acute injuries rice vs meth cover

Acute injuries: RICE versus METH

introduction

Now that we are in full swing of the fall sports season, there will be a plethora of injuries that need to be evaluated and treated during sideline management.  The most common modality used for acute injuries is ice.  This has been common practice for decades.  More recently, the RICE (Rest, Ice, Compression Elevation) has come under some scrutiny.  Some providers are electing for METH (mobilization, elevation, traction and heat).

​In 1978, Dr. Gabe Mirkin, a physician and former assistant professor at the University of Maryland, first used the acronym RICE as a way to treat an injury. However recently more and more people, and in fact Dr Mirkin himself, have started to question whether or not RICE is the best way to deal with an injury.  “Nobody believes in rest anymore,” Dr Mirkin says.  “You can get a hip replacement and you’re on the bike 12 hours after surgery.” As for ice, “there is no data to show that ice does anything more than block pain,” he says. “And there is data that shows it delays healing.” These opinions were cited in his own blog [1].  

When disruptions form in tissues, the body responds with three sequenced phases of recovery: inflammation, repair, and remodeling [2]. This sequence means that the process of inflammation must successfully occur in order for the body to shift its focus to the repair phase which must also be completed before proceeding to the remodeling phase. The magnitude of the inflammatory response is dependent upon the severity of the trauma, as well as the degree of vascularization of the tissue [2].

Inflammation is the first phase of a three-phase sequence of tissue repair, while swelling is “the accumulation of waste at the end of the inflammatory process that is not yet evacuated” [3] Inflammation is not an undesired outcome that needs to be reduced or delayed, but rather an instantaneous defense mechanism with the primary objective of controlling the extent of cell injury and preparing the tissue for the process of repair. As noted by Leadbetter, “inflammation can occur without healing, but healing cannot occur without inflammation [4].

Macrophages, which are cells that are essential for tissue development and repair, simultaneously enter the interstitial space to clear debris and produce growth factors[5]. Specifically, macrophages are responsible for the release of insulin-like growth factor (IGF1), which is an essential hormone required for muscle regeneration [1]. As the waste products produced by macrophages and neutrophils begin to accumulate around the damaged site in the form of fluid, the body relies on the lymphatic system to drain the area [5].  The inadequate functioning of the lymphatic system is the primary contributor to the accumulation of waste products, excess swelling, and the inability to allow for the optimal recovery of damaged tissues [1].

RICE method

Image 1: The RICE method.  Adopted from [25].

The premise of applying ice to damaged tissues is reducing inflammation. In certain cases, this can cause short-term relief of pain.  However, it is important to note that anything that reduces inflammation may also delay healing [1].  When topical cooling (ice) is applied to damaged tissues, it acts as a vasoconstrictor (the narrowing of local blood vessels). This physiological response impedes the transport of inflammatory chemicals and neutrophils to the site of trauma. It has been purported that icing can produce further damage to the body’s tissues due to the prolonged period of vasoconstriction that “is not directly dependent on the continuing existence of a cold state [6].”

Another older study by Meeusen and Lievens reported “When ice is applied to a body part for a prolonged period, nearby lymphatic vessels begin to dramatically increase their permeability. As lymphatic permeability is enhanced, large amounts of fluid begin to pour from the lymphatics in the wrong direction, increasing the amount of local swelling and pressure and potentially contributing to greater pain.”  An additional study conducted in 2013 examining the effect of cryotherapy (“ice therapy”) on muscle recovery and inflammation found that subjecting the tissues to 20 minutes of cooling was “ineffective in attenuating the strength decrement and soreness seen after muscle damaging exercise. [8]”

Tseng et al. concluded that topical cooling does not enhance, and may delay, the return to normal concentrations of muscle damage markers and subjective fatigue after eccentric exercise. Consequently, participants experienced an increased perception of pain and fatigue, as well as no change in their elevated levels of muscle damage markers, even after ice was applied to the site of trauma [9]. 

As previously mentioned, ice can give short term relief of pain and some studies have shown some benefit.  One literature review exploring the evidence in support of ice therapy, concluded “ice is effective but should be applied in repeated application of 10 minutes to be most effective, avoid side effects, and prevent possible further injury [10].” Bleakely explored the difference between the standard 20-minute icing protocol and an intermittent protocol and found that “intermittent applications may enhance the therapeutic effect of ice in pain relief after acute soft tissue injury. [11]” However, these reports did not show clear benefit.

Even when evidence is available, it has not always been consistent. Recent studies regarding the effects of cold therapy in DOMS have had conflicting results, the reasons for which are unknown. The various small studies differed with regard to study design, including the forms of cold therapy used, the manner in which exercise-induced muscle damage was provoked, and the manner in which muscle soreness was evaluated [23]. 

Although popular, research on the validity of compression for recovery enhancement is limited and most support for its application is anecdotal [12-14].  Pollard and Cronin concluded there is little evidence available that supports compression for all soft tissue ankle injuries [12]. The authors could not suggest a definitive recommendation regarding the level and type of compression. Another study dealing with adult ankle sprains had similar findings, concluding that “evidence to support the use of compression in the treatment of ankle sprains is limited [14].

Stages of healing

Figure 2.  Tissue healing and timing.  Adopted from [26].

Elevation is commonly used in an effort to reduce swelling in the extremities by increasing venous return [14]. However, “no evidence based on studies with high levels of evidence is available for the effectiveness of elevation.”  This falls in line with other modalities recommended in the RICE protocol.

There is an abundance of available information that suggests moving early in the recovery process is more beneficial than extended periods of stillness  [16-18].  Buckwalter advocated the importance of imposing a load on damaged tissues to enhance the recovery process stating that “although new approaches to facilitate bone and fibrous tissue healing have shown promise, none has been proven to offer beneficial effects comparable to those produced by loading healing tissues [15].” One study in 2016 compared the implementation of active recovery to canoeist and football players in an effort to demonstrate the importance of loading the tissues previously subjected to trauma. 

One group performed active recovery sessions targeting the muscles involved in a bout of exercise while the second group performed activities targeting muscles that were not utilized during a training session. Based on the findings, the authors concluded that “20 minutes of post- exercise active recovery by working the same muscles that were active during the fatiguing exercise is more effective in fatigue reduction than active exercise using those muscles not involved in the fatiguing effort [19].”

The METH method for injuries is the alternative to the rice method. It stands for movement, elevation, traction, and heat.  We have already covered the movement and elevation portions of this.  It has been proposed more recently as an alternative to the standard RICE method.

Heat is one of the proposed treatments for METH.  The therapeutic benefit of heat therapy for the management of acute and subacute low back pain was evaluated in a 2006 Cochrane Database review [20]. This review of 9 trials (n = 1117) examined the efficacy of superficial heat and cold therapies for low back pain and found that heat-wrap therapy provides small but significant short-term reductions in pain and disability for patients with low back pain.  Kettenmann et al. [88] compared low-level heat-wrap therapy with a no-heat control condition in a randomized trial in 38 patients with acute low back pain. Subjects in the heat-wrap group experienced significant reductions in perceived pain and stress, improvements in sleep at night, and a reduced need for daytime naps compared with controls [21].

Hassan et al. compared immersion in warm water versus cold water versus a no-treatment control group beginning 15 minutes after eccentric hamstring exercises in 60 young athletic males. Warm water significantly decreased markers of muscle stress reaction, including skeletal troponin I, creatine kinase, and myoglobin levels, compared with cold water or control. In contrast, cold-water immersion elevated levels of muscle stress reaction markers [22].

Traction refers to the practice of slowly and gently pulling on a joint.  It does fall along a similar path with heat in that most studies are done for low back pain.  There are very limited studies with other musculoskeletal injuries.

Clinically significant effects of traction on pain in adults who complained of low back pain have been shown in a recent systematic review, regardless of traction force delivered. Traction may be considered a therapeutic tool for the short-term reduction of pain and disability in patients with low back pain and lumbar radiculopathy and it is recommended to have at least 25 percent of the patient’s body weight [24].

Heat and cold therapy mechanisms

Image 3: Images from a dorsiflexion osteotomy  Adopted from [23].

Summary

In summary, a rehabilitation protocol for an acute athletic injury should prioritize pain free movement through a full range of motion as early as possible and gradually progress to higher intensities and more complex movements. In addition, the healthcare professional should evaluate the individual injury and work with the patient or athlete to decide which therapeutic modalities are most appropriate. If a patient or athlete believes that compression or elevation is beneficial to their recovery process then the two modalities can be used, as it has been purported that there are no adverse side effects associated with their application. The method and duration of the compression should be at the discretion of the healthcare professional, as no definitive guidelines have been defined. 

References

  1. Mirkin, G. (2015, September). Why ice delays recovery. Dr Gabe Mirkin on Health. Retrieved from www.drmirkin.com/fitness/why-ice-delays-recovery.html.
  2. Merrick, Mark. (2002, April-June). Secondary injury after musculoskeletal trauma: A review and update. Journal of Athletic Training, 37(2): 209-217. Retrieved from https://ncbi.nlm.nih.gov 
  3. Reinl, G. (2013). Iced! The Illusionary Treatment Option, 2 ed. United States of America: G. Reinl 
  4. Leadbetter WB. (1990) An introduction to sports-induced soft tissue inflammation. In: Leadbetter WB, Buckwalter JB, Gordon SL, eds. Sports-Induced Inflammation. Park Ridge, IL: American Academy of Orthopaedic Surgeons; 3–23. 
  5. Wantanabe, S., Misharin, A.V., & Budinger, S., (2019). The role of macrophages in the resolution of inflammation. J Clin Invest, 129(7), 2619- 2628. doi: 10.1172/JCI124615
  6. Khoshnevis, S, Craik, N, & Diller, K. (2015). Cold-induced vasoconstriction may persist long after cooling ends: an evaluation of multiple cryotherapy units. Knee Surgery, Sports Traumatology, Arthroscopy, 23(9), 2475–2483. 
  7. Meeusen, R., & Lievens, P. (1986). The use of cryotherapy in sports injuries. Sports Medicine. Vol. 3, 398–414. 
  8. Crystal, N.J., Townson, D.H., Cook, S.B. & LaRoche, D.P. (2013). Effect of cryotherapy on muscle recovery and inflammation following a bout of damaging exercise. European Journal of Applied Physiology, 113, 2577–2586. 
  9. Tseng, C., Lee, J.P., Tsai, Y.S., Lee, S.D., Kao, C.L., Liu, T.C., Lai, C. & Kuo, C.H. (2013). Topical cooling (Icing) delays recovery from eccentric exercise- induced muscle damage. Journal of Strength & Conditioning Research, 27(5), 1354- 1361.
  10. MacAuley, D. (2001, July). Ice therapy: How good is the evidence? International Journal of Sports Medicine, 22(5),
  11. Bleakley C, McDonough S & MacAuley D. (2006, August). Cryotherapy for acute ankle sprains: A randomized controlled study for two different icing protocols. British Journal of Sports Medicine, 40 (8), 700-705. 
  12. Block, Jon. (2010) Cold and compression in the management of musculoskeletal injuries and orthopedic operative procedures: a narrative review. Open Access J Sports Med, 1, 105-113
  13. Pollard A & Cronin G. (2005, October) Compression bandaging for soft tissue injury of the ankle: A literature review. Emergency Nurse: The Journal of the RCN Accident and Emergency Nursing Association 13(6), 20-25
  14.  Van den Bekerom M, Struijs P, Blankevoort L, Welling L, Van Dijk C & Kerkoffs G. (2012, July/August). What is the evidence for rest, ice, compression and elevation therapy in the treatment of ankle sprains in adults? Journal of Athletic Training, 47(4), 435-443. Doi: 10.4085/1062-6050-47.4.14. 
  15. Buckwalter, J. A., & Grodzinsky, A. J. (1999, September/October). Loading of healing bone, fibrous tissue, and muscle: Implications for orthopedic practice. Journal of American Academy of Orthopedic Surgeons, 7(5), 291-299
  16. Campbell, Ryan. (2013, December) MEAT vs RICE for injury management. Goodmed Direct Primary Care. Retrieved from https://goodmedclinic.com 
  17. Reinl, G. (2019, February) The cold hard facts: Weighing the evidence
  18. Robinson, J. (2017, October 18). MOVE an injury not RICE. University of British Columbia. Retrieved
  19. Mika, A., Oleksy, Ł., Kielnar, R., Wodka-Natkaniec, E., Twardowska, M., Kamiński, K., & Małek, Z. (2016). Comparison of two different modes of active recovery on muscles performance after fatiguing exercise in mountain canoeist and football players. PloS one, 11(10).
  20. FrenchSD,CameronM,WalkerBF,ReggarsJW,EstermanAJ. Superficialheatorcoldforlowbackpain.CochraneDatabase SystRev2006:CD004750.
  21. Kettenmann B, Wille C, Lurie-Luke E, Walter D, Kobal G. Impact of continuous low level heatwrap therapy in acute low back pain patients: subjective and objective measurements. Clin J Pain 2007;23:663–8
  22. Hassan ES. Thermal therapy and delayed onset muscle soreness. J Sports Med Phys Fitness 2011;51:249–54.
  23. Malanga, Gerard A., Ning Yan, and Jill Stark. “Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury.” Postgraduate medicine 127.1 (2015): 57-65.
  24. Vanti C, Saccardo K, Panizzolo A, Turone L, Guccione AA, Pillastrini P. The effects of the addition of mechanical traction to physical therapy on low back pain? A systematic review with meta-analysis. Acta Orthop Traumatol Turc. 2023 Jan;57(1):3-16.
  25. Borra, Vere, Emmy De Buck, and Philippe Vandekerckhove. “RICE or ice: what does the evidence say? The evidence base for first aid treatment of sprains and strains.” Filtering the information overload for better decisions. Paper presented at the 23rd Cochrane Colloquium Abstracts, Vienna, Austria. 2015.
  26. https://www.prohealthsys.com/blog/heat-vs-cold-evidence-suggests/