Rethinking RICE: The Old Standard Method May Not Actually Be the Best Treatment for Acute Injuries

Jul 12 2017 - 6:10pm
Sports injury RICE protocol

In my years working as a rehabilitation therapist, the standard treatment for acute musculoskeletal injuries was RICE - Rest, Ice, Compression, and Elevation. Without fail, we recommended this protocol to reduce inflammation and pain. Inflammation, we were taught, increases pain and delays healing. But a new school of thought may be turning the RICE protocol on its head.

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The history of RICE protocol for acute injuries

In 1978, Dr. Gabe Mirkin, MD coined the acronym RICE for treating acute injuries in his 1978 bestseller, The Sportsmedicine Book. His protocol soon became well-known, and has remained the standard of care for acute injuries for the past 4 decades. Moms everywhere know that if their kid tweaks their ankle playing soccer, they should spend a few days on the couch with their foot propped up on a pillow, with a bag of peas on top.
But what if this RICE protocol is actually wrong?

New studies have shown that efforts to reduce inflammation may actually be counterproductive. As a matter of fact, Dr. Mirkin himself has since recounted his earlier advice, and now maintains that both ice and complete rest may actually delay healing, instead of helping. Dr. Mirkin now maintains that the natural process of inflammation is necessary for healing. He points out that the natural inflammatory process is tied to our immune system. In the same way that our bodies respond to the presence of germs by sending macrophage cells and proteins into the infected area to kill the germs, the body sends these same cells to damaged tissues to promote healing. These macrophages release a specific hormone called Insulin-like Growth Factor (IGF-1) into the damaged tissues. The presence of IGF-1 is what actually stimulates tissue repair. When ice or anti-inflammatory medications (NSAIDS) are used for treatment, they actually prevent IGF-1 from being released, delaying healing.

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Mirkin also originally recommended immobilization and complete rest following an injury, to allow the tissues to heal, but now suggests that the best practice is to resume activity as tolerated as soon as possible, beginning range of motion activities as soon as the next day.

How should acute injuries be treated?

Dr. Mirkin says that if pain is severe, ice may be used for pain relief immediately after injury, but for short periods only. He suggests icing for no more than 10 minutes, with at least 20 minutes between ice sessions, and only for no more than the first six hours following injury. He suggests that when it comes to movement and weight bearing, pain should be our guide, and light activity should be resumed as much as possible, as soon as possible, gradually increasing as tolerated. If an injury is severe, Dr. Mirkin stresses that you should follow the advice of your doctor. Many other practitioners are also joining his call for allowing the natural inflammatory process to take place.

Other researchers are not so ready to give up on RICE. They stress that the and clinical evidence of pain reduction and healing with rest, ice, compression, and elevation over the years prove that the old way is still the best.

Each injury and each person is unique, and treatment protocols must ultimately be customized to fit their needs. A skilled healthcare provider remains the best bet for assessing your response to treatment and adjusting your plan of care to speed recovery.

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