We have all likely suffered from a pulled muscle or an ankle sprain and are familiar with the acronym RICE – rest, ice, compression and elevation. This has been the standard of care for years. We have rested and unloaded the joint for several days, immediately applied ice to the injured area, used an ace bandage for compression and elevated the area while resting. While this has proved effective, current research supports the new acronyms, Peace and Love, to take into account all the stages of normal tissue healing.
P: Protect – avoid activities and movement that increase pain during the 1st few days after an injury
E: Elevate – elevate the injured area higher than the heart as often as possible
A: Avoid Anti-inflammatories – avoid taking anti-inflammatory medication as they reduce normal tissue healing. Limited icing.
C: Compression – use of elastic bandage, lace up ankle brace or taping to reduce swelling
E: Education – listen to your body and let nature heal
L: Load – gradual loading to return to normal activities
O: Optimism – be positive that your body will heal
V: Vascularization – increase blood flow with pain-free cardiovascular activities
E: Exercise – restore mobility, strength and balance
Peace is used in the short term (1-3 days) in which we want to start with protection of the injury (possible use of crutches) to avoid further damage to the tissue. Begin loading the joint immediately but be mindful of the pain – let pain be your guide. Elevation is important to move fluids that may collect in the injured area. Not using anti-inflammatories is the big change in our recommendations and is supported by research. The inflammatory process is a normal response to injury and a part of the repair process. The use of anti-inflammatory medication and ice can slow tissue healing. It is okay to use ice immediately to potentially limit the area of damage, but try and avoid the use of those NSAID’s like ibuprofen, naproxen and aspirin. Compression helps to reduce excessive swelling. Education is understanding the importance of not over treating too early in the recovery. If you are not sure if you need an xray or other imaging – you may need to check in with your physical therapist or doctor.
Love begins about 3 days post injury. Optimal and progressively increased loading is important for the healing of tissue but we need to avoid any increase in pain or swelling. Stay optimistic during your recovery as it may be slow but positive thinking is critical to any healing. Pain-free exercises to increase the vascularization is important to increase blood flow and oxygen to the area and exercising smartly and safely helps restore mobility, strength and balance.
It is important to understand the 4 phases of tissue healing (i.e. muscle, ligaments, tendons) to allow proper healing of the area and to avoid re-injury which can result in chronic problems. Initially after any damage to a tissue our bodies attempt to heal. The 4 phases include:
- Hemostasis – this occurs immediately in which local traumatized blood vessels contract to avoid further blood loss (clotting)
- Inflammation – this occurs within days 1-3 – a series of events occur that increase swelling (vasodilation) which allows for increase in nutrients and cells that allow for growth of new tissue and removal of waste. This is the main reason why we don’t want to use anti-inflammatories and only minimal use of ice.
- Proliferation (Repair) – this occurs from about day 4-21 – this is the time for matric production, scar formation and reduction of inflammation. The fibroblasts that entered the site at day 1-3 are now laying down type 3 collagen, and platelets that came earlier establish good blood flow to the area which is essential for optimal healing. This tissue is weaker than normal collagen and can be easily stretched or re-torn. This is the reason for optimal loading; not overloading or stressing the tissue too much during this time frame. Remember to “let pain be your guide”.
- Maturation (Remodeling) – this occurs from about day 21 and can last up to a year. Type 3 collagen is being replaced by Type 1 collagen which is stronger tissue and during this year the collagen fibers are increasing in size, strength and orientation that make them less re-injury prone.
Healing can be slowed by multiple factors including age, post menopause, psychological stress, diabetes, smoking, and poor nutrition. Tendons and ligaments have a decreased blood supply compared to muscles and are slower to heal. That is why a careful balance between protection and graded stress to the tissue is necessary for healing. Complete immobilization is detrimental to healing tissue. However, doing too much too early in the healing process can restart the phases of healing and cause a disordered healing process and chronic tendon issues. Restored tissue will only be 80% as strong as the original so proper return to activity and sport is important to help in the prevention of future or chronic problems.
Physical therapy can help the tissue repair process by treating impairments that limit tissue healing like limited muscle flexibility, joint restrictions and strength deficits. During the maturation phase, therapy is important to guide loading in an appropriate manner, improve balance and strength to help facilitate a return to normal activities.
So the next time you have a sprained ankle or pulled hamstring try giving them some peace and love to improve the recovery process and help you return more quickly to the activities you love.
Thank you Annette DuPont, PT at Pivot Physical Therapy for writing this article for our newsletter