Getting away from the symptomatic approach to injury management

DSC_0329

Quick Summary:

  • Acute injuries that occur instantaneously need a diagnosis and tissue repair first
  • Start thinking of the body as one functioning unit as opposed to a series of independent conjoined parts
  • The pelvic girdle and spine influence every joint in the body, so start your rehabilitation process here, regardless if the injury lies elsewhere in the body
  • You have one spine. If you change the shape in one area, you decrease the ability to change the shape in another
  • The physical and emotional stress of an injury can often disrupt stable breathing mechanics, sometimes you need to relearn to breathe correctly before any other method of rehabilitation will hold
  • The strength of the aerobic system is a predictor of recovery time
  • Some methods of rehabilitation are inherently stimulatory, some are inhibitory, you should take the state of your nervous system into account when choosing the modality of treatment you require, or if unable, switch modalities if one is ineffective for you.
  • There is almost a way to train around an injury, it takes creativity, determination, and sometimes an experienced coach

Awhile back on Facebook, I asked people who follow the Blacksmith Fitness page what kind of injuries they had sustained that prevented them from training hard or enjoying their sport, and I received a diverse list ranging from quad tears to rotator cuff injuries, lower back strains, neck injuries etc. Originally I had planned of writing individual articles on how to manage each individual injury, how that injury may have affected movements mechanics via what mechanism, and what could be done to restore pain free motion to the joint in question; after reading the array of different cases, I realized that this wouldn’t be feasible nor would it be applicable to anyone but the person who posed the question, so instead I am going to address impaired movement in a more global perspective.

The first thing is that you should get a diagnosis for an acute instantaneous injury. This article isn’t aimed at someone who has an anterior humeral dislocation from Brazilian Ju-Jitsu competition; if your shoulder, wrist, back etc. hurts all the time because of an acute injury you need to start with the symptomatic approach and deal with the damaged tissue but once you have a diagnosis you can start to implement some of the strategies outline below.

Let’s continue with our BJJ athlete with the anterior dislocation, often this athlete will consult a physiotherapist who will assist with tissue repair and re-stabilization of the joint, hopefully the physiotherapist takes into account the fact that our fighter just finished a 12 week fight preparation, aggressive weight cut and sodium loss, an emotionally taxing loss in an important tournament and most likely has a compromised nervous system, but I digress, more on this later. Eventually the fighter should achieve full tissue healing and clearance to return the exercise; the only problem is that the fighter was sitting in anterior pelvic tilt, excessive lumbar lordosis, has poor ankle dorsiflexion, and has induced thoracic scoliosis due to anterior/posterior imbalance in the shoulder girdle. What does all this mean in plain English? Our athlete was creating the perfect storm for re-injury via the influence of other joints of which he had no pain in or awareness of dysfunction! But he knows that his shoulder clicks while going overhead and gets a “pinch” in his shoulder when loaded in certain planes.

No doubt at this point the athlete (or you!) would like to break this cycle, but how do you do it? Look for dysfunctional synergist(s) muscles. Don’t know what a synergist is? We’ll use a somewhat tongue in cheek in example: Say for instance you’re having a terrible day at work and your method of conflict resolution is to deliver a well placed front-kick to the groin of your employer. The quadriceps group is going to extend the knee towards your unsuspecting adversary, but the gracilis and sartorius among others all stabilize the knee joint to ensure the kick is delivered right on target. Now true movement analysis simply cannot be reduced to a blog post, but you don’t always need to know exactly what’s wrong to start improving your chances of breaking the cycle, and that’s because the muscles of the torso and hip are synergists to almost every human movement.

If there’s one common theme that I’ve observed in in 90%+ of the injured athletes I’ve worked with pre or post surgery, is that they all have poor motor control of the anterior core and transverse abdominals and compromised posture and range of motion in the hip girdle. Provided the injury is to one of the limbs (ankle, knee, shoulder, elbow, wrist etc.) there is no reason you cannot work on your control and strength in the muscles of the torso. Start in a supine lying position (lying on your back face up) and work on the ability to move the limbs in all directions with the entire back from the hip bones to the shoulder blades touching the ground. If the back raises from the floor (you go into extension) then use smaller movements with the limbs closer to the body. This can be accomplished by bending joints to pull the arms or legs in closer, or by using smaller movements that do not extend the limbs so far from the torso. You will be surprised with how many extremely strong people struggle just to get their backs flat against the ground! Eventually dead bugs or supported 3-months position can be progressed to something that looks like this Screen Shot 2014-12-27 at 1.50.36 AM

At this point you can progress to seated or standing torso control exercises, ensuring proper activation of the postural muscles before you move any of the extremities. Add some anti-rotational exercises by performing some side to side movement of the limbs and, congratulations! You are now more stable and at less risk of injury through all motions, both planned and reactionary.

Something I want to touch on quickly is the influence of spinal curvature on systemic movement. Simply you have one spine, and it must house the spinal cord, and each joint in the spine only has so much motion before it will herniate or impinge upon the spinal cord. For this reason the motion seen at the spine (such as bending over to touch your toes, or reach sideways and adjust the volume on your speakers) is actually the summed movement of the discs rotating or flexing in small 1-3 degree segments. So it stands to reason that if these discs are not working in a co-ordinated manner that the range of motion they could produce in one direction would be compromised. Some practical examples are:

– a hyper arched lower back (lordosis) often seen in women will reduce the ability of the ribs to face the abdominal cavity or the line of pull in the diaphragm often resulting in poor breathing mechanics and tension in the muscles of the neck and upper back

– head position can affect the ability of the shoulders to flex overhead or extend the hips

Both postural deviances affect almost every major joint, directly, or via their corresponding chains; A return to balance of regular spinal curve can improve the movement of almost every major joint. Consider that chiropractic adjustments of the spine are shown to significantly improve sprint times in the absence of any other physical training and you can start to see the importance of spinal joint mechanics on the efficiency of movement across the entire system.

The next few points have to do with the physical and emotional stress of a traumatic or chronic injury and the corresponding neural and biomechanics effects that are often ignored when effectively managing the rehabilitation process. I have already alluded to breathing mechanics and their effects on quality of movement, but first I want to remove any doubt you may have that something as simple as breathing can actually affect the range of usable motion. Try this simple self demonstration:

– Bend over and try to touch your toes. Can’t do it? No worries, Take a deep breath into your diaphragm until your hands actually rise away from your feet and you can feel the stomach pressing against the thighs. Now let the breath out through your mouth slowly and stretch down to reach your toes. You should be closer now. Try this 3-4 times. I bet you’re touching your toes now, and if not, you’re significantly closer.

What you’ve just done is used a biofeedback technique to stimulate the parasympathetic nervous system (aka the rest and digest system) to reduce residual neural tone in the spinal erectors resulting in decreased tension and increased range of motion.

When you are physically stressed from an injury, or emotionally stressed from the loss of function and the possible influence that this broken leg, torn tendon etc is going to have on your season, fitness goals, and enjoyment of life, this stress often this leads to a constant fight or flight response and sympathetic nervous system dominance; one of the first casualties of this state is proper breathing mechanics. All of a sudden muscles like the SCM, levator scapulae, and upper trapezius are being used to pull the ribcage up and increase lung volume, which is ok for a small period of stress like running from a grizzly bear or your in-laws, but not the greatest long term strategy. These muscles quickly become fatigued and end up in a state of constant tension and exhalation is severely compromised. As we already know from our little demonstration that proper exhalation is important for keeping nervous system balance and creating usable range of motion in the spinal joints, and we know from the “one spine” reference how important the range of those spinal joints are to the quality of movement in all joints; therefore, a proper rehabilitation program should include some form of breathing retraining. Whether you choose to do some form of yoga, or just use some simple breathing cues, these techniques can actually help other modalities like dynamic stabilization and soft tissue work “hold” for longer periods of time.

Ok, so now we know that for most injuries where doing so would not be contraindicative, you can add in some torso control, spinal posture correction, and breathing exercises, and expect to see some improvement in quality of motion at the injured or painful joint, but one of the most powerful recovery methods is still being ignored. ALL recovery happens aerobically via the blood. Seriously ALL recovery. So why isn’t your doctor or therapist telling you to get on the bike, rower, or literally any other low impact cardiovascular machine for 25-30mins 4+ times a week in the 100-120bpm range (for most people)? I actually have no idea. The strength of the aerobic system is a predictor of recovery from an injury, but does that mean that once you have the injury it’s too late to start developing the system’s efficiency? Absolutely not. One of my clients was on crutches the day previously, we got him on the rower for 25 minutes (with only one foot strapped in), reduced the swelling in his injured ankle to less than half, and had him walking with close to normal gait by the end of the session. The ability of the aerobic system to reduce chronic inflammation is one of the main reasons I have my contact sport athletes complete an aerobic phase in their early offseason, but note THE LOW INTENSITY DEVELOPMENT OF THE AEROBIC SYSTEM IMPROVES ALL BIOMOTOR ABILITIES, including flexibility and mobility, which should be of concern in all physical rehabilitation cases. Find a way to improve the aerobic system, even if means waving your hands around in the air with milk jugs and you can expect a shorter time on the IR.

Ok I’m going to try and be quick with the next couple points. Not everybody responds to a treatment. While some are considered more effective than others, nothing works for everybody all the time. There are predictor methods; if you are using the omegawave system (and you should be) if you are in sympathetic dominance choose passive modalities, if you are in parasympathetic dominance or in balance, you should be ready to progress to more active forms of therapy. Ask your therapist about the differences or feel free to email me for more info. Even if you don’t have access to this type of monitoring, beware of therapists that tell you the reason you’re not improving is just that you need more of the same thing; if you’ve seen the same person and haven’t seen improvement in approximately 3-4 sessions, it’s probably time to see someone else.

There is almost always a way to train around an injury and still achieve some level of fitness; it often takes creativity and I’d highly recommend working with an experienced coach and a written program during this sensitive time period. Lastly, do not stop your rehabilitation process at “pain free”; you must overbuild the structure to be resistant to future situations that risk re-injury. This doesn’t mean doing a bunch of small exercises with bands for the rest of your life, this means getting strong and cementing all those new or relearned neural patterns with centrally demanding exercise. More on that in another article for another time. For now I hope this has given you a few tools to help you in your quest of getting back to doing what you love, and after all, that’s what this is all really about!

As always feel free to contact me with your questions or comments, thanks for reading!

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s