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‘Pain is not the only problem’: Phases of Healing, Part 1

Healing and return to usual lifestyle (ADLs) or athletics (RTP) is the end-stage of LBP case management. It is not typical for a patient/athlete to desire only pain reduction while still experiencing the inability to perform personal care, loss of work & wages (RTW), continue with sports training, or emotionality that coincides with non-specific low back pain. It is important for the clinician to understand all of the patient/athlete values, expectations and desires in order to coordinate the right kind of care. However, it is not common for the medically-based clinician to manage the patient’s care in this way; therefore, patient expectations are not fully met, and LBP healing is unresolved.

The typical ‘Phases of Healing’ model is based on the concepts of time since injury: short term = acute as ‘-itis’, and long term = chronic, as ‘-osis’, or ‘-opathy’ indicating mixed stages. This model is a mis-representation of the complete healing process since important clinical features that can assure an effective LBP Course of Care have been overlooked while focusing only on time and pain. An updated Phases of Healing model (5-POH) demonstrates how the clinician can direct a more accurate Course of Care by understanding the presentation of the LBP injury within the Phases of Healing model. LBP injuries are tissue damages attempting to repair, sometimes for the first time, sometimes repeatedly, and sometimes unsuccessfully. LBP injuries may be in various stages of repair, sometimes in several stages at one time, and involve different tissues. It is unwise to frame an entire LBP diagnosis and Course of Care on information, such as advanced imaging or plain film, from an instance in time, since healing is a process. Further, it is impossible to determine which tissues were injured, and which tissues have successfully healed using imaging.

The 5-Phases of Healing (5-POH) model proposes that the usual 3-phase symptom-based model becomes a 5-phase model that focuses on the patient’s restoration to function (RTF.) The 5-POH/RTP model does not focus on the ‘days’ in a phase or pain, instead, it describes within each phase: (1) tissue healing indicators, (2) patient emotionality, (3) specific phase-sensitive care, and (4) markers for phase advancement. Part 3 is primarily the responsibility of the patient; palliative care is not provided, it is instructed. This model requires monitoring, guidance, and accountability by the managing clinician.

(1) Tissue healing indicators describe function improvement; whether tissue healing appears to be advancing and permitting expected performance, or whether symptoms and compliance are limiting or delaying healing. Tissue healing indicators describe variations from expected function improvement such as adaptation of faulty motor patterns, and creep. Tissue healing indicators do not assess pain.

(2) Patient emotionality indicators such as: fear, worry, anxiety, frustration, guarding, antalgia, and optimism, for example.

(3) Specific phase-sensitive care includes monitoring and guiding tissues toward healing and function. This includes a patient-accountable program utilizing a teaching and guidance platform to explain and demonstrate the individual steps and skills, including feedback reporting. 

(4) Markers for phase advancement describe the thresholds of tissue repair progress where further demands can be placed on the tissues while protecting prior healing accomplishments; phase advancement essentially ‘test-drives’ the next level of tissue demands.

Before a Course of Care can be prescribed, the clinician must be able to assess and determine the phase(s) of healing in the LBP patient. The various tissue damages (and FMPs) must be assigned into their respective phase(s). The clinician should not simply point the pencil eraser at an MRI and proclaim “Herniation” and stop there. Other tissue damages are expected in the entire patient presentation including; muscle spasm, muscle strain, postural strain, faulty motor patterns, inflammation (local-reactive and systemic), osteopathies, alignment, joint stability and function, prior and current scar, immunity and gut dysbiosis, for example.

Damaged tissue does not function properly. How, it does not function properly is as important as, why. When there is tissue damage, movement patterns are modified ‘around’ the injury (sometimes called ‘Plan B’) in order to preserve pain-free function. However ineffective, the attempt is made nonetheless, subconsciously as in antalgias, postural adaptations, and immobilization, or consciously in order to restore some function. When Plan B is utilized without pain, it eventually becomes the new-normal, also called ‘creep.’ When pain arises using Plan B, and no attempt is made to remodel/restore the injured tissue, another movement pattern is formed, Plan C, which may or may not provide a pain-free function. Nevertheless, optimal function is lost.

In essence, the tissue damage drives further faulty movement patterns that attempt to reduce painful movement. This can be observed when an athlete continues to train even when expected performance is hindered, or develops alterations in performance in order to keep playing, or play without pain. The original tissue damage was likely an undiagnosed faulty movement pattern. The tissue damage cycle is repeated every time there is a new movement pattern attempt ‘around’ the original injury. 

When we pull back the curtain, we can observe insufficiencies in treatment of LBP. LBP can be understood as layers of FMP in various stages of healing, not simply as chronic non-specific back injury, or acute incidental back injury. Medically-based clinicians can benefit from understanding the 5-POH & RTF model since it can explain their historical problems treating LBP, since ‘pain is not the only problem.’

LBP Blog General information

Series Description

These articles intend to (1) re-evaluate the prevailing clinical practices thought to manage low back ‘pain’, (2) submit and debate novel low back ‘pain’ contributors and mechanisms, (3) meet patient expectations & satisfaction and clinically meaningful results, (4) recommend a conservative non-surgical course of care to over-ride ‘pain’ instantly, and (5) restore ADLs and patient confidence on the first visit at low cost. This article has a companion podcast.

Dr. Dean Bio

Forester Dean is a chiropractic and physiotherapy sports medicine doctor practicing in Los Angeles, California. Dr. Dean is a lifetime athlete, and currently teaches tennis, track, boxing, yoga. The Core X System™ Campus flagship location was opened by Dr. Dean in 2020.

© Copyright 2021 SpineSync, Forester Dean, DC
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