Treatment in the chronic healing phase

by Dr. Jim Hoven

In my article last month, you learned about rehabilitating an injury in the sub-acute phase of healing, and how the process of increasing strength, range of motion, flexibility and endurance begins to occur for the patient. In the chronic healing phase, the focus is on increasing strength, flexibility, and range of motion - specifically, with getting the patient back to 100% in all three areas, and allowing the patient to return to 100% function of his or her daily activities without restriction.

Exercises in the chronic phase of healing become more intense, more complex, or both as the patient's clinical findings are now much more stable. At this time, the patient has fairly good strength and range of motion (up to about 85% of normal), little to no swelling of the injured area, and pain levels are described as none to moderate in nature.

It should be noted that exercises in this phase of rehabilitation may create discomfort as the resistance is increased and the movements become more challenging and complicated, thus taxing the patient's muscles and joints. That said, the pain felt by the patient should be less than a five on a scale of 10, and shouldn’t feel the same as the pain felt when the injury was first sustained. In other words, the pain should be that of a good workout, not that of an injured tissue. It’s critical that the provider explain this to the patient PRIOR to the beginning exercises in this phase of treatment. If the patient doesn’t work with enough resistance, or fails to give enough effort, the ability to gain the final 15% of strength, flexibility, and range of motion decreases. If the patient has too much resistance, or the movement performed is too challenging, there’s a risk of re-injury of the tissue, resulting in a setback to the person’s healing.

In the chronic healing phase, each exercise is performed in sets of 12-15 repetitions, with three sets being the standard number performed for each exercise. Depending on the area of the body being treated, the number of exercises will range anywhere from four to eight with the determining factor being the ability to exercise with pain levels of five or less. If the exercise begins to stress the tissue to the point where the pain levels creep up to five or more, the session should end, and the patient be supported with either a soft tissue technique, electrical stimulation modality, taping procedure, or a combination of the three.

Be aware that all rehab protocols should have an adjustment component where joint dysfunction or subluxations are involved. It’s the combination of proper joint movement and proper muscular balance that achieves the best outcomes for any soft tissue injury!

Some clinics may not have the facilities or the equipment to provide an extensive array of treatment options for the chronic phase of healing. If that’s true in your case, the first thing to do is to spend some time evaluating the level of rehabilitation you want to provide for your patients. If it’s to offer a place where they can receive treatment for injuries that are in any of the three healing phases (acute, sub-acute or chronic), then an inventory of your space and equipment is in order.

To provide care in the chronic healing phase, there’s little more required than a set of gym balls, several different resistance level tubes or bands, minimal dumbbells (up to 30 pounds is more than sufficient unless your practice focuses on the treatment of elite athletes), and a suspension trainer (Serius Strap, TRX strap, etc.). Even correct usage of a person's body weight can serve to rehab an injury in the chronic healing phase.

Besides these few items, a knowledge of the movement and exercises that bring back the final levels of function and performance is necessary. These can be easily found on any number of websites, exercise programs specifically designed for our profession, or through a reproduction of the movements that the patient undergoes as part of his or her daily activity.

If your office doesn’t have the space to provide a complete rehabilitation program, but you still want your patients to benefit from chronic healing phase exercises, look to create an environment where you demonstrate the movements and then have the patients perform the exercises at home. While this saves you space and puts patients directly in charge of their healing, it does come with a drawback: non-compliance. If you decide to go with home-based exercises, on each visit be sure to ask patients to demonstrate what they’ve been doing at home.

Commit yourself to learning more about the exercises that bring back function and watch your reputation as an expert in your community grow!

(A graduate of Logan College, Dr. Jim Hoven is vice president of education and compliance for HealthSource, a network of more than 250 chiropractic offices focusing on progressive rehabilitation. He has built several successful chiropractic practices throughout the Denver area and is a popular speaker at business, civic, and governmental events. Dr. Hoven has traveled the country consulting with medical clinics on documentation and coding issues related to physical medicine procedures.)