Interventions Week 4

• Tissue healing includes inflammatory, proliferative, and remodeling phases that overlap
• Healing processes apply to tendons, ligaments, fibrocartilage, articular cartilage, bone, and muscle tissues
• Each tissue type has specific healing characteristics and timelines
• Tendons and ligaments rely on fibroblast activity and collagen alignment for structural integrity
• Ligaments may take up to two years to fully remodel
• Fibrocartilage and articular cartilage healing is reliant on vascular supply
• Avascular areas do not heal effectively
• Bone heals through indirect or direct mechanisms contingent on stabilization and alignment.
• Bone-healing times vary based on size and patient age
• Muscle regeneration involves satellite cell activation with new fiber formation, and is susceptible to scar tissue.
• Understand healing timelines to apply forces to support remodeling and educate patients for recovery through physical therapy interventions

General Healing Phases

• Inflammatory Phase:
  • Macrophages remove damaged tissue
  • Chemical signals start repair
• Proliferative Phase:
  • Fibroblasts deposit collagen and extracellular matrix
  • Alignment happens due to applied forces
• Remodeling Phase:
  • Adapting to functional demands by strengthening and maturing tissue

Tendon Healing

• Function: Transmits force from muscles to bones for movement.
• Phases:
  • Inflammatory (1 week):
  • Getting rid of debris with macrophages
  • Capillaries and fibroblasts proliferate
  • Proliferative (1-5 weeks):
  • Collagen increases, fibroblasts align
  • Remodeling (2-4 months):
  • Align and mature collagen
• Gradual, safe loading ensures proper collagen alignment during therapy

Ligament Healing

• Function: Stabilizes joints by connecting bones and resisting separation forces
• Phases:
  • Inflammatory (5 days):
  • Damaged tissue is removed and fibroblast activity begins
  • Proliferative (5 days-6 weeks):
  • Collagen progressively strengthens from its initially weak state
  • Remodeling (4+ weeks, up to 2 years):
  • Stabilizing joints by aligning collagen with stress vectors
• Protect joints early during therapy since overloading can restart inflammation

Fibrocartilage Healing

• Function: Adds stability to the joint
• Examples: Meniscus (knee), Labrum (hip/shoulder)
• Healing Factors: Vascular zones heal; avascular zones do not.
• Phases:
  • Inflammatory (1 week): Fibrin clot forms
  • Proliferative (1-10 weeks): Scar tissue glues wound edges
  • Remodeling (Months): Tissue regains normal appearance

Articular Cartilage Healing

• Function: Provides a smooth surface for joint articulation.
• Key Differences:
  • Chondral injuries don't heal due to a lack of vascular supply
  • Osteochondral injuries may heal with bone involvement
• Phases:
  • Inflammatory (0-2 weeks): Blood from bone forms a clot
  • Proliferative (2–6 weeks): Collagen and proteoglycan matrix forms
  • Remodeling (6+ weeks): Scar tissue forms and healing is limited
• Protect cartilage to avoid damage and preserve joint health during therapy considerations

Bone Healing

• Types:
  • Indirect (Secondary):
  • Healing happens with micro-motion; Stabilization is not needed
  • Direct (Primary):
  • Requires anatomical reduction and stabilization
• Phases:
  • Inflammatory (0–7 days): Hematoma forms as macrophages clear debris
  • Reparative (7–14 days): Blood vessels invade and callus forms
  • Remodeling (3 weeks-Years): Callus resorbs as bone strengthens
• Healing Times:
  • Small bones: 3-6 weeks
  • Large bones: 8–12 weeks
• Stabilizing fractures and make sure of proper alignment for effective healing during therapy considerations

Muscle Healing

• Phases:
  • Degeneration (0–4 days): Infiltration of satellite cells after removing damaged tissue
  • Regeneration (4 days-6 months): New muscle fibers form
  • Remodeling: Muscle strengthens, but scar tissue reduces full recovery
• Gradual loading is key to restoring function during therapy considerations

Summary of Tissue Healing

• Healing is not linear, variables include tissue type and injury severity
• Therapist Role:
  • Base treatment on healing phases.
  • Teach patients how to protect tissues as they heal.
  • Gradually add stress to optimize remodeling of tissue
• Limitation: Healing tissue is not as strong as the original tissue

Stretching and Flexibility

• Stretching addresses restricted motion, improves flexibility, and counteracts issues,
• Stretching Types: static, cyclic, ballistic, or PNF
• Stretching should be done after tissues are warmed up, and the stretch should be held for 30-60 seconds
• Stretching exercises should happen 2–3 times per week or daily, focusing on major muscle groups before single-joint exercises
• Contraindications include acute inflammation, recent fractures, and hypermobility,
• Safe and effective outcomes are ensured by following ACSM guidelines and techniques such as manual, mechanical, or self-stretching

Types of Trauma

• Microtrauma: Repetitive stresses that occur a little at a time.
• Macrotrauma: major injury that happens in one instance

Why Stretching is Important

• Improves flexibility and motion.
• Addresses intrinsic and extrinsic factors.
• Helps counteract sedentary lifestyles, postural malalignments, muscle imbalances, and neuromuscular disorders.

Indications and Contraindications for Stretching

• Indications: Restricted ROM, muscle or soft tissue tightness
• Contraindications: Recent fractures or incomplete bony union, acute inflammation or sharp pain, hypermobile joints or when shortened tissue is needed for stability

Types of Stretching

• Static: Holding a stretch in a lengthened position.
• Static progressive stretches allow progression to new ROM.
• Cyclic (Intermittent): Low-velocity stretches applied and released cyclically. Limited use in healthy without neuromuscular conditions.
• Ballistic: Rapid, forceful stretches that necessitate caution.
• PNF: Uses active muscle contractions to increase flexibility.
• Techniques include hold-relax, contract-relax, and hold-relax with the agonist's contraction

Stretching Modes

• The therapist applies force in controlled manner to stretch tissues during manual stretching.
• Devices gradually stretch tissues over an extended period for mechanical stretching.
• Self-stretching: Independently performed, and helps to maintain flexibility.

Preparation and Technique

• Appropriately position the patient
• Raise tissue temperature to improve effectiveness by warming them up
• Educate patients on relaxation and technique.
• Stabilize the proximal segments and apply controlled force
• Hold stretches for 30–60 seconds, based on age.
• Relax force slowly to avoid muscle contraction.

ACSM Recommendations

• Stretch to a point of tightness or slight discomfort, 2-3 times/week
• Hold for specified time periods depending on age.
• A single repetition, held for sufficient duration, is effective per muscle group
• Use the RAMP principle by raising body temperature, activating muscles, mobilizing target joints, and readiness to potentiating

Key Points for Safety and Effectiveness

• Stretching is most effective for long-term gains if done after exercise
• Incorporate proper stabilization and gradual force to ensure safe tissue elongation
• Large, complex multi-joint movements should be prioritized before single-joint exercises
• Judiciously use ballistic stretches to avoid injuries