Have you just sprained your ankle or pulled a muscle? If so, what would you do first? Ice it? Rest it?
What if I was to tell you that this may not be the correct approach to the injury!
When I was at University, we were taught that in the first 72 hours after an injury that you should use the acronym of R.I.C.E., This stood for Rest, Ice, Compression, Elevation. The aim was to rest the injury as to not make it worse, ice it to reduce swelling, compress it to cause a back pressure to the swelling and elevate the area to again help swelling and this all sounds great.
However, we first realised that there was a problem with this acronym and it was with rest. People were resting completely, which is not good. Even back in 1970, Muller, reported that muscle strength reduced by 2-6% over the first 8 days. The absolute rest was causing de-conditioning, atrophy of muscle shortening and tightening of soft tissues and these were not good. It’s obvious that rest will accelerate de-conditioning but it also affects healing too. Malliaras et al (2013) found that tendons heal quicker when progressively loaded as opposed to rested.
So, the acronym changed to P.R.I.C.E. This stood for Protect, Rest, Ice, Compression, Elevation. This was to encourage protection of the injury rather than absolute rest but this didn’t cut it so the acronym changed yet again. This time to P.R.I.C.E.M. This stood for Protect, Rest, Ice, Compression, Elevation, Movement. Confused?
I would be, and it is obvious why this happened. How can you rest and move? Exactly. This acronym was not working. So next we moved onto P.O.L.I.C.E. This seems to be the answer! This stands for: Protect, Optimal Loading, Ice, Compression, Elevation. This was even discussed by Bleakely et al in 2012 but they did raise questions about the I.C.E parts of the acronym even at this point.
So where does this leave us now?
Well, for some time I have been questioning the role of ice in acute injury and more recently this has been backed up by various experts including Dubois et al (2020), who advocates a new acronym. So, this is the new one: P.E.A.C.E. & L.O.V.E.
This stands for the following: Protect, elevate, Avoid ice and anti-inflammatory drugs, Compression, Education (For the first 48 to 72 hours). Then, load it, Optimism, Vascularisation, Exercise. (After the P.E.A.C.E phase).
So, what does this all mean exactly?
- Protect – Avoid anything that irritates the injury. This doesn’t mean absolute rest though either. You need to move the area within it’s tolerance. So after or the next day there are no signs or symptoms increasing.
- Elevate – Obviously this only applies to areas that you can and this is done in between your movement and activities.
- Avoid ice and anti-inflammatory drugs – New thinking is moving away from the icing of acute injuries as it doesn’t help and may even hinder. The reasoning here is based on when you apply ice you get vasoconstriction in the skin and superficial area, which is designed to stop the blood from cooling too much. This blood has to go somewhere else and that place is deeper. meaning you have to vasodilate deeper, which will increase blood flow to the injury site, hence worsening the bleeding and swelling. It’s obvious when you consider that cryochambers are used by athletes to speed up recovery from injury and training and how does this work? It INCREASES blood flow!
Why no anti-inflammatory medication?
Now remember this is a rough guide, but inflammation is what essentially heals your body so why would you want less? Surely this will slow down the healing process? However here is the caveat, if pain is impeding your ability to progress your rehab then it may be worth taking them to lower pain and improve function but you shouldn’t use them for long and avoid them if you can.
- Compression – Using compression creates a back pressure to the injury site, making bleeding and swelling difficult to enter the area. This truly works but can’t always be used depending on the area.
- Education – this is more about your physio. This is giving you all the help and guidance to get through the first phases of injury.
After the first couple of days, you should start the L.O.V.E phase
- Load it – The biggest issue with injury is deconditioning or how to minimise it. No better is this illustrated by Bayer et al (2017). They found that patients with calf and thigh strains who started to rehab their injury at 2 days after their injury, got back to sport 3 weeks earlier than if rehab was started at 9 days after injury. They also found no increased risk of re-injury too. So this obviously doesn’t mean just hammer things on day two. You need to work is within it’s tolerance levels, monitoring after and next day effects on pain and swelling. As long as no negative effects occur then you are rehabilitating things at the correct level.
- Optimism – Be optimistic about your recovery. Research clearly find having high expectations of your recovery leads to better outcomes and the reverse can be said about negative thinking.
- Vascularisation – The rest of your body isn’t injured remember! Train your upper body and the other leg as this is not a problem. Plus there is a phenomenon called the cross over effect, which is where you can actually increase strength in the untrained limb (Andrushko et al 2018). So why not! Don’t forget Cardio too! If you have a lower body injury then you can train upper body in things such as swimming or a hand bike. If you have injured your upper body then vice versa. So again, why let this deteriorate for no good reason!
- Exercise – Build up your exercises slowly for the injured area. Gradually stretch and load progressively up, while monitoring signs and symptoms.
The content in this blog article is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation.