soft tissue and healing

• Merrick (2002) hypothesized 2 stages following tissue injury

  1. Primary injury – direct mechanical damage to cells e.g., crush, strain force, contusion, disrupting cell membranes causing loss of homeostasis and cellular death; could involve ligaments, tendon, muscle, nerve and connective tissues.
  2. Secondary injury – is the physiological responses following primary injury occurring at the periphery of the injury; it may occur as a hypoxic or ischaemic (decreased blood flow) and enzymatic mechanisms (destroys lysosomes, destroys cell membrane, causing cells to swell and subsequently die).
• phase 1 and 2 of tissue healing and repair

  • Phase 1: bleeding (0-10 hours) 
  • Phase 2: Inflammation (0-4 days)
• Physiotherapy interventions in Phases 1&2 (0-72 hours post-injury), the aims are: 

  1. Reduce pain 
  2. Limit inflammatory exudates 
  3. Reduce metabolic demands of tissues 
  4. Protect newly damaged tissue from further injury 
  5. Protect newly-forming tissue from disruption
  6. Promote new tissue growth and fiber realignment 
  7. Maintain general levels of cardiovascular and musculoskeletal fitness and activity 
• Phase 3: tissue proliferation, fibrous repair (1-10+ days post-injury)

  • Ongoing phagocytosis
  • Angiogenesis – formation of new blood vessels 
  • Proliferation of fibroblasts 
  • Production of collagen fibers – initially produced in an unordered and random fashion  
  • Absorption of inflammatory exudate
• What is one of the general aims of physiotherapy in the tissue proliferation stage during phase 3?


  Decreasing pain
• What is another aim of physiotherapy in the tissue proliferation stage?


  Decreasing swelling
• What is a third aim of physiotherapy in the tissue proliferation stage?


  Decreasing local temperature
• What is an aim of physiotherapy related to trauma in the tissue proliferation stage?


  Preventing further trauma
• What is an aim of physiotherapy concerning new tissue in the tissue proliferation stage?


  Protecting new tissue
• What is an aim of physiotherapy related to movement in the tissue proliferation stage?


  Increasing range of movement
• What is an aim of physiotherapy concerning muscle strength in the tissue proliferation stage?


  Maintaining/increasing muscle strength, timing and control
• What is an aim of physiotherapy regarding non-injured tissues in the tissue proliferation stage?


  Preventing soft tissue adaptation in non-injured tissues
• What is an aim of physiotherapy related to overall performance in the tissue proliferation stage?


  Improving function
• What is the general rule for returning to exercise and activity in the proliferative stage?


  • Any activity or exercise that provokes pain classified with a High SIN (pain severity, irritability, and nature) factor should be avoided.
• phase 4 tissue remodeling key processes

  • Ongoing fibroblasts activity and collagen production
  • Deposition of new fibrous tissue 
  • Scar tissue formation
  • Type III collagen fibers being replaced by type 1 collagen fibers
• factors influencing the clinical reasoning process for the management of patients tissue healing and repair

  • Anatomy
  • Environment
  • Pathology
  • Histology
  • Biomechanics
  • Sociology
  • Kinesiology
  • Psychology
  • Physiology
  • Therapeutic effects of treatment modalities
• What is the primary aim of physiotherapy in the remodeling stage, phase 4?


  To promote collagen growth and fiber/tissue realignment
• How does physiotherapy aim to increase range of motion (ROM) during the remodeling stage?


  By using active, passive, and accessory movements
• What is a key focus in increasing muscle strength during the remodeling phase?


  Improving control and timing of muscle contractions
• Why is it important to prevent soft tissue adaptation in both injured and non-injured tissues?


  To maintain optimal function and prevent complications
• What is the goal of maximizing function in physiotherapy during the remodeling stage?


  To enhance the overall performance of the injured structures
• When should movement and mobility of the injured structures be promoted post-injury?


  Between 3 to 10 days post-injury
• What is the purpose of preventing tissue contraction and adhesion formation during the remodeling phase?


  To ensure proper healing and restore function
• When should end-of-range stretching commence after an injury?


  In the 3rd week post-injury
• What happens to fibroblastic activity and collagen fibers during the remodeling stage?


  They continue to be laid down, peaking at 2-3 weeks post-injury
• How long can fibroblastic activity and collagen fiber deposition continue after a severe injury?


  Up to 4-6 weeks and longer