Our Injuries Need PEACE and LOVE
Suffering an acute musculoskeletal injury (e.g. muscle strain, ligament sprain, contusion, etc…) can be confusing given all of the different acronyms we now have to initially manage said injury. You may be familiar with longstanding PIER (pressure, ice, elevation, rest) or the synonymous RICE (rest, ice, compression, elevation) protocols. POLICE is a newer one that adds optimal loading to protection, ice compression and elevation. However, PEACE and LOVE is the newest mnemonic to remember, and maybe the best one for three main reasons:
1) PEACE provides an update on the use of ice and anti-inflammatory medications and how they may impact the healing process.
2) LOVE provides guidance on continuing care and rehabilitation of musculoskeletal injuries whereas PIER/RICE only deal with the acute management of injuries.
3) PEACE and LOVE promotes movement and physical loading of injured structures, which is the stimulus needed for our bodies to adapt and recover from injury.
Should you experience an acute musculoskeletal injury, here’s how you can apply PEACE for the first 1-3 days:
Protection- for the first few days, pain levels may be higher as a signal to help you avoid further injury. This can be done by unloading and limiting movement; however you don’t want prolonged rest either as this can affect strength later on. Let pain be your guide as you go through small, tolerable movements to help deal with swelling and preventing too much loss in range of motion.
Elevation- elevating your limb above the level of your heart can help limit swelling. It is important to limit swelling as this can bog up and slow the healing process. Think of swelling as a failure to remove the fluid that is brought in by the inflammatory process. However, there is not strong evidence to support elevation, but there is low risk. Adding some movement and/or compression may help additionally.
Avoid anti-inflammatory modalities- this includes ice. Inflammation following injury is a highly controlled, necessary process- it is the first stage of the healing process that cleans up the injured tissues and prepares the area for remodelling. Inflammation is needed. Using medication and/or ice to dampen inflammation just delays the healing process as inflammation continues once those modalities wear off.
Compression- using tape, bandages, wraps or sleeves to apply compression can help limit swelling, though there is mixed evidence for its effectiveness.
Education- it is our job as therapists to educate our patients on the healing process, what to expect and things to do to optimize tissue healing. This can help patients take the lead on their rehab as well as minimize catastrophization and over-treatment of injuries. Most injuries have favourable outcomes when managed conservatively; with the proper education, you should feel empowered throughout your recovery.
After the first few initial days following an injury, the active inflammatory phase ends and the remodelling phase begins. Now we need to apply LOVE:
Loading- Our muscles respond to load- it is the stimulus that drives adaptation in all tissues of our body. However, we need to begin with a load that is appropriate for what we can tolerate, but progressive as we recover and get stronger. Loading with exercises and regular daily activities should resume based on your symptoms, but should not exacerbate your pain (some tolerable pain is ok, and even beneficial).
Optimism- While it is easier said than done when we are hurt and removed from the activities we enjoy, optimistic expectations tend to result in better outcomes. When we’re optimistic, we’re motivated. We have a goal to progress towards, and we are confident in our ability to return to our activity. While flare ups and set backs may occur, they are not the end of the road.
Vascularisation- more research in terms of appropriate dosage is needed, but cardiovascular activity can play a role in injury healing. When dosed appropriately, relatively pain-free aerobic exercise gets us moving, which provides a physical load, provides optimism and increases blood flow throughout our body.
Exercise- exercise and strengthening should be the king of any rehab program for any injury because it applies a physical load and stress to the body to drive adaptation, healing and ultimately return to function and activity. Passive modalities (heat, ice, ultrasound, laser, cupping, acupuncture, scraping, tape) may feel good, but are temporary and do not apply physical load. Our musculoskeletal system responds to load.
Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med. 2020; 54(2).