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Using ICE in acute injuries, why the confusion?

Updated: Dec 6, 2023


applying ice to an injury


All First Aiders will know how to treat Soft Tissue Injuries using the RICE, PRICE, PRICER or PRICED principles:

Protect Rest Ice Compression Elevation (Refer) (Doctor)


In the Sports Therapy/Sports Medicine Profession there has been lots of conflicting and confusing information on using Ice on acute soft tissue injuries.


Hopefully I can clear up a little of the confusion, and give the difference between what we do as Sports Therapists, and what First Aiders do.


In First Aid, RICE is still the First Aid protocol for soft tissue injuries, and whilst I have always had some issue with this, if it is done correctly, there should be limited interference with the body's own natural healing process.


I am not a fan of wrapping ice bags over an injury, as in the image above. I think this has the potential to cause more issues with the healing process, and even the potential to cause harm, as in many cases the ice is left on the area far too long.


My preferred use of Ice is for pain relief, and an easy and manageable way to achieve this is by the 'ice cup massage method'. I've found that just a few minutes of this can produce some good analgesic effects (better than the freeze sprays etc), without interfering with the natural healing process. As a First Aider, you should always work within the First Aid guidelines that are legally set out by HSE.


applying an ice cup massage

So that's First Aid on acute soft tissue injuries, but what about Sports Therapists, what can we do?


The POLICE acronym was adopted by many health professionals since it was published in BJSM in 2012 (though used by many professional sports therapists for many years prior to this).


What does POLICE stand for?

Protect - (from further injury) Optimal Loading - (see below) ICE - ( a few minutes for analgesia) Compression - (or comfort. Elastic Cohesive Bandages are good for this, as they don't cut off circulation) Elevation - (to assist the lymphatic system)


Optimal Loading doesn’t mean getting someone to use maximal force through an injured limb straight away and some people do think that includes things such as massage therapy and strength training, which I would be dubious about teaching or using in a treatment, but what it does mean in my opinion, and what I have been teaching for years, is that careful mechanical loading during the inflammatory stage can have a positive influence on healing.


Note the word careful here, it should be done in a controlled manner. Optimal Loading can mean the use of gentle manual therapy such as Soft Tissue Mobilisation as well as (in the case of lower limb injuries) walking aids.


The POLICE protocol is best started 24 hours after injury has occurred.


Remember also the HARM acronym! What to avoid;

Heat Alcohol Running (Exercise) Massage


Using the HARM protocol in conjunction with POLICE means that really, you aren’t going to make the injury any worse. For those who think that Optimal Loading in an Acute Injury means strength training and massage this means you.


One of the most recent acronyms (BJSM 2019) to help with treating acute soft tissue injuries is PEACE & LOVE.


P - Protection. Unload or restrict movement for 1–3 days to minimise bleeding, prevent distension of injured fibres and reduce the risk of aggravating the injury. Rest should be minimised as prolonged rest can compromise tissue strength and quality. Pain signals should guide the cessation of protection.


E - Elevation. Elevate the limb higher than the heart to promote interstitial fluid flow out of tissues.


A - Avoid anti-inflammatories. Inhibiting inflammation using medications may negatively affect long- term tissue healing, especially when higher dosages are used.


C - Compression. External mechanical pressure using taping or bandages helps limit intra- articular oedema and tissue haemorrhage.


E. Education. Therapists should educate patients on the benefits of an active approach to recovery.


and


L - Load. Mechanical stress should be added early and normal activities resumed as soon as symptoms allow. Optimal loading without exacerbating pain promotes repair, remodelling and builds tissue tolerance and the capacity of tendons, muscles and ligaments through mechanotransduction.


O - Optimism. Optimistic patient expectations are associated with better outcomes and prognosis. Psychological factors such as catastrophisation, depression and fear can represent barriers to recovery.


V - Vascularisation. Cardiovascular activity represents a cornerstone in the management of musculoskeletal injuries. While research is needed on dosage, pain- free aerobic exercise should be started a few days after injury to boost motivation and increase blood flow to the injured structures.


E - Exercise. Exercises help to restore mobility, strength and proprioception early after injury. Pain should be avoided to ensure optimal repair during the subacute phase of recovery, and should be used as a guide for exercise progressions.

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