‘PEACE’ and ‘LOVE’ replace outdated soft tissue injury protocols
Thursday, May 30, 2019
When it comes to soft tissue injury treatment, you have most likely have heard of RICE; standing for rest, ice, compression, and elevation.
You may well have also heard of PRICE, where the additional P stands for protection. This was then updated to POLICE around 2012, replacing rest with optimal loading, alongside protection and the longstanding ice, compression and elevation.
But two new acronyms are doing the rounds, proposed last month on the British Journal of Sports Medicine’s blog.
An update to recommendations for the management of soft tissue injuries was necessary, due to previous versions dealing with only the acute management and not providing a guideline for sub-acute and chronic care.
In addition, previous acronyms did not cover psycho-social factors in relation to injury management. The use of ice is also removed due to the limited evidence to support its role in acute injury treatment.
PEACE for Acute Injury Management
The aim of this stage is to do no further harm and begin to promote recovery. Depending on the severity of injury, this phase usually lasts between 1 and 5 days.
Reduce the risk of further damage. Unload and support the area or even restrict motion with the use of bracing or taping, if necessary. This will help to reduce bleeding as well as distension of injured fibers.
Rest should, however, be minimized as excessive periods of non-weight-bearing and restricted motion can reduce tissue strength and quality. Pain level should be used to guide the level of activity that can be tolerated. As soon as pain allows, motion and then weight bearing should be slowly re-introduced.
Despite a lack of strong evidence to support its use, elevation is still recommended due to the low risks involved and potential benefits.
When resting, elevate the injured area higher than the heart. This will help interstitial fluid flow away from the injury.
Inflammation is a natural part of the healing process, so reducing this may be detrimental to the long-term tissue healing.
Whilst anti-inflammatories may be effective for pain relief in such situations, this should be weighed up against the potential negative side effects. Alternative forms of pain control should be utilized if necessary.
Despite some conflicting evidence, compression is still recommended. Applying tape or bandages helps to limit intra-articular edema and tissue hemorrhage.
The therapist’s role in the early days is to educate the patient on the benefits of an active recovery. Early weight bearing and the advantages of self-treatment in the form of exercise therapy should be encouraged.
It’s important that the patient understands their role in their own recovery and also do not become dependent on the therapist and the “need to be fixed.”
After that initial first few days, sub-acute and chronic injuries should be treated as follows.
An active recovery is encouraged and beneficial in most cases of soft tissue injury. Normal daily activity should be resumed as soon as possible, once pain levels permit it.
This helps promote repairing, remodeling and building tissue tolerance and the capacity of muscles and other connective tissues through mechanotransduction (the way in which cells detect physical force and convert that into biochemical and biological responses).
The psycho-social factors should always be considered with any injury. Feelings of negativity, fear and depression can easily creep in, especially in those who are normally highly active or involved in sport and exercise.
A pessimistic patient is more likely to have a suboptimal outcome. Therefore, a therapist should encourage a sense of positivity, whilst maintaining a realistic outlook.
Cardiovascular exercise is deemed an important factor in recovery from soft tissue injuries. Any activity should be pain-free but should be started as soon as possible after injury.
This acts to increase blood flow to the injured tissues and improve function, but will also increase patient motivation. Evidence suggests that CV exercise will also reduce the need for pain-medication.
Rehabilitation style exercises help to regain mobility, strength and proprioception after injury. This in turn will help to prevent a reoccurrence.
Pain should be used as an indicator and avoided in the sub-acute phase, working within pain limits and gradually increasing exercise intensity as pain permits it.
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