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Medscape.com
Laird Harrison
April 09, 2014

Story Source

The Wrong Therapy for Sprains and Strains?

Every now and then, a patient hobbles into the physical therapy offices of Eric Robertson, PT, DPT, still wearing a walking boot weeks after spraining an ankle.

“We kind of cringe,” says Robertson, a spokesperson for the American Physical Therapy Association and an Assistant Professor of Physical Therapy at Regis University in Denver, Colorado.

Patients should start moving most sprained and strained joints soon after the injury, yet many doctors go too far in applying the “rest” part of the traditional prescription of rest, ice, compression, and elevation (RICE), says Robertson. “This RICE construct doesn’t necessarily reflect modern science.”

RICE appears all over the Internet and in self-care books and pamphlets — wherever you can find advice about sprains and strains, including the Websites of the American Academy of Orthopaedic Surgeons (AAOS)^[1] and the American College of Sports Medicine (ACSM).^[2]

But the formula derives more from educated guessing than actual research. In recent years, a movement has grown to replace it with a more evidence-based approach. Even some defenders of RICE, such as AAOS spokesperson Barbara Bergin, MD, say RICE is not meant as a clinical guideline but more as a first-aid recommendation for laypeople.

A Problem That Affects Thousands of Patients

Sprains and strains may seem like a trivial problem. After all, they don’t kill anyone and usually heal without much intervention. But in the United States alone, some 28,000 ankle injuries occur every day.^[3]A recent systematic review in the American Journal of Medicine showed that only 35%-85% of sprained ankles heal in 3 years.^[4]

Such statistics have focused increasing attention on therapy for sprains. A 2012 editorial published in the British Journal of Sports Medicine called for replacement of RICE with a different set of guidelines: protection, optimal loading, ice, compression, and elevation (POLICE).^[5]

“Rest should be of limited duration and restricted to immediately after trauma,” the authors wrote. “Longer periods of unloading are harmful and produce adverse changes to tissue biomechanics and morphology.”

In 2013, the National Athletic Trainers Association (NATA) published some of the first official guidelines anywhere for ankle sprains.^[6] Researchers for the organization spent 6 years combing through the literature and assigning letter grades from “A” to “C,” from best to worst quality of the evidence behind each possible therapy.

Most elements of RICE got a “C,” yet lead author Thomas W. Kaminski, PhD, ATC, believes that many practitioners are still following the prescription too closely.

“I wish I could say that what we found is what is really being done in a clinical setting,” says Kaminski, Professor of Kinesiology and Applied Physiology at the University of Delaware in Newark. “That’s probably not the case.”

Evidence Supports Early Movement, Not Rest

The NATA researchers found level “A” evidence supporting functional rehabilitation — in other words, therapies that involve moving the ankle soon after the injury — for ankle sprains of grade I (stretching and damage to ligament fibers) and grade II (partial tearing of the ligaments).

No one recommends forcing patients to walk on their sprained ankles right away. But some randomized controlled trials have shown that beginning range-of-motion exercises within a couple of days, followed by gradual loading, can get patients back on their feet more quickly.^[6] Manipulation of the joint by trained therapists has also shown success in these trials.^[6]

For grade III ankle sprains (complete ligament tear), Kaminski and colleagues found “B” level evidence for immobilizing the joint for 10 days.^[6] After that, they recommend, patients should begin moving the joint. They also call for more conservative treatment of syndesmotic or “high” ankle sprains.

Which other therapies received an “A” for evidence? Balance training and nonsteroidal anti-inflammatory drugs (NSAIDs). That’s it.

Designed to improve proprioception, balance training reduced the risk for reinjury in some clinical trials.

NSAIDs are more controversial. Kaminski recommends not using them for the first 48 hours after the injury because they might interfere with the benefits of inflammation during that period.

But just because evidence is lacking for the rest of the RICE prescription, advocates of a revision aren’t ready to throw it out completely.

Rethinking RICE

Kaminski, for one, thinks ice, compression, and elevation still have a role to play. He’s most skeptical of ice.

“Maybe our European colleagues know something we don’t,” he says. “There is very little icing over there.” On the other hand, “We do know it’s a good pain reliever.”

With no contradictory evidence at hand, he’s willing to go along with the conventional wisdom behind compression and elevation: Compression can reduce the leaking of fluid through capillary into tissue spaces. And elevation can keep blood from pooling in the limb.

“Extreme swelling adds days, if not weeks, to the healing,” he says.

A similar line of thinking has convinced Stephen Rice, MD, PhD, former chair of the ACSM Health Science Policy Committee, to keep recommending ice, compression, and elevation for sprains and strains.

“I think nobody would make the argument that if you get a musculoskeletal injury you should just let it swell,” says Rice, a pediatric sports medicine specialist at Jersey Shore University Medical Center in Neptune, New Jersey. “I’ve known for many years that we don’t have the hard science, but I have nearly 40 years of experience that if you can control the swelling, people can return faster.”