조직 손상후 치유과정 2. 증식기 치료지침

[문형철]

조직 손상이 일어나면 염증기 4~6일

이후 증식기(proliferation, healing and healing stage) 2-3주 지속

염증기가 끝나고 10일~17일 지속된다는 사실이 중요하구나! 

환자들은 끊임없이 만성염증, 재손상 염증 등에 노출되기 때문에!!

증식기 치료지침은 무엇인가?

panic bird..

MANAGEMENT DURING THE SUBACUTE STAGE

Tissue Response—Repair and Healing

During the second to fourth days after tissue injury, the inflammation begins to decrease, the clot starts resolving, and repair of the injured site begins. This usually lasts an additional 10 to 17 days (14 to 21 days after the onset of injury) but may last up to 6 weeks.

- 조직손상후 2-4일이 지나는 동안, 염증은 시작되어 감소되고, 피떡(clot)이 만들어지기 시작하고, 손상조직은 회복되기 시작함. 

- 이 과정은 염증기가 끝나고 10-17일 지속되지만 6주까지 지속되는 경우도 있음.

The synthesis and deposition of collagen characterize this stage. Noxious stimuli are removed, and capillary beds begin to grow into the area. Fibroblastic activity, collagen formation, and granulation tissue development increase. Fibroblasts are present in tremendous numbers by the fourth day after injury and continue in large number until about day 21.The fibroblasts produce new collagen, and this immature collagen replaces the exudate that originally formed the clot. In addition, myofibroblastic activity begins about day 5, causing scar shrinkage (contraction).22 Wound closure usually takes 5 to 8 days in muscle and skin and 3 to 6 weeks in tendons and ligaments.9

- 증식기의 특성은 콜라겐 합성과 deposition임. 유해자극은 제거되고 혈관 베드가 만들어지기 시작함. 

- 섬유아세포 활성, 콜라겐 형성, 과립조직이 증가함. 

- 섬유아세포는 조직손상후 4일 이후에 어마어마한 숫자가 존재하고 21일까지 지속됨. 

- 섬유아세포는 새로운 콜라겐을 생성하고, 미성숙 콜라겐은 원래 형성되었던 피떡인 삼출물을 대신함. 게다가 myofibroblastic 활성은 5일 후에 시작하고 반흔조직의 응축을 만들어냄. 

- 상처봉합은 근육과 피부에서는 5-8일사이에 일어나고, 힘줄과 인대에서는 3-6주 소요됨. 

During this stage, the immature connective tissue that is produced is thin and unorganized. It is extremely fragile and easily injured if overstressed, yet proper growth and alignment can be stimulated by appropriate tensile loading in the line of normal stresses for that tissue. At the same time, adherence to surrounding tissues can be minimized.7

- 증식기 동안 미성숙 결합조직은 얇고 비조직화된 구조임. 이 상태에서 만약 과도한 부하가 주어지면 쉽게 손상됨. 하지만 적절한 성장과 배열은 적절한 장력부하에 의해서 자극됨. 동시에 주위조직의 유착은 최소화됨. 

Management Guidelines—Controlled Motion Phase

The therapist’s role during this stage is critical. The patient feels much better because the pain is no longer constant, and active movement can begin. It is easy to begin too much movement too soon or be tempted to approach intervention

cautiously and not progress rapidly enough. Understanding the healing process and tissue response to stresses underlies the critical decisions that are made throughout this phase of intervention. The key is to initiate and progress nondestructive exercises and activities (i.e., exercises and activities that are within the tolerance of the healing tissues, which can then respond without reinjury or inflammation). The information that follows is summarized in Box 10.2.

- 증식기에 치료사의 역할은 매우 중요함. 

- 환자는 통증이 없기 때문에 나아졌다고 생각하고 능동적 움직임을 시작함. 너무 많은 움직임이 시작될 가능성이 많고, 조심스러운 치료적 개입이 시행되어야 하는데, 충분치 않은 정도의 움직임 치료가 진행될 수 있음. 

- 치유과정의 이해와 장력에 대한 조직의 반응을 이해하는 것은 치료적 개입의 주용한 결정의 기초가 됨. 

- 핵심은 손상조직이 재손상되지 않으면서 움직임 운동을 시작하고 강도를 높이는 것임. 

Patient Education

Inform the patient about what to expect at this stage, the time frame for healing, and what signs and symptoms indicate that he or she is pushing beyond tissue tolerance. Encourage the patient to return to normal activities that do not exacerbate  symptoms, but caution against returning to recreational, sports, or work-related activities that would be detrimental to the healing process. Teach the patient a home exercise program and help him or her adapt work and recreational activities that are consistent with intervention strategies so the patient becomes an active participant in the recovery process.

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Management of Pain and Inflammation

Pain and inflammation decrease as healing progresses.

Criteria for initiating active exercises and stretching during the early subacute stage include decreased swelling, pain

that is no longer constant, and pain that is not exacerbated by motion in the available range. 

1. Monitor activities and exercises. 

As new exercises are introduced or as the intensity of exercises is progressed, monitor the patient’s response, so if symptoms warrant the intensity of exercise can be modified.

P R E C A U T I O N : The new tissue being developed is fragile and easily interrupted. The patient often feels good and returns to normal activity too soon, causing exacerbation of symptoms. Exercises progressed too vigorously or functional activities begun too early can be injurious to the fragile, newly developing tissue and therefore may delay recovery by perpetuating the inflammatory response.22,26 However, if movement is not progressed, the new tissue adheres to surrounding structures and eventually becomes a source of pain and limited tissue mobility.

- 손상후 증식기 조직은 쉽게 재손상됨. 환자는 통증이 없기때문에 너무 빨리 정상활동으로 돌아가려 함. 
- 치료적 운동이 너무 빨리 진도를 나가면 재손상되어 염증반응을 일으켜 치료를 지연시킬 수 있음. 
- 그렇다고 해서 치료적 움직임을 진도를 나가지 않으면 새로운 조직은 주위구조와 유착을 일으키고 결국 통증의 원인이 되고 움직임제한이 발생함. 

2. Initiation of Active Exercises

Because of the restricted use of the injured region, there is muscle weakness even in the absence of muscle pathology.

The subacute phase is a transition period during which active exercises within the pain-free range of the injured tissue can begin and be progressed to muscular endurance and strengthening exercises with care, keeping within the tolerance of the healing tissues (nondestructive motion). If activity is kept within a safe intensity and frequency, symptoms of pain and swelling progressively decrease each day. 

Patient response is the best guide to how quickly or vigorously to progress. Clinically, if signs of inflammation increase or the ROM progressively decreases, the intensity of the exercise and activity must decrease because chronic inflammation has developed and a retracting scar will become more limiting.2,3,15 

3. Multiple-angle, submaximal isometric exercises. 

Submaximal isometric exercises are used during the early subacute stage to initiate control and strengthening of the muscles in the involved region in a nonstressful manner. They may also help the patient become aware of using the correct muscles. The intensity and angles for resistance are determined by the absence of pain.

@ To initiate isometric exercise in an injured, healing muscle, place it in the shortened or relaxed position so the new scar is not pulled from the breached site.7,22

@ To initiate isometric exercises when there is joint pathology, the resting position for the joint may be the most comfortable position. The intensity of contraction should be kept below the perception of pain.

4. Active range of motion exercises. 

Active range of motion (AROM) activities in pain-free ranges are used to develop control of the motion. Initially, isolated, single plane motions are used. Emphasize control of the motion using

light-resistive, concentric exercises of involved muscle and

muscles needed for proper joint mechanics. Use of combined

motions or diagonal patterns may facilitate contraction

of the desired muscles, but care must be taken not to

use patterns of motion dominated by stronger muscles,

with the weaker muscles not effectively participating at

this early stage. Do not stress beyond the ability of the

involved or weakened muscles to participate in the motion.

5. Muscular endurance. 

Exercises for muscle endurance are

emphasized during the subacute phase because slow-twitch

muscle fibers are the first to atrophy when there is joint

swelling, trauma, or immobilization. Initially, only active

ROM is used, with emphasis on control. Later during the

healing phase, low-intensity, high-repetition exercise using light resistance is used rather than high-intensity resistance.

The therapist must be certain that the patient is using correct

motor patterns without substitution and is informed

of the importance of stopping the exercise or activity when

the involved muscle fatigues or involved tissue develops

symptoms. For example, if the patient is doing shoulder

flexion or abduction activities, substitution with scapular

elevation should be avoided; or if the patient is doing leglift

exercises, proper stabilization of the pelvis and the

spine is important to ensure safety and correct motor

learning.

6. Protected weight-bearing exercises. 

Partial weight bearing

within the tolerance of the healing tissues may be used

early to load the region in a controlled manner and stimulate

stabilizing co-contractions in the muscles. Reinforcement

from the therapist helps develop awareness of

appropriate muscle contractions and helps develop control

while the patient shifts his or her weight in a side-to-side

or anterior-to-posterior motion. As tolerated by the patient,

progress by increasing the amplitude of movement or by

decreasing the amount of support or protection. Resistance

is added to progress strength in the stabilizing muscles.

P R E C A U T I O N : Eccentric and heavy-resistance exercises

(such as PRE) may cause added trauma to muscle and

are not used in the early subacute stage after muscle injury

when the weak tensile quality of the healing tissue could be

jeopardized.16 For nonmuscular injuries, eccentric exercises

may not reinjure the part, but the resistance should be limited

to a low intensity at this stage to avoid delayed-onset

muscle soreness. (This is in contrast to using eccentric exercises

to facilitate and strengthen weak muscles when there

has been no injury to take advantage of greater tension

development with less energy in eccentric contractions,

which is described in Chapter 6.)

Initiation and Progression of Stretching

Restricted motion during the acute stage and adherence

of the developing scar usually cause decreased flexibility

in the healing tissue and related structures in the region.

To increase mobility and stimulate proper alignment of

the developing scar, initiate stretching techniques that are

specific to the tissues involved. More than one technique

may have to be used to regain the ROM.

Warm the tissues. 

Use modalities or active ROM to increase the tissue temperature and relax the muscles for ease in stretching.

Inhibition techniques. 

Muscles that are not relaxed interfere with joint mobilization and passive stretching of inert tissue. If necessary, utilize hold–relax techniques first to be able to take the tissues to the end of their available range.

Joint mobilization. 

If there is decreased joint play restricting

range, it is important to begin stretching with joint

mobilization techniques. Use grade III sustained or grade

III and IV oscillation techniques to restore some of the

joint slide prior to physiological stretching so as to minimize excessive compression of vulnerable cartilage. Joint

distraction and gliding techniques are applied to stretch

restricting capsular tissue (see Chapter 5 for the principles and techniques of joint mobilization).

Stretching techniques. 

Use of passive stretching techniques,

self-stretching, and prolonged mechanical stretching

are used to increase the extensibility of inert connective

tissue, which permeates every structure in the body. These

techniques are interspersed with neuromuscular inhibition

techniques to relax and elongate the muscles crossing the

joints (see Chapter 4 for the principles and techniques of

stretching).

Massage. Various types of massage can be used for their

soft tissue mobilizing effects. For example, cross-fiber friction

massage is used to mobilize ligaments and incision

sites so they move freely across the joint. Cross-fiber massage

is also used at the site of muscle scar tissue or tendon

adhesions to gain mobility of the scar tissue. The intensity

and duration of the technique is progressively increased as

the tissue responds.

Use of the new range. The patient must use the new range

to maintain any extensibility gained with the stretching

maneuvers and to develop control of the new range. Teach

home exercises that include light resistance using the agonist

in the new range as well as self-stretching techniques.

Also help the patient incorporate the new range into his or

her daily activities.

Correction of Contributing Factors

Continue to maintain or develop as normal a physiological

and functional state as possible in related areas of the body.

Correct postural stability problems or muscle length and

strength imbalances that could have contributed to the

problem. Resume low-intensity functional activities as the

patient tolerates without exacerbating symptoms. Continue

to reassess the patient’s progress and understanding of the

controlled activities.

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