Pain in the Sub-acute Stage of Inflammation – Part I – Early Sub-acute SOI

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Pain in the sub-acute stages of inflammation is less widespread than acute pain. There are two stages of sub-acute inflammation;

  1. fibroblastic repair (Early sub-acute) phase
  2. maturation-remodeling (Late sub-acute) phase

Early sub-acute injuries feel less red, hot, swollen and painful than in the Acute phase. This easing of symptoms continues into late Sub-Acute stage; with even less pain and signs of being less red, hot, and swollen  The hallmark of Sub-acute phases is  about forming and reforming the protective scar.

The goal of Early Sub -acute inflammation is:

  • to fill the damaged area with new tissue

Physiology – In order to fill in the damaged area with new tissue, the following physiological processes happen:

  • new capillary buds begin to form into the wound, allowing for an increase in blood flow that brings oxygen and essential nutrients for tissue regeneration
  • fibroblasts synthesize collagen in a loose connective tissue matrix which replaces the clot formed in the acute stage
  • the result of increased blood flow and building the connective tissue web is a very fragile granulation tissue, a scaffolding that lays down the basic framework for future collagen fibers to attach to.
  • lactic acid levels rise in the area – as a result of microphage activity and the hypoxia that ensues from the cell and toxin debris.  This also gives rise to increased collagen production.

Therefore, Pain treatment in the Early Sub -Acute SOI  focuses on continuing to decrease inflammation response, without damaging the fragile granulation tissue that has formed to fill in the area.

The Symptom Picture is :

  • decreased SHARP signs (Swelling, Heat, A loss of function, Redness and Pain)
  • decreased Muscle spasms (muscles contract to protect against trauma) that can now be addressed if treatment doesn’t cause more pain
  • Bruises are starting to heal and often turning yellow in color
  • Pain is more localized and felt when tissue is stretched to resistence

Treatment Plan (works to decrease the symptoms. Therefore

  • Continue to Decrease SHARP signs
    • remaining edema with diminished heat and redness
    • pain
    • can begin to address a loss of function
  • Maintain available ROM (range of motion) and strength
  • Begin to decrease spasms

Treatment follows directly from the Plan, So in addition to successful treatments from the Acute SOI, add in:

  • Reducing Spasms – using spasm relief techniques of

GTO (golgi tendon organ technique) for long tendons
OI (origin/ insertion technique) for short tendons
MA (muscle approximation technique) for the muscle bellies

  • Use PIR (post isometric relaxation) and RI (reciprocal inhibition) to maintain AROM and PROM without putting the stress of a stretch on fragile granulation tissue
  • Address trigger points that refer into the area of trauma, avoiding pressure directly on the injured area
  • Continuing to massaging the opposite side will decrease the stress on compensatory structures, and massaging proximal to the injury will also continue to push circulation back to the heart, speeding the removal of toxins from the injury

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

  • Educate the client on the importance of not overdoing/ re-injuring the area
  • Do encourage Pain-free movement of the area
  • PIR/RI exercises that you have identified on the table and practiced with client

Hydrotherapy : Mild contrast, beginning and ending with Cool

Contraindications include:

  • Do not massage with pressure or stretch that puts drag on the granulation tissue(so as not to redamage the compromised area)
  • Use only gentle squeezing and light strokes distal to the injury
  • If client experiences Pain or Spasm with massage or exercises, reduce or eliminate the process causing the Pain
  • 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