Therapeutic Exercise - Chapter 10 PDF

Chapter 10: Soft Tissue Injury, Repair, and Management Copyright ©2023 F.A. Davis Company  Background  It is important during the examination process to determine whether the tissues involved are in the acute, su...

Chapter 10: Soft Tissue Injury, Repair, and Management Copyright ©2023 F.A. Davis Company  Background  It is important during the examination process to determine whether the tissues involved are in the acute, subacute, or chronic stage of recovery so that the type and intensity of exercises do not interfere w/ recovery but can most effectively facilitate healing for maximum return of functioning and prevention of further problems. Copyright ©2023 F.A. Davis Company  Musculoskeletal Disorders and Tissue Response to Injury Examples of soft tissue lesions Strain Overstretching, overexertion, or overuse of soft tissue (muscle/tendon) Sprain Overstretching, overexertion, or overuse of soft tissue (ligament) Dislocation Displacement of a part, usually the bony partners in a joint Subluxation An incomplete or partial dislocation of the bony partners in a joint Copyright ©2023 F.A. Davis Company Copyright ©2023 F.A. Davis Company  Musculoskeletal Disorders and Tissue Response to Injury Muscle Tendon Rupture or Tear Partial Tear: pain when muscle is stretched or when it contracts against resistance Complete Tear: muscle does not pull against the injury; stretching or contraction does not cause pain Tendinopathy: tendon injury affected by mechanical loading Tenosynovitis: inflammation of the synovial membrane covering a tendon Tendinitis: inflammation of a tendon Tendinosis: degeneration of the tendon due to repetitive microtrauma Synovitis: inflammation of a synovial membrane (joint or tendon sheath) Copyright ©2023 F.A. Davis Company  Musculoskeletal Disorders and Tissue Response to Injury Hemarthrosis Bleeding into a joint Ganglion Ballooning of the wall of a joint capsule sheath Bursitis Inflammation of a bursa Contusion Bruising from a direst blow, resulting in capillary rupture, bleeding, edema, and an inflammatory response Overuse syndromes, cumulative trauma disorders, repetitive strain injuries Copyright ©2023 F.A. Davis Company Copyright ©2023 F.A. Davis Company  Musculoskeletal Disorders and Tissue Response to Injury The primary pathology is difficult to define or the tissue has healed w/ limitations, resulting in secondary loss of function resulting from trauma or pathology Dysfunction Loss of normal function of a tissue or region Joint Dysfunction Mechanical loss of normal joint play in synovial joints Contracture Adaptive shortening of skin, fascia, muscle, or joint capsule that prevents normal mobility or flexibility of that structure Adhesions Abnormal adherence of collagen fibers to surrounding structures Copyright ©2023 F.A. Davis Company  Musculoskeletal Disorders and Tissue Response to Injury Reflex Muscle Guarding Prolonged contraction of a muscle in response to a painful stimulus Intrinsic Muscle Spasm Prolonged contraction of a muscle in response to the local circulatory and metabolic changes that occur when a muscle is in a continued state of contraction Muscle Weakness Decrease in the strength of muscle contraction Myofascial Compartment Syndrome Increased pressure in a closed, nonexpanding, myofascial compartment that compromises the function of the blood vessels, muscles, and nerves. Copyright ©2023 F.A. Davis Company Copyright ©2023 F.A. Davis Company  Severity of Tissue Injury Grade 1 (first-degree) Mild pain at the time of injury or w/in the first 24 hours. Mild swelling, local tenderness, and pain occur when the tissue is stressed. Grade 2 (second-degree) Moderate pain that requires stopping the activity. Stress and palpation of the tissue greatly increase the pain Mild Laxity Grade 3 (third-degree) Near-complete or complete tear or avulsion of the tissue (tendon or ligament) w/ severe pain. Stress to the torn tissue usually painless; palpation may reveal a defect Copyright ©2023 F.A. Davis Company Grades of sprain and strain Copyright ©2023 F.A. Davis Company Copyright ©2023 F.A. Davis Company Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Acute Stage: Reaction and Inflammation The 1st phase of healing Swelling, redness, heat, pain at rest, and loss of function. Testing ROM – movement is painful and guarding occurs Irritates the nerve endings, increased tissue tension due to edema or joint effusion, and muscle guarding Lasts 4 to 6 days unless the insult is continued Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Tissue Response in the Acute Phase During the inflammatory stage: cellular, vascular and chemical responses occur. ‒ During first 48 hours vascular responses win out. ‒ Exudation of cells from blood vessels and clot formation occurs ‒ Phagocytosis: pac man cleaning up the area ‒ Neutralization of irritants ‒ Vasodilation then vasoconstriction ‒ Exudation of cells and chemicals ‒ Early fibroblastic activity- scar tissue ‒ New capillary beds begin to grow Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Acute Phase Management Guidelines: Maximum Protection Patient Education ‒ Expected duration of symptoms. What they can and cannot do, needs reassurance symptoms are short-lived Protection of the Injured Tissue ‒ Usually provided by protection, rest, ice, compression, and elevation ‒ POLICE: protection, optimal loading, ice, compression, and elevation ‒ Depending on the type and severity of the injury, manual methods of pain and edema control may be beneficial (massage) ‒ Protection w/ assistive devices for partial or non-weight-bearing ambulation may be required Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Prevention of Adverse Effects of Immobility Complete or continuous immobilization should be avoided whenever possible as it can lead to adherence of the developing fibrils to surround tissue, weakening of connective tissue, and changes in articular cartilage Tissue-Specific Movement Prevent abnormal adherence of the developing fibrils to surrounding tissue and avoiding future disruption of the scar Intensity of Movement Should be gentle enough so the fibrils are not detached from the site of healing Any movement at this stage is beneficial, but it must not increase the inflammation or pain. General Movement Active movement is appropriate in neighboring regions to maintain integrity in uninjured tissue and to aid in circulation and lymphatic flow. Copyright ©2023 F.A. Davis Company  Davis Law Ligaments, or any soft tissue, when put under even a moderate degree of tension, if that tension is unremitting, will elongate by the addition of new material; on the contrary, when ligaments, or rather soft tissues, remain uninterruptedly in a loose or lax state, they will gradually shorten, as the affected material is removed, until they come to maintain the same relation to the bony structures with which they are united that they did before their shortening. Copyright ©2023 F.A. Davis Company  Wolff’s Law of Bone States that bone grows and remodels in response to the forces that are placed upon it in a healthy person. After an injury to bone, placing specific stress in specific directions to the bone can help it remodel and become normal healthy bone again. Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Specific Interventions and Dosages for the Acute Phase Passive range of motion (ROM) ‒ w/in the limit of pain is valuable for maintaining mobility in joints, ligaments, tendons and muscles. Low-Dosage Joint Mobilization Techniques Muscle Setting ‒ Gentle isometric muscle contractions performed intermittently and at a very low intensity so as not to cause pain or joint compression. Massage ‒ Moves fluid and if applied cautiously and gently to injured tissue, it may assist in preventing adhesions. Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Range of Motion (ROM) Depending of the proximity to and the effect on the injured tissue (passively or actively) Resistance Exercise May be applied at an appropriate dosage to muscles not directly related to the injured tissue Functional Activities Supportive or adaptive devices may be necessary depending on area on injury and expected activities Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Subacute Stage: Proliferation, Repair and Healing The 2nd phase of healing Signs of inflammation progressively decrease and eventually are absent- somewhere around 2-4 days ROM: may experience pain along w/ encountering tissue resistance at the end of the available ROM. Pain occurs when new tissue is stressed beyond its tolerance or when tight tissue is stressed. Muscles may test weak and function is limited 10 to 17 days (14–21 days after onset of injury), but may last up to 6 weeks Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Tissue Response in the Subacute Stage Fibroblastic activity, collagen formation, and granulation tissue development increase Fibroblasts produce new collagen, and this immature collagen places the exudate that originally formed the clot ‒ Myofibroblastic activity begins about day 5 causing scar shrinkage Depending on the size of the injury, wound closure usually takes 5 to 8 days in muscle and skin and 3 to 6 weeks in tendons and ligaments Immature connective tissue that is produced is thin, unorganized, extremely fragile, and easily injured if overstressed. ‒ Be mindful of the tensile loading force being applied to the injured area Copyright ©2023 F.A. Davis Company  Types of Tensile Loading Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Specific Interventions and Dosages for the Subacute Phase The key is to initiate and progress non-destructive exercises and activities, that is to perform exercises and activities that are within the tolerance of the healing tissues, which can then heal w/out reinjury or inflammation Patient Education ‒ Encourage return to normal activities that do not exacerbate symptoms ‒ Teach a home exercise program and help them adapt work and recreational activities that are consistent w/ intervention strategies Management of Pain and Inflammation ‒ Must have before initiating active exercises/stretching: decreased swelling, pain that is no longer constant, and pain that is not exacerbated by motion in the available range ‒ As exercises are introduced monitor patient’s response. If symptoms increase, modify the intensity of exercises. Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Multiple-angle, Submaximal Isometric Exercises Place in the shortened, relaxed position so the new scar is not pulled from the breached site Resting position for the joint may be the most comfortable position Contractions kept below the perception of pain Active ROM Exercises Emphasize control of the motion using light-resistive, concentric exercises of involved muscle and muscles needed for proper joint mechanics. Use combine motions or diagonal patterns to facilitate contraction of desired muscles Do not stress beyond the ability of the involved or weakened muscles to participate in the motion Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Muscular Endurance Exercises Beginning – only use active ROM Later – low-intensity, high repetition exercises w/ light resistance ‒ Protected Weight-Bearing Exercises ‒ Provide reinforcement to help develop awareness or appropriate muscle contractions and to help develop control Restricted motion due to developing scar tissue which causes a decrease in flexibility ‒ Warm the tissues ‒ Muscle relaxation techniques ‒ Joint mobilization/manipulation ‒ Stretching techniques ‒ Massage ‒ Use of the new range Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Initiation and Progression of Stretching Correction of Contributing Factors Resume low-intensity activities as the patient tolerates w/out exacerbating symptoms. Continue to reassess the patient’s progress and understanding of controlled activities Therapist role during this stage of healing is critical. Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Chronic Stage: Maturation and Remodeling The 3rd phase of healing No signs of inflammation May be contractures or adhesions that limit ROM May be muscle weakness, poor endurance, or poor neuromuscular control limiting normal function Connective tissue continues to strengthen and remodel in response to the stresses applied to it. Stretch pain may be felt when testing tight structures at the end of their available range. Lasts 6 months to 1 year depending on the tissue involved and amount of tissue damage. Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Tissue response in the Chronic Phase: Maturation of Tissue ‒ Occur as collagen fibers become thicker and reorient in response to stresses placed on the connective tissue. Remodeling of Tissue ‒ Remodeling time is influenced by factors that affect the density and activity level of the fibroblasts, including the amount of time immobilized, stress placed on the tissue, location of the lesion, and vascular supply ‒ At 14 weeks, the scar tissue is unresponsive to remodeling  Adaptive lengthening in the tissue surrounding the scar or surgical release Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Specific Interventions and Dosages for the Chronic Phase Patient Education ‒ Instruct in biomechanically safe progressions of resistance and self stretching. ‒ Establish guidelines for what must be attained to return safely to ADLs or sport specific exercises. ‒ Re-examine and evaluate the patient’s progress and modify as necessary. ‒ Recommend modifications if they have any impairments that are preventing them from returning to ADLs or sport specific exercises. Considerations for Progression of Exercise ‒ Joint dynamics and muscle strength and flexibility should be balanced as the injured part is progressed to functional exercises. Copyright ©2023 F.A. Davis Company  Stages of Inflammation and Repair Progression of Stretching Progress the intensity and duration of the stretching maneuvers so long as no signs of increased irritation persist beyond 24 hours Progression of Exercises for Muscle Performance Progress strengthening exercises to simulate specific demands Progress trunk stabilization, postural control, and balance exercises Teach safe body mechanics and have patient practice activities that replicate their environment Return to High Demand Activities Develop exercise drills that simulate the work or sport activities Increase the repetitions and speed of the movement as necessary Progress by changing the environment and introducing surprise and uncontrolled events into the activity. Copyright ©2023 F.A. Davis Company  Cumulative Trauma: Chronic Recurring Pain Connective tissue that is repetitively stressed beyond the ability to repair itself, the inflammation process is prolonged. Causes of Chronic Inflammation Overuse, Cumulative Trauma, Repetitive Strain ‒ Repetitive microtrauma or repeated strain overload over time results in structural weakening or fatigue breakdown Trauma ‒ May be the result of too early return to high-demand functional activities before the original injury has properly healed Reinjury of an “Old Scar” Contractures or Poor Mobility Copyright ©2023 F.A. Davis Company  Cumulative Trauma: Chronic Recurring Pain Contributing Factors Imbalance between the length and strength of the muscles Rapid or excessive repeated eccentric demand Muscle weakness Bone malalignment or weak structural support Change in the usual intensity or demands Returning to activity too soon after an injury Sustained awkward postures or motions Environmental factors Age-related factors Training errors Combination of several contributing factors Copyright ©2023 F.A. Davis Company  Cumulative Trauma: Chronic Recurring Pain Chronic Inflammation: Acute Stage In addition to the use of modalities and resting the part, it is imperative to identify and then modify the mechanism of chronic irritation w/ appropriate biomechanical counseling. Chronic Inflammation: Subacute and Chronic Stages Mobilize scar that limits range or continually becomes irritated Muscle guarding could be a sign that the body is attempting to protect itself Identify the cause of faulty muscle and joint mechanics Focus on muscle endurance as a component of muscle re- education due to the inability to sustain repetitive activities Progress exercises to develop functional independence Work-conditioning and work-hardening programs may be used to prepare the person for return to work or sport specific Copyright ©2023 F.A. Davis Company Chronic Pain Disorder (Chronic Pain Syndrome) Persists longer than 6 months Includes pain that cannot be linked to a source of irritation or inflammation resulting in activity limitations and participation restrictions that affect many parameters of function. Management Patient education Help patients understand that they are not causing continued tissue injury while being active, while simultaneously experiencing positive outcomes that do not worsen their perceived pain. Teach patients with unexplained musculoskeletal pain about central sensitization and its relationship to persistent, chronic pain (referred to as pain neuroscience education or pain physiology education) Physical activity Utilize a time-contingent approach to physical activity. That is, emphasize performing an activity for a specific period rather than counting repetitions. Exercise also has the benefit of stimulating endogenous analgesia (a top-down decrease in pain perception). Copyright ©2023 F.A. Davis Company Copyright ©2023 F.A. Davis Company Copyright ©2023 F.A. Davis Company