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Monday, February 26, 2018
Courtesy of Russell R Van Hemert DC
Why You Shouldn't Do RICE for Sprains
Is the METH method a better option?
Updated July 11, 2017
Ask a doctor, a nurse, a paramedic, or an athletic trainer what to do for a twisted ankle and you're likely to hear the same advice: rest it, ice it, wrap it, and elevate it. It's a treatment regimen known as RICE—Rest, Ice, Compress, Elevate.
For decades, RICE has been the gold standard for orthopedic injuries like minor sprains and strains. Even fractures are subjected to RICE treatment until they can be surgically repaired or permanently immobilized, usually with a plaster cast.
Everybody knows it. Everybody does it.
But does it work?
RICE Reduces Blood Flow
The evidence for using RICE—especially the ice part—is sketchy at best. From the standpoint of patient comfort, it makes sense. Ice numbs the area around an injury and reduces pain, no doubt about it. Unfortunately, the reason that cold causes numbness is because the body doesn't want to lose heat to the outside and shunts blood away from the area where ice is applied.
The other components of RICE treatment are also designed to reduce blood flow to the area. Rest reduces blood flow by remaining immobile. One of the ways that the body helps move blood around the whole system is through muscle movements—not just the heart. As we move, stretch, and compress our musculature, we are squeezing blood through capillaries and veins. Relax the muscles and you relax the blood flow.
Compression is the same. By applying outside pressure to the tissues, we are restricting blood flow into the area.
Hold half of a sponge in your fist and put the whole thing under water. The part that's compressed will not soak up water, but the part that's exposed will. That's exactly how capillaries work.
Elevation controls blood flow with gravity. By keeping the area above the level of the heart, we are reducing the pressure of the blood that is pumped to there.
In combination with all of the other components of RICE, the reduced pressure results in reduced flow.
All of this is great for turning off the blood spigot. It reduces swelling and keeps the area a little numb to the pain of recovery. Unfortunately, it might also cause recovery to take a lot longer.
Blood flow is necessary for healing. Our bodies have to break down damaged cells and rebuild using raw materials. It's like a construction site. We have to keep the traffic flowing in order to haul away waste and debris as well as deliver nutrients and energy. Watch what a construction site does if the roads are blocked. Nothing happens. The whole process takes longer. That's exactly what the body does when blood flow isn't allowed to the area.
Instead of reducing blood flow, healing requires controlled blood flow. It seems that if left to its own devices, the body is pretty good at healing itself. That doesn't mean we can't do anything to help. Modern medicine has proved that we can certainly guide healing and help get the injured area back to pre-injury status. If we promote the right kind of controlled blood flow and rehabilitation, we might be able to improve upon the process.
It requires that we stop impairing blood flow in the name of comfort and encouraging the right blood flow to improve healing.
The METH Method—Movement, Elevation, Traction, and Heat
METH is emerging as the new RICE. It's an acronym for Movement, Elevation, Traction, and Heat. Right away, it seems as if we are going to do exactly the opposite of what we've been doing for years. That's not how this works. Heat instead of cold? A little. Movement instead of rest? Yes. But that doesn't mean we should throw out the baby with the bathwater. Some of what we did under RICE still applies. We are still going to elevate the injury to control the blood flow, just not stop it.
First, stop cutting blood flow to injured areas. It just makes the whole thing drag out and it puts the patient at risk for additional injury due to decreased sensation in the area. Let's control blood flow and encourage it in the right way.
Movement means what it says. Help the patient get some range of motion back in the injured area. If we're talking about an ankle, some flexion and extension exercises are best. Don't put too much weight on it, but don't avoid weight-bearing altogether. Listen to your body. There's a reason they call it "unbearable" pain (at least you can think of it that way). Encourage the muscles to remember how they're supposed to move.
Elevate the injury when you are resting. It's not an all-the-time need, but feel free to put your sprained ankle on a chair instead of letting it rest on the ground while you sit at your desk. Left to its own devices, your injury will swell more than you want it to. All that swelling is not good, either. You want to encourage blood flow, not turn your ankle or wrist into a sausage.
Traction is a method used by physical therapists to encourage healing. It basically means gently pulling on the joint. There are various techniques and it really shouldn't be done in earnest without training. However, a little goes a long way. You can have someone apply a little traction to your foot in the case of an ankle sprain. Imagine taking off a particularly tight pair of boots. In the case of a wrist sprain, you can pull traction yourself by grabbing something solid (like a metal guardrail) and pulling back to elongate your wrist. Don't fall over. The amount of traction should be as little as possible to get relief. Don't pull longer than a few seconds and release slowly. If it causes more pain rather than providing relief, don't do it.
Heat has always been around. Even if you subscribe to RICE, you've probably been told to switch to heat after a few days. Let's face it, the warmth feels good. It definitely encourages blood flow rather than stifling it. Just like with ice, don't overdo it. Heat shouldn't be applied for more than 30 minutes at a time and it doesn't need to be very hot. Don't burn yourself. A little goes a long way.
RICE vs. METH: What's Best?
There are competing guidelines out there for treating sprains (two are listed in the sources below) and there is no consensus. Just because RICE was easy to remember doesn't make it the right treatment for all minor orthopedic injuries. Like most first aid treatments, RICE developed through the time-honored technique of "I do it this way because my teacher told me to" rather than true, scientific research.
The use of ice as a healing mechanism is a bad idea. That said, it still has its function. Reducing swelling is important for fractures before putting on a cast. The more a broken arm or leg is swollen when the cast goes on, the more loose the cast will become as the healing continues. Ice helps with that.
METH isn't for high-grade (severe) sprains. If you can't move it or put weight on it, it's worth a trip to the doctor. Let her decide whether to go hot or cold.
Kerkhoffs GM, van den Bekerom M, Elders LAM, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med 2012;46:854-860.
National Guideline Clearinghouse (NGC). Guideline summary: Ankle stability and movement coordination impairments: ankle ligament sprains: clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2013 Sep 01.
Ramaraju, D., & Schenk, W. (2006). Barrel Sling Technique for Ankle Traction. Annals of The Royal College of Surgeons of England, 88(6), 589–590. http://doi.org/10.1308/003588406X130714a
Tseng CY, Lee JP, Tsai YS, Lee SD, Kao CL, Liu TC, Lai C, Harris MB, Kuo CH. Topical cooling (icing) delays recovery from eccentric exercise-induced muscle damage. J Strength Cond Res. 2013 May;27(5):1354-61.
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