Peace and Love Principle

Original Editor - Wanda van Niekerk

Top Contributors - Wanda van Niekerk and Candace Goh  

Introduction

Common and well-known principles of soft tissue injury management include principles such as RICE and POLICE, but there is so much more complexity to the management and rehabilitation of soft tissue injuries. These well-known methods focus on the acute management of soft tissue injuries and do not really provide any information on the sub-acute and chronic stages of soft tissue healing. More recently Dubois and Esculier (2019) proposed two new acronyms to optimise soft tissue recovery: PEACE and LOVE.[1] These two acronyms (PEACE and LOVE) include the full range of soft tissue injury management from immediate care to subsequent management. It highlights the importance of patient education and addressing the psychosocial factors involved that will aid recovery. It also highlights the potential harmful effects of using anti-inflammatory medication for recovery.[1]

Peace

"Immediately after a soft tissue injury, do no harm and let PEACE guide your approach"[1]

P = Protect

  • unload or restrict movement for 1 - 3 days
    • this reduces bleeding
    • prevents distension of injured fibers
    • reduce risk of aggravating injury[2]
  • minimise rest
    • prolonged rest compromises tissue strength and quality[3]
  • let pain guide removal of protection and gradual reloading

E = Elevate

  • elevate the injured limb higher than the heart
    • this 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[3][4]

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
    • making use of medications to inhibit the inflammatory process could impair the healing process[5][6]
  • avoid ice
    • use of ice is mostly 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[7]
    • ice may potentially disrupt inflammation, angiogenesis and revascularisation
    • ice may potentially delay neutrophil and macrophage infiltration
    • ice may potentially increase immature myofibers
      • this can result in impaired tissue regeneration and redundant collagen synthesis[8]

C = Compress

Intra-articular edema and tissue hemorrhage may be limited by external mechanical compression such as taping or bandages[5]

E = Educate

  • 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[4]
  • 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[4]
  • If physiotherapists nurture a patient's "need to be fixed" it may create dependence to the physio and actually contribute to persistent symptoms[9]
  • Patients need to be better education on their condition
  • Load management will avoid overtreatment of an injury
    • Overtreatment may increase the likelihood of injections or surgery and higher costs[10]
  • It is critical for physiotherapists to educate their patients and set realistic expectations about recovery times[1]

Love

"After the first days have passed, soft tissues need LOVE"

L = Load

  • Patients with musculoskeletal disorders benefit from an active approach with movement and exercises[11]
  • Normal activities should continue as soon as symptoms allow for it
  • Early mechanical stress is indicated
  • Optimal loading without increasing pain
    • promotes repair and remodeling[3]
    • builds tissue tolerance and capacity of tendons, muscles and ligaments via mechanotransduction[11]

O = Optimism

  • The brain plays a significant part in rehabilitation interventions[12]
  • Barriers of recovery include psychological factors such as:
    • catastrophisation
    • depression
    • fear
    • research shows that these factors may more explain the variation in symptoms and limitations after an ankle sprain than the degree of pathophysiology[13]
  • Pessimistic patient expectations influence outcomes and prognosis of an injury[14]
  • Stay realistic, but encourage optimism to improve the chances of an optimal recovery[1]

V = Vascularisation

  • Musculoskeletal injury management needs to include cardiovascular physical activity[12]
    • 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[15]

E = Exercise

  • Evidence supports the use of exercise therapy in the treatment of ankle sprains and it reduces the risk of a recurring injury
  • Benefits of exercise:
    • restores mobility
    • restores strength
    • restores proprioception, early after an injury[5]
  • Avoid pain to promote optimal repair in the subacute phase
  • Use pain as a guide to progress exercises gradually to increased levels of difficulty[1]
[16]

Clinical Bottom Line

The management of soft tissue injuries, whether it is a hamstring strain or an ankle sprain, should not just focus on short-term damage control. Clinicians should also focus on long-term outcomes and focus on treating the person with the injury and not just treating the injury of the person.[1]

Resources

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Dubois B, Esculier J. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine 2020;54:72-73.
  2. Bleakley CM, Davison G. Management of acute soft tissue injury using protection rest ice compression and elevation: recommendations from the Association of Chartered Physiotherapists in sports and exercise medicine (ACPSM)[executive summary]. Association of Chartered Physiotherapists in Sports and Exercise Medicine. 2010:1-24.
  3. 3.0 3.1 3.2 Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE?British Journal of Sports Medicine 2012;46:220-221.
  4. 4.0 4.1 4.2 Doherty C, Bleakley C, Delahunt E, Holden S. Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. British journal of sports medicine. 2017 Jan 1;51(2):113-25.
  5. 5.0 5.1 5.2 Vuurberg G, Hoorntje A, Wink LM, Van Der Doelen BF, Van Den Bekerom MP, Dekker R, Van Dijk CN, Krips R, Loogman MC, Ridderikhof ML, Smithuis FF. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British journal of sports medicine. 2018 Aug 1;52(15):956-.
  6. Duchesne E, Dufresne SS, Dumont NA. Impact of inflammation and anti-inflammatory modalities on skeletal muscle healing: from fundamental research to the clinic. Physical therapy. 2017 Aug 1;97(8):807-17.
  7. van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, Van Dijk CN, Kerkhoffs GM. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?. Journal of athletic training. 2012 Jul;47(4):435-43.
  8. Singh DP, Barani Lonbani Z, Woodruff MA, Parker TJ, Steck R, Peake JM. Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Frontiers in physiology. 2017 Mar 7;8:93.
  9. Lewis J, O’Sullivan P. Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?British Journal of Sports Medicine 2018;52:1543-1544.
  10. Graves JM, Fulton‐Kehoe D, Jarvik JG, Franklin GM. 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 services research. 2014 Apr;49(2):645-65.
  11. 11.0 11.1 Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. British journal of sports medicine. 2009 Apr 1;43(4):247-52.
  12. 12.0 12.1 Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, Straker L, Maher CG, O’Sullivan PP. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. British journal of sports medicine. 2020 Jan 1;54(2):79-86.
  13. Briet JP, Houwert RM, Hageman MG, Hietbrink F, Ring DC, Verleisdonk EJ. Factors associated with pain intensity and physical limitations after lateral ankle sprains. Injury. 2016 Nov 1;47(11):2565-9.
  14. Bialosky JE, Bishop MD, Cleland JA. Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain. Physical therapy. 2010 Sep 1;90(9):1345-55.
  15. Bleakley CM, O’Connor SR, Tully MA, Rocke LG, MacAuley DC, Bradbury I, Keegan S, McDonough SM. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. Bmj. 2010 May 10;340.
  16. La Clinique du Coureur. PEACE & LOVE: New acronym for the treatment of traumatic injuries. Published on 30 August 2019. Available from https://www.youtube.com/watch?v=HGTabgG7GIU (last accessed 25 June 2020)