The evidence has changed greatly over the last decade but in many ways this has caused more confusion as to the best way to manage an acute injury.

Are you following RICE…

PRICE… 

POLICE or the more recent…

PEACE & LOVE acute injury model?

What really is the best way to manage an acute injury?

With so many different methods and protocols it can be hard to make sense of it all.

This blog post help you make sense of what the current evidence is regarding acute injury management and give you the information you need to better manage the acute injuries you see.

What The Evidence Is Saying

Acute injury management has come along way since the early RICE (Rest, Ice, Compression, Elevation) concept was first used in the 1970’s.

PRICE came next. 

This model added ‘P’ (Protection) to the previous RICE model. 

Protection might include using a walker boot for for an ankle injury, a sling for a shoulder problem or a brace for a knee injury.

Next was POLICE (Protection, Optimal Loading, Ice, Compression, Elevation).

This model indicated a big change in that it replaced the concept of rest with ‘optimal loading’ indicating that completely resting an injury was often not the best course of action. 

This clearly makes sense as we know that all structures including bones, ligaments, tendons and muscles need loading to stimulate healing. 

More recently (2019), Dubois and Esculier (2019) proposed a new model (and acronym) to optimise soft tissue injury management…

PEACE & LOVE.

Protect

Elevate

Avoid anti-inflammatories

Compress

Educate

Load

Optimisation

Vascularisation

Exercise

This new model has been generally well received, but is it really the best way to manage acute injuries?

Let’s take a closer look.

To Ice or Not to Ice…That is the Question

A big omission from the PEACE & LOVE model is the use of ice.

More recent evidence has suggested that ice is ineffective in acute injury management and as a result should not be used.

But it is still used all the time.

A player gets a hamstring injury or rolls their ankle in a Premier League football game and 2 minutes later they have a bag of ice strapped to their injury.

So are the therapists that do this wrong?

If the evidence is saying not to do it, then why are they still persisting with ice?

Ice does has the benefit of mediating pain.

Applying ice to an injured area will cause vasoconstriction and aid the control of inflammation.

It is this inflammation that causes the pain and sends signals to the brain telling the body it has an injury.

So if we can limit excessive inflammation and reduce pain levels of the athlete or patient we are working with surely that’s a good thing, right?

I think so.

But it does have it’s limitations and should not be used in isolation.

Other than blunting that initial inflammatory response and reducing pain, the use of ice is going to become largely redundant beyond the first 48 hours post injury.

At this point other methods of acute injury management are more important – like compression, elevation and protecting the injured area e.g. using crutches or a brace.

You may still use ice in combination with these other methods e.g. ice and compression – like the commonly used game-ready’s that are used in sport and are reported to be beneficial both subjectively and objectively for those players or patients that use them.  

I still use ice and will continue to do so, as I feel it is effective short term and is easily accessible pitch-side, making it a great option to use when an injury first happens and something your player or patient can repeat themselves at home during that first 48 hours post injury. 

Another key element of the emerging evidence is the avoidance of anti-inflammatory medication, especially in the first few days post injury.

The important thing here is understanding that we never want to stop inflammation from occurring…

Rather we want to stop excessive inflammation occurring.

The process of inflammation is the first step towards tissue healing and is therefore something we need to happen. 

Preventing it completely would stop a muscle, tendon, bone or ligament actually healing at all.

The idea therefore of taking anti-inflammatory medication straight after an acute injury therefore makes no sense as these medications (ibuprofen, naproxen etc) act to stop the process of inflammation occurring.

Such medications can be effective and help with the management of injuries, but they just need to be used at the right time… 

And the first 72 hours post injury is certainly not the time to use anti-inflammatory medications.

Progressing an Acute Injury Back To Full Function

One great advancement in acute injury management in the PEACE & LOVE model is the focus NOT just focus on short-term damage control. 

You can look at PEACE & LOVE as two distinct stages.

Stage 1 (PEACE – Protect, Elevate, Avoid anti-inflammatories, Compress & Educate) is what to do in the first few days post injury.

Stage 2 (LOVE – Load, Optimisation, Vascularisation & Exercise) are the steps to follow after the first few days.

This clearly makes logical sense as there is a need to progress any injury from a relative period of ‘protection’ if you want to help your patient or athlete get back doing more active things.

This process and progressions were not included as part of the previous acute injury models (RICE, PRICE & POLICE).

Whether it is a ankle, knee, shoulder or lower back injury it does not matter…

Rehab needs to be logical and progressive to ensure the patient or athlete you work with gets better and is actually able to return to their chosen activities, whatever they may be.

Clearly acute injury management is important  to control inflammation and allow the injured tissues to ‘heal’ but progressive rehab is needed to recondition the tissues, help them tolerate load and prepare the injured tissues for a return to their previous level of function.

The PEACE & LOVE model brings both these key stages together well…

And is a great model to follow…

But I would still use ice in the early stages!

How about you?

How do you manage the acute injuries you see?

Do you use ice or not?

I’d love to hear from you.

Just send me an email to andy@newgradphysio.com and let me know your thoughts.

Andy

The New Grad Physio Mentor

PS. I have a special module in my new grad physio membership [www.newgradphysio.com/membership] that focuses solely on pitch-side injury management.

It covers more detailed content on many of the concepts discussed in this post plus additional learning materials on emergency action planning and a key webinar showing you how to stay safe and competent covering sports matches.

If you deal with a lot of acute injuries then you will find this content very helpful.

To find out how to get access to this content just head here [www.newgradphysio.com/membership] right now.