S1L1.1_Principles of Intervention (Part 1)

Stages of inflamm & repair

Acute

Subacute

Chronic

Acute stage aka

Reaction and inflammatory stage

Acute stage duration

Lasts 4-6 days unless insult is perpetuated

Acute stage causes

• Trauma

• Repetitive use

• Chemical irritants to reinstate homeostasis

Acute stage signs of inflamm

• Pain at rest (dolor)

• Swelling (tumor)

• Redness (rubor)

• Heat (calor)

• Loss of function

Acute stage: Pain & impaired mvmt during ROM are d/t

• Irritated nerve endings

• Inc tissue tension

  • D/t edema/joint effusion & m. guarding

The body’s way of immobilizing a painful area

Edema/joint effusion & m. guarding

Subacute stage aka

Proliferation, repair, and healing stage

Subacute stage: Duration

10 -17 days

• 14-21 days after onset

Subacute stage: May last up to __ in tendons (limited _)

6 wks

circulation

Subacute stage: signs of inflamm

Dec. progressively → eventually absent

Subacute stage: When is pain felt

• Synch. c encountering tissue resistance @ end of avail. ROM

• When newly developing / tight tissue is stressed beyond tolerance

Subacute stage: Muscle strength

• Weak

• Func. is limited d/t weak tissue

Subacute stage: This stage is characterized by the __ & __ of __

Synthesis & Deposition

Collagen

Subacute stage: Noxious stimuli

• Noxious stimuli: Removed

• Capillary beds start to grow into the area

Subacute stage: What activities inc during this stage

• Fibroblastic activity

• Collagen formation

• Granulation tissue dev.

Chronic stage aka

Maturation and remodeling stage

Chronic stage: Duration

6 mo. → 1 yr

• depends on type of tissue involved & amt of damage

Chronic stage: Inflammation

NO signs of inflamm

Chronic stage: There may be __ or __ that limit ROM + __ limiting normal func

Contractures or adhesions

M. weakness

Chronic stage: Connective tissue

Cont. to strengthen & remodel

• in response to applied stresses

Chronic stage: Scar retraction is completed by __

Day 21

Chronic stage: Collagen

Fibers thicken & reorient

• in response to stresses on tissue

Chronic stage: Remodeling time is influenced by __

Factors that affect density & activity lvl of the fibroblasts

• Time immob.

• Stress on tissue

• Loc. of lesion

• Vascular supply

Primary difference between the state of healing bw late subacute & chronic stages:

○ Improvement in quality (orientation and tensile strength) of collagen

○ Reduction of wound size during chronic stages

Wound healing process

Chronic inflamm: Happens when injured tissue is __

Stressed beyond its ability to repair

Chronic inflamm: Result of excessive stress on tissues (unable to respond to repetitive or excessive nature)

• Prolonged / recurring pain

• Limitations in activity & function

Chronic inflamm: Precaution:

Progressive loss of ROM d/t stretching → do NOT continue to stretch

Chronic inflamm: Symptoms

• Swelling

• M, guarding post-act.

• ↑ pain

• ↑ stiffness p rest

• Loss of ROM for 24 hrs

Chronic inflamm: Causes and contributing factors:

CROP MI CREB MEAT

• Cumulative trauma

• Repetitive strain

• Overuse

• Poor mobility

• M. imbalance

• Intensity of activity (change in usual)

• Contractures

• Reinjury of old scar

• Eccentric demand (rapid / excessive repeated)

• Bone malalignment

• M. weakness

• Environmental factors

• Age-related factors

• Training errors

Chronic Pain Syndrome: Duration

>6 mo.s

T or F: Chronic Pain Syndrome can be linked to a source of inflamm

FALSE

Can NOT be linked

Chronic Pain Syndrome: Leads to

Activity limitations & Participation restrictions

Tissue responses & characteristics: Acute

VC PEE (Video Call PEE)

• Vascular changes

• Clot formation

• Phagocytosis. neutralization of irritants

• Early fibroblastic activity

• Exudation of cells & chemicals

T or F: Vascular changes during the acute stage predominate the first 24 hrs of tissue response to inflamm

FALSE

first 48 hrs

Tissue responses & characteristics: Subacute

GC GEN (Grp Chat Generation)

• Growth of capillary beds into area

• Collagen formation

• Granulation tissue

• Easily injured tissue (very fragile)

• Noxious stimuli removal

Tissue responses & characteristics: Chronic

CoCoMaR(co)

• Contracture of scar tissue

• Collagen aligns to stress

• Maturation of connective tissue

• Remodeling of scars

Clinical signs: Acute

• Inflammation

• Pain before tissue resistance

Clinical signs: Subacute

• Dec inflamm

• Pain sync. c tissue resistance

Clinical signs: Chronic

• Absence of inflamm

• Pain p tissue resistance

The foundation in identifying the stages of inflamm

Clinical signs

Impairments: Acute

• Inflammation

  • Pain at rest

  • Edema

  • M. spasm

• Impaired mvmt

• Jt effusion

• Dec use of associated parts

Accumulation of fluid in areas of the affected jt

Jt effusion

Impairments: Subacute

• Pain @ end of ROM

• Dec edema

• Dec jt effusion

• Developing contracture

• Developing weakness from disuse

• Dec. func. use of the part & associated parts

Developing contracture is caused by __

inability to move the injured area d/t pain

Dec. functional use is d/t __ during the period of __, which may affect associated regions

Apprehension of pt to use injured area

Recovery

Ex. Pt c elbow fx → apprehensive to move affected UE → dec. functional use of __

Shoulder, wrist, & hand

Impairments: Chronic

• Contracture & adhesions

• Weakness, poor endurance & neuromuscular control

• Dec. functional usage of involved part

• Inability to function as expected

Skeletal muscle: Muscle damage is characterized by __

Disruption of fibers & impact on contractile strength

Skeletal muscle: Area at high risk for injury

Myotendinous junction

Skeletal muscle: Common MOI

High demand / impact activities

Significant force → muscle strain / contusion

Classification of m. injuries

Grade 1: Minor

Grade 2: Moderate

Grade 3: Severe

M. injuries: Grade 1 (Minor)

Few tears

Minimal loss of strength

M. injuries: Grade 2 (Moderate)

More damage to fibers

Associated loss of contractile strength

M. injuries: Grade 3 (Severe)

Cross-sectional rupture

Complete loss of contractile strength

Healing process of m. injuries: Phases

• Destruction

• Repair

• Remodeling

Healing process of m. injuries: Destruction phase

● Necrosis of contractile elements

● Hematoma formation & inflamm

● Fibrin & fibronectin form early linkage to provide support against contraction

Healing process of m. injuries: Repair phase

● After few days → few wks

● Phagocytosis of necrotic tissue

● Regeneration of contractile elements

● Stimulation of myofiber formation & scar formation

Healing process of m. injuries: Remodeling phase

● At least 4-6 wks

● Re-organization of tissue integrity & functional maturation

Muscle: Clinical implications for rehab: Small vs Large injuries

Small injuries → heal c muscle tissue

Large injuries → heal c scar tissue

Muscle: Clinical implications for rehab: __ is very important in the __ phase of rehab to promote healing process

Rest

Early

Muscle: Clinical implications for rehab: Modalities may be employed to control __

• Inflamm

• Edema

• Stiffness

Muscle: Clinical implications for rehab: Cryo → (what phase), Heat → (what phase)

Cryo → subacute

Heat → chronic

Muscle: Clinical implications for rehab: Early activity is advocated to prevent __

Adhesion formation

Muscle: Clinical implications for rehab: Adhesion has great effect on

LOM, dec muscle strength & function

Muscle: Clinical implications for rehab: Active stretching should be __ for __ post-injury to __

Postponed

3-7 days

Prevent reinjury

Tendon: Causes of tendinopathy

○ Repetitive motions or load → microtears

○ Abrupt forceful contraction of muscle

T or F: Tendons have a more consistent blood supply compared to other soft tissues leading to increased ability to heal fast

FALSE

less consistent blood supply

decreased ability to heal fast

Achilles Tendon Rupture: __% of ruptures occur during recreational sports

80%

Achilles Tendon Rupture: Common complaint

Weakness c pushoff

Achilles Tendon Rupture: Confirmation tests

MRI or US

Achilles Tendon Rupture: Healing duration

6-12 wks after innjury

Achilles Tendon Rupture: Athletes return to sports after __

3-6 mo.s

Healing process of tendinous injuries: Phases

• Inflammatory

• Proliferative repair

• Remodeling

• Scar formation

Healing process of tendinous injuries: Inflamm phase

● Several days → wks

● Inflamm

Healing process of tendinous injuries: Proliferative repair phase

• Few days → few wks (up to 6 wks)

• Collagen synthesis

• Correct faulty biomech. & compensatory posture

Healing process of tendinous injuries: Remodeling phase

● About 6 wks

● Induction of fibrous repair

● Collagen fibers align (based on direction of stress)

Healing process of tendinous injuries: Scar formation phase

● 10 wks → 1 yr

● Decline of metabolism & vascularity

● Strengthening

Tendon: Patient education is important during the __ phase to correct __

Proliferative repair

Faulty biomech. & compensatory posture

Tendon: Strengthening of tissue begins at the __ phase but intensity

given is __ to prevent __

Remodeling

Not too high

Re-injury

Tendon: Clinical implications for rehab: Avoid prolonged periods of __

Immobilization

• May lead to tightness, weakness, & contractures

Tendon: Clinical implications for rehab: Identify the postural dysfunction or biomechanical fault to __

Reduce recurrent & repetitive loading to the tendon

Tendon: Clinical implications for rehab: Strengthening & stretching interventions are carefully designed particularly during the __ phase to __

Remodeling

Prevent occurrence of re-injuries

Ligament: Ligamentous sprain can result from __

Excessive lengthening of the ligament

Ligament: Most commonly injured

Ankle → then ACL

Ligament: Classification of ligamental injuries

• Grade 1

• Grade 2

• Grade 3

Ligament: Classification of ligamental injuries: Grade 1

● Stretched

● Microfailure, few fibers in the plastic range are ruptured

● No excessive motion

● Intervention & protection ONLY → no surgery

Ligament: Classification of ligamental injuries: Grade 2

● Stretched c more fibers torn = Partial tear

● Mod jt laxity

● Surgery depends on goal & instability

Ligament: Classification of ligamental injuries: Grade 3

● Complete rupture / tissue failure

● Significant jt laxity

● Surgery

ACL Tear: Most prone to injury:

○ Football players

○ Basketball players

○ Soccer players

○ Skiers

One of the most common knee injuries sustained in sports

ACL tear

ACL tear: How it happens

Pop → severe swelling → extreme pain → difficulty walking

ACL tear: To confirm dx

Xray & MRI

ACL tear tx: Minor tear

Protective braces & PT (c strengthening exercises)

ACL tear tx: Full tear

Reconstructive surgery to rebuild ligament

Healing process of ligament injuries: Phases

Inflammatory

Regenerative

Remodeling

Healing process of ligament injuries: Inflammatory phase

● Healing w/i 72 hrs c hematoma formation

● Deposition of ground substance & disorganized collagen fibers

● (+) signs of inflamm

Healing process of ligament injuries: Regenerative phase

● Few days → 6 wks

● Fibroblast proliferation & collagen formation

Healing process of ligament injuries: Remodeling phase

• 6 wks post-injury → 1 yr

• Remodeling of ligament

• Improved collagen alignment