Being effective in Acute and Subacute states of healing.

If you are working with people in pain one of the worst things you can do as a therapist is be ineffective, but how do you be effective when your patient is in a stage of healing where you cannot use deep pressure or move their limbs around? Its easy to treat low back trigger points when you can apply some pressure, but what about when you can't?

This blog is devoted to something I do a lot of: working in the acute/subacute stage of healing. In school for orthopedics, we were taught that working in acute was cautioned, and that you were to use techniques such as lymphatic drainage, and working compensatory muscles (which for many therapists translates to 'far away from the injury') to treat patients while managing their expectations. And all of that is still true, however there is a lot more you can do too. These guidelines are taught with public health in mind, and by no means am I recommending that you blow by them, however it after you have been working for a while you might find that there are some other things that you can do as well. They don't break the rules, they just can't be explained in the rule because it would leave to much of a grey area open in treatment. Today we will look at low back as an example and in the next blog at the knee.

First off get your thinking cap on. Try in your assessment to separate the injury itself from the symptoms of the injury. Every injury has a symptom picture, however some of the aspects of the the injury are more secondary reflexes the body uses to protect and heal itself. Lets look at an example:

A client comes in with low back pain, slightly left of the spine at the SI joint. Yesterday, they were lifting an object and turning at the same time, and they felt a click in the left low back and now they cannot move. You are reasonably sure based on the symptom picture that they have sprained or subluxed an SI joint, but of course they can't move to do special testing. Palpating the site reveals there is heat over the joint but no palpable swelling and the low back is pretty fixed and seems splinted, as do the gluts. Other than the pain, there are no CI's and they called their doctor and said it was fine to have a treatment.

So now what? Well for me the splinting and the actual injury are two separate things. The injury is that the joint has moved out of place and it might still be out of place. The side effect of this injury is that the body neurologically saying "oh boy, things are really unstable, we had better build some more structure for this guy fast or things might fall apart". Most of the pain is actually caused by the splinting pulling on the injured joint.

To treat this type of injury, I start by making a plan based on the injury. In this case it's that swollen hot joint that is being pulled on by gutes, quadratus lumborum, and the psoas/iliacus. Reducing the splinting would help take the tension off the joint, lower the tone of the fascia, and allow fluid movement in the area to boost healing. But all my text books say don't manually remove splinting by force. So now what?

First I would try and get the tone down by working compensatory. Managing pain is awful; it stresses the body out and often leads to more pain. Getting your client into a relaxed state through working the cervical muscles is a great start. You can do this in prone so that you client does not have to roll over on the table. focus on getting the shoulders to relax and the scalenes moving.  This will signal to the body that its not time to 'fight or flight' this should help not just relax the tone, but also reduce the pain.

Continue with your treatment working towards the site of the pain, in this case that is the whole lower back. As you get to the site of the splinting you will have to switch to lymphatic work. If you don't have lymphatic training, you can substitute it with very gentle and slow feather light gliding touch over the skin. While you gently massage, you should be assessing the tone. You will probably notice while you are working in this area that although your client is breathing (I hope;) the low back and gluts are not moving much. When you watch your client breathe, the chest goes up, but the air stops in the thoracic spine. This is due to the splinting, and while you, as a therapist, should not attempt to remove this manually, the patient can remove it on their own, thereby lowering their own tone, activating the normal muscle pumping and relieving some of their pain.

I want to stress that during this process your job is not to apply pressure in anyway, your hand contact is only enough to palpate the muscle, to cue the client as to where the air should move, and asses the tone. Placing your finger tips on the lateral edge of quadratus lumborum (make sure its the side of the muscle not downward) palpate just deep enough to feel the muscle, your client should feel no pain at your touch. Then ask your client to take a long slow breath. If the air does not move down to where the lower back expands, que them by saying, "I want you to breath into where my hand is". As they breathe in and out, slowly expanding the area, you will likely notice that the tone in the low back falls as does the pain level.  This process could take up to five minutes on each quadratus lumborum. This same technique can also be used along the iliac crest (or any area where the client can move air such as the cervical spine)following the line of the top the glutes as the pelvic floor and iliac spine are also affected by breathing. If at any time your client responds with pain, immediately discontinue. For some cases I will aso put a pillow under the stomach to limit the amount of belly expansion and increase back expansion. Never push the client past where they want to go, at all times they should be in control of this activity.

What is happening? A few things actually. In one sense maybe you are doing nothing, but your clients slow steady breathing stimulates the parasympathetic system, and it reduces the symptoms by proxy. Secondarily, sometimes pain is manifested due to immobility. Your body uses immobilization in order to protect injured parts and when it proprioceptively realizes an area is not moving, it sends a signal back up saying "hey this bit is damaged, its not moving at all, we had better produce some pain so this guy knows not to do anything stupid". Getting the air to move normally in that area signals the start of movement and so leads the body to believe that things are on their way to ok. And lastly, your lymph system and some of your circulatory system, whether you know it or not, is driven by muscle pumping. When you approximate the air flowing into an area, you are also working the fluids like pumping a bellows, which is how the body in the end will heal itself.

If you are at all confused about a symptom picture, anything red flags, or feel in anyway unsure, always refer out. I find it extremely helpful to be as upfront with subacute clients that walk through the door by managing their expectations. During the consent I will almost always say something along the lines of "it sounds like _____ is happening, but I am not a doctor. We have to treat conservatively until you find out exactly what is going on. We can probably get you more comfortable while you wait however". Usually if it was nothing that serious, you have helped them a great deal and the next time you see them it will be to finish up the work that is headed for chronic. If the problem has not subsided, you have done no harm but performed your job as a supportive healthcare provider, by encouraging them to get a diagnosis from a qualified professional. Good luck!.


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