ABMP Scar Tissue Management Part 1

ABMP Scar Tissue Management: Part 1-Introduction

©2020, Associated Bodywork & Massage Professionals 1

SCAR TISSUE

MANAGEMENT

Part 1: Introduction

with Nancy Keeney Smithand Cathy Ryan

SCAR TISSUEMANAGEMENT SERIES

Part 1 Part 2 Part 3

Clinical Considerations

• Edema

• Techniques: Lymphatic system

• Fibrosis

• Techniques:Fascia and connective tissue

Assessment and Treatment Guidelines

• Assessment and evaluation

• Stages of wound healing

• Treatment protocols:Lymphatic system

• Treatment protocols:Fascia and connective tissue

Introduction

• MT role in scar tissue management

• Fascia and connective tissue

• Lymphatic system

• Wound healing: Normal and abnormal

Course Outline

❶ Introduction

❷ MT role in scar tissue management

❸ Fascia and connective tissue

❹ Lymphatic system

❺ Wound healing and scar formation:

Normal and abnormal

SCAR TISSUE

MANAGEMENT


What is the issue?

What needs to change?

How can our hands facilitate the needed changes?

Richard Lebert, RMT

The RMT Education Project

www.rmtedu.com

Course Outline

❶ Introduction





Normal and abnormal

SCAR TISSUE

MANAGEMENT


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Fascia and Connective Tissue (CT)

Dense and Loose

Fiber and Fluid

Fluid-filled space observable

only in living/hydrated tissue

GC Guimberteau – Interior Architecture, Handspring 2015

SLIDING NETWORKLOOSE CT

Fluid-filled space observable

only in living/hydrated tissue

• Capable of viscosity changes

• Volume and viscosity have a role in:

• Reducing friction

• Creating space (fluid gap) between articulating tissues and structures

• Sliding

GC Guimberteau – Interior Architecture, Handspring 2015

SLIDING NETWORKLOOSE CT

Organization and distribution of intramuscular connective tissue in normal and immobilized sketch muscles. Jarvinen, T et. Al, V(2002). Journal of Muscle Research and Cell Motility 23: 245-254

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Superficial Fascia • Provides a passageway for

larger nerves, blood, and lymphatic vessels

Deep Fascia • Creates muscle containers

(epi, peri, endomysium)

• Comprises dense and loose connective tissue

From “Scar Tissue Management,” Smith & Ryan 2016, Handspring Publishing

www.handspringpublishing.com

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Course Outline

❶ Introduction





Normal and abnormal

SCAR TISSUE

MANAGEMENT

Part 1: Introduction • The lymph system plays a vital role in inflammation

management. Lymphatic dysfunction may contribute to

the development of pathophysiological scars.

• Excess swelling/edema creates a tensional pull on tissue.

Increased mechanical tension drives collagen deposition.

Inflammation

• 1,000 plus nodes

• One-way system

• Cleanses fluid

• Collects information

Lymph Nodes

University of Virginia discovery of lymph vessels

in the brain

Glymphatic system

60% active while we sleep

Lymph System Discoveries

Conference2015 Joint Conference on Acupuncture, Oncology, and Fascia

PresentationLymphatics and Cancer Biology

PresenterMelody A. Swartz, PhDWilliam B. Ogden Professor, Institute of Molecular Engineering, University of Chicago, Illinois

Video Links

https://oshercenter.org/joint-conference-2015-video-presentations/

https://www.youtube.com/watch?v=01bGsu3H4Y8&t=499s

• Lymph fluid is rich with information

• The lymph system is hardy

• Inflammation issues are showing signs

of autoimmune issues (research coming)

Lymphatics and Cancer Biology

Dr. Melody Swartz

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https://www.youtube.com/watch?v=01bGsu3H4Y8&t=499s



What the system carries

Lymphatic Loads

• 96% water• Proteins• Cells• Fat (only in digestive system)

Two Aspects of the Lymphatic Vessel System

Surface Structures

Deep Structures

Fluids, Fascia, and The Lymphatic System - An Ortho-Bionomy® Approach - Liz Olivas, BFA, MT, CLT

The

Lymphatic

System


2

Thoracic Duct

• Originates anterior to vertebrae T1 - L2

• Runs upward to connect with the left venous angle

• Behind the left clavicle, it connects to the left subclavian vein and internal jugular vein

Esophagus

Trachea

Right lymphatic duct

Right subclavian vein

Right venous angle

Azygos vein

Diaphragm

Cisterna chyli

Right lumbar trunk

Left lymphatic duct

Left subclavian vein

Left venous angle

Aorta

Thoracic

duct

(thoracic

portion)

Hemiazgos vein

Left lumbar trunk


Unhealthy System

A dysfunctional lymphatic system cannot remove product that is collecting in the tissues at a rate that keeps the tissues properly cleansed.

This interferes with the homeostasis of the tissues.

• Four continuous minutes of abdominal lymph pumping

(1 pump/sec) has been shown to increase immune cell release from

mesenteric lymph nodes.

• Specialized T cells primed in the gut are faster-acting/superior-

performing immune cells.

• Recent studies suggest that abdominal lymphatic pumping may

inhibit solid tumor development and bacterial pneumonia.

(Hodge et al. 2010, 2013)

Important Role of the Lymphatic System in Traumatic Scar Wound Healing

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Conference

2015 Joint Conference on Acupuncture, Oncology, and

Fascia

Presentation

Manual Therapy and Lymphatics

Presenter

Lisa Hodge, PhD

Associate Professor, Department of Cell Biology and

Immunology, University of North Texas Health Science

Center, Texas

Video Links

https://oshercenter.org/joint-conference-2015-video-presentations/https://www.youtube.com/watch?v=MFMk76jdjxM&t=127s

Manual Therapy and Lymphatics

Dr. Lisa Hodge

• 5–7 minutes of abdominal pumping gets the system moving

• This action initiates the lymph-immune system

Course Outline

❶ Introduction





Normal and abnormal

SCAR TISSUE

MANAGEMENT


Wound Healing and Scar Formation

Physiological (Normal)

and

Pathological (Abnormal)

Days 5 201510 25

InflammationLasts 1–4 days(may last weeks)

ProliferationTypically lasts 4–21 days (may last up to 6 weeks)

Starts within 48-72 hours of initial injury

RemodelingLasts from months to years

Normal Stages of Wound Healing

HomeostasisImmediate

Normal Stages of Wound Healing

Homeostasis

• Clot formation to control bleeding

Inflammation

• Immune cells clean the area

• Various cells begin the process of healing

Proliferation

• Scar forms to heal the wound gap and restore tissue integrity

Remodeling

• Stronger scar material (collagen) is produced to increase the strength of the healed tissue and restore function

Several factors can influence and impact the process.

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https://www.youtube.com/watch?v=MFMk76jdjxM&t=127s



Primary Players in Skin and Connective Tissue/Fascia Remodeling and Collagen Production

• Fibroblasts

• Myofibroblasts

• Transforming Growth Factor: TGF-ß1

Can be influenced by

• Stress/anxiety

• Sympathetic nervous system/parasympathetic nervous system imbalance

• Neural hyperactivity or sensitization

• Excess or prolonged inflammation/edema

• Immobilization

• Tissue tension

• When collagen proliferation does not shut down,

abnormal scars will form.

• The physical hallmark of pathological scars is

excessive/anomalous (fibrotic) collagen.

• If (hyper) vascular/neural regression does not occur, the

scar and surrounding tissue function may be abnormal.

Abnormal Wound Healing

When collagen proliferation does not shut down, abnormal scars will form.


Keloid scar: abnormal collagen extends beyond the margin of the wound

Hypertrophic scar: abnormal scar within the wound margins (raised, pigmented)

From “Traumatic Scar Tissue Management,” Smith & Ryan 2016, Handspring Publishing


FibrosisFibrotic collagen: Fuzzy/rough, lacking normal crimp, dense, brittle, rigid,

pathological cross-links, and disorganized/chaotic arrangement

Healthy tissuespacious and well organized

Wound areadense and chaotic

Adapted from: Coelho, N. M., & McCulloch, C. A. (2016). Contribution of collagen adhesion receptors to tissue fibrosis. Cell and tissue research, 365(3), 521-538.

Wound healing doesn’t always

result in fibrosis.

So what happens?

How do we get there?

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Primary Drivers of Profibrotic Activity

Excessive/prolonged inflammation

Premature/anomalous tissue tension

InflammationTissue

tension

Excessive/prolonged inflammation

• Mediated by infection/ineffective cleanup, persistent presence of pro-inflammatory and sensitizing agents (smoking, deficient nutrition, rubbing/friction, stress/anxiety, immobilization, subsequent reinjury, and anomalous tissue tension).

Premature/anomalous tissue tension • Mediated by myofibroblast overactivity, excess/prolonged

edema, excess extrinsic tension, sympathetic/parasympathetic nervous system imbalance, neural hyperactivity.

Primary Drivers of Profibrotic Activity

• Appropriate intrinsic tension (physiological wound contraction) is

necessary for wound closure.

• Scar formation/closure/remodeling is also influenced by extrinsic

tensional forces.

• Excessive extrinsic forces can accelerate angiogenesis, neurogenesis,

cell proliferation, and collagen hyperproduction.

Ogawa et al. (2011)

TensionManual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury

Researchers: Geoffrey M. Bove, Michele Y. Harris, Huaqing Zhao, Mary F. Barbe

Published in Journal of the Neurological Sciences, www.jns-journal.com

Research Study

Myofascial-type therapy (MT) was performed bilaterally 5xs/week, for 10 minutes during 12 weeks of hard training.

The untreated group (no MT) displayed key overuse presentations:Pain-related behavioral changes (pain expression, guarding/protecting, movement reluctance, decreased strength) Fibrotic neural, muscular, and connective tissue/fascial changes. Classic collagen fibrotic changes: hyper-proliferation, incoherent organization, rigid, fuzzy/rough (dermis, subcutaneous tissue/superficial fascia, tendon, fascial coverings [epi, peri, endo], neural ECM)

The MT-treated group’s neural, muscular, and connective tissue/fascial tissue showed diminished fibrotic changes.

The MT attenuated changes appear to be related to tissue and serum levels of TGF-ß1.

Thus, MT, applied in the early stages of symptom development, may be an effective preventative for:• Decreasing excessive/anomalous collagen • Pain-related behavioral changes and consequent nerve compression pathology and conduction velocity changes

Anomalous Fibrotic Collagen

• Profuse, prolonged inflammation

• Tissue tension

• Neural distress or heightened activity

• Immobilization

Cathy [email protected]

www.handspringpublishing.com

Nancy Keeney [email protected]: NTouch Therapy LLC

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Scar Tissue Management Series

Reference List

Benjamin, M., Kaiser, E., & Milz, S. (2008). Structure‐function relationships in tendons: a review. Journal of Anatomy, 212(3), 211-228.

Berrueta, L., Muskaj, I., Olenich, S., Butler, T., Badger, G. J., Colas, R. A., ... & Langevin, H. M. (2016). Stretching impacts inflammation resolution in connective tissue. Journal of Cellular Physiology, 231(7), 1621-1627.

Bialosky, J. E., Beneciuk, J. M., Bishop, M. D., Coronado, R. A., Penza, C. W., Simon, C. B., & George, S. Z. (2018). Unraveling the mechanisms of manual therapy: modeling an approach. Journal of Orthopaedic & Sports Physical Therapy, 48(1), 8-18.

Bishop, M. D., Torres-Cueco, R., Gay, C. W., Lluch-Girbés, E., Beneciuk, J. M., & Bialosky, J. E. (2015). What effect can manual therapy have on a patient's pain experience?. Pain Management, 5(6), 455-464.

Bouffard, N. A., Cutroneo, K. R., Badger, G. J., White, S. L., Buttolph, T. R., Ehrlich, H. P., ... & Langevin, H. M. (2008). Tissue stretch decreases soluble TGF‐β1 and type‐1 procollagen in mouse subcutaneous connective tissue: Evidence from ex vivo and in vivo models. Journal of Cellular Physiology, 214(2), 389-395.

Bouffard N et al 2009 Tissue stretch decreases procollagen-1 and TGF-β1 in mouse subcutaneous fascia. Abstract. 2nd Fascia Research Congress. Free University of Amsterdam, Amsterdam.

Bove, G., & Chapelle, S. (2012). Visceral mobilization can lyse and prevent peritoneal adhesions in a rat model. Journal of Bodywork and Movement Therapies.

Chaitow (2014) Fascial dysfunction – manual therapy approaches. Pencaitland, UK: Handspring Publishing.

Chaitow, L. (Ed.) (2018). Fascial dysfunction – manual therapy approaches. 2nd Ed. Handspring Publishing.

Corey, S. M., Vizzard, M. A., Bouffard, N. A., Badger, G. J., & Langevin, H. M. (2012). Stretching of the back improves gait, mechanical sensitivity and connective tissue inflammation in a rodent model. PloS one, 7(1), e29831.


Reference ListCowman, M. K., Schmidt, T. A., Raghavan, P., & Stecco, A. (2015). Viscoelastic properties of hyaluronan in physiological conditions. F1000Research, 4.

Crane, J. D., Ogborn, D. I., Cupido, C., Melov, S., Hubbard, A., Bourgeois, J. M., & Tarnopolsky, M. A. (2012). Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. Science Translational Medicine, 4(119), 119ra13-119ra13.

Franchi, M., Ottani, V., Stagni, R., & Ruggeri, A. (2010). Tendon and ligament fibrillar crimps give rise to left‐handed helices of collagen fibrils in both planar and helical crimps. Journal of Anatomy, 216(3), 301-309.

Fritz, S. (2016). Mosby's Fundamentals of Therapeutic Massage. Elsevier Health Sciences.

Fryer G, Fossum C (2009) Therapeutic mechanisms underlying muscle energy approaches. Physical therapy for tension type and cervicogenic headache: physical examination, muscle and joint management, Boston: Jones and Bartlett

Gracovetsky, S. (2016). Can fascia’s characteristics be influenced by manual therapy? Journal of Bodywork and Movement Therapies, 20:893–897

Guimberteau, J. C., & Delage, J. P. (2012, October). The multifibrillar network of the tendon sliding system. In Annales de chirurgie plastique et esthetique (Vol. 57, No. 5, pp. 467-481).

Guimberteau (2012) Scars and Adhesions Panel – Lecture notes from The 3rd International Fascia Research Congress, Vancouver, 28-30 March

Hodge LM, Bearden MK, Schander A et al (2010) Abdominal lymphatic pump treatment mobilizes leukocytes from the gastrointestinal associated lymphoid tissue into lymph. Lymphatic Research and Biology 8: 103-10.

Hodge LM, Bearden MK, Schander A et al (2013) Lymphatic pump treatment mobilizes leukocytes from the gut associated lymphoid tissue into lymph. Lymphatic Research and Biology 8(2): 103-110.


Reference List

Hicks, M. R., Cao, T. V., Campbell, D. H., & Standley, P. R. (2012). Mechanical strain applied to human fibroblasts differentially regulates skeletal myoblast differentiation. Journal of Applied Physiology, 113(3), 465-472.

Huang, C., Holfeld, J., Schaden, W., Orgill, D., & Ogawa, R. (2013). Mechanotherapy: revisiting physical therapy and recruiting mechanobiology for a new era in medicine. Trends in Molecular Medicine, 19(9), 555-564.

Kanazawa, Y., Nomura, J., Yoshimoto, S., Suzuki, T., Kita, K., Suzuki, N., & Ichinose, M. (2009). Cyclical cell stretching of skin-derived fibroblasts downregulates connective tissue growth factor (CTGF) production. Connective Tissue Research, 50(5), 323-329.

Khan, K.M. and Scott, A. (2009) Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. British Journal of Sports Medicine 43, 247–252

Kisseleva, T., Cong, M., Paik, Y., Scholten, D., Jiang, C., Benner, C., ... & Evans, S. M. (2012). Myofibroblasts revert to an inactive phenotype during regression of liver fibrosis. Proceedings of the National Academy of Sciences, 109(24), 9448-9453.

Langevin, H. M. (2013). The science of stretch. The Scientist, 27(5), 32.

Langevin HM, Nedergaard M, Howe AK (2013) Cellular control of connective tissue matrix tension. Journal of Cellular Biochemistry, 114(8): 1714-9.

Matteini, P., Dei, L., Carretti, E., Volpi, N., Goti, A., & Pini, R. (2009). Structural behavior of highly concentrated hyaluronan. Biomacromolecules, 10(6), 1516-1522.

Ng, J. L., Kersh, M. E., Kilbreath, S., & Knothe Tate, M. (2017). Establishing the basis for mechanobiology-based physical therapy protocols to potentiate cellular healing and tissue regeneration. Frontiers in Physiology, 8, 303.

Ogawa, R. (2011). Mechanobiology of scarring. Wound Repair and Regeneration, 19, s2-s9.


Reference ListPohl, H. (2010). Changes in the structure of collagen distribution in the skin caused by a manual technique. Journal of bodywork and movement therapies, 14(1), 27-34.

Roman, M., Chaudhry, H., Bukiet, B., Stecco, A., & Findley, T. W. (2013). Mathematical analysis of the flow of hyaluronic acid around fascia during manual therapy motions. The Journal of the American Osteopathic Association, 113(8), 600-610.

Schleip R, Muller DG (2013) Training principles for fascial connective tissues: Scientific foundation and suggested practical applications. Journal of Bodywork and Movement Therapies, 17(1): 103-115

Simmonds, N., Miller, P., & Gemmell, H. (2012). A theoretical framework for the role of fascia in manual therapy. Journal of Bodywork and Movement Therapies, 16(1), 83-93.

Smith, N. & Ryan, C. (2016). Traumatic Scar Tissue Management – Massage Therapy Principles, Practice and Protocols. Pencaitland, UK: Handspring Publishing.

Stecco, C., Fede, C., Macchi, V., Porzionato, A., Petrelli, L., Biz, C., ... & De Caro, R. (2018). The fasciacytes: a new cell devoted to fascial gliding regulation. Clinical Anatomy, 31(5), 667-676.

Thompson, W. R., Scott, A., Loghmani, M. T., Ward, S. R., & Warden, S. J. (2016). Understanding mechanobiology: physical therapists as a force in mechanotherapy and musculoskeletal regenerative rehabilitation. Physical Therapy, 96(4), 560-569.

Threlkeld, A. J. (1992). The effects of manual therapy on connective tissue. Physical Therapy, 72(12), 893-902.

Tortora, G.J., Funke, B.R., Case, C.L. (2007). Introduction to Microbiology. San Francisco: Pearson Benjamin Cummings.

Tozzi, P., 2012. Selected fascial aspects of osteopathic practice. Journal of Bodywork and Movement Therapies, 16(4), 503e519.


Reference List

Troeger, J. S., Mederacke, I., Gwak, G. Y., Dapito, D. H., Mu, X., Hsu, C. C., ... & Schwabe, R. F. (2012). Deactivation of hepatic stellate cells during liver fibrosis resolution in mice. Gastroenterology, 143(4), 1073-1083.

Waters-Banker, C., Dupont-Versteegden, E. E., Kitzman, P. H., & Butterfield, T. A. (2014). Investigating the mechanisms of massage efficacy: the role of mechanical immunomodulation. Journal of Athletic Training, 49(2), 266-273.

Wynn, T. A. (2007). Common and unique mechanisms regulate fibrosis in various fibroproliferative diseases. The Journal of Clinical Investigation, 117(3), 524-529.

Zuther JE (2011) Lymphedema management: the comprehensive guide for practitioners, 2e. Stuttgart: Thieme

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ABMP Scar Tissue Management Part 1

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