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Yo u r M & B i s w o r t h 2 C E s ! G o t o w w w. a b m p . c o m / c e t o l e a r n m o r e . 89 contractility and the mechanical state of the matrix, the modulation of extracellular and intracellular tension may help to influence wound healing and development of fibro-contractive diseases." 38 • When the usually well-choreographed process of wound healing goes wrong and becomes excessive, "beneficial tissue repair turns into the detrimental tissue deformities." These may include hypertrophic scarring, fibromatoses, and fibro-contractive diseases. • There is a surprising connection between the individual's breathing pattern and how well wounds heal. • Inadequate healing results in the likelihood of adhesion development, reduced flexibility, and excessive scarring, preventing free movement between usually mobile tissues. • Chapelle and Bove summarize the process of adhesion formation in the abdominal viscera as: "Adhesions form following a number of injuries to the peritoneum, including mechanical trauma, drying, blood clotting, and foreign object implantation. The inflammation caused by peritoneal trauma from any etiology leads to a disruption of the balance between the fibrin-forming and fibrin dissolving capacities of the peritoneum, favoring the deposition of a fibrin-rich exudate on the damaged area. If the fibrin is not resolved by the fibrinolytic system within days, adhesions form…. Persistent adhesions can prevent the normal sliding of the viscera during peristalsis and movements of the body, such as respiration. Adhesions become both innervated and vascularized." 39 • Almost all surgery, even minor "keyhole" versions, results in adhesion formation with the potential for chronic pain and possible obstruction as a result. 40 • Scars have been shown to predispose toward formation of myofascial trigger points in adjacent tissues, with the potential for initiating pain in distant structures—an appendectomy scar, for example—causing low-back pain. 41 • Cramer et al. have confirmed in animal studies that inactivity and immobilization result in the development of adhesions in the zygapophy seal (facet) joints. 42 They found that the duration of immobility was directly linked ("small, medium, large") to the size and frequency of these spinal adhesions. They hypothesize that such adhesion development may have relevance to higher velocity spinal manipulation, which could theoretically break up Z-joint intra-articular adhesions. FIBROSIS AND KELOIDS Chronic inflammation leads to fibrosis, which may occur in soft tissues or organs as a result of excessive build-up of connective tissue. 43 As Fourie explains: "Fibrosis represents a pathologic excess of normal tissue repair. Excessive or sustained production of TGF- fil is a key molecular mediator of tissue fibrosis. It consistently and powerfully acts on cells to encourage the deposition of extracellular matrix. The connective tissue response to the internal (inflammatory mediators and growth factors) and external (motion and directional strain) stresses applied will determine how the scar matures. Thus, the scar can become either dense and unyielding or pliable and mobile. Remodeling is not restricted to the injured area only. Neighboring, noninjured tissue also changes its collagen production rate in response to inflammation." 44 Welshhans and Homs report that factors that predispose an individual toward poor wound healing and excessive scarring, including irregularly shaped keloid scars that may progressively enlarge, include the following: • Ethnicity may be a feature, with African, Hispanic, and Asian Indian individuals being more likely to have hypertrophic scar formation. • Previous exposure to radiation results in excessive fibrosis and poor cellular replication during scar healing. • Individuals who smoke or are being treated with corticosteroids and/or chemotherapy agents have increased risk for scarring. • Poor nutritional status, particularly involving vitamins C and K and zinc, impedes normal healing. • Having hyperplastic (hypermobile) joints due to increased levels of elastin. • In younger (pre-puberty) individuals, remodeling takes longer than in adults, leading to more lengthy erythema and hypertrophy. • Infection of foreign-body presence increases likelihood of excessive scarring. • Conditions such as diabetes, collagen vascular disease, hypothyroidism, immunocompromised states, and diseases with delayed healing, have an increased risk for scarring. 45 Notes 1. H. M. Langevin et al., "Reduced Thoracolumbar Fascia Shear Strain in Human Chronic Low Back Pain," BMC Musculoskeletal Disorders 12 (2011): 203. 2. W. Klingler, "Temperature Effects on Fascia," in Fascia: The Tensional Network of the Human Body, eds. R. Schleip et al. (Edinburgh: Churchill Livingstone Elsevier, 2012): 421–4. 3. A. Pilat, "Myofascial Induction," in Practical Physical Medicine Approaches to Chronic Pelvic Pain (CPP) and Dysfunction, eds. Chaitow et al. (Edinburgh: Elsevier, 2011). 4. A. Stecco et al., "Fascial Components of the Myofascial Pain Syndrome," Current Pain and Headache Reports 17, no. 8 (2013): 352; A. Stecco et al., "Ultrasonography in Myofascial Neck Pain: Randomized Clinical Trial for Diagnosis and Follow-Up," Surgical and Radiologic Anatomy 36, no. 3 (2014): 243–53. 5. T. Luomala et al., "Case Study: Could Ultrasound and Elastography Visualize Densified Areas Inside the Deep Fascia?" Journal of Bodywork and Movement Therapies 18, no. 3 (2014): 462–68. 6. H. M. Langevin et al., "Reduced Thoracolumbar Fascia Shear Strain." 7. H. M. Langevin et al., "Reduced Thoracolumbar Fascia Shear Strain." 8. A. Stecco et al., "Fascial Components of the Myofascial Pain Syndrome."; A. Stecco et al., "Ultrasonography in Myofascial Neck Pain: Randomized Clinical Trial for Diagnosis and Follow-Up."