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Acute Management Injury/Pain.

The following section is evidenced based information and advice which patients may find helpful in the self management of an acute (under 6 weeks) injury or onset of pain.

Acute Soft Tissue Healing Times

If you have had an acute onset of pain it is possible that there may have been minor soft tissue injury that has occurred and is contributing to the onset of the pain.

Once soft tissue damage has occurred there is a well-recognised healing process. This is summarised in the graph below:

 

Tissue Healing

 

 

This applies to musculoskeletal tissue including muscle, ligament and joint tissue such as joint capsule or disc.

Soft tissue healing can take up to 6-12 weeks. This means that your pain can take this length of time to improve. In 60-90% of patients their pain will fully resolve within 12 weeks.

 

Management of Acute Injuries or Pain.

When it comes to managing an acute injury/pain many patients may be aware of the RICE or PRICE method.  For those who have yet to come across this acronym it stand for Protect Rest Ice Compression Elevation.

This process was developed to deal with the immediate phase after a soft tissue injury, characterised by an acute inflammatory response.  The cardinal signs are as follows:Heat, Redness, Pain and Swelling. 

Research now suggests using the  POLICE method. Protect, Optimal Loading, Ice, Compression, Elevation.

 

PROTECT:

The purpose of protection is to avoid further injury to the area by protecting the injured structures. The type of protection used varies depending on the injured area but may include a bandage, splint, sling, protective tape, or over-the-counter brace.

 

OPTIMAL LOADING:

Why 'optimal loading' and not 'rest'?

Rest may be useful in the immediate short term (<48 hours), however continued rest could cause deconditioning of the tissues, joint stiffness, muscle weakness and tightness and reduced proprioception (control and balance).

Optimal loading will stimulate the healing process as bone, tendon, ligament and muscle all require some loading to stimulate healing.

The right amount of activity can help manage swelling. 

  

ICE:

Cryotherapy is an effective, inexpensive and simple intervention for pain management.  So what specifically does ice do?

From a pain perspective numerous studies have concluded that a person's Nerve Conduction Velocity (NVC) is significantly and progressively reduced concomitantly with skin temperature.  Associated with the changes in NCV, are increases in Pain Threshold and Pain Tolerance.  So in a nut-shell in acute pain states, application of ice will help to reduce your pain.

Previous other suggestions for the application of ice have been the role of controlling inflammation.  However current research is undecided at present.

How to Apply Ice:

Current research advocates the use of crushed ice only as this adequately cools the temperature of the area to between 10-13C (therapeutic ranges).  Length of time to reach this therapeutic range is typically 15 minutes, however suggested icing application is for 20 minutes as this limits the increase in temperature. This can be repeated every 2 hours if required.

Make an Ice Pack:

Place crushed ice into a small plastic bag and then tied off at the top. By using a small amount of ice, squeezing out all of the air from the bag, and tying the knot at the very top, you can produce an ice bag that can be flattened out and wrapped around an injury, completely covering the injured area.

WARNING:

Ice left on an area for too long (+60 minutes) can burn.

Contraindications to use of Ice:

  • Active Deep Vein Thrombosis (DVT) or Thrombophlebitis.
  • Areas near a chronic wound.
  • Cold hypersensitivity e.g. Raynaud's, cryoglobulinema, hemoglobulinemia.
  • Cold urticaria (cold allergy or hypersensitivity).
  • Impaired circulation.
  • Over regenerating nerves.
  • Tissues affected by tuberculosis.
  • Haemorrhaging tissue.
  • Untreated haemorrhagic disorder.
  • Areas with impaired circulation.

Precautions to use of Ice:

  • People with cardiac failure.
  • People with hypertension.
  • Areas of impaired sensation that prevent people from giving accurate and timely feedback.
  • Infected tissues.
  • Damaged or at-risk skin.

 

COMPRESSION:

The rationale for using compression pressure is to minimise initial tissue haemorrhage after injury however the research remains conflicting.

If you are to apply compression to your injured area attempt to complete this immediately after injury, with continuous use over the first 72 hours. 

How to Apply?

When applying compression you should aim for uniform pressure, from the highest point of the limb/injury to the lowest point.  Compression can be applied through the use of elastic compression bandages.

WARNING:

Research has suggested that compression should not be combined with elevation.

  

ELEVATION:

What it could do?

The theory for using elevation after injury is to try to restore the pressure gradients within the affected tissue.  Elevating an acutely injured joint could decrease the gravitational force exerted on the column of blood between the heart and limb. With the possible result being decreased hydrostatic pressure within the vasculature, minimising swelling and the resistance to venous and lymphatic flow around the injured tissue.

How to Elevate.

Despite clear rationale, the optimal duration or angle of elevation remains contentious.  However if you choose to elevate your limb try to complete this as long as can be tolerated. 

It is also important to know that some research suggests that after elevation the limb volumes return to their original measurements after 5 minutes, on return to a gravity dependent position e.g. Ankle - sitting with foot on the floor.  Clinically, a graduated return to standing after elevation is perhaps most likely to minimise rebound swelling and discomfort.  

So why Elevate? 

Well during the period of elevation is perhaps an opportunity for you to gently move the injured/painful tissues more easily which if repeated frequently could reduce localised stiffness.

 

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