Introduction to Tissue Healing PDF

# CHAPTER 10 Soft Tissue Injury, Repair, and Management ## Pain. Stress to the torn tissue is usually painless; palpation may reveal the defect. A torn ligament results in instability of the joint. ## Irritability of Tissue: Stages of Inflammation and Repair After any insult to connective tissue,...

# CHAPTER 10 Soft Tissue Injury, Repair, and Management ## Pain. Stress to the torn tissue is usually painless; palpation may reveal the defect. A torn ligament results in instability of the joint. ## Irritability of Tissue: Stages of Inflammation and Repair After any insult to connective tissue, whether it is from mechanical injury (including surgery) or chemical irritant, the vascular and cellular response is similar (Table 10.1). Tissue irritability, or sensitivity, is the result of these responses and is typically divided into three overlapping stages of inflammation, repair, and maturation/remodeling. The following table summarizes the clinical signs and symptoms. ### Acute Stage (Reaction and Inflammation) During the acute stage, the signs of inflammation develop; they are swelling, redness, heat, pain at rest, and loss of function. When testing the range of motion (ROM), movement is painful and the patient usually guards against the motion before completion of the range is possible (Fig. 10.2 A). The pain and impaired movement are from the altered chemical state that irritates the nerve endings, increased tissue tension due to edema or joint effusion, and muscle guarding, which is the body's way of immobilizing a painful area. This stage usually lasts 4 to 6 days unless the insult is perpetuated. ### Subacute Stage: Proliferation, Repair, and Healing - Removal of noxious stimuli - Growth of capillary beds into area - Collagen formation - Granulation tissue - Very fragile, easily injured tissue - Decreasing inflammation - Pain synchronous with tissue resistance ### Chronic Stage: Maturation and Remodeling - Maturation of connective tissue - Contracture of scar tissue - Remodeling of scar - Collagen aligns to stress - Absence of inflammation | Stage | Tissue responses and characteristics | Subacute Stage: Proliferation, Repair, and Healing | Chronic Stage: Maturation and Remodeling | |---|---|---|---| | Acute Stage: Inflammation | Vascular changes | Removal of noxious stimuli | Maturation of connective tissue | | | Exudation of cells and chemicals | Growth of capillary beds into area | Contracture of scar tissue | | | Clot formation | Collagen formation | Remodeling of scar | | | Phagocytosis, neutralization of irritants | Granulation tissue | Collagen aligns to stress | | | Early fibroblastic activity | Very fragile, easily injured tissue| Absence of inflammation | | Clinical signs | Inflammation | Decreasing inflammation | | | | Pain before tissue resistance | Pain synchronous with tissue resistance | | | Physical therapy goals and interventions for phases of rehabilitation | Phase I | Phase II | Phase III | | Phase I | Maximum Protection | Moderate Protection/Controlled-Motion | Minimum to No Protection/Return to Function | | | Control effects of inflammation: selective rest, ice, compression, elevation | Develop mobile scar: selective stretching, mobilization/manipulation of restrictions | Increase tensile quality of scar: progressive strengthening and endurance exercises | | | Prevent deleterious effects of rest: nondestructive movement: passive ROM, massage, and muscle setting with caution | Promote healing: nondestructive active, resistive, open- and closed-chain stabilization, muscular endurance, and cardiopulmonary endurance exercises, carefully progressed in intensity and range | Develop functional independence: functional exercises and specificity drills | # BOX 10.1 MANAGEMENT GUIDELINES- Acute Stage/Maximum Protection ## Impairments of Body Structure and Function: - Inflammation, pain, edema, muscle spasm - Impaired movement - Joint effusion (if the joint is injured or if there is arthritis) - Restricted use of associated areas ## Plan of Care 1. Educate the patient. 2. Control pain, edema, and spasm. 3. Maintain soft tissue and joint integrity and mobility. 4. Reduce joint swelling if symptoms are present. 5. Maintain integrity and function of associated areas. ## Intervention (up to 1 week postinjury) 1. Inform patient of anticipated recovery time and how to protect the part while maintaining appropriate functional activities. 2. Cold, compression, elevation, and massage (48 hours). Immobilize the part (rest, orthosis, tape, cast). Avoid positions of stress to the part. Gentle (grade I or II) joint oscillations with joint in pain-free position. 3. Appropriate dosage of passive movements within limit of pain, specific to structure involved. Appropriate dosage of intermittent muscle setting or electrical stimulation. 4. May require medical intervention if swelling is rapid (blood). Provide protection (orthosis, cast). 5. Active-assistive, free, resistive, and/or modified aerobic exercises, depending on proximity to associated areas and effect on the primary lesion. Adaptive or assistive devices as needed to protect the part during functional activities. ## PRECAUTIONS: The proper dosage of rest and movement must be used during the inflammatory stage. Signs of too much movement are increased pain or increased inflammation. ## CONTRAINDICATIONS: Stretching and resistance exercises should not be performed at the site of the inflamed or swollen tissue. and reinjures the tissue. The dosage of passive movement depends on the severity of the lesion. Some patients tolerate no movement during the first 24 to 48 hours; others tolerate only a few degrees of gentle passive movement. Continuous passive movement (see Chapter 3) has been useful immediately after various types of surgery to joints-intra-articular, metaphyseal, and diaphyseal fractures; surgical release of extra-articular contractures and adhesions; and other select conditions.24,25 Any movement tolerated at this stage is beneficial, but it must not increase the inflammation or pain. Active movement is usually contraindicated at the site of an active pathological process unless it is a chronic disease, such as rheumatoid arthritis. General movement. Active movement is appropriate in neighboring regions to maintain integrity in uninjured tissue and to aid in circulation and lymphatic flow. ## PRECAUTION: If movement increases pain or inflammation, it is either of too great a dosage or it should not be done. Extreme care must be used with movement at this stage. ## Specific Interventions and Dosages Passive ROM (PROM). PROM within the limit of pain is valuable for maintaining mobility in joints, ligaments, tendons, and muscles, as well as improving fluid dynamics and maintaining nutrition in the joints. 24,25 Initially, the range is probably very small. 31 Stretching at this stage is contraindicated. Any motion gained from the PROM techniques is because of decreased pain, swelling, and muscle guarding. Low-dosage joint mobilization/manipulation techniques. Grade I or II distraction and glide techniques have the benefit of improving fluid dynamics in the joint to maintain cartilage ==End of OCR for page 2== # BOX 10.2 MANAGEMENT GUIDELINES- Subacute Stage/Controlled Motion ## Impairments of Body Structure and Function: - Pain when end of available ROM is reached - Edema (decreasing but may still be present) - Joint effusion (decreasing but may still be present if joints are involved) - Soft tissue, muscle, and/or joint contractures (developing in immobilized region) - Muscle weakness from reduced usage or pain - Restricted ADLS and IADLs related to involved tissues ## Plan of Care 1. Educate the patient. 2. Promote healing of injured tissues. 3. Restore soft tissue, muscle, and/or joint mobility. 4. Develop neuromuscular control, muscle endurance, and strength in involved and related muscles. 5. Maintain integrity and function of associated areas. ## Intervention (up to 3 weeks postinjury) 1. Inform patient of anticipated healing time and importance of following guidelines. Teach home exercises and encourage functional activities consistent with plan; monitor and modify as patient progresses. 2. Monitor response of tissue to exercise progression; decrease intensity if pain or inflammation increases. Protect healing tissue with assistive devices, orthoses, tape, or wrap; progressively increase amount of time the joint is free to move each day and decrease use of assistive device as strength in supporting muscles increases. 3. Progress from passive to active-assistive to active ROM within limits of pain. Gradually increase mobility of scar, specific to structure involved. Progressively increase mobility of related structures if limiting ROM; use techniques specific to tight structure. 4. Initially, progress multiple-angle isometric exercises within patient's tolerance; begin cautiously with mild resistance. Initiate AROM, protected weight bearing, and stabilization exercises. As ROM, joint play, and healing improve, progress isotonic exercises with increased repetitions. Emphasize control of exercise pattern and proper mechanics. Progress resistance later in this stage. 5. Apply progressive strengthening and stabilizing exercises, monitoring effect on the primary lesion. Resume low-intensity activities involving the healing tissue that do not exacerbate the symptoms. ## PRECAUTIONS: The signs of inflammation or joint swelling normally decrease early in this stage. Some discomfort will occur as the activity level is progressed, but it should not last longer than a couple of hours. Signs of too much motion or activity are resting pain, fatigue, increased weakness, and spasm lasting beyond 24 hours. ■Teach the patient a home exercise program and help him or her adapt work and recreational activities that are consistent with intervention strategies so the patient becomes an active participant in the recovery process. ## Management of Pain and Inflammation Pain and inflammation decrease as healing progresses. Criteria for initiating active exercises and stretching during the early subacute stage include decreased swelling, pain that is no longer constant, and pain that is not exacerbated by motion in the available range. ■ As new exercises are introduced or as the intensity of exercises is progressed, monitor the patient's response. Exercises progressed too vigorously or activities begun too early can be injurious to the fragile, newly developing tissue and may delay recovery, cause pain, and perpetuate the inflammatory response. 7,27 If symptoms increase, modify the intensity of exercises. ## Initiation of Active Exercises Because of the restricted use of the injured region, there is muscle weakness even in the absence of muscle pathology. ==End of OCR for page 3== # 330 Management During the Chronic Stage neuromuscular system to respond to the demands of the activity (this may be referred to as Phase IV). Because remodeling of the maturing collagen occurs in response to the stresses placed on it, it is important to use controlled forces that replicate normal stresses on the tissue. 7,15,23 Maximum strength of the collagen develops in the direction of the imposed forces. Pain that the patient now experiences arises only when stress is placed on restrictive contractures or adhesions or when there is soreness due to increased stress of resistive exercise. To avoid chronic or recurring pain, the contractures must be stretched or the adhesions broken up and mobilized. Excessive or abnormal stress leads to re-injury and chronic inflammation, which can be detrimental to the return of function, The information that follows is summarized in Box 10.4. # BOX 10.4 MANAGEMENT GUIDELINES- Chronic Stage/Return to Function ## Impairments of Body Structure and Function: - Soft tissue and/or joint contractures and adhesions that limit normal ROM or joint play - Decreased muscle performance-weakness, poor endurance, poor neuromuscular control - Decreased usage of the involved part - Inability to participate normally in an expected activity ## Plan of Care 1. Educate the patient. 2. Increase soft tissue, muscle, and/or joint mobility. 3. Improve neuromuscular control, strength, and muscle endurance. 4. Improve cardiopulmonary endurance. 5. Progress activities and participation in life situations. ## Interventions (>3 weeks postinjury) 1. Instruct patient in safe progressions of exercises and stretching. Monitor understanding and compliance. Teach ways to avoid reinjuring the part. Teach safe body mechanics. Provide ergonomic counseling. 2. Stretching techniques specific to tight tissue: - Joint and selected ligaments (joint mobilization/manipulation) - Ligaments, tendons, and soft tissue adhesions (cross-fiber massage) - Muscles (neuromuscular inhibition, passive stretch, massage, and flexibility exercises) 3. Progress exercises: - Submaximal to maximal resistance - Specificity of exercise using resisted concentric and eccentric, weight bearing and nonweight bearing - Single plane to multiplanar motions - Simple to complex motions, emphasizing movements that simulate functional activities - Controlled proximal stability, superimpose distal motion - Safe biomechanics - Low repetitions to high repetitions at slow speeds; progress complexity and time; progress speed and time. 4. Progress aerobic exercises using safe activities. 5. Continue using supportive and/or assistive devices until the ROM is functional with joint play and strength in supporting muscles is adequate. Progress functional training with simulated activities from protected and controlled to unprotected and variable. Continue progressive strengthening exercises and advanced training activities until the muscles are strong enough and able to respond to the required demands ## PRECAUTIONS: There should be no signs of inflammation. Some discomfort will occur as the activity level is progressed, but it should not last longer than a couple of hours. Signs that activities are progressing too quickly or with too great a dosage are joint swelling, pain that lasts longer than 4 hours or that requires medication for relief, a decrease in strength, or fatiguing more easily. ==End of OCR for page 4== # BOX 10.5 MANAGEMENT GUIDELINES- Chronic Inflammation/Cumulative Trauma Syndromes ## Impairments of Body Structure and Function: - Pain in the involved tissue of varying degrees: - Only after doing repetitive activities - When doing repetitive activities as well as after - When attempting to do activities; completion of activity is prevented - Continued and unremitting - Soft tissue, muscle, and/or joint contractures or adhesions that limit normal ROM or joint play - Connective tissue weakness in painful region - Muscle weakness and poor muscular endurance in postural or stabilizing muscles as well as primary muscle at fault - Imbalance in length and strength between antagonistic muscles; biomechanical dysfunction - Faulty position or movement pattern perpetuating the impairment - Decreased use of the region for activities and participation in desired life situation ## Plan of Care 1. Educate the patient. 2. Promote healing; decrease pain and inflammation. 3. Maintain integrity and mobility of involved tissue. 4. Develop support in related regions ## Plan of Care 1. Educate the patient. 2. Develop strong, mobile scar. 3. Develop a balance in length and strength of the muscles. 4. Progress functional independence. 5. Analyze job/activity. ## Interventions During Chronic inflammation 1. Counsel as to cause of chronic irritation and need to avoid stressing the part while inflamed. Adapt the environment to decrease tissue stress. Implement a home exercise program to reinforce therapeutic interventions. 2. Cold, compression, massage Rest to the part (stop mechanical stress, orthosis, tape, cast) 3. Nonstressful passive movement, massage, and muscle setting within limits of pain 4. Posture training Stabilization exercises ## Interventions-Controlled Motion and Return to Function Phases 1. Ergonomic counseling in ways to prevent recurrence Home instruction in safe progression of stretching and strengthening exercises. Instruction on signs of too much stress (see Box 10.3) 2. Friction massage Soft tissue mobilization 3. Correct cause of faulty muscle and joint mechanics with appropriately graded stretching and strengthening exercises. 4. Train muscles to function according to demand; provide alternatives or support if they cannot. Train coordination and timing. Develop endurance. 5. Adapt home, work, and sport environment/tools. ## PRECAUTION: If there is progressive loss of ROM as the result of stretching, do not continue to stretch. Reevaluate the condition and determine if there is still a chronic inflammation with contracting scar or if there is protective muscle guarding. Emphasize stabilizing the part and training in safe adaptive patterns of motion. ==End of OCR for page 5==