RICE vs PEACE & LOVE
We are going to assume that most of you are familiar with the acronym RICE (Rest, Ice, Compresion, and Elevation) as it relates to the management of injuries, but as it turns out injury management is a little more complex than that.
The performance rehab world has steadily been adapting the new acronym PEACE & LOVE for management of soft tissue injuries (i.e., for muscles, tendons, and ligaments). In this blog, we will cover what PEACE & LOVE stands for and why RICE is antiquated as an acronym for the management of injuries, specifically soft tissue injuries long term.
First let’s cover the limitations of the RICE.
In short, there is insufficient evidence from randomized control trials to support the effectiveness of RICE, with ultimately more research needed to either support or refute its use. The main argument against RICE, is that it focuses on reducing swelling at an injury, which in theory could actually inhibit injury healing. Our bodies are smart and short-term swelling for acute injuries is associated with “good” inflammation, revascularization and cellular activity that is necessary for healing, tissue repair and collagen synthesis. RICE, particularly ice, is not altogether terrible, with benefits including pain control and keeping swelling in-check, however it is hard to determine if its benefits outweigh the risk of potentially impairing soft tissue healing. So, the argument against RICE can be controversial as at this time it lacks any research to support it, and as you’ll see below PEACE & LOVE doesn’t completely omit all the components of RICE, despite the lack of research supporting any of if.
Okay, now let’s dive into what PEACE & LOVE stands for.
PEACE - This part of the acronym summarizes recommendations for the management of new injuries.
P - PROTECTION. It is advised to protect an acute injury for 1-3 days. Pain will be your guide here. It is initially recommended to avoid activities that cause pain the first few days post injury in order to reduce the risk of aggravating the injury, however it should be noted that prolonged rest is not advised as it can lead to reduced tissue strength and quality.
E - ELEVATION. Yes, as in the “E” that was in “RICE.” As covered above, there is limited research to support this, yet it also doesn’t seem to impede injury recovery and in theory could help promote a decrease in swelling, so current recommendations are to still practice elevation. Note: it is recommended to elevate your injured limb above the level of your heart, so sitting at your desk with your swollen ankle propped up on a stool doesn’t count.
A - AVOID ANTI-INFLAMMATORY MODALITIES. Unlike elevation, anti-inflammatory medications, especially in large doses can be bad for long-term healing of soft-tissue injuries.
C - COMPRESSION. Similar to elevation, despite limited evidence to support compression, it still made the cut for this acronym, since it has been shown to limit swelling and improve quality of life for injuries such as ankle sprains. Compression can come in the form of taping, bandages and sleeves.
E - EDUCATE. This is where we, physical therapists, come in! Setting realistic expectations and understanding that an active approach vs relying solely on passive treatments (i.e., manual treatments, acupuncture, electrotherapies, laser, etc..) can help in the long term.
LOVE - This part of the acronym focuses on long term injury healing.
L - LOAD. Most of our clients are familiar with the concept of loading - or gradually placing more workload on the body, be it through progressive exercises, weight or resistance. Introducing load and mechanical stress, as symptoms allow, promotes necessary tissue repair and remodeling while improving tissue tolerance and resilience, helping you fully recover from an injury!
O - OPTIMISM. Fear-avoidance and catastrophizing are associated with prolonged recoveries and increased pain. Optimism on the other hand is associated with an improved prognosis. The power of positive thinking really does go a long way!
V - VASCULARIZATION. Aerobic exercise increases blood flow to an injury to help promote healing, thus it is recommended to start pain-free cardiovascular activities a few days after an acute injury. Bonus: cardio has even been associated with reduced need for pain medication in orthopedic related pain!
E - EXERCISE! Research widely supports exercise for the treatment of soft tissue injuries. Benefits of exercise for management of soft tissue injuries include helping to improve mobility, strength, and balance following an acute injury. Thus, it should be no surprise that exercise helps reduce the reoccurrence of injuries!
In summary, there has long been limited evidence for RICE modalities, and in fact in the short-term there is some good that comes from increased blood flow that our body sends to soft tissue injury sites, so it makes sense that it is theorized that we don’t want to completely impede this. Overall the acronym PEACE & LOVE is more comprehensive in its approach to the management of new soft tissue injuries and more research is needed to determine if there is any benefit or risk associated with icing an acute injury.
So what do we think? Ice can still be very helpful for pain relief and is preferred over anti-inflammatory medications. In theory ice could still be beneficial in managing an abnormal amount of swelling in order to help maintain some joint mobility. But as PEACE & LOVE suggests, taking a more active approach beyond just RICE is far more recommended and backed by research!
Sources:
Dubois, Blaise, and Jean-Francois Esculier. "Soft-tissue injuries simply need PEACE and LOVE." British journal of sports medicine 54.2 (2020): 72-73
Van Den Bekerom, Michel PJ, et al. "What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?." Journal of athletic training 47.4 (2012): 435-443.