Laurie's Blogs.

Ae you stuck in the past when it comes to acute injuries?  Are you still prescribing RICE? (Rest, Ice, Compression, Elevation)?  Maybe you moved on to PRICE (Protect, Rest, Ice, Compression, Elevation).  Maybe you actually thought you were already up to date because you followed the POLICE protocol (Protect, Optimal Loading, Ice, Compression, Elevation)?  What if I told you that all of these acute injury management acronyms were out of date?  Well, hold onto your shorts, because that’s what’s coming!  No more RICE.  No more PRICE.  Out with POLICE!  We’re now at PEACE & LOVE.  Read on to stay up to date!!!

The RICE protocol dates back to 1978 and was coined by Dr. Gabe Mirkin.  It was back in the day when we held the belief that ice was needed to minimize the inflammatory response in order to speed up healing.  That was the cornerstone of acute injury management for 20 years!  Then we added the ‘P’ (Protect).  14 years after the ‘P’ comes along the POLICE.  (Those keeping track in your head, this takes us up to 2012.)  The OL (Optimal Loading) came along after recognizing that loading tissues aids in recovery via cell regeneration and that rest or lack of movement is detrimental to recovery.

Next to take the hit is Ice.  Research is showing that ice may delay healing as well.  We need some inflammation for our body for the cells in the area to release Insulin-like Growth Factor (IGF-1).  IGF-1 has growth-promoting effects on almost every cell in the body and in turn stimulates healing.  Dampening this effect with ice is counterproductive.

Now, fast forward to 2019 when Ice is formally dethroned and the PEACE & LOVE moment takes hold.  Here’s what it stands for; Protection, Elevation, Avoid Anti-Inflammatory Drugs, Compression, Educate and Load, Optimism, Vascularization and Exercise.  

Protect: Unload or restrict movement for 1 – 3 days to minimize bleeding or aggravation of tissues… but should be confined to as shortened of a period as possible.

Elevate: Little evidence exist on this one, but it is not harmful and may help to promote interstitial fluid flow out of swollen tissues.

Avoid anti-inflammatories: NSAID use may negatively affect long term healing.  Soft tissue injuries in particular should not include NSAID medications.  Avoiding ice also fits into this category.

Compress: Conflicting studies surround compression, however it may reduce swelling, so could be utilized (if practical).

Educate: The education to be done is about the benefits of an active approach to recovery with less of a reliance of passive modalities.  Additionally, education regarding realistic expectations about recovery times is also of importance.

LOVE comes in after the first few days have passed, when the tissues are less reactive and pain is less of a factor.

Load: Mechanical stress needs to be incorporated early on.  Optimal loading without exacerbating pain promotes repair, remodeling and builds tissue tolerance and the capacity of tendons, muscles and ligaments.

Optimism: Optimism is associated with better outcomes and prognosis.  The psychological aspects of injury (such as catastrophizing, depression, and fear) can represent barriers to recovery.

Vascularization: Pain-free cardiovascular activity should be started early to improve blood flow to and through the injures structures.  

Exercise: Exercise not only aids in the treatment of soft tissue injuries, but it also helps to reduce the prevalence of recurrent injuries.  

Managing soft tissues injuries should be about more than dealing with the short-term damage.  As clinicians, we must also aim for the most favourable long-term outcomes as well.  Whether they are dealing with an ankle sprain or a hamstring strain, we hope this editorial will encourage clinicians to give PEACE a chance, because perhaps all soft-tissue injuries need is LOVE.

References:



Wikipedia.  Insulin-like growth factor 1.  https://en.wikipedia.org/wiki/Insulin-like_growth_factor_1  Accessed June 12, 2021.

Dubois B, Esculier J Soft-tissue injuries simply need PEACE and LOVE.  British Journal of Sports Medicine 2020;54:72-73. https://bjsm.bmj.com/content/54/2/72 

Wood, Z. To Ice or Not to Ice An Injury?  Physio Network.  https://www.physio-network.com/blog/ice-for-acute-injury/ Accessed June 12, 2021.