Healing Phases and Therapeutic Exercise

Original Editor - Wanda van Niekerk based on the course by Richard Jackson

Top Contributors - Wanda van Niekerk and Jess Bell  

Introduction to Aspects of Therapeutic Exercise

Therapeutic exercise is a key aspect of rehabilitation programmes after injury, deconditioning or disease. It promotes recovery and restores function. Prescribing therapeutic exercise can be complex and requires a great deal of clinical reasoning and patient monitoring. Exercises should be selected to meet the individual’s needs and be adjusted as necessary.

Important aspects of therapeutic exercise prescription include:

• ensuring an individualised, patient-centred approach
• creating relevant goals that are adjusted when required
• selecting appropriate exercises based on foundational concepts
• assessing the individual’s ability to perform the exercises and selecting the proper dosage
• ensuring that the individual knows how to perform their exercises effectively and efficiently
• monitoring and evaluating responses to exercise
• identifying contraindications and / or precautions to performing specific exercises

The severity, irritability, nature, stage and stability (SINSS) model can be used to determine the intensity and choice of exercise.

Severity

• related to the intensity of the symptoms and pain

Irritability

• how much activity is needed to aggravate the symptoms or pain?
• how long does it take for symptoms or pain to subside?

Nature

• what is the specific diagnosis?
• what is the specific nature or type of symptoms?
• which biopsychosocial factors impact the individual’s symptoms or pain?

Stage

• consider the phases of healing

Stability

• how have the symptoms progressed over time?
• are symptoms improving, worsening, not changing or fluctuating?

If you'd like, you can read more about the SINSS model and see its application in different case examples here.

Phases of Healing

Table 1. Phases of healing, the physiology and goals of therapeutic exercise during each phase (adapted and created from Dunleavy et al. 2o19)

Phase of Healing	Physiology	Goals of Therapeutic Exercise
Inflammatory phase (immediately to 3 - 10 days)	Normal response to injury or damage Necessary for healing Characteristics include redness, swelling, pain, heat Responsible for the removal of damaged tissue and the initiation of cellular mechanisms "to promote repair and avoid further damage" Bleeding and fluid release into the joint and extracellular spaces are part of this early response Nociceptive pathways are stimulated by tissue damage Inflammatory mediators such as histamine and bradykinin are released Secondary vasoconstriction occurs to reduce bleeding Muscle spasm to avoid further motion and damage This phase is meant to minimise and prevent further damage The removal of damaged cellular debris, the stimulation of fibroblastic activity and the formation of scar tissue indicate the end of the inflammatory phase	Support healing while limiting excessive inflammation (Peace and Love Principle) Protect the injured tissue Assist with removal of inflammation by-products such as metabolites and oedema Increase circulation Decrease pain Therapeutic exercises that limit the effects of immobility and / or deconditioning without adding too much stress on the injured tissue
Reparative phase (5 - 10 days to 3 months, depending on tissue type)	Also known as the proliferation phase Fibrous tissue bridges the gap in the damaged tissue Two actions occur during this phase: fibrous material production (fibroplasia) and new blood vessel formation (angiogenesis) Capillary buds form and grow towards the injured area Creation of granulation tissue Phagocytosis by specialised white blood cells New drainage system created by lymphatic vessels Fibroblasts contract the wound	Provide the optimal stimulus to promote tissue regeneration Reduce the effects of inactivity or immobilisation Protect injured tissue Improve muscle function by applying the correct amount of load (thus not placing undue stress on the injured tissue) Address impairments experienced by the individual
Remodelling phase (6 weeks to 2 years, depending on tissue type)	Maturation and remodelling of the injured tissue Removal of excessive fibrotic tissue Contraction of granulation tissue Intercellular bonds are formed by fibroblasts Collagen strength is increased through cross-bond formation between cells Continuous turnover of collagen Type III collagen is replaced by type I collagen	Restoration of functional movement Strengthen the tissue's capacity to withstand the forces required for function Progression of exercises to reach functional strength, power, coordination and speed Add more complex activities with increased intensities in multi-planar directions to achieve the individual's specific goals

The video below summarises the phases of healing and the timeframes for each phase: