We have all heard the I.C.E protocol (Ice, Compression, Elevation)for managing acute musculoskeletal injuries, and then its successors R.I.C.E and P.R.I.C.E (Rest, Ice, Compression and Elevation and then the addition of Protection). This advice then evolved to P.O.L.I.C.E (Protect, Optimal Loading, Ice, Compression and Elevation. However it has had another review and the acronym seems a whole lot more 'touchy feely' in its latest evolution.The newest management rehabilitation advice now cover the immediate care ((PEACE) to the longer term management (LOVE).So What does PEACE and LOVE have to do with injury management?
PEACE is useful in the initial phase after injuryP - ProtectUnload or restrict movement for 1 to 3 days to minimise bleeding, and reduce risk of aggravating the injury. Rest should be minimised as prolonged rest can compromise tissue strength and quality.Rely on pain signals to guide removal of protection and gradual reloading. E - ElevateElevate the limb higher than the heart to promote interstitial fluid flow out of tissue.Although there still isn't strong evidence to support elevation, and the difficulty of actually elevating to a useful height, it is still recommended given its low risk-benefit ratio. A - Avoid anti-inflammatory modalitiesIt seems that Anti-inflammatories are the first thing that people reach for when they have an acute injury, but we need to remember that inflammation is a NATURAL and NECESSARY part of the healing process. Anti-inflammatory medications may potentially be detrimental for long-term tissue healing. The various phases of inflammation contribute to optimal soft tissue regeneration, so avoiding anti-inflammatories as much as possible is advised.(we should also point out that there really isn't strong evidence for or against the use of ice, but again it may hinder tissue repair - although it is a well documented analgesic (painkilling) agent. C for CompressAppropriate compression using tape and bandaging helps with oedema and bleeding. E for EducateNever underestimate the impact of good education on injury management and prognosis of recovery.An active approach to recovery should be advocated for. Although there is some benefit from 'passive' treatments such as manual therapy and electrotherapy, their impact is nowhere as beneficial as an active approach. As therapists, our role is to make ourselves obsolete and provide the tools for clients to manage their injuries independently.The ‘need to be fixed’ can create dependence to the therapist, be a significant impediment to recovery, and thus contribute to persistent symptoms. By setting realistic expectations with patients about recovery times instead of chasing the magic treatment an honest relationship and recovery journey can be developed. After the first days have passed, soft tissues need LOVE
L for LoadAn active approach with movement and exercise benefits most patients with musculoskeletal disorders. Load should be added early and normal activities resumed as soon as symptoms allow. Optimal loading (without exacerbating pain) promotes repair, remodelling and building tissue tolerance and capacity of tendons, muscles and ligaments. O for OptimismThe brain plays a key role in rehabilitation interventions. Psychological factors such as catastrophisation, depression and fear can represent barriers to recovery. They are even thought to explain more of the variation in symptoms and limitations following an ankle sprain than the degree of pathophysiology (How amazing is that?!?!). Pessimistic patient expectations are also associated with worse prognosis. While staying realistic, optimism should be encouraged to enhance the likelihood of an optimal recovery. V for VascularisationPhysical activity that includes cardiovascular components represents a cornerstone in the management of musculoskeletal injuries. While research is needed on dosage, pain-free cardiovascular activity 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 function, work status and reduce the need for pain medications in individuals with musculoskeletal conditions. E for ExerciseThere is strong evidence supporting the use of exercises for treatment and for reducing the prevalence of recurring injuries. Exercises will help to restore mobility, strength and proprioception early after injury. 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.
Managing soft tissue injuries is more than short-term damage control. Long term outcomes should always be part of the decision making process from the outset with consideration for the person with the injury, and not just the injury in question.