The body's remarkable healing process
August 17, 2019
The human body has the fascinating ability to heal itself! To a certain extent, at least. But when you look at the condition of a house or a machine after 50, 60, or 80 years, this ability is truly remarkable!
And most people do put quite a strain on their bodies, albeit often not in the right way... because it's not movement that damages the body, but the wrong or lack of movement!
“It’s not movement that destroys a Machine, it’s friction”
We osteopaths and physiotherapists must thoroughly understand the process of wound healing and its phases to design our therapy optimally and effectively. This means, depending on the healing phase the patient is in, we as manual therapists must choose the right dosage of techniques and applications and plan the therapy accordingly.
The goal of wound healing is the complete functional restoration of the injured structures. The more optimal the physiological stimuli act on the injured tissue, the better the healing—resulting in less scar tissue.
Wound healing in the human body (whether it's with an injured intervertebral disc, a torn or operated cruciate ligament, a strained joint capsule or ligaments, or even a broken bone) always occurs through various phases. In physiotherapy and osteopathy, these wound healing phases are categorized and distinguished as follows:
Inflammation phase
Proliferation phase
Consolidation phase
Organization phase
Further, more detailed subdivisions are possible and sometimes made.
Healing progress of a heel surgery after 2 days, 15 days, 20 days, 6 months, Kaspar1892, Surgical suture, Healing progress, CC BY 3.0
These phases can overlap and vary depending on the tissue. Key factors influencing the duration of each phase are the blood supply to the injured tissue as well as the size of the damage. This also affects the tissue's turnover time: all tissues in the human body are replaced sooner or later. If the tissue has a good blood supply, the turnover time and healing time are relatively quick. An example is the skin: after a cut, there's nothing to see in a few weeks (the turnover time is about 3 weeks, meaning our skin is renewed every three weeks).
An intervertebral disc, on the other hand, which can be responsible for back pain or issues, has less blood supply and a turnover time of about 400-500 days (taking over a year for the tissue of an intervertebral disc to renew).
Depending on the acuity (in medicine describing the state of the tissue it's in, thus a chronic condition can be in a state of high acuity, e.g., activated osteoarthritis. Not to be confused with acute), which a therapist must identify, different therapy options and techniques with various goals are applied.
Abrasion of the hand – 32 minutes after injury, Jpbarrass, classified as public domain, Details on Wikimedia Commons
Inflammation Phase of Wound Healing
The inflammation phase lasts, depending on the tissue, between 3 and 7 days post-injury. It is characterized by pain and swelling caused by inflammation.
Inflammation creates optimal conditions to activate the body's own cells (e.g., macrophages, leukocytes, lymphocytes), substances, and enzymes (similar to a fever).
Through the oxygen-rich blood and proteins that leak into the injured tissue, body and connective tissue cells are regulated, activating an interdependent chain of processes. The released proteins also increase fluid retention, causing swellings. This makes the tissue looser, allowing body cells to migrate better into the injured area.
The tissue begins repairing the vascular system, with the body providing initial emergency care and repair through auxiliary tissue (collagen Type III) to close the wound as quickly as possible. Although collagen synthesis has already begun, the new formation of fibro- and myofibroblasts dominates this phase.
Pain-relieving and anti-swelling measures are paramount during this phase. Appropriate rest and unloading of the injured tissue are indicated. Perhaps compression bandages may be used. The sympathetic nervous system should be calmed. Pain-free movements within the matrix area of the tissue (either passive or active mobilization) are still important to stimulate the connective tissue. However, it is crucial to proceed cautiously with mechanical stress as the tissue remains very unstable due to the lack of basic substance production.
Electrotherapy or ultrasound can be excellent additions to the therapy in this phase.
The inflammation phase should be concluded by the body as quickly as possible. The therapy should support this process.
Abrasion of the hand – 2 days 22 hours 12 minutes after injury, Jpbarrass, classified as public domain, Details on Wikimedia Commons
Proliferation Phase of Wound Healing
This phase generally lasts between 3 and 10 weeks post-injury. In the proliferation phase, pain significantly decreases as mobility increases. There is regeneration of connective tissue (the initial restructuring of previously formed auxiliary tissue). Collagen synthesis is very pronounced during this phase, although initially still thin and closely aligned fibers. However, the production of the basic substance remains low, making the tissue still not very elastic and only limitedly stable.
It should be physiologically, functionally, and painlessly stressed so that the fibers of the connective tissue, which are synthesized in large numbers, can align optimally and no scar tissue with improper cross-links forms. This is crucial in this phase! Neuromuscular coordination towards natural movement and load is also a goal of the therapy. Measures to promote blood flow for metabolic optimization, as well as fostering the synthesis activity of the connective tissue cells, take center stage. Training volumes can be increased (but not or only adjusted intensity, to prevent creating new injuries in the tissue since it remains unstable as previously described). Functional, coordinative closed-chain exercises begin to improve proprioception (exercises in three-dimensional patterns).
Abrasion of the hand – 17 days 11 hours 30 minutes after injury, Jpbarrass, classified as public domain, Details on Wikimedia Commons
Consolidation Phase of Wound Healing
The consolidation phase lasts up to 12 weeks after an injury. The collagen network is rebuilt once again; fibers become thicker and more stable (collagen Type I). Due to increased basic substance production by fibroblastsduring this phase, the tissue's load capacity significantly increases, and the distance between the fibers enlarges. These are prerequisites for forming a stable network of collagen fibers, thereby improving the tissue’s elasticity.
During this phase, active therapies take precedence, focusing on the patient’s goals and needs: what they need and want (differences between an elite athlete or a desk worker). The load can be significantly increased (treatment in the collagen load area).
Repeated end-range mobilizations to achieve full mobility should be conducted to eliminate movement deficits. Tailored and gradually heavier functional three-dimensional exercises promote further improvement in proprioception and dynamic stability. Speed training can begin, including jump and run coordination training. Maximum strength training in a closed chain, as well as strength training with free weights, begins.
Abrasion of the hand – 30 days 4 hours 43 minutes after injury, Jpbarrass, classified as public domain, Details on Wikimedia Commons
Organization Phase of Wound Healing
The organization phase follows the consolidation phase and is also tied to the turnover time of tissue. The originally laid collagen Type III was mostly converted into stronger collagen Type I fibers. The originally injured area has developed from a largely cellular tissue into a normal collagenous connective tissue.
In this phase, ADL activities (activities of daily living) and the patient’s needs and demands take center stage: Function shapes structure! Exercises, training, and therapy should be aligned to the patient’s daily life, work, or sport.
Exercises target reactive capabilities, speed, and optimization of the stretch-shortening cycle. Eccentric loads, supra-maximal, and if possible, maximum strength training in closed and open chains, as well as sport-specific exercises, are employed. Trial competitions or competitive behavior might be included in training.
The load capacity of a tissue depends on which cells are active in each phase and which tissue components they synthesize.
Perhaps now it's clearer why a cast is usually worn for 6 weeks or why crutches are often used for 4-6 weeks after leg surgery.
All phases of wound healing actually begin simultaneously, as demonstrated through enzyme histochemical methods, and must be viewed in context. The phases overlap, and we as therapists must recognize when a phase is largely completed by the body to progress in therapy and provide optimal physiological stimuli in the tissue.
There's no faster healing than optimal healing! At BodyLab, we have the expertise to optimally support and accompany you as a patient with injuries of the musculoskeletal system. To alleviate your pain and to recognize or prevent delays and complications (such as infections or later deficits) early on. For an optimal, fastest, and best result.
If you need us, we are happily there for you!
Your BodyLab Team – Your specialists for physical injuries
Osteopathy and Physiotherapy | Rehabilitation and Training
Zurich Altstetten
Cover Image Credit
Carsten Niehaus (Lumbar), Wound sewed, CC BY-SA 1.0
