PEACE and LOVE

Hurt yourself for the first time? Strained a muscle? Sprained a joint? Tweaked your back or neck? Tendon pain flare-up? Now what?

During the first 1 to 3 days after injury or a pain flare-up, and if needed, a consultation with a medical professional, your sore muscle, ligament, or joint needs P.E.A.C.E.

• P stands for protect. Reduce some, but not all, movement of the sore area for 1 to 3 days to help your immune system respond and begin to calm things down. Do not plan for complete rest or additional days of rest, as too much rest can reduce the quality of healing and slow the return to full tissue strength. Your immune system will need some "coordinating" soon to ensure faster recovery. Do not mistake rest as long-term advice ("RICE, PRICE, POLICE - What's in and what's out?" + Soft-tissue injuries simply need PEACE and LOVE). 

• E stands for elevate. If swelling is present, elevate the sore limb above the level of your heart to reduce excessive swelling around the affected area as much as is comfortable over the next 1 to 3 days (The effect of three degrees of elevation on swelling). Some swelling, as a sign of inflammation, is a helpful immune response to strains and strains, but too much for too long is unhelpful and increases discomfort when trying to move an already sore area. Speaking of the importance of some inflammation…

• A stands for avoid anti-inflammatory modalities. There is no high-quality evidence that ice and non-steroidal anti-inflammatory medication are more effective than placebo for improving healing after sprains and strains. However, these “popular” options are unlikely to be harmful in one-off use for “pain relief,” especially when pain is disturbing sleep. They are just unlikely to have significant benefits for healing, as historically promised (Effect of NSAIDs on Recovery From Acute Skeletal Muscle Injury+ Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Their Effect on Musculoskeletal Soft-Tissue Healing + Cryotherapy for treating soft tissue injuries in sport medicine + Ice or Heat for Pain and Injuries? - E3 Rehab). Also, despite common social beliefs, these products also have little effect on swelling (Oral non‐steroidal anti‐inflammatory drugs versus other oral analgesic agents for acute soft tissue injury + Effectiveness of cryotherapy on pain intensity, swelling, range of motion, function).

• C stands for compress. Taping, bandages, or tight compression garments help reduce excessive swelling, improving movement tolerance (Acute ankle sprain: is there a best support? - PubMed + Putting the Squeeze on Compression Garments: Current Evidence and Recommendations).  

• E stands for seek education. Seek high-quality education on optimistic expectations for any other approaches to recovery. Good education on its own is often more helpful than other “physio” options, such as electrotherapy (ultrasound, red light therapy, shockwave, etc.), manual therapy (massage, joint manipulation, or “cracks”), or needling (including dry needling or acupuncture), early after injury (Assessing Reactive Approaches to Pain + The E3 Rehab Podcast: High vs Low Value Care). Be sceptical of thoughts or options selling a ‘need to be fixed’ which can lead to therapy-dependent behaviour (You don't need fixing - the value of resuming meaningful activities to get your life back). Your up-to-date medical educator should provide realistic expectations of how you will participate in your recovery to reduce the risk of persistence or recurrence. Seeking high-quality education should help you feel reassured and reduce excessive “cause-searching” or “shopping for answers” behaviour, which is common when symptoms are not understood but unfortunately is associated with persistent symptoms (Understanding stigma and pain: a-state-of-the-art review + Does working alliance have an influence on pain and physical functioning in patients with chronic musculoskeletal pain + The lived experiences of musculoskeletal physiotherapists managing patient expectations for diagnostic imaging + The worst pain is unexplained).

After the first day has passed, your sore muscle, ligament, or joint needs L.O.V.E.

• L stands for load. Progression of movement and exercise should be made for all seeking help. “Motion is lotion and potion.” Mechanical “stress” from tolerable but gradually progressive movement provided as soon as possible after injury promotes organized muscle, ligament, or joint repair, remodeling, and movement tolerance (Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair). Delaying loading can lead to persistent symptoms and/or disorganized tissue adaptation after injury (Pain in Training: What To Do?). “Doing is fixing.”

• O stands for optimism. Optimistic expectations about your recovery are associated with better and quicker positive outcomes. Psychological factors such as concern for future symptom worsening, depression, and fear of movement can cause behaviours that do not help recovery. Our beliefs and emotions have a significant impact on the type of “neuroplasticity” occurring affecting recovery from pain (50 Years of Research on the Psychology of Sport Injury + Positive affect and markers of inflammation: discrete positive emotions predict lower levels of inflammatory cytokines + Optimism, pessimism, and physical health among youth + Pain really is in the mind, but not in the way you think + How does chronic psychosocial distress induce pain? Focus on neuroinflammation and neuroplasticity changes + Beliefs about the body and pain + The effect of psychological factors on pain outcomes). Related to our immune system and recovery across the lifespan, being generally optimistic about most things is also associated with living longer (Optimism and Cause-Specific Mortality + Optimism and Healthy Aging in Women and Men  + How Positive Emotions Build Physical Health). Reframe unhelpful thoughts that might feel helpful in the short-term but predict persistent symptoms in the long term, such as:

  • “I need to avoid all painful movement as it will make my pain worse” (a behaviour implying “kinesiophobia” (Tampa Scale for Kinesiophobia), 

  • “My pain now will cause future disability” (a behaviour implying “catastrophisation” (Theoretical perspectives on the relation between catastrophizing and pain), 

  • “I should stop all participation in my valued activities as it will be painful until I am pain-free (“fear-avoidance” is a common pain behaviour causing “biographical disruption” or a feeling of “life on hold” (Chronic illness as biographical disruption + What Is the Relationship of Fear Avoidance to Physical Function and Pain Intensity in Injured Athletes? + Frontiers | Goal Pursuit in Individuals with Pain),

  • thinking about the negative effects of your pain a lot (a behaviour implying “rumination” (Examining the Relationship Between Collegiate Athletes’ Setback-Related Control Beliefs, Rumination, and Psychosocial Outcome).

  • Thoughts associated with beliefs of “I’m easy to harm and hard to heal” (Beliefs about the body and pain: the critical role in musculoskeletal pain management), 

  • With more helpful thoughts like:

    • “Painful movements are painful right now but will gradually become easier as I increase exposure to them again,”

    • “Things take time, which is why we live so long,”

    • “Gradual re-introduction to my valued activities will improve my tolerance and enjoyment of them,”

    • “What would I be doing if I didn’t have these symptoms,” and make plans or seek help to get back to those activities.

  • V stands for vascularisation. Some forms of cardiovascular or aerobic activity will be tolerable early in the management of your injury. Tolerable aerobic exercise (such as cycling, walking, swimming, rowing, or participating in easy non-contact sports) should be started a few days after the injury to boost motivation and increase blood flow to the recovering injured area. Early aerobic exercise improves physical function, supports return to work, and reduces the need for pain medication. “Your next posture is the best posture” (Walking exercise for chronic musculoskeletal pain + Does aerobic exercise affect pain sensitisation in individuals with musculoskeletal pain?). Heat packs, hot showers, or baths could also be helpful at this time. Still, they should never replace aerobic exercise (Local Heat Applications as a Treatment of Physical and Functional Parameters in Acute and Chronic Musculoskeletal Disorders or Pain + Heat Therapy for Pain - A Scientific Guide). And no, massage or foam rolling does not increase blood flow significantly to the sore area. Any blood flow change promised by someone offering massage is tiny compared to movement (Assessment of skin blood flow following spinal manual therapy + Massage Therapy Does Not Work by "Increasing Circulation" + What manual therapy can and can’t do), and….

  • E stands for exercise. Yes, more loading in the form of exercise should be emphasised for those recovering from a painful injury. Two letters for the same concept is how important movement as medicine is for recovery. A planned progressive movement helps restore movement tolerance, strength, coordination, and balance early after an injury. Pain tolerance should be used as a guide for exercise progressions. Rather than avoiding any painful exercise altogether, record and participate as tolerably as possible in these exercises (Should Rehab Be Pain-Free? - E3 Rehab). A specific painful movement is a hint about which exercise will be good for your recovery. Finding the “moving target” of a “tolerable dosage” of exercise over time is the complex but fun part (How does exercise help pain with Ben Cormack +  Physical Activity as a Central Pillar of Lifestyle Modification in the Management of Chronic Musculoskeletal Pain + Exercising when it hurts - by Tom Jesson + “Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ‘tissue capacity’: a core concept for clinicians + How To Train Around Pain Or Injuries - E3 Rehab).

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