Make PEACE&LOVE, not RICE…

For many years, we’ve heard that after an acute injury we should follow the RICE protocol, as in Rest, Ice, Compression; Elevation¹. Later, in 2011, Bleakley and colleagues² suggested adding Protection, making it PRICE.

It is not hard to realise that a process as complex as tissue healing may have in a PRICE protocol a very vague and non-specific approach that doesn’t change as the condition moves through the several stages of tissue healing and rehab.

For this reason, Blaise Dubois and Jean-Francois Esculier (2019), have recently suggested up-to-date evidence-based new acronyms that are much more comprehensive than previous proposals as they “encompass the rehabilitation continuum from immediate care (PEACE) to subsequent management (LOVE)” (Figure 1).

Immediately after a soft tissue injury, PEACE is the way:

Protect^3,4

Pretty much like when we cut ourselves, we try protecting the area, until the skin is again strong to take most of our daily activities, therefore unload the area and/or restrict movement for the first 3 days to minimise bleeding, prevent distension of injured fibers and reduce risk of aggravating the injury. However, prolonged rest can compromise tissue strength and quality, so this should be minimised. Your body will use Pain as an adviser on what an appropriate time and degree of loading will be.

Elevate^2-4,6

Elevate the limb higher than the heart to promote reduction of swelling in the injured area.

Avoid anti-inflammatory modalities (and ice)^5-9

Inflammation is a GOOD thing, it’s nothing more than the initial response of the body to heal the injured area, and its various phases contribute to optimal soft tissue regeneration. Inhibiting such an important process using pharmacological modalities is not recommended as it could impair tissue healing, especially when a higher dosage is taken. The pain that results form the inflammation process, it’s the body asking you to protect the area as suggested with the Protect.

Regarding the application of ice, there is no high-quality study on the efficacy of ice for treating soft tissue injuries. Even it mostly used to numb the pain and help cope with it, theoretically ice could potentially disrupt inflammation, creation of new vessels on the new tissue and delaying its healing/repair, reducing the final tissue quality.

Compress^2,5-10

External mechanical pressure using taping or bandages helps limiting joint swelling and tissue bleeding, as suggested by evidence.

Educate^5-15

Physiotherapists should educate patients on the benefits of an active approach to recovery. Passive modalities such as Electrotherapy, Manual Therapy or Acupuncture, early after injury may only have a trivial effect on pain and function compared with an active approach and should not be used alone, but only as an facilitator, always respecting the stage of soft tissue evolution, as an aggressive approach may even be counter-productive in the long term.

In an era of technology and hi-tech therapeutic options, it’s crucial to set realistic expectations with patients about recovery times and encourage an active role in their recovery. Patients need to feel empowered.

…”After the first days have passed, soft tissues need LOVE“

Load^4,5,16

Sensible levels of physical stress and load should be added early and normal activities resumed as soon as symptoms allow. If you listen to our body and allow optimal loading without exacerbating pain, this will promote repair, remodelling and building tissue tolerance, making tendons, muscles and ligaments, gradually strong again. As mentioned before, an active approach with movement and exercise benefits most patients with soft tissue injuries and dysfunctions.

Optimism^17-20

We now know, the brain plays a key role in rehabilitation interventions, therefore psychological factors such as catastrophisation, depression and fear can represent barriers to recovery physical structures in the body, as they are even thought to explain more of the variation in symptoms and limitations following an ankle sprain than the actual damaged sustained. Lower patient expectations are also associated with not-as-good outcomes.

Vascularisation^11,17,21

The cardiovascular component of active rehab and exercise, represents a cornerstone in the management of musculoskeletal injuries. Pain-free cardiovascular activity even addressing different areas of the body, should be encouraged early on and started a few days after injury to boost motivation and increase blood flow to the injured structures. “Early mobilisation and aerobic exercise improve function, work status and reduce the need for pain medications in individuals with musculoskeletal conditions.”

Exercise^5,6,11

There is a strong level of evidence supporting the use of exercises for treatment of ankle sprains and for reducing the prevalence of recurring injuries., as exercises will help to restore mobility, strength and balance early after injury. However, this must be done sensibly and high levels of pain should be avoided to ensure optimal repair during the subacute phase of recovery and should be used as a guide for progressing exercises to greater levels of difficulty.

This is it. I hope this post has answered some questions you may have if you’re facing an acute/subacute soft tissue injury. Shall you have any questions please get in touch and will be happy to help you reach your goals!

I also would like to praise Blaise Dubois and Jean-Francois Esculier, for this very comprehensive update, that makes so much more sense then the previous approaches. The full references’ list from their article will be listed below in case you would like to read more about some of the topics discussed.

References:

1. Dubois B, Esculier J-F (2019), “Soft tissue injuries simply need PEACE & LOVE”, British Journal of Sports Medicine: Blog, 26 April 2019, available at: https://blogs.bmj.com/bjsm/2019/04/26/soft-tissue-injuries-simply-need-peace-love/. Accessed on 6/5/2019
2. van den Bekerom MPJ, Struijs PAA, Blankevoort L, et al. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults. J Athl Train2012;47: 435-43.
3. Bleakley CM, Glasgow PD, Phillips N, et al. Guidelines on the management of acute soft tissue injury using protection rest ice compression and elevation. London: ACPSM, 2011.
4. Bleakley CM, Glasgow P, MacAuley DC. Price needs updating, should we call the police? Br J Sports Med2012;46: 220-1.
5. Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline. Br J Sports Med2018;52: 956.
6. Doherty C, Bleakley C, Delahunt E, et al. Treatment and prevention of acute and recurrent ankle sprain: An overview of systematic reviews with meta-analysis. Br J Sports Med2017;51: 113-25.
7. Duchesne E, Dufresne SS, Dumont NA. Impact of inflammation and anti-inflammatory modalities on skeletal muscle healing: From fundamental research to the clinic. Phys Ther Sport2017;97: 807-17.
8. Yerhot P, Stensrud T, Wienkers B, et al. The efficacy of cryotherapy for improving functional outcomes following lateral ankle sprains. Ann Sports Med Res2015;2: 1015.
9. Singh DP, Barani Lonbani Z, Woodruff MA, et al. Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Front Physiol2017;8: 93.
10. Hansrani V, Khanbhai M, Bhandari S, et al. The role of compression in the management of soft tissue ankle injuries: A systematic review. Eur J Orthop Surg Traumatol2015;25: 987-95.
11. Bleakley CM, O’Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: Randomised controlled trial. BMJ2010;340: c1964.
12. Kim TH, Lee MS, Kim KH, et al. Acupuncture for treating acute ankle sprains in adults. Cochrane Database Syst Rev2014;6: CD009065.
13. Lewis J, O’Sullivan P. Is it time to reframe how we care for people with non-traumatic musculoskeletal pain? Br J Sports Med2018;epub ahead of print, 25 June 2018.
14. Graves JM, Fulton-Kehoe D, Jarvik JG, et al. Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain. Health Serv Res2014;49: 645-65.
15. Webster BS, Choi Y, Bauer AZ, et al. The cascade of medical services and associated longitudinal costs due to nonadherent magnetic resonance imaging for low back pain. Spine2014;39: 1433-40.
16. Khan KM, Scott A. Mechanotherapy: How physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med2009;43: 247-52.
17. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: Systematic review. Br J Sports Med2019;Epub ahead of print; 2019 Mar 2.
18. Roy JS, Bouyer LJ, Langevin P, et al. Beyond the joint: The role of central nervous system reorganizations in chronic musculoskeletal disorders. J Orthop Sports Phys Ther2017;47: 817-21.
19. Briet JP, Houwert RM, Hageman MGJS, et al. Factors associated with pain intensity and physical limitations after lateral ankle sprains. Injury2016;47: 2565-9.
20. Bialosky JE, Bishop MD, Cleland JA. Individual expectation: An overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain. Phys Ther2010;90: 1345-55.
21. Sculco AD, Paup DC, Fernhall B, et al. Effects of aerobic exercise on low back pain patients in treatment. Spine J2001;1: 95-101.