4.6: Rehabilitation for Strains and Sprains

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Pathophysiology

Many of the current clinical practice guidelines for acute care of sprains and strains run counter to some long-held beliefs. One of the primary changes surrounding the management of acute injuries is that most guidelines recommend against the use of ice to control inflammation. It is now recognized that ice can delay healing, increase swelling, and possibly cause additional damage to injured tissues (Duchesne et al., 2017).

Examination

A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

Self-Rated Recovery Question
Patient Specific Functional Scale
Brief Pain Inventory (BPI)
Visual Analog Scale (VAS)

Treatment

Education

Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

Ascribing a patient’s pain solely to a tissue-driven pain problem is often an oversimplification of a complex process. This insight provides us with an opportunity to re-frame our clinical models. Gently stretching the muscles, neurovascular structures, and investing fascia activates endogenous pain modulating systems that help to modulate neuro-immune responses. There is initial evidence indicating that conservative methods (exercise or manual therapy) may be able to mitigate the development of fibrosis and other similar pathologies by attenuating tissue levels of fibrosis and TGF-β1 (Bove et al., 2016; Bove et al., 2019).

Self-Management Strategies

By following the principles of load and exercise progression early movement and rehabilitation for acute muscle strains may accelerate return to sport. A recent article published in the New England Journal of Medicine highlights the role of early movement and rehabilitation for acute muscle strains (Bayer et al., 2017), this study used a combination of loads to accelerate return to sport including:

Static stretching (Three times a day 30 seconds)
Isometric exercises
Dynamic resistance exercises
Heavy slow resistance exercises

PEACE & LOVE: New acronym for the treatment of traumatic injuries

One of the primary changes surrounding the management of acute injuries is that most guidelines recommend against the use of ice to control inflammation. It is now recognized that ice can delay healing, increase swelling, and possibly cause additional damage to injured tissues. Traditionally treatment of an acute sprain or strain consists of RICE (Rest, Ice, Compression, Elevation), the most recent recommendation has been to provide soft tissue injuries with the PEACE & LOVE protocol to encourage optimal loading of the joint and tissue around the affected injury can affect the amount swelling leading to a faster recovery (Dubois & Esculier, 2020).

PEACE makes up the first steps you would take after an injury. Immediately after the injury you would want to protect (P) the injured structure, followed by elevating (E) the limb higher than the heart, avoid anti-inflammatory (A) both over-the-counter or prescriptions and ice, as they slow down tissue healing. Compress (C) the injured area to decrease swelling. Ensure patient education (E) on the risks of overtreatment.
LOVE makes up the progressive return to activities a few days after the injury. Gradual load (L) will facilitate healing, optimistic (O) influences the perception of pain and recovery speed. Loading and progressive return to activity will facilitate vascularization (V) of the injured tissues. The last step involves activity exercises (E) can help recover range of motion, strength and proprioception.

Prognosis

Massage therapy as a therapeutic intervention is being embraced by the medical community. This is in part because it is a non-pharmacological therapeutic intervention that is simple to carry out, economical, and has very few side effects. Existing evidence suggests that massage therapy (soft tissue massage, neural mobilization, joint mobilization) can be utilized to help relieve pain, improve function, and reduce anxiety when integrated with standard care (Brasure et al., 2019). However, massage therapists should not overlook the importance of educating patients and addressing psychosocial factors to enhance recovery, which is the backbone of rehabilitation of acute injuries.

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for sprains and strains based on patient-specific assessment findings including, but not limited to:

Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
Hydrotherapy (hot & cold)
Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

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