Sudden Acute Traumatic Injury

by Shelly Prosko

“Hey I did it! Look everyone, I’m doing it!” was what I remember thinking when I was Double Dutch skipping at our recent family Christmas function.  I was feeling confident, smiling and showing off my superb skills at age 41. Even though I hadn’t skipped in 25 years, I could still keep up with the kids because I take such good care of myself—I’m fit, agile, do yoga for healthy aging, meditate, eat healthy, create joy, educate and inspire others to do the same. Life is good. I’m so perfectly healthy. Then I remember a sudden intense “hit” to the back of my lower calf at my Achilles tendon that accompanied a loud pop. I went down in excruciating pain—and shock. I was looking around to see what steel object had hit me at such supersonic speed. But I couldn’t find anything. My cousin said, “Nothing hit you, you just went down.” It was then that I knew from experience as a physical therapist that I had completely ruptured my Achilles tendon. This is an example of an acute unexpected orthopedic traumatic injury. I have treated several of these types of injuries over my career, but when you are the patient, it’s a completely different ball game.

Shari’s post on Acute Orthopedic Injuries defines what an acute orthopedic injury is and how it is managed. Today I’d like to discuss the process that you may go through after sustaining an unexpected traumatic injury and how yoga can help you through the process. This is based on my experience in treating these injuries over the past 15 years in an outpatient orthopedic setting, as well as my recent personal experience.

Immediately after my injury, I was in shock for about an hour after. I was also in denial, and not thinking clearly. I didn’t even go to ER that night. Intellectually I “knew” the treatment protocol and prognosis, but for some reason, I wasn’t relating it to my own situation. This makes me realize how important it is to have support and allow people to help you when you are going through trauma. I wasn’t in a balanced mental or emotional state, and I certainly wasn’t equipped to be making important decisions. However, it’s in this state, that we are asked to make a decision: Do you want to treat this surgically or take the conservative, non-operative approach?

The benefits of my regular yoga and meditation practice were becoming evident as I embraced the truth of the situation, surrendered and became completely present in the moment. The combination of increased mental clarity and wonderful support from family and friends led me to finally go to the ER the next morning.

I was informed that the recent literature shows that there is not much difference in the long-term outcome between surgical vs. non-operative approaches and that they don’t commonly do surgical repairs to the Achilles anymore. I would be placed in a plaster cast for two weeks, then transfer to a boot cast for six to eight more weeks after that. The surgeon said, “Okay?” I replied “Okay.” Then he left the room and started working on making my cast. I don’t remember asking many questions. Typically, I would ask many! But I was not my usual self. I was still overwhelmed with emotion: fear, anger, guilt and sense of loss. Everything was just happening so fast. I remember hearing similar stories from patients. I would guess many people go through this type of experience.

Over the next week, the question lingered: Should I get surgery or not? There are so many factors to consider when you are deciding whether or not to undergo surgery. For the first several days, I was using vijnanamaya kosha (intellect, wisdom) to aid my decision: researching evidence-based results online, reviewing my own anecdotal evidence from clinical experience, analyzing other PT’s opinions, having discussions with family members and spending time in self reflection. These methods certainly played a huge role in my decision. We must use our mind as a tool to process all the information, so that we make an “informed” decision. But as many of you know, when you have a difficult decision to make, and you’ve analyzed it over and over again from all angles, sometimes your mind is no longer of service to you. You just need to make the decision, and, as Shari said, “make the right choice for me.”

I want to share the role that meditation can play in making decisions. Simply observing all thoughts and emotions without trying to “fix” or “decide” for a few minutes each day helped me in my decision.  I found that connecting to that space where my true self lies—without expecting or looking for an answer to my dilemma—was very beneficial to creating a clear mind. Often times the answer comes effortlessly after this (although it’s not wise going into the meditation expecting the answer because then you have defeated the intention of the meditation practice in the first place).

A yoga therapist/PT friend recommended that I try accessing pranamayakosha (energetic body) to help with the decision, an approach you might want to try for yourself. He recommended that I visualize each scenario in detail, and simply watch how my breath responds. I also brought awareness to how each scenario physically felt in my body. It was astounding to see the difference between the two scenarios. In the end, I opted to stay with the conservative approach to treatment and I can say that I finally feel at peace with my decision.

But it’s not over. I was told that rehab would not START for another eight weeks. As a physical therapist and yoga therapist, I intuitively know that there are SO many other areas and issues that can be addressed immediately post injury, even if we cannot touch or move the injured body part.
Allow me to briefly outline how I’ve been able to immediately use yoga for rehabilitation of this acute traumatic orthopedic injury. Keep in mind that yoga is not simply asana practice. “Yoga” means to “yoke” or unite body, mind, breath and spirit. In yoga, we can address all five kosha layers to optimize healing:

Annamayakosha (physical body):

• Asana practice involving non-injured body parts will help me maintain overall physical conditioning, to prevent overuse injuries of areas being overworked due to abnormal mobility patterns and to improve overall feelings of well-being. My practice includes Cat/Cow pose, Thread the Needle hip opener, One-Legged Downward-Facing Dog pose, One-Legged Plank pose, Happy Baby pose, and modified standing poses with a chair and bolster (Warrior II, Extended Side Angle pose Resolved Extended Side Angle pose, Reverse Warrior pose, Eagle pose arms, Cobra pose, Supported Side Twist with bolster, and Legs Up the Wall pose. Here’s the first in a series of videos that show my practice (you can find the rest here on my youtube channel):

Vijnanamayakosha (intellectual/wisdom):

• Injury Education. I researched recent literature about my injury. 
• Meditation methods for pain and anxiety control. I’m using a variety of focused mantra meditations and mental/visual imagery via a body scan.

Pranamayakosha (energetic):

• Breathing methods to address pain and/or anxiety. I’m using belly breath, nadi shodana, and bee’s breath.
• Focused meditation on breath.  Simply watching/observing without trying to change pattern has been one of my most powerful tools for finding peace during times of intense crying and frustration.

Manomayakosha (mental/emotional):

• Resources and support for grief/loss (injuries resulting in any form of loss are traumatic regardless of ‘severity’). What is working for me includes conversations with trusted family and friends and readings from “Untethered Soul,” including this interpretation of Yoga Sutra 2.16: “Painful effects that are likely to occur should be anticipated and avoided.” (See here for more info.) 
• Meditation. I’m practicing observing and watching emotions without trying to change them, but knowing they are “not me.”

Anandamayakosha (spiritual):

• For me, spirituality is connection to that space within that is true self, therefore connecting us to nature and all living beings. Injuries commonly cause a reduction of participation in normal social activities, resulting in feelings of isolation, loss and even depression. Connecting to ourselves, to others and to nature (even a daily brief outdoor meditation) can help us continue to feel this deep connection to spirit, which I believe is essential in any healing process.

I will continue to address all five koshas over the next eight weeks of waiting for “official rehab” to begin. Of course, this outline is unique to my current situation and it obviously does not serve as medical advice for your injury. However, I hope this sheds some light on how you could use yoga to help promote your healing in similar ways, even after an acute unexpected orthopedic injury!

Shelly Prosko is a Licensed Physical Therapist, Professional Yoga Therapist and a Certified Pilates Instructor. She received her Physical Therapy degree at the University of Saskatchewan, Canada in 1998, her Yoga Therapist training through Professional Yoga Therapy Studies in North Carolina and her Pilates certification through Professional Health and Fitness Institute in Maryland. Currently, Shelly resides in Sylvan Lake, AB and travels across Canada and the United States offering specialty Physio-Yoga Therapy workshops, yoga classes, private PhysioYoga sessions, lecturing at University and College programs, instructing at Yoga Teacher Trainings and actively promoting the integration of medical therapeutic yoga into our current healthcare system. She believes that bridging the gap between Western and Eastern healthcare philosophies is essential in order to achieve optimal health. Her treatments are individually based and are a unique blend of both approaches. Please visit www.physioyoga.ca for more details and information.

Acute Orthopedic Injuries

by Shari

In my role as a physical therapist and yoga instructor, I see lots of clients and yoga students who have experienced both acute and chronic orthopedic injuries. In western medicine, an injury is considered acute rather than chronic when it is less than three months old from onset. In general, an acute injury is an injury that occurred as a result of a traumatic event, including:

• Muscle pulls
• Ligament sprains
• Fractures
• Dislocations
• Contusions (bruises)

Signs of an acute injury generally include one or more of the following:

• sudden, severe pain
• swelling, often with the inability to place weight on a limb
• extreme tenderness on palpation of limb or other body part
• inability to move a joint through full range of motion,
• extreme limb weakness, visible dislocation or breakage of a bone

In general, there are two types of acute injuries: an unexpected acute injury and a cumulative trauma. An unexpected acute injury is one that is sudden and immediate, for example, the result of a skiing accident or a fall. My friend Shelly Prosko, who will write a post for us in the near future, experienced an unexpected acute injury when she was Double Dutch skipping and ruptured her Achilles tendon. On the other hand, a cumulative trauma is one that has been building up for a long time, possibly due to micro-injuries to a specific, vulnerable area until a final “last straw” movement causes the injury. This was the case with my right knee medial meniscal tear, which happened during a yoga class when I was doing the same pose I had been practicing for many years.

After you experience either type of acute injury, you have a dilemma: do you seek immediate medical advice or practice the “wait and see” method? Obviously if you think you may broken a bone, have a concussion, are bleeding profusely or are in excruciating pain, you should go to the emergency room. Otherwise, if the injury seems minor, you can take a 48-hour wait and see approach. During this 48-hour assessment period, you can practice R.I.C.E first aid:

REST: The first 24-48 hours after the injury is considered a critical treatment period, and you should curtail your activities. Gradually use the injured extremity as much as you can tolerate, but try to avoid any activities that cause pain. Often using a splint, sling, or crutches is necessary to adequately rest the injured body part.

ICE:
 For the first 48 hours post injury, ice the sprain or strain 20 minutes at a time, every 3-4 hours. The ice pack can be a bag of frozen vegetables (such as peas or corn), allowing you to be able to re-use the bag. Another popular treatment method is to fill paper cups with water then freeze the cup. Use the frozen cube like an ice cream cone, peeling away paper as the ice melts. Do not ice a sprain or strain for more than 20 minutes at a time! You will not be helping heal the injury any faster, and you can cause damage to the tissues!

COMPRESS: Use compression when elevating a sprain or strain in early treatment. Using an Ace bandage, wrap the area overlapping the elastic wrap by one-half of the width of the wrap. The wrap should be snug, but should not cut off circulation to the extremity. So, if your fingers or toes become cold, blue, or tingle, re-wrap!

ELEVATE: Keep your sprain or strain elevated, higher than your heart if possible, to reduce swelling. Elevate at night by placing pillows under your arm or leg.

One of the most wonderful positions for reducing swelling (edema reduction) is Legs up the Wall pose (Viparita Karani). And you can even do this pose in bed if your bed is next to a wall and you have the agility to position yourself into the pose. If this isn’t possible, you can try using two bolsters propped up against a chair instead of a wall, especially if you have someone to place the bolsters for you. However, in acute trauma, this pose may NOT comfortable so short bouts might be more beneficial than longer periods of time.

Another spectacular pose for edema reduction is Chair Shoulderstand (see Judith Lasater's Favorite Poses), which you can do in a more passive position with your legs perpendicular or in more active position with your legs upright. The more passive pose is to rest your legs against the chair back, which requires less physical work and allows more relaxation (although this creates more of a backbend).

As you practice your R.I.C.E, keep assessing your pain levels. Sometimes the severity of an injury isn’t apparent immediately but if the pain worsens as the hours progress, this is a good indicator to seek medical care.

Ok, so your 48 hours have passed and you have religiously been practicing R.I.C.E. but you are no better, but no worse. At this point it is time to go to a medical doctor and learn as much as possible about the different possible treatments for your injury and then go through a careful decision process. And yoga can help you through all this.

In my situation with my right knee medial meniscal tear, I waited over six weeks of my own “conservative care” approach before the grim reality hit that things weren’t getting better. I didn’t follow my advice of getting medical help after 48 hours because I thought I could just heal my knee with a lot of RICE and restorative inverted poses. It did slowly get better over the six weeks but I reached a plateau in regaining movement and decreasing edema, and finally acknowledged I needed to be evaluated and diagnosed by a physician. (And frankly, I do have “white coat syndrome” and found it is easier hide my head in the sand and not acknowledge that my injury was more serious than I thought. There was no actual injury so I kept hoping it would get better. Sometimes we ALL practice avoidance!)

I then entered into the traditional medical model (see Fizzy Yoga!) and began non-surgical medical interventions. Along the way, I realized that I needed to add other C.A.M. (complementary alternative medical) approaches to my other endeavors. I realized that I needed to address all five koshas and sought out other medical practitioners that I trusted to aid me in my healing not just by addressing the physical injury but also by preparing me for the question that I had been avoiding: was I going to opt for surgical repair of my meniscal tear?

I meditated on the reason I wanted surgery and what would I gain from it. I had never in my 58 years had ANY surgical interventions, so even to contemplate surgery was a huge question for me to come to grips with. Many people told me to “just have the surgery, it is no big deal,” while others told me horror stories about failed meniscal surgeries and a NY Times article on why knee arthroscopy doesn’t work. But the surgeon who I consulted for this procedure was spectacular. He told me point blank that the decision was mine, but that I couldn’t be on the fence about it. I needed to believe it was the right choice for me. He even went as far to tell me that I could cancel in the surgical suite before anesthesia if I wanted to. His words changed the power dynamics and allowed me the space to meditate on my own fears and come to terms with them. He would do his job, but I had to do mine also.

Yoga helped me through the surgical process in many ways. Pre-op as I was waiting to be brought into the surgical suite, I was in a "comfy" type room with a recliner chair. I lay in that chair, covered myself with the blankets and practiced Ujaii breathing to calm myself. Also, I tried to clear my mind of all doubts and fears by just counting and following my breath. That practice helped immensely, and I was surprised on how low my blood pressure was when they took it before taking me into the operating suite. Just before the anesthesia was administered, I also tried to follow my breath as the lights literally went out. Post op in the recovery area again some Ujaii breathing helped to center me.

Once home, pranayama was helpful in quelling the anxiety and pain from the procedure. I didn't really start yoga asana practice till 24 hours post procedure. Starting with using my breath as I worked through my range of motion exercises and tried to be "kind” to my knee. Yoga is intimately connected to my current recovery. I really can't separate it out from my activities—everything I do now is with mindful attention to my knee and how it will respond to a new activity or asana position. Learning to GO SLOW is my current practice because when I don't, boy oh boy, does my knee balloon up! My knee is my teacher now and the rest of my body is the student—a different place to be for sure.

So, now it is two weeks post-op recovery. I have learned how to ask for help, which for me is really challenging. I have also learned that I need to still the little voice in the back of my mind that criticizes or is unhappy that I still can’t do something that I “should be able to do.” On the other hand, I’ve found it quite amazing how my knee has taught me how to experience asana differently. Yes, before I had to modify, modify, modify, but now the experience of gratitude is present. I ENJOY pranayama now and am practicing it more regularly. Also, I feel embraced by Chair Shoulderstand when I practice it. It is hard to describe but as soon as I am up in the pose I feel like I am getting a “big hug” that encompasses my entire being. The words don’t quite communicate the feeling of prana in my body!