Fundamentals of Initial Case Management Following Trauma
By Richard C. Schafer, DC, PhD, FICC
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Without a doubt, no other health-care approach equals the efficacy of chiropractic in the general field of conservative neuromusculoskeletal rehabilitation.
For many centuries, therapeutic rehabilitation was a product of personal experience passed on from clinician to clinician. In the last 20 years, however, it has become an applied science. In its application, of course, much empiricism remains that can be called an intuitive art –and this is true for all forms of professional health care.
INTRODUCTION
The word trauma means more than the injuries so common with falls, accidents, and contact sports. Taber1 defines it as “A physical injury or wound often caused by an external force or violence” or “an emotional or psychologic shock that may produce disordered feelings or behavior.” This is an extremely narrow definition for trauma can also be caused by intrinsic forces as seen in common strain. In addition to its cause being extrinsic or intrinsic, with a physical and emotional aspect, it also can be the result of either a strong overt force or repetitive microforces. This latter factor, so important in treating a unique patient’s specific pathophysiology, is too often neglected outside the chiropractic profession.
Taber1 states rehabilitation is “The process of treatment and education that lead the disabled individual to attainment of maximum function, a sense of well being, and a personally satisfying level of independence. The person requiring rehabilitation may be disabled from a birth defect or from an illness. The combined effects of the individual, family, friends, medical, nursing, allied health personnel, and community resources make rehabilitation possible.” It is surprising that Taber excludes trauma as a prerequisite for rehabilitation for it is the most common factor involved.
Other authors define rehabilitation strictly in terms of exercise and restorative therapeutic modalities and regimens. Some limit the term to preventing or reversing the noxious effects of the inactivity or lessened activity associated with the healing process. While it is true that these definitions hold significant components of clinical reconditioning and restoration, the scope of rehabilitation means much more to the chiropractic physician.
It has been the custom of the majority health-care profession not to consider rehabilitative procedures until late in case management. Like Welch2, allopaths generally place it 6th in the cycle of managing the body’s response to injury: (1) injury –> (2) pain, bleeding and traumatized tissue –> (3) inflammation –> (4) repair and regeneration –> (5) atrophy –> (6) rehabilitation. This author asks, “Why wait for signs of atrophy to begin rehabilitation? Nonparalytic atrophy beacons a neglected patient.”
Throughout many of my manuscripts, emphasis is placed on minimizing the noxious effects of fibrosis. Fibrosis parallels atrophy and leads to (1) impaired cellular nutrition and drainage, (2) stiff, shortened soft tissues, (3) trigger-point development, (4) adhesion development, and (5) articular fixations restricting normal ranges of motion.
Restricted joint mobility, in turn, encourages further atrophy, stasis, and a lack of mechanoreceptor input. Thus, a vicious cycle is established leading to a greater risk of residual impairment, reinjury, and progressive degeneration. After bleeding and pain are controlled, a primary objective is the normalization of soft-tissue flexibility, elasticity, and pliability as soon as possible.
Posttraumatic rehabilitative procedures ideally begin at the time the doctor first sees the patient. Hopefully, this will be an early stage –one occurring soon after injury. Alert care will usually control the ill effects of inflammation, enhance repair and regeneration mechanisms, and halt, if not nullify, the progress of atrophy and the formation of fibrosis. In many cases, customary surgery may be avoided. With individualized care, the result is a greater likelihood of obtaining an optimal goal of full function, strength, power, resistance, agility, and endurance.
THE APPROACH
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