Is it time to rethink ICE?
​PEACE and LOVE is the answer

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RICE is a common and well-known principles of soft tissue injury and stands for
RICE: Rest, Ice, Compress, Elevate.
With more research soft tissue injury management then changed to
POLICE: Protect, Optimally Load, Ice , Compress and Elevate 

But there is so much more complexity to the management and rehabilitation of soft tissue injuries. And cold therapy and anti-inflammatories have been moved to the outer.

Why the change? Yes, most patients will find that ice has an immediate analgesic effect and reduces pain in the short term of a soft tissue injury. But the use of cold also induces vasoconstriction, or reduces blood flow, which means less of the body’s natural inflammatory fighting cells are transported to the injured area by our circulation.

We must understand that anything that reduces inflammation also delays tissue healing since the process of inflammation is an essential aspect of recovery itself.

Because of this, recent evidence suggests that the use of ice can delay the healing and recovery process. Prolonged use of cold can even lead to tissue death and permanent nerve damage 

Anti- inflammatory medications and soft tissue injury 
There have been many studies that have investigated the effectiveness of anti-inflammatories (NSAIDs) in soft tissue injury.  
  • Short term use of NSAIDS may provide relief from pain and swelling after a bone fracture but long term use may result in poor bone healing
  • There is little role for use of NSAIDs in the treatment of tendon injuries
  • A short 3-7 day course of NSAIDs may be of benefit in managing a ligament injury, long term use impairs 
  • NSAIDs can help reduce pain and the time to return to full activity in a muscle injury 















Recently Dubois and Esculier (2019) proposed two new acronyms to optimise soft tissue recovery: 

PEACE and LOVE: which also highlights the potential harmful effects of using ice and anti-inflammatory medication for recovery. 

Immediately after a soft tissue injury, do no HARM (avoid heat, alcohol, re-injury, massage)  and let PEACE guide your way 
 
PEACE
 
P = Protect
  •  unload or restrict movement for 1 - 3 days
  •  this reduces bleeding
  •  and reduces risk of aggravating injury

E = Elevate
  •  elevate the injured limb higher than the heart

A = Avoid anti-inflammatories and ICE 
  •  anti-inflammatory medications may negatively affect long-term tissue healing
  • optimal soft tissue repair and regeneration is supported by the various phases of the inflammatory process
  • NSAIDs could impair the healing process 
  •  avoid ice (most of the time)
  • the use of ice is mostly for pain relief but can slow the healing process
  • ·although it is widely accepted as an intervention there is very little high-quality evidence that supports the use of ice in the treatment of soft tissue injuries
   (ice does play a role when there is extreme swelling around a joint to limit oedema since too much or prolonged swelling has been proved to impede the healing process)

C = Compress
  • Joint swelling band tissue bleeding may be limited by compression such as taping or bandages but should still allow full range of movement at the joint. 

E = Educate
  • education is key to promote an active approach to recovery instead of a passive approach

LOVE
"After the first 2-3 days soft tissues need LOVE"
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L = Load
  • Normal activities should continue as soon as symptoms allow for it
  •  Let pain guide your gradual return to normal activities, your body will tell you when it is safe to increase load

O = Optimism
  •  Optimistic patients have a better outcome 
  •  Condition your brain for optimal recovery by being confident and positive

V = Vascularisation
  • Choose pain free activities that increase blood flow to repairing tissues 

E = Exercise
  •  restores mobility
  • restores strength
  • restores proprioception, early after an injury[5]

 




References

1.Deepak S. Patel, MD, Brian A.adrian, MD, PhD. Do NSAIDs Impair Healing of Musculoskeletal Injuries?
The Journal of Musculoskeletal Medicine, The Journal of Musculoskeletal Medicine Vol 28 No 6, Volume 28, Issue 6 June 7, 2011

2. Dubois B, Esculier J. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine 2020;54:72-73.
 
3. van den Bekerom MPJ  No difference in pain, swelling or function with NSAIDs compared with paracetamol for soft tissue injuryEvidence-Based Nursing 2016;19:21.

4. Wang ZR, Ni GX. Is it time to put traditional cold therapy in rehabilitation of soft-tissue injuries out to pasture?. World J Clin Cases. 2021;9(17):4116-4122.



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