RECOVERY FRAMEWORKS

When it comes to recovery, the RICE method (Rest, Ice, Compression, and Elevation) is a widely known and accepted principle of soft tissue injury management.

However, emerging research has challenged certain aspects of the RICE protocol and suggests that complete rest, icing, and compression may actually impede the long-term recovery process by inhibiting the inflammatory response needed for healing.

More recently Dubois and Esculier (2019) proposed two new acronyms to optimize soft tissue recovery and have shown effectiveness over traditional methodologies of strict rest and icing:

PEACE & LOVE.

While PEACE & LOVE doesn’t completely omit all the components of RICE, this framework addresses the gaps left by previous approaches by offering a more comprehensive approach to recovery focusing on 3 key factors:

1.

Inflammation is essential to healing.

2.

Movement is important.

3.

Optimism helps you heal.

KEY DIFFERENCES

PEACE & LOVE

Includes immediate care for the acute injury but also considers long-term recovery.

Encourages active rehabilitation and early movement/exercise.

Highlights the potential harmful effects of using anti-inflammatory medication for recovery. 

Emphasizes the importance of psychological well-being during recovery, which can also aid the healing process.

RICE

Primarily focuses on the acute stage following injury.

Emphasizes reducing activity to minimize further damage.

Encourages anti-inflammatory management such as applying ice to reduce swelling and pain.

“Immediately after injury, do no harm and let PEACE guide your approach.”

(Vuurberg, 2018; Singh, 2017; Hansrani, 2015; Graves; 2014)

    • This minimizes bleeding, prevents, distension of injured fibers, and reduces the risk of aggravating the injury.

    • Rest should be limited, since prolonged rest can compromise tissue strength and quality.

    • Pain signals should guide the cessation of protection.

  • Elevating the injured limb above the heart promotes interstitial fluid flow out of tissues, which reduces swelling, improves circulation, and minimize discomfort. For dancers, this can mean faster recovery, better mobility, and less stiffness when returning to movement.

    • The various phases of inflammation help repair damaged soft tissues. Inhibiting inflammation using medications may negatively affect long-term tissue healing, especially when higher dosages are used.

    • Encourages inflammation as an essential biological response to aid the natural healing process.

  • Providing external mechanical pressure such as wraps or tape can limit excess swelling and protect the injured structure to help limit intra-articular edema and tissue hemorrhage

    • Better education on the condition and load management will help avoid overtreatment. This in turn reduces the likelihood of unnecessary injections or surgery, and supports a reduction in the cost of healthcare

    • Providers should advocate for active recovery and set realistic expectations with patients about recovery times instead of chasing the ‘magic cure’ approach

After the first days have passed, soft tissues need LOVE.”

(Briet et. al, 2016; Sulco et. al, 2001)

    • An active approach with movement and exercise benefits most patients with musculoskeletal disorders.

    • Optimal loading without exacerbating pain promotes repair, remodelling and builds tissue tolerance and the capacity of tendons, muscles and ligaments through mechanotransduction.

    • Optimistic patient expectations are associated with better outcomes and prognosis.

    • Psychological factors such as catastrophization, depression and fear can represent barriers to recovery.

  • Pain-free or pain-reduced activity should be started a few days after injury to increase blood flow to the injured structures.

  • Pain should be avoided to ensure optimal repair during the subacute phase of recovery, and should be used as a guide for exercise progressions.

Which method should I use?

  • 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!

    Read More

  • RICE is useful in the immediate aftermath, within the first 12 hours of an acute injury, to help ease pain and reduce any secondary injury.

    While the RICE protocol may still have some utility in the immediate aftermath of an acute injury; the PEACE and LOVE protocol is a more active, movement-based approach with early mobilization and exercise following the initial acute stage that may lead to better long-term outcomes for soft tissue recovery.

    Read More

  • Always consult a medical professional if:

    You're unsure of the severity of the injury

    Pain worsens over time

    You're unable to dance or walk without pain

    There’s visible deformity, numbness, or severe bruising

    Read More

REFERENCES

Briet, J. P., Houwert, R. M., Hageman, M., De Groot, J. A., Guitton, T. G., & Groenwold, R. H. H. (2016). Factors associated with pain intensity and physical limitations after lateral ankle sprains. Injury, 47(12), 2565–2569. https://doi.org/10.1016/j.injury.2016.09.016

Dubois, B., & Esculier, J. F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine, 54(2), 72–73. https://doi.org/10.1136/bjsports-2019-101253

Graves, J. M., Fulton-Kehoe, D., Jarvik, J. G., Turner, J. A., Franklin, G. M., & Wickizer, T. M. (2014). Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain. Health Services Research, 49(2), 645–665. https://doi.org/10.1111/1475-6773.12098

Hansrani, V., Khanbhai, M., Bhandari, S., & Gulihar, A. (2015). The role of compression in the management of soft tissue ankle injuries: A systematic review. European Journal of Orthopaedic Surgery & Traumatology, 25(6), 987–995. https://doi.org/10.1007/s00590-015-1607-4

Sculco, A. D., Paup, D. C., Fernhall, B., & Sculco, M. J. (2001). Effects of aerobic exercise on low back pain patients in treatment. The Spine Journal, 1(2), 95–101. https://doi.org/10.1016/S1529-9430(01)00026-2

Singh, D. P., Barani Lonbani, Z., Woodruff, M. A., Parker, T. J., Steck, R., & Prasadam, I. (2017). Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Frontiers in Physiology, 8, 93. https://doi.org/10.3389/fphys.2017.00093

van den Bekerom, M. P., Struijs, P. A., Blankevoort, L., Welling, L., van Dijk, C. N., & Kerkhoffs, G. M. (2012). 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), 435–443. https://doi.org/10.4085/1062-6050-47.4.14

Vuurberg, G., Hoorntje, A., Wink, L. M., van der Doelen, B. F., van den Bekerom, M. P. J., Dekker, R., & van Dijk, C. N. (2018). Diagnosis, treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline. British Journal of Sports Medicine, 52(15), 956. https://doi.org/10.1136/bjsports-2017-098106