All through my life, up until very recently, in fact, I thought that when someone injured a limb, e.g. sustained a sprain, the best thing to do (after getting it checked by a doctor, of course) was to stop using it altogether for an extended period of time. I thought immobilisation and rest were the way to go and that this would ensure optimal recovery.

It was quite shocking when part-way through my degree, I found out I’d been completely wrong. Indeed, it appears that early remobilisation might be the key to speeding up the recovery process and preventing some long-term negative consequences.

R.I.C.E.

Maybe you’ve heard of R.I.C.E., or perhaps you haven’t, but whether you’re aware of it or not, this is likely the treatment you’ll gravitate towards if you sustain a limb injury – and with good reason.

You see, R.I.C.E. stands for Rest, Ice, Compression, Elevation, and it’s generally the protocol we intuitively follow when we’ve just strained or sprained a joint or just after surgery. But crucially, it was originally viewed as a good first aid strategy to manage acute injuries, not treat them in the long term… and more recent evidence suggests it might not even be the optimal way to treat acute injuries either.

Let’s focus on Rest

Of course, if you’ve just injured a limb, it would make sense to take it out of action and rest it until you’ve seen a medical professional.

With that said, if you rushed to the emergency room in excruciating pain with an ankle sprain, you may be alarmed to hear your physiotherapist recommend you start putting weight on your foot within a few days. However, the science would be on their side.

It’s not new science either. At least as far back as the 1980s, studies showed that early joint movement helps with recovery (e.g. McAuliffe et al., 1987; Møller-Larsen et al., 1998), and in the early 2000s, the evidence began to be synthesised into reviews (e.g. Nash et al., 2004).

What seems apparent is that earlier work focused on remobilisation – sometimes passive mobilisation, but we now understand that mechanical loading is also important for rehabilitation, and this has gradually made its way into rehabilitation recommendations.

(Once again, please seek medical advice and follow the advice of the medical professional treating you if you have sustained an injury. The information in this blog post is not intended as direct medical advice. Always seek help from a medical professional as every injury is different.)

What does the evidence show about immobilisation and early remobilisation?

A 2014 paper by Järvinen et al., states that a brief period of immobilisation after muscle injury is required to allow the newly formed tissue from the healing process to be sufficiently strengthened to withstand forces applied to it. However, they also state that the immobilisation period should not last longer than a week, to minimise the adverse effects of immobilisation.

They go on to claim that it is then important to gradually begin remobilisation as soon as possible and pain-permitting. This is important to speed up regeneration of the injured muscle fibres (Järvinen, 1976), to ensure correct orientation and alignment of the muscle fibres (Järvinen, 1975), and to increase blood supply to the injured area through the formation of new blood vessels (Järvinen, 1976). Järvinen’s studies showed that early mobilisation resulted in superior recovery when compared to immobilisation.

What are the improvements in outcomes seen with early remobilisation?

A review by Nash et al., (2004) reported that patient outcomes following early remobilisation and sometimes mechanical loading in upper and lower limb injuries, were improved. In general, they report:

• Improvements in pain, stiffness and swelling
• Improvements in range of motion in the short-term (after a few weeks) and sometimes in the longer-term (after 12 months)
• Improved patient satisfaction and patients seemed to prefer early mobilisation to immobilisation
• Improved measures of global function in the longer term (6-12 months) which could include ‘pain, stiffness, swelling, use of supports, and ability to climb stairs, play sport, work, and undertake activities of daily life’
• Faster return to work and return to sport
• Reduced deformity in some fractures, although deformity increased in some situations (primarily in the case of Colles’ fractures)

P.O.L.I.C.E.

Given that it appears clear that early mobilisation leads to improved outcomes, it’s probably no surprise that R.I.C.E. was updated to P.O.L.I.C.E. in 2012. This stands for:

Protection – through rest or using supports

Optimal Loading – incrementally increasing mobilisation and mechanical loading as this improves rehabilitation compared to long-term rest – the way this is done should reflect the functional demands placed on the injured limb

Ice – used as an analgesic to reduce pain and inflammation

Compression – to reduce swelling

Elevation – keeping the injured area raised in space above the level of the heart to reduce the build-up of fluid at the site of injury

At the time, Bleakley et al. (2012) who discussed the acronym suggested that this should not only be used as a guideline for care, but also as a stimulus for further research in the area. They suggested that not enough research had been conducted on I.C.E. in the acronym and that more work was left to be done to ensure that the optimal rehabilitation strategy was used with patients.

P.E.A.C.E. & L.O.V.E.

Fast-forward to 2019 and we see that Bleakley and colleagues’ instincts were correct. P.O.L.I.C.E. is no longer the recommended strategy. Instead, it has been replaced by P.E.A.C.E. & L.O.V.E., which are still the most up-to-date guidelines available.

According to Dubois & Esculier (2019), P.E.A.C.E. is the strategy we should use for immediate management of an injury, while L.O.V.E. is used for longer-term care. So what do they stand for and how does the 2019 paper explain them?

Protection – through short-term rest and avoiding movements that cause pain

Elevation – above the level of the heart for as long as possible

Avoid anti-inflammatories – this is one of the biggest changes: using anti-inflammatory medications, ice or a cold compress is no longer recommended as it reduces the inflammatory response that acts to heal the injured tissues

Compression – can still be used to reduce swelling

Education – patients should be educated on the benefits of active recovery as compared to passive, and allow time and natural healing processes to do most of the work, to avoid overtreating injuries

and after the first few days

Load – take an active approach to recovery, mobilise the limb, load it and do exercise, using pain levels as a guide (load and move so long as it is not painful)

Optimism – optimistic expectations from patients are associated with better outcomes – opposing emotions can hamper recovery

Vascularisation – performing aerobic activity can help improve blood flow to the site of injury to improve physical function and return-to-work outcomes, as well boost motivation

Exercise – important as part of treatment to improve outcomes and to reduce the incidence of subsequent injuries

So if you ever find yourself in the emergency room with an injured limb, just remember, all you need is P.E.A.C.E. & L.O.V.E., and don’t be shocked if your doctor recommends a more active recovery – they’re doing it for your benefit.

One final time, and I cannot stress this enough: if you do suffer an injury and/or do indeed end up in the emergency room, please listen to the treatment and rehabilitation advice given to you by your doctor. They will be best placed to offer the most appropriate treatment, tailored to you and your injury.

References

Bleakley, C M, et al. “PRICE Needs Updating, Should We Call the POLICE?” British Journal of Sports Medicine, vol. 46, no. 4, 7 Sept. 2012, pp. 220–221, https://bjsm.bmj.com/content/46/4/220.

Dubois, B, and J-F Esculier. “Soft-Tissue Injuries Simply Need Peace and LOVE.” British Journal of Sports Medicine, vol. 54, no. 2, 3 Aug. 2019, pp. 72–73, https://bjsm.bmj.com/content/54/2/72.

Järvinen, M “Healing of a Crush Injury in Rat Striated Muscle. 2. A Histological Study of the Effect of Early Mobilization and Immobilization on the Repair Processes.” Acta Pathologica et Microbiologica Scandinavica. Section A, Pathology, vol. 83, no. 3, May 1975, pp. 269–82, https://pubmed.ncbi.nlm.nih.gov/1155096/.

Järvinen, M  “Healing of a Crush Injury in Rat Striated Muscle. 3. A Micro-Angiographical Study of the Effect of Early Mobilization and Immobilization on Capillary Ingrowth.” Acta Pathologica Et Microbiologica Scandinavica. Section A, Pathology, vol. 84, no. 1, 1 Jan. 1976, pp. 85–94, https://pubmed.ncbi.nlm.nih.gov/1251736/.

Järvinen, T A H, et al. “Regeneration of Injured Skeletal Muscle After the Injury.” Muscles, Ligaments and Tendons Journal, vol. 3, no. 4, 24 Feb. 2014, p. 337, https://pmc.ncbi.nlm.nih.gov/articles/PMC3940509/#b15-337-345.

McAuliffe, T B, et al. “Early Mobilisation of Colles” Fractures. A Prospective Trial.” The Journal of Bone and Joint Surgery. British Volume, vol. 69, no. 5, Nov. 1987, pp. 727–9, https://pubmed.ncbi.nlm.nih.gov/3316238/, 10.1302/0301-620X.69B5.3316238.

Møller-Larsen, F, et al. “Comparison of Three Different Treatments for Ruptured Lateral Ankle Ligaments.” Acta Orthopaedica Scandinavica, vol. 59, no. 5, Oct. 1988, pp. 564–6, https://pubmed.ncbi.nlm.nih.gov/3142203/, 10.3109/17453678809148786.

Nash, C E, et al. “Resting Injured Limbs Delays Recovery: A Systematic Review.” The Journal of Family Practice, vol. 53, no. 9, 1 Sept. 2004, pp. 706–712, https://pubmed.ncbi.nlm.nih.gov/15353159/.