1. 2 Concepts of Healing

2. Healing ______________________: Separation is large-2 nd ° Sprains Tissue must fill space-starting at bottom and sides of wound ______________________________ ______________________: ___________________________ Bridge of cells binds ends of wound together _________________________

3. Tissue Healing Phases

4. Inflammation Phase Necessary phase ________________________ Complex cellular and chemical interactions take place Neutrophils/PMN’s abound Macrohages replace PMNs in 24-48 h to debride area

5. Signs of Inflammation ______________ Temperature increase _____________ Pain ________________

6. The signs of inflammation occur because of the increased metabolic activity and fluid in the region and the tissue damage that has occurred. Loss of function is produced by the primary signs of inflammation. Causes of Inflammation

7. Immediate Injury Response

8. Proliferation Phase _______________ Angiogenesis and granulation tissue formation Increased fibroblasts by day 3-5 following injury; reduced PMNs _____________________________ ____________________________ ___________________

9. Signs of Proliferation Redness Swelling Pain Local temperature

10. Remodeling Phase ______________ Myofibroblasts cause wound contraction to minimize scar Tensile strength increases _____________________________ ____________________________ _____________________________

11. Signs of Remodeling Reduced redness Reduced edema Reduced pain No local temperature

12. Growth Factors Proteins Perform important roles in healing process Specific growth factors impact specific cells Named for target cells, source, behavior

13. Roles of Growth Factors in Healing - p. 42-43 Control migration and proliferation of cells Affect fibrin-plug formation Stimulate type III collagen removal, type I formation Control phagocytization Assist capillary endothelial production

14. Ligament Healing _______________________________ ___________________ Monocytes and macrophages infiltrate. ____________________________ _________________________ Fibroblasts appear, increase, produce extracellular matrix. Cellular and matrix structures replace the blood clot. Macrophages, fibroblasts diminish; type I collagen replaces type III.

15. Tendon Healing Wound gap filled by phagocytes Fibroblasts revert to tenocytes; type III collagen replaced with type I ____________________________ __________________________ Collagen synthesis Revascularization; synovial sheath rebuilt

16. Tensile strength -maximal amount of stress or force that a structure is able to withstand before tissue failure occurs—in this case, the amount of outside force that can be applied to a muscle, tendon, ligament, or bone before it tears or breaks

17. Muscle Healing Fragmentation of muscle fibers; macrophages appear __________________________ _______________________________ _____________________________ Day 7: scar tissue; near-normal muscle tension can be produced Day 7-11: near-normal tensile strength Regenerating myotubes; cross- striated muscle fibers

18. Articular Cartilage Healing Fibrin clot is formed Fibroblasts combine with collagen fibers to replace clot 1 month- fibroblasts separate; condrocytes appear 6 months—type I and II calcified cartilage with normal appearance 2 months—defect resembles cartilage, but collagen is type I

19. Bone Healing ___________________________ _____________________ ____________________________ ____________________________ _______________________ Hematoma forms; fractured edges become necrotic Osteoclasts/Osteoblast proliferate; soft turns hard callus develops External blood supply dominates; then inner bone circulation reestablished

20. Tensile strength -maximal amount of stress or force that a structure is able to withstand before tissue failure occurs—in this case, the amount of outside force that can be applied to a muscle, tendon, ligament, or bone before it tears or breaks

21. Tensile Strength During Healing Phases Inflammation ___________________________ _______________________________ Source of tensile strength: collagen, granulation tissue Proliferation Increase in tensile strength (continued)

22. Tensile Strength During Healing Phases Remodeling ____________________________ Ligament and tendon near normal in 17-50 weeks ____________________________

23. For a therapeutic exercise program to be successful, one must have respect for the healing process and a knowledge of tensile strength factors. Healing and Tensile Strength

24. Factors That Affect Healing Modalities Medications/Drugs Other modifying factors (age, disease, etc.)

25. Treatment Modalities Ice Electrical stimulation Deep heat Superficial heat

26. Influence of Modalities on Healing Relieve pain, spasm, edema Enhance protein synthesis Promote fibroblast production Retard atrophy, facilitate muscle activity Improve circulation Enhance collagen and neovascular production

27. half-life : definition and examples Factors in Medication Effectiveness – p.55 steady state of a drug : definition and examples

28. Effects of NSAIDs on Healing Inhibit prostaglandin production Increase blood clotting time Absorption rate decreased when NSAIDs used with antacids Decrease the effectiveness of other drugs

29. Drugs That Can Delay Healing Antibiotics Nicotine Corticosteroids

30. Other Modifying Factors That Can Affect Healing Surgical technique Age Edema Disease Muscle spasm Wound size Infection Nutrition

31. Role of Therapeutic Exercise in Inflammation Phase Control edema and pain ______________________________ ______________________________

32. Role of Therapeutic Exercise in Proliferation Phase Tissue is weak but improving in strength with collagen production. Patient can start range-of-motion and limited strengthening activities. Exception is in tendon repairs.

33. Role of Therapeutic Exercise in Remodeling Phase _____________________________ _____________________________ _________________________ Stress application must coincide with increase in tensile strength.

34. Considerations for Appropriate Course Usual healing sequence and timing Individual’s unique response to the injury and treatment

35. Signs of an Overly Aggressive Program Increased pain, especially postexercise Increased edema, especially if lasts more than 1 day postexercise Diminished function from the previous day’s treatment