Immobilization or Early Mobilization After an Acute Soft-Tissue Injury

[문형철]

손상후에는 당연히 움직여야 한다.

언제부터 어떻게 움직여야 하는가? controlled mobilization이어야 한다. 

4단계.

First is treating the damaged area with PRICES: protection, rest, ice, compression, elevation, and support. 

Second, during the first 1 to 3 weeks after the injury, immobilization of the injured tissue areas allows healing without extensive scarring. 

Third, when soft-tissue regeneration begins, controlled mobilization and stretching of muscle and tendons stimulate healing. 

Fourth, at 6 to 8 weeks post-injury, the rehabilitative goal is full return to pre-injury level of activity. 

Immobilization or Early Mobilization after an acute soft ti.pdf

Experimental and clinical studies demonstrate that early, controlled mobilization is superior to immobilization for primary treatment of acute musculoskeletal soft-tissue injuries and postoperative management. Optimal treatment and rehabilitation follow four steps that address response to trauma. 

First is treating the damaged area with PRICES: protection, rest, ice, compression, elevation, and support. 

Second, during the first 1 to 3 weeks after the injury, immobilization of the injured tissue areas allows healing without extensive scarring. 

Third, when soft-tissue regeneration begins, controlled mobilization and stretching of muscle and tendons stimulate healing. 

Fourth, at 6 to 8 weeks post-injury, the rehabilitative goal is full return to pre-injury level of activity. 

Acute soft-tissue injuries such as muscle-tendon strains, ligament sprains, and ligament or tendon ruptures occur frequently in sports and exercise. Without correct diagnosis and proper treatment, they may result in long-term breaks in training and competition. Far too often, injuries become chronic and end careers of competitive athletes or force

recreational athletes to abandon their favorite activity. For these reasons, an increased focus has been on finding ways to ensure optimal healing. In this regard, the question has centered on immobilization or early mobilization in treatment.

Acute inflammatory phase. 

In this phase, ischemia, metabolic disturbance, and cell membrane damage lead to inflammation, which, in turn, is characterized by infiltration of inflammatory cells, tissue edema, fibrin exudation, capillary wall thickening, capillary

occlusions, and plasma leakage. Clinically, inflammation manifests as swelling, erythema, increased temperature, pain, and loss of function. The process is time dependent and mediated by vascular, cellular, and chemical events culminating in tissue repair and sometimes scar (adhesion) formation.

Proliferative phase. 

These changes include fibrin clotting and a proliferation of fibroblasts, synovial cells, and capillaries. The inflammatory cells eliminate the damaged tissue fragments by phagocytosis, and fibroblasts extensively and markedly elevate

production of collagen (initially, the weaker, type 3 collagen, later type 1) and other extracellular matrix components.

Maturation and remodeling phase. 

In this phase, the proteoglycan-water content of the healing tissue decreases and type 1 collagen fibers start to assume a normal orientation. Approximately 6 to 8 weeks post-injury, the new collagen fibers can withstand nearnormal stress, although final maturation of tendon and ligament tissue may take as long as 6 to 12 months.

Injury and Four-Step Treatment

After an injury, the ideal treatment and rehabilitation program should include four steps.

1) PRICES. 

Immediately after injury, the damaged area should be treated with PRICES: protection, rest, ice (cold), compression, elevation, and support (table 2) (1,2). The aim is to minimize hemorrhage, swelling, inflammation, cellular metabolism, and pain, and to provide optimal conditions for healing (2). Since prolonged inflammation may lead to excessive scarring, early, effective treatment seeks to prevent it. On the other hand, one

must remember that inflammation is not only the body's response to insult, but also the initial step in healing.

2) Immobilization and protection. 

The second step is immobilization and protection of the injured tissue area during the first 1 to 3 weeks. In the early phase of healing, immobilization allows undisturbed fibroblast invasion of the injured area that leads to unrestricted cell proliferation and collagen fiber production. Premature and intensive mobilization at this time leads to enhanced type 3 collagen production and weaker tissue than that produced during an optimal immobilization period (2). Protection (such as with a cast or brace) prevents secondary injuries and early distension and lengthening of injured collagenous structures such as a torn anterior cruciate ligament (ACL) (3).

3) Maturation. 

About 3 weeks after injury, collagen maturation and final scar tissue formation begins (1,2,4). In this phase, injured soft tissues need controlled mobilization. Less injured portions of the tissue or joint, however, can be mobilized earlier, sometimes even during the proliferative phase. Prolonged immobilization, though, must be avoided to prevent atrophy of cartilage, bone, muscle, tendons, and ligaments (5-12). Controlled muscle stretching and joint movement enhance new collagen fiber orientation parallel to the stress lines of the normal collagen fibers; these activities also serve to prevent tissue atrophy from immobilization. Treatment can be supported with physical therapy to improve local circulation and proprioception, inhibit pain, and strengthen muscle-tendon units.

4) Resumption of activity. 

Approximately 6 to 8 weeks after the injury, new collagen fibers can withstand near-normal stress, and the goal for rehabilitation is rapid and full recovery to activity. If the previous steps were followed, protection is no longer needed, and each component of the damaged soft tissue is ready for a progressive mobilization and rehabilitation program (2).

Practical Applications

1) Avoiding atrophy. 

Obviously, the best method for preventing immobilization atrophy is usage. Complete immobilization should be minimal and often is not needed at all. During the last 10 to 15 years, many postoperative protocols, especially those involving knee and ankle ligament injuries, have undergone a major change from long, complete immobilization to early, controlled mobilization using elastic or other bandages, rehabilitative braces, continuous passive devices, or a combination immediately after the trauma. Also, active joint motion and weight bearing is allowed earlier than before, and

training during immobilization is becoming more and more effective (10). Even modern fracture treatment has considerably reduced the degree and duration of cast immobilization (10,25).

2) Early mobilization. 

Early mobilization is the best method to avoid joint contracture and its harmful consequences on articular cartilage. The technique also serves to maintain and return joint proprioception, which, in turn, may be important in preventing reinjury and in hastening recovery to full fitness. In addition, Frank et al (34) have suggested that joint motion may help reduce postinjury and postoperative pain, swelling, and thromboembolic complications. The efficacy of early motion in preventing immobilization atrophy depends on how well it controls pain, inflammation, and swelling. Inflammation and pain result in voluntary inhibition of muscle activity across the affected joint. Spencer et al (35) have even reported that pain is not required to cause muscle inhibition; swelling alone is sufficient (so-called reflex inhibition). Therefore, primary treatment should control all three factors using early controlled motion in combination with other treatment modalities such as

cold, anti-inflammatory analgesics, and transcutaneous neural stimulation.

3) Rehabilitation programs. 

For each joint and each type of injury, rehabilitation programs must be individualized, taking into account the injured structures that should be protected from premature and intensive mobilization, as well as the uninjured structures that should be mobilized as soon as possible. To prevent muscle dysfunction when immobilization must be used, diverse stimuli are needed throughout the entire period; these include strength, power, and endurance exercises. The modern operational principle in the treatment of acute soft-tissue injuries and during immobilization is that "within the limits

of pain, everything that is not explicitly forbidden is allowed." (10) This, of course, requires good cooperation between the patient and the attending physician and physical therapist.