Using Therapeutic Modalities To Affect The Healing Process.

Using Therapeutic Modalities To Affect The Healing Process

Using Therapeutic Modalities To Affect The Healing Process

Phases of the Healing ProcessPhases of the Healing Process

Inflammatory- Response PhaseInflammatory- Response Phase Fibroblastic-Repair PhaseFibroblastic-Repair Phase Maturation-Remodeling PhaseMaturation-Remodeling Phase

Healing Process Is A ContinuumHealing Process Is A Continuum

Injury Day 4 Week 6 2-3 Years

Inflammatory-Response Phase



Inflammatory-Response PhaseFibroblastic-Repair Phase



Inflammatory-Response PhaseFibroblastic-Repair PhaseMaturation-Remodeling Phase

Inflammatory-Response PhaseInflammatory-Response Phase

Symptoms Include Swelling, Pain, Warmth, Symptoms Include Swelling, Pain, Warmth, and Crepitusand Crepitus

Direct Destruction Of Soft Tissue CellsDirect Destruction Of Soft Tissue Cells Vascular ReactionVascular Reaction Cellular ReactionCellular Reaction

Vascular ReactionVascular ReactionInjury

Immediate Vasoconstriction Of Vascular Walls

Vasodilation With Hyperemia

Stagnation and Stasis

(Initial Effusion of Blood and Plasma Lasts24-36 Hours)

Immediate Vascular ReactionImmediate Vascular ReactionInjury

Vessels Endothelium Disrupted

Platelets Adhere To Exposed Collagen

Sticky Matrix For Platelets and Leukocytes

Formation of A Plug

Obstructs Local Lymphatic Drainage

Localizes Injury Response

Cellular ReactionChemical Mediators Released From Cell

Cellular ReactionChemical Mediators Released From Cell

Histamine Vasodilation & Cell PermeabilityHistamine Vasodilation & Cell Permeability Leucotaxin Margination Leucotaxin Margination (Leukocytes Line Cell Wall) (Leukocytes Line Cell Wall)

& Cell Permeability Forming Exudate& Cell Permeability Forming Exudate

Necrosin Turns On PhagocytesNecrosin Turns On Phagocytes

Clot Formation

Damaged Cell

Thromboplastin

Prothrombin

Thrombin

Fibrinogen

Fibrin ClotCompleted Within 48 Hours

Clot Formation

Damaged Cell

Thromboplastin

Prothrombin

Thrombin

Fibrinogen

Fibrin ClotCompleted Within 48 Hours


Injured Area Is Walled-OffInjured Area Is Walled-Off Leukocytes Phagocytize Foreign DebrisLeukocytes Phagocytize Foreign Debris Sets Stage For Fibroblastic-Repair PhaseSets Stage For Fibroblastic-Repair Phase Lasts 2-4 Days After Initial InjuryLasts 2-4 Days After Initial Injury

Chronic InflammationChronic Inflammation Occurs When Acute Response Does Not Occurs When Acute Response Does Not

Eliminate Injuring AgentEliminate Injuring Agent Leukocytes Replaced By Macrophages, Leukocytes Replaced By Macrophages,

Lymphocytes, and Plasma CellsLymphocytes, and Plasma Cells Specific Mechanism Which Causes Specific Mechanism Which Causes

Conversion Is UnknownConversion Is Unknown Overuse or Overload With Cumulative Overuse or Overload With Cumulative

Repetitive MicrotraumaRepetitive Microtrauma

Fibroblastic-Repair PhaseFibroblastic-Repair Phase

Proliferative, Regenerative Activity Which Proliferative, Regenerative Activity Which Leads To A Period Of Scar Formation Leads To A Period Of Scar Formation (Fibroplasia) And Repair Of Injured Tissue(Fibroplasia) And Repair Of Injured Tissue


FibroplasiaFibroplasia

Begins Within The First Few Hours Begins Within The First Few Hours Following InjuryFollowing Injury

Signs Of Inflammation SubsideSigns Of Inflammation Subside Pain and Tenderness To TouchPain and Tenderness To Touch May Last 4-6 WeeksMay Last 4-6 Weeks

Vascular ReactionVascular ReactionGrowth of Endothelial Capillary Growth of Endothelial Capillary

Buds Into the AreaBuds Into the Area

(Stimulated By Lack of Oxygen)(Stimulated By Lack of Oxygen)

Increased Blood FlowIncreased Blood Flow

Increased delivery of Essential Increased delivery of Essential Nutrients for Tissue RegenerationNutrients for Tissue Regeneration

Cellular ReactionCellular ReactionBreakdown of Fibrin ClotBreakdown of Fibrin Clot

Formation of Granulation TissueFormation of Granulation Tissue

(Fibroblasts,Collagen,Capillaries)(Fibroblasts,Collagen,Capillaries)

Fibroblasts Accumulate Along Fibroblasts Accumulate Along Capillary BedsCapillary Beds

Synthesizes Extracellular MatrixSynthesizes Extracellular Matrix

(Collagen,Elastin,Ground Substance)(Collagen,Elastin,Ground Substance)

By Day 6 or 7By Day 6 or 7

Fibroblasts Begin Producing Collagen Fibroblasts Begin Producing Collagen Which Is Deposited Randomly Throughout Which Is Deposited Randomly Throughout the Scarthe Scar

Tensile Strength Increases Proportionally Tensile Strength Increases Proportionally To Collagen SynthesisTo Collagen Synthesis

Normal SequenceNormal Sequence

Formation of Minimal ScarFormation of Minimal Scar Increase in Tensile Strength and a Decrease Increase in Tensile Strength and a Decrease

in the Number of Fibroblasts Signals the in the Number of Fibroblasts Signals the Beginning of the Maturation-Remodeling Beginning of the Maturation-Remodeling PhasePhase

Abnormal ResponseAbnormal Response

Persistent Inflammatory Response Causes Persistent Inflammatory Response Causes Extended Fibroplasia and FibrogenesisExtended Fibroplasia and Fibrogenesis

Maturation-Remodeling PhaseMaturation-Remodeling Phase

Realignment of Collagen Fibers Along Realignment of Collagen Fibers Along Lines of Tensile ForceLines of Tensile Force

Ongoing Breakdown/Synthesis of CollagenOngoing Breakdown/Synthesis of Collagen Increase in Tensile Strength of Scar MatrixIncrease in Tensile Strength of Scar Matrix At 3-weeks a Contracted, Non-vascular At 3-weeks a Contracted, Non-vascular

Scar ExistsScar Exists May Require Several Years To CompleteMay Require Several Years To Complete

Role of Controlled MobilityRole of Controlled Mobility

Wolff’s Law Wolff’s Law - Bone and Soft Tissue - Bone and Soft Tissue Will Respond to the Physical Will Respond to the Physical Demands Placed on Them Causing Demands Placed on Them Causing Them to Remodel Along Lines of Them to Remodel Along Lines of Tensile ForceTensile Force

You Must Expose Injured Structures To Increasing Loads

During The Maturation -Remodeling Phase

You Must Expose Injured Structures To Increasing Loads

During The Maturation -Remodeling Phase

Controlled Mobilization Superior To Immobilization

Controlled Mobilization Superior To Immobilization

Decreases Scar FormationDecreases Scar Formation Increases RevascularizationIncreases Revascularization Facilitates Muscle RegenerationFacilitates Muscle Regeneration Reorientation of Muscle and Ligament Reorientation of Muscle and Ligament

FibersFibers

Immobilization During the Inflammatory-Response Phase

Will Facilitate Healing By Controlling Inflammation

Immobilization During the Inflammatory-Response Phase

Will Facilitate Healing By Controlling Inflammation

Progression CriteriaProgression Criteria

Use Aggressive Active ROM ExercisesUse Aggressive Active ROM Exercises Use Pain and Increased Swelling as GuidesUse Pain and Increased Swelling as Guides

Factors That Impede HealingFactors That Impede Healing

Extent of InjuryExtent of Injury EdemaEdema HemorrhageHemorrhage Poor Vascular SupplyPoor Vascular Supply Separation of TissueSeparation of Tissue Muscle SpasmMuscle Spasm

Atrophy Atrophy CorticosteroidsCorticosteroids Keloids and Keloids and

Hypertrophic ScarsHypertrophic Scars InfectionInfection Humidity, ClimateHumidity, Climate Age, Health, NutritionAge, Health, Nutrition

Using Specific Modalities During Different Phases of

Healing

Using Specific Modalities During Different Phases of

Healing

Immediate First Aid Management of InjuryImmediate First Aid

Management of Injury

Minimize the Early Effects of Excessive Inflammation By:

Minimize the Early Effects of Excessive Inflammation By:

Controlling EdemaControlling Edema Modulating PainModulating Pain Facilitating HealingFacilitating Healing

Initially Everything You Do Should Be Directed Toward

Limiting The Amount Of Swelling

Initially Everything You Do Should Be Directed Toward

Limiting The Amount Of Swelling

If You Limit The Amount Of Swelling Initially You Will

Significantly Decrease The Time Required For Rehabilitation

If You Limit The Amount Of Swelling Initially You Will

Significantly Decrease The Time Required For Rehabilitation

Immediate First AidImmediate First Aid

PProtectionrotection

RRestricted Activityestricted Activity

IIce ce

CCompressionompression

EElevationlevation

ProtectionProtection Protect From Additional Injury By Protect From Additional Injury By

Applying Appropriate Splints, Pads, Braces, Applying Appropriate Splints, Pads, Braces, or Other Immobilization Devicesor Other Immobilization Devices

Restricted Activity(Rest)

Restricted Activity(Rest)

Allow the Inflammatory-Response Phase to Allow the Inflammatory-Response Phase to Do What It Is Supposed To Without Do What It Is Supposed To Without InterferingInterfering

Rest Does Not Mean Do Nothing!Rest Does Not Mean Do Nothing!

IceIce

Decreases metabolism To Control Decreases metabolism To Control Secondary Hypoxic InjurySecondary Hypoxic Injury

AnalgesiaAnalgesia Possibly Cause VasoconstrictionPossibly Cause Vasoconstriction Use for 20 Minutes - 1 HourUse for 20 Minutes - 1 Hour Use Ice Bags, Ice Packs, CryocuffUse Ice Bags, Ice Packs, Cryocuff

CompressionCompression

Mechanically Reduces Space For Swelling Mechanically Reduces Space For Swelling To AccumulateTo Accumulate

Use An Elastic Wrap and Compression Use An Elastic Wrap and Compression Dressing For At Least 72 HoursDressing For At Least 72 Hours

Use Intermittent Compression, Cryocuff, Use Intermittent Compression, Cryocuff, Elastic WrapsElastic Wraps

ElevationElevation

Reduces Pooling of Blood in the Reduces Pooling of Blood in the ExtremitiesExtremities

Facilitates Venous and Lymphatic DrainageFacilitates Venous and Lymphatic Drainage

Modulating PainModulating Pain

Cold Can Be Used For AnalgesiaCold Can Be Used For Analgesia Electrical Stimulating Currents May Also Electrical Stimulating Currents May Also

Be UsedBe Used Low-Power LASER Has Been Low-Power LASER Has Been

Recommended For Pain ModulationRecommended For Pain Modulation

Facilitating HealingFacilitating Healing

Low Intensity Ultrasound Can Be Effective Low Intensity Ultrasound Can Be Effective In Facilitating The Healing Proces and Can In Facilitating The Healing Proces and Can Be Used Safely Immediately Following Be Used Safely Immediately Following InjuryInjury

Inflammatory-Response PhaseInflammatory-Response Phase As with First Aid Management, modalities

should be used to control pain and reduce swelling

Cryotherapy should still be used to reduce likelihood of swelling

Ice bags, cold packs, or ice massages provide analgesic effects

Heating an injury too soon is a bigger mistake than using ice on an injury for too long


Intermittent compression can decrease swelling by facilitating resorption of the by-products of inflammatory process by lymphatic system

Electrical stimulating currents and low-power laser can be used to help reduce pain

Incorporate active and passive ROM exercise


Treatments may change from cold to heat

Thermotherapy techniques may include hydrocollator packs, paraffin, warm

whirlpool to increase circulation to the injured area to promote healing

Heat modalities can also produce some degree of analgesia.


Intermittent compression can facilitate removal of injury by-products

Electrical stimulating currents assist process by eliciting a muscle contraction inducing a muscle pumping action

Electrical currents can be used for modulation of pain, as can stimulation of trigger points with low-powered laser


Continue to stress importance of ROM and strengthening exercises and progress them appropriately during this phase


Heating modalities are beneficial to healing

Deep-heating modalities, ultrasound, shortwave and microwave diathermy used to increase circulation to deeper tissues

Superficial heating modalities are less effective


Electrical stimulating currents used both in pain modulation and to stimulate muscle contractions for increasing both ROM and strength

Low-power laser used to modulate pain

Role of controlled mobility

Goal For Using Therapeutic Modalities

Goal For Using Therapeutic Modalities

Assist the Natural Healing Processes of the Assist the Natural Healing Processes of the Body While Doing No HarmBody While Doing No Harm

Using Therapeutic Modalities To Affect The Healing Process.

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