Physical Therapy Approach to Pain and Injury Rehabilitation

When I write “Physical therapy approach to pain and injury rehabilitation,” I mean my personal approach in managing various musculoskeletal conditions. And my approach is mostly based on the works of Erson Religioso’s “Ecclectic Approach”, Greg Lehman’s  “Reconciling Biomechanics and Pain Science”, and some of Gray Cook’s “Functional Movement” principles. No, I don’t utilize nor promote Cook’s FMS screens. I only follow how he manages musculoskeletal problems where he starts with mobility and stability and concludes with strengthening. Following all these pattern and principles make it easier for me to treat injuries at a minimum amount of time, and with high success rate. I am not going to talk about specific techniques here but rather the flow of my treatment protocols. Specific techniques will be discussed separately some other time.

So here are the areas I work on when working on patients and clients with pain and/or injuries.

  • Pain Relief

Relief of pain would obviously be the most immediate immediate concern of most clients or patients with musculoskeletal conditions that come for physical therapy. They are in pain and as a result making them less functional and less productive. Treatment to relieve pain will depend on many factors including the stage of the underlying condition [whether acute, sub acute or chronic], the intensity and frequency of pain [constant or intermittent], accompanying symptoms, trigger factors, patient’s general lifestyle among many others. So generally I start my treatment with pain science education. Pain science education is winning half the battle in treating patients with musculoskeletal pain. It helps clients understand how pain works, how the treatments I do can help, and lessen their anxiety and fear avoidance.

no-pain

Next I do some manual techniques. Touch in itself has calming effects. It can decrease soft tissue tone and relieve spasm. It can stimulate mechanoreceptors in the skin and underlying tissues [nerve, fascia, muscles] that bring about neurophysiological changes in the brain that help desensitize the painful area. [Please note that I did not say release fascia, loosen scars, or break myofascial nodules and any therapist who tells you that has not evolved with the new evidences yet or tricking you with the skills they thought they have].

But pain can be tricky. Much of the pain we experience is an output from the brain and thus there are times the site of pain is not always the site in question. And so adjoining joints and tissues are also checked for any pathology, dysfunction or restrictions. Painful neck, check the shoulders. Painful back, check the thoracic or the hips, painful knee check the hips and ankles… The manual techniques I use depend on the problems I find in the assessments. And they are pretty simple. There are many manual therapy techniques out there that are unnecessary and only help the therapist look cool and seemingly more qualified.

  • Improving Mobility
ankle mobility exercise

Ankle Mobility Exercise

Pain and mobility are usually correlated. In the presence of pain, range of motion is decreased sometimes just owing to the fact that the person in pain will tend to guard the joint, to protect it from triggering more pain, or to avoid causing more harm. When pain is decreased, muscle guarding is decreased and joint range of motion is improved.

But mobility is not just about joint range of motion. In fact in many cases, textbook range of motion in some joints are not necessary for functional activities. The point of mobility drills is not how far you can go but how easily and smoothly you move. Movement patterns and joint proprioception are altered in the presence of pain or injury. Mobility drills have something to do with sending sensory information to the nervous system that can bring about change in movement and perception and improve joint proprioception.

  • Improving Stability

As mobility is improved, stability training comes next. Truth is, stability and movement co-exist in the human body kinetic chain. Mobility and stability are the cornerstone of movement. That is why they come first in many musculoskeletal rehabilitaion. Joint stability refers to the ability of the muscles to maintain or control joint movement or position. It’s training the  muscles and surrounding tissues of the joint to function in coordinated actions under the control of the nervous system. Just like mobility, satbility drills are neurophsyiological. Stability exercises aim to let the nervous system have the musculoskeletal units move in coordinated fashion producing efficient and smooth movements.

core - bird dog

Bird-dog Exercise for Trunk and Lower Back Stability

  • Improving Movement

Efficient movement is constant balance between mobility. After basic mobility and stability training, more dynamic, functional movements are introduced. Speed is increased as needed, and directions are varied. While I introduce mobility and stability initially in single planes, transverse planes and diagonal movement patterns are added.

Walking Lunge with Twist as Movement Retraining

Walking Lunge with Twist as Movement Retraining

Movement retraining follows functional movements, and are modified depending on the person’s daily, recreational and sporting activities. Movement retraining will help break the abnormal movement pattern the injured person has developed as a result of pain, muscle guarding and fear avoidance.

  • Strength and Conditioning

Injury and pain does not only affect mobility, motor control and movement but also strength and endurance and thus affect the body’s overall performance. Resistance exercises with the use of everything from body weight, to resistance bands, to free weights, to compound machines will not only strengthen and recondition the muscles, ligaments, tendons and bones but also help promote further healing.

Yes, we use weights in physical therapy!

Yes, we use weights in physical therapy!

Prof Karim Khan of the British Journal of Medicine explains in an interview podcast that exercise-based rehabilitation relies on the cells of the injured tissue sensing the exercises stimulus, converting the signal to protein synthesis, and repairing tissue. This is why rest doesn’t work.

In the event that my client would need a more vigorous strength, conditioning and functional training, I refer them to a more qualified strength and conditioning professional.

  • Return to Performance
voleyball pt meme

Do the things you love,,, pain free!

The highest goal of any kind of rehabilitation is for the injured person to get back to doing what they love – whether it’s running, or dancing, or sporting activities, or playing with the children. In some cases I go and supervise my clients start their sporting program again. I have had a client who’s been indoor rock climbing for five years. He’s had medial epicondylitis [yes, it’s acute] and pain around muscle guarding. After few sessions with him, I joined him at the indoor rock climbing site as he attempted to start climbing again. I’ve done the same thing with my client who is a professional contemporary dancer.

Don’t let pain and injury stop you… Physical therapy can help in more ways that you realize. A good physical therapist can help you in every step of the way – from your recovery to return to performance.

Repetitive Stress Injury (Overuse Injury)

Repetitive stress injury [RSI], or now commonly, Overused or Overload Injury is collective term used to describe physical pains caused by excessive strain on the muscles, tendons, nerves and fascia from repetitive movements. Repetitive microtrauma or repeated strain overload overtime results in structural weakening, or fatigue breakdown, of connective tissue.

repetitive_stress_injury

In a nutshell, this is how it happens… When connective tissue is injured, it goes through a reparative process. However, in connective tissue that is repetitively stressed beyond the ability to repair itself, the inflammatory process is perpetuated. Proliferation of fibroblasts with increased collagen production and degradation of mature collagen leads to a predominance of immature collagen. This has on overall weakening effect on the tissue.

Initial signs and symptoms of inflammation such as pain, redness, swelling and limited movement may be observed. Initially, the inflammatory response from the microtrauma is subthreshold but eventually builds to the point of pain and resulting dysfunction. The type of pain may show the stage or extent of the injury. There are stages for repetitive stress injury:

  •  Phase 1 – Pain is localized and is easily relieved when rested.
  •  Phase 2 – Pain radiates out to other parts of the body. Pain appears more quickly and disappears more slowly.
  •  Phase 3 – Pain is almost always present and can limit function.

Since RSI is a progressive condition, the longer you wait for treatment, the longer the period of recovery takes.

Repetitive stress injuries can occur anywhere in the body where there are repetitive and forceful movements. It is more common in the upper body including the neck, shoulders, elbows, wrists and hands. Overuse injury can be simple muscle tensions with recurring aching pain to involvement of other soft tissues like nerves, ligaments and tendons.

The following are the more serious types of repetitive stress injuries.

Thoracic Outlet Syndrome 

thoracic outlet

Thoracic outlet syndrome [TOS] is a term used to describe symptoms of pain and discomfort in the neck, shoulders and arms which can be associated with numbness especially in the fingers. The symptoms are cause by entrapment or impingement of the nerve bundle and/or blood vessels [artery or vein] as they pass through the scalene muscles in the neck, the first rib, or the clavicle [collar bone]. For a more detailed description check out my previous blog on this topic.

Lateral Epicondylitis [Tennis elbow]

tennis elbow

Pain in the common origin wrist extensor muscles along the lateral epicondyle and radiohumeral joint on gripping activities. Activities requiring repeated wrist extension such as the backhand stroke in tennis [thus, the term “tennis elbow”], computer keyboarding, pulling weeds in the garden can stress the musculotendinous [muscle and tendon] unit and cause pain.

Carpal Tunnel Syndrome

carpal tunnel

Carpal Tunnel Syndrome is an irritation of the median nerve as it passes through the carpal tunnel. The carpal tunnel is the tight space located in the wrist formed by fibrous bands and the carpal [wrist] bones. Any condition that causes swelling or change in position of the tissues within the carpal tunnel can cause irritation of the median nerve which results in tingling and numbness in the thumb, index and middle fingers which receive innervation from the median nerve.

Management:

The best way to manage RSI is through prevention. Avoid prolonged used of your joints by talking micro breaks every 30 minutes during working hours. Take some time to loosen your neck, shoulders, elbows, wrists, and fingers by moving and stretching them. A physical therapist can teach you the right mobility and reset drills that you can do few times throughout the day while at work.

In cases where you feel any recurring pain, numbness, tingling sensation, and limited joint range of motion in the neck, shoulder, and arms, conservative physical therapy is also the ideal first line of treatment.

Remember for aching and bothersome body pains, physical therapy is your initial option. This is cost effective as many medications, injections and imaging are unnecessary.

Get PT 1st.

Physical Therapy Treatments — What To Expect When Your Go For Physical Therapy

Yup, in 21st century, some people still think that physical therapists are just some bunch of dignified masseur and masseuse. As primitive as that may sound, it’s still a fact, though to a lesser degree now than before.

So what sort of treatment would you expect when you go for physical therapy? First of all, it really depends on the condition. The physio will start off with interview and assessment to get all the details pertaining to your chief complaints. From there, the physical therapist will do one or more of these:

Manual Techniques

pt manual

These are various interventions done with delicate and skilled maneuvers with the therapist’s hands. This is why the uniformed layman thinks we are just giving some form of  massages. Ouch! But these hand works actually take years of learning and practice with scientific evidences to back them up. These techniques include joint mobilization or manipulation, myofascial releases, neurodynamic techniques, stretching and muscle energy techniques, and the list goes on depending on the physiotherapist’s training and expertise.

Therapeutic Exercises

pt exercises

These are exercises designed to specific conditions. There are exercises for low back pain, and neck pains, and shoulder problems and scoliosis. There are exercises for Parkinson’s disease, stroke, and cerebral palsy. There are exercises to relive pain, correct posture, improve muscle control, increase strength and endurance, improve balance and stability, etc… you get the idea.

Thermal Agents

A physical therapist may choose to use some heating agents prior to doing manual techniques and giving exercises. Thermal modalities can provide temporary pain relief, increase local and systemic circulation which can be helpful in sub-acute and chronic stages of injury or inflammation, and increase tissue extensibility which is ideal  prior to stretching. The most common heating agents today are hot packs and ultrasound. Hot packs can cover a larger area of the body and the feeling of warmth can give some relaxing effect. However, the effect is only superficial. Therapeutic ultrasound is thought to have a deeper effect and only applied for a few minutes. Again, these are adjunct treatment and at times may not be necessary.

Cryotherapy

As fancy as it may sound, it’s actually just the application of cold for therapeutic purposes. Icing is most commonly used in acute musculoskeletal injuries for the purpose of relieving pain and reducing swelling and inflammation. Some argue that since inflammation is the initial stage of the healing process of an injured tissue, icing can only disrupt and delay healing process. Again, depends on the therapist’s clinical decisioning. Where swelling and inflammation are severe, icing maybe one of the first line of treatments in acute injuries along with compression and rest with some controlled movement.

Neuromuscular Electrical Stimulation [NMES].

Use of low frequency currents to facilitate muscle contractions. NMES is basically used in patients with paralysis as a result of injury to the nervous system circuit. Muscles need to contract to maintain its integrity and facilitates circulation. A paralyzed muscle losses its ability to contract voluntarily and NMES is used to electrically induce muscle contractions. In the past, high frequency currents like TENS and Interferrential current is used to relieve musculoskeletal pain. With increasing manual therapy techniques which afford lasting pain relief, these modalities are now rarely used. Although some clinicians still rely on these modalities, be sure to consult therapists who actually do hands-on treatments. Passive modalities like TENS and heating agents are not effective for long-term pain relief. And remember that the site of pain is not always the source of dysfunction.

Aquatic Therapy

pt aquatic

Not so many physical therapy clinics are equipped with a pool for aquatic therapy. But specialty clinics, especially those working among geriatrics and neurologic patients may have one. Water supports body weight, provides some resistance to range of motion, and eliminates the effect of gravity making exercising more tolerable.

So these are just some of the many physiotherapy treatments available to you. Again, the use of any of this will depend on your chief complaint, overall condition and further findings from your assessment. Except for manual therapy and therapeutic exercises which can, and should be, used in almost any, if not, all conditions. I would recommend that you ask the therapist if they do manual techniques in their treatment. Remember that modalities like hot packs, ultrasound, and electrical stimulators are only adjunct treatments and oftentimes not really necessary.

In recent years, many more new treatments are used in combination to the aforementioned treatments.

Examples of these are the following.

Dry Needling

pt dry needling

This the use of acupuncture needles to treat trigger points and muscle spasms and therefore relieves musculoskeletal pain. The therapist uses needles that pierce the skin to deactivate trigger points and the like in order to normalize the function of a certain muscle or joint and also to reduce the pain felt by the patient. Dry needling, in effect, releases the pain in the muscle and reduces the swelling and tension in that certain muscle area.

Muscle [Kinesio] Taping

Image

While muscle taping is not new, what many therapists use now are the stretchable colored tapes you most likely see on athletes. It’s known by the name Kineseo Taping, to distinguish it from other kinds of muscle taping. These are durable tapes that can stay on the skin even for 2-3 days… or more. It is used for many muscle and joint problems to help relieve pain, improve joint stability, inhibit or facilitate a muscle or muscle groups, drain swelling, correct posture, and some believe it can improve sporting performance.

These are just few of the common treatments used by physical therapist. Again, treatment depends on the physiotherapist’s assessment on your condition, as well as the physio’s training and expertise. While two different physician will give same prescription for low back pain, two PTs may give different treatments for same condition.

Suffering from injury or simply want to be more active? Consult a physical therapist now…

UPDATE to this blog: More than a year since I wrote this blog, my approach to physical therapy treatment have changed. I didn’t take a course in dry needling and I am happy for it. It is invasive, some clients swear that it’s painful, while I have found a much simpler way to tone down tensed muscle. It’s just a matter of understanding pain neuroscience and applying it to your treatment strategies.

Also, use of electrophysical agents have been proven to have of no significant therapeutic effects. I prescribe it to clients as home treatment but 10-120 minutes of that in the clinic is a waste of time. Much can be accomplished with manual and movement therapies that produce more significant and long lasting improvement.