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2 Myths That Will Prevent Your Full Recovery

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It is amazing!  
Today, we have more health apps, exercise gadgets, computerised movement machines and wellness technology for every man, woman and child than at any time in human history.  
Instantaneously, we can know everything from how many steps we have taken, to how many kilojoules we have burned, to how we slept, to our resting and exercise heart rates.
We have a pill or supplement for everything, whether it be to improve our health before we were born, to increasing our libido, improving sleep, building muscle, lowering stress, you name it.
We have more gyms, health clubs, personal trainers, exercise physiologists, boot camps, pilates studios, dance studios, gym studios, spin clubs, sporting clubs than ever.  
Likewise, there are more doctors, physiotherapists, osteopaths, chiropractors, myotherapists, remedial massage therapists, acupuncturists, podiatrists, Alexander Technique therapists, Feldenkrais practitioners, dietitians/nutritionists and naturopaths per capita than ever.1 And yet, the number of people getting scans, taking pain medication and having joint replacements, PRP injections and cortisone injections has never been higher.2
Take note as you drive or walk around any suburb and you will find a plethora of health-care places. Anyone would think that we are the sickest, most in pain, most dysfunctional generation of people, ever.
What is going on? Despite these so called health advances, the incidence of physical and mental illness and injury is not improving.3
And if you don’t care now, you will when your healthcare and life / income protection insurance premiums, as well as your taxes (Medicare rebate) go through the roof in an attempt to cover the explosion in healthcare costs that is happening and likely to increase in the future.  
Possibly the two greatest untrue myths of this crisis are our quick fix mentality and our blinkered, isolationist approach to healthcare.  
Let’s face it, modern sports medicine would have you believe that to get better you need to get a scan, have surgery and voila, you will be better.
Often, we are left with the impression that tissues and structures have magically healed. And it leads to the logical conclusion that we should also expect the same miraculous cure if we get injured.  
Very rarely however, is there any mention of the extent of the injury, the amount of treatment (often many times each day), ongoing injections and pain medication that an athlete may be taking as well as what the long term effects of the injury might be. 
Implied in this myth is that pain is the enemy. Pain medications, injections and even surgery tend to give the sense that pain must be avoided at all costs. And yet, legitimate pain is an essential aspect of healing. Why? Because legitimate pain, or pain that is logical, reasonable and purposeful, changes behaviour, in a positive way that facilitates healing. In fact, there is no more potent changer of behaviour than pain. 
Legitimate pain is like the warning lights on your car dash-board. Like these warning lights, legitimate pain indicates that something may be wrong. With your car you know that if you keep driving you risk doing major damage to your car.  
However, unlike our car warning lights, when we experience pain, we often try to ignore or repress it so that we can keep going, putting us at risk of further injury. And then, we wonder why our injury hasn’t healed and / or has worsened. It just doesn’t make sense.
Understand that the longer that you have had your problem and the more severe that it is, then generally the longer that it may take to get better.  
Hence, it is probably unrealistic to expect that if you have had your pain for longer than 3 weeks or longer, that it going to be better in one or two sessions. The reason is that not only has your injury not healed, but your body, brain (neural pathways) and even the way that you live, have already begun to adapt to your injury. 
In addition, treatment needs to be intense enough to create and reinforce a positive change. Even if you are seen for one hour a week, there are 167 other hours where the pressures of life can so easily undo all the benefits of your treatment. 
This is especially true in the first couple of weeks where healing may be more “fragile” and hypersensitive to stress. Consequently, treatment initially must be more intense to protect you from re-injury and then taper as you experience a progressively longer lasting result. 
To achieve any result however, your active participation in your recovery is absolutely vital. Without it, it is likely that your recovery will either be delayed or impeded.
If you need to use pain or other medication to control inflammation or to enable you to cope and function, then please do so under the guidance of your doctor. Know that this medication is not the end result, but a means to an end in your journey to be pain and limitation free.
The other untrue myth relates to our blinkered, isolationist approach to healthcare.  Becoming a specialist enables a health care professional to charge a lot more money. It also gives the impression that a health professional who has “specialised” in an area of the body, must be good at what they do. After-all they are a specialist. They must know more detail about the area of the body that they have studied than a generalist who just knows a little of everything.  
However, the evidence is that very rarely do physical problems in your body occur in isolation. For more information, please read The Surprising Cause of Pain 
In fact, it is possible that every mechanical pain felt in one part of your body might be caused by a seemingly unrelated tissue or structure in another part of your body. And the danger is that a specialist health professional, knowing just one area of your body well, doesn’t consider incorrect function in other areas of the body or even in the way that you live that may have led to the pain.
Over the last ten years or so, there has been a revolution in our understanding of the brain’s involvement in the experience and perpetuation of pain. Whilst once the brain was thought of as a receiver of pain, now it is known that after some time the brain may become a transmitter and perhaps even a magnifier of pain. 
Consequently, a major thrust of treatment has focused on normalising your experience of pain by accepting and embracing legitimate physical and psychological pain as a necessary aspect of healing and recovery.
Now, it is understood, that it is not your muscles, nor your nerves, nor your joints, nor any one tissue or structure that may be at fault. It may actually be all of these tissues and structures and more that may be contributing to your pain or problem based upon how you move and live.
Preventing and recovering from physical injury isn’t necessarily difficult, but it does take work, discipline and even sacrifice.
Every-day, I see classic examples of the falseness of these two myths.  
For example, just yesterday, Sue presented complaining of left and right foot big toe pain. She informed me that a couple of years ago she had bunions and neuromas (swollen, inflamed nerves) removed from the inside of her big toe.
When I looked at her feet and the way that she walked, immediately I could see her problem. Despite having her bunions removed and been given orthotics, Sue’s “bunions” were returning. In addition, her big toes were pushing inwards, squashing all of her other toes.  
Sue walked with her feet turned out and wide apart. The two possible reasons for this are lack of balance and poor hip strength, which were then confirmed on testing. 
Not only is walking with your feet wide apart inefficient and tiring, it means that Sue’s body weight is falling inwards. As a consequence, Sue’s thighs tended to roll inwards causing flattening of her feet (pronation) and leading her to push off the inside of her big toes with every single step.  
Walking like this then leads to foot pain, ankle stiffness, calf and outside thigh tightness, weakness of her quadriceps and buttock muscles, instability of her core and osteoarthritis of her feet, ankles, knee, hips, back and even her neck. No wonder Sue was in pain!
Fixing Sue’s problem is not hard, but it does take work. It involves, freeing up her hips and ankles, increasing her core, hip and thigh strength, improving her standing balance and correcting the way that she walks. Orthotics would also be helpful in accelerating and sustaining her progress.  
The bottom line is deal with your pain, actively. Address the sources and the causes of your pain. Be pro-active and disciplined in following through with a specific treatment strategy that will deliver you the result that you want.  
With your therapist, develop a strategic treatment plan complete with aims, actions, milestones and a timeline. Then monitor your progress. Celebrate your improvement and make adjustments where necessary to ensure that you stay on track. 
The modern world has duped us all into believing that injury prevention and recovery involves some magical pill or miracle technique. It is so appealing because it doesn’t take effort, costs little and is highly convenient.
But these are false myths. Injuries do not occur for no apparent reason and they do not tend to occur in isolation.
Your aches and pains, as well as any other signs or symptoms such as swelling, clicking, tightness, grating, is your body’s way of telling you that something may not be quite right.  
Don’t dismiss these warning signs. Learn about them, understand them and address them quickly and comprehensively. This is the best way for you to achieve the best, fastest result possible.  
The real question is, “Are you willing to do the work?” no matter how inconvenient, uncomfortable or time consuming it might be.
Because if you are not, then just be aware that you may be wasting your money, time and your life with costly, temporary, band-aide solutions, that may in fact lead to a worsen of your problems. In the end, it may cost you and all of us a lot more than just dealing with the causes of your problem in the first place.
The choice is yours.
If you have any questions or would like advice on any signs or symptoms that you might be experiencing, please call Bodywise Health on 1 300 BODYWISE (263 994).
I wish you the best of health and life.
Michael Hall
Director, Principal Physiotherapist
Bodywise Health
For more information on how Bodywise Health can help you to overcome your pain, please call Bodywise Health on 1 300 BODYWISE (263 994).
Please note:
  • Rebates are available through your private insurance extras cover;
  • For complex or chronic conditions, you may qualify for the CDM (Chronic Disease Management) allowing you to receive 5 allied health services each calendar year with a referral from your GP. For more information, please call Bodywise Health now on 1 300 BODYWISE (263 994).
References Available on Request

How to Know When to Return to Sport

Self Monitoring 01

It's one of the more challenging judgement calls to make. When to return to sport or pre-injury activities. Unfortunately, like so many things in healthcare, it is not an exact science.

There are so many things that need to be considered; so many variables. Some of these include:
1. The structure or tissues injured;
2. The severity of your injury;
3. The type of activities that you might be returning to;
4. Your work, living and or playing environment;
5. Your physiological, physical, psychological and social circumstances.

It is estimated that 12-34% of hamstring injuries 1 and 3-49% of anterior cruciate ligament injuries 2 re-occur as a result of incomplete rehabilitation and premature return to sport and their pre-injury activities.

People often severely underestimate the time needed to be able to return to their pre-injury level of performance. Lack of knowledge, lack of experience and lack of perseverance, all play a role.

For example, when a group of runners and dancers were asked to estimate how long it would take for them to return to their activities, the runners replied four weeks and the dancers replied one week. The actual average return was 16 weeks for the runners and 50 weeks for the dancers 3.

For physiotherapists it is a challenge as well. Even if injured tissues should theoretically be healed, trying to determine when they are able to withstand the unpredictable stresses of life and sporting activities is difficult if not impossible.

The Science behind Recovery

The starting point for staging when you can return to pre-injury activities and sport is having an accurate knowledge of the theoretical time-frame that it takes for various tissues to heal. For example, your blood cells turnover every 120 days, your bone building cells every 3 months and your skin cells every 2-4 weeks 4.

The healing time will vary for different tissues and structures but is primarily determined by the blood supply to the area; your age; genes; your general health and nutritional status (e.g. abundance of protein, Vitamin C) and even medication (e.g. Anti-inflammatory medication such as Ibuprofen is known to delay healing).

Soft Tissue Healing as a Guide to Your Treatment
Following trauma and injury, your body will always go through the same phases of healing, the length of each varies depending on the type of tissue damaged, the severity of the injury and the intervening treatment. Healing can be divided into four broad phases which overlap considerably. These phases include:
1. The Bleeding Phase
2. The Inflammatory Phase
3. The Proliferation Phase
4. The Remodelling Phase

The Bleeding Phase
This phase occurs immediately following injury and can last anywhere from 6 to 24 hours depending on the type of tissue injured. In the bleeding phase substances are released which enable the adhesion of various cells. The complication of this phase is excessive bleeding and swelling. This excessive "clot" along with the damaged tissue needs to be removed, thus delaying the laying down of new tissue.

Excessive swelling also delays healing as excessive fluid pressure effectively prevents oxygen from being delivered to the injured cells, leading to increased cellular death and even more debris which has to be removed.

Consequently, it is critical that IMMEDIATELY following trauma or injury, treatment is begun to prevent excessive bleeding and swelling. Treatment such as compression, immobilization, lymphodema massage (massage that removes swelling) and unloading damaged tissue (e.g. crutches), if implemented in the first 24 hours by a competent physiotherapist, CAN SAVE YOU WEEKS IF NOT MONTHS OF TREATMENT.

The Inflammatory Phase
Likewise, the Inflammatory Phase is critical for healing. Inflammation has the classic characteristics of heat, redness, swelling, and pain (which is often constant, throbbing and can wake you at night).

Inflammation escalates rapidly a couple of hours following injury, increases to a maximal reaction at 1-3 days before gradually resolving over the next couple of weeks. Essentially during the Inflammatory Phase, the role of the body's immune system is to act like a demolition company, clearing the 'construction site' of debris and damaged tissue.

The complication of this phase, is that the inflammatory process gets out of control leading to an acidic environment, excessive protein breakdown and further cellular death. Consequently, treatment should include all the same modalities as in the Bleeding Phase with more emphasis on cold packs (15 minutes at least 6 times a day with emphasis on hourly cold packs at the end of the day), compression as well as optimal loading reduce swelling and decrease the activity of the inflammatory cells.

The Proliferation Phase
The Proliferation Phase involves the formation of repair material, which in the case of musculoskeletal injuries is mostly scar (collagen) material. At about day 5, the collagen is weak and easily broken with any chemical and physical stress. From day 6 to day 14, this scar tissue gradually becomes more durable to the point that the fibres have knitted and the defect has been bridged.

Consequently, treatment must be geared towards increasing and optimizing the activity of the cells laying down the repair. Warmth and electromagnetic stimulation (which increases cellular activity) along with hands on techniques and easy pain-free movements that optimizes tissue tension to enhance the repair.

The proliferation phase peaks at about 2-3 weeks, (less time for more vascular tissues) before winding down over the next 4-6 months.

The Remodeling Phase
The Remodeling Phase results in a quality, organized, functional scar that can behave like the parent tissue that it replacing. New evidence indicates that the Remodeling Phase begins as early as the first week. Initially, collagen fibres are laid down randomly. However, with the expert application of specific tension, these fibres become aligned along the lines of force.

Collagen molecules also have an electric charge and stress on collagen fibres produces a piezo-electric effect which may also help to re-orientate fibres.

Whilst it is unclear however how much tension is necessary or optimal, it seems that working to the point of discomfort but not into pain, may be a good guide as to what might be the most optimal tension for ideal adaptation.

From this point, gradual, controlled, progressive, specific loading has been found to accelerate early return to sport4. For optimal rehabilitation, this specific loading must be integrated into graduated functional strengthening, beginning with low level, safe, static and progressing to more physically demanding, dynamic, reflexive sport or functional specific activities.

These dynamic, reflexive, functional or sport specific activities can then become the tests which help to determine if you are ready to return to sport or your pre-injury activities.

Special Tests for Return to Pre-Injury Activity

For Shoulder Injuries - Throw and Catch
The throw and catch test consists of the throwing of varying weighted balls at different speeds and angles and durations until the action replicates as best as possible the intensity of the sport.

For all leg injuries - Balance standing on injured leg to progressing to hopping and then to running
These tests involve being able to maintain alignment of your hip bone, middle of your knee cap and 2nd toe with progressively more demanding, dynamic activities.

This alignment is consistent with ideal biomechanical forces being placed on our body tissues and structures and requires adequate core and leg muscle strength and control as well as sufficient hip, knee and ankle mobility.

All of these activities can be progressed in various ways for example by increasing the instability of the surface (e.g. duradiscs), increasing the depth of squat; height of the step as well as the distance, angle and speed of hopping and running.

Other special tests include:
1. Single leg hop
2. 6 Metre timed loop
3. Triple hop for distance
4. Cross over hops for distance
5. Running Drills

The Importance of Ongoing Rehab

Even once you have returned to pre-injury activities, you need to continue with an ongoing conditioning exercise program to ensure that your body is able to cope with the daily demands that you place upon it.

This conditioning exercise program must consist of strengthening exercises for the injured area and associated areas as well as balance and core stability activities. This needs to be completed at least twice weekly for at least four weeks following return to full activities.

A Final Word

There is no doubt that most people have large misconceptions about when they think that they are better and able to return to their full pre-injury activities. Understanding the process and timeline for healing is a starting point for staging the healing of tissues. This however must be supplemented by specific, injury related, objective testing and compared with the non-injured side and valid data.

Finally, it is important that you stay positive and remain engaged and connected with others and that you celebrate the milestones on your journey back to full health.

If you are injured or if you know of someone else who has a physical injury, seek or encourage them to seek treatment as soon as possible. It may just save you weeks if not months of pain, frustration and isolation.

If you are injured or in pain and want to get back to doing the things that you love to do, please call Bodywise Health on 1 300 BODYWISE (263 994) for a complimentary*, no obligation assessment and Recovery Action Plan from one of our expert physiotherapists.

We look forward to helping you get your life back.

Until next time, Stay Bodywise,

Michael Hall
Physiotherapist, Director
Bodywise Health

Please note:
* Rebates are available through your private insurance extras cover;

* For complex or chronic conditions, you may qualify for the EPC (Enhanced Primary Care Program) allowing you to receive 5 allied health services each calendar year with a referral from your GP. For more information, please call Bodywise Health now on 1 300 BODYWISE (263 994).

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3. Br J Sports Med.2006 June;40:40-44.
5. The Phys Sport Med.2000 Mar;28(3);1-8.
6. Clinical Sports Medicine.2006,Revised Third Edition;Australia;McGraw-Hill.
7. Knee Surg Sports Traumatol Arthrosc.2010 Dec 18(12);1798-1803.
8. Phys Ther.2007 Mar;87(3):337-349.
9. Knee Surg Sports Traumatol Arthrosc 2006 14:778-788.
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