Tissue Response to Injury

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Tissue Response to Injury
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INJURY PROCESS

• Primary Response tissue destruction directly
  associated with traumatic force cant change
  amount of initial damage
• Secondary Response occurs from cell death caused
  by a blockage of O2 supply can assist to keep
  minimum damage to other tissues
• Injury Response Cycle pain-spasm-pain cycle
• (Chemicals stimulate free n. endings cause pain
  which causes m. spasm triggers bodys
  protective mechanism.)

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Three Phases of Healing

• Phase I Acute Inflammatory Phase
• Phase II Proliferation/Fibroblastic/
  Repair/Regeneration Phase
• Phase III Remodeling/ Maturation Phase

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Cardinal Signs of Inflammation
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Phase I Acute Inflammatory Phase

• Substrate Phase
• Begins almost right away, lasts approx. 2-4 days
• Goal
• Protect,
• Localize,
• Decrease injurious agents,
• Prepare for healing and repair
• Critical to the healing processes - If this phase
  does not accomplish what it is supposed to or if
  it does not subside, normal healing cannot take
  place.
• Lasts until damaged tissue has been removed new
  capillary network has been formed

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Acute Inflammatory Response

• Injury occurs
• Vascular changes
• Vasoconstriction immediately decreased blood
  flow to area (approx. 5-10 mins.) platelet plug
  formed blood coagulation produces local anemia
• Vasodilation increased blood flow increased
  hydrostatic pressure in blood vessels (?
  capillary permeability, plasma proteins leak out
  proteins attract H2O - edema)
• Cellular Changes chemical reactions start
  immediately
• Protein presence - changes osmotic relationship
  between blood adjacent tissues (Plasma protein
  ? while interstitial fluid protein ?. H2O
  follows plasma proteins out of vessel resulting
  in edema!)
• Neutralizes/destroys offending agents, restricts
  tissue damage to the smallest possible tissue
  prepares area for healing

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Phase II Proliferation/Fibroblastic Phase

• Repair/Regeneration or Fibroblastic phase
• Phase will extend from 48 hours to 3-6 weeks
• Phase removes debris temporary repair SCAR
  FORMATION (fibroplasia)
• Adenosine triphosphate (ATP) is a critical factor
  that regulates the rate quality of healing
• - cells primary source of energy
• - provides metabolism needed to restore cells
  membrane properties by moving Na2 K into
  out of cell, to build new proteins synthesize
  proteins

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Proliferation Phase

• 4 processes of soft tissue repair
• - fibroblast formation - tissue remodeling
• - synthesis of collagen - tissue alignment
• Dependent on levels of debris removal,
  endothelial production, production of fibroblasts
• Repaired through 3 phases
• Resolution - dead cells cellular debris are
  removed by phagocytosis (tissue left with
  original structure function in tact)
• Regeneration damaged tissue is replaced by
  cells of the same type (structure retains some or
  all of its original structure function)
• Repair original tissue is replaced with scar
  tissue (original structure function is lost)

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Phase III Remodeling/Regeneration/ Maturation
Phase

• Usually begins _at_ week 3
• Purpose is to increase strength of
  repaired/replaced tissues
• First 3-6 weeks involves laying down of collagen
  and strengthening of fibers
• 3 months to 2 years allowed for enhanced scar
  tissue strength
• Balance must be maintained between synthesis
  lysis
• of fibroblasts, myofibroblasts, macrophages
  reduced to pre-injury state
• of capillaries decrease, H2O content decreases
• Take into consideration forces applied,
  immobilization time frames relative to tissue and
  healing time
• Scars fade eventually return to near normal
  color
• Type I collagen continues to replace Type III
  collagen

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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

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Factors That Impede Healing

• Extent of injury
• Edema
• Hemorrhage
• Poor Vascular Supply
• Separation of Tissue
• Muscle Spasm
• Atrophy

• Corticosteroids
• Keloids and Hypertrophic Scars
• Infection
• Humidity, Climate, Oxygen Tension
• Health, Age, and Nutrition

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Importance of Controlling Swelling

• Initial injury management an swelling control is
  critical
• Swelling can result in increased pressure to the
  injured area, causing pain and altered
  neuromuscular function
• Swelling slows the healing process and normal
  function is not regained until swelling is
  eliminated
• To limit swelling use the RICE principle

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Importance of Controlling Swelling

• Protection Ice
• Protect the injury from further damage
• Splint, wrap, immobilize the injured site
• If the lower extremity is involved, crutches
  should be supplied

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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

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Importance of Controlling Swelling

• Compression
• Single most important factor in swelling control
• Mechanically reduces space available for swelling
  accumulation
• Using an elastic wrap, firm, evenly applied
  pressure can be achieved
• Compression should be maintained continuously for
  72 hours depends on severity
• With chronic inflammatory conditions compression
  should be applied until the swelling is almost
  entirely gone

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Importance of Controlling Swelling

• Elevation
• Used to eliminate the effects of gravity on blood
  pooling
• Assists venous and lymphatic drainage of blood
  and other fluids from the injured area
• Elevation should occur as often as possible
  during the first 72 hours of the acute injury
  depends on severity

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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

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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 athletes ability to perform
  rehab after surgery

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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 1st 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

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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

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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

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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