Use of Modalities to Affect Healing Process

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Use of Modalities to Affect Healing Process

• ESAT 3640
• Therapeutic Modalities

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Primary and Secondary Healing

• Healing by primary intention
• Healing by secondary intention

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Modalities and Healing

• Use of modalities based on theoretical knowledge
  and practical experience
• Protocols and progression based primarily on
  physiological responses of the injured tissue and
  an understanding of the healing process
• Signs and symptoms
• Phases of healing

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Healing Process

• 3 Phases on a continuum

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Inflammatory Phase

• Physiological changes in this phase set the stage
  for later stages of healing
• Once tissue is injured, the healing process
  begins immediately
• Cellular injury results in altered metabolism and
  the liberation of materials that initiate
  inflammatory response

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Signs of Inflammation

• Redness
• Swelling
• Tenderness to touch
• Increased temperature
• Loss of function

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Chemical Mediators

• Leucotaxin
• Responsible for margination in which leukocytes
  line up along the cell wall
• Increases cell permeability
• Necrosin
• Responsible for phagocytic activity

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Chemical Mediators

• Serotonin
• Kinins
• Prostoglandins

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Cellular Response During Inflammation

• Phagocytosis
• Destruction and ingestion of cellular debris
• Leukocytes
• Cellular reaction is generally protective
• Localization or disposal of injury by-product

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Vascular Reaction During Inflammation

• Vascular spasm
• Formation of a platelet plug
• Blood coagulation
• Growth of fibrous tissue

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Chemical Mediators

• Histamine
• Release from injured mast cells
• Causes vasodilatation increased cell
  permeability
• Swelling of endothelial cells then separation
  between the cells

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Edema

• What is edema?
• Amount of edema is proportional to
• Severity of injury
• Changes in vascular permeability
• Amount of primary and secondary hemorrhaging
• Presence of chemical inflammatory mediators

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Edema Continued

• Fluid movement depends on 3 basic forces
• Vascular hydrostatic pressure (capillary to
  tissue)
• Plasma colloid osmotic pressure (fluid from
  tissue to capillary)
• Limb hydrostatic pressure

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Function of Platelets

• Do not normally adhere to the vascular wall
• Injury disrupts endothelium exposing collagen
  fibers
• Platelets adhere to collagen fibers creating
  sticky matrix
• Forms a Plug
• Plugs obstruct local lymphatic drainage
  localizing the injury

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Clotting Process
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Chronic Inflammation

• Occurs when the acute inflammatory response does
  not eliminate the injuring agent and restore
  tissue to its normal physiological state
• Leukocytes are replaced by
• Macrophages, Lymphocytes, Plasma
• Accumulated in a highly vascularized innervated
  loose connective tissue matrix in the area of
  injury

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Chronic Inflammation

• Mechanism that changes acute to chronic is
  unclear
• Seems to be associated with overuse or overload
  with cumulative microtrauma to a particular
  structure

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Fibroblastic Repair Phase

• Scar formation and repair of injured tissues
• Fibroplasia scar formation
• SS of inflammatory phase subside
• Revascularization
• Capillary buds grow into wound in response to
  lack of O2
• Aerobic healing of wound

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Scar Formation

• Granulation tissue
• Forms as fibrin clot breaks down
• Consists of fibroblasts, collagen, and
  capillaries
• Reddish granular mass of connective tissue which
  fills in gaps during the healing process
• As capillary formation continues, fibroblasts
  accumulate and lay down parallel to capillaries

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Fibroblastic Cells

• Synthesize extracellular matrix containing
  collagen and elastin fibers, and a ground
  substance
• Day 6 or 7 fibroblasts begin producing collagen
  fibers that are randomly distributed throughout
  the forming scar
• As collagen increases, tensile strength of wound
  increases
• leading to fewer fibroblast
• Signals beginning of maturation phase

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Spaghetti Analogy
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Remodeling Phase

• Wound contraction
• Shrinking of scar
• Water content of scar reduced
• Vascularity and redness reduce
• Scar tissue density increases

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Maturation Remodeling Phase

• Long-term process
• Realignment of collagen fibers parallel to lines
  of tension
• Eventually takes on normal appearance and
  function
• However, scar tissue is never as strong as
  original tissue

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Factors That Impede Healing

• Extent of Injury
• Edema
• Hemorrhage
• Poor Vascular Supply
• Seperation of Tissue
• Muscle Spasm
• Atrophy

• Corticosteroids
• Keloids Hypertropic Scars
• Infection
• Humidty, Climate, O2 Tension
• Health, Age, Nutrition

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Different Phases of the Healing Process
Modalities

• Acute vs. Chronic Injury
• Immediate 1st Aid Management
• Rest
• Ice
• Compression
• Elevation
• EMS Currents and Gate Control

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Inflammatory-Response Phase

• Modalities that control pain and decrease
  swelling
• Contrast bath??
• Intermittent compression
• EMS Pain modulation
• AROM PROM

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Fibroblastic-Repair Phase

• May change from cold to heat
• Swelling as an indicator
• EMS
• Pain modulation
• Muscle contraction
• Trigger point stimulation

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Maturation-Remodeling Phase

• Deep Heat
• US
• EMS

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Progressive Controlled Mobility During Maturation
Phase

• Wolffs Law
• Bone and soft tissue will respond to the
  physical demands placed upon them causing them to
  remodel or realign along lines of tensile force
• Injury needs to be exposed to progressively
  increasing loads, especially in the remodeling
  phase