Peace and Love : Healing Acute Injuries and Inflammation
There is a healing for each of our wounds, but this healing is waiting in the indirect, oblique, and nonanalytic side of our nature. ~ John O'Donohue
Much of what we write about in Pain Science Yoga Life (1) uses yoga and pain-science to address the suffering that comes from persistent pain. But what about the pain many of us as teachers, care providers and active individuals also experience – acute pain? Acute pain is recent onset pain. It may have an easily identifiable source like injury, accident, surgery, or known overuse event, OR we may just wake up with inflammation, pain, or tissue sensitivity.
Inflammation is a necessary part of healing
Pain is normal; this concept is slowly becoming broadly understood and accepted. However, inflammation still tends to get a bad rap. Inflammation (swelling) is also normal and necessary for tissues to heal (2). Sprains, strains, twists, bumps and bangs can all initiate inflammation. So can overworking a muscle, ligament or joint. The inflammatory response changes the chemistry of the tissue and may promote nociception (danger signals) or tenderness of the area. This sensory sensitivity occurs when chemical responses turn up the sensitivity level of free nerve endings and receptor sites. After the initial injury or irritation, the inflammatory response is broken down into a continuum of stages (Fig. 1) (1,2). The goal of this healing process is to return the tissue to its prior state of health and function. Each stage—inflammatory, proliferation, and remodeling— have a relative timeline to them however they tend to overlap without a distinct beginning or end. All together they become the healing process for acute injuries or short-duration inflammatory based tissue sensitivities.
Fig 1. Stages of Inflammation (Ref 1,2)
Let’s look at these stages in a little more detail using a simple example of a strain to the hamstring muscle group.
Pretend for a moment you have been working on obtaining Hanumanasana, monkey pose, also known as ‘the splits’. You think, “oh I’m just going to sink in a little deeper” and suddenly—twing!—you feel a pull and pain in the back of the thigh on your front leg. Ooph! You wriggle yourself out of the posture hesitantly, knowing you have just pulled your hamstring.
What happened in the tissue when you felt the ‘twing’?
At the moment of the injury (your muscle went passed its limit, creating a tearing or fraying of the fibers), your proprioceptors (sensory receptors responsible for knowing where you are in space) and nociceptive receptors (sensory receptors responsible for indicating the potential of damage) said to your brain, “Whoops, you just took that muscle a bit further than its available range.” The tearing leads to bleeding and this is when stage 1 begins.
Stage 1: Onset of injury or irritation. This is the bleeding response. It occurs from the time of injury and potentially for as long as six hours post injury. Small capillaries tear and leak fluid. This fluid stimulates the immune system to kick into action and actually initiates the inflammatory response.
You may begin to notice a discoloration or bruising of the hamstring region.
Stage 2: Inflammatory response. From the moment of the injury and over the next 72 hours, your immune system releases inflammatory cells necessary for healing into the bloodstream. These cells include macrophages, which clean up the mess by absorbing damaged tissue.
During these first few days you may experience increased sensitivity of the leg. You may note continued discoloration and fluid or swelling under the skin and the muscle may feel weak or even vague, like you’ve lost coordination.
Phase 3: Proliferation. This phase begins as soon as forty-eight hours after the injury and lasts up to six weeks, depending on the severity of the damage and the amount of repair and rebuilding that needs to occur. Proliferation is when we begin producing new tissue for repair and scarring. In this example of the hamstring strain, proliferation is carried out by fibroblasts, myoblasts and tenoblasts: cells responsible for building collagen for connective tissue, muscle tissue and tendon, respectively. Other injuries may require the participation of other cells as well; for example, a bone fracture will require the involvement of osteoblasts.
Phase 4: Remodeling. This phase adapts all those newly formed tissues to sustain the loads and demands that are and will be placed on them during functional and recreational activities. Typically, this activity occurs in the first three months post injury. However, tissue remodeling can continue for many months.
Over these weeks to months you may notice an ebb and flow to your recovery. A feeling of improvement and healing may be met quickly with a sense of backsliding, depending on how well you find balance in the pacing of return to activity. Returning too quickly may result in aggravation of immature tissue. This could elicit a repeat burst of inflammation to stimulate more proliferation and/or sensitivity to remind you that you need to continue to allow yourself to heal. On the other side, returning too slowly may inhibit the remodeling phase. The input required to determine the appropriate load tolerance needed by the tissue to perform your chosen activities, may fall short, if we limit ourselves too much or for too long.
Promoting our own recovery through peace and love
Now that we understand a little more about what has taken place inside our tissues, let’s look at what we can do to promote healing and recovery along the way. One of the greatest things about modern day medicine is the continued progression of knowledge through research. For some this can feel frustrating because it means changing treatments and interventions. Most individuals who live an active lifestyle are familiar with the old standard of RICE (rest, ice, compression and elevation) to treat an acute injury. But you might be surprised to learn that RICE and even PRICE (protect, rest, ice, compression, and elevation) are progressing to PEACE and LOVE (3).
Table 1. Adapted from Dubois & Esculier, BJSM, 2019 (3)
The use of PEACE (protect, elevate, avoid, compress and educate) is advocated for the immediate management of soft tissue injuries. The two progressive changes here are ‘avoid,’ and 'educate'. Avoid includes avoiding inappropriate use or over-utilization of anti-inflammatory interventions. This includes ice and pharmaceuticals. Please note some use may be indicated (for pain and function) but it is important to allow the inflammatory mechanisms to do their job in order for us to heal (anti-inflammatories can interrupt tissue healing (1,3)).
Returning to the example of the pulled hamstring: the PEACE-ful intervention would initially promote protection by limiting activities and postures that put strain on the hamstring muscle group. This means limiting stretching as well as activation of the muscle under load. Therefore, your stride length may need to be shortened a little bit while walking and you may need to avoid picking heavy objects up from the floor. Adjusting your typical asana or movement practice will also likely be necessary. Elevation can aid resolution of swelling through the return of blood and fluids from the tissues via the venous system. Assuming positions like viparita-karani (waterfall or legs up the wall) position is one example of appropriate elevation of the hamstring. You may like to use an elastic wrap around the thigh to offer a bit of compression. A little ice and appropriate pharmaceuticals could be used on occasion to soothe the sensitivity of the tissues, if you are struggling with pain control. The education bit is what we are doing right now so you may want to keep this information handy to remind yourself what is happening in the tissues. Being mindful of typical timeframes (see Fig 1) for healing can help maintain appropriate expectations and guide graded return to activities.
LOVE (load, optimism, vascularization, exercise) is needed for recovery once the first few days and initial inflammatory response has passed (3). Loading of the tissues through physical stress in an appropriate and gradual way is important as touched on earlier to allow optimization of remodeling. Initially moving the body through gravity could be enough but as tissues heal strength building requires the graded addition of resistance (4,5). It is well established that our outlook, thoughts and beliefs can directly impact our ability to fully recover from injuries—not just mentally and emotionally, but also physically. Therefore, maintaining an optimistic outlook on the scenario and believing in your body’s ability to heal is important. Vascularization through early mobilization of the injured region and cardiovascular activity will help promote fluid exchange and allow your natural healing mechanisms to do their job. Finally, appropriate, graded exercise to gain mobility, strength, and stability returns you to the skill or sport you participate in, closing the loop from injury to recovery (5).
LOVEing your hamstring strain could include the following activities: gentle walking, maybe in an aquatic environment initially, or easy stationary biking to promote vascularization. Performing alternate leg lifts just to the initial feeling of stretch can act as a great mobility tool. The next step is beginning graded exercises that emphasize hamstring facilitation, such as, short duration, gentle, bridging (raising and lowering hips by pushing into heels, while lying supine with bent knees). This particular exercise can be progressed to single leg bridging and finally adding a bit of resistance (like holding a weight or pushing the hips up against an elastic band) while bridging will bring in the concept of progressing the load. Straight leg forward fold and return could also be progressed like the bridge. Initially bending to the sensation of a little pull to gain mobility then slowly progressing to lifting weight from the floor to gain strength in the mobile range.
Visualization of the activities you are planning on returning to and breathing techniques or pranayama may help promote optimism and soothe your nervous system. It is unfortunate, our injuries will remove us from performing our favorite activities or even activities we use as healthy coping strategies for a period of time. If we fall into negative thought streams or even catastrophic thinking (I'll never get better, I'm going to gain a ton of weight, all the training I've put in is lost) we may actually be further injuring ourselves and inhibiting our healing. Be kind to yourself. Take advantage of learning new or alternate activities. Getting on your mat and doing what you can do, even if it is only meditation and pranayama, can help to ensure you return to your practice when the time is right for your tissues.
Go forth and spread peace and love toward your body’s aches and pains, toward your deeper-self, and outward to others.
1. Moloney, N., & M. Hartman. PAIN SCIENCE - YOGA - LIFE. Chapter 6. 2020, United Kingdom: HANDSPRING Publishing LIM
2. Choo Lee, A., W. Quillen, D. Magee, and J. Zachazweski, Injury, Inflammation, and Repair: Tissue Mechanics, the Healing Process and Their Impact on the Musucloskeletal System, in Scientific Foundations and Principles of Practice in Musculoskeletal Rehabilitation, D. Magee, J. Zachazweski, and W. Quillen, Editors. 2007, Saunders Elsevier: St Louis, Missouri. p. 1-22.
3. Dubois, B. and J.F. Esculier, Soft-Tissue Injuries Simply Need Peace and Love. British Journal of Sports Medicine, 2019. http://dx.doi.org/10.1136/bjsports-2019-101253
4. Brukner P. Hamstring injuries: prevention and treatment-an update. Br J Sports Med. 2015 Oct;49(19):1241-4. doi: 10.1136/bjsports-2014-094427. Epub 2015 Jun 23. PMID: 26105015; PMCID: PMC4602251.
5. Blanch, P. and T.J. Gabbett, Has the Athlete Trained Enough to Return to Play Safely? The Acute:Chronic Workload Ratio Permits Clinicians to Quantify a Player's Risk of Subsequent Injury. British Journal of Sports Medicine, 2016. 50(8): p. 471-5.
6. Vuurberg, G., A. Hoorntje, L.M. Wink, B.F.W. van der Doelen, M.P. van den Bekerom, R. Dekker, C.N. van Dijk, R. Krips, M.C.M. Loogman, M.L. Ridderikhof, F.F. Smithuis, S.A.S. Stufkens, E. Verhagen, R.A. de Bie, and G. Kerkhoffs, Diagnosis, Treatment and Prevention of Ankle Sprains: Update of an Evidence-Based Clinical Guideline. British Journal of Sports Medicine, 2018. 52(15): p. 956.