2. Tissue Response to Injury

3. The Healing Process  Essential for ATCs & HCPs to understand the healing process Able to recognize each, sequence & time frame  Certain physiological events must occur during each phase  Needs opportunity to accomplish goals in each phase  Goal of ATC to create optimal healing environment for tissue

4. INTRODUCTION WHEN AN INJURY OCCURS IT MUST GO THROUGH 3 STAGES OF HEALING

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

6. InjuryDay 4Week 6 2-3 years Inflammatory Phase Repair/Regeneration Phase Maturation/Remodeling Phase Often discussed as 3 different phases, but really occurs on a CONTINUUM

7. Phase I: Acute Inflammatory Phase  Begins almost right away  Produces direct injury to cells of soft tissues  altered metabolism  release materials to initiate inflammatory response  Increase blood flow to the area that brings cells and chemicals to begin the healing process.  Phagocytes- Eat up dead cells.  Leukocytes- Infection fighting white blood cells.  Platelets-Carry blood clotting materials.  Neutralizes/destroys offending agents, restricts tissue damage to the smallest possible tissue & prepares area for healing

8. Phase I: Acute Inflammatory Phase  Lasts approx. 2-4 days  Goal Protect Localize Decrease injurious agents Prepare for healing and repair  CRITICAL TO ENTIRE HEALING PROCESS Delays in this response = abnormal healing

9. Cardinal Signs of Inflammation RednessHeatSwellingPainLoss of Function Caused by dilation of arterioles/ increased blood flow Increased chemical activity & increased blood flow to skin surface Caused by accumulation of blood & damaged tissue cells Direct injury of nerve fibers, pressure of hematoma on n. endings Chemical irritants – bradykinin, histamine, prostaglandin Increased pain/ swelling

10. 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

11. Phase II: Proliferation Phase  Repaired through 3 phases: Resolution - dead cells & cellular debris are removed (tissue left with original structure & function in tact) “get rid of debris”  fibroblast (tissue cells) formation  tissue remodeling

12. 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)  “bring in like cells” Repair – original tissue is replaced with scar tissue (original structure & function is lost)  Tissue lined up and scab is formed

13. Phase III: Remodeling Phase  Usually begins @ week 3  Purpose is to increase strength of repaired/replaced tissues Scab broken down  Take into consideration forces applied immobilization time frames relative to tissue healing time  Scars fade & eventually return to near normal color

14. Modifying Soft-Tissue Healing  Varying issues exist for all soft tissues relative to healing (cartilage, 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

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

16. Importance of Controlling Swelling  Initial injury management and swelling control is critical  Swelling increases pressure to the injured area  pain and altered neuromuscular function  Swelling slows healing process normal function is not regained until swelling is eliminated  To limit swelling use the P/RICE principle

17. Importance of Controlling Swelling  Protection Protect the injury from further damage Splint, wrap, immobilize the injured site Lower extremity = crutches Upper extremity = sling

18. 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

19. Importance of Controlling Swelling  Ice (Cryotherapy) 1. vasoconstriction 2. reduction of tissue metabolism 3. decrease in nerve conduction velocity  sense less pain 4. reduced muscle spasm 5. secondary vasodilatation

20. Importance of Controlling Swelling  Compression Single most important factor in swelling control! ↓ space available for swelling accumulation Using an elastic wrap, firm, evenly applied pressure can be achieved 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 Eliminates effects of gravity on blood pooling Helps lymphatic drainage of blood and other fluids from the injured area Occur as often as possible during the first 72 hours of the acute injury – depends on severity Elevate injured limb higher than the heart

22. Types of 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/ Tendons  Long full healing process (12 months)  Decent blood supply  Requires a lot of collagen being laid down

23. Skeletal Muscle Healing  Initial bleeding followed by laying down a ground substance  Healing could last 6-8 weeks depending on muscle injured

24. 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

25. 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

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

27. Managing the Healing Process through Rehabilitation  Phase I: Acute Inflammatory Phase Initial swelling management & pain control are crucial  PRICE  If you are too aggressive in the 1 st 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

28. Managing the Healing Process through Rehabilitation  Phase II: Fibroblastic Phase:  As inflammatory phase begins to subside & pain decreases with PROM, add Cardiorespiratory fitness Restore full ROM Restore or increase strength Re-establish neuromuscular control  Continued use of modalities for pain control

29. 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

30. 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