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Update: Is RICE still right? Andrew Coppin

My masters journey thus far has highlighted the apparent lack of between scientific research and ‘real world’ clinical practice. All too often we as physiotherapists base our therapeutic decisions on anecdotal evidence and habit however, in an age where scientific information is freely available the adage of ‘this is just how it has always been done’ will no longer cut it. To improve patient outcomes across the board as well as future proofing and driving our profession forward we all need to be speaking the same language and pulling in the same direction from researchers to clinicians.

One doesn’t have to look too far for an obvious example of this in everyday practice. Rest, ice, compression, and elevation (RICE) therapy is an accessible and highly popular method used in the management of acute injuries.(1) For anyone that has ever worked with a sports team (of any level) or watched a sports match for that matter, would know that a handy bag of ice is always kept close by in-case of injury. The RICE method has been considered the gold standard of acute injury management since it was established by Dr. Gabe Mirkin in 1978. It was widely accepted and implemented due to its ease and apparent effectiveness of use. But complete rest and ice (cryotherapy) have received much debate and opposition over the last few years and in the light of new research has caused Dr. Mirkin to retract his RICE recommendation.

‘Coaches have used my “RICE” guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping.’ In a paper written by Dr. Mirkin titled Why ice delays recovery he lays out what evidence has changed his thinking as well as new recommendations.(2)

Physiologically speaking there is little to no evidence that cryotherapy improves healing, with some research indicating a prolonged healing process. Inflammation is the body’s natural tissue response to injury. The inflammatory cells release a hormone called Insulin-like growth Factor (IGF-1) into the damaged tissues, which helps muscles and other injured parts to heal. Cooling has been shown to delay this inflammatory process but has seemingly no positive effect on healing over compression alone. Research suggests that applying ice delays this process by preventing the release of this hormone. Studies show that without this IGF-1 hormone healing is not possible. Healing therefore requires inflammation and ice prevents inflammatory cells from entering damaged tissues. (2)

See the problem?

Some of the same properties that make ice an effective analgesic (decreased blood flow to the cooled area) are also what delay the healing process. Ice, like other methods of inflammatory control including cortisone, NSAID’s and pain killers may provide relief in the moment but are likely to delay the healing process and should therefore be used with caution.

Consider the common injury of lateral ankle sprain (LAS). A study in 2012 found that there is insufficient evidence to support RICE as a treatment for LAS. However, RICE remains a widely advocated method in clinical settings as the ‘go-to’ treatment method of all acute injuries. We need to continually ask ourselves if our therapeutic modalities align with our desired treatment outcomes and if they are scientifically backed.

Ice is also often used as a short term on field pain reliever. Evidence suggests that muscle strength, speed and co-ordination are negatively affected short term by icing. (2)

Could we perhaps be increasing the risk of injury/exacerbation of injury by icing pitch-side before sending the player back onto the field?

Dr. Mirkins’ updated clinical recommendations for soft tissue injuries is to apply a compression bandage immediately post injury and to use rest and ice as needed. Ice may be used for short periods to reduce pain. Ice should be used conservatively for up to 10 minutes, before removing it for 20 minutes, and repeat the 10-minute application once or twice. After 6 hours ice is no longer an effective treatment of soft tissue injuries (2)

Unfortunately, this example of a treatment modality still being used after being disproven is not unique. As the new generation of physiotherapists, the onus is on us to progress and future proof our profession. We can only do this by improving patient outcomes and proving our efficacy as a discipline. One way to achieve this would be to bridge the gap between science and clinical practice to ensure only scientifically backed modalities are used within the clinic and in that way not rely on anecdotal methods or fads which have the potential to do more harm than good.

Physiotherapy: better forever, advancing together

REFERENCES

1. Van Den Bekerom MPJ, Struijs PAA, Blankevoort L, Welling L, Van Welling CN, Kerkhoffs GMMJ. 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.

2. Mirkin G. Why Ice Delays Recovery [online]. 2014;(November 2010):1–2. Available from: http://drmirkin.com/fitness/why-ice-delays-recovery.html

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