Articles Of The Week May 6, 2018

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Do we need to fix our patients, or help them get a bigger cup? Listen to their stories, and ask questions like: “How can you be healthier?” and more importantly “How can I help you be healthier?”

“Do Our Patients Need Fixing?” – Greg Lehman

This is a great little summary (and video) of what happens when your brain produces pain.

“Understanding The Complexity Of Pain” – Jenn Sharman

Communication is really important when talking to our patients. While this article is directed toward doctors, there is some information we can draw from this. Take an interest in your patient, make eye contact, communicate with them!.

“When You Talk To Patients, Do You Look At Them Or At A Computer?” – Milton Packer

All of us have patients with high blood pressure (because you do check it once in a while right?). While we can’t give advice on diet, we can give some advice on exercise, and maybe give a little nudge on sharing information with them. Here’s a great article you can share with them.

“Lower Your Blood Pressure Naturally” – Julie Upton

Using best evidence in practice is crucial for our profession moving forward. So, how do we apply the best evidence to something like patients with low back pain? This article gives you a great foundation and applicable guidelines to do just that. 

“How Do You Solve A Problem Like Low Back Pain?” – Monica Noij

Tissue Loading During Proliferation Phase Of Healing

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In our last blog post, we started to discuss the importance of tissue loading when helping a patient rehab injuries.

We took the approach of how you would manage tissue loading during the first couple of days post-injury, during the inflammatory phase of healing. Evidence has shown that using AROM and PROM while your patient is still on the table is an effective approach to begin loading the tissue while there is still inflammation going on, as long as you stay within pain tolerances.

The goal is to get the joint, or the tissue moving and start building strength in the tissue again. But where do we go and what is appropriate in the coming days/weeks in order to progress the patient through their rehab?

Well, there are a few steps to take in order to progressively load the tissue during and after your massage therapy treatment so you can have greater success in their rehab.

It’s important to understand what is happening as far as the tissue response, how it repairs and heals itself, and also important to know how to progressively load the tissue and manage patient expectations.

So, with this post, we will look at the next phase of healing and movement progression.

Proliferation Phase Of Healing

While the inflammatory phase happens over the first couple days of injury (but can last up to two weeks), it has essentially prepared the way for healing to happen by eliminating foreign material and dying tissue.

During the second to fourth days after injury, inflammation decreases, and repair of the injured site begins. Now is when the proliferation phase can start working its magic. During the second to fourth days after injury, inflammation decreases, and repair of the injured site begins. There is an extensive growth of epithelial cells, building up of collagen fibres in random patterns and while blood vessels continue to grow. Granulation tissue (new connective tissue) had already started to form during the inflammatory phase and continues to do so until healing occurs. The proliferation phase can last from four to six weeks depending on various factors and health of the patient. When the proliferation phase is done, the remodelling phase starts two weeks after the initial injury.

Now I get it, that seems like a lot of science talk, but the biggest take away to remember is that new tissue is being formed and inflammation should be decreasing at this point. 

Some other things to take into account is the tissue is still fragile at this point (although that’s not the wording I would use when talking to the patient) and could be reinjured if we tried to do too much, or overstress the injury site and interrupt this phase of healing. However, we do want to start loading in order to increase strength and assist in decreasing pain.

So, how do we start to load the tissue, without reinjuring the site, or interrupting healing?

Safely Loading To Encourage Healing

As we mentioned in the last post, your clinical reasoning is crucial here. 

At this stage we want to start using more active exercises, however, as a therapist, you have to monitor whether swelling in the area has started to decrease and must adjust the patients movements accordingly. Just like when you’re trying to educate a patient about their pain, or any other part of your treatment, patient education plays an important part here. When the area starts to feel better the patient may start to load the area on their own and end up overdoing it. 

Showing them how doing too much could be a bad thing because the tissue is still healing (remember we don’t want to use terms like fragile, instil resilience, not fear) and we don’t want to hinder that process. Part of patient education should include some goal setting, which could include returning to whatever their chosen sport, hobby, or activity of daily living might be.

Once goal setting is complete you can start to initiate submaximal isometric exercises. This is where the muscle is contracted but not to the full ability of the patient. Depending on how the area is doing as far as healing, swelling, and pain you can progress to multiple angle exercises.

Last article we gave the example of an ankle sprain and weight bearing on the ankle while using the massage table for balance. Now think, still using the table for balance, but with the other foot planted on the floor, starting to move that ankle into mild movements like; plantar flexion, dorsiflexion, supination, and pronation. It is important to only move the part into pain-free ranges and keeping within the tolerance of the injured portion, but still loading into that direction (for instance the lateral ankle with a sprain).

Giving some homecare of AROM exercises within pain-free range should help to keep the swelling down while beginning to strengthen the area. As the movements get easier, start to decrease the amount of support, and increase weight bearing. If there are no signs of inflammation for more than 24 hours, the patient can progress to include stretching and eccentric exercises (the muscle lengthens on contraction), for lower limb injuries

Continuous monitoring on your part is important because if inflammation starts to increase or range of motion in the area starts to decrease or cause more pain, these exercises need to pulled back to isometrics like we suggested in our last post. Remember, positive reinforcement from you can go a long way in helping the patient load and move into the injury, helping to increase healing and getting them back to their chosen activity. 

In the coming weeks, we will continue to discuss tissue loading during the next phases of healing and show some demonstrations of how you can do this in your clinic room.

 

Articles Of The Week April 22, 2018

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Where do we go as a profession and as a practitioner if we pursue higher education? Is there an opportunity to stay in the profession and be in research, or in other capacities? This is a great article interviewing some RMT’s who have pursued higher education and what they see as opportunities.

“Preventing Brain Drain: Opportunities And Challenges For Higher Education” – Donald Dillon

Many manual therapists combine meditation and mindfulness into their treatments. A new study is looking at how mindfulness and meditation are helping patients dealing with depression.

“When Science Meets Mindfulness” – The Harvard Gazette

Amazing what communication and education can do for a patient. In this case, it may be more successful in helping people with chronic spinal pain compared to other interventions.

“Neuroscience Education Seen Improving Chronic Spinal Pain” – Judy George

I cherish sleep and have to hit the snooze button every morning. However, according to this article, that may be doing me more harm than good!

“Snoozers Are, In Fact, Losers” – Maria Konnikova

While we can’t necessarily counsel a patient on their nutrition (depending on your scope), we can always share information. Here’s some information backed by data on high-fat diets, that gives a fair bit of info on several topics around it.

“The Truth About High Fat Diets” – Brad Dieter

 

Tissue Loading For Acute Injuries

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As we grow in our careers, there is a lot that can change.

If you’re keeping up with new research and promoting an evidence-based practice, the things you do now, are probably different than it was when you started your career. Whether it’s a technique, communication, your understanding of things, or just how you interact with patients, you’ve probably changed compared to say five years ago.

For me, a big change has come in how we treat and rehab injuries. 

With my first aid background, we used RICE when treating injuries, especially in the acute phase. Now while there is still some use for that (I know some of you are yelling at your computer right now, saying the evidence says otherwise), mainly right when the injury happens, and more as an analgesic rather than using ice to reduce inflammation, there is a better approach for us to use clinically.

When we used to rely on RICE for dealing with injuries, a big portion was “rest” and “compression, or splinting” the injury. However, the new research is telling us that loading the injured area does far more to promote healing and rehab the injury.

This of course also depends on the severity of the injury, you can certainly load a sprained ankle, or a muscle strain sooner than a fracture or a shoulder separation. It also depends on what phase of healing the injury is currently at, which also dictates the amount of load that can be used on the affected area. 

For this post, we will look at managing an acute injury, and in the next few weeks will talk about the next phases of healing and how to load appropriately.

Inflammatory Phase Of Healing

First off, it’s important to understand what’s going on and what time frames we are looking at for the length of healing.

Acute inflammation is the immediate response to an injury, which for the most part (with some variations) is similar throughout the body in any type of tissue. Chronic inflammation is longer lasting because of an unresolved acute inflammatory response or a persistent injury.

This is the initial phase of injury healing and usually last from 24-48 hours; however, can take up to two weeks. This is when we see pain, heat, redness, swelling and loss of function to the affected area. 

There is a whole host of cellular, vascular, and chemical responses that take place which promotes clot formation, cleaning up of dead tissue, and the formation of new capillary beds begin (this is a very simple explanation, it would take me plagiarizing three different textbooks to explain the cellular level of activity).

After this acute phase, the injury switches over to the proliferation phase which begins within the first few days of injury and lasts four to six weeks. Two weeks later the remodelling phase begins, and this is where maximum strength occurs at the injury site. We will talk about both of these phases in upcoming blog posts.

During this acute inflammatory phase, the body has essentially gone into protection mode and is sending danger signals to the area, causing the patient to guard the affected area, which can then result in a loss of function.

The question for us is, how do we manage an injury for a patient within this first week of injury?

Beginning To Load

There are several things to take into account when starting to rehab a soft tissue injury with your patients.

Choosing which interventions would be appropriate; exercise, psychological (careful with your scope of practice), or manual therapy that could influence muscle activation are all possible interventions we can use.

In addition to choosing what intervention to use, your clinical reasoning is a crucial part here. Getting a clear history, assessing for the degree of injury, and getting a defined mechanism of injury can all help in deciding your course of action. For instance, if someone came in with significant swelling around the ankle, couldn’t bear weight on it, and said they heard a “pop” when the injury occurred it would be best to refer to a doctor or medical clinic for imaging. However, if they just rolled their ankle, could walk on it, and there was just minor swelling…well, they’ve come to the right place.

One study had patients with an acute Grade I or II ankle sprain (less than 7 days) divided into a standardized group and an exercise group. The exercise group was given non-weight-bearing exercises that were to be repeated three times a day for one week. The exercises were focused on improving range of motion and strength. They found that the standard group spent less time walking and took fewer steps which showed that early therapeutic exercise may allow for higher volume and faster speed of walking post-injury.

Another study focused on athletes and overuse injuries (although the study was done on animals, so further study is required with humans) at the bone-tendon junction. They found that for 24 hours post-injury, low-intensity training brought improvement and did not deteriorate the injury, and 48 hours post-injury was an acceptable time delay to resume training.

A randomized control trial conducted on athletes with an injury to the thigh or calf muscle compared those who started exercise and therapy within two days compared to those who started nine days after injury. The results showed a quicker pain-free recovery and return to sports three weeks sooner.

The take away from these studies? Start to load the injured tissue soon after injury.

Part of what we will have to do is educate our patients. There can be fear of movement due to worry about the injury, and of course pain. But if we educate them that a little bit of pain is okay (we don’t want to overdo this as increased pain can cause a delay in healing), and the importance of getting the joint or limb etc. moving again, we can hopefully set them at ease and start loading the tissue.

You can easily start to load the tissue as part of your treatment by starting with some PROM and AROM exercise while the person is still on the table. Use your massage therapy techniques and gentle joint mobilizations to calm the area down, but we also need to start building strength in the tissue again. 

In the case of an acute injury, we want to start with an isometric exercise. Remember that an isometric exercise is one in which there is just tension put on the muscle. It doesn’t change in length or have any visible joint motion. So, in the case of an ankle sprain, it can be as simple as using your massage table for balance and standing beside the table, then weight bearing on the ankle within pain tolerances. Have the patient resist the pressure you put against a joint (ie: resist dorsiflexion in the ankle without allowing motion at the joint). If they can do AROM it can also help with decreasing inflammation in the area, which in turn may let you start to increase load on the joint sooner. Remember, part of what you want to do is instil confidence in your patient by showing them that an exercise is safe and appropriate so they will continue to do the chosen exercise as homecare. 

In the coming weeks, we will continue to talk about ways to load tissue to promote healing and help rehab patients injuries.

Articles Of The Week April 15, 2018

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There was quite the buzz over the past couple of weeks about a newly discovered organ. Some groups were jumping all over it, trying to use this as a way to reinforce their modalities. But, maybe this new discovery is not quite as it seems. 

“Two ‘Newly Discovered’ Human Organs Aren’t What They Seem” – Andrew Tarantola

If it hasn’t happened to you yet, it’s going to happen eventually. There will be a point in your career, where you learn something that disrupts some of the beliefs you had in certain modalities, or concepts about manual therapy. So, you have a choice to either continue to go along with it or confront it. Here’s a good example of someone who chose to confront it.

“Confronting The Challenges Of A Major Paradigm Shift” – Whitney Lowe

Do you treat many patients who are dealing with a tendinopathy? Here’s some great info on how to progressively load tendons to rehab the injury.

“Lifters Guide To Treating Tendinopathy” – Sean Jacobs

You know how we feel about busting massage myths around here, so this article was of immediate interest. We know that when we give a massage, we aren’t flushing out toxins, but there is still some belief that you can sweat out toxins. Well, you can share this article with your patients to show them, that’s not a thing either!

“Fact Or Fiction: Can You Really Sweat Out Toxins?” – Erika Engelhaupt

Massage is awesome! In fact, it would be great if we had more confidence in it and didn’t try to use so many fancy explanations around modalities, but just use simple defensible reasoning on helping our patients.

“What’s With The Resistance?” – Taylor Laviolette

Pathologizing: Our Words Matter

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As a physical therapist trained in the 1980’s, biomechanical explanations for pain and movement disorders were the norm.

As I drifted into a myofascial release manual therapy in the early 1990’s, the biomechanical model was reinforced and made more narrow through the beliefs that pain and movement dysfunction stem from issues of fascial tightness/restriction. All had evidence to support their views, as well as well-presented logical assumptions.

Myofascial suffered from testimonial-type of evidence, which seemed very compelling to a casual scientific observer (me), who was unwilling to question the sources of presented information.

Biomechanical still are well represented throughout the manual therapies, as evident by the daily squabbles regarding the importance, or lack of, with such issues as posture, weakness, and asymmetry when it comes to both pain as well as movement disorders.

This post is not intended to address these issues, but to briefly discuss the language we use when conversing with our patients/clients. 

The Power Of Our Words

Patients pay us to help them.

This help is most often accompanied by the thorough evaluation, after which we proclaim our findings on both what is wrong with them and what should be done to rectify the situation.

We may call this our assessment or diagnosis, depending on the scope of practice allowances and limitations of your profession. Patients expect it and we feel it necessary to give them what they want and deserve, but is it always in their best interest, especially when there is a lack of consensus on the validity of our assessment’s claims?

Biomechanical factors and judgement, such as poor posture being the cause of pain, are popular and logical assumptions which many of our patients believe and you may believe it to be true as well, but is it always true?

While at the computer, I leave my Facebook notifications turned on, which is probably one reason I am so easily distracted. As I was writing this post a notification came in that I will sanitize and post here:

“I’m new to this group, but curious as to many issues a (named surgical procedure) could help with. My biggest issues are forward head posture – my (type of) therapist once told me it was the worst she had ever seen – neck/shoulder/upper back tension that my chiropractor gave up on treating because he didn’t understand why he couldn’t fix it, jaw clenching, anxiety, etc). Anyway, does anyone have a recommendation for a practitioner in (certain city)?”

The writer of this post was speaking from genuine self-concern and must have found some solace in her therapist’s statement about the severity of her forward head, but what does she now do with that?

If she is the worst case her health professional has ever seen, it would seem to me that makes it less likely that she can be helped. There is information easily available that casts doubt on the degree of forward head posture and neck pain, but that therapist has planted a seed in the patient’s brain that she is one of the worst out there, at least from her therapist’s perspective.

Do we really need to say things like this?

Below are some studies that were recently posted to a thread on one of the many groups there, all speaking to the effect of the power of our words. If you’ve never given this much thought, please read through some of the abstracts and papers.

Our words have power, and often the message conveyed negatively impacts outcomes.

Easy to Harm, Hard to Heal: Patient Views About the Back.

CONCLUSION: Negative assumptions about the back made by those with LBP may affect information processing during an episode of pain. This may result in an attentional bias toward information indicating that the spine is vulnerable, an injury is serious, or the outcome will be poor. Approaching consultations with this understanding may assist clinicians to have a positive influence on beliefs.

The enduring impact of what clinicians say to people with low back pain. (Full-text link)

CONCLUSIONS: Health care professionals have a considerable and enduring influence upon the attitudes and beliefs of people with low back pain. It is important that this opportunity is used to positively influence attitudes and beliefs.

Importance of psychological factors for the recovery from a first episode of acute non-specific neck pain – a longitudinal study. (Full-text link)

CONCLUSIONS: Psychological factors emerged from this study as relevant in the early phase of acute neck pain. Particularly persistent anxiety and depression at baseline might be risk factors for a transition to chronic pain that should be addressed in the early management of neck pain patients.

‘Talking a different language’: a qualitative study of chronic low back pain patients’ interpretation of the language used by student osteopaths. 

CONCLUSIONS: The language used by student osteopaths’ influences patient beliefs about LBP in a variety of ways. The current study furthers understanding of how language contributes to these beliefs, identifying ways through which communication can contribute to improved healthcare through enhancing patient engagement.

Words That Harm, Words That Heal. (Full-text link)

Both positive and negative beliefs are important in patients with spine pain: findings from the oioc registry.

CONCLUSIONS: Our study demonstrates that both negative and positive beliefs are associated with perceptions of disability, however, in this study only positive beliefs were associated with treatment outcome.

Do you have any studies to share regarding this topic? I’d love to have a look!

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