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View Sample Pages Here 3 Introduction When properly developed, communicated and implemented, guidelines improve the quality pathophysiological scars further com- of care that is provided and patient outcomes. pounded by traumatic emotional sequelae Guidelines are intended to support the health- and other comorbidities. care professional’s critical thinking skills and judgment in each case. Traumatic scars can occur as a result of acci- In addition to guiding safer, more effective and dents, acts of violence and other catastrophic consistent outcomes, the authors can only dare events (e.g. disease, burn accident and surgery). to dream that these guidelines will also support better constructed MT research methodology Over the last several decades, advancements in and designs, ultimately leading to the inclusion medical technology have led to improved surgi- of MT professionals in mainstream interprofes- cal techniques and emergency care (Blakeney & sional healthcare. Creson 2002). Simply put, more people are sur- viving injuries that would have been fatal 20 or 30 What Defines Traumatic Scarring? years ago, and an increase in survival rate means an increased need for professionals skilled in The American Psychological Association defines treating people with scars. Working successfully trauma as an emotional response to a terrible with traumatic scars requires expert navigation, event like an accident, sexual assault or natural not only of the physicality of the scar material but disaster (APA 2015). also inclusive of the whole clinical presentation. Scar or cicatrix, derived from the Greek eschara – This book will provide the information needed to meaning scab – is the fibrous replacement tis- help guide the development of that expertise. sue that is laid down following injury or disease Given the complexity of traumatic scars, where (Farlex 2012). such presentations and/or appropriate treat- Scars are not obligated to be problematic – where ment fall outside of the MT profession’s scope of would we be without our body’s natural ability to practice, suggestions will be provided for appro- heal itself following a wound? However, normal priate referral resources to support the patient’s physiological processes can be altered in a vari- best possible biopsychosocial outcomes. ety of ways and, when altered, this constitutes It is the authors’ intention that the end product will what is termed pathophysiology. comprehensively cover both the physiological/phys- Abnormal or pathophysiological scars can ical and empathetic elements of MT and in doing so impact function within and beyond their physi- honour both the art and science of the work. Like cal borders and present considerations outside of interprofessional collaboration, integration of art the physical/physiological aspect of the scar tis- and science are essential for excellence in contem- sue (Lewit & Olsanska 2004, Bouffard et al. 2008, porary healthcare and achieving the best possible Valouchová & Lewit 2012, Bordoni & Zanier 2014). patient-focused outcomes for people with scars. Problematic scarring following planned and unplanned trauma can be accompanied by seri- Overview of Chapters ous physiological and psychological consider- Individual chapters will cover normal/abnormal ations and, as such, this brings us to traumatic scar formation; the role of various systems in scars as defined by the authors: wound healing; the impact of pathophysiological Chapter 1.indd 3 12/3/2015 12:55:43 PM 4 Chapter 1 scars and associated sequelae; the biochemical and emotional impact of trauma; communica- The views expressed in these pages are tion skills (including interprofessional commu- founded on the result of several years of close nication); assessment and treatment protocols; observation, study, and experiment. It is pos- client/therapist self care and shared experiences sible some of my deductions are erroneous, from therapists and people with scars. but at least they are capable of being argued and are not merely arbitrary. In order to assist with research translation, throughout this book pathophysiological and J.B. Mennell (1920) clinical considerations will be interspersed as Boxes where it makes sense to do so. References Andrade CK (2013) Outcome-based massage: putting Fritz S (2013) Mosby’s Fundamentals of therapeutic evidence into practice. 3rd edn Baltimore Md: Lippincott massage, 5th edn. St Louis, Elsevier, p 45. Williams & Wilkins. Goel A, Shrivastava P (2010) Post-burn scars and scar APA (2015) American Psychological Society. Available contractures. Indian Journal of Plastic Surgery: official at: https://apa.org/topics/trauma/index.aspx [Accessed publication of the Association of Plastic Surgeons of India 16 February 2015]. 43(Suppl): S63. Berman B, Bieley HC (1995) Keloids. Journal of American Haraldsson BG (2006) The ABCs of EBPs. How to have Academy of Dermatology 33: 117–23. an evidence-based practice. Massage Therapy Canada. Blakeney P, Creson D (2002) Psychological and physical Available at: http://www.massagetherapycanada.com/ trauma: treating the whole person. Available at: http:// content/view/1402/[Accessed 7 December 2014]. www.jmu.edu/cisr/journal/6.3/focus/blakeneyCreson/ Lewit K, Olsanska S (2004) Clinical importance of active blakeneyCreson.htm [Accessed 10 December 2014]. scars: abnormal scars as a cause of myofascial pain. Bordoni B, Zanier E (2014) Skin, fascias, and scars: Journal of Manipulative and Physiological Therapeutics symptoms and systemic connections. Journal of 27(6): 399–402. Multidisciplinary Healthcare 7: 11–24. Mennell JB (1920) Physical treatment by movement, Bouffard NA, Cutroneo KR, Badger GJ et al (2008) Tissue manipulation and massage, 2nd edn. Philadelphia: stretch decreases soluble TGF-β and type I procollagen Blakiston. in mouse subcutaneous connective tissue: evidence from Sackett DL, Rosenberg W, Gray JA et al (1996) Evidence ex vivo and in vivo models. Journal of Cellular Physiology based medicine: what it is and what it isn’t. BMJ 312(7023): 214: 389–395. 71–72. Cho YS, Jeon JH, Hong A et al (2014) The effect of burn Sackett DL, Strauss SE, Scott Richardson W et al (2000) rehabilitation massage therapy on hypertrophic scar Evidence-based medicine: how to practice and teach after burn: a randomized controlled trial. Burns 40(8): EBM, 2nd edn. New York, Churchill Livingstone. 1513 –20. Sund B (2000) New developments in wound care. Diamond M (2012) Scars and adhesions panel. Third London, PJB Publications. International Fascia Research Congress, Vancouver. Valouchová P, Lewit K (2012) In: Schleip R, Findley T, Chaitow Farlex (2012) Medical Dictionary for the Health Professions L, Huijing P (eds) Fascia the tensional network of the human and Nursing. © Farlex 2012. body. Edinburgh: Churchill Livingstone Elsevier, p 343. Chapter 1.indd 4 12/3/2015 12:55:43 PM 8 Chapter 2 responses, the internal to external and cell-to-cell Skin Structure and Function linkage mechanism provides the means by which the organism can sense and respond to mechani- In order to better understand the formation of cal demand or forces placed upon it – monitoring scar tissue, we need to look at the marvelous and regulating ‘enough tension’ to ensure the organ that is our skin. shape and integrity of any given cell and the entire Along with the glands, hair and nails, skin makes musculoskeletal/myofascial system. up the integumentary system. On average, skin Figure 2.1 Layers and components of skin. Stratum corneum Stratum granulosum Epidermis Stratum spinosum Stratum basale Arteriovenous plexus Free nerve ending Dermis Sebaceous gland Runi’s ending Arteriovenous plexus Pacinian corpuscle Sweat gland Erector pili Hair follicle nerve ending Hypodermis (subcutaneous Hair root tissue superficial Collagen fibre fascia) Lymph vessel Arteriovenous plexus Dense connective tissue Loose connective tissue containing adipocytes Deep fascia Skeletal muscle Chapter 2.indd 8 12/3/2015 12:58:49 PM 9 Skin and fascia constitutes 10% of human body mass. Skin acts as describe fiber orientation and configuration a barrier to the outside world and plays an impor- within a particular sheet, layer or area of tissue tant role in homeostasis. The skin, our outer layer (Terminologia Histologica 2008). of protection, is susceptible to infections, injuries, growths, rashes, cysts, boils, discoloration, burns, adhesions and scars. Clinical Consideration Skin Histology As CT is intimately associated with other tissues and The skin comprises: organs it may influence the normal or pathological • Epithelium processes in a wide variety of organ systems (Findley et al. 2012). • Connective tissue (CT). Epithelium CT, fascia and the sliding mechanism There are three basic types of epithelial tissue: One of the more recent discoveries in the world of squamous, cuboidal and columnar – arranged in fascia research is the sliding/gliding that occurs either a one-layer (simple) or multilayer (strat- throughout the CT and fascial systems, which ified) configuration. Epithelium forms many facilitates unimpeded, frictionless movement glands and lines the cavities and surfaces of struc- (McCombe et al. 2001, Guimberteau & Bakhach tures throughout the body (e.g. the epidermis 2006, Stecco et al. 2008, Wang et al. 2009). Some consists of stratified squamous keratinizing epi- suggest that sliding layers are interspersed between thelium) (Marieb et al. 2012). CT and fascial layers; however, Guimberteau sug- CT gests that rather than separated or superimposed layers there exists a singular, highly hydrated, tissu- Considered
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