Day 2 Orthopedic Management, Tissue Response Concorde Career College

 Movement as medicine  Structure determines function  Function will change structure over time  Human body can adapt to load/stress over time  PT and PTA’s as experts in arranging, sequencing, organizing movement progressions and regressions over time.  Not all movement is created equal  Movement that is functional  Movement that is single plane that contributes to tri-planar movement

 PTA as movement assessor  A successful PTA will understand what normal movement looks like and how each component part contributes to the functional movement patterns orchestrated by the CNS to accomplish a functional task  A successful PTA will know how to identify inadequate movement patterns and effectively communicate the pattern to the PT  A successful PTA will progress and regress the procedures within the plan of care

 Sequenced process and procedures for maximum impact and effectiveness  Prep - Ice/MHP/CPM/US/  Relax – STM, Stretching, ROM, Manual Techs  Movement Restoration/Instruction Strengthening – PNF, resistance training, Fx movt Coordination – PNF, functional movement  Calm – Modalities  Learning Consolidation HEP Concorde Career College

 Describe the major classifications of musculoskeletal injuries  Discuss orthopedic diagnoses to include surgical repairs  Describe therapeutic interventions to include precautions and contraindications Concorde Career College

 Strains  Sprains  Dislocation  Subluxation  Muscle/tendon rupture or tear  Tendinopathy  Synovitis  Hemarthrosis  Ganglion  Bursitis  Contusion  Overuse Syndrome Concorde Career College

 Strain Overstretching Overexertion Overuse of soft tissue. Generally refers to disruption of the musculotendinous unit. Concorde Career College

 Sprain Severe stress, stretch, or tear of joint capsule, ligament, tendon, or muscle. Generally refers to disruption of a ligament. Graded  1st degree - mild  2nd degree - moderate  3rd degree - severe

 Dislocation- Displacement of a part, usually the bony partners of a joint. Leads to soft tissue damage, inflammation, pain and muscle spasm  Subluxation- Incomplete or partial dislocation of the bony partners. Involves secondary trauma to surrounding tissue  Rupture or Tear- Either partial or complete Partial tear- pain upon stretching or contraction Complete- no pain with stretching or contraction

Concorde Career College

 Tendinopathies Tendinitis- inflammation of a tendon Tenosynovitis - inflammation of the synovial membrane covering a tendon Tendinosis- degeneration of the tendon due to repetitive microtrauma  Synovitis- Inflammation of a synovial membrane Concorde Career College

 Hemarthrosis- Bleeding into a joint, usually due to severe trauma  Ganglion- Ballooning of the wall of a joint capsule or tendon sheath  Bursitis- Inflammation of a bursa  Contusion- Bruising from a direct blow Concorde Career College

 Overuse Syndromes A term used to describe a group of disorders that occur due to excessive stress on an anatomic area of the body. Typically, microtrauma occurs as a repeated injury usually not noticed initially because the injury is microscopic in magnitude. Over time, the cumulative trauma leads to inflammation and pain. Concorde Career College

 Dysfunction  Joint dysfunction  Contractures  Adhesions  Reflex muscle guarding  Intrinsic muscle spasm  Muscle weakness  Myofascial compartment syndromes Concorde Career College

 Dysfunction Loss of normal function of a tissue or region  Joint Dysfunction Mechanical loss of normal joint play in synovial joints  Contractures Adaptive shortening of skin, fascia, muscle or a joint capsule that prevents normal mobility or flexibility of that structure  Adhesions Abnormal adherence of collagen fibers to surrounding structures Concorde Career College

 Reflex muscle guarding Prolonged contraction of a muscle in response to a painful stimulus  Intrinsic muscle spasm Prolonged contraction of a muscle in response to the local circulatory and metabolic changes that occur when a muscle is in a continued state of contraction Concorde Career College

 Muscle weakness A decrease in the strength of a muscle  Myofascial compartment syndrome Increased interstitial pressure in a closed, nonexpanding, myofascial compartment that compromises the function of the blood vessels, muscles, and nerves. Concorde Career College

 Arthritis - Inflammation of a joint  Arthrosis -Limitation of a joint without inflammation  Common signs and symptoms: Impaired Mobility Impaired Muscle Performance Impaired Balance Functional Limitations Concorde Career College

 Osteoarthritis (Degenerative Joint Disease) A chronic degenerative disorder primarily affecting the articular cartilage of synovial joints, with eventual bony remodeling and overgrowth at the margins of the joints  Rheumatoid Arthritis An autoimmune, chronic, inflammatory, systemic disease primarily affecting the synovial lining of joints as well as other connective tissue Concorde Career College

 Chronic pain syndromes Fibromyalgia- Individuals process nociceptive signals differently Myofascial Pain Syndrome- localized changes in the muscle Concorde Career College

 A structural break in the continuity of a bone, an epiphyseal plate, or a cartilaginous joint surface. Classified according to their character and location.  Symptoms and Signs of a possible fracture: History of fall, direct blow, twisting injury, accident Localized pain aggravated by movement Muscle guarding with passive movement Decreased function of the part Swelling, deformity, abnormal movement Sharp, localized tenderness at the site Concorde Career College

 Fractures defined by Site Extent Configuration Relationship of the fragments Relationship to the environment (closed/open) Complications Concorde Career College

 Approaches: Open, Arthroscopic, Arthroscopically Assisted Procedures  Tissue Grafts: Autograft, Allograft, Synthetic grafts  Soft Tissue Repair or Reconstruction: Muscle, Tendon, Ligament, Capsule Stabilization, Tendon transfer  Soft Tissue Release, Lengthening or Decompression

 Joint Procedures: Synovectomy, debridement, microfracture, osteochondral auto/allografts, arthroplasty, arthrodesis  Extra-Articular Bony Procedures: ORIF- Open Reduction and Internal Fixation Osteotomy Concorde Career College

 Stages: Inflammatory phase- hematoma formation and cellular proliferation Reparative phase- callous formation uniting the breach and ossification Remodeling phase- consolidation and remodeling of the bone Concorde Career College

Why is it important to understand the healing process?

 Understanding the healing process is vital to developing safe and effective therapeutic exercise programs  Not understanding can result in therapeutic exercise programs that impede healing and cause additional injury Concorde Career College

 Primary healing: Separation is small Bridge of cells binds ends of wound together Minor wounds, sutured tissues  Secondary healing Separation is large Tissue must fill space More scarring, longer healing time

Concorde Career College  Primary  Direct  Acute – direct trauma  Superficial – epidermis & or dermis  Primary intention : typically small separation of tissue [IE:- surgical wounds]  Bridge of cells binds wound stump ends together  Secondary  Inflammatory  Chronic – overuse  Deep – involving deeper structures  Secondary intention:  Typically more severe  Stump ends farther apart  Tissue produced from bottom & sides to fill in  Longer to heal & larger scar

 Phases: Inflammation (Acute)  Protection Phase Proliferation (Subacute)  Repair and Healing Phase Remodeling (Chronic)  Maturation and Remodeling Phase Concorde Career College

 Lasts 4-6 days  Complex chemical & cellular interactions occur  Necessary, but should not be prolonged or extensive Chronic Inflammation  Treatment goal: Allow movement, but minimize excessive movement  Rest, Ice, Compression, Elevation (RICE) Minimize and contain damage  Modalities   blood flow when circulation becomes stable from injury,  pain and spasm Concorde Career College

P.R.I.C.E  Protection: Using splinting or wrapping  Rest: Avoid further activity  Ice: Reduce inflammation, decrease acute effusion, use cool to prevent reflex vasodilatation  Compression: Minimize the amount of swelling/effusion  Elevation: Decrease pooling of blood by elevating. Improve lymphatic drainage

 Controlled Motion Phase  days long  Synthesis and deposition of collagen characterize this stage  Fibroblasts are present  The immature connective tissue that is produced is thin and unorganized  Keloid scars may form secondary to uncontrolled collagen production

 Swelling: fluid from fibroblast activity  Redness: new capillaries  Sensation: pressure-sensitive nerves and tension-sensitive nerves are hypersensitive Concorde Career College

 Return-to-Function Phase  May last 6 months to one year  Be aware of Chronic Inflammation or  Overuse Syndrome Increased pain, swelling, and muscle guarding that lasts more than several hours after activity Concorde Career College

 Caused by inability to move from inflammation phase to proliferation phase  May be due to: Lack of proper growth factors Disturbed immunity Poor nutritional support Not enough quality rest Continued low grade functional or environmental irritants

 Persists longer then 6 months  Pain cannot be linked to irritation or inflammation  Functional limitations and disability including physical, emotional and psychological parameters Concorde Career College

 Treatment modalities  Drugs  Surgical repair  Age  Disease  Wound size infection  Nutrition  Muscle spasm  Swelling

 Ligament  Tendon  Muscle  Cartilage  Bone Concorde Career College

 Inflammation First few hrs: Ligament stumps and becomes progressively more friable 24 hrs: Fibroblasts begin to appear  Healing and Repair 1-2 wks: Vascular buds appear in the wound and begin to communicate with existing capillaries. 2d-6wk: Matrix structures replace the blood clot during inflammation  Remodeling Up to 12 mo: Ligament becomes more normal wks: Near-normal tensile strength is restored

 Inflammation 5 days: Wound gap is filled by phagocytes 1 wk: Collagen synthesis is initiated and placed in a random disorganized way.  Healing and Repair (Proliferation) 4 wks: Collagen is fully oriented with the tendon’s long axis  Remodeling 2 mo: Collagen is mature and realigned along tendon’s axis wks: Strength is 85-95% normal

 Inflammation 6 hrs: Fragmentation of injured muscle fibers begins 1 wk: Muscle tension is progressively reduced, scar tissue is seen in large muscle injury, muscle is able to produce near normal tension  Healing and Repair 13 days: Regenerating myotubes are seen 18 days: Cross-striated muscle fibers appear  Remodeling 6wks to 6mo: Contraction is 90% normal.

 Inflammation 48 hr: Clot is formed to fill the defect 5 d: Fibroblasts in the area, combine with collagen fibers to replace the clot  Healing and Repair 2 wks: Fibroblasts differentiate, islands of chondrocytes appear  Remodeling 2 mo: Defect resembles cartilage in appearance 6 mo: Type I and type II calcified cartilage has a normal appearance

 Inflammation 3 - 4days: Fractured edges become necrotic. Osteoclasts mobilize in the area  Healing and Repair Up to 4 wks: Osteoblasts proliferate to form soft callus 3-4wks: Hard callus develops 4-6 wks: External blood supply dominates  Remodeling 3-4 mo:Fracture is healed, but remodeling continues 12 wks:Near-normal strength is attained

 The maximal amount of stress or force a structure is able to withstand before tissue failure occurs  Once injury occurs, normal tensile strength seldom returns to 100% of its prior level Concorde Career College

 Inflammation (acute) phase- Protection No exercise Relief of pain, spasm, and edema  Repair and Healing (subacute) phase- Controlled Motion Range of motion (ROM) exercises Pain relief  Maturation & Remodeling (chronic) phase- Return to Function Strength, coordination, power, agility Restoration of optimal function

 Inflammation phase Modalities for pain, edema, spasm relief No stretching No resistance Maintenance of conditioning of cardiovascular system and uninjured segments Concorde Career College

 Repair and Healing phase (Early) Easy ROM  Active assistive ROM (AAROM)  Passive ROM (PROM) Isometrics Proprioception Exercises for cardiovascular system and other segments

 Repair and Healing Phase (Late) AROM, PROM Isotonic, proprioception, balance Continuation of exercises for Cardio Vascular system and other segments Concorde Career College

 Maturation and Remodeling phase Return to function phase Increase strength and alignment of scar OK for progressive stretching, strengthening, endurance training, functional exercise and specificity drills Concorde Career College

 Cold packs for inflammatory regulation  Electrical stimulation for pain control, enhanced protein synthesis in repair phase, facilitated muscle contraction for mechanical edema pumping and increased muscle tone.  Ultrasound for deep mechanical and thermal effects  Drugs as pain suppressors, muscle relaxants, and NSAIDs  Therapeutic exercise for flexibility, strength and tissue loading Concorde Career College

1 st :Correct deviations & reduce pain 2 nd :Range of motion and flexibility 3 rd :Strength and endurance 4 th :Proprioception and balance 5 th :Agility and coordination 6 th :Performance

 Make the program challenging but appropriate for the healing phase  Make the program interesting and fun; use your imagination  Keep short-term and long-term goals in mind  Psychological encouragement Concorde Career College

 Observe closely for exercise responses  Don’t assume patient knows the correct way to perform an exercise  Watch continuously for substitutions  Assess, assess, and assess Concorde Career College