Rehabilitation – Moving forward with injury repair

Introduction

This article will discuss the instigation of controlled movement early in the management of musculoskeletal injuries to aid functional repair.

Tissue Repair

Following injury or surgical repair the body undergoes an active repair process – the process of inflammation. The mention of the word “inflammation” has generally been seen as a “bad thing” – patients are prescribed anti-inflammatory medication to “reduce” the inflammation present.

Inflammation is a Positive Process: Repair cannot take place without inflammation.

The inflammatory response can been seen to have two major roles:

The inflammatory process has three distinct phases 2:

During the acute inflammatory phase injury manifests as swelling, redness, heat, pain and loss of function. Within this time the main aim of treatment is to minimize haemorrhage, swelling, inflammation, cellular metabolism and pain, and also provide ideal conditions for healing and repair processes 3.

During the subacute proliferative phase, the debris of damaged cells is removed by phagocytosis, and fibroblast cells produce weak collagen fibres which begin to form weak scar tissue. Increased amounts of scar tissue (collagen) and reduced cross-links between fibres have been associated with increases in the strength of the tissue 4.

During this phase the irritation produced by early tissue mobilization is desirable. There is an accumulating body of research that supports the role of controlled mechanical stress to connective tissue to aid repair and provide optimal healing. This mechanical stress can be brought about by exercise and manual therapy techniques5. This process is highly dependent on stresses that are imposed on the scar tissue 6, 7.

Tension and movement to connective tissue encourages normal collagen turnover and aligns the collagen fibrils along the lines of stress within the repairing tissue.

When stress is applied to tissues, adaptation occurs through a process of mechanotransduction, whereby the mechanical or manual therapy is converted into biochemical signals which bring about the synthesis of “repair cells” within the connective tissue or muscle 7, 8.

Hence the repair will be incomplete if the tissues are not provided with the correct level of mechanical stress. Evidence of incomplete repair includes excess scar tissue with adhesions and a mechanically weaker tissue.

The mechanical tension applied to the healing tissue should be within the pain-free range and to the onset of tissue tension – as felt by the therapist (if utilizing a manual technique) or the patient (if utilizing active or passive movement). This motion should be dynamic and rhythmical in order to stimulate adequate repair 9, 10, 11.

Controlled clinical trials of acute soft tissue injuries provide support for the use of early controlled motion at the site of injury to provide superior healing results; the strength of repaired ligaments has been shown to be greater in animals which were allowed to continue to exercise rather than rest12. Following surgical repair, tendons which were mobilized rather than immobilized have higher tensile strength and a reduced re-rupture rate 13, 14, 15.

Movement is paramount in the healing of tissues. As stated by Lederman1: “Movement is the blueprint for repair. Tissues that heal with functional movement are better suited to meet functional demands when the individual returns to daily activities. Tissues that have repaired without movement or with limited movement will fail to meet the functional demands of normal daily movement”.

Conclusion

The instigation of controlled movement early in the management of musculoskeletal injuries, both acute and following surgical repair, has been shown to expedite recovery and return to full function, when compared to immobilization.

So, how should this be accommodated within clinical practice? I will leave you with the recommendations of Kannus et al 16:

“Within the limits of pain, everything that is not explicitly forbidden is allowed.”

Ian Horsley MSc, MCSP, Clinical Lead Physiotherapist, English Institute of Sport (EIS) North West, of BackinAction Physiotherapy and Sports Injury Clinic, Wakefield, UK.

References

  1. Lederman E. (2005). The Science and Practice of Manual Therapy 2005, ed. 2, Elsevier, Edinburgh.
  2. Jozsa L, Kannus PA. Human Tendons: Anatomy, Physiology and Pathology. Human Kinetics 1997, Champaign.
  3. Jarvines MJ, Lehto MU. The effects of early mobilization and immobilization on the healing process following muscle injuries. Sports Med 1993; 15 (2): 78-89.
  4. Tipton CM, Vailas AC, Matthes RD. Experimental studies of the influences of physical activity on ligaments, tendons and joints: a brief review. Acta Medica Scand 1996; 711 (suppl): 157-168.
  5. Noel G, Verbruggen LA, Banbaix E, et al. Adding compression to mobilization in a rehabilitation program, after knee surgery. A preliminary clinical observational study. Manual Therapy 2000; 5 (2): 102-107.
  6. Gelberman RH, Menon J, Gonsolies M, et al. The effects of mobilization on vascularization of healing flexor tendons in dogs. Clin Orthop 1980; 153: 283-289.
  7. Buckwater JA, Grodzinsky AJ. Loading of healing bone, fibrous tissue, and muscle: implications for orthopaedic practice. J. Am Acad Orthop Surg 1999; 7 (5): 291-299.
  8. Williams P, Watt P, Bicik V, et al. Effect of stretch combined with electrical stimulation on the type of sarcomeres produced at the end of muscle fibers. Exp Neurol 1986; 93: 500-509.
  9. Takai S, Woo SL, Horibe S, et al. The effects of frequency and duration of controlled passive mobilization on tendon healing. J. Orthopaed. Res 1991; 9 (5): 705-713.
  10. Gelberman RH, Woo SL, Lothringer K, et al. Effects of early intermittent passive mobilization on healing canine flexor tendons. J. Hand Surg (Am) 1982; 7 (2): 170-175.
  11. Woo SL, Gelbermann RH, Cobb NG. The importance of controlled passive mobilization on flexor tendon healing. A biomechanical study. Acta Orthop Scand 1981; 52 (6): 615-622.
  12. Woo SL, Hilderbrand KA. Healing of ligament injuries: from basic science to clinical practice. Baill Clin Orthop 1997; 2 (1): 63-79.
  13. Enwemeka CS, Speilholz NJ, Nelson NJ. The effects of early functional activities on experimentally tenotomized Achilles tendons in rats. Am J. Phys Med. Rehabil 1988; 67 (6): 264-269.
  14. Murrell G A, Jang D, Deng XH et al. Effect of exercise on Achilles tendon healing in a rat model. Foot Ankle 1998; 19 (9): 598-603.
  15. Gelberman RH, Manske PR, Vande Berg JS et al. Flexor tendon repair in vitro: a comparative histologic study of the rabbit, chicken, dog and monkey. J. Orthop Res 1984; 2 (1): 305-312.
  16. Kannus P, Jozsa L, Renstrom T, et al. The effects of training, immobilization and remobilization on musculoskeletal tissue. 1: training and mobilization. Scand J. Med Sci Sports 1992; 2 (3): 100-118.

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