When a Solution Becomes a Problem
By Ruth Werner
This article was originally published in the July/August issue of Massage Bodywork.
Anyone who studies the structure and function of the human body must be amazed by its remarkable ability to heal. Our poor bodies are insulted every day by irritated hangnails, blisters from sunburn, scraped elbows, bruised shins, and overworked livers. Even inactivity takes a toll: actin and myosin in underworked muscles may disintegrate with lack of use, and the fascial sheaths around and within muscles can dry up and become sticky. And that's just everyday wear and tear, not more major events like a tendon rupture, the broad spectrum of injuries called whiplash, or "trauma by appointment": the aftermath of surgery.
Somehow, we come through these buffets and function just like new, or pretty close. This happens because we have the ability to produce scar tissue, the amazing fibrous material that knits us back together when we begin to unravel. Producing scar tissue is a normal, healthy, even vital function. The results of not being able to heal from minor and major injuries would mean a drastically shortened life span, but for many people the forces that promote scar tissue formation outweigh the forces that inhibit it or reverse it. In other words, scar tissue becomes a problem, not a solution.
What is Scar Tissue?
Scar tissue is the body's natural response to the disruption of healthy cells. This disruption can take the form of any kind of external or internal injury, infection, chronic inflammation, or radiation. Any of these phenomena can damage cells, leading to a cascade of events that culminates in the formation of collagen fibers that bind up and tie together our broken pieces.
Cells that have been damaged--by direct trauma like burns, cuts, or rips; insidious stress like infectious agents that secrete toxic wastes; or chronic irritation like that seen with autoimmune diseases--respond by secreting a variety of chemicals. Some of these chemicals reinforce an inflammatory reaction. Some act as a beacon to nearby fibroblasts, causing the fibroblasts to proliferate, invade affected tissue, and spin out collagen and other extracellular matrix. Some enzymes trigger nearby capillaries to sprout new vessels that support the fibrous tissue that is forming. Local short-term hypoxia may also alter cell function, causing the secretion of more proinflammatory enzymes and interfering with apoptosis--the normal cell death that would inhibit and reverse these processes. Ultimately, if the activity of chemicals that promote scar-tissue formation is more powerful than the activity of those that inhibit it, the result may be nonfunctional gobs of sticky collagen, which can take the form of keloid or hypertrophic scars on the surface of the skin, or internal adhesions--places where surfaces that should slide freely over each other become essentially glued together.
Not All Collagen is Created Equally
The terms collagen and scar tissue are sometimes used interchangeably, and this is technically inaccurate. Collagen is a term that describes a group of protein molecules produced by fibroblasts. It is a vital component of our body, accounting for some 25-35 percent of our whole-body protein count.
Different types of collagen fibers are found in different areas, but the basic pattern is that each fiber is composed of a triple-helix of molecules. At this point, 28 subtypes of collagen have been identified, but the vast majority of our tissues are invested with some combination of five types.
Type I collagen is found anchoring the skin, in tendons and ligaments, and as the scaffolding for working cells of organs and the mineral deposits of bones.
Type II collagen is found in a three-dimensional matrix holding the liquid and chemicals that make up articular and elastic cartilage.
Type III collagen is found with type I.
Type IV collagen is found in cell basement membranes.
Type V collagen is found on some cell surfaces, in hair follicles, and in the placenta.
Scar tissue is usually formed of types I and III collagen. Fibroblasts expel the fibers as a random mass, but if the injury is in a muscle, ligament, or tendon, then weight-bearing force during the postacute phase of inflammation helps those fibers to align along with functioning tissues for the best quality healing. This is why it is important to mobilize a musculoskeletal injury (within pain tolerance) as soon as possible.
When Scar Tissue Becomes a Problem
When the forces that promote its formation outweigh the forces that inhibit or reverse its formation, scar tissue becomes a problem. The result is that type I and III collagen fibers are deposited around and within tissues. They may never fully align with functioning lines of force, and they may be in an extracellular matrix that promotes stickiness rather than slickness. As scar tissue matures, it begins to pull in on itself, dragging other tissues along with it. In organs, this can interfere with function (think of a liver imbued with scar tissue: this is cirrhosis); in tubes, it can cause obstructions; and in serous membranes, it can make surfaces stick together (this is a description of pleurisy, which limits lung function and can raise the risk of life-threatening pneumonia). Even the pericardium can develop adhesions, dragging directly on the heart muscle or sticking to the chest wall.
Excessive collagen production on the surface of the skin can lead to prominent, permanent, sometimes disfiguring scars. When piles of collagen are elevated from the skin, but stay essentially within the boundaries of the wound, this is called hypertrophic scarring. When the scar tissue appears to expand beyond the edges of the wound and even invest nearby tissues, this is called keloid scarring. Anywhere that scar tissue becomes problematic--internally or on the surface of the skin--it can entrap, irritate, and restrict nerves, leading to chronic pain.
The rest of this discussion will focus on some subtypes of scarring run amok where massage has been demonstrated to have a particularly useful role. The articles where this information is documented are listed in the Resources section.
Burns that penetrate through the dermis leave permanent scars that become elevated, reddened, and rigid. They are especially likely to contract and pucker, leading sometimes to a major loss of range of motion and function in nearby tissues. Skin grafts aim to prevent this, but with only middling success. Massage therapy for burn survivors has multiple benefits. In addition to providing pain relief during the excruciating initial treatment and healing process, it can improve the long-term outlook as well. It doesn't radically change the appearance of scars, but it can reduce vascularization and itching, and improve pliability, especially if it is applied as soon as the skin can tolerate shearing forces. In addition, massage can be a helpful part of treatment for depression (and accompanying self-esteem challenges) in severely burned patients.
The role of postsurgical massage for scar tissue varies a bit by location. In this context, we will consider two subgroups that have been researched: massage for postmastectomy and lymph node dissection surgery, and massage for postabdominal or pelvic surgery.
Breast Cancer Surgery. Breast cancer surgeries range from lumpectomies to full mastectomies, and can also involve axillary lymph node dissection, creating scar tissue at an additional site. The postsurgical scarring that accumulates over the pectoral and axillary areas can affect tissues far beyond the chest and shoulder, and it is particularly capable of trapping branches of the brachial plexus to create chronic nerve pain that can be tremendously difficult to treat. Normal range of motion can be severely limited, which affects a patient's ability to return to work or normal daily activities. (An additional problem, although not yet well documented, is the possibility of postsurgical scarring that changes posture and locomotion to the extent that falls may become more likely; for breast cancer patients, who are often mature women also at risk for osteoporosis, this is a significant danger.)
The use of soft-tissue manipulation to help treat postsurgical scarring for mastectomy demonstrates that this intervention can restore a functioning range of motion and significantly decrease pain. Similar findings were documented for women who had undergone lymph node dissection, as those treated with advice, exercise, and soft-tissue manipulation found that pain and shoulder mobility were restored to better levels than those who were given informative brochures for self-treatment.
Abdominal and Pelvic Surgery. Internal adhesions follow abdominal and pelvic surgery close to 100 percent of the time, and this is true whether the surgery is open or laparoscopic. For many patients, this is not a significant problem, but for some, postsurgical adhesions can interfere with peristalsis and cause a dangerous bowel obstruction. Other surgeries can cause adhesions that interfere with the ovaries, uterine tubes, and other structures, leading to infertility and chronic pelvic pain. Many people who undergo surgery require a repeat procedure to destroy adhesions (adhesiolysis), which, naturally, puts them at risk for more adhesions.
Much research has gone into creating tools or protocols to reduce the rate of postsurgical adhesions. Mesh, sprays, and other strategies have been employed, with mostly disappointing results. Until recently, massage for this problem was not considered a viable option. Then, a team induced abdominal adhesions in rats and had a massage therapist who was experienced with visceral massage work on the healing rodents to mobilize the abdominal contents of some of the rats. A clinician who was not informed as to which rats received massage evaluated the animals postmortem. Not surprisingly, the massaged animals had a much lower rate of adhesions than the control group.
This finding challenges a few things about how massage is taught and utilized. For one thing, it requires that massage therapists work with the abdomen--an area of the body that many prefer to skip. It requires that they develop palpation skills to become sensitive to sites of adherence. And for best results, it requires that massage therapists begin this work long before the four to six week delay that is often suggested for working with patients after surgery. That is a guideline developed out of conservatism and passed down out of respect for tradition, but as long as the skin can withstand gentle movement, stitches aren't disrupted, and the risk of infection is avoided, then abdominal manipulation can be safe and effective within pain tolerance very soon after surgery. In some ways, this is simply another application of the "use it as soon as possible" strategy that we've seen with musculoskeletal injuries.
Work in Progress
Scar tissue as a pathology topic is a tricky issue for several reasons. Scar tissue isn't tied to any specific disease or condition; its development can be not only desirable, but lifesaving; and the line between enough scar tissue and too much can be razor thin. But it seems clear that humans' propensity to form scar tissue sometimes outperforms its usefulness, and the result can range from annoying to debilitating to downright life-threatening. If massage can safely and effectively intervene when scar tissue becomes problematic, then it is a benefit we should explore.
eMedicineHealth, "Adhesions, General and After Surgery." Accessed May 2012. www.emedicinehealth.com/adhesions_general_and_after_surgery/article_em.htm.
Alpay, Z. et al. "Postoperative Adhesions: From Formation to Prevention." Seminars in Reproductive Medicine 26, no.4 (2008): 313-21. www.medscape.com/viewarticle/580001.
Beurskens, C. et al. "The Efficacy of Physiotherapy Upon Shoulder Function Following Axillary Dissection in Breast Cancer, a Randomized Controlled Study." BMC Cancer 7 (2007): 166. www.biomedcentral.com/1471-2407/7/166/prepub.
Bove, G.M., Chapelle, S.L. "Visceral Mobilization Can Lyse and Prevent Peritoneal Adhesions in a Rat Model." Journal of Bodywork and Movement Therapies 16, no. 1 (2012): 76-82.
Fourie, W.J., Robb, K.A. "Physiotherapy Management of Axillary Web Syndrome Following Breast Cancer Treatment: Discussing the Use of Soft Tissue Techniques." Physiotherapy 95, no. 4 (2009): 314-20.
Fourie, W.J. "Considering Wider Myofascial Involvement as a Possible Contributor to Upper Extremity Dysfunction Following Treatment for Primary Breast Cancer." Journal of Bodywork and Movement Therapies 12, no. 4 (2008): 349-55.
Patino, O. et al. "Massage in Hypertrophic Scars." Journal of Burn Care and Rehabilitation 20, no. 3 (1999): 268-71.
Syed, F. et al. "Fibroblasts from the Growing Margin of Keloid Scars Produce Higher Levels of Collagen I and III Compared With Intralesional and Extralesional Sites: Clinical Implications for Lesional Site-Directed Therapy." The British Journal of Dermatology 164, no. 1 (2011):83-96. www.medscape.com/viewarticle/735009.
Young, S.R. "Effects of Skin Rehabilitation Massage Therapy on Pruritis, Skin Status, and Depression in Burn Survivors." Journal of Korean Academy of Nursing 37, no. 2 (2007): 221-26. www.ncbi.nlm.nih.gov/pubmed/17435407.
Ruth Werner is a writer and educator approved by the NCBTMB as a provider of continuing education. She wrote A Massage Therapist's Guide to Pathology (Lippincott Williams Wilkins, 2012), now in its fifth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or firstname.lastname@example.org.