The acute and hyper-acute injury
by James Hoven, DC
When people come to you for help after experiencing an injury that has them sidelined, it's important you have the knowledge to get them feeling better as quickly and effectively as possible. Let me offer a few easy-to-apply principles you need to know to get your patients better faster.Like any injury that requires rehabilitation, there are three questions to be answered when treating the acute and hyper-acute injury that will assure a safe, effective rehab program.
Question #1. Is this injury acute? When an injury is in the acute stage, the most common findings will include a very limited range of motion; mild to severe swelling over the injured area, a sense of warmth to the touch; redness and/or bruising of the skin; and pain that could be described as exquisite, localized, and sharp.
Question #2. What are the goals of treatment in the acute stage of healing? When treating an acute or hyper-acute injury, there are certain specific goals that need to be achieved before moving the patient into a more aggressive form of treatment. Progressing too fast through an acute or hyper-acute injury can actually produce damage to already injured tissues, thus complicating the injury and lengthening the time of healing. The goals that should be reached during the acute stage of healing include:
- Pain reduction - Pain is usually rated as a 7 or more out of 10 in acute and hyper-acute injuries. Before the patient can begin movements to increase strength and flexibility, he or she must first have a reduced level of pain!
- Swelling reduction - Swelling is a way of stabilizing injured tissues. As swelling decreases, it's a sign the body's healing, and that it's ready to progress to more complex motions that can increase balance, strength, and flexibility. Until swelling subsides, there's no good reason to put high levels of stress on the soft tissues or the joints.
- Increased range of motion - During the acute phase, one goal is to create increased circulation to the injured area. This is accomplished by introducing a very controlled, very limited range of motion. They key to range of motion in this phase of healing is keeping the movement "low and slow," meaning the motions are small and completely controlled.
- Increased flexibility - Injured tissues need to have a certain amount of motion to speed removal of metabolic waste products. Working on the tissue flexibility will begin this process.
Question #3. What exercises should I use? This can be the most complicated of all the questions in treating the acute or hyper-acute injury. The answer is simple, but the application can be confusing until the doctor takes the time to learn a variety of exercises and movements suitable to the acute stage of healing. When choosing exercises or movements, remember that they need to meet the goals of reducing pain, reducing swelling, increasing range of motion and increasing flexibility. To do that, follow these two simple guidelines:
- Always perform ALL movements within a pain-free zone. For example, if you can move the injured area 10 degrees with no pain and 15 degrees with pain, the movement should be no more than 10 degrees. This will assure that no more damage occurs to the soft tissues or joints while performing the prescribed motions.
- Perform sets of 35-100 reps for each motion. On the surface, this sounds completely counterintuitive. Most of us couldn't imagine doing sets of 100 biceps curls on our best day, never mind if we had an elbow, arm, wrist or shoulder injury! In the case of the acute healing phase, the 35+ repetitions is done in a pain-free fashion, which means that the range of motion will be small...very small! In fact, depending on the joint and the tissue involved as well as the movement performed, the range of motion may be in the range of 5-10 degrees. That equates to not much more than a small muscular contraction. This process will allow a pumping action to take place to move metabolic waste out of the tissues while moving blood (which aids in healing) into the tissues. It'll also increase neurological action to the tissues, which is important in helping to increase flexibility and range of motion. With the chosen exercises, the number of reps should be at least 35 and should be continued until a sense of fatigue sets in. At that point, the patient stops, rests and begins another set of 35+ reps until fatigue once again begins to set in. Acute phase exercises commonly incorporate 5-10 sets daily, or more.
Following these guidelines will help you achieve great results with your patients who suffer acute or hyper-acute injuries. While no specific exercises were provided here, the concepts you've learned can be applied to all the exercises you already know! If you don't have a list of exercises, look some up in your rehab books, online, or look into one of the many software programs that do a great job of listing out protocols for all body parts.
(A graduate of Logan College, Dr. Jim Hoven is vice president of education and compliance for HealthSource, a network of more than 250 chiropractic offices focusing on progressive rehabilitation. He has built several successful chiropractic practices throughout the Denver area and is a popular speaker at business, civic, and governmental events. Dr. Hoven has traveled the country consulting with medical clinics on documentation and coding issues related to physical medicine procedures.)
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