Over my 14 year career as a physiotherapist this is the most commonly asked question at the end of an initial consultation and one that I feel I gain more confidence in answering with each patient I treat. Within this blog post I aim to give you an understanding for how I, as a physiotherapist, approach a musculoskeletal injury and some of the thoughts and processes I go through to give my patients an answer. As with all my posts, however, I want to be clear on the fact that I talk about optimal treatment: the treatment required to get back to functional activities and sport pain free and with reduced risk of injury recurrence. I am very aware that money and time impose significant constraints on us but to give you the RIGHT and HONEST answer it is essential to recognise that the best clinical care will involve a treatment ‘programme’ and investing in this results in the best outcomes.
FACTORS INFLUENCING RECOVERY
When I first meet a patient there are factors about their injury that I need to take into consideration as I begin to plan their treatment programme in my head. I will balance one against the other and combine it with my experience of treating numerous injuries and different patients over the years to predict my role in the patient’s recovery. Some of the initial factors include:
- Severity of the condition: Acute injuries occur more suddenly e.g. a sprained ankle or muscle tear. We can also place traumatic injuries e.g. ACL rupture and fractures into this category as well as post- operative cases. The earlier they are seen the quicker a diagnosis can be made and treatment plan can be put in action. Surgery may be necessary or a period of offloading which will influence the number of treatment sessions needed. Chronic injuries will develop and persist over a longer period of time and can sometime be quite complex. An overuse injury that has persisted for months or years can lead to maladaptive movement patterns, weakness and secondary injuries which will require more treatment input.
- Diagnosis/what tissue or structure is affected? Bone, muscle, tendons, ligaments and nerves will all be managed differently. Ligament tears or ruptures may need surgical reconstruction and thus more physiotherapy input will be required. Fractures will need to be offloaded, (and may be operated on) and though healthy bone can heal in 6 weeks, the recovery after to restore strength and mobility etc can take up to a year. Tendons and nerves tend to be more tricky to treat and thus predicting how they will respond to treatment can be very difficult.
- Past Medical history/general health: various medical conditions can affect the way that your musculoskeletal system heals itself. Poor bone health e.g. osteoporosis will extend fracture recovery, and disorders that attack the immune system will delay tissue recovery. Smoking, obesity and poor diet are other factors that impede the human body’s ability to regenerate.
- Compliance with treatment programme: post operatively joints can become very stiff and need treatment to restore range. Missing appointments or not doing home exercises will delay this stage of recovery. Restoring strength also requires consistent, progressive loading of specific muscle groups. The odd exercise once a week will, therefore, not be enough to develop muscle. Poor compliance will inevitably lead to more physiotherapy input! Doing exercises more than what is prescribed, however, can also lead to problems. The recovering tissues can be overloaded beyond their capacity causing pain and maybe swelling and thus delays in recovery occur. The programmes of treatment are carefully designed for you and the injury you have sustained. Following your programme of treatment leads to best outcomes.
- Age: unfortunately, the older we are the slower we heal. Age must therefore be taken into consideration when planning treatment.
- Goals: no matter the injury, your whole body needs to become robust enough to cope with the demands you are going to place on it. Returning to netball or football will therefore need you to be strong and agile enough to cope with jumping, landing, twisting and turning with good control. If you aim to simply walk to the shops then your programme will be adapted for this. It is therefore understandable that more sessions may be needed to achieve higher levels of function.
STAGES OF TREATMENT AND RECOVERY
After contemplating the above factors I need to consider at what stage of recovery my patient is in. The above factors will influence how quickly you will move through these stages:
- Diagnosis: I will not apologise for mentioning this AGAIN! An incorrect or delayed diagnosis will lead to a protracted recovery. If you are not progressing in your treatment as expected then you may very well be trying to push a square peg into a triangular hole!
- Management of pain, swelling, wound management: traumatic injuries or post-operative cases will require early stage management to get pain under control, allow wounds to heal and for you to recover from the trauma or surgery. Your body is exceptionally skilled at this and it must be allowed to do its job. It takes time and you must be patient. In the case of chronic or overuse injuries this stage may be easier to manage by simply addressing the aggravating factors, e.g. reduce the amount of running.
- Range of movement: our bodies adapt to pain. They can become stiffer in some areas and more mobile in others to compensate for it. Maintaining or restoring range of movement is essential to enable your joints and soft tissues to have a balance in load across their surface area. Failure to do so can lead to secondary problems and more physio!
- Strength endurance, strength, stability and control: following surgery you may have to learn to walk again, gain confidence in loading the affected area and tackle functional activities such as stairs. All of this requires adaptations within your neuromuscular system. Getting strong requires consistency, specificity and load progression.
- Landing control, impact tolerance: as a patient we are always in a rush to start running again. In some cases the above stages can take up to 4-6 months and so it is understandable that we become bored with the rehabilitation process and desperate to move to something that feels more ‘normal’. When running, each step we take involves your body weight landing heavily onto the ground. The way we land and the strength in the muscles to absorb this load is an important factor to consider. Most patients progress into this stage too early, which leads to set backs in recovery and thus more physiotherapy input.
- Goal-specific drills (as mentioned above): rehabilitation will be specific to your needs. If you want to return to netball after an ACL rupture you are going to need more physiotherapy sessions than my patient who likes to play snooker!
SO HOW MANY SESSIONS DO YOU NEED?
As you can see, there are numerous variables that influence this answer. On average a course of physiotherapy will involve 6-8 sessions but healthcare is not an exact science and so the goal posts can change. In the same way you will be prescribed a course of antibiotics you will be ‘prescribed’ a physiotherapy programme. The two work completely differently but in both cases they need to be completed to have best effects. My blog covers a lot of specific sports injuries which will give you a more detailed idea of recovery times, but in short your physiotherapy journey will be bespoke to you and focusing on the stages above are key.
With advances in technology and science we are becoming increasingly used to everything happening so quickly. Our dinner can arrive at the press of a button, we can speak to someone else on the other side of the world at the press of a button and even some stages of surgery are now performed at the press of a button! BUT…….recovery takes time, be nice to your body when it has been injured and allow it to heal. Set realistic goals with your therapist, be consistent with your treatment and be patient as the best outcomes are going to take time. If you try to take shortcuts it will inevitably end up costing you more in the long term.