by Adam Gershowitz, DPT
This topic has come up again and again as we continue to deal with the impact of Covid-19 on our lives and in our communities. While asked to remain flexible and open to the unknowns around us, those patients engaged in physical therapy are asking another set of questions about how to keep up with – or sometimes, begin – their rehabilitation and recovery from an injury or procedure. It may be helpful to answer these questions by first breaking down recovery into rehab categories, each of which requires its own care plan and PT regimen.
PRE-OPERATIVE. Many patients were scheduled to have an orthopedic or other surgical procedure that had to be postponed because of the pandemic. Unfortunately, having to re-schedule your surgery doesn’t make your unstable knee act more stable or the bone spur in your neck stop pressing on that sensitive nerve. But we can use this unscheduled time to better prepare the body and mind for surgery and recovery.
We strive to treat each patient as unique, and when considering surgery for a patient, multiple factors are used to determine the optimal time (Shelbourne & Patel, 1995). The most critical factors include:
- Severity of injury, including how many structures are involved
- Condition of the joint(s) involved, including swelling, range of motion, strength, control, etc.
- Mental preparedness of the patient
- School/Work/Social Schedules
Often there is time to delay surgery. In fact, there are instances when postponing a surgical procedure can have a more positive outcome, given the additional time to undergo pre-operative training. Unless it’s an emergency, delay is ok! Certain orthopedic procedures have been shown to have minimal-to-no difference in clinical outcomes when surgery is delayed (Smith, Davies, & Hing, 2009). And with certain conditions, such as ACL reconstruction, a delay between injury and surgery allows for faster progression of quadriceps strength and quicker progression to sport-specific training (Shelbourne & Foulk, 1995). If you are waiting to have surgery that has been unexpectedly postponed, here are some guidelines to consider:
- Find a qualified Physical Therapist first. Don’t go it alone! A PT will develop a customized protocol for you that will improve the strength and stability of even the most compromised joints. You can implement this protocol while awaiting your surgical appointment.
- Train your deficits. Identify those factors most affected when determining your surgery date. For example, if you have a torn rotator cuff tendon which leaves the shoulder stiff and weak, include shoulder range of motion and strength exercises in your pre-op regimen, and schedule your surgery when you’re stronger and more flexible.
- Range of Motion is critical. When in doubt, focus on your range of motion, i.e. your flexibility or joint stiffness. Simply put: if it doesn’t move and it’s supposed to, it’s not functional. Retaining functionality is goal #1 in physical therapy.
- Set Goals. Work with your PT to set realistic goals for your range of motion, flexibility, strength, and function to achieve more successful outcomes.
Taking extra time to prepare yourself objectively and subjectively for the upcoming surgery can result in better surgical outcomes and a speedier recovery. You can help your surgeon help you!
POST-OPERATIVE. This group includes patients who had an orthopedic surgical procedure in the 0 – 12 months prior to the pandemic outbreak. You may have progressed to a certain point of a rehabilitative protocol with the goal of returning to the same, if not better, functionality than prior to surgery. Continuing treatment in-person may very well be essential, but we have also discovered that the use of telehealth appointments can provide a productive interim step. Consider these post-op guidelines:
- Stay in touch with your providers. Communicate regularly with your care team, including your surgeons, physical therapists, trainers, family, and friends is crucial. Set a minimum of twice a week for check-ins. Determine if in-person care is required or if virtual care may be sufficient.
- Know your protocol. Rehabilitation starts with a customized PT protocol, a set of guidelines and recommendations for the progression of your condition. Any final decisions about the prescription of therapeutic exercises and the progression of phases should be made by your rehab professional in consultation with you. One of the most effective ways to achieve your post-op goals is to understand your protocol and what it requires of you. Be sure to request a copy of your protocol from your provider. Then, practice, practice, practice.
- Stay the course. Setbacks happen to every patient. Control what you can and focus on today’s challenge. Stay motivated! COVID-19 may slow your progress, but within those confines consider those elements of your care that you CAN control. Create a set of small achievable goals, such as working for five more degrees of knee flexion, getting up and down from the floor after knee/hip replacement, standing on one leg for 30 seconds, or increasing your running duration from 10 – 60 sec. Use your protocol to set milestones.
- Focus on Recovery Health Behaviors. Use your time at home to improve other healing factors. Become familiar with nutrition for optimal rehabilitation, understand the link between hydration and recovery, and read up on the psychology of healing. Ask your provider for recommended resources and pay attention to upcoming posts.
SPRAIN/STRAIN. For those already under treatment for a sprain or strain, or with new overuse injuries sustained while waiting out the pandemic at home, be in touch with your provider right away. Thanks to the increased use of telemedicine, patients are finding surprising success in virtual encounters with their providers. In the meantime, consider the following guidelines:
- Practice the PRICE Rule. PRICE stands for Protect, Rest, Ice, Compress, Elevate. This acronym is a handy way to remember the first-aid steps for an acute onset of a sprain, strain and other soft tissue injury.
- Consult a PT Quickly. Be in touch with a PT to obtain a working diagnosis and an explanation of a typical progression for your diagnosis.
- PLAN, PLAN, PLAN. Follow your protocol by the schedule. Protocols will become more criteria-specific as you progress, i.e. “if you can do this, AND it’s been this long, then begin to do this.” Understanding the criteria for advancing to a new exercise will encourage you to meet those criteria and minimize the potential for a set-back. Design a rehab schedule based on the required criteria, time since injury onset, and your own personal schedule considerations.
- Practice patience. Most soft-tissue injuries take 4-6 weeks to heal fully. While healing is very individual, expect to be symptomatic and operating at a deficit for at least 6 weeks. But that doesn’t mean 4-6 weeks of complete immobility! Slow and steady progress wins the race now. The appropriately progressed type and amount of stress on an injured tissue can accelerate tissue healing, and by carefully increasing tissue prep and loading, along with using sport specific drills, you will heal at a faster rate than by rest alone. Take time and be gentle with yourself.
- Concentrate on Nutrition. Eat to heal! There is an increased body of evidence regarding nutritional requirements for rehabilitating tissues. By eating low inflammatory foods, increasing protein intake, and drinking plenty of water, you can improve the quality and quantity of your recovery time.
PAIN. Myofascial Pain Syndrome, chronic pain, postural pain – these can all be a common part of the rehabilitation experience. The Mayo Clinic defines Myofascial Pain Syndrome as a chronic pain disorder involving pressure on sensitive points in your muscles (trigger points). This causes pain in the muscle and sometimes in seemingly unrelated parts of your body. This is called referred pain. This syndrome typically occurs after a muscle has been contracted repetitively as in repetitive motions, jobs, hobbies, or by stress-related muscle tension. Typically, PT patients can experience a wide range of pain symptoms during recovery, from deep aching to burning/tingling tightness. Consider these guidelines:
- Motion is Lotion. The proven way to reduce pressure on sensitive pain points is to perform comfortable movements that increase blood flow systemically and allow for tissues to loosen and stretch. Walking is a perfect example of a motion that acts as a “lotion” for the connective tissues of the body.
- Understand the factors. Sometimes it is difficult to remember exactly when or why certain pain symptoms started. Repetition of certain movement patterns over time can have a deleterious effect on the body. Suddenly you may experience an acute pain episode that is actually the result of long-term misuse of proper body mechanics. For example, during this pandemic you may be sitting every day at a make-shift desk at home, often uninterrupted, in a position where your hips are flexed and your hip muscles shortened. This can result in hip, low back or leg pain – seemingly coming out of nowhere! Getting up regularly, walking around your kitchen, or doing some gentle stretches for the hips can equalize the time your muscles are in flexion, and relieve the pain you’re experiencing.
- Practice Patience. While it usually takes time to develop your pain symptoms, it will also take time to change your movement patterns to relieve the pain. PT treatments involve a variety of movement screens, stretches, and exercises that will reduce the pressure on targeted areas and allow them to become desensitized.
- Nutrition. Myofascial pain can be affected by what and how much you drink. Being dehydrated can have a negative impact on your nutrient delivery system responsible for transferring energy from your blood to your cells. Be sure to drink an adequate quantity of water each day, preferably around 64 fluid ounces.
In summary, there are some common themes across all categories of rehabilitation and recovery. COMMUNICATE. NUTRITION. PATIENCE. Especially during these uniquely uncertain times, it’s important to keep your eye on the prize and recognize that meaningful progress takes time and practice. Stay in touch with your provider and exert control in your life where you can. By following these guidelines and staying positive, you will make headway with your recovery and you will feel better!