Is it time to rethink RICE for soft-tissue injuries?

Evelyn Lewin

15/10/2019 3:34:26 PM

RICE – rest, ice, compression, elevation – has been the mainstay of soft-tissue injury treatment, but experts are questioning the ice.

Icing an injury
Ice has been a core component of treatment post soft-tissue injury, but the tide may be turning away from its use.

‘Put some ice on it.’
RICE – rest, ice, compression, elevation – has been the standard recommended treatment for soft-tissue injuries for many years.
But experts are now voicing concern over whether applying ice after an injury actually aids healing – or if, in fact, hinders it.
American sports doctor Dr Gabe Mirkin coined the term ‘RICE’ in 1978. However, he backtracked on his initial hypothesis in 2015, writing that ice ‘may delay healing, instead of helping’.
Dr Mirkin this week reiterated these thoughts when speaking to The Age.
‘Cold and ice are safe pain medicines, but they delay healing,’ he said.
Dr Rachael Murray, a researcher at the Queensland University of Technology and immediate past president of the Australasian Wound and Tissue Repair Society, agrees with these concerns.
‘At the moment, there’s no evidence to suggest that RICE – or at least the ice part of it – is better than not icing,’ she told newsGP.
She explains that one of the first things that happens in wound healing is an inflammatory phase, where inflammatory cells recognise damaged extracellular matrix (the part that houses the cells).
‘And when they do that, they then recruit other immune cells in,’ Dr Murray said.
‘So you start off with your neutrophils, then your macrophages a day later. The neutrophils are mainly to clear the wound up, any damage, to do a process called phagocytosis, which is eating all the debris.
‘Then the macrophages come in, and their job is to finish cleaning up and they secrete a whole range of factors.’
The factors macrophages secrete are initially pro-inflammatory, Dr Murray said, but then become anti-inflammatory.
‘Within that, they secrete lots of growth factors and other things that tell the cells within the wound that they should start proliferating, migrating, moving into particular areas, making a new blood supply, that kind of thing,’ she said.
According to Dr Murray, studies have shown this repair mechanism is very common and interfering with this process may worsen outcomes.
‘If you don’t have that initial inflammation, [injuries] don’t heal as well as they could, or as fast,’ she said.
The problem with using ice as a vasoconstrictor is that, while it limits blood supply and therefore reduces swelling, it also limits arrival of immune cells and thus interferes with core parts of healing.
‘If you immediately ran off … and stuck ice on [an injury], you may actually be delaying your healing process slightly,’ Dr Murray said.
Dr Murray is keen to note, however, that her advice is based on theory, rather than practice, and more studies are needed to verify its actual effects.

Left: Sports physician Dr Peter Baquie believes claims of not using ice may be overstated. ‘It’s a bad message,’ he said. Right: Dr Rachael Murray said, ‘There’s no evidence to suggest that RICE – or at least the ice part of it – is better than not icing’.

Meanwhile, Dr Peter Baquie comes to this topic from an observational standpoint, rather than an evidence-based one.
He worked as a GP for 11 years before becoming a sport and exercise physician, and told newsGP he believes there are times when doing RICE is ‘less appropriate’, such as for upper-limb injuries that do not involve the wrist or fingers.
But in the majority of cases, he still recommends RICE – and ice, in particular – as an initial strategy in response to a higher grade soft-tissue injury, strain and contusions especially for lower limbs.
‘For ankles and contusions of the feet, I think if someone lands from a jump, has an inversion or eversion strain, immediate swelling, pain, inability to weight bear … I think it’s really important if patients do RICE for 24 or 72 hours, maybe longer,’ he told newsGP.
‘I think that makes a huge difference to the immediate disability and longer-term outcome.’
While Dr Baquie understands the argument for utilising an inflammatory response to aid healing, he expressed concern that the non-specific inflammatory response involving a joint leads to swelling, which can then hinder the healing process.
‘Unchecked post-injury bleeding, swelling and pain may prevent early introduction of physical progressions in terms of weight-bearing, range of motion and balance drills, which are so critical in the second phase of injury care,’ he said.
He said this can then lead to delay in functional progression.
Dr Baquie said he often sees ankles at six, eight or 10 weeks’ post-injury when RICE has not been used.
‘And they’re stiff, they’re swollen and they’re sore,’ he said. ‘So the inflammatory phase can be counterproductive, as the healing is non-specific to joint lining and within the joint itself.’
As for suggestions that using ice can inhibit healing, Dr Baquie believes those claims may be ‘a little bit overstated’ and worries about the impact if people were to stop icing their soft-tissue injuries.
‘It’s a bad message,’ he said.
Dr Baquie is keen to note that this is not necessarily a one-size-fits-all issue, saying there are circumstances when ice is more needed than in others; for example, higher grade injuries, particularly of lower limbs, will see better short- and long-term improvements when using ice.
However, his general takeaway message for treating soft-tissue injuries is simple.
‘I think I’m pretty keen that, if someone has an injury with a lot of pain and it’s swollen, they do RICE across the board,’ he said.

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A.Prof Christopher David Hogan   20/10/2019 11:24:58 PM

"Dr Murray is keen to note, however, that her advice is based on theory, rather than practice, and more studies are needed to verify its actual effects." Indeed.
A theory is a beautiful thing but sadly Medicine & the life sciences are the graveyard of theories. Theories are only extrapolations of what is already known or thought to be known. Living things, especially humans, are so complex that for us to believe that we know everything is optimistic at best & arrogant at worst. It is not enough that a theory make sense- it must work in practice. Unexpected results are one of the joys & frustrations of being a researcher.
Dealing with uncertainty is a key role of General Practice & a key defence against boredom.
To research the "Ice of RICE" we need to ask the proper questions>
* What temperature is the ice? Wet ice with a temp of 4 degrees Celsius or colder?
* Applied directly to the affected area or packaged in some way?
* For how long is the ice applied & how often etc, etc