Early Injury Treatment – it’s still PRICE right?

Well no, actually it’s changed! Just when every client with even a vague knowledge and interest in self-management of early injuries had got the hang of – Protection, Rest, Ice, and Elevation, they go and change it … It’s hard even for us physios working at the coalface to keep up!

Who’s changing it anyway?

Research studies are constantly looking at clarifying or debunking accepted theories and to be fair the RICE acronym has been around since the late 70’s – over 40 years.It’s probably a good thing they’ve come up with some new or more researched ideas.

The Protection - P was added in the late 90’s. There was a further update in 2012 that passed many people by but was important in that the Rest R was changed to Optimal Loading OL – the idea that complete rest of the tissues was detrimental to recovery and instead that light loading stimulated cell regeneration and healing. So PRICE became POLICE.

So what do we have now?–

What we now have is PEACE & Love! - – you have to hand it to the sports scientists – they love a good Acronym.

PEACE - Protection, Elevation, Avoid Anti-imflammatories, Compression, and Education in the early stages followed by LOVE – Load, Optimism, Vascularisation and Exercise

Why the Changes and is Ice and Rest not recommended any more?

It was generally felt that the earlier acronyms dealt only with the very early (acute) stage of the injury without referencing the sub-acute and more chronic stages of tissue healing and this update proposes a more comprehensive, longer-term approach and guidance. Since many people self-manage injuries this change is to be welcomed in improving widespread knowledge on how to effectively manage acute soft-tissue injuries.

Ice has good evidence to back up it’s use as a pain reliever – but it’s effect is short term and it doesn’t greatly change the temperature of the underlying tissues.It is also thought that it may have a role in limiting inflammation and that this might actually interfere with the inflammation-mediated processes that are needed for tissue repair – so it might actually delay the healing process.

The widespread use of anti-imflammatory medication was thought important enough to specifically mention that these should ideally be avoided if possible. The early stages of tissue healing are crucially led by inflammatory changes in the tissues – these act as signposts for the body to release the correct hormones that limit tissue damage and direct healing. So it’s not helpful to mask or limit them by using ice or anti-inflammatories.

So what do we have now?

Protect: Aim to unload or restrict movement for 1-3 days post-injury depending on the pain levels. This minimises bleeding and swelling and reduces the risk of aggravating the injury. Pain levels should guide the end of this period.

Elevate: The evidence supporting raising the limb higher than the heart is still fairly weak but it’s proposed as a low risk, possible benefit option.

Avoid Anti-inflammatories to minimise masking the inflammation and delaying healing especially in higher doses.

Compression using an elastic bandage or taping techniques – mostly studied in ankle sprains ad appear to reduce swelling and improve comfort.

Educate An active approach to injury management should be promoted for early soft-tissue injuries – the benefit of passive treatment modalities is most likely short-term at best and in some cases counter-productive. Advice on early exercise intervention and relative joint or tissue unloading can be empowering and prevent overmedicalisation.

And LOVE is for after the first few days have passed.

Load – Corrected applied stresses to the tissues with the resumption of normal activities as much as possible promotes repair and remodelling of the tissue and builds tissue tolerance and capacity. The use of pain monitoring as a guiding factor for activity and progression is important.

Optimism – Optimistic patient expectations are associated with better outcomes and prognosis. Psychological factors such as catastrophisation, depression and fear can interfere with the healing process.

Vascularisation – Cardiovascular activity is important for promoting blood flow to injured tissues and improving motivation. Pain-free aerobic exercise is to be encouraged within a few days post injury supporting a return to normal activities and minimising the need for pain medication.

ExerciseThere is strong evidence for the role of exercise for the treatment of soft tissue injuries such as ankle sprains and for reducing injury recurrence. Exercises help to restore normal movement, strength and proprioception (the body’s ability to know where it is in space – guided by tiny receptors in the joints and subsequently compromised by injury). Pain should be avoided in the early stages of recovery after injury and used to guide exercise progression.

Final point - Is there ever a role for Ice or anti-inflammatory medication?

Guidelines are produced to direct the vast majority of cases and therefore there is never ‘one size fits all’.For major swelling following an injury, ice application might still be helpful especially in association with elevation and compression in the early stages. Similarly for a more severe, very painful sprain or strain, anti-inflammatory medication may not be completely contraindicated but just bear in mind the important role of inflammation in the recovery process and that you don’t want to eliminate it completely.

Ref: Soft tissue Injuries simply need Peace & Love - Dubois B, Esculier J-F, Br J Sports Med January 2020 Vol 54 No 2

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