Forget the R.I.C.E Method: Part 3 of 3

In the first two articles in this series, I highlighted the pitfalls and myths surrounding soft tissue injuries and recovery. It turns out, soft tissue injuries need PEACE AND LOVE not RICE!

Recently, the British Journal of Medicine (BJM) published an article highlighting the positive recovery effects of these two new acronyms - PEACE and LOVE. One of the biggest differences between the RICE Method and the newer PEACE and LOVE is the comprehensive approach from immediate care (PEACE) to subsequent management (LOVE). Whereas the RICE Method is strictly for managing the acute stages of inflammation post-injury, this PEACE and LOVE approach provides a more comprehensive strategy to help recover properly from a soft-tissue injury

Immediately following an injury use PEACE!

P - Protection is vital as we do not want to engage into anything which could further harm us after an injury. Unload or restrict certain movements for the first 1-3 days to minimize any bleeding, prevent distention of injured muscle fibers, and reduce the risk of aggravating the injury. Please note, this is not complete rest! Resting should be minimized as prolonged rest can compromise the tissue’s ability to recover properly and has been shown to delay tissue strength and quality! In this stage, it is also advised to allow pain signals should guide the cessation of protection.

E - Elevate the limb higher than the heart the help promote interstitial fluid flow out of the injured tissues. Especially helpful for lower leg injuries, elevating helps to temporarily minimize the effects of swelling in the ankle and feet. Oftentimes, this swelling creates a very stiff and rigid joint which can become quite challenging to overcome after an injury.

A - Avoid taking anti-inflammatory modalities to help the various stages of inflammation do their jobs. This one might seem counterintuitive, but by masking the swelling and inflammation by taking an anti-inflammatory, you could create negative long-term effects on your body’s ability to recover from tissue injuries and damage. This includes the use of cryotherapy, as there is not one single high-quality evidence on the efficacy of ice for treating soft-tissue injuries. In my opinion, cryotherapy, or icing, disrupts the inflammatory process which delays angiogenesis (new blood vessel healing and formation), revascularization, delayed neutrophil and macrophage infiltration. Neutrophils and macrophages are two really important “clean up” cells which our body’s produce naturally to go into an area of inflammation to clear out all the dead cells, which “died” as a result of the soft-tissue injury. I don’t know about you, but I would prefer my body’s neutrophils and macrophages free reign to go into an area of injury and clean up the mess. I wouldn’t want to do anything to inhibit them doing their job - which is exactly what icing does! So, no ice for me for soft tissue injuries.

C - Compression via external mechanical pressure such as bandages can be quite useful to help limit intra-articular edema and tissue hemorrhage. One example where compression has been shown to be effective has been in ankle sprains, where the compression helped reduce tissue swelling and improve quality of life.

E - Education about soft tissue injuries should be a lengthy conversation throughout the injury process from the therapist, clinician or doctor. In fact, informed consent dictates one knows the Benefits, Risks, Alternative Options and the risk of doing nothing for each intervention proposed by the rendering doctor. How many providers have successfully given you complete informed consent on your injuries? (That’s a topic for another day, because studies continually show how providers know the treatment guidelines for common conditioning such as low back pain and yet, ignore them completely!)

After the first few days (1-3), we can begin to initiate the LOVE Progression for soft tissue injuries. After all, these soft tissues need some LOVE.

L - Load the tissue! What we mean by “load” is where you increase you movements, add resistance bands, weights and changes in intensity. Mechanical stress is a great thing for soft tissues! After all, isn’t playing a sport mechanically stressful? Wouldn’t you rather engage in mechanical stress as a part of your rehabilitation program than to experience mechanical stress for the first time when you step back onto the field? Mechanical stress should be added early and normal activities resumed as soon as symptoms permit. Optimal loading strategies, without exacerbating pain, promotes proper tissue repair, remodeling and builds tissue tolerance. It also builds the capacity of tendons, muscles and ligaments. That’s why at our Carol Stream clinic we are “default aggressive” on soft-tissue injuries. Once we can, we load it. And a crazy thing has happened as a response to our default-aggressive approach… patients love it! They love the feeling they get of a tough workout even though they have sustained a relatively recent soft tissue injury. Gone are the days of bracing, icing, and resting for 6-8 weeks for an ankle sprain. If anyone has been told to rest for 6-8 weeks with a high ankle sprain, please call our office today as you have been fed a healthy bowl of misinformation. Better yet, text our office now (630) 765-0575 and we’ll get you safely through the PEACE and LOVE approach and help get you back to your sport, event or activity you love!

O - Optimism is vital for recovery. Optimistic patient expectations are associated with better outcomes, research shows. You cannot neglect the powerful effects the mind has on recovering from an injury. Psychological factors catastrophization, depression and fear all lead to lengthy recovery. Beliefs and emotions are thought to explain more of the variation in symptoms following an ankle sprain, for example, than the degree of the injury itself. Again, high achievers and elite athletes that we’ve worked with in our office all approach rehabilitation and their plan of care as a process for them to get back to their sport. They don’t internalize the injury and begin to doubt themselves, but rather, view it as an opportunity to improve upon.

V - Vascularization, especially cardiovascular activity represents a key component of the injury recovery journey. Nothing irks coaches more than when a player gets “cleared to play” and is put in a game, only for them to be completely exhausted just moments later. This occurs because the injured tissue became the sole focus and the cardiovascular system, along with the respiratory system, were not challenged during rehab. So, nowadays, rehab professionals (at least the best in the business) have initiated cardiovascular and respiratory rehabilitation into their comprehensive treatment plans. This includes early, pain-free aerobic exercise just days after an injury is sustained in order to help boost motivation and increase blood-flow to the injured structures.

E - Exercise should remain a part of the patient’s journey, even after recovery. This include specific movements, drills and exercises specifically designed to help mitigate the risk of a future, similar injury. For example, a patient recently came to our office with an ankle sprain, and we started his exercise program off with single-leg balance exercises. He was tasked with standing on one leg for 5 rounds of 30 seconds each leg before we progressed into the next level of difficulty (eyes closed). He will be asked to continue this single-leg drill for the remainder of his high school soccer season to help limit the risk of another ankle injury. (Please note the wording in that last sentence, as we are aiming to reduce the risk of a future injury, but we cannot say we can prevent a future injury).

So there you have it! We’ve busted the myth of the RICE Method and provided a solution by outlining the PEACE and LOVE Strategies for soft-tissue injuries. It’s one thing to point out the flaws without offering up a solution, so we’ve aimed to strategically space out the issues we have with the RICE Method while at the same time offering up simple, effective, and tangible strategies everyone can implement on their own. It is worth mentioning, though, that managing soft-tissue injuries are more than a short-term quick fix. Our office strives to address the short-term needs of each patient, most notably the reduction of pain, and build a comprehensive plan of action for the future weeks, months and years. After all, we feel it is our responsibility to share long-term strategies to help our patients stay in the game, match or event they love. We’ve helped hundreds from patients recover from soft-tissue injuries, without the need for extra rest, anti-inflammatories, and unnecessary injections. By following the PEACE and LOVE Approach, we’ve set ourselves apart in the Chicagoland area as one of the few clinics who are willing to aggressively treat our patients and help them get back to their sport, as safely and effectively as possible. That’s our commitment.

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Dedicated to restoring your health.

Dr. Alex Earl, DC DACRB

Resources:

British Journal of Medicine: Soft Tissue Injuries simply need PEACE and LOVE” https://bjsm.bmj.com/content/bjsports/54/2/72.full.pdf