Download Tissue Response to Injury

Tissue Response to
Injury
The Healing Process
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Essential for ATCs & HCPs to understand the
healing process
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Able to recognize each , sequence & time frame
Certain physiological events must occur during
each phase
Needs opportunity to accomplish goals in each
phase
Goal of ATC to create optimal healing environment
for tissue
INTRODUCTION
WHEN AN
INJURY
OCCURS IT
MUST GO
THROUGH 3
STAGES OF
HEALING
Three Phases of Healing
Phase I: Acute Inflammatory Phase
Phase II:
Proliferation/Repair/Regeneration
Phase
Phase III: Remodeling/ Maturation Phase
Inflammatory Phase
Repair/Regeneration Phase
Maturation/Remodeling Phase
Often discussed as 3 different phases,
but really occurs on a CONTINUUM
Injury
Day 4
Week 6
2-3
years
Phase I: Acute Inflammatory Phase
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Begins almost right away
Produces direct injury to cells of soft tissues
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Increase blood flow to the area that brings
cells and chemicals to begin the healing process.
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 altered metabolism
 release materials to initiate inflammatory
response
Phagocytes- Eat up dead cells.
Leukocytes- Infection fighting white blood cells.
Platelets-Carry blood clotting materials.
Neutralizes/destroys offending agents,
restricts tissue damage to the smallest possible
tissue & prepares area for healing
Phase I: Acute Inflammatory Phase
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Lasts approx. 2-4 days
Goal
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Protect
Localize
Decrease injurious agents
Prepare for healing and repair
CRITICAL TO ENTIRE HEALING
PROCESS
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Delays in this response = abnormal healing
Cardinal Signs of Inflammation
Redness
Heat
Swelling
Pain
Loss of
Function
Caused by
dilation of
arterioles/
increased blood
flow
Increased
chemical activity
& increased
blood flow to
skin surface
Caused by
accumulation of
blood & damaged
tissue cells
Direct injury of
nerve fibers,
pressure of
hematoma on n.
endings
Chemical
irritants –
bradykinin,
histamine,
prostaglandin
Increased pain/
swelling
Phase II: Proliferation Phase
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“Repair/Regeneration”
Phase will extend from
48 hours to 3-6 weeks
Phase removes debris &
temporary repair –
SCAR FORMATION
(fibroplasia)
Dependent on levels of:
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debris removal
skin cell production,
production of fibroblasts
Phase II: Proliferation Phase
 Repaired
through 3 phases:
 Resolution - dead cells & cellular
debris are removed (tissue left with
original structure & function in tact)
 “get rid of debris”
fibroblast
(tissue cells) formation
tissue remodeling
Phase II: Proliferation Phase
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Regeneration – damaged tissue is replaced
by cells of the same type (structure
retains some or all of its original
structure & function)
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“bring in like cells”
Repair – original tissue is replaced with
scar tissue (original structure & function
is lost)
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Tissue lined up and scab is formed
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Phase III: Remodeling Phase
Usually begins @ week 3
Purpose is to increase strength of
repaired/replaced tissues
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Take into consideration
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Scab broken down
forces applied
immobilization time frames relative to tissue
healing time
Scars fade & eventually return to near
normal color
Modifying Soft-Tissue Healing
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Varying issues exist for all soft tissues
relative to healing (cartilage, muscle,
nerves)
Blood supply and nutrients is necessary for
all healing
Healing in older athletes or those with poor
diets may take longer
Certain organic disorders (blood conditions)
may slow or inhibit the healing process
Factors That Impede Healing
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Extent of
injury
Edema
Hemorrhage
Poor Vascular
Supply
Muscle Spasm
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Atrophy
Infection
Health, Age,
and Nutrition
Importance of Controlling Swelling
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Initial injury management and
swelling control is critical
Swelling increases pressure to the
injured area  pain and altered
neuromuscular function
Swelling slows healing process
 normal function is not regained
until swelling is eliminated
To limit swelling use the P/RICE
principle
Importance of Controlling Swelling
 Protection
 Protect
the injury from
further damage
 Splint, wrap, immobilize
the injured site
 Lower extremity =
crutches
 Upper extremity = sling
Importance of Controlling Swelling
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Restricted Activity (Rest)
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Healing immediately begins after injury
Without rest, external stresses are still placed on the
injured area, interfering with the healing processprolonging recovery
Controlled mobility is superior to immobilization
24-48 hours of rest should be applied prior to active
rehabilitation – depends on severity
Rest applies to the injured body part
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cardiovascular fitness, strengthening and flexibility should
be maintained
Importance of Controlling Swelling
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Ice (Cryotherapy)
 1. vasoconstriction
 2. reduction of tissue
metabolism
 3. decrease in nerve conduction
velocity  sense less pain
 4. reduced muscle spasm
 5. secondary vasodilatation
Importance of Controlling Swelling
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Compression
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Single most important factor in
swelling control!
↓space available for swelling
accumulation
Using an elastic wrap, firm, evenly
applied pressure can be achieved
Maintained continuously for 72 hours
– depends on severity
With chronic inflammatory conditions
compression should be applied until
the swelling is almost entirely gone
Importance of Controlling Swelling
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Elevation
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Eliminates effects of gravity on blood pooling
Helps lymphatic drainage of blood and other fluids from
the injured area
Occur as often as possible during the first 72 hours of
the acute injury – depends on severity
Elevate injured limb higher than the heart
Types of Tissues and their Healing
Cartilage
 Limited capacity to heal
 Little or no direct blood supply
 Articular cartilage that fails to clot
heals very slowly
Ligaments/ Tendons
 Long full healing process (12 months)
 Decent blood supply
 Requires a lot of collagen being laid down
Skeletal Muscle Healing
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Initial bleeding followed by laying down a ground
substance
Healing could last 6-8 weeks depending on
muscle injured
Grades of Sprains/Strains
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Grade I – some pain, minimal loss of
function, no abnormal function, & mild
point tenderness
Grade II – pain, moderate loss of
function, swelling & instability
Grade III – extremely painful,
inevitable loss of function, swelling
Managing the Healing Process
through Rehabilitation
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Pre-surgical Phase:
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If surgery can be delayed, exercise may
help to improve outcome
Maintaining or improving ROM, strength,
cardiovascular fitness, neuromuscular
control may enhance the athlete’s ability
to perform rehab after surgery
Rehab Phases
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Phase 1 – Acute
Inflammatory Phase
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Phase 2 – Proliferation
Phase
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Phase 3 - Remodeling
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Inflammation
Mobility
Proprioception
Resistance
Endurance
Sport Specific
Managing the Healing Process
through Rehabilitation
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Phase I: Acute Inflammatory Phase
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Initial swelling management & pain control are
crucial
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PRICE
If you are too aggressive in the 1st 48 hours the
inflammatory process may not have time to
accomplish what it needs to
By days 3-4 some mobility exercises should
be performed along with gradual increase
of weight bearing status
Use of NSAIDs
Managing the Healing Process
through Rehabilitation
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Phase II: Fibroblastic Phase:
As inflammatory phase begins to subside &
pain decreases with PROM, add
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Cardiorespiratory fitness
Restore full ROM
Restore or increase strength
Re-establish neuromuscular control
Continued use of modalities for pain control
Managing the Healing Process
through Rehabilitation
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Phase III: Remodeling Phase:
Longest phase with the ultimate goal of
returning to activity
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Regain sports-specific skills
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Continued collagen realignment
Pain continues to decrease
Dynamic functional activities
Sports-directed strengthening activities
Plyometric strengthening
Functional testing
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Determine specific skill weakness
Pain Management
Reduce pain!
 Control acute pain!
 Protect the patient from further injury
while encouraging progressive exercise
 Minimize further tissue damage
 Encourage psychological interaction
(positive thinking, etc.)
 Medications
 Communication with athlete
 Use of modalities to reduce pain
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