Tissue Loading During Remodelling Phase Of Healing

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Over the past few weeks, we have been going over how to safely load tissues during the acute and sub-acute phases of an injury.

Along with instructions on loading, we have been reviewing what happens during the inflammatory and proliferative phases of healing.

This is all important because it’s crucial a therapist recognize what stage of healing the tissue is at in order to load the tissue safely, recognize when the tissue is taking too long to heal, and refer back to their doctor.

We are going to continue with the topic and look at the remodelling phase of healing, which is a longer, and increased changes occur. It also means we can be more aggressive in the movements we recommend and help our patients take part in. However, there is still a risk of re-injury that we must be mindful of as we progress through the rehab process.

As we have outlined in our past couple of posts on the topic, your clinical judgement and decision making is crucial for success, so we will look at how to implement and understand what’s happening during the remodelling phase with this post. 

Repair And Remodelling 

There are two phases to the remodelling phase; the consolidation, and the maturation stage.

During this consolidation phase, the tissue becomes more fibrous and stronger due to type III collagen becoming type I (due to macrophages breaking the type III collagen tissue down). The body starts to convert the wound into scar tissue and there is a carryover of functions that occurred in the remodelling phase that continues to take place (wound contraction). This lasts for 21-60 days, and scar tissue should stop increasing in size because of the wound contraction.

During the maturation phase takes place from days 60-360.  Collagen structure, arrangement, and turnover continues to occur and is the primary function at this point until (after about four months) the tissue becomes tendon-like, and this can continue for 12-18 months.

But remodelling time has some outside influences that can either hinder or encourage the process. The amount of time immobilized, stress on the area, vascularity, and location of injury can change the amount of time remodelling takes. During the proliferative phase, the fibres were laid down in a random direction, but the injury becomes stronger if the fibres are organized in a parallel direction. This happens due to external forces being applied to the injury site, and there is a window to assist with this remodelling for 10 weeks.

Now, when we talk about external forces, it is quite often promoted that doing massage on the area is an appropriate outside force in order to realign these fibers. However, one study shows that while physical force can alter connective tissue, there is almost no data that shows manual therapy techniques have any real ability to realign fibers. 

But, guess what does? Exercise!

Tissue Loading During Remodelling 

As we mentioned earlier, this is where we can get a bit more aggressive as far as load and movement, but we want to make sure not to overdo it.

But, we do want to start placing force along the lines of stress in order to help with the collagen tissue.

At this point there should be no signs of inflammation and movement should be getting easier. You’ve progressed your patient through some mobility, PROM, and AROM exercises along with some eccentric movements. Now you can start to ramp things up a bit. 

The movements can start to go from isolated, into more multidirectional patterns and movements. We have used the example of an ankle sprain in the past couple of articles, start to think about movements like side lunges to load into the injury site, or some active movements going from side to side cutting in different directions. Use concentric (the muscle shortens) and eccentric (muscle lengthens) movements along with weight-bearing exercises. Some you can even do on your table during the massage, just to get things going. For instance, you could manually resist at the ankle (with the patient prone) while they bend the knee as a hamstring contraction, then resist again as they lower the ankle to the table (if you were rehabbing a hamstring injury).

Hopefully, along the way, you’ve had some good communication with your patient as far as what goals they had in getting back to activities. This is where you can start to build some more active exercises. Have them start to do modifications of those activities.

If the patients activity is as simple as getting a jar out of the cupboard, have them start to practice with and an empty jar for a few repetitions until they have no problem doing it with a heavy full jar.

If your patient is an athlete, get them into modified versions of their activity. Recommend slower speed with a lighter load, until more of each can be tolerated. Once it can be tolerated start including plyometric movements (explosive movement ie: jumping) for example, standing on one leg, crouching down and jumping straight up on that previously injured ankle.

In any case, as more tolerance is attained, increase the repetitions and speed of each movement. But make sure you take the time to educate your patient. Show them how a little pain is okay, but not excessive so they can avoid any possibility of re-injuring the area. Also, whatever exercises you choose, make sure they are important to the person. Choose movements you know they will do, there’s no point in recommending a nice light walk to a crossfitter, or sprints to someone whose goal is to pick up their child pain-free. Make it applicable to each individual and their individual goals. Helping a patient rehab an injury doesn’t have to be complicated, it just takes your clinical knowledge and progressing movement properly, all of which you can do in your treatment room. If exercise prescription isn’t in your scope, AROM and PROM probably are, so there’s no reason you can’t implement various movements into your treatment whether on the table or off of it.

 

 

Articles Of The Week May 13, 2018

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How many times have we heard about the importance of communication with our patients? This post highlights that same importance, but why it’s important during the initial intake to make a great first impression with your patient.

“Reading Your Audience: Determining Your Treatment Approach For Each Individual” – Ryan Darling

With summer coming, so are Ironman competitions. Here’s some great info you can use in practice, or pass on to your patients who are in training for their first, or their tenth Ironman.

“How To Prevent Injury During Ironman Training” – Mike James

More and more it is being recognized that rehab and exercise is a much better choice over surgeries and injections for back pain. This article goes through many of the dangers associated with steroid injections for back pain. Great to share with patients if they are considering having injections done.

“FDA Warns About Dangers Of Epidural Steroid Injections For Back Pain” – USA Health Times

This one is actually a video, but a great watch. Three leading pain researchers answer common questions about pain.

“Pain Scientists Answer Common Questions About Pain” – Lorimer Moseley, David Butler, Tasha Stanton

Sometimes ego can get in our way. We start to think that we are ‘fixing’ people or ‘healing’ people. There can be some serious issues with this line of thinking. This great article points out how this thinking can be harmful to us as a therapist, and how it can be harmful to the patient.

“Magical Thinking” – Rebecca Sturgeon

Where Does The Social Fit In Biopsychosocial?

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BIAS ALERT: I LOVE the biopsychosocial model.

I must tell you my bachelor’s degree is in psychology.  When I started my master’s in physical therapy and we focused on biomedicine, I constantly was screaming “but what about the rest of the patient?!?”

I had been exposed to enough injury through my athletic training degree and personally with my father’s chronic disease to know it wasn’t just about a biologic derangement.  Pain, recovery,  and function are much more complicated than that.

The reality is, this model has been around since 1977 when Dr George Engel published his paper critiquing biomedicine.  The paper considered the patient-clinician relationship, the patient’s perspective of the symptoms, the fact that pain can exist without a biological derangement and how patients are profoundly influenced by the way they are studied.

The last couple decade’s technology has allowed neuroscience to study the brain and give us a new understanding why.  Luckily people treating pain got involved and clinically applied the neuroscience to patient care.  I was thrilled when Adrian Louw, Lorimer Moseley and David Butler started a big push in the physical therapy world to incorporate pain science (therapeutic neuroscience education) to our regular PT interventions.

Traditionally our coursework focus on the bio portion of this model: What tissue issue does the patient have?  More recently many published articles focus on the psychological portion of the model.  How do the patient belief systems, stresses, mental health, and expectations affect their pain?

The focus has not been on the social piece of the model.  Arguably the social piece impacts the psychological.  Patient’s interpersonal relationships can be stressors or helpers in their pain story.  The cultural norms can also affect the patient’s mental health.

Should we use the social part of this model to tap into strengths and facilitate our patient’s recovery?  Is there research behind this? 

Prescribing The Social

I started reflecting on these questions recently.

I currently treat a patient referred for chronic pelvic pain and urgency/frequency with urination.  She is an insulin dependent diabetic, has RA and has had multiple pelvic and abdominal surgeries.  She is married to a professional who travels a lot for work. Travelling with her partner used to be an option, however, with a recent trip coming, was very upset she couldn’t go.

Although there has been an improvement with treatment, and I felt like she could travel with a few modifications for her pelvic/coccyx pain.  After a long discussion I essentially “assigned” her to go on the trip. 

We discussed all sorts of strategies to manage her pain, her urgency, and allow her to enjoy her trip.  She came back a completely different person.  What also amazes me is the exceptional progress she’s made in the last 3 weeks and has even gone on another trip.

This made me think about another patient I had last year.

Their history is way too long but the short version: hysterectomy that led to pelvic pain that led to the doctor telling her “don’t do it if it hurts” which led to self-imposed bed rest for an entire year.  She was so deconditioned by the time I saw her she was wheelchair and housebound.  About 6 months into her treatment, I gave her the HEP (home exercise program)  to have lunch with her friends.  This was an activity she had done at least once a week prior to her surgery 2 years earlier.  Since the surgery, she hadn’t even allowed people to visit her in her home.  We discussed the importance of seeing her friends and how much they cared for her.  It started with her friends bringing her lunch.  Within 2 weeks she was going out to a close restaurant for lunch.

Again, this seemed to be a catalyst for recovery.

So, What Does The Research Say?

First,  the research suggests chronic pain in adults and adolescents negatively affects social relationships.

People with persistent pain have fewer friends, worse peer relationships, hindered ability to take part in social activities and tend to withdraw from social peers.  Adolescents in pain are perceived by their peers to be less likeable and less fun to spend time with.

But does increasing social interaction decrease pain?

Studies suggest that dynamic interaction and social interaction and empathy of others may reduce pain and have a positive effect on coping.  One study published in February 2018 looked at physical social interaction and pain.  Two people held hands while one was administered a painful stimulus.  Both subjects were connected to EMG.  When the two subjects were holding hands, the pain subject reported less pain and their EMG was less active in the correlative centres.

The control was the administration of the stimulus while they were not touching.  This suggests that physical touch and social interaction may change a patient’s pain experience.  It’s important to note, the subject not receiving the pain stimulus had an INCREASE of brain EMG activity and reported empathy for the pain subject.

So what does this mean?

Because the social piece closely ties with the psychological piece, we should look for opportunities to utilize this as a patient strength to facilitate recovery.  However, not all social interactions are good interactions.  We must find out what matters to the patient.  Who do they want to see? What outings matter the most to them? 

Dosing social interactions may be very similar to dosing exercise.

My patient wasn’t ready to ride in a car and go out to a restaurant after almost 2 years of being housebound.  The first graded exposure involved people coming to her and sitting a shorter time.  After that, she was ready to leave the house.

However, some people may need to repeat something like this several times before venturing out of the house.  We may need to brainstorm scenarios and coping strategies to set our patients up for success.  You can’t do this without pain education.  The patient needs to understand soreness doesn’t equal damage.  And just like exercise, we need to follow-up with them to assess tolerance and give them advancement to their program.

Next time you have a patient whose pain is causing isolation, I challenge you to look for opportunities to make social activity part of their home program.  Getting our patients to return to supportive social environments could be an important part of their care.

 

References:

Engel G. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129-136

Engel G. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137:535-544

Borrell-Carrio F et al.  The Biopsychosocial Model 25 Years Later: Principles, Practice and Scientific Inquiry. An Fam Med. 2004: December 576-582.

Markris U et al. Physical, Emotional and Social Impacts of Restricting Back Pain in Older Adults: A Qualitative Study. Pain Medicine. 2017; 18:1225-1235.

Block P et al. Social Interaction and Pain. Social Science and Medicine. Jan 2018: (196) 47-55

Goldstein P et al. Brain-to-Brain Coupling during Handholding is Associated with Pain Reduction. PNAS March 13, 2018. 115 (11) E2528-E2537

Articles Of The Week May 6, 2018

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Do we need to fix our patients, or help them get a bigger cup? Listen to their stories, and ask questions like: “How can you be healthier?” and more importantly “How can I help you be healthier?”

“Do Our Patients Need Fixing?” – Greg Lehman

This is a great little summary (and video) of what happens when your brain produces pain.

“Understanding The Complexity Of Pain” – Jenn Sharman

Communication is really important when talking to our patients. While this article is directed toward doctors, there is some information we can draw from this. Take an interest in your patient, make eye contact, communicate with them!.

“When You Talk To Patients, Do You Look At Them Or At A Computer?” – Milton Packer

All of us have patients with high blood pressure (because you do check it once in a while right?). While we can’t give advice on diet, we can give some advice on exercise, and maybe give a little nudge on sharing information with them. Here’s a great article you can share with them.

“Lower Your Blood Pressure Naturally” – Julie Upton

Using best evidence in practice is crucial for our profession moving forward. So, how do we apply the best evidence to something like patients with low back pain? This article gives you a great foundation and applicable guidelines to do just that. 

“How Do You Solve A Problem Like Low Back Pain?” – Monica Noij

Tissue Loading During Proliferation Phase Of Healing

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In our last blog post, we started to discuss the importance of tissue loading when helping a patient rehab injuries.

We took the approach of how you would manage tissue loading during the first couple of days post-injury, during the inflammatory phase of healing. Evidence has shown that using AROM and PROM while your patient is still on the table is an effective approach to begin loading the tissue while there is still inflammation going on, as long as you stay within pain tolerances.

The goal is to get the joint, or the tissue moving and start building strength in the tissue again. But where do we go and what is appropriate in the coming days/weeks in order to progress the patient through their rehab?

Well, there are a few steps to take in order to progressively load the tissue during and after your massage therapy treatment so you can have greater success in their rehab.

It’s important to understand what is happening as far as the tissue response, how it repairs and heals itself, and also important to know how to progressively load the tissue and manage patient expectations.

So, with this post, we will look at the next phase of healing and movement progression.

Proliferation Phase Of Healing

While the inflammatory phase happens over the first couple days of injury (but can last up to two weeks), it has essentially prepared the way for healing to happen by eliminating foreign material and dying tissue.

During the second to fourth days after injury, inflammation decreases, and repair of the injured site begins. Now is when the proliferation phase can start working its magic. During the second to fourth days after injury, inflammation decreases, and repair of the injured site begins. There is an extensive growth of epithelial cells, building up of collagen fibres in random patterns and while blood vessels continue to grow. Granulation tissue (new connective tissue) had already started to form during the inflammatory phase and continues to do so until healing occurs. The proliferation phase can last from four to six weeks depending on various factors and health of the patient. When the proliferation phase is done, the remodelling phase starts two weeks after the initial injury.

Now I get it, that seems like a lot of science talk, but the biggest take away to remember is that new tissue is being formed and inflammation should be decreasing at this point. 

Some other things to take into account is the tissue is still fragile at this point (although that’s not the wording I would use when talking to the patient) and could be reinjured if we tried to do too much, or overstress the injury site and interrupt this phase of healing. However, we do want to start loading in order to increase strength and assist in decreasing pain.

So, how do we start to load the tissue, without reinjuring the site, or interrupting healing?

Safely Loading To Encourage Healing

As we mentioned in the last post, your clinical reasoning is crucial here. 

At this stage we want to start using more active exercises, however, as a therapist, you have to monitor whether swelling in the area has started to decrease and must adjust the patients movements accordingly. Just like when you’re trying to educate a patient about their pain, or any other part of your treatment, patient education plays an important part here. When the area starts to feel better the patient may start to load the area on their own and end up overdoing it. 

Showing them how doing too much could be a bad thing because the tissue is still healing (remember we don’t want to use terms like fragile, instil resilience, not fear) and we don’t want to hinder that process. Part of patient education should include some goal setting, which could include returning to whatever their chosen sport, hobby, or activity of daily living might be.

Once goal setting is complete you can start to initiate submaximal isometric exercises. This is where the muscle is contracted but not to the full ability of the patient. Depending on how the area is doing as far as healing, swelling, and pain you can progress to multiple angle exercises.

Last article we gave the example of an ankle sprain and weight bearing on the ankle while using the massage table for balance. Now think, still using the table for balance, but with the other foot planted on the floor, starting to move that ankle into mild movements like; plantar flexion, dorsiflexion, supination, and pronation. It is important to only move the part into pain-free ranges and keeping within the tolerance of the injured portion, but still loading into that direction (for instance the lateral ankle with a sprain).

Giving some homecare of AROM exercises within pain-free range should help to keep the swelling down while beginning to strengthen the area. As the movements get easier, start to decrease the amount of support, and increase weight bearing. If there are no signs of inflammation for more than 24 hours, the patient can progress to include stretching and eccentric exercises (the muscle lengthens on contraction), for lower limb injuries

Continuous monitoring on your part is important because if inflammation starts to increase or range of motion in the area starts to decrease or cause more pain, these exercises need to pulled back to isometrics like we suggested in our last post. Remember, positive reinforcement from you can go a long way in helping the patient load and move into the injury, helping to increase healing and getting them back to their chosen activity. 

In the coming weeks, we will continue to discuss tissue loading during the next phases of healing and show some demonstrations of how you can do this in your clinic room.

 

Articles Of The Week April 22, 2018

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Where do we go as a profession and as a practitioner if we pursue higher education? Is there an opportunity to stay in the profession and be in research, or in other capacities? This is a great article interviewing some RMT’s who have pursued higher education and what they see as opportunities.

“Preventing Brain Drain: Opportunities And Challenges For Higher Education” – Donald Dillon

Many manual therapists combine meditation and mindfulness into their treatments. A new study is looking at how mindfulness and meditation are helping patients dealing with depression.

“When Science Meets Mindfulness” – The Harvard Gazette

Amazing what communication and education can do for a patient. In this case, it may be more successful in helping people with chronic spinal pain compared to other interventions.

“Neuroscience Education Seen Improving Chronic Spinal Pain” – Judy George

I cherish sleep and have to hit the snooze button every morning. However, according to this article, that may be doing me more harm than good!

“Snoozers Are, In Fact, Losers” – Maria Konnikova

While we can’t necessarily counsel a patient on their nutrition (depending on your scope), we can always share information. Here’s some information backed by data on high-fat diets, that gives a fair bit of info on several topics around it.

“The Truth About High Fat Diets” – Brad Dieter

 

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