Therapeutic Exercise I Chapter 10

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Therapeutic Exercise IChapter 10

• Soft Tissue Injury, Repair, and Management

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Three Stages of Tissue Recovery

• Acute (Inflammatory reaction) redness, swelling,
  heat, pain at rest and lost of
• motion muscle guarding is a way to immobilize
  the area and usually last 4-6 days
• Sub-Acute (Repair and healing) signs of
  inflammation decreases, pain is felt when
  stressing
• new tissue beyond its tolerance, muscle may test
  weak and function will be limited usually
• lasts 10-17 days (14-21 days after onset) and
  may last up to 6 weeks
• Chronic (Maturation and remodeling) no signs of
  inflammation, may have contractures/adhesions
  with limited ROM and weakness, poor endurance and
  neuromuscular control limiting function,
  connective tissue remodel/strengthen during this
  stage and may last
• up to 6 months to 1 year pending the amount of
  damage
• The Physical Therapist will examine, evaluate,
  and create a program to assess the impairments
  and develop functional and obtainable goals for
  the patient. The programs will be patient
  specific and appropriate for the stage of healing

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Examples of Soft Tissue Lesions-Musculoskeletal
Disorders

• Strain
• Sprain
• Dislocation
• Subluxation
• Muscle/Tendon rupture or tear
• Tendinous lesion/tendinopathy
• Tenosynovitis
• Tenovaginitis
• Tendinosis

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Continued Examples of Soft Tissue
Lesions-Musculoskeletal Disorders

• Synovitis
• Hemarthrosis
• Ganglion
• Bursitis
• Contusion
• Overuse Syndrome

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Clinical Conditions Resulting from Trauma
Pathology

• Dysfunction
• Joint dysfunction
• Contractures
• Adhesions
• Reflex muscle guarding
• Intrinsic muscle spasm
• Muscle weakness
• Myofascial compartment syndromes

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Severity of Tissue Injury

• Grade 1 (first degree)-Mild pain within the first
  24 hours, with mild swelling, local tenderness,
  and pain when the tissues are stressed
• Grade 2 (second degree)-Moderate, requires
  stopping the activity, stress and palpation to
  the tissue causing increase pain, when it is a
  ligament-some fibers are torn resulting in
  increase joint mobility
• Grade 3 (third degree)-Severe, near
  complete/complete tear of avulsion of the tissue
  (tendon/ligament) with severe pain, stresses to
  the joint do not involve pain and palpation may
  reveal defect, torn ligaments results in
  instability of the joint

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Irritability of Tissue Stages of Inflammation
and Repair

• Acute Stage
• Subacute Stage Discussed in
  earlier slide
• Chronic Stage
• Chronic Inflammation (Overuse syndrome)-increase
  complaints of pain, swelling, and muscle guarding
  lasting more than several hours after activities,
  stiffness, loss of ROM 24 hours after activity
• Chronic Pain Syndrome persistent pain longer
  than 6 months-physical, emotional, and
  psychosocial parameters pain inconsistent with
  source of irritation, inflammation, functional
  limitation, disability

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Management Guidelines-Protection Phase

• Control the effects of swelling, facilitate wound
  healing and maintain normal joint function
• Patient education (HEP)
• Minimize pain/swelling by 1st 24-48 hours with
• rest, cold, compression and elevation
• Prevent adverse reactions from immobilization
• Tissue specific movement to prevent abnormal
  adherence
• Gentle intensity to prevent increase
  pain/swelling
• General movements to uninjured tissue and to aid
• in circulation/lymphatic flow

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Specific Interventions And Dosage For The
Protection Phase

• PROM
• Low-dosage joint mobilization techniques
• Muscle setting
• Massage
• Interventions for Associated Areas- ROM, Muscle
  performance, functional activities, and
  circulation

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Management Guidelines-Controlled Motion Phase

• During the 2nd-4th day after tissue injury, the
  inflammation begins to decrease
• Clots start and repair begins
• Last 10-17 days and may last up to 6 weeks
• Noxious stimuli are removed, and capillary beds
  begin to grow
• Fibroblastic activity, collagen formation, and
  granulation tissue development increases
• Production of new collagen takes place of the
  formed clot
• Scar linkage caused by myofibroblastic activities
  occurs at
• day 5
• Wound closure in muscles and skin takes 5-8 days
• Wound closure in tendons and ligaments takes 3-6
  weeks

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Management Guidelines-Controlled Motion
Phase-Continued

• The key is to initiate and progress
  nondestructive exercises/activities
• Patient education (HEP)
• Management of pain and inflammation prior to
  initiating active exercise and stretching.there
  should be no increase signs of pain/swelling
• Monitor activities and exercise specifically new
  ones and modify as needed

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-In The Controlled Phase-Initiation of

• Active Exercises
• --Multiangle, submaximal isometrics
• --Active ROM
• --Muscular endurance
• --Protected weight bearing
• activities

• Stretching
• --Warm the tissues
• --Inhibition techniques
• --Joint mobilization
• --Stretching techniques
• --Massage
• --Use of new range
• --Correction of contributing
• factors

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Management Guidelines-Return to Function Phase

• Scar retraction from activity of the
  myofibrobalsts is usually complete by the 21st
  day and it stops increasing in size
• From 21-60 day, there is a predominance of
  fibroblasts that are easily remodeled
• Maturation begins late in the sub-acute stage and
  continues for several months
• Remodeling time is influenced by factors how
  long immobilized, stress placed on tissue,
  location of lesion, and vascular supply
• Maturation of tissue is possible up to 10 weeks
  and at
• 14 weeks the tissue becomes unresponsive to
• remodeling

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Management Guidelines-Return to Function
Phase-Continued

• Safe combination of stretches and strengthening
  to maturing tissuethis should be a balanced
  combo
• Patient education (HEP)
• To avoid pain/soreness, contractures need to be
  stretched/mobilized or adhesions broken up ie
  cross friction massage
• Proper performance/guidelines set up
• Consideration of progression of exercisesas long
  as no adverse reaction is felt

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Tissue Response To Chronic Inflammation-(Prolong
/Recurring Pain)

• Tissue that is stressed beyond the ability to
  repair itself, the inflammation is perpetuated
• New immature collagen is produced, which weakens
  the effect of tissue
• Microfibroblastic activities continues, which may
  lead to loss of motion
• With efforts to stretch the inflamed tissue, this
  may lead to additional irritation and progressive
  limitations
• Mechanical causes need to be identified

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Management of Chronic Inflammation

• Start treatment as it is an acute condition with
  the focus on decreasing the inflammation to avoid
  continued tissue breakdown and excessive scar
  formation-
• avoid cross friction massage
• Once inflammation is down, treat impairments and
  functional limitation
• Acute stage with use of modalities and rest and
  correct faulty biomechanics
• Educate the patient in repeated trauma and the
  lack of healing process
• Allow only non-stressful activities/exercises

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Sub-acute and chronic stages of healing following
Chronic Inflammation

• Once decreased, progress exercises slowly to
  allow connective tissue to be able to withstand
  the stresses in functional activities
• May need to mobilize a scar
• If ROM is lost, too much stretching has been
  applied
• Remember Muscle guarding is a protective
  mechanism
• Identify faulty movements
• Work on muscle endurance to sustain repetitive
  activities
• Progress towards function (HEP)
• May use work-conditioning/work-hardening programs
  or sports-specific exercises

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Break for Lab with Lecture on UE Manual
Resistance Exercises, Mechanical Resisted
Exercises,Selected Resistance Training Regimens,
Equipment for Resisted Training

• Resistance Techniques in Anatomical Planes of
  Motion/Diagonals of the UEs
• (If time permits may review LEs)