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Steps to Successful RehabilitationDon't Let a Sprain/Strain Injury Keep You on the SidelinesBy Dr. K. Jeffrey Miller Soft-tissue injuries are just that: injuries involving the soft tissue of the body - non-bone tissues that surround and connect structures and organs -and we've all experienced this type of injury before. Muscle and ligament sprains and strains are common soft-tissue injuries, and while they may seem minor, they often cause significant pain and disability. It's important to have a basic understanding of soft-tissue injuries for several reasons. First, they happen frequently. Second, when an injury does occur, it helps to know the fundamentals of rehabilitation/recovery so you and your doctor can work together to achieve proper healing in the shortest, safest amount of time. This understanding will help in all aspects of rehabilitation including stretching, aerobic exercise and strength training. Sprains are injuries (tears) of ligaments. Strains are injuries (tears) of muscles and/or their tendons. Both develop from macrotrauma and/or microtrauma to the tissues. Macrotrauma is a more sudden and violent type of injury that results in significant tearing of tissues. Microtrauma results in small tears over a period of time. Either way, the healing process for the tissues will be the same. Essential Elements of Successful Rehabilitation
Three fitness activities that are often minimized or completely overlooked: warming up, stretching and cooling down. While they are often considered important for working out or training, they are also vital to the overall rehabilitation process. Whether recovering from an injury or just training for a sport, many people skip these activities and go straight to their primary workout, which is a big mistake.
Warming Up There are two types of warm-ups: general and specific. General warm-up is for the entire body and is not the focus of a particular event or sport. In patient rehabilitation, general warm-up is preferred and is typically achieved by walking, jogging slowly or riding a stationary bicycle. Five to 10 minutes of one of these activities readies the patient/athlete for exercise by slowly increasing heart rate, blood flow, muscle temperature, respiration rate, perspiration and the viscosity of joint fluid. Specific warm-up uses the movements that will be used in the exercise or sport. An example of specific warm-ups can be seen prior to most baseball games. The majority of running in baseball involves short sprints between bases or to field a ball. Players can be seen running short sprints prior to a game, usually at a slower speed than they would during the game. Swinging a bat in the on-deck circle prior to an at-bat is another example of a specific warm-up exercise. Players are using the muscles they will use in competition, but in slower and less forceful ways. Stretching Stretching of muscles, tendons and joints is important. Many claim it helps prevent injury or re-injury. Some claim there is no conclusive proof of this; however, I am of the opinion that it helps and certainly cannot hurt if performed correctly. Stretching can be performed prior to warming up, after warming up or during cooldown. It can also be performed independently of any exercise session. I prefer stretching after warming up. Stretching can also be general or specific. General is for full-body benefit, while specific is for the body regions used in the specific activity or sport. Regardless of the type of stretching employed, there are a few rules that should always be followed to obtain maximum benefit:
Cooling Down Cooling down is obviously the opposite of warming up. Slowing activity levels down to the intensity of the warm-up period provides several benefits. Heart rate and blood pressure will slowly return to normal. Continued muscle contraction enhances venous return of blood to the heart. These factors help prevent light-headedness and dizziness after exercise. Continued circulation as activity decreases also helps remove lactic acid that accumulated during exercise. The body can disperse heat generated during the exercise session and respiration can return to normal. A working knowledge of warming up, stretching and cooling down is essential before proceeding to aerobic and/or resistance exercises.
Four steps in particular are necessary when formulating a plan for aerobic exercise for the heart and lungs. Following these steps in order will assure that all bases are covered with each care plan. Exercise Mode The type of aerobic exercise employed is the mode of exercise. Walking, running, riding a stationary or road bike, elliptical trainer, or stair-step machine, swimming, and performing many other exercises are possibilities. The choice of which to use is based on what equipment is available, the expense involved, your physical condition and commitment to participation. Again, work closely with your doctor during this phase of care. The easiest form of aerobic exercise is walking. It does not require a membership and cost is limited to a good pair of shoes and flexible, custom-made orthotics (shoe inserts) for proper support. It can be performed indoors or out and does not require a great deal of athletic ability. The benefits of walking are numerous, particularly if you've suffered a soft-tissue injury. Walking will help maintain fitness and keep you mobile while your injury starts to heal. Training Frequency The number of times exercise is performed per week is the training frequency. The frequency may be low at first and build as your health improves. As a general rule, three sessions per week is the minimum number needed to produce noticeable results. Frequency can increase up to seven sessions per week depending upon the intensity of exercise mode chosen. Exercise Duration The number of minutes performed and/or distance traveled during aerobic exercise is termed the exercise duration. Treadmills, stationary bikes and other machines allow you to track one or both of these factors. In the absence of a monitor to measure distance, time can be used as the benchmark, as measured by a watch. Duration should not fall below 10 minutes. Optimal time is 20 minutes or more. Training Intensity
Many people will make statements like, "I walk in the factory all day at work. I don't need to walk for exercise." While walking all day is better than sitting all day, it is not exercise if it is what you do every day. The walking may not be fast enough to evoke the physical response necessary for training and improving the body. The daily activities also likely involve many stops and starts that prevent the duration of the activity from being continuous enough to be beneficial. The intensity must stress the body above normal activities, but not to the point of detriment or injury. Monitoring Training Intensity: As a general rule of thumb, if you are not sweating after 10 minutes of exercise, then you are not achieving the minimal amount of intensity needed to improve health. On the opposite side of the coin, if you cannot carry on a conversation while exercising, then the training intensity is too high. Heart rate is another good method for tracking intensity. To do this, subtract your age from 220 and then multiply that number by the intensity you and your doctor have selected. For example, if your doctor wants you to start at 60 percent of maximum heart rate, and you are 50 years old, then subtract 50 from 220 = 170, and then multiply 170 by .60, obtaining a target heart rate of 102 beats per minute. Monitor your heart rate during exercise to maintain the 102 level, being careful not to drop below or exceed this number. Exercise Velocity (Pace): Intensity can also be monitored by tracking the velocity (speed) at which the exercise is performed. Obviously the higher the velocity, the higher the intensity of the exercise. Velocity must be taken into consideration with the other methods of measurements of intensity. Beginning a walking program is recommended early (within two weeks) after injury, especially spinal injury. This will help the healing process and speed recovery. Early professional care and developing an aerobic fitness base will aid in the transition to the next phase of rehabilitation, strength training.
Once soft-tissue healing is significant enough for tissue to be a tensile strength and a foundation in aerobic training is underway, six specific steps are necessary when developing a plan for resistance exercise. Following these steps in order will assure that all bases are covered with each exercise plan. As mentioned previously, this care plan should be developed in conjunction with your doctor. What Muscles Need Attention? Determining the muscles that must be stretched and those that must be strengthened is a good first step. Evaluating the ratio between aerobic and resistive exercise is a good second step. In most cases resistive exercise should follow aerobic training. The effects on the injury or injuries being rehabbed must be considered to avoid re-injury and setbacks. Which Exercises Are Best? Full-body resistance training is good for almost everyone following a soft-tissue injury. A mixture of core, multi-joint and assistance exercises must be considered. Exercises that are specific to the injured area or the sport in which you are participating are also important for improving flexibility and strength in the injured area(s). This is a key to returning to health and preventing re-injury.
Core exercises are important to everyone, but especially if you're suffering from a spinal condition. Multi-joint exercises are less specific and generally work multiple areas and involve heavier resistance. Assistance exercises are more specific, placing the majority of work on a single muscle. The type of resistance selected is also important. Free weights and machines are common resistant equipment, but may be less practical than rubber tubing or other equipment, depending on the injury. How Often Will I Be Exercising? How often you will exercise is a key to effectiveness and the prevention of re-injury. Too little exercise (low frequency) will not produce the results desired, and too much exercise (high frequency) may result in re-injury. Initially the frequency should be timed to coincide with office visits to your doctor. This will make the transition to exercise frequencies specifically for the home or outside gym facilities smooth. Should I Perform Exercises in Any Particular Order? This is the sequence in which exercises should be performed during each session. Warm-up and aerobic exercises should be used to prepare for resistance training. In resistance training, core and multi-joint exercises are generally performed first, followed by assistance exercises. When a choice between lower body and upper body exercises is necessary, the lower body should be exercised first. How Much Load, How Many Repetitions? The load refers to the amount of resistance used during the exercise. Repetition refers to how many times the resistance will be used during a set or grouping. The load for someone rehabbing an injury should be minimal initially. The key here is to become familiar with the exercises in the program. This helps develop muscle coordination and the movements involved. Resistance can be added once you are familiar with the exercise program. Even then the resistance should increase slowly. One of the primary causes of injury during resistance training is advancing the exercise load too rapidly. A general rule for repetitions is fewer repetitions with higher resistance for muscle building and higher repetitions with lighter resistance for muscle toning. In rehabilitation, toning is the initial focus. When using rubber tubing, for resistance, use the smallest diameter tubing until the exercise routine is familiar. Stronger tubing can then be utilized as you gain strength. Thinner and longer tubing provides lower resistance. Thicker, shorter tubing provides greater resistance. Again, start light. Heavy resistance early may cause re-injury.
Rest must be factored into every rehabilitation and exercise program. This is closely related to exercise frequency and is a key factor in avoiding over-exercising, re-injury or developing new injuries. Without rest, you will get too much of a good thing. Resistance exercises help in soft-tissue and scar remodeling by helping reorient the scar tissue along the lines of the original tissue to help achieve the highest degree of healing. It is vital and effective as long as soft-tissue healing is on the right path and aerobic exercise has assisted in developing a basis for you to continue to the point that resistance exercise is possible. Soft-tissue injuries can be painful, and depending on their severity, they can land you on the sidelines for a few days to weeks or even months. Regardless, it's essential that you and your doctor work together to get you on the road to a speedy, complete recovery, which is why it's so important to understand the successful steps to rehabilitation. Talk to your doctor for more information. The Three Phases of Soft-Tissue Healing Phase One: The Inflammatory Phase. Inflammation is the highlight of the first phase, which lasts 48-72 hours. Torn tissues leak blood and exudates into the area. Swelling begins and the blood and exudates (water, white/red blood cells, etc.) irritate surrounding tissues, causing pain. The key to controlling phase one is controlling the inflammation. Rest, Ice, Compression and Elevation (RICE) are standard procedures just after injuries. Therapy modalities aimed at reducing swelling and pain are helpful, which is why you should involve your doctor in the process immediately. Early movement with minimal weight-bearing and stress is recommended. Phase Two: The Repair Phase. After the initial 48-72 hours, the repair phase begins and lasts six or more weeks. During this period of time, care is predominately passive and the tissues begin to repair and regain tensile (functional) strength. Increases in exercise, stretching, and aerobic and resistance activity are all gradually employed (see below). Once the tissues have achieved the strength needed to stabilize the area and resist further tearing, the remodeling phase begins. Activity usually increases significantly during the phase. Care is a mixture of passive and active activities during the repair stage. Phase Three: The Remodeling Phase.Remodeling occurs as the body redirects the healing fibers attempting to increase the strength and orient the tissue fibers along the lines of greatest stress. This is the longest of the three phases. Beginning at six weeks, the process can continue for up to two years. This may seem like a very long time, but it is a necessary process. To provide an example of this time frame, think about a surgical scar you or someone you know had or currently has. The scar remains red for a considerable period of time after surgery. It eventually fades from red to skin color. The red color seen after surgery is the result of capillary vessels in the scar that are supplying the nutrients for healing and remodeling the scar. Once remodeling is complete, the capillaries are absorbed and the red color (blood) will disappear. Care is predominately active during the remodeling phase. It is obvious the soft-tissue healing is not a quick process. Additionally, the process is not perfect. The scars formed during soft-tissue healing are not as functional as the injured tissues. Scars are fibrous, inflexible and weaker than the original tissue. This leaves the area of the injury vulnerable to future injury. Appropriate rehabilitation helps reduce the factors, but it is not a complete or perfect cure. The key is to start treatment early and receive proper care during each phase in order to achieve the best results. Grading the Severity of a Soft-Tissue Injury The soft-tissue-injury grading system based on numbers (I-IV) has been in use for a few decades. Prior to its use, the terms mild, moderate and severe were used. Mild equaled a grade I sprain or strain. Moderate equaled a grade II sprain or strain. Severe equaled a grade III sprain or strain. However, this original system fell into disfavor as it was often confused with the system uses for rating a patient's degree of pain as mild, moderate or severe. If the doctor found physical evidence of a moderate sprain and/or strain, and the patient rated their pain a severe, an immediate conflict occurred. Third parties often choose to interpret the patient's "severe" as a complete rupture. To avoid this situation, grades I through IV are used to assess tissue damage and a 0-10 pain scale is used to rate pain.
While the grades for sprains and strains are usually described as individual entities, they can occur in combination. More than one grade can be present in a joint or series of joints. For example, varying degrees of sprain and strain can occur in the cervical spine (neck) following cervical acceleration-deceleration (whiplash) injuries. K. Jeffrey Miller, DC, MBA,is an assistant professor of chiropractic at the University of Missouri Orthopedic Institute, a branch of the University of Missouri Health System. He is a graduate of Palmer College of Chiropractic and the author of several practitioner and patient texts. |
