Week 2 TI Summary PDF

2.1 intro to muscular skeletal injury & healing soft tissue injury classification 2 base classifications of soft tissue injuries term applies to initial onset of trauma ex: lifting injury= would cause primary injury to muscle due to force overload other ex: strain of muscle, sprain of ligament, con...

2.1 intro to muscular skeletal injury & healing soft tissue injury classification 2 base classifications of soft tissue injuries term applies to initial onset of trauma ex: lifting injury= would cause primary injury to muscle due to force overload other ex: strain of muscle, sprain of ligament, contusion of soft tissue, subluxation of jnt or fracture of bone term applied to disruptive and self propagating changes that occur in our tissues that lead to further dysfxn and death of tissue and appear to have initial insult (prim injury) common ex: due to msk prim injury- hypoxia damage and enzymatic damage 11 L soft tissue stages of normal healing 3 soft tissue stages of normal healing classification or 1. inflammatory phase • an acute presentation of an injury I in addition to its temporal characteristics, will also have a - characteristic physiological 2. proliferative phase difference w regards to tissue • an early to middle sub-acute presentation of an injury 3. maturation and remodeling phase 2 • a late sub-acute and/or chronic presentation of an injury. L healing as compared to other phases , soft tissue healing factors I 5 things that impact speed of quality of healing 1. demographics 2. environmental 3. medical management (wont go into this, for this lecture) 4. disease/comorbidities 5. psychosocial components soft tissue management 1. acute- inflammatory 2. sub-acute- proliferation first 3 refer to normal tissue healing types 3. chronic- maturation and remodeling 4. chronic inflammatory- refers to a diseased state depending on • • • type of injury: primary or secondary stage of healing the different factors that influence that healing our management for that patient will vary. • primary categories that we develop plans of care for are determined by the acuity or the time of injury. summary 1. 2 pathophysiological classifications of soft tissue injuries a. primary b. secondary 2. 3 normal stages of soft tissue healing a. inflammatory b. proliferative c. maturation 3. different factors that influence the efficiency and effectiveness of soft tissue healing 4. stage of soft tissue healing predicates the plan of care management 2.2 musculoskeletal lesions classification msk lesions pt case JT 43 yo acute ligament injury (sprain) recreational runner R ankle - 1 week ago sharp pain when loading thru heel • potential grade 2 • we cant diagnosed bc there needs to be imaging aggravating factors: stair climbing, walking on unstable surfaces no symptoms while cycling swelling and bruising at midfoot and ankle history: type 2 diabetes types of msk lesions each of these lesions - characterized by anatomical location, and pathophysiological processes that are due to a type of injury. pathological model 1. primary injuries -injury that has an immediate impact on tissue ex: contusion on the elbow after hitting it 2. secondary injuries -self propagating damage that occurs after a primary insult, ex: I fell down, I bumped my elbow and there is actually a tissue that does get impacted by the inflammatory primary injuries: strains for muscles, sprains for ligaments, contusions, subluxations for joints and fractures for bone. processes which leads to hypoxic conditions or enzymatic • reactions ex: muscle atrophy 2 types of secondary injuries (most common) 1. hypoxic 2. somatic clinical manifestations 1. dysfunctions 2. contractures 3. guarding 4. swelling 5. infection 6. spasms 7. weakness all going to change with regards to how the injury happened. contextual factors: • if they got immediate help or not • medication • disease or dysfxn clinical manifestations are very useful to us because it gives us a means to further characterize what has happened as the result of an injury. primary injury classification closed fractures (tscherne) sprains and strains -bones- grade 1: mild injury w lower level of pain grade C0- minimal tissue damage w closed fracture and decrease levels of local inflammation grade C1- superficial abrasions & contusions w fracture grade 2: more severe presentation, grade C2- deep abrasions w impending compartment associated with moderate pain and more syndrome diffuse inflammatory processes, increase grade C3- skin and vascular damage and compartment pain and inflammation syndrome -pt may have more fear avoidance behavior —more likely for secondary injury grade 3: very severe and severe pain, more diffuse inflammation sprains refer to injuries to ligaments, strains referred to injuries to muscle tissue. Characteristics of the injuries, predicate, grading and classification schemes • classifications vary bw structures • include degree of injury and secondary trauma to surrounding tissue msk lesions stage refers to a physiological healing process speaks to the soft tissue healing time of involved associated tissue 1. acute. first 4–7 (6) days following an injury The time frames above aren’t universal. 2. sub-acute. >7 days to 3 months 3. chronic. >3 months 4. acute on chronic. acute injury with chronic healing stage. • going to change depending on the tissue highly vascularized tissue (ex: muscle) • muscle adheres to the scheme ^^^ • bone will take longer bc it doesnt have the same vasculature summary 1. injuries to the musculoskeletal system can result from a wide variety of causes and cause many different lesions. 2. categorization of injuries vary with many different factors associated with the lesion, including but not limited to location, time since injury, clinical presentation and mode of injury. 3. most common classifications for soft tissue injuries include scales that grade degree of and time since injury. 2.3 Musculoskeletal Healing Phases Phases of healing 1. Inflammatory Phase - ACUTE presentation of injury ALL refer to physiological changes NOT 2. Proliferative phase pain, more about tissue healing - early to mid subacute injury 3. Maturation & Remodeling Phase - late subacute & or chronic presentation of injury Inflammatory Phase Physiology (4-7 days) • inflammation - exudation of chemicals/cells • clot formation • phagocytosis • early fibroblastic activity Proliferation Phase Physiology (2-3 weeks in high vascularity areas) (6 weeks in less vascular like tendons) • capillary growth • granulation tissue formation • fibroblast proliferation - collagen synthesis - increased macrophage & mast cell activity Maturation & Remodeling Physiology (3 weeks to 3 months) • scar tissue retraction • thicker collagen & reorients to stress • 3 months to a year following an injury • improvement in quality & orientation of collagen • • increase collagen, scar tissue, density Initial healing tissue to scare tissue based on stress response adaptation! pain w/ resting - aching bc of altered chemical state vascular changes - predominates first 3 days • inflammatory phase clinical presentation - sensitization of nociceptors w/in or around injury • pain w/ AROM - open end feel w/ PROM & apply over pressure • pain w/ objective testing - mmt, palpation tissue may feel warm/swollen • compensatory mvmt patterns & loss of fxn - muscle guarding & muscle inhibition Proliferation phase clinical presentation • • pain w/ AAROM/AROM (less severe than acute phase) limited ROM & strength - causes altered fxn & tolerance in ADLs - earlier stages fine but more restriction w/ activity - later stages decreased sensitivity to peripheral nociception = feel less = feel better = push limits = more risk of injury Maturation & Remodeling Clinical Presentation • loss of muscle control & strength secondary to prolonged activity modification • pain MAY be felt @ end ROM (EROM) w/ excessive stress/after an activity • no signs of inflammation/acute healing processes • increased tolerance to fxnal activities return to fxn w/o restriction pain early in ROM for acute injuries able to achieve EROM but pain w/ over pressure some over pressure tolerated Summary 2.4 Musculoskeltal Healing Factors Abnormal Healing: disruption of normal healing cycle AKA disease state = chronic stage abnormalities & limitations in tissue healing can occur • can result dif clinical presentations • - mvmt dysfxn - contractures - adhesions - muscle weakness - guarding/spasms Soft Tissue Dysfxn: altered state of fxn of soft tissue that can lead to can be predicated by subj factors • muscle imbalance • hypo/hypermobility type/degree of trauma • • weakness viability of new tissue • • irregular mvmt social support • • guarding access to medical care • • therapeutic alliance basically SDOHs Abnormal healing conditions - resulting in soft tissue dysfxn • chronic inflammation, chronic pain syndromes • hyper contraction • scarring • altered neuromuscular control which can lead to General Healing Factors Biopsychosocial Healing Factors environmental • - ergonomic conditions, activities daily medical management • - type of care prior, medications, type of therapy (could be counseling) disease/comorbidities • - poor lymphatic drainage, metabolic dysfxn, diabetes psychosocial components • - therapeutic alliance can help pt stick to routine • age • illness • hypertrophic scarring • altered bs • edema • repeated trauma • weak structural support • genetics behaviors • Chronic Inflammation - repeated injury/overuse • numerous clinical presentations - increased pain, visible fusion, loss of ROM/stiffness, compensatory recruitments, muscle guarding, neurosensitization relationship b/w stress & physiological change in tissue • • load on tendon measuring deformation/change in length tissue is elastic to a certain extent - normally can heal microscopic but with excess force cant return = chronic inflammation blue- can return to normal pink - can recover just longer green - cant recover bc of repeated stress Keloid Scarring: natural process • some cases of soft tissue dysfxn collagen produces extra & past normal healing time creating significant scar tissue adhesions - genetic predisposition - common w/ burn pt • can result in - decreased ROM - PROM have thick, stiff end feel - effects epidermis Summary • multitude of biological, environmental, & personal factors can predicate efficiency & effectiveness of soft tissue healing • abnormal soft tissue healing can lead to numerous clinical presentations reflecting impaired fxn 2.5 Soft Tissue Healing Management Objective: explain the relationship between mechanotherapy and soft tissue management Also summarize treatment approaches for 2 things: Normal Healing, and Abnormal Chronic Inflammation Mechanotherapy/Mechanotransduction is physiological process of tissues adapting Modeling, REmodeling, and repair is related to muscle adaptation to a stress. A stress could be a stretch, or demand of load regeneration and growth is the cellular response to stress Purpose? To restore or optimize tissue to bring a patient back to a previous stage of function ACUTE STAGE OF HEALING emphasizes on protection. This is the most vulnerable stage of healing because this is where reinjuries can happen. Educate patients on how to manage inflammation and pain Some treatment strategies can include passive range of motion, soft tissue mobilization, simple single plane isometric exercises Passive range of motion can be used as treatment as well as a tool to gather data in determining a patient’s current state of injury Should work around the area of inflammation SUB-ACUTE STAGE OF HEALING - initial heavy amount of inflammation has gone down STILL want to emphasize protection while restoring function Controlled functional training- Active assisted range of motion, and Active range of motion Tissue is STILL in vulnerable state Activities only to level of tolerance Postural restoration exercises can begin to address compensation habits CHRONIC STAGE A lot of tissue healing has occured. Tissue has become more resistant to external stresses Focus on return to function Progress stretches and load safely Trunk control and body mechanics Focus on more complex movements Focus on injury prevention CHRONIC INFLAMMATION Falls outside of normal soft tissue healing phases Goal for this phase is to look at controlling inflammatory processes of pain. 2.6 Intro to Musculoskeletal Pain Definitions Pain - An unpleasant sensory & emotional experience associated w/, or resembling, actual or potential tissue damage - Highlights biological, psychological, & social components of pain Noxious Stimulus - Stimulus that is damaging or threatens damage to normal tissue Nociception Neural - Process of encoding noxious stimulus Nociceptive Pain - Pain that arises from actual or threatened damage to tissue b/c activation of nociceptors Neuropathic Pain - Pain caused by injury or disruption of somatic neural system Nociplastic Pain - Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain Pain is NOT Nociception - Pain & nociception are 2 different but related processes - Nociception is neither necessary nor sufficient to cause pain Introduction - Pain is 1 of many protective mechanisms in everybody - Pain is the only mechanism we are necessarily aware of that causes us to protect ourselves - Pain is modulated by info (External/Internal) associated w. ‘perceived’ threat/danger - Brain is bioplastic system - Have ability to escape restrictions of own genome & adapt to environmental factors & changes within body/life experiences - Internally have ability to detect danger, & respond appropriately 2.7 Intro to Nociception Definitions Nociception - Neural process of encoding noxious stimulus Nociceptor - A high threshold sensory receptor the peripheral somatosensory nervous system that is capable of transducing & encoding noxious stimuli - Produce action potentials in response to noxious stimuli Primary Modes - Mechanical - Thermal - Chemical Lock & Key Analogy - Key is the stimulus - Lock is receptor - Appropriate key is used & enough magnitude of force is applied, lock will produce action potential - Action potential transmitted to brain, signal could be processed as pain Key Points - Information from somatic & visceral structures - Process involves both PNS & CNS - Nociception is an INPUT (afferent) of the PNS - Pain is OUTPUT - 5 Steps to Nociception - Transduction - Conduction - Transmission - Modulation - Perception Synchronous Session Two Faculty Name PT, PhD Jeffrey Foucrier PT, DPT Orthopedic Clinical Specialist Week Two Soft tissue healing – foundational clinical application. 1. Biophysiological Classification of Injuries 1. Primary 2. Secondary 2. Clinical Classifications (examples): 1. Sprains / Strains 2. Soft tissue injury following a bone break 3. Soft Tissue Healing Phases 1. Acute 2. Sub-Acute 3. Chronic 4. Chronic Inflammatory 4. Healing Factors 5. Soft Tissue Healing Phases - Treatment 6. Musculoskeletal Pain (Review) REMEMBER THESE YALL Activity: Discussion – Injury Classification Systems Pathophysiological • <Enter Text> Soft-Tissue • <Enter Text> Activity: Waterfall– Injury Classifications Choices 1 • Contusion • Strain – Moderate Pain • Laceration • Sprain • Hypoxic cell death • Sprain – Local Inflammation • Superficial bone contusion • Compartment syndrome 4 1 1 2 3 7 9 1. Primary 2. Secondary 3. Grade 1 4. Grade 2 5. Grade 3 6. Grade C0 7. Grade C1 8. Grade C2 9. Grade C3 Activity: Matching – Stages of Healing 1. Inflammatory Phase 1. 2. 2. Proliferative Phase 3. 3. Maturation and Remodeling Phase An acute presentation of an injury. An early to middle sub-acute presentation of an injury. A late sub-acute and/or chronic presentation of an injury. Activity: Multiple-Choice – Stages of Tissue Healing chemical sensitization causes decreased tolerance to working on tissues • Decreasing inflammation and increased tolerance working into tissue resistance. Phase 1 • Phase 2 Phase 3 Phase 2 Phase 3 Absence of inflammation and no pain during tissue resistance. Phase 1 • Phase 3 Emphasize passive range of motion and muscle setting. Phase 1 • Phase 2 Complete selective stretching and begin soft tissue mobilization of scar tissues. Phase 1 • Phase 3 Minimum to no protection during functional activity with a focus on return to sport. Phase 1 • Phase 2 Phase 2 Phase 3 Phase 2 Phase 3 Maximum protection during functional activity. Phase 1 Activity: Clinical Application – Stages of Tissue Healing • Phase 1 Interventions (Acute) • <Enter Text> protect heat/cold PROM education isometrics/muscle setting • Phase 2 Interventions (Sub-Acute) • <Enter Text> controlled motion: selective stretching, tissue mobs, promoting muscle endurance through more advanced isometrics, concentric and potentially eccentrics • Phase 3 Interventions (Chronic) • <Enter Text> eccentrics, fxnal stab return to sport, light plyos, discharge testing, return to fxn, aggressive loading, sport specific training, complex movements Be prepared to explain why. Activity: Roleplaying – Chronic Healing vs Chronic Inflammation Chronic Healing Normal Chronic Inflammation abnormal healing pathological Activity: Discussion What is the connection between healing factors and the following content: 1. Biopsychosocial Model 2. Prevention 3. Risk Factors The classification of healing factors is rooted in the biopsychosocial model. identifying risk factors to healing factors are intergral in forming proper interventions to prevent diseased states from occurring or progressing Activity: Waterfall and Discussion – Case Application 1. A patient you are seeing has been running for three months and over the course of the last 8 weeks the tendon below their kneecap has become increasingly painful. If we assume that the pain is localized to a tendon, how might you classify this injury? primary - chronic-inflammatory- grade 1 soft tissue mob, stretching, off loading tissue, encourage a little inflammation to restart healing so can heal normally 2. An 80-year-old individual was pulling a large blanket out of his dryer seven days ago when he felt severe pain in his shoulder. He dropped the blanket and when he tried to pick it back up, he noticed that he could no longer lift his arm. As he speaks with you today, he says that he still can’t lift his arm, but his shoulder is not painful and really hasn’t been sore since the initial incident. How might you classify this injury? primary - acute/subacute - grade 3 Can it still be called acute even when he isn’t experiencing pain anymore? Doesnt that mean inflammation is gone? no pain bc not stressing tissue Or is it cause it JUST happened 7 days ago, its still considered pretty recent ? refer out What interventions would you MOST likely provide in each case? Activity: Waterfall and Discussion – Case Application 1. Your patient who suffered the hamstring strain is 9 weeks out from her initial injury. She has been back in the weight room and jogging without discomfort, but she would like to progress her rehabilitation. This individual would like to return to high jumping as soon as possible. What practice type would you recommend? primary - late sub acute/chronic-strain blocked -> random dependent on pt performance 2. Your patient suffered an acute, severe sprain of his anterior talofibular ligament this morning and presents to you as a PT in a primary care role. He says that after a Google search, he learned that he should wrap his ankle in ice, keep it elevated, rest and try and keep his ankle immobile. Based on your patient’s statement regarding how he should rehabilitate himself, what advice might you provide this patient? primary - acute - sprain educate, peace and love, DONT immob, PROM Do Not Immobilize, Only immobilize in the case of a fracture/broken bone What interventions would you MOST likely provide in each case?