The rise and fall of RICE The RICE treatment protocol for injuries, which stands for Rest, Ice, Compression, and Elevation, was developed in the 1970s but has increasingly come under scrutiny. While ice was once considered standard treatment for pain relief, numerous studies now show ice may delay healing by reducing blood flow and inflammation needed for tissue repair. Compression and elevation also lack strong evidence of benefits. Alternatives like movement and heat are gaining support as better options for promoting healing through increased blood flow and growth factors. The traditional RICE protocol is falling out of favor as evidence demonstrates movement and inflammation are important parts of the body's natural healing response.

1. The rise and fall of RICE
Mr Nagaraj, Prashanth
MBBS,MS(ORTHO),MRCS Ed, FRCS Ed(Tr &Orth)
Fellow –Foot and ankle-(Avon orthopaedic centre-Bristol)

2. Mirkin G, Hoffman M. “The Sports
Medicine “Book. Sydney:
Landstowne ; 1978
RICE was a term coined back in the 1970s by sports medicine professional, Dr Gabe
Mirkin. From this, ice was quickly adopted as the standard treatment for injuries and
sore muscles, primarily because it helps relieve the pain associated with damaged
tissue
Philosophy
Dr Mirkin’s recommends “Since applying ice to an injury has been shown to reduce
pain, it is acceptable to cool an injured part for short periods soon after the injury
occurs. You could apply the ice for up to 10 minutes, (not more than 10 minutes at
any given part of time)
remove it for 20 minutes,
and repeat the 10 minute application once or twice.
There is no reason to apply ice more than six hours after you have injured yourself.”

4. Kellett (1986, October)
“Cryotherapy (crushed ice) for 10 to 20 min, 2 to 4 times/day for the
first 2 to 3 days is helpful in promoting early return to full activity.”
Swenson, Sward & Karlsson (1996, August)
“The application of cold has also been found to decrease the
inflammatory reaction in an experimental situation. Cold appears to be
effective and harmless and few complications or side-effects after the
use of cold therapy are reported. Prolonged application at very low
temperatures should, however, be avoided as this may cause serious
side-effects, such as frost-bite and nerve injuries.”
MacAuley (2001)
“It is concluded that 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.”
Hubbard, Aronson & Denegar (2004, Jan-Mar)
“Our review of the 4 randomized, controlled clinical trials suggests that
cryotherapy may be effective in reducing the time to return to
participation; however, the extremely low quality of the studies
reviewed is of concern. Despite the extensive use of cryotherapy in the
management of acute musculoskeletal injury, few investigators have
actually examined the effect of cryotherapy alone on return to
participation.”
Bleakley, McDonough & MacAuley (2006, August) “Intermittent applications may enhance the therapeutic effect of ice in
pain relief after acute soft tissue injury.” However, “there were no
significant differences between groups in terms of function, swelling,
or pain at rest.”
Singh et al. (2017, March)
“In conclusion, although icing disrupted inflammation and some
aspects of angiogenesis/revascularization, these effects did not result
in substantial differences in capillary density or muscle growth.

5. Rest???
• Periods of rest following an acute musculoskeletal injury does not
enhance the recovery process. As previously mentioned, the lymphatic
system is responsible for draining the accumulation of waste products
from the damaged site. In order to do so, this passive system relies on
the voluntary contraction of the tissues surrounding the site of trauma in
order to produce a propulsive force.
Gustafsson found that “VEGF is upregulated in human skeletal muscle by a
single bout of dynamic exercise.” Consequently, we can infer that active
contraction of the skeletal muscles surrounding the site of trauma will enhance
the body’s ability to revascularize the damaged tissue.
Myostatin, a growth factor responsible for inhibiting muscle growth, has been
hypothesized to play a role in muscle regeneration . Hittel et al. concluded that
“aerobic and resistance exercise reduces muscle and circulating myostatin levels
in human subjects.” Therefore, activity following a musculoskeletal injury will
inhibit myostatin and may reduce the possibility of muscular atrophy (muscle
loss).

6. Movement, not
rest
The Wharton’s
Stretch Book
• That recovery after injury is improved with movement, not
rest, was published in that banner year, 1996, by Dr Jim and
Phil Wharton in The Wharton’s Stretch Book .
• They suggested the acronym MICE to replace RICE, where
Rest is replaced with Movement. The Wharton's advocated
that once fracture or catastrophic injury is excluded:
movement is best, not rest, to treat an injury.

7. • That movement also directly
stimulates tissue healing was
clarified by Dr. Khan (Editor of
the British Journal of Sports
Medicine) and Dr. Scott (Director
of Vancouver Hospital’s Tendon
Laboratory) Called
Mechano-transduction,
• the actual physical deformation
of tissue by mechanical load of
movement leads to release of
chemical growth factors from
cells. These enhance synthesis of
protein and structural scaffolds,
which maintain, repair and
strengthen bone, cartilage,
tendon and muscle.

8. Ice???
However, Dr Mirkin has now come out against the term that made
him famous, citing more than 20 scientific articles that show almost
no evidence that combining ice and compression speed up the
healing process faster than using just compression!!
“When you apply ice to your body, it constricts the blood
flow to that area. By reducing the blood flow, you’re
minimising the amount of healing cells that can get there”
Mirkin G, Hoffman M
A summary of 22 scientific articles found almost no evidence that ice and
compression hastened healing over the use of compression alone, although ice
plus exercise may marginally help to heal ankle sprains (The American Journal of
Sports Medicine, January, 2004;32(1):251-261).” 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. Doi: 10.1136/bjsm.2006.025932
He wrote the forward to Gary Reinl’s 2013 self-published book, Iced! The Illusionary
Treatment Option, which has become the bible of the growing anti-ice movement.

9. 1986, a study published in the journal Sports Medicine showed that when ice is applied
for a prolonged period, lymphatic vessels become more permeable, causing a backflow
of fluid into the interstitial space. That means local swelling at an injury site will increase,
not decrease, with the use of ice.
Ice delays process of healing by constricting blood vessels and allowing less fluid to reach
the injured area, as demonstrated in a 2013 study in the Journal of Strength and
Conditioning Research. This research showed that topical cooling delays recovery from
eccentric exercise-induced muscle damage.
A 2014 study published in the Journal of Strength & Conditioning Research and another
done by the University of Queensland showed cold water immersion after training — ice
baths — substantially reduces long-term gains in muscle mass and strength by stunting
the cell activity crucial for building stronger muscles. When you hit the cold tub after
hard exercise, thinking you are reducing inflammation, you’re actually delaying recovery.
Additionally, a 2015 article published in Knee Surgery, Sports Traumatology, Arthroscopy
showed that the narrowing of blood vessels caused by icing persists after cooling ends
and the resulting restriction of blood flow can kill otherwise healthy tissue; that is, icing
causes more damage on top of the existing injury.

10. • The resulting
vasoconstriction from
cooling, not only reduces
tissue oxygenation with
necrosis if extreme, but
inhibits the inflammatory
response needed to initiate
healing.
• The release of kinins and
cytokines from damaged
tissue is meant to increase
vascular influx, which brings
fibrinogen and platelets for
haemostasis, leukocytes and
monocytes to phagocytose
necrotic debris, and
fibroblasts for collagen and
protein synthesis.

11. The body deploys its
repair and clean-up crew
in the form of
macrophages, white blood
cells that engulf and
digest cellular debris.
They produce the protein
insulin-like growth factor
1, which is required for
muscle repair and
regeneration.
The same study showed
that blocking
inflammation delays
healing by preventing the
release of IGF-1.

12. Leadbetter “inflammation can occur without
healing, but healing cannot occur without
inflammation.”

13. Compression???
Pollard and Cronin concluded there is little evidence available that supports
compression for all soft tissue ankle injuries. The authors could not suggest
a definitive recommendation regarding the level and type of compression.
Van der Bekerom had similar findings, concluding that “evidence to support
the use of compression in the treatment of ankle sprains is limited. No
information can be provided about the best way, amount, and duration of
compression or the position in which the compression treatment is given.”
There is also a lack of definitive evidence that supports compression used in
conjunction with ice therapy when treating an acute musculoskeletal injury.
Block et al completed a literature review regarding the cold and compression
management of musculoskeletal injuries and found that “the studies are not
uniform in their choices of experimental and control groups, study duration,
sample size or surgical procedure, rendering the evidence diluted.” Until we
can definitively prove the validity of utilizing compression with ice in clinical
trials, we cannot assume it expedites the recovery process.

14. • Elevation is commonly used in an effort to reduce
swelling in the extremities by increasing venous
return. However, “no evidence based on studies
with high levels of evidence is available for the
effectiveness of elevation” .
• Bayer et al. concluded that elevation, along with
the rest of the RICE protocol, “is well tolerated by
patients, but there is no evidence that these
methods enhance tissue repair.”
Elevation ???

15. • Does topical cooling help?
• Does icing has any effect on outcome of acute
soft tissue injuries?
• Does immersion to cold water after exercise
has ant benefit?
• Does Ice massage and exercise benefit DOMS?
• Heat Vs cold which is better?

16. Further evidence….
Topical Cooling (Icing) Delays Recovery From Eccentric
Exercise–Induced Muscle Damage
Tseng, Ching-Yu1; Lee, Jo-Ping2; Tsai, Yung-Shen2; Lee, Shin-Da3; Kao, Chung-Lan4; Liu, Te-Chih2; Lai, Cheng- Hsiu2; Harris, M. Brennan5; Kuo, Chia-Hua1,3Author
Information
Journal of Strength and Conditioning Research: May 2013 - Volume 27 - Issue 5 - p 1354-1361 doi: 10.1519/JSC.0b013e318267a22c
This study examined the influence of topical cooling on muscle damage markers and hemodynamic changes
during recovery from eccentric exercise. Eleven male subjects (age 20.2 ± 0.3 years) performed 6 sets of elbow
extension at 85% maximum voluntary load and randomly assigned to topical cooling or sham groups during
recovery in a randomized crossover fashion. Cold packs were applied to exercised muscle for 15 minutes at 0, 3,
24, 48, and 72 hours after exercise. The exercise significantly elevated circulating creatine kinase-MB isoform
(CK-MB) and myoglobin levels. Unexpectedly, greater elevations in circulating CK-MB and myoglobin above the
control level were noted in the cooling trial during 48–72 hours of the post-exercise recovery period. Subjective
fatigue feeling was greater at 72 hours after topical cooling compared with controls. Removal of the cold pack
also led to a protracted rebound in muscle hemoglobin concentration compared with controls.
Measures of interleukin (IL)-8, IL-10, IL-1β, and muscle strength during recovery were not influenced by
cooling.
A peak shift in IL-12p70 was noted during recovery with topical cooling. These data suggest that
topical cooling, a commonly used clinical intervention, seems to not
improve but rather delay recovery from eccentric exercise–induced
muscle damage.

17. Is ice right? Does cryotherapy improve outcome for acute soft
tissue injury?
N C Collinshttp://dx.doi.org/10.1136/emj.2007.051664
Aims: The use of ice or cryotherapy in the management of acute soft tissue injuries is
widely accepted and widely practised. This review was conducted to examine the
medical literature to investigate if there is evidence to support an improvement in
clinical outcome following the use of ice or cryotherapy.
• Methods: A comprehensive literature search was performed and all human and
animal trials or systematic reviews pertaining to soft tissue trauma, ice or
cryotherapy were assessed. The clinically relevant outcome measures were (1) a
reduction in pain; (2) a reduction in swelling or oedema; (3) improved function; or
(4) return to participation in normal activity.
• Results: Six relevant trials in humans were identified, four of which lacked
randomisation and blinding. There were two well conducted randomised
controlled trials, one showing supportive evidence for the use of a cooling gel and
the other not reaching statistical significance. Four animal studies showed that
modest cooling reduced oedema but excessive or prolonged cooling is damaging.
There were two systematic reviews, one of which was inconclusive and the other
suggested that ice may hasten return to participation.
• Conclusion: There is insufficient evidence to suggest that cryotherapy improves
clinical outcome in the management of soft tissue injuries.

18. Effects of cold water immersion on the symptoms of exercise-induced
muscle damage
Eston R, Peters D. J Sports Sci 17: 231–238, 1999.
• Subjects in the cryotherapy group immersed their exercised arm in cold water (15
degrees C) for 15 min immediately after eccentric exercise and then every 12 h for
15 min for a total of seven sessions.
• Muscle tenderness, plasma creatine kinase activity, relaxed elbow angle, isometric
strength and swelling (upper arm circumference) were measured immediately
before and for 3 days after eccentric exercise. Analysis of variance revealed
significant (P < 0.05) main effects for time for all variables, with increases in muscle
tenderness, creatine kinase activity and upper arm circumference, and decreases
in isometric strength and relaxed elbow angle.
• There were significant interactions (P<0.05) of group x time for relaxed elbow
angle and creatine kinase activity. Relaxed elbow angle was greater and creatine
kinase activity lower for the cryotherapy group than the controls on days 2 and 3
following the eccentric exercise.
• We conclude that although cold water immersion may reduce muscle stiffness
and the amount of post-exercise damage after strenuous eccentric activity, there
appears to be no effect on the perception of tenderness and strength loss, which
is characteristic after this form of activity.

19. The effects of ice massage, ice massage with exercise, and exercise on the prevention and
treatment of delayed onset muscle soreness J Athl Train
1992;27(3):208-17.
W K Isabell, E Durrant, W Myrer, S Anderson
Abstract
We investigated the effects of ice massage, ice massage with exercise, and exercise on
the prevention and treatment of delayed onset muscle soreness (DOMS). Twenty-two
subjects were randomly assigned to one of four groups. Pre exercise measures were
recorded for range of motion (ROM), strength, perceived soreness, and serum creatine
kinase (CK) levels. Subjects performed up to 300 concentric/eccentric contractions of
the elbow flexors with 90% of their 10 repetition maximum to induce muscle soreness.
Dependent variables were assessed at 2, 4, 6, 24, 48, 72, 96, and 120 hours post
exercise. Significant differences occurred in all variables with respect to time
(ANOVA(p<.05)). However, no significant mode of treatment, or mode of
treatment/assessment time interaction was present. Decreases in range of motion and
flexion strength correspond with increases in perceived soreness
The nonsignificant mode of treatment/assessment time interaction suggests that the
use of ice massage, ice massage with exercise, or exercise alone is not effective in
significantly reducing the symptoms of delayed onset muscle soreness. In fact, though
not statistically significant, the pattern of the data suggested the use of ice in the
treatment of DOMS may be contraindicated. Further investigation is recommended.

20. Mechanisms and efficacy of heat and cold therapies for
musculoskeletal injury Gerard A. Malanga1,2, Ning Yan3 & Jill
Stark4
• Abstract Nonpharmacological treatment strategies for acute musculoskeletal injury revolve around
pain reduction and promotion of healing in order to facilitate a return to normal function and
activity. Heat and cold therapy modalities are often used to facilitate this outcome despite
prevalent confusion about which modality (heat vs cold) to use and when to use it. Most
recommendations for the use of heat and cold therapy are based on empirical experience, with
limited evidence to support the efficacy of specific modalities. This literature review provides
information for practitioners on the use of heat and cold therapies based on the mechanisms of
action, physiological effects, and the medical evidence to support their clinical use. The
physiological effects of cold therapy include reductions in pain, blood flow, edema, inflammation,
muscle spasm, and metabolic demand. There is limited evidence from randomized clinical trials
(RCTs) supporting the use of cold therapy following acute musculoskeletal injury and delayed-onset
muscle soreness (DOMS). The physiological effects of heat therapy include pain relief and increases
in blood flow, metabolism, and elasticity of connective tissues. There is limited overall evidence to
support the use of topical heat in general;
• however, RCTs have shown that heat-wrap therapy provides short term reductions in pain and
disability in patients with acute low back pain and provides significantly greater pain relief of
DOMS than does cold therapy.
• There remains an ongoing need for more sufficiently powered high-quality RCTs on the effects of
cold and heat therapy on recovery from acute musculoskeletal injury and DOMS.

21. And it continues……
Bleakley CM, Costello JT, Glasgow PD. Should athletes return to sport after
applying ice?: a systematic review of the effect of local cooling on functional
performance. Sports Med 2012;42:69–87.CrossRefPubMedWeb of
ScienceGoogle Scholar
Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call
the POLICE? Br J Sports Med 2012;46:220–1.FREE Full TextGoogle Scholar
Bleakley CM, Glasgow P, Webb MJ. Cooling an acute muscle injury: can basic
scientific theory translate into the clinical setting? Br J Sports Med
2012;46:296–8.Abstract/FREE Full Text Google Scholar
Bleakley CM, McDonough SM, MacAuley DC. Some conservative strategies
are effective when added to controlled mobilisation with external support
after acute ankle sprain: a systematic review. Aust J Physiother 2008;54:7–
20.CrossRefPubMedWeb of ScienceGoogle Scholar
Leeder J, Gissane C, van Someren K, et al. Cold water immersion and recovery
from strenuous exercise: a meta-analysis. Br J Sports Med 2012;46:233–
40.FREE Full TextGoogle Scholar

22. Meeusen & Lievens (1986, Nov-Dec) “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.”
Thorsson (2001, March) “Experimental studies, however, show no effect of cryotherapy on muscle
regeneration, and no controlled clinical study has shown a significant effect in
emergency treatment of soft tissue sports injuries.”
Hubbard & Denegar (2004, Jul- Sep)
“Based on the available evidence, cryotherapy seems to be effective in decreasing
pain. In comparison with other rehabilitation techniques, the efficacy of cryotherapy
has been questioned. The exact effect of cryotherapy on more frequently treated
acute injuries (eg, muscle strains and contusions) has not been fully elucidated.”
Collins (2008, February) “There is insufficient evidence to suggest that cryotherapy improves clinical outcome
in the management of soft tissue injuries.”
Takagi et al. (2011, February)
Icing applied soon after a muscle crush injury could have retarded proliferation and
differentiation of satellite cells at the early stages of regeneration through retardation
of degeneration and macrophage migration, which play a crucial role in muscle
regeneration, and could have induced not only a delay in late stages of muscle
regeneration but also impairment of muscle regeneration along with a thicker
collagen deposition around the regenerating muscle fibers. Judging from these
findings, it might be better to avoid icing, although it has been widely used in sports
medicine.
Summarization of publications that refute any aspect of the R.I.C.E Protocol

23. van den Bekerom et al. (2012, August)
“Based on our review, evidence from RCTs to support the use of ice in the treatment
of acute ankle sprains is limited.”
Tseng et al. (2013, May)
“Topical cooling, a commonly used clinical intervention, seems to not improve but
rather delay recovery from eccentric exercise- induced muscle damage.”
Crystal, Townson, Cook & LaRoche (2013, October)
“20 min of cryotherapy was ineffective in attenuating the strength decrement and
soreness seen after muscle-damaging exercise but may have mitigated the rise in
plasma CCL2 concentration. These results do not support the use of cryotherapy
during recovery.”
Yamane, Ohnishi & Matsumoto (2015, July)
“Regular post-exercise cold application to muscles might attenuate muscular and
vascular adaptations to resistance training.”
Khoshnevis, Craik & Diller (2015, September)
“The condition of reduced blood flow persists long after cooling is stopped and local
temperatures have rewarmed towards the normal range, indicating that the
maintenance of vasoconstriction is not directly dependent on the continuing existence
of a cold state. The depressed blood flow may dispose tissue to NFCI (non- freezing
cold injury).”
Tomares (2018, February)
“R.I.C.E. therapy should strive to avoid sub-0°C conditions when possible” due to the
potential risks of injury and exacerbation of inflammation associated with such
conditions.
Bayer et al. (2019, February)
“The application of ice, compression, and elevation is well tolerated by patents, but
there is no evidence that these methods enhance tissue repair.”
Miyakawa et al. (2020, April)
“Numbers of the neutrophils at 3 h after the injury and the MCP-1+ cells at 6 h and
later after the injury in the icing group were significantly lower than those in the
non-icing group, suggesting that these phenomena contribute to the retardation
of macrophage migration.”
R

25. Nothing!!! but SAVE THE ICE FOR
YOUR DRINKS-Thank U