Treatment of Acute Injuries

You've just been rear-ended in an automobile collision and you begin to feel your neck stiffen up. Or, while cleaning out the garage you twisted your back while lifting a box of old clothing - you felt a mild "twinge" at the time, but 2 days later you wake up with a very painful stiff back. Perhaps you twisted your ankle or bent a finger while playing a sport. What should you do to relieve (or prevent) these aches and pains?

This is a very frequently asked question. Knowing which treatments are appropriate can save you significant recovery time and discomforts, not to mention medical costs ( it is much cheaper, overall, to treat an injury when it is fresh, rather than after it has had time to get worse.)

Although it is always necessary to exclude broken and dislocated bones as a source of pain, especially in a "whiplash" condition, most of the time we are dealing with so-called "soft-tissue" injuries. "Soft tissues" refer to the non-bony structures of your body, in particular, the ligaments, muscles, and their associated connecting tissues called fascia and tendons. [Note: a sprain refers to an injury involving joint ligaments; strains refer to muscle or tendon injuries]

It is important to understand the process of inflammation in order to explain the symptoms and treatment of soft tissue injuries. A normal "warmed up" muscle has elastic properties, much like a rubber band, so that it has some degree of resiliency or "give" when stretched. A "cold" or tight muscle, however, has characteristics resembling scotch tape - when stretched, it eventually has to tear.

When muscle fibers tear (microscopically), they leak out tissue fluid that begins to accumulate locally near the site of injury. Inflammation is the result of this tissue fluid build-up and is characterized by localized swelling and tenderness. Frequently the region will be warm and have a reddish color due to the increased circulation. (All tissues can swell to some degree, whether you see it or not; an ankle sprain can be easily seen because a relatively small region is involved and there is nothing lower in the body to where gravity can pull the fluid.)

This process begins immediately after an injury, but it can take 24-72 hours for enough tissue fluid to accumulate in order to cause symptoms of pain and stiffness (from swollen muscles). This is why many people frequently do not see their physicians immediately after an accident or injury - it simply doesn't hurt enough (or it may not hurt at all) initially.

It is important to stress that the simple application of ice/cold packs can go a long way towards keeping an individual comfortable. Not only will it help to alleviate any symptoms of pain that are already being experienced, but it will help to prevent a significant amount of the tissue fluid accumulation (swelling) from occurring. This in turn will significantly shorten the duration of any injury-related disabilities (e.g. time off from work or athletic duties) and hasten a return back to full function.

REMEMBER: ICE IS NICE!

Heat, on the other hand, has just the opposite effect when applied to acute (fresh) injuries - it increases the circulation to the injury site and greatly enhances the tissue swelling, whereby increasing the pain. Therefore the rule is to apply ice/cold packs for the first 24-72 hours or so after an acute injury to decrease the degree of local tissue swelling and pain.

The simplest way to apply ice is to seal some cubes in a plastic bag, (mixed with a little cool water to help disperse the cold), cover this with a thin towel, and then apply it to the injury site for about 10-15 minutes at a time, every few hours. ["blue ice", frozen vegetables and other creative alternatives also work just fine] In general, the more ice the better (taking care not to freeze your skin) during those first 2-3 days. After completing the period of ice therapy, then heat may possibly be used (e.g. 10-15 minutes 3-4 times daily) for certain injuries, but check first with your physician.

When an injury involves the lower portions of your arms or legs, you must also consider the effects of gravity on the swelling. Not only was it responsible for the apples falling on Isaac Newton's head, but it also tries to pull our blood and other tissue fluids to the lowest parts of our bodies as well. Once the fluids accumulate in either your hands or feet, there is nowhere else for them to go. Therefore, those parts of our bodies that are the most gravity-dependent (i.e. lowest) tend to swell the most.

Fighting gravity (without getting hurt !!!)

To combat this problem, you must try to keep the affected part elevated as much as possible. For a hand or wrist problem, use a sling. Legs can easily be propped up on a chair for ankle or knee injuries. You should not expect miracles, however; it takes approximately 4 hours of elevation to counteract every hour that your leg is down, but do the best that you can.

The use of compression bandages, such as ace wraps, can also assist in reducing the amount of swelling by limiting the elastic capability of the skin and other tissues. These should be applied firmly, but not too tight, and always wrap from the point farthest away from you and go in the direction towards your heart/trunk. [note: the ace wrap can also be used to secure the ice bag while it's being used.]

Also, when you use any part of your body the circulation to that region increases. This can promote additional swelling around the injury because of the additional fluids made available (like feeding fuel to a fire). We therefore recommend resting the affected part as much as possible for the first few days. [note: the mnemonic R.I.C.E. (Rest, Ice, Compression, Elevation) is a helpful aid to remember the above first aid basics.]

Anti-inflammatory medications are also very helpful if employed early. They help to reduce the amount of tissue swelling through other means, and in turn also succeed at controlling associated pain. When taken early on in the course of an injury, they can eliminate the need for muscle relaxants (and their associated problems). Although these are non-narcotic agents, many of the prescription strengths of these anti-inflammatory medications are more effective than codeine-derivatives, and hence side-effects such as sedation and nausea can be avoided.

There are several over-the-counter anti-inflammatory preparations available that can tide you over until you speak with or are examined by a physician. Our old friend aspirin has been around for many years and this works just fine for most people. The most frequent complaint amongst aspirin-takers, however, is an upset stomach.

Ibuprofen (prescription trade names: Motrin, Rufen) is generally better tolerated than aspirin, making it easier to take and there are several lower dosage (200 mg) over-the-counter forms (Motrin IB, Advil, Nuprin) that are presently available for the home medicine cabinet. (Typical dose for an acute injury: 600mg 4x/day or 800 mg 3x/day). Naproxen Sodium (Anaprox) has also been released for non-prescription use (Aleve). (Typical dose would be 220 - 440 mg 2x/day.) Be aware that both ibuprofen and naproxen are relatives of aspirin; individuals who have allergies/sensitivities to aspirin, have problems with ulcers, or are on blood thinners should consult their physicians first.

Tylenol, it should be noted, has absolutely no anti-inflammatory effects; while it may help to deal with the pain, it will do nothing for the swelling that develops (the cause of the pain), whereas both aspirin and ibuprofen will deal effectively with both. However, if you are allergic or hypersensitive to aspirin-like products, Tylenol is the safest alternative available.

An aggressive physical therapy program can often restore an individual back to daily function quickly, if initiated early enough in the injury process. Therapists may use modalities such as electrical stimulation to reduce tissue inflammation and, later on, add ultrasound as a source of deep heat when it is needed to help relax any muscle spasm or to mobilize edema fluid (swelling). Physical therapists are also excellent teachers who can instruct patients in proper techniques specific to their occupations, or activities of daily living, to help prevent reinjury in the future.

What about spinal manipulation? After an injury, your body's natural response is to stiffen up in order to try and protect the affected part(s). While this is perfectly fine for the first few days, it is certainly annoying when you are trying to work during the following week. Medical gospel used to hold that everybody should be put to absolute bedrest for a period of 2-3 weeks following a back injury. Nowadays, however, 2-3 days is pretty much the maximum and the goals are to restore persons back to function as early as possible to avoid developing prolonged stiffness.

Manipulation refers to the mobilization of restricted regions of motion. A good example is the stiff neck following a whiplash injury. In uncomplicated cases, spinal manipulations can be a useful adjunct to the therapies outlined earlier, helping to improve the ranges of motion and reducing local painful neck muscle spasms.

There are many different techniques used for mobilizations ranging from very gentle to fairly "aggressive." The decision to utilize any particular technique is based individually upon the patient 's age, nature of injuries, and the skills of the practitioner (usually an Osteopathic physician, chiropractor, or physical therapist).

It is very important that you let your physician know how you feel following mobilizations; while a certain amount of discomfort may possibly be experienced (because your body is being coaxed to move when it doesn't want to), it should not be outright painful. If you have any questions or reservations, please do not hesitate to discuss them with your physician or therapist so that your rehabilitation program can be adjusted accordingly.

Generally, if manipulation is going to be effective as part of a treatment regimen, improvements should be seen within a two week period (a longer trial without any noted benefits is probably a waste of time and money). The majority of back and neck patients require 4 weeks or less of manipulation/physical therapy in order to be returned to their normal function.