Wednesday, December 25, 2013
Injury Rehabilitation: The Magical 80% Rule
80% is not 100% or 99% or 95%, but is the most talked about number in sports rehabilitation. Why? When you look at the pain scale, the numbers are graded from 0 to 10, with 10 being agonizing pain and 0 no pain. With most injuries, it takes 20% of the overall rehabilitation to reduce the symptoms 80% (normally between 0 and 2), and another 80% of the overall rehabilitation to knock out that remaining 20% (to daily 0 with no reflares). Therefore, sports medicine providers attempt with most injuries to reduce the symptoms to between 0-2 (80% better) and hold the symptoms there for a long time. The patient still has some symptoms as they get back into activity. It can be quite unnerving to some patients to still be experiencing pain while re-attempting to participate in an activity. However, since it takes 20% of the overall rehabilitation to get there, and for simplicity let us say it took 2 months to reduce the pain from 8-10 down to 0-2, then it will take 80% of the time (8 more months) to completely eliminate all the pain. If we wait for no pain to begin activity, the wait is much longer than necessary, and the body gets stiffer, weaker, more deconditioned, and overall, more vulnerable to re-injury when starting up again. So, 80% reduction in symptoms down to levels 0 to 2 pain is considered the gold standard in treating injuries. Golden Rule of Foot: When 80% of symptoms are reduced, and normal walking occurs without limping, a return to activity program can be initiated. This is the 80% related to the pain scale.
But, what about the 80% related to activity. 80% better for function is when you can start running again. Running is the basis of almost all athletic endeavors. The way I look at and discuss with patients the function scale is:
0 to 20% bed ridden,or non weight bearing on crutches or Roll-A-Bout
20 to 40% from beginning to bear weight to off crutches (normally needs removable boot/cast)
40 to 60% Gradually feeling less pain with walking with or without boot
60 to 80% Walking with increased speed with mild symptoms, beginning to do sports specific activities like volleying in tennis, or shooting around in basketball
80% Passed the 30 minute hard walk test without set back, can begin a walk/run program, can begin to play sport with some idea of gradation back into full activity.
It is the magical merging of these two 80% scales that will allow the patient to begin their sport at a high level and begin to feel normal again psychologically. Many patients the scales don't match for a while and the health care provider must have them wait. For example, many patients have 80% pain relief by icing, medications, activity modification, braces, orthotic devices, etc, but when they attempt to walk hard for 30 minutes (standard test), or attempt sport specific activities like solo volleying in a squash court, they have definite increase in symptoms. They are still in the 60-80% range of function. This is the time that physical therapy, injections, changes in orthotic devices, chiropractic, accupuncture, etc, is utilized to get their function off this plateau and onto the 80-100% plateau where they can dramatically increase their activities. A good sports medicine provider is very skilled at this task of raising the plateau. Since the 80-100% plateau can be filled with reflares, minor setbacks, and many good pain/bad pain decisions, it can be the most difficult and challenging time in treating active patients. It is in this time period that most treatment of all the possible causes of the problem occur---short legs, flat feet, lordosis, weak muscles, tight muscles, dietary, etc, etc, etc. It is the fun part of rehabilitation.
I hope this post explaining the magical 80% rule used by most in the rehabilitation world has been helpful. Do not wait until you have no pain to begin to exercise you love, but there is so much thought on how to return to activity during this 80-100% prolonged plateau safely. Good luck!!