Journal of Sports Science and Medicine
Journal of Sports Science and Medicine
ISSN: 1303 - 2968   
Ios-APP Journal of Sports Science and Medicine
Androit-APP Journal of Sports Science and Medicine
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©Journal of Sports Science and Medicine (2021) 20, 799 - 800   DOI: https://doi.org/10.52082/jssm.2021.799

Letter to editor
Minor Soft Tissue Injuries may need PEACE in the Acute Phase, but Moderate and Severe Injuries Require CARE
Konstantinos Fousekis , Elias Tsepis
Author Information
Therapeutic Exercise and Sports Rehabilitation Lab, Physical Therapy Department, University of Patras, Psaron 6, Egio 25100, Greece

Konstantinos Fousekis

Email: kfousekis@upatras.gr
Publish Date
Received: 09-09-2021
Accepted: 10-09-2021
Published (online): 01-10-2021
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Dear Editor-in-chief

For the past 30 years, conflicting and confusing theories have abounded for the acute-stage treatment of musculoskeletal injuries due to a lack of sufficient, high-quality research that substantiates an ideal approach. The main controversy concerns the use of cryotherapy. While cryotherapy has become established as a vital component of the initial treatment of musculoskeletal injuries as part of the rest, ice, compression and elevation (RICE) approach (Mirkin and Hoffman, 1978), doubts about its efficacy have arisen in recent years. In fact, the latest proposal is to use the protection, elevation, avoid, compression and education (PEACE) approach as acute-stage treatment of musculoskeletal injuries (Dubois and Esculier, 2020). This involves protection and elevation of the injured limb, avoidance of anti-inflammatory drugs and cryotherapy, compression of the injured limb and patient education.

The proposal to avoid cryotherapy is based on the hypothesis that ice negatively affects the healing process by delaying neutrophil and macrophage infiltration and impairing tissue repair. However, this assumption is based on the results of limited animal studies (Singh et al, 2017; Ramos et al, 2016), none of which have led to evidence-based conclusions that prove cryotherapy should be avoided. Furthermore one of these studies concluded that while ice reduced or delayed inflammation, it did not affect the healing process or recovery time (Ramos et al, 2016).

In addition, the proposal to avoid the use of cryotherapy in the acute stage of injuries has not taken into account an essential factor that impacts the choice of rehabilitative treatment: the severity of the injury. Swelling is typically minimal in minor injuries; however, significant oedema may form in a moderate to severe injury, leading to pressure on the tissues and nerves, limited movement and reduced functionality (Scott et al, 2004). Significant joint swelling is also associated with arthrogenic muscle inhibition and decreased joint functionality (Rice et al, 2009).

Each of these adverse effects of moderate and severe musculoskeletal injuries can be reduced by the immediate application of cryotherapy in the acute stage. The goal of this therapy should not be to completely avoid oedema (this is not feasible), but to reduce the extent of oedema. There is strong evidence that ice can reduce pain (Bleakley et al, 2006) and moderate evidence that cryotherapy significantly reduces oedema if applied immediately after acute trauma and improves joint range of motion (Kalli and Fousekis, 2019). Reducing swelling through cryotherapy will also reduce the secondary hypoxic injury resulting from the compression and hypoxia of healthy neighbouring structures (Ho et al, 1994).

Therefore, first, we propose that the PEACE approach (Dubois and Esculier, 2020) be used to treat minor soft-tissue injuries that have minimal swelling. Second, we propose a new acute treatment approach for moderate and severe injuries with significant tissue damage and swelling: the cryotherapy and compression, avoid, rehabilitation and elevation (CARE) approach.

This approach consists of cryotherapy and compression, avoiding harmful movement and loading, specific rehabilitation techniques and elevation. While the evidence supporting the effectiveness of rehabilitation techniques continues to be documented and definitively proven, we must avoid the use and spread of non-evidence-based approaches. These mislead and confuse the academic, healthcare and general communities. Taking the extent of injury into account when determining acute treatment is a good step on the path to applying appropriate treatment. Based on the above, moderate and severe musculoskeletal injuries should be treated with CARE in the acute stage (Figure 1).

AUTHOR BIOGRAPHY

Journal of Sports Science and Medicine Konstantinos Fousekis
Employment: Therapeutic Exercise and Sports Rehabilitation Lab, Physical Therapy Department, University of Patras, Greece
Degree:
Research interests:
E-mail: kfousekis@upatras.gr
 

Journal of Sports Science and Medicine Elias Tsepis
Employment: Therapeutic Exercise and Sports Rehabilitation Lab, Physical Therapy Department, University of Patras, Greece
Degree:
Research interests:
E-mail:
 
REFERENCES
Journal of Sports Science and Medicine Bleakley C.M., McDonough S.M., MacAuley D.C. (2006) Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. British Journal of Sports Medicine 40, 700-705.  Crossref
Journal of Sports Science and Medicine Dubois B., Esculier J.F. (2020) Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine 54, 72-73.  Crossref
Journal of Sports Science and Medicine Ho S.S., Coel M.N., Kagawa R., Richardson A.B. (1994) The effects of ice on blood flow and bone metabolism in knees. The American Journal of Sports Medicine 22, 537-540.  Crossref
Journal of Sports Science and Medicine Kalli K., Fousekis K. (2019) The effects of cryotherapy on athletes’ muscle strength, flexibility, and neuromuscular control: A systematic review of the literature. Journal of Bodywork and Movement Therapies 24, 175-188.  Crossref
Journal of Sports Science and Medicine Mirkin G., Hoffman M. (1978) The sports medicine book.. New York. Little Brown and Co.
Journal of Sports Science and Medicine Ramos G.V., Pinheiro C.M., Messa S.P., Delfino G.B., de Cássia Marqueti R., de Fátima Salvini T., Durigan J.L (2016) Cryotherapy reduces inflammatory response without altering muscle regeneration process and extracellular matrix remodeling of rat muscle. Scientific Reports 6, 18525.  Crossref
Journal of Sports Science and Medicine Rice D., McNair P.J., Dalbeth N. (2009) Effects of cryotherapy on arthrogenic muscle inhibition using an experimental model of knee swelling. Arthritis Rheumatology 61, 78-83.  Crossref
Journal of Sports Science and Medicine Scott A., Khan K.M., Roberts C.R., Cook J.L., Duronio V. (2004) What do we mean by the term “inflammation”? A contemporary basic science update for sports medicine. British Journal of Sports Medicine 38, 372-380.  Crossref
Journal of Sports Science and Medicine Singh D.P., Barani Lonbani Z., Woodruff MA., Parker TJ., Steck R., Peake J.M. (2017) Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Frontiers in Physiology 8, 93.  Crossref
Journal of Sports Science and Medicine Song M, Sun X., Tian X., Zhang X., Shi T., Sun R., Dai W. (2016) Compressive cryotherapy versus cryotherapy alone in patients undergoing knee surgery: a meta-analysis. Springerplus 5, 1-2.  Crossref
 
 
 
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