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Concepts of Healing
HealingHealing
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Separation is large-2nd ° Sprains
Tissue must fill space-starting at bottom and sides of wound______________________________
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Bridge of cells binds ends of wound together
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Tissue Healing PhasesTissue Healing Phases
Inflammation PhaseInflammation Phase
Necessary phase
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Complex cellular and chemical interactions take placeNeutrophils/PMN’s abound
Macrohages replace PMNs in 24-48 h to debride area
Signs of InflammationSigns of Inflammation
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Temperature increase
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Pain
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The signs of inflammation occur because of the increased metabolic activity and fluid in the region and the tissue damage that has occurred. Loss of function is produced by the primary signs of inflammation.
Causes of InflammationCauses of Inflammation
Immediate Injury Response
Proliferation PhaseProliferation Phase
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Angiogenesis and granulation tissue formation
Increased fibroblasts by day 3-5 following injury; reduced PMNs
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Signs of ProliferationSigns of Proliferation
Redness
Swelling
Pain
Local temperature
Remodeling PhaseRemodeling Phase
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Myofibroblasts cause wound contraction to minimize scar
Tensile strength increases
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Signs of RemodelingSigns of Remodeling
Reduced redness
Reduced edema
Reduced pain
No local temperature
Growth FactorsGrowth Factors
Proteins
Perform important roles in healing process
Specific growth factors impact specific cells
Named for target cells, source, behavior
Roles of Growth Factors Roles of Growth Factors in Healing - p. 42-43in Healing - p. 42-43
Control migration and proliferation of cells
Affect fibrin-plug formation
Stimulate type III collagen removal, type I formation
Control phagocytization
Assist capillary endothelial production
Ligament HealingLigament Healing_______________________________ ___________________
Monocytes and macrophages infiltrate.
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Fibroblasts appear, increase, produce extracellular matrix.
Cellular and matrix structures replace the blood clot.Macrophages, fibroblasts diminish; type I collagen replaces type III.
Tendon HealingTendon Healing
Wound gap filled by phagocytes
Fibroblasts revert to tenocytes; type III collagen replaced with type I
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Collagen synthesisRevascularization; synovial sheath rebuilt
Tensile strength
-maximal amount of stress or force that a structure is able to withstand before tissue failure occurs—in this case, the amount of outside force that can be applied to a muscle, tendon, ligament, or bone before it tears or breaks
Muscle HealingMuscle HealingFragmentation of muscle fibers; macrophages appear
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Day 7: scar tissue; near-normal muscle tension can be producedDay 7-11: near-normal tensile strength
Regenerating myotubes; cross-striated muscle fibers
Articular Cartilage HealingArticular Cartilage Healing
Fibrin clot is formedFibroblasts combine with collagen fibers to replace clot
1 month- fibroblasts separate; condrocytes appear
6 months—type I and II calcified cartilage with normal appearance
2 months—defect resembles cartilage, but collagen is type I
Bone HealingBone Healing___________________________
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Hematoma forms; fractured edges become necroticOsteoclasts/Osteoblast proliferate; soft turns hard callus developsExternal blood supply dominates; then inner bone circulation reestablished
Tensile strength
-maximal amount of stress or force that a structure is able to withstand before tissue failure occurs—in this case, the amount of outside force that can be applied to a muscle, tendon, ligament, or bone before it tears or breaks
Tensile Strength During Tensile Strength During Healing PhasesHealing Phases
Inflammation
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Source of tensile strength: collagen, granulation tissue
Proliferation
Increase in tensile strength
(continued)
Tensile Strength During Tensile Strength During Healing PhasesHealing Phases
Remodeling
____________________________Ligament and tendon near normal in 17-50 weeks____________________________
For a therapeutic exercise program to be successful, one must have respect for the healing process and a knowledge of tensile strength factors.
Healing and Tensile Healing and Tensile StrengthStrength
Factors That Affect Factors That Affect HealingHealing
Modalities
Medications/Drugs
Other modifying factors (age, disease, etc.)
Treatment ModalitiesTreatment Modalities
Ice
Electrical stimulation
Deep heat
Superficial heat
Influence of Modalities Influence of Modalities on Healingon Healing
Relieve pain, spasm, edema
Enhance protein synthesis
Promote fibroblast production
Retard atrophy, facilitate muscle activity
Improve circulationEnhance collagen and neovascular production
half-life: definition and examples
Factors in Medication Factors in Medication Effectiveness – p.55Effectiveness – p.55
steady state of a drug: definition and examples
Effects of NSAIDs Effects of NSAIDs on Healingon Healing
Inhibit prostaglandin production
Increase blood clotting time
Absorption rate decreased when NSAIDs used with antacids
Decrease the effectiveness of other drugs
Drugs That Can Delay Drugs That Can Delay HealingHealing
Antibiotics
Nicotine
Corticosteroids
Other Modifying Factors Other Modifying Factors That Can Affect HealingThat Can Affect Healing
Surgical technique
Age
Edema
Disease
Muscle spasm
Wound size
InfectionNutrition
Role of Therapeutic Role of Therapeutic Exercise in Inflammation Exercise in Inflammation PhasePhase
Control edema and pain
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Role of Therapeutic Role of Therapeutic Exercise in Proliferation Exercise in Proliferation PhasePhase
Tissue is weak but improving in strength with collagen production.Patient can start range-of-motion and limited strengthening activities.Exception is in tendon repairs.
Role of Therapeutic Role of Therapeutic Exercise in Remodeling Exercise in Remodeling PhasePhase
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Stress application must coincide with increase in tensile strength.
Considerations Considerations for Appropriate Coursefor Appropriate Course
Usual healing sequence and timing
Individual’s unique response to the injury and treatment
Signs of an Overly Signs of an Overly Aggressive ProgramAggressive Program
Increased pain, especially postexerciseIncreased edema, especially if lasts more than 1 day postexerciseDiminished function from the previous day’s treatment