news feed
9 - Summary of Guidelines
Guideline 1 - Protection
| Guideline | Evidence | |
|---|---|---|
| 1 | Protection should be applied during the early stages of the healing process (at least up to day three). | Biological (II) |
| 2 | The duration of application should be dictated by the severity of pain and the extent of injury. Animal studies suggest that a moderate (second degree) injury requires three to five days protection; mild (first degree) injuries may require a shorter period and severe (third degree) longer. | Biological (II) + consensus (literature + panel) |
| 3 | The mode of application of protection will depend on the site and nature of injury and its severity. This may range from protection from full weight-bearing (crutches) or general support (slings) to specific support for the injured structure/s (braces, splints, taping). | Consensus (literature + panel) (C) |
| 4 | Whilst supporting / protecting the injured structure/s, the mode of protection should avoid complete immobilisation of the part whenever possible. | Consensus (literature + panel) (C) |
| 5 | The mode of protection must be capable of accommodating oedema. | Consensus (literature + panel) (C) |
Guideline 2 - Rest
| Guideline | Evidence | |
|---|---|---|
| 1 | Rest should be applied to the injured part immediately following injury. | Biological (II) |
| 2 | Stress on the injured tissue should be avoided during the early (inflammatory) phase of the healing process, as the tensile strength of the injured tissue is greatly reduced at this time. | Biological (II) |
| 3 | The optimum period of rest appears to be one to five days, depending on the severity of injury. Moderate (second degree) muscle injuries require three to five days ‘immobilisation’. Mild (first degree) injuries may require only 24 hours rest and severe (third degree) injuries may require at least a week’s rest. | Biological (II) + panel consensus (based on biological and empirical evidence) |
| 4 | Early mobilisation following the period of rest should initially avoid undue stress on the healing tissue. | Empirical (III) |
| 5 | Isometric work may be performed during the period of rest, within the limits of pain tolerance. | Consensus (literature + panel) (C) |
| 6 | Overall general activity should be reduced to avoid increasing metabolic rate and producing a generalised increase in blood flow. | Empirical (III) (+ consensus based on physiological principles). |
Guideline 3 - Ice
| Guideline | Evidence | |
|---|---|---|
| 1 | Ice should be applied immediately following acute musculoskeletal injury. | Consensus (panel) (C) |
| 2 | Chipped/ crushed ice in a damp towel appears to be the most effective application of cold, followed by ice in a plastic bag, and then frozen gel packs. | Empirical (II) |
| 3 | Damp towels should always be applied directly to the skin before using crushed ice and commercial cold packs, to avoid an ‘ice burn’. A maximum period of 30 minutes is recommended. | Consensus (panel) (C) |
| 4 | The most effective duration of application of ice appears to be 20 to 30 minutes, applied every two hours, with a recommended maximum of 30 minutes to avoid tissue damage. | Biological + empirical (II) |
| 5 | Areas with >2cm subcutaneous fat may require longer applications (30 minutes), since it has been found that ten minutes of application produces no muscular cooling effect in these circumstances. | Empirical (III) |
| 6 | Cold application should cover the entire area affected by the injury. | Empirical (III) |
| 7 | The athlete should not return to participation immediately following application of ice (or other types of cold application), as nerve conduction velocity, sensation and connective tissue flexibility are likely to be reduced by cold application. | Consensus (panel) (C) |
| 8 | Care should be taken in the application of ice to patients with little subcutaneous fat since cold-induced nerve injury may result. To compensate for this, the duration of application should be reduced (no more than ten minutes) or an insulating material placed between the skin and ice application. | Empirical (based on case-study observations) (III) |
| 9 | Application of cold is contraindicated for patients who have previously developed cold-induced hypertension during cold treatment, who have allergy to cold (urticaria, joint pain), or who have Raynaud’s syndrome, peripheral vascular disease or sickle cell anaemia. | Consensus (literature + panel) (C) |
| 10 | If nerve damage as a result of the injury is suspected or if there is a history of reduced skin sensation, application of cold should not exceed 20 minutes and skin condition should be checked every five minutes. | Consensus (panel) (C) |
Guideline 4 - Compression
| Guideline | Evidence | |
|---|---|---|
| 1 | Always apply in a direction from distal to proximal, irrespective of the type of bandage/compression agent. | Consensus (panel) (C) |
| 2 | Pressure must not be greater proximally than distally. Application of pressure should be uniform throughout the compression. | Empirical (II) |
| 3 | Apply compression a minimum of six inches above and below the site of injury. At distal sites (e.g. ankle, wrist) apply from heads of metatarsals/metacarpals to the joint proximal to the site of injury. | Consensus (literature + panel) (C) |
| 4 | Apply as per manufacturer’s instructions, when available. | Consensus (panel) (C) |
| 5 | Compression must be capable of accommodating oedema immediately following injury, and of continuing to apply pressure when the swelling is diminishing.Therefore:
|
Empirical + Consensus (literature + panel) (II) |
| 6 | Compression using an elastic legging (or equivalent) should not be applied in the recumbent (lying) position, or in association with elevation. | Empirical (I) |
| 7 | Remove and reapply if uniform and constant pressure is not maintained, or to administer other treatment modalities. Otherwise, reapplication is recommended within 24 hours. | Consensus (panel) (C) |
| 8 | Compression should be applied as soon as possible following injury. | Consensus (literature) (C) |
| 9 | Intermittent compression may be applied (30 minutes daily at a compression of 60mmHg, 30 seconds on, 30 seconds off) in addition to compression, during the first five days. | Empirical (II) |
| 10 | Continue compression for the first 72 hours following injury, when not lying down. | Empirical (II) |
| 11 | Distal areas should be checked immediately following application of compression for signs of reduced circulation (cold, pallor) and then regularly checked throughout the continued application of compression. | Consensus (panel) (C) |
| 12 | The following materials may be considered for purposes of application of compression: cohesive bandage, tubigrip, elastic adhesive bandage, adjustable neoprene supports, inflatable pressure devices. Elastic bandages and tubigrip are the most effective mode of continuous compression. | Empirical (II) |
Guideline 5 - Elevation
| Guideline | Evidence | |
|---|---|---|
| 1 | Elevate the injured part above the level of the heart as much as possible during the first 72 hours following injury. | Empirical +Consensus (literature + panel) (III) |
| 2 | Ensure that the elevated part/limb is adequately supported (e.g. by pillows, slings). | Consensus (panel) (C) |
| 3 | Elevate the injured part as soon as possible following injury. | Consensus (literature + panel) (C) |
| 4 | Avoid placing the limb in the dependent position immediately following elevation as the ‘rebound phenomenon’ will tend to increase oedema. | Empirical (II) |
| 5 | If the limb can be maintained in elevation, do not apply compression simultaneously. | Empirical (I) |
Trackback by Anonymous — October 12, 2018 @ 7:01 pm