Most people who have had a sports injury, or any injury for that matter, would be familiar with the acronym RICE: Rest, ice, compression and elevation. Coined by the American doctor in sports medicine, Dr Gabe Mirkin in 1978, this strategy is known to reduce the inflammation that occurs post injury. Though the concept of R.I.C.E continues to be followed in injury rehabilitation, recent reports, including one by Dr Mirkin himself, suggest that excessive resting and icing could be detrimental to the healing process.
Studies in the late 1900s suggested that early resumption of movement and guided exercises for controlled loading of injured tissues hold the key to faster recovery and restoration of lost tissue function.
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A 2009 review article published in the British Journal of Sports Medicine curated multiple studies to further elucidate how mechanical loading could be used as a therapy to stimulate tissue repair and remodelling in bones, cartilage, tendons and muscles, by one of the body’s natural processes known as mechanotransduction. Mechanotherapy has shown better promise at healing tissues than the newer approaches using cytokines, cell transplants and gene therapy, says a study.
Thus, people with musculoskeletal injury and those who have recently had surgeries are now being treated with controlled physical activity that loads their healing tissues.
So, now that one knows the importance of early movement in recovery, is there a golden formula stating the ideal rest-activity balance? The answer lies in the basics.
Types of injuries and rest
There are two types of injuries – acute and chronic.
“Acute injuries are fresh injuries. Anything that lasts more than three weeks is called a chronic injury,” says Bengaluru-based sports medicine specialist, Dr Bharath Kumar B, founder-director of Kinesis Sports Clinic and The MediFit Clinic. “Anything that lasts between one and three weeks is called sub-acute, in which we will not have the features of a lot of pain, disability, swelling, redness [etc.].”
Rest is prescribed only if the injuries get worse by activity.
“The principle [in acute injuries] is to mobilise the affected area in a limited way so that it does not hurt the existing injury, but at the same time the function of the joint or the affected region does not deteriorate,” explains Dr Bharath. “This is known as modified rest, or optimal loading or active rest.”
Injury and active rest
Rest depends on the grade of injury. One can keep fit by switching over to alternate, minimal-impact activities. This is the concept of active rest. Selective mobilisation, on the other hand, is a movement that does not affect the specific injury to a joint.
Aarti Prasad, a senior physiotherapist at Ramakrishna Super Speciality Hospital, Bengaluru, points out that the nature and duration of rest depend on the condition, status of pain, the type and location of the injury and the way it has been treated or managed. A mild injury may require 48 to 72 hours of rest. A severe muscle tear may require surgery, followed by a period of immobilisation and rest. One can then prescribe slowly graded exercises and mobilisation.
Bed rest too calls for scrutiny. “It [bed rest] is not at all necessary and is, in fact, detrimental, especially to the musculoskeletal system which thrives on movement,” cautions Dr Bharath.
The LOVE formula for rehabilitation
Prasad shares an interesting formula for injury management: “The LOVE formula. Load the part, be Optimistic about your injury, be active to improve the Vascularisation [blood supply] and Exercise,” she says before explaining how a typical rehab progresses. It starts with gentle loading or controlled loading, followed by isolated patterns of rehabilitation – single movement patterns gradually made more complex. This is followed by sports activity.
Dr Bharath points out that guided exercises including muscle strengthening and balance training prevent the injury from becoming chronic. With inadequate rehab, the person loses strength and the function of the part/joint, leading to associated injuries.
What about the pain?
“Post injury, the first thing that we need to do is pain management,” says Dr Bharath, adding that the pain is graded before determining the mitigation.
“We employ VAP – Visual Analog Pain score,” adds Dr Bharath. “So, we ask the injured to rate his or her pain from one to 10, one being the minimal and 10 the maximal pain that they can bear. So, if the pain is less than 10, we tell them to bear it and continue because it will aid in healing. When the pain is more than five, and there are associated injuries, we tell them not to exercise, or move the joint.”
How to deal with muscle wasting
Addressing muscle atrophy (loss of muscle mass) due to resting, Prasad says, “There will be a certain amount of atrophy, but [the muscle function] can always come back. And one can easily get back into shape on resumption [of the exercise/activity].”
Here, the concept of relative rest comes in. One need not entirely suspend physical activities. For example, for injuries of the lower limb, load-bearing activities like walking and stair climbing can be reduced and replaced by swimming, cycling or even bed and core exercises to maintain and improve muscle power.
However, in the case of fractures where the entire limb is immobilised with a cast, the rule is thus: one joint above and one joint below must be immobilised. In that case, muscle stimulation cannot happen. So, atrophy is inevitable.
“But in cases where the fracture is surgically fixed, after about three days, we put the patient on something called a muscle stimulator,” says Dr Bharath. “It prevents atrophy. Step two is an isometric exercise where the joint does not move but the muscles contract. Once the joints are movable, you can start an isotonic exercise [moving the joints through a full range of motion with constant tension]. An example would be a bicep curl – where you lift the dumbbell and then you curl it.”
Injury healing and scar tissue formation
Scarring occurs after an injury due to the accumulation of white blood cells in the injured tissue. This is the natural inflammatory (healing) process of the body.
“When the muscle is torn, wherever a gap is there in the muscle, blood accumulates, clots and a framework of fibres appear. This is fibrous tissue. It undergoes a process called remodelling,” says Dr Bharath.
This fibrous tissue formed is not the native tissue but has to get converted to muscle fibres. “This process of remodelling happens over weeks, months or years, depending upon the severity of the injury,” points out Dr Bharath.
If a lot of rest is given, or if the joint is immobilised inappropriately, the stimulus for the remodelling goes missing. Strengthening exercises aid in this stimulus.
- Resting post injuries, though important, is advisable in moderation.
- One can ensure a decent level of fitness despite an injury by adopting the concept of active rest — resting the injured tissue, while exercising the other parts, as far as the body allows.
- Excessive rest and improper rehabilitation may result in chronic injuries and increase the chances of re-injuries.
- An ideal rehabilitation plan consists of controlled loading, followed by strengthening and balance training exercises, under the guidance of a professional.