Download Chapter 10 - PHT 1227 Therapeutic Exercise I

Therapeutic Exercise I
Chapter 10
Soft Tissue Injury, Repair, and
Management
Three Stages of Tissue Recovery
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Acute (Inflammatory reaction) redness, swelling, heat, pain at rest and lost of
motion; muscle guarding is a way to immobilize the area and usually last 4-6 days
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Sub-Acute (Repair and healing) signs of inflammation decreases, pain is felt when stressing
new tissue beyond its tolerance, muscle may test weak and function will be limited; usually
lasts 10-17 days (14-21 days after onset) and may last up to 6 weeks
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Chronic (Maturation and remodeling) no signs of inflammation, may have
contractures/adhesions with limited ROM and weakness, poor endurance and neuromuscular
control limiting function, connective tissue remodel/strengthen during this stage and may last
up to 6 months to 1 year pending the amount of damage
The Physical Therapist will examine, evaluate, and create a program to assess the impairments and
develop functional and obtainable goals for the patient. The programs will be patient specific and
appropriate for the stage of healing
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Examples of Soft Tissue
Lesions-Musculoskeletal
Disorders
Strain
Sprain
Dislocation
Subluxation
Muscle/Tendon rupture or tear
Tendinous lesion/tendinopathy
– Tenosynovitis
– Tenovaginitis
– Tendinosis
Continued: Examples of Soft Tissue
Lesions-Musculoskeletal Disorders
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Synovitis
Hemarthrosis
Ganglion
Bursitis
Contusion
Overuse Syndrome
Clinical Conditions Resulting
from Trauma Pathology
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Dysfunction
Joint dysfunction
Contractures
Adhesions
Reflex muscle guarding
Intrinsic muscle spasm
Muscle weakness
Myofascial compartment syndromes
Severity of Tissue Injury
• Grade 1 (first degree)-Mild pain within the first 24
hours, with mild swelling, local tenderness, and pain
when the tissues are stressed
• Grade 2 (second degree)-Moderate, requires stopping
the activity, stress and palpation to the tissue causing
increase pain, when it is a ligament-some fibers are torn
resulting in increase joint mobility
• Grade 3 (third degree)-Severe, near complete/complete
tear of avulsion of the tissue (tendon/ligament) with
severe pain, stresses to the joint do not involve pain and
palpation may reveal defect, torn ligaments results in
instability of the joint
Irritability of Tissue: Stages of
Inflammation and Repair
Acute Stage
Subacute Stage
Discussed in earlier slide
Chronic Stage
Chronic Inflammation (Overuse syndrome)-increase
complaints of pain, swelling, and muscle guarding lasting
more than several hours after activities, stiffness, loss of
ROM 24 hours after activity
• Chronic Pain Syndrome – persistent pain longer than 6
months-physical, emotional, and psychosocial parameters;
pain inconsistent with source of irritation, inflammation,
functional limitation, disability
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Management GuidelinesProtection Phase
• Control the effects of swelling, facilitate wound
healing and maintain normal joint function
• Patient education (HEP)
• Minimize pain/swelling by 1st 24-48 hours with
rest, cold, compression and elevation
• Prevent adverse reactions from immobilization
• Tissue specific movement to prevent abnormal
adherence
• Gentle intensity to prevent increase pain/swelling
• General movements to uninjured tissue and to aid
in circulation/lymphatic flow
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Specific Interventions And
Dosage For The Protection
Phase
PROM
Low-dosage joint mobilization techniques
Muscle setting
Massage
• Interventions for Associated Areas- ROM, Muscle performance,
functional activities, and circulation
Management GuidelinesControlled Motion Phase
• During the 2nd-4th day after tissue injury, the inflammation
begins to decrease
• Clots start and repair begins
• Last 10-17 days and may last up to 6 weeks
• Noxious stimuli are removed, and capillary beds begin to
grow
• Fibroblastic activity, collagen formation, and granulation
tissue development increases
• Production of new collagen takes place of the formed clot
• Scar linkage caused by myofibroblastic activities occurs at
day 5
• Wound closure in muscles and skin takes 5-8 days
• Wound closure in tendons and ligaments takes 3-6 weeks
Management GuidelinesControlled Motion Phase-Continued
• The key is to initiate and progress
nondestructive exercises/activities
• Patient education (HEP)
• Management of pain and inflammation
prior to initiating active exercise and
stretching….there should be no increase
signs of pain/swelling
• Monitor activities and exercise specifically
new ones and modify as needed
-In The Controlled PhaseInitiation of:
Active Exercises
--Multiangle, submaximal
isometrics
--Active ROM
--Muscular endurance
--Protected weight bearing
activities
Stretching
--Warm the tissues
--Inhibition techniques
--Joint mobilization
--Stretching techniques
--Massage
--Use of new range
--Correction of contributing
factors
Management GuidelinesReturn to Function Phase
• Scar retraction from activity of the myofibrobalsts is usually
complete by the 21st day and it stops increasing in size
• From 21-60 day, there is a predominance of fibroblasts that are
easily remodeled
• Maturation begins late in the sub-acute stage and continues for
several months
• Remodeling time is influenced by factors: how long immobilized,
stress placed on tissue, location of lesion, and vascular supply
• Maturation of tissue is possible up to 10 weeks and at
14 weeks the tissue becomes unresponsive to
remodeling
Management GuidelinesReturn to Function Phase-Continued
• Safe combination of stretches and
strengthening to maturing tissue…this
should be a balanced combo
• Patient education (HEP)
• To avoid pain/soreness, contractures need to
be stretched/mobilized or adhesions broken
up ie: cross friction massage
• Proper performance/guidelines set up
• Consideration of progression of exercises—as
long as no adverse reaction is felt
Tissue Response To
Chronic Inflammation•
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(Prolong/Recurring Pain)
Tissue that is stressed beyond the ability to
repair itself, the inflammation is perpetuated
New immature collagen is produced, which
weakens the effect of tissue
Microfibroblastic activities continues, which
may lead to loss of motion
With efforts to stretch the inflamed tissue, this
may lead to additional irritation and progressive
limitations
Mechanical causes need to be identified
Management of
Chronic Inflammation
• Start treatment as it is an acute condition with the focus
on decreasing the inflammation to avoid continued
tissue breakdown and excessive scar formationavoid cross friction massage
• Once inflammation is down, treat impairments and
functional limitation
• Acute stage with use of modalities and rest and correct
faulty biomechanics
• Educate the patient in repeated trauma and the lack of
healing process
• Allow only non-stressful activities/exercises
Sub-acute and chronic stages of healing
following Chronic Inflammation
• Once decreased, progress exercises slowly to allow
connective tissue to be able to withstand the stresses in
functional activities
• May need to mobilize a scar
• If ROM is lost, too much stretching has been applied
• Remember: Muscle guarding is a protective mechanism
• Identify faulty movements
• Work on muscle endurance to sustain repetitive
activities
• Progress towards function (HEP)
• May use work-conditioning/work-hardening programs
or sports-specific exercises
Break for Lab with Lecture on UE Manual
Resistance Exercises,
Mechanical Resisted Exercises,
Selected Resistance Training Regimens,
Equipment for Resisted Training
Resistance Techniques in Anatomical Planes
of Motion/Diagonals of the UE’s
(If time permits may review LE’s)