Should bone, soft-tissue, and joint injuries be treated with rest or activity?
✍ Scribed by Joseph A. Buckwalter
- Publisher
- Elsevier Science
- Year
- 1995
- Tongue
- English
- Weight
- 120 KB
- Volume
- 13
- Category
- Article
- ISSN
- 0736-0266
No coin nor oath required. For personal study only.
✦ Synopsis
Clarification of the roles of rest and activity in the treatment of musculoskeletal injuries provides a convincing example of how basic research can answer clinically important questions. In the last decade of the 19th century, two widely respected orthopaedists strongly advocated opposing treatments of bone, soft-tissue, and joint injuries. Hugh Owen Thomas in Liverpool taught that injuries should be treated by "enforced, uninterrupted, prolonged rest," and that an overdose of rest was impossible. He noted that movement of injured tissues increased inflammation and that "It would indeed be as reasonable to attempt to cure a fever patient by kicking him out of bed, as to benefit joint disease by a wriggling at the articulation." Just Lucas-Championniere in Paris took the opposite position. He argued that early activity accelerated healing and restoration of function and that enforced rest injured cartilage, ligaments, and muscles. He also observed that slight movement at a fracture site promoted healing rather than retarded it. In the early part of the 20th century, many orthopaedists followed the teachings of Hugh Owen Thomas, but in the last half of the century, clinical practice generally has become more consistent with the recommendations of Lucas-Championnikre-a change promoted and supported by an expanding body of research.
Investigations by Sarmiento, Kenwright, Goodship, and others have shown that, in fractures of long bones, early loading and limited movement, including induced micromotion, promotes fracture healing and that decreased loading can have the opposite effect. Akeson, Woo, and others have documented the adverse affects of prolonged rest on dense fibrous tissues, and Gelberman, Woo, Vailas, and others have demonstrated that early controlled loading and motion of tendon and ligament repair tissue stimulates collagen synthesis, increases strength, and helps align the repair cells and collagen fibrils, whereas lack of tension leaves repair tissue cells and matrix disoriented.
Experimental studies by Jarvinen, Lehto, and colleagues have shown that although immediate mobilization of injured muscles increases scar formation and interferes with orderly regeneration of myofibers, activity following a short period of immobilization promotes resolution of the hematoma and inflammation; stimulates more extensive, rapid, and organized regeneration of myofibers; and increases tensile strength and stiffness. In contrast, prolonged immobilization after injury causes muscle atrophy and poor organization of the regenerating myofibers.
Observations by Enneking, Palmoski, Kiviranta, Jurvelin, and others have shown that prolonged immobilization and unloading of joints damages articular cartilage and eventually causes adhesions to form between articular surfaces. Other work has shown that cyclic loading of cartilage increases the synthetic activity of chondrocytes, and studies by Salter and colleagues have indicated that passive motion promotes healing of experimental osteochondral injuries.
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