손상후 치유과정 3. remodeling phase 치료지침

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MANAGEMENT DURING THE CHRONIC STAGE

Tissue Response—Maturation and Remodeling

Scar retraction from activity of the myofibroblasts is usually complete by the 21st day and the scar stops increasing in size, so from day 21 to day 60 there is a predominance of fibroblasts that are easily remodeled.22 The process of maturation begins during the late subacute stage and continues for several months. The maturation and remodeling

of the scar tissue occurs as collagen fibers become thicker

and reorient in response to stresses placed on the connective

tissue. Remodeling time is influenced by factors that

affect the density and activity level of the fibroblasts,

including the amount of time immobilized, stress placed

on the tissue, location of the lesion, and vascular supply. 

Maturation of Tissue

The primary differences in the state of the healing tissue

between the late subacute and chronic stages are the

improvement in quality (orientation and tensile strength) of

the collagen and the reduction of the wound size during the

chronic stages. The quantity of collagen stabilizes; and

there is a balance between synthesis and degradation.

Depending on the size of the structure or degree of injury

or pathology, healing, with progressively increasing tensile

quality in the injured tissue, may continue for 12 to 18

months.9,17,22

Remodeling of Tissue

Because of the way immature collagen molecules are held

together (hydrogen bonding) and adhere to surrounding tissue,

they can be easily remodeled with gentle and persistent

treatment. This is possible for up to 10 weeks. If not

properly stressed, the fibers adhere to surrounding tissue

and form a restricting scar. As the structure of collagen

changes to covalent bonding and thickens, it becomes

stronger and resistant to remodeling. At 14 weeks, the scar

tissue is unresponsive to remodeling. Consequently, an old

scar has a poor response to stretch.7 Treatment under these

conditions requires either adaptive lengthening in the tissue

surrounding the scar or surgical release.

Management Guidelines— Return to Function Phase

The therapist’s role during this phase is to design a progression

of exercises that safely stress the maturing connective

tissue in terms of both flexibility and strength so

the patient can return to his or her functional and workrelated

activities. Individuals returning to high-intensity

activities require more intense exercises to prepare the tissues

to withstand the stresses and train the neuromuscular

system to respond to the demands of the activity.

Because remodeling of the maturing collagen occurs

in response to the stresses placed on it, it is important to

use controlled forces that duplicate normal stresses on the

tissue. Maximum strength of the collagen develops in the

direction of the imposed forces. Pain that the patient now

experiences arises only when stress is placed on restrictive

contractures or adhesions or when there is soreness due to

increased stress of resistive exercise. To avoid chronic or

recurring pain, the contractures must be stretched or the

adhesions broken up and mobilized. Excessive or abnormal

stresses leads to reinjury and chronic inflammation, which

can be detrimental to the return of function. The information that follows is summarized in Box 10.4.

Patient Education

Unless there is restrictive scar tissue requiring manual

techniques for intervention, the patient becomes more

responsible for carrying out the exercises in the plan of

treatment. Instruct the patient in biomechanically safe progressions

of resistance and self-stretching and how to selfmonitor

for detrimental effects and signs of excessive

stress (Box 10.3). Establish guidelines for what must be attained to return safely to recreational, sport, or workrelated

activities. Re-examine and eval‎uate the patient’s

progress and modify the exercises as progress is noted or

if problems develop. Recommend modifications in living,

work, or sport activities if they are contributing to the

patient’s impairments and preventing return to desired

activities.

Considerations for Progression of Exercises

Free joint play within a useful (or functional) ROM is necessary

to avoid joint trauma. If joint play is restricted,

joint-mobilizing techniques should be used. These stretching

techniques can be vigorous so long as no signs of

increased irritation result.

Joint motion without adequate muscle support causes

trauma to that joint, or faulty neuromuscular patterns will

be used as functional activities are attempted. Zohn and

Mennell26 recommended that the criterion for strength

should be a muscle test grade of 4 on a 5-point scale in

lower extremity musculature before discontinuing use of

supportive or assistive devices for ambulation. Although

this advice was given during the 1970s, it emphasizes

the importance of muscle support in the protection of

joints.

To increase strength when there is a loss of joint play,

use multiple-angle isometric exercises.

Once joint play within the available ROM is restored,

use resistive dynamic exercises within the available

range. This does not imply that normal ROM needs to be

present before initiating dynamic exercises but that joint

play within the available range should be present (see

Chapter 5 for information on joint play).

In summary, joint dynamics and muscle strength and

flexibility should be balanced as the injured part is progressed

to functional exercises.

Progression of Stretching

Stretching of any restricting contractures or adhesions

should be specific to the tissue involved using manual techniques such as joint mobilization, myofascial massage,

neuromuscular inhibition techniques, and passive stretching

in addition to instruction in self-stretching (see Chapters

4 and 5 and the self-stretching exercises described in

Chapters 16 to 22). At this stage, progress the intensity

and duration of the stretching maneuvers so long as no

signs of increased irritation persist beyond 24 hours.

Progression of Exercises for Muscle

Performance: Developing Neuromuscular

Control, Strength, and Endurance

As the patient’s tissues heal, not only does treatment

progress to stimulate proper maturation and remodeling in

the healing tissue, but emphasis is also placed on controlled

progressive exercises designed to prepare the

patient to meet the functional outcomes.

If the patient is not using some of the muscles because

of inhibition, weakness, or dominance of substitute patterns,

isolate the desired muscle action or use unidirectional

motions to develop awareness of muscle activity

and control of the movement.

Progress exercises from isolated, unidirectional, simple

movements to complex patterns and multidirectional

movements requiring coordination with all muscles

functioning for the desired activity.23

Progress strengthening exercises to simulate specific

demands including both weight-bearing and non-weight-bearing (closed and open chain) and both eccentric

and concentric contractions.

Progress trunk stabilization, postural control, and balance

exercises as well as coordinate with extremity

motions for effective total body movement patterns.23

Teach safe body mechanics and have the patient practice

activities that replicate his or her work environment.

Often overlooked but of importance in preventing injury

associated with fatigue is developing muscular

endurance in the prime mover muscles and stabilizing

muscles as well as cardiovascular endurance.

Return to High-Demand Activities

Patients who must return to activities with greater-thannormal

demand, such as is required in sports participation

and heavy work settings, are progressed further to more

intense exercises including plyometrics, agility training,

and skill development. Develop exercise drills that simulate

the work12 or sport2,23 activities using a controlled

environment with specific, progressive resistance and plyometric

drills. As the patient demonstrates capabilities,

increase the repetitions and speed of the movement.

Progress by changing the environment and introducing surprise

and uncontrolled events into the activity.1,23

The importance of proper education to teach a safe

progression of exercises and how to avoid damaging stresses

cannot be overemphasized. To return to the activity that

caused the injury prior to regaining functional pain-free

motion, strength, endurance, and skill to match the

demands of the task would probably result in recurring

injury and pain.