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Acute injuries- should we use ice?

We all grew up with the acronym R.I.C.E. for the management of injuries- Rest, Ice, Compression and Elevation. This acronym was developed by an American Sports Physician, Dr Gabe Mirkin in 1978. Essentially it was a theory that made sense but wasn’t the subject of rigorous scientific study at the time of its inception. Recently there has been a lot of debate about whether we should be using this R.I.C.E. approach with acute injuries. Some other acronyms have been developed instead, including one by Dubois & Esculier: “P.E.A.C.E. & L.O.V.E.”, with the PEACE part applying to the immediate care, and LOVE being the subsequent phase.

So why the change?

It is theorised that ice may delay some of the important events that occur at a cellular level when we have an injury. There is a cascade of events that your body automatically swings into action when an injury occurs and some believe that ice may negatively interfere with this process, potentially delaying the healing process. But it should also be said that at the current time there is not strong evidence for this theory either.

What does PEACE stand for?

PEACE is for immediately following the injury.

Protect: limit movement of the injured area for a few days to protect the injured tissues and reduce aggravation. This doesn’t always mean “rest” as gentle activities may be fine.

Elevate: for limb injuries, raise the injured area higher than your heart to reduce swelling. If it’s a lower limb, then remember “toes higher than your nose” 😊.

Avoid anti-inflammatories: particularly for muscle strains as there is some evidence that they may negatively affect the long term healing.

Compress: may help to reduce swelling but also offers a sense of support to the area which may reduce pain and improve function.

Educate: see a health professional early on to find out what you can and can’t do. There are often safe forms of exercise to do whilst you rest the injured area. A therapist can also provide information on expected healing times – you can’t rush biology!

A few days after the initial injury, we can give it some LOVE.

Load: early appropriate exercise is beneficial for healing (and your mental health!).

Optimism: keeping a positive frame of mind is associated with better outcomes. Seeking professional advice may help this rather than relying on well meaning friends or family with their own horror-stories…

Vascularisation: a fancy term for blood flow. Movement and early appropriate loading appears to assist with tissue healing.

Exercise: whilst respecting pain, appropriate pain free exercise improves your mood and can stop you losing all your hard-earned fitness!

So what about ice and heat?

There can be benefits to using ice in the early part of an injury. Ice can be very good for reducing pain as it has a numbing effect. We have been using RICE since 1978 so some people need further evidence before ditching it altogether! Many people with limb injuries will still use ice in the first 24 hours after injury and most of the benefit is probably pain relief.

Heat can have a soothing relaxing effect, so it may be used effectively by some people, particularly a few days after a limb injury.

For spinal pain, anecdotally it seems more people prefer heat to ice in the early stages and this may be more about reducing the resultant muscle tightness/spasm that may occur with injuries in this region.

Some people will try ice and heat and decide neither gave them much benefit. Some will use heat pre-exercise to get the area moving more freely, then ice afterwards to reduce the potential for pain.

Essentially don’t be frightened to use either, or neither, as we really don’t have a solid evidence base for the best approach to acute injury management. Like most things in life, and certainly on the internet, the truth probably lies somewhere in the middle- there will be times when ice feels better and times when heat feels better.

Get early advice from a health professional and combine whichever approach works for you with a well-designed, early exercise program, as this is the bit that is most likely to give you the best outcome.

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