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| '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | | '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} |
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| == Introduction ==
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| [[File:Scar.jpg|right|frameless]]
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| After an injury, soft tissue structures in the body undergo a natural healing process through specific phases of healing.
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| * The timeline for healing depends on: the individual; the extent of the injury; age; overall health status.
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| * Physiotherapy helps facilitate healthier healing - resulting in a smaller risk of re-injury, chronic pain and dysfunction.
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| * One of the main risks of future injury is how the soft tissue was rehabilitated or recovered, from previous injury/ surgery.
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| Soft tissue healing is defined as the replacement of destroyed tissue by living tissue in the body.<ref>Walter JB, Israel MS. General Pathology, Churchill Livingstone. Six. Ed., Edinburg. 1987:151-3.</ref> This process consists of two parts - regeneration and repair.<ref name=":0">Electrotherapy on the web. Soft Tissue Repair and Healing Review. Available from http://www.electrotherapy.org/modality/soft-tissue-repair-and-healing-review (accessed 20/02/2019).
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| </ref> Note - There are no defined boundaries between stages as the wound healing response “transitions” into the next stage of healing<ref name=":1">Stroncek JD, Reichert WM. [https://www.ncbi.nlm.nih.gov/books/NBK3938/ Overview of wound healing in different tissue types. Indwelling neural implants: strategies for contending with the in vivo environment.] 2008:3-40.Available from:https://www.ncbi.nlm.nih.gov/books/NBK3938/ (last accessed 31.5.2020)</ref>.
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| * During the regeneration component, specialized tissue is replaced by the proliferation of surrounding undamaged specialized cells.
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| * In the repair component, lost tissue is replaced by granulation tissue which matures into scar tissue.<ref name=":0" />
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| The cellular reaction after injury depends on the tissue type as well as the extent of the wound.
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| * In injury to CNS tissue that damages [[Neurone|neurons]] and the supporting [[Glial Cells|glial]] cells, the body’s response is unforgiving, as regeneration of lost neurons is not possible. Activated astrocytes wall off the lesion, creating a glial scar.
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| * In contrast, in non-CNS tissue, a single tissue type can have multiple responses depending on the magnitude of injury.<ref name=":1" />
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| [[File:Wound healing phases.png|center|frameless|880x880px]]
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| == Phases of Healing ==
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| The different healing phases are not mutually exclusive and tend to overlap quite a lot.<ref name=":0" />
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| === Bleeding Phase ===
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| [[File:Grade3hamstrings.jpg|right|frameless]]
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| Short phase immediately after injury - lasting about 6-8 hours, up to 24 hours after a crush injury.
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| * Time of the bleeding will depend on the extent of the soft tissue injury and the management thereof.
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| * The more vascular the injured structures, the more bleeding will occur.<ref name=":0" />
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| === Inflammation Phase ===
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| The goal of the inflammation phase is to stop the bleeding phase.
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| * This phase starts rapidly within a 6-8 hours after the soft tissue injury, reaches the maximal reaction between 1-3 days and gradually resolves in a few weeks.<ref name=":0" />
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| * Achieved by vasoconstriction, retraction of injured blood vessels, fibrin deposition and clotting.
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| * The blood supply to the area increases in this time, causing [[Edema Assessment|edema]] and redness.
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| * Phagocytosis ("the engulfing and usually the destruction of particulate matter by phagocytes that serves as an important bodily defence mechanism against infection by microorganisms and against occlusion of mucous surfaces or tissues by foreign particles and tissue debris<ref>“[https://www.merriam-webster.com/dictionary/phagocytosis Phagocytosis].” Merriam-Webster.com Dictionary, Merriam-Webster, <nowiki>https://www.merriam-webster.com/dictionary/phagocytosis</nowiki>. (Accessed 19 Mar. 2020).</ref>") happens during this phase.<ref name=":0" /><ref name=":3">Oishi Y, Manabe I. [https://academic.oup.com/intimm/article/30/11/511/5079207?login=true Macrophages in inflammation, repair and regeneration]. International immunology. 2018 Nov;30(11):511-28.</ref>
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| # The acute inflammatory response involves activities that generate exudates - plasma-like fluid that exudes out of tissue or its capillaries and is composed of protein and granular [[leukocytes]] (white [[Blood Physiology|blood]] cells).<ref name="p2">Pasadena. Soft tissue healing. Available from www.pasadena.edu/files/syllabi/rxaguilar_11913.doc soft tissue healing (accessed 28/02/2019).</ref><ref name=":3" />
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| # The chronic inflammatory response is of prolonged duration and involves the presence of nongranular leukocytes and the production of scar tissue.
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| The acute phase involves three mechanisms that act to stop blood loss from the wound:<ref name="p2" />
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| # Local vasoconstriction occurs, lasting a few seconds to as long as 10 minutes. Larger vessels constrict due to neurotransmitters and capillaries and smaller arterioles and venules constrict due to the influence of serotonin and catecholamines released from platelets. The resulting reduction in the volume of blood flow in the region promotes increased blood viscosity or resistance to the flow, which further reduces blood loss at the injury site.<ref name=":4">Rodrigues M, Kosaric N, Bonham CA, Gurtner GC. [https://journals.physiology.org/doi/full/10.1152/physrev.00067.2017 Wound healing: a cellular perspective. Physiological reviews]. 2019 Jan 1;99(1):665-706.</ref>
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| # The platelet reaction provokes clotting as individual cells irreversibly combine with each other and with fibrin to form a mechanical plug that occludes the end of a ruptured blood vessel. The platelets also produce an array of chemical mediators in the inflammatory phase: serotonin, adrenaline, noradrenaline, and histamine. Also, [[Adenosine triphosphate (ATP)|ATP]] is used for energy in the healing process.<ref name=":4" />
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| Approximately 1-hour post-injury, swelling or edema, occurs as the vascular walls become more permeable and increased pressure within the vessels forces a plasma exudate out into the interstitial tissues. This happens in:
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| * Mild trauma - for a few minutes with a return to normal permeability in 20-30 minutes.<ref name="p2" />
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| * More severe traumas - can result in a prolonged state of increased permeability, and sometimes result in delayed onset of increased permeability, with swelling not apparent until some time has elapsed since the original injury.
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| Bradykinin, a major plasma protease present during inflammation, increases vessel permeability and stimulates nerve endings to cause pain<ref name="p2" />.
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| === Proliferation Phase ===
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| This phase starts between 24-48 hours after injury, lasts up to 2-3 weeks when the bulk of the scar tissue is formed.<ref name=":0" />
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| ==== Fibroplasia and Granulation Tissue Formation ====
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| * The central event during the proliferative phase.
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| * Occurs 3-5 days following an injury and overlaps with the preceding inflammatory phase.
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| * Granulation tissue includes inflammatory cells, fibroblasts, and neo vasculature in a matrix of fibronectin, collagen, glycosaminoglycans, and proteoglycans.<ref name="p1">Medscape. Simon, PE. Skin Wound Healing. Available from: https://emedicine.medscape.com/article/884594-overview (accessed 28/02/2019).</ref>
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| ==== Epithelialization ====
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| Formation of epithelium over a denuded surface. The process begins within hours of tissue injury.
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| * Involves the migration of cells at the wound edges over a distance of less than 1 mm, from one side of the incision to the other. Incisional wounds are epithelialized within 24-48 hours after injury. This epithelial layer provides a seal between the underlying wound and the environment.<ref name="p1" />
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| * Epidermal cells at the wound edges undergo structural changes, allowing them to detach from their connections to other epidermal cells and to their basement membrane. Intracellular actin microfilaments are formed, allowing the epidermal cells to creep across the wound surface.
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| * Occlusive and semi occlusive dressings applied in the first 48 hours after injury may maintain tissue humidity and optimize epithelialization.<ref name="p1" />
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| * When epithelialization is complete, the epidermal cell assumes its original form,<ref name="p1" />
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| ==== Fibroplasia ====
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| Fibroplasia begins 3-5 days after injury and may last as long as 14 days.
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| * Skin fibroblasts and mesenchymal cells differentiate to perform migratory and contractile capabilities.<ref>Tottoli EM, Dorati R, Genta I, Chiesa E, Pisani S, Conti B. [https://www.mdpi.com/1999-4923/12/8/735/htm Skin wound healing process and new emerging technologies for skin wound care and regeneration.] Pharmaceutics. 2020 Aug;12(8):735.</ref>
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| * Fibroblasts are responsible for the production of collagen, elastin, fibronectin, glycosaminoglycans, and proteases.
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| * Fibroblasts fill the defect left by an open wound as the number of inflammation cells decrease.<ref name="p1" />
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| * As granulation tissue matures, the fibroblasts produce less type III collagen and become more spindly in appearance. They begin to produce the much stronger type I collagen.
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| ==== Angiogenesis ====
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| Angiogenesis results in greater blood flow to the wound and, consequently, increased perfusion of healing factors. Angiogenesis ceases as the demand for new blood vessels ceases. New blood vessels that become unnecessary disappear by apoptosis.<ref name="p1" />
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| * A rich blood supply is vital to sustaining newly formed tissue (as is appreciated in the erythema of a newly formed scar).
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| * The macrophage is essential to the stimulation of angiogenesis and produces macrophage-derived angiogenic factor in response to low tissue oxygenation.<ref name="p1" />
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| [[File:Scars from skin flap.jpg|right|frameless]]
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| ==== Contraction ====
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| * Contraction results in a decrease in wound size eg a 2-cm incision may measure 1.8cm after contraction.
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| * Loose tissues contract more than tissues with poor laxity, and square wounds tend to contract more than circular wounds.
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| * Wound contraction depends on the myofibroblast located at the periphery of the wound, its connection to components of the extracellular matrix, and myofibroblast proliferation.<ref name="p1" />
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| * Radiation and drugs, which inhibit cell division, have been noted to delay wound contraction.
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| === Remodeling Phase ===
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| This phase starts around the peak of the proliferation phase. The result of this phase is an organised, quality and functional scar similar to the tissue it is busy repairing.<ref name=":0" />
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| The ultimate endpoint following remodeling depends on the tissue type.
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| * Non-central nervous system (CNS) tissue that undergoes primary healing, very little remodeling occurs because of the lack of extracellular matrix produced during the repair. Secondary healing, in contrast, involves fibre alignment and contraction to reduce the wound size and to reestablish tissue strength. Complete recovery of original tissue strength is rarely obtained in secondary healing because repaired tissue remains less organized than non-injured tissue, which results in scar formation.<ref name="p1" /> Collagen-rich scars are characterized morphologically by a lack of specific organization of cellular and matrix elements that comprise the surrounding uninjured tissue.
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| * CNS tissue - there is no repair or regeneration of injured neurons, relatively little reestablishment of structural integrity in the region. During CNS remodeling, activated astrocytes wall off the lesion, creating a glial scar. These activated astrocytes may prevent further tissue damage, although neuron axonal regrowth is inhibited.<ref name=":1" /><ref name="p1" />
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| == Summary of Phases ==
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| === Phase 1: Acute Phase (1 - 7 Days) ===
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| * Goal: Minimize inflammation and pain.
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| * Treatment:
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| **[[RICE]]-method: Rest, ice, compression and elevation
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| ** Pain-free range of motion with cryotherapy<ref name=":4" />
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| === Phase 2: Subacute Phase (Day 3 - < 3 Weeks) ===
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| This phase starts when signs of inflammation begin to reduce. Inflammation signs are heat, swelling, redness and pain.
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| * Goal: Prevent muscle atrophy
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| * Treatment:
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| ** Pain-free full range of motion: concentric strengthening
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| ** If any pain present: decrease the intensity of exercises
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| === Phase 3: Remodeling Phase: ( 1 - 6 Weeks) ===
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| * Stretching to avoid a decrease in flexibility
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| * Eccentric strengthening
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| * It is important to make sure that the muscle is already regenerated, to prevent risk of re-injury
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| === Phase 4: Functional Phase: (2 Weeks - 6 Months) ===
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| * Goal: Return to sport without re-injury.
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| * Treatment:
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| ** Increase their strength, endurance, speed, agility, flexibility and [[proprioception]]
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| ** Sport-specific activities
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| === Phase 5: Return to Competition Phase: (3 Weeks to 6 Months) ===
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| * Goal: Avoid a re-injury
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| * Criteria: Full range of motion, strength, coordination and psychological readiness
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| * Treatment:
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| ** Address deficits in criteria
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| ** Progressive agility and trunk stabilization<ref name="Sherry et al.">Sherry MA, Best TM. [https://www.jospt.org/doi/pdfplus/10.2519/jospt.2004.34.3.116 A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains.] Journal of Orthopaedic & Sports Physical Therapy 2004;34(3):116-25.</ref>
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| {{#ev:youtube|watch?v=i05wu5gI_4o&t=14s}}<ref>Flex Physiotherapy. Soft tissue injury and the healing process. Published on 26 August 2017. Available from https://www.youtube.com/watch?v=i05wu5gI_4o&t=14s [last accessed 19 March 2020]</ref>
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| == POLICE == | | == POLICE == |
| During the acute phase discussed above, the [[RICE]]-method: Rest, Ice, Compression and Elevation was suggested. Most people are familiar with the acronym [[RICE]] when dealing with musculoskeletal injury, however, current thoughts have expanded the RICE acronym to the POLICE method: Protection, Optimal Loading, Ice, Compression, Elevation. Optimal loading or mechanical loading is the time where physiotherapists need to use good clinical decision making to assist with recovery and prevent chronic conditions from forming.<ref name=":2">Horsley, I. Injury and Healing in Sports Physiotherapy Course. Physioplus. 2022. | | During the acute phase discussed above, the [[RICE]]-method: Rest, Ice, Compression and Elevation was suggested. Most people are familiar with the acronym [[RICE]] when dealing with musculoskeletal injury, however, current thoughts have expanded the RICE acronym to the POLICE method: Protection, Optimal Loading, Ice, Compression, Elevation. Optimal loading or mechanical loading is the time where physiotherapists need to use good clinical decision making to assist with recovery and prevent chronic conditions from forming.<ref name=":2">Horsley, I. Injury and Healing in Sports Physiotherapy Course. Physioplus. 2022. |
