1. Understanding and Managing the Healing Process

2. Primary and Secondary Healing  Primary – direct ( acute)  Secondary – inflammatory (chronic)  When an injury occurs the healing process that follows depends on the extent of the injury, the approximation of the wound site  Small separation – a bridge will bind the ends together – this is called primary intention  More severe wound when there is not close tissue approximation – the space is filled from the bottom and sides of the wound – secondary intention  This take longer and more of a scar is formed

3. Healing Process PHASES OF HEALING:  Inflammatory Phase  2-4 days  Fibroblastic-Repair Phase ( proliferation)  First few hours post-injury to 4-6 weeks  Maturation-Remodeling  3 weeks to several years  Must be understood that the healing process is a continuum, phase may and do over lap and have no definite beginnings or end

4. Inflammatory response  Injury occurs body recognizes the problem and begins a series of defensive maneuvers to stabilize the wound site and protect it  Extremely complex process 2-3 days up to a week or more to complete  Inflammation often considered negative but it is an important and necessary step  With out inflammation body would not be able to complete the healing process  However inflammation becomes detrimental when prolonged  Goal is to allow inflammation to happen but to minimize it and encourage healing to continue along its normal path

5. Inflammatory response  Signs of inflammation  Response is characterized by redness, swelling, pain tenderness, loss of normal function and increased temperature  The initial inflammatory response is critical to the entire healing process, if it does not occur normal healing will not occur

6. Vascular Reaction  Vascular spasm  Formation of a platelet plug  Blood coagulation  Growth of fibrous tissue  Immediate response is vasoconstriction of vascular walls form seconds to minutes  Then an increase in blood flow which is transitory and gives way to a slowing of the flow in dilated vessels  This initial effusion of blood and plasma may last for 24 to 36 hours

7. Chemical Mediators  Chemical mediators are important in limiting the amount of exudate and thus swelling after an injury  Complex chemical reaction

8. Fibroblastic Repair Phase  During this phase activity leads to scar formation and repair of injured tissue  At this time s/s associated with the inflammatory response subside.  Tenderness and pain with some certain movements may still occur but should decrease as the scar formation progresses  As we progress to repair the tensile strength increases and there is minimal scar tissue.

9. Maturation -Remodeling Phase  This phase is a long term process  Features realignment or remodeling of the collagen fibers that make the scar tissue, according to the tensile forces to which they are subjected.  Tissue gradually assumes normal appearance and function, although a scar is rarely as strong as the normal tissue

10. Factors that Impede Healing  Extent of injury  Edema / swelling  Hemorrhage  Poor vascular supply  Separation of tissue  Muscle spasm  Corticosteriods  Infection  Health – disease  age  Nutrition  Surgical repairs

11. Drugs  Therapist should have a basic understanding of drugs  Not going to know them all or different names  Always remember drugs should be taken by individual as prescribed by physician and if undesirable effect should occur they should contact physician immediately

12. Drugs  Duration of action – length o f time the drug is in the blood above the level needed for action  Half life – the amount of time it takes for level of drug in blood stream to be diminished by half  The frequency of the drug is administered based on the drugs half life. Shorter half life the more frequent the drug is administered  Thus goal is a steady state – 4- 5 half lives of the drug  Eg -Naproxen – half life 14 hours – dosage 2twice a day – ibuprofen half life, administered 2 hours – 3 – 4 times a day  More is not better – higher concentrations may have a toxic effect

13. Drugs  Taking medication  Orally – absorbed in small intestine – should be taken with a glass of water – not just a swallow – liquid helps dissolve the medication thus increasing the speed which the drug moves from stomach to small intestine  If taken with food it is absorbed at a slower rate – however that is required of some medications  Medication will not be absorbed as quickly if taken prior to exercise as blood is taken from small intestine to working muscles, so not a good idea to take anti- inflammatories just before exercise

14. NSAIDs  NSAIDs and athletic injuries, research supports use in early days but no significant data to support long term use  Used to decrease pain and inflammation, hopefully by doing this the therapist can work ROM and other therapeutic exercises and promote healing  Important to remember lots of choices and some may find one works better than the other – work with physician if patient having difficulty – most commonly stomach upset - Naproxen

15. Swelling  The one common problem to almost all injuries is swelling  Swelling can be caused by a number of factors, bleeding, production of synovial fluid, accumulation of inflammatory by products, edema or a combination of factors.  No matter the process, swelling produces increased pressure, and thus increased pain, as well can cause neuromuscular inhibition, which results in weakness of the muscle  Once swelling has occurred the healing process significantly slowed

16. Swelling  The injured area cannot return to normal until the swelling is all gone.  “therefore everything that is done in first aid management should be directed toward controlling the swelling”  How do we do this?????

17. PIER & METH  P- Pressure  I- Ice  E-Elevation  R- Rest  M- Movement  E-Elevation  T – Traction  H- Heat

18. METH  Traction – realignment  Heat- blood flow – healing – nutrients  http://theelitetrainer.com/wp/the-new-injury- rehabilitation-paradigm-rice-is-not-nice-do-meth- instead/  Movement “Garbage in Garbage out”  Muscle contraction to move lymph  Elevation - drainage

19. Chronic Inflammation  Occurs when the acute inflammatory response does not eliminate the injuring agent and restore tissue to its normal physiological state.  Chronic inflammation does appear to be resistant to both physical and pharmacological treatments.