The Rice Myth
Shanta Plansinis
The use of ice to treat injuries was never part of medical protocol prior to the events of May 23, 1962 and the notion to utilize ice for tissue preservation was quickly published by newspapers around the globe. Subsequently, as the story was continuously retold by individuals not directly involved in the surgery, facts began to change. Eventually, the general public was quickly accepting the notion that any injury should be treated with the application of ice, regardless of its severity or how it occurred (36).
Subsequent research shows that rest and ice can actually delay recovery. Mild movement helps tissue to heal faster, and the application of cold suppresses the immune responses that start and hasten recovery. Icing does help suppress pain, but athletes are usually far more interested in returning as quickly as possible to the playing field. So, today, RICE is not the preferred treatment for an acute athletic injury (36).
Based upon the available evidence, the only plausible conclusion is that the use of the RICE technique to accelerate the recovery process is unequivocally a myth. Its validity was unequivocally compromised in 2015 when Dr. Mirkin publicly recanted his original position from 1978.
There is an abundance of scientific evidence purporting proven methods to accelerate the healing of muscle, ligament, and tendon injuries that do not include extended periods of rest used in conjunction with ice, compression, and elevation. To debunk the RICE myth, it is prudent to explore the physiological responses to injury and the effect ice, compression, elevation and inactivity have on those processes. The ultimate conclusion is that there are more optimal techniques to accelerate the recovery process that do not include a period of inactivity in which compression and topical cooling (ice) is simultaneously applied to the affected area.
The rapid process of inflammation is caused by necrosis, or accidental cell death (34), and begins with a brief period of vasoconstriction and hemostasis which restricts blood flow and allows for a blood clot to form (7). The formation of the blood clot prevents substantial blood loss. Immediately after this transitory period of vasoconstriction, damaged tissue mast cells degranulate, releasing inflammatory chemicals such as histamine, which cause local vasodilation and an increased permeability of the lining of the blood vessels (34). Local vasodilation is the process in which the blood vessels in the immediate area begin to widen in an effort to enhance blood flow. This increase in vascular permeability and vasodilation allow neutrophils, which are white blood cells that have been attracted to the area of trauma by the inflammatory chemicals, to enter the interstitial space where they can optimally interact with damaged tissues (34). Macrophages, which are cells that are essential for tissue development and repair, simultaneously enter the interstitial space to clear debris and produce growth factors (51). Specifically, macrophages are responsible for the release of insulin-like growth factor (IGF-1), which is an essential hormone required for muscle regeneration (31).
Another key aspect of the repair phase is the construction of a temporary extracellular matrix, which is accomplished by fibroblasts. Fibroblast are collagen producing cells, which create weak granulation tissue composed of collagen and fibronectin that will provide the framework for the development of new tissue (10). Immediately after the body reestablishes a vascular network and produces the framework for tissue reconstruction, the process of remodeling is initiated (phase three of the recovery process). The granulation tissue that was laid down during the repair phase is gradually remodeled into stronger tissue and the recovery process is completed.
Although ice seems like a beneficial option to reduce swelling according to decades of assumptions about the R.I.C.E. technique, clinical research indicates that its utilization does not reduce the accumulation of fluid and can actually result in a greater degree of swelling. According to Meeusen and Lievens (27)
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.
Not only has topical cooling (ice) been proven to be an ineffective method for recovery of tissues, it has also been proven to delay the healing process and produce additional damage. Tseng et al. (49) concluded that topical cooling does not enhance, and seems to delay, the return to normal concentrations of muscle damage markers and subjective fatigue after eccentric exercise. Consequently, participants experienced an increased perception of pain and fatigue, as well as no change in their elevated levels of muscle damage markers, even after ice was applied to the site of trauma (49).
The authors of these studies have merely supported the notion that ice therapy may be beneficial in pain management, but not one could definitively prove that ice decreased swelling or attenuated the recovery process. In some cases, the authors suggested that evidence in support of icing is insufficient and more studies are warranted (8, 16, 47). There is no evidence in the available literature that definitively supports the notion that ice belongs in a rehabilitation protocol for an acute musculoskeletal injury, unless pain reduction is the only desired outcome.
It is difficult to assert that compression and elevation are always advantageous when utilized in a recovery protocol, as clinical research has not yet provided definitive guidelines on their usage. However, besides the possibility of applying too much pressure to the limbs and reducing circulation, there are no adverse side effects associated with applying compression. Consequently, if the application of compression or elevation creates a placebo effect and makes the athlete, patient, or client feel better during the recovery process then it may be justified to continue their use. However, prioritizing the application of compression or elevation over another therapeutic approach is unsubstantiated.
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. Therefore, a period of stillness will not adequately evacuate the damaged site and the area will remain congested with metabolic waste. This congestion can delay the completion of the inflammatory process, which will result in an inability to progress to the processes of repair and remodeling (43).
MEAT (movement, exercise, analgesia, treatment) has been proposed as a more optimal alternative and effectively addresses the discrepancies surrounding the RICE protocol. Instead of resting an injury, this acronym suggests moving the damaged area through a range of motion that is pain free in an effort to provide the propulsive force required to adequately move lymph throughout the body. Exercise with resistance should be the next step beyond simple movements. Campbell (6) suggests that eccentric loading should be prioritized when rehabilitating a tendon injury.
The final aspect of the MEAT protocol is treatment. This is a broad category that consists of treating the individual injury using a variety of therapeutic approaches that are utilized on a patient to patient basis. Campbell (6) suggests the consumption of certain supplements/nutrients that reduce inflammation, as well as the application of rehabilitation modalities such as kinesiology taping or acupuncture.
In addition, the application of ice, or cryotherapy, has been found to not only delay recovery, but to also damage tissue in the process (9, 20, 27, 49). The evidence suggests that the application of ice is only necessary if pain reduction is the desired outcome (3, 8, 16, 19, 26). Evidence in support of compression and elevation is lacking, as most studies are inconclusive (4, 35, 51) and fail to establish definitive application guidelines that are supported by research. These findings, along with the public recant from Dr. Gabe Mirkin in 2015 (31), support the premise that the RICE protocol, which is a generally preferred method of immediate treatment for acute musculoskeletal injuries, is a myth.
Based on the available literature, a rehabilitation protocol for an acute athletic injury should prioritize pain free movement through a full range of motion as early as possible and gradually progress to higher intensities and more complex movements. In addition, the healthcare professional should evaluate the individual injury and work with the patient or athlete to decide which therapeutic modalities are most appropriate. If a patient or athlete believes that compression or elevation is beneficial to their recovery process then the two modalities can be used, as it has been purported that there are no adverse side effects associated with their application. The method and duration of the compression should be at the discretion of the healthcare professional, as no definitive guidelines have been purported. However, there should be little to no utilization of ice or NSAIDs, unless the only desired outcome is pain reduction.
Women's opportunities for competitive physical activity were limited in America until Federal Legislation, commonly referred to as Title IX, became law. It required American society to recognize a woman's right to participate in sports on a plane equal to that of men. Prior to 1870, activities for women were recreational rather than sport-specific in nature. They were noncompetitive, informal, rule-less; they emphasized physical activity rather than competition. In the late 1800's and early 1900's, women began to form clubs that were athletic in nature. Efforts to limit women's sport activity continued as they became more involved in competitive sports. This paper will present a history of women's involvement in sport prior to the federal legislation enacted to eliminate sexual discrimination in education and sport.