Injured? Try a little PEACE

Introduction

In the previous newsletter, PEACE was introduced for the acute phase of a soft tissue injury. PEACE not only promotes physical management of the injury, but it also encompasses education and mental well-being. 

Similarly, the subsequent management of the injury should highlight the importance of physical and psychosocial factors. 

The LOVE (Load, Optimism, Vascularisation, Exercise) protocol simplifies evidence in managing a subacute injury.  

L for load

Adopting an active approach will benefit soft tissue injuries. These include the facilitation of recovery through movement and exercises. Returning to usual activities should commence as soon as symptoms such as swelling and pain are manageable. Increasing load without increasing pain has been shown to promote tissue repair and recovery. This can be done by systematically increasing the workload or stress on the injured area in a controlled manner. 

 Progressive increase in workload can be based on the FITT principles (Frequency, Intensity, Time, Type). Frequency refers to how often the exercise is done. Intensity is represented by how difficult the session or exercise is. Time indicates the duration of the session, and type refers to the mode of exercise (eg, mobility, strength, and plyometrics). Monitoring the level of pain and swelling during and after the activity can inform whether rehabilitation should be progressed or regressed. If pain or swelling increases significantly without timely resolution, rehabilitation should be regressed. If symptoms in the injured area are maintained following several sessions at a similar workload, rehabilitation can progress. Adopting this can facilitate the strengthening of tissues such as tendons, muscles, and ligaments.

O for Optimism

Research has shown that the degree of injury does not always correlate to the severity of symptoms and functional limitations. It has been suggested that psychological factors such as catastrophization, depression, and fear explain the variations in the level of the post-injury post experience. 

 The brain plays a significant part in motivation, pain management, and injury perception. Encouraging optimism while staying realistic improves the chance of optimal recovery as it orientates the patient towards self-efficacy. Conversely, pessimism has been found to correlate with lower self-efficacy and influence outcomes and prognosis of an injury negative.

V for Vascularisation

Recovery post-injury should include pain-free cardiovascular physical activity. It not only facilitates blood flow to injured structures, it is also a mood booster. Early mobilization and aerobic exercise have proven to be beneficial in terms of function, work status, and reduced need for analgesics. If running is not possible, alternatives can include cycling, swimming, or walking in the pool. The amount of exercise should follow FITT principles as explained under Load. 

An eventual target of 150 – 300 minutes of moderate-intensity aerobic exercise a week should be worked towards.

E for Exercise

Specific to ankle sprains, evidence supports using exercise therapy to reduce the risk of recurrence. Exercise has been proven to restore movement, strength, and proprioception early after an injury. Pain should be used as a guide to progress exercises to increasing difficulty levels. 

A sample progression of exercises following an ankle sprain could be as follows: 

Restoration of ankle range in the first few days can be done with simple movements such as moving the ankle up and down or turning in and out, through the full available range. A progression can be to combine the movements, such as drawing alphabets with the ankle. Exercises can initially be done in sitting, with the ankle free to move, and progress to standing and putting more weight, For example, seated heel raises and squats. 

Weight shifting towards the injured side as tolerated can begin, progressing towards standing on 1 leg and maintaining balance for as long as possible to regain proprioception. 

Over the next few days and weeks, the injured ankle should be progressively loaded through more range, and eventually weights to regain strength.

Exercises such as lunges, step downs, and Bulgarian split squats can be utilized to facilitate loading into dorsiflexion. Heel raises can be progressed from the double leg, biased to the injured side, then single leg. Weights can be added to the exercises. 

Plyometric exercises should be introduced later in the rehabilitation stages when symptoms are well managed despite loading. These involve being able to generate force to jump as well as absorbing impact from the jump. 

Contributed by: 

Ms Melissa Chan, Physiotherapist, Department of Physiotherapy, Outpatient Rehabilitation – Musculoskeletal, Sengkang General Hospital (SKH)

This is part of an outreach program by the Department of Physiotherapy, Sengkang General Hospital. 

Their 1st article was in the previous issue of the SPEA newsletter (2023 Issue No, June/July). 

References

Bleakley, C. M., O’Connor, S. R., Tully, M. A., Rocke, L. G., MacAuley, D. C., Bradbury, I., ... & McDonough, S. M. (2010). Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. Bmj, 340.

Bleakley, C. M., Glasgow, P., & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE?. British journal of sports medicine, 46(4), 220-221.

Briet, J. P., Houwert, R. M., Hageman, M. G., Hietbrink, F., Ring, D. C., & Verleisdonk, E. J. J. (2016). Factors associated with pain intensity and physical limitations after lateral ankle sprains. Injury, 47(11), 2565-2569.

Dubois, B., & Esculier, J. F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British journal of sports medicine, 54(2), 72-73

Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., ... & O’Sullivan, P. P. (2020). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. British journal of sports medicine, 54 (2), 79-86.

McKeon, P. O., & Donovan, L. (2019). A perceptual framework for conservative treatment and rehabilitation of ankle sprains: an evidence-based paradigm shift. Journal of Athletic Training, 54 (6), 628-638.

Vuurberg, G., Hoorntje, A., Wink, L. M., Van Der Doelen, B. F., Van Den Bekerom, M. P., Dekker, R., ... & Kerkhoffs, G. M. (2018). Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British journal of sports medicine, 52 (15), 956-956

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