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‘Pain is not the only problem’: Phases of Healing, Part 2

The 5-POH model describes a case-management plan for non-specific low back pain, the commonest presentation seen clinically. The purpose of these articles is to propose a model for low LBP care that provides better patient outcomes, and better clinical management since the focus is taken off only managing pain. Instead of focusing on pain, the 5-POH model focuses on return to function (RTF) by monitoring and restoring movement patterns that align with the commmoneest patient expectations: ADLs, RTW, and RTP

In order for a treatment plan to begin, an injury/lesion (or complex of inter-connected injuries/lesions) must be identified and diagnosed. Pain is not an injury; pain is a subjective experience that may or may not be related to real or imagined tissue damage. Pain is not a diagnosis. It is important that the clinician explain the importance of identifying and correcting faulty movement patterns (FMPs) as the primary goal within the Course of Care. The inflammatory response is a key healing process since it initiates the tissue repair process; however, chronic systemic inflammation (CSI) will interfere with healing. The clinician must also prescribe diet and lifestyle re-habituation skills to reduce or eliminate CSI, while reinforcing its influence on persistent low back pain. An anti-inflammatory low histamine diet (AILHD) plan is easy to prescribe and monitor at very low cost.

The Acute Phase (AC) describes the first phase when there is no remodeling of the primary lesion, and is accompanied by significant reduction or complete loss of function (functio laesa). The injury is commonly incidental (traumatic), and commonly presents with swelling (tumor), tenderness (dolor), redness (rubor), and warmth (calor.) The patient/athlete may experience fear, worry, concern, anger, or frustration. The patient/athlete may react with guarding, antalgia, or immobilization. Care involves immediate medical attention, establishing a patient-doctor relationship, patient education, and reassurance.

The Post-acute Phase (PAC) describes the second phase where remodeling begins with minor restoration of function that primarily occurs ‘around’ the injury/lesion. Scar formation begins, and injury-related inflammation resolves. Adjacent joints should be assessed for acquired FMP or reactive immobilization. The patient/athlete may experience emotionality or anticipation related to restoration of ADL/RTW/RTP. Patient expectations should be discussed, as well as an RTF plan and protocol. Care involves guidance to support early remodeling, management of scar formation, and support for patient expectations. With proper care management, the injury/lesion heals as anticipated, and function is restored. The patient/athlete resumes activities with diet and lifestyle improvements, and is discharged.

The Chronic Phase describes a failure (full, or in part) of the remodeling process to produce anticipated restoration of function. The chronic phase implies only failure of function, not presentation of symptoms. To be clear, the patient may have symptoms related to (or not) a healed injury/lesion; symptoms do not imply persistence of tissue damage. Also, the patient may have a FMP related to (or not) a healed injury/lesion; a FMP does not imply persistence of tissue damage. LBP is commonly associated with FMPs that produce tissue damage and symptoms, and non-incidental tissue damage (non-traumatic.) When symptoms resolve, the FMP that causes LBP is still un-treated; therefore, the patient/athlete’s condition becomes chronic… not just because the patient/athlete is still symptomatic. RTF does not describe treating only to establish usual movement, it describes treating to eliminate the FMP, and correcting the entire patient/athlete’s awareness of FMPs.

The Chronic Phase describes the re-emergence of symptoms and changes in function with irregular temporal presentation. The patient may experience frustration with concerns about injury resolution. Athletes may be concerned about loss of training and play time, or about being taken off the team. Care involves guiding the remodeling process, supporting patient/athlete expectations, and managing scar formation. The clinician should investigate the reasons for injury persistence. With proper care management, the injury/lesion heals as anticipated, and function is restored. The patient/athlete resumes activities with diet and lifestyle improvements, and is discharged.

The Post-Chronic Phase (PCR) describes either: (1) minor functional deficiency/faults of the primary injury/lesion, and asymptomatic (pain, tone, aROM, etc.) or, (2) no resolution of the primary injury/lesion with sequela involving novel symptoms. A sequela presents as a secondary lesion attributed to the healing process. The post-chronic phase implies significant improvement in primary injury/lesion function and ADLs/RTW/RTP, and suggests (1) mis-diagnosis or incomplete diagnosis of the primary injury/lesion, or (2) care mis-management requiring re-evaluation. Injuries in the PCR phase should be assessed and treated together; this is possible since the sequela is acquired not incidental/traumatic. Care involves guidance to manage scar formation, and support for patient expectations. With proper care management, the injury/lesion heals as anticipated. The patient resumes activities with diet and lifestyle improvements, and is discharged. *Athletes require specialized care management to preserve certain movement patterns.

The Return to Function Phase (RTF) describes resolution of the primary injury/lesion and sequela, full function is achieved with complete patient satisfaction. Athletes can return to training and competition. Minor FMP should be monitored and treated in real-time. Patient care should include awareness and guidance for work and daily activities injury prevention, strength training, core training, nutrition, and mental support, including optimism. Athlete care should include awareness and guidance for goal-setting, training protocols & periodization, joint & core-spinal stability, endurance & resilience, and access to excellence in sport-specific coaching, 

The clinician’s role does not end when the patient no longer complains of LBP. Since phase five describes ongoing monitoring to manage and treat novel FMP in real-time. This includes accessibility between the patient and the clinician even when there is no LBP. Phase 5 describes the lost art of medicine: to be a doctor is to be a doctor. ‘First, do no harm’ actually means never do harm, and ‘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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