RICE No More! Hello PEACE & LOVE

If you play recreational sports, you have likely experienced some sort of injury, such as a sprained ankle or pulled hamstring. When this happens, our automatic first thought is to get the ice on it ASAP. However, is this really the best way for us to manage injuries initially? And where did the acronym RICE come from?

Let’s take it back to 1962. There was a medical case study of a young patient, who had suffered a severed arm following a train accident. Following the process of re-attachment, the application of ice was used to help the healing process, which was a novel approach not seen anywhere in medical protocols up to this point. Since the surgery was successful, this started the notion of treating injuries with ice (7). 

Fast forward to 1978, where Dr Gabe Mirkin coined the term RICE in his publication ‘Sports Medicine Book’, which explained that Rest, Ice, Compression and Elevation was key for most sports related injuries for good recovery. Despite the lack of evidence backing this approach, it remained the standard of care for soft tissue injuries for around 40 years. 

Around 2013, the long-standing practice of icing injuries began to be questioned. In the book Iced! The Illusionary Treatment Option, the RICE protocol—Rest, Ice, Compression, Elevation—was criticized for being ineffective in accelerating recovery and potentially even harmful. These concerns are grounded in our understanding of tissue healing, which occurs in three essential phases: 1) inflammation, 2) repair, and 3) remodeling. Each phase must occur in sequence, and if the inflammatory phase is disrupted, the subsequent phases cannot proceed effectively. Ice acts as an anti-inflammatory agent by causing blood vessel constriction, which can reduce blood flow to the injured area. As a result, the delivery of critical healing chemicals is impaired, possibly delaying or hindering recovery. In light of this evidence, Dr. Gabe Mirkin—the originator of the RICE protocol—publicly revised his stance on icing in 2014 via a statement on his website (4). 

What should we be doing instead? Two more comprehensive acronyms, PEACE and LOVE, were put forward as a more appropriate model for soft tissue injury management (1). PEACE applies to the immediate post-injury care model, and LOVE includes information about ongoing injury care.

This approach encourages more active recovery to the injury recovery process. Elevation and compression are still included as options to treat, however the biggest change is the advice to avoid anti-inflammatory agents (including ice) to help promote healing in the early days following a soft tissue injury. The new addition of ‘optimism’ highlights the importance of psychosocial factors in injury recovery.

This isn’t to say we need to get rid of ice forever. There may still be times when this is helpful, particularly in the case of severe injuries or uncontrollable swelling that is limiting joint recovery (5). So yes, there may still be a role for ice, but it should not be our first option. Instead, look to PEACE & LOVE for guidance, and most importantly, consult a health care professional to help manage your specific injury, because no two injuries will be exactly alike!  

Link to full article HERE. 

Blog Author:  Erica Augsten, Physiotherapist

References: 

1. Dubois, B. & Esculier, J-F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine. 54, 72-73.
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. Mirkin, G. & Hoffma. M. (1978). The sports medicine book. (1st Ed.). Little Brown and Co. 
4. Mirkin, G (2014). Why Ice Delays Recovery. https://www.drmirkin.com/fitness/why-ice-delays-recovery/html
5. Palmieri, R. M., Ingersoll, C. D., et al. (2004). Arthrogenic muscle response to a simulated ankle joint effusion. British Journal of Sports Medicine. 38, 26–30
6. Reinl, G. (2013). Iced! The Illusionary Treatment Option, 2nd ed. United States of America: G. Reinl’ 
7. Scialoia, D., Swartzendruber, A. J., & Scialoia Saint Joseph, D. (2020). The RICE protocol is a myth: A review and recommendations. The Sport Journal, 24.