Soft-tissue Injuries Simply Need PEACE and LOVE PDF

Editorial Soft-tissue injuries simply need PEACE Passive modalities, such as electrotherapy,...

Editorial Soft-tissue injuries simply need PEACE Passive modalities, such as electrotherapy, Br J Sports Med: first published as 10.1136/bjsports-2019-101253 on 3 August 2019. Downloaded from http://bjsm.bmj.com/ on 3 August 2019 by guest. Protected by copyright. manual therapy or acupuncture, early and LOVE after injury have insignificant effects on pain and function compared with an active approach,2 and may even be coun- Blaise Dubois,1 Jean-Francois Esculier‍ ‍ 1,2 terproductive in the long term. Indeed, nurturing an external locus of control or the ‘need to be fixed’ can lead to thera- py-dependent behaviour. Better education Rehabilitation of soft-tissue injuries can be especially when higher dosages are used.2 on the condition and load management complex. Over the years, acronyms Standard of care for soft-tissue injuries will help avoid overtreatment. This in guiding their management have evolved should not include anti-inflammatory turn reduces the likelihood of unneces- from ICE to RICE, then on to PRICE and medications. POLICE.1 Although widely known, these We also question the use of cryotherapy. sary injections or surgery, and supports a previous acronyms focus on acute manage- Despite widespread use among clinicians reduction in the cost of healthcare (eg, due ment, unfortunately ignoring subacute and the population, there is no high-quality to disability compensation associated with and chronic stages of tissue healing. Our evidence on the efficacy of ice for treating low back pain).5 In an era of hi-tech ther- contemporary acronyms encompass the soft-tissue injuries.2 Even if mostly analgesic, apeutic options, we strongly advocate for rehabilitation continuum from immediate ice could potentially disrupt inflammation, setting realistic expectations with patients care (PEACE) to subsequent management angiogenesis and revascularisation, delay about recovery times instead of chasing (LOVE). PEACE and LOVE (figure 1) neutrophil and macrophage infiltration the ‘magic cure’ approach. outline the importance of educating as well as increase immature myofibres.3 patients and addressing psychosocial This may lead to impaired tissue repair and factors to enhance recovery. While anti-in- redundant collagen synthesis.3 After the first days have passed, flammatories show benefits on pain and soft tissues need LOVE. function, our acronyms flag their potential C for compress L for load harmful effects on optimal tissue repair. External mechanical pressure using taping An active approach with movement We suggest that they may not be included or bandages helps limit intra-articular and exercise benefits most patients with in the standard management of soft-tissue oedema and tissue haemorrhage.2 4 Despite musculoskeletal disorders.2 6 Mechanical injuries. conflicting studies,2 compression after an stress should be added early and normal ankle sprain seems to reduce swelling and activities resumed as soon as symptoms Immediately after injury, do no improve quality of life.4 allow. Optimal loading1 without exac- harm and let PEACE guide your erbating pain promotes repair, remodel- approach. E for educate ling and builds tissue tolerance and the P for protect Therapists should educate patients on the capacity of tendons, muscles and liga- Unload or restrict movement for 1–3 days benefits of an active approach to recovery. ments through mechanotransduction.6 to minimise bleeding, prevent disten- sion of injured fibres and reduce the risk of aggravating the injury. Rest should be minimised as prolonged rest can compro- mise tissue strength and quality.1 Pain signals should guide the cessation of protection. E for elevate Elevate the limb higher than the heart to promote interstitial fluid flow out of tissues. Despite weak evidence supporting its use, elevation shows a low risk-to-ben- efit ratio. A for avoid anti-inflammatory modalities The various phases of inflammation help repair damaged soft tissues. Thus, inhib- iting inflammation using medications may negatively affect long-term tissue healing, 1 The Running Clinic, Lac Beauport, Quebec, Canada 2 Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada Correspondence to Mr Blaise Dubois, The Running Clinic, Lac Beauport, QC, G1M 2S8, Canada; ​blaisedubois@​me.c​ om Figure 1 PEACE and LOVE acronyms. Dubois B, Esculier J-F. Br J Sports Med Month 2019 Vol 0 No 0    1  Editorial O for optimism of recovery, and should be used as a guide To cite Dubois B, Esculier J-F. Br J Sports Med Epub Br J Sports Med: first published as 10.1136/bjsports-2019-101253 on 3 August 2019. Downloaded from http://bjsm.bmj.com/ on 3 August 2019 by guest. Protected by copyright. Optimistic patient expectations are associ- for exercise progressions. ahead of print: [please include Day Month Year]. doi:10.1136/bjsports-2019-101253 ated with better outcomes and prognosis. Managing soft-tissue injuries is more Psychological factors such as catastrophi- than short-term damage control. Similar Accepted 16 July 2019 sation, depression and fear can represent to other injuries, clinicians should aim Br J Sports Med 2019;0:1–2. barriers to recovery. Beliefs and emotions for favourable long-term outcomes and doi:10.1136/bjsports-2019-101253 are thought to explain more of the varia- treat the person with the injury rather tion in symptoms following an ankle sprain than the injury of the person. Whether References than the degree of pathophysiology.7 1 Bleakley CM, Glasgow P, MacAuley DC. Price needs they are dealing with an ankle sprain or updating, should we call the police? Br J Sports Med a hamstring strain, we hope this editorial 2012;46:220–1. V for vascularisation will encourage clinicians to give PEACE 2 Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, Cardiovascular activity represents a a chance, because perhaps all soft-tissue treatment and prevention of ankle sprains: update of injuries need is LOVE. an evidence-based clinical guideline. Br J Sports Med cornerstone in the management of 2018;52:956. musculoskeletal injuries. While research A longer version of this idea was posted 3 Singh DP, Barani Lonbani Z, Woodruff MA, et al. is needed on dosage, pain-free aerobic on the BJSM blog https://​blogs.​bmj.​com/​ Effects of topical icing on inflammation, angiogenesis, exercise should be started a few days after bjsm/​ 2 019/ ​ 0 4/ ​ 2 6/ ​ s oft- ​ t issue- ​ i njuries-​ revascularization, and myofiber regeneration in skeletal injury to boost motivation and increase simply-​need-​peace-​love/ in April 2019. muscle following contusion injury. Front Physiol 2017;8:93. blood flow to the injured structures. Early That version has 20 references. 4 Hansrani V, Khanbhai M, Bhandari S, et al. The role mobilisation and aerobic exercise improve of compression in the management of soft tissue physical function, supporting return to Contributors BD proposed the initial idea. BD ankle injuries: a systematic review. Eur J Orthop Surg work and reduce the need for pain medi- and J-FE drafted the article and provided input on Traumatol 2015;25:987–95. subsequent versions. 5 Graves JM, Fulton-Kehoe D, Jarvik JG, et al. cation in individuals with musculoskeletal Funding The authors have not declared a specific Health care utilization and costs associated with conditions.8 adherence to clinical practice guidelines for early grant for this research from any funding agency in the public, commercial or not-for-profit sectors. magnetic resonance imaging among workers with E for exercise acute occupational low back pain. Health Serv Res Competing interests None declared. 2014;49:645–65. There is a strong level of evidence Patient consent for publication Not required. 6 Khan KM, Scott A. Mechanotherapy: how physical supporting the use of exercise for the therapists’ prescription of exercise promotes tissue treatment of ankle sprains and for Provenance and peer review Not commissioned; repair. Br J Sports Med 2009;43:247–52. internally peer reviewed. reducing the prevalence of recurrent inju- 7 Briet JP, Houwert RM, Hageman M, et al. Factors ries.2 Exercises help to restore mobility, © Author(s) (or their employer(s)) 2019. No commercial associated with pain intensity and physical limitations re-use. See rights and permissions. Published by BMJ. after lateral ankle sprains. Injury 2016;47:2565–9. strength and proprioception early after 8 Sculco AD, Paup DC, Fernhall B, et al. Effects of aerobic injury.2 Pain should be avoided to ensure exercise on low back pain patients in treatment. Spine J optimal repair during the subacute phase 2001;1:95–101. 2 Dubois B, Esculier J-F. Br J Sports Med Month 2019 Vol 0 No 0