understanding and managing healing process through rehabilitation

Understanding and Managing Understanding and Managing Healing Process through Healing Process through

RehabilitationRehabilitation

Rehabilitation Techniques for Sports Medicine and Athletic Training

William E. Prentice

IntroductionIntroduction

Rehabilitation requires sound knowledge and understanding of tissue healing process

Athletic Trainer designs, implements and supervises rehab programs

Rehab protocols and progressions must be based on physiologic responses of tissues to injury and understanding of how various tissues heal

IntroductionIntroduction

Primary Injury– Injury from acute or chronic trauma

Secondary Injury– Inflammatory response to primary injury

3 Phases of Tissue Healing3 Phases of Tissue Healing

Inflammatory –response phase

Fibroblastic-repair phase

Maturation-remodeling phase

– Healing process is a continuum and phases overlap one another with no definitive beginning or end points

Inflammatory-Response Inflammatory-Response PhasePhase

After injury, healing process begins immediately– Destruction of tissue produces direct injury to

cells of various soft tissue– Characterized by redness, swelling, tenderness

and increased temperature– Critical to entire healing process


Leukocytes and other phagocytic cells delivered to injured tissue– Dispose of injury by-products through

phagocytosis


Vascular reaction– Blood coagulation and

growth of fibrous tissue occurs

– First 5-10 minutes vasoconstriction occurs

Best time to evaluate

Followed by vasodilation

Effusion of blood and plasma last 24 to 36 hours

Chemical mediators– Released from damaged

tissue, white blood cells and plasma

– Histamine, leukotrienes and cytokines assist in limiting exudate/swelling

– Amt of swelling directly related to extent of vessel damage

Inflammatory Response Con’tInflammatory Response Con’t

Formation of Clot– Platelets adhere to

collagen fibers and create sticky matrix

Platelets and leukocytes adhere to matrix to form plug

Clot formation occurs 12 hours after injury and is complete w/in 48 hrs

Set stage for fibroblastic phase

Chronic inflammation– Acute phase does not

respond sufficiently to eliminate injury agent and restore tissue to normal physiologic state

– Damage occurs to connective tissue and prolongs healing and repair process

– Response to overuse and overload

Inflammatory Response Con’tInflammatory Response Con’t

Entire phase last 2-4 days– Greater tissue damage longer inflammatory phase

– NSAIDS may inhibit inflammatory response thus delaying healing process

Will assist with pain and swelling

Fibroblastic-Repair PhaseFibroblastic-Repair Phase

Proliferative and regenerative activity leads to scar formation– Begins w/in 1st few hours after injury and can

last as long as 4-6 weeks– Signs and Symptoms of inflammatory phase

subside– Increased O2 and blood flow deliver nutrients

essential for tissue regeneration


Break down of fibrin clot forms connective tissue called granulation tissue– Consist of fibroblast, collagen and capillaries

Fills gap during healing process– Unorganized tissue/fibers form scar

Fibroblast synthesize extracellular matrix consisting of protein fibers (Collagen and Elastin)

– Day 6 –7 collagen fibers are formed throughout scar– Increase in tensile strength increases with rate of collagen

synthesis


Importance of Collagen– Major structural protein that forms strong,

flexible inelastic structure– Type I, II & III

Type I found more in fibroblastic repair phase Holds connective tissue together and enables tissue

to resist mechanical forces and deformation– Direction of orientation of collagen fibers is along lines of

tensile strength

Fibroblastic-Repair PhaseFibroblastic-Repair PhaseImportance of Collagen

– Mechanical properties Elasticity

– Capability to recover normal length after elongation

Viscoelasticity– Allows slow return to normal length and shape after

deformation

Plasticity– Allows permanent change and deformation

Maturation-Remodeling PhaseMaturation-Remodeling Phase

Long term process that involves realignment of collagen fibers that make up scar– Increased stress and strain causes collagen fibers to

realign to position of maximum efficiency Parallel to lines of tension Gradually assumes normal appearance and function Usually after 3 weeks a firm, contracted,

nonvascular scar exist– Total maturation phase may take years to be

totally complete


Wolf’s law/Davies Law– Bone and soft tissue will respond to physical

demands placed on them Remodel or realign along lines of tensile force Critical that injured structures are exposed to

progressively increasing loads throughout rehab process

– As remodeling phase begins aggressive active range of motion and strengthening

– Use pain and tissue response as a guide to progression


Controlled mobilization vs. immobilization– Animal studies show Controlled mob. Superior

to Immobilization for scar formation However, some injuries may require brief period of

immob. During inflammatory phase to facilitate healing process

Factors that impede healing Factors that impede healing

Extent of injury– Microtears vs.

macrotears

Edema– Increased pressure

causes separation of tissue, inhibits neuro-muscular control, impedes nutrition, neurological changes

Hemorrhage– Bleeding causes same neg.

effect as edema

Poor vascular supply– Tissues with poor vascular

supply heal at a slower rate– Failure to deliver

phagocytic cells and fibroblasts for scar formation

Factors that impede healingFactors that impede healing

Separation of tissue– How tissue is torn will

effect healing Smooth vs. jagged

Traction on torn tissue, separating 2 ends– Ischemia from spasm

spasm Atrophy

Corticosteroids– In early stages shown

to inhibit healing

Keloids or hypertrophic scars

Infection Health, Age and

nutrition

Healing Process-Ligament Healing Process-Ligament SprainsSprains

Tough, relatively inelastic band of tissue that connects bone to bone– Stability to joint– Provide control of one articulating bone to

another during movement– Provide proprioceptive input or sense of joint

position through mechanoreceptors 3 Grades of lig. tears


Physiology– Inflammatory phase-loss of blood from

damaged vessels and attraction of inflammatory cells

– During next 6 weeks-vascular proliferation with new capillary growth and fibroblastic activity

Immediately to 72 hours– If extraarticular bleeding in subcutaneous space

– If intraarticular bleeding occurs in inside joint capsule


Essential that 2 ends of ligament be reconnected by bridging of clot– Collagen fibers initially random woven pattern with

little organization– Failure to produce enough scar and of ligament to

reconnect 2 reasons ligaments fail Maturation

– May take 12 months to complete– Realignment/remodeling in response to stress and

strains placed on it

Healing Process-Ligament SprainsHealing Process-Ligament Sprains Factors that effect healing

– Surgery or non surgical approach Surgery of extraarticular ligaments stronger at first

but may not last over time Non surgical will heal through fibrous scarring , but

may also have some instability– Immobilization

Long periods of immobilization may decrease tensile strength weakening of insertion at bone

Minimize immobilization time Surrounding muscle and tendon will provide

stability through strengthening and increased muscle tension

Healing Process-CartilageHealing Process-Cartilage

Cartilage– Rigid connective tissue that provides support

Hyaline cartilage: articulating surface of bone Fibro cartilage: interverterbral disk and menisci.

Withstands a great deal of pressure Elastic cartilage: more flexible than other types-

auricle of ear and larynx


Physiology of healing– Relatively limited healing capacity

Dependant on damage to cartilage alone or subchondral bone.

Articular cartilage fails to elicit clot formation or cellular response

Subchondral bone can formulate granulation tissue and normal collagen can form


Articular cartilage repair– Patients own cartilage can be harvested and implanted

into damages tissue to help form new cartilage– Promise for long term results

Fibrocartilage/Menisci– Depends on where damage occurs– 3 zones of various vascularity

Greater that blood supply better chance of healing on own

Healing Process-BoneHealing Process-Bone Similar to soft tissue healing, however

regeneration capabilities somewhat limited– Bone has additional forces such as torsion, bending and

compression not just tensile force– After 1 week fibroblast lay down fibrous collagen– Chondroblast cells lay down fibrocartilage creating

callus– At first soft and firm, but becomes more firm and

rubbery– Osteoblast proliferate and enter the callus

Form cancellous bone and callus crystallizes into bone

Healing Process-BoneHealing Process-Bone

Osteoclasts reabsorb bone fragments and clean up debris– Process continues as osteoblast lay down new

bone and osteoclasts remove and break down new bone

Follow Wolfs law-forces placed on callus-changes size, shape and structure

Immobilization longer 3 to 8 weeks depending on the bone

Healing Process-MuscleHealing Process-Muscle

Similar to other soft tissue discussed– Hemorrhage and edema followed by phagocytosis to

clean up debris– Myoblastic cells from in the area and regenerate new

myofibrils– Active contraction critical to regaining normal tensile

strength according to Wolff's Law– Healing time lengthy-Longer than ligament healing

Return to soon will lead to re-injury and become very problematic

6-8 weeks?

Healing Process-TendonHealing Process-TendonNot as vascular as muscle

– Can cause problems in healing– Fibrous union required to provide extensibility

and flexibility Abundance of collagen needed to achieve good

tensile strength Collagen synthesis can become excessive can result

in fibrosis: adhesions from in surrounding structures– Interfere with gliding and smooth movement– Tensile strength not sufficient to permit strong pull for 4

to 5 weeks• At risk of strong contraction pulling tendons ends

apart

Healing Process-NerveHealing Process-NerveNerve cell is specialized and cannot

regenerate once nerve cell dies– Injured peripheral nervenerve fiber can

regenerate if injury does not affect cell body– Regeneration is very slow 3-4 mm /day

Axon regeneration obstructed by scar formation Damaged nerve within CNS regenerate poorly

compared to peripheral nervous system– Lack connective tissue sheath and nerve cells fail to

proliferate

Rehabilitation philosophyRehabilitation philosophy Choose therapeutic exercises/modalities that

facilitate healing process at specific phases– Stimulate structural function and integrity of injured

part– Positive influence on the inflammation and repair

process to expedite recovery of function– Minimize early effects of inflammatory process

including pain, edema control, and reduction of muscle spasm.

Produce loss of joint motion and contracture

– Finally concentrate on preventing reoccurrence of injury by assuring structural stability of injured tissue

Appropriate return to play guidelines

understanding and managing healing process through rehabilitation

Documents

damaged tissue

daysgreater tissue damage

collagen fibers

healing processwill

fibroblastic repair

direct injury

injury agent

repair processresponse