Physical Medicine 204
What is primary intention?
Healing that occurs with minor wounds (small separation of tissue) or surgical wounds (where stump ends are sutured together). Re-epithelialization closes the wound in about 48 hrs
What is secondary intention?
Healing that occurs in large wounds (large separation of tissue) associated with soft tissue loss, usually with large scar formation and the healing process takes longer
In _________ , if the wound is dermal, infection may occur due to the greater length of time needed to close the wound.
Following an injury, the healing process that follows depends on __________ .
The extent of the injury and the approximation of the wound site's stump ends
When an injury occurs, damage to tissue causes chemicals to be released; examples of the chemicals are:
Histamine, prostaglandins, bradykinin, free radicals, etc.
What is a local tissue hormone that is activated by the interaction of proteases with the Hageman factor (a.k.a factor XII)? It is a very potent local vasodilator which increased vascular permeability, and it stimulates local pain receptors.
What is a local tissue hormone released by mast cells and granulocytes? It increases vascular permeability to proteins and fibronectin.
What is a hormone that is formed primarily from arachidonic acid as result of cell membranes damage? It mediates cell migration during inflammation and modulates serotonin and histamine.
What does PGE1 do with respect to the healing process?
Increases vascular permeability by causing vasodilation
What does PGE2 do with respect to the healing process?
It is a chemotactic that attracts other leukocytes to the area
Oftentimes chemicals affect cells by attaching to ________ on the cells; these chemicals can then enter the cell to stimulate or repress the cell's functions or alter the cell.
What are the four phases of tissue healing?
Hemostasis (immediate), inflammatory (acute), proliferative (subacute), and remodelling (can be chronic)
Chemicals released due to tissue damage have the following effects:
Nocistimulation (increased pain sensitivity), increases capillary permeability, and secondary cell damage (with too strong of a chemical response)
Specialized peripheral sensory neurons that alert us to potentially damaging stimuli at the skin by detecting extremes in temperature and pressure and/or injury-related chemicals, and transducing these stimuli into long-ranging electrical signals that are relayed to higher brain centres
Before applying rehabilitation techniques, it is important to discuss the following:
Proper nutrition and the role of proteins, vitamins, and minerals that play a part in tissue healing
The healing process is ________ without ________ between the healing phases. The body continues the process until the end is achieved.
Ongoing; clear-cut delineations
With any injury, local blood vessels are damaged, and it is the damage to the vasculature that ________ the body's response in the healing process.
In the hemostasis phase of healing, the main response is to:
Stop the blood flow into the injury site from locally damaged vessels
When blood and lymph vessels suffer damage, there is an immediate ________ that occurs in the small vessels. It is shortly followed by _________ .
In the hemostasis phase:
Platelets are activated when they reach the site of injury within the damaged vessels
Platelet activation (binding to exposed college ends) leads to the:
Creation of blood clot(s) via adhesion, the release of clotting factors, growth factors (e.g., PDGFs), cytokines, and the release of phospholipids
Platelets tether to collagen ends and thrombin in the formation of a blood clot, as well as ________ and ________ which bind together to reinforce the clot.
A blood clot provides the only ________ to a wound in the early stages of healing.
Lymph vessels are more _______ than blood vessels, and can also be damaged at the time of injury.
A ______ plug will be formed in lymph vessels, which blocks the lymph vessel and their ability to remove the excess fluid from the site of injury causing edema.
Once the injured site becomes stable, _________ is released that converts the insoluble fibrin to soluble fibrin and the lymph vessels start to perform their proper function (at about day 3).
The inflammatory phase is necessary to completely heal from an injury. However, _______ inflammation can be ________ .
If inflammation did not occur in the healing process, ________ , ________ , and ________ would not take place.
Proliferation; maturation; final resolution
The goal of the rehabilitation clinician is to allow _______ to occur, but to ________ it.
With inflammation, the goal is to minimize it, which is accomplished at the time of _______ by applying initial _______ (ice, compression, elevation, and rest).
Once a _____ forms the _______ phase begins, and it can take up to 2-3 days to 10 days to complete.
Platelets and other cells forming the fibrin clot release a wide array of chemicals at the site of injury, some of which attract other cells to the area: examples of cells are:
Leukocytes, fibroblasts, and additional platelets
At the injured site, cytokines are released by a variety of cells (platelets, WBC's, and endothelium). The roles of cytokines are:
- Expression of growth hormones
- Attracting macrophages, fibroblasts, and neutrophils
- Stimulating neovascularization
Within the first few hours of injury, the body tries to remove debris from the site via _______ .
Monocytes and macrophages move into the site of injury to remove debris (phagocytosis) and are predominate within ________ hours.
24 to 48
An ________ is formed from the fluid escaping from local vessels, dead tissue from injury, and dying neutrophils.
Inflammatory exudate if commonly _______ , whereas, exudate from an infection is more ________ due to its bacterial content.
Vascular permeability is initially caused by _______ release at the site of injury.
Histamine is ________ at the site of an injury, and serotonin (released by mast cells and platelets) and kinins (released by plasma) continue vascular permeability once histamine subsides.
Kinins are also short-lived at the site of injury, and prostaglandins take over once the _______ is formed.
Redness (Rubor), pain (dolar), swelling (tubor), hot (calor), and loss of function (laesea)
In the inflammatory phase, there can be ________ that leads to _______ and possible adhesion formation.
In the inflammatory phase the injury is often ________ , and the inflammatory phase typically lasts between 3 to 5 days.
Predominate cell types in the inflammatory phase:
PMN (neutrophils), macrophages, and fibroblasts
Anti-inflammatory drugs target _______ and _______ .
Inflammatory pain is caused by _________ which cause local nerve endings to become hypersensitive and irritable.
Histamines, prostaglandins, bradykinin, and pressure from local edema
Inflammatory temperature increase is caused by the increase in local ________ and _______ activity.
Inflammatory redness is caused by local ______ release at the site of injury and subsequent _______ .
Hormone (e.g., histamine); vasodilation
Inflammatory swelling is caused by increased ________ with the leakage of fluids, cells, and chemicals into the area. It is also caused by the blockage of _______ due to the fibrin plug.
Vascular permeability; lymph nodes
Inflammatory pain causes a _____ reflex, which can reduce the function of surrounding structures, limiting the patient's normal functioning ability.
The proliferation (subacute) phase of healing duration is from ________ weeks.
2 to 4
Once the macrophages in the inflammation phase remove the debris and dead tissue the ________ phase of healing starts.
Once debridement is completed, the proliferation phase begins with the growth and development of ________ . The cells responsible for this growth and development are the _______ .
New blood vessels and granulation tissue; fibroblasts
The transition to the proliferation phase sees an increase in ________ and a reduction or non-existence in ________ .
Fibroblasts; Polymorphonuclear leukocytes (neutrophil)
Fibroblasts are primarily responsible for new capillary and ________ formations during the proliferative phase.
Extracellular matrix (ECM)
During the proliferation phase, the initial wound matrix is soon replaced by a _______ matrix that is stronger which protects the new blood vessels that are forming.
Collagen (via fibroblasts)
The proliferation phase matrix presents as an _______ , where _______ start to lay down a significant amount of ______ collagen.
Unorganized scar; fibroblasts; Type III
By day 12 in the proliferative phase of healing, the stronger _______ collagen begins to replace the weaker _______ collagen.
Type I; Type III
The development and growth of new blood vessels (angiogenesis) and granulation tissue happens in the _______ of healing.
The combination of the matrix (fibrous (collagen, reticulin, and elastin) and non-fibrous (ground substance and GAG elements) and newly formed capillary buds form the _______ tissue.
Granulation tissue tends to have a bright _______ appearance due to the presence of capillary buds.
What is the enzyme that prevents overproduction of collagen in a wound, where overproduction would lead to the formation of a keloid?
During the proliferation phase, Type III collagen is _______ laid down, and later replaced by Type I collagen (more durable and stronger).
________ a GAG element, is a part of the extracellular matrix that draws water into the area to provide room for the proliferative fibroblasts.
_______ may form during the proliferation phase of healing.
Swelling during the proliferation phase is due to the:
Increase in new capillaries and water volume (via hyaluronic acid)
The remodelling (chronic) phase of healing can last between ______ months.
6 to 18
During the remodelling phase, the wound matures and converts into a ______ .
During the remodelling phase, wound _______ and _______ transition continue to occur.
_______ and _______ are responsible for wound contraction during the remodelling phase. Wound contraction makes the scar smaller.
Myofibroblasts (primarily); Fibroblasts (conversion to myofibroblasts)
If an injury occurs at or near a joint, scar tissue contraction and adhesions can cause a loss of ______ at that joint.
The scar of the remodelling phase continues to shrink, and can still be disorganized, as it would depend on any ________ .
During the remodelling phase there is reduced sensitivity to _______ and possible _______ weakness.
During the remodelling phase ________ continues to transition from Type III to Type I.
Scar tissue is often disorganized tissue, not as strong as the original, can form adhesions, but can be improved with _________ of the injured area.
Mobilization, exercise, etc.
_______ fibers with rehabilitation can be more in _______ (direction) with the original tissue. This increases the strength of the collagen.
Th greatest degree of function and mobility occurs when collagen is organized in a _______ fashion, as it can form the greatest number of _______ .
__________ is when the normal healing process gets STUCK in the inflammatory phase. This is where inflammatory cells such as macrophages and neutrophils are still present which would've normally diminished in number after the inflammatory phase was complete.
Pain of an injury can lead to ________ inhibition and disuse.
Muscle inhibition and disuse can lead to ______ .
Atrophy of muscle & ligament/bone, and altered movement patterns (biomechanics)
An immobilization of a muscle can lead to an ______ per week to ______ pre day loss of strength.
Weaker muscles, weaker connective tissue, and inefficient biomechanics can lead to ______ .
Chronic condition(s) or repeat injury
Goals of rehabilitation try to promote reduction in _______ and to promote ______ (strength, endurance, ROM, coordination, general fitness etc.).
The goals of rehabilitation _______ as an injured tissue progresses through the phases of healing.
How do you know what phase of healing an injury is in?
Range of motion (ROM), time from injury, history, and inflammation signs
What are the goals in the acute/inflammatory phase (first 3-5 days)?
- PRICE – protection, rest, ice, compression, elevation
- Prevent further injury
- Control inflammation
- Control pain
What are the goals in the subacute/proliferation phase (2-4 weeks after injury)?
- Do not aggravate the weak/healing tissue
- Control pain
- Gentle stretching (active/passive) and motion – prevent adhesions, maintain ROM, help quality of scar being formed, reduce congestion/swelling
- Gentle manual therapy – similar reasons
- Therapy to other areas affected but not directly injured sites (e.g., when you hurt the wrist, still work on elbow, shoulder)
What are the goals in the chronic/remodelling phase (6-18 months after injury)?
- Strengthen scar tissue to maximal attainable
- Strengthen surrounding muscle –disuse atrophy, pain inhibition
- Remove any trigger points (can be due to muscle imbalance)
- Restore function: ROM, strength, muscle balance, coordination, skill
With the application of cold to a site of injury there is an immediate ______ , then there is a long slow ________ .
Vasoconstriction with the application of cold is useful during which phase of healing?
After 5-20 minutes of cold application we see the _________ .
Lewis Hunting reaction (alternating vasodilation/constriction)
What are the effects of prolonged exposure to cold?
Local destructive freezing (e.g., frostbite, etc) and severe prolonged vasoconstriction which can lead to ischemia and necrosis of tissue.
What are the therapeutic effects of cold?
- Rate of conduction in peripheral nerves is slowed (less pain, less tissue damage)
- Slow local metabolic rate – slow chemical reactions (less inflammation)
What is the management for prolonged severe cold exposure?
Rapid warming in core-temperature water
When using cold therapies, you are cooling down an area and the body should be able to heat it back up again. However, with an abnormal Baruch test, using cold application can cause _______ .
What is the Baruch test used for?
To determine the vascular response to a cold stimulus, to also see if therapeutic cold is contraindicated
If the skin remains white after the Baruch test, follow up with the following procedure:
Wring out an ice towel and wrap around the forearm – rub briskly for 20 seconds. With cold and friction the blanched area should go red. If it remains white therapeutic cold is contraindicated.
A normal response to the Baruch test?
Scratch the skin with a blunt instrument: skin blanches, then turns red (even a slight flare)
Contraindications to cold therapy are:
- Reynaud's Disease/Phenomenon
- Heart disease (esp. MI with in 6 months)
- Peripheral nerve and peripheral vascular disease
- Compartment syndrome
- Psychological aversion to cold
- Cold allergies – histamine release, can even get anaphylaxis
- Pernio (sequela to frostbite, the area heals but has hypersensitivity to cold)
Indications for cold therapy are for ________ as it helps reduce inflammation, congestion, and pain.
Acute musculoskeletal injuries
When applying cold therapy, the patient may feel:
CBAN – Cold, Burning, Aching, Numbness – process takes ~ 10 min (for maximal therapeutic benefit)
Examples of cold application:
Cold Packs, ice (cube) Massage, ice towels, immersion/Ice bath (Set TIMER to ensure no more than 10-15 min!!!!!!!)
During the acute/inflammation phase, you can apply cold every _______ hours, because you want the body to warm in between.
1 to 2
Cold application can be used after activity during the ________ .
Application of superficial heat usually penetrates less than or equal to ______ millimetres.
Examples of heat application:
Hydrocollators, microwaveable gel packs, electric heating pads, etc.
Superficial heat physiological effects are:
Vasodilation (helpful in later phases of healing), increase in metabolic rate (Vaunt Hoff Law), and sedative effect on nerves (less spasm and pain)
________ is contraindicative in the acute/inflammatory phase of healing, as heat can increase swelling.
Superficial heat is not to be used if diagnosis of ______ is unknown, you must also rule out any contraindications.
Contraindications for superficial heat therapy are:
Acute inflammation, malignancy, deep infection, bleeding or clotting disorders, decompressed heart disease, peripheral vascular disease (clinically evident), diabetes (small vessel disease), inflammatory skin conditions, contact dermatitis, high fever, eyes, burns of any kind, infants, pregnant uterus (whole body)
Indications for superficial heat therapy are:
Neuritis/neuralgia, contusion (bruise - following inflammatory phase), sprain/strain, pain or spasm, tendonitis, synovitis, tenosynovitis, fibrositis, fasciitis, myofascitis, myofibrositis, bursitis, arthritis, superficial skin infections, and frost bite