If you're kicking off the new year with an exercise buzz then it's very important to know that if you get injured, early intervention can get you back exercising quicker and keep your New Year good habit going. In our latest blog post we look at how this works.
Many athletes and members of the general population believe immediate and prolonged rest is an imperative component of recovery following injury. Although immediate rest is still advocated, longer than immediate rest is actually a proven hindrance to early recovery following injury. Historically patients were advised by multitudes of health care professionals to rest for many days after injury to allow the body time to recover. In more recent years this theory has been blown out of the water by research looking at the importance of loading a joint or limb optimally after injury. Up to the most recent past physio’s included were advising a protocol described as P.R.I.C.E (Protection, Rest, Ice, Compression and Elevation) following injury for the management of acute soft tissue injuries. These recommendations were first published in 1996 and are now somewhat out of touch with research. Although aspects of this acronym are still seen as essential in early injury management the research behind this protocol is somewhat suspect. So let’s break down what evidence is available for the PRICE protocol.
Protection and rest support the use of joint restriction and unloading for various periods. Recent studies such as that of Bring in 2009 show that short periods of unloading are required after acute soft tissue injury and that aggressive ambulation or exercise should be avoided. But, rest should be of limited duration and restricted to immediately after trauma. Longer periods of unloading are harmful and produce adverse changes to tissue recovery and biomechanics.
Ice is generally described as essential for the reduction of inflammation following an acute injury however numerous studies suggest that the greatest benefit of Ice therapy immediately after injury is a pain relieving effect and a reduction of the cellular metabolism therefore reducing the risk of secondary cell injury (Vant Hoff’s law). Current best evidence is associated with animal studies and suggests optimal metabolic effects are only achieved when the relevant temperature is gained at the layer of tissue directly affected at the site of injury. This is often impossible with general sporting injuries such as hamstring and quad tears due to the depth of tissue. Therefore, currently for the vast majority of injuries ICE should only be advocated as a pain relieving mechanism and to induce vasoconstriction to limit the effects on vascular tissue, thus reducing Oedema a physiological event associated with inflamation.. More high quality research on humans is required to further investigate the effect of ice on inflammation. Clinical studies into compression and elevation are also lacking, and much of its rationale is taken directly from research relating to DVT and lymphedema management.
So where do we go from here? Progressive mechanical loading is more likely to restore the strength and promote tissue repair in tendonous and ligamentous tissue, Bring 2009. For instance early mobilisation with accelerated rehabilitation is seen as being most effective after acute ankle strain.
Functional rehabilitation of ankle sprain, which involves early weight-bearing usually with an external support, is superior to immobilisation for most types of sprain severity (Bleaky 2010). This may be described as a form of mechanotherapy in which mechanical loading prompts cellular responses that promote tissue structural change by up regulating key proteins associated with soft tissue healing (Khan 2009). The difficulty as patients and clinicians is finding the correct balance between loading and unloading during tissue healing. If tissues are stressed too aggressively after injury it may cause re-bleeding or further damage. Protection of vulnerable tissues therefore remains an important principle. But, too much rest may be harmful and directly inhibit recovery. The secret is to find the ‘optimal loading’.
In essence we therefore must replace rest in the PRICE protocol with a balanced rehab program where tissue recovery is encouraged by an incremental unique loading strategy specifically designed for each injury and associated with sporting activities.
In late 2012 a new acronym was proposed by Bleaky et al, 2012 advocates this mentality and is called the POLICE (Protection, Optimal loading, Ice Compression and elevation) protocol. Optimal loading is indeed a challenge for clinicians and outlines the need for early intervention following injury. The challenge for clinicians is to determine what is optimal in relation to nature, dosage and timing. The challenge for patients is to ignore historical and sometimes recent advice to “rest for extended periods and then seek physiotherapy advice” if your goal is to return to your general activities or your sporting endeavours don’t delay in seeing a chartered physiotherapist ASAP.