Why R.I.C.E. is not always nice

What happens in the tissues when the body is injured?
An injury occurs when you stretch tissue past its functional limit or traumatize it in some other way. We understand quite well how the body reacts to injury. When tissue tears or ruptures, bleeding occurs. A sequence of events then follows: tissue swelling, reabsorption of dead tissues and remodeling with new collagen. The injury stimulates the body to recruits cells and blood vessels into the area, so that at the end of the day healthy tissues replace the injured ones.

How do you best treat an injury? Is R.I.C.E. (rest, ice, compression and elevation) still the best way?
The tools we use right now are focused mainly around reducing swelling and stimulating cells to lay down their collagen, thereby strengthening the tissues. However, what we’ve accepted as “standard interventions” for those tasks are not necessarily the best ones.

Reducing swelling, for instance. We traditionally use ice, soft tissue massage and elevation to help reduce swelling. But that initial swelling is part of the body’s healing response. Warmth is caused by vessels migrating to the site of the injury, and massage can displace the tissues that are trying to heal. Elevation decreases the blood pressure to the site that needs increased perfusion. So, in a sense, each of those things is counter to the healing process that we are trying to stimulate.

On the other hand, carefully calibrated “active” rest — where the rest of the body is exercised while the injury is protected — can be very beneficial, especially when combined with ice, elevation and skillful soft-tissue mobilization.
With all of these steps, the question is when — and how. We already see, for example, that temperature regulation in an injured area changes the outcome — but what is best? Is it heat or cold or oscillations between those? Is the optimal temperature regulation cycle very quick or very slow? Should it be oscillating or intermittent?

As our knowledge increases, each one of these interventions will see new ways toward achieving the desired outcomes.

Are you saying that R.I.C.E. is not the optimal way to encourage your tissues to heal?
It is not always the best and almost always can be augmented.

That kind of flies in the face of everything we have ever been taught. So if swelling is good for us, why have we been taught to reduce it?

Swelling isn’t good for us all the time. It initially helps by recruiting healing factors that accelerate how quickly cells migrate to the site of injury — but swelling is also bad because it destructs and distends the tissues and distorts the anatomy. Fluid enzymes within the swollen fluid break down tissue as well as stimulating it.

So there’s good and bad swelling?
Actually immediate swelling is required for tissue repair. Immediate swelling releases enzymes that break down tissue, along with anabolic factors and cells that rebuild tissue. Late swelling is almost always harmful, as those same enzymes have already done their job and now attack healthy tissue.
The bottom line is that there is a wonderful and mysterious balance between when is swelling good and when is swelling bad. The question for doctors and patients is: What is the timing for swelling reduction, and what is the optimal way to do it? With advances in technology, we will get better at exposing the injured tissue to the optimal components of swelling for just the right amount of time.

What is the next leap in post-injury interventions?
During the last few hundred years of medical science, we have figured out how to intervene with very bold strokes in many problems. For example, we have anti-inflammatory drugs. If you hit something with an anti-inflammatory today, you hit all the tissues in the body. The entire patient gets that hammer of anti-inflammatories. It’s similar for antibiotics. Even if you have a little tooth infection, you are bombing your entire body with antibiotics — and that upsets the balance in the system.

To add to the complexity, the truth is that we have limited ways of controlling what happens when you use both heat and elevation, ice and elevation, or an anti-inflammatory and ice. It’s a complex dynamic. And that’s what the next few years of trauma repair science will focus on: understanding and managing those interactions.

What comes next, then?
The next big leap will be targeted interventions. What you might be able to do for an injury is take an anti-inflammatory within the first three minutes, then a stimulating factor the next three minutes and then another factor the next three minutes. Or three seconds. Or three microseconds.

Again, we are just figuring out the timing optimization curve, but we are not far from understanding how to sequentially add factors and create beneficial interactions in a cycle of healing.

Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco. He pioneers advanced orthopedic surgical and rehabilitation techniques to repair, regenerate and replace damaged cartilage and ligaments.

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