Learn the new protocols for your soft-tissue injuries
Traditionally, the recommended management for soft tissue injuries has been the RICE, PRICE or POLICE methods. These models only accommodate for the acute management of these injuries, the first 72 hours following injury. A process as complex as tissue healing may have in those protocols a very vague and non-specific approach that doesn’t change as the condition moves through the several stages of tissue healing and rehabilitation.
For this reason, researchers Blaise Dubois and Jean-Francois Esculier, 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).
Immediately after an injury, use the PEACE protocol listed below…
P for Protect – 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 minimize 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 minimized. Your body will use pain as an adviser on what an appropriate time and degree of loading will be.
E for Elevate – Elevate the limb higher than the heart to promote reduction of swelling in the injured area.
A for Avoid Anti-Inflammatory Modalities (and ICE) – Avoid anti-inflammatories as these can be detrimental to tissue healing. Inflammation is a good thing, as it’s 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 anti-inflammatories is not recommended as it could impair tissue healing, especially when a higher dosage is taken.
Regarding the application of ice, there is no high-quality study on the efficacy of ice for treating soft tissue injuries. Ice is mostly used to numb the area of pain and help you cope with the pain. Theoretically ice could potentially disrupt inflammation, creation of new vessels on the new tissue and delaying its healing and repair, thus reducing the final tissue quality.
C for Compress – Compression to affected area, via bandaging or compression bandage helps to limit joint swelling and reduce loss of range of movement.
E for Educate – Education provided by health professional, a crucial part of injury management. An active approach to recovery should be encouraged, including strength-based rehabilitation exercises. Realistic goals and time frames for recovery should be set, and patient workloads managed accordingly.
AND after the first days after the injury have passed, your soft tissue needs LOVE:
L for Load – Load the area, gradually and as tolerable. An active approach to therapy via exercise is beneficial to most musculoskeletal injuries. This promotes tissue healing and remodeling and helps improve the tissue tolerance to further loading in future.
O for Optimism – A positive outlook towards rehabilitation has a massive impact patient prognosis. Focusing on pain, catastrophizing (thoughts that you will never recover), depression and fear can lead to poorer or longer recoveries.
V for Vascularization – Get the limbs moving to promote blood flow in and out of the area. Some early cardiovascular exercises (walking, running, cycling, swimming) can help improve tissue recovery and pain, and also serves to help improve motivation.
E for Exercise – There is a strong level of evidence supporting the use of exercises for treatment of sprains/strains and for reducing the prevalence of recurring injuries. Exercise as therapy in musculoskeletal injuries will help restore mobility, strength, and proprioception of the affected area. However, this must be done sensibly and high levels of pain should be avoided to ensure optimal repair during the subacute phase (between the 4th to the 21st day after the injury occurs) of recovery and should be used as a guide for progressing exercises to greater levels of difficulty.
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.