"I know that you are teaching me these exercises, but are you also going to do things to help put me back into alignment?"
"This is great, but can you teach me how I can do this for myself at home?"
These quotes were spoken by my last two patients of today. They stand in contrast with each other in terms of the differing attitudes that people bring to the clinic each day.
The latter patient is seeking help in figuring out the best strategies for rehabilitating her dislocated shoulder. When I taught her the Turkish get up, she enthusiastically expressed how she saw its value in helping her regain stability in her shoulder. She remarked that a self-administered soft tissue release technique nearly replicated the passive technique I had performed with her earlier. This patient sought the tools to help herself.
The former views herself as "broken" and is reliant on others to "fix" her. She speaks with negative terms about her body "falling apart". In fact, when I met her last week, she told me that she had been going to physical therapy on and off for the past 10 years for "maintenance". This is not what physical therapy is all about!
Last year, I read somewhere (and I wish I could remember exactly where so that I can give proper credit) a simple definition of what physical therapy should be all about:
"The restoration of thoughtless, painless movement."
I know there are much more elaborate and descriptive definitions of physical therapy, but to me, the above quote captures the essence of what I try to help my patients achieve every day. I believe the most important aspect of my profession is empowering people to learn how to care for themselves through education. I didn't always feel that way. When I first graduated from physical therapy school in 2001, I thought I was on a mission to fix broken bodies. But now I no longer think like that. Physical therapists aren't healing anybody. Time does that. What we can do is teach you about the body, why it gets injured, how to provide the optimal environment for healing, and how to diminish risk of recurrence.
If you find yourself in need of a physical therapist, try to find one who empowers you to take control of your own rehabilitation as much as possible. Beware the health care practitioner who makes you feel dependent on them to feel better. After all, you will only spend a fraction of your week in their presence. It's all the hours outside of their clinic walls where properly guided intervention will take most effect.
Wednesday, November 12, 2014
Saturday, November 8, 2014
A Quick Guide To Soft Tissue Injuries
Recently, I've treated a couple of friends for calf muscle injuries. Each of them asked virtually the same questions about what to expect with the healing process, and when they'd be able to return to sport. While I'm sure all of you have dealt with soft tissue injuries in your lives, I figured it might be a good idea to share what I told them about the healing process. It may put your mind at ease if and when you get injured, knowing that the healing process won't let you down if you respect the process and allow it to run its course. I hope this helps you.
Healing tissue goes through three stages: Inflammation, repair and remodeling. I'll discuss each phase with the use of an analogy.
Imagine a partial building collapse. The damaged portion of the building is your tissue damage. With the building damage, there is generally an immediate rush to the site by first responders. Those first responders are there to help remove the part of the collapsed building that are now useless. Similarly, your blood carries all sorts of specialized (inflammatory) cells to your site of injury to carry away the waste and initiate the healing process. Remember ninth grade biology and phagocytosis? This is the garbage removal process by cells called macrophages. There are also a number of chemical releases which help mediate the process, akin to the commanders of an emergency response crew organizing search, rescue and cleanup. As with the building collapse, this acute response can last several days.
The second part of the healing process is called the repair phase. Picture erected scaffolding around the damaged portion of that partially collapsed building. With your soft tissue damage, this scaffolding comes in the form of collagen fibers laid down by your body. It's the framework upon which new healthy tissue will form. This collagen "scaffolding" will begin to take some shape, but will hardly be the long term solution, as it's comprised of weak and disorganized pieces. This repair phase will generally begin a few days after the initial inflammatory response has dissipated, and can last up to 2 months.
The third and final stage of tissue repair is called remodeling. During this period, which can last up to a year, the disorganized scar tissue and new healthy tissue will become more organized and grow stronger. Think of the collapsed portion of the building being replaced by new material, surround by that scaffolding. This is the last step towards the building, and your tissue, becoming whole once again.
So, what can you expect during each of these phases of the healing process, and what can you do to provide the optimal environment that will allow time to do its thing?
In the inflammation stage, you'll likely experience pain, swelling and redness around the area of injury. Your body is going into protective mode in order to prevent further injury. Think of swelling as a natural "splint" to limit movement. It's during this initial phase where the old acronym R.I.C.E. (Rest, Ice, Compression, and Elevation) comes into play. (There has actually been some recent controversy in the world of rehabilitation regarding the use of ice to treat an injury, but more on that later). Your goal for the first several days is to protect the area, control excessive swelling (edema) and control pain.
During the repair phase, you can expect your pain level to dissipate. You'll find your movement slowly begin to return, although you may still experience some swelling and bruising, even away from the actual site of injury. You may begin to stress the healing tissue by active movement, gentle stretching, and soft tissue work. This will help align the collagen fibers that comprise your scar tissue, aiding them in becoming stronger. Other surrounding joints may also be exercised (even beginning in the first phase, barring increased pain to the site of injury). It is during this phase, a few weeks after the initial injury, that you are most susceptible to re-injury. This is because you won't necessarily be feeling pain with basic movements, but unexpected demands placed on the body may overwhelm this still weakened and repairing area.
The remodeling phase takes the longest, lasting many months. It's during this final phase where rehabilitative efforts ought to focus on continued strengthening of the healed tissue, with a goal of returning to full activity or sport. Concentric (contracting and shortening of a muscle) followed by eccentric (contracting and lengthening of a muscle) loading activities will prepare the injured tissues for 100% function.
A key point in the healing process is that while it always involves these three phases, the time frames for each may vary. Factors such as age, previous tissue quality and extent of injury will all play a role. These guidelines are meant to give you an understanding of what to expect and what to do about it when it comes to soft tissue injuries.
A quick sidebar on R.I.C.E., the term coined in 1978 by Dr. Gabe Mirkin. It has essentially been the gold standard when it comes to treating acute injuries. However, just this year, Dr. Mirkin wrote an article claiming that he may have been wrong about the ice part (http://drmirkin.com/fitness/why-ice-delays-recovery.html). Those who are opposed to icing EVER argue that it blocks the body's natural response to injury (inflammation), thereby slowing the healing process. "How can we presume to know better than the body?", has been the typical refrain voiced by those looking to turn conventional wisdom upside down.
I know that it certainly got me thinking about the topic, as I believe it's ALWAYS important to remain open to new pieces of evidence. It's not always easy, especially with something as ingrained as icing acute injuries. I have read articles, listened to podcasts, and read countless comments from all sorts of healthcare and training professionals. For me, the best commentary on the subject was found in an article entitled "Misinflammation", by Dr. Jonathan Sullivan (http://startingstrength.com/index.php/site/inflammation_sullivan). After reviewing many studies on ice, he concluded that the evidence just isn't solid enough either way to allow folks to make such declarative statements as "You should NEVER use ice." Even Dr. Mirkin, as part of his reversal on ice, still advocates for its use for the first six hours after the injury occurs. The human body is just too variable to completely rule out ice for everyone. In my opinion, ice is a good thing during the acute phase of healing, for its analgesic effects alone. It just needs to be used judiciously, for roughly ten minutes at a time, and in conjunction with the R.C.E. part of R.I.C.E.
So, to summarize, here are some key points to remember about soft tissue injuries:
-three phases always occur: inflammation, repair, and remodeling
-those three phases follow general time frames, but may vary. Always ask your healthcare professional if you have any concerns about your progress, or lack thereof.
-ice (in my opinion) is still okay to use during the acute phase of injury, as long as it's used judiciously and never placed in direct contact with the skin.
-Just because pain has evaporated, you are still susceptible to re-injury as the body goes through its healing phases. By having a general understanding of what occurs during each phase, and knowing how to provide the best environment to allow each to play out, you'll minimize your re-injury risk and maximize your outcomes.
Of course, being armed with this knowledge should not preclude you from contacting your doctor in the event of an injury. It can't hurt to be cautious. In addition to consulting a doctor, physical therapists are trained to help educate and assist in the process. They are also experts at identifying and correctly the compensatory movement patterns that typically develop with painful injuries.
Healing tissue goes through three stages: Inflammation, repair and remodeling. I'll discuss each phase with the use of an analogy.
Imagine a partial building collapse. The damaged portion of the building is your tissue damage. With the building damage, there is generally an immediate rush to the site by first responders. Those first responders are there to help remove the part of the collapsed building that are now useless. Similarly, your blood carries all sorts of specialized (inflammatory) cells to your site of injury to carry away the waste and initiate the healing process. Remember ninth grade biology and phagocytosis? This is the garbage removal process by cells called macrophages. There are also a number of chemical releases which help mediate the process, akin to the commanders of an emergency response crew organizing search, rescue and cleanup. As with the building collapse, this acute response can last several days.
The second part of the healing process is called the repair phase. Picture erected scaffolding around the damaged portion of that partially collapsed building. With your soft tissue damage, this scaffolding comes in the form of collagen fibers laid down by your body. It's the framework upon which new healthy tissue will form. This collagen "scaffolding" will begin to take some shape, but will hardly be the long term solution, as it's comprised of weak and disorganized pieces. This repair phase will generally begin a few days after the initial inflammatory response has dissipated, and can last up to 2 months.
The third and final stage of tissue repair is called remodeling. During this period, which can last up to a year, the disorganized scar tissue and new healthy tissue will become more organized and grow stronger. Think of the collapsed portion of the building being replaced by new material, surround by that scaffolding. This is the last step towards the building, and your tissue, becoming whole once again.
So, what can you expect during each of these phases of the healing process, and what can you do to provide the optimal environment that will allow time to do its thing?
In the inflammation stage, you'll likely experience pain, swelling and redness around the area of injury. Your body is going into protective mode in order to prevent further injury. Think of swelling as a natural "splint" to limit movement. It's during this initial phase where the old acronym R.I.C.E. (Rest, Ice, Compression, and Elevation) comes into play. (There has actually been some recent controversy in the world of rehabilitation regarding the use of ice to treat an injury, but more on that later). Your goal for the first several days is to protect the area, control excessive swelling (edema) and control pain.
During the repair phase, you can expect your pain level to dissipate. You'll find your movement slowly begin to return, although you may still experience some swelling and bruising, even away from the actual site of injury. You may begin to stress the healing tissue by active movement, gentle stretching, and soft tissue work. This will help align the collagen fibers that comprise your scar tissue, aiding them in becoming stronger. Other surrounding joints may also be exercised (even beginning in the first phase, barring increased pain to the site of injury). It is during this phase, a few weeks after the initial injury, that you are most susceptible to re-injury. This is because you won't necessarily be feeling pain with basic movements, but unexpected demands placed on the body may overwhelm this still weakened and repairing area.
The remodeling phase takes the longest, lasting many months. It's during this final phase where rehabilitative efforts ought to focus on continued strengthening of the healed tissue, with a goal of returning to full activity or sport. Concentric (contracting and shortening of a muscle) followed by eccentric (contracting and lengthening of a muscle) loading activities will prepare the injured tissues for 100% function.
A key point in the healing process is that while it always involves these three phases, the time frames for each may vary. Factors such as age, previous tissue quality and extent of injury will all play a role. These guidelines are meant to give you an understanding of what to expect and what to do about it when it comes to soft tissue injuries.
A quick sidebar on R.I.C.E., the term coined in 1978 by Dr. Gabe Mirkin. It has essentially been the gold standard when it comes to treating acute injuries. However, just this year, Dr. Mirkin wrote an article claiming that he may have been wrong about the ice part (http://drmirkin.com/fitness/why-ice-delays-recovery.html). Those who are opposed to icing EVER argue that it blocks the body's natural response to injury (inflammation), thereby slowing the healing process. "How can we presume to know better than the body?", has been the typical refrain voiced by those looking to turn conventional wisdom upside down.
I know that it certainly got me thinking about the topic, as I believe it's ALWAYS important to remain open to new pieces of evidence. It's not always easy, especially with something as ingrained as icing acute injuries. I have read articles, listened to podcasts, and read countless comments from all sorts of healthcare and training professionals. For me, the best commentary on the subject was found in an article entitled "Misinflammation", by Dr. Jonathan Sullivan (http://startingstrength.com/index.php/site/inflammation_sullivan). After reviewing many studies on ice, he concluded that the evidence just isn't solid enough either way to allow folks to make such declarative statements as "You should NEVER use ice." Even Dr. Mirkin, as part of his reversal on ice, still advocates for its use for the first six hours after the injury occurs. The human body is just too variable to completely rule out ice for everyone. In my opinion, ice is a good thing during the acute phase of healing, for its analgesic effects alone. It just needs to be used judiciously, for roughly ten minutes at a time, and in conjunction with the R.C.E. part of R.I.C.E.
So, to summarize, here are some key points to remember about soft tissue injuries:
-three phases always occur: inflammation, repair, and remodeling
-those three phases follow general time frames, but may vary. Always ask your healthcare professional if you have any concerns about your progress, or lack thereof.
-ice (in my opinion) is still okay to use during the acute phase of injury, as long as it's used judiciously and never placed in direct contact with the skin.
-Just because pain has evaporated, you are still susceptible to re-injury as the body goes through its healing phases. By having a general understanding of what occurs during each phase, and knowing how to provide the best environment to allow each to play out, you'll minimize your re-injury risk and maximize your outcomes.
Of course, being armed with this knowledge should not preclude you from contacting your doctor in the event of an injury. It can't hurt to be cautious. In addition to consulting a doctor, physical therapists are trained to help educate and assist in the process. They are also experts at identifying and correctly the compensatory movement patterns that typically develop with painful injuries.
Monday, November 3, 2014
Hips on a Swivel
This past weekend I briefly assessed a friend's hip as he had tweaked a flexor playing platform tennis last week. Aside from the acute pain he was experiencing on his right side, the most obvious finding was his lack of hip rotation on both sides.
Why does this matter?
Your body was designed to be both mobile and stable. But some areas are better suited for mobility, and others for stability. When a big ball-and-socket joint like the hip isn't as mobile as it ought to be, then your body will seek it elsewhere. Usually, that's somewhere above or below in your kinetic chain. With the hip, that means the knee and/or the lumbar spine, neither of which are designed for a heck of a lot of rotational movement. When you force a relatively stable segment of your body to move beyond its capacity, you risk painful dysfunction.
As I've written about in the past, many of us are living life in only one "lane" of movement, the sagittal plane. That's the front to back plane. Since we generally don't run around playgrounds in our adulthood as kids so aptly do, we lose mobility in one or more of these three planes. Then, we head out for our weekend warrior activities and injuries ensue.
Be mobile where you were meant to be mobile, and allow your stable parts to do their thing. Normal ranges of motion for hip internal and external rotation are 45 degrees. That is to say, if you were to lie prone on your abdomen with your knee bent to 90 degrees, you ought to be able to make a windshield wiper movement with you lower leg totaling roughly 90 degrees, without your pelvis coming off the surface of the floor/table. It looks like the middle image below:
Grab 30 seconds and do a self assessment. If you find yourself limited in either direction, or have a large right to left asymmetry, then get to work doing something about it. Your back and knees will thank you for it.
Why does this matter?
Your body was designed to be both mobile and stable. But some areas are better suited for mobility, and others for stability. When a big ball-and-socket joint like the hip isn't as mobile as it ought to be, then your body will seek it elsewhere. Usually, that's somewhere above or below in your kinetic chain. With the hip, that means the knee and/or the lumbar spine, neither of which are designed for a heck of a lot of rotational movement. When you force a relatively stable segment of your body to move beyond its capacity, you risk painful dysfunction.
As I've written about in the past, many of us are living life in only one "lane" of movement, the sagittal plane. That's the front to back plane. Since we generally don't run around playgrounds in our adulthood as kids so aptly do, we lose mobility in one or more of these three planes. Then, we head out for our weekend warrior activities and injuries ensue.
Be mobile where you were meant to be mobile, and allow your stable parts to do their thing. Normal ranges of motion for hip internal and external rotation are 45 degrees. That is to say, if you were to lie prone on your abdomen with your knee bent to 90 degrees, you ought to be able to make a windshield wiper movement with you lower leg totaling roughly 90 degrees, without your pelvis coming off the surface of the floor/table. It looks like the middle image below:
Grab 30 seconds and do a self assessment. If you find yourself limited in either direction, or have a large right to left asymmetry, then get to work doing something about it. Your back and knees will thank you for it.
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