Not too long ago we went over the different phases of tissue healing and how to start properly loading the tissues to promote healing and help get our patients stronger. This is ALWAYS a great way to reinforce the manual therapy you do with your patients on the table and can also be a way to start the treatment.

If someone comes in who is having some S.I. Joint pain, Glute pain, or just pain in the posterior hip, in general, this is a good way to start getting them moving again. Quite often when a patient is dealing with pain, they become afraid to move because they associate pain with the movement.

This is where doing a solid intake interview (remember to rule out red flags) is important to listen to your patient and let them be heard regarding their pain. All too often patients feel like no one will actually listen to them and rush to get into a treatment, rather than listening to what they are fearful about, or acknowledging that their pain is real.

However, if you can get the person into a different plane of movement and apply some graded exposure techniques you’ll find they become less fearful and start to move more. Even if the movement is just a minor increase each time, it can make a huge difference for the patient. 

This video shows just one way to do some graded exposure, but I would encourage you to try some different movements to instil that feeling of safety with your patients. Remember, pain is a protection mechanism and sometimes we just need to send signals to the brain to show that movements are safe again.

Once you’ve done some treatment, this is a way to start loading the tissue.

During the acute phase (the first 24-48 hours) these isometrics would be most appropriate. As you can see there is some movement as the patient loads and pushes up into the glute bridge, but once they are there have them hold the contraction at the top of the range for 20-45 seconds (depending on their tolerance) and gradually add a little bit more time to the contraction as they build strength. 

Once your patient can confidently do the exercises in the video above, see if they can handle doing the same exercise, one hip at a time.

These are still an isometric load, we’re just building more strength on each side by removing the assistance of the opposite hip. 

Once the patient can do the single leg isometric exercises, you can start to add more difficulty by using an eccentric load, as they are now in the proliferative phase of healing and it’s safe to start adding more load.

In this case, we are going to provide stability for the patient by coming up into the bridge using both hips, but then applying the eccentric load to only one side. This way if the patient is feeling weak or unable to do a full range, the opposite hip is there to provide safety in case the movement feels like it’s too much at any point. 

Now as we progress hopefully your patient is going through the ranges in a more pain-free movement as you’ve been doing great treatments and appropriately loading the tissue.

If by their third or fourth visit they can do the above eccentric exercises, you can start to apply concentric loads. By this point they have probably reached the remodelling phase of healing, so we can start to be a little more aggressive, but still need to stay within the patient’s pain tolerance. 

Takeaways

• Remember that your patient may be fearful of movement due to their experiences with pain, this is where using graded exposure to the movement is the most beneficial.
• Encourage the patient that movement is a good thing, even if they are a bit sore from it the next day. If they haven’t been moving for a while, some discomfort the next day will be normal, just like going to the gym for the first time after a long absence.
• As important as your communication with the patient is, their communication and feedback are far more important, listen to their concerns and address them appropriately.
• Educate on how a little bit of pain during movement is okay, just remind them not to overdo it.