3 Things to avoid when treating an Acute Injury or post-surgical patient

by: Mike Stella, MA, ATC, PES, CES

There is so much misinformation out there when it comes to how to handle acute injuries or trauma like after surgery.  Whether you are treating athletes and seeing a high number of acute injuries, or a therapist in a clinic managing post op cases, the process of healing is a complex, integrated, and important thing to understand so that you are maximizing your patients ability to heal, instead of getting in the way.  

Fact is, human beings are very good at healing.  Think about it, if you were to buy a new car, the best day of that car’s life, is the day you drive it off the lot.  It will not, and can never be, better than that day with use.  Even though many clinicians use car metaphors to explain human function, the reality is, our bodies can get better with time, given the right circumstances, care, and stress.

I tell my athletes all the time, injuries can be UNFORTUNATE OPPORTUNITIES to learn about your body, how to treat it right, and move forward with a heightened awareness of the process.  It is our job as clinicians, not to FIX the problem, but to FACILITATE their recovery by educating, and providing resources, in addition to our treatment methods.  The best results happen, when you combine the RIGHT treatment, with education and support…

For today, let’s just talk about the 3 things NOT to do when dealing with a patient or athlete who just got hurt, or is seeing you after surgery.

#1.  BURY THEIR INJURY IN ICE - This is perhaps the most common intervention method used in hospitals, physical therapy clinics, athletic training rooms, and as an at home remedy for anything that hurts.  It is also, perhaps, one of the worst things you can do to an injury consistently over time.  Now, there is a time and place for everything, including icing, but the way it is doled out as a silver bullet treatment across healthcare, and worse, WIDELY accepted as the “correct” thing to do, absolutely boggles my mind.  Why does it boggle my mind, you ask?  Because over 40 years since the famous RICE acronym was introduced, there still is little to no scientific evidence to support its use and role in the treatment of acute injuries.  The term RICE, which stands for Rest, Ice, Compression, and Elevation, was coined by Dr. Gabe Mirkin in the 1970s, and in 2014, Dr. Mirkin recanted his statements, and apologized to the medical community based on the current evidence!!!  Yet, this inexpensive, easy to get, and misunderstood modality, still persists in healthcare every single day. 

Here’s the skinny.  Ice, or cryotherapy, while an effective pain reducer, also is a vasoconstrictor, meaning it restricts capillary flow to the affected tissues.  To keep this simple, vascular flow is important to deliver nutrients, oxygen, and immune factors like monocytes, to the area to begin the healing process.  Burying their injury in ice only serves to further limit their bodies ability to deliver the necessary components of healing to the area of injury.  

But Mike, what about getting rid of swelling and inflammation!? 

Is the response I am most often met with… and usually, I answer this question, with another question…

Why is inflammation a bad thing?  

You see, we have been programmed by outdated science, to think that inflammation is the enemy.  It’s not. In fact, it’s step one of the healing process.  Inflammation is part of our Immune systems response to injury…AND YOU CAN’T SKIP IT!  You can, however, slow it down, which just delays the inevitable.  So when you slap that ice and electric stim on a patient, you are basically just re-arranging the deck chairs on the titanic, and wasting their time, and your own.  So unless they are in a lot of pain, save the ice for your post work cocktail…

#2.  IMMOBILIZE OR TELLING THEM TO “JUST REST IT”  - This kind of piggy backs off of reason #1. Immobilization is SOP (Standard Operating Procedure) in pretty much every doctors office, of any kind, that deals with an acute injury.   Again, depending on the situation, immobilization may be required, like in the case of a bone fracture, or other more complicated structural compromise, as well as, post operative scenarios.  Outside of that, however, immobilizing something like, let’s say a mild ankle sprain or muscle strain, is only going to further compromise the bodies ability to heal… and is the main issue when giving a blanket statement of treating ALL injuries the same way.  Easier and cheaper for you and the business, but not necessarily in the best interest of the patient…  

You see, in order to evacuate swelling, again a normal, necessary process of inflammation, your body needs to activate the lymphatic system.  The lymphatic system is basically where your circulatory and immune systems meet and mingle, and is the waste removal system of the body.  Swelling, in essence, is a process that occurs when these systems collide in response to injury and yes, in many cases, needs to be managed…not ceased altogether. 

However, our lymphatic system, doesn’t have its own “heart” or pump…it relies on movement, and muscle contractions to create the pressure to drive lymph through the system, and deliver all that cellular waste and debris back to the blood stream, so it can be filtered out and evacuated.  Throwing that ankle in a boot, or cam walker, while protecting the injury, perhaps, also takes away the bodies ability to pump that swelling out, and thus, creating a situation where all you will have is MORE SWELLING, which limits ROM, increases pain, increases the need for pain meds, and further extends the time of recovery.  To me, and the current body of evidence, the juice just isn’t worth the squeeze… Again, there is a time and place for everything, but if the goal is an expedited recovery with the best possible outcome, shutting everything down definitely isn’t the answer…

#3.  RECOMMEND ANTI-INFLAMMATORY DRUGS -  Another one of those tricky SOP tactics doled out at every doctors office across the country, and shockingly even more prevalent in team sports.  It’s all too common when someone comes in with an acute injury, or post surgical patient, they have been given, or are recommended to take anti inflammatory drugs like NSAIDs, which stands for Non-Steroidal Anti Inflammatory Drugs.

Why is this an issue?  Well for basically the same reasons as above!  The upside to drugs, which is small at best, is that they are easy, and can be effective for pain and even swelling.  The downside, is the treasure trove of side effects that come with that little pill.  In fact, many other countries have BANNED NSAIDS like Dexamethasone, a drug still very popular in the US, because of the stark increases in risk for cardiovascular compromise.  True story…after my knee surgery in 2004, I was given a prescription for VIOXX, a drug that a few years later, was taken off the market for basically killing people...In addition, there have been NUMEROUS studies showing the myriad of potential negative side effects on health that come with using NSAIDS.  Other deleterious effects include, Kidney/Renal dysfunction, Liver compromise, Gastrointestinal ulcers, increased risk of miscarriage in expecting mothers, and of course, risk of anaphylaxis.  To this, I am often met with the following statement from clinicians of various backgrounds…

“BUT… if they only use them for a short period of time, then its ok…”

To answer this, I defer to Dr. Judy Racoosin, the Deputy Director of the FDA, Division of Anesthesia, Analgesia, and Addiction who stated that when it comes to NSAIDS, “There is NO period of use shown to be without risks.”  

For many clinicians, I may have just slammed 3 of the most commonly used methods of the treatment of acute injuries and post-surgical scenarios.  You may be asking, if not this…then what?

A NEW METHOD

Thats why I put together my new Online course, The End of The Ice Age: A Modern Approach to Acute Care.  This course, geared towards clinicians of various backgrounds, will go into much greater depth of the physiological reasons behind avoiding these discussed tactics, in addition to examining the current body of scientific evidence, and using that information to come up with modern, evidence informed strategies for helping our patients in the short term, while keeping long term prognosis in mind.  Strategies, that in my opinion, are EVEN MORE EFFECTIVE anyway…  The course comes with TONS of included resources for you to use to help your patients with greater care and precision than ever before…

Don’t believe me?  Enter your email below, and download my FREE Mini-Course, and take a look for yourself, I’ll even go one step further and offer you a SPECIAL discount on the full course, just for downloading the mini course!  

Why Acute Care Matters

by Mike Stella, MA, ATC, PES, CES

Acute care…is one of those things in Physical Therapy and Athletic Training that we often overlook, and in my humble opinion, is the lowest hanging fruit in accelerating post op results.  Seeing as though that acute stage only lasts a few days, and its easier in many cases to let it “run its course”, then get on to the “important stuff,” like restoring ROM and strength…after all, acute care is just pain and swelling management…a few NSAIDS should take care of that, no?

Truthfully, this devil may care attitude drives me crazy.  At best, its lazy, and at worst, well let’s just say it’s certainly not the patient that benefits from this “approach, “ or lack thereof.  

First off, the term “acute care” is one of the main reasons its overlooked.  By definition, the acute care stage is generally equated to the inflammatory stage of the healing process, therefore only a few days in duration, and considered to be the down time before a patient can begin rehab anyway…  To this, I say BLASPHEMY!  First off, acute care takes place wayyyyyyyyyy longer than just 3 days… If your patient is still dealing with swelling and pain on any level, then you are still in the acute care phase, and depending on the person, this may last days, weeks, and in some cases even months!  

Stay with me here… how many patients have you seen, months into their rehab…still dealing with post therapy pain and/or daily swelling…
Thats what I thought…TONS!  And that, right there, is one of the many reasons quality acute care is more important that you may think… 

The problem is, as clinicians, we have been programmed by insurance companies to time stamp every step of the rehab process…this is a business model of rehab, not a clinical model…  So we move people through the process, and when things don’t go well, we blame them for not doing their home exercise program! (Don’t even lie, thats the first place your mind goes, isn’t it?😜)  The reality… We need to do a better job recognizing the factors that delay our patients progress, and have a systematic way of intervention that is CRITERIA BASED, not time based.  In addition, how well are we providing resources to our patients as far as best practices are concerned?

For example, let’s take 2 identical surgical procedures…let’s say an uncomplicated, isolated ACL Reconstructions.  Patient A, a 25 year old fitness enthusiast, who eats clean, exercises regularly, gets consistent sleep, and generally speaking, does all the basic things right.  Patient B, a 25 year old who eats fast food regularly, sits at a computer for work and recreation all day, stays up allll night on Fortnite, and sporadically takes part in questionable health decisions like smoking/drinking.  

Is it reasonable to assume these 2 individuals would go through a rehab process, especially the acute stage, at the same pace?  OBVIOUSLY NOT!  The common sense in all of us shouts that these 2 individuals will likely have a far different experience in their prospective recoveries…

However, if we have been trained to identify lifestyle, and other factors that may impede progress, we could educate and inspire both patients, in ways specific to them, to optimize their recovery by giving them the tools and guidance to make better decisions before, during, and after the surgery takes place… versus just give them NSAIDs, which, by the way, carry with them even more health risks than someone might already have based on their lifestyle. Don’t believe me? Google it…In fact, we use NSAID drugs here in the US that have been BANNED by European countries for being unsafe.

Another important reason acute care matters is that it will impact a patients long term outcome.  How could the first month, impact the next year, you ask?  Well, just like any race, where you start, will impact where you finish.  In fact, A 2015 cohort study in the Journal of Athletic Training showed that the first 2 months of rehab directly correlated to long term function outcomes and patient satisfaction.  What does this mean?  Well the patients who scored higher on functionality tests in the 1-2 month post-op range, also scored higher at 1+ year(s) follow ups.  Again, where you start —> where you finish…

So for all those patients who got an ice pack for acute care, if we had a more integrated, holistic system of approach, could feel better sooner, move better sooner, and have those long term results that send referrals through your door for years to come.  

Is there such a system?  There is now! This is exactly why I came up with The MINDFUL Method of acute care.  The MINDFUL Method replaces those old, outdated, evidence bereft acronyms like RICE, PRICES, POLICE, and so on and so forth.  Yes…another acronym, but one that finally gives us cues for treating the short term, with the long term in mind, and that can used as a guide well beyond the “acute stage” Want to learn more about what the MINDFUL Method is??? Thought so!

I cover the MINDFUL method in great detail in my new course, THE END OF THE ICE AGE: A MODERN APPROACH TO ACUTE CARE.  You can pre-register on my website, and get early access AND A SPECIAL DISCOUNT, only available to those on the list!, Just drop the old email in the form at www.mikestellamovement.com/learn.

Lessons learned on my 33rd trip around the sun.

Another year older. Another year wiser...hopefully. I like having a December birthday, it makes the end of the year all the more valuable of a time to recap and reflect, with the notable exception of the dreaded “Birthmas” present... if you’re born in December...you know what I’m talking about 🤣. 

So I wanted to take this opportunity to highlight a few lessons learned this year, on my latest trip around the sun. I tried to keep these lessons as generic and applicable as possible, as obviously I am writing from very specific experiences this past year.  The first has been a lesson over many, many years, but the impact truly felt recently, as context tends to drive it home.  So here are 3 lessons/insights from the past year, and I hope you can draw on them as much as I have…

1. GRATITUDE IS EVERYTHING. Yeah I get it. Plenty of IG influencers out there preaching gratitude but I bet most of them don’t even know what that actually means. In any case, 33 was an awakening age for me. It was the same age as my dad was when he suddenly, and unexpectedly died from a heart attack in 1988. I was 2. Yeah, 33… ain’t that a bitch. I imagine there were plenty of things he had hoped and dreamed of accomplishing, thinking that there was plenty of time to do all the things. But he didn’t, despite what his “plans” may have or not have been. Suffice it to say last year when I turned 33 I was struck by this inescapable feeling of my own mortality. This realization caused a very sudden, and drastic shift in the way and manner in which I made even small, daily decisions. We all know we’re going to die, but actually looking at my fathers death, as a reflection of my own, has been one of the most meaningful realizations I have ever had in my entire life. By comparison, all the trivial shit that stresses us out on a day to day basis pales one comparison to the finality of death. Not trying to be morose, but as the year went on I could see just how pivotal a stoic mindset can be. This year I took more chances, went for “it” when previous Mike may have played is safe, had more fun, actively attacked learning new skills, and spent more meaningful time doing things I love with people I admire. In any case, the “don’t wait...tomorrow may not come mentality” certainly opened up some doors, and made me REALLY appreciate every single moment. Good and bad. That’s gratitude. All the blessings I have. All the hardships. All of it. I welcome it and am truly thankful to have the opportunity to throw down. Gratitude, man. It’s the realest game changer there is...and it’s some powerful shit too.

2. TIME IS THE MOST IMPORTANT THING I CAN GIVE. This applies to every relationship in my life, both professionally and personally. Friends, family, clients, employees, romantic interests, even strangers, all represent areas of time spent. 2019 was a busy year. Like, CRAZY BUSY. Traveling, teaching, new business, life, dating(or attempting to), and making some time for me too, makes time my most valuable commodity at this point in my life. Who and how I spend my time with is a harder and more important decision than ever before. May sound selfish, and it is, admittedly so, but it’s something that my younger self didn’t even recognize, and subsequently I spent a lot of time with people who frankly didn’t deserve my time. So yes, I’m more picky now, however, if you are someone that I talk to, spend any amount of time with, interact with on any level, just know that you are very important to me, and I wouldn’t spend my time any other way. I choose to spend my time with you. Not because I have to, because I want to. Being deliberate about how I allocate and spend time has really enriched my life and I’ve spent more days happy and excited than really ever before and I believe that this change was in part the reason…

3. BE CAREFUL OVER YOUR EXPECTATIONS OF OTHER PEOPLE. This was a bit more of a tough pill to swallow for me, because I think innately we tend to see others as we see ourselves, or at least that’s how most of us were raised and taught. However, you can’t expect other people to live by the same standard of morals or ethics as you do. You just can’t. Even people whom you consider to be close friends. or even family…there is one hard truth of being a human being…which is when push comes to shove...a person will default to their own best interest, even if that means fucking you over. It’s called survival instinct…I don’t have to outrun the lion, just the person running next to me… Friend, family, or anyone else for that matter. It sucks but it’s true. You can’t go through life expecting others to notice your hard work, passion, dedication, sacrifice, and reward it, ipso facto, “do the right thing” on their own. They won’t. Or, at least, YOU SHOULDN’T EXPECT THEM TO. There probably is no better feeling than being rewarded for a job well done, and we all put our best foot forward in hopes that those around us will acknowledge us on some level. It feels even better when that reward was given, without having to ask for it. On the other hand, it is clear what happens in the aftermath of when your expectations and reality don’t line up… We feel taken advantage of, disrespected, and it ultimately leads to an equal level of disappointment and resentment towards the other party. The only way to combat this, is to manage OUR OWN expectations of others, and/or make sure our expectations are known, in advance, and agreed upon by both parties. If this is a business relationship, that means agreed to IN WRITING! I think we all get that feeling of… “in writing? Why, you don’t trust me?” but it has nothing to do with trust, it’s simply an act of intention. If someone doesn’t want to put what they agree to in writing, it’s basically because their intention is to not hold up their end of the bargain. Period. I made this mistake with a friend turned business partner, and it cost me a brand which I had spent 4 years building, a growing business, time, a lot of money, but more importantly, a long standing friendship. Mistakes were made on both sides, but the truth is, I was being taken for a ride, and I knew it while it was happening, but just kept believing… ”He’ll do the right thing…we’re friends…” Well…he didn’t, and I am just as much to blame for expecting him to.

Im going to try to add to this blog more.  I enjoyed writing this article, and getting my thoughts on paper.  It was cool to write this, and really reflect actively on the lessons learned.  My hope is the lessons I learned on my 33rd trip around the sun may serve you in some capacity.  Failure and pain tend to be our biggest teachers.  Some of you will read this article, and make the same mistakes anyway…and guess what…thats ok!  It happens, it’s part of being human… The only tragedy from failure or pain is not learning from it.  If you’ve read this far, thanks for taking the time.  I’d love for you to leave a comment, and let me know what you think or please share your experiences.  

WHY ATCs SHOULD TO GO TO NATA!

Until last year, 2018 in New Orleans…I hadn’t been to an NATA conference in 9 years.  In 2015, I let my NATA Membership expire without renewing it.  I felt like it wasn’t worth the money anymore…

It was my “civil disobedience..” so to speak

Why am I telling you this?  Because I WAS WRONG.

You see, I had become extremely disheartened with the Athletic Training profession.  I spent years studying, honing my craft, to be the best sports medicine practitioner I could be… the result…Long hours, very little pay in comparison to the work being done and the amount of student loan debt I had incurred to do so…

 My options seemed to be…shut up, and stop complaining because this was my choice of profession, or, go to PT or Chiro school, and take on even more student debt, to basically do what I do now, just under a different title.  

Neither option was very appealing.  After all, I feel like I am skilled enough to help people within my scope as an Athletic Trainer.  To be honest… we all are.  

So I chose option 3, the road less traveled…

Athletic Trainer in private practice.

With no real guidance, or precedent, I jumped in head first, not knowing whether it would “work” or even the true legal status of what I was attempting to do.  So I started my business, started treating and training athletes privately, and began making content and posting on social media what I was doing as an ATC…

It was working. I was making money, and getting 🔥🔥🔥 results.

Then NATA 2018 came around.  I went with the RockTape team, to help promote a brand I love…  That’s when it hit me…

YOU… You ATCs out there.  Who don’t even realize the VALUE you can bring to so many.  The knowledge and skill you are sitting on. The lives we are capable of changing…including our own.

You started sharing YOUR STORIES with me.  How my content inspired you to stick with AT, or to pursue it further, rather than jumping ship to another profession whose grass looks a bit greener.  

After NATA 2018, I rejoined the NATA, and on the plane, asked RockTape if I could do the NATA conference EVERY YEAR… 

Why the shift?  Because OUR PARTICIPATION DOES MATTER!  You guys showed me it does and for that I am eternally grateful….You showed me it wasn’t enough to just be a good AT… We can’t just stop there, and hope everything works out…

We have to give it back.

Want to see change happen in this profession?  THEN YOU HAVE TO BE ABOUT IT, NOT JUST TALK ABOUT IT.

Let’s have the hard conversations.  Let’s be real with the fact that the only limits we put on this profession are the ones WE PUT IN PLACE OURSELVES!!!

NATA is a great time to connect with ATCs from across the country, so many of whom are actively taking steps to push this profession forward.  I am one of those people, despite not realizing it until you all showed me that I was…

So, I am asking you to come to NATA in Las Vegas.  Yes, in two weeks.  Come be a part of the conversation and the progression of a profession that I have fallen back in love with. 

Participate.  Educate.  Collaborate.  Be a part of the SOLUTION… 

See you in Vegas!  Please stop by the RockTape booth, share your story, and lets help each other move this thing in the right direction! ✊