The evo­lu­tion of guide­lines for man­ag­ing soft tis­sue in­juries is a tes­ti­mo­ny of the dy­nam­ic na­ture of sports and em­pha­sis­es the need for per­sons to keep abreast of changes.

In 1994 when I grad­u­at­ed with my diplo­ma in Phys­i­cal Ther­a­py, ICE was the gov­ern­ing prin­ci­ple for treat­ment of acute in­juries. You iced the in­jured area with icepacks or ice im­mer­sion, wrapped with a com­pres­sion ban­dage and el­e­vat­ed. Be­tween then and now, we have been through the acronyms RICE, PRICE, PO­LICE and are now at PEACE and LOVE.

RICE sim­ply rep­re­sent­ed the ad­di­tion of rest to Ice, Com­pres­sion and El­e­va­tion. Com­mon sense in­di­cat­ed that an in­jured in­di­vid­ual would need some lev­el of rest to re­duce stress­es on the in­jured ar­eas.

Short­ly there­after, it was recog­nised that the in­jured area should al­so be pro­tect­ed through the use of splints, braces, tape or oth­er sup­port­ive de­vices and so PRICE was born (Pro­tect, Rest, Ice, Com­press and El­e­vate).

PRICE re­mained around for a while. How­ev­er, it was ob­served that long pe­ri­ods of rest would lead to re­duc­tion in strength and flex­i­bil­i­ty and func­tion­al out­comes were poor. Re­search in an­i­mal mod­els showed that a short pe­ri­od of un­load­ing was nec­es­sary to pro­mote heal­ing, but this should be re­strict­ed to the pe­ri­od im­me­di­ate­ly af­ter in­jury. Long pe­ri­ods of com­plete un­load­ing led to bio­me­chan­i­cal and mor­pho­log­i­cal changes in tis­sues.

Added to this, re­search on ICE, which most­ly fo­cused on the anal­gesic ef­fect, was not very con­vinc­ing re­gard­ing its ef­fec­tive­ness in man­ag­ing soft tis­sue in­juries.

PO­LICE emerged around 2011 (Pro­tec­tion, Op­ti­mal Load­ing, Ice, Com­pres­sion and El­e­va­tion).

Stud­ies showed that grad­u­al­ly adding load soon af­ter in­jury led to bet­ter out­comes. For ex­am­ple, it was found that per­sons with an­kle sprains who be­gan ear­ly par­tial weight bear­ing, whilst in a cast, had far bet­ter out­comes than those who were com­plete­ly im­mo­bilised and un­weight­ed for six weeks. Per­sons with back pain did far bet­ter when ear­ly move­ment was ini­ti­at­ed com­pared to those who were told to rest in bed for six to eight weeks.

Op­ti­mal load­ing means re­plac­ing rest with a bal­anced and in­cre­men­tal in­crease in ac­tiv­i­ty. How­ev­er, the chal­lenge is de­ter­min­ing how much is ide­al. In­juries and peo­ple dif­fer, so we can­not use a ‘one size fits all’ ap­proach. The load­ing strat­e­gy must con­sid­er the unique me­chan­i­cal stress­es that will be placed on the in­jured tis­sues as ac­tiv­i­ty be­gins.

In 2019, Blaise Dubois and Jean-Fran­cois Es­culi­er, in a blog on the British Jour­nal of Sports Med­i­cine, sug­gest­ed that ICE, RICE and PRICE fo­cused on acute man­age­ment and ig­nored sub-acute and chron­ic stages of tis­sue heal­ing.

Al­though these acronyms were com­mon­ly known, the ev­i­dence sup­port­ing their use was still lim­it­ed. Though PO­LICE gave some thought to the post-acute phase, the ap­proach was thought to be lim­it­ed. PEACE & LOVE was pro­posed.

Ac­cord­ing to Dubois and Es­culi­er, you should prac­tice PEACE im­me­di­ate­ly af­ter the in­jury.

P for Pro­tect—Im­mo­bilise and avoid all move­ments that can cause pain 1-3 days post in­jury.

• E for El­e­vate—The in­jured area should be el­e­vat­ed above the lev­el of the heart.

• A for Avoid an­ti-in­flam­ma­to­ry modal­i­ties of treat­ment—The in­flam­ma­to­ry process is a nat­ur­al part of the heal­ing process and da­ta is emerg­ing to show that use of an­ti-in­flam­ma­to­ry treat­ments can in fact hin­der long term heal­ing of dam­aged tis­sues. Ice, which is the main­stay of all the ear­li­er ap­proach­es for man­ag­ing acute in­juries, is in­clud­ed for its anal­gesic ef­fect and a pos­si­ble an­ti-in­flam­ma­to­ry ef­fect. In this new ap­proach, ice is not in­clud­ed in in­jury man­age­ment.

• C for Com­pres­sion—Us­ing com­pres­sion ban­dages im­me­di­ate­ly af­ter in­jury has been shown to re­duce swelling and aid re­cov­ery.

• E for Ed­u­cate—It is well known that an ed­u­cat­ed client will be far more com­pli­ant and ac­tive in their re­cov­ery process than some­one who does not un­der­stand their in­jury and its man­age­ment.

Af­ter the first few days have passed, we should move on to pro­vide LOVE to the tis­sues.

• L for Load—Me­chan­i­cal stress­es should be added with at­ten­tion be­ing paid to the con­cept of Op­ti­mal Load as de­scribed in PO­LICE. Op­ti­mal load­ing should not ex­ac­er­bate pain and will pro­mote re­pair, re­mod­el­ling and build tis­sue strength.

• O for Op­ti­mism—The psy­cho­log­i­cal im­pact of in­jury should not be ig­nored. Fo­cus must be placed on en­sur­ing in­jured per­sons re­main op­ti­mistic. Per­sons who cat­a­strophise in­juries and be­come de­pressed will have poor­er out­comes than those who re­main op­ti­mistic.

• V for Vas­cu­lar­i­sa­tion—Pain free aer­o­bic ac­tiv­i­ty should be start­ed as soon as the per­son can tol­er­ate it. This aids with in­creas­ing blood flow to the dam­aged tis­sues and mo­ti­vates the in­jured per­son.

• E for Ex­er­cise­—Ex­er­cis­es fo­cused on strength, mo­bil­i­ty and pro­pri­o­cep­tion of the in­jured area will lead to bet­ter func­tion­al out­comes.

Are we ready to em­brace PEACE and LOVE?

Dr Sharmel­la Roopc­hand Mar­tin is the Head of the Mona Acad­e­my of Sports and can be reached at sharmel­la.roopchand­martin@uwi­mona.edu.jm