Rehabilitation of soft tissue injuries can be complex. Over the years, acronyms guiding their management have evolved from ICE to RICE, then to PRICE and POLICE. Although widely known, the evidence supporting the elements of these treatments is limited. ICE/RICE/PRICE focus on acute management, unfortunately ignoring sub-acute and chronic stages of tissue healing.
We posit that two new acronyms can optimize recovery. Our acronyms encompass the rehabilitation continuum from immediate care (PEACE) to subsequent management (LOVE). PEACE & LOVE outlines the importance of educating patients and addressing psychosocial factors to enhance recovery. In addition, while anti-inflammatories show benefits on pain and function, our acronyms flag their potential harmful effects on optimal tissue repair. We suggest that they may not be included in the standard management of soft tissue injuries.
Immediately after a soft tissue injury, do no harm and let PEACE guide your approach
P for 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 for 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.[1-3]
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 a higher dosage is taken.[4, 6]
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.[1, 4, 5, 7] 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.[7, 8]
C for Compress
External mechanical pressure using taping or bandages helps limiting intra-articular edema and tissue hemorrhage.[4, 9] Despite conflicting studies,[1, 4] compression after an ankle sprain seems to reduce swelling and improve quality of life.
E for Educate
Therapists should educate patients on the benefits of an active approach to recovery.[5, 10] 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; [4, 5, 11] 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).[13, 14] 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.[4, 15] 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.[16, 17] 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 for 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.[10, 20]
E for 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.[4, 5, 10] 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.
Managing soft tissue injuries is more than short-term damage control. Similar to other injuries, clinicians should aim for long-term outcomes and treat the person with the injury rather than the injury of the person. Whether they are dealing with an ankle sprain or a hamstring strain, we hope this BJSM blog post will encourage clinicians to give PEACE a chance, because perhaps all soft tissue injuries need is LOVE.
Blaise Dubois (@blaisedubois) is the president and founder of The Running Clinic, an organization providing continuing education internationally. In the clinic and in research, Blaise is interested in the prevention and treatment of running injuries, with a particular focus on footwear and biomechanics. He is also an avid runner and co-owner of PCN physiotherapy clinics (Quebec City, Canada).
Jean-Francois Esculier (@JFEsculier) combines clinical research (Department of Physical Therapy, University of British Columbia) with patient care (Allan McGavin Sports Medicine Clinic, Vancouver) and knowledge translation (The Running Clinic, Canada). He loves to educate and empower patients so they can become the main actor of their rehabilitation. Email: firstname.lastname@example.org
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 Bleakley CM, Glasgow PD, Phillips N, et al. Guidelines on the management of acute soft tissue injury using protection rest ice compression and elevation. London: ACPSM, 2011.
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