by Jack Rayment, Physiotherapist. M, Physiotherapy, B.Hlth.Sci (Human Movement)
Introduction
Traditional first aid management of acute (new) musculoskeletal injuries has been
Rest, Ice, Compress and Elevate (RICE)
The mnemonic was coined by sports physician Dr Gabe Mirkin in 1978 without significant change in 34 years.
Time to throw out the RICE and call the POLICE?
In 2012,
Protect, Optimally Load, Ice, Compress, Elevate (POLICE)
became the dominant protocol used by physiotherapists and doctors globally. Since then, the management of acute soft tissue injuries has been a contentious topic among primary healthcare professionals.
In 2020 the prestigious British Journal of Sports Medicine published a landmark, and somewhat controversial, paper declaring “Soft-tissue injuries simply need PEACE AND LOVE
Despite the title of the paper describing the management as “simple”, it highlights the complexities of management extending beyond the use of previously used mnemonics.
“Although widely known, these previous acronyms focus on acute management, unfortunately ignoring subacute and choric stages of tissue healing” (Dubois & Esculier 2020)
So why the change?
You will have noticed the removal of “Rest”. Absolute rest compromises tissue strength, cellular structure and result in the development of fear avoidance behaviours, stiffness and weakness. There is a plethora of studies confirming that total rest is rarely, if ever, the correct management for an injury. This gave way for clinicians and academics to challenge what has been a widely accepted as best practice.
Let’s break it down
Protect
Instead of the R in rest, we first need to ‘Protect’ the injury, making sure it is adequately supported and stabilised so it won’t be injured further. This can be achieved using a sling, brace, taping or splints.
Elevate
Elevation reduces oedema (swelling) and facilitates waste removal from the site of injury. Elevation will prevent swelling by directing blood to the trunk (systemic circulation) and lowering the (hydrostatic) pressure in peripheral blood vessels .
Avoid anti-inflammatory medications and ice
This one is controversial and hotly debated in fields of sports medicine. Remember Dr Gabe Mirkin, the sports doctor who coined the mnemonic RICE? In 2015 he backtracked on his initial hypothesis, writing that ice “may delay healing, instead of helping”. Similarly, Non-Steroid Anti-Inflammatory Drugs (NSAIDs), while commonly used post-injury to manage pain, can actually impair our body’s natural healing process.
The updated advice is to avoid NSAIDs for 3-5 days until the acute inflammatory progress has subsided, however, it is important to consult your doctor or pharmacist on the use of medications. When it comes to ice, the consensus directs that if the pain is unbearable then ice can be used as a helpful analgesic.
Compression
Compression serves to provide minimal protection of the injured body part from excessive movement, although this is not it's primary purpose. The use of compression is primarily used to reduce bleeding and prevent further oedema as a result of the inflammatory process. Compression can be achieved by use of elasticated bandages, plastic wraps and taping.
Educate
Education is one of the strongest skills physiotherapist can use to help anyone who presents for care. Patients need to be better educated on their condition to achieve optimal outcome. Education is:
• Specific to the individual
• Facilitates self-management strategies
• Avoids poor management and potentially aggravating factors
• Sets realistic expectations and recovery times
• Associated with greater prognosis
Load
Patients with soft tissue injuries benefit from an active approach with the early use of movement and exercises.
Optimal loading without increasing pain promotes repair and remodelling of the bodies tissue.
Physiotherapists are skilled at finding the correct level of loading. The goal is to find the right level of optimal loading, specific to the individual’s profile and injury, that will challenge the joint, muscle, tendons and bone sufficiently to reduce the secondary weakness and stiffness.
Additionally, optional loading is crucial in preventing the development of habits of over-protecting the injured area and moving in un-natural motor patterns (how we move).
Patients are often surprised when we don’t advise less activity.
A good physiotherapist will skilfully encourage patients to do more than they thought possible.
Optimism
Evidence shows optimistic patient expectations are associated with better outcomes and prognosis (Laferton et al 2017)(Kastner et all 2021). Prevalent barriers to recovery include psychological factors such as: catastrophisation, depression and fear. Research shows these factors play an important role in recovery, sometimes even greater than the degree of the physical injury.
Vascularisation
Cardiovascular activity represents a cornerstone in the management of musculoskeletal injuries. Pain-free aerobic exercise increases blood flow to repairing tissues and boosts motivation. Early movements improves physical function, supports early return to activity and reduces the need for pain medication (Sculco et all 2001)
Exercise
There is a strong level of evidence supporting the use of exercise for the treatment and reducing the prevalence of recurrent injuries. Exercises help to restore mobility, strength and proprioception early after injury.
Conclusion
The modern management of musculoskeletal injuries presents a strong focus on an “active” approach to rehabilitation. By engaging in early activity, the injured person will achieve an accelerated recovery, improved outcomes and slash the risk of future injury.
Now considered the world standard, PEACE & LOVE help injured persons regain their physical goals.
References
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Briet JP, Houwert RM, Hageman M, et al. Factors associated with pain intensity and physical limitations after lateral ankle sprains. Injury 2016;47:2565–9.
Graves JM, Fulton-Kehoe D, Jarvik JG, et al. 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 Serv Res 2014;49:645–65.
Hansrani V, Khanbhai M, Bhandari S, et al. The role of compression in the management of soft tissue ankle injuries: a systematic review. Eur J Orthop Surg Traumatol 2015;25:987–95.
Kästner, A., Leong, V. S. N. K., Petzke, F., Budde, S., Przemeck, M., Müller, M., & Erlenwein, J. (2021). The virtue of optimistic realism-expectation fulfillment predicts patient-rated global effectiveness of total hip arthroplasty. BMC musculoskeletal disorders, 22(1), 1-14.
Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med 2009;43:247–52.
Laferton, J. A., Kube, T., Salzmann, S., Auer, C. J., & Shedden-Mora, M. C. (2017). Patients’ expectations regarding medical treatment: a critical review of concepts and their assessment. Frontiers in psychology, 8, 233.
Sculco AD, Paup DC, Fernhall B, et al. Effects of aerobic exercise on low back pain patients in treatment. Spine J 2001;1:95–10
Singh DP, Barani Lonbani Z, Woodruff MA, et al. Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Front Physiol 2017;8:93.
Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med 2018;52:956.