PEACE & LOVE for Soft Tissue Injuries
Injury…….
It is a word, which having the multidirectional viewpoints and intervention strategies where most of the Health professionals, Coaches, Trainers debate a lot. But, where it comes as subjective to the matter people having their own way of handling it. Being a Health care professional (Physiotherapist) I always been attentive to the people who come to my OP with Injury because we have to be clear whether it is ACUTE, SUBACUTE & CHRONIC.
Clinically ACUTE cases will present with inflammatory signs like “Pain, Swelling, Redness, Local Temperature Raise, and Loss of Function”. So, to address this from many years clinicians and Sport related Trainers and coaches were using the protocol called “I.C.E”.
I – Icing
C – Compression
E – Elevation
Then, it evolved from I.C.E to R.I.C.E, (where R stands for Rest) then on to P.R.I.C.E (where P stands for Protection).1
One study published in the Journal of Athletic Training found a lack of solid evidence that the R.I.C.E. treatment for ankle sprains leads to better outcomes. In fact, some experts believe that applying ice right after an injury impedes the normal healing process.
Another problem with the R.I.C.E or P.R.I.C.E technique is that many people take the "rest" phase a little too far. Often after acute injury, a little bit of rest is necessary. However, you may feel compelled to rest your injured muscle or joint for far longer than is actually necessary. That can lead to decreased muscle strength and flexibility, which can delay your return to normal function and activity.
So, the recommendations are now towards the P.O.L.I.C.E protocol for these Acute soft tissue injuries where the acronym P.O.L.I.C.E stands for -
P – Protection
O – Optimization
L – Loading
I – Icing
C – Compression
E – Elevation.
But, usage of ICE in Acute stage is always a debatable concept among several health and fitness professionals from decades. British Journal of Sports Medicine published an article which stating, “Intermittent application of ICE is superior to the traditional prolonged application of ice for acute injuries”.2
Also the above said protocols mainly addressing the Acute stage of soft tissue injuries but fails in further progression. To fulfill that space, now the new protocol is emerging as PEACE & LOVE. Here the first acronym PEACE plays vital role in acute stage and the other acronym LOVE for sub acute and chronic stages of tissue healing. Here the PEACE & LOVE stands for -
Image Courtesy -Dubois B, Esculier J. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine 2020;54:72-73.
“Immediately after a soft tissue injury, do no harm and let PEACE guide your approach”
P – Protection
· Unload or restrict movement for 1 - 3 days to reduce the bleeding, to prevent distension of injured fibers and reduce risk of aggravating injury.
· Minimize rest to avoid comprising tissue strength and quality
· Let pain guide removal of protection and gradual reloading.
E – Elevation
· Elevate the injured limb higher than the heartto promotes interstitial fluid flow out of the injured tissue, although poor evidence for it - it still is recommended, as there is a low risk- benefit ratio.
A – Avoid Anti-inflammatory Modalities
· Anti-inflammatory medications may negatively affect long-term tissue healing. Optimal soft tissue regeneration is supported by the various phases of the inflammatory process. So, making use of medications to inhibit the inflammatory process could impair the healing process.
· Avoid usage of ice even though it been used mostly as an analgesic. Although it is widely accepted as an intervention there is very little high quality evidence that supports the use of ice in the treatment of soft tissue injuries.
· Ice may potentially disrupt inflammation, angiogenesis and revascularization and potentially delay neutrophil and macrophage infiltration which leads to increase of immature myofibers which results in impaired tissue regeneration and redundant collagen synthesis.
C – Compression
· Intra-articular edema and tissue hemorrhage may be limited by external mechanical compression such as taping or bandages.
E- Education
· It is our responsibility as physiotherapists to educate our patients on the many benefits of an active approach to recovery instead of a passive approach. Early passive therapy approaches such as electrotherapy, manual therapy or acupuncture after an injury has a minimal effect on pain and function when compared to an active approach.
· If physiotherapists nurture a patient's "need to be fixed" it may create dependence to the Physio and actually contribute to persistent symptoms. Patients need to be better education on their condition.
· Load management will avoid overtreatment of an injury and at same time, Overtreatment may increase the likelihood of injections or surgery and higher costs.
· It is critical for physiotherapists to educate their patients and set realistic expectations about recovery times.
“After initial days have passed, soft tissue needs LOVE”
L - Loading
· Patients with musculoskeletal disorders benefit from an active approach with movement and exercises.
· Normal activities should continue as soon as symptoms allow for it
· Early mechanical stress is indicated to build tissue tolerance and capacity of tendons, muscles and ligaments via mechanotransduction.
· Optimal loading should advise without increasing pain to promote repair and remodeling.
O – Optimism
· The brain plays a significant part in rehabilitation interventions.
· Barriers of recovery include psychological factors such as: catastrophisation, depression and fear. Research shows that these factors may more explain the variation in symptoms and limitations after a soft tissue injury than the degree of pathophysiology.
· Stay realistic, but encourage optimism to improve the chances of an optimal recovery to avoid over expectations of any pessimistic patients which influence outcomes and prognosis of an injury.
V- Vascularisation
· Musculoskeletal injury management needs to include cardiovascular physical activity.More research is needed on specific dosage, but pain free cardiovascular activity is a motivation booster and it increases blood flow to injured structures.
· Benefits of early mobilisation and aerobic exercise in people with musculoskeletal disorders include: Improvement in function, improvement in work status, reduces the need for pain medication.
E - Exercise
· Evidence supports the use of exercise therapy in the treatment of soft tissue injuries and it reduces the risk of a recurring injury.
· Benefits of exercise are: Restores mobility, restores strength, restores proprioception, early after an injury.
· Use pain as a guide to progress exercises gradually to increased levels of difficulty by avoiding pain provoking activities to promote optimal repair in the subacute phase.3,4
In summary, never think only about the ACUTE stages of injury while handling the Soft tissue injuries. Treatment must be include with the approaches which address the CHRONIC stages as well. In general terms, short-term benefits are always not be a prime goal, Long-term interventions and benefits are the prime and always qualitative interventions for soft tissue injuries with PEACE & LOVE.
References:
1. Bleakley CM, Glasgow P, MacAuley DC. Price needs updating, should we call the police? Br J Sports Med2012;46:220–1.
2. C M Bleakley et. al,. Cryotherapy for acute ankle sprains: a randomized controlled study of two different icing protocols. Br J Sports Med 2006;40:700–705.
3. Dubois B, Esculier J. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine 2020;54:72-73.
4. https://www.physio-pedia.com/Peace_and_Love_Principle.
