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EHR315 - Week 2 Dr Stephen Bird
1
Understanding the Healing Understanding the Healing ProcessProcess• Primary Injury
• Inflammatory Response
• Role of Mobility
• Injuries to Various Tissues
• Musculoskeletal StructuresMusculoskeletal Structures
• Managing the Healing Process
Reading: Chapter 2
Quiz 2: Functional anatomy
The Healing ProcessPrograms based on healing process framework
1 Bl di
No definitive beginning or
end
1. Bleeding (Inflammatory)
2. Fibroblastic-repair
(Proliferation)
3. Maturation-(remodeling)
EHR315 - Week 2 Dr Stephen Bird
2
The Primary Injury• Acute or chronic
1. Macrotraumatic injuriesA t t i di t i /di bilit
Look away if you don’t like pain
• Acute trauma; immediate pain/disability
• Fractures, dislocations, sprains, strains
2. Microtraumatic injuries• Overuse injuries, repetitive overload, incorrect mechanics
• Tendinitis, tenosynovitis bursitis
• Secondary injurySecondary injury– Inflammatory or hypoxia response
EHR315 - Week 2 Dr Stephen Bird
3
1. Inflammatory Response PhaseInjury = altered cellular metabolism = chemical mediators
• Macroscopic characteristicsMacroscopic characteristics
1. Swelling2. Tenderness3. Redness4. Increased temperature
• Initial response is critical in healing process
– Leukocytes, phagocytic cells and exudate delivered to tissue
– Protective response, localization and removal of injury by-products
Stages of Inflammation
• Vasoconstriction• 5-10min post-injury• Initial response lasts 24-48 hoursp
• Histamine: causes vasodilation cell permeability• Leukotrienes: causes margination• Cytokines: attract leukocytes to site of InF
Pl b l l l h i fl id d i• Plug obstructs local lymphatic fluid drainage• Results in localization of the injury• Begins 12hrs post-inj; complete within 48hrs
EHR315 - Week 2 Dr Stephen Bird
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Vascular Reaction
Chemical mediators
Cl tClot Formation
2. Fibroblastic-Repair Phase
Proliferative/regenerative activity leads to scar formation– referred to as fibroplasia
begins within 2 hrs can last– begins within 2 hrs, can last _________________
• Signs associated with InF response subside
Granulation tissue• Breakdown of the fibrin clot
• Consists of fibroblasts, collagen and capillaries
Collagen deposited randomlyg p y _________________• Results in scar tensile strength
Persistent InF response promotes extended fibroplasiaresulting in increased scarring
EHR315 - Week 2 Dr Stephen Bird
5
CollagenMajor structural protein
– Forms strong structures that hold connective tissue together
Enables tissue to resist mechanical forces/ deformation– Enables tissue to resist mechanical forces/ deformation
• Collagen fibrils: ___________ elements of connective tissue
– Mechanical/physical properties allow collagen to respond to loading /deformation
• Elasticity, visco-elasticity, plasticity, creep response, hysteresis
– Limitations exceed, injury results
3. Maturation-Remodeling Phase
Realignment of _________________– Continued breakdown and synthesis of collagen
Increased stress/strain results in increased collagen realignment– Increased stress/strain results in increased collagen realignment
• ___ wks firm, strong, contracted, nonvascular, scar present– Fibroplasia - can last 4-6 wks
• Maturation long-term process– may require several years to complete
EHR315 - Week 2 Dr Stephen Bird
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Role of Progressive Mobility• Wolff’s law: soft tissue respond to physical demands
placed upon them, causing tissue to remodel along lineof tensile forceof tensile force– Controlled mobilisation superior to immobilisation for scar
formation, revascularisation & muscle regeneration
1. InF Response Phase
2. Repair Phase
3. Remodeling Phase
• Extent of Injury
• Edema
• Atrophy
• Corticosteroids
Factors that Impede Healing
• Hemorrhage
• Poor vascular supply
• Separation of tissue
• Muscle Spasm
• Infection
• Age
EHR315 - Week 2 Dr Stephen Bird
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Injuries to Ligament
Sprains: damage to a ligament
• Ligamentsg
Inelastic band of tissue, provides joint stability
Controls bone position during joint motion
Provides proprioceptive input
t S
pra
ins
G d II t ( i )
Grade I tear
minor stretching, tearing of the ligaments; no joint instability
of
Lig
amen
t
Grade II tear (major) major tearing, separation of the ligament; moderate to severe joint
i t bilit d t t i
Grade II tear (minor)major tearing, separation of the ligament; moderate to severe joint
instability; moderate to severe pain
Gra
des
o
Grade IIIcomplete tear, gross joint instability; injury may involve multiple joint
structures
instability; moderate to severe pain
EHR315 - Week 2 Dr Stephen Bird
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Ligament HealingSame course of repair as with other vascular tissues
– Extra-articularly ligament sprains bleeding in subcutaneous space
– Intra-articular ligament sprains bleeding within the capsule
Vascular
• vascular proliferation, fibroblastic activity and clot formation• during the initial _________________________
Collagen Granulation tissue
• bridge torn ends of ligaments via scar tissue formation• scar maturation and collagen tensile strength increase
Factors Affecting Healing1. Surgically repaired extra-articular ligaments
– Heal with less scarring Stronger than un repaired ligaments– Stronger than un-repaired ligaments
2. Non-surgically repaired ligaments
– Heal via fibrous scarring = ligament lengthening / joint instability
3. Intra-articular ligament damage
– synovial fluid presence, diluting hematoma, disrupting clot/healing
4. Ligament healing/immobilization: decreased tensile strength
– Muscle strength training can enhance joint stability
EHR315 - Week 2 Dr Stephen Bird
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Injuries to Musculotendinous Structures
• Skeletal muscle exhibits 4 traits (page 31)
– .
– .
– .
– .
• Muscle size and architecture often contributeto type and magnitude of motionyp g
– (gross vs. fine, powerful vs. coordinated)
Mechanics of Muscular Contraction
Review the following:
1. .2. .3. .4. .
EHR315 - Week 2 Dr Stephen Bird
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Muscle StrainsStrains occur when the musculotendinous unit is:
1. Overstretched
2 F d t t t i t t t2. Forced to contract against too great a resistance…. (_________________)
• Damage occurs
– Muscle
– Tendon
– ..
– Tendon-bone interface
Armfield, D. R., Kim, D. H.-M., Towers, J. D., Bradley, J. P., & Robertson, D. D. (2006). Sports-related muscle injury in the lower extremity. Clinics in Sports Medicine, 25(4), 803-842.
sifi
cati
on
s
Grade I tear
• some fibers have been stretched or actually torn
• resulting in tenderness and pain on active ROM
• movement painful but full range present
Str
ain
Cla
ss
Grade II tear (minor)
• number of fibers have been torn and active contraction is painful,
• usually a depression or divot is palpable
• some swelling and discoloration result
Mu
scle
S
Grade III
• Complete rupture of muscle or musculotendinous junction
• significant impairment,
• initially a great deal of pain that diminishes due to nerve damage
EHR315 - Week 2 Dr Stephen Bird
11
4 st
ages
• produce gel-like matrix leading to fibrosis and scarring
• lead to phagocytosis
1Hemorrhaging
and edema
2Fibroblasts and ground
Hea
ling
: 4 and edema and ground
substance
3Myoblasticcell infiltrate the region
4Collagen
undergoes maturation
Mu
scle
• promotes myofibril regeneration
• active contractions critical to apply tensile stress
the region maturation
Lengthy recovery for each grade, Patience is a must
TendinitisDescribes multiple pathological tendon conditions
– Tendon InF, with no involvement of paratenon
• Paratenonitis
– InF of tendon outer layer
– Friction injury
• Tendinosis
– Degenerative tendon changes no clinical/histological signs of InF
• Chronic tendinitis significant tendon degeneration
– Most common: _______________________________
EHR315 - Week 2 Dr Stephen Bird
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Tendon HealingTime frame dependant on severity of injury
Wk 0 2Wks 0-2
• healing tendon adheres to the surrounding tissue
Wks 3-4
• tendon separates (varying degrees) from tissues
Wks 5+
• tensile strength increases
Managing the Healing Process Through Rehabilitation
Pre-Surgical Phase
• If surgery can be delayed, ExTh may help to improve outcome
• Maintaining/increasing strength, ROM, CV fitness, NM control enhance athlete’s ability to perform rehabilitation after surgery
EHR315 - Week 2 Dr Stephen Bird
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Phase I – Acute Injury Phase
Initial swelling management / pain control crucial
______________________________
Loading too aggressive first 48hr InF process may not accomplish what it needs toneeds to....
Immobilization for 24-48hrs????
• Day 3-4 engage in mobility ex
gradually bear weight if lower extremity injury
Use of NSAID’s (table 2.1 p.41)
Järvinen, T. A. H., Järvinen, T. L. N., Kääriäinen, M., Äärimaa, V., Vaittinen, S., Kalimo, H., et al. (2007). Muscle injuries: optimising recovery. Best Practice and Research Clinical Rheumatology, 21(2), 317-331.
Phase II – Repair Phase
As InF subside = pain passive ROM ex added
CV fitness
Restore ROM
Regain / increase strengthRegain / increase strength
Re-establish NM control
• Continued modality use for pain modulation and ______________________
Cryotherapy ?
Electrical stimulation (TENS)?• Transcutaneous Electrical Nerve Stimulation
Hubbard, T.J., & Denegar, C.R. (2004). Does cryotherapy improve outcomes with soft tissue injury? Journal of Athletic Training, 39(3), 278-279.
Machado, A., et al. (2012). The effects of transcutaneouselectrical nerve stimulation on tissue repair: A literature review. Plastic Surgery, 20(4), 237 – 240.
Finberg, M., et al.. (2013). Effects of electro-stimulation therapy on recovery from acute team sport activity. Int J Sports Physiol Perf, 8(3), 293-299.
EHR315 - Week 2 Dr Stephen Bird
14
Phase III – Remodeling Phase
Longest phase; ultimate goal R2S/R2A
Continued collagen realignment
Pain continues to decrease with activity
• Regain sports-specific skills
Dynamic functional activities
Sports-directed strengthening activities
Plyometric strengthening
• Functional testing
Determine specific skill weakness Determine specific skill weakness
Werner, G. (2010). Strength and conditioning techniques in the rehabilitation of sports injury. Clinics in Sports Medicine, 29(1), 177-191. p183
Phase III – Remodeling Phase (continued)
• Heating modalities
Ultrasound, diathermy
Increase circulation in deeper tissue
• Manual therapy
Massage: reduce guarding, spasm, pain
Techniques include Hoffa massage Friction massage, Rolfing Acupressure,Connective tissue massage, Myofascial release
Enhanced lymphatic flow will deliver essential nutrients and increase breakdown/removal of waste.
EHR315 - Week 2 Dr Stephen Bird
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Summary: Key Points1. Healing process
– Inflammation
– Fibroblastic-repair
– Maturation-remodeling
2. Tissue response to injury: _____________________________
– How does injury effect the mechanics of muscular contraction?
3. Expedite recovery of function– ROM strength cardiorespiratory fitness NM control– ROM, strength, cardiorespiratory fitness, NM control
4. Prevent recurrence of injury the phased-approach to rehab– Phase I:
– Phase II:
– Phase III: