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Chapter 2: Understanding

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Title: Chapter 2: Understanding the Healing Process Through Rehabilitation Last modified by: Owner Created Date: 5/2/2003 9:24:17 PM Document presentation format – PowerPoint PPT presentation

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Title: Chapter 2: Understanding


1
Chapter 2 Understanding Managing the Healing
Process Through Rehabilitation
2
Understanding the Healing Process
  • Programs must be based on healing process
    framework
  • Phases
  • Inflammatory
  • Fibroblastic-repair
  • Maturation-remodeling
  • No definitive beginning or end

3
The Primary Injury
  • Described as either chronic or acute
  • Macrotraumatic injuries
  • Result of acute trauma
  • Produce immediate pain and disability
  • Fractures, dislocations, sprains, strains
  • Macrotraumatic injuries
  • Overuse injuries, resulting from repetitive
    overload, incorrect mechanics
  • Tendinitis, tenosynovitis bursitis
  • Secondary injury
  • Inflammatory or secondary hypoxic injury

4
Inflammatory ResponsePhase I
  • Injury results in altered cellular metabolism and
    chemical mediators
  • Macroscopic characteristics
  • Swelling
  • Tenderness
  • Redness
  • Increased temperature
  • Initial response is critical in healing process
  • An injury must cause the Inflammatory Response

5
  • Vascular Reaction
  • Involves vascular spasm, formation of clot and
    fibrous tissue growth
  • Vasoconstriction occurs 5-10 minutes following
    injury
  • Causes anemia followed by hyperemia due to
    dilation
  • Ultimately a slowing of blood flow occurs
    progressing to stasis and stagnation
  • Initial response lasts 24-48 hours

6
  • Chemical Mediators
  • Histamine
  • Vasodilation and increased cell permeability
  • Leukotaxin
  • Margination
  • Increased permeability
  • Necrosin
  • Phagocytic activity
  • Swelling is directly related to extent of vessel
    damage

7
  • Clot Formation
  • Disrupted vessel walls expose collagen within
    endothelium walls
  • Platlets adhere to vascular wall in conjunction
    with leukocytes forming a plug
  • Plug obstructs local lymphatic fluid drainage
  • Results in localization of the injury
  • Precipitated by fibrinogen ? fibrin conversion
  • Cascade of events involving thromboplastin,
    prothrombin, and thrombin
  • Clot formation begins 12 hours after injury and
    is complete within 48 hours
  • Clot vs. Scab

8
  • Chronic inflammation
  • Occurs when acute inflammation does not eliminate
    injuring agents and restore normal physiological
    state
  • Leukocytes are replaced with macrophages,
    lymphocytes and plasma cells
  • Specific mechanism is unknown
  • Overuse and overload related
  • No specific time frame in which acute becomes
    chronic inflammation
  • Resistant to physical and pharmacological agents
  • Introduction of non-steroidal anti-inflammatory
    drugs (NSAIDs) some research indicates impedance
    of healing

9
Fibroblastic-Repair Phase II
  • Fibroplasia
  • Active scar formation
  • May last 4-6 weeks
  • Signs and symptoms will subside
  • Endothelial capillary buds develop allowing for
    aerobic healing
  • Increased blood flow for nutrient delivery

10
  • Fibroblastic-Repair (continued)
  • Granulation tissue develops with breakdown of
    fibrin clot
  • Granulation tissue composed of fibroblasts,
    collagen and capillaries
  • Fibroblasts synthesize extracellular matrix
    containing collagen and elastin
  • Proteoglycans
  • Glycosaminoglycans
  • Fluid
  • Collagen is deposited randomly at day 6 or 7
  • Results in increased scar tensile strength
  • Persistent inflammatory response promotes
    extended fibroplasia, resulting in increased
    scarring

11
Maturation-Remodeling Phase III
  • Realignment of collagen
  • Continued breakdown and synthesis of collagen
  • Increased stress and strain results in increased
    collagen realignment
  • Nonvascular, contracted, strong, firm scar
    present after 3 weeks
  • Maturation may require several years to complete

12
Role of Progressive Controlled Mobility
  • Wolffs Law
  • Bone and soft tissue will respond to physical
    demands placed upon them
  • Remodeling and realignment
  • Initial immobilization is necessary what
    happens to ligaments, tendons, bone?
  • Controlled mobilization enhances
  • Scar formation
  • Revascularization
  • Muscle regeneration and fiber reorientation
  • Tensile properties
  • Controlled activity allows for gradual return to
    normal levels of function

13
Factors that Impede Healing
  • Extent of Injury
  • Edema
  • Hemorrhage
  • Poor Vascular Supply
  • Separation of tissue
  • Muscle spasm
  • Atrophy
  • Corticosteroids
  • Keloids and hypertrophic scars
  • Infection
  • Humidity, climate, and oxygen tension
  • Health, age, and nutrition

14
Pathophysiology of Injury to Various Tissues
  • Epithelial Tissue
  • Covers internal and external surfaces
  • Skin, outer layer of organs, inner lining of
    blood vessels, glands
  • Purposes
  • to protect and form structure for other tissues
  • Function in absorption and secretion
  • Relies on diffusion for fluid, oxygen, waste and
    nutrient transport
  • Injuries
  • Abrasions, lacerations, punctures, avulsions
  • Infection, inflammation or disease

15
  • Connective Tissue
  • Functions
  • Provides body framework, fill space, stores fat
  • Helps repair tissue, produces blood cells,
    protects against infection
  • Cell types
  • Defined by extracellular matrix (fibers, ground
    substance)
  • Macrophages, mast cells, fibroblasts
  • Collagen
  • Strong, flexible inelastic structure that holds
    connective tissue together
  • Enables tissue to resist mechanical deformation
    oriented in direction of tensile stress
  • Mechanical properties
  • Elasticity, viscoelasticity, plasticity
  • Physical properties
  • Force-relaxation, creep response, hysteresis

16
  • Types of Connective Tissue
  • Fibrous
  • Dense tendon, aponeurosis, fascia, ligaments,
    joint capsule
  • Loose adipose
  • Cartilage
  • Rigid connective tissue composed of chondrocytes
    within a collagen, elastin, ground substance
    matrix
  • Poor blood supply slows healing
  • Hyaline, fibrocartilage and elastic
  • Reticular connective tissue
  • Composed of collagen and supports structural
    walls of organs
  • Elastic connective tissue
  • Composed of elastic fibers and found in blood
    vessels, airways and hollow organs

17
  • Bone
  • Consists of living cells and mineral deposits
  • Cancellous spongy bone
  • Cortical bone solid
  • Rich blood supply
  • Functions to provide support, movement and
    protection

18
  • Blood
  • Compose of various cells suspended in fluid
    intracellular matrix (plasma)
  • Plasma contains red blood cells, white blood
    cells and platelets
  • Essential for nutrition, cleansing, and
    physiology of the body

19
Ligament Sprains
  • Sprains involve damage to a ligament
  • Ligaments
  • Inelastic band of tissue
  • Provides joint stability, controls bone position
    during joint motion, provides proprioceptive input

20
  • Grades of Ligament Sprains
  • Grade I - some pain, minimal loss of function, no
    abnormal motion, and mild point tenderness
  • Grade II - pain, moderate loss of function,
    swelling, and instability
  • Grade III - extremely painful, inevitable loss of
    function, severe instability and swelling, and
    may also represent subluxation

21
Ligament Healing
  • Follows same course of repair events as with
    other vascular tissues
  • Ligaments sprained extra-articularly result in
    bleeding in the subcutaneous space
  • Intra-articular ligament sprains result in
    bleeding within the capsule
  • Vascular proliferation, fibroblastic activity and
    clot formation occur during the initial 6 weeks
    of recovery
  • Collagen and ground substance work to bridge torn
    ends of ligaments via scarring
  • Scar maturation will gradually occur and collagen
    tensile strength will increase

22
Factors Affecting Ligament Healing
  • Surgically repaired extra-articular ligaments
  • Heal with less scarring
  • Stronger than un-repaired ligaments
  • Non-surgically repaired ligaments
  • Heal via fibrous scarring resulting in ligament
    lengthening and increased joint instability
  • Intra-articular ligament damage
  • Results in synovial fluid presence, diluting
    hematoma, disrupting clot and healing
  • Ligament healing and immobilization
  • Muscle strength training can enhance joint
    stability

23
Fractures of Bone
  • Acute bone fractures - partial or complete
    disruption that can be either closed or open
    (through skin) serious musculoskeletal condition
  • Risk of infection is increased with open
    fractures
  • Type of fractures include
  • greenstick, impacted, longitudinal, oblique,
    serrated, spiral, transverse, comminuted,
    blowout, and avulsion

24
A Greenstick B Transverse C Oblique D Spiral
E Comminuted F Impacted G Avulsion
25
  • Stress fractures- no specific cause but with a
    number of possible causes
  • Overload due to muscle contraction
  • Altered stress distribution due to muscle
    fatigue, changes in surface
  • Rhythmic repetitive stress vibrations
  • Signs and symptoms
  • Focal tenderness and pain
  • Pain with activity
  • Pain becomes constant and more intense,
  • Does not show up on X-ray until osteoblastic
    activity begins callus formation
  • Treatment
  • Removal from activity for at least 14 days
  • Does not usually require casting unless normal
    fracture occurs

26
Bone Healing
  • Significantly different from soft tissue healing
  • Additional functional elements associated with
    healing
  • Torsion
  • Bending
  • Compression
  • Trauma results in disruption of blood vessels,
    periosteal damage and clot formation
  • Fibrous collagen network is constructed after 1
    week -serves as framework for chondroblasts

27
  • Cartilage begins to infiltrate callus
  • Osteoblasts begin to proliferate, forming
    cancellous and trabeculae
  • Callus crystallizes remodeling begins
  • Osteoclasts appear to resorb bone fragments and
    clean debris
  • Bone transition during remodeling
  • Fibrous cartilage ? fibrous bone ? lamellar bone
  • Osteoblasts and osteoclasts respond to stresses
    placed on bone
  • Immobilization is required for 3-8 weeks
  • Dependent on bone, severity, location, patient age

28
Cartilage Damage
  • Osteoarthritis
  • Arthritis is an inflammatory condition with
    secondary destruction
  • Arthrosis degenerative process with cartilage
    destruction, bone remodeling and secondary
    inflammation
  • Cartilage fibrillates
  • Release of fibers and ground substance into joint
  • Often occurs in peripheral cartilage
  • Fibrillation degenerative process associated
    with poor nutrition and disuse
  • Can extend to stressed areas and increase
    proportionally to stress applied

29
  • Osteophytosis
  • Attempt at increasing surface area to decrease
    contact force
  • Chondromalacia
  • Non-progressive cartilage transformation with
    areas of irregularity and softening
  • Begins in non-weight bearing areas and progresses
    to areas of stress
  • Use patterns, external force application, altered
    joint mechanics (laxity or trauma related) can
    serve as predisposing factors

30
  • Injuries conducive to osteoarthritic changes
  • Dislocations and subluxations
  • Osteochondritis dissecans
  • Recurrent synovial effusion and hemarthrosis
  • Ligament damage resulting in altered mechanics
    and cartilage damage
  • Additional factors
  • Loss of ROM, strength, power
  • Altered mechanics

31
Cartilage Healing
  • Limited healing capacity
  • Variable healing depending on damage to cartilage
    and or subchondral bone
  • Articular cartilage fails to undergo clot
    formation or cellular response
  • Defective region remains defective
  • When subchondral bone is involved the
    inflammatory process proceeds as normal

32
Injuries to Musculotendinous Structures
  • Skeletal muscle exhibits 4 traits
  • Elasticity
  • Extensibility
  • Irritability
  • Contractility
  • Muscle size and architecture often contribute to
    type and magnitude of motion (gross vs. fine,
    powerful vs. coordinated)

33
Muscle Strains
  • Strains occur when the musculotendinous unit is
  • Overstretched
  • Forced to contract against too great a resistance
  • Damage occurs
  • Muscle
  • Tendon
  • Musculotendinous junction
  • Tendon-bone interface

34
Muscle Strain Classifications
  • Grade I
  • some fibers have been stretched or actually torn
    resulting in tenderness and pain on active ROM,
    movement painful but full range present
  • Grade II
  • number of fibers have been torn and active
    contraction is painful, usually a depression or
    divot is palpable, some swelling and
    discoloration result
  • Grade III
  • Complete rupture of muscle or musculotendinous
    junction, significant impairment, with initially
    a great deal of pain that diminishes due to nerve
    damage

35
Muscle Healing
  • Similar healing to other soft tissues
  • Hemorrhaging and edema lead to phagocytosis
  • Fibroblasts and ground substance produce a
    gel-like matrix leading to fibrosis and scarring
  • Myoblastic cell infiltrate the region promoting
    myofibril regeneration
  • Collagen undergoes maturation with active
    contractions being critical to apply tensile
    stress
  • Lengthy recovery for each grade
  • Patience is a must

36
Tendinitis
  • Term used to describe multiple pathological
    tendon conditions
  • Inflammation of tendon, with no involvement of
    paratenon
  • Paratenonitis
  • Inflammation of tendon outer layer
  • Friction injury
  • Tendinosis
  • Degenerative tendon changes with no clinical or
    histological signs of inflammation

37
  • Chronic Tendinitis
  • Tendon degeneration
  • Loss of normal collagen and cellularity
  • No inflammatory cellular response
  • Signs and symptoms
  • Pain with movement
  • Swelling
  • Crepitus
  • Key treatment rest
  • Additional treatment options
  • NSAIDs and modalities
  • Alternative activities

38
Tenosynovitis
  • Due to friction and decreased space for sliding
    synovial sheaths are necessary in tendons
  • Overuse results in inflammation and development
    of sticky adhesions within the sheath
  • Signs and symptoms
  • Similar to tendinitis
  • Movement may be more limited with tenosynovitis
  • Treatment is the same as if the athletic trainer
    were treating tendinitis

39
Tenosynovitis
40
Tendon Healing
  • Large amounts of collagen are required for
    adequate healing
  • However, collagen synthesis can become excessive
    resulting in fibrosis and interfering with tendon
    sliding action
  • Scar tissue will gradually elongate allowing for
    appropriate tendon motion
  • If a synovial sheath surrounds an injured tendon
    the injury could be devastating
  • Typical tendon healing may require 4-5 weeks
    before strong contractions can be imparted on
    tendon

41
Injury to Nerve Tissue
  • Generally involve contusion or inflammation
  • More severe injuries involve crushing or severing
  • Causes life-long disability
  • Paraplegia or quadriplegia

42
  • Peripheral nerves can regenerate if injury does
    not impact cell body
  • Slower regeneration with proximity to cell body
  • Regeneration requires an optimal environment
  • Degenerative changes occur
  • Increased metabolism and protein production for
    regeneration
  • While cell body contains genetic material
    necessary to maintain axon is does not transmit
    to distal segments of axon
  • Schwann cells
  • If cut contacts Schwann cells re-innervation of
    distal segments is more likely

43
  • New axon buds will develop on the proximal axon
  • One sprout will form new axon
  • Contact with Schwann cells will allow for Schwann
    cell proliferation new myelin
  • Regeneration is slow
  • Occurs at a rate of 3-4 mm per day
  • Can be obstructed by scar formation
  • CNS nerves regenerate poorly due to lack of
    connective tissue support

44
Additional Musculoskeletal Injuries
  • Dislocations and Subluxations
  • Dislocations present with total disunion of bone
    apposition between articular surfaces- requiring
    manual or surgical realignment
  • High level of incidence in fingers and shoulder
  • Subluxations are partial dislocations causing
    incomplete separation of two bones
  • Reduction should not occur without and X-ray
    (necessary to rule out fractures)
  • Inappropriate reduction may complicate the injury
  • Return to play is largely governed by the degree
    of soft tissue injury

45
Bursitis
  • Result of excessive movement or trauma to bursa
  • Causes irritation, inflammation and increased
    synovial fluid production
  • May continue to become inflamed with repeat
    irritation with increasingly more pain
  • Commonly impacted bursa
  • Pre-patellar
  • Olecranon
  • Subacromial

46
Muscle Soreness
  • Overexertion in strenuous exercise resulting in
    muscular pain
  • Two types of soreness
  • Acute-onset muscle soreness
  • accompanies fatigue, muscle pain experienced
    immediately after exercise
  • Delayed-onset muscle soreness (DOMS)
  • pain that occurs 24-48 hours following activity
    that gradually subsides
  • Caused by slight microtrauma to muscle or
    connective tissue structures
  • Prevention and treatment
  • Gradual build-up of intensity
  • Some form of stretching

47
Contusions
  • Result of sudden blow to body
  • Can be both deep and superficial
  • Hematoma results from blood and lymph flow into
    surrounding tissue
  • Localization of extravasated blood into clot,
    encapsulated by connective tissue
  • Speed of healing dependent on the extent of
    damage
  • If muscle damage occurs ROM will be impacted
  • Incidents of repeated blows may result in
    myositis ossificans development
  • Prevention rest and protection
  • Allow for calcium re-absorption

48
Managing the Healing Process Through
Rehabilitation
  • Pre-Surgical Phase
  • Involves only those athletes requiring surgery
  • If surgery can be delayed, exercise may help to
    improve outcome
  • Maintaining or increasing strength, ROM,
    cardiorespiratory fitness, neuromuscular control
    may enhance the athletes ability to perform
    rehabilitation after surgery

49
Phase I Acute Injury Phase
  • Initial swelling management and pain control are
    crucial
  • PRICE
  • If the athletic trainer is too aggressive during
    the first 48 hour the inflammatory process may
    not have time to accomplish what it needs to
  • Immobilization for 24-48 hours is a must
  • By days 3-4 the athlete should be engaged in some
    mobility exercises and should be encouraged to
    gradually bear weight if it is a lower extremity
    injury
  • Use of NSAIDs

50
Phase 2 Repair Phase
  • As the inflammatory process has subsided and pain
    decreases with passive ROM exercises should be
    added
  • Increase cardiorespiratory fitness
  • Restore full ROM
  • Restore or increase strength
  • Re-establish neuromuscular control
  • Continued modality use for pain modulation and
    swelling control
  • Cryotherapy
  • Electrical stimulation

51
Phase 3 Remodeling Phase
  • Longest phase with the ultimate goal being return
    to play
  • 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

52
  • Heating modalities
  • Ultrasound, diathermy
  • Increase circulation in deeper tissue
  • Manual therapy
  • Massage
  • Reduce guarding, spasm, pain
  • Enhanced and lymphatic flow will deliver
    essential nutrients and increase
    breakdown/removal of waste, respectively

53
Using Medication to Effect the Healing Process
  • Used primarily for pain modulation
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Aspirin, acetaminophen, ibuprofen, naproxen
    sodium, ketoprofen
  • Aspirin
  • Aspirin interferes with pain signal transmission
    from thalamus
  • Tissue damage results in release of arachidonic
    acid from phospholipid walls
  • Results in production of prostaglandins,
    thromboxane, prostacyclin
  • Mediate inflammatory response

54
  • Effects
  • NSAIDs block pain and inflammation by inhibiting
    prostaglandin synthesis
  • Modulate lysosomal membrane destruction (enzymes)
  • Aspirin (only NSAID) that irreversibly inhibits
    cyclooxygenase (other NSAIDs reversible)
  • Alters sympathetic outflow of hypothalamus for
    fever reduction
  • Side effects
  • Gastric distress, heartburn, nausea, tinnitus,
    headache, diarrhea
  • Cautions
  • Impairs clotting, irreversible inhibition of
    cyclooxygenase
  • Prolonged bleed risk

55
  • Ibuprofen
  • Analgesic and antipyretic effects
  • Similar side effects
  • No impact on platelet aggregation
  • Dose of 400mg serves as analgesic and
    anti-inflammatory agent
  • Acetaminophen
  • Analgesic and antipyretic effects
  • Limited anti-inflammatory capabilities
  • Used to somatic pain and fever reduction
  • No gastric irritation or bleeding
  • No impact on clotting factors

56
  • NSAIDs
  • Anti-inflammatory, analgesic and antipyretic
    agents
  • Should not be used if suffer from aspirin allergy
    triad
  • Use cautiously if athlete is exposed to
    dehydration
  • Inhibits prostaglandin synthesis, compromising
    elaboration of prostaglandins in kidney
  • Ischemia within kidneys occurs
  • Fewer side effects and longer lasting than
    aspirin
  • May require liver function monitoring
  • While medications can be effective, irritating
    agent causing inflammation must also be
    eliminated

57
  • Oral muscle relaxants
  • Reduce spasm and guarding
  • Facilitate rehabilitation programs
  • No evidence of superiority over analgesics or
    sedatives
  • Many analgesics and anti-inflammatory products
    are available over the counter (OTC)
  • Combination of products
  • Chronic aspirin, phenacetin or acetaminophen use
    can result in papillary necrosis or
    analgesic-associated nephropathy
  • Caffeine dependence

58
Sports Medicine Approach to the Healing Process
  • Assist/manipulate the natural process of the body
    while doing no harm
  • Primary goals
  • Have a positive influence on inflammation and
    repair process
  • Expedite recovery of function
  • ROM, strength, cardiorespiratory fitness,
    neuromuscular control
  • Minimize early effects of inflammatory process
  • Pain, spasm, edema accumulation, decreased motion
  • Prevent recurrence of injury
  • Resist future periods of tissue overload through
    strengthening
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