Stages of healing
Healing is a natural process. Our bodies are designed to repair injuries naturally. These repairs take time. They involve a cascade of chemical reactions and cellular processes and neurological changes that build on each other to repair lesions.
The healing process can be grouped into three stages. We slowly move from one to the other. The treatment applied needs to differ in each phase as the body transitions from acutely injured to fully resilient.
The first stage is the inflammatory phase.
Immediately after the trauma the damaged tissues release chemicals that create swelling and constrict the dilated blood vessels. The white blood cells are focussed on removing damaged tissue and the platelets begin staunching blood flow and begin the bridging of separated tissue. The neurological response creates weakness and we lose coordinated motion. Our brain immediately changes and we lose awareness of the area. The pain overrides the position sense.
The pain is most severe at this time often sharp, throbbing and can be painful at rest.
Treatment during the inflammatory phase should consist of rest, protection, controlling pain and excessive inflammation. We need to hold the edges of the damage together and protect the fragile repair to limit further damage. Excessive swelling can reduce blood flow and stretch other structures. Physiotherapists can educate on good positioning and taping and support. Medications and modalities can be used to reduce pain and inflammation. Massage or manual therapy needs to be extremely gentle. The goal is to relieve pain, reposition displaced joints and flush swelling.
The inflammatory phase can last from 1-5 days, depending on the severity of the injury and type of tissue injured.
The second stage is the repairing (proliferation) phase.
After the initial scab has formed the fragile bridge over the damaged tissues begins to strengthen. The cellular turnover is highest during this phase. New blood vessels begin to grow into the wound. The inflammatory response initiates the laying down of a collagen matrix. This scar tissue slowly creeps along the scab bridge laying down a thick mesh of collagen. This scar develops in response to the stresses put through it. Excessive strain will injure the fresh repair and revert to the inflammatory phase. The nervous system begins to reactivate the area. This begins with tightening of the fast twitch muscles, often creating muscle knots interspersed with flaccid supporting muscles. The brain then begins to develop awareness and coordination of the area.
The repair phase is still tender and painful with excessive movement. Pain pathways are sensitive and the scar is still weak. Light gentle movement feels good. We need gentle light motion to encourage blood flow and stimulate optimum scar healing. The blood flow flushes the waste products out and brings in needed nutrients. The gradual addition of the appropriate stresses on the tissue encourage more scar production and begins to shape the scar to respond to stresses. At this point, we need to balance muscle tension, create good sensations through the injured area and don’t reinjure.
Treatment will include gradual progression of strength, mobility and awareness. Optimizing muscle function and blood flow is helped with hands on massage and manual therapy. A home exercise program is essential. Protection and support is still important, as it allows the injury to heal at the right length and remind the body what the normal movement is.
The repair phase lasts 4-8 weeks.
The third phase is the remodelling (maturation/regeneration) phase.
The third stage of healing shapes and strengthens the scar, ideally replacing it with appropriate cells. Repair is healing with a suitable structure but regeneration is repairing with an exact copy of the original tissue. The cell turnover is slower during this stage. The collagen scar gets more pliable and the mesh realigns along the lines of stress through the structure. The initial collagen gets replaced with a stronger type oriented along the lines of tension. The brain recognizes the body part and returns to the original body map. The nerves develop the appropriate balance between fast and slow conduction and proprioception (position sense) improves.
The maturation phase can tolerate vigorous stretching and exercise. The body needs directed activity to guide the regeneration of the tissues. Discomfort is tolerated and almost necessary, but pain is never helpful. Manual Therapy and massage are still useful because the stresses will cause abnormal joint mechanics and muscle changes. Reducing these impairments will allow the body to form the strongest most flexible production of itself. Mild irritation of the tissues will reinvigorate the healing process and provide the increase in blood flow and growth hormone production. Awareness and proprioceptive exercises are important to guide mental growth. Bracing and taping may be needed if the tissue did not heal short enough and instability persists, awareness isn’t fully developed or if activities go beyond present physical tolerances.
This phase lasts 2 months to 12 months.
The body never stops repairing, regenerating and progressing. We can improve strength and flexibility well after injuries and into old age. The regeneration phase can always be activated by dedicating attention to the body and direct growth.
In summary I want you to know that healing happens naturally and we do a good job of it. The key factor is doing the right thing at the right time. Listen to where your body is at and guide it gently through the recovery.
Written by Stan Metcalfe, physiotherapist