One of the most common discussions we have with patients is to ice or not to ice? The short answer is “it depends why you are using it”. Unfortunately, there is never a one size fits all approach to these questions, so let’s take a look at the research.
When managing soft tissue injuries such as muscle tears, ligament sprains etc there have been many different protocols such as RICE, RICER, PRICE and POLICE. These protocols have focused on the short term management (1-7days) of soft tissue injury and have evolved as we understand more about the physiology of tissue damage and healing. So, what happens when you have an injury? What is inflammation? Is inflammation important? And should we be trying to limit inflammation by using ice?
When a tissue is injured e.g., a sprained ankle or muscle strain, there is physical damage to the ligament or muscle tissue. This usually occurs because the tissue has been taken beyond its normal range of movement. As a result, we can have macro or microscopic tearing of these tissues. Following this, inflammation occurs causing swelling, redness, pain, heat and a loss of function. Blood vessels dilate allowing more fluid and white blood cells into the area to begin the healing process. The brain creates protective muscle spasm to limit movement and prevent further injury. This process continues for a few days or weeks and depends largely on the location and severity of the injury.
Over the years there have been many protocols which aim to manage / reduce the inflammatory process, but is this what we should do? Most people have heard of the RICER protocol which is: Rest, Ice, Compress, Elevate and Refer. Over the last few years there has been a push away from this RICER protocol and towards a protocol called PEACE and LOVE. The ‘Ice’ part of the protocol came under the most debate and consequently there has been a change in understanding ice’s role in the initial management of injuries. It was thought that ice’s role was to reduce / limit the inflammation process by constricting blood vessels. This was thought to help aid in recovery thus aiding in a quicker return to activity. However, there is very little evidence that supports the use of ice past beyond an analgesic or to help manage pain. There is some evidence to suggest that the use of ice delays the healing process by disrupting the process of revascularization, white blood cell activity, tissue regeneration and collagen synthesis.
The primary aim of this updated protocol is to provide strategies for the first few days of injury (PEACE) and strategies for longer term care of acute, sub-acute and chronic injuries (LOVE).
| Protect – Avoid activities that increase pain during initial few days post injury. Prolonged rest inhibits tissue healing.
| Elevate – Elevate the affected region above the level of the heart as often as possible
| AVOID – Ice and Anti-inflammatories, both limit inflammation and may also limit tissue healing.
| Compress – Use a bandage or garment to reduce swelling and bleeding.
| Educate – Ask your practitioner about appropriate and active approaches for recovery. The more you know the better equipped you will be in managing your injury.
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| Load – Mechanical loading of musculoskeletal injuries is important in promoting repair and remodeling of tissue. Apply an active approach, emphasising movement and exercise as your pain allows. Getting back to your normal activities as soon as pain allows is important.
| Optimism – Patients who are optimistic about their recovery often have better outcomes. Often this is easier when you understand your injury and what you can do to manage it. Pessimism, fear, depression and catastrophising may all increase the prognosis of your injury.
| Vascularisation – Adding pain free cardio exercise such as cycling or swimming can be crucial in improving blood flow to affected areas.
| Exercise – the strongest evidence for managing soft tissue injuries is exercise. It will help restore overall strength, mobility and function to not only the affected area but have a positive outcome on your mental health.
So, the next time you or someone you know has an acute injury think PEACE initially and then LOVE following. If you’d like to know more about the management of musculoskeletal pain and injury we are happy to help.
