Diploma of Remedial Massage Case studies Introduction to Aetiology

1. Diploma of Remedial Massage Case studiesIntroduction to Aetiology

2. Aetiology What does Aetiology actually mean? • The study of the causes, e.g., of a disorder. • It is the science that deals with the causes or origin of disease, the factors which produce or predispose toward a certain disease or disorder. .."the aetiology is unknown." Translation -we don't know the cause.

3. Aetiology What is an injury? • An injury may be defined as an interruption in the continuity of a tissue. • Tissue: • Bone • Ligament • Tendon • Muscle • Cartilage • Skin • Others?

4. Aetiology How do injuries occur? • When stress or strain is placed on tissue • STRESS = is the amount of load or tension per unit cross-sectional area placed on the specimen • STRAIN = the temporary elongation that occurs when stress is applied within physiologic limits.

5. Aetiology Injury: • When stress is applied to tissue in a sustained fashion and recovery is allowed to occur, a constant load produces strain. • This additional and gradual lengthening of a tendon and is termed creep.

6. Aetiology Creep: Creep in tendons occurs at 2 levels: • Temporary elongation that shows recovery when stretched within physiological limits • Permanent elongations that progresses to irreversible damage and rupture.

7. Aetiology Injury: • When a stress or force is placed on an area of the body that is beyond physiological limits: • Path of least resistance • i.e. The weakest section will be damaged • Could be bone, muscle, tendon, ligament

8. Aetiology Collagen: • Collagen is the most common protein in the animal world • Provides extracellular framework • Without collagen a human being would reduced to a clump of cells interconnected by a few neurons

9. Aetiology Collagen cont... • Types: • Cross-linking is a major contributor to the tensile strength of collagen

10. Aetiology Repair/Healing: • The repair process begins straight away • With the exceptions of teeth, all tissue within the body are capable of repairing injuries • Generally speaking, mammals do not regenerate tissue, they repair it with Deep Connective Tissue (DCT) scarring.

11. Aetiology Phases of Healing: • Inflammatory Phase • Fibroplastic Phase • Remodelling Phase We have several treatment decisions to make with every client. Sports injuries may be at varying stages of healing, we need to understand each phase to enable us to enhance healing and promote function.

12. Aetiology Phases of wound healing:

13. Aetiology Inflammation: • Closely intertwined with the process of repair • A protective response • Without inflammation: • Wounds would never heal • Infections would go unchecked • Injured organs would potentially remain festering sores

14. Aetiology Acute Inflammation: 􀂀 • Relatively short duration • Up to 3 days • Main characteristics: • Oedema (exudation of fluid and plasma proteins • Migration of leucocytes (white blood cells) (predominately neutrophils)

15. Aetiology Acute Inflammation: • Immediate and early response to an injurious agent • Three major components • Increase in blood flow • Structural changes in the capillaries allow plasma proteins and leukocytes to leave the circulation • Accumulation of leukocytes in the focus of the injury

16. Aetiology Clinical signs of acute inflammation: • Pain • Heat • Redness • Swelling • Loss of Function

17. Aetiology Chronic Inflammation: • Longer duration • Associated with lymphocytes and macrophages (immune responses) • Associated with the proliferation of • Blood vessels • Fibrosis • Tissue necrosis • Leads to nasties: RA, atherosclerosis, lung fibrosis, “...itis”

18. Aetiology Pain due to acute inflammation: • During acute inflammation the vascular response almost always involves pain • Engorgement of tissues/pressure • Chemical irritation of the free nerve endings

19. Aetiology Fibroplastic Phase: • Known also as Granulation or Proliferative Phase • Lasts 3 weeks • Responsible for scar formation by synthesising new collagen (Type III) and ground substance

20. Aetiology Wound Contraction: • Contraction commences approximately a week after wounding, and peaks at 5 to 15 days post wounding • Contraction can last for several weeks and continues even after the wound is completely healed. • Wounds can contract at a speed of up to 0.75 mm per day, depending on how loose the tissue in the wounded area is. • Actininmyofibroblasts contracts and the wound edges are pulled together. • Fibroblasts lay down collagen to reinforce the wound as myofibroblasts contract

21. Aetiology Remodelling Phase: • New scar tissue will undergo remodelling in an effort to strengthen the wound along appropriate lines of stress • By increasing the tensile strength of the scar –the ultimate goal of this function is to restore function • Two components: • Consolidation • Maturation

22. Aetiology Maturation: • Occurs when the levels of collagen production and degradation equalise • Can last for a year or longer, depending on the size of the wound and whether it was initially closed or left open • Type III collagen is degraded and replaced with stronger Type I • .

23. Aetiology Maturation cont.: • Originally disorganised collagen fibres are rearranged, cross-linked, and aligned along tension lines. • Tensile strength of the wound increases, with the strength approaching 50% (of normal tissue) by three months • Can get to 80% as strong as normal tissue

24. Aetiology Sum Up: • The initial response to injury is bleeding and the formation of a blood clot. • If exposed to air, the upper portion of the clot dries out to form the scab while the lower part is the setting for many of the key processes of wound healing. • Fibroblasts move into the blood clot from surrounding tissue, break it down and replace it with scar tissue.

25. Aetiology Scar Tissue: • Scar tissue is composed of the same main protein (collagen) as normal tissue, but with differences in details of composition • The protein fibres in normal tissue have a random (basket weave) appearance • Those in scar tissue have pronounced alignment in a single direction.

26. Aetiology Scar Tissue cont.: • Has less innervations than normal tissue • Decreased protective sensations • Decreased sensitivity to cold • Can itch during healing due to release of histamines and oils • Massage can loosen adhesions formed between scar and surrounding soft tissues • Slow sustained elongation of the scar will promote function

27. Aetiology Grades of Injury: • MUSCLES/LIGAMENTS/TENDONS • Grade 1 • 0-25% • Grade 2 • 25-75% • Grade 3 • >75%-rupture

28. Aetiology Bone: • Fracture vs. Break??? • Open vs. Closed • Comminuted (broken in several places) • Stable vs. Unstable • Intra-articular (into the surface of a joint) • In children • Salter-Harris Grades (fracture classification)

29. Aetiology Tendinopathy: • Refers to a disease of a tendon • Tendin“itis” • Tendin“osis” • Tenosynovitis • Ensethopathy (site of attachment to bone)

30. Aetiology Delayed Onset Muscle Soreness: • No-one really knows! • Originally thought to be due to lactic acid accumulation • A recently developed theory states DOMS is caused by the breakdown of muscular fibres due to stress allowing the muscles to hypertrophy

31. Aetiology Delayed Onset Muscle Soreness cont.: • DOMS is not caused by the pain from damaged muscle cells, but from the reinforcement process. • The muscle responds to training by reinforcing itself up to and above its previous strength by increasing the size of muscle fibres. This causes cells to swell in their compartment and put pressure on nerves and arteries, producing pain.

32. Aetiology DOMS cont.: • The type of muscle contraction seems to be a key factor in the development of DOMS. • Exercises that involve many eccentric contractions, such as downhill running or slow “negatives” in weight training will result in the most severe DOMS. • More muscle cell damage occurs in eccentric vs concentric contractions