How can we help?
Working with patients to promote wound healing and manage scar tissue formation is a very legitimate use of a therapists skills and knowledge. Guiding a patient through their recovery and including thoughtful and targeted interventions can significantly improve long term outcomes. This blog outlines both the why and how, with references and clinical guidance notes.
Scar Tissue
Scar tissue is one of those visible signs of injury or surgery that remain following recovery. If the healing process is managed correctly scar tissue rarely causes persistent symptoms. However, if scar tissue is allowed to form and mature in the absence of normal movement then pain and functional limitations are likely to occur. The majority of soft tissue elasticity comes from the dermis, the layer just beneath our skin, a loss of the elastic properties within this layer from scarring causes significant mobility restrictions that can limit function and cause pain. Manual therapy forms part of a holistic approach to scar management, but when can it be used and what type of approach is best?
Breaking down scar tissue, really?
We cannot break down scar tissue! As much as we would like to achieve this, the reality is that mature scar tissue (type I collagen) is stronger than the surrounding normal tissue and therefore anything too vigorous is likely to cause trauma and inflammation within the healthy tissues surrounding the scar. Manual therapy can have a positive effect on immature scar tissue (type III collagen) if the treatment is delivered with the correct amount of stimulus, a factor largely determined by a knowledge of healing times, tissue physiology, and the individual patient.
How to use manual therapy for scar tissue management and soft tissue healing.
The time to consider the use of localised tissue mobilisation to aid wound healing is typically from day six post-injury. At this time the inflammatory response should be minimised, and the overlapping proliferation phase should be gaining momentum. The proliferation phase is characterised by tissue repair with the deposition of immature collagen fibres (type III) whose alignment is determined by the forces placed upon them, forces determined by localised tissue stress from muscle contraction and the surrounding skin and joint motion.
Many factors such as age, health and injury severity would likely delay a healing process. For this reason, we need to consider the patient and if they are ready for some IASTM, Cupping or Hands-on techniques
During the proliferation phase (6-21 days) it may be advisable to provide a very light motion stimulus to the tissues around the healing wound, monitoring for any pain or post-treatment inflammation. After approximately 21 days the remodelling phase begins to dominate over the proliferation phase. During remodelling, the scar matures and you can start to experiment with sheering in different directions to see if any unique restrictions exist. Paying particular attention to normal movement-based tissue stress by pushing and pulling the skin in the directions it normally gets pulled and pushed into.
An important part of what we do as therapists is to encourage movement and this is especially important for the healthy alignment of healing tissue. Progressing towards normal motion is all that’s required. Don’t make the initial rehab too fancy as it might make it less likely to be completed.
Evidence-Informed Guidelines for the use of IASTM and Cupping in the management of wound healing and scarring.
Standard soft tissue healing time frames:
Inflammatory phase: 0-6 days
Proliferation phase: 6-21 days
Remodelling phase: from day 21+
Note 1: Healing times are often delayed by individual factors.
Note 2: For large wounds, the healing phases may be different in different areas. This is most common in burns.
Note 3: If too much mechanical stimulation is applied in the early healing phase it will cause re-injury and a new inflammatory response.
Inflammatory Phase, 0-6 days.
Inflammation is the first and vital component of the immune response. For wound healing, the inflammatory response aims to stop bleeding and clear the injured tissue of any invading pathogens. Avoid manual therapy in the presence of acute inflammation due to the risk of prolonging this phase.
Proliferation Phase, 6-21 days.
The proliferation phase ensures that new collagen fibers form in the injured area. The initial collagen fibers form with no specific alignment and orientation in what has been described as a connective tissue ball. This forming ball of weaker type III collagen is highly sensitive to the forces placed upon them and therefore the provision of these normal strain forces forms the bases of successful wound healing. This connective tissue ball would remain a ball, eventually hardening into stronger type I collagen, if the area was immobilised and unable to move normally.
Remodelling Phase 21 days +.
The weaker type III collagen is reabsorbed and replaced by a strain resistant type I collagen, often referred to as mature scar tissue, these fibers would now require a longer and more forceful stimulus to alter their alignment. The application of this force is challenging and risks re-injury or new injury to the surrounding tissue.
How much force should you apply?
The aim of the therapeutically applied manual techniques are not, as previously assumed, to align collagen fibres purely by stretching, but to trigger biological processes within the cells with adequate stimulation.
Cell responses can be initiated by minimal forces and functional alignment achieved with gentle manual therapeutic interventions. We are not trying to break down scar tissue and we are not trying to untangle with force.
It’s difficult to quantify just how much force is required but here are some guidelines:
During the proliferation phase, you should apply a light sheering force within the normal elastic limits of the tissues.
During the remodelling phase you can mobilise the soft tissues up to the point of resistance and if tolerated consider manipulating the soft tissue into resistance.
How should this force be applied?
Now this is interesting, research suggests that a cyclical strain stimulus of 0.2Hz produces the most resilient tissue repair (Balestrini & Billiar 2009).
Here is a 0.2Hz sound wave: https://www.youtube.com/watch?v=Xo4UJy-Zrsc
0.2Hz is also the frequency that triggers motion sickness, apparently: https://pubmed.ncbi.nlm.nih.gov/11277284/
How often should you perform the soft tissue work for wound healing?
60 seconds per position
3-5 times per session
1-2 times per day
We will be discussing the above on our RockTape courses and developing a free CPD video in the coming weeks. Please comment and let us know your thoughts or questions.
References sources:
A great BJSM Blog by Christopher Swallow
Free here: https://blogs.bmj.com/bjsm/2021/01/09/scarwork-a-timeline-for-treatment-stimulus-in-sport/
An Excellent review by Thomas Koller: Mechanosensitive Aspects of Cell Biology in Manual Scar Therapy for Deep Dermal Defects. International Journal of Molecular Sciences. 2020 Jan;21(6):2055. Free here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7139679/pdf/ijms-21-02055.pdf
Interesting study that guides clinical applications: Balestrini JL, Billiar KL. Magnitude and duration of stretch modulate fibroblast remodelling. J Biomech Eng. 2009 May;131(5):051005. doi: 10.1115/1.3049527. PMID: 19388775.
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