Most people are familiar with the RICE protocol for injury treatment: You tweak your knee or twist your ankle, and without hesitation, you rest the injured area, put ice on it, apply compression, and elevate the injured limb. Doctors, coaches, and athletic trainers have used RICE for decades, since Gabe Mirkin, MD, coined the acronym in his 1978 book, The Sportsmedicine Book.
Over the past several years, however, sports-medicine experts have been pointing to evidence that RICE falls short when treating soft-tissue injuries. In fact, Mirkin himself revised his opinion in 2014: “Subsequent research shows that rest and ice can actually delay recovery,” he wrote. “Mild movement helps tissue to heal faster, and the application of cold suppresses the immune responses that start and hasten recovery.”
So, if RICE is out, then what should we do?
In 2019, Canadian physiotherapists Blaise Dubois, PT, and Jean-François Esculier, PT, PhD, proposed the acronyms PEACE and LOVE.
PEACE addresses the acute phase — the first hours and days immediately after an injury. LOVE, meanwhile, speaks to the subacute and chronic phases of soft-tissue injuries.
These new acronyms don’t replace all the advice in RICE (you’ll note that elevation and compression still have a place), but they do strongly challenge much of the protocol, particularly the use of anti-inflammatory modalities. Instead, PEACE and LOVE offer a more comprehensive approach to injury healing that includes physical treatment as well as psychosocial factors and patient education.
Here’s how to implement PEACE and LOVE.
PEACE
Immediately following an injury, let PEACE be your guide.
Protection: Protect the affected area by avoiding activities and movements that increase pain — which does not necessarily translate to rest. “With an acute condition, rest is good for some days. The problem is, we didn’t know how long to rest. Now we know that resting for too long is not the best way to create tolerance of the tissue,” says Dubois.
He recommends no more than three days of rest and letting pain guide your gradual return to movement and loading.
Elevation: Raise the injured area higher than the heart to drain interstitial fluid — fluid outside of the body’s cells and blood vessels — away from the injury and reduce swelling and pressure. Dubois suggests elevating the affected area as often as possible immediately following an injury.
Avoidance of anti-inflammatories: Steer clear of modalities that reduce inflammation, including NSAIDs and ice, both of which have been shown to delay healing by disrupting the natural inflammation process. “When we are injured, we want an inflammatory effect. We want cell proliferation and remodeling because that is what makes the tissue stronger,” explains Dubois.
Ice can provide benefits as an analgesic for some patients, says Kane Thompson, PT, DPT, ATC, a physical therapist in Oak Park, Ill. “For clientele who catastrophize pain, it’s hard to get them to do anything. If ice improves someone’s tolerance for movement and early mobilization after injury, application of ice for a short term can be OK. As long as you’re aware of the physiological process, it doesn’t have to universally be one or the other.”
Compression: Compress the affected area immediately after an injury to help reduce swelling, prevent edema and tissue hemorrhage, and relieve some pain. Dubois and Thompson advise using tape or bandages, applied with the help of a physical therapist or other professional, that allow for a bit of movement at the joint — and avoiding highly compressive sleeves or devices that limit range of motion and decrease comfort.
Education: The final step of PEACE calls on medical professionals to educate patients and clients about the benefits of taking an active approach to recovery. Many patients want to be “fixed” with passive therapies such as ultrasound or massage, says Dubois, which not only have limited effectiveness but also can create dependence on the medical practitioner.
LOVE
One to four days after an injury, begin applying LOVE.
Load: It’s important to gradually start loading the area of the soft-tissue injury. Depending on the severity, you can begin as early as the day after the injury and definitely by day four, says Dubois. “If you have an ankle sprain, you need to start to move your ankle and walk. Stressing the ligaments is the best way to make them stronger, as they adapt to stress. The goal is to find a sweet spot where you create adaptation and don’t irritate and inflame the tissue more.”
Work with a professional to determine what types of movements to do and to what intensity you should load an area after injury, he adds. Consider not just whether you feel pain during an activity but also how you feel afterward.
Optimism: Studies show that positive thinkers recover more quickly from a range of musculoskeletal injuries than negative thinkers. “If you are a positive person and think your injury will repair faster, it’s a better predictor of healing than the grade of pathology,” says Dubois.
Vascularization: Engage in pain-free cardiovascular activities to increase blood flow to healing tissues. “We know that cardiovascular activity increases the vascularization and metabolism of tissue, which is a key factor of faster repair,” Dubois explains.
Cardio also boosts endorphins, improves sleep, and works as a physical pump to get the lymphatic system working, moving waste through your body so it can be removed.
Exercise: By training mobility, strength, and proprioception, you can help with healing and reteaching the injured area how to move and how to work with the rest of the body. If you had an ankle sprain, Dubois advises, you would start with stretching to restore full range of motion; then progress to heel raises to strengthen the calf muscles; and then practice balancing on one leg to improve proprioception.
The thought of exercising an injured body part can be frightening, but it’s important to understand that controlled, intentional movement promotes healing, Thompson notes. Not only does it help you return to daily life and activities, he says, but it can help break down mental walls around how safe you truly are. “There’s something transformational about telling your body it’s OK to move.”
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This new approach sounds good — but for older people, trying to move something too soon can cause re-injury, which happened to me with my rotator cuff injury.