RICE treatment mechanism

[Tiz]

What are the physiologic mechanisms of RICE (rest, ice, compression, elevation) treatment for sports injuries?

 

I'm not sure there is a lot of good literature on the subject but I am just trying to understand how each of these components actually help after, say, a sprained ankle.

 

Little help?

[PhoenixFlare500]

They help with inflammation and swelling.

[futureGP]

What are the physiologic mechanisms of RICE (rest, ice, compression, elevation) treatment for sports injuries?

 

I'm not sure there is a lot of good literature on the subject but I am just trying to understand how each of these components actually help after, say, a sprained ankle.

 

Little help?

 

my understanding is it's a symptomatic treatment to just manage pain/discomfort and prevent any further bleeding/injury and particularly has to deal with inflammation management (since inflammation can often times lead to more damage)

 

rest - to prevent further injury and harm to the region

 

ice - decrease inflammation by reducing heat and also helps with pain

 

compression - to reduce swelling and further bleeding (slow blood flow to the region so decreased inflammatory response... although you can also argue too much compression is bad cuz it can lead to ischemia

 

elevation - to decrease blood flow again to prevent swelling/blood flow

 

i also like to add 'protection' -- protect the wounded site through some kind of a splint to stabilize it (e.g. a fracture)

 

 

really it's a first-aid maneuvre as a symptomatic but also facilitate further damage before something definitive can be done

e.g. casting, surgery, splint etc

[Tiz]

Okay yeah that is generally what I thought.

 

But how does ice specifically decrease inflammation?

[Larrivee]

Vasoconstriction

[Larrivee]

Tissue injury. -> release of cytokines and inflammatory mediators -> leaky vessels and allow immune cells' diapedesis as well as fluid extravasation. Vasoconstriction will decrease this. T least that is how I make sense of it.

[BoyInTheBubble]

Who said ice helps?

 

Ice acts by reducing heat, that's deep! I supposed cold weather causes colds too.

[leviathan]

Who said ice helps?

 

Ice acts by reducing heat, that's deep! I supposed cold weather causes colds too.

 

Tissue injury. -> release of cytokines and inflammatory mediators -> leaky vessels and allow immune cells' diapedesis as well as fluid extravasation. Vasoconstriction will decrease this.

 

Ice = vasoconstriction.

[leviathan]

In reality, "the art of medicine is amusing the patient while nature affects the cure."

[BoyInTheBubble]

Ice = vasoconstriction.

 

No evidence that reducing the inflammatory process actually helps. Perhaps our bodies respond like that intentionally?

[Larrivee]

Inflammation -> sensitization of peripheral nerves -> more pain. I'd say that patients probably think decreasing pain is helpful

[BoyInTheBubble]

Inflammation -> sensitization of peripheral nerves -> more pain. I'd say that patients probably think decreasing pain is helpful

 

You just made that up. Feels right though, doesn't it?

 

How does ice improve flow through the lymphatic system? Why would blunting the inflammatory response improve recovery of an injury in the first place? Why would putting ice on after the injury provide any benefit? Why doesn't it just cause vasoconstriction and bring the lymph drainage to a halt.

 

Dogma or not. The onus is you to prove that RICE (especially the icing, or 'cryotherapy' in research land) actually provides benefit. The numbing feeling ice provides is convenient but that doesn't make your injury heal faster. There is no evidence that it works, it likely is silly and slows recovery (but I can't make that claim due to the lack of evidence going both ways.)

[Larrivee]

I did not make that up, I just had a huge neuro exam yesterday so I could explain in detail how inflammation leads to peripheral sensitization (via substance P, PGE2, and the rest of the gang), but I don't feel like typing that much. I didn't make it up tho,

[BoyInTheBubble]

I did not make that up, I just had a huge neuro exam yesterday so I could explain in detail how inflammation leads to peripheral sensitization (via substance P, PGE2, and the rest of the gang), but I don't feel like typing that much. I didn't make it up tho,

 

The difference is are you athlete wanting to recover faster or a student repeating a chapter from a textbook? Compression and movement reduce swelling better if you're interested in returning to normal activity quicker.

[markov79]

what? LOL where did the athlete thing come from?

[BoyInTheBubble]

what? LOL where did the athlete thing come from?

 

The first post:

 

What are the physiologic mechanisms of RICE (rest, ice, compression, elevation) treatment for sports injuries?

 

I'm not sure there is a lot of good literature on the subject but I am just trying to understand how each of these components actually help after, say, a sprained ankle.

 

Little help?

 

If you sprain your ankle, compression, movement and elevation (at rest, eg on the couch). Ice and no movement is dumb.

[markov79]

LOL owned 10 ch

[leviathan]

How does ice improve flow through the lymphatic system? Why would blunting the inflammatory response improve recovery of an injury in the first place? Why would putting ice on after the injury provide any benefit? Why doesn't it just cause vasoconstriction and bring the lymph drainage to a halt.

Vasoconstriction decreases bloodflow into the injured area, allowing lymphatic drainage to work with less opposition to incoming blood supply. It doesn't to my knowledge affect the lymphatic drainage but I could be wrong about that. It's been a long time since I've done basic path, but infection prevents proper wound healing, but is it the infection itself that causes that or is it the inflammation secondary to the infection.

 

Dogma or not. The onus is you to prove that RICE (especially the icing, or 'cryotherapy' in research land) actually provides benefit. The numbing feeling ice provides is convenient but that doesn't make your injury heal faster. There is no evidence that it works, it likely is silly and slows recovery (but I can't make that claim due to the lack of evidence going both ways.)

There is weak evidence that cryotherapy helps improve healing time and improvement in functional status in ankle sprains. There is strong evidence it reduces swelling and pain. Rather than spend time to cite it all, a quick search will give you lots of info:

http://scholar.google.ca/scholar?q=cryotherapy+ankle+sprains&btnG=&hl=en&as_sdt=0%2C5

[BoyInTheBubble]

Vasoconstriction decreases bloodflow into the injured area, allowing lymphatic drainage to work with less opposition to incoming blood supply. It doesn't to my knowledge affect the lymphatic drainage but I could be wrong about that. It's been a long time since I've done basic path, but infection prevents proper wound healing, but is it the infection itself that causes that or is it the inflammation secondary to the infection.

Infection in an ankle sprain or other msk injury?

 

There is weak evidence that cryotherapy helps improve healing time and improvement in functional status in ankle sprains. There is strong evidence it reduces swelling and pain. Rather than spend time to cite it all, a quick search will give you lots of info:

http://scholar.google.ca/scholar?q=cryotherapy+ankle+sprains&btnG=&hl=en&as_sdt=0%2C5

 

It's an illusion! The weak evidence is just repeated opinions. Read those articles. Hardly convincing. (Do I tell people to RICE their injuries when I'm in emerge? Obvi. Do I do it on myself or advise my friends to do it? No.)

[physio2med]

Ok, as a physiotherapist with 5 years experience in MSK who has rehabbed about 500 ankle sprains (yes, about 2 a week) I can tell you that it depends on the stage of healing and the grade of injury (1-2-3rd degree ankle sprain).

 

First off, all acute ankle sprains should get ice. Ankles swell up immediately, and yes, it's what the body is "supposed to do", but it's often excessive. Excess swelling around healthy tissues will cause compression, therefore unnecessary pain. Have you ever seen someone's ankle swell to the point you can't see the malleoli? Not good for the tendons and even the nerves. Often patients have paresthesias (numbness, tingling) at this point because of the compression on nerves or vascular supply. Get the swelling down quickly to free up the surrounding tissue. Elevation helps, since the ankle is at the bottom of a long chain, and blood tends to pool. This is also why bruising from an ankle sprain will end up along the side of the foot, about an inch or two below the injury. I usually recommend ice for the first few days to weeks as needed. Especially after activity, when things will tend to swell again. Hot and cold contrast baths are excellent for swelling after the first few days, as they induce vasodilation/vasoconstriction, which has a pump-like effect on the blood vessels. By opening and closing, this helps to get the fluid moving. Water is also good by virtue of the pressure gradient, thereby tending to push fluid up. If possible, standing/walking in a pool at this point is awesome. Even if the ice is "just for pain", the fact is, less pain, more movement. An anxious achey patient will be unwilling to move the joint, so by providing relief, they will have a better progression. It's also easy enough to elevate and ice together.

 

Rest is actually meant for relative rest. It doesn't mean do nothing. Unless there is a suspicion of fracture, or avulsion fracture, or dislocation or something nasty... if the patient is able to move, they should start circulatory exercises which means elevate the leg and do small circles, back and forth movements, etc, and weight-bearing as tolerated. Activating the calf muscles is great, since they also provide a pump-mecanism to compress and release the blood vessels. This moves swelling along. We say rest because we don't want you running or playing sports on it at this point, or even walking excessively. Everything is done to tolerance in the early stages.

 

At this point, physiotherapists also advocate for what's called PRICEMEM (Protection, Rest, Ice, Compression, Elevation, Mobilization, Early motion, Modalities or Meds) The mobilization is KEY. That's where physiotherapy comes in. If we can get in there quickly and induce glides at the joint surfaces, this will increase mobility within the joint, without straining the damaged tissue (they are done in the resting position of the joint, with no strain on ligaments) Research has proven the effectiveness of the addition of early mobilization on outcomes for ankle sprains. Also, I might add that sometimes a manipulation is necessary. The subtalar joint (between the talus and the calcaneum at the back) often becomes fixated into inversion with an inversion (lateral ankle) sprain. The mechanism of injury literally pulls the heel out of alignment. If this is the case, it needs to be corrected with a quick and low-amplitude thrust. This often has immediate results at is decompresses the joint and realigns the movement axis. Not all physiotherapists do this, and I've often seen patients with old fixations from 10 year old sprains. The truth is, they often never resolve spontaneously, and can lead to chronic sprains and other problems along the chain (medial meniscus degeneration!!)

 

Ankle sprains are one of the most under managed injuries, and can often lead to chronicity and other joint issues (see above). I see so many patients who have gone through emerge, had an X-ray, were given crutches and sent home: "you'll be fine in a week". They usually show up for physio because things are not progressing well after 2,3 sometimes as much as 6-8 weeks. I explain to them that the X-ray ruled out fracture, but there was an injury to the soft tissue, and that does require management. All I would ask, is that the docs in emerge and walk-in clinics say the three magic words: "go to physio". If it's bad enough to go to the doctor for, it's probably worth at least checking it out. If anything, a quick session of education and exercise progression for prevention will go a loooooong way.

 

[youngdad]

Ok, as a physiotherapist with 5 years experience in MSK who has rehabbed about 500 ankle sprains (yes, about 2 a week) I can tell you that it depends on the stage of healing and the grade of injury (1-2-3rd degree ankle sprain).

 

First off, all acute ankle sprains should get ice. Ankles swell up immediately, and yes, it's what the body is "supposed to do", but it's often excessive. Excess swelling around healthy tissues will cause compression, therefore unnecessary pain. Have you ever seen someone's ankle swell to the point you can't see the malleoli? Not good for the tendons and even the nerves. Often patients have paresthesias (numbness, tingling) at this point because of the compression on nerves or vascular supply. Get the swelling down quickly to free up the surrounding tissue. Elevation helps, since the ankle is at the bottom of a long chain, and blood tends to pool. This is also why bruising from an ankle sprain will end up along the side of the foot, about an inch or two below the injury. I usually recommend ice for the first few days to weeks as needed. Especially after activity, when things will tend to swell again. Hot and cold contrast baths are excellent for swelling after the first few days, as they induce vasodilation/vasoconstriction, which has a pump-like effect on the blood vessels. By opening and closing, this helps to get the fluid moving. Water is also good by virtue of the pressure gradient, thereby tending to push fluid up. If possible, standing/walking in a pool at this point is awesome. Even if the ice is "just for pain", the fact is, less pain, more movement. An anxious achey patient will be unwilling to move the joint, so by providing relief, they will have a better progression. It's also easy enough to elevate and ice together.

 

Rest is actually meant for relative rest. It doesn't mean do nothing. Unless there is a suspicion of fracture, or avulsion fracture, or dislocation or something nasty... if the patient is able to move, they should start circulatory exercises which means elevate the leg and do small circles, back and forth movements, etc, and weight-bearing as tolerated. Activating the calf muscles is great, since they also provide a pump-mecanism to compress and release the blood vessels. This moves swelling along. We say rest because we don't want you running or playing sports on it at this point, or even walking excessively. Everything is done to tolerance in the early stages.

 

At this point, physiotherapists also advocate for what's called PRICEMEM (Protection, Rest, Ice, Compression, Elevation, Mobilization, Early motion, Modalities or Meds) The mobilization is KEY. That's where physiotherapy comes in. If we can get in there quickly and induce glides at the joint surfaces, this will increase mobility within the joint, without straining the damaged tissue (they are done in the resting position of the joint, with no strain on ligaments) Research has proven the effectiveness of the addition of early mobilization on outcomes for ankle sprains. Also, I might add that sometimes a manipulation is necessary. The subtalar joint (between the talus and the calcaneum at the back) often becomes fixated into inversion with an inversion (lateral ankle) sprain. The mechanism of injury literally pulls the heel out of alignment. If this is the case, it needs to be corrected with a quick and low-amplitude thrust. This often has immediate results at is decompresses the joint and realigns the movement axis. Not all physiotherapists do this, and I've often seen patients with old fixations from 10 year old sprains. The truth is, they often never resolve spontaneously, and can lead to chronic sprains and other problems along the chain (medial meniscus degeneration!!)

 

Ankle sprains are one of the most under managed injuries, and can often lead to chronicity and other joint issues (see above). I see so many patients who have gone through emerge, had an X-ray, were given crutches and sent home: "you'll be fine in a week". They usually show up for physio because things are not progressing well after 2,3 sometimes as much as 6-8 weeks. I explain to them that the X-ray ruled out fracture, but there was an injury to the soft tissue, and that does require management. All I would ask, is that the docs in emerge and walk-in clinics say the three magic words: "go to physio". If it's bad enough to go to the doctor for, it's probably worth at least checking it out. If anything, a quick session of education and exercise progression for prevention will go a loooooong way.

 

Slow clap.  

Quality post my friend.