06-02: Tissue Repair Flashcards
Acute vs. Chronic
- All injuries have beginning point (Acute)
- Trauma = Acute
- Overuse, repetitive = chronic
Macrotears
- Greater soft tissue damage
- Results in clinical Sx and functional loss
- Associated with acute trauma
- Includes Fx, dislocations, subluxations, sprains, strains, contusions
Microtears
- Minor damage
- May not see clinical signs/symptoms in early stages
- Associated with overuse
- Includes repetitive motion injuries
Primary injuries
Microtears and Macrotears
Secondary injuries
Inflammatory or hypoxia responses that occur with macrotears and microtears
3 phases of healing
- Inflammatory response phase
- Proliferative phase (Fibroblastic-repair)
- Maturation-remodeling phase
- Phases overlap and have no definite beginning and ending - although there are ranges
Inflammatory-Response Phase
- Lasts 0-4 days
- Occurs secondary to trauma or disease
- Presents with calor (heat), rubor (redness), tumor (neoplasm; solid lesion), dolor (pain)
- Phagocytic cells (leukocytes) enter injured area to begin cleaning up injury by-products (blood, damaged cells)
- Prepares for repair
Inflammatory Phase of Healing (Thromboplastin –> Fibrin Clot)
- Takes blood 11-16 secs to clot
- Thromboplastin –> Prothrombin –> Thrombin –> Fibrinogen –> Fibrin Clot
Inflammatory Phase of Healing (Injury –> Clot)
Injury to cell –> Chemical mediators liberated –> Vascular reaction –> Platelets, leukocytes adhere to vascular wall –> Phagocytosis –> Clot formation
Chronic inflammation
- Results when acute inflammatory response does not respond sufficiently to eliminate the injuring agent and does not restore tissue to its normal physiological state
- Involves macrophages, lymphocytes, plasma cells
- Causes tissue necrosis and fibrosis
- Can occur with overuse injury
Fibroblastic-Repair Phase
- Begins within few hours through 4-6 weeks
- Inflammatory S/S diminish, scar formation increases, tenderness decreases
- Granulation tissue increases, growth of endothelial capillary buds (restore blood supply)
- Increased blood = nutrients for tissue regeneration
Fibroblastic-Repair (Granulation)
- Delicate reddish granular, connective tissue that fill in gaps during healing
- Breakdown of fibrin clot
- Consists of fibroblasts, collagen, capillaries
Fibroblastic-Repair (Ground Substance)
- Fibroblasts parallel to capillaries
- Collagen random pattern –> forms a scar
- Non-elastic tissue
- Increased collagen = increased tensile strength
- Fibroblasts decrease, begins maturation phase
Maturation-Remodeling Phase
- Day 9 and ongoing
- Long term; scar forms after 3 weeks, but can take up to years to fully mature
- Collagen Re-orientation
Collagen re-orientation
- Tensile forces cause collage to reorganize; increases tensile strength of scar
- Collagen realigns parallel to lines of tension
- Scar rarely as strong as original tissue
- Scar is non-vascular
Scarring
Forms when collagen production > lysis
Keloid Scar
- Extends beyond boundaries of the original wound and damages healthy tissue
- Treat with compression, steroid injections, cryotherapy, surgery
Hypertrophic Scar
- Remains within boundaries of original wound; increase in collagen production
- Resolves over time
- Treat with steroids, compression
Factors that impede healing
- Extent of injury (microtears, macrotears)
- Edema
- Hemorrhage
- Poor vascular supply (lead to avascular necrosis)
- Separation of tissue
- Muscle spasm
- Atrophy
- Corticosteroids (Long-term)
- Keloids and hypertrophic scars
- Infection
- Humidity, climate, oxygen tension
- Health, age, nutrition
Modalities - Promote Healing
- Begin on Day 1 following injury
- Modalities are adjiunct to PT interventions, not treatment in and of themselves
- Modalities facilitate pt’s ability to participate in exercise and functional activities
Indications for modalities
- Inflammation and repair
- Pain
- ROM Restriction
- Abnormal tone
Modalities - Initial Acute Injury Phase
- Rest for 48-72 hours
- Goals: Reduce edema, reduce pain
- Modalities: Cryotherapy, Compression (Ace Wrap), Electrical stimulation. Ultrasound (nonthermal parameters), Low-power laser
Modalities - Inflammatory Response Phase
- Goals: Reduce pain, reduce edema, increase ROM at end of initial stage
- Modalities: Cryotherapy, Intermittent compression, E-stim, Low-power laser, Exercise
Modalities - Fibroblastic Repair Phase
- Goals: Promote healing, promote scar formation, increase circulation
- Modalities: Thermotherapy, Intermittent compression, E-stim, Low-power laser, Exercise
- Precaution: Don’t use modalities that increase edema
Modalities - Maturation Remodeling Phase
- Goals: Return to activity, very little to no pain
- Modalities: Any modality can be used, deep heating modalities (ultrasound, diathermy), E-stim, Low-power laser
Progressive mobility
- Wolff’s Law: Bone and soft tissue respond to physical demands placed on them, causing remodeling or realignment along tensile force
- Immobilization: Beneficial during inflammatory phase
- Tissue Repair: Return to normal flexibility and strength
- Remodeling: Aggressive AROM and strengthening exercises
- Pain may guide intensity of exercise
- Exacerbation of pain or edema must be reported to PT
