"After an injury tissues heal, but muscles learn. They readily develop habits of guarding that outlast the injury" - Janet Travell, MD
Guarding after an injury is normal and it is to be expected. However, when left unidentified and untreated, guarding or protective patterns can become common reasons for chronicity and why someone "hasn't got better". This is why we must go beyond structural injury and think function in treatment rehabilitation.
From the functional viewpoint, we must evaluate for these guarding patterns that patients readily default to due to injury/pain. Identifying and treating these guarding patterns appropriately will often times enable patients to feel better almost immediately.
While yes it is important to evaluate for structural injury (fracture, dislocation, ligament sprains, tendinopathies, disc herniations, etc.) and manage them accordingly, the reality is these tissues will heal in time. However, after these injuries heal, there can be presentations within the body that create complications in achieving full recovery or become reasons for relapse.
Often times patients will complain about tight calves and hamstrings after spraining an ankle or tightness in their low back and hips after a disc rupture. Or they may have developed pain and/or sensitivities in other areas of their body seemingly unrelated to their initial site of injury.
The ankle ligaments will heal. The disc will heal. But the body will guard and protect and this becomes programmed within the nervous system. This is exactly what we need to treat for patients to get better and this new reality becomes very liberating for patients.
When patients come to understand that their injury has healed, but it's their brain and muscles that must re-learn how to work as they did before the injury, they become less fearful and more confident in a positive outcome. Essentially, they come to understand that we must reset their body so their neuromuscular function returns to pre-injury status.
To reset the right things in the body, we must assess and analyze the problem then utilize corrective measures in treatment and/or training. This system helps us develop efficiency in treatment and enables us to expect results.
What type of corrective measures? The gold standard becomes manual therapy and therapeutic exercise. When combined, these serve to get patients out of pain and improve the function in their body.
Yes these results can often times be rather immediate, however in some cases recovery can test a patient's patience as the process may be slower than they aniticipated.
When progress is slow, it is important to remember the following:
- Therapeutic exercise is the most evidence-based treatment.
- Passive treatments (tape, modalities,etc.) may offer temporary relief but are not helpful in medium and long term recovery.
- Injections and surgery have been not shown any greater effectiveness in outcomes than exercise.
- Seek advice and treatment from a licensed professional who specializes in functional movement. Ideally this would be a rehabilitation chiropractor or physical therapist with movement specializations are the gold standard here. These practitioners focus on the functional paradigm of manual/physical medicine. And no, your "functional trainer" at the gym doesn't count.
- Self-management is key. Reduce activities that provoke pain, apply gradual exposure to activities to build confidence and tissue capacity through exercise. Exercise must be tailored to you to reduce pain and improve strength and function throughout your entire body.
- Progress load and exposure gradually. The key is to be consistent with your exercise therapy. Forget about how much you were doing before the injury and what others are able to do. Everyone responds differently. Focus on your recovery and what works to get you back on track.
- Getting back on track can take a long time. In some cases, upwards of 3 to 12 months depending on a number of factors including duration of symptoms, functional deficits and patient compliance during their exercise program. Keep in mind, other treatments can offer faster recovery but nothing has demonstrated better long-term results than progressive exercise.
When patients understand that guarding is normal, that we must reset and improve their body's function and they understand the process, they in turn are very likely to experience a positive outcome.
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