It’s been 44 years since the initial release of the ‘Sports Medicine Book’ within the book one of the key topics was the treatment of acute musculoskeletal injuries, for example sprained or torn ankles. The text suggested the now widely used R.I.C.E protocol. Which entails the following.
R. REST
Stop doing activities that might aggravate the injury further for 48 hours.
I.ICE
Make sure to apply ice to the area for 15-20 minutes every 2-3 hours. After the injury occurred for 24-48 hours.
C. COMPRESSION
Use adequate compression on the injured area to help reduce inflammation.
E.ELEVATE
Make sure to kick back and elevate the injured area 6 to 10 inches above the heart.
Within the past four decades new research has been varied while there has been supportive evidence supporting the use of the R.I.C.E protocol for pain reduction, several studies also have found an inverse effect. Mainly in its use of cold treatment (cryotherapy) in reducing pain and inflammation.
When the body starts the healing process, inflammation is the first sign of recovery. The area which is injured will produce white blood cells to destroy the damaged tissue and release the Insulin-like Growth Factor (IGF-1) hormone to help stimulate new tissue.
In a study conducted by the Federation of American Societies for Experimental Biology, using mice. One group of mice were genetically modified to have lower pain sensation. Whereas the other group weren’t modified at all. The results showed that in the group that weren’t modified recovered much faster and displayed higher amounts of IGF-1 (Federation of American Societies for Experimental Biology, 2010).
Therefore, using cold therapy to ‘numb’ the injured area might slow down the recovery rate. Furthermore, critics of R.I.C.E point out the lack of clear guidance on how to proceed after the injury has improved after 48 hours.
During mid 2019, ‘The British Journal of Sports Medicine’ updated a new comprehensive nine-step guideline. This protocol was named ‘PEACE & LOVE’ and contains a variety of different protocols which completely differed from the previously used guidelines suggested in R.I.C.E.
PEACE & LOVE although relatively new shed light on the problems R.I.C.E had as well as suggested post-recovery procedures. This protocol calls for the following.
P. PROTECT
Reduce movement and weight bearing activities for 1-3 days. Which helps reduce bleeding and does not exacerbate the inflammation. We should use the injury to inform us which movements to avoid and rest adequately. Nevertheless, not over-resting or not activating any muscle at all will also be detrimental to recovery.
E. ELEVATE Keep the injury area elevated above the heart.
A. AVOID ANTI-INFLAMMATORY MODALITIES
This is the protocol that differs the most from R.I.C.E whereas R.I.C.E suggests the usage of cold treatment to reduce inflammation. PEACE & LOVE proposes that we should avoid this to increase the speed of recovery.
C. COMPRESS
Use adequate compression on the injured area to help reduce swelling.
E. EDUCATE
Education is paramount, it’s our responsibility as health professionals to contribute to communicating the benefits of maintaining an ‘active lifestyle’. When compared to an active approach, early passive therapy such as electrotherapy, manual therapy or acupuncture after an injury has a minimal effect on pain and function. Load management will avoid over-treatment of an injury, whereas over-treatment can hinder recovery.
After the first day has passed, we should then move on towards using the LOVE protocol to assist in further healing.
L. LOAD
As discussed, whenever the symptoms of the injuries allow for it, an active approach to movement and exercise is encouraged. As optimal loading without increased pain promotes repair and remodelling of the injured area.
O. OPTIMISM
The brain plays a significant part in rehabilitation interventions, research has shown that factors such as depression or fear may more explain the variation in symptoms and limitations after an ankle sprain than the degree of pathophysiology.
V. VASCULARISATION
Musculoskeletal injury management needs to include cardiovascular physical activity. Benefits of early mobilisation and aerobic exercise tend to lead to improvement in function and less reliance on pain medication.
E. EXERCISE
Evidence supports the use of exercise therapy in treatment of common injuries such as ankle sprains. Using pain as a guide to progress exercises gradually is recommended, as exercise will aid with restoring mobility, strength and proprioception.
All in all, the point of this article is to provide an informative road map into new research into dealing with acute injuries. Remember, it’s not only R.I.C.E anymore, but it’s time to show some ‘PEACE & LOVE’.
ABOUT THE AUTHOR
Sirapob Puangin is a decorated Strength and Conditioning Specialist (CSCS). He also holds qualifications from the IWF NSCA and NASM and is currently a graduate student of Sports Science at Chulalongkorn University. He serves as the weightlifting and head coach at Iron Hive Gym. And has competed in numerous Weightlifting and Powerlifting competitions.