Physiotherapy in Soft Tissue Injury
Soft tissue injury is a common part of our life. You may walk very slowly but still can twist your ankle. Most of us ignore this kind of things until it creates a big problem. Any kind of soft tissues need an intensive care for a good healing so that in future it shouldn't cause any secondary problems. Physiotherapy has a great role to facilitate a good healing process, minimize secondary changes and re orientation of functions to the affected one. To understand the actual outcome of physiotherapy we can have a review about natural healing process.
Healing of soft tissue
It has divided mainly 3 stages
Inflammatory phase (0-5 days approx)
Injury- Transient vasoconstriction 5-10 minutes -vasodilatation-Hemorrhage- oedema- The red blood cells breakdown in cellular derbies -phagocytes -Deposition of fibropectin and fibrin with fibroblast and collagen fibre (tissue glue -a structural protein) in the hemorrhage and make scaffold for lying down of platelet encourage for further lying down of fibroblast-blood clot (1st few hours) -The new vuscularisation within 12 hours continue to 3-4 days-supply of blood and nutrient to affected area.
In early stage Blood vessels become more permeable -plasma and leukocytes leak into the surrounding tissues
Vascular responses due to direct trauma to blood vessel wall and indirectly due toe the influence of chemical mediators e.g. heparin, histamine serotonin. Bradikinms, prostaglandins.
Over all vascular response is responsible for the cardinal signs for inflammation
Pain Mechanical origin-due to mechanical stress, tissue damage, muscle spasm and the accumulated oedema causing excess pressure on surrounding tissue.
Chemical origin -arises through chemo sensitive nerve receptors, which are sensitive to histamine, serotonin bradykinins and prostaglandin.
Swelling may take few hours to develop and aim depend on tissue type e.g. muscle bellies may produce considerable bleeding but the tendon prevents the collection of fluid and do not easily swell. Ligament also don't swell easily but some intrinsic joint ligaments ACL of knee may provoke a huge swelling and haemathrosis as it has got many blood supply.
Repair Stage (6-21 Days)
Wound is prepared by phagocytosis macrophage become main cell to activate the fibroblast to lay down in big number (starts to appear within 24 hours and continue up to 5-10 days and don't decrease in 3 weeks) -Synthesise the connective tissue matrix and collagen fiber- The arrangement glues together- Cross linkage -Slowly increase tensile strength of the wound within 1st 3 week about 15-20 per cent of the normal strength- This process of maturation called repair.
The repair is directly related to the size of the wound. A small wound will heal quickly with a minimal inflammatory response and collagen fibers will be laid down early and large wounds are deep and wide need initially healed with the formation of granulation tissue, it may be several weeks alter injury before the fibroblasts initiate fiber formation and several weeks before there is sufficient collagen to provide enough tensile strength.
Remodeling (22 days - 6 months)
The new collagen or scar tissue attempt to take on the physical characteristics of the tissue in is replacing and responsible for final structure orientation and tensile strength- Weak and Randomly organized collagen starts to reorganize according to the line of stress - Scar- Contraction
Cross-linking is responsible for the tensile strength of new, desirable scar tissue, but if the cross-linking becomes excessive it will be responsible for the tightness and lack of resilience of unwanted fibrous adhesions.
Normal tissue adjacent to the wound induces structure in the replacement scar tissue thus dense tissue induces dense highly cross-linked scar tissue whilst pliable tissue induces loose coiled less cross-linked scar tissue.
Factor Involves Soft Tissue Healing
- Chronic trauma can cause excessive movement or tension promotes unwanted scaring. E.g. chronic overuse syndrome.
- Haematoma acting as and irritant producing a mechanical blockage, which separates the torn edges and provides a medium for infection.
- Infection -delays the healing
- Age can delay cell migration and proliferation and decrease the tensile strength of wound
- Medication -NSAID inhibit production of histamme serotonin and prostaglandin Aspirin in addition inhibit platelet aegreaation and prolog bleeding
- Oral intake corticosteriods inhibits collagen synthesis reduce tensile strength and delays wound healing but if after 3 days (alter macrophage migration) is much better
- Anti coagulant Hepanin Warfrin prolong the bleeding
- Chemotherapy may affect collagen synthesis
- Radiotherapy radiation may damage fibroblasts cause vascular damage and decrease collagen production
- Vitamin A And C deficiency Protein Systemic vascular disorder and systemic connective tissue disorders
Physiotherapy Treatment Principle
- PRICE principle
- Faction massage (Transverse friction Massage)
- Proprioceptive training especially with any kind of ligament Injury.
- Strengthening programme
- Gradual increase of functional movement when there is enough tensile strength in the wound.
- Gradual increase in the depth of transverse friction massage.
- Gradual increase in the range of mobilization.
- Return to normal function
The principle that charted above is applied according to stage of healing process. For an example-In Acute Contractile lesion- the Cold therapy used to prevent access bleeding, access accumulation of inflammatory exudates thus facilitating to reduce pain and other unwanted complication. Relative rest has been given by different immobilization procedure e.g. Bandaging. Special Tapping technique etc.
In repair stage Gentle friction massage together with gentle mobilization will agitate tissue fluid and increase the chance contact of the macrophage with cellular debris so promoting healing. Physical or other modalities that also achieve this effect e.g. Ultrasound therapy.
In the next stage the application of appropriate stress by performing pain tree movement ensures that collagen fibre orientation occurs throughout the tissue and matches its function.
To avoid adverse scar tissue ton-nation, gentle friction massage and progressively increasing rang e of mobilization should be continue until a full pain tree range of movement is restored.
In chronic lesion deep friction massage and vigorous mobilization are applied to mobilize the existing scar tissue to make them pliable as much as possible.
All the treatments describe above are very effective it' these can be apply very accurately and skillfully so that we don't give the patient re-injury. Now a day's physiotherapists are working in different health sector such as Orthopedic and Rheumatology, Neurology, Pediatric, Cardiovascular. Respiratory, Gynecology, Geriatric. Sports Injury etc, to give a complete treatment to the sufferers.
The author is a Lecturer, Department of Physiotherapy.
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