AT Chapter 10

Essential for clinicians to know…

• the healing process

• phases, time frames, and physiological changes associated with each phase

Healing is a….

continuum

• healing happens over time

synovial fluid primary purposes

1. lubricate joint

2. provide nourishment inside joint

• joint can’t create synovial fluid unless it’s moving

Response phases

1. inflammatory response phase

2. fibroblast repair phase

3. maturation and remodeling phase

length of each response phase

1. inflammatory response phase- as long as 4 days

2. fibroblast repair phase- lasts up to week 6

3. maturation and remodeling phase- can last 2-3 years

Cardinal signs of inflammation

1. rubor (redness)

2. tumor (swelling)

3. calor (heat)

4. dolor (pain)

5. function lasea (loss of function)

Phase 1: inflammatory response phase

• healing begins immediately

• goals:

  • protect injury site to prevent further injury

  • localize (keep damage as localized as possible)

  • decrease things that cause injury to get worse

  • prepare for healing and repair

Chemical mediators

• causes vasodilation and increases cell permeability increasing swelling

• ice can help decrease chemical mediators to prevent swelling, but once swelling occurs ice can no longer help

vascular response (blood vessels)

• vasoconstriction and coagulation occur to seal blood vessels (helps reduce blood loss), and chemical mediators are released

• followed by vasodilation 5-10 mins later (allowing more blood flow into injured area)

  • initially increases blood flow

  • vasodilation decreases blood flow (helps reduce blood loss), increases blood viscosity resulting in edema (swelling)

  • initial effusion of blood and plasma lasts 24-36 hours

Clot formation

• platelets adhere to exposed collagen fibers leading to formation of a plug (clot)

• clots obstruct lymphatic fluid drainage and localize injury response

  • stops mediators from causing swelling to spread outside of injury site

Chronic inflammation

• occurs when acute inflammatory response does not eliminate injuring agent

• tissue not restored to normal physiological state

• as inflammation persists necrosis and fibrosis prolong the healing process

• necrosis: to die off

• fibrosis: different type of tissue that does not respond well

cause of shift from acute to chronic is unknown

Phase 2: fibroblast repair phase

• scar formation through two phases

1. resolution (occurs when there is little tissue damage so there is just normal restoration) (tissue returns to normal condition)

2. regeneration (replacement of tissue by same tissue)

scar formation

• formation of delicate connective tissue (granulation tissue)

• tensile strength increases with proliferation of collagen

  • tension force (pulling apart) are reduced by collagen

  • collagen keeps tissue from being torn when stretched

Phase 3: maturation and remodeling

• long term process- can impact patients mental health

• realignment of collagen is relative to tensile force

• tissue will gradually assume normal appearance

• may require several years to complete

Role of progressive mobilization

• initially: immobilization to allow for initial healing

• repair phase: controlled activity should be added

  • work toward regaining normal flexibility and strength

• remodeling phase: aggressive ROM and strength exercises should be incorporated

  • facilitates tissue realignment and remodeling

• must be aware of pain

factors that impede healing

• extent of injury

• infection

• edema

• poor vascular supply

• health, age, and nutrition

Is bone considered soft tissue

BONE IS NOT CLASSIFIED AS SOFT TISSUE

4 types of soft tissue

• epithelial tissue- skin

• connective tissue- ligaments and tendons

• muscle tissue- skeletal muscle

• nerve tissue- peripheral nerve

Soft tissue adaptations

• metaplasia- transformation of tissue from one type to another that is not normal for that tissue (type of cell)

• dysphasia- abnormal development of tissue (incorrect size or shape)

• atrophy- decrease in the size of tissue due to cell death and reabsorption or decreased cell proliferation

• hyperplasia- increase in number of cells

• hypertrophy- increase in size of cells

Cartilage healing

• limited capacity to heal

• little or no direct blood supply

  • (cartilage does not have its own blood supply)

  • (synovial fluid provides nutrients to cartilage when there is movement in the joint)

ligament healing

• follows similar healing process as other vascular tissues

• proper care will result in acute, repair, and remodeling phases in same time required as other vascular tissues

• repair phase will involve random laying down of collagen that, as scar forms, will mature and realign in reaction to stresses and strain

  • collagen can be harmful if it isnt laid down correctly

• full healing may take 12 months

factors affecting healing of ligaments

• surgically repaired ligaments tend to be streonger due to decreased scar formation

• exercised ligaments are stronger

• exercise versus immobilization

• muscles must be strengthened to reinforce the joint

  • increased tension will increase joint stability

skeletal muscle healing

collagen will mature and orient along lines of tensile force

tendon healing

• abundance of collagen is required for good tensile strength

• tensile strength is not strong enough until 4-5 weeks

peripheral nerve healing

• regeneration can take place within a nerve fiber

• for regeneration, an optimal environment is necessary

  • not too much stress but not too little

• rate of healing occurs at 3 to 4 mm per day (SLOW)

therapeutic modalities

• modality: something that makes someone better

• Major aim is pain free movement, full strength, power, and extensibility of associated muscles.

6 elements all clinicians should consider in decision making

1. indication- a valid reason (ex: symptom) to use a particular medicine, test, etc.

2. contraindication- anything that will absolutely cause adverse effect

3. effectiveness

4. precautions

5. advantages

6. disadvantages

Platelet Rich Plasma Injections

• uses the patients own platelets to promote the natural healing of musculoskeletal conditions

• Medicine is always evolving

Bone healing

follows same phases as soft tissue healing

less complex process

acute fracture management

• must be immobilized, until x ray shows presence of hard callus

• fractures can limit participation for weeks or months

• a clinician must be certain that the following areas do not interfere with healing

  • poor blood supply

  • infection

  • poor immobilization

infection

• may interfere with normal healing, particularly with compound fractures

• severe streptococcal and staphylococcal infections

• modern antibiotics reduce the risk

• closed fractures are not immune to infection

healing of stress fractures

• early recognition is necessary to prevent complete fractures

• decreased activity and elimination of factors causing excess stress are necessary to allow for appropriate bone remodeling

pain

• major indicator of injury

• pain is individual and subjective

pain sources

• cutaneous

• deep somatic

• visceral

• psychogenic

cutaneous

• sharp, bright, burning

• fast or slow onset

deep somatic

originates in tendons, muscles, joints, periosteum, and blood

visceral

begins in organs and is diffused at first and may later be localized

psychogenic

felt by the individual but is emotional rather than physical

acute vs chronic pain

• acute: lasts less than 6 months

• chronic: lasts more than 6 months

referred pain

pain that occurs away from the actual site of injury

• may elicit motor and/or sensory response