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.
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
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.
- 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.
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.
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
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.