PT Tip of the Month

RICE vs. MEAT Protocol

The long standing treatment for acute injuries is often been remembered by the pneumonic RICE - rest, ice, compression, and elevation. But, is this always the most effective approach to healing and recovery? This month, we discuss when to use “Rest” and “Ice” versus “Motion” and “Exercise”.

Injury Staging

The acute stage, also considered the inflammatory stage, occurs directly after sustaining an injury. The characteristics of this stage include swelling, sudden or severe pain, and redness. Depending on the location or type of injury, difficulty bearing weight, weakness, loss of range of motion, blue/black bruising, and muscle spasm can occur. This stage typically lasts up to 72 hours (three days) after the initial injury.

The subacute phase begins when tissue begins to grow and repair damaged tissue. This newly created tissue is very fragile and prone to re-injury. Inflammation and pain begin to decrease, while motion often increases. Bruises will start to fade and become more green and yellow in color. The length of this stage can vary, however on average it lasts from day four to approximately three weeks from the time of injury.

The chronic phase follows the subacute phase and can last weeks, months, or even years if the injury is not correctly addressed. By this phase, the scar tissue has matured and this may cause fewer symptoms. Pain may not be present, but can occur with overuse or at end ranges of joint motion. After use, a dull ache at rest may also be noted. In this stage, signs of inflammation and bruising are gone.

Treatment Protocols

RICE is the traditional plan for management of injuries - using rest, ice, compression, and elevation. This protocol is a passive treatment to help address the acute phase and decrease inflammation.

  1. Rest can include immobilizing a joint with a brace, using crutches, or taking time off from doing activities that involve the affected area.
  2. Ice helps to decrease blood flow (vasoconstriction), which brings down excessive swelling and inflammation. Ice is typically recommended in 20 minute intervals a few times a day.
  3. Compression helps to keep the swelling at bay during activity.
  4. Elevation is commonly combined with ice, particularly when addressing injuries of the lower extremities. Elevating helps to drain fluid that pools in the affected area, which can improve range of motion.

While the RICE protocol has been tried and true for many years, we must keep in mind that it has a time and a place - the acute phase. If only passive treatment is used, the healing tissue does not strengthen and is at a higher risk for re-injury. By performing exercise, the injured tissue remodels and strengthens due to the forces placed on it. This phenomenon is known as Wolff's Law. Once the initial pain, swelling, and bruising subsides from the acute phase, the MEAT protocol can be helpful to speed up recovery and prevent slipping into the chronic phase of injury.

The MEAT protocol is a pneumonic for movement, exercise, analgesics, and treatment.

  1. Movement can help to stimulate blood flow, reduce the formation of poorly aligned scar tissue, and therefore improve recovery.
  2. Exercise is the next step following gentle movement. Exercise encourages further growth and strengthening of tissues, and like movement, is a great way to encourage circulation. Increased blood flow brings nutrients into the injured area while facilitating the clearance of damaged tissue and formation of new tissue. Gentle and progressive strengthening will help the body to reinforce this new tissue with collagen, therefore making it stronger and more resilient.
  3. Analgesics and pain management can be a helpful component to allowing people to maintain or regain function. It has been shown that by reducing pain, our body has an increased ability to heal. However, NSAIDs should be avoided directly after injury. There is good evidence that anti-inflammatories can inhibit healing. This may be hard to conceptualize, however inflammation is a crucial step in the early phases of the healing process. By inhibiting this initial reaction, recovery can be prolonged or impeded. That being said, in the subacute phase, NSAIDs used sparingly and as directed can help reduce pain without harm. Other forms of pain management can include acupuncture, supplements, and modalities.
  4. Treatment by a clinician can help to appropriately outline the above methods for healing. In many cases and recent studies, physical therapy has been show to be better or equally effective with less risk for healing certain injuries when compared to surgery.

Research to Support Movement/Exercise

  1. Low Back Pain - A 2010 literature review published in the Cochrane Library by Norwegian Centre for Health Services examined ten research experiments that compared bed rest (passive treatment) versus gentle exercise in individuals with low back pain. The group who performed exercises show a higher reduction of back pain and a greater ability to function compared to the bed rest group at 4 weeks and 12 weeks.
  2. Ankle Sprains - A study published in British Medical Journal in 2010 compared early therapeutic exercise after acute ankle sprains with a standard protection protocol of rest, ice, compression, and elevation intervention. They concluded that an accelerated exercise protocol during the first week after ankle sprain improved ankle function for walking, step count, and light activity exercise. Overall, the group receiving this intervention was more active during the first week post injury than the group receiving standard care.
  3. Soft Tissue Injuries - A 2004 study published in the Journal of Family Practice reviewed 49 trials of immobilization for soft tissue injuries and fractures of both upper and lower limbs, tallying data from 3366 patients. All studies in this review reported either no difference between rest and early mobilization protocols, or found in favor of early mobilization. Reported benefits of mobilization included earlier return to work, decreased pain, swelling, and stiffness, and an ability to maintain greater range of joint motion. Early mobilization caused no increased complications or residual symptoms.

References

  1. Caring Medical and Rehabilitation Services (2010). MEAT vs RICE Treatments. Retrieved from http://www.caringmedical.com/symptoms/meatvsrice.
  2. Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database of Systematic Reviews 2010, Issue 6. Art. No.: CD007612. DOI: 10.1002/14651858.CD007612.pub2.
  3. Bleakley CT, O’Connor SR, Tully MA, Rocke LG, MacAuley D, Bradbury I, et al (2010). Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ 34.
  4. Nash C. Resting injured limbs delays recovery: a systematic review. The Journal of Family Practice. 2004;53(9). Retrieved online on 7/12/15 from http://www.jfponline.com/Pages.asp?AID,

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