It is not only the world of dietetics that is being challenged with “less carbs, more proteins”. There has recently been a paradigm shift with the management of injuries.
The RICE principle has been known for years, guiding injury management. Rest, Ice, Compress and Elevate the injured area has been the primary principle that everybody followed. Later on, a ‘P’ for Protect was added to the acronym to form PRICE. These principles were widely used and perhaps abused? Currently the once-size-fits-all approach which seems to be followed with these two principles are being criticized. The management of a repairing tissue should rather be adapted from one scenario to another. There is now being suggested that we take the following into account before jumping to RICE or PRICE: the time that has passed since the injury, the type of tissue that has been injured, as well as the extent of the injury. To use different approaches for different situations might make more sense.
The Different Approaches
RICE and PRICE aims at preventing severe swelling and decreasing pain. It also aims at preventing further damage by protecting and resting the injured area. Applying ice to the injured area, will lead to constriction the blood vessels and a decrease in metabolism of the cells in the area (less by-products released), and also decreases pain by cooling the skin which decreases the conduction of the nerves. Additionally, compression and elevation also decreases blood flow to the area.
Recently, the POLICE approach has also been called to action. Protect, Optimally Load, Ice, Compression and Elevation. This approach is similar to the two mentioned above, but has a movement component to it. By weight bearing on the injured area, gently moving or stretching the injured tissues, one can start loading the healing fibres. These actions aim to stimulate the synthesis of new fibres and aligning them as they are being laid down again. This increases the strength of the injured area as more fibres are organized to pull in the same direction. The loading of the fibres should be discussed and determined by a health practitioner after a thorough examination, taking the extent of the injury into account. Generally, it should not take long after the injury that the POLICE arrives on site. The quicker the fibres can be appropriately loaded, the quicker it will be able to resist its normal forces.
The shift is now to get the RICE off the table and introduce the MEAT approach. MEAT is for Movement, Exercise, Analgesics and Treatment. This approach suggests that gentle movement of the injured area will enhance blood flow to support the healing process and reduce swelling by preventing the pooling of fluids in the area. The lymph system is dependent on muscle contraction to move the lymph fluids through the body. The muscles squeezes around the lymph vessels and pushes the fluids on, allowing a constant flow instead of pooling. Exercise aims to strengthen the tissues around the injured area or improving muscle dysfunctions which might have led to the injury. It is a progression of gentle movement and should start as soon as the scar tissue is strong enough. Stretching may also be necessary to lengthen the injured muscle as the scar tissue contracts in the later phase of healing. Intense and prolonged pain may disturb the healing process and lead to chronic pain. Pain should therefore be well controlled from the early stages of healing. Pain medication (analgesics) should be used in the acute phase, however anti-inflammatories should be avoided as inflammation is necessary for healing. Treatment can involve any physiotherapy techniques which aims at increasing blood flow, stimulating healing and increasing the strength of the healing fibres.
How Do I Choose an Approach?
The ultimate goal after injury is healing. Healing is done in different stages which means that the needs of the tissue changes as the healing process progresses. The approach should therefore frequently be adapted and reconsidered depending on the healing process and the type of tissue. During the first phase of healing, inflammation and pain should be well controlled to prevent complications, such as compartment syndrome due to severe swelling, which will slow down the healing process. Here RICE and PRICE may still be appropriate to reduce the swelling and pain, and prevent further damage by resting and protecting the area. However, inflammation is the natural response of the body and is critical for the first stage of healing where the inflammatory cells need to clean and clear the area and start laying down new fibres. Decreasing the blood flow, by applying RICE and PRICE, may decrease inflammation and subsequently inhibit healing as well. Therefore, the use of RICE and PRICE should be limited and used according to the extent of the injury and the type of tissue injured. Muscles have richer blood supply than ligaments and tendons which increases the risk of severe swelling. In contrast, decreasing the blood flow to ligaments and tendons which already has little blood supply, may disturb the healing process. There are propositions that ice can generally be applied intermittently for 10min. at a time and only during the first 2-4 hours after injury. Research has also suggested that although short periods of unloading are required to prevent further damage, rest should be limited and restricted to a short duration after injury. Therefore, there is merit for RICE to be replaced with the MEAT approach.
As the healing process continues to the second phase, the new fibres of the tissue should be laid down, and lastly, the scar tissue should be smoothed out, stretched and strengthened to match the undamaged parts of the tissue. Movement is ideal as it improves the scar tissue’s mobility and strength together with enhancing the blood flow in the area to decreases swelling by preventing pooling of fluids at the injured site. Early activity promotes early recovery.
There is thus a place for the RICE protocol, but evidence is suggesting that it should only be used in specific situations and for short periods, where there is a possibility of severe swelling and further damage to be prevented, such as muscle injuries or severe trauma. The POLICE approach should always be considered above RICE, if loading is safe for the healing fibres. The MEAT approach should firstly be considered when dealing with ligament or tendon injuries. The MEAT approach should also ultimately be followed in the later stages of all other injuries where inflammation is under control and the strength of the fibres are increasing.
So maybe we should give Tim Noakes a break and give the MEAT principle a chance in the management of injuries. There is still more research needed to be done to support this shift, but for now it should make us all think before we routinely follow the RICE approach. In summary, the focus after injury should be to get the repairing tissues moving in order for them to adapt to forces from an early stage, however, this approach should be followed once potential complications such as severe swelling has been addressed.
You are welcome to share your thoughts on this paradigm shift – it is open for debate and further research.
Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sport Med. 2004; 32:251–261.
Bleakley C, O’Connor S, Tully M, Rocke L, MacAuley D, McDonough S. The PRICE study (Protection Rest Ice Compression Elevation): design of a randomised controlled trial comparing standard versus cryokinetic ice applications in the management of acute ankle sprain. BMC Musculoskeletal Disorders. 2007; 8:125.
Bleakley C, Glasgow, MacAuley D. PRICE needs updating, should we call the POLICE? Br J Sports Med. 2012; 46:220–221.