What to do When You Have an Acute Injury: Follow PEACE & LOVE and the Stoplight Pain Management Model
The days of RICE (rest, ice, compression, and elevation) are over. New evidence suggests it is much more effective to stay moving post soft tissue injury, and soft-tissue injuries just need PEACE and LOVE. Below, explains the revised acronym, which we want to follow post injury:
PEACE: 5 things to do immediately after an injury
LOVE: 4 things to do to a few days after an injury, soft tissues need LOVE
PEACE – 5 things to do immediately after an injury
P: PROTECT: Avoid activities and movements that increase pain the first few days after injury
Helps reduce bleeding, reduces risk of further aggravating the injury, and prevents further injury to muscle & tendon fibers
Extended rest compromises tissue strength & movement quality
The amount of pain you have will be the guide for removal of protection phase (See red/yellow/green technique)
E: ELEVATE: Elevate the limb above the heart as often as possible.
Promotes blood flow away from the injured tissue (While there is limited evidence for this step, there is a low risk to benefit ratio
A: AVOID: Avoid Anti-inflammatories: Avoid taking anti-inflammatory meds as they reduce tissue healing and avoid Icing.
Recent evidence has found that anti-inflammatory medication (NSAIDS) may negative effects on long-term tissue healing, despite their impact on pain. Natural inflammation helps promote tissue repair and regeneration and is needed to help tissues heal. Blunting this response with anti-inflammatory can impair the healing process. Consider a non-NSAID pain relief instead, such as Acetaminophen (ie: Tylenol).
Consult your Physical Therapist regarding other PT related non-medication-based pain relief based on your specific case.
Similarly, while ice can be effective on pain, minimal evidence supports its use in acute soft tissue injuries.
Ice can slow down inflammation, formation of blood vessels and blood flow, which in turn may delay white blood cells infiltration, and may increase immature muscle fibers all contributing to impaired tissue regeneration.
C: COMPRESSION: Use elastic bandage or taping to reduce swelling.
Compression can reduce Intra-joint (within-joint) swelling and tissue injury, as long as full range of motion of the joint is allowed.
Wrap an ACE wrap about 50% overlay slightly tighter at the bottom below the joint and work your way above the joint with slightly less pressure. Make sure you still have FULL range of motion of the joint.
Example: Leg -Ankle to thigh (you may need multiple ACE wraps)
E: EDUCATION: Your body knows best. Avoid unnecessary passive treatments and medical investigations and let nature play its role.
An active approach (patient involvement) to recovery outweighs a passive approach (provider-based treatment).
It is found that early passive therapy approaches such as Electrical Stimulation, manual therapy, or acupuncture after an injury have been found to have a minimal effect of pain and function when compared to an active approach. It is recommended that physical therapists encourage active involvement vs. creating a dependence to manual therapy and passive treatments, as it can contribute to persistent symptoms.
It is important to be educated on your condition, recovery time, and to ask any questions you may have about your condition. Your PT can help set realistic timelines for recovery.
Patient education on load management will help improve avoiding over-treatment of an injury.
(See below Green, yellow, red technique)
LOVE – 4 things to do to a few days after an injury, soft tissues need LOVE
L: LOAD: Let pain guide your return to normal activities. Your body will let you know when it is time to increase load.
Musculoskeletal disorders will benefit from an active approach with movement and PT exercises with progressive overload strengthening.
Resume normal activities as soon as you are able to, letting pain be your guide.
We want to optimize/increase loading without increasing pain, this in turn will help promote tissue repair, increase load tolerance and capacity of muscle, tendon, ligaments, via mechanotransduction.
Mechanotransduction defined: "The process by which the body converts mechanical loading into cellular responses. These cellular responses, in turn, promote structural change.”
For example: In the case of bone healing adapting to load, a small, relatively weak bone can become larger and stronger in response to the appropriate weight bearing or strength training stimulus through the process of mechanotransduction(Kahn & Scott, 2009).
O: OPTIMISUM: Condition your brain for optimal recovery by being confident and positive.
We know that those who believe they will get better, they get better. The brain plays a large role in rehab interventions. Psychological factors and barriers to recovery such as Catastrophizing (assuming the worst will happen), depression, anxiety, and fear play a large role in the healing process.
Having a negative outlook on recovery directly impacts patient outcomes from an injury or surgery.
Overall, we want to be realistic, but optimistic about the chances of a full recovery.
V: VASCULARISATION: Choose pain-free cardiovascular activities to increase blood flow to remaining tissues.
Pain-free cardiovascular exercise helps increase blood flow to injured tissues, think of it as “watering the grass”.
Early mobilization (movement) and aerobic exercise in individuals with musculoskeletal disorders benefits include: increased function, work status and reduction in pain medication intake.
E: EXERCISE: Restore mobility, strength, and proprioception by adopting an active approach to recovery.
Exercise is supported in the treatment of soft tissue disorders and can help reduce the risk of repeat injury
Potential benefits:
Restores mobility, strength, proprioception (body’s awareness in space)
Can help promote optimal tissue repair
Pain as your guide will help you progress your load tolerance and exercise difficulty. (See green, yellow, red technique)
Train your non-injured limb while healing your injured limb can help promote strength in the injured limb. Discuss with your PT how to also workout the non-injured areas to help prevent deconditioning/loss of strength.
While, this new acronym is great for soft tissue acute injuries. Please consult with your medical provider prior to implementing if you have had surgery or have a chronic condition. There are times when using pain medications or ice for example may be necessary and you have to weight the pros vs. cons. Your physical therapist can help implement the most effective exercises, dosage, and modifications needed for you. Choosing the correct exercises can be done with the help of your PT. It can be extremely helpful to employ the stop light method for pain management. This method classifies prescribed exercises as green/yellow/red exercises.
Stop Light Method:
Green: Safe Zone: Pain (when performing is limited to 0-2/10)
Yellow: Acceptable Zone: Pain 2-5/10 (Generally speaking we do not want pain > 5/10 during PT exercises, post PT, or 24 hrs after PT. In addition, in the treatment of tendinopathy, we may want pain with PT exercises (especially in the “Yellow” zone), but not to exceed 5/10 ideally).
Red: High Risk Zone: Pain 5-10/10 (Do not perform exercise, this exercise is not indicated at this time. As pain levels and rehab progresses exercises that were once “Red” may turn into “yellow” or “green” exercises)
*Other things to note when using this scale/method:
We do not want pain/stiffness to progress/increase week to week
Let your Physical Therapist progressively add in harder exercises as pain improves
*Clinical example: Low back pain – pain with flexion
Green exercises: Extension (bending backward)
Ie: Prone press up – laying flat and arching up – pain 1/10
Perform these exercises as much as you want
Yellow exercises: Partial weight bearing
Ie: Cat cow – pain 4/10
Proceed with caution, make sure the exercises does not turn into a “red” exercise pain > 5/10
Red exercises: Flexion (bending forward) activities in standing
Ie: Forward bending – pain 8/10 - do not perform
This method can be very helpful and gives the patient autonomy with their physical therapy program. Consult with your evaluating physical therapist, as each individual has specific needs and injury presentation, and irritability (Pain levels). These factors play a large role in how to best classify exercises for your home exercise program.
Dr. Tessa Kothe, PT, DPT
References:
Bmj. (2021, February 12). Soft tissue injuries simply need peace & love. BJSM blog - social media's leading SEM voice. Retrieved February 21, 2023, from Duchesne, E., Dufresne, S. S., & Dumont, N. A. (2017, May 15). Impact of inflammation and anti-inflammatory modalities on skeletal muscle healing: From Fundamental Research to the clinic. OUP Academic. Retrieved February 21, 2023, from https://academic.oup.com/ptj/article/97/8/807/3826991
Khan, K. M., & Scott, A. (2009, April 1). Mechanotherapy: How physical therapists' prescription of exercise promotes tissue repair. British Journal of Sports Medicine. Retrieved February 21, 2023, from https://bjsm.bmj.c
Peace and love principle. Physiopedia. (n.d.). Retrieved February 21, 2023, from https://www.physio-pedia.com/Peace_and_Love_Principle
