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.