Transcript The Body*s Response to Injury

The Body’s Response
to
Physiological Injury
The Healing Process of Soft Tissue

3 phases:
Inflammatory Response Phase
 Repair and Regeneration (Subacute) Phase
 Remodeling (Maturation) Phase

M/R
FR
IR
Injury
Day 4
Week 6
2-3 Years
Inflammation
 While
the word usually has
a bad connotation, it
should be noted that:
 It’s
the body’s normal
response to injury
 Necessary for healing to
occur
Inflammation
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Classic Signs of Inflammation include:
Tumor (swelling)
 Calor (heat)
 Functio laesa

(loss of function)
Rubor (redness)
 Dolor (pain)
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Inflammation
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Characterized by (acronym) S.H.A.R.P.
 Swelling
 Heat
 Altered
function
 Redness
 Pain
Inflammatory Response Phase
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Healing begins immediately after an injury
Inflammatory response is critical to the
entire healing process
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It allows normal healing in following stages to
take place
Series of events that attempts to
protect the body
 localize injury agents
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Reaction time: 1-4 days
Inflammatory Response Phase
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What Happens:
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First 10-15 minutes
SHARP
 Vasoconstriction – body attempts to control bleeding
 Blood coagulation
 Chemical release
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Histamines – helps vasoconstrict
Serotonin – helps vasoconstrict
Bradykinin – increases cell permeability, causes pain
MARGINATION = WBC line up along cell walls
Inflammatory Response Phase
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What Happens:
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Post 10-15 minutes
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Vasodilation
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Increase in blood thickness (viscosity)
sticky matrix obstructs fluid drainage
Capillary permeability increases
 Leukocytes (WBC’s) and Erythrocytes (RBC’s) leave
the capillaries into the surrounding tissues
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Phagocytosis begins
Formation of platelet plug
INFLAMMATION SHOULD LAST
NO MORE THAN 4 DAYS!!!
Inflammatory Response Phase
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CHRONIC INFLAMMATION occurs
when the acute inflammatory response does
not eliminate injuring agents and restore
tissue to “normal” physiological state for
repair
Reasons for chronic inflammation are not
clearly understood
 It is resistant to both physical and
pharmacological treatments
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Inflammatory Response Phase
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It’s crucial to begin a rehabilitation program
promptly and correctly
This helps not delay what may already be an
extended period of “out” time.
Inflammatory Phase Treatment
REST
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Stop participation in sport activity
Prevent further injury or increased injury of
the area
ICE
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Apply ice for 20 minutes directly to the skin
Causes vasoconstriction of vessels initially
Is a natural anesthetic after several minutes
of use
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Provides pain relief
COMPRESSION
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Use of an elastic (Ace) wrap will keep
constant pressure on the injured area
Limits swelling
ELEVATION
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Keeping the injured area above the level of
the heart promotes venous return
Repair Phase
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Reaction time: 4 – 21 days
Tissue is still dying
Most inflammatory signs should be nearly gone
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Tenderness & discomfort may still remain with
particular movements
Regeneration leads to repair of tissue following
vascular and drainage phenomenon of
inflammation
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Once blood network is developed
Repair Phase
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What Happens:
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Granulation tissue forms
Delicate new connective tissue
 Scar tissue = collagen
 Process called fibroplasia
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Like bone it too constantly rebuilds and breaks
down
 Laid down in a helix formation (bird’s nest) to
help add strength
 Increased blood flow to area nourishes and
stimulates growth
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Repair Phase
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Chronic inflammation can also cross over
into this stage
Causes an extension of fibroplasia called
fibrosis
Overproduction of tissues leads to an
abundance of scarring
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Causes irreversible damage to the injury site
Tendons, ligaments, bursae, and muscle are the
most vulnerable to this phenomenon
Maturation/Remodeling Phase
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Long term process beginning in late stages of
sub-acute repair phase
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Reaction time: 1 year +
Need a balance between building (synthesis_
& breakdown (lysis) of scar tissue (collagen)
Tissue gradually assumes normal appearance
and function
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Mimics the characteristics of surrounding tissue
Maturation/Remodeling Phase
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Motion will influence the structure as it heals
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Immobilization might completely heal but allows
for poor function
By the end of 3-4 weeks in this phase
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beginnings of a firm, strong, contracted,
nonvascular scar exists
Maturation/Remodeling Phase
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This is the most frustrating stage for athletes
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It is when they likely become noncompliant
Athletes feel and function normally, so they
discontinue rehabilitative maintenance against
medical advice
Just because it feels better doesn’t mean it’s
fully healed!
Incidence of re-injury is high during this time.
Maturation/Remodeling Phase
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Wolff’s Law:
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“bone and soft tissue will respond to the physical
demands placed on them, causing them to
remodel or realign along lines of tensile force.”
Therefore:
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It is critical that injured structures be exposed to
progressively increasing loads throughout the
rehabilitative process.
Maturation/Remodeling Phase
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Controlled mobilization is preferred for
Optimal scar formation
 Revascularization
 Muscle regeneration
 Re-education
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Unless immobilization is needed initially
during inflammation
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Sometimes it is if weight-bearing is not
permissible
Maturation/Remodeling Phase
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Range-of-Motion (ROM) and strengthening
exercises are done in this phase
Pain is the indicator for rate of progression
 Signs and symptoms (S&S) are constantly
monitored and evaluated
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There is a difference between discomfort
and excruciating pain
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Rehab is not painless!
Watch for return of inflammation
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Avoid this so as to not set back recovery time
Different Tissue Responses
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Cartilage
Limited healing capacity due to lack of
vascularization
 Reparability depends on location and extent of
injury (i.e. meniscus)
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Different Tissue Responses
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Ligament
Fairly good blood supply
 Can immobilize for a short time, but must move
as soon as possible to increase elasticity of tissue
 Can take as long as a year to fully scar and heal.
 Weakness may still be present
 Must continue strengthening even after
symptoms have subsided
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Different Tissue Responses
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Muscle
Similar to ligamentous tissue
 Follows Wolff’s Law
 Active contraction of muscle is critical to
regaining normal tensile strength
 Time to rehab is usually longer (up to 6-8 weeks
depending on severity) than ligaments because
muscles are never fully at rest
 Must not return to activity too soon
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Different Tissue Responses
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Tendon
Difficult due to dense fibrous nature of tissue
that must be extensible and flexible
 Fibrosis often occurs because of the amount of
collagen necessary to rebuild tendons
 Time is critical as to not pull tendon ends apart
when they start to heal
 Can cause avulsion fractures too
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Different Tissue Responses
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Nerve
Nerve tissue does not regenerate if the whole
cell is involved
 Peripheral nerves can regenerate if the cell has
not been affected, but it takes a LONG time.
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Different Tissue Responses
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Bone
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Healing process is very different from soft tissue
Average time for bone healing is 6 weeks
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1.
2.
3.
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Depending on site, severity, and type of fracture
Acute bone healing goes through 4 stages:
Hematoma formation (clot)
Cellular proliferation
Callus formation (soft)
Ossification (hardening)
and Remodeling (fill-in & bind)
Management Concepts
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Non-Steroidal Anti-Inflammatory Drugs
NSAIDS
 Do not use too soon!
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Therapeutic modalities
Cold & Heat
 Electric devices (Ultrasound and E-Stim)
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Therapeutic Exercise
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Activities that lead up to pain-free ROM,
strength, and extensibility within 90% of
“normal.”
Factors that Impede Healing
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Extent of injury
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Micro tears vs. Macro tears
Edema = swelling (pitting)
Hemorrhage = internal bleeding
Poor vascular supply = some bones, cartilage
Separation of tissue
Smooth edge vs. not
 Incisions (primary intention) vs. Lacerations
(secondary intention)
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Factors that Impede Healing
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Muscle spasm
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Pain/Spasm/Pain Cycle
Factors that Impede Healing
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Atrophy
Happens immediately
 Strengthening & mobilization need to happen
ASAP
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Corticosteroids
Sometimes used to treat inflammation
 Can deteriorate tissues
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Factors that Impede Healing
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Keloids and Hypertrophic scars
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Excessive collagen production vs. collagen
breakdown during maturation phase
Infections = bacterial delays
Health & Age
Elastic qualities of skin decrease with age
 Degenerative diseases (diabetes) concern
wound healing
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Factors that Impede Healing
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Nutrition
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Vitamin C
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Vitamin K
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immune system
Zinc
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clotting
Vitamin A
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collagen synthesis and immune system
enzyme systems
Amino acids
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protein synthesis
A Few Final Thoughts…
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Athletic trainers MUST recognize the sequence
and time frames of each injury phase
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Not all injuries are reported when they happen!
We cannot speed up the healing process
physiologically
We can create optimal environments to
eliminate the factors that impede healing
Each person is different and should be treated
as such