Abstract/article from Dr Christopher Norris book
The Complete Guide To Exercise Therapy published by Bloomsbury (2013)
Re-produced and edited with the kind permission of Dr Norris
Dr Christopher Norris is a physiotherapist with a phD in spinal rehabilitation and an Msc in exercise science. He is the founder of physiotherapy practice norris associates and author of 10 books on physiotherapy and exercise. Chris is an external lecturer to several universities and teaching hospitals and an international speaker.
Chris has been a friend and colleague of both Drummond Education and Drummond Clinic for many years and we are proud to feature this abstract/article in our monthly news letter.
Dr Norris’s latest book is available at Amazon by following the link above and look out for his next book in April 2014 Complete Guide To Back Rehabilitation
Understanding the soft tissue healing process will help you as a trainer structure your exercise programmes to assist your clients back to full function quickly, safely and effectively. It is important to understand the process phases and recognise the role exercise can play, ensuring that the client has been released to exercise by a primary clinical practitioner.
The Healing Process
Healing can be divided into three phases (acute, sub-acute & remodelling). During these three phases the strength of the healing tissue changes.
Acute Phase
Initially during injury tissues have torn or been bruised so tissue strength rapidly reduces from normal. In this phase, we must protect the damaged tissues from further injury and so exercise is not used – we say it is contraindicated. As the tissues begin to heal a bridge begins as a blood clot forms and shrinks, so although the tissue is changing it is still weak and easily disrupted by movement. This represents the lag phase. Although time ensures tissue begins to heal, tissue strength has not changed at all. Exercise on the injured area remains contraindicated until about 24-48 hours after injury. The time variation is dependent on the size of the injury.
Sub-Acute Phase
After this time we progress to the next stage of healing, were the blood clot is being replaced by fibrous tissue and we enter the phase of regeneration – as fresh tissue grows the area gradually becomes stronger. As tissue strength increases, the amount of exercise you are able to use can increase. It is important that the pace of increase in exercise matches the increasing tissue strength. Too much and the new tissue can break down and re-injure, too little and the new tissue will be weak. Tissue strength continues to increase until we reach a point where no new tissue is formed.
Remodelling Phase
From this point tissue strength slows, and the tissue begins to change to match that which existed prior to injury. This phase occurs 4-6 weeks after injury. Fibrous tissue never exactly matches the original which it has replaced, but importantly full function will return with correct rehabilitation.
In addition to local changes, whole body changes have also occurred. The quality and quantity of movement have both become impaired, and this will be greater for larger injuries affecting a greater amount of tissue, and for long term injuries which present a greater temporal (timing) effect. The body will try to protect the injured tissues by unloading them. This may mean an alteration in the way a bodypart is moved.
i.e. An ankle or foot injury may result in your client laterally rotating their leg and rolling over the medial border of the foot for example to reduce the amount of ankle dorsiflexion required. These are examples of a movement dysfunction.
Over time, the alteration in movement which occurs as a result of injury places greater physical stress (overload) on some tissues and far less on others. The result is imbalance of the tissues with some becoming weaker and underused and others becoming painful through overuse. In the example above, twisting the leg and roller over the inner aspect of the foot reduces stress on the injured ankle joint, but places greater stress on the inside of the knee. In time medial knee pain is often the result. Further up the kinetic chain the rotation occurring in the low back can also result in asymmetry.
Monitoring Pain Feedback During Exercise
An injury is painful. It is important during a rehab exercise session to gain feedback. We can use a hospital based numerical rating scale This is a score from 0 (no pain) to 10 (maximum pain) . Pain intensity should be no higher than 5 or 6 on the pain scale.
If it is higher than this, reduce the intensity of the exercise. As you exercise if pain is caused by stiffness and new tissue stretching out the pain should reduce with activity. You may score 6 for the first 2 or 3 reps and this might reduce to 4 or 5 as you get into the exercise. After a rest when you perform your second set of an exercise the pain may once more reduce. This is a sign that the tissue is reacting in a positive way to the exercise and you can continue. However, if your pain score begins at 5 or 6 and increases to 7 or 8, you must stop immediately. Increasing pain means that you are putting too much stress on the healing tissues and they are likely to breakdown, tear or become inflamed.
Reaction To Rehab
Following a rehab session, the next session must begin with a re-assessment of your clients symptoms. Have they got better or worse? How did they react to exercise? A simple pneumonic S.I.N, standing for Severity, Irritability, and Nature can be helpful here. Severity of a condition can be determined by the amount of pain and typically this is done in hospitals on a pain scale (visual analogue scale or VAS) detailed above. Irritability is how quickly a condition is stirred up, generally measured as the length of time your client does something before their pain increases (walking, bending, lifting for example) and how quickly the pain settles once the activity is stopped. If your client has an injured knee which is painful after only 2 or 3 steps and takes 2 minutes to settle, it is more irritable than someone with a similar condition who can walk for 10 minutes before pain occurs, and then it settles within a couple of seconds.
Clinically we combine our impression of these three factors to limit treatment where SIN factors are high.
Define Outcome Measures
An outcome measure is really a standard against which rehab can be measured. How do we know that the rehab program has been effective? We need to measure something before, perhaps during, and certainly after the program to track improvement. Outcome measures may be the number of pain killers that a client is taking for example – if these reduce it would indicate that pain is lessoning.
It is no good saying that pain has reduced and so the client is discharged if the client’s main concern is giving way in their knee which has not changed. For this reason we normally use a Patient Reported Outcome Measure (PROM). These are normally standard hospital forms which measure changes in mobility, self-care, usual activities, pain, and anxiety for example.
The MYMOP standing for Measure Yourself Medical Outcome Profile (Patterson 1996). form is available as a free download from this site
Movement Assessment
Look at the whole movement and determine which joints are moving and therefore contributing to the action and which are not. If we take as an example someone raising from a squat, we need to look at the client from in front, behind, and the side to get enough information. Movement certainly occurs at the hips, knees, and ankle as well as the shoulders. However, look more closely. Are they moving their spine at all? Are they lifting their ankles from the ground so that movement occurs in the mid foot? Is the arm movement just occurring at the shoulders, or are their elbows and wrists moving as well. Look even more closely at the shoulder. Is movement occurring just at the shoulder joint (glenohumeral joint) or do they shrug in which case movement also occurs at the shoulder blade (scapulo thoracic joint).
Once we know which joints are moving we also need to know in which plane are they moving, sagittal, frontal and or transverse. All body movements move in a plane but about an axis. This is important because most modern gym machines only work in uniplanar actions, and this may not match the requirements of your client. For example lets say that we want to strengthen the knee and we decide that the movement required is knee extension. This occurs in a sagital plane about a transverse axis. However, close observation may show that your client’s kneecap points outwards in sitting and forwards in standing, so some rotation is occuring perhaps at the hip/ knee and ankle. The gym machine will not re-create this, so we may need to chose a free weight activity instead.
Range of Motion
Again we need to observe an action closely to determine which movement range is occurring, inner to outer, so that we can recreate this during rehabilitation, or perhaps change / re-educate it.
If we look at the knee joint in our squat example, the knee moves within mid and outer range for extension. However, if we look more closely does the knee stop moving when the leg is vertical or does movement continue with the knee joint hyperextending (genu recurvatum). This action places considerable stress on the posteriorly placed knee structures, and if we were to use this action as an exercise we would need to prevent hyperextension.
Muscle Work & Function
Muscle work may be concentric to accelerate an action, isometric to stabilise, or eccentric to decelerate. In our squat example or getting up from seated, the leg muscles work concentrically to raise the body. However, when we look closely we may see a brief eccentric action if they rock backwards to pre-stretch the hip flexor muscles and gain momentum as they lunge the trunk forwards to initiate the action. The forward angle of the trunk is initiated by concentric hip flexor activity and maintained by eccentric action of the spinal extensors where the trunk bends (flexes) or hip extensors where the pelvis anteriorly tilts. Typically both actions occur to some extent, but where trunk flexion is excessive pelvic tilt may have to be encouraged using a rocker board or sit-fit cushion.
We should also note asymmetry when viewing the action from the front or back as often clients may favour one leg or tilt the spine to one side shortening the trunk side flexors on the concave side.
To get a client back to full function it is important to structure an exercise programme safely and effectively and with referral from a clinical practitioner at the correct phase of healing. Whilst returning to full function is dependent on movement the movement must match the stage of healing. Too much movement in terms of volume and or intensity in the early stages will cause tissue breakdown and negative healing.
If you are keen to develop your knowledge in working in this more specialist area consider enrolling for your Level 4 Back Pain Specialist instructor course or your CYQ Sports Massage Therapy (Soft Tissue) course today.