Pain in the Chronic stage of inflammation

Chronic inflammation occurs when the natural inflammatory response of an acute injury does not fully resolve.  Failure of a tissue to fully heal can happen with repeated small tears and overuse. Conditions such as an autoimmune disorder or the presence of a foreign material such as a suture or implant may also contribute to chronic inflammation. Pain in the chronic stage of inflammation may be hard to detect. It may only become evident with pressure or pull on the area. More commonly experienced symptoms are reduced range of motion and postural distortions, which if tested, invoke Pain.

It is important to note that chronic inflammation is not the same as chronic pain. Chronic Pain has been discussed in previous blogs and will be reviewed again in future posts as it is a major part of my practice and a personal concern, as I cope with medically unexplained chronic pain every day.   But back to Chronic SOI -

Chronic inflammation may not feel red, hot, swollen and painful at all.  In fact, the area typically feels cold, hard, stiff and has a pale or bluish hue, due to lack of blood flow.

The goal of Chronic inflammation is: to protect the formerly injured area.  In order to do so, scars reorient and remodel in response to pulls and tensions placed on them during daily activities.

Physiology - In order to protect the area, the following physiological processes happen:

• scar tissue continues to remodel and reorient in response to stress . This process is rapid in the first few months of chronic inflammation stage and then the remodeling slows and takes more force to change
  
• scar tissue strengthens 
  

  Therefore, Pain treatment in the Chronic SOI  focuses on softening adhesions and scar tissue that limit pain-free range of motion, increasing range of motion, and decreasing postural distortions due to habitual patterns that were once protective but are no longer serving a useful function.Persistent low grade inflammation damages connective tissue, causes necrosis and fibrosis and prolongs the healing process.  Granulation and fibrotic tissue continue to develop within the loose (superficial) CT which is highly vascular and innervated, thus further constricting blood flow and nerve impulses. Increased collagen production amidst this background leads to increased scar tissue and adhesion formation.

The Symptom Picture is :

• resolved SHARP signs (Swelling, Heat, A loss of function, Redness and Pain) except for A loss of function
• loss of full ROM (range of motion)
• decrease in functionality
• postural changes
• Pain is pinpoint and felt with overpressure or overstretch
• increased scar tissue and adhesions
  

Treatment Plan (works to decrease symptoms). Therefore LMT's and other therapists work to:

• Continue to Decrease remaining Spasms
• Increase available AROM and PROM (active and passive range of motion) 
• Increase strength
• Change proprioception / reverse somatic amnesia (forgetting what it is like to move with ease)
• address TP's that remain after fascial release
• Reduce scar tissue and adhesions

Treatment follows directly from the Plan, So in addition to successful treatments from the Acute and Subacute SOI's,

• Add in Passive Stretch to increase PROM
  
• Continue to Use PIR (post isometric relaxation) RI (reciprocal inhibition) to maintain AROM and PROM
  
• Continue to use RM (rhythmic mobilization) to reset proprioception and remind restricted tissues of how far they can move without Pain
  
• Intersperse focused work with relaxing full body Swedish, shiatsu, RM
  
• Continue scar and adhesion reduction with MFR, XFF and muscle stripping
  
• Continue to  Reduce remaining Spasms - using GTO, OI and MA
  
• Continue to massage the opposite side will decrease the stress on compensatory structures, and proximal to the injury
  
• Address remaining trigger points
  

Self Care Recommendations follow the Plan too, so good recommendations include

• Active Stretches identified in the massage as restricted
  
• PIR/RI exercises that you have identified on the table and practiced with client
  
• Other strengthening exercises - using theraband, gravity, wall as resistance
  
• Balancing movements - coordinating injured side with unaffected area
  

Hydrotherapy : Heat at rest, heat before and ice after activities or receiving bodywork,

Contraindications include:

• Do not massage with pressure or stretch that causes Pain or Spasm
  
• recognize that Pain Medications can affect the patient's perceptions of pressure that may be causing more damage, so try to get clients to space these out and take the next dose after, rather than right before a session