POLICE: Optimal loading optimize recovery

Making appropriate calls for when a player has to miss out a game can be the crunch between playing that all important 1 game or being out for the remainder of the season.  It’s a tough call and the pressure that medical staff can be under is huge particularly when it’s a star player or a big game and you have a manager breathing down your neck asking when they will be fit. There are a multitude of components to the recovery process, how you prep before a game, what your post event after care includes (Cold Water Immersion, Massage, Stretches, foam rolling), what foods to eat after exercise, what to eat to optimize injury recovery (see my post on this here), getting appropriate rest and how you prepare mentally before and after a game.

That’s a lot to cover for an athlete, yet it’s also important for Joe public to consider the same in order to minimize the risk of injury.  We all stretch, hydrate, eat and relax after we exercise but what is the advice on managing our acute injuries.  I’m sure you have all heard of the PRICE acronym – Protection Rest Ice Compression Elevation.  This approach to acute injury management has been the norm for a number of years. Through revisiting and understanding the physiological processes that occur in our tissue cells and understanding how the body repairs itself it is appropriate to consider a different approach to acute injury management.

When an injury occurs there are specific stages of healing tissue undergoes. I have covered the stages of healing (here) in a previous post, so lets take a look at what can be done to influence tissue healing and potentially expedite the recovery process. In the Musculoskeletal system cells are stimulated by load and activity, cells need to be able to communicate with each other and can then adapt appropriately (reference). Therefore when we sustain an injury stimulating the cells is important.  Bone tissue is a bit different as a period of immobilization is required to allow a bone callous to form. Soft tissues heal within about 6-8 weeks depending on the severity of the injury during that time we can begin to influence the way that tissue heals.

Changing acute injury management to include optimal loading is important as it preserves movement and function of tissues. Rest tends to be included in components of the acronym such as in protection and elevation. However resting for long periods can disturb tissue make up and as such can cause poor healing of tissue.  This can affect movement of a limb, how the limb can tolerate load and can give rise to ongoing pain. Therefore we substitute the Rest part of acute injury management to get POLICE (Protection Optimal Loading Ice Compression Elevation) (reference).

Let me explain the steps:

Protection is straightforward we need to protect the injured limb from further damage, observing the injury looking for changes in the color of the skin, monitoring your symptoms and avoiding any extreme loading or movements of the injured tissues will optimize this component. Thus rest is included as part of protection.

Optimal Loading involves the gradual loading of tissues to stimulate their ability to tolerate load and to align tissue make up. This could be gently moving the injured limb, using massage, using crutches or a brace to support the tissues all done for a short duration with a progressive approach to increasing loading as the tissue repairs and becomes stronger. Historically crutches and bracing have been stigmatized as an intervention that will cause dependence resulting in muscle inhibition decreasing limb function. The right education and understanding on the use of crutches/bracing can help to preserve movement patterns, optimize tissue makeup, maintain limb and body function, support the recovering limb and increase confidence.

On the use of crutches – it has come to my attention that it is necessary to explain the correct use.  Crutches are there to help with keeping the weight of the limb but they are also used for maintaining correct movement and function of the injured limb.  When using two crutches you want to make sure that the injured limb is supported between the two crutches. When using one crutch it should be placed in the opposite hand to the injured limb.  Watch the videos here to see crutch walking technique with 1 and 2 crutches.  When it comes to stairs you should ascend stairs with the good leg leaving the elbow crutches till last.  Down stairs the injured leg leads first.  Think good leg to heaven, bad leg to hell.

Ice has been shown to have an analgesic effect either through reducing nerve conduction or muscle spasm.  It is also thought to help reduce swelling by causing vasoconstriction of blood vessels.  The agreed time frame for the application of ice is about 5-15 minutes with periods of reapplication throughout the day, which can gradually tier off as tissues recover (reference).  A common problem is that we leave ice on for too long. It seems that the ice age is truly over!  A recent blog this year has posed many reasons why ice should not be used, in particular a very interesting point that anything that reduces inflammation also delays healing.

This includes

• Anti-inflammatory medication like ibuprofen 
• applying cold packs or ice

In addition some other studies have suggested that ice also reduces strength, speed, endurance and coordination. 

There should be a maximum amount of time it is applied, no more than 10 minutes!! It should only be repeated once or twice!

Compression involves using a bandage to wrap the injured limb.  Compression is thought to help control swelling by reducing blood flow.  Compressing the injury can also make it feel better.

Elevation involves raising the limb above the level of the heart, again to reduce blood flow and to help with pain control.

In isolation the components have some benefit but in order to optimize the tissue recovery process a combination is advised. Early intervention and graded activity will enhance tissue recovery but due to the variability of injuries and their severity there is not one standardized strategy or dosage.  Yet treating appropriately and increasing the load gradually as you recover can help you gauge what your tissues can tolerate. Remember injuries vary in severity and in all cases it is necessary to seek further advice, speaking to your GP or health professional to gain an understanding of the injury sustained and tissue healing.  Your health professional can also provide reassurance that nothing sinister is going on or make the appropriate call for further investigation.

So when you sustain an injury following the acronym above can help to optimise recovery and tissue healing. The use of ice however, although still controversial, should be used with vigilance.  It is always suggested that you do seek medical advice whenever you sustain an injury in order to rule out other serious pathology and to provide you with reassurance.  The strategy discussed above is to help manage your acute injuries however after any injury a period of rehabilitation is required to restore function.  Seeing a physiotherapist to provide you with a rehabilitation program will aim to get you back to playing your sport safely and sustainably.

Thanks again for having a read, if you have any comments, please share them below.

TNP

P.S. – since publishing this post I have found an interesting systematic review that supports the effectiveness of using compression garments on enhancing recovery for exercise induced muscle damage (DOMS).  Happy days for compression!!! (reference)