A Basic Rehabilitative Template
Clinical Monograph 1
By R. C. Schafer, DC, PhD, FICC
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.
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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Most authorities would agree with Harrelson when he lists the goals of rehabilitation as:
- decreased pain;
- decreased inflammatory response to trauma;
- return of full pain-free active joint ROM;
- decreased effusion;
- return of muscle strength, power, and endurance; and
- 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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