5 Variations On Cervical Retraction

 

The cervical retraction exercise is a classic and works very well for cervical pain, cervicogenic headaches, and general upper quarter complaints. Yes, posture does not directly predict or relate to pain any more than knee flexion causes knee pain. However, common prolonged or repeated activities often cause predictable triggers that should be avoided and novel movements in the opposite direction often desensitize the area and reset the symptoms.

Here are 5 variations on the cervical retraction to make it as comfortable and effective as possible. Remember, it’s the dosage of the home program that really promotes recovery between patient visits, not what you treat the patient within the clinic.

Are Painful Flare Ups To Exercise, Just Like A Sunburn (and why we might need analogy anyway)

Whilst Exercise CAN be a wonderful tool to use during the rehab process we must remember it is not a stick on, we can’t just fire and forget or plug and play and for every success, there are also failures. There just is not such a thing as a magic bullet in rehab.

Sorry about dat!

Before we get to the analogy stuff we might want to first ask WHY we might want to help people understand what is happening to their bodies and how ANALOGY can help with that?

In some cases, it can be much more about HOW we do things rather than WHAT we actually do.

Why? 

For all the studies we have extolling the virtues of exercise, although make sure you consider the effects sizes, an important question to ask is how generalisable are they to the real world? If I was being all sciencey and shit we could term this the external validity of a study.

Why might these studies lack external validity? In the tightly controlled world of the scientific study participants probably tend to adhere a little bit more to the protocol laid out than they do on their own, otherwise, studies would never get finished. Researchers can also employ things like the “intention to treat” analysis (ITT) that are designed to scientifically smooth out things like dropouts and missing data.

Out in the real world when we throw in the complications of life, exercises, however evidence-based, in some cases can tend to fall by the wayside. This is a problem with human beings they don’t always just fit neatly into EBM boxes. In fact, they can render all the science a touch redundant through things like their beliefs, preferences and lifestyles.

Differences in the definition of adherence used, measurement and estimative of how many patients do not comply with their prescribed exercises vary, but evidence converge on a figure of 50% or higher”  *HERE*

We can all agree that that is a pretty high percentage of shit that is not getting done! What we CAN say is exercise is likely to infer some benefits IF IT GETS DONE! SO how do we go about doing that? And that, of course, is the $1 million question!

Barriers

This is an awesome piece of research that looks at barriers to people adhering to therapeutic exercise programs *HERE* One of the major reasons that people don’t adhere, or a much better term to use, commit, to exercises or exercise programs when they have pain is the fear of INCREASING that pain.

Here is a slide from my recent presentation at the San Diego pain summit.

 

Now, this is completely understandable. Our fears drive our behaviours, so if I am scared of making the problem worse that may drive me to, well, simply not do it. It may then be key to help people make sense of what they feel and how they can manage that.

For a lot of people, the science of both pain and exercise are pretty alien subjects. What’s the difference between exercise-induced discomfort and actual pain? For someone who has never experienced the former then perhaps not a lot! I have been pretty sore from training before and found some activities really quite painful.

The likelihood of getting some DOMS from prescribed exercises for someone with no real history of exercise and a low ‘zone of homeostasis’ could be pretty high, so it is vital we can put these sensations into perspective, allay fears and help people to SELF-manage their rehab.

A useful phrase I picked up a long time ago is “go to the P in Pain not the Y in Agony” which is a really nice way to say go into some discomfort, which of course is normal, but try to avoid rip-roaring pain. We still don’t know if painful exercise is actually bad for outcomes but certainly, it may dissuade someone from carrying on with it.

Things can and will go wrong and setbacks are normal. These setbacks can be influenced by a whole bunch of factors including stress and lifestyle that can negatively affect recovery, and no rehab plan will ever follow a linear upwards trajectory, especially if we are attempting to push the envelope and ‘vaccinate’ against future reoccurrences.

*HERE* we see psychological stress actually impairs recovery from exercise so we must be mindful of this. It may not be the intensity of the sensation that some struggle with but how LONG it goes on for. Desired adaptations such as strength might also be affected by stress too. *HERE*

Pain is often accompanied by worry and stress and could be both a cause and an effect of the current state of the individual. This is why we must be aware that our rehab programs carry the possibility that they could cause an adverse reaction in times of stress.

Analogy

Equipping people with the knowledge to both understand AND address these factors is vital for self-efficacy, another key player in the COMMITMENT to a rehab program.

An analogy is a fantastic way of helping people understand subjects that they have very little background in and for many folks, both pain and exercise fall neatly into this bracket. One of my favourite analogies for exercise discomfort AND pain is SUNBURN. The reason for this is it (hopefully) places the pain or discomfort into perspective and allows it to be seen as a temporary thing and one that can be easily modified.

Rather than viewing an exercise as simply being WRONG, a comparison to sunburn allows it to be viewed more as an issue with the dosage applied and the bodies response. We generally don’t see the sun as a BAD thing, of course, some do but we could put that on the spectrum of fear avoidance! Most people will get sunburn at some point in their lives and just see it is a little bit too much of a GOOD thing!

So what do we do if we overdose on the sun? Generally just ALTER the dosage, simply get less sun the next day by sitting under the umbrella or covering up my burnt bits with a towel, we may have just tried to rush the natural adaptation.

The negative physical reaction is only temporary, often just like the pain triggered from overdosing on exercise, the angry red skin and spiky feeling when in the shower will, of course, go away if I just alter the dose and let nature run its course. What we do see if dosed correctly is a slow natural adaptation that leaves us positively glowing.

What do you usually do next after burning? Well just be more careful when re-exposing yourself. Spend less time in the sun or apply a higher factor. We don’t freak out, in fact often we berate ourselves for being stupid! We know this happens after all. We can do the same with our exercises, just take a little time off or reduce the amount we do before building up again.

Why might we overdose? Perhaps we have been previously been underdosed. Just like coming out of a long sunless winter, not having exercised for a while probably reduces the amount I can tolerate and hence potential adverse reactions. This may explain why just a few sets could leave me pretty sore.

If we have previously been good at a sport we tend to be able to play at a much higher intensity than perhaps we can CURRENTLY handle. In fact being good at something could actually be a risk factor for some! Our skill level may far outweigh our tolerance for the level of intensity we can play at. The same is true of tanning, we tend to remember the lazy long days at the END of a holiday applying Hawaiian tropic rather than the blotchy days in the beginning, piling on factor 30.

Some people can exercise till the cows come home and never feel a thing, a bit like those really annoying people who go an amazing shade of brown by just looking at the sun! We may be predisposed genetically to being LESS tolerant of physical activity. We see discussion of the role of genetics in sensitivity *HERE*

People with fair skin and red hair are often less tolerant of the sun by nature of their Celtic heritage and those of Mediterranean or African origin far better genetically equipped to handle a greater dosage of the sun.

Now, no analogy is free from a negative misinterpretation. Whilst the sun could be seen as having dangerous consequences such as skin cancer from extreme overdosing we also see problems with underdosing such as depression from reduced serotonin. Like all things, it has an OPTIMAL dosage, after all too much or little water or oxygen can also kill you too!

How can we alter the dosage?

  • Frequency – How often. More is not always better.
  • Intensity – How heavy or how fast.
  • Volume – How much. Sets, reps and rest.

Read more here about dosage *HERE*

Take Homes

  • People don’t just fit neatly into science
  • Increasing pain is a real worry with rehab exercises
  • Arm people with information about what to expect and what they are feeling
  • Be smart in the first place – Less can be more.
  • Self-management. Give them the tools to manage the dosage.
  • Give support. If it does go wrong to help people get back on track

Tissue Loading During Remodelling Phase Of Healing

Over the past few weeks, we have been going over how to safely load tissues during the acute and sub-acute phases of an injury.

Along with instructions on loading, we have been reviewing what happens during the inflammatory and proliferative phases of healing.

This is all important because it’s crucial a therapist recognize what stage of healing the tissue is at in order to load the tissue safely, recognize when the tissue is taking too long to heal, and refer back to their doctor.

We are going to continue with the topic and look at the remodelling phase of healing, which is a longer, and increased changes occur. It also means we can be more aggressive in the movements we recommend and help our patients take part in. However, there is still a risk of re-injury that we must be mindful of as we progress through the rehab process.

As we have outlined in our past couple of posts on the topic, your clinical judgement and decision making is crucial for success, so we will look at how to implement and understand what’s happening during the remodelling phase with this post. 

Repair And Remodelling 

There are two phases to the remodelling phase; the consolidation, and the maturation stage.

During this consolidation phase, the tissue becomes more fibrous and stronger due to type III collagen becoming type I (due to macrophages breaking the type III collagen tissue down). The body starts to convert the wound into scar tissue and there is a carryover of functions that occurred in the remodelling phase that continues to take place (wound contraction). This lasts for 21-60 days, and scar tissue should stop increasing in size because of the wound contraction.

During the maturation phase takes place from days 60-360.  Collagen structure, arrangement, and turnover continues to occur and is the primary function at this point until (after about four months) the tissue becomes tendon-like, and this can continue for 12-18 months.

But remodelling time has some outside influences that can either hinder or encourage the process. The amount of time immobilized, stress on the area, vascularity, and location of injury can change the amount of time remodelling takes. During the proliferative phase, the fibres were laid down in a random direction, but the injury becomes stronger if the fibres are organized in a parallel direction. This happens due to external forces being applied to the injury site, and there is a window to assist with this remodelling for 10 weeks.

Now, when we talk about external forces, it is quite often promoted that doing massage on the area is an appropriate outside force in order to realign these fibers. However, one study shows that while physical force can alter connective tissue, there is almost no data that shows manual therapy techniques have any real ability to realign fibers. 

But, guess what does? Exercise!

Tissue Loading During Remodelling 

As we mentioned earlier, this is where we can get a bit more aggressive as far as load and movement, but we want to make sure not to overdo it.

But, we do want to start placing force along the lines of stress in order to help with the collagen tissue.

At this point there should be no signs of inflammation and movement should be getting easier. You’ve progressed your patient through some mobility, PROM, and AROM exercises along with some eccentric movements. Now you can start to ramp things up a bit. 

The movements can start to go from isolated, into more multidirectional patterns and movements. We have used the example of an ankle sprain in the past couple of articles, start to think about movements like side lunges to load into the injury site, or some active movements going from side to side cutting in different directions. Use concentric (the muscle shortens) and eccentric (muscle lengthens) movements along with weight-bearing exercises. Some you can even do on your table during the massage, just to get things going. For instance, you could manually resist at the ankle (with the patient prone) while they bend the knee as a hamstring contraction, then resist again as they lower the ankle to the table (if you were rehabbing a hamstring injury).

Hopefully, along the way, you’ve had some good communication with your patient as far as what goals they had in getting back to activities. This is where you can start to build some more active exercises. Have them start to do modifications of those activities.

If the patients activity is as simple as getting a jar out of the cupboard, have them start to practice with and an empty jar for a few repetitions until they have no problem doing it with a heavy full jar.

If your patient is an athlete, get them into modified versions of their activity. Recommend slower speed with a lighter load, until more of each can be tolerated. Once it can be tolerated start including plyometric movements (explosive movement ie: jumping) for example, standing on one leg, crouching down and jumping straight up on that previously injured ankle.

In any case, as more tolerance is attained, increase the repetitions and speed of each movement. But make sure you take the time to educate your patient. Show them how a little pain is okay, but not excessive so they can avoid any possibility of re-injuring the area. Also, whatever exercises you choose, make sure they are important to the person. Choose movements you know they will do, there’s no point in recommending a nice light walk to a crossfitter, or sprints to someone whose goal is to pick up their child pain-free. Make it applicable to each individual and their individual goals. Helping a patient rehab an injury doesn’t have to be complicated, it just takes your clinical knowledge and progressing movement properly, all of which you can do in your treatment room. If exercise prescription isn’t in your scope, AROM and PROM probably are, so there’s no reason you can’t implement various movements into your treatment whether on the table or off of it.

 

 

Tissue Loading During Proliferation Phase Of Healing

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.

 

Tissue Loading For Acute Injuries

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

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