Joint Motion’s Influence On…
And The Potential Pitfalls Of Clinical Joint Immobilization
Back in 1984, orthopedic surgeon Sir James Cyriax, MD, reviewed The Concept Of Motion in his Textbook of Orthopaedic Medicine, Diagnosis of Soft Tissue Lesions (1). In this text, Dr. Cyriax carefully noted that harmful infections create tissue destruction, resulting in inflammation.
A current prevailing concept in explaining this observation is the body recognizes this inflammation and attempts to “wall off” the infectious pathogens by creating a fibrous response.
This is in fact in agreement with Dr. William Boyd who states in his pathology text (2):
“The inflammatory reaction tends to prevent the dissemination of infection. Speaking generally, the more intense the reaction, the more likely the infection to be localized.”
Physiologist and physician Arthur Guyton (3) provides support for this concept as well in his statement:
“One of the first results of inflammation is to ‘wall off’ the area of injury from the remaining tissues. This walling-off process delays the spread of bacteria or toxic products.”
Some interpret this type of response to mean that (in a world prior to the availability of antibiotics, inflammation, with reactive walling-off fibrosis to contain pathogens) it is desirable because it increases survivability of the host.
As explained by three vaunted researchers Cyriax, Boyd, and Guyton above, the trigger to the walling-off fibrosis response of the body is inflammation.
Problems appear to only seriously arise when the inflammatory trigger is non-infectious inflammation.
In such cases, excessive tissue fibrosis creates local impairments in biomechanical function.
This impairment in local biomechanical function affects performance, can generate pain, and accelerate degenerative changes. These impairments can adversely affect the patient for years or even decades.
Fortunately, abnormal tissue fibrosis can be minimized with early, persistent, controlled motion. Once established, abnormal tissue fibrosis can be improved with the use of a variety of motion applications.
Cyriax’s text (1) states the following:
“The excessive reaction of tissues to an injury is conditioned by the overriding needs of a process designed to limit bacterial invasion.
If there is to be only one pattern of response, it must be suited to the graver of the two possible traumas. However, elaborate preparation for preventing the spread of bacteria is not only pointless after an aseptic injury, but is so excessive as to prove harmful in itself. The principle on which the treatment of post-traumatic inflammation is based is that the reaction of the body to an injury unaccompanied by infection is always too great.” (Cyriax, p.14)
Cyriax finds support in the sports trauma text authored by physicians Steven Roy and Richard Irvin (4), who state:
“It is important to realize that the body’s initial reaction to an injury is similar to its reaction to an infection. The reaction is termed inflammation and may manifest macroscopically (such as after an acute injury) or at a microscopic level, with the latter occurring particularly in chronic overuse conditions.” (Roy, p. 125)
Additional support for these concepts from Cyriax and Roy/Irvin are the writings of
physician I. Kelman Cohen and associates (5). In their 1992 text Wound Healing, these authors note:
“There are two important consequences of being a warm-blooded animal. One is that body fluids make optimal culture media for bacteria. It is to the animal’s advantage, therefore, to heal wounds with alacrity in order to reduce chances of infection.”
“The prompt development of granulation tissue forecasts the repair of the interrupted dermal tissue to produce a scar.” In addition to providing tensile strength, scars are believed to be a barrier to infectious migration.
The chronic nature of this scar tissue or fibrosis is expressed in the 1998 article by Thomas Melham and associates (6).
These authors note that post-traumatic scar tissue can cause pain with activity, pain on palpation, decreased range of motion, and loss of function, and that these problems are resistant to surgery and to conventional physical.
Excessive scar tissue contributes to chronic soft tissue dysfunction that cause significant disabilities and time lost from work or training activities, and these problems are often difficult to successfully treat. The authors extensively elaborate on the mechanical and neurological adverseness caused by connective tissue fibrosis, noting:
“Many athletes develop excessive connective tissue fibrosis (scar tissue) or poorly organized scar tissue in and around muscles, tendons, ligaments, joints, and myofascial planes as a result of acute trauma, recurrent microtrauma, immobilization, or as a complication of surgical intervention.”
“This can lead to soft tissue adhesions, tendonitis, tendonosis, fascial restrictions, and chronic inflammation or dysfunction which in many cases responds poorly to conventional treatments.”
These authors present an argument that carefully and precisely applied external forces “appear to stimulate connective tissue remodeling through resorption of fibrosis, along with inducing repair and regeneration of collagen secondary to fibroblast recruitment.”
As noted above, abnormal tissue fibrosis can be minimized with early, persistent, controlled motion.
Once established, abnormal tissue fibrosis can be improved with the use of a variety of motion applications.
Support for the value in using motion to treat soft-tissue injuries has been throughout the literature for decades.
As an example, Beverly Hills neurosurgeon Emil Seletz, associated with the medical school at the University of California, Los Angeles (UCLA), noted in the Journal of the American Medical Association in 1958, the following, with respects to the management of whiplash soft-tissue injuries (7):
“During injury, hemorrhage within the capsular ligaments gives rise to swelling of the nerves and eventually adhesions between the dural sleeve and the nerve root; these factors give rise to symptoms that may be prolonged for months or even years after the injury.”
“In reviewing the types of treatment with a number of specialists in this field, it is found that, while therapy naturally varies to suit the individual need, it consists primarily of local heat in the form of hot wet packs and cervical traction, followed by very gentile massage and manual rotations.”
“The importance of a carefully planned scheme of treatment must be emphasized to the patient, and treatments must be religiously carried out daily during the first two or three weeks (and then about three times weekly), depending, of course, on the individual case.”
“Delay or faulty treatment leads to adhesions about the facets and scarring about the capsular ligaments, persistent spasm, congestive lymph edema, and fibrosis of muscles, swelling, and eventual adhesions of nerves within the nerve root canals.”
“The resultant faulty posture in neglected cases enhances the degeneration of the intervertebral disks, as well as spur formation in the lateral co-vertebral articulations, which on the roentgenogram has come to be known as traumatic arthritis.”
“I cannot too strongly emphasize the urgency of early and persistent therapy, always by a specialist in this field.”
“Occasionally, a patient is seen with persistent complaints of head, neck, and shoulder pain, who has had on surgical exposure persistent swelling and adhesions of several nerve roots within the dural sleeve of exit. It is most likely that early, persistent, and adequate therapy by those expertly trained in physical medicine will prevent most patients from developing a surgical condition.”
On this very same topic, Cyriax’s comments include a review of the 1940 primary research by ML Stearns (8), stating:
“Her (Stearns) main conclusion on the mechanics of the formation of scar tissue was that external mechanical factors, were responsible for the development of the fibrillary network into orderly layers.
Within four hours of applying a stimulus, an extensive network of fibrils was already visible around the fibroblasts; during the course of 48 hours this became dense enough to hide the cells almost completely: and in 12 days a heavy layer of fibrils had appeared.
At first the fibrils developed at random, but later they acquired a definite arrangement, apparently as a direct result of the mechanical factors.
Of these factors, movement is obviously the most important and equally obvious it is most effective and least likely to cause pain before the fibrils have developed an abnormal firm attachment to neighboring structures.
When free mobility was encouraged from the onset, the fibers in the scar were arranged lengthwise as in a normal ligament.
Gentle passive movements do not detach fibrils from their proper formation at the healing breach but prevent their continued adherence at normal sites.
The fact that the fibrils rapidly spread in all directions provides sufficient reason for beginning movements at the earliest possible moment; otherwise they develop into strong fibrous scars (adhesions) that so often cause prolonged disability after a sprain.” (Cyriax, p. 15)
Cyriax notes further:
“When pain is due to bacterial inflammation, Hilton’s advocacy of rest remains unchallenged and is today one of the main principles of medical treatment.
When, however somatic pain is caused by inflammation due to trauma, his ideas require modification.
When non-bacterial inflammation attacks the soft tissues that move, treatment by rest has been found to result in chronic disability, later, although the symptoms may temporarily diminish.
Hence, during the present century, treatment by rest has given way to therapeutic movement in many soft tissue lesions.
Movement may be applied in various ways: the three main categories are:
(a) active and resistive exercises:
(b) passive, especially forced movement: and
(c) deep massage.” (Cyriax, p.14)
“Tension within the granulation tissue lines the cells up along the direction of stress.
Hence, during the healing of mobile tissues, excessive immobilization is harmful.
It prevents the formation of a scar strong in the important direction by avoiding the strains leading to due orientation of fibrous tissue and also allows the scar to become unduly adherent, e.g. to bone.” (Cyriax, p.15)
In 1983, sports physicians Steven Roy and Richard Irvin also note (4):
“The trauma, or initial lesion, leads to an increase of the friction that occurs between moving tissues as well as to a release of chemical mediators, both of which may start the inflammatory process.
This process may present macroscopically with a number of signs, particularly (a) pain (b) swelling, and (c) redness and warmth. However, microtrauma may not present with any of these signs, particularly during the early stages, even though the inflammation is proceeding at the microscopic level.” (p. 125)
“The injured tissues next undergo remodeling, which can take up to one year to complete in the case of major tissue disruption.
The remodeling stage blends with the later part of the regeneration stage, which means that motion of the injured tissues will influence their structure when they are healed.
This is one reason why it is necessary to consider using controlled motion during the recovery stage.
If a limb is completely immobilized during the recovery process, the tissues may emerge fully healed but poorly adapted functionally, with little chance for change, particularly if the immobilization has been prolonged.
Another reason for encouraging controlled motion is that any adhesions that develop will be flexible and will thus allow the tissues to move easily on each other.
Caution should be observed during the first two weeks, as mentioned previously, as the tensile strength of the tissues may be markedly reduced.” (p.127)
In 1986, physician John Kellett notes (9):
Acute inflammation is beneficial when one has acute infection. However, the “acute inflammatory phase of the body’s response to trauma is apparently of no benefit.”
“The micropathology of acute soft tissue trauma has been investigated. Healing of ligaments and soft tissue injuries in general has been shown to occur by fibrous repair (scar tissue) and not by regeneration of the damaged tissue.”
“Early mobilization, guided by the pain response, promotes a more rapid return to full activity.”
“Early mobilization, guided by the pain response, promotes a more rapid return to full functional recovery.”
“The collagen is remodeled to increase the functional capabilities of the tendon or ligament to withstand the stresses imposed upon it.”
“It appears that the tensile strength of the collagen is quite specific to the forces imposed on it during the remodeling phase: i.e. the maximum strength will be in the direction of the forces imposed on the ligament.”
Dr. Kellett summarizes the benefits of early mobilization following soft tissue injury as follows:
1) Improvement of bone and ligament strength, reducing recurrence of injury.
2) The strength of repaired ligaments is proportional to the mobility of the ligament, resulting in larger diameter collagen fiber bundles and more total collagen.
3) “Collagen fiber growth and realignment can be stimulated by early tensile loading of muscle, tendon, and ligament.”
4) Collagen formation is not confined to the healing ligaments, but adheres to surrounding tissues. The formation of these adhesions between repairing tissues and adjacent structures is minimized by early movement.
5) With motion, “joint proprioception is maintained or develops earlier after injury, and this may be of importance in preventing recurrences of injuries and in hastening full recovery to competitive fitness.”
6) The nutrition to the cartilage is better maintained with early mobilization.
7) Following this acute inflammatory phase and largely guided by the pain response of the patient, early mobilization is commenced, based upon the premise that the stress of movement on repairing collagen is largely responsible for the orientation and tensile strength of the tendons and ligaments.
Dr. Cohen (5) and associates also comment even further on the value of range of motion exercises in the management of soft tissue injury, by stating:
“During the phase of wound contraction, the active cellular process is locked into position by increasing amounts of rigid collagenous scar. Frequent, gentle exercise can be used to put an extremity joint through a full range of motion and keep the newly developing scar tissue stretched and remodeled. Frequent use of the range of motion exercises is important to keep the developing and contracting scar tissue from becoming a rigid, fixed scar contracture. Range of motion exercises concentrate on remodeling the newly laid collagen before it develops into a rigid scar contracture.” (p. 110)
In 1994, Halldor Jonsson and associates (10) performed surgical evaluations of 50 patients with chronic whiplash symptoms, showing a “high incidence of discoligamentous injuries in whiplash-type distortions.” The authors noted:
“The injured spinal segments had become increasingly stiffer over 5 years, which may reflect healing of unrecognized soft tissue injuries.”
“The most likely source of radicular symptoms is perineural scarring.
Therefore, patients with neck distortions after traffic accidents should be mobilized early within the limits of pain to prevent scar transformation of hidden injuries.”
In 1996, orthopedic surgeon Joseph Buckwalter, MD, from the University of Iowa, adds to the concepts with the following points from an article published in the journal Hand Clinics (11):
1) Treatment of tissue injuries with prolonged rest delays recovery and can cause irreversible changes in tissue strength and function.
2) Early motion of tissue injuries maintains the structure and composition of normal bone, tendon, ligament, articular cartilage and muscle.