After a joint injury, different levels of braking are usually applied to the damaged joint or joints around the damaged area to ensure smooth healing of the damaged tissue and to prevent secondary injuries. Although the degree of braking varies, there is one commonality that is inevitable: braking inevitably causes dysfunction. Dysfunction can be manifested in many ways (see my previous post), and this post specifically addresses joint mobility (ROM) disorders. A comprehensive assessment of the patient is required before a targeted rehabilitation program can be developed. This includes the patient’s age, gender, communication skills, occupational requirements, chronic medical history, injury history, post-injury management, surgical options (if any), level of surgery (actual assessment), current level of injury healing, current level of function, original level of function, level of function of the healthy side (one limb injury), and the patient’s expectations for his or her own rehabilitation. It is important to understand how the patient can get the most cost-effective treatment plan for him/her). With this information, we can have a clear and comprehensive understanding of the patient we are dealing with, so that we know what we are dealing with, how to respond, “what to do”, and what to expect in terms of treatment outcomes. To develop appropriate treatment plan for the actual situation of the patient Before the implementation of any plan, it is very important to obtain the full trust of the patient, imagine facing a patient full of doubts and suspicions, good cooperation between doctors and patients is difficult to achieve anyway, so then we need to provide a good impression for the patient with a friendly attitude, scientific explanation (brief), after obtaining the initial trust of the patient The treatment can be initiated. As you can imagine, after a long period of braking, the majority of patients will have obvious joint mobility disorders. In order to ensure the therapeutic effect, it is inevitable to apply heavy manipulation to the patient in order to release joint adhesions and pull contracted tissues. Before starting the treatment, it is also important to take precautions and explain the possible situations in advance so as not to overstimulate the patient. In order to ensure that the patient’s confidence is not shattered after the first treatment, the amount of treatment should be gradual and progressive, from small to large. At the beginning of the treatment, relatively gentle techniques can be used so that the patient can adapt more easily and feel confident to continue the treatment in the future. When the patient is fully confident and convinced of the need, the training can be gradually increased in intensity to speed up the treatment process. As mentioned above, braking is not a one-day problem, and the dysfunction that results from braking can be very complex. Intra-articular adhesions, adhesions between surrounding tissues, contractures of the soft tissues around the joint (muscles, tendons, ligaments, joint capsule, fascia, skin, scarring, etc.) may all lead to severe ROM impairment. In this complex situation, manipulation for ROM generally produces strong stimulation of the patient, strong irritation of the corresponding tissues, and even some degree of damage. During such treatment, pain, capillary damage between soft tissues, and joint stress reaction (inflammatory response), may follow. At this point, it is necessary to readjust the training volume according to the patient’s response. It is important to understand that although pain is inevitable, it is never our aim to create pain for the patient, and it is important to try to avoid all painful sensations that can be avoided during the treatment. During the treatment, it is important to maintain good communication with the patient at all times, and carefully ask and attentively appreciate the changes in the location, nature, and degree of pain of the patient. According to the observation, in general, patients subjectively feel the painful sensation of pulling on the contracted tissues during joint loosening manipulation, the dull painful sensation generated by tearing the adhesions inside and outside the joint, the painful sensation of swelling in the joint caused by a large amount of fluid accumulation in the joint, and the sharp painful sensation caused by the synovial membrane embedded in the joint are the most common cases. First of all, pulling pain is the feeling that I personally want to see in patients. When this happens, it can be considered that within a certain range, the impact of joint adhesions in the affected limb has been less than contracture, and as long as gentle and persistent pulling force is used, after a certain period of time, the contracted soft tissue can be given a certain physiological length and gradually become normal tension. At this time, it is important not to overdraw and violently pull, otherwise it will be counterproductive. Due to a number of factors, the degree of adhesions in and around joints varies. For small adhesions that are new (usually no more than three months old), it may be possible to tear them with a small number of high-intensity manipulations (what some textbooks call 4- to 5-grade joint release), using rapid, small-scale (not significantly exceeding the patient’s limit) manipulations, which usually result in a subtle The tearing is usually accompanied by a subtle “tearing thread-like sound” and a feeling of “breakthrough”. For long time (usually more than three months) the formation of more stubborn adhesions, generally no longer use this method, then the technique should still take a stronger maneuver, to a longer time in the emergence of greater resistance to the patient’s sensory limit before pushing a relatively small stroke, so that it is possible to tear the adhesions part, if the adhesions are stubborn to a significant degree so that it is impossible to tear, then it is If the adhesions are so stubborn that they cannot be torn away, then a longer-term effort is required, and persistence is needed on the part of both the patient and the doctor. During the course of treatment, the patient will also often feel a sharp pain in the joint space, which is most likely a reaction of the synovial membrane in the joint. Synovial congestion, synovial crepitus, and synovial adhesions due to irritation can cause the synovial membrane to be squeezed in the joint space during movement. In this case, according to the actual situation, a certain amount of axial distraction should be performed on the operated joint without violating the normal direction of human joint movement, and joint release combined with axial distraction can improve the phenomenon of synovial compression as much as possible. Axial distraction is a commonly used joint loosening technique, which belongs to joint accessory motion, with more sliding between joint surfaces. Different joints are suitable for axial distraction along different directions, and it depends on the operator’s personal experience as to how much force is used for the operation, which is difficult to quantify. As for the swelling and pain caused by simple joint effusion, it is basically caused by excessive movement before. Imagine that a fully inflated balloon is also difficult to pinch. At this point, suspend the treatment, appropriate braking, icing, and physical therapy can produce better results, and when the fluid is absorbed to a certain extent, the joint movement can be normalized. If there are no good sterilization conditions, joint puncture is not recommended to extract the fluid, because the stimulation of the joint may lead to more serious fluid accumulation, and we should trust the body’s own regulation ability. There is also a kind of patient, obviously dysfunction is very serious, but in the process of receiving treatment but no pain, function is also difficult to improve, this indicates that adhesions, contractures have reached the point of irremediable, sometimes, persuade patients to give up appropriately is also relatively economic. Of course, it is not possible to just let go, that must be a reluctant decision made only after trying hard and after much deliberation. These changes are never the only ones in functional exercises, they may occur collectively or in other new situations, so it is important to analyze the specific problems, to adopt a contingency plan for the new situation, to enhance the ability to anticipate hidden problems and to nip them in the bud before they occur in order to obtain maximum efficiency. How much training should be appropriate? Multiple times a day? Once a day? Or once a day? In my personal experience, for example, depending on the patient’s injury, I first arrange for a lot of training with strong stimulation three to five times a week at the beginning of treatment. In several years of practice experience, there have been cases where the training was never interrupted for more than one day, and cases where the training was rested for six days a week. It seems that the established rehabilitation program cannot be implemented mechanically, and only by adjusting and changing it at any time according to the actual situation can the changes in the patient’s injury be grasped and the correct treatment be made. Be bold and good at doubting and denying the established rehabilitation program at any time! It is important to know that real rehabilitation is not static, but in a state of flux at all times. Only by mastering the laws of changes in the patient’s condition can we take the initiative in our treatment work.