Three stages of healing.
Every musculoskeletal injury goes through 3 stages. The stages are inflammation, repair and remodeling. Each of these stages makes an important contribution to healing. The time frames and the therapeutic activities associated with each stage overlap, with each one blending into the other in the continuum of healing.
The inflammatory stage is the period immediately following the injury. This period generally lasts from 3 to 5 days. Pain, swelling and redness characterize inflammation. The redness and swelling may be concealed beneath other tissues but the injured area will tender to the touch and the pain is constant. The constancy of pain is the best indicator that the pain is caused by inflammation. With inflammatory pain, no time of the day or night is pain-free. If rest or a change of position provides relief of pain, the condition has progressed to the repair stage.
On a cellular level, inflammation attracts specialized cells called fibroblasts to the site of the injury. The chemicals of inflammation cause the fibroblasts to begin spinning webs of connective tissue to bind the wound together and seal off or limit the flow of fluids through the area. This process can be readily observed in a scratch or puncture wound. The scab that forms after such an injury is similar to the process that occurs within the body in a musculoskeletal injury. This is a protective measure that begins the process of repair.
The process of inflammation is therefor an important part of the healing process. In some cases however, the severity of the pain is so great that the person cannot sleep and therefor, does not heal well. In other conditions such as auto-immune forms of arthritis, the inflammation continues for such a long period of time that too much scar tissue and immobility is produced. In both these cases, anti-inflammatory medication may be needed to reduce the inflammation and pain associated with the injury.
Medications should be used with care, as they do interrupt the normal process of inflammation and repair, and they also have side effects of their own. Many anti-inflammatory medications increase the risk of stomach ulcers, and liver and kidney damage. Natural alternatives to medication include Omega 3 and Omega 6 fatty acids, found in vegetable oils like flax seed and fish oils, and anti-oxidant nutrients such as Vitamin C, E, Selenium, bioflavenoids, etc.
The difference between medication and nutrients is that the medication interrupts a natural process while the nutrients provide your body with the raw materials to limit inflammation or its effects on normal tissue. The nutrients do not stop inflammation. They merely give your body the tools to control it. Supplying proper nutrition gives your body greater control over the inflammatory process. Nutrients aren't always enough however. In those situations, medications can provide significant relief.
Regardless of whether you use nutrients, drugs or both, the standard treatment for acute injury is Rest, Ice, Compression and Elevation, also known by the acronym "RICE". Rest prevents further irritation and injury. Ice and compression reduce swelling. Elevating the injured area above the level of the heart allows swelling to drain. Treatment with RICE is generally only done for a 3 to 5 days after an acute injury, though these methods can be used whenever swelling or tenderness to the touch re-occurs.
Putting the affected joint through a gentle range of motion is useful during this stage if it does not aggravate the pain or swelling. Care must be taken not to create additional injury by moving too vigorously however, most injuries do well with gentle range of motion exercises. For example, patients coming out of knee surgery often wake up to find that their leg is strapped to a machine that is moving their leg in circles as if they were riding a bicycle. Patients coming out of back surgery are generally up and walking the same day.
The repair stage begins about the 5th day after injury and continues for 4 to 6 weeks. This stage is characterized by increased fibroblast activity, resulting in increased connective tissue strength and formation of adhesion. During the repair stage, it is essential to begin moving the injured joint through a full range of motion as soon as possible.
If pain or the fear of pain prevents movement during this stage, the fibroblasts will lay down scar tissue randomly throughout the affected tissues. These fine threads of adhesion will bind the muscle fibers to one another and also bind connective tissue to muscles and joints. The result will be painfully restricted motion. If however you put the affected joint through a full range of motion during this stage, the cross fibers of adhesion binding muscles and other tissues together will be broken, while the fibers that support the normal range of motion will become stronger.
During the repair phase, the pain comes and goes depending on the position or movement of the joint. This is how you know you are out of the inflammatory stage.
The muscles and connective tissues are not yet at their full strength and the area remains subject to re-injury. With stretching and strength training, pain gradually subsides, while strength and range of motion increase. Failure to stretch and exercise at this time will result in weak, contracted tissues that are intermittently painful and subject to re-injury.
Beginning about the third or fourth week after an injury, the muscles should be challenged with strength training. Strength training is essential to the full recovery of the muscles and connective tissues. If pain, fear of pain or re-injury, or lack of commitment to the process prevent strength training, the tissue that forms is disorganized, weak and at risk of re-injury.
At this time, pain is only felt on certain movements or activities if it is felt at all. If pain occurs during the end-range of movement or during the last repetitions of a weight-lifting routine, that is normal. If pain from strength training occurs the following day, you should back off the intensity of the program.
The remodeling phase lasts at least 6 months after the injury. Failure to put the joint through the full range of motion during this time can still lead to painful, contracted tissues. Stretching at this point should take the joint to the end-range, even to the point of discomfort in the joint. Pushing the limits of motion forces the joint to remodel according to your demand for full mobility.
Strength training should begin gently and progressively increase. Stressing the muscles and connective tissues stimulates growth and improved function. Failure to do so results in weakened tissues that are vulnerable to re-injury. In the beginning, strength training consists of gentle resistance exercises that can be performed on a daily basis. As you improve, you can work up to doing resistance or weight training that takes the muscle to the point of failure in 3 sets of 10 repetitions. At this intensity, a day or two of rest between sessions allows for the muscles to respond to the increased demand by growing bigger and stronger.
Chronic pain and dysfunction
Failure to perform any requirements of the 3 stages of inflammation, repair and remodeling results in weak, contracted tissues that are painful and dysfunctional for months or years. The process of rehabilitation requires going back and re-doing each of the 3 stages. Deep tissue massage, manual manipulation or other therapies can break up adhesion and re-stimulate inflammation. Stretching and exercise can then begin the process of rehabilitation.
Most individuals with chronic pain and dysfunction tend to avoid exercise and stretching. This results in generalized muscle de-conditioning, poor circulation and low metabolism. In this situation, an initial period of aerobic conditioning is needed to prepare for strength training. One half hour per day of walking, cycling, swimming or similar activities for a month may be required to prepare for strength training. During the aerobic conditioning phase, stretching and gentle exercise to the affected areas may be performed. Drinking plenty of water and avoiding sweets will also help to relieve soreness and improve energy levels.
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