Trauma and Immobilization SCAR. Summary: Acute Inflammation & Healing. TRAUMA Wound Healing: Three Phases
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1 Upper Extremity Stiffness and Contracture After Trauma Phil PT, PhD, FAPTA Trauma and Immobilization SCAR TRAUMA Wound Healing: Three Phases Inflammation (0-5 days) Fibroplasia (Repair, Phase II) (5-28 days) Maturation (Remodeling, Phase III) (28 days - 1 year) Summary: Acute Inflammation & Healing Inflammation is necessary to start healing process Need the recruitment of neutrophils to destroy/degrade environment Recruitment of macrophages to clean up remains and serve a major trophic role Repair phase--fibroblasts secreting collagen Remodeling phase--improving the tensile strength of collagen Pathoanatomic Considerations (most critical to surgeon) Anatomic Causes Joint surface incongruity Loose bodies, Osteophytes, Heterotopic bone Synovitis Capsule / Ligament Tendon Nerve Superficial fascia Skin PIP example Dupytren s Fascia /skin contracture Flexor tendon repair Tendon adhesion to adjacent structure Joint Injury / Fx Bony congruity, capsular contracture +/- adhesions Adapted from :Hildebrand, J Hand Surg 2013 Functional Considerations: Shoulder example (most critical to therapist) Non- Structural Acute Inflammation Pain is primary Muscle Guarding stiff & painful freezing stage Structural Periarticular Fibrosis ant-inf cap recess subscap synovial recess (rot interval) coracohumeral lig Pain is secondary Limited motion > 3 wks Greatest % loss of ext rot PM, Flowers KR. Treatment of limited shoulder motion: a case study based on biomechanical considerations. Physical Therapy 72: ,
2 Trauma & Immobilization Likely Two Processes Contracture Adaptive shortening of periarticular tissue Collagen reorganization i Myofibroblast activation Muscle shortening:loss of sarcomeres Rabbit MCL -immob -early motion Adhesion formation Loss of gliding Scar formation between 2 tissues that normally glide on each other (or unfold ) Immobilization of CT Biochemical Changes collagen biosynthesis enzyme activities mrna for type I & III collagen Appears to be stretch sensitive collagen degradation expression of matrix metalloproteinases (MMP s) Increased cross-links (reducible, weaker) Decreased GAG, HA, water content Immobilization of CT Biomechanical Changes Decreased tissue stiffness Decreased load to failure Increased joint stiffness weaker and shorter Image from: Monument et al, 2013, J Orthop Science More stiff Physical Stress Level Injury Hypertrophy Maintenance (Homeostasis) Atrophy Adaptation Physical Stress Level Injury Hypertrophy Maintenance (Homeostasis) Atrophy Injury Hypertrophy Mi Maintenance (Homeostasis) Atrophy Physical Stress Theory Mueller MJ, Maluf KS, Phys Ther 82(4): , 2002 Decreased use lowers the threshold for changes Physical Stress Theory Mueller MJ, Maluf KS, Phys Ther 82(4): ,
3 Load-Deformation Yield Point (Elastic Limit) Plastic Deformation (Tearing, material failure) K. Hildebrand MD 2012 Weiland Award J Hand Surg 2013 Deformation (Strain) Load (A Applied force or torque) Elastic (transient) Deformation (Length, ROM) Load (A Applied force or torque) Plastic (permanent) Deformation (Length, ROM) CONNECTIVE TISSUE Viscoelastic Visco (ground substance) + Elastic (fibers) Viscoelasticity All biologic tissue Demonstrate these mechanical phenomenon: Creep Stress relaxation Pre-conditioning CREEP Constant Load (below elastic limit) TIME Example: stiff elbow with weight on wrist => increase extension 3
4 Stress-Relaxation Constant Length Cyclic Loading Pre-conditioning Max load tolerated (elastic limit) TIME Example: stiff elbow with static splint => less tissue tension Deformation (ROM) Example: stiff elbow with manual therapy and passive ROM => increase extension All of these viscoelastic mechanical phenomenon (creep, stress relaxation, preconditioning) are achieved in minutes. Are they permanent ( plastic ) ortransient? PRECONDITIONING Increased tissue deformation with cyclic loading temporarily all stretched out allows valid ROM comparison between sessions Plastic deformation should not be confused with the phenomenon of creep[or stress relaxation, pre-conditioning]. If the load was within the elastic limits of the tissue, the tissue will gradually return to the resting length after the load dis removed. this phenomenon represents the redistribution of water from the tissue to the anatomical spaces surrounding the tissue. Threlkeld, 1993, Physical Therapy. Stretch Model It is important to note that a low level of CT damage must occur in order to produce permanent elongation. The collagen breakage will be followed by a classical cycle of tissue inflammation, repair, and remodeling that should be therapeutically managed in order to maintain the desired tissue elongation. Threlkeld, 1993, Physical Therapy 4
5 Growth Model It is better not to use the word STRETCH for what should be long term GROWTH. If we want to restore normal length to a tissue that has shortened after disuse, we need to reverse the process and apply the stimulus of activity, or better, the stimulus of holding the tissue in the moderately lengthened position for a significant time. Then it will GROW. Brand, wks immob 6 wks interm prom MCL Tissue Stress Parameters Intensity (How hard?) Frequency (How often?) Duration (How long?) Rehabilitation of Joint Stiffness Stress Dosage Intensity (how much tension?) Frequency (how often?) Duration (how long?) Medication Analogy overdose ( pain, ROM) underdose (no change) therapeutic dose ( ROM, pain ok) Rehabilitation of Joint Stiffness Stress Dosage Hierarchy of Tensile Stress Methods Manip Under Anesthesia Tissue Tearing Intensity (how much tension?) Frequency (how often?) Duration (how long?) TERT = Total End Range Time TERT = frequency X duration Key parameter to modify dosage 24 hrs/day splinting Long periods (4-8 8h hrs/day) end-range Short periods (1-2 hrs/day) end-range ROM ex s + Manual tech + home prog Traditional ROM ex s in clinic Immobilization Remodeling: Forces within elastic limit 5
6 Joint Mobilization : High load brief stress High load brief stress: rotator interval (ant-sup capsule) Inf glide with GH ext rot Passive stretch: ext & ext rot Inferior Glide Anterior Anterior Glide Glide Home Exercises: Int Rot Ext Rot Elevation Rehabilitation of Shoulder Stiffness Low-Load Prolonged Stress Prolonged duration methods near end-range positioning splints pulley traction CPM Growththrough biologic remodeling More permanent changes Image from: LaStayo & Jaffe, 1994 J Hand Ther & Flowers, 1992 Phys Ther 6
7 Low-load prolonged stress : overhead pulley + wts Static Splinting: Low load prolonged stress LaStayo & Jaffe, 1994 J Hand Ther LaStayo & Jaffe, 1994 J Hand Ther active exercises up to and beyond the pain threshold Joint Active Systems Device Dynasplint Gentle thawing of the frozen shoulder: a prospective study of supervised neglect vs intensive physical therapy in 77 patients with frozen shoulder followed for two years. Diercks et al. JSES, 2004 Abnormal Scapular Motion GH stiffness Rot Cuff weakness Abnormal motor pattern difficult to unlearn Early attention Pt education Hand contacts Mirror 7
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