 hours after an injury. It depends on the extent of the injury and other factors, but at least two to three days of rest is usually recommended.

However, you may not want to keep the injured area totally immobile. Talk to your healthcare provider about whether you should do some light exercises or movements to prevent stiffening and pain. Sloan J. Soft tissue injuries: introduction and basic principles. Emerg Med J. Krafts KP. Tissue repair: The hidden drama. American Academy of Orthopaedic Surgeons. Sprains, strains and other soft-tissue injuries. Is it time to put traditional cold therapy in rehabilitation of soft-tissue injuries out to pasture?

University of Michigan Health. Tran K, McCormack S. September 19, by John Fernandez. All Rights Reserved. Toggle navigation. Link 1 Link 2 Link 3 Link 4. Maybe not CDC: 7 Out of 10 Kids Kids with Cancer, Now Survivors: Proton Hispanics and Their Health: Understanding Higher Exercising Outdoors? Make Sure to Stay Fighting Rare Pediatric Cancer at Miami Vaccinations, Hygiene and More: Fighting the Understanding the Vital Importance of Routine Chronic Pain Management: Wider Range of Postpartum Depression is a Mental Health Urinary Leakage and Other Pelvic Floor Baptist Health Experts on Closing the Orthopedic Surgeon Details Evolving Technology in Monitoring Your Health: Benefits and Limits When Precision Matters: New Technology at Robotic Hernia Repair on the Rise 0.

Fitness Trackers: Equipped to Stay Fit 0. Be safe with medicines. Read and follow all instructions on the label. When your soreness and pain are gone, begin stretching and strengthening exercises slowly, then gradually increase these exercises.

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