Authors:
Dr. Neeraj Mehta, Ph.D.¹ᐟ²*, Pankaj Mehta, M.P.Ed.², Dr. Anya Petrova, M.D., Ph.D.³, Dr. Umesh Kumar, Ph.D.⁴, Sumit Khoney, MMSx Pro¹, Priya Sharma, BPT², David Lee, M.Sc.³
Affiliations:
¹Active India Health and Fitness Trust, India
² GFFI Fitness Academy, New Delhi, India
³ Indian Institute of Kinesiology and Biomechanics Science (IIKBS), Pune, India
⁴ Indra Gandhi Physical Education Institute (IGPEI), New Delhi, India
* MMSX AUTHORITY INSTITUTE FOR MOVEMENT MECHANICS & BIOMECHANICS RESEARCH, INC, USA
*Corresponding Author: Dr. Neeraj Mehta, Ph.D.
Protocol created by : MMSX AUTHORITY INSTITUTE FOR MOVEMENT MECHANICS & BIOMECHANICS RESEARCH, INC, USA
Email: info@mmsxauthority.com | Tel: +1 (614) 822-8038, +91-9910047204
ABSTRACT
Background: Traditional Rest, Ice, Compression, and Elevation (RICE) protocols have been the standard of care for acute musculoskeletal injuries in athletes for decades. However, emerging evidence suggests that early, progressive mobilization may accelerate recovery and optimize return-to-sport outcomes. The Movement-Oriented Velocity of Engagement (MOVE) Protocol represents a paradigm shift toward active rehabilitation.
Objective: To compare the efficacy, safety, and time-to-return-to-sport between traditional RICE therapy and the MOVE Protocol in elite Indian national-level athletes across multiple sports disciplines.
Design: Multi-center retrospective comparative cohort study conducted across eight training centers in India (2023).
Participants: Sixty-six (N=66) national-level Indian athletes (age range: 19-33 years; 38 male, 28 female) representing six sports disciplines (cricket, taekwondo, marathon running, sprinting, weightlifting, gymnastics) with acute or subacute musculoskeletal injuries. Athletes were divided into two matched cohorts: RICE group (n=33) and MOVE group (n=33).
Intervention: RICE group received traditional passive therapy (rest, ice, compression, elevation) for 7 weeks. MOVE group received the structured 7-week MOVE Protocol emphasizing early mobilization, progressive load optimization, neural control validation, and metabolic energization.
Main Outcome Measures: Primary outcomes included pain reduction (Numeric Rating Scale, NRS 0-10), functional improvement (Sport-Specific Functional Scale, SSFS), time-to-return-to-training, and time-to-return-to-competition. Secondary outcomes included strength recovery (30-second Sit-to-Stand test), balance restoration (Single-Leg Stance test), and athlete-reported recovery perception (Global Rating of Change, GROC).
Results: The MOVE group demonstrated statistically and clinically superior outcomes across all measures. Mean pain reduction at Week 7 was significantly greater in the MOVE group (ΔNRS = -6.2 ± 1.1) compared to the RICE group (ΔNRS = -3.8 ± 1.4; p < 0.001). Functional improvement was substantially higher in the MOVE group (ΔSSFS = +31.8 ± 8.2) versus RICE (ΔSSFS = +15.3 ± 9.1; p < 0.001). Most remarkably, median time-to-return-to-training was 12 days (IQR 8-16) in the MOVE group compared to 42 days (IQR 35-56) in the RICE group (p < 0.001). Time-to-return-to-competition was similarly accelerated: MOVE 21 days (IQR 14-28) versus RICE 63 days (IQR 49-84; p < 0.001). No serious adverse events occurred in either group.
Conclusions: The MOVE Protocol dramatically outperformed traditional RICE therapy in elite Indian athletes, reducing pain more effectively, restoring function faster, and accelerating return-to-sport by approximately 3-4 weeks. These findings challenge the conventional passive approach to sports injury management and provide compelling evidence for early, criterion-based mobilization as the new standard of care for athletic populations.
Keywords: RICE protocol, MOVE protocol, sports injury rehabilitation, elite athletes, early mobilization, return-to-sport, mechanotherapy, pain management, functional recovery
1. INTRODUCTION
1.1 The Historical Dominance of RICE
For over four decades, the RICE (Rest, Ice, Compression, Elevation) protocol has been the cornerstone of acute musculoskeletal injury management in sports medicine (Mirkin & Hoffman, 1978). This passive approach was predicated on the assumption that immobilization and cryotherapy would minimize inflammation, reduce pain, and protect injured tissues from further damage. The RICE paradigm became so deeply entrenched in clinical practice that it was taught as gospel in medical schools, athletic training programs, and coaching certifications worldwide (Bleakley et al., 2004).
However, as our understanding of tissue healing and mechanobiology has evolved, significant questions have emerged about the efficacy—and even the appropriateness—of prolonged rest and passive modalities. Contemporary research in mechanotransduction has revealed that mechanical loading is not merely safe during the healing process; it is, in fact, essential for optimal tissue repair and functional restoration (Khan & Scott, 2009; Heinemeier & Kjaer, 2011). Controlled mechanical stimuli promote collagen synthesis, enhance neuromuscular re-education, and accelerate the transition from inflammatory to proliferative healing phases (Magnusson et al., 2010).
1.2 The Emergence of Active Rehabilitation Paradigms
In recent years, sports medicine has witnessed a paradigm shift away from passive rest toward active rehabilitation. The POLICE (Protection, Optimal Loading, Ice, Compression, Elevation) framework introduced by Bleakley and colleagues (2012) was an early attempt to integrate progressive loading into injury management. More recently, Dubois and Esculier (2020) proposed the PEACE & LOVE principles, which explicitly advocate for early mobilization and discourage prolonged anti-inflammatory interventions that may impede natural healing processes.
Despite these conceptual advances, the clinical implementation of active rehabilitation has been inconsistent, particularly in high-performance athletic settings where the pressure to return to competition is intense. Coaches, athletes, and medical staff often default to conservative, passive approaches out of fear of re-injury or exacerbating symptoms. This creates a paradox: the very interventions intended to protect athletes may, in fact, delay their recovery and compromise long-term outcomes.
1.3 The MOVE Protocol: A Structured Framework for Active Rehabilitation
The MOVE Protocol (Movement-Oriented Velocity of Engagement), developed by Dr. Neeraj Mehta in 2021 under the MMSx Authority Institute for Movement Mechanics & Biomechanics Research, is a clinically validated rehabilitation framework. The protocol is structured around four progressive phases:
1.M — Mobilize Early: Pain-free active range of motion (AROM), breath-led mobility, and gentle joint oscillations to initiate mechanotransduction and prevent the deleterious effects of immobilization.
2.O — Optimize Load: Progressive resistance training from isometric to isotonic to eccentric loading, dosed according to Rate of Perceived Exertion (RPE) and guided by the 48-hour flare rule to build tissue capacity safely.
3.V — Validate Neural Control: Balance, proprioception, and perturbation training to restore neuromuscular coordination and motor control, reducing the risk of re-injury.
4.E — Energize Recovery: Low-intensity cardiovascular work (Zone 2-3) to enhance circulatory function, metabolic readiness, and systemic recovery.
The MOVE Protocol is not a rigid prescription but a flexible, individualized framework governed by explicit progression gates. Athletes advance through phases only when specific safety and performance criteria are met, ensuring that rehabilitation is both aggressive and safe.
| Parameter | RICE Protocol (Rest, Ice, Compression, Elevation) | MOVE Protocol (Movement-Oriented Velocity of Engagement) |
|---|---|---|
| Philosophy | Passive rest and inflammation control | Active mobilization and neuromuscular engagement |
| Primary Goal | Reduce swelling and pain through immobilization | Accelerate recovery through controlled motion and tissue activation |
| Approach | Suppresses biological healing responses | Stimulates natural repair via graded mechanical loading |
| Movement Strategy | Restricts movement to avoid pain | Encourages early, pain-tolerant mobilization (Pain ≤ 3/10) |
| Tissue Adaptation | Delays collagen alignment and muscle activation | Enhances collagen remodeling, tendon elasticity, and load tolerance |
| Circulation | Reduced blood and lymph flow | Improves microcirculation and metabolic exchange |
| Neuromuscular Control | Decreases proprioceptive feedback | Re-establishes motor control and coordination |
| Recovery Timeline | Prolonged recovery due to inactivity | Faster recovery through phase-based progression |
| Pain & Function Outcomes | Short-term comfort, delayed functional gain | Faster pain reduction and superior functional restoration |
| Clinical Philosophy | “Rest to heal” | “Move to heal and perform” |
| Scientific Basis | Traditional injury management (1970s concept) | Modern evidence-based mechanotherapy (Dr. Neeraj Mehta, 2021) |
1.4 The Indian Athletic Context
India is home to a rapidly growing population of elite athletes competing at national and international levels across diverse sports disciplines. However, access to evidence-based sports medicine and rehabilitation services remains limited, particularly outside major metropolitan centers (Kumar et al., 2018). Many athletes continue to rely on outdated protocols, often resulting in prolonged recovery times, incomplete functional restoration, and elevated re-injury rates.
The Indian Institute of Kinesiology and Biomechanics Science (IIKBS) and GFFI Fitness Academy, in collaboration with the MMSx Authority, recognized the urgent need for a rigorous, comparative evaluation of rehabilitation protocols in the Indian athletic context. This study was conceived to provide definitive evidence on the relative efficacy of RICE versus MOVE in a real-world, multi-center setting involving elite national-level athletes.
1.5 Study Objectives and Hypotheses
The primary objective of this study was to compare the efficacy, safety, and time-to-return-to-sport between traditional RICE therapy and the MOVE Protocol in elite Indian athletes with acute or subacute musculoskeletal injuries. We hypothesized that the MOVE Protocol would result in:
1.Greater pain reduction at Week 7
2.Superior functional improvement at Week 7
3.Faster time-to-return-to-training
4.Faster time-to-return-to-competition
5.Comparable or superior safety profile (incidence of adverse events)
This study represents the first large-scale, multi-center comparative evaluation of RICE versus MOVE in an elite athletic population, and the findings have profound implications for sports medicine practice in India and globally.
2. METHODS
2.1 Study Design and Setting
This was a multi-center retrospective comparative cohort study conducted across eight training centers in India during the 2023 calendar year. The study was coordinated by the Indian Institute of Kinesiology and Biomechanics Science (IIKBS) in Pune and GFFI Fitness Academy in New Delhi, with data collection occurring at six associate training centers:
Primary Coordinating Sites:
•Site 1: IIKBS, Pune, Maharashtra
•Site 2: GFFI Fitness Academy, New Delhi
Associate Training Centers:
•Associate Center 1: Mumbai, Maharashtra
•Associate Center 2: Chandigarh, Punjab
•Associate Center 3: Gurgaon, Haryana
•Associate Center 4: Dehradun, Uttarakhand
•Associate Center 5: Ludhiana, Punjab
•Associate Center 6: Jaipur, Rajasthan
All sites were equipped with standard rehabilitation facilities, including treatment rooms, strength and conditioning equipment, and access to certified sports physiotherapists and biomechanics specialists. The study was conducted in accordance with the Declaration of Helsinki (2013) and received ethical approval from the IIKBS Institutional Ethics Committee (IEC Approval No.: IIKBS/IEC/2023/042, dated January 15, 2023).
2.2 Participants
2.2.1 Inclusion Criteria
Athletes were eligible for inclusion if they met ALL of the following criteria:
1.Age: 19-33 years (intermediate to advanced athletic maturity)
2.Athletic Status: National-level competitors or regional-level athletes training for national selection
3.Injury Type: Acute or subacute musculoskeletal injury (≤14 days from onset)
4.Baseline Pain: Pain intensity ≥5 on the Numeric Rating Scale (NRS, 0-10)
5.Functional Limitation: Sport-Specific Functional Scale (SSFS) score ≤60/80
6.Medical Clearance: No red flag symptoms (fracture, complete rupture, neurological deficit, systemic illness)
7.Informed Consent: Voluntary participation with written informed consent
2.2.2 Exclusion Criteria
Athletes were excluded if they had any of the following:
1.Fracture or complete tissue rupture requiring surgical intervention
2.Neurological deficits (e.g., radiculopathy, myelopathy)
3.Systemic inflammatory conditions (e.g., rheumatoid arthritis, lupus)
4.Uncontrolled comorbidities (e.g., diabetes, hypertension)
5.Pregnancy
6.Previous participation in a structured rehabilitation program within the past 3 months
7.Inability to comply with the 7-week protocol due to competition schedule
2.2.3 Sample Size and Allocation
A total of 66 national-level athletes were enrolled in the study. Athletes were allocated to either the RICE group (n=33) or the MOVE group (n=33) based on the treatment protocol available at their respective training center at the time of injury. While not a randomized controlled trial, efforts were made to match the two cohorts on key variables including age, sex, sport discipline, injury type, and baseline pain/function scores.
2.2.4 Participant Demographics
The final cohort consisted of:
•Total N: 66 athletes
•Age Range: 19-33 years (Mean ± SD: 25.4 ± 3.8 years)
•Sex Distribution: 38 male (57.6%), 28 female (42.4%)
•Sport Disciplines:
•Cricket: 12 athletes (18.2%)
•Taekwondo: 11 athletes (16.7%)
•Marathon Running: 11 athletes (16.7%)
•Sprinting: 11 athletes (16.7%)
•Weightlifting: 11 athletes (16.7%)
•Gymnastics: 10 athletes (15.2%)
2.3 Injury Classification and Matching
To ensure comparability between the RICE and MOVE groups, athletes were stratified into five injury categories based on anatomical location and tissue type. Each category represented common sports injuries with similar healing timelines and functional demands:
Injury Group 1: Lower Limb Muscle Strains
•Conditions: Hamstring strain (Grade I-II), quadriceps strain, calf strain
•RICE Group: n=7 | MOVE Group: n=7
•Representative Sports: Sprinting, cricket, football
Injury Group 2: Knee and Ankle Ligament Sprains
•Conditions: Lateral ankle sprain (Grade I-II), medial collateral ligament (MCL) sprain, patellar tendinopathy
•RICE Group: n=7 | MOVE Group: n=7
•Representative Sports: Taekwondo, gymnastics, marathon running
Injury Group 3: Shoulder and Upper Limb Injuries
•Conditions: Rotator cuff strain, shoulder impingement, elbow tendinopathy
•RICE Group: n=6 | MOVE Group: n=6
•Representative Sports: Cricket (bowlers), weightlifting, gymnastics
Injury Group 4: Lumbar and Thoracic Spine Dysfunction
•Conditions: Acute lumbar strain, thoracic spine stiffness, sacroiliac joint dysfunction
•RICE Group: n=7 | MOVE Group: n=7
•Representative Sports: Weightlifting, cricket, gymnastics
Injury Group 5: Overuse and Chronic Exacerbations
•Conditions: Patellofemoral pain syndrome (PFPS), Achilles tendinopathy, plantar fasciitis
•RICE Group: n=6 | MOVE Group: n=6
•Representative Sports: Marathon running, sprinting, taekwondo
2.4 Interventions
2.4.1 RICE Protocol (Control Group, n=33)
Athletes in the RICE group received traditional passive therapy for 7 weeks, administered by certified sports physiotherapists at their respective training centers. The protocol consisted of:
Week 1-2: Acute Phase
•Rest: Complete cessation of sport-specific training; athletes instructed to avoid loading the injured area
•Ice: Cryotherapy applied for 20 minutes, 4-6 times per day
•Compression: Elastic bandage or compression garment worn continuously during waking hours
•Elevation: Injured limb elevated above heart level whenever possible
•Pain Management: Over-the-counter analgesics (acetaminophen or NSAIDs) as needed
•Passive Modalities: Ultrasound, electrical stimulation, or manual therapy at therapist discretion
Week 3-4: Subacute Phase
•Gradual Introduction of Passive Range of Motion: Therapist-assisted stretching and joint mobilization
•Continued Ice and Compression: Frequency reduced to 2-3 times per day
•Light Activities of Daily Living (ADL): Walking and basic movements permitted, but no sport-specific loading
Week 5-7: Late Rehabilitation Phase
•Progressive Strengthening: Introduction of light resistance exercises (e.g., theraband, bodyweight exercises)
•Functional Training: Sport-specific drills at reduced intensity (50-70% of pre-injury level)
•Gradual Return-to-Sport: Clearance for full training only if pain-free and functional tests passed
Key Characteristics of RICE:
•Emphasis on tissue protection and inflammation control
•Passive modalities dominate early phases
•Delayed introduction of active loading
•Progression based primarily on time elapsed, not functional criteria
2.4.2 MOVE Protocol (Intervention Group, n=33)
Athletes in the MOVE group received the structured 7-week MOVE Protocol, delivered by MMSx-certified movement specialists and sports physiotherapists. The protocol was divided into three phases, each with explicit progression gates:
Phase 1: Mobilize & Optimize Initial Tolerance (Weeks 1-2)
Goal: Reduce pain (NRS) below 5 and establish pain-free Active Range of Motion (AROM).
Key Components:
1.Pain-Free AROM Drills:
•Pelvic tilts, cat-cow, controlled joint oscillations
•Dosage: 5-10 minutes, 3-5 times per day
•Focus: Smooth, pain-free movement to initiate mechanotransduction
2.Breath-Led Mobility:
•Diaphragmatic breathing, rib cage expansion drills
•Dosage: 5 minutes, 3 times per day
•Focus: Reduce sympathetic tone, enhance parasympathetic recovery
3.Initial Load: Isometric Holds:
•Core bracing, isometric holds at injured joint (e.g., isometric shoulder external rotation for RC strain)
•Dosage: 10-second holds, 5 repetitions, 2 sets
•Intensity: RPE 2-4 (minimal effort)
4.Energize: Brisk Walking:
•Controlled walking with nasal breathing
•Dosage: 10-15 minutes per day
•Focus: Maintain cardiovascular base without exacerbating symptoms
Progression Gate: No sharp/tearing pain; no swelling increase >24 hours; pain ≤3/10 during/after exercise; DOMS <48 hours.
Phase 2: Validate Control & Advanced Optimization (Weeks 3-4)
Goal: Substantial pain reduction (NRS <4) and significant functional improvement.
Key Components:
1.Isotonic/Tempo Loading:
•Hip hinge (bodyweight or light load), controlled squats, sport-specific movement patterns
•Dosage: 3 sets × 10 repetitions
•Intensity: RPE 4-6
2.Eccentric Focus:
•Slow, controlled eccentric loading (e.g., 3-second descent squats, eccentric hamstring curls)
•Dosage: 3 sets × 8 repetitions
•Focus: Build tissue capacity and resilience
3.Proprioception Training:
•Double-leg balance on foam, single-leg stance on stable surface
•Dosage: 10-15 minutes per session
•Progression: Eyes open → eyes closed → dynamic perturbations
4.Control Drills:
•Step-downs, controlled lunges, sport-specific agility patterns
•Dosage: 8-10 reps per side, 2-3 sets
•Focus: Hip/knee alignment, no valgus collapse
5.Energize: Brisk Walk or Cycle:
•Zone 2 intensity cardiovascular work
•Dosage: 20-25 minutes per session, 4-5 days per week
Progression Gate: Movement control maintained; pain ≤3/10; stable mechanics (no lumbar collapse/valgus); task competence achieved.
Phase 3: Performance Integration & Energize (Weeks 5-7)
Goal: Achieve maximum function, restore full strength and balance, prepare for return to competition.
Key Components:
1.Functional Compound Lifts:
•Trap bar deadlift, goblet squat, overhead press (sport-dependent)
•Dosage: 3 sets × 5-8 repetitions
•Intensity: RPE 6-7, focus on velocity and power
2.Sport-Specific Loading (Multi-Plane):
•Rotational medicine ball throws (cricket), plyometric drills (taekwondo), explosive starts (sprinting)
•Dosage: 3 sets × 10-12 reps/throws
•Focus: Integrate core bracing with dynamic, multi-planar movement
3.Reactive Balance & Perturbations:
•Respond to external forces (light pushes/pulls), hop-prep drills
•Dosage: 10-15 minutes per session
•Focus: Quick, stable landings and reactive stability
4.Full Neuromuscular Control:
•Controlled jumping, landing, and agility drills (e.g., square hops, cutting maneuvers)
•Assessment: Landing stability, absence of valgus, symmetrical movement
5.Energize: Advanced Cardio (Interval Training):
•Alternating Zone 3 and Zone 4 intensity intervals
•Dosage: 20-25 minutes per session, 3-4 days per week
•Focus: Improve Heart Rate Recovery (HRR) and metabolic capacity
6.Maintenance Routine & Self-Care:
•Personalized routine of 3-5 key exercises (mobility + strength)
•Dosage: 2-3 times per week, ongoing
•Focus: Long-term injury prevention and performance optimization
Final Endpoint: Achieve pre-injury Sit-to-Stand (STS) reps, significant increase in Single-Leg Stance (SLS) time, clearance for full, unrestricted sport participation.
Key Characteristics of MOVE:
•Emphasis on early, criterion-based mobilization
•Active loading introduced immediately (within pain tolerance)
•Progression governed by functional gates, not arbitrary timelines
•Integration of all four pillars (Mobilize, Optimize, Validate, Energize) throughout
2.5 Outcome Measures
All outcome measures were assessed at Baseline (Week 0), Week 2, Week 4, and Week 7 by blinded assessors (physiotherapists not involved in treatment delivery).
2.5.1 Primary Outcomes
1. Pain Intensity (Numeric Rating Scale, NRS)
•Description: Self-reported pain on a 0-10 scale (0 = no pain, 10 = worst imaginable pain)
•Assessment: Athletes rated their pain “at rest” and “during sport-specific movement”
•MCID: ≥2 points (Farrar et al., 2001)
2. Sport-Specific Functional Scale (SSFS)
•Description: Customized functional assessment based on sport demands (0-80 scale)
•Assessment: Athletes rated their ability to perform 8 sport-specific tasks (e.g., sprinting, cutting, jumping) on a 0-10 scale
•MCID: ≥9 points (Hefford et al., 2012)
3. Time-to-Return-to-Training (Days)
•Definition: Number of days from enrollment to clearance for full, unrestricted team training
•Criteria: Pain ≤2/10, SSFS ≥70, clearance by team physician and coach
4. Time-to-Return-to-Competition (Days)
•Definition: Number of days from enrollment to participation in official competition
•Criteria: Athlete self-report of readiness, coach approval, medical clearance
2.5.2 Secondary Outcomes
5. Functional Strength (30-Second Sit-to-Stand Test, STS)
•Description: Number of complete sit-to-stand repetitions in 30 seconds
•Assessment: Standardized chair height (45 cm), arms crossed over chest
•Normative Data: Age- and sex-adjusted norms (Jones et al., 1999)
6. Balance and Proprioception (Single-Leg Stance Test, SLS)
•Description: Duration (seconds) of unassisted single-leg stance with eyes open
•Assessment: Hands on hips, opposite leg flexed to 90°, test terminated if foot touches down or hands leave hips
•Normative Data: Age-adjusted norms (Springer et al., 2007)
7. Athlete-Reported Recovery (Global Rating of Change, GROC)
•Description: Self-reported perception of overall change on a 15-point scale (−7 = very much worse, 0 = no change, +7 = very much better)
•Assessment: Administered at Week 7 only
•Clinical Significance: Score ≥+5 indicates meaningful recovery (Jaeschke et al., 1989)
8. Adverse Events (AEs)
•Definition: Any untoward medical occurrence, including symptom exacerbation, new injury, or systemic illness
•Classification: Minor (resolved within 48 hours with protocol modification) vs. Serious (required medical intervention or withdrawal from study)
2.6 Data Collection and Management
All data were collected on standardized case report forms (CRFs) and entered into a secure, password-protected database (REDCap, Vanderbilt University). Data quality checks were performed weekly by the coordinating center (IIKBS). Missing data were minimal (<3% of total data points) and handled using Last Observation Carried Forward (LOCF) for single missing time-points.
2.7 Statistical Analysis
All statistical analyses were performed using R version 4.3.0 (R Core Team, 2023) and SPSS version 28.0 (IBM Corp., Armonk, NY). Statistical significance was set at α = 0.05 (two-tailed).
2.7.1 Baseline Comparability
Baseline characteristics were compared between the RICE and MOVE groups using:
•Continuous variables: Independent samples t-tests (normally distributed) or Mann-Whitney U tests (non-normally distributed)
•Categorical variables: Chi-square tests or Fisher’s exact tests
2.7.2 Primary Outcome Analysis
Pain (NRS) and Function (SSFS):
•Within-group changes: Paired t-tests comparing Baseline vs. Week 7
•Between-group comparisons: Independent samples t-tests comparing change scores (Δ = Week 7 − Baseline)
•Effect sizes: Cohen’s d (small: 0.2-0.5, medium: 0.5-0.8, large: >0.8)
Time-to-Return-to-Training and Time-to-Return-to-Competition:
•Survival analysis: Kaplan-Meier curves with log-rank tests
•Median time: Reported with interquartile range (IQR)
2.7.3 Secondary Outcome Analysis
Functional Strength (STS) and Balance (SLS):
•Same approach as primary outcomes (paired and independent t-tests, effect sizes)
Athlete-Reported Recovery (GROC):
•Mann-Whitney U test comparing GROC scores at Week 7
Adverse Events:
•Descriptive statistics (frequency, percentage)
•Fisher’s exact test comparing incidence between groups
2.7.4 Subgroup Analysis
Exploratory subgroup analyses were conducted to examine whether treatment effects varied by:
•Sport discipline (6 categories)
•Injury type (5 injury groups)
•Sex (male vs. female)
•Age (19-25 years vs. 26-33 years)
3. RESULTS
3.1 Participant Flow and Baseline Characteristics
A total of 68 athletes were initially screened for eligibility. Two athletes were excluded (one due to fracture requiring surgery, one due to inability to commit to 7-week follow-up). The final cohort consisted of 66 athletes (RICE: n=33, MOVE: n=33). All 66 athletes completed the full 7-week protocol with no dropouts or loss to follow-up (100% retention rate).
3.1.1 Baseline Demographic and Clinical Characteristics
Table 1. Baseline Characteristics of Study Participants
| Characteristic | RICE Group (n=33) | MOVE Group (n=33) | p-value |
| Age (years), mean ± SD | 25.2 ± 3.9 | 25.6 ± 3.7 | 0.68 |
| Sex, n (%) | 0.82 | ||
| Male | 19 (57.6%) | 19 (57.6%) | |
| Female | 14 (42.4%) | 14 (42.4%) | |
| Sport Discipline, n (%) | 0.99 | ||
| Cricket | 6 (18.2%) | 6 (18.2%) | |
| Taekwondo | 6 (18.2%) | 5 (15.2%) | |
| Marathon Running | 5 (15.2%) | 6 (18.2%) | |
| Sprinting | 6 (18.2%) | 5 (15.2%) | |
| Weightlifting | 5 (15.2%) | 6 (18.2%) | |
| Gymnastics | 5 (15.2%) | 5 (15.2%) | |
| Injury Group, n (%) | 1.00 | ||
| Group 1: Lower Limb Muscle Strains | 7 (21.2%) | 7 (21.2%) | |
| Group 2: Knee/Ankle Ligament Sprains | 7 (21.2%) | 7 (21.2%) | |
| Group 3: Shoulder/Upper Limb Injuries | 6 (18.2%) | 6 (18.2%) | |
| Group 4: Lumbar/Thoracic Spine Dysfunction | 7 (21.2%) | 7 (21.2%) | |
| Group 5: Overuse/Chronic Exacerbations | 6 (18.2%) | 6 (18.2%) | |
| Days Since Injury, median (IQR) | 8 (5-12) | 7 (4-11) | 0.71 |
| Baseline Pain (NRS 0-10), mean ± SD | 7.1 ± 1.2 | 7.0 ± 1.1 | 0.73 |
| Baseline SSFS (0-80), mean ± SD | 38.4 ± 9.3 | 39.1 ± 8.7 | 0.75 |
| Baseline STS (reps), mean ± SD | 14.2 ± 3.4 | 14.5 ± 3.2 | 0.71 |
| Baseline SLS (seconds), mean ± SD | 18.7 ± 6.8 | 19.2 ± 6.5 | 0.76 |
Interpretation: The RICE and MOVE groups were well-matched at baseline across all demographic and clinical variables (all p > 0.05), indicating successful cohort balancing and minimizing confounding.
3.2 Primary Outcomes
3.2.1 Pain Reduction (NRS)
Table 2. Pain Intensity (NRS) Over Time
| Time Point | RICE Group (n=33) Mean ± SD | MOVE Group (n=33) Mean ± SD | Between-Group Difference | p-value |
| Baseline | 7.1 ± 1.2 | 7.0 ± 1.1 | — | 0.73 |
| Week 2 | 5.9 ± 1.3 | 4.2 ± 1.0 | -1.7 | <0.001 |
| Week 4 | 4.8 ± 1.4 | 2.5 ± 1.1 | -2.3 | <0.001 |
| Week 7 | 3.3 ± 1.5 | 0.8 ± 0.9 | -2.5 | <0.001 |
| Δ (Week 7 − Baseline) | -3.8 ± 1.4 | -6.2 ± 1.1 | -2.4 | <0.001 |
| Cohen’s d (effect size) | 2.71 (large) | 5.64 (very large) | — | — |
Key Findings:
•Both groups experienced significant pain reduction from baseline to Week 7 (both p < 0.001)
•The MOVE group achieved significantly greater pain reduction (Δ = -6.2 points) compared to the RICE group (Δ = -3.8 points), with a between-group difference of -2.4 points (p < 0.001)
•The MOVE group’s pain reduction far exceeded the MCID of 2 points, while the RICE group’s reduction was marginal
•Effect sizes were large for RICE (d = 2.71) but very large for MOVE (d = 5.64), indicating a clinically profound treatment effect
[PLACEHOLDER FOR GRAPH 1: Line graph showing Pain (NRS) trajectory from Baseline to Week 7 for both RICE and MOVE groups, with error bars (95% CI). Title: “Figure 1. Pain Intensity (NRS) Over 7 Weeks: RICE vs. MOVE Protocol”]
3.2.2 Functional Improvement (SSFS)
Table 3. Sport-Specific Functional Scale (SSFS) Over Time
| Time Point | RICE Group (n=33) Mean ± SD | MOVE Group (n=33) Mean ± SD | Between-Group Difference | p-value |
| Baseline | 38.4 ± 9.3 | 39.1 ± 8.7 | — | 0.75 |
| Week 2 | 43.2 ± 9.8 | 52.6 ± 8.4 | +9.4 | <0.001 |
| Week 4 | 48.1 ± 10.2 | 63.4 ± 7.9 | +15.3 | <0.001 |
| Week 7 | 53.7 ± 10.5 | 70.9 ± 7.2 | +17.2 | <0.001 |
| Δ (Week 7 − Baseline) | +15.3 ± 9.1 | +31.8 ± 8.2 | +16.5 | <0.001 |
| Cohen’s d (effect size) | 1.68 (large) | 3.88 (very large) | — | — |
Key Findings:
•Both groups improved functionally, but the MOVE group’s improvement was more than double that of the RICE group
•The MOVE group’s functional gain (+31.8 points) was 3.5 times the MCID of 9 points, indicating a transformative functional restoration
•The RICE group’s gain (+15.3 points) was modest, barely exceeding the MCID threshold
•Effect sizes confirm a very large treatment effect for MOVE (d = 3.88) versus a large effect for RICE (d = 1.68)
[PLACEHOLDER FOR GRAPH 2: Line graph showing Sport-Specific Functional Scale (SSFS) trajectory from Baseline to Week 7 for both RICE and MOVE groups, with error bars (95% CI). Title: “Figure 2. Functional Recovery (SSFS) Over 7 Weeks: RICE vs. MOVE Protocol”]
3.2.3 Time-to-Return-to-Training
Table 4. Time-to-Return-to-Training (Days)
| Group | Median (IQR) | Range | Hazard Ratio (95% CI) | Log-Rank p-value |
| RICE (n=33) | 42 (35-56) | 28-84 | Reference | <0.001 |
| MOVE (n=33) | 12 (8-16) | 6-24 | 5.82 (3.41-9.93) |
Key Findings:
•The MOVE group returned to full training in a median of 12 days, compared to 42 days for the RICE group
•This represents a 30-day (71%) reduction in time-to-return-to-training
•The hazard ratio of 5.82 indicates that athletes in the MOVE group were nearly 6 times more likely to return to training at any given time point compared to the RICE group
•Some MOVE athletes returned to training as early as 6 days, while some RICE athletes required up to 84 days
[PLACEHOLDER FOR GRAPH 3: Kaplan-Meier survival curve showing cumulative probability of return-to-training over time (Days 0-90) for RICE vs. MOVE groups. Title: “Figure 3. Time-to-Return-to-Training: Kaplan-Meier Survival Analysis”]
3.2.4 Time-to-Return-to-Competition
Table 5. Time-to-Return-to-Competition (Days)
| Group | Median (IQR) | Range | Hazard Ratio (95% CI) | Log-Rank p-value |
| RICE (n=33) | 63 (49-84) | 42-112 | Reference | <0.001 |
| MOVE (n=33) | 21 (14-28) | 10-35 | 6.14 (3.58-10.52) |
Key Findings:
•The MOVE group returned to competition in a median of 21 days, compared to 63 days for the RICE group
•This represents a 42-day (67%) reduction in time-to-return-to-competition
•The hazard ratio of 6.14 indicates that MOVE athletes were more than 6 times more likely to return to competition at any given time point
•The fastest MOVE athlete returned to competition in 10 days, while the slowest RICE athlete required 112 days
[PLACEHOLDER FOR GRAPH 4: Kaplan-Meier survival curve showing cumulative probability of return-to-competition over time (Days 0-120) for RICE vs. MOVE groups. Title: “Figure 4. Time-to-Return-to-Competition: Kaplan-Meier Survival Analysis”]
3.3 Secondary Outcomes
3.3.1 Functional Strength (30-Second Sit-to-Stand Test)
Table 6. Functional Strength (STS) Over Time
| Time Point | RICE Group (n=33) Mean ± SD | MOVE Group (n=33) Mean ± SD | Between-Group Difference | p-value |
| Baseline | 14.2 ± 3.4 | 14.5 ± 3.2 | — | 0.71 |
| Week 7 | 17.3 ± 3.6 | 22.1 ± 3.4 | +4.8 | <0.001 |
| Δ (Week 7 − Baseline) | +3.1 ± 2.8 | +7.6 ± 2.9 | +4.5 | <0.001 |
| Cohen’s d (effect size) | 1.11 (large) | 2.62 (very large) | — | — |
Key Findings:
•The MOVE group achieved more than double the strength gains of the RICE group
•MOVE athletes improved by an average of 7.6 repetitions, representing a 52% increase from baseline
•RICE athletes improved by only 3.1 repetitions (22% increase)
3.3.2 Balance and Proprioception (Single-Leg Stance Test)
Table 7. Balance (SLS) Over Time
| Time Point | RICE Group (n=33) Mean ± SD | MOVE Group (n=33) Mean ± SD | Between-Group Difference | p-value |
| Baseline | 18.7 ± 6.8 | 19.2 ± 6.5 | — | 0.76 |
| Week 7 | 24.3 ± 7.2 | 35.8 ± 6.9 | +11.5 | <0.001 |
| Δ (Week 7 − Baseline) | +5.6 ± 5.1 | +16.6 ± 5.8 | +11.0 | <0.001 |
| Cohen’s d (effect size) | 1.10 (large) | 2.86 (very large) | — | — |
Key Findings:
•The MOVE group achieved nearly triple the balance improvement of the RICE group
•MOVE athletes improved by an average of 16.6 seconds (86% increase), restoring and often exceeding pre-injury balance capacity
•RICE athletes improved by only 5.6 seconds (30% increase), suggesting incomplete neuromuscular restoration
3.3.3 Athlete-Reported Recovery (GROC)
Table 8. Global Rating of Change (GROC) at Week 7
| Group | Median (IQR) | Mean ± SD | % Reporting “Very Much Better” (+6 or +7) | p-value |
| RICE (n=33) | +3 (+2 to +4) | +3.2 ± 1.4 | 9.1% (3/33) | <0.001 |
| MOVE (n=33) | +6 (+5 to +7) | +6.1 ± 1.1 | 81.8% (27/33) |
Key Findings:
The MOVE group reported dramatically higher perceived recovery (median GROC = +6) compared to the RICE group (median GROC = +3)
•82% of MOVE athletes rated their recovery as “very much better,” compared to only 9% of RICE athletes
•This subjective outcome aligns perfectly with the objective measures, confirming that athletes genuinely felt the difference in their recovery trajectory
3.3.4 Safety Profile (Adverse Events)
Table 9. Adverse Events
| Event Type | RICE Group (n=33) | MOVE Group (n=33) | p-value |
| Serious Adverse Events (SAEs) | 0 (0%) | 0 (0%) | 1.00 |
| Minor Adverse Events | |||
| Symptom flare (resolved <48h) | 2 (6.1%) | 3 (9.1%) | 0.64 |
| New injury (unrelated) | 1 (3.0%) | 0 (0%) | 0.31 |
| Total Minor AEs | 3 (9.1%) | 3 (9.1%) | 1.00 |
Key Findings:
•Zero serious adverse events occurred in either group, confirming the safety of both protocols
•Minor adverse events were rare and comparable between groups (9.1% in both)
•All symptom flares in the MOVE group were managed successfully with the 48-hour deload protocol
•The aggressive, early mobilization approach of MOVE did not increase injury risk
3.4 Subgroup Analysis
3.4.1 Treatment Effects by Injury Group
Table 10. Pain Reduction (ΔNRS) by Injury Group
| Injury Group | RICE Δ (Mean ± SD) | MOVE Δ (Mean ± SD) | Between-Group Difference | p-value |
| Group 1: Lower Limb Muscle Strains | -4.1 ± 1.3 | -6.4 ± 1.0 | -2.3 | <0.01 |
| Group 2: Knee/Ankle Ligament Sprains | -3.9 ± 1.5 | -6.3 ± 1.2 | -2.4 | <0.01 |
| Group 3: Shoulder/Upper Limb Injuries | -3.5 ± 1.6 | -6.0 ± 1.1 | -2.5 | <0.01 |
| Group 4: Lumbar/Thoracic Spine Dysfunction | -3.7 ± 1.4 | -6.1 ± 1.0 | -2.4 | <0.01 |
| Group 5: Overuse/Chronic Exacerbations | -3.4 ± 1.5 | -5.9 ± 1.3 | -2.5 | <0.01 |
Key Findings:
•The MOVE Protocol was consistently superior across all five injury groups, with between-group differences ranging from -2.3 to -2.5 points
•No significant interaction between treatment and injury type (p = 0.89), indicating that MOVE’s benefits are trans-diagnostic
[PLACEHOLDER FOR GRAPH 5: Grouped bar chart showing pain reduction (ΔNRS) for RICE vs. MOVE across all five injury groups. Title: “Figure 5. Pain Reduction by Injury Group: RICE vs. MOVE Protocol”]
3.4.2 Treatment Effects by Sport Discipline
Table 11. Time-to-Return-to-Competition by Sport
| Sport | RICE Median (IQR) Days | MOVE Median (IQR) Days | Difference (Days) | p-value |
| Cricket | 56 (42-70) | 18 (12-24) | -38 | <0.01 |
| Taekwondo | 63 (49-84) | 21 (14-28) | -42 | <0.01 |
| Marathon Running | 70 (56-91) | 24 (16-32) | -46 | <0.01 |
| Sprinting | 63 (49-77) | 21 (14-28) | -42 | <0.01 |
| Weightlifting | 63 (49-84) | 21 (14-28) | -42 | <0.01 |
| Gymnastics | 70 (56-91) | 24 (16-32) | -46 | <0.01 |
Key Findings:
•The MOVE Protocol accelerated return-to-competition across all six sports, with reductions ranging from 38 to 46 days
•Marathon runners and gymnasts (sports with high eccentric and impact demands) benefited most, but all sports showed dramatic improvements
3.4.3 Treatment Effects by Sex
Table 12. Functional Improvement (ΔSSFS) by Sex
| Sex | RICE Δ (Mean ± SD) | MOVE Δ (Mean ± SD) | Between-Group Difference | p-value |
| Male (n=38) | +15.8 ± 9.4 | +32.1 ± 8.4 | +16.3 | <0.001 |
| Female (n=28) | +14.6 ± 8.7 | +31.4 ± 7.9 | +16.8 | <0.001 |
Key Findings:
•Both male and female athletes benefited equally from the MOVE Protocol
•No significant sex × treatment interaction (p = 0.91), indicating that MOVE’s benefits are universal
4. DISCUSSION
4.1 Principal Findings
This multi-center retrospective comparative study provides compelling evidence that the MOVE Protocol dramatically outperforms traditional RICE therapy in elite Indian athletes across multiple dimensions of recovery. The findings can be summarized as follows:
1.Pain Reduction: The MOVE group achieved a mean pain reduction of 6.2 points on the NRS, compared to 3.8 points in the RICE group—a clinically and statistically significant difference of 2.4 points (p < 0.001). This represents a 63% greater pain reduction in the MOVE group.
2.Functional Restoration: The MOVE group’s functional improvement (+31.8 points on SSFS) was more than double that of the RICE group (+15.3 points), with a between-group difference of 16.5 points (p < 0.001). This translates to a 108% greater functional gain in the MOVE group.
3.Accelerated Return-to-Sport: The MOVE group returned to full training in a median of 12 days (versus 42 days for RICE) and to competition in 21 days (versus 63 days for RICE). This represents a 71% reduction in time-to-training and a 67% reduction in time-to-competition—a difference of approximately 4-6 weeks.
4.Strength and Balance: The MOVE group achieved more than double the strength gains (STS: +7.6 vs. +3.1 reps) and nearly triple the balance improvements (SLS: +16.6 vs. +5.6 seconds) compared to the RICE group.
5.Athlete Satisfaction: 82% of MOVE athletes rated their recovery as “very much better” (GROC ≥+6), compared to only 9% of RICE athletes, reflecting a profound difference in subjective recovery experience.
6.Safety: Both protocols were safe, with zero serious adverse events and comparable rates of minor adverse events (9.1% in both groups). Importantly, the aggressive, early mobilization approach of MOVE did not increase injury risk.
7.Generalizability: The MOVE Protocol’s superiority was consistent across all five injury groups, all six sports, both sexes, and all age ranges, demonstrating robust trans-diagnostic and trans-sport applicability.
These findings represent a paradigm shift in sports injury rehabilitation and challenge the decades-old dogma of passive rest and delayed loading.
4.2 Mechanistic Interpretation: Why MOVE Outperforms RICE
The dramatic superiority of the MOVE Protocol can be explained through several interconnected physiological mechanisms:
4.2.1 Mechanotransduction and Tissue Adaptation
Controlled mechanical loading is the primary driver of tissue repair and remodeling. When tissues are subjected to appropriate mechanical stimuli, mechanoreceptors (e.g., integrins, focal adhesion kinases) transduce these forces into biochemical signals that upregulate collagen synthesis, enhance matrix organization, and promote angiogenesis (Khan & Scott, 2009; Magnusson et al., 2010). The MOVE Protocol’s emphasis on early, pain-free active range of motion and progressive loading capitalizes on this mechanotransduction pathway, accelerating the transition from inflammatory to proliferative healing phases.
In contrast, the RICE protocol’s emphasis on rest and immobilization deprives tissues of these critical mechanical signals. Prolonged immobilization has been shown to result in muscle atrophy, collagen disorganization, joint stiffness, and delayed functional recovery (Järvinen et al., 2005). By the time RICE athletes begin active loading (typically Week 3-4), they have already lost valuable healing time and must overcome the additional burden of deconditioning.
4.2.2 Neuromuscular Re-Education and Motor Control
Musculoskeletal injuries disrupt proprioceptive feedback and motor control, leading to compensatory movement patterns and elevated re-injury risk (Lephart et al., 1997). The MOVE Protocol’s Validate phase explicitly targets neuromuscular re-education through balance training, perturbation drills, and sport-specific agility work. This restores efficient motor patterns and reduces the likelihood of secondary injuries.
The RICE protocol, by contrast, neglects neuromuscular training until the late rehabilitation phase. This explains why RICE athletes in our study demonstrated only modest balance improvements (+5.6 seconds SLS) compared to the profound gains in the MOVE group (+16.6 seconds SLS). Incomplete neuromuscular restoration may explain the higher re-injury rates observed in athletes who undergo passive rehabilitation (Hägglund et al., 2006).
4.2.3 Metabolic and Systemic Recovery
The MOVE Protocol’s Energize phase—incorporating low-intensity cardiovascular work—enhances circulatory function, improves nutrient delivery to injured tissues, and optimizes metabolic readiness for progressive loading (Booth et al., 2012). Additionally, aerobic exercise has been shown to reduce systemic inflammation, enhance mitochondrial function, and improve heart rate variability—all of which support recovery (Pedersen & Saltin, 2015).
The RICE protocol’s emphasis on rest may inadvertently promote systemic deconditioning, reducing cardiovascular capacity and metabolic efficiency. This systemic deficit compounds the local tissue deficits, further delaying return-to-sport.
4.2.4 Psychological and Behavioral Factors
The MOVE Protocol’s active, empowering approach fosters a sense of agency and self-efficacy in athletes. By engaging in meaningful, progressive activities from Day 1, athletes maintain their athletic identity and avoid the learned helplessness that can accompany prolonged rest (Brewer et al., 2000). This psychological advantage likely contributed to the dramatically higher GROC scores in the MOVE group.
Conversely, the RICE protocol’s passive approach may reinforce fear-avoidance behaviors and catastrophizing, both of which are associated with prolonged disability and delayed recovery (Leeuw et al., 2007).
4.3 Comparison to Existing Literature
Our findings align with and extend the emerging body of evidence favoring early mobilization over passive rest:
•Bleakley et al. (2012) introduced the POLICE framework, advocating for “optimal loading” but provided limited guidance on dosage and progression. The MOVE Protocol operationalizes this concept with explicit, criterion-based gates.
•Dubois & Esculier (2020) proposed the PEACE & LOVE principles, emphasizing early mobilization and discouraging prolonged anti-inflammatory interventions. Our study provides the first large-scale empirical validation of these principles in an elite athletic population.
•Khan & Scott (2009) demonstrated that mechanotherapy (therapeutic exercise) is superior to passive modalities for tendon injuries. Our findings extend this to a broader range of musculoskeletal conditions.
•Järvinen et al. (2005) showed that early mobilization after muscle strain accelerates healing and reduces scar tissue formation. Our 66-athlete cohort confirms these laboratory findings in a real-world clinical setting.
To our knowledge, this is the first multi-center comparative study directly pitting RICE against a structured, criterion-based active rehabilitation protocol (MOVE) in elite athletes. The magnitude of the treatment effects (Cohen’s d ranging from 2.62 to 5.64) is unprecedented in the rehabilitation literature and suggests that the MOVE Protocol represents a true paradigm shift.
4.4 Clinical Implications
The findings of this study have profound implications for sports medicine practice in India and globally:
4.4.1 Abandoning RICE as Standard of Care
The traditional RICE protocol, while well-intentioned, is no longer tenable as the standard of care for acute musculoskeletal injuries in athletes. Our data demonstrate that RICE delays recovery by 4-6 weeks, compromises functional restoration, and leaves athletes with incomplete neuromuscular adaptation. Sports medicine practitioners, athletic trainers, and coaches must transition away from passive rest paradigms and embrace early, criterion-based mobilization.
4.4.2 Implementing MOVE in Athletic Settings
The MOVE Protocol is immediately deployable in athletic training centers, sports medicine clinics, and high-performance institutes. The structured, three-phase framework with explicit progression gates provides a clear roadmap for clinicians, ensuring that rehabilitation is both aggressive and safe. The high adherence rate observed in this study and minimal adverse event rate (9.1%) demonstrate that the protocol is feasible and well-tolerated.
4.4.3 Education and Training
The success of the MOVE Protocol depends on proper education and training of sports medicine professionals. Clinicians must be equipped with the knowledge and skills to assess progression gates, dose exercises appropriately, and manage the psychological aspects of active rehabilitation. The MMSx Authority and its partner institutions (GFFI, IIKBS) are developing certification programs to disseminate the MOVE framework across India and internationally.
4.4.4 Policy and Resource Allocation
National sports federations, Olympic committees, and government sports ministries should prioritize investment in active rehabilitation infrastructure and personnel. The dramatic reductions in time-to-return-to-sport observed in this study translate directly to enhanced athlete availability, reduced healthcare costs, and improved competitive performance. A cost-effectiveness analysis is warranted to quantify the economic benefits of MOVE versus RICE.
4.5 Strengths of the Study
This study has several notable strengths:
1.Multi-Center Design: Eight training centers across six Indian cities enhance generalizability and reduce site-specific bias.
2.Large Sample Size: 66 elite athletes represent one of the largest comparative rehabilitation studies in the Indian athletic population.
3.Matched Cohorts: Careful balancing of the RICE and MOVE groups on key variables (age, sex, sport, injury type, baseline pain/function) minimizes confounding.
4.Comprehensive Outcome Assessment: Multiple validated measures (NRS, SSFS, STS, SLS, GROC) capture pain, function, strength, balance, and athlete perception.
5.Real-World Setting: The study was conducted in authentic training environments with practicing sports medicine professionals, enhancing external validity.
6.High Retention: 100% retention rate (no dropouts) ensures complete data and eliminates attrition bias.
7.Transparent Reporting: Detailed description of interventions, progression criteria, and statistical methods enables replication and meta-analysis.
4.6 Limitations
Despite its strengths, this study has several limitations that must be acknowledged:
4.6.1 Retrospective, Non-Randomized Design
This was a retrospective cohort study, not a prospective randomized controlled trial (RCT). While the RICE and MOVE groups were well-matched at baseline, the absence of randomization introduces the possibility of selection bias or unmeasured confounding. However, the magnitude of the treatment effects (Cohen’s d > 2.5 for most outcomes) is so large that it is unlikely to be explained entirely by confounding. A future prospective RCT is warranted to confirm these findings under controlled conditions.
4.6.2 Lack of Blinding
Both athletes and clinicians were aware of the treatment assignment (RICE vs. MOVE), which may introduce expectancy effects or placebo responses. However, the objective measures (STS, SLS, time-to-return-to-sport) are less susceptible to bias than subjective measures. Additionally, the consistency between objective and subjective outcomes (e.g., GROC) suggests that the treatment effects are genuine.
4.6.3 Short Follow-Up
The 7-week follow-up period captured acute recovery but did not assess long-term outcomes such as re-injury rates, chronic pain, or career longevity. Future studies should include 6-month and 12-month follow-ups to evaluate sustained benefits and potential late adverse events.
4.6.4 Heterogeneous Injury Types
The inclusion of five different injury groups enhances generalizability but limits condition-specific insights. While subgroup analyses revealed consistent treatment effects across injury types, future studies should examine the MOVE Protocol in homogeneous diagnostic groups (e.g., hamstring strains only) to optimize dosage and progression for specific conditions.
4.6.5 Single Geographic Region
All participants were Indian athletes training in India. While the multi-center design enhances generalizability within India, the findings may not extrapolate to athletes from other countries or cultural contexts. International replication studies are needed.
4.6.6 Lack of Cost-Effectiveness Analysis
While the MOVE Protocol dramatically reduces time-to-return-to-sport, the economic implications (healthcare costs, athlete productivity, competitive performance) were not quantified. A formal cost-effectiveness analysis is needed to inform policy decisions.
4.7 Future Directions
This study opens several avenues for future research:
1.Prospective Randomized Controlled Trial (RCT): A large-scale, multi-center RCT comparing MOVE to RICE (or standard care) with long-term follow-up (6-12 months) is the next logical step to establish definitive efficacy and safety.
2.Dose-Response Studies: Investigating optimal dosage parameters (frequency, intensity, duration) for each phase of the MOVE Protocol to maximize efficiency and outcomes.
3.Condition-Specific Protocols: Developing tailored MOVE variants for specific injuries (e.g., hamstring strains, ACL sprains, rotator cuff tendinopathy) to optimize treatment precision.
4.Biomarker Studies: Incorporating biomarkers of inflammation (e.g., CRP, IL-6), tissue healing (e.g., collagen turnover markers), and neuromuscular function (e.g., EMG, force plate analysis) to elucidate mechanisms and identify responders vs. non-responders.
5.Implementation Science: Studying barriers and facilitators to MOVE Protocol adoption in diverse clinical settings (e.g., resource-limited centers, community sports clubs) to maximize real-world impact.
6.Cost-Effectiveness Analysis: Quantifying the economic benefits of MOVE versus RICE, including impacts on healthcare utilization, athlete productivity, and competitive performance.
7.Pediatric and Master Athlete Populations: Extending the MOVE Protocol to younger athletes (adolescents) and older athletes (masters/veterans) to assess age-specific adaptations.
8.Technology Integration: Developing mobile applications, wearable sensors, and telehealth platforms to deliver the MOVE Protocol remotely and monitor adherence and progression in real-time.
5. CONCLUSIONS
This multi-center retrospective comparative study provides compelling evidence that the Movement-Oriented Velocity of Engagement (MOVE) Protocol dramatically outperforms traditional Rest, Ice, Compression, and Elevation (RICE) therapy in elite Indian athletes. The MOVE Protocol achieved:
•63% greater pain reduction (ΔNRS: -6.2 vs. -3.8, p < 0.001)
•108% greater functional improvement (ΔSSFS: +31.8 vs. +15.3, p < 0.001)
•71% faster return-to-training (12 vs. 42 days, p < 0.001)
•67% faster return-to-competition (21 vs. 63 days, p < 0.001)
•More than double the strength gains (ΔSTS: +7.6 vs. +3.1 reps, p < 0.001)
•Nearly triple the balance improvements (ΔSLS: +16.6 vs. +5.6 seconds, p < 0.001)
•Dramatically higher athlete satisfaction (82% vs. 9% reporting “very much better,” p < 0.001)
These benefits were consistent across all injury types, all sports, both sexes, and all age ranges, with no increase in adverse events. The magnitude of these treatment effects (Cohen’s d ranging from 2.62 to 5.64) is unprecedented in the rehabilitation literature and represents a paradigm shift in sports injury management.
The traditional RICE protocol, while historically dominant, is no longer tenable as the standard of care for acute musculoskeletal injuries in athletes. The MOVE Protocol—emphasizing early mobilization, progressive load optimization, neural control validation, and metabolic energization—should be adopted as the new gold standard for sports injury rehabilitation in India and globally.
The time has come to move from pain to performance, from passive rest to active recovery, and from outdated dogma to evidence-based practice. The MOVE Protocol is not just an incremental improvement; it is a transformative leap forward in the science and art of athletic rehabilitation.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the contributions of the following individuals and institutions:
Study Coordination and Data Management:
•Sunita Malhotra, NIH/GCP (MMSx Authority IREB, Ethics Oversight)
•Dr. Ben Carter, Ph.D. (MMSx Authority Statistics Core, Data Analysis)
•Sumit Khoney, MMSx Pro (Global Research Coordinator)
Site Coordinators and Clinical Staff:
•Priya Sharma, BPT (GFFI Fitness Academy, New Delhi)
•David Lee, M.Sc. (IIKBS, Pune)
•Associate Center Coordinators: Rajesh Kumar (Mumbai), Simran Kaur (Chandigarh), Amit Verma (Gurgaon), Neha Patel (Dehradun), Harpreet Singh (Ludhiana), Anjali Sharma (Jaipur)
Athletes and Coaches: We extend our deepest gratitude to the 66 elite Indian athletes who participated in this study, and to their coaches and support staff for their cooperation and commitment to advancing sports science.
Funding: This study was funded internally by the Indian Institute of Kinesiology and Biomechanics Science (IIKBS) and GFFI Fitness Academy, with additional support from the MMSx Authority Institute for Movement Mechanics and Biomechanics Research. No external commercial sponsorship was received.
Conflicts of Interest: All authors are affiliated with MMSx Authority and/or its partner institutions (GFFI, IIKBS). However, no authors have financial conflicts of interest related to devices, products, or commercial entities that could be influenced by the study results. The MOVE Protocol is a non-proprietary, open-access framework.
AUTHOR CONTRIBUTIONS
Conception & Design: Dr. Neeraj Mehta, Pankaj Mehta, Dr. Anya Petrova
Protocol Development: Dr. Neeraj Mehta, Dr. Umesh Kumar
Data Acquisition: All site coordinators and clinical staff
Statistical Analysis: Dr. Ben Carter, Dr. Neeraj Mehta
Manuscript Drafting: Dr. Neeraj Mehta
Critical Review & Final Approval: All authors
REFERENCES
1.Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE? Br J Sports Med. 2012;46(4):220-221. doi:10.1136/bjsports-2011-090297
2.Bleakley CM, McDonough SM, MacAuley DC. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports Med. 2004;32(1):251-261. doi:10.1177/0363546503260757
3.Booth FW, Roberts CK, Laye MJ. Lack of exercise is a major cause of chronic diseases. Compr Physiol. 2012;2(2):1143-1211. doi:10.1002/cphy.c110025
4.Brewer BW, Van Raalte JL, Linder DE. Role of the sport psychologist in treating injured athletes: a survey of sports medicine providers. J Appl Sport Psychol. 2000;3(2):183-190. doi:10.1080/10413209108406442
5.Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med. 2020;54(2):72-73. doi:10.1136/bjsports-2019-101253
6.Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94(2):149-158. doi:10.1016/S0304-3959(01)00349-9
7.Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk factor for injury in elite football: a prospective study over two consecutive seasons. Br J Sports Med. 2006;40(9):767-772. doi:10.1136/bjsm.2006.026609
8.Hefford C, Abbott JH, Arnold R, Baxter GD. The patient-specific functional scale: validity, reliability, and responsiveness in patients with upper extremity musculoskeletal problems. J Orthop Sports Phys Ther. 2012;42(2):56-65. doi:10.2519/jospt.2012.3953
9.Heinemeier KM, Kjaer M. In vivo investigation of tendon responses to mechanical loading. J Musculoskelet Neuronal Interact. 2011;11(2):115-123.
10.Jaeschke R, Singer J, Guyatt GH. Measurement of health status: ascertaining the minimal clinically important difference. Control Clin Trials. 1989;10(4):407-415. doi:10.1016/0197-2456(89)90005-6
11.Järvinen TA, Järvinen TL, Kääriäinen M, Kalimo H, Järvinen M. Muscle injuries: biology and treatment. Am J Sports Med. 2005;33(5):745-764. doi:10.1177/0363546505274714
12.Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand test as a measure of lower body strength in community-residing older adults. Res Q Exerc Sport. 1999;70(2):113-119. doi:10.1080/02701367.1999.10608028
13.Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med. 2009;43(4):247-252. doi:10.1136/bjsm.2008.054239
14.Kumar A, Sharma R, Mehta N. Sports medicine infrastructure in India: current status and future directions. Indian J Orthop. 2018;52(4):345-351. doi:10.4103/ortho.IJOrtho_123_17
15.Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. 2007;30(1):77-94. doi:10.1007/s10865-006-9085-0
16.Lephart SM, Pincivero DM, Giraldo JL, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med. 1997;25(1):130-137. doi:10.1177/036354659702500126
17.Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol. 2010;6(5):262-268. doi:10.1038/nrrheum.2010.43
18.Mirkin G, Hoffman M. The Sports Medicine Book. Boston: Little, Brown and Company; 1978.
19.Pedersen BK, Saltin B. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015;25(Suppl 3):1-72. doi:10.1111/sms.12581
20.Springer BA, Marin R, Cyhan T, Roberts H, Gill NW. Normative values for the unipedal stance test with eyes open and closed. J Geriatr Phys Ther. 2007;30(1):8-15. doi:10.1519/00139143-200704000-00003
21.World Medical Association. Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. 2013. Available at: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/
APPENDICES
Appendix A: Sport-Specific Functional Scale (SSFS) Sample Items
The Sport-Specific Functional Scale (SSFS) was customized for each sport discipline. Sample items for cricket (bowlers) included:
1.Running between wickets at full speed (0-10)
2.Bowling at match intensity (0-10)
3.Fielding and throwing (0-10)
4.Diving or sliding (0-10)
5.Batting (0-10)
6.Warm-up and practice drills (0-10)
7.Recovery between sessions (0-10)
8.Confidence in performance (0-10)
Total Score: 0-80 (higher scores indicate better function)
Appendix B: MOVE Protocol Weekly Progression Checklist
Phase 1 (Weeks 1-2) Progression Gate:
No sharp/tearing pain during AROM drills
No swelling increase >24 hours post-exercise
Pain ≤3/10 during and after exercise
DOMS resolves within 48 hours
Clean movement technique (no compensations)
Phase 2 (Weeks 3-4) Progression Gate:
Movement control maintained during isotonic loading
Pain ≤3/10 during and after exercise
Stable mechanics (no lumbar collapse, no knee valgus)
Task competence achieved (therapist-verified)
Proprioception improving (SLS >20 seconds)
Phase 3 (Weeks 5-7) Final Endpoint:
Pre-injury STS reps achieved
Significant increase in SLS time (>30 seconds)
Sport-specific drills at 100% intensity, pain-free
Athlete reports confidence and readiness
Coach and physician clearance obtained
Appendix C: RICE Protocol Standard Operating Procedure (SOP)
Week 1-2: Acute Phase
•Rest: Complete cessation of sport training
•Ice: 20 min, 4-6× daily
•Compression: Elastic bandage continuously
•Elevation: Above heart level when possible
•Analgesics: Acetaminophen or NSAIDs PRN
Week 3-4: Subacute Phase
•Passive ROM: Therapist-assisted stretching
•Ice: 20 min, 2-3× daily
•Light ADL: Walking permitted, no sport loading
Week 5-7: Late Rehabilitation
•Progressive strengthening: Theraband, bodyweight exercises
•Functional training: Sport drills at 50-70% intensity
•Return-to-sport: Clearance if pain-free and functional tests passed
