KNES 377 Principles of Rehab and Pathophysiology

Rehabilitation: definition 1

Restoration of function to the greatest possible degree in the shortest possible time.

Rehabilitation: athlete definition

Return to preinjury physical and psychological competitive fitness.

Rehab goal

Return the patient as quickly and safely as possible.

Patient's team role

Main team member; person, not injury; take responsibility and commit.

Physician's team role

Diagnose, oversee rehab, and manage return-to-play.

Rehab clinician's role

Director of the rehabilitation program.

Family and others

Family supports compliance; coach, friends, and teammates are also involved.

Rehab communication

Clinician communicates with patient, physician, family, students, and coach.

HIPAA

Health Insurance Portability and Accountability Act; protect patient privacy.

Professionalism

Professional appearance, attitude, respect, privacy, current knowledge; touch needs a specific purpose.

Legal standards

Informed consent; patients cannot be forced to perform rehab exercises.

Evidence-based practice

Research evidence + patient preferences + clinical circumstances + clinician experience/judgment.

Patient-rated outcome measures

Assess injury impact on ADLs, work, recreation; examples: pain scale, FAAM, LEFS.

Clinician-rated outcome measures

Assess impairments; examples: isokinetic testing, MMT, goniometer measures, joint laxity.

Why use outcome measures?

Show treatment effectiveness, guide progression/regression/discontinuation, and support insurance needs.

Rehab components

Therapeutic modalities and therapeutic exercise.

Primum non nocere

Avoid aggravation; do no harm.

Rehab principles

Early timing, compliance, individualization, sequencing, sound progression, and total patient.

Timing principle

Begin early; strength is lost faster than recovery occurs.

Compliance principle

Explain content, length, expectations, and patient responsibility.

Individualization principle

Patients respond differently; do not compare patients.

(Clinical) Sound progression principle

Challenge the patient without increasing injury.

Total-patient principle

Maintain unaffected body areas and cardiovascular conditioning.

Rehab misconception

Rehab does not speed tissue healing; it creates an optimal healing environment.

Rehab objectives

Prevent deconditioning and rehabilitate the injured part.

Preventing deconditioning

Maintain cardiovascular conditioning and exercise the uninvolved extremity.

Patient injury knowledge

Know the injury, healing process, and rehabilitation methods.

Therapeutic exercise components

Pain/deviation correction; ROM; strength/endurance; proprioception/coordination/agility; function.

Flexibility vs ROM

Flexibility = muscle mobility/length; ROM = movement possible at a joint.

ROM considerations

Early ROM is desired; scar tissue matures and contracts.

ROM variables/factors

Active/passive, static/dynamic, physiological/accessory; affected by bone, fat, skin, muscle/tendon.

Strength vs endurance

Strength = single maximal voluntary contraction; endurance = repeated contractions over time.

Proprioception/coordination/agility

Body awareness/response; complex movement; directional control of body/parts.

Functional/performance activities

Job/sport transition exercises after balance/coordination; may coincide with agility.

Power

Maximal force in minimal time.

Strength/power training variables

Concentric/eccentric; open/closed chain; single/multi-joint; isometric/isotonic/isokinetic; weights/manual; plyometrics.

Cardiovascular endurance

Ability to deliver fuel/oxygen; train ~3×/week, ≥20 min; LSD/intervals; limits: heart, lungs, blood, vessels.

Stages of grief

Denial, anger, depression, acceptance; refer when needed.

Psychological rehab

Motivation/confidence; goal setting, imagery, positive self-talk, relaxation/anxiety reduction.

Goal setting

Objective, measurable, short/long term, specific, challenging, positive, written, target-dated.

Clinician psychological role

Educate, listen, encourage, support, build rapport, respect culture, set goals, make rehab fun.

Factors affecting rehab

Severity, fitness, time, situation, insurance/access, adherence, psyche, and available tools.

Full/complete release of patient (clearance)

Pain-free, no swelling, normal JROM, strength/power/endurance, NM control/function, physician approval.

Healing importance

Healing knowledge supports safe/effective exercise and understanding technique impact.

Tissue healing characteristics

Predictable, chemically mediated, and varies by tissue, severity, and health.

Healing determinants

Extent of injury and approximation of wound/stump ends.

Primary vs secondary intention

Primary: minor/surgical wound, good approximation. Secondary: severe/poor approximation, longer, bigger scar.

Healing phases

Hemostasis → inflammation → proliferation/repair → remodeling/maturation; phases overlap.

Hemostasis

Vessel disruption; vasoconstriction/hypoxia; then vasodilation brings blood, serum, platelets, proteins.

Margination and diapedesis

Margination: cells adhere along vessel walls; diapedesis: formed elements pass through intact vessel walls.

Platelets in hemostasis

Bind collagen; release phospholipids, growth factors, fibrinogen, and fibronectin.

Fibrin plug

Fibronectin + fibrin form a plug; traps cells, stops bleeding, gives early strength, then becomes type III collagen.

Lymph/fibrinolysin

Fibrin plugs lymph vessels; fibrinolysin dissolves the plug so lymph can drain edema.

Inflammation timing/purpose

Begins after clot; usually 2–3 days, up to 7–10; necessary but harmful if prolonged.

Debris removal

Neutrophils arrive first; monocytes/macrophages follow and remove dead tissue.

Exudate

Escaped vessel fluid + dead tissue + dying WBCs; proteins absorbed by lymph, water by capillaries.

Macrophages

Clear debris and release growth factors that regulate tissue growth.

Chemotaxis

Cells stimulate chemicals that attract/produce cells at injury; vascular permeability is an example.

Histamine/serotonin/kinins

Histamine starts permeability and attracts WBCs; serotonin and kinins continue response → prostaglandins.

Inflammation signs

Discoloration (Rubor), temperature (calor), pain/tenderness (dolor), swelling (tumor), decreased function.

Inflammatory pain

Histamine, prostaglandins, bradykinin, and edema pressure sensitize nerve endings.

Proliferation timing

Generally 2–4 weeks; macrophages, angiogenesis, granulation tissue, and fibroblasts are key.

Growth factors/cells

Platelet/macrophage chemotaxis recruits fibroblasts, myofibroblasts, and endothelial cells.

Fibroblasts

Produce extracellular matrix and support new capillary growth; activity begins around days 3–5.

Granulation tissue

Matrix + new capillary buds; bright red; includes collagen, reticulin, elastin.

Ground substance/ECM

Fills spaces between fibers; early ECM is weak and later replaced by collagen.

Collagen sequence

Type III appears around 48–72 h and is weak; type I begins around day 12 and is more durable.

Collagenase/tensile strength

Collagenase limits excess collagen (keloid); tensile strength depends on collagen amount, type, and arrangement.

Proliferation treatment

Control pain/limit fibrosis; restore JROM, CV endurance, NM control; begin strength/power/endurance.

Remodeling

About 6–18 months; capillaries, redness, swelling, and sensitivity diminish.

Collagen remodeling

Cross-links increase strength; parallel collagen is strongest; healed tissue is rarely original strength.

Wolff's Law

Tissues respond to physical demands by remodeling along lines of tension.

Tensile strength

Maximum stress tissue withstands before failure; drops in inflammation and rises around day 5.

Maturation treatment

Restore strength/power/endurance and function.

Ligament healing

Early approximation + limited immobilization; progressive stress later.

Ligament timeline/outcome

Proliferation: 2 d–6 wk; remodeling: 6–12 mo; final healing ~1 yr.

Ligament problems

Poor approximation can fail healing; intra-articular ligaments do not heal.

Tendon healing

Immobilize for revascularization; movement timing is critical; adhesions common.

Tendon outcome/conditions

Tensile strength ~85–95%; tendinosis, tendinitis, tenosynovitis, peritendinitis.

Muscle healing

Minor injury regenerates via satellite cells; major injury heals by fibrosis.

Muscle outcome

Healing takes ~1–6 months; tensile strength loss possible(10-50% loss).

Articular cartilage

Diarthrodial load dissipation; mostly type II collagen; 60–80% water.

Articular cartilage protection

Accepts compression and releases water; deeper collagen continues protection.

Fibrocartilage

Transfers loads between tendon/ligament/bone; found in discs and TMJ.

Cartilage healing

Articular cartilage heals slowly; fibrocartilage heals better.

Cartilage defects

Small full-thickness defects may heal; partial defects do not.

Bone healing cells

Osteoclasts remove damaged bone; osteoblasts build bone.

Bone healing sequence

Callus → soft callus → spongy bone → compact bone.

Bone timeline

Immobilization ~6–8 weeks; remodeling may take years.

Exercise and healing

Inflammation: minimal force; proliferation: gradual loading; remodeling: return to normal.

Chronic inflammation

Persistent inflammation from repeated trauma or inadequate repair.

Ice/e-stim/heat

Ice reduces edema; e-stim may aid healing; heat increases circulation.

Ultrasound/NSAIDs

Ultrasound promotes collagen; NSAIDs reduce pain and inflammation.

NSAID mechanism

Inhibit prostaglandins, reducing pain and vascular permeability.

Other healing factors

Surgery, age, disease, wound size, nutrition, infection, swelling, and muscle spasm affect healing.

Factors that affect healing

Poor nutrition, smoking, swelling, spasm, infection, and age can impair healing.