Muscular strains- not enough treatment techniques!!

[cleehaddock]

Hello all.

I am starting to see more and more muscle strains- rec fem and medial head of gastroc. Although this may sound silly, but am struggling to fill out a half an hour session. especially injuries in the acute/ sub acute stage. I feel the patient comes for treatment, not just to be given a load of exercises. Apart from stretches, ultrasound and active release I am struggling to come up with anymore treatments.

Many thanks

[karen.hankey]

In the acute stage there isn't a great deal you can do apart from ultrasound and gentle stretches and for them to ice at home. At this stage getting rid of any bruising is important.

If the patient has tenderness on palpation when sub-acute, when pain allowed I would start DTF's. As pain to palpation decreased I would start strength exercises starting at isometric if needed.

[ramywhite]

Ice is great in acute stage with rest at home. Gentle massage with active assisted or active free ROM without pain. You can start gentle stretch in sub-acute stage and upgrade to isometric exercises if there is no pain.
Why should we fill out a half an hour? Do what patient needs whatever it takes. It doesn't matter if it takes only 15 minutes.

[linbin]

hi
i agree with the others suggestions.you can even try soft tissue release in the subacute phase.

[ameerpt]

like others i suggest RICE in firs 3-7 days adding to immobilization but mobilization should be started after first 3- 7 days ( depends on case severity)

[sarapollo08]

HI VERY NICE TO HEAR UR DIFFERENT APPROACH IN TREATMENT OF MUSCULAR STRAINS
.VARIOUS OTHER TREATMENT TECHNEQUIES APART FROM THE USUAL ONES ARE
1. MYO FASCIAL RELEASE - can start from the sub acute phase itself
2. POSITION RELEASE TECHNEQUIES
3.TRIGGER POINT RELEASE
4.P.N.F TECNEQUIES -can start even from acute phase




just try and see all these after having any idea of this surely u can show good difference in ur treatment when compared to the usual ones
BYE
PRATHAP

[physiobob]

Originally Posted by cleehaddock

Hello all.

I am starting to see more and more muscle strains- rec fem and medial head of gastroc. Although this may sound silly, but am struggling to fill out a half an hour session. especially injuries in the acute/ sub acute stage. I feel the patient comes for treatment, not just to be given a load of exercises. Apart from stretches, ultrasound and active release I am struggling to come up with anymore treatments.

Many thanks

Perhaps consider "Why" they are injured. I could spend an hour easily on a torn calf looking at the why and strengthening/stabilizing/releasing any issues that might have contributed to their injury in the first place. So the simple answer is to look above and below the injury and consider prevention as part of acute treatment protocol as they might not still be with you if you wait until the tissue trauma has resolved.

[physiomitch]

Hi

Like a previous reply said, it is more important to look at the possible causes rather than trying 'speed up' recovery through localised treatments. I find a lot of injuries like this have another component to them. Commonly if it is a traumatic injury, eg a blow to the thigh/calf, then it may be local, although there could still be secondary changes in how the body responds. If it is a 'tear' or strain then it may mean the area of injury has been put under unnecessary stress through some other muscle malfunction. eg if the hip muscles are weak, this results in extra work being done by the quads and calf to compensate, as well as by the back muscles (common cause of LBP), thus this continuous overload can result in fascial tightening of the quads and calf sheathings and eventually a tear (most 'tears' are fascial not muscular...bleeding occurs with muscle tears). So always check hip strength and other muscle strengths above and below the injury to assess possible causes or responses in other muscles. Myofascial release is great for correcting these problems, as most weakness is as a result of myofascial tightness, NOT lack of exercise. It makes no sense to stress the body more by introducing exercise as a form of treatment when it is often exercise that caused it in the first place. Once normal base strength and full ROM is restored then exercise can be re-introduced.

Cheers

Pete (see next reply for ideas on RICE)

[physiomitch]

Fllowing on from the previous reply. Some have mentioned RICE in the initial phases. I have a few things which might make you think about this differently. Although it is widely held that this is an acceptible approach to use for acute injuries, I feel we may be missing the point here. Theoretically ice reduces swelling, inflammation and pain, restricts blood flow to reduce bruising, however, this is theory, and yes these are the effects of applying ice to the body. But why would we want to starve an injured area of a natural blood flow for anything up to an hour. Inflammation, swelling, pain, bruising are all natural part of the injury process, BUT THEY ARE ALSO NATURAL PARTS OF THE HEALING PROCESS! Without these the brain will never know for sure the injury occured. So reducing these inputs can severely diminish the body's ability to repair itself. Where is the research to prove RICE helps the repair process or shortens the recovery period of an injury? I have not seen any, just as I have not seen any regarding ice baths! It is a SYMPTOMATIC APPROACH, not treatment approach. The ironic thing is that if injured and left to its own devices the body responds with vasodilatation in the injured area, NOT vasoconstriction, which goes against anything we have been told. So if the body itself increases the blood flow to the area, why are we shutting it down? For repair to begin the body needs platelets, red and white blood cells in the area, so it makes sense to increase the amount of blood in the area, but this takes place almost immediately, yet if we restrict blood flow, this cannot happen. Bruising will eventually stop as blood vessels repair quite quickly, so we should not worry about that and swelling is from damaged cells...they cannot get any more damaged and only have a certain amount of fluid in them.

In my opinion we should focus more on trying to influence more blood to the area, not away from it. This can be done by using small doses of ice (10 secs at a time, removed until the skin warms up again), below the injured area if possible to stimulate flow THROUGH the injured area, not around it which is what happens with orthodox icing.

My opinion: RICE...rest, yes. Ice, NO!

What do you think?

Pete

[mackenziephysio]

Hi
Pete I think you are missing a key point related to the use of ice and that is that vaso constriction is only a short lived phenomena it is followed by vaso dilation and finally vaso motion both within a relatively short period of time once ice is removed

[physiomitch]

Key phrase there being 'once ice is removed'. But what is happening while the ice is applied for 20 minutes or more at a time (I had a petient who was told to put ice on for an hour), if only once the ice is removed do these effects occur? So why leave the ice on for so long if the effect we should want is one of improved RATE of blood flow to flush injury byproducts away and allow fresh nutrients to get to the area? It boils down to maximising the rate of blood flow and encouraging the body to repair itself as soon as possible and for us to get the patient back on the road as soon as physiologically and physically possible. Our job is to remove obstacles to enhance healing not to install them surely?

Pete

[Dr Damien]

there is no argument on the importance of ice in acute soft tissue lesions. It is standard practice and the evidence behind it is tremendous however based on protocol several are out there but in no way do I think icing anywhere for more than 20 minutes is therapeutic, let alone one hour.Icing in low doses, 10 seconds etc is also in my book not as effective. The reason is, the deep anatomy of the muscles being treated. The literature behind intramuscular temperature suggests that muscle does not start to cool until approximately 8 to ten minutes after icing(remember you have the fatty tissue insulation and countercurrent vascular exchange to deal with) . this is where your low dose theory will not work except u intend to stay there the whole year. moreover, intramuscular temperature decreases long after the skin temp has stabilized lasting several hours so therefore your best bet is too cool for the therapeutic time and leave alone for a few hours, authors suggest 2 hours and then recool but depending on the acute symptoms u may want to do it every hour but being practical two hours is enough. Vasodilation (lewis hunting reaction)that u claim occurs after vasoconstriction is questionable, current literature questions it however if it does occur it brings in deoxygenated blood low in hemoglobin which is not too beneficial to healing is it?so therefore stick to the current practice, people have researched it and the literature is consistent. If u are considering new management plans for your patient, then consider other forms of massage.gentle(and I repeat gentle) transverse frictions from a few short sweeps to probably numbness may be used but u need to judge from ur assessment and ur patients level of tolerance. stretching should be gentle in combination. The reasoning behind, this type of management is simple, transvers efriction ensures that the fibers heal without an abnormally formed scar and gentle stretching realigns, with adequate cooling your patient should be good to go in 3weeks or a little more because muscles are very vasculrized anyway. Change to heat after swelling and pain has subsided, that is standard practice. use your NSAID gels if necessary. you can become creative in the types of exercises(eccentric contractions,oneleg stance etc) you give but honestly the management cannot be better than that. if you decide to use US make sure it is pulsed mode u start with in the first few days and u can use phonophoresis of an NSAID if you want. but that is the practice and it is the practice because it works.
Work with what u see and create along the lines of what u see.I know that a gastroc tear will affect gait and step phase because of stretching, so I may want to strap the strap the gastroc or provide crutches in the interim get it?but the practice still remains the the same for soft tissue lesions.Holla back if you disagree or have new info, its always good to hear opinions.

[physiomitch]

Hi Dr Damien

Thanks for the input, always good to see different ideas.

I understand your points and do not agree with the proven effectiveness, but i only have one question and this is probably the main reason I wrote about RICE. Is the application of ice seen to be effective because it gives symptomatic relief, or is it actually proven to shorten the repair time of an acute injury?

My argument is that all the research into the effectiveness of RICE seems to be based on treatment of symptoms, which fair enough, is sometimes called for, but I would like to see some proof of whether RICE is more effective in the entire recovery, compared to another approach, for example acupuncture, myofascial release and normalising sympathetic control of blood flow rate to the injured area. I have used this approach, eg on a sprained ankle (lateral ligs),and had the dancer performing (although slightly abbreviated performance) the next night after the injury. I used no ice no elevation, only ensured that the leg was well supported by the hip and upper leg and that the calf muscles were functioning to support the ankle. This eas done with acupuncture and myofascial release massage, freeing the space for muscles and ensuring correct natural biomechanical stability. Added to this I ensured the sympathetic nervous system was controlling blood flow rate. I saw him once more and he was back to full time dancing. The point is, would he have improved as well if he had iced his injury immediately after the injury? I would like to see this type of research, not research which tells us how the body responds to cold...we already know that.

Sometimes I think we might have been baffled by evidence of symptom relief, and because it is so widely used, we accept it as gospel. I am not saying it is not effective, just is it effective for symptoms or for the bigger picture of full repair. Personally I feel our job is not to treat the damaged tissues but to support the body in it time of repair. If we can remove any obstacles getting in the way of the body repairing itself, eg poor blood flow rate, tight fascial tissues (not necessarily scar tissues...normal in repair), weak supporting muscles, and if necessary pain (acceptable in certain cases), then I think we are well on the way to guiding the body into full repair.

What we must remember is that every injury is new for the body, and as much as it is designed to repair damaged tissues, a knee injury is different to an elbow injury , and it is our job to guide the body, educate it, and show it how to repair each area of the body, so it does a good job first time. Eg, it makes no sense using weight bearing exercise for the elbow when it is a hing joint in an essentially non-weight bearing arm.

Personally I am not sure about cross frictions as scar tissue is natural and I feel it has been given a bad name by my profession's teaching as if it ALWAYS sticks, which makes the use of x-frictions sound feasable. I all my years of practice, I have rarely seen poor scarring in an acute muscle/ligament injury, and believe it should be left alone to repair without any outside interference. It makes the body sound like it is completely inept at fixing itself, which is crazy. Tissues will heal, we must ensure the environment of the repair is satisfactory.

By the way, not sure if you heard, but I have been led to believe, about 8 years ago US was proven in research not to work. For this reason and for the reason that deep heating can slow the rate of blood flow by deep vasodilatation, thus decreased O2, etc. I have not and will not use US in practice at may not be evidence based. Once again, just because we know what it does to the body does not prove it is actually effective.

Please also see other thread on RICE in forum...I think in Sports or general discussion.

Thanks for your input again, I think it is important to question treatment regimens sometimes, even though the approach might be seemingly solid. As we learn more about the body so things should change.

regards

Pete

[Dr Damien]

Well like I said before lateral thinking is fine, there is absolutely nothing wrong with it.But to make a really arguable case, then something should be wrong that one has seen or experienced over and over again. first of all, the question I have is what was the grade of the ankle sprain, how long did you have to treat for?since we all know that ligament sprains do not always carry the same extent of injury what was the situation with the patient you treated. I can not say what the situation would be if I gave u 30 patients to treat with the same protocol with differing scenerios.see what I mean?

Many of these techniques you mention are also lacking in evidence base so why pick out a technique that has consistently shown to be effective?I dont know if I am making sense? the evidence base of acupuncture is poor even though new papers turn out every other day.

Cryotherapy involves several techniques and my point is understanding why you do whatever you do.

Cryotherapy is not a symptomatic treatment alone, if anything at all acupuncture is because it addressed only pain in the most part just like Tens would.Myofascial release techniques work just like any soft tissue mobilization so where is the justification for thinking ice is problematic?

You sound like you have a great of experience doing what you do but I tell you if cryotherapy was not working effectively I would support your argument a 100% but it is and we have the literature to prove it.

I like the way you think and it is good, perhaps you should work more in research rather than in the clinic.this is where you and I are different, I will give weight bearing exercise to the upperlimb if I see reason to, for instance in a neuro case were weight bearing experience is important not because the patient will walk on his hands but because it helps joint memory.

I agree with you that you need to make the area satisfactory for healing but I tell you one thing about scars and inflammation, they can get excessive depending on personal body responses. So I would not go treating every patient like I treated the last, I would rather judge from what I see and act accordingly, if inflammation is not excessive then I may not consider ice. this brings me back to my initial question what was the state of ur patient?

if the body is so good at handling its own problems then why do we have diseases?why do we die?why can a simple infection turn fatal, why do we even need to guide healing? Maybe if we had never introduced the concept of medicine before then we may have evolved into superhuman beings but that is not the case.

I had a cut in my wrist some few years backthat was pretty deep but not deep enough to cause too much damage. I got it stitched and always tried to move it so it did not get stiff. yeah, if i did not have the pain to guide me then I may have moved it too much and caused more damage. Then again if I did not have the inflammation controlled with drugs who knows what the scars may have been like. this is eight years since and I still have a scar to show for it although its clearing up. Imagine having an excess scar tissue that is one ugly to look at disorganised in collagen laid down and quite frankly was a keloid.

So scar tissue are what they are temporary bridges between injured sites, they are not the main tissue but a replica and they need to be moved to ensure they organise properly. That is what frictions and mobilizations do.

Concerning the treatment of US being non effective, you need to be clear where the literature says US is not effective and its mostly in degenerative conditions and the reason is simple.Its degeneration, not too much inflammation going on, modalities designed to address that are likely to be ineffective.

I'm sure you know some physios who still believe US is ok and they have every right to believe so because they have used it and it worked.

trust me if you left a tendon, muscle or ligament to heal on its own.If you are lucky nothing will happen, if you are unlucky and with a muscle you get tethering or calcifications and you suddenly try exercises and you get myositis ossificans then you will appreciate the value of some of these doctrines.

Manual based physios are not strong advocates of therapeutic modalities anyway. I am a manual physio and I dont use any of them not because I do not want to but because I think I can do something with my hands;its a training thing for me.

If you must criticize anything at all, start by criticizing some of these techniques you use that lack evidence base.

I for one am not against anything that is being done, I am fully evidence based but I am also very practical, if the evidence is strongv and consistent within all parameters, sample size, blinding, randomized,methodology is good , equipments used are reliable and results are consistent then its most likely good.

when you think of changing the practice prove that something is wrong somewhere causing abnormal results, its that simple not imagining that things should work according to how you are used to doing them.Then everyone might as well claim that their practice is the best.see what I mean?

I respect ur opinion because it takes a fantastic mind to think like you do but I will be honest with you after sampling every single evidence out there and you have criticized them properly, then you can make an informed statement. For someone who is pro-acupuncturev and Myofascial release ,i am surprised that you want to pit against ice when these ones are even more on shaky grounds evidence based wise.

if the thought still bothers you and you cant seem to find the evidence to answer your question, then carry out a study and get it published but you must realise nothing that comes out from your study says anything, its only going to be an added piece to the jigsaw puzzle because after critical appraisal for methodological issues, no one's study is considered to be above anyone elses. they all add to knowledge somehow.

thanks for your reply, holla me if you feel the need to discuss anything, we could always clarify each other out.

by theway, you do not see abnormal scar tissue or excessive adhesions because the sites are deep and are not fully immobilized. so consider what is happening to your patient during your management as well, what are they doing or not doing.