Peace and Love for injuries

Posted by Dr. Rick Cohen on Jul 11th 2019

Get ready to learn something that will dramatically change how you should treat an acute injury

Does any of this sound familiar?

“I rolled my ankle bad today, headed to get an x-ray. X-ray confirms an avulsion fracture.”

“I took a really bad fall and slammed my knee into a rock. It’s swollen and I can’t bend it.”

“I rolled my ankle on the trails today. It’s swollen and purple”.

Caring for injuries is an inevitability for any active person. Oftentimes these injuries come in the form of some random ankle roll or stumble (as in the examples above). Others are classic overuse injuries like tendonitis, a strain, or even a stress fracture. In any case, the better you handle any injury, the better your return to action.

While your first course of action in these cases may have always been icing and anti-inflammatory agents, this philosophy is now long outdated.

Injury treatment was formerly known by the acronym

RICE (Rest Ice Compression Elevation) which evolved to PRICE (Protection Rest Ice Compression Elevation) and then finally to

POLICE (Protection Optimum Loading Ice Compression Elevation). 

And now a recent blog in the British Journal of Sports Medicine proposes new acronyms for treating and rehabilitating injuries. In fact, they are suggesting, a combination of acronyms should be used to address both the acute phase of the injury as well as the continuum of care needed. They are aptly calling this PEACE and LOVE

PEACE: Protect, Elevate, Avoid anti-inflammatories, Compress, Educate

LOVE: Load, Optimism, Vascularization, Exercise.

While the acronyms are getting longer. And yes, they are a bit corny, it is a huge step forward for both how to treat an injury, as well as how to treat yourself during the injury process.

Intentionally, the two individual acronyms represent what you should do in the immediate hours and days after a soft tissue injury (PEACE) and then what to do after the first few critical days (LOVE).

Here are the steps. Afterward, I’ll address the most important aspects.

P for Protect

Unload or restrict movement for 1 to 3 days to minimize bleeding, prevent distension of injured fibers and reduce the risk of aggravating the injury. Rest should be minimized as prolonged rest can compromise tissue strength and quality. Rely on pain signals to guide the removal of protection and gradual reloading.

E for Elevate

Elevate the limb higher than the heart to promote interstitial fluid flow out of the tissue. Despite weak evidence supporting its use, the elevation is still recommended given its low risk-benefit ratio.

A for Avoid anti-inflammatory modalities

Anti-inflammatory medications may potentially be detrimental for long-term tissue healing. The various phases of inflammation contribute to optimal soft tissue regeneration. Inhibiting such an important process using pharmacological modalities is not recommended as it could impair tissue healing, especially when the higher dosage is taken.

We also question the use of cryotherapy. Despite widespread use among clinicians and the population, there is no high-quality evidence on the efficacy of ice for treating soft tissue injuries. Even if mostly analgesic, ice could potentially disrupt inflammation, angiogenesis and revascularization, delay neutrophil and macrophage infiltration as well as increase immature myofibers, which may lead to impaired tissue regeneration and redundant collagen synthesis.

C for Compress

External mechanical pressure using taping or bandages helps to limit intra-articular edema and tissue hemorrhage. Despite conflicting studies, compression after an ankle sprain seems to reduce swelling and improve the quality of life.

E for Educate

Therapists should educate patients on the benefits of an active approach to recovery. Passive modalities such as electrotherapy, manual therapy or acupuncture, early after an injury have a trivial effect on pain and function compared with an active approach; it may even be counter-productive in the long term. Indeed, nurturing the ‘need to be fixed’ can create dependence on the therapist, be a significant nocebo, and thus contribute to persistent symptoms. Better education on the condition and load management will help avoid overtreatment which has been suggested to increase the likelihood of injections or surgery and higher costs to healthcare systems because of disability compensation (e.g. in low back pain). In an era of technology and hi-tech therapeutic options, we strongly advocate for setting realistic expectations with patients about recovery times instead of chasing the magic treatment approach.

After the first days have passed, soft tissues need LOVE

L for 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, remodeling and building tissue tolerance and capacity of tendons, muscles, and ligaments through mechanotransduction.

O for Optimism

The brain plays a key role in rehabilitation interventions. Psychological factors such as 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. Pessimistic patient expectations are also associated with suboptimal outcomes and worse prognosis. While staying realistic, practitioners should encourage optimism to enhance the likelihood of optimal recovery.

V for Vascularization

Physical 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 mobilization and aerobic exercise improve function, work status and reduce the need for pain medications in individuals with musculoskeletal conditions.

E for Exercise

There is a strong level of evidence supporting the use of exercises for the treatment of ankle sprains 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.

Got it.

Ok, let’s look at the key points a bit more deeply.

Think Long-Term

Above all else, if you take one thing away from PEACE and LOVE it is that you need to care for both the acute injury and (this is a newer part of the recommendation) take physical and psychological steps for the long-term rehab. Previous suggestions and their associated acronyms were almost entirely focused on the physical and immediate actions to take (reduce swelling, protect the injured tissue, etc.).

We’ve since realized that injury care should extend beyond the initial, and often traumatic, physical phase. Care should also encompass medium-term rehabilitation as well as psyche and emotions. If you get banged up, immediately fix what’s broken and then work on the long process of getting well.

Don’t take anti-inflammatory medicines especially NSAIDs Ibuprofen (or as I lovingly known by many as Vitamin-I) and ice has been the long-held common practice treatments for injuries. In fact, those who are oft-injured runner may pop a few Ibuprofen at least once a week to manage the little niggles that are inevitable from activities. Even worse many iced down after every hard work out trying to cool aching muscles and joints. Little did we know that they helped us feel better in the short-term ice and anti-inflammatories actually impair tissue healing. If you roll your ankle or have some sort of other soft tissue injuries, skip the drugs and the ice and you will be better off.

Mind Matters

When active people become injured, they can feel hopeless and can’t see the light at the end of the tunnel. It feels like their hard-earned fitness feels is slipping away. Yet, research is showing us more and more that when you are injured, your outlook impacts your recovery prospects. As the authors note, “Psychological factors such as catastrophizing, depression and fear can represent barriers to recovery.” Basically, if you feel like your injury is going to last forever, it probably will. You can help the process by staying optimistic and not blowing things out of proportion.

In Summary

The more active you are the more likely you are going to get banged up. It’s just a matter of when, not if, you are going to get injured and have to sit on the sidelines. When the time comes, give yourself and your injury some PEACE and LOVE. Treat the injury immediately and then settle in for the long haul.