Rest is not an intervention, except when it is…

Man at rest on a mountain road

The principle of RICE – Rest, Ice, Compression, Elevation – still underpins the starting point of injury management. The thing is, it’s slightly flawed model. Rest has become ‘Rest from aggravating activities’, Ice has become ‘Ice, maybe, but only in the first 48 hours’, Compression has become ‘C… probably not for most injuries’ and Elevation has become… yeah, Elevation stays, especially for lower limb injuries.

In this blog we are going to focus on the ‘Rest’ bit of the acronym and look at why you might be getting it wrong and what to do about it. 

Ginger cat asleep in a cat bed

RICE has gone through a number of acronym changes in the past:

“RICE” – Rest, Ice, Compression, Elevation

“HI-RICE” – Hydration, Ibuprofen, Rest, Ice, Compression, and Elevation

“PRICE” – Protection, Rest, Ice, Compression, and Elevation

“PRICE” – Pulse (Typically Radial or Distal), Rest, Ice, Compression, and Elevation

“PRICES” – Protection, Rest, Ice, Compression, Elevation, and Support

“PRINCE” – Protection, Rest, Ice, NSAIDs, Compression, and Elevation

“RICER” – Rest, Ice, Compression, Elevation, and Referral

“DRICE” – Diagnosis, Rest, Ice, Compression, and Elevation

So it’s understandable that it is a little confusing for patients when injuries occur. What you notice throughout, however, is the use of the words “rest” and “protect”. Both are binary, assertive words that offer little to no nuance. None of the models offer direction regarding movement in the acute phase of injury, something that has significant impact on fluid transfer (pumping inflammation out of the joint), muscle recruitment, and reduction in muscle spasm, hence the move towards ‘Rest from aggravating activities’.

I could write case studies for days that include the phrase “patient rested for [insert number of weeks] with no other intervention, and then re-injured the [insert structure] again”. And my response is always “rest is not an intervention”. And in an acute injury, rest is NOT an intervention! Of course, this does not mean that you should go and run a marathon on a torn hamstring, but it does mean that you should be moving up to the point where discomfort begins. This may mean that you should be on crutches, but using them to partial weight bear and progressively increase the walking load on the limb. It may mean that you are in a sling but taking your arm out five times a day to do some low impact mobility exercises. Or it may mean that you are cycling and swimming instead of running whilst you rehabilitate an ankle sprain. It would certainly mean that we work together to put in place an exercise regime that allows you to maintain fitness as best as possible without aggravating the injury, as well as loading any limbs that are not injured – do not detrain if you can help it!

Let’s put that supposed case study into context. Patient A has a hamstring strain that occurred during a hockey match. They rested it for two weeks before returning to hockey and re-injuring the hamstring during their first game back. In the acute phase – the first 48 hours post-injury – they were indeed correct to rest. Let the healing process get going, do not annoy it. After that, where symptoms allow and still with a view to maximising healing, it would have been advisable to start loading the hamstring to improve the strength and function and return it to pre-injury strength status, as well as loading in a general movement sense where symptoms allow (i.e. not getting stuck to the sofa). This may have started with some isometric (load, but no movement) loading in mid-range (where the muscle is strongest) and progressed as strength allowed over the course of the next 4-10 weeks (depending on the severity of the injury) to isotonic (loading through full range) loading with increasing velocity until the patient reached full fitness. During this period, including during the first 48 hours post-injury, the patient could be in the gym loading all three other limbs, and their trunk, to maintain strength/training load.

So whilst we are making use of a period of rest to allow healing to occur, there is still a positive intervention occurring that moves the patient closer to their goal of returning to full fitness. The patient may be “out of competition” longer, but we are managing the injury in a more productive manner and reducing the risk of re-injury. 

There is significant benefit, therefore, in visiting us at seventy9 Sports Therapy soon after injury occurs so that we can start putting in place a positive intervention.

And whilst this strategy of early intervention and modified loading to avoid aggravating activities works well in a muscle injury context, for tendon injuries it becomes even more pressing. Tendons love load, they are designed purely to manage and transmit muscular tension to our bones. Therefore in a rehabilitation setting, it is really important to start loading the tendon with a good, targeted loading programme as soon as we can as leaving it in an unloaded, sedentary setting increases the tendon symptom. If you’ve ever had an achilles tendon issue, you will recognise the soreness of the first couple of minutes of walking after waking up in the morning, after which the tendon starts to ease and the symptoms reduce. Overnight the tendon is unloaded and sedentary, increasing the unwanted stiffness which is reduced via loading (walking).

So when should you rest?

Total rest is really important in managing fatigue and allowing the body to assimilate training load. In fact in the world of cycling, there is a cardinal rule that states ‘don’t stand when you can sit, don’t sit when you can lie down’. But in an injury setting, total rest is not always the direction we want to take, especially if our goal is to return progressively and effectively to our pre-injury fitness.

I guess the new model could be ‘load at an optimal intensity and volume such that progression is made, but never beyond the point of aggravation or to the detriment of the management of fatigue’. 

I grant you, it is not quite as catchy and does not quite fit so neatly in an acronym, I guess I am just an ideas guy?

Have you picked up a niggle or injury recently? Why not book yourself an appointment at seventy9 Sports Therapy and let us check it out and put you on the right path to being injury free.

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