Soft Tissue Injuries

Original Editor - Abbey Wright 'Top Contributors - Abbey Wright and Kim Jackson


Introduction

Acute soft tissue injuries have classically been managed through various acronyms the most well known being RICE and POLICE. These acronyms have been around for many years and focus primarily on the acute stages of a soft tissue injury, as research has progressed these acronyms have become outdated and inaccurate. For example we now know that the use of NSAIDs in an acute injury can actually be detrimental to the recovery and healing process.[1]

Most of the research uses an acute lateral ankle sprain as the clinical example so it can be helpful to think of applying these principles to a patient with that type of injury.

The new research has produced new acronyms which can be applied to the acute and sub-acute stages of an injury and promote loading and activity:

PEACE and LOVE

Ankle sprain.png

PEACE and LOVE

In the acute stage of an injury PEACE should be applied.[1]

P: protect

E: elevate

A: avoid anti-inflammatories/ice

C: compression

E: educate

In the sub-acute stage LOVE should be used

L: load

O: optimism

V: vascularisation

E: exercise

History of soft tissue management

ICE

Initially soft tissue injuries were managed through ICE.

I: ice

C: compression

E: elevation

This focused heavily on the use of cryotherapy.

We now know that ice can potentially cause slower healing times as it disrupts normal inflammation and revascularisation. Although there is evidence to show that ice is useful for analgesia. More evidence is required to fully understand the physiological processes that occur when ice is used in an acute injury. [2]

Compression and Elevation are also advised in the ICE acronym. These are mainly anecdotal in recommendation and there is no set advice regarding duration of compression or elevation. Elevation has been show to help reduce inflammation however, this inflammation is normal and is useful in the normal process of healing. [2]

RICE and PRICE

RICE and PRICE were then recommended as an addition to ICE.

R: rest

P: protect

PRICE picture.jpg

Long periods of rest and protection can be detrimental to recovery, leading to muscle wastage and altered bio-mechanics of the limb.[3] However, following an acute injury rest and protection of the limb is still recommended in the acute stages.

Early mobilisation and weight bearing has been shown to accelerate recovery in acute soft tissue injury[4].

POLICE

POLICE was introduced to promote loading in the affected area and prevent long term immobilisation.

P: protection

O L: optimal loading

ICE: as above.

Optimal Loading has been shown to promote tissue healing and maximizes physiological adaptation.[5] This works in a process known as mechanotransduction: the body's way of turning mechanical loading into cellular responses which is the primary way to recover from any soft tissue injury.[6]

Clinical bottom line

As research has progressed the need to educate and promote loading has become apparent in order to recover fully from an injury. As physiotherapists this is not new information, however, the need for PEACE and LOVE to be more publicized should be priority in physiotherapy clinics.

The advice to "avoid anti-inflammatories" has been contradictory although the evidence supports this in the acute stages of injury. [7]

PEACE and LOVE is useful for clinicians and patients as it does not only focus on the immediate short term injury but in fact promotes rehabilitation and exercise.

Resources

PRICE principle

PEACE and LOVE explained

PEACE and LOVE in our clinics

References

  1. 1.0 1.1 Dubois B, Esculier J Soft-tissue injuries simply need PEACE and LOVE British Journal of Sports Medicine 2020;54:72-73
  2. 2.0 2.1 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.
  3. Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE?British Journal of Sports Medicine 2012;46:220-221.
  4. 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.
  5. Glasgow P, Phillips N, Bleakley C. Optimal loading: key variables and mechanisms. British journal of sports medicine. 2015 Jan 6:bjsports-2014
  6. 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.
  7. 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-.