understanding and managing healing process through rehabilitation
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Understanding and Managing Healing Process through Rehabilitation. Rehabilitation Techniques for Sports Medicine and Athletic Training William E. Prentice. Introduction. Rehabilitation requires sound knowledge and understanding of tissue healing process - PowerPoint PPT PresentationTRANSCRIPT
Understanding and Managing Understanding and Managing Healing Process through Healing Process through
RehabilitationRehabilitation
Rehabilitation Techniques for Sports Medicine and Athletic Training
William E. Prentice
IntroductionIntroduction
Rehabilitation requires sound knowledge and understanding of tissue healing process
Athletic Trainer designs, implements and supervises rehab programs
Rehab protocols and progressions must be based on physiologic responses of tissues to injury and understanding of how various tissues heal
IntroductionIntroduction
Primary Injury– Injury from acute or chronic trauma
Secondary Injury– Inflammatory response to primary injury
3 Phases of Tissue Healing3 Phases of Tissue Healing
Inflammatory –response phase
Fibroblastic-repair phase
Maturation-remodeling phase– Healing process is a continuum and phases
overlap one another with no definitive beginning or end points
Inflammatory-Response Inflammatory-Response PhasePhase
After injury, healing process begins immediately– Destruction of tissue produces direct injury to
cells of various soft tissue– Characterized by redness, swelling, tenderness
and increased temperature– Critical to entire healing process
Inflammatory-Response Inflammatory-Response PhasePhase
Leukocytes and other phagocytic cells delivered to injured tissue– Dispose of injury by-products through
phagocytosis
Inflammatory-Response Inflammatory-Response PhasePhase
Vascular reaction– Blood coagulation and
growth of fibrous tissue occurs
– First 5-10 minutes vasoconstriction occurs
Best time to evaluate Followed by
vasodilation Effusion of blood and
plasma last 24 to 36 hours
Chemical mediators– Released from damaged
tissue, white blood cells and plasma
– Histamine, leukotrienes and cytokines assist in limiting exudate/swelling
– Amt of swelling directly related to extent of vessel damage
Inflammatory Response Con’tInflammatory Response Con’t
Formation of Clot– Platelets adhere to collagen
fibers and create sticky matrix
Platelets and leukocytes adhere to matrix to form plug
Clot formation occurs 12 hours after injury and is complete w/in 48 hrs
Set stage for fibroblastic phase
Chronic inflammation– Acute phase dos not
respond sufficiently to eliminate injury agent and restore tissue to normal physiologic state
– Damage occurs to connective tissue and prolongs healing and repair process
– Response to overuse and overload
Inflammatory Response Con’tInflammatory Response Con’t
Entire phase last 2-4 days– Greater tissue damage longer inflammatory phase
– NSAIDS may inhibit inflammatory response thus delaying healing process
Will assist with pain and swelling
Fibroblastic-Repair PhaseFibroblastic-Repair Phase
Proliferative and regenerative activity leads to scar formation– Begins w/in 1st few hours after injury and can
last as long as 4-6 weeks– Signs and Symptoms of inflammatory phase
subside– Increased O2 and blood flow deliver nutrients
essential for tissue regeneration
Fibroblastic-Repair PhaseFibroblastic-Repair Phase
Break down of fibrin clot forms connective tissue called granulation tissue– Consist of fibroblast, collagen and capillaries
Fills gap during healing process– Unorganized tissue/fibers form scar
Fibroblast synthesize extracellular matrix consisting of protein fibers (Collagen and Elastin)
– Day 6 –7 collagen fibers are formed throughout scar– Increase in tensile strength increases with rate of collagen
synthesis
Fibroblastic-Repair PhaseFibroblastic-Repair Phase
Importance of Collagen– Major structural protein that forms strong,
flexible inelastic structure– Type I, II & III
Type I found more in fibroblastic repair phase Holds connective tissue together and enables tissue
to resist mechanical forces and deformation– Direction of orientation of collagen fibers is along lines of
tensile strength
Fibroblastic-Repair PhaseFibroblastic-Repair PhaseImportance of Collagen
– Mechanical properties Elasticity
– Capability to recover normal length after elongation
Viscoelasticity– Allows slow return to normal length and shape after
deformation
Plasticity– Allows permanent change and deformation
Maturation-Remodeling PhaseMaturation-Remodeling Phase
Long term process that involves realignment of collagen fibers that make up scar– Increased stress and strain causes collagen fibers to
realign to position of maximum efficiency Parallel to lines of tension Gradually assumes normal appearance and function Usually after 3 weeks a firm, contracted,
nonvascular scar exist– Total maturation phase may take years to be
totally complete
Maturation-Remodeling PhaseMaturation-Remodeling Phase
Wolf’s law– Bone and soft tissue will respond to physical
demands placed on them Remodel or realign along lines of tensile force Critical that injured structures are exposed to
progressively increasing loads throughout rehab process
– As remodeling phase begins aggressive active range of motion and strengthening
– Use pain and tissue response as a guide to progression
Maturation-Remodeling PhaseMaturation-Remodeling Phase
Controlled mobilization vs. immobilization– Animal studies show Controlled mob. Superior
to Immobilization for scar formation However, some injuries may require brief period of
immob. During inflammatory phase to facilitate healing process
Factors that impede healing Factors that impede healing
Extent of injury– Microtears vs.
macrotears
Edema– Increased pressure
causes separation of tissue, inhibits neuro-muscular control, impedes nutrition, neurological changes
Hemorrhage– Bleeding causes same neg.
effect as edema
Poor vascular supply– Tissues with poor vascular
supply heal at a slower rate– Failure to deliver
phagocytic cells and fibroblasts for scar formation
Factors that impede healingFactors that impede healing
Separation of tissue– How tissue is torn will
effect healing Smooth vs. jagged
Traction on torn tissue, separating 2 ends– Ischemia from spasm
spasm Atrophy
Corticosteroids– In early stages shown
to inhibit healing
Keloids or hypertrophic scars
Infection Health, Age and
nutrition
Healing Process-Ligament Healing Process-Ligament SprainsSprains
Tough, relatively inelastic band of tissue that connects bone to bone– Stability to joint– Provide control of one articulating bone to
another during movement– Provide proprioceptive input or sense of joint
position through mechanoreceptors 3 Grades of lig. tears
Healing Process-Ligament Healing Process-Ligament SprainsSprains
Physiology– Inflammatory phase-loss of blood from
damaged vessels and attraction of inflammatory cells
– During next 6 weeks-vascular proliferation with new capillary growth and fibroblastic activity
Immediately to 72 hours– If extraarticular bleeding in subcutaneous space
– If intraarticular bleeping occurs in inside joint capsule
Healing Process-Ligament Healing Process-Ligament SprainsSprains
Essential that 2 ends of ligament be reconnected by bridging of clot– Collagen fibers initially random woven pattern with
little organization– Failure to produce enough scar and of ligament to
reconnect 2 reasons ligaments fail Maturation
– May take 12 months to complete– Realignment/remodeling in response to stress and
strains placed on it
Healing Process-Ligament SprainsHealing Process-Ligament Sprains Factors that effect healing
– Surgery or non surgical approach Surgery of extraarticular ligaments stronger at first
but may not last over time Non surgical will heal through fibrous scarring , but
may also have some instability– Immobilization
Long periods of immobilization may decrease tensile strength weakening of insertion at bone
Minimize immobilization time Surrounding muscle and tendon will provide
stability through strengthening and increased muscle tension
Healing Process-CartilageHealing Process-Cartilage
Cartilage– Rigid connective tissue that provides support
Hyaline cartilage: articulating surface of bone Fibro cartilage: interverterbral disk and menisci.
Withstands a great deal of pressure Elastic cartilage: more flexible than other types-
auricle of ear and larynx
Healing Process-CartilageHealing Process-Cartilage
Physiology of healing– Relatively limited healing capacity
Dependant on damage to cartilage alone or subchondral bone.
Articular cartilage fails to elicit clot formation or cellular response
Subchondral bone can formulate granulation tissue and normal collagen can form
Healing Process-CartilageHealing Process-Cartilage
Articular cartilage repair– Patients own cartilage can be harvested and implanted
into damages tissue to help form new cartilage– Promise for long term results
Fibrocartilage/Menisci– Depends on where damage occurs– 3 zones of various vascularity
Greater that blood supply better chance of healing on own
Healing Process-BoneHealing Process-Bone Similar to soft tissue healing, however
regeneration capabilities somewhat limited– Bone has additional forces such as torsion, bending and
compression not just tensile force– After 1 week fibroblast lay down fibrous collagen– Chondroblast cells lay down fibrocartilage creating
callus– At first soft and firm, but becomes more firm and
rubbery– Osteoblast proliferate and enter the callus
Form cancellous bone and callus crystallizes into bone
Healing Process-BoneHealing Process-Bone
Osteoclasts reabsorb bone fragments and clean up debris– Process continues as osteoblast lay down new
bone and osteoclasts remove and break down new bone
Follow Wolfs law-forces placed on callus-changes size, shape and structure
Immobilization longer 3 to 8 weeks depending on the bone
Healing Process-MuscleHealing Process-Muscle
Similar to other soft tissue discussed– Hemorrhage and edema followed by phagocytosis to
clean up debris– Myoblastic cells from in the area and regenerate new
myofibrils– Active contraction critical to regaining normal tensile
strength according to Wolff's Law– Healing time lengthy-Longer than ligament healing
Return to soon will lead to re-injury and become very problematic
6-8 weeks?
Healing Process-TendonHealing Process-TendonNot as vascular as muscle
– Can cause problems in healing– Fibrous union required to provide extensibility
and flexibility Abundance of collagen needed to achieve good
tensile strength Collagen synthesis can become excessive can result
in fibrosis: adhesions from in surrounding structures– Interfere with gliding and smooth movement– Tensile strength not sufficient to permit strong pull for 4
to 5 weeks• At risk of strong contraction pulling tendons ends
apart
Healing Process-NerveHealing Process-NerveNerve cell is specialized and cannot
regenerate once nerve cell dies– Injured peripheral nerve- nerve fiber can
regenerate if injury does not affect cell body– Regeneration is very slow 3-4 mm /day
Axon regeneration obstructed by scar formation Damaged nerve within CNS regenerate poorly
compared to peripheral nervous system– Lack connective tissue sheath and nerve cells fail to
proliferate
Rehabilitation philosophyRehabilitation philosophy Choose therapeutic exercises/modalities that
facilitate healing process at specific phases– Stimulate structural function and integrity of injured
part– Positive influence on the inflammation and repair
process to expedite recovery of function– Minimize early effects of inflammatory process
including pain, edema control, and reduction of muscle spasm.
Produce loss of joint motion and contracture
– Finally concentrate on preventing reoccurrence of injury by assuring structural stability of injured tissue
Appropriate return to play guidelines