Got A Sprain, Strain Or Tear? Read The New Guidelines On What To Do.
| With winter sport pre-season and in-season programs being so disrupted by COVID, flu and wet weather this year, we are seeing more sprains, strains and tears than usual. Most of us are familiar with the RICE (Rest, Ice, Compression, Elevation) principles for managing an acute soft tissue injury (by the way a soft tissue injury is basically anything that doesn’t involve bone so it covers all the common sprains, strains and tears that we see in sports). But like most things in medicine, as we learn more the way we manage these injuries needs to change to keep up. There are now updated guidelines that are more effective and comprehensive than RICE. They are designed to be used by sports people of all levels from recreational to elite, as well as physios, trainers and sports medicine doctors. The acronyms PEACE and LOVE form the basis for the new system, so lets see what it’s all about. |
What’s Changed About Managing Sports Injuries?
| The RICE acronym provided basic guidance for what to do straight after an injury. But injuries are complex and the RICE system was only appropriate in the very early stages of treatment. So although it was simple, the RICE approach didn’t take into account several important variables of soft tissue injuries, and also didn’t help with what to do after the first few days. To fix these issues, the British Journal of Sports Medicine published updated guidelines in 2019[1]. These guidelines are now accepted as standard practice for use in sports injury treatment by players, trainers. physios and medical staff. They use the acronyms PEACE and LOVE. The acronyms PEACE and LOVE help you recover better by taking into account more variables of how best to manage acute injuries. They also give guidance on what to do after the first few days, going into what’s called the sub-acute and chronic stages of injury recovery. They highlight the important role of injury education and understanding, plus the hugely under-estimated role that mindset and expectations have on your recovery. |
SOFT TISSUE INJURIES NEED PEACE AND LOVE
PEACE
“Immediately after injury, do no harm and let PEACE guide your approach”
P = PROTECT
– Unload or restrict movement for 1–3 days to minimise bleeding, prevent distension (stretching) of injured fibres and reduce the risk of aggravating the injury
– Minimise rest, because prolonged rest can compromise tissue strength and quality
– Let pain guide the removal of protection and gradual reloading
E = ELEVATE
– Elevate the limb higher than the heart to promote interstitial fluid flow out of the tissues and help reduce swelling
A = AVOID ANTI-INFLAMMATORIES
– The phases of inflammation are an important part of the tissue repair process, so early use of medications that inhibit inflammation may negatively affect tissue healing, especially when higher dosages are used
– Standard care for soft-tissue injuries should not include anti-inflammatory medications, especially at higher doses
– The use of ice (cryotherapy) is also questionable. Surprisingly, despite widespread use there is no high-quality evidence showing that ice is helpful in treating soft-tissue injuries.
– The main role of ice is analgesia (reduced pain). However, ice could potentially disrupt inflammation and other parts of the healing process. This may lead to impaired tissue repair and redundant collagen synthesis, reducing the overall effectiveness of the healing process. More research needs to be done to give a definite answer on whether to use ice for acute soft-tissue injuries.
C = COMPRESS
– Providing external compression using tape or bandages helps limit joint swelling and tissue bleeding
– Sprained ankles are especially prone to large amounts of swelling. Research shows that, despite some conflicting evidence, ankle compression after a sprain is helpful to reduce swelling and improve quality of life.
E = EDUCATE
– Physiotherapists must educate clients on the benefits of an active (i.e. exercise-based) approach to recovery. This is far more effective than relying heavily on passive treatments like electrotherapy, manual therapy or acupuncture,
– Relying excessively on early passive treatments may be counterproductive in the long term. Nurturing an external locus of control or the ‘need to be fixed’ can lead to therapy-dependent behaviour.
– Better education regarding the injury and treatment principles such as load management (i.e. how to balance activity and rest/recovery) is very important for recovery
– Effective education reduces the likelihood of unnecessary injections or surgery. It also reduces the costs of the treatment program.
– Education and discussion must also include agreeing on goals, setting realistic timeframes, and avoiding chasing the ‘magic cure’ approach
LOVE
“After the first days have passed, soft tissues need LOVE”
L = LOAD
– Most injuries benefit from early movement and exercise
– Mechanical stress (load) should be added early to promote tissue healing. Continue normal activities when able, or stop/reduce them initially and resume them as your symptoms allow
– Optimal loading of tissues without aggravating the pain promotes a strong repair and increases the loading capacity of tendons, muscles and ligaments
O = OPTIMISM
– The brain and our expectations for recovery play a significant role in determining our outcome
– Put simply, your recovery is likely to be better if you are optimistic about it, and vice versa
– Research shows that psychological factors such as catastrophisation (i.e. expecting the worst), depression and excessive fear negatively impact recovery
– Ankle sprain recovery may be more impacted by client beliefs and emotions than the degree of tissue damage, the research shows
V =VASCULARISATION
– Pain-free cardiovascular activity should be started early after injury
– Early cardiovascular exercise boosts circulation to injured tissues, plus it increases motivation and physical function to improve mindset and recovery expectations
– Early mobilisation and aerobic exercise has also been shown to reduce the need for pain medication and facilitate an earlier return to work
E = EXERCISE
– Research strongly supports the use of exercise for the treatment of most common soft-tissue injuries
– Exercise is often essential in protecting against recurrent injuries including ankle sprains, ligament injuries and muscle strains,
– Exercise is used to restore mobility, strength and proprioception after injury
– Pain should be avoided in the early stages to allow optimal repair during the subacute phase of recovery
– Pain can be used as a guide for exercise progression
Main Take-Home Message
Managing soft-tissue injuries is about more than just short-term damage control. Following the PEACE and LOVE acronyms help you do the right thing straight away, plus progress your management program appropriately as you recover.
Possibly the most significant differences from the traditional RICE system are that;
1. You should generally minimise rest, and instead work on early pain-free activity and exercise to promote healing
2. The early inflammatory process is an important part of tissue healing so we usually want to let it run it’s course. Therefore, it’s usually best to avoid the use of anti-inflammatory medications, and possibly also ice.
3. It is more effective to take a holistic view of injury management that includes psychological factors like optimism and education for positive expectations of recovery, rather than just focus on local tissue damage and repair. As they say;
“Treat the person with the injury rather than the injury of the person.”
Using these new guidelines will help maximise your recovery from most common soft tissue injuries like sporting sprains, strains and tears. Doing the right things early on by following the PEACE principles will promote healing, reduce pain and swelling, and get you up and moving again as quickly as possible. Then progressing through the LOVE stage of management will fully restore your strength, tissue capacity, and reduce your risk of future problems.
If you would like any more information on these guidelines, or help managing an injury, please feel free to call us on 9280 2322 to speak to one of our friendly physios, or click below to ask a question online.
REFERENCE
The information in this article is drawn from the guidelines published in BJSM as cited below. In developing the guidelines the authors performed an extensive meta-analysis of relevant research. For full references please follow the link to the article below.
Dubois B, Esculier J, Soft-tissue injuries simply need PEACE and LOVE, British Journal of Sports Medicine 2020;54:72-73.
