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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