Issue link: https://www.massageandbodyworkdigital.com/i/1256819
R egardless of etiology (surgery, burn, sport injury, overuse/repetitive strain), tissue insult is reconciled by the four overlapping stages of wound healing. Remodeling is the final stage of that process. In the tissues we commonly address, collagen constitutes the physical fabric of remodeled tissue. Collagen has the tensile strength of steel. I'm no delicate flower, and my hands are pretty strong . . . but not that strong. Attempting to manually break steel-like collagen—ouch!—is not only futile, but also does not seem to fit with a client-considerate approach to care. Further, dense collagen (e.g., dense fascia, like the IT band) is only deformable (i.e., stretch or alteration of shape) under extreme forces 1 —again, strong hands, but not that strong. Gil Hedley, PhD, and founder of Somanautics Workshops, demonstrates beautifully the strength of collagen in his video "Fascia is All Around Us!" 2 That said, while collagen may not be breakable by manual methods, it does appear to be changeable. What, then, are physiologically possible changes that underlie the outcomes we facilitate in our clinical practice when working with scar tissue? Evidence-Informed: Physiologically Plausible Changes Before we dive into how our work works, let's go a bit deeper into what scar tissue is. Understanding what it is—what we are working with—is paramount to delivering safe and productive care. Tissue Interrupted Scars are not obligated to be problematic. Scars "construct" us back together when tissue integrity has been interrupted. The renovation may not be totally homogenous. Even normal scars (nonpathological) may look, and the tissue function, somewhat differently than the original material. Regulatory mechanisms ensure that remodeling—the laying down of new collagen—terminates once tissue homeostasis is reestablished. If these mechanisms fail, unchecked/anomalous collagen proliferation ensues (i.e., fibrosis), typified by chaotic organization, pathological cross-links, stiffness, and abnormal crimp. Irrespective of etiology and scar type (surgical, burn, axillary webbing, frozen shoulder, or repeat strain), fibrosis constitutes the characteristic physical attribute of abnormal (pathological) tissue remodeling in response to insult. Fibrosis can impact a person's function and quality of life in several ways. For example, it can cause interference with tissue sliding, muscular stretch, strength capacity, and organ, blood, lymphatic, and nerve function. In a nutshell, fibrotic collagen is the "what" in the question: "What is going on in there?" Therefore, manual therapy scar tissue management should aim to temper fibrogenesis or facilitate meaningful change once fibrosis has been established. Manual Therapy and the Early Stages of Healing "Manual therapy is certainly, at the moment, one of the best options to improve the new recovering subcutaneous and cutaneous structures and to diminish the tissular retraction and rigidity." —Jean-Claude Guimberteau, MD 3 Part of the impetus for writing Traumatic Scar Tissue Management (Handspring, 2016) came from our observation that manual therapy education and protocols for working with scar tissue are largely directed to after the fact—dealing with mature scars: an important part of client care, but not of optimal comprehensive care. Evidence supports that in addition to addressing problematic mature scars, timely and skillfully applied manual therapy can augment the wound-healing process, thereby reducing the risk of pathological scar formation and consequent issues (e.g., movement restrictions, undesirable scar characteristics, pain, and sensory 54 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 2 0 disturbances, such as pruritus and altered proprioception and interoception). 4 Fibrosis can be a challenging issue to reconcile, so prevention is key. Two primary drivers of profibrotic activity have been identified: excessive or prolonged inflammation and premature or anomalous tissue tension. Other important factors to consider are neural hyperactivity/sensitivity, immobilization, and the client's psychological state. In the early stages of wound healing, manual therapy is aimed at managing these factors and any of their instigators. Lymphatic drainage, autonomic nervous system (ANS) balancing, and neural sedation methods reign supreme during this time frame. For any stage of care, dosage variables are important determinants of safety and effectiveness. The amount of pressure applied; the expanse of tissue engaged; and the direction, speed, and angle of contact all matter, as does the type of therapeutic loading. 5 The treatment of scars and adhesions cannot be described as a set modality. As Willem Fourie wrote in Fascial Dysfunction: Manual Therapy Approaches, "Treatment could be rather defined as a management strategy using combinations of different massage and manual techniques to constitute a therapeutic approach aimed at improving tissue quality and mobility." 6 Mature Scars: Change Agent, Not Break Agent Although fibrotic tissue is often considered an inactive scaffold, precluding potential for change, fibrosis is neither static nor irreversible but a continuous remodeling process and thereby susceptible to intervention. 7 If problematic mature scars or adhesions are in an ongoing state of flux (remodeling), then it seems reasonable that change is possible. What then does this influx tissue need in order to change into something that functions better? Current fascia research is the primary purveyor of physiologically plausible (positive) collagen changes mediated by