Our bodies and minds are amazing and resilient. You only have to look at some of the tragic circumstances and horrific injuries that individuals have endured and survived, to appreciate the incredible capacity human beings have to recover and thrive.
We meet people in challenging situations every day and every one of them is different. Each individual comes with their own personal presentation. They present with problems in different areas of their body, they come from different backgrounds, and they have different demands on them whether that be at home, at work or in leisure or sporting pursuits.
Acknowledging the different aspects of a person’s being is imperative in looking after the individual wholly and holistically. This is what is known as the biopsychosocial approach to care. This approach is the most up to date way of addressing all the aspects that may impact on someone’s health. This ensures we are able to target the issue you are presenting with from all angles and to ensure you get the best results possible.
Although the biopsychosocial approach is now widely accepted as the optimal approach to health care, many still adopt a biomedical approach focussed on biology and structures as the sole cause of dysfunction. Although this model still has merit, particularly in the case of acute injury, it is not able to explain why problems often persist after healing has occurred. To understand the processes involved we must look to other contributors of pain such as psychological factors and social factors, comorbidities and genetic factors. Indeed if we do not look at the other contributors to someone’s presentation and address these we may find that the results we get reflect this by achieving a less than desirable outcome.
Traditionally people are used to looking at biophysical factors such as joint stiffness, weak muscles, poor recruitment patterns, altered postures, increased weight and inappropriate loading of the tissues. Other issues like poor sleep may also be playing a role and smoking too.
Other comorbidities and genetic factors may come into play and often these cannot be changed but their significance is important to acknowledge. For example, diabetics have delayed healing, and this can impact on recovery and outcomes.
The impact of psychological factors cannot be downplayed and this can vary from real mental health issues like depression and anxiety, to adverse childhood events and psychological trauma, to the more insidious unhelpful thoughts and beliefs that can impact on one’s health. For example thinking that ‘pain always equals damage’, ‘pain means I need complete rest’ or ‘I won’t bet better without surgery’.
Social factors also come into play, with those from non-English speaking or with low socioeconomic status often having poorer outcomes. Social support from loved ones is important and stress within families or at work can introduce barriers to recovery.
Seeing an individual as a whole person in their individual context is important for best results and this gives us many options to improve things from manual therapy and exercise, to getting out and having fun, to talking to a friend about our issues, to losing weight, to getting professional help for relationship issues. The options are endless and they are all helpful.
Homing in on what we can do with physiotherapy to address an individual’s presentation, we will first look at an acute injury and discuss the healing process.
To keep things simple we will discuss a simple muscle strain, ligament sprain or fractured, also known as ‘broken’, bone. In the first seconds after injury the tissue bleeds until clotting occurs to stem the bleeding.
Immediately inflammation occurs as a response to the bleeding, causing an influx of fluid and chemicals to the area causing it to become swollen, hot, and painful. This process can occur for up to about 7 days depending on the extent of the injury.
Within the first 2-3 days the repair process kicks off and this lasts several weeks to months depending on the tissues involved. For example, a simple muscle strain may repair with a couple of weeks, a standard ligament tear may take 6 weeks and a broken bone 12 weeks. Ideally pain is proportionate to the risk to the tissues and as such pain is usually more intense initially as the tissues have only just started to heal and therefore need more protection. It is appropriate to feel pain early in the healing process and this is helpful, so you don’t do too much and injure yourself further. After about 2-3 weeks there will be sufficient healing to improve the integrity of the tissues and so they are able to withstand more load and stress, and this is usually when pain reduces, and we feel happier to do more.
Once there is decent repair, after about a few weeks, remodelling begins, and this can last for many months as scar tissue softens and stretches and strengthening occurs.
Knowing what is happening after an acute injury helps us to realise that pain, although unpleasant is completely appropriate. It is also useful to utilise appropriate analgesia and anti-inflammatories at this stage as this is when these medications are most useful and reducing the severity of pain at onset is predictive of better outcomes helps get us moving sooner.
Sometimes tissues may not be torn but they may have just been overloaded or subjected to more stress than they like. This can also cause pain, irritation, and inflammation. This is what usually occurs in cases of tendinopathy such as rotator cuff related shoulder pain, tennis elbow and greater trochanter pain syndrome (lateral hip pain). In these cases, often it is sufficient to reduce stress and unload the tissues to allow them to settle down before recommencing graded loading and applying stress once again. All of us would have felt pain like this at some point, and if we don’t continue stressing the tissues or start worrying or panicking about the pain, things usually settle quite quickly.
So stay positive, keep moving at appropriate levels, consider your whole person and where undue stress may be affecting you, and get guidance from your physio if your pain is persisting and not settling as expected.
