Posts Tagged ‘physiotherapist’

Healing Series #4 – Sprains

| February 14th, 2011 | No Comments »

I was trying to stop my toddler from running about the parking lot while coaxing my slightly lame dog into the back of the minivan. In frustration, I bent forward, wrapped my arms around the dog’s middle and lifted him into the back of the vehicle. I felt a funny twinge in your back but nothing seems to come of it – until later. Stiffness and pain began in my low back and radiated down into my butt.  I had sprained my ilio-lumbar ligament (it is right at the base of the spine and goes from the ilium to the 5th lumbar vertebrae). It was a mild injury, a moderate grade one. The grading for sprains is similar to strains, which were roughly outlined in the my muscle strains post.

As with all the other healing processes we have looked at there will be the clearing out of damage and the repairing of the tissue. In a ligament we see scar tissue fill in the ruptured area, restoring the continuity of the ligament. The differences comes from the fact that this is the first avascular, poorly innervated structure we will be looking at.

First, let’s look at what a ligament is and what it is supposed to do. Ligaments are sheets of tightly packed, closely aligned collagen cells.  Structures with little elasticity or extensibility, they are the brakes on the engine of muscular motion.

Without direct circulation, ligaments will be slower to send out the chemicals that signal the need for healing. The exchange of healing materials for waste products will be slow and inefficient. This slow fluid exchange will create and prolong irritation and inflammation. The lack of innervation will further slow healing.  The body’s ability to know when it is being re-injured is be limited. Most of the pain will come when surrounding tissues become over-taxed, irritated and inflamed.  The ankle and low back, two of the most frequently sprained regions, also have the highest rates of re-injury and chronic acute conditions (basically when the area is so regularly being injured it never truly heals and is always painful).

the ligament fibers end up looking as messy as these twigs

How long is slow? A year. It takes a year for a ligament to fully restore itself. If there is no intervention you will be lucky to get 50% functional integrity at the injury site.

For the first three months you are especially vulnerable to re-damaging the healing ligament. After three months most of the basic repair is done and the new scar is in place. We are entering that retraining period I talked about in the muscle strains blog. This is one of the most tricky times, you need to be active, you are generally pain free, but your ligament is just not capable of what it once was. Directional stress tells scar tissue fibres what direction they need to line up and be strong in. To be functional, ligaments need proper structure, something that can only be achieved through safe movement. By six months or so you might be okay in most activity but be aware that you are still at risk. The wrong move at the wrong time can spell a reversal back to the beginning.

 

How much of a difference can proper care make? Immensely, think 98% integrity vs the aforementioned 50%. What is proper care? In

with good healing the fibers flow together smoothly in line

the early stages RICE is the answer. If an activity brings on pain, stop it. Get help or modify for safety activities you need to do. Once you are moving without pain through normal activity, return to more vigorous pursuits. If the activity creates similar risks to the injury, tape the injured area. Tape creates some small physical stability, and, more importantly, it brings your brain’s attention to the area.

The other aspect of proper care is some professional assistance. Help to keep compensating structures healthy and ensure optimal circulation using massage therapy, physiotherapy, or acupuncture. The first two, along with a kinesiologist can help with rehabilitation exercises. The kinesiologist can help with bad movement patterns too, as can Alexander technique instructors or Feldenkrais practitioners. You do not have to use the whole spectrum of care, but think about what you need help with and what you have to invest in your health and match that to the practitioner best suited to assist you.

Finally – be patient. This is a long haul situation, if you try to shortcut it you will make it worse.

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Healing Series #3 – Muscle Strains

| February 4th, 2011 | No Comments »

Trying out skates for the first time in over a decade, sticking close to the wall, wobbling along. You come up on someone even slower than you (shocking!) and decide to brave open ice and go around. You start your big move, its going well, you glance away for a moment…toe pick…crap! Your knee is throbbing, your hand is sore where the ice scraped it, and your shoulder is a bit achy. You are on your belly, on the ice, feeling like an idiot.

The next morning, with a bruise as big as a salad plate on your knee, you think the limp will be your biggest problem, until you try to take off your sleep shirt. That achy shoulder from yesterday is not interested in heading up over your head. You have to take your shirt off like a 2 year old – one arm at a time, then over the head. You suck it up and head on about your day but quickly realize that every time you try to reach out in front of yourself, or up over your head your shoulder protests – bitterly. You haven’t thought about your knee all day.

What has happened? You have a first degree strain of your subscapularis muscle (it is in you armpit). Strain not sprain (strain = muscle, sprain = ligament), and only first degree (they go from a few torn fibers at 1st, a small to large gap at 2nd or a complete rupture at 3rd). What now?

As I have previously stated the first major stage is inflammation, you can read about it in its own blog. The rest of the steps are not radically different from deep wound healing. The body sends cells and microscopic nutrients and components to the wound that clean it, keep infection out and rebuild. The difference comes in the result.

Almost no regrowth of muscle is possible. Occasionally muscle cells with extra nuclei can divide to replace damaged tissue on a very small scale. The intact muscle cells can enlarge. The majority of the healing though will be the laying down of scar tissue. Fibrous collagenous tissue with limited blood flow, minimal extensibility, no contractility and little elastic recoil, all contrary to the nature of muscle. A muscle is designed to move, to get longer and shorter and to return to its starting length. And most importantly muscle is expected to generate force through contraction. Scar tissue can not do any of this.

Creating a mobile scar in dermal tissue is a good thing both functionally and esthetically, in muscle a healthy scar is essential. A healthy scar ensures that you are able to continue unrestricted activity and that you will not re-injury yourself. How you treat your body during this healing phase is critical. For the first 24-72 hours you should RICE (Rest, Ice, Compress and Elevate). Light daily life activity is okay, just try to avoid doing more damage. After that, provided you have no resting pain, you need to start moving that muscle, right to its pain barrier, and in all the directions you want to use it for the rest of your life. Do not use weights or resistance at this point, just want move it (you are doing ROM exercise). By educating the emerging tissue as to it responsibilities you encourage the scar to be of sufficient size to fill the space without shortening the muscle, you also encourage all the little collagen fibres to lie down in alignment with the stretch you place on the muscle (meaning you will have a scar of maximum strength) , and your uninjured muscle, your proprioceptors, and your brain are all learning how to deal with their new situation.

Realistically, for a first degree sprain you shouldn’t have any trouble doing this. There is minimal pain and you should be comfortable moving it quite quickly. The scar will be very small and change the way your muscle behaves minimally. You will likely be unaware of the alteration and re-injury is a small risk. The principles though hold all the way up to a full rupture.

With a rupture the time before safe movement is longer and you would need to have the structure repaired before ROM could make a difference. There would also be a need to progress from ROM to resistance exercise in order to gain back the strength that would be lost through the period of inactivity and the loss of contractile fibres. The key is that you want to retrain your body to deal with the new state of affairs. You can not just “rest” it for three weeks, using only 25% of your regular movement, and have your body know how to behave. You will have a very short, poor quality scar. You will be more likely to have tiny little tears occurring all around it as you try to expand your usage of the muscle. Basically, you will be causing small injuries over and over again, creating more and more scarring.

The issue with muscle healing is that you need your muscles to move, that is their job. If you do not ensure that they learn how to move in their post-injury state they will keep trying to move the way they used to, with poor results. Remember, for injuries the intervention of a health professional can speed the healing process and provide guidance on safe ways to rehabilitate. For mild strains a registered massage therapist or a physiotherapist would be your best choices. If you believe your have a more significant injury a visit to your physician is a must. A reputable RMT or physio will assess your injury and let you know if a doctor’s help is needed. A good doctor will send you to a RMT or physio when it is safe.

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My Willem Fourie Course

| June 2nd, 2010 | No Comments »

I was one of a lucky few who got to attend a three day course on treating connective tissue in breast cancer patients taught by Willem Fourie. This course provided me with more specific knowledge and alternate approaches for helping women with breast cancer.

As a Registered Massage Therapist I am required to take a certain number of continuing education hours every two years to maintain my professional standing. A practice I wholeheartedly support and enjoy. When this course was offered, even though I didn’t need all the credits, I leaped at the chance to attend.

Mr. Fourie is a physiotherapist from South Africa and a student of anatomy. He brought an enthusiasm and curiosity to the course that was wonderful. This was not a course full of recipes for treatment, this was a course about understanding. Understanding the structure of the body and what treatment for breast cancer does to that structure. He had brought many dissections that included intact connective tissue, something that is not usual in anatomy books, and ultrasound examinations of post-cancer treatment patients that were enlightening.

This excellent basis was then used to apply our skills in an intelligent, thoughtful way to create better function and ease for our patients. Though I learned few specific techniques in the class, the learning for me was in the specific knowledge about surgery – both tumour removal and reconstruction – that was presented, and the approaches and thought processes used.

Mr. Fourie has a great deal of respect for the human body, and for the human being within that body, which informs all of his approaches. I found his thinking very much in tune with what I try to bring to my work and welcomed the opportunity to work with other professionals in my industry that bring the same thoughtfulness to their work.

Mr. Fourie has participated as a presenter at both the fascial congresses that have happened and taught hundred of practitioners in the UK about his very successful approaches to breast cancer aftercare.

I thoroughly enjoyed this event and am already bringing some of the approaches into my practice – even on non-cancer patients. I look forward to bringing this enrichment of my skill set to more breast cancer patients in future.

 

Willem Fourie’s website

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