Over the past few weeks, we have been going over how to safely load tissues during the acute and sub-acute phases of an injury.
Along with instructions on loading, we have been reviewing what happens during the inflammatory and proliferative phases of healing.
This is all important because it’s crucial a therapist recognize what stage of healing the tissue is at in order to load the tissue safely, recognize when the tissue is taking too long to heal, and refer back to their doctor.
We are going to continue with the topic and look at the remodelling phase of healing, which is a longer, and increased changes occur. It also means we can be more aggressive in the movements we recommend and help our patients take part in. However, there is still a risk of re-injury that we must be mindful of as we progress through the rehab process.
As we have outlined in our past couple of posts on the topic, your clinical judgement and decision making is crucial for success, so we will look at how to implement and understand what’s happening during the remodelling phase with this post.
Repair And Remodelling
There are two phases to the remodelling phase; the consolidation, and the maturation stage.
During this consolidation phase, the tissue becomes more fibrous and stronger due to type III collagen becoming type I (due to macrophages breaking the type III collagen tissue down). The body starts to convert the wound into scar tissue and there is a carryover of functions that occurred in the remodelling phase that continues to take place (wound contraction). This lasts for 21-60 days, and scar tissue should stop increasing in size because of the wound contraction.
During the maturation phase takes place from days 60-360. Collagen structure, arrangement, and turnover continues to occur and is the primary function at this point until (after about four months) the tissue becomes tendon-like, and this can continue for 12-18 months.
But remodelling time has some outside influences that can either hinder or encourage the process. The amount of time immobilized, stress on the area, vascularity, and location of injury can change the amount of time remodelling takes. During the proliferative phase, the fibres were laid down in a random direction, but the injury becomes stronger if the fibres are organized in a parallel direction. This happens due to external forces being applied to the injury site, and there is a window to assist with this remodelling for 10 weeks.
Now, when we talk about external forces, it is quite often promoted that doing massage on the area is an appropriate outside force in order to realign these fibers. However, one study shows that while physical force can alter connective tissue, there is almost no data that shows manual therapy techniques have any real ability to realign fibers.
But, guess what does? Exercise!
Tissue Loading During Remodelling
As we mentioned earlier, this is where we can get a bit more aggressive as far as load and movement, but we want to make sure not to overdo it.
But, we do want to start placing force along the lines of stress in order to help with the collagen tissue.
At this point there should be no signs of inflammation and movement should be getting easier. You’ve progressed your patient through some mobility, PROM, and AROM exercises along with some eccentric movements. Now you can start to ramp things up a bit.
The movements can start to go from isolated, into more multidirectional patterns and movements. We have used the example of an ankle sprain in the past couple of articles, start to think about movements like side lunges to load into the injury site, or some active movements going from side to side cutting in different directions. Use concentric (the muscle shortens) and eccentric (muscle lengthens) movements along with weight-bearing exercises. Some you can even do on your table during the massage, just to get things going. For instance, you could manually resist at the ankle (with the patient prone) while they bend the knee as a hamstring contraction, then resist again as they lower the ankle to the table (if you were rehabbing a hamstring injury).
Hopefully, along the way, you’ve had some good communication with your patient as far as what goals they had in getting back to activities. This is where you can start to build some more active exercises. Have them start to do modifications of those activities.
If the patients activity is as simple as getting a jar out of the cupboard, have them start to practice with and an empty jar for a few repetitions until they have no problem doing it with a heavy full jar.
If your patient is an athlete, get them into modified versions of their activity. Recommend slower speed with a lighter load, until more of each can be tolerated. Once it can be tolerated start including plyometric movements (explosive movement ie: jumping) for example, standing on one leg, crouching down and jumping straight up on that previously injured ankle.
In any case, as more tolerance is attained, increase the repetitions and speed of each movement. But make sure you take the time to educate your patient. Show them how a little pain is okay, but not excessive so they can avoid any possibility of re-injuring the area. Also, whatever exercises you choose, make sure they are important to the person. Choose movements you know they will do, there’s no point in recommending a nice light walk to a crossfitter, or sprints to someone whose goal is to pick up their child pain-free. Make it applicable to each individual and their individual goals. Helping a patient rehab an injury doesn’t have to be complicated, it just takes your clinical knowledge and progressing movement properly, all of which you can do in your treatment room. If exercise prescription isn’t in your scope, AROM and PROM probably are, so there’s no reason you can’t implement various movements into your treatment whether on the table or off of it.
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