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2
Concepts
of Healing
Healing
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Bridge of cells binds ends of wound
together
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Separation is large-2nd ° Sprains
Tissue must fill space-starting at bottom
and sides of wound
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Tissue Healing Phases
Inflammation Phase
Necessary phase
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Complex cellular and chemical
interactions take place
Neutrophils/PMN’s abound
Macrohages replace PMNs in
24-48 h to debride area
Signs of Inflammation
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Temperature increase
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Pain
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Causes of Inflammation
The signs of inflammation occur because
of the increased metabolic activity and
fluid in the region and the tissue damage
that has occurred. Loss of function is
produced by the primary signs of
inflammation.
Immediate Injury Response
Proliferation Phase
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Angiogenesis and granulation tissue
formation
Increased fibroblasts by day 3-5
following injury; reduced PMNs
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Signs of Proliferation
Redness
Swelling
Pain
Local temperature
Remodeling Phase
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Myofibroblasts cause wound
contraction to minimize scar
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Tensile strength increases
Signs of Remodeling
Reduced redness
Reduced edema
Reduced pain
No local temperature
Growth Factors
Proteins
Specific growth factors impact
specific cells
Named for target cells, source,
behavior
Perform important roles in healing
process
Roles of Growth Factors
in Healing - p. 42-43
Control migration and proliferation
of cells
Affect fibrin-plug formation
Control phagocytization
Assist capillary endothelial
production
Stimulate type III collagen removal,
type I formation
Ligament Healing
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Monocytes and macrophages
infiltrate.
Fibroblasts appear, increase, produce
extracellular matrix.
Cellular and matrix structures replace
the blood clot.
Macrophages, fibroblasts diminish;
type I collagen replaces type III.
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Tendon Healing
Wound gap filled by phagocytes
Collagen synthesis
Revascularization; synovial sheath
rebuilt
Fibroblasts revert to tenocytes; type
III collagen replaced with type I
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Tensile strength
-maximal amount of stress or force
that a structure is able to withstand
before tissue failure occurs—in this
case, the amount of outside force that
can be applied to a muscle, tendon,
ligament, or bone before it tears or
breaks
Muscle Healing
Fragmentation of muscle fibers;
macrophages appear
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Day 7: scar tissue; near-normal
muscle tension can be produced
Day 7-11: near-normal tensile
strength
Regenerating myotubes; crossstriated muscle fibers
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Articular Cartilage Healing
Fibrin clot is formed
Fibroblasts combine with collagen
fibers to replace clot
1 month- fibroblasts separate;
condrocytes appear
2 months—defect resembles
cartilage, but collagen is type I
6 months—type I and II calcified
cartilage with normal appearance
Bone Healing
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Hematoma forms; fractured edges
become necrotic
Osteoclasts/Osteoblast proliferate;
soft turns hard callus develops
External blood supply dominates;
then inner bone circulation
reestablished
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Tensile strength
-maximal amount of stress or force
that a structure is able to withstand
before tissue failure occurs—in this
case, the amount of outside force that
can be applied to a muscle, tendon,
ligament, or bone before it tears or
breaks
Tensile Strength During
Healing Phases
Inflammation
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Proliferation
Increase in tensile strength
Source of tensile strength: collagen,
granulation tissue
(continued)
Tensile Strength During
Healing Phases
Remodeling
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Ligament and tendon near normal in
17-50 weeks
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Healing and Tensile
Strength
For a therapeutic exercise program to be
successful, one must have respect for the
healing process and a knowledge of
tensile strength factors.
Factors That Affect
Healing
Modalities
Medications/Drugs
Other modifying factors (age,
disease, etc.)
Treatment Modalities
Ice
Electrical stimulation
Superficial heat
Deep heat
Influence of Modalities
on Healing
Relieve pain, spasm, edema
Enhance protein synthesis
Retard atrophy, facilitate muscle
activity
Improve circulation
Enhance collagen and neovascular
production
Promote fibroblast production
Factors in Medication
Effectiveness – p.55
half-life: definition and examples
steady state of a drug: definition
and examples
Effects of NSAIDs
on Healing
Inhibit prostaglandin production
Increase blood clotting time
Decrease the effectiveness of other
drugs
Absorption rate decreased when
NSAIDs used with antacids
Drugs That Can Delay
Healing
Antibiotics
Nicotine
Corticosteroids
Other Modifying Factors
That Can Affect Healing
Surgical technique
Age
Disease
Wound size
Infection
Nutrition
Muscle spasm
Edema
Role of Therapeutic
Exercise in Inflammation
Phase
Control edema and pain
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Role of Therapeutic
Exercise in Proliferation
Phase
Tissue is weak but improving in
strength with collagen production.
Patient can start range-of-motion and
limited strengthening activities.
Exception is in tendon repairs.
Role of Therapeutic
Exercise in Remodeling
Phase
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Stress application must coincide with
increase in tensile strength.
Considerations
for Appropriate Course
Usual healing sequence and timing
Individual’s unique response to the
injury and treatment
Signs of an Overly
Aggressive Program
Increased pain, especially
postexercise
Increased edema, especially if lasts
more than 1 day postexercise
Diminished function from the
previous day’s treatment