PEACE & LOVE – New early injury management

Introducing the NEW acronym for early injury management – PEACE & LOVE


For as long as I can remember, and I am starting to get old now, I have been taught in First Aid courses that the “best practice” for soft tissue injury management such as hamstrings and calf strains, ankle sprains, knee injuries, etc, was R.I.C.E.  For those who are not familiar with it, R.I.C.E. stands for Rest,Ice, Compression, Elevation.

This acronym was a change in philosophy from the original ICE, with Rest being added. The ‘rest’ component of RICE was believed to be beneficial for the first 24-48 hours of acquiring the injury to allow for healing. It was thought that the rest would reducing the amount of small blood vessel bleeding, tissue damage and you will be aiding in a quicker recovery.  However recent studies have shown that complete rest for longer than 48 hours can actually cause more harm than good, as it results in joint stiffness and weakness. In addition to this, increased rest time causes adaptation and compensation at neighbouring joints causing a change in biomechanics. This increases the chances of re-injury and can also cause pain/injury in other areas of the body. For this reason, RICE is no longer the recommended protocol.

It was then believed that the best way to prevent more damage was by following PRICE (Protection, Rest, Ice, Compression, Elevation) and then POLICE (Protection, Optimal Loading, Ice, Compression, Elevation) principles.

However, the British Journal of Sports Medicine has spent much time studying the literature and they now suggest the use of their two new acronyms to optimise recovery. PEACE for initial injury management and LOVE for subsequent management.

Below is an extract from what is now being suggested as the optimal soft tissue management by them.

During the first few days, soft tissues need PEACE

P : Protect

Unload or restrict movement for 1 to 3 days to minimise bleeding, prevent distension of injured fibers 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 : Elevate

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

A : 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 a 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 revascularisation, delay neutrophil and macrophage infiltration as well as increase immature myofibers, which may lead to impaired tissue regeneration and redundant collagen synthesis.

C : Compress

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

E : 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 injury has 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 to 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 : 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 : Optimism

The 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. Pessimistic patient expectations are also associated with suboptimal outcomes and worse prognosis. While staying realistic, practitioners should encourage optimism to enhance the likelihood of an optimal recovery.

V : Vascularisation

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

E : Exercise

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

And don’t forget to avoid HARM

We strongly believe that following the above management will aid in the quickest possible recovery, however remember to still avoid H.A.R.M. (Heat, Alcohol, Running, Massage) regime. It is still considered vitally important to avoid this, particularly within the first 48-72 hours to improve your chance of a speedy and full recovery.  For those who aren’t familiar with H.A.R.M., it stands for :

H : Heat

Avoid hot baths/showers, heat packs, spas or saunas in the first 48-72 hours as this will lead to an increase in blood flow to the region, thus increasing the swelling.

A : Alcohol

Alcohol increases the swelling and bleeding whilst having an effect on delaying healing.

R : Running

Any form of exercise too soon is detrimental to the healing tissues.  Blood clot / haematoma formation may be compromised – blood flow will increase to the region and healing times will be longer.

M : Massage

Massage performed over the affected area within 48-72 hours may aggravate the damaged tissue and increase swelling in the area.  Massage performed around the area and at distant sites by a qualified Osteopath may help reduce the swelling and small vessel bleeding in the area.

If you have injured yourself playing your chosen sport, make sure you either call the clinic on 02 6021 1975 or book online here ASAP to make sure you are appropriately managing your injury.

Dr Vaughan Saunders

B Sc (Clin Sc) M Hlth Sc (Osteo)

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