The PRICE of Injury Treatment: Out With the Old and In With the New : ACSM's Health & Fitness Journal

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The PRICE of Injury Treatment: Out With the Old and In With the New

Busby, Cal ATC, MAT

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ACSM's Health & Fitness Journal 27(1):p 5-7, 1/2 2023. | DOI: 10.1249/FIT.0000000000000825
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Rest, ice, compression, elevation (RICE) and protection, rest, ice, compression, elevation (PRICE) have long been the go-to answer for many in the sports medicine world when confronted with an acute soft tissue injury (1). Whether it is acute damage to shoulders, elbows, wrists, knees, or ankles, the RICE, or similarly PRICE, techniques have been widely used for decades to help our patients limit swelling, minimize pain, and allow rest to injured tissues. The RICE/PRICE approach is simple, relatively cost-effective, and quite often easily understood by patients and clients as part of their take-home instructions. It is likely that the phrase “Let's get some ice on that and rest” is a common phrase uttered in fitness and sport settings around the globe. But is this way of thinking supported by research? Despite the decades of usage and popularity for this early-stage acute soft tissue injury treatment, randomized controlled trials conducted in the last several decades of the 20th century were often unable to determine the relative effectiveness of RICE and fully support its continued use. Regardless, its popularity remains throughout the fitness and sports medicine world (2–5).

REST

The aspect of rest, and more specifically just how long to rest, has been reexamined with more recent studies (5). Although early protection with rest in soft tissues immediately after injury can help to unload a joint and allow time for the tissues to begin the healing process with minimal disruptions, evidence has proven that longer duration of rest or unloading can be harmful and even cause changes to the biomechanics of the tissue (4).

ICE AND COMPRESSION

From Hippocrates first mentioning the benefits of snow as a method to control edema in ancient times to a more scientific approach of cryotherapy beginning in the 1960s and continuing to this day, cryotherapy has been long held as an effective way to help heal tissues and return our patients to the activities they desire (6). However, ice accompanied by compression has demonstrated significantly more effectiveness as a method of achieving pain relief than just ice alone (3). Similarly, clinical studies of compression by itself are lacking for much of the last several decades, and region-specific (i.e., hamstring, lateral ankle) cryotherapy treatments were often limited in showing support for the full use of the RICE model (2).

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It is important to note that a single episode of cryotherapy (i.e., ice bags, cold water, or even full-body immersion) does very little to cool tissue temperatures or limit secondary injury (6). The treatment timing and duration of ice application have implications to consider because shorter periods, or infrequent bouts of icing, can negate any potential positive effects of pain relief that ice and compression can achieve (6). Icing and other cryotherapy modalities must be approached with the “big picture” in mind, realizing many populations will need realistic and achievable instructions on the use of ice. It is likely newer approaches may dispel long-standing myths held by patients and clients such as “ice until the tissue goes numb”, or “only ice 2 to 3 times per day” (6).

Pain relief is an important component of the healing process and often very important to the patient, but a clinician is often faced with a wide range of symptoms and challenges when working with his or her injured patients, and focusing on pain can cause one to miss the bigger picture. Collectively, the lack of cohesive evidence for the various elements of the RICE method has led to a push for a more comprehensive approach at ways to easily and—most importantly—appropriately use a more focused approach (2–4).

NEW PARADIGMS

In 2013, a new model was proposed by researchers that presented a paradigm shift in how to harness the benefits of cryotherapy and aims to change how soft tissue injuries are typically treated in the fitness and sporting industries (4). This new acronym and approach—POLICE—stands for protection, optimal loading, ice, compression, and elevation (4). Although not a complete transformation from the traditional previous regimens of RICE or PRICE, POLICE takes into account methods supported from the literature and calls for the design of treatment and rehabilitation plans that are injury-, sport-, and even activity level-specific (4,5). Ice, compression, and elevation are still supported aspects of the model, but the question of protection and resting as early key components of PRICE and RICE have come under more scrutiny (5). Moving forward, think of ice, compression, and elevation as key tools to help address pain, and protection and optimal loading as ways to help clients get back to the activities and functional level they were at before the injury.

An “early and often” use of cryotherapy is still an essential part of this POLICE model because cryotherapy tools have the ability to slow metabolism in damaged tissues and can reduce muscle guarding that can accompany pain signals after injury (1,6). Evidence supports the use of cold therapy as a way to reduce the pain signals, which can be one of the greatest benefits during the early stage of an acute injury (5,6). A variety of modalities can be used including ice packs, whole-body cryotherapy, and cold water immersion (5,6). Typical recommendation for cold application such as ice bags is 20 to 30 minutes every hour, with care not to use cold for prolonged periods because there may be damage to otherwise healthy tissues (1). For whole-body cryotherapy and cold water immersion, the recommendations on timing and duration are much lower, 2 to 4 minutes for whole-body cryotherapy and 10 to 15 minutes for cold water immersion (6). Other key benefits of the POLICE approach that remain from the RICE model include proper compression, especially in the earliest moments after injury, because this early compression can provide benefits such as decreasing hemorrhage and edema (1). Elevation also can assist with mechanically moving fluids from injured tissues and can reduce the overall amount of internal bleeding (1). Oftentimes, elevation and compression can be used simultaneously to move fluids and can be necessary during the first 24 hours after injury when rest is most recommended (1). At this point, evidence still supports the use of cold-induced analgesia, compression, and elevation (4).

Although there are still key similarities from the RICE model, one of the key tenets that makes POLICE different from the past use of RICE is the concept of optimal loading when faced with an acute soft tissue injury (4–6). Optimal loading relies on the clinician to determine the appropriate progression of activities ranging from protecting the tissue to progressive mechanical loading of the tissue to best facilitate healing (1,4,5). Through this concept of optimal loading, individual approaches are designed for each unique injury. Starting with the idea of protection, crutches and braces that were originally thought of as tools to allow for “rest” can now be seen as devices to help protect the area while undergoing optimal loading (4). For example, during the early stages of rehabilitation, patients may use their crutches through a balance progression where they progressively, and appropriately, load the tissues. Rather than telling the patient with an ankle sprain to use crutches and not put any pressure on the involved limb, start with small bouts of crutch-assisted balance and then move to balance with eyes closed before eventually removing bases of support and adding further challenges to continually, yet safely, optimally load the tissues. See the supplemental digital content video to learn more: https://links.lww.com/FIT/A279.

Optimal loading incorporates an early and active rehabilitation program, and although the early evidence has primarily focused on ankle sprains, the approach can be used when faced with other acute soft tissue injuries across the body (4,5). It is likely that most fitness professionals have already had experience with optimal loading and is something they will find as a natural way to help clients adjust in a safe and controlled manner. With regard to proper healing, the true benefit of optimal loading lies within the deeper concept of mechanotransduction (7). Simply put, the idea of mechanotransduction is how a mechanical load can actually stimulate bone, ligament, tendon, or muscle cells to change and even heal (7). It is an ongoing process that happens with normal and healthy tissues because cells respond to load through creating structural changes (7). In the absence of activity, this process slows and causes negative changes in tissues, but when tissues are stimulated through mechanical load, mechanotransduction allows for the body to adapt and change in a positive manner (7). From this understanding of mechanotransduction on the cellular level, the concept of mechanotherapy (i.e., optimal loading) has been promoted as a way to frame the reason for exercise prescription on a cellular basis and the value of understanding how healthy and injured tissues will respond to a load (7).

At the time of its first implementation in the sports and fitness world, the RICE model was a novel attempt to give practitioners a framework with how to apply ice when working in situations of an acute soft tissue injury. However, with the recent introduction of the POLICE model for treatment of soft tissue injuries, fitness professionals can work alongside sport medicine clinicians to reframe how to approach these situations using evidence-supported methods.

Through a wider view of how mechanotherapy and optimal loading can positively affect tissues, we can start to develop better and more comprehensive rehabilitation and treatment plans for individuals experiencing acute soft tissue injuries. We can move forward to developing protocols and plans that are supported by the latest evidence-based guidelines. We can work to dispel the common myths that may be with our patients regarding rest or protection after an injury and work to educate on the proper methods and parameters with which to apply the tools of cryotherapy. It is the inclusion of optimal loading that makes POLICE a new and novel approach as well as a new direction for which further research should be done to develop new protocols and methods that can be used throughout the sports medicine and fitness worlds.

References

1. Prentice W. Rehabilitation Techniques for Sports Medicine and Athletic Training. 7th ed. West Deptford (NJ): Slack, Inc.; 2020. p. 736–80.
2. van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, van Dijk CN, Kerkhoffs GM. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?J Athl Train. 2012;47(4):435–43.
3. Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft tissue injury?J Athl Train. 2004;39(3):278–9.
4. Bleakley CM. PRICE needs updating, should we call the POLICE?S. Afr. J. Sports Med. 2013;25(1).
5. Bizzini M. Ice and modern sports physiotherapy: still cool?Br J Sports Med. 2012;46(4):219.
6. Kwiecien SY, McHugh MP. The cold truth: the role of cryotherapy in the treatment of injury and recovery from exercise. Eur J Appl Physiol. 2021;121:2125–42.
7. Khan KM, Scott A. Mechanotherapy: how physical therapists' prescription of exercise promotes tissue repair. Br J Sports Med. 2009;43:247–52.

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