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Acute management of soft tissue injuries

Rehabilitation of soft tissue injuries can be complex. Acute soft tissue muscle strains or joint sprains are one of the most common injuries we see as Physiotherapists. 

Over the years, a number of different acronyms have been used to help guide our management of these injuries, from ICE to RICE, PRICE and POLICE. Most people would be familiar with the ‘RICE’ (Rest, Ice, Compression, Elevation) protocol which was introduced in 1978 by Dr Gabe Merkin. Although widely known, there is limited evidence for these treatments and their role in promoting soft tissue healing. In fact, some components of the protocol have since been shown to impair or delay healing by inhibiting inflammation.

Inflammation is our body’s natural initial response to an acute injury and helps trigger the next stage of tissue healing. BJSM (British Journal of Sports Medicine) published an editorial piece in 2019 that introduced a new acronym, encompassing the rehabilitation continuum from immediate care (PEACE) to subsequent management (LOVE). These acronyms, ‘PEACE & LOVE’ not only consider the acute stages of tissue healing but also places emphasis on the importance of educating patients and addressing the psychological factors of injury in order to enhance recovery. 

Let’s breakdown what this really means:

An acute soft tissue injury (i.e. up to 72 hours post injury) needs PEACE

P= Protection.

You should unload and restrict movement for 1-3 days to minimise bleeding, swelling and prevent aggravation of the injury. However, it is important to minimise prolonged rest as this can then start to negatively impact tissue strength and quality. Pain signals should guide when to stop protection.

E= Elevation.

Elevate the limb higher than the heart to help promote flow of any excessive tissue fluid or swelling.

A= Avoid anti-inflammatories.

As mentioned earlier, the various phases of tissue inflammation trigger and assist with the body’s natural healing process of injured tissues. Therefore, inhibiting this inflammatory process using medications, particularly in higher doses, has been shown to negatively affect long-term tissue healing. Icing (or cryotherapy) has historically widespread  use within the population. However it lacks any high-quality evidence of its efficacy in managing acute soft tissue injuries. Whilst it can aid in providing analgesia, ice can also potentially disrupt inflammation and disrupt tissue repair.

C= Compression.

Use taping or bandages to limit the spread of swelling or bleeding of injured tissues.

E= Education.

Physiotherapists can help educate patients on the benefits of an active approach to their recovery, and avoid an over-reliance on passive modalities as they often have insignificant effects on pain and function. For example, if you understand the condition and set realistic goals and expectations, it will help minimise ‘overtreatment’ and reduce patient anxiety and frustration.

After the first few days of an acute injury have passed, tissues need LOVE.

LOVE

L= Loading.

Optimal loading without exacerbating pain promotes tissue repair, remodelling and builds tissue tolerance and capacity. Therefore, mechanical stress or loading, through movement and exercise, should be added early and normal activities can resume as soon as symptoms allow.

O= Optimism.

Often overlooked, optimistic expectations are associated with better outcomes and prognosis. Likewise, catastrophising, depression and fear can provide significant barriers to recovery.

V= Vascularisation.

Pain-free aerobic exercise should be started a few days after injury to boost motivation and improve blood flow to injured structures. Similarly, it improves physical function, reduces the need for pain medication and supports return to work and play.

E= Exercise. 

Exercise is the cornerstone of managing various musculoskeletal conditions.
There is a strong level of evidence to support the use of exercise, not only in its benefits for acute/sub-acute injury management but also to reduce the prevalence of recurrent injury and injury prevention. Furthermore, early, targeted exercises to help restore mobility, strength and proprioception are encouraged. These can be suitably progressed to meet your long-term outcomes and goals.

For more information on how this framework can be tailored to your injury to get you back on track to your health and wellness goals, please contact any one of our PMPP Physiotherapists. 

– Diana

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