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29 July 2014

Health On Monday: A new way to rehab injuries – it’s called exercise!

 - Monday, 21 March 2011, 00:00 , by Richard Geres

Once home, you search the web and find an athletic injury website that confirms what you remember: R.I.C.E. can relieve pain, limit swelling and protect the injured tissue, all of which help to speed healing.

The issue is settled. Well, not quite. You should think twice before you go RICE-ing that ankle, according to a new school of thought on how to recover from athletic injuries.

A growing number of sports medicine specialists say that the advice to rest after an injury may be outdated and counterproductive. In what may seem like heresy, they’re advising their patients to keep exercising. You see, over the past three decades, medical researchers have gradually realized the possible benefits of exercising when injured.

Peggy Houglum, Ph.D., an assistant professor in the department of athletic training at Duquesne University in Pittsburgh, traces the evolution of what we could label ‘early exercise’ after injury. ‘During the late 1979’s, a common treatment for a surgical repair of ACL (anterior cruciate ligament) was to place the leg in a cast for several weeks,’ she says. ‘People’s knees suffered a loss of motion and tendon damage that were very difficult to overcome. Shortly after that, continuous passive motion machines were devised, and doctors had patients put their knees into them immediately after surgery, with tremendous results.

Finally, as research into tissue healing became more prominent, we discovered that early motion could be beneficial for injuries and surgical repairs.’

Of course, before you continue your workouts you should ensure you do not have a more serious injury, one that actually does require rest (see How to Know when to Call the Doctor.)

While we’d all prefer a precise prescription for the proper time and level at which to resume exercise, Denegar says that there is no scientific consensus. ‘I tell people two things: First, your activity should not be painful to the point where it alters your normal movement pattern. If you’re limping you should probably rest, but if you have nagging pain and you’re not altering your stride, you’re OK. The other caveat is that you should be able to do tomorrow what you do today. If you work out after an injury and the following day you have lasting soreness, then it’s time to take a few days off. ‘

If a physician rules out broken bones and torn ligaments, tendons or muscles (which would require rest), and if pain is no worse after exercising than it is when you’re walking or engaging in other natural movements, you can resume your workouts. But if you’re diagnosed with tendonitis or a sprained muscle or tendon from overtraining, don’t resume your exercise at the same level of intensity. If you’re a runner, experts recommend that you do shorter distances or the same distance at a slower pace.

Carroll says that one sports medicine ‘lineage’ believes that after an injury, people should cross-train at least part of the time. Others think that the safest course to completely shift to another sport/exercise mode until the pain is gone. So, if you’re a runner you could swim instead, or if you’re a cyclist you could play tennis or use a stationary bike or a rowing machine. The goal is to maintain your current cardiovascular level without risking re-injury. And there’s the rub. Because no matter how safe you play it, there’s always a risk of exacerbating the injury. Carroll says, ‘Especially if you’re not in shape, you’re going to have a tougher time coming back or in rehab, and doing it by starting in a state of paincan be pretty hard.’

The risks for the weekend warrior are probably greater than for the elite athlete, says Houglum. That’s because the average Joe- who may be getting a ton of conflicting advice from the Internet and fellow sports enthusiasts- is more likely to conduct a misguided self-diagnosed or to receive a misdiagnosed by what she calls ‘an appropriate healthcare provider.’ Either outcome could lead to the wrong treatment or no treatment at all.

Anti-inflammatory drugs are another point of controversy, says Houglum. ‘Some studies advocate taking them to reduce the inflammatory chemicals the body releases during the initial phase of healing. Yet there are studies that indicate anti-inflammatories do nothing to accelerate the healing time and may, in fact interfere with it, since inflammation is a normal part of the healing process.’ These drugs also can cause gastrointestinal problems such as stomach ulcers, and put stress on the liver, where they’re metabolized.

Experts are also divided on whether to ice the injured area. The conventional wisdom is to do so 20 minutes before and after resuming exercise. The reasoning was that the ice would constrict blood vessels, thereby preventing some of the inflammatory white blood cells from reaching the injured tissue.

However, Houglum says that recent research weighs against the use of ice. She says that icing may prevent the body from feeling pain and mask- at least temporarily- a more serious injury. It may also suppress the natural healing mechanism by suppressing inflammation.

Perhaps the strongest argument against resting after an injury is the psychic toll it can take. ‘The worst thing I can do to someone participating in regular sports is to have him or her completely discontinue them’ says Denegar.

‘We use exercise to dissipate stress and feel good about ourselves, and to totally shut down is pretty stressful. Also, the older you get, the harder it is going to be to come back after being completely inactive.’

Despite the growing evidence in favour of post-injury ‘early exercise’, many physicians feel uncomfortable giving their patients what they consider a premature green light, for fear the patients will aggravate the injury and blame the doctor.

According to Denegar, physicians who feel this way have a legitimate concern. He adds that the kind of advice a physician dispenses depends on the degree of familiarity between him and his patients, as well as the physician’s background. ‘If a doctor knows a patient well and thinks he’s got common sense, he can feel more comfortable advising him to continue exercising.

Of course, a sports medicine specialist will have more experience and knowledge dealing with athletic injuries than a general practitioner. Finally, if the doctor is conservative and not physically active, he may just pass that on to his patients by telling them to rest.’

How to know when to call a doctor

Peggy Houglum, Ph.D., of Dunquesne University says you should ask yourself the following questionsto determine if you should consult a physician about your athletic injury.

• If you have a leg injury, can you walk on it without limping?

• If it’s an injury to an upper extremity, can you work the body part and lift items without making unnatural adjustments?

• Is there significant swelling?

• Is the area black and blue? (This indicates that something has torn)

• On a 0-10 point scale, how much pain do you have? (Anything above 6 is serious.)

• Does the injury make it difficult to get a good night’s sleep?

• Does it interfere with your daily activities?

She adds that in such situations, ‘X-rays are overrated, they only tell you if a bone is broken or a joint is out of place.’ Most sports injuries are not bone injuries, but soft tissue injuries, and these do not show up on X-rays. MRIs are used to diagnose soft tissue injuries, but these can be expensive.’

Knowledge of one’s body and how it reacts to injury is very important, Houglum adds. For example, do you swell easily when you get injured? Do you have high or low pain tolerance? As you get older, it takes your body longer to heal, and so an ankle sprain you suffered as a teenager may be more problematic when you’re 55. You need to consider this when evaluating how your body is reacting to an injury.’ She notes that conditions such as asthma and diabetes also affect healing.

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