Alas, and so it must be; all good things come to an end!
In the final instalment of May’s ‘Physifitt does shoulders’, we’re looking at common treatment methods and what techniques may be more beneficial than others. If you haven’t already, check out Part one and Part two on shoulder anatomy and common injuries. It will make this part a lot easier to follow.
In the last post we looked at the top 3 issues that we Physios commonly see and treat: frozen shoulder, rotator cuff issues and cartilage tears. This post is going to look at treatment modalities we use to assist your recovery from these issues. Remember folks, get yourself assessed by a Physio before commencing any treatment.
Generally, shoulder pain will improve by itself in around 2 weeks. However, you can often help this recovery by giving yourself some PEACE and LOVE. For those of you who follow me on social media, you’ll have seen the infographic I posted recently about this which was originally published by the BJSM. Historically, we advised on protection, rest, ice, compression and elevation (PRICE) in the first instance following injury. As everything, we’ve moved on from here and are starting to think that PEACE and LOVE might be more beneficial. Let’s take the PEACE first.
The P is for protect. We want to have a period of restriction for 24-72 hours immediately post injury as this helps to reduce bleeding to the area. The E is for elevate which says what it means on the tin – get the arm higher! This is going to help reduce swelling. We know it’s not got great evidence to support its use but it is still recommended due to the low risk. A is for avoiding anti-inflammatories. Inflammation is the first part of the healing process and we actually need this to help kick start our recovery. Anti-inflammatories reduce this and their use – especially for prolonged periods and at high doses – can be detrimental for long term recovery when used in the immediate phase post injury. C is for compress – tighten it up! Tape, bandages, pushing it all help reduce swelling and bleeding as well as giving some feedback for decreasing pain. Finally, the E is for education. It’s important for us Physios to help you understand straight away the likely recovery times, what’s happened, that there is nothing serious occurring and that you will recover. It’s also important for us to help you take an active approach to your recovery – things like massage, acupuncture and electrotherapy in the immediate stages post injury do virtually nothing and have been shown to be more detrimental in the long run than taking an active approach.
After the first 1-3 days have passed, we’re looking at giving ourselves some LOVE.
L is for load. Listen to your body and be guided by your symptoms on this one. If your pain levels exceed 5-6/10 then it’s probably not a good idea to continue with that task. But loading an injured area early has been shown to have positive outcomes by improving repair and remodelling phases (the next 2 phases of healing after inflammation), improving tissue tolerance so it’s less likely to ‘fail’ treatment and improves the strength and capacity of muscles, tendons and ligaments which will improve your overall performance. O is for optimism. It’s so easy to become down, get frustrated with yourself when you’re injured, become annoyed that you can’t do the things you normally do but remember that you will get better, nothing serious or sinister has occurred and it’s safe to participate in the rehab plan your Physio has created – they would have referred you on to someone else if they were concerned about any of these things! V is for vascularisation. Cardiovascular work like walking, rowing and swimming all help to keep blood flow going to the injured area boosting the healing process as well as keeping it mobile to reduce any stiffness or reduction in range of motion. Finally, E is for exercise. Exercise in general will help with your flexibility, strength and proprioception early on in the injury process. Remember that it’s ok to be uncomfortable as exercise isn’t supposed to be easy but pain shouldn’t be occurring – remember >5-6/10 stop! (if you want to read more on Peace and Love check out the BJSM website).
And that’s the first few weeks! Simple right? But what happens next?
Well, your rehab plan should be progressed to make it harder! I’m sure that’s exactly what you wanted to read! Once the acute symptoms have settled, we can make things more difficult to make sure we have full range of movement. It’s interesting as often purely stretching will be prescribed to try and achieve this but there’s a host of research now advocating the use of strengthening (in particular the eccentric phase) as using resistance helps the joints move through their full range especially on the lengthening part of the movement. That’s not to say stretching doesn’t have a place – of course it does! – but let’s maybe think a bit wider and incorporate both fitness elements to ensure the best possible position for recovery.
When your range of movement has improved this is when we’re going to push you further again and start looking more at strength and conditioning principles – think global and explosive! We’ll be starting to bring in lower reps and cranking the weight up to make you work – it won’t be easy and your pain and RPE should be taken in to consideration at this point. We will also be looking at things like throwing, bouncing, dropping and catching. Interestingly, this is where most people drop away from Physio. Generally, the initial symptoms are under control and pain has almost fully settled but there’s still work to be done in terms of building that tissue tolerance to make it BETTER than it was before your injury. What’s the point in taking you purely to where you were when you got injured? You got injured for a reason at the end of the day so should we not strive to be better than this state?
Once this phase has been completed, you are generally good to go. After a final evaluation where all of your outcome measures should have improved your Physio will likely discharge you back to fitness. RESULT! You made it – well done =D.
I’ve focussed a lot on active recovery through this post and that’s because it really is what has the most support in our research and evidence for long term recovery with the lease harmful effects. When people think of harm they think of physical harm like bleeding from an injection for example. We’ve found a lot of emotional harm can come with excessive use of manual therapy – things like reliance upon your therapist, beliefs being instilled that harm has occurred and it’s not safe to move or load, encouraging avoidance behaviours and negative thinking. None of that’s very good is it?
This isn’t to say there isn’t a place for manual therapy. It’s something I still use in practice. When you look at deep tissue massage for example there’s some evidence suggesting that the power of touch is wonderful at assisting with rapport and reducing sensitivity, but it isn’t what’s going to make you better in the long term. That’s the same with acupuncture – there’s some evidence to support its use in creating inflammation to promote the healing process as well as stimulating the body’s natural painkillers but it’s not what’s going to make you better in the long term. Electrotherapy – things like ultrasound and interferential – has been shown to help with building rapport and reduce sensitivity as well but it’s not what’s going to get you better in the long term.
What do all of these things have in common? PAIN REDUCTION!!!!!
They MIGHT help at reducing your pain giving you a window of opportunity to work through your rehab plan, engage in social activities, stay at work and live your life.
My main take away with manual therapy is that it’s not a demon but the narrative that comes along with it is. Please understand that no amount of manual therapy is going to ‘fix’ or ‘cure’ you. It isn’t the thing that’s improving tissue length or increasing your strength. Give yourself some credit – you’re the one doing that!! You’re the one putting in the effort day in and day out to get yourself better. You’re the one that’s trying your damned hardest to improve your symptoms by sourcing help. Manual therapy facilitates your recovery but it’s YOU that’s going to get there with the Physio coaching you through your rehab plan along the way.
It is important to note that sometimes Physio doesn’t work for a variety of reasons and we may then make a referral to our medical colleagues to review you. They might talk to you about exploring injections which is basically a steroid being put in to the joint to reduce inflammation or even surgery. Most Orthopedic surgeries don’t have great outcomes and ordinarily a little longer with the Physio will get you there so don’t go jumping straight for the scalpel without doing your research and chatting with your provider first.
And there we have it folks! A brief overview for shoulder treatment although I suppose the principles could be applied to most soft tissue injuries. I’ve tried to keep things to what we Physios should be doing according to our governing bodies recommendations but if you have any questions or queries about anything at all just get in touch!
Thanks for taking the time to be a part of my shoulder series. I’ve really enjoyed putting this together and I think I might now have a theme of the month going forward. If you have any suggestions on what you’d like to see let me know!
Until next time x