The Remodel Phase of Healing


Dr. Joe Papia

Chiropractor in Tampa FL 33602

What Happens to the Tissue

Usually runs from 12 weeks on

Overlaps repair and regeneration

  1. Purpose is to increase strength of repaired/replaced tissues
    1. First 6-12 weeks involves laying down of collagen and strengthening of fibers
    2. 3 months to 2 years allowed for enhanced scar tissue strength
  2. Balance must be maintained between synthesis & lysis
    1. # of fibroblasts, myofibroblasts, & macrophages reduced to pre-injury state
    2. # of capillaries decrease, H2O content decreases
  3. Take into consideration forces applied, immobilization time frames relative to tissue and healing time
  4. Scars
    1. Type I collagen continues to replace Type III collagen

Chronic Inflammation

  1. Result of failed acute inflammation resolution within one month termed sub-acute inflammation
  2. Inflammation lasting months/years termed chronic
    1. Results from repeated microtrauma and overuse
  3. Proliferation of connective tissue and tissue degeneration
  4. Presence of lymphocytes, plasma cell, macrophages(monocytes) in contrast to neutrophils (during acute conditions)
  5. Major chemicals include
    1. Kinins (bradykinin) – responsible for vasodilatation, permeability and pain
    2. Prostaglandin – responsible for vasodilatation but can be inhibited with aspirin and NSAID’s

Objective:

  1. Increase Strength
  2. Align Collagen Scar Tissue
  3. Decrease Nerve Sensitivity

Treatment:

Phase III: Remodeling Phase (Longest Phase):

  1. Goal of returning to normal functional capacity
    1. Continued collagen realignment
    2. Pain continues to decrease
  2. Regain activity-specific skills
    1. Dynamic functional activities
    2. Activity-directed strengthening activities
    3. Plyometric strengthening
  3. Functional testing
  4. Determine specific skill weakness

Injury Response/ Pain-Spasm-Pain Cycle

If you have any further questions about how the body heals in the remodel phase give me a call at 813-229-0207.

Dr. Joe Papia Chiropractor in Tampa FL 33602

The Repair Phase of Healing


Dr. Joe Papia

Chiropractor in Tampa FL 33602

What Happens to the Tissue

Phase II: Proliferation/Fibroblastic/ Repair/Regeneration Phase

  1. “Repair/Regeneration or Fibroblastic phase”
  2. Phase will extend from 48 hours to 3-12 weeks
  3. Phase removes debris & temporary repair – SCAR FORMATION (fibroplasia)
  4. Adenosine triphosphate (ATP) is a critical factor that regulates the rate & quality of healing- cell’s primary source of energy- provides metabolism needed to restore cell’s membrane properties by moving Na2+ & K+ into & out of cell, to build new proteins & synthesize proteins

Processes of soft tissue repair

  1. Fibroblast formation
  2. Tissue remodeling
  3. Synthesis of collagen
  4. Tissue alignment

Soft Tissue Repair Dependent on Levels of:

  1. Debris removal
  2. Endothelial production
  3. Production of fibroblasts

Repaired through 3 phases:

  1. Resolution – (little tissue damage and normal restoration) dead cells & cellular debris are removed by phagocytosis (tissue left with original structure & function in tact)
  2. Regeneration – (replacement of tissue by same tissue) damaged tissue is replaced by cells of the same type (structure retains some or all of its original structure & function)
    1. Related to
      1. i. Health,
      2. ii. Nutrition
      3. iii. Tissue type
    2. Dependent on levels of:
      1. i. Debris (phagocytosis)
      2. ii. Endothelial production (hypoxia and macrophages stimulate capillary buds)
      3. iii. Production of fibroblasts (revascularization allows for enhanced fibroblast activity and collagen production which is tied to Vitamin C, lactic acid, and oxygen

      Repair – (if resolution is delayed) original tissue is replaced with scar tissue (original structure & function is lost)
      Phase will extent from 6 to 12 weeks following cleaning of fibrin clot, erythrocytes, and debris

      Results in Scar formation
      i. Less viable than normal tissue, may compromise healing
      ii. Firm, inelastic mass devoid of capillary circulation
      iii. Develops from exudates with high protein and debris levels resulting in granulation tissue
      iv. Invaded by fibroblasts and collagen forming a dense scar and while normally requiring 3-14 weeks may require 6 months to contract

    1. Primary healing (healing by first intention-Resolution)
      1. Closely approximated edges with little granulation tissue production
    2. Secondary healing (heal by secondary intention-Repair)
      1. Gapping, tissue loss, and development of extensive granulation tissue
      2. Common in external lacerations and internal musculoskeletal injuries

    Objective:

    1. Continue Pain Relief
    2. Increase Joint Motion
    3. Restore Ligament Elasticity
    4. Reduce Tension on the Injured Connective Tissues
    5. Restore Ligament Integrity
    6. Improve Ligament Laxity
    7. Prevent Muscular Atrophy and Weakness

    Treatment:

    Phase II: Fibroblastic Phase:

    1. As inflammatory phase begins to subside & pain decreases, add
      1. Active Motion
      2. Restore full ROM
      3. Restore or increase strength
      4. Re-establish neuromuscular control
    2. Continued use of modalities for:
      1. Pain Control
      2. Decrease Muscle Spasm or Tension
      3. Increase Joint Range of Motion
      4. Increase Muscle Strength
      5. Restore Sensory or Motor Loss

    If you have any further questions about the repair phase of healing please call me at 813-229-0207.

    Dr. Joe Papia Chiropractor in Tampa FL 33602

    The Inflammation Phase of Healing


    Dr. Joe Papia

    Chiropractor in Tampa FL 33602


    What Happens to the Tissue:

    1. External and internal injury result in tissue death and cell death
    2. Decreased oxygen to area increases cell death
    3. Phagocytosis will add to cell death due to excess digestive enzymes

    First hour

    1. Vasoconstriction and coagulation occur to seal blood vessels and chemical mediators are released
    2. Immediately followed by vasodilatation of blood vessels

      Second hour

      1. Vasodilatation decreases blood flow, increased blood viscosity resulting in edema (swelling)
      2. Exudates increases (high concentration of RBC’s) due to increased vessel permeability
      3. Permeability changes generally occur in capillary and venules
      4. Margination occurs causing leukocytes to fill the area and line endothelial walls
      5. Through diapedesis and chemotaxis leukocytes move to injured area

      Cellular response

      1. Mast cells (connective tissue cells) and leukocytes (basophils, monocytes, neutrophils) enter area
      2. Mast cells with heparin and histamine serve as first line of defense
      3. Basophils provide anticoagulant
      4. Neutrophils and monocytes are responsible for small and large particles undergoing phagocytosis – ingestion of debris and bacteria

          4. Cellular mediation

          1. Histamine provided by platelets, mast cells and basophils to enhance permeability and arterial dilation
          2. Serotonin provides for vasoconstriction
          3. Bradykinin is a plasma protease that enhance permeability and causes pain.
          4. Heparin is provided by mast cells and basophils to prevent coagulation
          5. Leukotrienes and prostaglandins are located in cell membranes and develop through the arachadonic acid cascade
          6. Leukotrienes alter permeability
          7. Prostaglandin add and inhibit inflammation

          5. Complimentary systems

          1. Enzymatic proteins that destroy bacteria and other cells through their impact on cell lysis

            6. Bleeding and exudates

            1. Amount dependent on damage
            2. Initial stage: thromboplastin is formed
            3. Second stage: Prothrombin is converted to thrombin due to interaction with thromboplastin
            4. Third stage: thrombin changes from soluble fibrinogen to insoluble fibrin coagulating into a network localizing the injury

              Tissue Damage Results In:

              1. Redness: Caused by dilation of arterioles/increased blood flow
              2. Heat: Increased chemical activity & increased blood flow to skin surface
              3. Swelling: Caused by accumulation of blood & damaged tissue cells
              4. Pain: Direct injury of nerve fibers, pressure of hematoma on n. endings
              5. Chemical irritants: – bradykinin, histamine, prostaglandin
              6. Loss of Function Increased pain/ swelling

              Tissue Response:

              Vascular changes

              1. Vasoconstriction – immediately; decreased blood flow to area (approx. 5-10 mins.); platelet plug formed; blood coagulation; produces local anemia
              2. Vasodilation – increased blood flow; increased hydrostatic pressure in blood vessels (­ capillary permeability, plasma proteins leak out; proteins attract H2O – edema)
              1. Cellular Changes – chemical reactions start immediately
              2. Protein presence – changes osmotic relationship between blood & adjacent tissues (Plasma protein while interstitial fluid protein ­. H2O follows plasma proteins out of vessel resulting in edema!)
              3. Neutralizes/destroys offending agents, restricts tissue damage to the smallest possible tissue & prepares area for healing

              Objectives in Inflammation Phase:

              1. Decrease Pain
              2. Reduce Swelling
              3. Reduce Muscle Spasm

              Goal to Limit Swelling using R.I.C.E Principle:

              1. Rest
              2. Ice
              3. Compression
              4. Elevation are critical to limiting cell death

              Restricted Activity (Rest)

              1. Healing immediately begins after injury
              2. Without rest, external stresses are still placed on the injured area, interfering with the healing process- prolonging recovery
              3. Controlled mobility is superior to immobilization
              4. 24-48 hours of rest should be applied prior to active rehabilitation – depends on severity

                Protection & Ice

                1. Protect the injury from further damage
                2. Splint, wrap, immobilize the injured site depends on severity

                  Compression

                  1. Single most important factor in swelling control
                  2. Mechanically reduces space available for swelling accumulation
                  3. Using an elastic wrap, firm, evenly applied pressure can be achieved
                  4. Compression should be maintained continuously for 72 hours – depends on severity
                  5. With chronic inflammatory conditions compression should be applied until the swelling is almost entirely gone

                    Elevation

                    1. Used to eliminate the effects of gravity on blood pooling
                    2. Assists venous and lymphatic drainage of blood and other fluids from the injured area
                    3. Elevation should occur as often as possible during the first 72 hours of the acute injury – depends on severity

                      Treatment:

                      Phase I: Acute Inflammatory Phase

                      Initial swelling management & pain control are crucial

                      • R.I.C.E
                      • Chiropractic Adjustment
                      • Electrical Muscle Stimulation-Pulsed
                      • Ultrasound-Pulsed
                      • Passive Joint Motion

                      If you have any further questions about the inflammation phase of healing call me at 813-229-0207.

                      Dr. Joe Papia Chiropractor in Tampa FL 33602