The Scar as a Representation of the Osteopathic Principles

Sarah Belden, DO,* Jenifer Lloyd, DO,** Michael Rowane, DO***

*Traditional Rotating Intern, University Hospitals Regional Hospitals, Richmond Heights, OH **Program Director, Dermatology Residency Program, University Hospitals Regional Hospitals, Richmond Heights, OH ***Director of Medical Education, University Hospitals Regional Hospitals, Richmond Heights, OH

Abstract A scar is the manifestation of the skin’s healing process following an injury. It can be a cosmetic concern to some individuals while dismissed and disregarded by others. New treatment options continue to be investigated, but no solution currently exists for erasing a problematic scar. By viewing the scar as a source of somatic dysfunction using the four osteopathic principles, the dermatologist is able to employ the use of osteopathic manipulative treatment techniques as an adjunctive tool in scar management. Here we explore the scar through an osteopathic lens and describe treatment strategies that have been shown to be effective in improving the somatic dysfunction caused by the presence of a scar. Introduction the saying “a scar is more than skin deep,” a scar Principle 2. The body is capable of self-regulation, A scar, or cicatrix, is the end result of the may have a deeper value to one person but not to self-healing, and health maintenance. wound repair mechanism in adults and children another. It can serve as a permanent reminder of Upon any introduction of trauma to the skin, the following an injury, either traumatic or surgical, the past, whether it is pleasant or unpleasant, that body elicits an instant repair mechanism that is beyond the epidermis. It is the consequence of extends to the body, mind and spirit. designed to restore the natural homeostasis of the tissue. This repair mechanism is divided into a a surgical incision and is inevitable despite the It is known that the connection between the skin series of stages, each having unique characteristics. surgeon’s best efforts to hide it within the skin’s and the mind is a powerful one. For example, natural contour lines. stress can exacerbate psoriasis and cause acne The first stage of wound healing is known as It is a common lesion encountered in dermatology, breakouts.7 Stress can also play a role in scar the inflammatory phase, where cytokines and and it is the source of much cosmetic concern. formation. Furtado et al. found that psychological inflammatory cells are recruited and infiltrate the More than 230 million surgical procedures are stress influences the rate of recurrence of keloids site to destroy potential pathogens, remove debris, performed around the world each year, all of when stress is experienced the day before and initiate coagulation through the formation of keloid excision, increasing the chances of keloid an initial thrombus.12 The inflammatory pathway which result in cutaneous wounds that heal 8 with scars.1 A recent survey indicated that 91% recurrence by 34%. The location of the scar of wound healing, a large determinant of the of patients who underwent a routine surgical and the patient’s age or gender are factors that outcome of a scar, has long been the focus of procedure would value any improvement in influence its impact. A scar on the chest of a attack for anti-scarring research, but strategies 2 young female, for example, may cause increased that block inflammation alone have so far proved scarring. Scars also affect other body systems 13 including the musculoskeletal system or deep self-consciousness and impact the clothing she suboptimal with significant side effects. 3,4 viscera in the form of adhesions. They are also chooses to wear. The second stage, called proliferation, is 5,6 linked to pain and depression. There is a variety of psychosocial comorbidities characterized by the fibroblast cell. Fibroblasts The cosmetic outcome of a scar and its subsequent associated with scarring. Depression is the are responsible for producing collagen, which implications on a patient’s overall wellbeing is of predominant finding in patients suffering provides the structure to the wound and creates a primary importance in dermatology. Patients are from burn scars5. A combination of anxiety, new matrix—the groundwork of a scar. often left desperate for treatment options after depression and PTSD-related disorders were Remodeling, the final stage of wound repair, first-line treatments—such as silicone sheeting, seen in 64% of the patients who developed scars begins at about two to three weeks following following ICU admission for severe soft-tissue pressure dressings and intralesional steroids— 6 trauma and can last for years depending on the Other psychosocial 12 fail. Osteopathic manipulative treatment infections in one study. size of the wound. During this stage, fibroblasts (OMT) is a non-invasive, cost-effective therapy characteristics of patients with scars, particularly are responsible for organizing and cross-linking for scar management that may be employed within the burn population, include avoidance the collagen, increasing the strength of the new 9 loneliness10 and living a by considering the scar as an application of of social interaction, site, and causing contraction of the wound edges solitary lifestyle.11 osteopathic principles and practices. Here, we in the process. apply A.T Still’s four osteopathic principles Thus, the first step in scar management is to The appearance of a scar is influenced by many to the scar and describe the mechanisms consider the whole patient. The stressors and factors: the depth of trauma (injury limited to the responsible for the interaction between the scar history behind the scar are important to address epidermis can heal without scarring), the location and its surrounding skin as a source of somatic prior to subsequent treatment. Approaches such (the chest is an area more susceptible to scar dysfunction. The OMT techniques applicable as suggesting stress-management techniques formation), whether the patient is at risk of keloid to scar management are reviewed and their perioperatively may help improve the chances of or hypertrophic scarring (genetics, ethnicity, etc.), effectiveness explored, revealing the growing a better scar outcome. Counseling or referring 3,12 age, and nutritional and vitamin deficiencies. opportunity for further osteopathic research. to psychiatry is important for patients displaying psychological symptoms. Education plays a It is important to appreciate that the dynamics helpful role, such as teaching the patient the between the wound repair process and the scar Discussion do not end immediately. Rather, an interplay Osteopathy and scars importance of keeping the scar covered from the sun and applying sunscreen after the surgery. It between the traumatized tissue, the scar, and Principle 1. The body is a unit; the person is a unit of is important to consider the whole patient when the surrounding non-traumatized tissue results body, mind, and spirit. performing a procedure; the patient’s age, incision in altered tissue arrangement that manifests as This osteopathic principle represents how a scar length and location should be respected in order tissue texture changes contributing to the scar’s 3,14,15 can affect a person’s entire wellbeing. Much like to ensure the best possible scar outcome. appearance.

BELDEN, LLOYD, ROWANE Page 11 This mechanism can best be explained through disorders, female infertility, and chronic lower changes listed in Table 1. The extent of the tissue the osteopathic bioelectric model of fascia as abdominal pain.3,21 texture changes and the restriction and resistance described by Judith O’Connell, DO, FAAO, which Scars can also cause dysfunction of major muscles (pathological barriers) of the deeper tissue may be illustrates the important relationship between the determined by palpation.24 15,16 and joints. Frozen shoulder, for example, is a dermis and its underlying fascia. Fascia is well-known complication of the shoulder joint found between the deep and superficial adipose following rotator cuff injury where the shoulder Table 1. Tissue texture changes associated with layers and is connected to the dermis through exhibits pain and neurological symptoms from chronic somatic dysfunction of a scar* 17 It perpendicular septa of fibrous extensions. scar accumulation. communicates with the dermis via bioelectric Ropiness: cord-like, fibrotic feeling Muscular dysfunction may be observed in the currents through the extracellular fluid, which is (in the scar itself) considered a homeostatic relationship within the dermatological arena following the formation skin.15,18 of facial scars. The SMAS is a structure that Stringiness: fine or string-like ensheaths the facial muscles and neurovasculature The presence of a scar applies extra mechanical myofascial structures and plays an intricate role in coordinating and tension to the tissue, causing a disruption of the 22 exaggerating facial expressions. If a scar extends Firmness, hardening normal homeostatic signaling between the fascia to the level of the SMAS, the thickened fibrosis and dermis. The collagen within the scar itself Temperature changes may cause stiffness of the fascia, which may lead also releases microelectrical-potential changes Increased/decreased moisture 15,18 to altered range of motion of the facial muscles, into the extracellular fluid. This aberrant 18 affecting normal facial expression. Lymphedema bioelectric current not only alters the local architecture of the dermis and fascia but also Principle 4. Rational treatment is based on an *Adapted from: American Association of Colleges the arrangement of surrounding tissue (neural, understanding of the basic principles of body unity, of Osteopathic Medicine - Educational Council muscular, vascular, and lymphatic), resulting in self-regulation, and the interrelationship of structure on Osteopathic Principles. Glossary of osteopathic and function. terminology. Chevy Chase, MD: American Association changes such as stiffness, altered motion, pain, and of Colleges of Osteopathic Medicine; rev. Nov 2011. edema that can be restored using OMT.3,15,16,19 Treatment relies on a full understanding of how a scar can affect the entire body while Thus, it is important to acknowledge that the acknowledging the first-line evidence-based Lymphedema is a common finding associated wound repair process and its end product, the treatment strategies and knowing alternatives with the chronic somatic dysfunction of a scar. scar, is not a static process. Rather, there are many for more refractory cases. First-line treatment The term “scar lymphedema” is used to describe dynamic homeostatic elements that are ongoing for scars includes a variety of options such as the localization of lymphatic fluid around the scar following scar formation that contribute to the silicone sheeting, pressure dressings, intralesional site due to the damage of the lymphatic channels overall somatic dysfunction and scar appearance. steroids, 5-FU, bleomycin, and verapamil, as and pathways caused by the surgical incision.25 Principle 3. Structure and function are reciprocally well as laser therapy, localized radiotherapy, The difference between edema and lymphedema interrelated. micro-needling, and intralesional cryotherapy surrounding a scar is based upon location of the 23 This principle stems from Dr. Still’s belief that for the more refractory cases. Osteopathic swelling. With lymphedema, swelling affects abnormal tissue structure is likely to result in manipulative therapy is a cost-effective and non- only the “upstream” side of a healed incision (such disruptions in tissue function and vice versa. A invasive treatment option that may be employed as the circumscribed central area of a U-shaped scar disrupts the normal architecture and function as an adjunct and for those scars resistant to scar), whereas nonspecific edema will surround of surrounding skin. The clinical result is an area the standard therapy. Several techniques may the entire scar.26 of skin tissue whose biomechanical function and be utilized and have been shown to be effective “Active scar” is another term used to describe a normal viscoelastic behavior is compromised; it is in improving the appearance of a scar and its scar that would benefit from OMT; it is “active” an area of somatic dysfunction. surrounding tissue. if it exhibits soft-tissue changes characterized by The skin’s basic protective functions are altered It is important for the osteopathic dermatologist increased skin drag, owing to increased moisture in the presence of a scar. The fibrotic infiltration to gain an understanding of which scar (sweating), impaired skin stretch, and a thickened of a scar alters the complex arrangement characteristics are clinically relevant for OMT skin fold.24 of desmosomes and elastin that is used to and the rationales for treatment based on the The exact timeline of when it is appropriate to provide protection and support, leaving the site models of osteopathic care. treat scars using OMT has not been formally susceptible to mechanical damage. Similarly, established.27 The use of pressure therapy on scars protection against UV radiation is compromised Identifying a scar to be treated The first step in effective OMT is to properly after burn injury showed that earlier treatment as a scar alters the arrangement of melanin 12 identify whether a scar and its surrounding (scars treated <6 months after burn injury) pigments. The processes of hyperkeratinization tissue would benefit from treatment. Its level of resulted in better outcome than those treated and DNA repair are also compromised by 28 20 acuity must be assessed. It is important to not It has been proposed that noninvasive the altered vascularization created by a scar. later. manipulate acute scars, i.e., hot, boggy, tender or Sensation becomes impaired when the anatomy scar management, such as manipulation, typically erythematous scars, or those exhibiting venous of the skin’s free nerve endings that normally occur within the early maturation phase of the congestion/edema. Manipulation of an acute extend to the epidermis is altered even by the wound healing process in order to improve scar scar would delay the wound healing process, 29 most superficial of scars. Adnexal structures (e.g. outcome and accelerate time of scar maturity. which would worsen the structure and function More studies are needed to investigate the most hair follicles, sweat and sebaceous glands) as well dynamics of the scar.24 appropriate time to implement OMT. as components of the dermal extracellular matrix may fail to regenerate following the formation of The scar should exhibit chronic somatic a scar, resulting in a loss of normal skin function dysfunction. By its standard definition, chronic Treatments and impaired morphology.12 somatic dysfunction is “impairment or altered The biomechanical model and the respiratory- function of related components of the somatic circulatory model of osteopathy help guide the Scars, in the form of adhesions, have the potential (body framework) system characterized by dermatologist to select the most appropriate to disrupt normal visceral function. Intra- tenderness, itching, fibrosis, paresthesia and tissue OMT therapies. Based on these models, soft- abdominal adhesions are cited to occur after contraction; identified by TART”.25 The forces tissue techniques, myofascial release and a 50% to 100% of the surgical interventions of the 4 exerted by the scar to the surrounding tissue, as lymphatic approach to the scar are considered. abdomen. They can lead to bowel obstruction, described above, may manifest as tissue texture The therapeutic principles of the models in irregular bowel movements, meteorism, digestive

Page 12 THE SCAR AS A REPRESENTATION OF THE OSTEOPATHIC PRINCIPLES respect to the scar are explained below. Biomechanical Model: Soft Tissue Techniques and Myofascial Release The goal of the biomechanical model seeks to address problems with the soft tissue, muscle and fascia by removing the restrictive forces of the tissue.30 As previously mentioned, there are many restrictive forces or tissue texture abnormalities that may be palpated surrounding the scar. Soft tissue OMT and scar (myofascial) release are two techniques that address these forces and have been shown to improve scar outcome. Both techniques utilize the concept of pressure restoring balance to the scar. Physical pressure at the site of a scar causes local hypoxia, which induces the regeneration of fibroblasts, suppresses collagen production, and activates collagenase, which overall expedites collagen dismantling.33 The fibroblasts, which play a role in contracting Figure 2: Diaphragm release of the palmar fascia to induce motion patterns in multiple planes of an elbow scar.

collagen lattices, are relaxed through the pressure of manipulation.34,35 This relaxation results in increased microcirculation to the site owing to the restoration of tissue texture abnormalities.36 It has been shown that manipulation encourages collagen fibrils of the dermis to realign.37 The immediate result of these changes can be palpated through the form of a release.30 There is a variety of soft-tissue techniques that may be used for treating scars. The treatment goals include increasing tissue elasticity, enhancing circulation to local fascial structures, improving local tissue nutrition and oxygenation, improving local immune response, and providing a general state of relaxation.38 Scar soft- tissue manipulation is distinguished from scar massage therapy in that it makes use of the barrier-and-release phenomenon; scar massage does not.24 Soft-tissue techniques used for scars include effleurage, skin rolling, stretching, and petrissage.24,38,39,40 Effleurage is a light stroking soft-tissue technique that is used on more superficial scar tissue. McKay performed a five-week treatment of soft-tissue techniques including effleurage to improve the appearance and function of cleft-lip scars.39 Based upon patient subjective results, she found soft-tissue manipulation to be an effective means Figure 1: for increased patient satisfaction and improvement of the appearance of the scar. Indirect myofascial scar release of an elbow scar. Skin rolling is another soft-tissue technique. It involves lifting the skin away from the deeper structures and “rolling” the skin fold along the body.38 Pohl examined the changes in the structure of collagen in scars following

BELDEN, LLOYD, ROWANE Page 13 manual treatment using skin rolling with Table 2. Diaphragms to treat based on scar location* ultrasound.36 Prior to therapy, the tension of the scar was appreciated using ultrasound echoes Scar Scalp, face, Upper Chest, upper Abdomen, Lower that detected higher densities within the collagen Location neck extremity back lower back, extremity fibers. Following the skin-rolling technique, she buttocks, found a reduction in the densifications of collagen pelvis within the dermis as well as an overall increase Suggested Tentorium Palmar fascia Respiratory Pelvic Plantar fascia of thickness in the dermis. These changes were 32,34,35 Diaphragm thoracic inlet diaphragm diaphragm attributed to the relaxation of fibroblasts.

Soft-tissue stretching along the site of a scar *Adapted from: O’Connell J. Chapter 47. Myofascial release approach. In: Chila AG, Carreiro JE, Dowling DJ, has also been shown to be effective in scar Gamber RG, Glover JC, Habenicht AL, Jerome JA, Patterson MM, Rogers FJ, Seffinger MA, Willard FH. management. Soft-tissue stretch engages the Foundations of Osteopathic Medicine. 3rd ed. Philadelphia, Baltimore: Lippincott Williams & Wilkins. 2001. barrier palpated along the distal ends of the scar while slowly stretching and releasing the fibrin and collagen.42 resume tissue stretch in all directions. surrounding tissue in multiple planes.24 Lewit et al. used soft-tissue skin stretching in combination The proposed application of lymphatic treatments 5. Upon resistance, apply simple pressure in the with heat on “active” scar sites following a variety to scars involves first opening the myofascial direction of the pathological barrier until release of operations including appendectomy, breast pathways to increase microcirculation to the site is felt. (via the soft-tissue techniques and myofascial surgery and gynecologic surgery and found 6. Achieve relaxation of the tissue by lightly release), and then treating the diaphragms.42 marked immediate results with general soft- stroking the scar and surroundings. tissue stretch. 24 The treatment led to decreased By definition, diaphragms occur at important 16 pain and increased tissue mobility in the majority anatomical crossroads in the body where curves Diaphragm release (Figure 2) of cases. The scar ends were found to be the most and cavities change and where passage points for major circulatory and lymphatic vessels Based on the location of the scar and patient active sections of the scar, and treatment was 16 history, choose the most appropriate diaphragm aimed predominately at these sites. occur. Maximizing the motion of diaphragms helps to improve circulatory and lymphatic to treat, as noted in Table 2. Petrissage, which is a deeper kneading and flow, which would be beneficial in the setting of 1. Using compression, distraction or the full squeezing pressure, is considered to be an a scar exhibiting lymphedema in the setting of 41,42 deep respiration cycle, induce motion and note excellent soft-tissue technique for scars. chronic somatic dysfunction.30 In dermatology, the different patterns of interaction between the Morien et al. investigated a combination of the relevant diaphragms are both peripheral and normal and dysfunctional tissue response. effleurage, petrissage, stretching and rolling in central, based on the location of the scar as listed 2. The dysfunctional pattern, whether a barrier a group of post-burn patients, which showed in Table 2. Clinical studies are needed in order or point of ease, should become apparent at the improvement in range of motion at the scar to explore the outcome of diaphragm release and 40 diaphragm, making the primary dysfunction at site and overall patient satisfaction. Field other lymphatic treatments for scars. et al. compared a group of post-burn patients the scar evident, and a release should begin. who received a combination of skin rolling, Examples of Osteopathic Manipulative 3. If treating using respirations, motion in the stretching and stroking to a group who received Treatment Techniques tissue should begin as a release occurs, with a new 43 no manipulation. It was found that those in Indirect myofascial scar release (Figure 1)14 end point of motion manifesting. the manipulation group experienced a relief of pruritus, pain, anxiety and improvement in mood 1. Place fingers parallel to either side of the scar. associated with their scarring. Conclusion 2. Approximate your fingers gently to reduce By viewing the scar through an osteopathic lens, “Scar release” is an indirect form of a myofascial- tension on the scar. the dermatologist is able to gain an understanding release technique that may be used to reduce 3. Move the tissues on either side gently in of how the scar is more than just a fibrosis on asymmetric tension and restore functional balance different directions (cephalic, caudal, left, right) to the skin; it represents how one dermatological to the stresses transmitted through a scar.­ It is determine the tension pattern in the surrounding lesion can affect the entire person. It is an active utilized to engage deeper tissue such as muscle tissues. participant within the homeostatic environment and fascia. Successfully releasing the deep fascial of the skin that can affect both structure and 4. Gently move your fingers on either side of the restriction and correcting the restrictive forces in function of the human body. Based on available 16 scar in the direction that most reduces tension turn activates surrounding bioenergetic tissue. clinical data, osteopathic manipulative treatment until you perceive a sense of balance. It has been reported to be an effective technique should be considered in the dermatological arena in improving post-mastectomy axillary cord 5. Hold in the balanced position until you perceive as a therapeutic strategy for scar management. anchoring secondary to scar formation, leading a release, that is, a further relaxation of tension. Further clinical studies are needed to establish to improvement of axillary-scar appearance and the most effective OMT modalities and the most 44 6. Have the patient exhale and hold the breath in surrounding lymphedema. step 5 to enhance the balance of tension. appropriate time to initiate and continue therapy. Respiratory-Circulatory Model: 7. Reassess tension of the soft tissue surrounding Diaphragm Release and Lymphatic Pump the wound or scar. References Based upon the respiratory-circulatory model, 1. Weiser TG, Regenbogen SE, Thompson KD, lymphatic techniques are designed to remove Direct myofascial release skin stretch with heat24 Haynes AB, Lipsitz SR, Berry WR, Gawande AA. An estimation of the global volume of surgery: a impediments to lymphatic circulation and 1. Lightly stroke the whole area of the scar and 42 modeling strategy based on available data. Lancet. promote and augment the flow of lymph. area around it for relaxation. As previously noted, lymphedema can be a 2008 Jul;372(9633):139-44. 2. Undergo skin stretching in all directions. prominent feature of the chronic scar; it may 2. Young VL, Hutchison J. Insights into patient even be measured using lymphoscintography.26 3. Apply a hot pack to the site for a short duration and clinician concerns about scar appearance: Mobilizing the tissue surrounding the scar can along with pressure and shifting the soft tissue in semiquantitative structured surveys. 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