Restology

Rest and underuse is an essential part of the way to tackle not only overuse injuries but also some acute injuries. Remember though that these injuries should more appropriately be referred to as misuse injuries and though overuse is an important part of misuse there are other aspects such as not building up training gradually enough and posture.

What is rest?

Rest seems like such an obvious concept but alas, as with most or all things in this complex universe that we inhabit, it is not really such a simple concept. We tend to think that e.g. sitting is resting, which I guess is one of the reasons why Cumulative Upper Limb Trauma (so-called Repetitive Strain Injury) is often not taken seriously.  Sitting actually puts quite a lot of pressure through the back because in order to maintain this posture our bodies are resisting the forces of gravity. Likewise with mental cumulative trauma injuries, it is easy to think that the best way to deal with them is to do less, whereas the reality is that more activity may be beneficial in certain cases.  How can we resolve this complexity within rest? We need a science of rest, let’s call it ‘Restology’. In the meantime, these are my thoughts on Restology…

Recovery time

The answer is that rest (in this context) refers to recovery time that enables the reduction of stress. Time is a great healer and recovery time is the time it takes to recover from the stress induced by activity.  This does not always equate to a simple absence of activity or what appears to be an absence of activity. Simply sitting a lot as a way of resting may not be appropriate because of the added strain on the back and neck in this position. Similarly, in relation to mental trauma, simply avoiding activity may also increase as much as it decreases stress, maybe because of an increase in social isolation or the stress that comes from a lack of stimulation.  So it is quite easy to avoid one stress to replace it with another one that may carry the illusion of being stress-free.

Read the page about Repetitive Strain Injury for some examples of how recovery time can be used to avoid or manage RSI.

These periods of recovery time or breaks must also involve not doing a very similar activity, such as playing the piano immediately after typing.

Recovery time will vary with different activities.  When training with weights it is normally advised not to train the same muscle group on consecutive days and to have at least one day a week off from any kind of exercise.

There is some evidence that frequent brief breaks from activity (such as repetitive typing) are more effective than longer breaks. Some people also recommend that if you undertake certain sports it is wise to have a few months off every year to give your body a real chance of recovering from injuries that may be in the wings. In regard to cycling, there may be something to be said for giving cycling a break during the winter months when there is also a greater risk of accidents.

All of this taking breaks can seem like a bit of an encumbrance.  However, there are some benefits as well – I have found that when I give something a break I go back to it with a fresher perspective and new ideas. It’s quite easy to get into a rut doing something and a sabbatical can provide a reinvigorated approach. Even with problem solving, I have noticed that it’s not always good to keep plugging away, maybe because when you leave the problem your mind is quietly working away at it in the background. I have also found that I probably get more things done when I divide my time with a variety of activities, maybe because there is a law of diminished returns with focusing obsessively on just one thing.

In a sense part of this approach involves just slowing down a bit and sometimes the principle ‘the more haste, the less speed’ does apply. Less often is more.

Rest can mean any combination of a reduction in certain activities, an increase in others or carrying out activities more ergonomically in such a way that stress is reduced and not simply displaced.

A lot of stress is ‘silent stress’. I think that this applies to both mental and physical stress. I have noticed that when I spend time by myself I often do not feel stressed, but when I eventually return to interacting with people I can sense a feeling of built up isolation. Similarly with physical stress, if our bodies would tell us when we were putting them through too much stress it would be a lot easier to avoid overuse injuries.

 

How to rest

Be prepared for discomfort, rest is hard

Resting is easier said than done because most people still need to try function – to get around, to socialise, to eat, to work, to do all of these basic things. One of the main barriers that I have had to rest is the pressure I have felt to return to work to avoid accruing sick leave because of being worried about being sacked.

Complete inactivity: This is where you avoid any movement of the affected part. One mistake that I have made when resting is that I have rested from the activity that I believe caused the injury (the ‘triggering activity’) but then kept doing everything else as normal.  I think for a certain period of time you need to rest from the triggering activity and other activities as well. Depending how many activities you avoid you are on a spectrum with complete inactivity of the affected part as the most extreme option

Complete inactivity may apply to joint injuries because it is difficult for cartilage to heal due to its lack of blood supply. For example when I injured my left knee I avoided the activity that I believe caused the injury (balance board exercises) but I was still generally moving around as normal. I then developed a chronic tear to my meniscus. However on another occasion I developed eczema on my hands which I realised was due to using artificial liquid soaps without first wetting my hands with water. I not only avoided using the artificial liquid soaps on my hands but I also avoided any contact of water with my hands. The eczema completely cleared up and now I can use the artificial liquid soaps again as long as I wet my hands first with water. Another example is that when I injured my right knee I realised that it was connected to carrying my bicycle up and down many flights of stairs every day. I avoided carrying my bike up and downstairs and cut back on cycling but eventually discovered that I had a severe tear to my patello-femoral cartilage. If I had completely rested my knee for a couple of weeks, maybe just moving around my flat, and combined this with avoiding the triggering activity I think that there would have been a much greater chance avoiding the chronic tear that I now have. So, it probably depends on the individual, the nature of the injury and whether you have any underlying vulnerabilities. On the spectrum of rest from complete inactivity to moving the part as normal and I think that if you have high risk injuries – which could be defined as an injury to a vulnerable part of the body such as joint – if you have underlying anatomical weaknesses affecting this part or a more severe injury, then you will need to err to spending more time on the complete inactivity part of the spectrum.

Modified activity: This where you ‘keep doing things but modify your approach’.

Essentially you are reducing the amount and the intensity of what you are doing, increasing the recovery time or changing your technique e.g. by using a more ergonomic approach.

i) Vary your activities: a change is as good as a rest. I find that by varying my activities I can still get things done.  At work I break up typing with a phone call or a face to face meeting, thinking, writing or tidying my desk.  With music I break up keyboard use with playing the harmonica or singing. The good thing about using variation of activity as a way of resting is that you are still getting things done. The comparable principle in sport is cross training, which I think may be the preferable way to exercise for people with anatomical variations such as scoliosis that can predispose one to injury.

ii) Avoid high stress movements. There are certain movements which might be considered to be ‘high stress movements’. These are not always immediately obviously. It was only after injuring my right knee that I learnt that going up and down stairs puts a great deal of stress through the knee joint. I think it is wise to be aware of what these ‘high risk’ movements are, not so that you avoid them altogether but just so that you are aware of not overdoing them, particularly if you have anatomical variations such as pes cavus (high arches in the feet). This is essentially about avoiding excessive stress.

iii) Keep an activity diary where you log the intensity, duration and frequency of some of the things that you are doing when you are trying to reduce the activity or gradually start again.

Whilst resting

Learn: When you are resting you need to learn new ways of doing things so that if you need to go back to what you were doing before you won’t reinjure yourself.  This is true for both mental and physical health problems. If you have been off work with depression, for example, it may be helpful if whilst you are off you learn ways to deal with the things that you found difficult at work.

Avoid compensating

It is easy to become reinjured through incorrect rest.  I have tended to compensate for the loss of function that an injury causes by overusing another part of my body. This can lead to a string of injuries which can cause depression.

It’s easy to think that a compensatory behaviour is essential.  I have found that when I have stopped doing what I thought were essential things to compensate for an injury or health issue, it didn’t really make that much difference.

Rest an injury as much as is possible within the limitations of avoiding any compensatory behaviours. So for example with my right knee injury I could have applied this approach of modified rest and avoiding compensatory behaviours by not using my left knee to compensate whilst avoiding for example going up and down stairs unnecessarily. This approach avoids creating an injury cascade, however it may mean that the new injury may not be rested adequately.

If you feel you need to compensate then possibly if you do this in a gradual way you may not injure the compensating part.  When I injured my right knee I compensated by using my left knee and this led to a meniscal tear in my left knee. I don’t know if I had gradually started using my left knee more whether this would have prevented the meniscal tear. This is where possibly the ten percent rule may come into play (i.e. where you only increase the amount of an activity by 10 % per week).

How long to rest for?

It takes 100 days for collagen to be synthesised. Resting is probably needed for longer than most people would guess. Taking tendon overuse injuries as an example, mild injuries take 2 to 4 weeks, moderate 4 to 6 weeks, and severe 6 to 12 weeks.

One guide is to rest for as long as it takes until you are free of pain and then add a week.

After rest

Return to activity gradually: If you rest and then suddenly simply resume what you were doing before you can get reinjured.  This is probably because you are suddenly increasing your amount of activity and so you are making the same mistake that you made when you were originally injured. Remember overuse injuries are caused by ‘too much, too soon, too fast’. When you return to activity, return gradually. It can be difficult to, for example, to gradually return to work, but remember that normally you may have some control over the intensity, duration and frequency of the activity.  So if you return to jogging, for example, after a running injury you can go back to jog more slowly, or avoid hills.  Or if you return to typing you can type more slowly.  This is an example of reducing the intensity of the activity. The duration can be altered by taking more breaks and the frequency by maybe having complete days off.

Why doesn’t rest always help?

During injury scar tissue can build up which can lead to continuing problems even if you have rested properly. This can happen with tendons. This is where rehab is important.

Cartilage has a limited blood supply so when it is injured healing can be difficult. This is why it is crucial to rest joint injuries as soon as possible to give the maximum opportunity for cartilage to heal or not be injured through secondary injury.

If you rest and simply go back to what you were doing before the injury then the injury will return. Injury is caused by the load exceeding the body’s capacity so you need to reduce the load by either changing your technique or undertaking rehab to improving your body’s capacity to deal with the load.