What Is PEACE and LOVE?

We may have been told when we were younger that putting ice on an injury will help. This thinking may have risen from Dr Gabe Mirkin, in 1978, who coined the term RICE (Rest, Ice, Compression, Elevation) and suggested that the process should be used in the first 24-48 hours post-inury to decrease inflammation and pain.

Since this, there has been suggestions that this may be too simple a protocol to follow considering the complexities of soft-tissue injuries, with RICE focussing on on the acute management of soft tissue injuries and do not really provide any information on the sub-acute and chronic stages of soft tissue healing.

Dubois and Esculier (2019) proposed two new protocols that may be better suited to soft tissue recovery. The new protocols include a more full range of soft tissue injury management and highlights the importance of patient education, psychological factors that can aid recovery and the potentially detrimental effects of anti-inflammatory medication. Importantly, the new protocols question the use of ice during injury recovery.

Maybe, what we all our injury needs is PEACE and LOVE.

PEACE is used immediately after the injury.

Protect:

The first step is to unload or restrict movement in the area of injury for the next few days. This could require the use of a sling for arm injuries or crutches for lower limbs. This reduces the risk of aggravating the injury further.

You should, however, minimise prolonged rest as this can comprimise tissue strength during and after recovery.


Elevation:

As with RICE, elevate the injured limb higher than the heart. This promotes the flow of interstitial fluid out of the injured tissue.


Avoid Anti-inflammatories:

The inflammatory response seen after an acute injury involves increased blood flow and release of mediators such as histamines which will attract immune cells to the site of inury to initiate repair. The use of anti-inflammatory medications can inhibit this process and slow the initiation of tissue repair.

The use of ice can also be analgesic (reduces pain) but can disrupt the inflammation, angiogenesis (formation of new blood vessels) and revascularisation processes which can delay tissue repair.


Compression:

Intra-articular oedema (fluid build-up) and tissue haemorrhage may be limited by external mechanical compression such as taping or bandages. The compression should still allow for full range of motion at the joint.


Education:

It is our responsibility as practitioners to take an active approach to the education of our patients on their injury. Ultimately, we want to get you to a point where you no longer need to see us for the injury and can return to normal life pain free. If we create an environment where you feel you constantly “need to be fixed”, this can create a dependancy which can contribute to persistent symptoms.


LOVE is then used after the first few days have passed since the injury.

Load:

Increased activity should take place once symptoms allow it. Pateints with MSK inuries often benefit from movement in the injury site once the level of pain allows. Loading without pain can promote repair and builds tolerance of muscles, tendons and ligaments with the tissue.


Optimism:

Studies have shown that the brain can play a significant part in the rehabilitation process. During rehabilitation, we can often feel fear and can catastrophise to the point of depression. It is important to stay realistic, but encourage optimism to improve the chances of optimal recovery.


Vasculerisation:

It is thoguth that MSK injury management should include some form of cardiovascular activity. Althoygh more research is needed, pain-free cardivascular activity can act as a motivation booster, as well as increasing blood flow to the injured tissue. This can improve function in the tissue and reduce the need for pain medication.



Exercise:

We will often prescribe exercises to our patients during our treatment for them to do at home. Some evidence supports the theory that exersie therapy between treatments can reduce the risk of reinjury, by restoring mobility, strength and proprioception.


Current literature suggests that the PEACE and LOVE approach, which emphasizes protection, optimal loading, addressing psychosocial factors, improving vascularization, and incorporating exercises, may provide a more comprehensive and evidence-based strategy for managing acute injuries, when compared to RICE.

Icing during the inflammatory response seems to be the mains sticking point. Ice can temporarily reduce pain, but inflammation is a natural and necessary part of healing.