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220 The acronym PRICE (protection, rest, ice, compression and elevation) has been central to acute soft tissue injury management for many years despite a paucity of high-quality, empirical evidence to support the various components or as a collective treatment package. Treatment paradigms in sports medicine must be updated based on contemporary research evidence. As a recent example, the widespread use of non-steroidal antiinfl ammatory drugs in acute soft tissue injury management has been challenged, particularly with ligament and muscle injuries. 1 Ice compression and elevation (ICE) is the basic principle of early treatment. Most research has focused on the analgesic effect of icing or the associated skin or intramuscular temperature changes; a recent randomised controlled trial by Prins and colleagues, 2 which examined the effectiveness of ice on recovery from acute muscle tear, is the fi rst of its kind. Clinical studies into compression are also lacking, and much of its rationale is extrapolated from research relating to deep venous thrombosis prophylaxis and lymphoedema management; there is little clinical research on elevation. 3
Editorial
Br J Sports Med March 2012 Vol 46 No 4220
The acronym PRICE (protection,
rest, ice, compression and eleva-
tion) has been central to acute
soft tissue injury management
for many years despite a pau-
city of high-quality, empirical
evidence to support the various compo-
nents or as a collective treatment package.
Treatment paradigms in sports medicine
must be updated based on contemporary
research evidence. As a recent example,
the widespread use of non-steroidal anti-
infl ammatory drugs in acute soft tissue
injury management has been challenged,
particularly with ligament and muscle in-
juries.
1
Ice compression and elevation (ICE)
is the basic principle of early treatment.
Most research has focused on the anal-
gesic effect of icing or the associated skin
or intramuscular temperature changes;
a recent randomised controlled trial by
Prins and colleagues,
2 which examined
the effectiveness of ice on recovery from
acute muscle tear, is the fi rst of its kind.
Clinical studies into compression are
also lacking, and much of its rationale is
extrapolated from research relating to
deep venous thrombosis prophylaxis and
lymphoedema management; there is little
clinical research on elevation.
3
Protection and rest after injury are sup-
ported by interventions that stress shield ,
unload and/or prevent joint movement for
various periods. Recent animal models
4
6
show that short periods of unloading
are required after acute soft tissue injury
and that aggressive ambulation or exer-
cise should be avoided. But, rest should
be of limited duration and restricted to
immediately after trauma. Longer peri-
ods of unloading are harmful and produce
1 Health and Rehabilitation Sciences Research Institute,
University of Ulster, Jordanstown, Newtownabbey, UK
2 Sports Institute of Northern Ireland, University of Ulster,
Jordanstown, Newtownabbey, UK
3 Association of Physiotherapists in Sports and Exercise
Medicine, London, UK
4 UKCRC Centre of Excellence for Public Health (NI),
Queens University Belfast, Royal Victoria Hospital,
Belfast, UK
Correspondence to C M Bleakley, Health and
Rehabilitation Sciences Research Institute, University
of Ulster, Jordanstown, Newtownabbey, County Antrim
BT370QB, UK; chrisbleakley@hotmail.com
PRICE needs updating,
should we call the POLICE?
C M Bleakley, 1,3 P Glasgow, 2,3 D C MacAuley 4
adverse changes to tissue biomechanics
and morphology. Progressive mechani-
cal loading is more likely to restore the
strength and morphological characteris-
tics of collagenous tissue.
4
5 Indeed, early
mobilisation with accelerated rehabilita-
tion is effective after acute ankle strain.
7
Functional rehabilitation of ankle sprain,
which involves early weight-bearing usu-
ally with an external support, is superior
to cast immobilisation for most types of
sprain severity.
8
9
Functional rehabilitation aligns well
with the principles of mechanotherapy,
whereby mechanical loading prompts
cellular responses that promote tissue
structural change.
10 There are consistent
ndings from animal models that dem-
onstrate how mechanical loading upregu-
lates mRNA expression for key proteins
associated with soft tissue healing.
4
6 The
diffi cult clinical challenge is fi nding the
balance between loading and unloading
during tissue healing. If tissues are stressed
too aggressively after injury, the mechani-
cal insult may cause re-bleeding or further
damage. Protection of vulnerable tissues
therefore remains an important principle.
But, too much emphasis creates a default
mindset that loading has no place in acute
management. Rest may be harmful and
inhibits recovery. The secret is to fi nd the
‘optimal loading’.
Optimal loading means replacing rest
with a balanced and incremental reha-
bilitation programme where early activity
encourages early recovery. Injuries vary so
there is no single one size fi ts all strategy
or dosage. A loading strategy should refl ect
the unique mechanical stresses placed
upon the injured tissue during functional
activities, which varies across tissue type
and anatomical region. For example, a
muscle injury to the lower limb has cyclic
loading through normal ambulation. The
upper limb may require additional cyclic
load to be factored into the rehabilitation
program in order to maximise mechanical
stimulus.
POLICE, a new acronym, which rep-
resents protection, optimal loading, ice
compression and elevation, is not simply
a formula but a reminder to clinicians to
think differently and seek out new and
innovative strategies for safe and effective
loading in acute soft tissue injury man-
agement. Optimal loading is an umbrella
term for any mechanotherapy interven-
tion and includes a wide range of manual
techniques currently available; indeed
the term may include manual techniques
such as massage refi ned to maximise the
mechano-effect. Paradoxically, crutches,
braces and supports, traditionally associ-
ated with rest, may have a greater role in
adjusting and regulating optimal loading
in the early stages of rehabilitation.
POLICE should make us think more
about research into designing rehabilita-
tion strategies that are appropriate to the
nature and severity of injury in different
sports and activities. If the primary princi-
ple of treatment is to restore the histologi-
cal and mechanical properties of injured
soft tissue, optimal loading may indeed
be sport specifi c. The challenge is in deter-
mining what is ‘optimal’ in terms of the
dosage, nature and timing.
POLICE is not just an acronym to guide
management but a stimulus to a new fi eld
of research. It is important that this research
includes more rigorous examination of the
role of ICE in acute injury management.
Currently, cold-induced analgesia and the
assurance and support provided by com-
pression and elevation are enough to retain
ICE within the acronym.
Competing interests None.
Provenance and peer review Not commissioned;
externally peer reviewed.
Accepted 3 August 2011
Published Online First 7 September 2011
Br J Sports Med 2012;46 :220–221.
doi:10.1136/bjsports-2011-090297
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doi: 10.1136/bjsports-2011-090297
September 7, 2011
2012 46: 220-221 originally published onlineBr J Sports Med
C M Bleakley, P Glasgow and D C MacAuley
POLICE?
PRICE needs updating, should we call the
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Injured tendons require mechanical tension for optimal healing, but it is unclear which genes are upregulated and responsible for this effect. We unloaded one Achilles tendon in rats by Botox injections in the calf muscles. The tendon was then transected and left to heal. We studied mechanical properties of the tendon calluses, as well as mRNA expression, and compared them with loaded controls. Tendon calluses were studied 3, 8, 14, and 21 days after transection. Intact tendons were studied similarly for comparison. Altogether 110 rats were used. The genes were chosen for proteins marking inflammation, growth, extracellular matrix, and tendon specificity. In intact tendons, procollagen III and tenascin-C were more expressed in loaded than unloaded tendons, but none of the other genes was affected. In healing tendons, loading status had small effects on the selected genes. However, TNF-alpha, transforming growth factor-beta1, and procollagens I and III were less expressed in loaded callus tissue at day 3. At day 8 procollagens I and III, lysyl oxidase, and scleraxis had a lower expression in loaded calluses. However, by days 14 and 21, procollagen I, cartilage oligomeric matrix protein, tenascin-C, tenomodulin, and scleraxis were all more expressed in loaded calluses. In healing tendons, the transverse area was larger in loaded samples, but material properties were unaffected, or even impaired. Thus mechanical loading is important for growth of the callus but not its mechanical quality. The main effect of loading during healing might thereby be sought among growth stimulators. In the late phase of healing, tendon-specific genes (scleraxis and tenomodulin) were upregulated with loading, and the healing tissue might to some extent represent a regenerate rather than a scar.
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Previous data from spaceflight studies indicate that injured muscle and bone heal slowly and abnormally compared with ground controls, strongly suggesting that ligaments or tendons may not repair optimally as well. Thus the objective of this study was to investigate the biochemical and molecular gene expression of the collagen extracellular matrix in response to medial collateral ligament (MCL) injury repair in hindlimb unloaded (HLU) rodents. Male rats were assigned to 3- and 7-wk treatment groups with three subgroups each: sham control, ambulatory healing (Amb-healing), and HLU-healing groups. Amb- and HLU-healing animals underwent bilateral surgical transection of their MCLs, whereas control animals were subjected to sham surgeries. All surgeries were performed under isoflurane anesthesia. After 3 wk or 7 wk of HLU, rats were euthanized and MCLs were surgically isolated and prepared for molecular or biochemical analyses. Hydroxyproline concentration and hydroxylysylpyridinoline collagen cross-link contents were measured by HPLC and showed a substantial decrement in surgical groups. MCL tissue cellularity, quantified by DNA content, remained significantly elevated in all HLU-healing groups vs. Amb-healing groups. MCL gene expression of collagen type I, collagen type III, collagen type V, fibronectin, decorin, biglycan, lysyl oxidase, matrix metalloproteinase-2, and tissue inhibitor of matrix metalloproteinase-1, measured by real-time quantitative PCR, demonstrated differential expression in the HLU-healing groups compared with Amb-healing groups at both the 3- and 7-wk time points. Together, these data suggest that HLU affects dense fibrous connective tissue wound healing and confirms previous morphological and biomechanical data that HLU inhibits the ligament repair processes.
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To investigate the feasibility of a randomized controlled trial and the preliminary effectiveness of ice therapy in the acute phase of a gastrocnemius tear for the quality of functional recovery. A pilot version of an intended prospective randomized controlled clinical trial was conducted. A total of 19 patients with an acute tear in the gastrocnemius muscle were randomly allocated to either active or control treatment. The intervention consisted of the repeated application of crushed ice. Primary outcome measures were functional capacity and reconvalescence time. Secondary outcome measures were pain and work absenteeism. The number of patients we could include within the 6-hour time window and dropping out from the pilot study were regarded as indicators of the feasibility of ice therapy. A total of 16 patients were excluded from the study because diagnosis was not made within 6 hours after onset of the complaint. The 19 patients included completed the treatment. For functional capacity, reconvalescence time, work absenteeism and pain relief, no significant differences between the intervention and control group were found. The execution of a randomized controlled trial on ice therapy for acute gastrocnemius tear is feasible though quite an enterprise. First, it is recommended to improve the recruitment processes. Second, power analysis demands inclusion of 396 participants. Preliminary effectiveness in our limited-sized trial indicates that the use of ice is not beneficial for people who receive ice therapy.
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Non-steroidal anti-inflammatory drugs (NSAID) are commonly used in sports medicine. NSAID have known anti-inflammatory, analgesic, antipyretic and antithrombotic effects, although their in-vivo effects in treating musculoskeletal injuries in humans remain largely unknown. NSAID analgesic action is not significantly greater than paracetamol for musculoskeletal injury but they have a higher risk profile, with side-effects including asthma exacerbation, gastrointestinal and renal side-effects, hypertension and other cardiovascular diseases. The authors recommend an approach to NSAID use in sports medicine whereby simple analgesia is preferentially used when analgesia is the primary desired outcome. However, based both on the current pathophysiological understanding of most injury presentations and the frequency that inflammation may actually be a component of the injury complex, it is premature to suppose that NSAID are not useful to the physician managing sports injuries. The prescribing of NSAID should be cautious and both situation and pathology specific. Both dose and duration minimisation should be prioritized and combined with simple principles of protection, rest, ice, compression, elevation (PRICE), which should allow NSAID-sparing. NSAID use should always be coupled with appropriate physical rehabilitation. NSAID are probably most useful for treating nerve and soft-tissue impingements, inflammatory arthropathies and tenosynovitis. They are not generally indicated for isolated chronic tendinopathy, or for fractures. The use of NSAID in treating muscle injury is controversial. Conditions in which NSAID use requires more careful assessment include ligament injury, joint injury, osteoarthritis, haematoma and postoperatively.
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Background: Acute lateral ankle ligament injuries (ankle sprains) are common problems in acute medical care. The treatment variation observed for the acutely injured lateral ankle ligament complex suggests a lack of evidence-based management strategies for this problem. Objectives: The objective of this review was to assess the effectiveness of methods of immobilisation for acute lateral ankle ligament injuries and to compare immobilisation with functional treatment methods. Search strategy: We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001); the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966-May 2000), EMBASE (1988-May 2000), reference lists of articles, and contacted organisations and researchers in the field. Selection criteria: Randomised and quasi-randomised controlled trials comparing either different types of immobilisation or immobilisation versus functional treatments for injuries to the lateral ligament complex of the ankle in adults were included. Trials which investigated the treatment of chronic instability or post-surgical treatment were excluded. Data collection and analysis: Data were independently extracted by two authors. Where appropriate, results of comparable studies were pooled using fixed effects models. Individual and pooled statistics were reported as relative risks with 95% confidence intervals for dichotomous outcomes and weighted (WMD) or standardised (SMD) mean differences and 95% confidence intervals for continuous outcome measures. Heterogeneity between trials was tested using a standard chi-squared test. Main results: Twenty-one trials involving 2184 participants were included. The mean validity score of the included trials increased from 9.1 (SD 3.0) to 10 (SD 2.9) after retrieving further information (maximum 18 points). Statistically significant differences in favour of functional treatment when compared with immobilisation were found for seven outcome measures: more patients returned to sport in the long term (relative risk (RR) 1.86, 95% confidence interval (CI) 1.22 to 2.86); the time taken to return to sport was shorter (WMD 4.88 (days), 95% CI 1.50 to 8.25); more patients had returned to work at short term follow-up (RR 5.75, 95% CI 1.01 to 32.71); the time taken to return to work was shorter (WMD 8.23 days, 95% CI 6.31 to 10.16); fewer patients suffered from persistent swelling at short term follow-up (RR 1.74, 95% CI 1.17 to 2.59); fewer patients suffered from objective instability as tested by stress X-ray (WMD 2.60, 95% CI 1.24 to 3.96); and patients treated functionally were more satisfied with their treatment (RR 1.83, 95% CI 1.09 to 3.07). A separate analysis of trials that scored 50 per cent or more in quality assessment found a similar result for time to return to work only (WMD (days) 12.89, 95% CI 7.10 to 18.67). No significant differences between varying types of immobilisation, immobilisation and physiotherapy or no treatment were found, apart from one trial where patients returned to work sooner after treatment with a soft cast. In all analyses performed, no results were significantly in favour of immobilisation. Reviewer's conclusions: Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated.
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Inversion ankle sprains are one of the most common injuries in sports. Although these injuries are often considered minor, they can lead to persistent disability in athletes. We conducted a systematic review of the literature to evaluate the effect of immobilization versus early functional treatment on time to return to preinjury activity after inversion ankle sprain. Residual subjective instability, recurrent injury, and patient satisfaction were secondary outcomes. A systematic review identified 9 randomized controlled trials. Return to preinjury activity was less with early functional treatment in 4 of 5 studies that evaluated this outcome. Subjective instability was less in 3 of 5 studies. Similarly, reinjury rate was less in 5 of 6 studies. Patient satisfaction was not substantially different in the two studies that evaluated this outcome. Limitations of the identified trials included small sample size, heterogeneity of treatment methods, and lack of standardized outcome measures. However, based on our review the current best evidence suggests a trend favoring early functional treatment over immobilization for the treatment of acute lateral ankle sprains.