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• Response to Phillip Page, correspondence 'Evidence for RICE in acute sprains?'
  Gwendolyn Vuurberg, Gino M.M.J. Kerkhoffs
  Published on: 29 October 2018
• The Ankle Roll Guard is a Tested & Effective Alternative to Braces & Tape for Lateral Ankle Support
  Christopher N Dean
  Published on: 24 August 2018
• Evidence for RICE in acute sprains?
  Phillip Page
  Published on: 21 August 2018

• Published on: 29 October 2018

  Response to Phillip Page, correspondence 'Evidence for RICE in acute sprains?'

  • Gwendolyn Vuurberg, PhD student Department of Orthopaedic Surgery, Amsterdam UMC, location AMC
  • Other Contributors:
    • Gino M.M.J. Kerkhoffs, Orthopaedic surgeon

  Dear Phillip Page,
  Thank you for your compliments concerning our updated guideline. We would like to take the opportunity to respond to your feedback and the questions you raised.
  First, concerning RICE as a treatment modality and our recommendation in the guideline not to use RICE in the treatment of ankle sprains. Through our extended literature search we found insufficient evidence to support RICE as a treatment modality by itself based on reported effectiveness and therefore we could not include it as a recommendation. Despite its frequent use in daily clinical practice, especially in the acute setting, we did not find a beneficial effect of any of the individual aspects or RICE.[1-4] However, as you correctly point out, RICE in combination with other treatment modalities they seem to provide a beneficial effect to patients.[5, 6] The beneficial effect that can be measured when combining RICE clinically with other interventions such as exercise, may also derive from the other intervention. For this reason we assessed each treatment and prevention modality individually, in addition to an in-text discussion of articles that studied combined therapy.
  In your letter you mentioned that emphasis in our recommendation was missing that it concerned single therapy by adding the word ‘alone’. This is a keen observation, and even though we did use the word alone in our in-text recommendation we did not include it in our summary (table 8): “There is no evidence t...

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  Dear Phillip Page,
  Thank you for your compliments concerning our updated guideline. We would like to take the opportunity to respond to your feedback and the questions you raised.
  First, concerning RICE as a treatment modality and our recommendation in the guideline not to use RICE in the treatment of ankle sprains. Through our extended literature search we found insufficient evidence to support RICE as a treatment modality by itself based on reported effectiveness and therefore we could not include it as a recommendation. Despite its frequent use in daily clinical practice, especially in the acute setting, we did not find a beneficial effect of any of the individual aspects or RICE.[1-4] However, as you correctly point out, RICE in combination with other treatment modalities they seem to provide a beneficial effect to patients.[5, 6] The beneficial effect that can be measured when combining RICE clinically with other interventions such as exercise, may also derive from the other intervention. For this reason we assessed each treatment and prevention modality individually, in addition to an in-text discussion of articles that studied combined therapy.
  In your letter you mentioned that emphasis in our recommendation was missing that it concerned single therapy by adding the word ‘alone’. This is a keen observation, and even though we did use the word alone in our in-text recommendation we did not include it in our summary (table 8): “There is no evidence that RICE alone, or cryotherapy, or compression therapy alone have any positive influence on pain, swelling or patient function. Therefore, there is no role for RICE alone in the treatment of acute LAS (Level 2).”. However, all recommendations are provided per treatment or prevention modality and do not include combination therapy unless otherwise specified and therefore it could be discussed that the content, despite adding clarification, in essence would not change. If readers do wish to learn more on the specifics of each treatment or preventive modality we would like to invite them to read the rest of the guideline and the paragraphs that elaborate on their desired topic.
  You outline we did not include any meta-analyses on RICE interventions in supplement 3. This is correct as we were limited due to the heterogeneity in outcome measures, therapy methods and application methods, which did not allow data pooling. Even though multiple studies outlined a decrease in swelling and pain, this was measured using different methods, again not allowing pooling of data. We therefore reported the results in a qualitative manner by means of the number of studies and patients and the level of evidence.
  Concerning harmful effects, again this is a just question. Due to the current extent of the evidence we chose to present to the readers, the guideline turned out quite voluminous. We chose to present the most important findings. Where we could or when included evidence outlined harmful effects, we highlighted the potential presence or absence of harmful or side effects: “Use of an ankle brace results in better outcome compared to other types of functional treatment such as sports tape (non-elastic) or kinesiotape (elastic), without showing any side effects[7].”. Unfortunately, the combination of limited information on harmful effects in the included studies and the length and great number of included treatment modalities in our guideline, required us to prioritize and limit our overview.
  Another observation you made concerned treatment with NSAIDs, for which we describe prescription should be done so cautiously as they may negatively affect the natural healing process. Although ideally this statement would be based on a recently published RCT including a large cohort, we based it on a systematic review performed in 2003, which we still consider valid. We did not identify any new studies that described this subtopic and this component of NSAID usage was deemed so important that we agreed it should be included in this guideline. It was our task to provide an overview of the evidence on ankle sprain diagnostics, treatment and prevention, health care professionals can further decide which information they require and how they wish to implement this in clinical practice. We specifically mentioned there may be a risk at delay of the natural healing process.
  Also, concerning NSAIDs you mention the presentation of our results are conflicting. We understand that you outline the effect of oral NSAID usage on swelling stating 2/3 favored placebo. However, as of all three comparisons of oral NSAID usage the confidence interval still includes 0, we cannot say that either NSAID or placebo is favored. Grouping oral with topical NSAIDs does not change this effect as the confidence interval still includes 0. In defining a recommendation we included these non-significant results with the studies of which we could not pool our data due to heterogeneity of used outcome measures. We understand that, recommending that NSAIDs may be used to reduce pain and swelling, despite an evident effect in our meta-analyses, is confusing. This recommendation was made based on the evident positive effect regarding pain reduction and the fact that some studies were able to show a positive effect, especially of topical NSAIDs on swelling. We agree that some form of clarification going into more detail may have been required to avoid confusion.
  In conclusion, even though we have managed to write an extensive overview to describe the current best evidence practice to help professionals in clinical health care in their decision making for patients who have sustained a lateral ankle sprain, we are aware of the fact that we did not present all the evidence out there in literature. In our statements and recommendations we have made our best effort to be as concise as possible. We thank you for your great feedback and will use it in our future research, as we continue to strive to improve!
  On behalf of the guideline committee,

  Yours sincerely,
  Gwendolyn Vuurberg and Prof. Gino M.M.J. Kerkhoffs

  1. Cote, D.J., et al., Comparison of 3 Treatment Procedures for Minimizing Ankle Sprain Swelling. Physical Therapy, 1988. 68(7): p. 1072-1076.
  2. Airaksinen, O., P.J. Kolari, and H. Miettinen, Elastic bandages and intermittent pneumatic compression for treatment of acute ankle sprains. Arch Phys Med Rehabil, 1990. 71(6): p. 380-3.
  3. Rucinkski, T.J., et al., The effects of intermittent compression on edema in postacute ankle sprains. J Orthop Sports Phys Ther, 1991. 14(2): p. 65-9.
  4. Tsang, K.K., J. Hertel, and C.R. Denegar, Volume Decreases After Elevation and Intermittent Compression of Postacute Ankle Sprains Are Negated by Gravity-Dependent Positioning. J Athl Train, 2003. 38(4): p. 320-324.
  5. Hing, W., et al., Comparison of multimodal physiotherapy and "R.I.C.E."self-treatment for early management of ankle sprains. New Zealand Journal of Physiotherapy, 2011. 39(1): p. 13-19.
  6. Bleakley, C.M., et al., Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. British Medical Journal, 2010. 340.
  7. Kemler, E., et al., A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types. Sports Med, 2011. 41(3): p. 185-97.

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  Conflict of Interest:
  None declared.

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• Published on: 24 August 2018

  The Ankle Roll Guard is a Tested & Effective Alternative to Braces & Tape for Lateral Ankle Support

  • Christopher N Dean, Owner & Inventor, The Ankle Roll Guard Ankle Roll Guard, LLC

  The Ankle Roll Guard (anklerollguard.com) is a patented & independently tested, brace-less ankle support that cushions the ankle from an inversion or “roll”. Unlike conventional ankle braces, it wraps securely around the outside of any shoe type and allows the user to retain full ankle mobility and comfort.
  Benefits:
  - Patented outside shoe design allows user to retain ankle mobility & comfort while still having ankle protection (no ankle restriction like a brace)
  - Provides ankle stability & protection for users with chronic lateral ankle instability
  - Clinical, independent testing at Boise State University using a motion analysis system showed equivalent inversion protection plus better range of motion & vertical jump versus a brace or tape
  - Weighs only 2.4 ounces so users do not feel it

  Independent Testing at Boise State University
  White Paper Completed January, 2018:
  “Of all the devices (Ankle Roll Guard, Brace, Tape), only the Ankle Roll Guard appears to allow the user normal ankle motion (i.e. typical anatomical joint motion), while preventing excessive ankle inversion” 
  – Tyler Brown, PhD, CSCS, Director COBR
  ​Conclusion: The Ankle Roll Guard may provide similar prevention of excessive inversion as either the brace or tape, but without the mechanical restriction of the joint that reportedly limits physical performance when wearing ankle prophylactic devices.  With the Ankle Roll Guard, p...

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  The Ankle Roll Guard (anklerollguard.com) is a patented & independently tested, brace-less ankle support that cushions the ankle from an inversion or “roll”. Unlike conventional ankle braces, it wraps securely around the outside of any shoe type and allows the user to retain full ankle mobility and comfort.
  Benefits:
  - Patented outside shoe design allows user to retain ankle mobility & comfort while still having ankle protection (no ankle restriction like a brace)
  - Provides ankle stability & protection for users with chronic lateral ankle instability
  - Clinical, independent testing at Boise State University using a motion analysis system showed equivalent inversion protection plus better range of motion & vertical jump versus a brace or tape
  - Weighs only 2.4 ounces so users do not feel it

  Independent Testing at Boise State University
  White Paper Completed January, 2018:
  “Of all the devices (Ankle Roll Guard, Brace, Tape), only the Ankle Roll Guard appears to allow the user normal ankle motion (i.e. typical anatomical joint motion), while preventing excessive ankle inversion” 
  – Tyler Brown, PhD, CSCS, Director COBR
  ​Conclusion: The Ankle Roll Guard may provide similar prevention of excessive inversion as either the brace or tape, but without the mechanical restriction of the joint that reportedly limits physical performance when wearing ankle prophylactic devices.  With the Ankle Roll Guard, participants exhibited more natural ankle motions (i.e. plantar flexion) during both the sudden inversion event and vertical jump.  This motion allowed the participants to perform better during the vertical jump with the Ankle Roll Guard as compared to the more restrictive brace and tape.

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  Conflict of Interest:
  Owner & inventor of the Ankle Roll Guard

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• Published on: 21 August 2018

  Evidence for RICE in acute sprains?

  • Phillip Page, Physical Therapist Performance Health

  I congratulate the authors for such a well-rounded and informative update of this CPG. I was not surprised to see the conclusion in the text that the evidence is 'unclear' in the use of ice on acute ankle injuries. There simply are not enough well-controlled RCTs can support RICE's efficacy when used alone. Clinically, we always combine ice with other interventions such as exercise. Your recommendation in the text was, "There is no evidence that RICE alone, or cryotherapy, or compression therapy ALONE (emphasis added) has any positive influence on pain, swelling or patient function. Therefore, there is no role for RICE ALONE (emphasis added) in the treatment of acute LAS." Based on the evidence, I would agree with that statement. However, Table 8's "Final Recommendations" for RICE states, "RICE is not advised as treatment modality after a LAS." I would argue that the authors should have inserted the word, "ALONE" in this recommendation; otherwise, they are making a blanket conclusion that ice is NOT effective when in fact, the evidence remains unclear (there may be some benefit when used in conjunction with other treatments) and potential harmful effects were not discussed if that was part of the decision-making. Unfortunately, I was unable to find the meta-analysis data upon which these recommendations against RICE were made, as Supplement 3 did not include any analysis on RICE interventions. While I am not a...

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  I congratulate the authors for such a well-rounded and informative update of this CPG. I was not surprised to see the conclusion in the text that the evidence is 'unclear' in the use of ice on acute ankle injuries. There simply are not enough well-controlled RCTs can support RICE's efficacy when used alone. Clinically, we always combine ice with other interventions such as exercise. Your recommendation in the text was, "There is no evidence that RICE alone, or cryotherapy, or compression therapy ALONE (emphasis added) has any positive influence on pain, swelling or patient function. Therefore, there is no role for RICE ALONE (emphasis added) in the treatment of acute LAS." Based on the evidence, I would agree with that statement. However, Table 8's "Final Recommendations" for RICE states, "RICE is not advised as treatment modality after a LAS." I would argue that the authors should have inserted the word, "ALONE" in this recommendation; otherwise, they are making a blanket conclusion that ice is NOT effective when in fact, the evidence remains unclear (there may be some benefit when used in conjunction with other treatments) and potential harmful effects were not discussed if that was part of the decision-making. Unfortunately, I was unable to find the meta-analysis data upon which these recommendations against RICE were made, as Supplement 3 did not include any analysis on RICE interventions. While I am not a proponent of quick and repeated prescription of NSAIDS, I was disappointed to see the statement concluded that NSAIDS may "delay the natural healing process," based on a review commentary published 15 years ago in a non-peer reviewed journal, rather than basing this comment on at least one well-controlled study with evidence that NSAIDS do, in fact, delay the healing process (which I have never seen). Furthermore, when I examined the meta-analysis data on oral NSAIDS on Swelling (3 studies), I noticed that 2 out of 3 favored the placebo, and none of the studies had a significant difference as their confidence intervals all included zero. Only grouping oral with topical NSAIDS provided a favorable effect size. You can't have it both ways when it comes to making statements based on the literature by holding the evidence to different standards to support such statements.

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  Conflict of Interest:
  None declared.

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