Tissue Injury and Healing

Stage of disorder

1. Acute → inflammation [recent]

2. Sub-acute → proliferation [swelling, ROM returning, restoration of motion, start loading]

3. Recurrent → recurring injury: healing disrupted along the continuum; tissue keeps being re-provoked.

4. Chronic/persistent → ongoing symptoms: the atypical response symptoms outlast expected healing.

Is The Clinical Translation Framework the same as stages of tissue healing?

Stages of disorder in CTF NOT EQUAL to stages of healing

Very related and overlap, but slightly different

Types of tissues and where they are

• Epithelial: skin, linings

• Nerve: peripheral nerves

• Muscle: skeletal mm

• Dense regular connective: tendon, ligament [heals differently despite being in same category]

• Dense irregular connective: fascia

• Specialized connective: bone, cartilage

Muscle Tissue Characteristics

1. Lots of blood flow. Heals quickly (2-4 wks)

2. Overload = mm strain, insufficient = atrophy

3. Stronger, more resistant to injury. Lose mm @ diff stages of life. Anytime mm can be built

4. How much experience in load mm, gym experience/activities

Ligaments - Dense Regular Connective Tissue characteristics

Stabilize. Least blood supply.

Overload causes injury

Tendons respond to load

Surgical intervention bc its avascular. Less able to regenerate

• Consider other injuries, less BF, changes in activity level

Rx: Rest initially, then stabilize, then use light weights

Strengthen mm around or brace to compensate

Tendons - Dense regular connective tissue characteristics

Less blood supply. Tension stimulates supply

Respond to load

Progressive overload as part of Rx

• Load @ reasonable pace

Specialized connective tissue characteristics

Regenerate, immobilize

Built up during puberty, lose density as age (menopause)

Loading/resistance to treat.

Normal age-related changes that may look pathological but aren’t

Nerve tissue characteristics

Can regrow/regenerate, but slowly

Mechanical overload/stress on the nerve causes damage- impairs healing

• Strain limits

Heals slower, more sensitive

Keep an eye on other things while rehab nerve

Bone tissue characteristics

• Bone spurs - lay too much bone

• Too little, too fragile

• WB + load normalize healing

• Blood flow dictates healing

Cartilage Tissue Characteristics

Avascular and aneural

Inactivity = harm

WHAT DO WE DO AS PTs w/ Tissue Healing?

1. Address symptoms: education, manual therapy, modality, brace, referral, tape

2. Promote an optimal healing environment: modify ADL, return to loading the injured tissue

3. Help move more + better: AROM, PROM, stretch, neurodynamics, assistive devices. Hands-on techniques

4. Progressively load tissue: strengthen, fxnl training, restore capacity

Tissue tolerance

Amount of load tissue takes be4 damage

Build up or erode overtime

Tissue stress

Mechanical/physiological demands placed on tissue

Injury = stress > tolerance

Mechanical factors that stresses tissues

• Load: force

• Reps

• Frequency

• Amplitude: how large the movement is?

• Direction: along line of stress?

• Rate: quickly applied?

Guides towards tissue type + injury

3 Overlapping Phases in Tissue healing

1. Inflammation: acute

2. Proliferation: subacute

3. Remodelling

Duration of phase depends on:

• amount of damage, tissues involved, physical demands placed on tissue, general health of person

What can PT do @ inflammation stage?

Pain, swell, red, heat, bleeding, less ROM

• Protect + position

• Educate

• Pain-free mid-range ROM

• Light iso’s

Keep unaffected side working

WE CANNOT SPEED UP HEALING, but shape rehab journey

What can PT do @ Proliferation stage (sub acute)?

Pain w/ tissue resistance, less swell, increased ROM

• Educate

• PROM-AROM + joint play

• Gentle stretch

• Multi-angle iso

• Low resistance isotonics

Hold them back a little to prevent setbacks

What can PT do @ remodelling stage (subacute)?

No swell/resting pain

Pain when activity stresses scar

• Progressive strengthening

• Multi-directional neuromuscular control

• High-level task-specific functional training

  • Can do active recovery

  • Strengthen other body parts

• Advance from uniplanar

• Progressively load + repeat loads influence scar formation

  • Made based off load exposure

Phases Duration (onset + peak)

Bleeding: immediate > 4-6 hrs > hours

Acute inflammation: 1-3 hrs > 1-3 days > weeks

Proliferation: 24-48 hrs > 2-3 wks > 4-6 weeks. BEGINS WHILE INFLAMMATION IS STILL RESOLVING!

Remodelling: 2-3 wks > mos > mos (6-8 wks)

Healing is a continuum.

Scarring

State where you are fxnl, not state be4 injury

Protocol post-acute injury

Immediately:

Protect

Elevate

Avoid anti-inflammatory modalities @ HIGH dose

Compress

Educate

After 1st few days

Load

Optimism: outlook on injury

Vascularization (aerobic activity)

Exercise

CARE > PEACE & LOVE?

Cryotherapy + compression

Avoid harmful loading

Rehab

Elevate

• Argument that ice vasoconstricts

Typical healing response

Inflammation → proliferation to remodel

Progress to fxnl scar

Atypical healing response

Disruption along the continuum

Persistent inflammation, recurring injury or chronic ongoing symptoms

Stuck in 1 phase

Criteria for good scar formation/when is remodelling phase complete?

1. Collagen formed along line of stress: fibres lined up w/ previous tissue

2. Reach same length (full rom)

3. Move independently of adjacent tissue: connect layers is problematic

4. Sufficient quality: strong enough to transmit force

Irritability

How easily symptoms are provoked

How long it takes to settle

• High = easily flare and linger

• Low= hard to provoke, settles fast

Severity

Intensity of condition

How much affects ADL

• Don’t test certain things bc pain so severe will impact rest of day!