Bleakley, Chris M

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Physiotherapy Ireland. 2009;30(2)www.iscp.ie 19Treating soft tissue injuries with protection, rest, ice,compression and elevation has been the mantra ofphysiotherapists for many years. Commonly shortened by theacronym ‘PRICE’, this approach is also widely accepted bylayman as an essential component of first aid practice.O’Sullivan and Keane’s1 interesting survey of female Gaelicfootballers published in the current issue of PhysiotherapyIreland, sought to determine the depth of athletes’ knowledgeon using PRICE for self-management of soft tissue injuries.Although most of the participants were aware of its basicconcept, there were wide variations in practice, particularlyregarding the choice of dosage, and the optimal modalitycombination. Given that none of the athletes included in thesurvey were medically qualified, we might have anticipatedthe observed variation in O’Sullivan and Keane’s1 results.What may be more surprising however, is that similar surveysconducted on physiotherapists and other medical practitioners,have also yielded disjointed results.So why is there such a lack of consensus when it comes totreating acute soft tissue injuries? O’Sullivan and Keane1suggest that shortcomings in the evidence base areundoubtedly a factor. Indeed, the majority of clinical studies inthis particular area lack internal validity and few haveconsidered or reported adequate details on treatment dose.2However, a lack of good quality randomised controlled trialsmay just the tip of the ice pack (berg)! Delving into thepreclinical research in this area also shows that a number ofseemingly basic concepts cannot be fully explained.For many clinicians, their rationale for using modalities suchas ice and compression after an injury is simply that it controlsthe clinical signs of inflammation. Applying a cold compresson an injury that is hot, red and swollen is commonsensical;but it clearly overlooks other potentially importantphysiological, cellular and molecular events. We use the terminflammation constantly in the clinic when referring to acuteinjuries however few can define what they mean by it. There iscontinued confusion as to whether inflammation is a ‘bad’process, or, whether it is in fact fundamental for optimalrepair.3 With major advances in our understanding of theinflammatory response in recent years, we can now begin toput these questions into context and consider the clinicalimplications and pathophysiological rationale for commoninterventions such as ice.Usually soft tissue damage relates to an acute mechanicaloverload and resultant (primary) cell injury. Although we areaware that an inflammatory response then ensues, many maynot appreciate the complexity of these molecular and cellularevents. For example there is a growing body of evidence toshow that the characteristic rapid influx of neutrophilsimmediately after injury is an event that requires particularattention. Primarily neutrophils remove tissue debris; howevercertain aspects of their function may also be destructive tohealing. This is thought to relate to their production of oxygenfree radicals and toxic enzymes. These products, coupled withthe typical ischaemic environment associated with an injurysite, can cause further (secondary) cell injury. One of thepotential benefits of applying ice is that it decreases the risk ofsecondary cell injury. This concept is supported by findingsthat cryotherapy decreases the influx of neutrophils in acutelyinjured rat tissue.4 Animal studies also show that coolingreduces the metabolic demand of cells around an injury site,allowing them to survive for longer periods in an ischaemicenvironment.5 Although these mechanisms of effect arepromising, we must consider their clinical context. Toadequately lower cellular metabolism in animal models,treatments of between 5 and 6 hours of continuous coolingwere required. Compare this to O’Sullivan and Keane’s study1where the majority of athletes favoured durations of betweenjust 5 and 10 minutes. These small dosages cause littlefluctuation to deep tissue temperature and are thereforeunlikely to influence cell metabolism. Employing longertreatment durations in the clinic is one answer; however, wemust also consider the associated impracticality, andincreased risk of side effects such as ice burns.Quantifying the degree to which our treatment modalitiescan target key events such as cell metabolism, neutrophilactivity and free radical production will be an exciting areafor future research. Indeed, the panacea may be to find amethod of inhibiting the damaging effects of cells such asneutrophils, whilst maintaining all their benefits.6 This iscertainly a challenging idea, but it is perhaps unrealistic toexpect the humble ice pack to have such a precise effect!For now, it may be more important to consider themagnitude of temperature reductions that we can achievesafely in injured humans. Whilst influencing temperature indeep tissues remains difficult, skin temperatures can bereduced significantly. The magnitude of the reduction dependslargely on the mode and duration of treatment, and thepresence or absence of a barrier. It is interesting thatO’Sullivan and Keane1 found very few athletes opted to usecrushed ice. Paradoxically, this is one of the most effectivemodes of cooling, and quickly decreases skin temperature tobelow 15°C. Physiologically, this is an important temperaturethreshold to reach, as it is associated with a number ofimportant effects including; decreases in nerve conductionvelocity, pain threshold7 and ultimately pain management. Inaddition, these effects form the basis for interventions such as‘cryokinetics’ which use cold induced analgesia to facilitateweight bearing, therapeutic exercise and normal movementstrategies after injury. Currently, it is difficult to suggest howwell cryokinetics fit with the protection and rest components ofPRICE; however it does suggest that ice could still have a roleto play beyond the acute phases of injury.It is clear that physiotherapists cannot recommend anCurrent Concepts in the Use of PRICE for Soft Tissue InjuryManagementBleakley CM11Health and Rehabilitation Sciences Research Institute, School of Health Sciences, University of Ulster, Jordanstown, Northern Irelandoptimal protocol for ice application beyond conjecture.Similarly, deciding on the most effective compressionbandage or quantifying how much rest to advice, is alsochallenging. O’Sullivan and Keane’s1 study provides furtherevidence that developing clearer evidence based guidelinesfor PRICE is an important aim for the future. However, giventhe complexity of contemporary models of inflammation, wemust also consider if is still realistic to produce one set ofdefinitive guidelines to suit every type of soft tissue injury?Furthermore, we must consider that by recommending PRICE,we are recommending a combination of different treatmentmodalities each with their own unique molecular, cellular,physiological and clinical effects.Correspondence to: Dr Chris Bleakley.Email: chrisbleakley@hotmail.comREFERENCES1. O’Sullivan K, Keane N. Female Gaelic Football Players’ AcuteSoft Tissue Injury Management. Physiotherapy Ireland.2009;30:13-18.2. Bleakley C, McDonough S, MacAuley D. The use of ice inthe treatment of acute soft-tissue injury: a systematic reviewof randomized controlled trials. Am J Sports Med. 2004;32:251-261.3. Scott A, Kahn KM, Roberts CR, Cook JL, Duronio V. What do wemean by the term “inflammation”? A contemporary basic scienceupdate for sports medicine. Br J Sports Med. 2004;38: 372-380.4. Schaser KD, Disch AC, Stover JF, Lauffer A, Bail HJ,Mittlmeier T. Prolonged superficial local cryotherapy attenuatesmicrocirculatory impairment, regional inflammation, and musclenecrosis after closed soft tissue injury in rats. Am J Sports Med.2007;35: 93-102.5. Merrick MA, Rankin JM, Andres FA, Hinman CL. A preliminaryexamination of cryotherapy and secondary injury in skeletalmuscle. Med Sci Sports Exerc. 1999;31:1516-21.6. Toumi H, Best TM. The inflammatory response: friend or foe formuscle injury? Br J Sports Med. 2003;37:284-6.7. Algafly AA, George KP. The effect of cryotherapy on nerveconduction velocity, pain threshold and pain tolerance. Br J SportsMed. 2007;41:365-369.20 www.iscp.iePhysiotherapy Ireland. 2009;30(2)

Current concepts in the use of PRICE for soft tissue injury management

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Current concepts in the use of PRICE for soft tissue injury management

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