31/01/2023

In our last blog we looked at how to recognise the signs of an acute injury. Today, lets follow that up by going through some of the best ways to manage the early stages of an acute injury. 

There are a number of acronyms used to recall what to do in the case of a sprained ankle or swollen thumb or bruised knee. There have been a number of iterations as the guidelines developed over time including:

• I.C.E. (Ice, Compress, Elevate)
• R.I.C.E. (Rest, Ice, Compress, Elevate)
• P.R.I.C.E. (Protect, Rest, Ice, Compress, Elevate)
• M.I.C.E (Move, Ice, Compress, Elevate)
• P.O.L.I.C.E. (Protect, Optimal Loading, Ice, Compress, Elevate)

Most recently an editorial in the British Journal for Sports Medicine has suggested P.E.A.C.E. (Protect, Elevate, Avoid Anti-inflammatories, Compress, Educate), meaning that ice, one of the core strategies of all previous approaches is not included. The authors provide a strong rationale for “ice” being left out. While it is acknowledged that ice can provide some pain relieving effects it could potentially disrupt the very important processes of inflammation, similar to anti-inflammatories. The role of inflammation in acute injury is to remove the injured tissues, lay down temporary tissues including blood vessels to support the development of mature or more purpose-specific tissues. Therefore, my own advice would be to use ice and anti-inflammatories sparingly if at all following an acute injury. 

Let’s go through the remaining strategies. 

1. Protect

Firstly, it is critical to protect the injured area. Specifically, the aim is to avoid moving the area or putting the tissues under load/stress. For example in the case of a calf muscle injury, minimise movement of the ankle and walking. If it was a biceps injury the goal would be to avoid elbow and shoulder movements or lifting. Strappings, braces, supports or crutches can be used depending on the injury. This is where it can be valuable to consult a physiotherapist. 

Generally, the restrictions should be applied for 1-3 days with a very gradual increase in movement, time moving or the amount of force used in the affected area. This prevents further injury, while also encouraging the development of greater tissue strength and quality. 

2. Elevate

Keep the affected area elevated above the level of the heart. It is quite usual for somebody with a leg injury to elevate the leg but not above heart level. The desired effect of reducing the fluid flow to the area will not be optimal if the limb is below heart level. For a leg injury you can lie on your back and put the heel on 1-2 pillows. This can be done for long periods including overnight provided there are no significant heart issues. The area can be elevated on and off for the first 24-72 hours depending on the degree of swelling.

3. Avoid Anti-Inflammatories

See above. 

4. Compress

Applying gentle pressure with specific tape or bandage limits movement but is mainly aimed at reducing excessive swelling and bleeding in the area. It is very important that any compression is applied with light to moderate pressure at the most. If the compression pressure is strong it can be more painful and potentially restrict some of the important inflammatory processes. The compression bandage can be worn for the first 1-3 days and reduced gradually over that time for pressure and degree of bandage applied, to allow for a gradual increase in movement. 

5. Educate

If you can meet your local physiotherapist, they can give you helpful advice on the nature and degree of the problem, the likely recover process and time-frame, and most importantly the approach to rehabilitation which should be focussed on gradually increasing various demands on the area through a specific programme of exercises and other daily activities. 

Once these steps have been followed for 1-3 days it is important to give the injury some L.O.V.E. (Load, Optimism, Vascularisation, Exercise). Let’s look at what you should expect from these strategies.

1. Load

The objective is to gradually increase the mechanical demands on the affected tissues. It is important that all movements and activities that involve the area are pain-free for a minimum of 5-7 days and that any pain that does occur after that is on the low end of a 1-10 scale and that it does not worsen during or persist for much time after the activity or movement. This will help to promote further healing and strengthening of the tissues. 

2. Optimism

The physiotherapist may spend some time addressing any concerns you have about the injury, recovery process and/or return to your normal activity. It is well recognised that if are expectations of recovery are more optimistic through understanding the results are better. If for example a person is very fearful or worried that they will never be able to do an activity again, the results tend to be poorer. Please ask your physiotherapist about any concerns that you have regarding the injury and future activity. 

3. Vacularisation

This strategy is really about getting activity that increases the heart and breathing rates – cardiovascular exercise. It is known that starting this type of exercise early improves general physical ability and reduces the need for pain medications. There is also an increase in blood flow and likely improved motivation which help the recovery process. The type of cardiovascular exercise you get at the start does not have to involve the affected area. For example, if you injure your shoulder and you normally swim, you could start with cycling, fast walking or running. If you have a calf muscle injury, then you could swim (without pushing off the wall) or use a bike that you can cycle with your arms. This can gradually increased to involve the affected area. 

4. Exercise

This strategy is really part of the 1st and 3rd strategies of load and vascularisation, where we are looking to target specific deficits that will have occurred following the injury. For example if you have a knee injury, we will be looking to improve movement, strength and balance throughout the whole limb. The exercises should be progressively more challenging as your ability improves and the tissues are healing due to the gradual demands you are placing on them. Similar to before, it is important that pain is minimised at the start, but as time goes on mild pain that is not worsening or persisting is acceptable and may even have a beneficial role as the demands you are placing on the area are challenging it to a sufficient level to induce improvements in the tissue strength and quality. 

In both the P.E.A.C.E. and L.O.V.E. stages it is important to involve a Physiotherapist to assess and guide you on maximising your recovery. Hopefully, these simple acronyms will help you to know what to expect. 

Till the next blog, stay active and stay well!

Lonan Hughes

Chartered Physiotherapist