4. Perfusion.

It is an important concept to realize that loading a tissue can increase its healing rate.  At the core of this mechanism is using exercise to increase tissue perfusion.  A paper offered by Buckwalter and Grodzinski reminds us of the basic scientific and clinical investigations which have shown that fibrous tissue and skeletal muscle do respond to certain patterns of loading by increasing matrix synthesis in many instances by changing the composition, organization, and mechanical properties of their matrices. 

Though many new approaches have been introduced to affect healing rates, none have shown the usefulness that loading of healing tissues have shown through exercise. 

Moreover, in an in vivo study of peri-tendonous tissue in humans conducted by a group of Scandinavian researchers, it was demonstrated that acute exercise caused an increase in metabolic activity, accumulation of prostaglandins and increased formation of collagen type 1. 

So how does one use this information? 

If we keep in mind that when exercising for endurance or if using eccentrics in the treatment of tendonopathies, one will increase tissue perfusion if the vigor of the exercise is adequate.  Proper loading is the key.  Too much load and the tissue is overwhelmed; too little and it will not heal properly.  Both scenarios may be responsible for recurrent injuries to the tissue. 

Combining it all.

While there is no one particular protocol that would fit everybody one could use the above principles to meet the needs of his or her patient.  One has to ask themself what it is the patient really needs.  Then with the fundamental knowledge of what exercise can do they can then craft an appropriate rehab protocol to accomplish their goals.  

As a good rule of thumb, one should clear the neural pathway (i.e. spinal dysfunction)to an, then ensure proper activation and timing, then vigor and endurance.  Perfusion will come as a result of doing the preceding steps correctly.  And if loading is appropriate, the result achieved should be good.