Category — Injuries

After discussing the healing process in Part 1 and the goal of massage in the inflammatory stage (the first stage of the healing process) in Part 2 it is now time to move into the ways in which I believe massage can be used during the regeneration phase of healing following an injury.

Once again, just to reiterate what I wrote in part 1 and my disclaimer:

There may be a number of things affected by an acute injury (labrum, disc, meniscus, fractures, etc) but the purposes of this blog series we will only talk about soft tissue injuries such as ligamentous sprains or musculotendious strains (pulls, tears, etc).

Disclaimer: To be clear, this is not to suggest, in any way, that massage is the only thing that needs to be done – it is only a small piece of the puzzle. The athlete should ALWAYS be encouraged to see a medical professional and then massage therapists should be encouraged to work as part of the team of professionals (Dr., PT, DC, ATC, Strength Coach) to ensure the athlete has a safe and healthy return to sport.

Part 3: The Regeneration Phase

The regeneration phase is the second phase of the healing process and follows the acute, inflammatory phase. Most of the literature would suggest that the regeneration phase can last anywhere from 5-12 days, or 1-3 weeks.

The regeneration phase, sometimes referred to as the proliferation phase, is characterized by a decrease in pain and swelling (the tissue may begin to look bruised and discolored) however the individual may still have pain with tissue stretch, muscular contraction, or palpatory pressure. Additionally, this phase marks the formation of new collagen as the less mature, type III collagen fibers begin the process of rebuilding tensile strength. This phase is often when scar tissue remodeling takes place.

During this phase the massage therapist has two key goals:

1. General reflexive treatments as discussed in the inflammatory phase in Part 2 of this series.
2. Assisting in functional scar tissue formation

General Reflexive Treatments

As I discussed in Part 2 of this series, the role of the massage therapist to provide general treatments that are reflexively based in order to stimulate the physiological system to create a shift into a more relaxed state, where healing can occur, and to address global soft tissue changes that may have come about from the acute phase where movement patterns are altered in order to prevent further damage to the injured tissue is a critical piece of the puzzle. (For my discussion on general approaches to massage please see a previous article I wrote, Sports Massage: Don’t Forget the Basics).

In this phase, this goal should still be of prime importance. As the athlete’s swelling begins to be reduced and light passive and active movements may begin to take place these sorts of treatments are essential to assist the athlete in an overall feeling of well-being and confidence. Just that psychological shift alone can be the “candy for the brain” that makes the healing process and the return to play that much quicker.

Assisting in Functional Scar Tissue Formation

During the recovery process scar tissue is laid down as a means of re-enforcing the damaged tissue to help assist in strength and stability and prevent further injury. As stated above, in this phase, the first pieces of collagen to be laid down are Type III collagen and they are less strong or mature then than the Type I collagen fibers which will be more prevalent in the final phase of healing, the remodeling phase.

That being said, connective tissue, like bone, is modeled along patterns of stress/strain. If we have more stress in one direction or plane of motion then there is a greater amount of tissue that is laid down to support it. In the later phase of the regeneration process the athlete will transition into a period where pain is now minimal (or completely gone save for some pain with palpation or possibly tissue stress). During this time period the athlete may see a decrease in range of motion or some muscle weakness but some local massage can begin in this later phase. You must work with the medical professional in your team (this is a team approach) to get their ideas of when you can begin to work on the area directly and what their thoughts are.

In this later portion of the regeneration phase, when I begin with local massage, I prefer more superficial type of work over pushing directly down into the tissue that may be painful (or may still have some residual swelling). Light skin work and gentle movement – starting with passive, pain free range of motion progressing to gentle active range of motion – to help the process along as far as getting the newly formed collagen fibers to remodel in the line of stress/strain that we are attempting to create, rather than allowing the individual to be totally passive and allow the collagen to form a mass of scar tissue and fibrosis that may limit function later on down the road. I always start gentle with this work and never force anything. Exercise caution (remember, this tissue being laid down is still not totally mature), start easy, and, again, always be sure to discuss the approach with the medical professional involved.

Wrapping up

The two main goals for a massage therapist during the regeneration phase are to assist the athlete into a state of relaxation and recovery (similar to the approach during the inflammatory phase) and to begin to assist the the tissue in healing by encouraging functional scar tissue formation and discouraging non-functional fibrosis to develop. Through this process the athlete should begin to see further reductions in pain (if there is pain still present), improved range of motion, and strength returning back to a normal level.

In the final part of this series I will cover the last phase of the healing process, the remodeling phase.

patrick@optimumsportsperformance.com

In Part 1 of this series I briefly discussed the healing process. To recap, the healing process has three main phases:

1. Inflammatory phase (0-5 days)
2. Regeneration phase (5-21 days)
3. Remodeling phase (21-360 days)

To review from Part 1:

There may be a number of things affected by an acute injury (labrum, disc, meniscus, fractures, etc) but the purposes of this blog series we will only talk about soft tissue injuries such as ligamentous sprains or musculotendious strains (pulls, tears, etc).

And to reiterate the disclaimer from Part 1:

Disclaimer: To be clear, this is not to suggest, in any way, that massage is the only thing that needs to be done – it is only a small piece of the puzzle. The athlete should ALWAYS be encouraged to see a medical professional and then massage therapists should be encouraged to work as part of the team of professionals (Dr., PT, DC, ATC, Strength Coach) to ensure the athlete has a safe and healthy return to sport.

Part 2: The Inflammatory Phase

The inflammatory phase is the most acute phase, occurring just after the injury or insult to the tissue has happened and typically lasts for 0-5 days. This phase can be broken down into two sub-phases:

1. Vascular Phase – The phase were bleeding is at its highest and characterized by a lot of swelling
2. Cellular Phase -The phase where myofibroblasts move in to begin the healing process

Because of all the bleeding, swelling, and bruising, and because the myofibroblasts are have not formed strong, stable bonds with the tissue yet, being aggressive and going directly into the damaged tissue with your fingers, thumb, or elbow would not be the wisest idea – additionally, the amount of pain the individual is experiencing in this acute phase would indicate that they probably don’t want you jamming your fingers in there anyway. While this may seem like common sense, I can’t tell you how many times I have heard from strength coach friends of mine that a massage therapist took their elbow aggressively to the hamstring of one of their players who experienced a pull in the game the previous day.

Allowing the medical professional in your network to deal with the acute inflammation would make the most sense but this doesn’t mean that you, as the massage therapist, can’t play a role in trying to enhance the healing process.

Goal: Influence Physiology and Psychology

Below is nothing more than my own ideas on how a massage therapist can assist in facilitating the healing process. It should not be taken as gospel and is supported by nothing more then my own experiences.

Physiology

Injury is an unfortunate part of sport and when it happens athletes are often put into a heightened state of alert as the damage that just took place is telling their brain that something is wrong, there has been a threat to the system, and the pain they are experiencing is telling them that they need to re-act to prevent further damage to the area. This reaction comes in the form of tightening/stiffening up and changing their movement to limit the amount of stress/load they place on the damaged tissue.

Tightening up doesn’t just happen locally on in the extremity that has been damaged (IE, tightening up the leg and limping if there is an ankle sprain or quad tear) but can be seen over the entire body as the stress and pain their are feeling has a global impact on how they move and experience their environment – you may see tension in the neck, the shoulders shrugging, tension in their face, and their thoracic spine in a more kyphotic position as they limp around and brace their body. Additionally, with this heightened state of stress and with the increase in inflammatory compounds being released at the site of injury there is an increased sympathetic state as the body is try to resist the stress that has been placed on it.

In this instance, massage can be part of the solution to help influence the individuals physiology. Our goal is not to locally work on the damaged site but to work remote to that site, on non-affected tissue, in order to:

1. Minimize stress in tissue that is compensating for the damaged region
2. Encourage a shift into a more parasympathetic state

Minimizing stress in tissue that is compensating for the damaged region can be extremely beneficial as part of the recovery process, especially as the athlete gets into later phases of healing and begins to work back into their return to play protocols. Oftentimes, changes that occurred in an individual’s movement during the acute phase of the injury can last even after the the damaged region has healed. These changes may be seen in loss of mobility, trigger point (or whatever people want to call them these days – abnormal impulse generating sites, etc) development in muscles remote to the area of damage which can create referral patterns and satellite trigger points within those referral patterns or antagonistic muscles that cause changes in movement or a painful response, and a lack of movement efficiency once the athlete is healed and ready to return to play. Working globally allows us to address the body as a whole and approach tissue that may be negatively influenced from the injury as it is forced to compensate and take on an additional role in this time of damage.

Encouraging a shift into a more parasympathetic state following an acute injury is critical in my mind, as I view this as a way of trying to get the person into a state where healing can occur. If we can tune-down the system and get the individual relaxed we may be able to influence the way their body heals as this relaxed state can be a very healthy environment for the body – rather than allowing the person to sit there, stressed out and constantly dwelling on the injury and how bad it is. More general techniques, again remote to the site of damage, can be useful when taking this approach. Unfortunately, many sports massage therapists may discard these general techniques once they get out of massage school, in favor of more directed/specific techniques. I believe there is value to these basic techniques as I discussed in a previous blog article, Sports Massage: Don’t Forget the Basics.

Influence Psychology

Athletes have very distinct maps of their bodies and psychologically they are very dialed in when it comes to how their body feels and how certain body parts are moving or not moving. For example, a pitcher really understands his arm, how it feels, and when something feels “off” or “not right”, just like a soccer player is very aware of his hips, how they move, how they feel, and whether or not their “groin feels a little tight” or their “hamstring feels a little stiff today”. I believe this is a quality that great athletes posses and it allows them to sense things in their body at a level that to most normal people probably wouldn’t matter that much. For example, if my shoulder is a little sore today it usually is not that big a deal to me but it may be a huge deal to a starting pitcher.

This “hyper-awareness” is both a blessing and a curse. A blessing because it allows them to do what they do at a high level and a curse because when something goes wrong, psychologically, it can really go wrong! I am reminded of a story that Butler and Mosely told in their book, Explain Pain, about the professional violinists who were put in a study with normal people off the street and everyone’s finger was pricked with a little pin to assess their perception of what they felt. For the people of the street the pin prick was nothing more than a pin prick and no big deal. For the professional violinists it was a huge deal and they registered it being painful. The enhanced sensory map and awareness of their hands that a professional violinist has makes them hypervigilant to anything that may be remotely threatening. I believe that this may work the same way in an athlete.

That shoulder pain that doesn’t really bother me is a pretty big event for the Major League pitcher and, when an actual injury happens – for example a professional soccer player pulls their hamstring – then psychologically this is a huge “threat” to them and this alone may cause an increased amount of swelling and inflammation as their body is maybe “overcompensating” for the injury. This goes back to what I discussed above regarding an increased sympathetic state and our goal of getting the individual to shift into a parasympathic state. Sometimes, the injury might not even be “that bad” but because the athlete is so hyper-aware and sensitive to that region of their body they over produce the inflammatory response and things get over-exaggerated and blown out of proportion.

Side Note: I wonder if when a soccer player “flops” they actually do experience pain or a sensation that feels “abnormal” to them – in some of these instances because obviously in other instances they really are just doing their best acting job – due to this hyper-awareness? They then roll around on the ground for 20-30sec only to realize that it is nothing and then get up and sprint back into the game.

Our goal with massage during this phase should be to allow the athlete to experience ease and comfort. Sometimes, this alone, allows them to calm down enough to realize, “Hey, things aren’t that bad! This isn’t as horrible as I thought it was! It doesn’t even hurt that much right now!”, allowing us to “get inside their head”, so to speak, and turn the tables and create an environment which is favorable for healing to take place. Sometimes, this psychological shift, can influence swelling, inflammation, movement, and pain perception as the individual is now starting to feel confident and not so worried.

Wrapping Up

There are a few approaches that a massage therapist can take in the acute phase of an injury and these approaches are to try and influence the body in a more reflexive way rather than a very direct way, on the area of damaged tissue. The global approach to massage during this time should be centered around three key phases:

1. Minimize stress in other regions of the body
2. Cause a shift to a parasympathetic state
3. Influence the psychology of the athlete and get them into a state of mind that is more relaxed

In Part 3 of this study I’ll get into some of the goals of massage in the second phase of healing, the Regeneration Phase.

patrick@optimumsportsperformance.com

Injuries are unfortunately a part of sport and while we attempt to train and do everything we can to prevent them sometimes they just happen (be it a freak incident or a traumatic injury that you had no way of preparing for).

Motivated athletes will often seek out any method possible that will allow them to rush back to play in the shortest time possible.  Obviously, when dealing with an individual’s health there are a number of things that need to be taken into consideration and that being said there may be things we can do, as massage therapists, to help facilitate the recovery process and get the athlete into the best state for healing to occur.

Over the next couple of blog articles I will talk a little bit about some ideas on massage and acute soft tissue injuries. There may be a number of things affected by an acute injury (labrum, disc, meniscus, fractures, etc) but the purposes of this blog series we will only talk about soft tissue injuries such as ligamentous sprains or musculotendious strains (pulls, tears, etc).

Disclaimer: To be clear, this is not to suggest, in any way, that massage is the only thing that needs to be done – it is only a small piece of the puzzle. The athlete should ALWAYS be encouraged to see a medical professional and then massage therapists should be encouraged to work as part of the team of professionals (Dr., PT, DC, ATC, Strength Coach) to ensure the athlete has a safe and healthy return to sport.

The Healing Process

Acute injuries are characterized by a three step process of recovery with each step being represented by a general time frame:

1. Inflammatory phase (0-5 days)
2. Regeneration phase (5-21 days)
3. Remodeling phase (21-360 days)

The Inflammatory Phase

Following an acute injury there is often a significant amount of bleeding/inflammation in the tissue and various chemical mediators (e.g., cytokines, prostaglandins, etc) are released in order to jump start the healing processes. The inflammatory phase can be broken down into two smaller phases: A Vascular Phase, where the bleeding is at its highest and then a Cellular Phase where myofibroblasts are called in to begin the wound healing process.

This phase is often accompanied by pain, swelling, and redness, which then begins to become black and blue or purplish in color over subsequent days. Additionally, there is a certain amount of guarding that takes place in order to protect the area from further damage. This guarding can be seen as an individual limping when they have a sprained ankle or holding their arm close to their body when they just sustained a shoulder injury.  It is important to keep in mind that the guarding taking place at the injured site is not the only guarding to consider. The individual may alter several other motor functions in this time of damage and pain.

The Regeneration Phase

The regeneration phase, sometimes called the proliferation phase, is characterized by the formation of new collagen – a weak, less mature type III collagen. Type III collagen is the start of the tissue beginning to regain its strength and integrity but there may be reduced mechanical stability and damage if the tissue is overloaded in this phase. However, some stress may be needed in order to ensure that the tissue is remodeled in a way that is similar to its normal physiological stress. There may be residual swelling, pain, and reduced function and range of motion in this phase (guarding). Additionally, the tissue may still appear to be discolored.

The Remodeling Phase

During the remodeling phase stability begins to return as type I collagen is now synthesized. Along with this stability may also come a significant amount of scarring within the tissue – which type I collagen is often associated with – and may present chronic dysfunctions if not addressed. Pain is often decreased once the athlete has progressed to this phase but may still persist for a variety of reasons (range of motion restrictions limiting normal movement on the field of play and altering function, psychological hang ups with the previous amounts of pain, etc).

Looking Ahead

This brief intro into the healing process will serve as the basis for the subsequent blogs in this series which will delve deeper into each phase and discuss potential areas where massage therapy may be used intervene and help facilitate the healing process and (potentially) be a factor in speeding up recovery.

patrick@optimumsportsperformance.com

Massage therapy has gained a considerable amount of popularity over the past several years. In some occupational settings massage has been offered to employees as a potential modality for decreasing stress, boosting morale, and potentially keeping ergonomic stress, from repetitive movements (e.g., typing on a computer for 10hrs a day), to a minimum.

A recent paper (Engen DJ, et al. Feasibility and effect of chair massage offered to nurses during work hours on stress-releated symptoms: A Pilot Study. Compl Thera Clin Prac 2012; 18: 212-215.) looked at the impact that massage can have on occupational and ergonomic stress on nurses during working hours.

Subjects

Thirty-eight nurses (5 men/33 women) participated in the study. The nurses received a weekly, 15min chair massage, for 10 weeks. The subjects were assessed at baseline, 5wks, and 10wks using a self assessment scale, a perceived stress scale, an anxiety scale, and a symptom visual analog scale.

Treatment

In this particular study, the massage treatment was set up in such a way that it allowed the therapist the ability to customize the treatment to the client based on their requests. For example, if the client was seeking stress reduction then various techniques such as light strokes, slower paced massage strokes, and slow compressions might be used to help induce a more parasympathetic state. If the subject was asking for pain reduction or a decrease in tightness or stiffness then the therapist tailored the treatment towards more compression and stretching techniques, joint mobility techniques, and trigger point/accupressure compression techniques depending on how the client was responding to the therapy.

Results

Some of the interesting findings included:

• Stress and anxiety related symptoms improved over the entire study at both 5 and 10 weeks.
• Thirty-five or the thirty-eight subjects had positive comments about their massage with regard to improved sleep and reduction of pain, headaches, tension, and stress. They also noted that they felt more relaxed and re-energized.
• Thirty of the nurses felt that they had improved job satisfaction due to the massage and twenty-three of them reported that they would be willing to pay $10-25 for a 15min massage if it were regularly available at work.

Practical Applications

Interesting study and one of the biggest limitations is that it did not include a control group. That being said, it is a pilot study and hopefully more studies will look at some of the effects of massage on stress.

From a practical standpoint, even those the subjects are not athletes, I am always trying to think about what I can take away from the study and how it can be applied to the population and clientele I work with.

One thing I took away from this study was the benefits massage can have on morale, well-being, and stress reduction,  something I have discussed a number of times in previous blog articles:

Trigger Points and a Sympathetic State

Using Soft Tissue Therapy to Enhance Stress Resistance

Massage, Stress, and HRV

With athletes, especially during the competitive season when trying to be at your best for every game is paramount, finding ways to improve the athletes’ psychological well-being and decrease stress can be an essential component to keeping people healthy.

Not only is stress reduction a benefit of massage but I believe, when used appropriately, it can be helpful for enhancing stress resistance as we attempt to boost the athlete’s buffer zone and increase their ability to tolerate the stresses placed on them – obviously this is only one piece to a large puzzle of stress resistance, as enhancing fitness, nutritional intake, and sleep (as well as numerous other factors) go into developing quality stress resistance. Massage can be one tool to assist in this capacity.

What I did like about the approach used in this paper was that the therapist was given the ability to alter the treatment based on the client’s needs. Often massage research is conducted in such a way that there is a protocol being tested (IE, 5min of gliding, 5min of kneading, 2min of cross-fiber friction, 3min of gliding) which is very limiting as human beings are not protocols. Humans are living, adapting organisms and, while we all have many similarities, we are all individual and have different needs. Making changes to the session based on what the individual needs is a key component to therapy and can impact the result you get.

I do feel that a proactive approach to stress and stress resistance should be emphasized. In the sports and athletic arena, professionals often tend to be very reactive (only doing something when an athlete complains of a problem) rather than trying to build a program that heads issues off at the pass. When used properly, massage may be one potential tool that can assist in this proactive approach.

patrick@optimumsportsperformance.com

Several months back I was asked to be a part of a roundtable discussion on Heart Rate Variability conducted by Craig Weller for T-nation.com.

The roundtable included a number of other industry experts (a group of individuals I am happy to be included in):

- Andrew Flatt
- Joel Jamieson
- Simon Wegerif
- Jonathan Pope
- Mike T. Nelson
- James Heathers
- Dave Tenney

Big thanks for Craig Weller for putting this together.

If you are interested in reading the roundtable discussion CLICK HERE.

Patrick
patrick@optimumsportsperformance.com