Scar Tissue and Adhesion Treatment

When the body has sustained tissue damage, the wound that is created goes through several stages.

The 4 Stages of Wound Healing:

  1. Homeostasis

  2. Inflammatory Phase

  3. Proliferative Phase

  4. Remodeling

4 Stages of Wound Healing | physical therapy

The first stage of wound healing is called hemostasis, which basically means “blood-stay.” Makes sense, right? Since we all know that the body doesn’t want its blood to leave. The body constricts surrounding blood vessels to prevent excessive blood loss. This is accomplished by a type of cell called platelets whose purpose is to coagulate and form clots. Next, the body then solicits the services of a molecule called fibrin to keep the clot at the injury site. This is necessary to prevent the clot from breaking off and landing somewhere potentially harmful, like in the brain. Notice that when you cut your hand or scrape your knee, the bleeding typically stops within a minute or two, because the clotting process starts immediately after blood is exposed to air.

The second stage is the inflammatory phase. This occurs when the body is trying to send the cells responsible for healing and repair to the injury site in order to prevent infection. During this time the body experiences swelling, erythema (redness), warmth, and pain. Inflammation is the body’s natural way of removing damaged cells or bacteria; replacing them with white blood cells to fight infection and deliver nutrients to damaged cells.

The third stage is called the proliferative phase. During this time, the body grows a new network of blood vessels and lays down new collagen to reform the skin. This temporary, highly vascularized pink tissue is called granulation tissue.  The body then summons cells called myofibroblasts that  contract the wound (sort of like a muscle contracts) to protect the new delicate tissue as it is reinforced. From the outside-in, the granulation tissue will undergo a process called epithelialization. This is when the skin cells regrow across the length of the wound tissue.

The fourth and final phase, remodeling, can take anywhere from two weeks to two years. Now is a good time to mention a theory I learned in physical therapy school regarding the body’s method of managing scar tissue (shout out to Dr. Steve Ferdig). The theory states that while the body is repairing a wound, it dumps down all the materials necessary like a pile of sticks. Fibroblasts, which are cells that synthesize collagen and extracellular matrix, lie down collagen fibers haphazardly. It won’t be until later in the remodeling phase that the fibers will be more aligned in accordance with the forces of motion imposed on the tissue. During this period, the non-functional fibroblasts are replaced with functional ones, and the tissue remodels so that the fibers are aligned with the directions of tensile and compressive forces that are applied to the tissue. Areas that are subjected to higher forces are reinforced with thicker collagen, and vice versa.

scar tissue and adhesion treatment

What does it mean for a scar to heal sub-optimally?

As we know, there are times when a scar heals sub-optimally. What does that mean? I will start with the obvious ones- hypertrophic scarring and keloids. Hypertrophic (means too much nourishment) scars are ones that grow outside the original boundaries of the wound. Hypertrophic scars often appear thick, wide, and raised from the skin. Similarly, a keloid is a raised, hyper-pigmented (reddish, different from normal skin tone) nodule that develops at the site of an injury [3]. Keloids result from too much fibroblast activity, thus causing an over-proliferation of scar tissue. Both hypertrophic scars and keloids are considered a form of abnormal wound healing, which can result in poor functionality of the tissue. Outside the categories of hypertrophic or keloid, a scar can also become dysfunctional if it doesn’t get mobilized properly during the healing process.  

Following an abdominal surgery, there is potential for the formation of internal adhesions which are abnormal fibrous connections. Adhesions may include vascular channels (blood supply) which bind tissues together in abnormal locations [5]. The formation of adhesions can bind the visceral organs to other tissues of the abdominal and pelvic wall, causing bowel obstruction, infertility, low back pain, painful bladder syndrome, severe pain with menstruation/ovulation, and decreased mobility.

NOW, LET’S TALK ANATOMY.

Now that we have detailed the phases of scar healing, I want to touch on how scar tissue affects the anatomy. For the sake of this blog, I’m going to focus on the abdomen, since that’s where our patient population at Sarton Physical Therapy tends to have the most scar-action. In the region of the abdomen south of the belly button, there are two layers of fascia (continuous connective tissue) that run external to the abdominal muscles and four layers that run between and/or deep to the abdominal muscles. When the abdominal wall undergoes surgical incision, each of these fascial layers is penetrated. As the incision heals, scar tissue anchors each of the layers together, interrupting the ability of each of the muscular layers to glide over one another as they contract and relax. This is another example of suboptimal healing.

What do we as physical therapists do to affect scar healing?

physical therapy for scars | scar treatment

We manipulate the tissue using techniques such as skin rolling, cupping, myofascial release, and instrument-assisted soft tissue mobilization (IASTM) to help the collagen in scar tissue and fascia to become more aligned. These techniques also help to improve blood flow to the area which aids in the healing process. Our goal is to introduce motion and nutrition to the affected tissue which will affect the alignment of the collagen fibers through the process detailed in the “remodeling phase” discussed previously. For patients with whom visceral adhesions are suspected, we perform over-skin visceral mobilization combined with fascial manipulation to restore optimal mobility of the abdominal wall and organs within.

I’d like to share a clinical example of a patient with scar tissue. She was a new mommy (1 year postpartum) and came to therapy with complaints of low back pain, abdominal weakness, and belly tissue that was bulging along the midline whenever she contracted her ab muscles (this is called tenting). She was experiencing Diastasis Rectus Abdominis, or the non-traumatic separation of the two muscle bellies of the “6-pack” muscle, called rectus abdominis. It’s normal for this separation to happen during pregnancy, and the muscles should return to their midline, approximated position within a few months after childbirth.  It turned out this patient had a c-section delivery. Her horizontal incision from the c-section, located a few inches above the pubic bone, was hypertrophic (see above) and severely adhered to the surrounding tissue, limiting the motion of the lower abdominal wall and fascia around the bony pelvis. Do you think this dysfunctional scarring has the potential to keep the rectus abdominis muscle bellies from naturally returning to their original midline position? Of course it does! Remember the continuous layers of abdominal fascia discussed previously? The layer of fascia continuous with the rectus abdominis muscles (called the rectus sheath) is the same as the one that was sutured together in a horizontal orientation in the lower abdomen. In this case, the incision and subsequent scarring was anchoring the rectus abdominis sheath in its widened, separated position. Without adequate scar and abdominal wall mobilization, the RA muscle bellies would never have migrated back to the midline where they belong.

My treatment plan for this patient consisted of aggressive tissue mobilization at the site of the incision, the lateral (side) abdominal walls, and the joints, muscles, and fascia of the thoracic and lumbar spine. We also worked on therapeutic exercise aimed at strengthening abdominal muscles, mobilizing the spine, and retraining the muscles and fascia to allow for improved muscle closure (called form-closure) around the bony pelvis.

If you or a friend has dysfunctional scar tissue or adhesions that have not been treated, please reach out to a pelvic floor  therapist near you for a consultation. Patients who get scar tissue addressed earlier on, tend to have better outcomes. Physical therapy has the greatest potential to affect tissue healing within the remodeling phase of healing, so get help now!

 
 

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