Soft tissue injuries simply need PEACE & LOVE

 

By Blaise Dubois @blaisedubois and Jean-Francois Esculier @JFEsculier

Rehabilitation of soft tissue injuries can be complex. Over the years, acronyms guiding their management have evolved from ICE to RICE[1], then to PRICE[2] and POLICE[3]. 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.[4] 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.[2] Rest should be minimised as prolonged rest can compromise tissue strength and quality.[3] 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,[5] 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,[1] ice could potentially disrupt inflammation, angiogenesis and revascularisation, delay neutrophil and macrophage infiltration as well as increase immature myofibers,[8] 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.[9]

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.[12] 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 [3] without exacerbating pain promotes repair, remodeling and building tissue tolerance and capacity of tendons, muscles and ligaments through mechanotransduction.[15]

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.[18] Pessimistic patient expectations are also associated with suboptimal outcomes and worse prognosis.[19] 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.[16] 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.[4] 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.

Do you agree with us? Let us know what you think! Tag us on Twitter with the hashtag #PeaceLove @blaisedubois @JFEsculier @BJSMPlus to continue the conversation.

PS- This blog and infographic are also available in French and Spanish!

***

Competing interests

None declared

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 (@JFEsculiercombines 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: jfesculier@therunningclinic.com

References

[1]        van den Bekerom MPJ, Struijs PAA, Blankevoort L, et al. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults. J Athl Train2012;47: 435-43.

[2]        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.

[3]        Bleakley CM, Glasgow P, MacAuley DC. Price needs updating, should we call the police? Br J Sports Med2012;46: 220-1.

[4]        Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline. Br J Sports Med2018;52: 956.

[5]        Doherty C, Bleakley C, Delahunt E, et al. Treatment and prevention of acute and recurrent ankle sprain: An overview of systematic reviews with meta-analysis. Br J Sports Med2017;51: 113-25.

[6]        Duchesne E, Dufresne SS, Dumont NA. Impact of inflammation and anti-inflammatory modalities on skeletal muscle healing: From fundamental research to the clinic. Phys Ther Sport2017;97: 807-17.

[7]        Yerhot P, Stensrud T, Wienkers B, et al. The efficacy of cryotherapy for improving functional outcomes following lateral ankle sprains. Ann Sports Med Res2015;2: 1015.

[8]        Singh DP, Barani Lonbani Z, Woodruff MA, et al. Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Front Physiol2017;8: 93.

[9]        Hansrani V, Khanbhai M, Bhandari S, et al. The role of compression in the management of soft tissue ankle injuries: A systematic review. Eur J Orthop Surg Traumatol2015;25: 987-95.

[10]      Bleakley CM, O’Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: Randomised controlled trial. BMJ2010;340: c1964.

[11]      Kim TH, Lee MS, Kim KH, et al. Acupuncture for treating acute ankle sprains in adults. Cochrane Database Syst Rev2014;6: CD009065.

[12]      Lewis J, O’Sullivan P. Is it time to reframe how we care for people with non-traumatic musculoskeletal pain? Br J Sports Med2018;epub ahead of print, 25 June 2018.

[13]      Graves JM, Fulton-Kehoe D, Jarvik JG, et al. Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain. Health Serv Res2014;49: 645-65.

[14]      Webster BS, Choi Y, Bauer AZ, et al. The cascade of medical services and associated longitudinal costs due to nonadherent magnetic resonance imaging for low back pain. Spine2014;39: 1433-40.

[15]      Khan KM, Scott A. Mechanotherapy: How physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med2009;43: 247-52.

[16]      Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: Systematic review. Br J Sports Med2019;Epub ahead of print; 2019 Mar 2.

[17]      Roy JS, Bouyer LJ, Langevin P, et al. Beyond the joint: The role of central nervous system reorganizations in chronic musculoskeletal disorders. J Orthop Sports Phys Ther2017;47: 817-21.

[18]      Briet JP, Houwert RM, Hageman MGJS, et al. Factors associated with pain intensity and physical limitations after lateral ankle sprains. Injury2016;47: 2565-9.

[19]      Bialosky JE, Bishop MD, Cleland JA. Individual expectation: An overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain. Phys Ther2010;90: 1345-55.

[20]      Sculco AD, Paup DC, Fernhall B, et al. Effects of aerobic exercise on low back pain patients in treatment. Spine J2001;1: 95-101.

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