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Rest & Injury Rehabilitation

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.


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.

It's essential to protect the tissue from damage and to handle pain. To provide protection, braces crutches and strappings are often used as treatment tools. It is important not to just think about loading from a standing perspective from a standing standpoint but also to include moves in sitting, supine or side lying too with gravity assisted or removed (1). It's the expertise of the clinician that ought to determine the amount of loading appropriate for severity and the character of the tissue. The ice, compression and elevation (ICE) components of POLICE continue to be essential as part of the initial stages of the management of an acute injury to handle the inflammatory response. In certain situations, it's critical to keep an structure motionless to allow for repair, but movement is advised to promote the formation of collagen networks.

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.

The remodeling of scar tissue is most effectively influenced immediately after the inflammatory phase of repair as scar tissue is more pliable at this point(3). Scientists from the University of Tampere, Finland, stated that after a muscle tear the limb needs to be immobilized initially, to allow for a sufficient scar to form before activity is recommenced within the limits of pain(7). However, restricting movement over a longer period allows for the orientation of the scar tissue to not be put down in the direction of the applied stress (Box 3)(3). As the construction is positioned ultimately, during healing, it is optimal for the tissue fibers to align in the direction of stress. A factor is that re-injury could occur if the collagen fibers are not uniformly aligned in the direction of stress.


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.


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.

1. B J Sports Med, 2012, 6 (4), 220-221.
2. Br J Sports Med, 2009, 43, 247-251.
3. The Iowa Ortho J, 1995, 15, 29-42.
4. West J Med, 2000, 172 (2),
5. The Science and Practice of Manual Therapy, 2005, Elsevier Churchill Livingston, London.
6. Rehabilitation Techniques, 2011, McGraw Hill, Singapore.
7. Aust J Physiotherapy, 2007, 53, 247-252.
8. Best Pract Res Clin Rheumatol, 2007, 21 (2), 317-331.
9. BMJ, 2010, 340, c1964.
10. The American Journal of Knee Surgery, 1994, 7 (3), 109-114.
11. Knee Surg Sports Traumatol Arthrosc 1999, 7: 378–81.
12. Br J Sports Med, 2004, 38, 8-11.
13. J Multidiscip Healthc, 2011, 4, 383-392.
14. Med Sci Sports & Exerc, 2010, 42 (5), 856-864.

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The information herein is not intended to replace a one-on-one relationship with a qualified health care professional, licensed physician, and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request. We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to contact us. Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN* email: phone: 915-850-0900 Licensed in: Texas & New Mexico*