What are the stages of healing and what is anti-deformity positioning?
- Response to injury is proportional to the trauma
- Many internal and external factors impact healing
- Prolonged or delayed healing leads to scar formation, which can result in deformity and functional deficits
- The physical therapist’s (or occupational therapist’s) job is to promote optimal healing while preserving factors which contribute to function (ROM, joint integrity, muscle strength, neuromuscular control, etc.)
- Can be broken into 3 main phases
The three main phases of wound healing are the inflammatory phase, fibroplasia and proliferation, and finally maturation and remodeling phase.
- Begins immediately after injury
- Marked by influx of white blood cells, vascularity, and swelling to promote healing
- This phase facilitates rapid healing but can persist and tend to “over-heal,” which results in scarring
Therapy's main role in this stage is to immobilize and protect affected joints and to keep joints in antideformity positions.
The body wants to move into a position of comfort with everything flexed which is a position of comfort. However, that's a position of deformity. All of our functional movements are with extension at most every joint. That is the position we function in the world. For larger injuries, traumas, and burns, bed positioning occurs early on should occur. For smaller injuries, splinting and wrap the body areas is done to prevent those contracted deformity positions. We want to preserve extension and regain flexion. You can always regain flexion, but it's really hard to regain extension if you've let something heal in flexion. That is the concept of anti-deformity positioning.
Fibroplasia and Proliferation
- Begins 4-5 days after injury and lasts two-six weeks
- The stage is marked by collagen synthesis and hypersynthesis (Tomasek, et al, 2002)
- Wound healing begins with the appearance of granulation tissue
Therapy's main role in this phase is at weeks one to three immobilizing and protecting affected joints to allow for increased vascularization and protect new collagen deposits (Bouffard, et al., 2008). Weeks three to six include progressive mobilization of joints to facilitate tissue growth and elongation as well as joint function.
Maturation and Remodeling
- Collagen fibers need assistance to reorganize otherwise tend to bunch up and will line up along the lines of stress (Ghosh, et al., 2020)
- Tensile strength of collagen steadily increases and can pull joints out of place – estimated 12 times that of normal skin
- Normal skin can stretch up to 50% of original length; active scars can extend 15% and mature scars only 4% (Parry, et al., 2019)
Therapy's main role in this phase is to mobilize joints, using pressure and stretch to match the increasing tensile strength and use of orthoses as needed to counteract tensile strength.
For more information on scar management and the therapist's role, check out the course, Scar Management for Therapists