Managing musculoskeletal injuries.
The mnemonic RICE (Rest, Ice, Compression and Elevation) has been in use since 1978 when first documented by Dr Gabe Mirkin and Marshall Hoffman in their book “The Sports Medicine Book” (1) and it was quickly and widely accepted as a simple, easy to apply, method for dealing with soft tissue injuries. After nearly 30 years of research there is very little evidence to support this protocol but it is still taught and administered.(2)
The merit of teaching RICE is that it is easy and we apply it to all injuries, fractures, sprains, strains and dislocations. Rather than having to worry about diagnosing the injury and treating that injury in a particular way, we can treat all injuries in the same way. Easy? Or just lazy?
Add to the confusion that there are many variations to RICE, which one do you subscribe to?
PRICE – Protection, Rest, Ice, Compression, and Elevation (4)
HI-RICE – Hydration, Ibuprofen, Rest, Ice, Compression, and Elevation (9)
PRICES – Protection, Rest, Ice, Compression, Elevation, and Support (10)
PRINCE – Protection, Rest, Ice, NSAIDs, Compression, and Elevation (11)
RICER – Rest, Ice, Compression, Elevation, and Referral (12)
POLICE – Protection, Optimal Loading, Ice, Compression, and Elevation (13)
The REAL First Aid approach to musculoskeletal injuries
The approach has three distinct phases that are taught and applied in a simple model.
2. Pain Management
Whilst we may not be able to diagnose a sprained wrist from a fracture we can – and should – assess the injury. Doing so:
a) will provide a benchmark for reassessment of both pain and damage to determine improvement or deterioration over time
b) might reveal damage to important underlying structures.
Questioning - PQRST
Pain is incredibly subjective and the term ‘pain’ is wildly vague. For the casualty to say “I’m in immense pain!” tells me nothing other than something is not normal. A critical, structured approach can help gather more detailed and relevant information:
Provocation – What caused the pain? Does anything aggravate the pain?
Quality – Can you describe the pain? Is it a dull ache, a sharp stabbing pain, a vice-like gripping pain or a numb tingly pain, for example?
Radiates or Refers – Some pain radiates outwards; is the pain spreading? Neuropathic pain will ‘refer’ i.e. the pain is felt elsewhere. A common example is sciatic pain felt caused by a trapped nerve at the base of the spine which may be felt anywhere down the leg all of the way to the foot.
Severity – Because pain is so subjective, to describe the intensity is practically worthless; a paper-cut can be agony to one person or a mild annoyance to another. A more representative assessment would be to ask the casualty to score the pain out of 10 (10 being the worst possible pain). This again is a worthless value on its own as it is simply one person’s opinion. However, if this question is repeated a change in the value stated will indicate an increase or decrease in pain. This is particularly useful if dealing with casualty’s for an extended period of time, after treating an injury or after administering pain relief.
Time – When did it start? Is it constant or does it come and go?
The answers you get may enable you to make an informed decision or they may not mean anything to you. They will mean something to someone so whether you understand the answers or not, all communication is documented and handed over to definitive care.
A physical examination may reveal more sinister damage to blood vessels or nerves.
The assessment of Circulation, Sensation and Movement (CSM) will be done before the injury is treated and after. If there is a loss of one or more of these features after treatment, it could be a result of your treatment. If this is the case, undo all of those bandages and reassess.
These features will also be assessed regularly along with the casualty’s vital signs until further help arrives. If one of these features is lost at some point, note the time and pass that information on in your handover.
2. Pain Management
Pain in itself is not life threatening but pain can cause physiological changes in blood pressure, breathing and pulse. This is interesting but the main reason to manage a casualty’s pain, is to make your life and theirs more bearable.
A pain-free casualty will be
- more compliant
- more willing to engage in their own treatment
- less dependent on others
- easier to move and transport
- more willing to accept potentially painful procedures such as examination or wound cleaning, for example.
- Better rested with less disturbed sleep, less stressed and generally a nicer person to be around. This is especially important in remote areas when living in small groups or teams and in confined areas!
What is Pain?
Pain has two primary etiologies: nociceptive and neuropathic. The difference is whether the pain stimulus comes from a nerve receptor, intended to sense pain, touch, temperature, or pressure (nociceptive); or if the pain stimulus comes directly from injury to the nerve itself (neuropathic).
Nociceptive pain, for example, is the pain that occurs when you hit your thumb with a hammer. The impact stimulates the nerve receptors, sending pain signals to the brain. If you push on the area of pain, it will make the pain worse.
Neuropathic pain, on the other hand, is radiating or referring pain that occurs when a nerve itself is injured. For example, the casualty may have ruptured a disk in their lower back, and that disk is now compressing the left L5 nerve root of the sciatic nerve. As a result, they will have pain that radiates down the back of their leg to their foot. When you push on the areas of apparent pain – the foot - it does not cause more discomfort because the problem is at the disc, not where the pain is presenting.
Nociceptive pain is easily managed with non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen in the US) and opioids. Neuropathic pain does not respond as well to these usual pain relievers, making it harder to manage.
There are two methods we can employ to help reduce pain; medicated and non-medicated.
Non-Medicated Pain Control
Pain can be reduced, to some degree, without the need of medications.
Rest: Rest for the first 48-72 hours (4)
Ice: Apply cool compresses to the affected area to cause vasoconstriction, reducing swelling and thus reducing pain. This also minimizes any further bleeding into the damaged tissue. Ice is a metaphor for cool – NEVER apply ice directly to skin. If you have ice available (from a drinks bucket, a bag of frozen peas or even snow or ice itself), wrap the ice in something wet which will conduct heat quickly but will reduce the chance tissue damage.
A regime of a 15-20 minutes every 2-3 hours during the day for the first 48-72 hours following the injury (4). This ensures vasoconstriction does not lead to frostbite in the affected limb and, furthermore, alternate cooling and rewarming is more effective than continual cooling as the affected area also needs a good supply of blood to remove waste products and promote healing.
Comfortable position: The conscious casualty will always support an injury in a comfortable position. Again, telling casualties to elevate an injury if it is not already elevated is a nonsense. The comfortable position will provide more pain relief than the purported benefits of elevation. Don’t worry about whether you should be applying a ‘high arm sling’ or a ‘broad arm sling’ – the best treatment you can provide to the casualty here is to support the injury in the position found.
In terms of positioning the casualty, conscious casualties will always adopt a comfortable position, be it laying down, going 'foetal' or sitting up. Do not force a casualty into a position; let them adopt the position they want.
Further reading - Casualty Positions
Reassurance – Pain is a physiological response to either the stimulus of nerve receptors or the presence of chemical mediators but the perception of pain can be exacerbated or suppressed depending on the level of emotional support provided to the casualty. Do not underestimate the value of emotional support.
Distraction – By the same token, do not do everything for the casualty. The best way to make someone feel helpless is to treat them as though they are. Engaging the casualty in their own treatment and keeping them occupied is an effective method of distraction.
Further reading - The Art of Questioning
Traction can relieve pain but training is essential.
Medicated Pain Control
There are a lot of myths which are still spread in society and on some formal training courses regarding our ability to give casualties medication. Providing over-the-counter pain relief to casualties is appropriate if done properly. This article provides simple advice on over-the-counter medicines, this article goes into more detail on the administering of medicines.
A mild analgesia that is known for its additional quality of ‘thinning the blood’. It doesn’t actually thin the blood but it is what’s known as a platelet aggregation inhibitor; it inhibits blood clotting. This can be used to good effect as prophylactic medication at altitude or for these with cardiac problems but can cause continued bleeding in a soft tissue injury.
300mg – 600mg every 6 hours to a maximum of 4g a day. Take with food and avoid if there is a history of stomach ulcers or an allergy to ibuprofen.
A much underrated pain relief; paracetamol is an effective pain killer to the extent that IV paracetamol is regularly used in A&E departments where lay-people would commonly expect much ‘stronger’ pain relief to be used.
When we think of anti-inflammatory drugs we typically think of Ibuprofen but paracetamol is also an effective anti-inflammatory.
Paracetamol – like all drugs – does not come without warning. Paracetamol is toxic in comparatively small amounts.
500mg – 1g (one to two tablets) every 4-6 hours to a maximum of 4g a day. Paracetamol should be avoided where there is a history of liver problems
Ibuprofen (or ‘brufen’) is well known as an anti-inflammatory and therefore ideal for bone or joint injuries however as platelet aggregation inhibitor (although to a lesser degree than aspirin) it should be avoided in the first two days of injury as it may promote bleeding into the tissue (14, 15, 16) , in which case start with paracetamol and add ibuprofen if needed.
200mg-400mg 8 hourly – with food – to a maximum of 1200mg a day.
Paracetamol + Ibuprofen
Paracetamol and Ibuprofen can be combined safely to increase the efficacy to greater effect than some narcotics (17).
400mg ibuprofen 8 hourly (to a maximum of 1200mg in 24hrs) + 1g paracetamol 6 hourly (to a maximum of 4mg in 24 hours)
Both ibuprofen and paracetamol are currently available with codeine over-the-counter. These represent the strongest openly available analgesics.
Codeine has a constipative effect so your casualty may need to consider laxatives after several doses of codeine. Codeine is addictive and should not be taken for more than three days.
After pain has been managed, our treatment is limited to reducing movement. Movement aggravates pain and inhibits healing. How involved our treatment is will depend on several factors.
- Are they able to support the injury themselves?
- How much pain is the casualty in?
- Do we have to move the casualty?
- How long will we be with the casualty?
For example, a casualty who has fallen onto an outstretched hand, with only a mild amount of pain, close to definitive care, who has full range of movement and CSM, who is not going to be moved may not require any additional support other than ‘nursing’ their arm whilst cold therapy or pain relief is administered.
A casualty with an obvious fracture dislocation, whose ankle is clearly displaced, in considerable pain and is far from help will clearly require immobilisation.
This requires the care giver to make an informed decision. Immobilisation is time consuming, always more difficult in reality than in the classroom and is likely to cause pain whilst being applied to the casualty. As such a more pragmatic approach is promoted of “doing as little as is needed, not as much as can be done”.
The options available to us are:
Rather than promoting RICE as a panacea for all injuries a more considered, pragmatic approach is required. This three stage model allows the First Aider to assess, make informed decisions and treat the casualty appropriately and to the best of their ability.
Mirkin G. and Hoffman M. (1978) The Sports Medicine Book. Little Brown and Co. p.94
- van den Bekeron, M.P.J., Struijs, et al ( 2012 ) What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults?. Journal of Athletic Training. 47( 4), 435- 443.
- Kerr KM, Daley L, Booth L, Stark J. PRICE guidelines: guidelines for the management of soft tissue (musculoskeletal) injury with protection, rest, ice, compression, elevation (PRICE) during the first 72 hours (ACPSM) ACPOM. 1998;6:10-11.
http://www.csp.org.uk/publications/price-guidelines-guidelines-management-soft-tissue-musculoskeletal-injury-protection-re. Accessed 28th July 2016.
- National institute for Clinical and Healthcare Excellence (2016). "Sprains and strains". Clinical knowledge Summaries. http://cks.nice.org.uk/sprains-and-strains#!scenario Accessed 28th July 2016
- MacAuley D. (2001) Do textbooks agree on their advice on ice? Clinical Journal of Sport Medicine 2001;11(2):67-72.
- Hansrani, V., Khanbhai, et al ( 2015 ) The role of compression in the management of soft tissue ankle injuries: a systematic review. European Journal of Orthopaedic Surgery & Traumatology. 25( 6), 987- 995.
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- Airaksinen O, Kolari PJ, Miettinen H. Elastic bandages and intermittent pneumatic compression for treatment of acute ankle sprains. Archives of Physical Medicine and Rehabillitation. 1990;71(6):380–393.
- Tilton B. (2003) “Trekker’s handbook – Strategies to Enhance your Journey”. Mountaineers Books, Seattle, Washington. p94
- Kannus P. (2000) Immobilization or early mobilization after an acute soft-tissue injury? The Physician and Sportsmedicine. 2000 Mar;28(3):55-63.
- Blesi M, Wise BA, Kelley-Arney C. (2011) Medical Assisting Administrative and Clinical Competencies. Cengage Learning. p1241
- Llewelyn H, Ang HA, Lewis K, Al-Abdullah A. (2014) Oxford Handbook of Clinical Diagnosis. Oxford University Press. p447.
- Starkey C. (2013) Therapeutic Modalities. FA Davies. p14.
- Braund, R., Haxby Abbot and J. ( 2007 ) Analgesic recommendations when treating musculoskeletal sprains and strains. New Zealand Journal of Physiotherapy. 35( 2), 54- 60.
- Orchard, J.W., Best, et al ( 2008 ) The early management of muscle strains in the elite athlete: best practice in a world with a limited evidence basis. British Journal of Sports Medicine. 42( 3), 158- 159.
- Carter, D. and Amblum-Almer and J. ( 2015 ) Analgesia for people with acute ankle sprain. Emergency Nurse. 23( 1), 24- 31
- Mehlisch DR, Aspley S, Daniels SE, Southerden KA, Christensen KS. (2010) "A single-tablet fixed-dose combination of racemic ibuprofen/paracetamol in the management of moderate to severe postoperative dental pain in adult and adolescent patients: a multicenter, two-stage, randomized, double-blind, parallel-group, placebo-controlled, factorial study.". Clinical Therapeutics. 2010 Jun 32 (6): 1033-4