How frequently have patients said something like, "I've been resting my leg since the injury so it doesn't get worse"? Injury expert, Dr. Alexander Jimenez looks at the use of 'rest' in acute injury management.
Introduction
RICE has long been recognized through the acronym of rest, ice, compression and elevation, with the ‘p’ in PRICE referring to protection. The usage of the term 'rest' has been widely criticized with a key emphasis now on the degree of loading or motion to facilitate the recovery process (1). The purpose of the review is to highlight the advantages of movement of loading during the early stages of rehabilitation and the suitable degree. To explain that we refer to the word mechanotherapy and how loading and movement can optimize soft tissue repair by suitably loading the body's own systems (two). The term 'rest' can be misinterpreted by the practicing athlete or gym user and in when they ought to return to loading and what form the individual ought to be inactive. Although therapists use these protocols as part of practice, it is essential to draw upon the research to reevaluate the RICE acronym is now perhaps not the best tool for helping injury management.
History Of Rest Vs Activity
Differences of opinion relating to activity compared to rest date back to the early 1700s(3). Several high profile researchers and doctors in the 1700s and 1800s encouraged the benefits of motion and loading . Julius Wolff published his research to what we now refer to as Wolff's law of bone loading to invigorate the adaption of bone remodeling and recognized. Lucas- Championniere went farther in the 1800s to say that the healing response time accelerated with rest inhibiting muscle, cartilage and ligament regeneration and remodeling.In contrast, their contemporaries John Hilton and John Hunter widely recognized rest as an important treatment modality, suggesting that early motion was a cause of increased bleeding which eased adhesion formation(3). Researchers during the 1800s had scientific evidence available pertaining to tissue recovery to support their claims of movement. Consequently, rest became the favored safe strategy, especially for patients with acute back pain and mattress rest undoubtedly became a frequent feature of lumbar spine rehabilitation(4). Bed rest became a precursor to the disablement of the human motor system amongst patients with musculoskeletal injury, which predisposed the patient to additional health complications(3). Current evidence now relates to that of the initial findings of Championnaire, which gives rise to a movement and tissue loading approach.
Suggested Acronym Alternatives
Other acronyms which were suggested within the literature and clinical practice include MICE(5) (movement, ice, compression and elevation) and PRICE, with 'rest' being replaced with 'restricted activity and controlled mobility'(6). An acronym recently published in the British Journal of Sports Medicine is the POLICE guidelines (Box 1) that changes rest for optimal loading(1). However, it is essential to protect the injured body part during the inflammatory stage in the first 3-6 days to prevent bleeding.Consequences Of The Term 'Rest'
An individual will be advised that rest (combined with ice, compression and elevation) is the appropriate treatment and they'll perceive that as when they were told to do 'nothing'. For the novice exerciser, being advised to rest may mean that they have a return to activity or perhaps don't return at all which could have a significant impact on their health to game. For the elite athlete, being told to rest may have impacts that are emotional during the rehab process that they cannot do some kind of conditioning. Although one body part may be injured, with loading this is an fantastic opportunity for the individual to maintain their physical state and to work on areas that are poorer. This is where the therapist's skills come to prevent excessive or undesirable loading to the part. For instance, a grade 1 muscle strain requires 'rest' from the field of play but not break from activity and demands controlled loading. The diagram in Box 2 illustrates the patient should be encouraged by a therapist to perceive an injury, which is an fantastic opportunity to develop skills and conditioning rather than to rest, which the RICE protocol encourages..
Mechanotherapy
Mechanotransduction is a term used for evolving physiological processes evident throughout the human body(2). The skeleton is an example as it lays cells down through a network of bone cells, ie the mentioned Wolff's law. Without physical loading the process of regulation is weak and bone cells are not able to be distributed efficiently and subsequently . Researchers from the University of Queensland, Australia, used a randomized controlled trial design with assessor blinding to measure the effect of an applied pneumatic cuff pressure in patients with a distal radius fracture(8). Twenty-one patients were allocated to either the treatment (with cuff pressure) or control group with both groups performing grip strength exercises for six months whilst immobilized and four weeks post-immobilization. The results yielded increased muscle strength in the treatment group from week one to week 10 as measured by a power grip test. Furthermore, at 10 weeks post-fracture the treatment group had 10-15 percent more range of movement than the control group and was 24-29 % more powerful. It is clear how controlled loading during fracture healing has the capacity although this was a study.A research carried out by scientists at the University of Ulster, Ireland, found that ancient exercises for grade 1 and 2 ankle sprains started during the first week of rehabilitation significantly accelerated tissue healing(9). The study was a randomized controlled trial design, with assessor blinding, whereby 101 participants were allocated to either a group that is PRICE or a PRICE group with ankle exercises to improve range of strength and movement. There were significant gains in the time spent walking, step count and time being physically active in the therapy group. There were, however, no substantial differences observed during swelling and activity in pain. The re-injury speed was 4% (two participants from either group). This is an example of optimizing and enhancing the integrity of the ankle ligaments can promote scar tissue formation to encourage an early return.
Early passive motion is recommended for joint injuries and post-surgical interventions like cartilage defects undergoing repair(5). Continuous passive motion (CPM) is an example of providing movement using a low-level 'optimal loading' whilst in a non or touch weight bearing position to promote fluid drainage. It's vital to track the forces of surgically-treated cartilage defect with low loads and with use of a CPM machine for 6-8 hours each day for 6-8 weeks allows for enhanced grade of injury(10). It forms an abundance of data pertaining to movement after articular cartilage repair although this research is dated. This reinforces the need for another approach to the 'rest' aspect of the RICE protocol, which the POLICE acronym provides: that opportunity for loading.
Achilles tendinosis is a injury within a clinic and has proved hard to treat. In a Achilles tendon there's a concentration of the neurotransmitter glutamate but not the inflammatory substance prostaglandin E2 in normal tendons. There is no chemical inflammation present in the chronic stage of the injury(11). Researchers from the University Hospital of Emeå, Sweden, analyzed the effect of eccentric loading in 25 patients' tendons (26 tendons in total) using focal tendon thickening, hyperechoic regions and irregular limb structure. All patients were followed up after 3.8 years(12). The patients had symptoms averaging 17 months prior to eccentric loading. At followup, 22 of the 25 were satisfied with the treatment provided and that tendon thickness had decreased on ultrasonography. There were no areas identified at follow- up. This research reaffirms the requirement and the best loading is vital in contrast to the age-old 'rest' approach.
Patellofemoral pain syndrome is a frequent diagnosis in sports injury clinics and is efficiently managed through strengthening exercises for the vastus medialis muscle to give medial control to the patellofemoral joint(13). This study was a randomized controlled trial design, with assessor blinding, which investigated patients with a history of anterior pain during simple exercises(14). The treatment group were supplied with a comprehensive rehabilitation program for six weeks to be completed daily (Box 4). The results indicated significant improvement during stair ascent following the analysis and at eight months follow-up in VMO activation. This advancement in VMO firing had the capacity to reduce symptoms of pain proximal to the joint. This is an excellent example of optimal loading with steps to reduce pain by resting from aggravating activities but not resting from strength exercises.
Summary
The review has highlighted and reemphasized the requirement during the early phases of rehabilitation of loading and movement to increase tissue healing. Although movement is broadly used by therapists and controlled loading in their rehab protocols, it is very important that we look at moving on to an acronym commensurate with movement and loading, which the POLICE acronym acknowledges well from RICE. It is essential to be able to influence the phase of healing, that the therapist explains the value of optimal loading. Patients should be encouraged to use the term POLICE in sports injury practices and they should be educated on what optimal loading is compared to rest. This is where the therapist's skills are powerful and it ought to be recalled that the patient doesn't have the understanding of a trained therapist.References
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