STRENGTH AND FLEXIBILITY TRAINING

Dr. Dubin is a certified strength conditioning specialist. He can customize a strength and flexibility program for individuals to conduct at home or in a gym. A good home exercise routine might include the Flexband®, Thera-ball®, and/or ankle weights. At the gym, Dr. Dubin recommends a program plus a meeting with an experienced personal trainer to review form and technique. These programs will speed up the time of recovery and are helpful in the prevention of re-injury.

ADJUSTMENTS

Adjustments, which are high-velocity, low-force techniques, are used by chiropractors to restore motion to the joints in the spine and extremities. Back pain can be caused by trauma and postrual overstrain. This can cause entrapment of the synovial folds in the facet joints of the spine, which can lead to pain, spasm, and swelling. Adjustments can free up the synovial folds, providing pain relief.

ULTRASOUND

Ultrasound is a treatment that can be useful in speeding up the healing process of injured tissues. Ultrasound travels into the damaged tendons and muscles, causing the molecules to collide, resulting in a deep heating effect. This thermal reaction causes increased metabolic activity and vasodilation of the blood vessels, allowing for more nutrients and oxygen to reach the damaged tissues while washing away many of the pain producing chemicals. The thermal effects of ultrasound decrease pain of the damaged tissues. Ultrasound also has a mechanical effect on the tissues that possibly causes the breakdown of scar tissue. During the first 24-48 hours of a soft tissue injury (the acute stage), the acronym “PRICES” is the preferred method of treatment to control the inflammatory response (Protect-Rest-Ice-Compression-Elevation-Stabilize). Ice, not heat, should be utilized during this period of healing. Pulsed ultrasound can be utilized in the acute stages of an injury to break up scar tissue without the heating effects of continuous ultrasound.

ELECTRIC MUSCLE STIMULATION

Electric muscle stimulation is another therapy that is useful in speeding up the healing process of injured tissues. This device sends an impulse into the damaged tissues, causing the muscles in that region to contract. Ongoing contraction of these muscles will decrease reflex inhibition and help to restore normal muscle tone, and the sensory input of this modality will decrease pain and spasm.

COMBOTHERAPY

Combotherapy combines ultrasound and electric muscle stimulation as a single treatment device. Based on clinical experience, combotherapy is a more effective treatment than just using ultrasound or muscle stimulation separately. Ultrasound and electric muscle stimulation are useful treatment modalities for creating a more favorable environment for the body to heal itself.

ACTIVE RELEASE TECHNIQUE

Dr. Dubin treating Mac Martin, world class athlete, utilizing ART on his Iliotibial Band.

Tissue damage can be caused by:

• excessive postural overstrain (e.g. sitting long hours at a computer screen in an ergonomically incorrect posture)
• repetitive strain injuries (e.g. repetitive typing on a keyboard that does not allow for full range of motion of the metacarpo-phalangeal joints of the fingers)
• direct trauma (e.g. a running back being blindsided by a 300 pound linebacker)

Active Release Technique (ART) is one of the most effective deep tissue techniques for breaking down scar tissue/adhesions and restoring function and movement. Active release technique involves the doctor locating adhesions that are causing the problem, applying tension with the thumbs over these lesions in the direction of the fibers, and then having the patient elongate the musculature while the doctor continues to apply tension to the lesion. By breaking up the adhesions and restoring proper blood flow to the tissues, the patients’ condition will steadily improve. Dr. Dubin was the first doctor credentialed in Active Release Technique in Massachusetts. Active release technique protocols, combined with adjustments, strength training, flexibility training, and other modalities such as combotherapy, enable Dr. Dubin to have predictable treatment success when dealing with musculoskeletal injuries involving the spine or the extremities.

The Role of Active Release Technique in the Three Stages of Tissue Healing

The first 24-48 hours of the tissues’ initial healing response is termed the “reactive phase.” During this phase, prostaglandins are produced, causing pain and inflammation as well as activation of the body’s local and systemic healing processes. The PRICES method of self-treatment is crucial during the initial stage of the injury to limit the primitive response of inflammation and create a better environment for the body to heal itself. The second stage of healing is called the “reparative phase” and consists of three reactions. First, the body’s immune system attacks and breaks down the debris at the site of injury. Then, new blood vessels form in the tissues, supplying them with increased oxygen and nutrients. Finally, there is fibroblast proliferation, which involves the replacement of the injured tissue with new muscle fibers. However, these fibers are not aligned properly, and contracted scar tissue formation can be expected. During this phase, the patient frequently experiences pain in the trigger points, which are regions where the scar tissue/ adhesions exist. The contracted scar tissue has a decreased blood flow that not only limits oxygen and nutritional uptake, but also slows down removal of noxious chemicals. This is why these trigger points are tender to the touch. A contracted muscle is not nearly as strong as an elongated muscle; a contracted muscle will limit full rehabilitation potential. Also, a contracted muscle demands more energy then an elongated relaxed muscle, and this is further impeded by decreased blood flow. The last phase is “tissue repair,” where the goal of treatment is to regain the pre-injury strength and flexibility of the damaged tissue. During phases 2 and 3, treatment focus should be on restoring proper alignment and function of the newly laid down and disorganized muscle fibers. This will create a more favorable environment for healing to occur and will potentially allow the patient to regain 100% function to this region. Deep tissue manipulation such as ART enables the doctor to achieve this goal.

TREATING INFLAMMATION

An injury caused by a forceful trauma (such as an ankle sprain) or a repetitive strain (such as overuse of the back from lifting) will result in an inflammatory response. Inflammation isolates the injury and activates the local and systemic defense and repair processes. Inflammation is a good thing, as it is necessary for proper healing of the tissues to occur. However, inflammation is a primitive response, and may become detrimental to the healing process if it is not controlled. Too much inflammation can lead to a delay in the healing process, as well as excessive scarring, ongoing chronic pain, and improper movement patterns. The key to tissue healing is to maximize the positive effects and minimize the negative effects of inflammation, thereby creating the ideal environment for the body to heal itself. When cell membranes of tissues are damaged, prostaglandin is released into the surrounding region, causing the surrounding capillaries to swell. Prolonged inflammation will decrease nutritional flow to the injured tissues, cause scarring, and ultimately lead to dysfunctional muscle groups, improper motion patterns, prolonged dysfunction, and ongoing pain sensitivity. The acronym PRICES has been used by the medical community to describe the proper measures to take in the acute phases (first twenty-four to forty-eight hours) of an injury.

• P = protect
• R = rest
• I = ice
• C = compress
• E = elevate
• S = stabilize

Ice will cause vasoconstriction of the capillaries. Both ice and compression result in improved reabsorption of fluids and decreased pain. Elevation will help drain fluids away from the injury. These three methods will limit the primitive responses of inflammation and create the optimum environment for tissue healing. As a general rule, ice should be applied to the injured tissue over a 20-minute period with a 1-hour rest period between applications. Studies have suggested that ice therapy combined with compression is more effective then ice therapy alone, so the ice pack should be secured with an ace bandage. Individuals suffering from Raynauds phenomenon, peripheral vascular disease, or susceptibility to frostbite should be cautious when utilizing this technique.

Using a typical inverted ankle sprain as an example, here is how PRICES works:

• As soon after the injury as possible, take two ice/gel packs and place one on the outside and one on the inside of ankle.
• Wrap an ace bandage around the foot and ankle for support and compression.
• Place three pillows under the leg and rest the ankle in an elevated position.

During the first 6 days of the inflammatory process, non-steroidal anti-inflammatory drugs (such as Ibuprofin) are useful in inhibiting prostaglandin formation, thereby limiting inflammation. These medications may be purchased over the counter or prescribed by your doctor (for stronger doses) and should be taken after a meal to prevent gastric upset.