A little peace and love to treat sprains

Many people often wonder about the right way to react when they have just suffered an acute injury (ankle sprain (link to the pathology section - ankle sprain), muscle strain (link to the pathology section - hamstring strain), wrist sprain (link to the pathology section - wrist sprain)), etc.
Should I apply heat or ice? Can I walk on it or not? Should I take anti-inflammatories or painkillers? Should I stay in bed or continue my day?

These are all excellent questions, and PEACE and LOVE is here to answer them.

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What is PEACE and LOVE?

It's the updated acronym that summarizes what to do to properly heal from an acute injury. You may be familiar with older acronyms like GREC, PRICE, RICE, POLICE? Well now, it's PEACE and LOVE.

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Why change acronyms?

Firstly, because science is constantly evolving, and recommendations must always be adjusted based on new studies. Secondly, because the old acronyms don't consider all the factors to manage when an injury occurs.

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So, how do we concretely follow PEACE and LOVE?

The beauty of it is that the acronym allows you to follow the steps in the order of application.

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The first step is PEACE. It starts immediately after the injury. This step generally lasts 48 hours.

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P = Protection

Avoid doing anything that increases the pain. Why? Because after an acute injury, pain is your best indicator of what you are allowed to do or not.
Depending on the injury, crutches, ankle braces, or orthotics can be used to help with the protection phase.

This means you should continue doing anything that doesn't cause pain. Did you just severely sprain your ankle? Is your ankle the size of a grapefruit, but walking doesn't hurt? Then you can walk on it without any problem.

Rest should be minimized because if it is too prolonged, it will hinder tissue healing and the return of muscle strength.
Pain should guide the duration of the protection phase.

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E = Elevation

When possible, elevate the injured area above the heart, especially when you are sitting or lying down. Why? This helps to reduce some of the swelling in certain tissues.

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A = Avoid Anti-inflammatories

Yes, you read that right! Science now shows that these medications can harm the long-term healing of our tissues.
Although they greatly help reduce pain in the short term, they can weaken our tissues in the long term. So, if the pain level is manageable with good protection of the area, it is better to avoid these medications.
However, if the pain is so severe that it prevents you from sleeping well, then it may be beneficial to take them to get a good night's sleep. Sleep is very important for injury healing.

Obviously, the use of anti-inflammatories should be supervised by a doctor or pharmacist.

*For ice,

science does not conclude that it is very effective and necessary for acute injuries. We, therefore, advise you to use ice only if you are unable to manage the pain with good protection or if it prevents you from sleeping. If ice doesn't relieve you, don't use it!

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C = Compression

Use a compression bandage or taping to surround the injured area. This helps reduce swelling.

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E = Education:

When you have just been injured, it is important to have access to good sources of information to reduce your worries and fears. We recommend the following:

Avoid useless passive modalities:

• Such as electrotherapy (TENS, ultrasound, and other electrical currents). They can make the patient dependent on therapists and do not promote patient responsibility in healing their injury.

Avoid over-investigation:

• It is often unnecessary to have X-rays, MRIs, and CT scans.
• The results of these tests often do not change the treatment plan.
• Of course, certain signs and symptoms will be monitored by your doctor or physiotherapist to ensure that imaging is not necessary.
• On the other hand, it's proven that undergoing unnecessary medical imaging increases distress in patients due to the findings on the images. Read our blog post on medical imaging to learn more (link to blog #11).

Avoid over-medication:

• Medication should primarily be used when pain prevents sleep or remains very intense despite proper application of the PEACE protocol.

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The second step is LOVE, which should be gradually started after 48 hours. These steps should be supervised by a physiotherapist. Here are the principles to follow:

L = Load

• We want to gradually reintroduce weight-bearing and movement to the injured area. Start moving the injured area and using the injured limb in your daily tasks without increasing the pain.
• As soon as the pain decreases, we must gradually resume our normal activities without increasing the pain too much.
• A significant increase in pain, swelling, or discomfort at night when resuming activities is a sign that the dosage is too high or too fast.

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O = Optimism

• It's proven that if you are positive and confident that you will recover well, you will actually heal faster than if you are worried, anxious, or fearful.
• Know that it is very normal to have worries or fears following an injury. Therefore, talk about your fears and concerns with your physiotherapist. They will be able to reassure you.

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V = Vascularisation

• Light to moderate cardiovascular activity without pain accelerates healing.
• Depending on the affected limb, here are some examples of cardio activity to start with:
  
  • Walking
  • Use a stationary bike
  • Run if you don't have pain
  • Swim without pain
  • Aquajogging
  • Going up/down stairs
  • Dance until you are out of breath
  • Jump rope
  • Any other cardio activity that does not increase pain
• Start with 5 minutes, then progress to 20 minutes, twice a day, depending on your physical condition.

Note that you could place the injured ankle (for example) on a small bench next to a stationary bike and pedal with only one leg. This will still be effective for blood circulation.

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E = Exercise

• Get guidance from a physiotherapist to regain your mobility, strength, proprioception, and muscle control.

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Is PEACE and LOVE good for all injuries?

NO!
This protocol is the course of action for acute soft tissue injuries (ligaments, muscles) following a specific traumatic incident. It is not the right treatment plan for an overuse injury or an injury that appears gradually.

Here are some examples of when to apply PEACE and LOVE:

• An ankle sprain (link to the pathology – ankle sprain section)
• A muscle strain
  
  • For example, a hamstring strain (link to the pathology – hamstring strain section) while running
• A wrist sprain (link to the pathology – wrist sprain section) from falling on your hand
• A knee sprain (link to the pathology – knee sprain section) from falling or making a wrong move

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Here are some examples of when PEACE and LOVE is not the primary course of action:

Consult your physiotherapist to establish the right treatment plan.

• Any pain that has appeared gradually for no specific reason
• Pain that appears suddenly, but without a specific incident. For example:
  
  • Waking up one morning with a stiff back or neck for no reason
  • Waking up with shoulder pain and not being able to move your arm well for no reason.
• A concussion (link to the pathology – concussion section). Read our blog articles on concussions (link to blog #1, #2 and #10).
• An overuse injury.

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Sources

• Doherty C, Bleakley C, Delahunt E, Holden S. Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. British journal of sports medicine. 2017 Jan 1;51(2):113-25.
• Singh DP, Barani Lonbani Z, Woodruff MA, Parker TJ, Steck R, Peake JM. Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Frontiers in physiology. 2017 Mar 7;8:93.
• Duchesne E, Dufresne SS, Dumont NA. Impact of inflammation and anti-inflammatory modalities on skeletal muscle healing: from fundamental research to the clinic. Physical therapy. 2017 Aug 1;97(8):807-17.
• Boos N, Rieder R, Schade V, Spratt KF, Semmer N, Aebi M. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Spine. 1995 Dec 15;20(24):2613-25.
• Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE.
• Dubois, B. (2019). La clinique du coureur, la santé par la course à pied. Mons Eds.

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