Chapter 10: Tissue Response to Injury © 2011 McGraw-Hill Higher Education. All rights reserved.

Chapter 10:Chapter 10:Tissue Response to Tissue Response to

InjuryInjury

© 2011 McGraw-Hill Higher Education. All rights reserved.

The Healing ProcessThe Healing Process

Essential for athletic trainer to possess in Essential for athletic trainer to possess in depth knowledge of healing processdepth knowledge of healing process

Three Phases:Three Phases:1. Inflammatory Response1. Inflammatory Response

2. Fibroblastic Repair Phase2. Fibroblastic Repair Phase

3. Maturation- Remodeling Phase3. Maturation- Remodeling Phase Healing is a continuumHealing is a continuum Can not speed up the process but one can Can not speed up the process but one can

impede itimpede it


Figure 10-1


Inflammatory Response Inflammatory Response PhasePhase

Once tissue is injured- the process of Once tissue is injured- the process of healing begins immediatelyhealing begins immediately

Cardinal Signs of Inflammation (caused Cardinal Signs of Inflammation (caused by damged tissue)by damged tissue)Rubor (redness)Rubor (redness)Tumor (swelling)Tumor (swelling)Color (heat)Color (heat)Dolor (pain)Dolor (pain)Functio laesa (loss of function)Functio laesa (loss of function)


Phase I: Inflammatory Phase I: Inflammatory Response PhaseResponse Phase

Injury results in altered metabolism and Injury results in altered metabolism and liberation of various materialsliberation of various materials

Initial reaction by leukocytes and Initial reaction by leukocytes and phagocytic cells phagocytic cells GoalGoal

ProtectProtectLocalizeLocalizeDecrease injurious agentsDecrease injurious agentsPrepare for healing and repairPrepare for healing and repair


Chemical MediatorsChemical Mediators Derived from invading organisms, damaged tissue, Derived from invading organisms, damaged tissue,

plasma enzyme systems and white blood cells plasma enzyme systems and white blood cells (WBC’s)(WBC’s)

Histamine (from mast cells)Histamine (from mast cells)Causes vasodilatation and changes cell permeability Causes vasodilatation and changes cell permeability

owing to swellingowing to swelling Leukotrienes & prostaglandins: Impact margination Leukotrienes & prostaglandins: Impact margination

(adherence along cell walls)(adherence along cell walls) Increase permeability locally for fluid and protein Increase permeability locally for fluid and protein

passage (diapedesis)passage (diapedesis)


QUESTIONQUESTIONWhat are the 5 cardinal signs of What are the 5 cardinal signs of

inflammation?inflammation?What are the goals during the What are the goals during the

inflammatory phase?inflammatory phase?

Vascular ResponseVascular ResponseVasoconstrictionVasoconstriction (decrease in diameter of blood (decrease in diameter of blood

vessel) and coagulation occur to seal blood vessel) and coagulation occur to seal blood vessels and chemical mediators are releasedvessels and chemical mediators are released

Followed by Followed by vasodilationvasodilation (increase in diameter of (increase in diameter of blood vessel) 5-10 minutes laterblood vessel) 5-10 minutes laterInitially increases blood flow (transitory)Initially increases blood flow (transitory)SwellingSwellingWBC’s able to adhere to wallsWBC’s able to adhere to wallsInitial effusion of blood and plasma lasts 24-36 hoursInitial effusion of blood and plasma lasts 24-36 hours


Figure 10-3


QUESTIONQUESTION

What happens to the vascular system What happens to the vascular system during the Inflammatory Phase?during the Inflammatory Phase?

Clot FormationClot FormationPlatelets adhere to exposed collagen leading to formation of Platelets adhere to exposed collagen leading to formation of

plug (clot)plug (clot)

Clots obstruct lymphatic fluid drainage and aid in localizing injuryClots obstruct lymphatic fluid drainage and aid in localizing injury

Requires conversion of fibrinogen to fibrinRequires conversion of fibrinogen to fibrinInitial stage: thromboplastin is formedInitial stage: thromboplastin is formedSecond stage: Prothrombin is converted to thrombin due to interaction Second stage: Prothrombin is converted to thrombin due to interaction

with thromboplastinwith thromboplastinThird stage: thrombin changes from soluble fibrinogen to insoluble fibrin Third stage: thrombin changes from soluble fibrinogen to insoluble fibrin

coagulating into a network localizing the injurycoagulating into a network localizing the injury



Figure 10-2

Chronic InflammationChronic InflammationOccurs when acute inflammatory response does not eliminate Occurs when acute inflammatory response does not eliminate

injuring agentinjuring agentTissue not restored to normal physiologic stateTissue not restored to normal physiologic state

Involves replacement of leukocytes with macrophages, Involves replacement of leukocytes with macrophages, lymphocytes and plasma cellslymphocytes and plasma cellsAs inflammation persists necrosis and fibrosis prolong healing processAs inflammation persists necrosis and fibrosis prolong healing processGranulation and fibrotic tissue continue to develop within highly Granulation and fibrotic tissue continue to develop within highly

vascular and loose connective tissue.vascular and loose connective tissue.Cause for shift from acute to chronic is unknownCause for shift from acute to chronic is unknown

Typically associated with overuse, overload, cumulative microtraumaTypically associated with overuse, overload, cumulative microtrauma


SCENARIO- INFLAMMATORYSCENARIO- INFLAMMATORY

Phase II: Fibroblastic Repair Phase II: Fibroblastic Repair PhasePhase

Scar formation (begins within the first few Scar formation (begins within the first few days and last as long as 4- 6 weeks)days and last as long as 4- 6 weeks)

Patient has complaints of pain and Patient has complaints of pain and tenderness gradually subside during tenderness gradually subside during this periodthis period

Persistent inflammation = extended Persistent inflammation = extended fibroplasiafibroplasia



Figure 10-2

Phase III: Maturation & Phase III: Maturation & RemodelingRemodeling

Long-term process, may require several Long-term process, may require several years to completeyears to complete

Realignment of collagen relative to applied Realignment of collagen relative to applied tensile forcestensile forces

Continued breakdown and synthesis of Continued breakdown and synthesis of collagen = increased strengthcollagen = increased strength

Tissue will gradually assume normal Tissue will gradually assume normal appearanceappearance



Figure 10-2

Role of Progressive MobilizationRole of Progressive Mobilization Initially must maintain some immobilization in order to allow Initially must maintain some immobilization in order to allow

for initial healing during Inflammation Phasefor initial healing during Inflammation PhaseAs healing moves into repair phase controlled activity should As healing moves into repair phase controlled activity should

be addedbe addedWork towards regaining normal flexibility and strengthWork towards regaining normal flexibility and strengthProtective bracing should also be incorporatedProtective bracing should also be incorporated

During remodeling aggressive ROM and strength exercises During remodeling aggressive ROM and strength exercises should be incorporatedshould be incorporatedFacilitates remodeling and realignmentFacilitates remodeling and realignment

Must be aware of pain and other clinical signs – may be too Must be aware of pain and other clinical signs – may be too much too soonmuch too soon


Factors That Impede HealingFactors That Impede Healing Extent of injury: Extent of injury:

macrotears (acute) vs microtears macrotears (acute) vs microtears (chronic)(chronic)

Edema Edema (swelling)(swelling)

Hemorrhage Hemorrhage (bleeding)(bleeding)

Poor Vascular SupplyPoor Vascular Supply Separation of Tissue Separation of Tissue

(smooth vs jagged edge)(smooth vs jagged edge)

Muscle SpasmMuscle Spasm AtrophyAtrophy

CorticosteroidsCorticosteroids Keloids and Keloids and

Hypertrophic ScarsHypertrophic Scars InfectionInfection Humidity, Climate, Humidity, Climate,

Oxygen TensionOxygen Tension Health, Age, and Health, Age, and

NutritionNutrition


SCENARIO- MATURATION- SCENARIO- MATURATION- REMODELING PHASEREMODELING PHASE

Tissues of the BodyTissues of the Body Bone - not classified as soft tissueBone - not classified as soft tissue 4 types of soft tissue4 types of soft tissue

1. Epithelial tissue1. Epithelial tissueSkin, vessel & organ liningsSkin, vessel & organ linings

2. Connective tissue2. Connective tissueTendons, ligaments, cartilage, fat, blood, and boneTendons, ligaments, cartilage, fat, blood, and bone

3. Muscle tissue3. Muscle tissueSkeletal, smooth, cardiac muscleSkeletal, smooth, cardiac muscle

4. Nerve tissue4. Nerve tissueBrain, spinal cord & nervesBrain, spinal cord & nerves


Cartilage HealingCartilage HealingLimited capacity to healLimited capacity to healLittle or no direct blood supplyLittle or no direct blood supply If area involves subchondral bone If area involves subchondral bone

(enhanced blood supply) granulation (enhanced blood supply) granulation tissue is present and healing proceeds tissue is present and healing proceeds normallynormally


Ligament HealingLigament Healing Follows similar healing course as other vascular Follows similar healing course as other vascular

tissuestissues Proper care will result in acute, repair, and Proper care will result in acute, repair, and

remodeling phases in same time required by remodeling phases in same time required by other vascular tissuesother vascular tissues

Repair phase will involve random laying down of Repair phase will involve random laying down of collagen which, as scar forms, will mature and collagen which, as scar forms, will mature and realign in reaction to joint stresses and strainrealign in reaction to joint stresses and strain

Full healing may require 12 monthsFull healing may require 12 months


Factors affecting ligament healingFactors affecting ligament healingSurgically repaired ligaments tend to be stronger due Surgically repaired ligaments tend to be stronger due

to decreased scar formationto decreased scar formationWith intra-articular tears (inside the joint capsule) With intra-articular tears (inside the joint capsule)

synovial fluid prevents clotting and spontaneous synovial fluid prevents clotting and spontaneous healinghealing

Exercised ligaments are strongerExercised ligaments are strongerExercise vs. ImmobilizationExercise vs. Immobilization

Muscles must be strengthened to reinforce the jointMuscles must be strengthened to reinforce the jointIncreased tension will increase joint stability since ligament Increased tension will increase joint stability since ligament

is more laxis more lax


Skeletal Muscle HealingSkeletal Muscle Healing

Collagen will mature and orient along lines Collagen will mature and orient along lines of tensionof tension

Healing could last 6-8 weeks depending Healing could last 6-8 weeks depending on muscle injuredon muscle injured


Tendon HealingTendon Healing Requires dense fibrous union of separated Requires dense fibrous union of separated

endsends Abundance of collagen is required for good Abundance of collagen is required for good

tensile strengthtensile strength Too much = fibrosis – may interfere with glidingToo much = fibrosis – may interfere with gliding

Initially injured tendon will adhere to Initially injured tendon will adhere to surrounding tissues (week 2)surrounding tissues (week 2)

Week 3 – tendon will gradually separateWeek 3 – tendon will gradually separate Tissue not strong enough until weeks 4-5Tissue not strong enough until weeks 4-5


Nerve HealingNerve Healing Nerve cell cannot regenerate after injuryNerve cell cannot regenerate after injury Regeneration can take place within a nerve fiberRegeneration can take place within a nerve fiber Proximity of injury to nerve cell makes Proximity of injury to nerve cell makes

regeneration more difficultregeneration more difficult For regeneration, optimal environment is requiredFor regeneration, optimal environment is required Rate of healing occurs at 3-4 mm per dayRate of healing occurs at 3-4 mm per day Injured central nervous system nerves do not heal Injured central nervous system nerves do not heal

as well as peripheral nerves as well as peripheral nerves


Modifying Soft-Tissue Modifying Soft-Tissue HealingHealing

Blood supply and nutrients is necessary Blood supply and nutrients is necessary for all healingfor all healing

Healing in older patients or those with Healing in older patients or those with poor diets may take longerpoor diets may take longer

Certain organic disorders (blood Certain organic disorders (blood conditions) may slow or inhibit the conditions) may slow or inhibit the healing processhealing process


Management ConceptsManagement Concepts

Drug utilizationDrug utilizationNon-steroidal anti-inflammatory agents Non-steroidal anti-inflammatory agents

(NSAID’s)(NSAID’s)Medications will work to decrease Medications will work to decrease

vasodilatation and capillary permeability vasodilatation and capillary permeability Concerns may interfere with Inflammatory Concerns may interfere with Inflammatory

PhasePhase


Therapeutic ModalitiesTherapeutic ModalitiesThermal agents are utilizedThermal agents are utilized

Heat facilitates acute inflammation Heat facilitates acute inflammation Cold is utilized to slow inflammatory processCold is utilized to slow inflammatory process

Electrical modalitiesElectrical modalitiesTreatment of inflammationTreatment of inflammationUltrasound, microwave, electrical stimulation Ultrasound, microwave, electrical stimulation

(includes transcutaneous electrical muscle (includes transcutaneous electrical muscle stimulation and electrical muscle stimulation)stimulation and electrical muscle stimulation)


Therapeutic ExerciseTherapeutic ExerciseMajor aim involves pain free movement, full Major aim involves pain free movement, full

strength, power, and full extensibility of strength, power, and full extensibility of associated musclesassociated muscles

Immobilization, while sometimes necessary, Immobilization, while sometimes necessary, can have a negative impact on an injurycan have a negative impact on an injuryAdverse biochemical changes can occur in collagenAdverse biochemical changes can occur in collagen

Early mobilization (that is controlled) may Early mobilization (that is controlled) may enhance healingenhance healing


PART IIPART II

Bone HealingBone Healing Follows same three phases of soft tissue Follows same three phases of soft tissue

healinghealing Less complex processLess complex process Acute fractures have 5 stagesAcute fractures have 5 stages

Hematoma formationHematoma formationCellular proliferationCellular proliferationCallus formationCallus formationOssificationOssificationRemodelingRemodeling



Figure 10-6 A: Blood vessels broken, forms a hematoma B: Blood vessels grow into the fracture, soft callus C: Fibrocartilage becomes ossified forms a bony cartilage D: Osteoclasts remove excess tissue

Hematoma FormationHematoma Formation

Trauma to the periosteum and Trauma to the periosteum and surrounding soft tissue occurs due to the surrounding soft tissue occurs due to the initial bone traumainitial bone trauma

During the first 48 hours a hematoma During the first 48 hours a hematoma within the medullary cavity and the within the medullary cavity and the surrounding tissue developssurrounding tissue develops

Blood supply is disrupted by clotting Blood supply is disrupted by clotting vessels and cellular debrisvessels and cellular debris


Hard callus becomes more well-formed Hard callus becomes more well-formed as osteoblasts lay down cancellous as osteoblasts lay down cancellous bone, replacing cartilagebone, replacing cartilage

With crystallization of callus remodeling With crystallization of callus remodeling beginsbegins

Less than ideal immobilization produces Less than ideal immobilization produces a cartilaginous union instead of a bony a cartilaginous union instead of a bony unionunion


Ossification is complete when bone has been Ossification is complete when bone has been laid down and the excess callus has been laid down and the excess callus has been resorbed by osteoclastsresorbed by osteoclasts

Bone continually adapts to applied stressesBone continually adapts to applied stressesBalance between osteoblast and osteoclast activityBalance between osteoblast and osteoclast activity

Time required is dependent on various factorsTime required is dependent on various factorsSeverity and site of fractureSeverity and site of fractureAge and extent of traumaAge and extent of trauma

Time will range from 3-8 weeksTime will range from 3-8 weeks


Acute Fracture ManagementAcute Fracture Management

Must be appropriately immobilized, until X-rays Must be appropriately immobilized, until X-rays reveal the presence of a hard callusreveal the presence of a hard callus

Fractures can limit participation for weeks or Fractures can limit participation for weeks or monthsmonths

A clinician must be certain that the following A clinician must be certain that the following areas do not interfere with healingareas do not interfere with healingPoor blood supplyPoor blood supplyPoor immobilizationPoor immobilization InfectionInfection


Poor blood supplyPoor blood supplyBone may die and union/healing will not occur Bone may die and union/healing will not occur (avascular (avascular

necrosis)necrosis)Common sites include:Common sites include:

Head of femur, navicular of the wrist, talus, and isolated bone Head of femur, navicular of the wrist, talus, and isolated bone fragmentsfragments

Relatively rare in healthy, young athletes except in navicular Relatively rare in healthy, young athletes except in navicular of the wristof the wrist

Poor immobilizationPoor immobilizationResult of poor casting allowing for motion between bone partsResult of poor casting allowing for motion between bone partsMay prevent proper union or result in bony deformityMay prevent proper union or result in bony deformity


InfectionInfectionMay interfere with normal healing, particularly with May interfere with normal healing, particularly with

compound fracturescompound fracturesSevere streptococcal and staphylococcal infectionsSevere streptococcal and staphylococcal infectionsModern antibiotics has reduced the risk of infectionsModern antibiotics has reduced the risk of infectionsClosed fractures are not immune to infections within Closed fractures are not immune to infections within

the body or bloodthe body or blood If soft tissue alters bone positioning, surgery If soft tissue alters bone positioning, surgery

may be required to ensure proper unionmay be required to ensure proper union


Healing of Stress FracturesHealing of Stress Fractures

Result of cyclic forces, axial compression Result of cyclic forces, axial compression or tension from muscle pullingor tension from muscle pulling

Electrical potential of bone changes Electrical potential of bone changes relative to stress (compression, tension, or relative to stress (compression, tension, or torsional)torsional)

Constant stress axially or through muscle Constant stress axially or through muscle activity can impact bone resorption, activity can impact bone resorption, leading to microfractureleading to microfracture


If osteoclastic activity is not in balance with If osteoclastic activity is not in balance with osteoblastic activity bone becomes more osteoblastic activity bone becomes more susceptible to fracturessusceptible to fractures

Management: Decreased activity and elimination Management: Decreased activity and elimination of factors causing excess stress will be necessary of factors causing excess stress will be necessary to allow for appropriate bone remodeling to allow for appropriate bone remodeling To treat stress fractures a balance between osteoblast To treat stress fractures a balance between osteoblast

and osteoclast activity must be restoredand osteoclast activity must be restoredEarly recognition is necessary to prevent complete Early recognition is necessary to prevent complete

cortical fracturescortical fractures


What are the 4 Conditions that What are the 4 Conditions that may interfere with fracture may interfere with fracture

healing?healing?

Poor Blood SupplyPoor Blood SupplyPoor ImmobilizationPoor Immobilization InfectionInfectionSoft Tissues between severed ends of Soft Tissues between severed ends of

bonebone

PainPain

Major indicator of injuryMajor indicator of injury Pain is individual and subjectivePain is individual and subjective ATC needs to have balance between pain ATC needs to have balance between pain

and progressionand progression Factors involved in painFactors involved in pain

Anatomical structuresAnatomical structuresPhysiological reactionsPhysiological reactionsPsychological, social, cultural and cognitive Psychological, social, cultural and cognitive

factorsfactors


Scenario- Fracture HealingScenario- Fracture Healing

Pain CategoriesPain Categories

Pain sourcesPain sourcesFast versus slow painFast versus slow painAcute versus chronicAcute versus chronicProjected or referred painProjected or referred pain


Pain sourcesPain sourcesCutaneous pain: is sharp, bright and burning Cutaneous pain: is sharp, bright and burning

with fast and slow onset (lacerations, burns, with fast and slow onset (lacerations, burns, bumps)bumps)

Deep somatic pain: originates in tendons, Deep somatic pain: originates in tendons, muscles, joints, periosteum and blood vesselsmuscles, joints, periosteum and blood vessels

Visceral pain: begins in organs and is diffused at Visceral pain: begins in organs and is diffused at first and may become localized (appendix)first and may become localized (appendix)

Psychogenic pain: is felt by the individual but is Psychogenic pain: is felt by the individual but is emotional rather than physicalemotional rather than physical


What are the 4 Pain Sources?What are the 4 Pain Sources?

CutaneousCutaneousDeep somaticDeep somaticVisceralVisceralPyschogenicPyschogenic

Acute versus Chronic PainAcute versus Chronic PainAcute pain is less than six months in Acute pain is less than six months in

durationdurationChronic pain last longer than six monthsChronic pain last longer than six monthsChronic pain classified by International Chronic pain classified by International

Association for the Study of Pain (IASP) as Association for the Study of Pain (IASP) as pain continuing beyond normal healing timepain continuing beyond normal healing time


Referred PainReferred PainPain which occurs away from actual site of Pain which occurs away from actual site of

injury/irritationinjury/irritation

Unique to each individual and caseUnique to each individual and case

May elicit motor and/or sensory responseMay elicit motor and/or sensory response

Three types of referred pain include: myofascial, Three types of referred pain include: myofascial, sclerotomic, and dermatomicsclerotomic, and dermatomic


Myofascial PainMyofascial PainTrigger points or small hyperirritable areas Trigger points or small hyperirritable areas

within muscle resulting in bombardment of within muscle resulting in bombardment of CNS CNS

Acute and chronic pain can be associated Acute and chronic pain can be associated with myofascial pointswith myofascial points

Active points cause obvious complaintActive points cause obvious complaintTrigger points do not follow patternsTrigger points do not follow patterns


Nociception: Pain receptorsNociception: Pain receptorsPain receptors -free nerve endings Pain receptors -free nerve endings

sensitive to extreme mechanical, sensitive to extreme mechanical, thermal and chemical energythermal and chemical energy

Located in meninges, periosteum, skin, Located in meninges, periosteum, skin, teeth, and some organsteeth, and some organs

Afferent nerve fibers: transmit nerve Afferent nerve fibers: transmit nerve fibers towards the spinal cordfibers towards the spinal cord

Efferent nerve fibers: transmit nerve Efferent nerve fibers: transmit nerve fibers from the spinal cord to the fibers from the spinal cord to the periphery periphery


Facilitators and Inhibitors of Facilitators and Inhibitors of Synaptic TransmissionSynaptic Transmission

Nervous system is electrochemical in nature Nervous system is electrochemical in nature Chemicals called neurotransmitters are released by Chemicals called neurotransmitters are released by

pre-synaptic cell to transmit messagepre-synaptic cell to transmit message Two types mediate painTwo types mediate pain

EndorphinsEndorphinsSerotoninSerotonin

Neurotransmitters release stimulated by noxious Neurotransmitters release stimulated by noxious stimuli- resulting in activation of pain inhibition stimuli- resulting in activation of pain inhibition transmissiontransmission


Mechanisms of Pain Mechanisms of Pain Control:Control:

Three Models or TheoriesThree Models or Theories


1. Gate Theory1. Gate TheorySensory information from cutaneous receptors Sensory information from cutaneous receptors

enters the spinal cordenters the spinal cordPain simultaneously travels along A-delta and c-Pain simultaneously travels along A-delta and c-

fibersfibersSensory information overrides pain information, Sensory information overrides pain information,

closing gate, Pain message never receivedclosing gate, Pain message never receivedGate control occurs at the level of the spinal cordGate control occurs at the level of the spinal cord

Example: When you bump your head you rub it . Example: When you bump your head you rub it . Why?Why?


Gate Gate Control Control TheoryTheory

Figure 10-7


Descending Descending Pathway Pain Pathway Pain

ControlControl


Figure 10-8

2. Central Biasing (Descending pathway)2. Central Biasing (Descending pathway)Stimulation of descending pathways used to inhibit pain Stimulation of descending pathways used to inhibit pain

transmissiontransmission Involves release of enkephalin and norepinephrine Involves release of enkephalin and norepinephrine

release in dorsal horn blocking and inhibiting synaptic release in dorsal horn blocking and inhibiting synaptic transmissiontransmissionThe pain from the cut on your hand eventually subsides or The pain from the cut on your hand eventually subsides or

reduces to a lower intensity. reduces to a lower intensity. If you consciously distract yourself, you don't think about the If you consciously distract yourself, you don't think about the

pain and it bothers you less. pain and it bothers you less. People given placebos for pain control often report that the People given placebos for pain control often report that the

pain ceases or diminishes.pain ceases or diminishes.


Release of Release of ββ--

EndorphinsEndorphins


Figure 10-9

3.3. Release of B-endorphinsRelease of B-endorphins• Noxious stimuli can trigger endorphin Noxious stimuli can trigger endorphin

releaserelease• Stimulation of pain sensory fibers requiredStimulation of pain sensory fibers required• Causes release from hypothalamusCauses release from hypothalamus• Strong analgesic effectsStrong analgesic effects• IE: acupuncture, acupressure, runner’s IE: acupuncture, acupressure, runner’s

highhigh

Pain assessment: subjectivePain assessment: subjectiveSelf report is the best reflection of pain and discomfortSelf report is the best reflection of pain and discomfortUtilize multi- and uni-dimensional questionnairesUtilize multi- and uni-dimensional questionnairesAssessment techniques include: Assessment techniques include:

Visual analog scales (0-10, marked no pain to severe pain) Visual analog scales (0-10, marked no pain to severe pain) Pain charts: Location and scalePain charts: Location and scaleMcGill Pain questionnaire: 78 words may take 20 minutesMcGill Pain questionnaire: 78 words may take 20 minutesActivity pain indicator profiles: housework, runningActivity pain indicator profiles: housework, runningNumeric rating scale: VerbalNumeric rating scale: Verbal


Visual Analog ScaleVisual Analog Scale

Pain chart. Use the following instructions: “Please use all of the figures to show me exactly where all Pain chart. Use the following instructions: “Please use all of the figures to show me exactly where all your pains are, and where they radiate to. Shade or draw with your pains are, and where they radiate to. Shade or draw with blue markerblue marker. Only the athlete is to . Only the athlete is to fill out this sheet. Please be as precise and detailed as possible. Use yellow marker for fill out this sheet. Please be as precise and detailed as possible. Use yellow marker for numbness and tingling. Use red marker for burning or hot areas, and green marker for cramping. numbness and tingling. Use red marker for burning or hot areas, and green marker for cramping. Please remember: blue = pain, yellow = numbness and tingling, red = burning or hot areas, green Please remember: blue = pain, yellow = numbness and tingling, red = burning or hot areas, green = cramping.” Used with permission from Melzack R: Pain measurement and assessment, New = cramping.” Used with permission from Melzack R: Pain measurement and assessment, New York, 1983, Raven Press.York, 1983, Raven Press.

ModalitiesModalitiesMust have clear rationale for useMust have clear rationale for useUsed to relieve pain and control other signs and Used to relieve pain and control other signs and

symptoms of injury/surgerysymptoms of injury/surgeryMust use in conjunction with exerciseMust use in conjunction with exercise Induced analgesiaInduced analgesia

Introduce thermal agents for pain controlIntroduce thermal agents for pain controlUtilize electrical modalities to reduce painUtilize electrical modalities to reduce painTENS, superficial heat/cold, massage used to target Gate TENS, superficial heat/cold, massage used to target Gate

TheoryTheoryAcupuncture, electrical stimulation, deep massage used to Acupuncture, electrical stimulation, deep massage used to

stimulate endorphin releasestimulate endorphin release

Treating PainTreating Pain


Pharmacological AgentsPharmacological AgentsOral, injectable medicationsOral, injectable medicationsCommonly analgesics and anti-Commonly analgesics and anti-

inflammatory agentsinflammatory agents Important to work with referring physician Important to work with referring physician

or pharmacist to ensure patient is taking or pharmacist to ensure patient is taking appropriate medicationsappropriate medications


Psychological Aspects of Psychological Aspects of PainPain

Pain can be subjective and psychologicalPain can be subjective and psychological Pain thresholds vary per individualPain thresholds vary per individual Pain is often worse at night due to solitude and Pain is often worse at night due to solitude and

absence of external distractionsabsence of external distractions Personality differences can also have an impactPersonality differences can also have an impact Patients, through conditioning, are often able to Patients, through conditioning, are often able to

endure pain and block sensations of minor endure pain and block sensations of minor injuriesinjuries


Chapter 10: Tissue Response to Injury © 2011 McGraw-Hill Higher Education. All rights reserved.

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Transcript of Chapter 10: Tissue Response to Injury © 2011 McGraw-Hill Higher Education. All rights reserved.