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Editorial

loading in acute soft tissue injury man-


PRICE needs updating, agement. Optimal loading is an umbrella
term for any mechanotherapy interven-
tion and includes a wide range of manual
should we call the POLICE? techniques currently available; indeed
the term may include manual techniques
C M Bleakley,1,3 P Glasgow,2,3 D C MacAuley4 such as massage rened to maximise the
mechano-effect. Paradoxically, crutches,
braces and supports, traditionally associ-
The acronym PRICE (protection, adverse changes to tissue biomechanics ated with rest, may have a greater role in
rest, ice, compression and eleva- and morphology. Progressive mechani- adjusting and regulating optimal loading
tion) has been central to acute cal loading is more likely to restore the in the early stages of rehabilitation.
soft tissue injury management strength and morphological characteris- POLICE should make us think more
for many years despite a pau- tics of collagenous tissue.4 5 Indeed, early about research into designing rehabilita-
city of high-quality, empirical mobilisation with accelerated rehabilita- tion strategies that are appropriate to the
evidence to support the various compo- tion is effective after acute ankle strain.7 nature and severity of injury in different
nents or as a collective treatment package. Functional rehabilitation of ankle sprain, sports and activities. If the primary princi-
Treatment paradigms in sports medicine which involves early weight-bearing usu- ple of treatment is to restore the histologi-
must be updated based on contemporary ally with an external support, is superior cal and mechanical properties of injured
research evidence. As a recent example, to cast immobilisation for most types of soft tissue, optimal loading may indeed
the widespread use of non-steroidal anti- sprain severity.8 9 be sport specic. The challenge is in deter-
inammatory drugs in acute soft tissue Functional rehabilitation aligns well mining what is optimal in terms of the
injury management has been challenged, with the principles of mechanotherapy, dosage, nature and timing.
particularly with ligament and muscle in- whereby mechanical loading prompts POLICE is not just an acronym to guide
juries.1 cellular responses that promote tissue management but a stimulus to a new eld
Ice compression and elevation (ICE) structural change.10 There are consistent of research. It is important that this research
is the basic principle of early treatment. ndings from animal models that dem- includes more rigorous examination of the
Most research has focused on the anal- onstrate how mechanical loading upregu- role of ICE in acute injury management.
gesic effect of icing or the associated skin lates mRNA expression for key proteins Currently, cold-induced analgesia and the
or intramuscular temperature changes; associated with soft tissue healing.46 The assurance and support provided by com-
a recent randomised controlled trial by difcult clinical challenge is nding the pression and elevation are enough to retain
Prins and colleagues,2 which examined balance between loading and unloading ICE within the acronym.
the effectiveness of ice on recovery from during tissue healing. If tissues are stressed
Competing interests None.
acute muscle tear, is the rst of its kind. too aggressively after injury, the mechani-
Clinical studies into compression are cal insult may cause re-bleeding or further Provenance and peer review Not commissioned;
externally peer reviewed.
also lacking, and much of its rationale is damage. Protection of vulnerable tissues
extrapolated from research relating to therefore remains an important principle. Accepted 3 August 2011
deep venous thrombosis prophylaxis and But, too much emphasis creates a default Published Online First 7 September 2011
lymphoedema management; there is little mindset that loading has no place in acute Br J Sports Med 2012;46:220221.
clinical research on elevation.3 management. Rest may be harmful and doi:10.1136/bjsports-2011-090297
Protection and rest after injury are sup- inhibits recovery. The secret is to nd the
ported by interventions that stress shield, optimal loading. REFERENCES
unload and/or prevent joint movement for Optimal loading means replacing rest 1. Paoloni JA, Milne C, Orchard J, et al. Non-
steroidal anti-inflammatory drugs in sports
various periods. Recent animal models46 with a balanced and incremental reha- medicine: guidelines for practical but sensible use.
show that short periods of unloading bilitation programme where early activity Br J Sports Med 2009;43:8635.
are required after acute soft tissue injury encourages early recovery. Injuries vary so 2. Prins JC, Stubbe JH, van Meeteren NL, et al.
and that aggressive ambulation or exer- there is no single one size ts all strategy Feasibility and preliminary effectiveness of ice therapy
in patients with an acute tear in the gastrocnemius
cise should be avoided. But, rest should or dosage. A loading strategy should reect muscle: a pilot randomized controlled trial.
be of limited duration and restricted to the unique mechanical stresses placed Clin Rehabil 2011;25:43341.
immediately after trauma. Longer peri- upon the injured tissue during functional 3. Bleakley CM, Glasgow PD, Philips P, et al; for the
ods of unloading are harmful and produce activities, which varies across tissue type Association of Chartered Physiotherapists in Sports
and anatomical region. For example, a and Exercise Medicine (ACPSM). Guidelines on
the Management of Acute Soft Tissue Injury Using
muscle injury to the lower limb has cyclic Protection Rest Ice Compression and Elevation.
1Health and Rehabilitation Sciences Research Institute, loading through normal ambulation. The London: ACPSM, 2011:1521.
University of Ulster, Jordanstown, Newtownabbey, UK
2Sports Institute of Northern Ireland, University of Ulster, upper limb may require additional cyclic 4. Bring DK, Reno C, Renstrom P, et al. Joint immobilization
load to be factored into the rehabilitation reduces the expression of sensory neuropeptide
Jordanstown, Newtownabbey, UK receptors and impairs healing after tendon rupture in a
3Association of Physiotherapists in Sports and Exercise program in order to maximise mechanical rat model. J Orthop Res 2009;27:27480.
Medicine, London, UK stimulus. 5. Martinez DA, Vailas AC, Vanderby R Jr, et al.
4UKCRC Centre of Excellence for Public Health (NI),
POLICE, a new acronym, which rep- Temporal extracellular matrix adaptations in ligament
Queens University Belfast, Royal Victoria Hospital, during wound healing and hindlimb unloading.
Belfast, UK resents protection, optimal loading, ice
compression and elevation, is not simply Am J Physiol Regul Integr Comp Physiol
Correspondence to C M Bleakley, Health and 2007;293:R155260.
Rehabilitation Sciences Research Institute, University a formula but a reminder to clinicians to 6. Eliasson P, Andersson T, Aspenberg P. Rat Achilles
of Ulster, Jordanstown, Newtownabbey, County Antrim think differently and seek out new and tendon healing: mechanical loading and gene
BT370QB, UK; chrisbleakley@hotmail.com innovative strategies for safe and effective expression. J Appl Physiol 2009;107:399407.

220 Br J Sports Med March 2012 Vol 46 No 4


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Editorial

7. Bleakley CM, OConnor SR, Tully MA , et al. Effect functional treatment. Clin Orthop Relat Res 10. Khan KM, Scott A . Mechanotherapy: how physical
of accelerated rehabilitation on function after 2007;455:16972. therapists prescription of exercise promotes tissue
ankle sprain: randomised controlled trial. BMJ 9. Kerkhoffs GM, Rowe BH, Assendelft WJ, et al. repair. Br J Sports Med 2009;43:24752.
2010;340:c1964. Immobilisation and functional treatment for acute
8. Jones MH, Amendola AS. Acute treatment of lateral ankle ligament injuries in adults. Cochrane
inversion ankle sprains: immobilization versus Database Syst Rev 2002;3:CD003762.

Br J Sports Med March 2012 Vol 46 No 4 221


Downloaded from http://bjsm.bmj.com/ on September 5, 2017 - Published by group.bmj.com

PRICE needs updating, should we call the


POLICE?
C M Bleakley, P Glasgow and D C MacAuley

Br J Sports Med 2012 46: 220-221 originally published online September


7, 2011
doi: 10.1136/bjsports-2011-090297

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Collections Editor's choice (343)
Injury (957)
Trauma (845)
Drugs: musculoskeletal and joint diseases (87)

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