RICE

 

Introduction

RICE is an acronym that stands for Rest, Ice, Compression and Elevation.

This system is used as current best management practice in the first 24-48 hours following an acute soft tissue injury. Minimising bleeding and swelling at the injury site is important because the application of more aggressive interventions, for example, Massage, will cause further tissue damage. When used appropriately, the RICE approach can improve recovery time and reduce discomfort.

Rest

Today, we have quite a considerable amount of scientific, mostly experimental evidence to support this treatment approach. The most persuasive proof for the use of rest has been obtained from studies on the effects of immobilization on muscle healing. A short period of immobilisation is beneficial, but should be limited to the first few days after injury.[1]. This allows the scar tissue to connect the injured muscle stumps to withstand contraction-induced forces without re-rupturing. By restricting the length of immobilisation to a period of less than a week, the adverse effects of immobility can be minimised. The meaning of rest is relative to the location of injury but involves functions such as weighbearing or any other strenuous activity involving increasing blood flow to the injuried part.

Ice

Ice therapy, also known as cryotherapy reduces tissue metabolism [2] and causes blood vessel constriction. This physiological change slows and prevents further swelling - an important consideration for early active ROM exercises after the initial period of rest. Ice also decreases the proprogation of nocioceptive neural stimuli to the brain which can reduce pain and muscle spasm. [3] However, applying cryotherapy for an extended period of time can be detrimental to the healing process. Damage can be worsened if blood flow is excessively reduced and the risk of skin burns and nerve damage increases with prolonged ice application. There is limited evidence surrounding appropriate dosage for cryotherapy in acute injury however systematic reviews suggest that 10-minute ice treatments combined with 10-minute periods without ice are most effective[4]. Keep in mind that there is no optimal dosage that will be ideal for all body locations and as a clinician, one should use clinical judgement and consider the specific details of each case.

Practice caution when using cryotherapy in people who are hypersensitive to cold (e.g. Raynaud’s syndrome, diabetes, cold urticaria, paroxysmal cold hemoglobulinuria) and patients' who have a circulatory insufficiency. It is recommended that the ice is wrapped in a damp towel or cloth to minimise the risk of superficial nerve or skin damage. Wider reading into cryotherapy is recommended.

Compression

Compression serves to prevent further Oedema (swelling) as a result of the inflammatory process and also by reducing bleeding at the site of tissue damage. An elasticated bandage should be used to provide a comfortable compression force without causing pain or constricting blood vessels to the point of occlusion. Bandaging should begin distal to the injury and move proximally, overlapping each previous layer by one half. It can also serve to provide minimal protection of the injured body part from excessive movement, although this is not it's primary purpose.

Some examples of compression bandaging:

Elevation

Elevation will prevent swelling by increasing venous return to the systemic circulation, and reducing hydrostatic pressure thereby reducing oedema and facilitating waste removal from the site of injury. Ensure that the lower limb is above the level of the pelvis.

Variations

  • HI-RICE - Hydration, Ibuprofen, Rest, Ice, Compression, Elevation.
  • PRICE, Protect, Rest, Ice, Compression, Elevation (i.e. using crutches to protect the painful part from further injury).
  • PRICES - Protection, Rest, Ice, Compression, Elevation and Support (e.g. bandaging or taping).
  • PRINCE - Protection, Rest, Ice, NSAIDs, Compression, and Elevation.
  • RICER - Rest, Ice, Compression, Elevation, Referral.
  • POLICE - Protection, Optimal Loading, Ice, Compression, Elevation.


References

  1. Tero A. H. Järvinen, Teppo L. N. Järvinen, Minna Kääriäinen, Hannu Kalimo and Markku Järvinen, Muscle Injuries : Biology and Treatment, The American Journal of Sports Medicine 2005 33: 745
  2. Bleakley, C., McDonough, S. & MacAuley, D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. American Journal of Sports Medicine, 2004; 32(1):251-61.
  3. Järvinen TA, Järvinen TL, Kääriäinen M, Aärimaa V, Vaittinen S, Kalimo H, Järvinen M, Muscle injuries: optimising recovery, Best Pract Res Clin Rheumatol. 2007 Apr;21(2):317-31.
  4. Brucker, P. & Kahn, K. (2006). Clinical Sports Medicine, page 130.