The rehabilitation of soft tissue injuries can be complex, to say the least. Over the years there has been much debate in determining best practice in the acute management of soft tissue injuries.
Many people will be familiar with various acronyms or protocols they may have encountered over the years such as “PRICE - Protection, Rest, Ice, Compression, Elevation”, the outdated and all too often go-to advice or treatment after “pulling your hamstring” or “going over on your ankle”. This is a passive approach focused on unloading the affected area and avoiding movement to prevent further subsequent damage.
Another one you might recognise is “POLICE - Protection, Optimal Loading, Ice, Compression, Elevation”, an updated and more proactive approach, whereby rest is replaced with a balanced and incremental rehabilitation programme with the premise that early activity accelerates tissue healing and promotes early recovery.
It’s clear that there’s still much debate and conflicting views regarding clinical best practice. This more often than not leads to confusion amongst patients and clinicians alike, when deciding which protocol to implement for the desired treatment outcomes. Moreover, it’s important to note that both protocols alluded to above have one common flaw, they’re solely focused on acute management.
Unfortunately, both fail to recognise the subacute and chronic stages of tissue healing. Nonetheless, recent researchers have developed a more contemporary acronym that encompasses the entire rehabilitation continuum from immediate care (PEACE) to subsequent management (LOVE). This protocol also assumes a more holistic strategy which outlines the importance of educating patients and addressing a variety of factors during treatment to enhance recovery. So what exactly is PEACE & LOVE?
“Immediately after injury, do no harm and let peace guide your approach”
Protect
Avoid any aggravating activities/movements and deload the affected area for 1–3 days to minimise bleeding, reduce swelling and mitigate the risk of aggravating the injury.
However it’s advised to keep rest to a minimum, as prolonged rest can compromise tissue strength and quality. Pain should be used to guide the cessation of the protection phase.
Elevate
Elevate the limb higher than the level of the heart to promote fluid to flow out of tissues and reduce swelling.
Avoid Anti-Inflammatory Modalities
The various phases of inflammation actually help repair damaged soft tissues. Thus, inhibiting inflammation using medications may negatively affect long-term tissue healing, especially when higher dosages are used. Therefore, the use of anti-inflammatory medications should be avoided.
Surprisingly, cryotherapy (ice therapy), even if used mostly as an analgesic, should be avoided. This is because ice could potentially disrupt the inflammatory process, impair tissue repair and promote premature scar tissue formation.
Compression
External mechanical pressure using taping or bandages helps limit intra-articular oedema and tissue haemorrhage (reduces swelling and bleeding).
Educate
Patients should be educated on the benefits of an active approach to recovery and establish realistic expectations about recovery timeframes instead of chasing the ‘magic cure’ approach. Passive modalities, such as electrotherapy, manual therapy or acupuncture, early after injury have insignificant effects on pain and function compared with an active approach and may even be counterproductive in the long term.
&
“After the first days have passed, soft tissues need love”
Load
An active approach with movement and exercise benefits most patients with musculoskeletal disorders. Mechanical stress should be added early and normal activities resumed as soon as symptoms allow.
Optimal loading without exacerbating pain promotes repair, remodelling and builds tissue tolerance and the capacity of tendons, muscles and ligaments through a process known as mechanotransduction.
Optimism
Optimistic patient beliefs and expectations are associated with better treatment outcomes and prognosis. Psychological factors such as catastrophization, depression and fear can represent barriers to recovery.
Vascularisation
Pain-free aerobic exercise should be started a few days after injury to boost motivation and increase blood flow to the injured structures. Early mobilisation and aerobic exercise improve physical function, supporting return to work and reduce the need for pain medication in individuals with musculoskeletal conditions
Exercise
Exercises help to restore mobility, strength and proprioception early after injury and reduces the risk of re-injury. Pain should be avoided to ensure optimal repair during the subacute phase of recovery, and should be used as a guide for exercise progressions.
From what has been highlighted in this blog, it’s safe to conclude that the management of soft-tissue injuries involves more than just short-term damage control as once prioritised by the ‘PRICE’ and ‘POLICE’ protocols. However, treatment paradigms must be continually updated based on contemporary research evidence. Therefore, whilst anti-inflammatory modalities (Medications/Ice) show benefits on pain and function, the innovative ‘PEACE & LOVE’ acronym flags their potential harmful effects on optimal tissue repair.
Consequently, clinicians and patients alike should seek to achieve more favourable long-term outcomes by incorporating this holistic and novel approach to treatment. This all encompassing approach to the management of soft tissue injuries focuses on treating the person at hand, not just the injury.
For that reason, in future practice whether it be dealing with an acute ankle sprain or a hamstring strain it’s helpful to encourage PEACE, because all that soft-tissue injuries require is some LOVE.
Resources
- Dubois, B. and Esculier, J., 2019. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine, 54(2), pp.72-73.
- 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.