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A Basic Rehabilitative Template

A Basic Rehabilitative Template

The Chiro.Org Blog


Clinical Monograph 1

By R. C. Schafer, DC, PhD, FICC


INTRODUCTION

Injuries can be classified into 13 types: abrasions, contusions, strains, ruptures, sprains, subluxations, dislocations, fractures, incisions, lacerations, penetrations, perforations, and punctures. This paper will not detail the management of burns or injuries requiring referral for operative correction, suturing, or restricted chemotherapy.

Objectives

Except for the most minor injuries, traumatized neuromusculoskeletal tissues are benefited by alert restorative procedures. The more serious the injury, the more prolonged is and the greater the need for professionally guided rehabilitation. The first step in rehabilitation is to explain to the patient that rehabilitation is just as important as the initial care of the injury. The goal is not only to restore the injured part to normal activity or as near normal as possible in the shortest possible time but also to prevent posttraumatic deterioration. It is an individualized process that requires patient dedication. The author recognizes that it is easier to write about comprehensive planning than to motivate some patients to follow prescriptions after pain has subsided.

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Chiropractic Rehabilitation

Most authorities would agree with Harrelson when he lists the goals of rehabilitation as:

  1. decreased pain;
  2. decreased inflammatory response to trauma;
  3. return of full pain-free active joint ROM;
  4. decreased effusion;
  5. return of muscle strength, power, and endurance; and
  6. regain of full asymptomatic functional activities at the preinjury level (or better).

One should keep in mind, however, that the goal of decreasing the inflammatory and effusion response does not mean to eliminate it. It is a normal response that should be controlled, not expunged. These normal responses are necessary to spur natural repair and regeneration processes. Unfortunately, the responses often manifest to a greater degree than need. Thus, control of the mechanisms, not their obliteration, is the clinical directive. Healing is also influenced by the age, tone, health, psychic, and nutritional status of the victim. The protocols of clinical chiropractic are based on logic in harmony with nature. For example, we know that a small skin cut that normally heals in a few days takes months to heal in a completely sterile environment (eg, within a sterile bubble). This suggests that common airborne particles, bacteria, air currents, etc, act as stimulants to the healing process. It does not mean that secondary infection should be invited.

Basic Effects of Trauma

No injury is static: It continues to produce harmful effects on the injured person until either the injury or the person is defeated. As these effects are similar, the response to injury is also both systemic and local. It is for this reason that injuries and their effects must be evaluated from the standpoint that the whole person is injured and not from the view that an otherwise well-off person is afflicted with a local disability or that only a part of the total system is affected. Since the effects of injury and the body’s efforts to defeat them are constantly changing, the doctor cannot rely on one observation or one outstanding symptom in evaluating the condition of the patient, especially one seriously injured. Repeated observations must be made and indications of the patient’s circulatory condition, neural expression, temperature, blood pressure, pulse, respiration, color, strength, vitality, and emotional status must all be considered to obtain as clear a picture as possible of the patient’s holistic condition and what treatment may be required at the moment the particular observation is made.

Managing Patient Discomfort

The triune of pain, tenderness, and local swelling is the primary index for evaluating the progress of recovery. Anesthetized joints will never reveal that overstress was suffered. Without the warning signal of pain, the physician has no guideline for controlling the rehabilitative program. Thus, a compromise must be made between patient comfort and rehabilitation control.

Though extensive and prolonged immobilization assures a less painful recovery in most instances, it always carries with it related fibrosis and atrophy. On the other hand, quickly but logically initiated and gradual rehabilitation speeds the reduction of swelling and tenderness, and minimizes fibrosis and atrophy.

Enforced inactivity following major surgery leaves an indurated scar of thick fibrous tissue that remains tight and uncomfortable for a long time after surgery. Likewise, major joint and skeletal injury inevitably result in overabundant scar tissue from necessary immobilization. Even minor disorders treated with long-term immobilization develop large scar masses that permanently restrict function. On the other hand, uncomplicated surgery, wounds, and sprains followed by ambulation in a few days result in a cicatrix that is not tight, but rather soft and pliable.

Until recent years, the standard treatment for a sprained ankle was 3 days in a plaster boot, followed by 3-4 days of radiant heat and whirlpool baths, and then crutches for another week, all totaling about 2 weeks of therapy. The result was an individual exhibiting a distinct limp for 2-4 weeks and an indurated leather-like ankle where motion was restricted in all normal arcs. It was not uncommon to take several months before the ankle was considered functionally normal.


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Enjoy the rest of Dr. Schafer’s Monographs at:

Rehabilitation Monograph Page

4 comments to A Basic Rehabilitative Template

  • I find that when I work with athletes they are more compliant than the patient that has never been involved with sports. I try to explain the remodeling process, but many times when they feel relief they do not want to continue with the exercises that have helped them. Any suggestions?

    • Hi Russell

      Reggie Gold called that the “hole-in-the-bucket” practice, and had his own inimitable approach to patient education to prevent that. I guess the biggest problem is how far the doctor is willing to go to educate the patient. I believe (and hope that) the day of scare tactics via degeneration charts is over.

      It’s our job to advise them that they need to be stabilized to reduce repeat performances, but just like leading a horse to water, we can’t force them.

      In my office, when patients get to the no-pain state, I tell them I am happy for them, and at this point, they have a choice to make. They can leave and hope it doesn’t reoccur, or they can continue on a less-frequent stabilizing plan, which is what I recommend. If they choose to d/c care, just know that I will be here for them should they crash and burn.

      Often, the one who refuses stabilizing care (the 1st time) willingly accept it after they crash and burn again, and chiropractic gets them well that second time, usually faster than the first time. That’s what usually closes the deal.

  • In the spirit of both chiropractic rehab AND prevention, I’ll mention that we just released the Volleyball Injury Prevention (VIP) Program — a pre-play performance and prevention warm-up specifically targeted at preventing ACL injuries in volleyball athletes.

    We’re looking for organized athletics programs to participate in a research study on this protocol. If any of you know anyone who might like to implement it, I’d love to talk with them.

    Here’s a link to the protocol: http://www.austinspineandsport.com/volleyball-injury-prevention-program/

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