Soft tissue injuries need PEACE and LOVE
When it comes to injury management , you may have heard of the acronyms RICE (rest, ice, compression, elevation), POLICE (protection, optimal loading, ice, compress, elevate) or maybe MEAT (movement, exercise, analgesics, treatment). But now there’s a new kid on the block - PEACE and LOVE. This new concept, proposed by Dubois and Esculier (2019), guides both the early and subsequent management of acute soft tissue injuries based on the latest research. This concept also includes the psychosocial factors associated with injury, the importance of education and the potential risks of using anti-inflammatory medication.
In the initial stage after an injury, the PEACE principle applies. This replaces the previous RICE which is still widely use. One of the most notable changes include that ice is no longer part of the management.
P - Protect
For the first 1-3 days after injury, we want to avoid load on the injured area that may aggravate the injury or cause further bleeding. However, this should not be continued for too long as prolonged rest can compromise tissue strength. It is usually a safe option to let pain guide you on when to gradually start loading the injured structure.
E - Elevate
This is one part of acute management that remains widely used, and mostly undisputed despite the lack of evidence to support it. It is believed that elevating the injured limb above the heart can help to reduce swelling and prevent further interstitial fluid build-up.
A - Avoid anti-inflammatories
The concept of avoiding anti-inflammatories may seem strange to many people, but interrupting the inflammatory process can actually delay healing, especially when high dosages are used. The body needs to go through all the phases of our natural inflammatory process for optimal soft tissue regeneration. It is therefore not advised to take anti-inflammatory medication in the first 48 hours after injury. This is also why it is now advised to avoid ice - icing an injury is not supported by evidence, and even though it may help reduce pain it can lower blood flow to the area and disrupt your body’s natural healing process.
C - Compress
Compressing the injured area is still recommended to help manage swelling, as in the original “RICE” regimen. Bandages or taping can be used for compression, but note that it should not block your ability to move a joint completely.
E - Educate
It is important for health care professionals to educate their patients on the importance of an active approach to recovery. The patient should also be educated on what to expect in terms of length of recovery, and how they can play an active part in their healing. Patients should not be led to believe that they are completely dependent on someone else for recovery, or that certain “quick fixes” such as injections or surgeries are necessary if not applicable to the patient.
After a few days of following the PEACE regimen, we progress to LOVE.
L - Load
Optimal loading should commence as soon as symptoms allow. Mechanical stress without aggravating the symptoms promotes tissue repair and builds tissue tolerance. Physiotherapists are equipped with the knowledge to guide gradual loading of injured structures during this phase.
O - Optimism
The PEACE and LOVE principle recognises that the brain has a significant influence on recovery. Patients with an optimistic approach to recovery have been shown to have better outcomes. We want to avoid catastrophisation, fear and depression.
V - Vascularisation
Promoting cardiovascular exercise during recovery can help to improve blood flow to the injured area which helps to optimise recovery. It also boosts the mood of the injured person if they are still able to do some form of exercise and can help to manage pain.
E - Exercise
Guided exercise forms an integral part in complete injury rehabilitation and preventing reoccurrence of injuries. Exercise helps to restore mobility, muscle strength and proprioception after injury. The progression of exercise should be guided by pain levels and should not aggravate symptoms. It is best to seek guidance from a qualified health care professional, such as a physiotherapist, to ensure you are doing the right type of exercises and to progress appropriately.
These new principles should be followed to ensure we do not only focus on short term relief of symptoms, but also the long term outcomes and full integration back into daily life.
Reference: Dubois B, Esculier J-F. Br J Sports Med 2020;54:72–73.
