Injury recovery massage and rehabilitation strategies
Injury recovery massage and rehabilitation strategies by Philip Earle
This article discusses potential massage and rehabilitation strategies for the acute, sub-acute and remodelling phases of injury including:
Overview of the stages of injury recovery
The role of massage at each stage
The role of exercise/rehabilitation at each stage
This article is concerned with soft tissue injuries i.e. to muscles/ligaments/tendons. In practice, the injury phases tend to overlap another.
It is important to note that any massage and rehabilitation strategy employed must be based primarily on the tissue's physiological response to the injury/trauma. The strategy should consider the signs and symptoms that the client is displaying and be modified accordingly - the specifics of any strategy will be determined by the nature of the injury and client medical history.
It should also be noted that elements of the rehabilitation strategy below may be undertaken/supervised by suitably qualified professionals for which the required appropriate referrals would be made.
Acute (inflammatory response) phase - 24 to 48 hours after injury has occurred
Tissue response: Tissue damage initiates clotting (haematoma) and chemicals to injury site to remove damaged tissue and to prepare it for healing. The result is inflammation, with likely symptoms being pain, swelling, discoloration, heat and loss of function.
Rehabilitation strategy: It is important to note that if injury is serious, e.g. if there is a dislocation, then the client should be referred to the appropriate health professional(s) e.g. hospital. Immediately after the injury has occurred, the rehabilitation is primarily first aid based to prevent further injury, and to reduce discomfort and blood flow to the affected area. Most acute injuries can be treated in the client's home using the PRICE principle:
Protection - purpose of this is to prevent further injury to the affected area by protecting it. The type of protection used depends on the injury but could include a bandage, splint, tape or brace.
Rest - this allows the body's own healing processes to occur by restricting movement, which could result in increased circulation, causing further damage and/or increased swelling. If the injury is on a lower extremity e.g. ankle, it may be advisable to keep the weight off the leg e.g. by using crutches.
Ice - cold helps to reduce pain and swelling and should be applied as soon as possible. Ice packs could be used, but these should not be applied directly to the skin, but through a towel for example, otherwise burning may occur.
Compression - this also helps to decrease swelling. A compression wrap can be used, such as an elastic bandage.
Elevation - reduces the amount of blood flow to the area. The principle is that the injured area is above the client's heart level.
Note: there are variations of the above e.g. RICE (Rest, Ice, Compression, Elevation) or more notably POLICE (Protection, Optimal Loading, Ice, Compression, Elevation) - the main difference is the use of Optimal Loading, such as gentle movement, instead of rest - the school of thought here is that too much rest can actually delay the healing process and progressive loading may be more beneficial. However, this depends on the nature of the injury and the advice of another professional (e.g. physiotherapist) should be sought if in doubt.
Massage strategy: During the acute phase there is a need to proceed cautiously, to avoid re-injury and further pain. To this end, it is advisable to avoid working directly on the injured area as a precaution. Areas adjacent to the injury site can be worked (again with caution, light effleurage could be most suitable) as this may help to increase blood and lymph circulation, therefore clearing/draining waste products caused by inflammation away from the injury. Note - any sharp pain indicated by client could be an indicator of tissue damage. In other non-injured areas, other appropriate techniques can be used - this could have the benefit of reducing of any anxiety caused by the injury by relaxing the client, also reducing their sensitivity to any pain they are experiencing. Attention should be paid to any muscles that may be compensating for the injured area (an example is for an ankle injury, the body protects the ankle by transferring weight to the other leg, possibly causing tension in muscles in this ‘splinting’ leg) - massage will also help to decrease tension in these areas. For muscle and tendon injuries, no stretching of the injured area should take place, as apart from causing pain, this could re-open any haematoma developed as part of the inflammatory process.
Sub - acute (repair/regeneration) phase - 48hrs to 6-8 weeks post injury
Tissue response: This is the tissue healing phase, where new cells adjacent to the wound are produced to replace the ones destroyed by injury. The aim during this phase is to encourage the repair and replacement of the damaged tissue through the development of a scar, resulting from Collagen formation. The massage and rehabilitation employed must also encourage correct alignment of the scar, so as not to compromise the joint Range of Motion (ROM).
Massage strategy: The aim is to promote circulation in affected the area, so that nutrients are available for tissue healing and to increase ROM. No deep work should be done on the affected area at this stage to avoid breaking the scar and causing re-injury. Again, light effleurage could be employed. The depth of the strokes can be slowly increased as appropriate as this phase progresses. For muscle/tendon injuries, any strokes would be in the direction of the fibres to encourage correct scar alignment. Feedback from the client regarding pain should always be sought - if the pain level increases, the therapist should stop working on the affected area and move on to another area. As with the acute phase, in other non-injured areas, various techniques can be used to reduce anxiety and sensitivity to any pain. Again, attention should be paid to any muscles that may be compensating for the injured area.
Rehabilitation strategy: This is influenced to a degree by the location of the injury i.e. upper body/limb or lower body/limb. This is the point where rehabilitation commences in earnest in that the process of actively moving towards (as far as possible) pain free activity starts. The rehabilitation in the sub-acute phase consists of two element - early stage and mid stage, described below. Prior to any exercise rehabilitation, hot and/or cold therapy are often used - hot therapy (e.g. heat packs) induces vasodilation (widening of blood vessels) and increased blood flow to the affected area, which delivers oxygen nutrients into the affected tissue, and removes waste products. Heat also relieves pain. Cold therapy (e.g. cold packs) induces vasoconstriction (narrowing of blood vessels), reducing inflammation and pain. Contraindications associated with hot therapy (e.g. acute inflammatory conditions) and cold therapy (e.g. poor circulation) must be considered. Contrast bathing - also known as hot/cold immersion therapy, is another method for stimulating tissue healing - the vasodilation due to heat and vasoconstriction due to cold creates a pumping action that stimulates circulation.
Early-stage rehabilitation: The remaining rehabilitation activities could consist of the following:
Progressive controlled mobilisation/ROM - controlled mobilisation promotes the principles of Wolff's law i.e. (bone and) soft tissue will respond to physical demands placed on them; and remodelling and realignment - in particular, scar formation, revascularisation, muscle regeneration and fibre reorientation and increase in scar tensile strength. This controlled activity permits a gradual return to ‘normal’ functional levels.
Static proprioception and balance exercises to begin to restore these, as injury can impair proprioception capability, a common symptom being poor balance for lower limb injuries e.g. for an ankle sprain a balance or wobble board could be used - this reprogrammes the body to react to the wobbling movements without conscious thought.
Sub-maximal isometric strength exercises are typically used when moving a joint might be contraindicated and will help to increase strength in the affected area, these are performed to a percentage of full capacity, for example contracting the muscle to 50%. Examples are squeezing the thighs together with a solid object placed between the knees for an injured adductor muscle.
At the point where weight-bearing forces can be gradually applied through the limb and approximately 2/3 normal ROM can be achieved without pain, the client can progress to mid-stage rehabilitation.
Mid-stage rehabilitation: This is as below:
Active and passive mobilisation/ROM will help to restore further ROM within affected joint.
Progressive resistance exercises - this is a method of increasing the strength of an injured muscle by systematically increasing the resistance against it e.g. by incremental increase of weight lifted, increasing the number of repetitions or sets; or the use of resistance bands, progressing from light to heavy resistance.
Functional exercises are aimed at gearing the client back towards their sport or activity. At this stage there are numerous generic exercises, applicable to multiple sports, that can be performed, such as closed kinetic chain exercises - where the distal aspect of the extremity e.g. hand (for the arm) or foot (for the leg) is fixed and cannot move. The extremity remains in constant contact with an immovable object, such as the ground or a machine. Examples are press ups, pull-ups, dips (upper body) or squats, lunges, leg presses (lower body). With the distal aspect being fixed, movement at any one joint in the kinetic chain requires movement at the other joints in the chain - both the proximal and distal parts undergo resistance training simultaneously.
Cardiovascular (CV) exercise - as appropriate for the injury, this can commence to maintain and improve CV levels during the rehabilitation phase.
Remodelling phase (6/8 weeks - months/years (unknown):
Note: Although the timescales above should be considered, it should also be confirmed that suitable progress (there should be full and pain-free ROM and control in all joints on the affected limb, with no apparent compensatory patterns while performing functional and resistance exercises) has been made prior to the next stage of rehabilitation (late stage of rehabilitation, described later).
Tissue response: The purpose of this phase is to strengthen the repaired tissue - the scar tissue continues to harden.
The massage and rehabilitation strategy should continue with mobilisation to restore functional capacity and aim to limit adhesion formation. The rehabilitation is now more activity specific.
Massage strategy: A wider range of techniques can be employed at this stage, including deeper techniques (e.g. deeper effleurage and petrissage) on the affected area. Localised deeper techniques (e.g. friction) can also be used to break down any adhesions that may have formed due to mature scar tissue. Soft tissue release could be employed to help to lengthen and encourage flexibility in the scar tissue and realign collagen fibres. Neuromuscular techniques such as Muscle Energy Technique (MET) could be employed to further assist with ROM increase and control within the joint range. Myofascial release, a technique that releases restrictions in fascia caused by the injury could also be used as required.
Rehabilitation strategy: This is the late stage of rehabilitation which is now more sport/activity specific - the aim is to restore the client normal functional activity in the injured limb/area and prepare to return them to normal everyday unrestricted activity and is more of a ‘total body’ approach. This can include the following:
Overload resistance exercises – these build upon the progressive overloading in the previous phase and aims to improve muscle strength by making it work at a higher level than normal.
Proprioception exercises - continue with these to maintain muscular control and balance.
Activity specific functional exercises - these are related to the client's activity (job or sport) which they are returning to.
CV work - to continue to improve this towards a level similar to that before the injury.
In addition:
Continue with heat therapy as in sub-acute phase. Improve/maintain flexibility – e.g. through stretching exercises.
Strapping and taping (e.g. kinesiology taping) - to protect and support the affected area when undertaking exercise.
Progress is considered be made when:
The Client has full, normal active and passive ROM in all joints of affected limb, which should be unaffected post exercise.
All movements should be full and pain free.
There is no evidence of swelling post exercise.
There is good proprioception.
The Client has regained/retained level of CV fitness similar to that prior to injury.
The Client has demonstrated that they have regained/retained the required skills relevant to their activity or sport.
To close any other ‘gaps’ in the process before the client is discharged, other questions should be asked:
Have they recovered physically from the injury?
Do they have the necessary fitness and skills to perform everyday activities?
Have they recovered psychologically from the injury?