Common myths seen in injury rehab & what makes a good injury rehab program.
Introduction
“Cure back pain with this one exercise,” “bulletproof your knees with this protocol,” ice, rest, flexion, Deadbugs, scans, prehab…the list goes on regarding do's and don't of rehab and it's EXHAUSTING. As someone with over 10 years of experience coaching, competing in powerlifting and studying rehabilitation and physiotherapy, even I sometimes have no idea what to do because there is so much misinformation and unfortunately money and clickbait content seem to make the world go round. Well, I’m here to set the record straight, maybe it will help and if nothing else maybe it will enable you to be more curious, ask more questions and take more control in your injury rehab journey.
The 7 Deadly Myths
1) There are specific exercises for prehabilitation, training, and rehabilitation.
Wrong. Loosely speaking all exercise is a good exercise if it correlates to your goals, function, ability, and stimulus needs. Your prehab and rehab should be built upon your training, areas of weakness or where injury risk is increased and goals. Doing movements or training systems that don’t reflect your sport and injury profile is counter-productive and quite frankly a waste of your time.
Side note: depending on the severity of an injury will dictate how similar your rehab should look to your actual sport but the professional who is guiding this should be able to demonstrate the link between what they prescribe and the goal of return to sport.
2) Ice, ice baby.
It seems to be the go-to quick fix for any and all injuries and while in the first 12/24hrs, it can help especially if there is excessive swelling and a scan is needed for the most part ice is a hindrance in long-term injury healing.
There is strong evidence that icing an injury reduces blood flow through vasoconstriction, which decreases blood flow to the area. While this can help reduce swelling immediately after an injury, it can also limit the supply of oxygen and nutrients essential for healing. Ice can inhibit the inflammatory process, Inflammation is a critical part of the healing process, helping to clear out damaged tissue and initiate repair. Ice can blunt the inflammatory response, potentially prolonging healing time.
For years we as therapists followed the PRICE protocol (protect, rest, ice, compression and elevate). Recent evidence has developed a new protocol called PEACE & LOVE and really for the most part it has binned off ice as it's just not got the evidence to support it.
3) Pain is the bad guy.
Nobody likes pain, well in the context of an injury. Pain equals damage right? Wrong. Pain is the most complex multifaceted stimulus our brains translate. Pain can be a warning sign based on previous experience, pain can be physical or psychological, pain can be an indicator of progress and also pain can be defensive. Based on the fact pain is massively informative and also very subjective it should be utilised, it can guide us in when to push and when to halt. Changes in pain and symptoms allow us to make decisions on progressing training and also working with pain reduces the risk of fear avoidance and kinesiophobia.
A good rule of thumb is to keep pain below a 4/10 on a pain scale specific to your experiences. This scale will also be dependent on the type of injury and timeframe but the take home message is that pain is a byproduct of rehabilitation and not to be avoided after the acute phase.
Furthermore, analgesics (specifically opioid-based products such as co-codamol) have a heavy body of research highlighting the long-term effects of use. These include an increase in pain sensitivity and a reduction in pain tolerance. Don't fear pain, work with it.
4) Rest is best.
Many believe that the best way to heal is to rest completely. In reality, while rest is crucial immediately after an injury, movement is also essential for recovery. Gentle range-of-motion exercises can promote blood flow, reduce stiffness, and enhance healing. The acute stage of an injury is between 24 – 72 hours post-injury, this is the time to rest, eat good food and use some passive treatment (if ya really want). After this point, you gotta get moving again, slow, and steady, be sensible especially if there are still symptoms and let your body guide you.
5) Massage, ultrasound, electrotherapy, acupuncture (oOOooh fancy)
Now I’ll admit as a clinician and a coach I have always had a bias towards exercise as medicine and passive treatments such as massage, ultrasound, electrotherapy, and acupuncture have never been my bag and funnily enough the science also leans towards the fact passive modalities usually show no significant benefit. They can potentially do more damage in the fact that yes they speed up the repair phase of injuries but they don’t improve the quality of that repair.
There is nothing wrong with utilising these modalities in conjunction with an individualised rehab/training program or as part of your general feel good recovery but relying on these as solo methods of recovery or rehab is likely doing more harm than good.
6) Inflammation is the devil.
Many people automatically go to the use of anti-inflammatories (NSAIDs) the moment that an injury occurs, viewing the natural processes of the body such as swelling or pain as a negative. While NSAIDs of course have their place, it is important to be aware that inflammation is part of healing and Inflammation plays a critical role in the body’s natural healing process. It helps to bring immune cells to the injury site to clear out damaged tissue and promote repair. Reducing inflammation too much can slow down this healing process. NSAIDs can potentially mask symptoms such as pain, which might lead individuals to push themselves too hard during recovery. Lastly, NSAIDs can Impact Tissue Repair, some studies suggest that prolonged use of anti-inflammatory medications can interfere with the regeneration of tissues, such as muscle and cartilage, by affecting cellular activity necessary for healing.
7) There is a gold standard way to recover.
I'm sorry to say no there isn't, if it were that easy I'd be out of a job for sure. There is a huge amount of trial and error, personal factors such as self-determination and life to figure out alongside recovery and training. It's not simple and sometimes it sucks. There will always be guidelines and protocols to assist us but in all honesty, every injury is as individual as the person injured. The reps and sets are pretty arbitrary in all honesty and there are only so many sequences 3x10, 6x5, 10x2, the stimulus is where it matters, too light and you won’t create adaptation and too much too soon can aggravate things. In my experience utilising RPE (rate of perceived exertion) is the best way to get the right balance and I would recommend between a 6-8rpe (within the 4/10 pain) for many soft tissue injuries.
Summary
Firstly it takes a village of professionals to support an athlete's rehab journey. Your coach, your team, and your rehab professional should ALL be communicating and working together with and for you. I promise you it is a lot harder when your training and rehab are segmented. Secondly, injuries happen and sometimes they don’t make any sense, as an athlete it’s pretty unavoidable. Don’t panic or beat yourself up and remember the human body is bloomin’ fantastic and 9/10 times it's going to figure itself out and although maybe not the most glamours; a little rest, hydration, good food and a progressive movement program is gunna be the best thing you can do.
When in doubt PEACE & LOVE.
Sadie x
BSc Hon sports rehabilitation
MSc Student Chartered Physiotherapist
Interesting reads and research
· Dubois, B. and Esculier, J.-F. (2020) Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine, 54(2) 72–73. Available from https://bjsm.bmj.com/content/54/2/72 [accessed 23 December 2022].
· Tucker, H.-R., Scaff, K., McCloud, T., Carlomagno, K., Daly, K., Garcia, A. and Cook, C.E. (2020) Harms and benefits of opioids for management of non-surgical acute and chronic low back pain: a systematic review. British Journal of Sports Medicine, 54(11) 664–664. Available from https://bjsm.bmj.com/content/54/11/664 [accessed 21 March 2023].
· Davis, H.L., Alabed, S. and Chico, T.J.A. (2020) Effect of sports massage on performance and recovery: a systematic review and meta-analysis. BMJ Open Sport & Exercise Medicine, 6(1) e000614. Available from https://bmjopensem.bmj.com/content/6/1/e000614 [accessed 3 April 2023].
· Lavazza, C., Galli, M., Abenavoli, A. and Maggiani, A. (2021) Sham treatment effects in manual therapy trials on back pain patients: a systematic review and pairwise meta-analysis. BMJ Open, 11(5) e045106. Available from https://bmjopen.bmj.com/content/11/5/e045106 [accessed 5 January 2023].
· Maestroni, L., Read, P., Bishop, C. and Turner, A. (2020) Strength and Power Training in Rehabilitation: Underpinning Principles and Practical Strategies to Return Athletes to High Performance. Sports Medicine, 50(2) 239–252. Available from https://doi.org/10.1007/s40279-019-01195-6 [accessed 30 January 2023].
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