Acute injury management – do no HARM?

It seems medical folk love a good acronym! We’ve had 3 already in managing acute injury. First we had RICE, then PRICE and then POLICE. I wonder if they just think up the word then fit the advice into it!?

What’s next Mobilisation Avoid NSAIDs Load Optimally Vertically Elevate? I can see it now on the RW Forum’s….”acute injury? What you need is MANLOVE!”….

Sadly manlove isn’t a recognised acronym in acute pain. Yet….

HARM though is a recognised acronym and details the things to avoid in the first 72 hours following an injury;

  • Heat
  • Alcohol
  • Running (or Re-injury depending on what version you use, both mean avoid excessive exercise)
  • Massage

I’ve highlighted avoid there in case you all get the wrong end of the stick and run around drunk with heat packs strapped to you, trying to massage each other!

 

What they say makes sense and is a helpful addition to the recommendations of POLICE and suggestions on use of NSAIDs.


Heat is thought to increase blood flow by causing blood vessels to dilate. This could lead to increased bleeding and swelling.

 

Alcohol is also likely to increase bleeding and may delay healing. Also it’s hard to follow the advice in POLICE if you’re rat-arsed!

 

Running or Re-injury through excessive exercise is sensible too. Healing tissue isn’t strong enough to manage the impact in running and is likely to breakdown causing further injury. You might think this would be fairly obvious but I have known runners to continue to run with alsorts of issues, including fractures!

 

Massage is also thought to increase bleeding and swelling, so I would avoid massaging directly over the injured area. A Physio may choose to massage distal to the swelling (further down the limb) to help reduce swelling, they may also massage to help acute low back pain so there are some exceptions.

 

This guidance comes from the New Zealand Guidelines Group and is available to download in full here.

 

As ever with injury the message from RunningPhysio is clear – if in doubt, get it checked out!

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Anti-inflammatory Medication and Sport

Before we kick off, I should point out I’m not a pharmacist or GP! I am not qualified to prescribe medicine and the aim of this article is not to make recommendations. What I will do though is feedback the findings of a fairly recent article by Paolini et al. 2009 in the British Journal of Sports Medicine. I’ve also had some help from Pharmacist Vaggelees Zachos who has very kindly advised me on this topic. Look him up on Twitter @vaggeleeszachos.

The article, which is currently freely available online on the link above, gives a nice overview of current thinking in the use of Non-Steroidal Anti-inflammatory Drugs (NSAIDS) in sport. Use of NSAIDs in runners appears fairly common and in elite athletes is reported to be as high as 25-35%, so it’s well worth reviewing if we are using them correctly.

When are NSAIDs contraindicated?

With some clinical conditions NSAIDs are contraindicated – this means they can’t be used. The risk of side effects in these conditions far outweighs the potential benefits. Contraindications are detailed nicely here. Some of the contraindications listed there may be fairly unlikely in runners – such as heart failure or impaired liver or kidney function but others are certainly more common. Asthma is seen as a potential contraindication but your GP may offer you a trial of the medication to see if you can tolerate it. Gastrointestinal problems are also a contraindication and are fairly common. If the problem is mild (such as indigestion like symptoms rather than peptic ulcer or gastrointestinal bleeding) the GP may provide NSAIDs with additional medication to protect the stomach. NSAIDs cause a gradual destruction of the protective mucosa of the stomach lining. As a result treatment may be limited to 5-7 days and Lansoprazole is commonly prescribed with NSAIDs, especially for athletes who are on 5 or more days of treatment. Vaggelees tells me that Fast-Tab Lansoprazole is especially effective with NSAIDs.

NSAIDs, such as Ibuprofen, are available without prescription, if you have any questions regarding whether they are safe for you to take make sure you discuss them with your GP.

When are NSAIDs most likely to help?

In inflammatory pathologies. No great surprise there – they work best when inflammation is present this includes;

  • Impingement conditions – including nerve and soft tissue impingement
  • Tenosynovitis – inflammation of the fluid filled sheath that surrounds the tendon. Acute bouts of tendon pain (e.g. From the Achilles,Tibialis Posterior and Patella tendons) are more likely to involve inflammation so NSAIDs will probably be more effective in acute tendon pain than chronic.
  • Inflammatory arthropathy – this includes things like Rheumatoid Arthritis and Psoriatic Arthritis. These are systemic conditions that can effect the whole body, not to be confused with Osteoarthritis which tends to effect individual joints.
  • ??ITBS – several studies I’ve read have suggested NSAIDs for ITB problems. Paolini et al. 2009 don’t mention it specifically. As the condition is reported to involve inflammation of the tissues around the ITB you might expect NSAIDs to be helpful.

With some conditions NSAIDs are a viable option but their usage would depend on clinical findings;

  • Ligament and joint sprains – there is evidence that NSAIDs can delay healing of ligament and bone and so probably should not be used in treatment of joint or ligament injuries. However sometimes the use of NSAIDs allows early movement and mobilisation which encourages healing. Usage would depend on the situation and whether an alternative medication might provide pain relief without adversely affecting healing.
  • Osteoarthritis and other joint conditions
  • Haematomas
  • Post operatively – be guided by your consultant on appropriate medication

What about muscular injuries?

Paolini et al. 2009 concluded that use of NSAIDs in muscular injuries was controversial and should be used with caution. There was some suggestion that NSAIDs could be used in the sub-acute stage after the initial inflammation had settled, however there was concern that NSAID could have adverse effects on healing. A suggestion has emerged from the research (although not from this article) that NSAIDs should not be used at all in the first 48 hours after a soft tissue injury, due to their effects on healing. Like anything in medicine this is not set in stone and there may be some situations where NSAIDs in this time frame may be helpful.

In what conditions are NSAIDs contraindicated because they may compromise healing?

  • Chronic tendinopathies – these are common in runners, especially Achilles Tendinopathy and Patella Tendinopathy. Research has found that chronic tendinopathies are more of a degenerate process than an inflammatory one.
  • Fractures – be guided by your consultant or GP when managing pain post fracture.

What’s the alternative?

According to Paolini et al. 2009 paracetamol has similar pain relieving effects to NSAID’s and yet has fewer risks. They suggest paracetamol should be chosen if the main aim is to reduce pain. Although generally considered a fairly mild drug and widely available with prescription paracetamol does have contraindications. Over the counter medications also combine paracetamol with caffeine (such as Panadol Extra) which may be more effective (although the research doesn’t comment on this). Anti-inflammatory creams, especially those containing Nimesulide or Diclofenac (both NSAIDs) can prove helpful for those athletes having gastrointestinal problems.

The article also mentions that medications should be combined with PRICE (Protection, Rest, Ice, Compression and Elevation) to optimise healing. I’ve recently done a piece on acute pain management here which details an update on PRICE – POLICE.

There are a multitude of different pain relieving medications available. Typically as the drug’s strength increases so do it’s potential side effects. Opioid pain relief (Codeine, Tramadol, Dihydrocodeine etc) are quite commonly prescribed but patients often complain of constipation or drowsiness.

If you are struggling to manage your pain for any reason, or struggling with side effects from medication always discuss this with your GP.

 

 

 

Acute injury management – Woop Woop! That’s the sound of da POLICE!?

When it comes to managing an acute injury many of you will have heard of RICE and some will have seen it progress to PRICE. For those that missed it, it stands for;

 

  • Protect
  • Rest
  • Ice
  • Compression
  • Elevation

 

But a recent study by Bleakley, Glasgow and MacAuley 2012 in the British Journal of Sports Medicine has suggested this needs updating and in their words we “call the POLICE”. Aside from the obvious fact that the acronym now spells a word that can be used in mildly amusing blog titles (and awesome songs) it does make sense. So POLICE would be;

 

  • Protect
  • Optimal Loading
  • Ice
  • Compression
  • Elevation

 

So why replace rest with “optimal loading”?

 

  1. While rest may be helpful in the very short term, continued rest may lead to deconditioning of the tissues – joint stiffness, muscle weakness and tightness and reduced proprioception (control and balance)
  2. Optimal loading will stimulate the healing process as bone, tendon, ligament and muscle all require some loading to stimulate healing.
  3. The right amount of activity can help manage swelling. For example in the ankle, contraction of the calf muscles helps to move swelling up the body against gravity. Complete rest would the prevent this.

 

The key word here is optimal.

 

In some cases optimal loading may be no loading. Unstable fractures, complete tendon ruptures etc are unlikely to benefit from loading and may require casting, bracing or surgical repair. There is no recipe for this, each situation needs to be managed based on the person and their injury and usually under the guidance of a health professional.

 

Like so many things in health and injury it's about balance. I'm not suggesting you ditch your crutches and run off down the street! When it comes to managing acute injuries I recommend you seek medical advice, especially if there is noticeable swelling or any restriction in joint range of movement or a sensation of giving way. Bony tenderness or difficulty weightbearing are also signs that you should get checked out.

 

With acute injuries I see I tend to adopt a policy of weightbearing as tolerated. Meaning do as much as you feel comfortable to do and don't push through pain. This usually fits within the idea of optimal loading but as ever comes with the caveat, if in doubt, get it checked out. This also includes exercises, and I encourage people to gently move the joints around the affected area, again listening to the body and not pushing through pain. It's usually better to do this little and often to prevent stiffness rather than a lot at one sitting which is more likely to cause pain. Offload taping can also be very useful to support an area when you load it, for example the Achilles taping demonstrated in my tendonopathy post. For more on the affects of loading and exercise see this excellent (though quite technical) study by Khan and Scott 2009.

 

Ice

 

 

You might be surprised to hear that the research behind the use of ice is far from conclusive. There is a real lack of high quality evidence and very little guidance in terms of how ice should be used. Despite this we all tend to reach for the ice pack when nursing an injury and I think we are right to continue to do so.

 

Although the research may not be conclusive most of us have seen from personal experience that ice can reduce pain and swelling post injury and aid a quicker return to sport.

 

There area a few of safety points with ice;

 

  1. Don't ice over a numb area or open wound. If the skin is numb you won't notice if you're developing an ice burn and ice on an open wound would risk a infection
  2. Be wary of ice burns – don't apply ice directly to the skin, wrap an ice pack in a clean, damp tea towel before applying. Avoid prolonged exposure to ice, 10-20 minutes in usually adequate and also be careful applying the ice with too much pressure (e.g. Resting your leg on the ice bag).
  3. If you use frozen peas don't eat them after!

 

Practical details in the use of ice

 

Having read several reviews of the use of ice in the literature it's very hard to make an evidence based recommendation for use of ice in terms of how long to apply it and how frequently. There is some evidence that as little as 10 minutes can be effective to create tissue cooling and that, although fairly rare, ice burn can occur after just 20-30 minutes. Baring that in mind, and in the spirit of getting the most benefit with the smallest risk of harm I'd recommend the following very general guide;

 

Apply ice wrapped in a damp towel for 10-20 minutes 2-3 times per day for the first 5-7 days post injury.

 

Stop applying ice if there are any negative effects such as increase in pain or swelling or skin soreness.

 

I'll continue to look into the research for ice and cryotherapy and will update the post if i find any more specific recommendations. If you have a different method and it works for you, stick with it! Also worth noting is that cooling can be achieved using cooling gels if you prefer.

 

Compression

 

Similar to ice the research behind compression is far from conclusive. From personal experience I find compression very useful in managing swelling and it can be used in both the acute and more chronic stages. A simple tubigrip bandage can be used, especially good for ankles and knees and I tend to use 2 layers. The area should feel compressed but not uncomfortable or painful. Ensure there is good circulation distal to the bandage (I.e. in the toes if the ankle is compressed). I usually recommend patients to remove the bandage at night for comfort when sleeping and also because swelling is usually fairly well controlled when we are lying down.

 

Elevation

 

Elevation can be very effective in reducing swelling and pain. You can combine it with gentle exercises that aid circulation such as moving the ankle up and down or tightening the thigh muscles to straighten the knee. Obviously this will depend on your injury and the guidance you get from your health professional.

 

Hang on a mo….who's taken the P?

 

Yep I've forgotten to cover P for protection. Protection is part of optimal loading and involves the use of crutches, casts, braces etc to help protect the area as it heals. Think of it as a tool to prevent excessive loading in the early stages and it's especially useful if you are struggling to weightbear and need some extra help (in which case you need to make sure you've had your injury checked out).

 

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