Tissue Response to Injury

1. Tissue Response to Injury

2. Cardinal Signs of Inflammation

3. Review - Three Phases of Healing

4. Three Phases of Healing Phase I: Acute Inflammatory Phase Phase II: Proliferation/Fibroblastic/ Repair/Regeneration Phase Phase III: Remodeling/ Maturation Phase

5. Phase I: Acute Inflammatory Phase • Begins almost right away, lasts approx. 2-4 days • Goal • Protect • Localize • Decrease injurious agents • Prepare for healing and repair

6. Acute Inflammatory Response • Vascular changes • Vasoconstriction – immediately; decreased blood flow to area (approx. 5-10 mins.); platelet plug formed; blood coagulation; produces local anemia • Vasodilation – increased blood flow; increased hydrostatic pressure in blood vessels ( capillary permeability, plasma proteins leak out; proteins attract H2O - edema) • Cellular Changes – chemical reactions start immediately • Protein presence – proteins are the building blocks. • Neutralizes/destroys offending agents, restricts tissue damage to the smallest possible tissue & prepares area for healing

7. Phase II: Proliferation Phase • “Repair/Regeneration” • Phase will extend from 48 hours to 3-6 weeks • Phase removes debris & temporary repair – SCAR FORMATION (fibroplasia) Dependent on levels of: debris removal, skin cell production, production of fibroblasts

8. Phase II: Proliferation Phase • Repaired through 3 phases • Resolution – • dead cells & cellular debris are removed (tissue left with original structure & function in tact) • fibroblast (tissue cells) formation • tissue remodeling

9. Phase II: Proliferation Phase • Regeneration – • damaged tissue is replaced by cells of the same type (structure retains some or all of its original structure & function) • synthesis of collagen (fencing) • Repair – • original tissue is replaced with scar tissue (original structure & function is lost) • tissue alignment

10. Phase III: Remodeling Phase • Usually begins @ week 3 • Purpose is to increase strength of repaired/replaced tissues • First 3-6 weeks involves laying down of collagen and strengthening of fibers • 3 months to 2 years allowed for enhanced scar tissue strength • Balance must be maintained between synthesis & lysis • Build up (synthesis) and break down (lysis)

11. Phase III: Remodeling Phase • Take into consideration • forces applied (mechanism of injury) • immobilization time relative to tissue healing time • Scars fade & eventually return to near normal color

12. Soft-Tissue Healing • Varying issues exist for all soft tissues relative to healing (cartilage, ligament, 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

13. Extent of injury Edema Hemorrhage Poor Vascular Supply Muscle Spasm Atrophy Infection Health, Age, and Nutrition Factors That Impede Healing

14. Types of Soft 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 • Long full healing process (12 months) • Decent blood supply • Requires a lot of collagen being laid down

15. Types of Soft Tissues and their Healing Muscle Healing • Initial bleeding followed by laying down a ground substance • Healing could last 6-8 weeks depending on muscle injured

16. Types of Soft Tissues and their Healing Nerve tissue Healing • Nerve tissue, unlike other soft tissue, has the ability to regenerate. • if the damage is not too devastating to the neurons in the injured area for regeneration to occur • Healing = restoration of injured tissue; scar; non- functional • Regeneration = natural replacement of a lost or damaged part or tissue; functional

17. Importance of Controlling Swelling • Initial injury management an swelling control is critical • Swelling can result in increased pressure to the injured area, causing pain and altered neuromuscular function • Swelling slows the healing process and normal function is not regained until swelling is eliminated • To limit swelling use the RICE principle

18. Importance of Controlling Swelling • Protection & Ice • Protect the injury from further damage • Splint, wrap, immobilize the injured site • If the lower extremity is involved, crutches should be supplied

19. Importance of Controlling Swelling • Restricted Activity (Rest) • Healing immediately begins after injury • Without rest, external stresses are still placed on the injured area, interfering with the healing process- prolonging 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 – cardiovascular fitness, strengthening and flexibility should be maintained for rest of body

20. Importance of Controlling Swelling • Compression • Single most important factor in swelling control • Mechanically reduces space available for swelling accumulation • Using an elastic wrap, firm, evenly applied pressure can be achieved (wrap towards heart – not away) • Compression should be maintained continuously for 72 hours – depends on severity • With chronic inflammatory conditions compression should be applied until the swelling is almost entirely gone

21. Importance of Controlling Swelling • Elevation • Used to eliminate the effects of gravity on blood pooling • Assists venous and lymphatic drainage of blood and other fluids from the injured area • Elevation should occur as often as possible during the first 72 hours of the acute injury – depends on severity

22. Grades of Sprains/Strains • 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

23. Managing the Healing Process through Rehabilitation • Pre-surgical Phase: • 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

24. Phase 1 – Acute Inflammatory Phase Phase 2 – Proliferation Phase Phase 3 - Remodeling Inflammation Mobility Proprioception Resistance Endurance Sport Specific Rehab Phases

25. Managing the Healing Process through Rehabilitation • Phase I: Acute Inflammatory Phase • Initial swelling management & pain control are crucial • PRICE (RICE w/ Pain control) • 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 (nosteroidal anti-inflammatory drugs)

26. Managing the Healing Process through Rehabilitation • Phase II: Fibroblastic Phase: • As inflammatory phase begins to subside & pain decreases with PROM, add (to the injured part) • Cardio-respiratory fitness • Restore full ROM • Restore or increase strength • Re-establish neuromuscular control • Continued use of modalities for pain control • Modality = a physical agent used for therapy • i.e.) ultrasound; heating pad; ice massage; whirlpool; etc.

27. Managing the Healing Process through Rehabilitation • Phase III: Remodeling Phase: • Longest phase with the ultimate goal of returning to activity • Continued collagen realignment • Pain continues to decrease • Regain sports-specific skills • Dynamic functional activities • Sports-directed strengthening activities • Plyometric strengthening • Functional testing • Determine specific skill weakness

28. 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