Reducing Pain Uncategorized

Rehabilitation Management of Soft Tissue and Fracture After Trauma or Surgery: Principles for Improving Functional Outcomes

Phases of Soft Tissue Healing-Intervention 

Inflammatory Phase:  Immobilizing splint or sling may be used to protect tissue.  (2 days to 1 week)

Fibroblastic Phase:  Splint or device may be used to allow protected mobility.  This allows the healing tissue to strengthen while minimizing the negative effects of scar adhesion with the surrounding tissue. Passive Range of Motion is provided in the direction of the injury (Active concentric movement is minimized so as not to disrupt the repair).   Light resistance or dynamic pulleys may be used in the direction away from the injury.  This will allow eccentric recruitment of the injured tissue and helps improve the long term tensile strength of the repair.  Active assisted and place and hold exercise are graduated to active and resisted exercise by the end of the phase (up to 8 weeks post surgery). Pressure applications may help to control scar development.

Maturation Phase:  Healing tissue is strong; however, there may be hypertrophic scar due to tissue density (increased molecular bonds) and disorganized collagen fibers.  Splint or device may be used to provide low load stretch (static progressive splint or serial casting).  This would coincide with manual soft tissue and joint mobilization along with progressive strengthening and activity.

Note:  During the Fibroblastic phase, it is important to initiate controlled movement as soon as possible. Protocols are established for various injuries and surgical repairs.  Frequency of therapy will depend on the patient’s pain levels and/or ability to comply with a home exercise program to provide early gliding of the tissues. Frequency may also be governed by the size of the involved joints.

During the late Fibroblastic and Maturation Phase, therapy should be more frequent (depending on patient compliance) and it should be progressive.  The emphasis is on specific adaptation to imposed demand (SAID).  Respect should be given to pain so as not to disrupt the healing tissue or develop a secondary inflammatory response (which will perpetuate the scarring effect).  Anti-inflammatory medication and physical agents may be necessary to control inflammation.  Manual therapy is a very important intervention during this phase for soft tissue management and to reestablish joint balance and muscle length-tension. Again, care should be taken not to be too aggressive. The requirement for aggressive manual therapy should be minimized by the proper implementation of movement during the 2nd phase of healing. The patient’s compliance with a home exercise program for flexibility and gradual strengthening is very important.  Research indicates a direct correlation with low load total end-range time (TERT) and the effect of lengthening and modeling scar tissue.  

Phases of Fracture Healing

“Movers” versus “Resters” Fractures that are closed, relatively non-displaced and stable can be managed by protection without reduction or immobilization. Fractures that are non-displaced but are unstable or load bearing require immobilization such as a cast or fracture brace.  Open reduction is required when bone fragments cannot be approximated through closed reduction alone and internal fixation devices are then used.  

With immobilization by cast there is slight movement of the fracture sight and immature woven bone or external callous forms first as the bone consolidates and remodels.  When external callous forms first, more healing time may be required. A bone healing stimulator may be used.

With internal fixation, direct healing occurs and may be faster depending on the nature of the fracture and the number of fragments.  

Fracture Healing estimated time tables according to Apley and Solomon (1994)

Upper limb Lower limb

Callus visible: 2-3 weeks 2-3 weeks

Union: 4-6 weeks 8-12 weeks

Consolidation: 6-8 weeks 12-16 weeks

Immobilization or Early Mobilization Early mobilization treatment programs have specific focused protocols which govern timing type and quantity of desired movement. Advancement is determined by the stability of the fracture and radiographic indication of fracture healing.  Any immobilizing device should be monitored for signs of adverse response such as constriction of circulation or skin breakdown. Hinged splinting may be used to allow some restricted movement of a joint.  Care must be taken to preserve joint function above and below the fracture site. Co-contraction of the muscles isometrically across the fracture site is encouraged to facilitate circulation and bone healing.

Early Consolidation Therapy begins to focus on active use of the effected limb.  Active therapy may include specific resistance training as well as activities and tasks designed to remediate the muscles of the injured region.  There is continued focus on edema control and soft tissue management in the adjacent regions.  If there are changes in body posture or compensatory movement patterns these must be addressed.  Adherent or hypertrophic scar should be treated as previously described. Increased Muscular activity will help with edema control and the scar modeling.

The Final phase:  Once the orthopedic specialist gives clearance, Physical or Occupational Therapy should include activities to reintegrate the injured extremity to the body scheme and to condition the individual for specific ADL, IADL and vocational tasks. This allows intrinsic recovery of function and neurological relearning. Whole body exercise and activity should be incorporated to reverse any deconditioning that occurred during the convalescent period.  Sufficient data may be gleaned from the measurement of function and performance during this time in the program.  A Functional Capacity Evaluation may be necessary to determine job readiness and placement.  

Additional resource: Occupational Therapy for Physical Dysfunction 6th Edition 

If you need assistance with soft tissue rehabilitation management, contact the team at REHAB AT WORK today to schedule a consultation, or refer a patient for our services.

Richard Wilson, OTR

Reducing Pain

What Causes Pain? How Can We Reduce It?

In this blog by Marian Kirk, PT, we’ll look at what causes pain in humans, and what we can do to reduce and manage it.

Pain is produced by the brain when the brain perceives a threat. Pain does not automatically happen after an injury. For example, if you sprain your ankle, the nerves in your ankle send a message to your brain. If you are walking across the street and a bus is quickly coming towards you, your brain will focus on the threat of the bus and ignore the message from your ankle. While you are getting out of the way of the bus, you will be unaware of your ankle sprain and will not feel any pain. Once you are safely on the sidewalk and your brain no longer perceives a threat from the bus, your brain will cause you to feel pain in your ankle and allow you to take care of your ankle. 

When you experience pain for a longer period of time, the pain can start taking over your life. Many people become less physically and socially active and more stressed. If you are afraid that moving your back could hurt you, then you may stop doing activities that you enjoy like bowling or dancing. People often become isolated and depressed. How do you get your life back?

Research shows that you can slowly build up your activity level even if you have pain. If you begin with gentle aerobic exercise like walking, you will find that you can gradually increase the time and length of your walking. Aerobic exercise stimulates your brain to release specialized hormones (endorphins) into your bloodstream. The “runners’ high” give people a feeling of well-being and decreases their stress level. Whenever we are stressed or “uptight”, our muscles tend to tighten up and can cause more discomfort so less stress helps the tight muscles to relax.

We hope this blog has given you some additional insight into what causes pain, and how best to reduce it. Do you have a lingering injury causing you pain? Contact the team at REHAB AT WORK today to see if physical therapy might be the next step for you. You can also refer someone if they need services.


Louw A., Puentedura EJ, ZimneyK., Diener I., Schmidt S., “Know Pain, Know Gain? A perspective Pain Neuroscience Education in Physical Therapy. J Orthopaedic Sports Physical Therapy Mar 2016; 46(3):131-134

Louw A., Puentedura E., Schmidt S., Zimney K. “Pain Neuroscience Education Vol 2. Minneapolis, MN:OPTP; 2018