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Understanding The Healing Process as a Personal Trainer

The Healing Process NESTAcertified

As a fitness professional or trainer, you should have a clear understanding of the healing process to help prevent your client or athlete client from jeopardizing the healing process, and thus, delaying their return to activity.

These healing phases are not independent of one another; but are interdependent on one another, occurring in union along a healing continuum.  

Soft Tissue Healing (skin, tendons, cartilage, and muscle)

Inflammatory-Response Phase

(duration: approximately 4-6 days)

Inflammation is the body’s localized tissue response and common to all injuries (whether a specific trauma or an overuse injury).  

The inflammatory response begins immediately after an injury and is often considered the most critical phase because it sets the stage for the remainder of the healing process.

Inflammation attempts to limit the extent of the injury, while at the same time, cells are releasing chemicals that help to remove necrotic (dead) tissue and initiate tissue repair or regeneration.  

Although the inflammatory response phase plays a primary and critical role, if inflammation does not subside, normal healing cannot take place.

Signs of acute inflammation are redness, swelling, tenderness and pain, warm to the touch, and loss of function.

Fibroblastic-Repair Phase

(duration: approximately three days to 6 weeks)

In this phase, the body begins to repair and regenerate the damaged tissue.  Tissue damage stimulates fibrocytes and the creation of fibroblasts.

A fibroblast is a cell that makes up the basic substance of connective tissue and gives rise to other cells, such as bone cells, fat cells, and smooth muscle cells.  

It is also in this phase that scar tissue forms –a process that begins just hours after the injury and may continue for weeks afterward.

Complaints of pain or tenderness at the injury site can help signal the progression of this phase, as such complaints tend to diminish as scar formation advances.

Maturation-Remodeling Phase– (duration: approximately 5 weeks to 2-3 years)

In this, the longest of the healing phases, collagen density increases.  Scar tissue “remodels”, or reorganizes itself, to improve its tensile strength, but rarely will scar tissue be as strong as the original tissue.  

As the tissue remodels itself to become more like the original tissue it is replacing, the simultaneous process of “maturation” is taking place and will eventually complete the healing process.  

But the final stage of maturation varies in duration depending on the individual and the tissue being repaired.  For example, soft tissue maturation can continue for a year or more, while bone maturation can continue for many years after a fracture.

Bone Healing

Bone healing or fracture healing is the repair of a fractured bone. While immobilization and surgery facilitate this process, a fracture still requires adequate physiological healing.  

Depending on the size of the bone, normal periods of immobilization can range from three weeks to three months. Casting is required for the long bones, but not always for the smaller bones.  Sometimes a splint or brace is enough.

Healing times are affected by the severity, site of the fracture, other medical conditions, medications, nutrition, health, and age of the patient. While bone healing essentially follows the same 3-phase path to healing as soft-tissue, there are some differences.   

With fractures, the healing cells originate in the periosteum (the tissue membrane covering the bone).  Bone marrow also participates in the healing process.  These cells later become osteocytes that produce bone. The structure surrounding the fracture becomes harder; this is a provisional callus.  As time goes on, the callus becomes smaller as more and more bone is woven.  Over the next few months, as activity resumes, cells called osteoclasts function to reshape the bone (absorb and remove bone until it is reshaped) to complete the remodeling phase.

Avoiding Obstacles on the Healing Path

As a fitness professional or trainer, you can assist your client’s healing process by ensuring they avoid activities that might lead to increased swelling, or contraction of the injured tissue before it has sufficiently begun the healing process.

Some of the obstacles to prompt and complete healing include chronic edema, poor blood supply to the area, poor immobilization, atrophy, infection, hemorrhaging, and muscle spasms/contraction (or stretching) which cause the torn tissue to separate before it can heal itself.

Cartilage injuries heal poorly (or not at all) due to the fact cartilage has little or no blood supply.

Additionally, your client’s age, general health, medications, smoking habits, and diet can also help or hinder their healing. Encouraging a continued healthy diet rich in essential vitamins and ample hydration cannot be overstressed.  

You can also help prevent muscle atrophy by assisting your client as they engage in medically approved movement and exercises. The role of movement during healing is key. It helps to increase blood flow to tissues and maintain flexibility, and actually improve the tensile strength of the remodeled tissue.

You must be aware that while your client’s return to activity is the ultimate goal, a premature return to activity can be detrimental to both your client and yourself.  Never allow a client’s enthusiasm or verbal assurances of “feeling ready” to replace sound judgment, or permit a return to activity before medically cleared to do so.

Pain Types and Sources

Pain is the body’s warning mechanism and should not be ignored.  Also, keep in mind that pain is an individual and subjective response that differs greatly from person to person. For that reason, assessing and quantifying the severity of pain can be difficult. For example, a conditioned marathoner accustomed to the release of endorphins during prolonged exercise might not rate their pain levels after injury the same as a newcomer to exercise.  However, nearly all pain falls into one of three categories and stems from one of four sources.

Three Types of Pain

  1. Acute – pain lasting shorter than six months.
  2. Chronic – pain lasting longer than six months.
  3. Referred – occurs away from the actual site of injury.  An example is a sciatic nerve that originates in the lower back commonly refers pain down the buttocks, thigh, calf, and foot.

Four Sources of Primary Pain

  1. Cutaneous – sharp and burning external pain, with either fast or slow onset
  2. Deep – stems from tendons, muscles, bones, joints, and blood vessels
  3. Visceral – stems from internal organs (e.g., appendicitis)
  4. Psychogenic – the cause of the pain is emotional, not physical

Mechanisms of Pain Control

Modalities 

While a fitness professional can do little to actually speed the process of repair and remodeling, the following modalities can be used during the early phases and throughout rehabilitation to reduce pain, swelling, and muscle spasm, thus facilitating the natural healing process and hastening a return to activity.

Cryotherapeutic Techniques – ice bags, ice cup massages and ice whirlpools help to reduce swelling and counter the pain associated with acute inflammation. They are natural pain relievers. An ice bag should not be left on longer than 20 minutes, as the skin can burn or become frostbitten.  An ice cup massage is done by freezing water in a paper cup, then tearing off half the paper to expose the ice, and massaging the injured area with ice for 10 minutes. This method is excellent for superficial focal injuries, such as tendinitis and muscle strains. An ice whirlpool or ice bucket should be used for 12-15 minutes at 55 degrees for optimal results. 

Cryotherapy used after activity may be helpful in reducing swelling and muscle soreness. There are four stages of sensation felt when using cytotherapeutic techniques. First is the sensation of cold, followed by burning, then aching and finally numbness.

Cyrotherapeutic techniques are most effective when used in conjunction with the PRICE method for an acute injury.

Heat Therapeutic Techniques – heat packs and warm whirlpools (98-102 degrees) increase circulation and promote healing.  Heat can reduce stiffness and increase the range of motion, assisting with a more pain-free rehabilitation and eventual return to activity. Heat can also be used to assist in warming a muscle pre-activity. Sports heat rubs (Flex-All 454 and Icy Hot) are local analgesics that increase blood circulation, redness, and superficial skin temperature. They reduce local, mild pain by producing such an intense sensation, thus diminishing the awareness of the pain.

Because heat also can increase swelling, it should not be applied until swelling has stopped, the area is no longer tender to the touch, and discoloration is dissipating. Use a hot pack for 10-20 minutes. The pack should feel warm-hot, not hot-hot.  It is possible to burn the injured area, especially if there is decreased sensation.

Additional modalities that aid in controlling pain when applied in a clinical setting include ultrasound, iontophoresis, electrical muscle stimulation, and T.E.N.S.

Medications that Reduce Pain and Inflammation

As with all medications, even over-the-counter medicines require the user to follow recommended dosing per package instructions or your medical doctor.

Over The Counter Medications 

Acetaminophen (Tylenol) – To be taken for pain and fever reduction, it is not an anti-inflammatory. It does not thin bodily fluids (blood and cerebrospinal fluid) and does not have negative side effects on the gastrointestinal system.  To be taken every 4-6 hours, two tablets of 325 mg – 500 mg each (not to exceed 8 in 24 hours).

Ibuprofen (Advil and Motrin) – a Non-Steroidal Anti-Inflammatory Drug (NSAID), fever reducer and analgesic (reduces pain without decreasing sensitivity). Taken every 4-6 hours, 1-2 tablets of 200mg each (not to exceed 6 in 24 hours). If not taken every 6 hours, the drug cannot build in the system, and therefore the maximum anti-inflammatory effect will not be achieved. It should be taken on a regular schedule to act as an anti-inflammatory and not just a temporary pain reliever.

Naproxen sodium (Aleve) – Also an anti-inflammatory (NSAID); taken every 8-12 hours, 1 tablet of 220 mg each (not to exceed 3 in 24 hours). It has a longer time-release than ibuprofen.

NSAIDs are effective in decreasing pain, inflammation, and fever. Should be taken with food to help minimize the chance of stomach upset/bleeding/ulcers. Take with a large glass of water to help dissolve more quickly and safely. NSAIDs have fewer negative side effects on the gastrointestinal system than aspirin. Higher doses may be obtained by prescription from a medical doctor. Furthermore, NSAIDs and aspirin are not opiates and therefore, do not cause physical or psychological dependence.

Aspirin/Acetylsalicylic Acid (Bayer or Excedrin) – acts as an analgesic, anti-inflammatory, and fever reducer. Aspirin use carries with it a high incidence of gastrointestinal bleeding.  It is not recommended in an athletic setting because it thins the blood, thus delaying blood clotting time. To be taken every 4-6 hours, 1-3 tablets of 325 mg each (not to exceed 12 in 24 hours).

Heat Rubs/Balms (Flex-All 454 and Icy Hot) – are topical local analgesics that increase blood circulation, redness, and superficial skin temperature. They reduce local, mild pain by producing such an intense sensation, temporarily diminishing the athlete’s awareness of the pain.

Prescription Medications

Narcotic Analgesics/Painkillers (Codeine and Morphine) – are used to depress moderate to severe pain sensations, and do not have an anti-inflammatory effect. They are addictive and can be fatal when combining with alcohol or other medications. These medications cannot be taken before or during athletic events because they mask pain, lower respiratory rate and cause drowsiness.

Muscle Relaxants (Robaxin and Soma) – produce skeletal muscle relaxation to decrease muscle spasm and guarding. These drugs should not be used before or during athletic events because they act as a tranquilizer affecting the higher brain centers and cause drowsiness.

Corticosteroid Injections (Cortisone) – are used to decrease chronic inflammation in the tendon or synovial sheaths and bursa sacs. They should be limited to 3 per injury site and be given once every 3-6 months. The injury site must be rested at least 4 days after the injection and be used only after conservative treatment has failed.

Prescription-Level Anti-Inflammatory (Indocin, Voltaren, Anaprox, Feldene) – Prescription strength anti-inflammatories are similar to their OTC counterparts, but contain higher daily doses.

Other Medication Reminders

Antihistamines, decongestants, anti-depressants, and diuretics may contribute to dehydration and heat illness.  Antibiotics can increase sun sensitivity and cause severe sunburn.

Psychological Response

Pain is both a physiological and psychological occurrence. Pain is a subjective phenomenon and pain thresholds vary from person to person. The psychological aspects of pain, and the injury itself can cause emotional changes in even the most well-adjusted individual. It is important to remember that all pain is very real to the injured person. There are three techniques an injured person can use to help control pain.

  1. Employ a muscle relaxation technique to reduce muscle tension.
  2. Employ a visualization technique to redirect attention from the injury to a pleasurable event.
  3. Use their imagination to alter the pain sensation to another more positive sensation.

Learn more about injury prevention and personal training by enrolling and earning your certification as a Sports Injury Specialist.

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