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.