Today’s article comes from soon to graduate La Trobe University podiatry student Philip Young.
Acute soft tissue injuries have traditionally been treated using the RICE method. Using this method, we are told that immediately following a soft tissue injury we must Rest, Ice, apply Compression and Elevate the affected structure. Whilst rest of affected structures is important following an acute injury, is this mindset tending towards patients and practitioners being too conservative and wary of exercise following an acute injury?
Since 2011 there has been a movement to supplant RICE with POLICE (Bleakley, Glasgow and MacAuley, 2011). POLICE stands for Protection, Optimal Loading, Ice, Compression and Elevation. This short article discusses optimal loading, and how is can be used during rehabilitation of your clients.
What is optimal Loading?
Optimal loading describes the amount of load that results in the largest physiological adaptation to affected structures (Glasgow, Phillips and Bleakley, 2015). It is based on the principle of mechanotherapy, whereby mechanical loading prompts cellular responses that promote structural changes in tissue. Indeed, optimal loading is a term that encompasses all exercises that drive tissue repair through the process of mechanotransduction, these exercises range from isometric and isotonic contractions, to manual therapies such as massage and passive range of motions. Optimal loading is achieved through applying a mechanical stimulus which induces a variety of neural and cellular changes that result in physiological adaptations to the affected structures (Glasgow, Phillips and Bleakley, 2015). The key component of optimal loading is the manipulation of mechanical loading variables such as magnitude, direction, duration, intensity and frequency to maximise the desired physiological adaptations.
When should loading occur?
Optimal loading is early loading! In saying this, it is important to be aware that protection of an injured structure immediately following an injury is important. However, the period of rest following an injury should be as short as possible. An interesting concept to consider when rehabilitating an athlete, is that you cannot take stimulus away. What we must realise is that absence of load is a physiological stimulus in itself. The principle is that we still want to protect the tissue, but in the early stages adding a mechanical stimulus to impart changes at a biological level is important as it influences tissue molecularly, cellularity and changes the tensile properties of the tissue (Glasgow, Phillips and Bleakley, 2015). If we add this load in a gentle, controlled environment, then we are effectively imparting physiological changes through optimal load.
How should we apply load?
Load should be applied in a specific and individual manner. We must firstly determine the sport the athlete partakes in, and then perform a thorough assessment to ascertain he structures that are repetitively loaded, the intensity of loading and the direction of the load.
So the questions we must ask are:
- What is the activity your client needs to return to?
- How are the injured tissues loaded during the activity?
- How do we restore normal form and function of tissue to expedite return to activity?
Early stages of rehabilitation
In the early stages of rehabilitation we are looking for consistency and quality of movement. Exercises should be performed with strict form and under close guidance. Progression should be maintained however exercises should be added gently and with caution. Passive movements are fantastic in this stage, as are aquatic and isometric activities.
The goals in the early stages of rehabilitation are:
- Reduction in pain
- Maximisation of re-capillirisation
- Reduction in scar tissue
- Facilitate recruitment of muscle tissue
Later stages of rehabilitation
Optimal loading needs to have appropriate progression, and should be performed in a systematic and progressive manner that is specific to the individual’s sport/activity.
At this stage in the rehabilitation our aim is to integrate newly formed robust tissue into specific loading and movement patterns. Exercises still need to be controlled, however, our aim is to now facilitate exercises that require the person to look for better movement solutions. At this stage, we are looking to restore specific loading patterns based on the individuals sport, and we achieve this through exercise selection, but also working across all ranges of the force velocity curve.
Return to sport
Activities and exercises should be performed at game speed, under pressure and include unpredictable variability. The rate of loading should be in line with the individuals function and pain, and muscles should be recruited at varies lengths. Exercises should include changes of direction, bounding, high speed work, directional and rate of speed changes. Unpredictability is an important aspect at this stage, as reactive agility is the foundation for successful performance of most sports. Training for this is incredibly important as is requires activation of the entire neuromuscular system.
Until Next Time
Director/ Chief Editor
Bleakley, C., Glasgow, P. and MacAuley, D. (2011). PRICE needs updating, should we call the POLICE?. British Journal of Sports Medicine, 46(4), pp.220-221.
Glasgow, P., Phillips, N. and Bleakley, C. (2015). Optimal loading: key variables and mechanisms. British Journal of Sports Medicine, 49(5), pp.278-279.
Glasgow, P. (2017). Optimising load to optimise outcomes. British Journal of Sports Medicine, 51(13), pp.985-985.