The cornerstone of nonpharmacologic therapy for acute injury in the first 48 to 72 hours is known by the acronym RICE: rest, ice, compression, and elevation10 (Table 60—1). Rest eases pressure on the affected area and promotes pain control during the acute inflammatory phase (the first 1-5 days after injury). Ice, compression, and elevation initially minimize bleeding from broken blood vessels. Cold causes vasoconstriction, assisting in prevention of a large hematoma and providing analgesia by slowing nerve impulses. Compression, achieved by wrapping the area with an elastic bandage, also reduces the size of the developing hematoma. Preventing hematoma formation is important because a large hematoma can limit mobility and range of motion.
Both cold and compression also decrease interstitial edema and swelling that accompany the injury. Elevation decreases blood flow and increases venous return from the affected area.
In addition to minimizing the acute inflammatory response, rest prevents additional injury to the affected area.14 The properties of the muscle-tendon unit are altered during the acute injury, with limitations on the ability of the muscles and tendons to stretch. Early activity predisposes a patient to further injury, but prolonged inactivity can lengthen recovery times.
FIGURE 60-3. Treatment plan for musculoskeletal injury or disorder.
Tticrapy_General Gu Id?lin* i
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Clinicians should instruct patients to use crushed ice or ice chips because the area will cool more evenly than with large pieces of ice. Patients should not apply ice directly to the affected area or leave it on for longer than the recommended 20 minutes because frostbite can occur.11 A thin sheet or napkin will protect the skin and also allow for better cold transfer than thicker material such as a towel. Alternatively, soaking the area for 20 minutes in a cool bath (13°C [55°F]) provides effective cooling.
For small areas, an ice massage for 5 to 10 minutes can cool the area and add re-
lief This is accomplished by freezing water in a paper cup and removing the top part of the cup to expose the ice. The exposed ice is rubbed on the affected area. Any ice application should be stopped if the area becomes white or blue.
Heat should not be applied during the acute injury phase (the first 48 hours) because it promotes swelling and inflammation.11 After the first 48 hours, many patients find that heat decreases pain and eases muscle stiffness associated with immobility. A heating pad, heat wrap, or warm bath can be used on day three or later as long as no swelling develops after heat is applied. Heat should be discontinued if increased swelling occurs. Clinicians should educate patients to avoid sleeping with, or sitting or lying on heating pads because this can result in burns. Low-level heat, such as that supplied by therapeutic heat wraps (e.g., ThermaCare) may provide a safer means of heat application. 7 However, the elderly should still be cautioned about the risk of burns and be advised to wear the wrap over thin clothing.
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