1/16/07, updated 9/29/09

The Art of Rest

The finer points of resting for injury and pain rehabilitation

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

When you are injured, how much rest is enough rest? Is there such a thing as too much? Is it necessary to rest completely, or is it adequate to rest only the injured part? How do you know when to lay off and when to “use it or lose it”?

These questions don’t seem like they would be especially difficult to answer, and they are not even interesting with regards to most ordinary injuries — you sprain an ankle, you stay off it for a while, no big deal, no “art of rest” there.

But these question become important when you have an injury that is not healing well, or a pain problem that cannot quite be diagnosed. It is also a more worthwhile subject when you are hurt in a place that you need to earn your living, or in a place that is hard to stop using (feet), or when the amount of rest required for healing seems to be cruel and unusual punishment, as with some tendinitises.

If this is you, you should definitely read on.

Bourne concentrated on rest and mobility. From somewhere in his forgotten past he understood that recovery depended upon both and he applied rigid discipline to both.
The Bourne Identity, by Robert Ludlum, p137

Bed rest is dead

Bed rest or total rest is pretty much dead as a concept in rehabilitation. These days, doctors won’t even cast a fracture if they can avoid it — fractures heal faster when they aren’t completely immobilized.1 Even a hip fracture doesn’t get you a get-out-of-exercise card any more.2

Replacing bed rest is the concept of “early mobilization” or “active rehabiliation.” The idea is to get you moving as soon as possible — short of actually reinjuring you.3 A great deal of scientific evidence suggests that the stimulation of movement, especially in the early stages of healing, is a crucial part of recovery from injuries and surgeries.

The idea of early mobilization is to get you moving as soon as possible — short of actually reinjuring you.

Acute low back pain has been shown to respond much better to normal activity than to bed rest.4 5 Achilles tendon ruptures have been shown to heal faster with early mobilization after surgery.6 Whiplash victims recover much faster if they get moving right away after their accident, rather than wearing a collar.7

All of this is why therapeutic exercises like PF-ROM, mobilizations, functional training, reflex stimulation, endurance training, and many more are such a crucial part of serious rehabilitation.

One the other hand, sometimes active rehabilitation is too active …

You can’t exercise your way out of every problem

There is a common attitude in rehabilitation that patients can exercise their way out of any problem. I routinely see patients who have been encouraged by health professionals at every turn to challenge their tissues with therapeutic exercise. They receive this advice despite a strong possibility that exercise is actually dangerous in many cases. Long before breaking under a strain, tissue gets “sick” — a loss of homeostasis. Once that happens, the tissue loses the ability to tolerate even minor stresses. Activities that used to be just fine are suddenly a problem. There’s only one way out of that trap: adequate rest is critical. You have to almost completely stop challenging the tissue, or it will never have a chance to recover.

In my experience, I have often seen patients in this predicament who have suffered years of chronic pain simply because they never rested adequately. (They may believe that they have, but “taking it easy” for a couple weeks is often not actually enough rest.) This predicament is particularly tragic because rest is so cheap and safe that there’s hardly any reason not to try it.

And yet patients are often pushed to exercise. Why? In 1995, a publicly owned insurance company published a report about whiplash, authored by an organization called The Quebec Task Force on Whiplash-Associated Disorders.8 People in my line of work refer to this report as “The Quebec Task Force,” or even just “Quebec” as in “In 1995, Quebec recommended active rehabilitation,” as though the province of Quebec was somehow personally involved.

“Quebec” was bullish on the whole idea of active rehabilitation, and more or less gave insurance companies everywhere a great reason to push people hard through rehabilitation. Countless insurance adjusters, physiotherapists and doctors started telling accident victims to get back into the gym as soon as possible. But how do you define “as soon as possible”?

“Quebec” was bullish on the whole idea of active rehabilitation.

Unfortunately, many fans of the QTF were pretty aggressive about it. I’ve seen cases where people were sent to the gym to do strength training exercises within days after an accident, when the tissue is still inflamed. Those of us less enthusiastic about the QTF9 witnessed a huge increase in the number of patients who had been pushed much too hard, much too soon. Yikes.

There is a balance to be struck. On the one hand, it’s clear that early mobilization and general activity is valuable. On the other hand, it’s just as clear that you can aggravate and even re-injure yourself by trying to do too much, too soon. If you feel that a physiotherapist or doctor is pushing you too hard, there’s a good chance that they are.

Re-injury and collateral injury10 are real risks. People get hurt trying to get over being hurt all the time. Keep this in mind!

Relative Rest

One of the most useful concepts in rehabilitation is the idea of “relative” rest: continuing to do any kind of exercise that does not compromise healing. Relative rest is resting the injury only, while continuing to seek ways of remaining active.

There are two kinds of people who need this idea:

Inactive people who suddenly lose the ability to continue doing the only exercise that they were getting before injury. For instance, someone who gets no exercise except walking to work gets a case of plantar fasciitis, and stops walking altogether.
Determined athletic people who have a hard time giving up their favourite sports. For instance, a runner who gets plantar fasciitis, but keeps right on running.

Both of these people need to rest relatively. Both need a new activity!

Relative rest will come to you naturally if you like to be active, but respect the importance of taking it easy on your injury. You will simply seek out safe alternative activities for the duration.

Warning: are you really resting?

Some patients (you know who you are) take the idea of relative rest as a sort of blank cheque to train and workout as hard as they want, as long as they aren’t directly or obviously irritating their injury. If this is you, you need to carefully ask: are you really resting?

Many activities that do not cause symptoms as quickly as others are still a problem — just less of one. Consider the following classic example:

A runner has plantar fasciitis, a kind of tendinitis on the sole of the foot, and running on pavement clearly irritates the condition within fifteen minutes, so he sensibly refrains from running altogether. Cycling, however, feels fine to him, and so he insists on cycling for an hour every day instead of running: relative rest, right?

Many activities that do not cause symptoms are still a problem.

Cycling, especially in clips, is potentially irritating to plantar fasciitis — just a lot less obviously than running on pavement. It might take up to 90 minutes of cycling before you felt a problem, yet every hour-long ride is causing about two thirds of that irritation. This example person is not really resting at all, and will likely turn up in my office saying, “I don’t understand it, I rested from running for six weeks and the problem is still just as bad as ever!”

These are the kinds of complexities that make up the art of resting!

Handling awkward body parts

Some injured locations are harder to rest than others. Take the feet, for example. (Other tricky locations are the knees, the dominant hand or wrist, the neck, and any body part essential to your job.)

Using plantar fasciitis as a good example again: it’s a painful condition, but not usually crippling. Yet every step is an irritation that keeps it going, or makes it worse. As long as you keep using your feet, it’s probably not going to go away. In such cases, people often think that they have already done enough resting, when in fact they have done no better than “taking it easy” for a few days. I’m going to pick on runners again, because they are invariably the worst offenders:

ME: Have you tried resting?

RUNNER: Yes, I really took it easy for a month.

ME: Did you stop running?

RUNNER: Stop? Oh, no, I just dropped down to 10K.

ME: A week?

RUNNER: A day.

ME: Sounds like you were still running quite a bit.

RUNNER: There was the half marathon, too …

Runners are often their own worst enemies!

But for all patients, healing from plantar fasciitis does seem to require an unfair and unreasonable amount of inconvenience: this nagging pain in your feet, a mere irritated slip of connective tissue, can require nearly as much rest as a broken leg in the worst cases.

Unfortunately, hardly anyone takes plantar fasciitis seriously enough to rest as much as they need to. A change in perspective may be necessary: think of your feet as broken, and you’re on the right track. They are broken! And they’ll probably stay broken if you don’t get off them for a while.

So, um … how long?

Let’s recap: you know that bed rest is dead and some movement of all but the most serious injuries is important … but you can’t over do it either. I’ve explained that you can use the concept of “relative rest” to rest your injured part, but otherwise remain active. And we’ve discussed how injuries in some locations are especially tricky to rest. The astute reader will have noticed that I still haven’t said how long: there is still a need to rest something, and the $64,000-question is, “How long?”

As long as it takes, of course.

With some injuries, you can tell whether or not you’re better yet, and you don’t have to guess about how long you need to rest: you just rest until you can tell that it feels better, and then add another couple weeks just to be safe. Easy!

But lots of injuries are “quiet” when you are resting. They only act up after 30 minutes of running, say. Some injuries are completely undetectable with anything less than competition intensity. Running soccer drills might be fine, but soccer itself still impossible. Skiing itself might be fine, but falling down is still a problem.

Many of injuries are “quiet” when you are resting.

Plantar fasciitis, medial tibial stress syndrome, whiplash, carpal tunnel syndrome, iliotibial band syndrome, tennis elbow … these common problems, and many more, can feel more or less completely fine until you’ve been working/playing for a little while, and then you discover the hard way, after already irritating it, that it’s still vulnerable. How can you know how long to rest such a condition? How can you “test” it without pissing it off again?

Every case is different. In some cases you can (sort of) test it without irritating it (much). In other cases, there is no hope of this: testing will irritate the condition and potentially delay recovery.

In these cases, you must choose between two methods: the “get it over with method” and the “if at first you don’t succeed” method.

Two styles of resting

You can see why I avoided saying “how long” at first: it’s pretty hard to generalize. There is no “right” answer. It’s like trying to tell someone whether they should choose safe investments, or riskier but more profitable investments: it all comes down to your personal situation and style …

Method 1: Get it over with …

Some people prefer the “get it over with” or “overkill” method, and choose to rest a lot on the first try, to generously rest for at least 2–3 weeks that you really think is necessary “just in case,” and not to challenge/test your injured part at all during the rest period. The benefit of this approach is that it is virtually foolproof. The disadvantage, of course, is that you may actually end up resting much more than you actually needed to.

This method is fine for people who enjoy a better-safe-than-sorry approach to life, and for people who are patient. But if you are the sort of person who can’t wait to open your Christmas presents …

Method 2: If at first you don’t succeed …

Others are so unable or unwilling to rest that they prefer the “if at first you don’t succeed” or “go for the parking spot you want”11 method, in which you try resting the minimum amount that might work. The advantage? You might succeed on the first or second try, getting away with a relatively small amount of inconvenience.

The disadvantage, of course, is that your desire for efficiency could backfire, and you could end up having to try five progressively longer rest periods, resulting a much larger investment in rehabilitation than if you’d just rested adequately the first time. Ouch.

As you can see, even if you have to try twice, you might succeed on your second try and have about the same total weeks of resting as the “get it over with” method. Or you might not. The worst case scenario with method 2 is pretty bad!

The risk is real: last year I had a client, a young woman athlete with shin splints, who had tentatively tried resting for several periods of 2–4 weeks spread out over an entire year, not one of which was adequate. It was only when I counselled her to rest adequately, no matter how “painful,” that she finally started to make progress. The final rest took three full months. In all likelihood, she could have rested successfully for just 3–4 weeks on the first try, a full year before!

The risk of resting inadequately several times in a row is real.

Here are a few more points to bear in mind when deciding how long you should try to rest:

Old problems are usually more prone to being irritated, and usually require more rest to recover from.
Don’t be too afraid of “testing” an injured part. There are almost always creative methods of testing that minimize stress to the injury, but can still tell you something about how it’s doing.
It’s up to you to decide how deeply to “bury” a problem. Do you need it to mostly go away? Or completely go away? If the goal is perfection, you’re going to have to rest longer.

If you can’t take the heat …

“But I can’t do nothing!!”

“I can’t quit everything!”

“I have to do something!”

These are the howls of protest I hear from athletes and active younger patients when they start to realize that “relative rest” isn’t perfect, and doing it properly means giving up everything they consider to be fun or rewarding. They may still be able to swim or walk or aerobics classes or yoga, but if they are shut out of their favourite activities — skiing, running, ultimate, whatever — they tend to think the world is coming to an end.

I sympathize. I really do! I’ve been there.12

And this is just part of being an athlete. Suck it up and treat it like earning a scout badge. Rehabilitation is a rite of passage: there is hardly a serious athlete in the world who hasn’t had to go through it. Twice. Goes with the territory. If you can’t take the heat, stay out of the kitchen.

Rehabilitation is a rite of passage: there is hardly a serious athlete in the world who hasn’t had to go through it … twice.

The hard part is just coming to emotional grips with the fact that seemingly “minor” injuries like plantar fasciitis, iliotibial band syndrome, shin splints, chronic low back pain, tennis elbow, etc, are actually not going to go away until they are treated like real injuries.

Enjoy your own “rehab montage.” Have fun with it. And if you can’t take the heat? Stay out of the kitchen! Give 110% to something else for a while.

Notes

Consider a modern example: One of my clients broke her arm, and was told by her doctor: “Look, I can put this in a cast and it will be nice and safe, or we can leave it out and it will heal three weeks faster if you can protect it properly until then.” My client chose to skip the cast, and was simply very careful with her arm for a little while. Sure enough, the wound was healed in excellent time. Even though she was very careful with it, the gentle stresses of gravity and slight movements alone were enough to stimulate accelerated healing. Return to text.
Oldmeadow et al. ANZ J Surg. 2006. From the abstract: “Early mobilization after hip fracture surgery accelerates functional recovery and is associated with more discharges directly home and less to high-level care.” Return to text.
Which is not an unimportant point. Obviously there is such a thing as too much of a good thing here. For instance, in 2009, Lamb showed that severe ankle sprains heal much better when completely immobilized by a cast initially. This is a direct contradiction to the fashionable practice of aggressive active rehabilitation, in which the ankle is stabilized only by a brace or a tube bandage, and the patient is encouraged to get the joint back into the action when it’s still seriously unstable. Return to text.
Hagen et al. Spine. 2005. From the abstract: “For people with acute low back pain, advice to rest in bed is less effective than advice to stay active.” Return to text.
Vroomen et al. New England Journal of Medicine. 1999. From the abstract: “Among patients with symptoms and signs of a lumbosacral radicular syndrome, bed rest is not a more effective therapy than watchful waiting.” Return to text.
Sorrenti. Foot & Ankle International. 2006. From the abstract: “Surgery combined with early mobilization reduces range of motion loss, increases blood supply, and reduces the degree of muscle atrophy that typically occurs after Achilles tendon rupture, thereby decreasing the time to resumption of normal activities.” Return to text.
See Mealy, Vassiliou, McKinney, and Schnabel. Return to text.
Spitzer et al. Spine. 1995. Return to text.
Freeman et al. Spine. 1998. From the abstract: “Although the Task Force set out to redefine whiplash and its management ... its publications instead have confused the subject further.” Return to text.
Collateral and Re-Injury Prevention Return to text.
Some people assume that they aren’t going to find the best parking spot, so they don’t even try. But you’ll never get the best parking spot if you don’t check! Return to text.
In 1996, I discovered the sport of ultimate, and was instantly addicted … only to get a nasty case of iliotibial band syndrome about one year later. I didn’t know how to treat it back then, and I went through several stages of not-quite-enough-rest for two full years, because it was very hard for me to stay out of the game. Return to text.