Is PRICE Overrated? Rest Vs. Loading

Early rehabilitation aims to reduce the impact of the cardinal signs of inflammation, namely redness (rubor), swelling (tumour), heat (calor), pain (dolor) and loss of function (function laesa). Redness and heat occur due to the increase blood flow to injured extremities, whereas oedema (swelling) occurs because of fluid diffusion from the blood vessels to the surrounding tissues and cells in the damaged area. Pain can be caused by either the stretching of sensory nerves due to oedema or mediators from initial damage and the inflammatory response. The combination of damage, pain and oedema can lead to a loss of joint range of motion and function. Therefore, the immediate aims of rehabilitation are to stabilise bleeding and promote the initiation of the repair-regeneration cascade within hours post-injury.

Traditionally, the PRICE (Protect, Rest, Ice, Compress, Elevate) protocol has been used to manage acute soft tissue injuries. Protection and resting strategies, such as using crutches, slings and avoiding activity, may be warranted within the acute phase to provide an appropriate recovery environment and reduce the excessive scar tissue. However, long periods of unloading can result in adverse changes in tissue biomechanics and morphology. Equally, immobilisation results in rapid muscle atrophy, specifically in weight-bearing muscles, therefore normal loading should be achieved as soon as pain-free movement allows to prevent reduction of muscle mass.

To solve this problem, the POLICE (Protect, Optimally Load, Ice, Compress, Elevate) and PEACE & LOVE (Protect, Elevate, Avoid, Compress, Educate and Load, Optimism, Vascularisation, Exercise) protocols has been proposed. Optimal loading refers to utilising gradually progressive exercises that represent the mechanical stress applied to the injured tissue during functional activities to promote early recovery and limit preventable atrophy. Mechanical loading has been found to up-regulate mRNA expression for proteins associated with soft tissue healing and tissue structural change. However, if mechanical loading is applied too aggressively, then re-bleeding or further damage may occur. Therefore, there should be a significant reduction in load compared to pre-injury levels before gradually increasing load; failure to do this may lead to chronic injury. Responses to loading (e.g., pain, inflammatory responses and range of motion) should be closely monitored as excessive load may inhibit recovery and increase the risk of secondary injury.

In the early phase of rehabilitation, isometric exercises can be performed against a resistance within pain-free ranges of motion. Low intensity isometric contractions in mid-range joint positions can be used to minimise the stress placed upon the injured site whilst being in an advantageous joint angle to produce force. As one of the aims of early rehabilitation is to minimise muscle atrophy, isometrics should be performed for 3-30 seconds of sustained contraction per repetition at 70-75% maximum voluntary contraction, totalling 80-150 seconds per session to increase muscle hypertrophy. Isometrics can be gradually progressed through increasing external load, applying asymmetrical load, and increasing speed and movement complexity as responses to loading allow. Once a full pain-free range of motion is achieved, dynamic exercises should be performed to develop muscular strength, which can be achieved by performing 2-4 sets of 8-12 repetitions at 60-70% 1-repetition maximum with 2-3 minutes rest between sets, repeated 2-3 days per week. This can further be progressed to 3-5 sets of 1-5 repetitions at 80-90% 1-repetitions maximum with 1-2 minutes rest between sets, repeated 2-3 days per week, to develop strength-endurance and robustness.

Additionally, active and passive stretching. should be used as tolerated. It should be noted that stretching is contraindicated when hyper mobility, joint ankylosis, osteoporosis, recent surgery site, painful or stiff joints, joint inflammation, nerve compression, or angiopathy are present. Static stretching for 2-4 repetitions of 10-30 seconds at an intensity yielding mild discomfort has been proposed to improve range of motion, as well as reduce intramuscular pressure, reduce tissue stiffness, improve blood perfusion, improve tissue recovery, accelerate metabolite clearance, and reduce stimulation of pain and pressure receptors.

It is important that general fitness and strength is maintained during rehabilitation, but avoiding activities that apply undue stress to the injury should be avoided (e.g., upper-body conditioning block, single-leg training, or recumbent training). Maintaining general fitness and strength levels will help with returning to training later in the rehabilitation process. Additionally, the inclusion of aerobic cardiovascular activities (e.g., walking, cycling, running, rowing) for 20-60 minutes at moderate-vigorous intensity repeated 3-5 days per week can aid the development of the cardiovascular system, leading to improved recovery and a reduced need for pain medications.

In conclusion, while PRICE has a place immediately following injury, as soon as pain allows, optimal loading should replace the ‘rest’ component to limit preventable atrophy and risk of secondary injuries. Optimal loading refers to the inclusion of isometric exercises, active and passive stretches, and maintenance of the cardiovascular and (unaffected parts of) the musculoskeletal system. Both the POLICE and PEACE & LOVE protocols have been linked with improved patient outcomes.

References:

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Blazevich, A. (2016) ‘Flexibility in injury prevention and performance' in Joyce, D., and Lewindon, D. (ed), Sports Injury Prevention and Rehabilitation Integrating Medicine and Science for Performance Solutions. 1st Edn. Oxon: Routledge, pp.167-178.

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