Following an injury or pathological process there is an immediate inflammatory response. Scott et al. (2004) describe inflammation as a complex process that can be viewed at four levels: clinical, physiological, cellular and molecular, and suggest that it is the application of clinical reasoning skills that allows us to define which level is relevant in any given situation. Discussion of the complex biochemical sequences involved in the inflammatory process are beyond the scope of this chapter – the reader is referred to the wealth of books which discuss these biochemical and pathological aspects in more detail.

The inflammatory response has been reported to last for several days, or even weeks, but usually peaks around 2–3 days post-injury. During this inflammatory phase there may well be several clinical features evident. These include redness, swelling, pain and loss of function. During inflammation there is primarily a vascular and cellular response. The vascular response is a result of chemical inflammatory mediators and also a neural effect on the arterioles. There is an initial vasoconstriction that lasts only a period of seconds, followed by a more prolonged vasodilation response. There is also an increase in the permeability of the capillary walls allowing migration of large plasma proteins into the interstitial space. This alters the osmotic pressure in the tissue and exudate will gather in the interstitial space causing swelling. As cells migrate across the vessel wall into the interstitial fluid this will become cellular exudate. This exudate will contain mainly neutrophils initially and then lymphocytes and monocytes as the inflammatory process progresses (Mutsaers et al. 1997).

The cellular response is mediated and maintained by chemical mediators, which results in altered cellular activity. These processes will eventually aid the removal of any microorgansims and damaged tissue debris. Pain is caused by both irritation of damaged nerve endings from these chemical mediators and pressure on nocioceptors from the increase in exudate.

Often, clinically, this inflammatory phase is seen as a hindrance to the repair process and interventions that have an anti-inflammatory action are often employed with the aim of halting and slowing this process. It should be noted, however, that inflammation is, in fact, a normal response to injury and should be facilitated in order for the patient to progress through the healing and repair continuum.

Clinical note

There is some debate as to whether non-steroidal anti-inflammatory drug (NSAID) therapy should be used in soft tissue injury as it may slow down this phase of tissue healing, thus slowing overall recovery. Alternatively, the suggestion is that if it controls the inflammatory response and prevents it becoming exaggerated or prolonged this may, in fact, facilitate progression through the healing continuum.

Occasionally, individuals will develop a prolonged or exaggerated inflammatory response that fails to resolve within the normal timeframes. The mechanisms behind the development of chronic inflammation are not yet fully understood and are beyond the scope of this chapter.

Physiotherapy interventions in phases 1 and 2 (0–72 hours post-injury)

When considering the physiotherapy approaches that we can employ at these early stages of tissue injury, we must consider the physiological processes occurring and the aims and physiological responses to treatment.

When treating any patient with an acute injury, for example a ligament sprain or a muscle contusion, the aims of treatment must be decided in specific relation to the individual, in order to plan treatment accordingly.

General physiotherapy aims of early phase management (phases 1 and 2)

The aims are:

• to reduce pain;

• to limit and reduce inflammatory exudates;

• to reduce metabolic demands of tissue;

• to protect newly damaged tissue from further injury;

• to protect the newly-forming tissue from disruption;

• to promote new tissue growth and fibre realignment;

• to maintain general levels of cardiovascular and musculoskeletal fitness/activity.

The PRICE principles

PRICE is a mnemonic for the principal interventions commonly used in the immediate early stages following tissue injury. PRICE stands for :

These interventions together are applied in principle to address the seven aims of early phase tissue injury and healing management. These interventions are discussed below. The reader is also referred to the guidelines written in conjunction with the Association of Chartered Physiotherapists in Sports Medicine (ACPSM), on the immediate management of soft tissue injury using the PRICE principles (Bleakley et al. 2010).

Protection

When soft tissue injury has just occurred it is important to protect tissues from further damage, both chemical and mechanical (secondary), and also to protect newly forming collagen fibrils in the following days. Measures to prevent tissues from this further mechanical damage are generally described as protective modalities and may include treatments such as strapping, use of crutches, slings and braces, and modification of exercises and movements.

Strapping

There are various techniques of strapping that can be applied in the early stages to protect injured areas from further damage while allowing the individual to continue with other activities and exercise. When deciding on the use of a strapping technique it is important to consider the structure(s) damaged and the movement(s) which are likely to stress the damaged area. Strapping can be applied in a manner to allow maximal movement while protecting from the movement(s) likely to cause further damage. Again, this emphasises why it is essential that the physiotherapist has a detailed knowledge of anatomy and human movement when treating injured and healing tissues.

It is important to remember that any strapping applied in these early stages must be able to accommodate a change in size or circumference because of swelling, to prevent compromise of the circulatory system. Often compression bandaging (as discussed below) will alone restrict movement and may be sufficient to protect from unwanted movement. Alternatively, additional specific strapping may be applied to reinforce and prevent specific movement patterns.

Clinical note

If someone has injured their anterior talofibular ligament in their ankle it will be necessary in these early stages to protect this structure from stresses into inversion and plantar flexion while allowing eversion and dorsiflexion movements. This can be achieved through accurate strapping.

Strapping needs to be reapplied regularly and also needs to be monitored regularly to ensure its safety and effectiveness. The physiotherapist will need to consider if the patient is able to reapply strapping independently or not, which may influence its use if the patient has limited contact with the physiotherapist.

The patient must also understand the limitations of the strapping. Some individuals may feel able to continue with all activities while wearing strapping when, in fact, this could be detrimental to the injured and surrounding tissues.

Other methods of protecting injured and healing tissues

The main factors affecting the physiotherapist’s decisions to use a protective device are the individual’s needs, the extent and nature of the tissue injury and the location of the damage. Devices such as slings may serve the purpose of elevating the limb while also having a protective role.

Clinical note

In the case of a patient having had a fasciectomy for release of Dupuytren’s contracture, a splint is required immediately postoperatively to put the newly cut tissues under stress and encourage lengthening in order to prevent newly forming tissue from re-tightening, thus causing continued reduced function of the hand.

Walking aids

Walking aids will need to be provided if gait is altered. Also, partial weight-bearing may be advised in the early phases to protect damaged tissues, which will be stressed excessively during weight-bearing. Remember that the main aim of prescribing a walking aid is to promote a normal gait pattern within the limits of any restricted weight-bearing. This is essential to allow normal movement patterns of adjacent joints and body segments and to minimise any secondary problems.

Rest

Rest, in this context, usually refers to some form of relative rest in terms of general movement and activity to reduce metabolic demands and, hence, further secondary chemical damage to tissues. Rest from specific activities (relative rest) will also go some way towards protecting damaged and newly forming tissue.

However, it must be remembered that excessive unloading of the structures and prolonged rest can do harm to the patient so must be balanced carefully with appropriate activity (Bleakley et al. 2010). Therefore, the physiotherapist needs to carefully balance these protection and rest aims with those of promoting movement in order to maintain normal function of adjacent joints and structures.

In the very early stages (0–48 hours) when the tissues are still likely to be bleeding and the inflammatory process will be underway, the patient should be encouraged to rest the injured area fully to prevent increased bleeding and inflammatory response.

As this very early phase ends (around 48 hours), very gentle movement is needed to help improve circulation and removal of waste products, and to provide the necessary stresses for the correct alignment and orientation of newly forming tissue fibres. Both local and systemic exercise can assist in this process through changes in haemodynamics and lymphatic function (Bleakley et al. 2010).

This trade off between rest and activity can often form conflicting advice for the patient – the physiotherapist needs to ensure that advice regarding movement and activity is clearly understood by the patient for maximum benefit.

Again, it is worth remembering at this stage that effective physiotherapy practice is underpinned by firm clinical reasoning where individuals’ physical, social and psychological needs, their tissue damage and stage of healing are all considered in light of considered best practice in that treatment area.

Clinical note

It is essential with both elite and recreational athletes that they are advised and managed in terms of maintaining cardiovascular fitness and musculoskeletal fitness. This may require the individual to do a reduced or non-weight-bearing activity/programme such as exercise in water or reduced impact activity, or activities that do not involve the affected area. Remember, athletes may be eager to restart activity prematurely and the physiotherapist must take an active role in ensuring the patient fully understands the implications of all activities on the likely outcome of their injury/problem.

Cryotherapy (ice therapy)

Cryotherapy is defined as the use of cold and cooling agents used for therapeutic benefits, and has long been considered an important part of early tissue injury management. There are various methods of cooling tissues including the application of crushed ice, ice/gel packs, cold compressive devices and ice submersion. The comparative effects of these have not been fully investigated and the method of application is still mainly determined by the nature of the injury, equipment variability and therapist preference. The use of cryotherapy has not been fully investigated in terms of scientific research and much of physiotherapy practice in this area is based upon experiential evidence.

The primary reason for applying ice in the immediate early injury management is to cool the affected tissues, hence reducing the metabolic demands of the neighbouring cells. This should enable more cells to survive the ischaemic phase, thus minimising secondary tissue damage. It is suggested that to maximise the therapeutic effects of cryotherapy, an optimal tissue temperature reduction of 10–15° is required (MacAuley 2001). If the application of cryotherapy can reduce the number of cells damaged overall, the healing and repair process will be quicker, hence speeding up return to function.

Traditionally, the application of cryotherapy may have been thought to induce vasoconstriction of the small blood vessels, thus reducing blood supply to the area and hence causing increased ischaemia to the tissues and further secondary damage as initially described by Knight (1989). Merrick (2002) suggests that the secondary injury model described above now better describes the effects of cryotherapy. It must be noted, however, that there is very little conclusive evidence that investigates how cryotherapy affects the metabolic processes and whether it can influence inflammation (Bleakley et al. 2010).

The duration, application and frequency of cooling to achieve maximum therapeutic benefits has not yet been determined scientifically, yet these factors will greatly affect the degree of tissue cooling. Not all modes of cooling are equally effective; however, crushed ice provides effective cooling and is probably the safest (Bleakley et al. 2010). Subcutaneous fat covering will insulate deeper tissues and thus limit cooling significantly. Therefore, some areas may require slightly longer cooling times. Other important points are that the cold application should cover the whole area of injured tissue and a damp towel should be placed between the cooling agent and the skin to avoid skin and tissue damage. Using a thick, dry protective layer is likely to significantly reduce the cooling effects. It is also worth noting that research suggests that deep tissue temperature stays the same or continues to cool for up to 10 minutes following removal of an ice pack (Bleakley et al. 2010).

The use of cryotherapy is widespread in practice and it is generally accepted that it is a very safe and easy-to-use modality, making it very popular. However, it is very important to remember that direct cold application can cause what are commonly described as ‘ice burns’. This may be described as superficial frostbite and the symptoms are similar to a thermal burn with pain, redness, swelling and blistering. It has been highlighted recently that ice burns are probably under-reported and are much more common than was previously thought. Remember to exercise caution when applying cryotherapy and reassess the patient regularly. If the patient has reduced sensation, or nerve injury is suspected, extreme caution must be used and it is advisable to avoid cryotherapy until this has been fully assessed.

Clinical note