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

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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.

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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 Ru ni’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

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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 a system, CT consists of several differ- lar architecture which can maintain the necessary ent types of cells (e.g. fibroblasts and adipocytes), space between structures to facilitate optimal slid- protein fibers (elastin and collagen) surrounded ing and tissue excursion (Guimberteau & Bakhach by the gelatinous ECM (Schleip et al. 2012a, 2006, Guimberteau 2012) – see Figure 2.2. Andrade 2013). Whether the presentation is layers between CT is a continuous bodywide system that plays a layers or a singular architecture, the sliding well-identified role in integrating the functions of mechanism comprises loose CT – consisting of diverse cell types within each tissue it invests (e.g. predominantly fine collagen strands, adipocytes skeletal muscle, tendon, bone, viscera (Langevin and an abundance of HA. 2006)). CT is highly variable in its presentation. Various terms are used to describe CT typology, The sliding mechanism occurs bodywide on both for example: a macro and micro level; between interfascial planes, endofascial fibers, endomuscular fibers • Dense and loose are used to describe how and intracellular fibers (Guimberteau et al. 2005, dense, tightly or spread out the fibers are ­Ingber 2008, Stecco et al. 2008, Wang et al. 2009, packaged within an array of tissue ­Langevin 2010). The impact of traumatic scarring • Regular, irregular, unidirectional, multidirec- on the sliding mechanism and clinical considera- tional, parallel ordered and woven are used to tions will be noted throughout this book.

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Fascicular between articulating structures and surfaces. The loose well-hydrated sliding layers also fall into this Fascicular fascia augments continuity and force category. transmission, provides proprioceptive feedback and protection of nerve, blood vascular and Functions of Fascia: Summary lymph vessels. Fascia physiology in brief: as a component of the locomotor system, fascia performs essentially Clinical Consideration three mechanical functional roles: separation, connection and energy facilitation. Perimysium plays a significant role in force transmis- sion. Perimysium is commonly thicker in postural mus- Fascia as a tissue of separation: creates space cles, tends to display a higher concentration of MFBs which serves as an interface for ease of sliding and can adapt more readily to changes in mechanical and gliding of structures and tissues in relation to one another. Spatial separation supports tension. The driving force behind long-term, sustained unimpeded motion and motion ensures the contracture and pronounced muscular ‘stiffness’ healthy functioning of tissues and structures could be explained in part by the presence of MFBs and the sliding–gliding interface. in fascia – in particular in the perimysium. Surgical reconstruction processes (e.g. distraction osteogene- Fascia as a tissue of connection: links together vari- sis, psoas lengthening) are frequently accompanied ous anatomical components (bones, joints, mus- cles etc.) thereby creating an architecture that by increased muscle stiffness, shown to correlate augments the transfer of forces across a broader with a significant increase in perimysial thickness – array of tissues/structures. Connection enhances a response to the (sudden) increased tissue stretch strength, stability and efficient coordinated (Schleip et al. 2005, Huijing 2007). movement. Bodywide perceptive and functional continuity affords linked tissues the ability to function and, potentially, dysfunction together. Clinical Consideration Fascia as an energy facilitator: healthy, springy or crimped collagen is a potential energy gen- Muscle spindles are embedded in the endomysium. If erator or storehouse rather than an energy the enveloping fascia is too rigid (e.g. fibrosis, contrac- consumer, such as muscle. When stretched, ture), this may alter the stretch of the muscle spindle collagen will rebound, augmenting propul- and adversely affect its normal firing (Stecco 2004). sion (especially flatter, sheet-like fascia and tendons, e.g. Achilles tendon and Achilles Compression ­aponeurosis) (Schleip & Müller 2013). Ultra- sound-based measurements indicate that fas- Compression fascia forms a pressurized com- cial tissues are commonly used for a dynamic partment to augment vascular function (e.g. energy storage (catapult action) during oscil- venous return) and enhances proprioception, latory movements, such as walking, hopping muscular efficiency and coordination. or running, and during such movements the supporting skeletal muscles contract Separating more isometrically while the loaded fascial Separating fascia provides structural support, elements lengthen and shorten like elastic helps absorb shock, limits the spread of infection springs (Fukunaga et al. 2002). The rebound/ and reduces friction and augments movement catapult potential of fascia decreases the need

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for muscular energy – resulting in greater effi- ciency and endurance.­ Clinical Consideration (Cont.)

Myokinetic/Myofascial Chains and Meridians In the field of MT we commonly encounter fascial The continuity seen throughout the fascial system changes associated with acute injury and trauma, is a key functional characteristic. It is agreed upon chronic strain (physical or emotional), immobiliza- by many that dysfunction (scarring, densification, tion and the spectrum of subsequent sequelae (e.g. fibrosis) anywhere along the chain or meridian adhesions, fibrosis, myofascial trigger points, dimin- can impact function in other regions. ished gliding within the sliding layers, neural and When challenged by stretch or movement dense circulatory consequences). and/or restricted fascia may alter proprioceptive afferent signals that lead to eventual abnormal biomechanics, aberrant movement patterns, muscle compensation, joint distress and pain Clinical Consideration (Bouffard et al. 2008). In the absence of normal physiological elastic- According to Lewit and Olsanska (2004), scars may ity, receptors embedded within the fascia may contribute to the formation of myofascial trigger also be in an active state even at rest. Any further points in adjacent tissues along with the potential stretching, even that produced by normal mus- for pain in other regions (e.g. low back pain associ- cular contraction, could cause excessive stimula- ated with appendectomy). tion with consequent propagation of nociceptive afferents. Furthermore, over a certain threshold (i.e. consistent stimulus over time), all receptors As the impact of a scar can reach far beyond its can potentially become algoceptors (pain recep- physical borders, in addition to the degree or tors) in response to consequent propagation of depth of the scar – from a MT perspective – it nociceptive signals (Ryan 2011). is also important to consider how a scar in one region of the body can impact functioning in dis- Chain/meridian clinical considerations will be tant (seemingly unrelated) tissues or areas. covered in greater detail in Chapter 9. According to Bordoni and Zanier (2014): Clinical Consideration

Fascia supports and functions in tandem with our Every element or cell in the human body skin and all of our soft and hard tissues. There- produces substances that communicate and fore it is reasonable to suppose that some degree respond in an autocrine or paracrine mode, of fascial involvement may be seen in conjunction consequently affecting organs and structures with any functional loss and pain associated with that are seemingly far from each other. This scarring – as well as the milieu of compensatory applies to the skin and subcutaneous fas- ciae. When the integrity of the skin has been musculoskeletal disorders that often accompany altered, or when its healing process is dis- burns and problematic scars (e.g. cumulative trauma/ turbed, it becomes a source of symptoms that overuse syndromes, chronic low back pain (ChLBP) are not merely cutaneous. Additionally, the and/or dysfunction and compression syndromes). subcutaneous fasciae is altered when there is

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Clinical Consideration Lymph is the new blood Readily visible, blood and its associated vessels have been studied for centuries, garnering much attention including detailed, shiny color plates in health science textbooks. However, a recent stunning discovery challenges current textbooks, calling for more in-depth study and an extreme make-over for anatomy and physiology editions. Generally presumed by manual lymph therapists but unverified, researchers have now discovered that the meningeal linings of brain have a lymphatic vessel network that connects to the systemic lymphatic system. Until now, lymphatic vessels in the central nervous system (CNS) have remained elusive (i.e. no shiny color plates), but the development of better imaging methods has changed all that (Aspelund et al. 2015, Louveau et al. 2015, University of Helsinki 2015, University of Virginia Health System 2015). Vessels displaying all the molecular hallmarks of lymphatic vessels have been discovered and mapped, running parallel Fig 3.5 to the dural sinuses, arteries, veins and cranial nerves. It is Brain lymphatic vessels. suggested that they serve as a direct clearance route for the brain and cerebrospinal fluid macromolecules out of the skull University of Virginia Health System 2015). and into the deep cervical lymph nodes (Aspelund et al. 2015, Researchers find it highly possible that brain–lymph Louveau et al. 2015, University of Helsinki 2015, University of connection will prove important in neuro-immunological Virginia Health System 2015). diseases as well as in diseases characterized by the As is known, the lymph system clears fluids and macromol- pathological accumulation of misfolded proteins or fluid into ecules and plays an important role in immune function. the brain parenchyma (e.g. Alzheimer’s disease, MS and Previously, the CNS has been considered devoid of autism). In Alzheimer’s for example, there are accumulations lymphatic vasculature, leaving immunologists puzzled as to of big protein chunks in the brain and it has been suggested how lymphocytes access and exit the brain (Aspelund et al. that these chunks may be accumulating because they're not 2015, Louveau et al. 2015, University of Helsinki 2015, being eciently removed by the CNS lymph system University of Virginia Health System 2015). (Louveau et al. 2015). The extensive lymph network found in the brain changes our Given the lymph and immune systems role in wound healing, understanding of how the brain is cleared of excess fluid and one can surmise that future work in this area may reveal calls for the rethinking of brain disease etiology and significant considerations for scar management. treatment approaches. This discovery has also raised several new questions concerning some fundamental brain functions and changes how we look at the relationship between the CNS and immune system (Aspelund et al 2015, Louveau et al. 2015, University of Helsinki 2015,

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Heart Figure 3.6 Blood vascular circulation loop and lymph transport flow. Lymph duct

Lymph trunk

Lymph node

Lymph collecting Venous vessels, Arterial system with valves system

Lymph capillary

Interstitial fluid becomes lymph

Loose connective tissue around capillaries Capillary bed

and armpit. It sometimes strikes individuals who painful, red streaks below the skin surface. This have had coronary artery bypasses using a saphe- is a potentially serious infection that can rapidly nous vein from the leg: the removal of this vein is spread to the bloodstream and be fatal. accompanied by removal of related structures of the Lymph nodes are filters that can catch malig- lymphatic system, lowering immunity to infection. nant tumor cells or infectious organisms. When Acute lymphangitis is a bacterial infection in they do, lymph nodes increase in size and are the lymphatic vessels, which is characterized by easily felt.

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While lymph nodes are the most common cause • Surgical procedures that interrupt normal lym- of a lump or a bump in the neck, there are other, phatic function, such as surgery for cancer in much less common causes, e.g. cysts from abnor- the breast or groin areas, may prevent lymph malities of fetal development or thyroid gland flowing naturally through its system (Zuther enlargement. 2011) Wound Healing • Radiation therapy can damage an otherwise healthy lymphatic system by causing scar tis- As with the blood vascular system, successful tis- sue to form, subsequently interrupting the sue repair requires the regrowth and reconnec- normal flow of lymph (Zuther 2011) tion of lymphatic structures. In the early stages of wound healing, the formation of lymphatic • Traumatic scars may affect the lymphatic sys- vessels in circumferential wounds helps bridge tem, damaging the normal flow of lymph. the margins of a newly forming scar (Bellman & Oden 1958, Oliver & Detmar 2002). Clinical Consideration In full-thickness skin wounds angiogenesis in newly formed granulation tissue largely dom- Four continuous minutes of abdominal lymph pump- inates the delayed and comparatively less pro- ing (1 pump/sec) has been shown to increase immune nounced formation of new lymphatic vessels cell release from mesenteric lymph nodes. Spe- (lymphangiogenesis) (Paavonen et al. 2000, cialized T cells primed in the gut are faster-acting/ ­Oliver & Detmar 2002). superior-performing immune cells. Recent studies During tissue repair, lymphatic vessels recon- suggest that abdominal lymphatic pumping may nect with lymphatic vessels – not with blood ves- inhibit solid tumor development and bacterial pneu- sels – and cultured lymphatic endothelial cells monia (Hodge et al. 2010, 2013). remain separate from blood vascular endothelial cells during tube formation in vitro (­Kriehuber et al. 2001). It is known that in adults lymphangiogene- Pathophysiological Consideration sis can occur by outgrowth from pre-existing lymph vessels (Clark & Clark 1932, Paavonen Abdominal scarring may interfere with the effective- et al. 2000) but it is unclear if during tissue repair ness of local lymph pump techniques (Hodge et al. lymphangiogenesis involves progenitor cells, as 2010, 2013). in angiogenesis. In addition, repeated episodes of infection can Impact of Trauma and cause progressive closure of the lymphatic sys- Pathophysiological Scars on tem, thus worsening the condition. the Lymphatic System If the transport pathway becomes congested, blocked, damaged or severed, fluids can accumu- Trauma and scars can disrupt the network of late in the surrounding tissues leading to edema lymph capillaries, which can hinder fluid drain- and fibrosis. Eventually cell pathology may age and negatively affect the healing process. occur. If the lymph system is incapacitated in The development of scar tissue that hinders the any way (e.g. burns, ulceration, chronic inflam- flow of lymph can have various causes: mation, hematoma), wound healing processes

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can be impaired (e.g. transport of damaged cells The stagnation of water, proteins, waste prod- and inflammatory byproducts away from the ucts and cell debris in the tissue can cause dam- injury site). Healing and recovery can be assisted age to the tissue. It also reduces the ability of the by supporting healthy lymphatic function. immune response due to the lack of circulation of the macrophages and lymphocytes. This can Lymphatic Inadequacy lead to a high incidence of infections such as Inadequacy in the lymphatic system occurs if cellulitis (Zuther 2011). the lymphatic load is more than the transport Combined capacity can handle. When lymphatic tissues or lymph nodes have been damaged, destroyed Combined inadequacy results from the lym- or removed, lymph cannot drain normally from phatic load being slowed due to the stagnation of the affected area. When this happens excess the transport capacity. In other words, the sys- lymph accumulates and results in the swelling tem is very sluggish and not moving the fluid at a that is characteristic of edema and lymphedema normal rate. When this occurs, the combination (Zuther 2011). can lead to necrosis (severe tissue damage) and chronic inflammation (Zuther 2011). Edema Clinical Consideration Edema – the medical term for swelling – is consid- Compression bandages promote reduction in cap- ered to be a symptom. Edema can occur as a natural illary hypertension and lymphatic load – creating a response of the body to injury or insult. Increased massaging effect to influence venous and lymphatic fluid in the affected area can be beneficial by assist- ing the delivery of immune cells to the area to fight hemodynamics resulting in reduction of edema (Földi an infection and assist with debris cleanup. et al. 2005, Williams 2005). Edema can be isolated to a small area (localized) or can affect the entire body (generalized). There are three types of inadequacies which may result in lymphedema or edema: dynamic, Pregnancy (preeclampsia or toxemia), tissue mechanical and combined (Zuther 2011). trauma, infections, medications and various conditions can result in edema; for example, Dynamic venous insufficiency, obstruction of flow (e.g. thrombosis, tumor), low albumin, allergic reac- Dynamic inadequacy occurs when the active tions, congestive heart failure, liver and kidney and passive edema protective measures are disease, and critical illness (WebMD 2015). depleted and results in edema. Medications known to result in lower extremity Mechanical edema include non-steroidal anti-inflamma- tory drugs (NSAIDs), corticosteroids and some Mechanical inadequacy occurs when the trans- medications used for hormone replacement, port capacity of the lymphatic load slows due to diabetes, depression and high blood pressure functional or organic causes, such as surgery, (WebMD 2015). radiation, and trauma, or to a response from cer- tain drugs or toxins. Due to the pressure exerted Discussion of the role of edema in critical illness, and leakage of proteins into the lymphatic wall such as a burn or surgery, will be discussed in structure, fibrosis may occur. Chapter 5.

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Alerts Change in muscle/ proprioceptive system CNS stimulation fascial tonus

Manual Stimulation of manipulation mechanoreceptors Stimulates Global tonus Palpable and hypothalamus response visible tissue response and client response Change in Palpable tissue ANS stimulation (HR, breathing, fluid dynamics response and relaxation, improved tissue ease) hydration Stimulation of MFBs Change in tissue tension and tonus

Figure 4.10 Mechanoreceptor mediated effects.

Clinical Consideration Clinical consideration (Cont.)

Although muscle spindles (stretch receptors) have tradi- (Jones 1944) or myokinetic linkage system­ (Stecco tionally been associated with muscle tissue, more recent 2004). For example, such is seen in the thoracolumbar research indicates that these receptors are embedded region during locomotion and load lifting (Jones 1944, in myofascial tissue. Muscle spindle response to detect- Vleeming et al. 1995, Graceovetsky­ 2007). able stretch can be altered if myofascia (e.g. endo or perimysium) is too rigid. In such cases, normal firing of the muscle spindles can be altered (Stecco 2004). Clinical Consideration

The form of stimulus to which a receptor responds and Clinical Consideration where they are found in higher concentrations factor into our ability to achieve desired effects/productive results. Retinaculae in particular display a greater density of nerve receptors than that typically seen in muscle bellies Example 1 or some other soft tissues (Stecco et al. 2010). It is sug- According to Cottingham (1985), Golgi receptors are gested that fascia plays an integrating function as a pro- stimulated during soft tissue manipulation, Hatha prioceptive organ and that it can coordinate the action of yoga postures and slow active stretching resulting in different muscles by acting as a common ‘ectoskeleton’ a lower firing rate of specific alpha-motor neurons,

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Clinical Consideration (Cont.) Pathophysiological Consideration

Example Pain experts suggest that pain due to peripheral or central neural damage or aberration (neuropathic Hypersensitive nerves (associated with muscle) are pain) may differ in clinical features and responsive- prone to spontaneous electrical impulses that trigger ness to pharmacological therapy, from pain caused false pain signals or provoke involuntary muscular by activation of primary afferents in somatic or vis- activity such as increased tone or tension (Culp & ceral tissues (nociceptive pain). Ochoa 1982). In turn, this increase in tone/tension can subsequently increase the risk of secondary injury (e.g. sprain/strain, tendinopathies, MTrPs). Clinical Consideration

Neuropathic pain may be resistant or less responsive Clinical Consideration to opioid therapy, suggesting the necessity of using alternative analgesics to achieve pain relief in patients Hypersensitive afferents can display other forms of with neuropathic pain (Wilkie et al. 2001). Addition- aberrant behavior. ally, there is growing concern over the detrimental side effects, including opioid-induced hyperalgesia. Example 1 Although this family of drugs provides analgesic and Hypersensitized nerve fibers become receptive to antihyperalgesic effects initially, subsequently they are chemical transmitters all along their length rather than associated with the expression of hyperalgesia, sug- just at their receptor endings (Thesleff & Sellin 1980). gesting that opioids can activate both pain inhibitory and pain facilitatory systems. Paradoxically, opioid Example 2 therapy aiming at alleviating pain may render patients Hypersensitized nerves are prone to accept con- more sensitive to pain and potentially may aggravate tacts from other types of nerves including autonomic their pre-existing pain (Angst & Clark 2006). and sensory nerve fibers (Thesleff & Sellin 1980). Impaired communication between sensory and auto- nomic nerves may contribute to complex regional pain Clinical Consideration syndrome. MT has been found to be an effective and safe adju- vant therapy for the relief of acute postoperative pain in patients undergoing major operations. Patients reported Clinical Consideration markedly less intense and less unpleasant pain and less anxiety than patients who received standard pain It is suggested that local twitch response (associated medication or individual attention but no MT. The day with MTrPs) may be due to altered sensory spinal after surgery, some patients reported that massage processing resulting from hypersensitized peripheral delivered about as much pain relief as a dose from a mechanical nociceptors (Mense et al. 2001). morphine drip. It is suggested that MT works by creating

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Irritation or compression at any point along the Clinical Consideration (Cont.) complex network of the NS can evoke changes not only locally but also in distant regions and a competing sensation to block pain or by stimulating can elicit autonomic disturbances. humoral mediators (e.g. endorphins), which reduce Excessive scarring in the layers of tissue a nerve is pain and promote a sense of well-being. The study also travelling through can impede all manner of NS notes the crucial – often undervalued – role of touch in functioning (e.g. nerve and electromagnetic con- medicine: human touch and a comforting presence can duction, local and systemic responsiveness, sen- help alleviate anxiety and ease pain. It is also important sitization, intraneural blood and nerve supply). to note that there were no adverse events related to the Additionally, injured or distressed somatic MT intervention (Mitchinson et al. 2007). tissues adjacent to nerve structures release inflammatory substances that can chemically Wound Healing irritate neural elements. This suggests that a nerve does not have to be entrapped in scar The NS plays an important role in mediating nor- tissue, it can also be impacted by scarring in mal wound healing via the involvement of various neighboring tissue. neuropeptides and growth factors. Noxious stim- uli causes nerves to release neuropeptides such as Pressure and compression constitute the most substance P and CGRP and certain growth factors common forms of nerve injury as complete sev- (e.g. NGF). And, along with healthy scar forma- erance is rare. While nerve injury grading clas- tion, in order to re-establish normal functioning sification systems, such as Seddon (1943) and post-injury, innervation of the injured tissue must Sunderland (1952), describe the severity of neu- also be re-established. ral injury (neuropraxia, axonotmesis, neurotme- sis) and consider negative symptomology (e.g. Wounds initially display hyperinnervation, similar numbness and weakness), they do not include to hypervascularization seen in early wound heal- considerations for positive symptomology like ing. With normal wound healing, nerve density will neuropathic pain. normalize with scar maturation. Although densities may return to normal, normal responsiveness is not always re-established, as nerve end organs cannot Clinical Consideration regenerate and therefore sensory deficit or aberran- cies may occur. In spite of the clinical significance Neural and circulatory structures are often bundled of abnormal innervation in scars, the NS has been and track together; therefore, it is important to con- largely ignored in the pathophysiology of scars. sider neurovascular implications associated with The role of the NS in wound healing, normal and pathophysiological scars. As is the case with neural abnormal, is covered in greater detail in Chapter 5. structures, circulatory function can also be impacted Impact of Trauma and by compression as a result of dense, fibrosed tissue (e.g. impact on blood vascular and lymphatic func- Pathophysiological Scars on the NS tion). Circulatory sequelae associated with patho- As nerves traverse throughout the body they track physiological scars include ischemia, hypoxia, edema between and pass through various tissues and struc- and tissue congestion. In and of themselves, circu- tures. The greater proportion of our larger nerves latory sequelae are important clinical considerations track in the superficial fascia and smaller nerves in and can lead to or exacerbate neural distress. the clefts created between perimysial bundles.

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• Display textural variations (e.g. rough, lumpy, ­hypervascularization that lasts beyond the dimpled, puckered) ‘normal’ time frame (i.e. early stage of wound healing). • Tend to exhibit compromised elasticity and mobility Types of Pathophysiological Scars • May display altered or abnormal neuro-function- ing (hypersensitivity, hyposensitivity, increased In order to assist with this next section, a few key electrical activity with movement) (Bordoni & terms are briefly described in Table 5.2. Zanier 2014, Valouchová & Lewit 2009) The type of tissue damage and severity • Some mature scars may be pale due to lim- of the injury factor significantly in forming ited blood supply or appear reddish due to the proper protocol for long-term recovery

Remodeling

Proliferation Pathological scarring

Inflammation

Hemostasis

Matrix Vessel overgrowth overproduction Nerve overgrowth Monocytes

Platelets Neutrophils Macrophages

VEGF Keratinocytes Fibroblasts TNFα NGF bFGF EGF Endothelial cells TGFβ

Growth factors cytokines

Figure 5.3 Adapted from Huang et al. (2013). Pathophysiological scar formation can begin in the inflammatory stage of wound healing and continue through the remodelling stage; characterized by prolonged and stronger inflammation stage with inappropriately released cytokines culminating in an aberrant healing response and abnormal scar.

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and rehabilitation.­ Being able to identify the center around specifics on scarring from burns, ­differences in the types of scar tissue will surgery (e.g. mastectomy) and other types of trau- help to safely and effectively deliver care and matic events. Special consideration will be given develop more precise long-term protocols for to each type of scar presentation along with spe- clients. cific treatment protocols. Traumatic scars will be explored in greater detail A few key terms and an overview of the various in subsequent chapters where discussion will types of pathophysiological scars are briefly

Term Definition and other information

Scar Commonly used in reference to the ‘normal’ end product – describing a mark left in the skin, fascia, muscle (or other tissue) and organs as a result of healing of a wound, sore or injury

Adhesion Commonly used to describe problematic areas of profuse or abnormal scarring occurring in organs and tissues. Adhesions can result in pain/dysfunction

Fibrosis Replacement of the normal structural elements of tissue by excess accumulation of dysfunctional fibrotic tissue (Rodriguez & del Rio 2013). A process driven by excessive or sustained production of TGF-ß1 and consequent superfluous MFB activity (Smith et al. 2007, Karalaki et al. 2009, Fourie 2012). When used in reference to the myofascial/musculoskeletal system this term is commonly used to describe what occurs as a result of onerous tension or mechanical strain associated with poor remodeling following injury; culminating in superfluous, maladaptive, poorly constructed collagen (e.g. aberrant fiber/bundle arrangement, increased incidence of pathological cross-links and reduced elastic-malleability) (Henry & Garner 2003, Diegelmann & Evans 2004). It is a reasonable conclusion that prevention or resolution of fibrosis can diminish the occurrence of common sequelae and comorbidities

Pathophysiological consideration It is reasonable to consider fascial tension/rigidity as an etiological factor in myofascial injuries and in pathophysiological scars (Gabbiani 2003, Solon et al. 2007, Grinell 2008, Chiquet et al. 2009, Hinz 2009, Heiderschelt et al. 2010, Rodriguiz & del Rio 2012). Pathophysiological consideration Fibrosis is commonly considered to be a by-product of an abnormal or chronic inflammatory response as a result of cumulative or overuse-type trauma, immobilization and poor wound healing. When not effectively managed, fibrosis can result in a milieu of functional deficits. The fall-out from fibrosis include the following and associated sequelae: increased risk of recurrent injury, muscle contraction dysfunction, altered force transmission, impaired tissue; slide/ glide and stretch, neural, circulatory and lymphatic compression, antalgia, pain and pain translation (i.e. shift from acute to chronic pain) (Simons, Travell & Simons 1999, Gabbiani 2003, Shah et al. 2005, 2008, Hinz 2007, Grinell 2008, Chiquet et al. 2009, Lowe 2009, Ciciliot & Schiaffino 2010). Clinical consideration Mechanical disruption of fibrotic tissue increases the pliability of scars (Bhadal et al. 2008, Chan et al. 2010, Cho et al. 2014).

Table 5.2 Important pathophysiological scar-related terms

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Immobilization Clinical Consideration (Cont.)

abnormal movement patterns (Bouffard et al. 2008). Absolute perimysial stiffness is considered to be Diminished fluid responsible for the rapid ‘muscular’ stiffening seen uptake in tissues during the first week of immobilization (Williams & Goldspink 1984). It is becoming evident that the key to effectively treating chronic contracture and ‘mus- cle’ stiffness may lie in the ability to impact tissue fluid Dehydration and increased viscosity dynamics and MFB-mediated fascial tone and fascial mobility (i.e. slide/glide).

Diminished space As noted by Barbe at the FRC III in 2012, immo- between collagen fibers bilization may result in correlating grey matter shrinkage and subsequently there is a dimin- ished or lost ability for movement stimulus and/or coordination. Nerve regions that were originally Formation of devoted to sensing, initiating and controlling pathologic cross-links movement lack activity/stimulation when the region is immobilized, resulting in re-allocation of these nerves to other functions and/or actual shrinkage of grey matter (Granert et al. 2011). Stiness, fibrosis, altered slide/glide, altered movement stimulus Clinical Consideration and coordination Here we see three mechanisms contributing to move it or lose it: fibrosed/stuck can’t( move); it hurts (avoid Figure 5.4 moving or alter movement pattern); and where the The fall-out associated with immobilization. neural network that governs movement is affected (can’t generate, control or coordinate movement).

Clinical Consideration The Nervous System: Wound Healing And Immobilization of a muscle in a shortened posi- Pathophysiological Scars tion can result in stiffness (related to fibrosed/ As noted in Chapter 4, the NS plays an important thickened intramuscular fascia) as quickly as within role in wound healing. Noxious stimuli triggers the 2 days of immobilization (Schleip et al. 2005). In release of neuropeptides such as substance P and turn, impaired mobility can lead to chronic pain and calcitonin gene-related peptide (CGRP) and cer- tain growth factors such as NGF. Neuropeptides

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Burns, mastectomies and other traumatic scars

Someone who has experienced trauma has gifts to offer all of us – in their depth, their knowledge of our universal vulnerability, and their experience of the power of compassion. Sharon Salzberg (2015)

Burns, mastectomies and other traumatic inju- excessive ­scarring into hypertrophic and keloid ries can involve significant penetration of the scar formation and defined their distinguishing skin layers, sometimes penetrating deeper layers characteristics: both scar types rise above skin of tissue down to bone. Extensive tissue damage level, but while hypertrophic scars do not extend due to trauma (planned or unplanned) can com- beyond the initial site of injury, keloids typically promise sensation, proprioception, circulation, project beyond the original wound margins lymphatic drainage, thermoregulation and der- (Gauglitz et al. 2011). mal excretory capacities (Fitch 2005). Excessive or pathophysiological scars form as a As discussed in previous chapters, scar tissue result of prolongations or aberrations of physio- can affect the body in a variety of ways. Fibrotic logic wound healing and may develop following scars and scars that are bound to the underly- any injury to the deep dermis, including burn ing tissues, organs or skeletal structures can injury, lacerations, abrasions, surgery, piercings restrict movement and organ motility (Fitch and vaccinations. Wound healing in pathophysi- 2005, Bove & Chapelle 2012). In addition to phys- ological scars is characterized by a prolonged and ical disability and dysfunction, traumatic scars stronger inflammation phase with inappropriately can also result in a spectrum of psychosocial released cytokines followed by a subsequent delay sequelae, which will be covered in greater detail in the healing response (Huang et al. 2013). Exces- in Chapter­ 7. sive scarring resulting in pain, pruritus, adher- ences and contractures can affect quality of life, The depth and extent of the scar strongly influ- physically, physiologically and psychologically ence the consequent sequelae. Extensive tis- (Gauglitz et al. 2011). Scar depth can have a neg- sue damage requires additional recovery time ative impact on the healing process and, subse- and increases the potential for complications, quently, impact the functions of the dermal layer including excessive scarring and successive sur- and deeper layers of tissue (e.g. muscle, fascia). geries (Kania 2012). Each year in industrialized nations, 100 million The aim of this chapter is to provide more people develop scars as a result of 55 million in-depth understanding of the types of patho- elective operations and 25 million operations physiological scars and scars seen in conjunc- due to trauma (Gauglitz et al. 2011). From 55% to tion with specific types of trauma. 100% of surgical patients will experience post- Excessive Scarring surgical scar/adhesion complications that may not become evident until months or years later Excessive scarring was first described in the (­Diamond 2012). Smith papyrus around 1700 BC (Berman & Bieley 1995). A few millennia later, Mancini & Quaife Although there is extensive research on the (1962) and Peacock et al. (1970) differentiated pathophysiologic process of wound healing and

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scar formation, there is still no consensus on Table. 6.1 for a comparative summary of hyper- the best treatment strategy for preventing and trophic and keloid scars. reducing the issues associated with pathophys- Wound healing is an intricate biological process iological scars (Van der Veer et al. 2009, Cho involving overlapping phases. When this process et al. 2014). is disrupted or altered, abnormalities in scarring appear. Both hypertrophic and keloid scars are a result of disruption in the fundamental processes Clinical Consideration of wound healing. Race, age, genetic predisposi- tion, hormone levels, atopy/hypersensitivity and Postsurgical scar complications, including chronic immunologic responses, type of injury, wound pain, can occur as a result of incisions (even less size/depth, anatomic region, and local mechani- invasive ‘keyhole’ incisions), cauterization, suturing or cal tension all factor into wound healing process fusing together of segments that are normally meant and subsequent nature of the scar (Niessen et al. to be separate from one another (e.g. spinal fusion) 1999, Cho et al. 2014). (Lee et al. 2009, Fourie 2012). The side-effects of Multiple studies on hypertrophic and keloid scar peritoneal adhesions have been reported to occur in formation have been conducted over several dec- 90–100% of cases following surgery. With abdom- ades, leading to many therapeutic strategies to pre- inal surgeries, organ function can be compromised vent or attenuate excessive scar formation. Most (e.g. impaired motility, obstructions, infertility, pelvic therapeutic approaches remain clinically unsat- pain). Detection and diagnosis are hindered by lack of isfactory, however, with an agreement that there identifiable biomarkers, poor imaging methods or the is a meager understanding of the complex mech- onset of other health issues masking the underlying anisms underlying the processes of scarring and scar/adhesion sequelae. Re-operating to remove the wound contraction and fibroproliferative disorders in general (Gauglitz et al. 2011, Rabello et al. 2014). offending scar tissue appears to be a case of fighting fire with fire – with questionable productive outcomes Scar pathogenesis involves cellular and extracel- (Diamond 2012). The most recent cost estimate of lular matrix (ECM) components in both the epi- morbidity associated with abdominal adhesions is dermal and dermal layers that are regulated by $5 billion in the US alone (Bove & Chapelle 2012). a wide array of interfering factors in the inflam- It is evident that prevention and appropriate early mation, proliferation, and remodeling stages of healing (Huang et al. 2013). intervention are the most cost-effective and patient-­ considerate approaches. Hypertrophic scarring after deep or ­partial-thickness wounds is common. A review of the literature on the prevalence of hypertrophic A Deeper Look at Hypertrophic and scarring found that females, children, young adults, and people with darker, more pigmented Keloid Scars skin are particularly at risk and, in this subpopu- Chapter 5 provided a brief overview of the various lation, the prevalence is up to 75% (Engrav et al. types of pathophysiological scars and how scars 2007). Hypertrophic scars are morphologically form. To further the understanding of the heal- characterized by (Linares 1996, Cho et al. 2014): ing process and the impact of traumatic scars, • Abnormal collagen this next section will provide a more in-depth look at hypertrophic and keloid scars – see • Reduced elastin

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discovered around the lymphatic limb (Dylke 2008); for example, the fascia of the clavicular et al. 2013). head of the pectoralis major displays a thicken- ing of collagen fibers that extend into the ante- Auxillary Web Syndrome or Cording rior brachial fascia, surrounding the biceps and thereby creating a continuous functional Axillary web syndrome (AWS), also known link (i.e. myokinetic chain/myofascial merid- as ‘cording’ in the postsurgical breast cancer ian). Additionally, the fascia from the sterna patient, is characterized by painful cording or and ­costal heads are continuous with the strings of hardened lymph tissue in the axilla of axillary fascia and the medial brachial fascia the affected side. It affects functioning by caus- (­Fourie 2008). ing pain and restriction in arm ROM, especially abduction. Alexander Moskovitz refers to the In addition to musculature and fascia, five iden- syndrome as: ‘axillary pain radiating down the tifiable groups of lymph nodes are found in the ipsilateral arm, shoulder ROM limitation, and axilla. These groups reside in the fatty CT of the an axillary web of tissue attempts abduction of axilla or are arranged around the blood ves- the arm.’ It appears that the axillary lymph node sels such as the lateral thoracic and subscapu- dissection of the breast procedure is the trigger lar arteries and the axillary vein. These nodes to the lymphatic disruption that causes AWS drain the lymphatic vessels of the ipsilateral (Bock 2013). upper quadrant (both anterior and posterior), the ipsolateral mammary gland and the ipsilat- AWS may manifest with one large cord or sev- eral extremity (Zuther 2011). Seventy-five per- eral distinct, smaller cords running down the cent of the lymph from the breast and areolar arm. These cords usually start near the site of plexus drains into the anterior pectoral group any scarring in the underarm region and extend of lymph nodes before they move to the central down the inner arm to the inside of the elbow. nodes. Sometimes they can continue all the way down to the palm of the hand. In some people, cord- When any of the lymph nodes are removed, the ing can extend down the chest wall instead of, flow and pathway of lymphatic fluid is disrupted or in addition to, the inner arm (BreastCancer. and fibrosis may occur contributing to the devel- org 2015b). opment of AWS. The anatomy of the axilla bears review for a full As scar formation is the body’s mechanism for understanding of AWS. The axilla compartment restoring tissue integrity, all wounds are subject is home to a fascial sheath that contains neu- to the repair process. For internal tissue injuries rovascular bundles, 20–30 lymph nodes, and is and inflammation involving fascia, scarring and bounded superiorly by the head of the humerus, adhesions contribute to the occurrence of tissue covered by the coracobrachialis and the short rigidity, abnormal movement patterns and pain. head of the biceps. The axilla is bound anteriorly Issues after breast cancer surgery that result in by the pectoralis major; posteriorly by the sub- AWS may arise from the maturing process of CT scapularis, latissimus dorsi and teres major; and and the prolonged inflammatory phase of wound inferiorly by the ribcage which is covered by the healing. The CT maturation could result in either serratus anterior (Calais-Germain 2007). a dense, non-pliable scar or a pliable mobile The fasciae that envelopes the regional muscles scar. A prolonged inflammatory phase results in is continuous with the brachial fascia, which hypertrophic scarring and increased fibrosis in plays a significant functional role (Stecco et al. the damaged area (Fourie 2008).

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• Pain, tingling, burning, weakness, tickling, Clinical Consideration or numbness in arms, hands, legs, and feet

It has been demonstrated – via ultrasound imaging – • Sudden, sharp, stabbing, or shocking pain sensations that skin rolling can modify collagen density (Pohl 2010). • Loss of touch sensation • Clumsiness Scar tissue can develop up to 6 months after • Trouble using hands to pick up objects or fas- treatment is complete. The skin may become ten clothing. hard, thick or feel bound in the areas that have been irradiated; surgical sites can also be aggra- Other possible symptoms include: vated (MacDonald 2003). • Balance problems and difficulty walking Scarring from radiation or surgery disturbs the • Hearing loss lymphatic flow and, if not addressed, can cre- ate an environment for fibrosis. Add to this the • Jaw pain fact that lymphatic pathways do not re-establish • Constipation themselves across scars and you could draw the conclusion that un-drained lymphatic fluid • Changes in sensitivity to temperature ­contributes to the pathogenesis of the raised • Decreased reflexes and swollen tissues abutting a scar (Warren & Slavin 2007). • Trouble swallowing Although no protocols exist, several excellent • Trouble passing urine case studies indicate that a combination of • Blood pressure changes. manual lymph drainage techniques, myofascial release, snapping or popping of the cords and Other treatments for breast cancer can cause ROM exercises with passive stretching can bring neuropathy as well. Surgery and radiation ther- about productive outcomes (Bock, 2013). apy cause damage to nerve plexuses in the chest and axillary areas that include the brachial and Breast Cancer-Related Neuropathy cervical plexuses. Chemotherapy-associated peripheral neuro- Nerve plexuses serve the motor and sensory pathy is the most common cause of breast needs of the limb (Marieb 2003). To fully under- ­cancer-related neuropathy. Chemotherapy med- stand the implications of damage or impinge- ications travel throughout the body, where they ment to these plexus, we need to take a look at can cause damage to the nerves (BreastCancer. how they weave through the area affected by the org. 2015c). surgery (Fig. 6.2). Certain chemotherapy medications can The brachial plexus is shaped by the anterior cause neuropathy. Chemotherapy-associated branches of the last four cervical and first tho- neuropathy may begin as soon as treatment racic nerve before they begin their peripheral starts, and it may worsen as treatment continues. distribution. The brachial plexus traverses the Usually it begins in the toes, but it can expand subclavian triangle where it rests on the poste- to include the legs, arms, and hands. The most rior scalene. The brachial plexus is covered by common symptoms include: the omohyoid muscle and the middle and deep

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Figure 6.2 Nerves plexuses in the chest and axillary areas.

Brachial plexus C5

C6

C7

C8

T1

Nerves Musculocutaneous (C5 to C7) Median (C6 to C8, T1) Radial (C5 to C8, T1) Ulnar (C(7), 8, T1)

cervical aponeuroses. It is separated by the sub- intertransverse muscles behind the vertebral clavian muscle behind the clavicle. Its rests on artery. the first rib and the superior digitation of the ser- ratus anterior. It is behind the pectoral muscles, The cervical plexus is situated behind the pos- anterior to the subscapularis tendon and flanked terior edge of the sternocleidomastoid, deep by the two scalenes. The subclavian artery is to the internal jugular vein, internal carotid found at the lower section of the plexus, slightly artery and the vagus nerve. It anastomoses with anterior to it (Croibier 1999) – see Figure 6.3. the ­hypoglossal, vagal and sympathetic nerves (Croibier 1999). The cervical plexus is a string of anastomoses formed by the anterior branches of the first Trauma to these plexuses can lead to neuropathic four cervical nerves before they divide. The symptoms such as pain, numbness, tingling, anterior branches are lodged in the groove that and/or increased sensitivity in those areas. Tar- is formed by the superior surface of the trans- geted drug therapies (Perjeta® – generic name: verse ­processes, and pass between the two pertuzumab – and Kadcyla® – generic name:

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Stress 2000). Human stress response is innately intended to enhance coping, adaptation and- chances of survival. Stress response is rooted in Day in and day out, our hands feel it – the capacity for rapid recognition of potentially STRESS. Tissue so tightly wound and densely harmful stimuli and the ability to mobilize a compressed, we pause for a moment and con- defense/stress response. Mobilization of stress template … is this bone or is this flesh??? response is adaptive and resilient and normally Cathy Ryan RMT terminates as soon as the danger has passed (Friedman 2015). Lazarus and Folkman (1984) define stress as:‘a relationship between the person and the environ- Stress Adaptation Response ment that is appraised by the person as taxing or A vast array of potential stress responses exist. In exceeding his/her resources and endangering his/ any given circumstance one may run like crazy, her wellbeing’. Appraisal and coping are key to this fight when cornered, stand perfectly still so as not definition and lead to the subjective experience of to be seen or gather with others; commonly referred stress. And generally speaking, the degree of per- to as fight, flight or freeze and tend/befriend. ceived threat (appraisal) influences the magni- The phrase fight or flight was coined by Cannon tude of the stress response. in the 1920s to describe the typical behaviors Stress response is psychobiologically complex, that occur in the context of perceived threat. A involving the individual’s appraisal of the situa- freeze response, or tonic immobility, may occur tion, coping skills/behaviors and the resources in some threatening situations (Gallup 1977, the individual has available to draw on. Resources Barlow 2002). Tend and befriend refers to cop- include both extrinsic (e.g. social support) and ing with stress through social or group support intrinsic in the form of the functioning of the (i.e. befriending) and providing or receiving involved systems. When an individual can no protection, nurturing or emotional support (i.e. longer cope with stressful situations, affective, tending to others or being tended to). Social iso- behavioral, and physiological changes result lation significantly enhances risk of mortality, (Cohen et al. 1997, Lucas 2011). whereas securing social support results in bene- ficial health outcomes, including reduced risk of Whether you are human, cat, dog or mouse, illness and death (Cohen & Willis 1985). ­experiencing stress is simply a part of life. But neither stress nor stress response are inherently Fight, flight or freeze are recognized as the initial harmful and certainly stress response does have stage of stress response adaptation. Fight may its time and place, such as when we need to run manifest not only as a physical exchange but also fast or leap far to avoid some calamity. Therefore, as vocally aggressive or argumentative behavior. it is important to differentiate between acute Flight can occur as escaping in either a sensory stress, a beneficial adaptation response and way (e.g. social withdrawal, substance abuse or chronic stress, which can prove detrimental. television viewing – Friedman & Silver 2007) or a physical way (e.g. running away from something Stress Response and Stress Hormones perceived as threatening or toward something that is needed or feels safe). Stress response encompasses the hormonal and metabolic changes that are activated by real or Freeze response may occur when fleeing or perceived danger, injury or trauma (­Desborough aggressive responses are perceived to likely be

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Clearly MT fulfils a number of the strategies for Pathophysiological Consideration (Cont.) stress support (e.g. tend and befriend, providing a safe and calming environment) and is a means energy following a threat are also innate mecha- by which to safely and effectively address the nisms for restoring autonomic balance. If behavioral adverse impact of prolonged stress response on conditioning or circumstances prevents or interferes the softtissues. with our innate restoration mechanisms, our ability to Psychological Stress and Wound return to a normal state of autonomic nervous system (ANS) functionality is impacted (Payne et al. 2015). Healing Studies over the last 30 years have shown that the effects of psychological stress on healing are Clinical Consideration moderate to large, resulting in poor surgical out- comes and poor wound healing associated with Prolonged stress response has been shown to sup- other forms of trauma (Padgett & Glaser 2003, press the immune system, disturb diurnal rhythm, Lusk & Lash 2005, Starkweather 2007, Von Ah & stimulate or sustain obesity, adversely impact the Kang 2007, Rosenberger et al. 2009, Lucas 2011, Broadbent & Koschwanez 2012). body’s pH balance and increase the incidence of chronic myofascial tension. Substantial data suggest that psychological stress and the subsequent immune system dis- ruption can negatively impact wound heal- ing, both directly and indirectly, with the most Clinical Consideration prominent impact occurring due to the effects of stress on cellular immunity. Stress and the myofascial system; psychological Cellular immunity plays an important role in distress and anxiety have clearly been identified as wound healing through the production and reg- a source of unnecessary muscular tension. Unneces- ulation of pro- and anti-inflammatory cytokines, sary muscle tension being; the confusing intermediate which mediate many of the complex intrica- between a non-voluntary muscle contraction (spasm) cies of wound healing. Dysregulation of various and viscoelastic tension showing no EMG activity cytokines disrupts normal wound healing leading (Simon & Mense 2007). According to Chaitow (2013): to delayed or improper healing, increased heal- ing time, increased risk of infection, prolonged edema and wound complications, such as patho- …the shortened fibers of the soft tissues may physiological scars (Glaser et al. 1999, Broadbent be the result of a combination of structural et al. 2003, Ebrecht et al. 2003, Lucas 2011). anomalies, trauma, and/or physical or emo- Psychological considerations, such as distress, tional stress, and are always influenced by depression and anxiety, have also been shown to underlying nutritional and behavioral ele- slow wound healing. Patients reporting greater ments. Some of these shortened fibers and than average symptoms of depression or anxiety tender spots (i.e. trigger points) may be the source of reflex symptoms and pain. All such were four times more likely to be categorized as soft tissue dysfunctions respond to man- slow healers compared with patients reporting ual pressure in the form of modalities like less distress. Heightened distress, associated with ­massage therapy. unhealthy behaviors, such as smoking, substance abuse, poor nutrition and alteration of normal

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Professional Ethics intimate human contact, interaction and response. The therapist’s interactions and The purpose of practicing our profession eth- responses to the client are of parallel ically is to promote and maintain the welfare of ­importance to skillful assessment and treatment the client. Through their behavior, professionals (Fitch 2005). can comply both with the law and with profes- sional codes. If compliance with the law is the A few rules in the professional setting are only motivation in ethical behavior, the person absolutes: a professional does not breach sex- is said to be practicing mandatory ethics. If, ual boundaries with a client; clients are to be however, the professional strives for the highest referred when the skills required are out of possible benefit and welfare for the client, he or the scope of practice or training of the pro- she behaves with aspirational ethics (Corey et al. fessional; all care must focus on giving help 2006, Fritz 2013), see Box 8.2. and avoiding harm; and clients are to be given complete information about the treatment (Fritz 2013). Box 8.2 Eight principles that guide professional ethical behav- Communication ior (adapted from Fritz 2013): Ethical and professional dilemmas tend to occur • Respect (esteem and regard for clients, other pro- as a result of ineffective or mis-communication. fessionals, and oneself) Without a direct communication approach, eth- ical dilemmas tend to escalate and both parties • Client autonomy and self-determination (the right suffer in the process. To make ethical decisions to decide and the right to sufficient information to and resolve ethical dilemmas, we must commu- make the decision) nicate effectively. Good communication skills are required to retrieve information, maintain • Veracity (the right to the objective truth) charting and client records, and provide infor- • Proportionality (benefit must outweigh the burden mation effectively so that the client can give of treatment) informed consent (Fritz 2013). A traumatic scar injury can have multiple phys- • Non-maleficence (the profession shall do no harm ical, neurological and cognitive consequences and prevent harm from happening) (Grigorovich et al. 2013). Many traumatic scar cli- • Beneficence (treatment should contribute to the ents bring experiences of multiple surgeries, doc- client’s well-being) tors’ appointments and physiotherapy visits before they walk through your clinic door. Or other con- • Confidentiality (respect for privacy of information) sultations may be concurrent; the client may have • Justice and non-judgement (ensures equality just arrived at your door after such a visit. among clients). With this understanding, it is imperative to gather a more complete picture of the client’s needs prior to each session. Pay attention to their mood Ethical therapist behavior and clear communi- and physical condition as they step through your cation are essential for a productive therapeutic clinic door. These are clues to open up dialogue relationship. The technical and interpersonal about the pain they are experiencing and how to aspects of care are symbiotic. Touch demands proceed in the session; for example, if the client

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presents tense and displays a more deliberate gait safety. Active listening skills along with attention or holding pattern, ask about their day. Know- to the responses will give the therapist the infor- ledge about their day-to-day life and prior expe- mation needed to formulate the proper protocol riences leading up to their session may indicate a for the treatment session (Fitch 2014). need for changes in pressure and depth. As massage therapists, we are visual and palpa- It is important to actively listen and emphati- tory observers of the body. We may see scars that cally respond to the client as a whole person, not no-one in the client’s family or friends have seen just the area of injury or symptom and create an and we may touch scars that no-one else, includ- appropriate set of protocols for each treatment ing the individual themselves, have touched. session (Fitch 2014). Traumatic scars carry their story within the tis- sue and mechanics of the body. Flexibility, com- fort, edema and movement can play a significant Effective Listening and Empathetic Response role in the quality of life of the client (Fitch 2014). Effective listening involves the development Clinical experience has shown that gaining knowl- of focusing skills. You cannot listen effectively edge about the traumatic scar provides the ther- if you are distracted in anyway (e.g. planning apist with important data, which helps shape or preparing your response). Reflective listen- protocol and enhance follow-up questions during ing involves restating the information to indi- each intake prior to the beginning of the session. cate that you have received and understood the message. Active listening may clarify a feeling attached to the message but does not add to or Clinical Consideration change the message (Fritz 2013). Never understimate the far-reaching, therapeutic Active listening is an important part of the ther- value of attentive and compassionate listening. A criti- apeutic process. Listening carefully to the clients responses and making the client feel they are cal turning point in a client’s healing journey can occur heard enables them to describe their situation when he/she feels as if their story has been heard. more fully (Fitch 2014). Using your active listening The authors have experienced numerous times, and observation skills to validate client discom- over decades of practice, the client (and sometimes fort helps to build the therapeutic relationship. therapist) reduced to tears when the client discloses; ‘you are the first care provider to take the time to, Supportive, active listening when taking a case his- tory (e.g. being non-judgmental and maintaining really, ­listen to my story’. In that moment something good eye contact) and asking open-ended ques- within the client shifts, hope is sparked and where tions, enables your client to provide responses in there is hope, change begins to unfold. Herein lies their own words. one of the unique aspects of a MT practice, the lux- ury of time. Our clinical structure differs from many There are some key concepts to the therapeutic listening relationship. When engaging a client forms of healthcare in that appointments are typically during the intake, truly listen to the answer and an hour long, providing the opportunity for clients the body language in which the statement is pre- to more thoroughly share the complexities of their sented. Asking questions concerning the client’s experience. This, in combination with therapeutic history can sometimes feel uncomfortable and touch, can impact the client in significant ways beyond intrusive to the therapist and the client; however, the physical/functional value of the work. asking direct questions is necessary for client

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This is not to imply that we do not address the trauma (Andrade & Clifford 2008, Andrade 2013, abdominal region; as a region it is addressed, but Dryden & Moyer 2012). the work is directed to the skin, fascia, muscles, Specific to this book are impairments asso- vessels and nerves rather than, specifically, the ciated with pathophysiological scars, such as adherences between viscera and articulating tis- adherences, contractures, fibrosis, postural and sues and structures. movement adaptations, edema, pain, anxiety, sympathetic nervous system (SNS)-hypera- Clinical Consideration rousal, disturbed sleep and altered or impaired body awareness, which are representative of One important note on postsurgical abdominal and the realm of considerations that accompany the aftermath of trauma and poor wound healing visceral adhesions is made by Chapelle. In personal outcomes. email correspondence, in her research with Bove, she indicated that: … no specific time course for intervention has Clinical Consideration been clearly identified; however, it appears that adhesion formation occurs 6–12 hours Reduction of anxiety and musculoskeletal pain are after surgery. Early manual mobilization is a among the most established outcomes for massage hypothesis of prevention – keep things moving (Moyer et al. 2009). to avoid adherence and subsequent complica- tions. Mostly, once established, adhesions are difficult to affect. Clinical Consideration Seems the old adage applies – an ounce (man- ual mobilization) of prevention outweighs a pound In a cancer patient study it was determined that while (­subsequent surgical lysing) of cure. One can rea- both healing touch and massage lowered anxiety and sonably surmise that ‘keeping things moving’ as a pain, massage also reduced the need for pain medi- means to prevent adherences can also apply to other cine (Post-White et al. 2003). tissues and the sliding layers between tissues and structures.­

As massage therapists we are not called upon, Clinical Consideration nor is it within our scope of practice, to treat medical conditions and illnesses (e.g. diabetes, MT has been found to be effective for reducing cancer) or acute critical trauma. Our primary burn-related depression, pain, pruritus and state role is to provide treatment that is designed to anxiety­ , and positively impacting scar characteristics facilitate the wound-healing process or elicit a such as thickness, melanin deposition, erythema, desired change in consequent complications transdermal water loss, and elasticity/tissue mobility in the form of impairments, such as any loss (Eti et al. 2006, Roh et al. 2007, Goutos et al. 2009, in body function or abnormal body structures Gürol et al. 2010, Cho et al. 2014). that occur as a result of a medical condition or

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pathway is cleared so excess fluid can drain into stretching of the skin. The MT may use their the terminus without becoming congested. entire palm flat on the skin surface and may use one or both hands to achieve the result. The hand Pumping is in a palmar flexion with ulnar deviation and Pumping technique is mainly used on the extrem- transitions into radial deviation and wrist exten- ities and continues the use of the circle-shapted sion at the end of the stroke (see Fig. 9.3).

Extension

Flexion

Radial deviation Ulnar deviation Pronation Supination

A

B C D

Figure 9.3 Pumping: clearing the extremities (right arm). Pumping is mainly used on the extremities and also involves circle-shaped stretching of the skin and SF. The MT may use their entire palm, flat on the skin surface and may use one or both hands to achieve the result. The hand is in wrist flexion with ulnar deviation and transitions into radial deviation and wrist extension at the end of the stroke. All strokes begin proximal to the terminus and move distal. (A) Directional movements of the hand/wrist; (B–D) arrows indicate the direction of lymph flow.

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A

Figure 9.15 ‘Cs’. Begin as noted in Fig. 9.10 – grasp the bulk of tissue in an approximation-compression manner. Simultaneously apply pressure into the tissue with the thumbs and deviate the wrists in an ulnar direction (curved arrows), bending the tissue into the letter ‘C’ until barrier/bind is felt.

B

Figure 9.17 J-stroke. Begin at one end of the scar (X), apply compression (pressure grading can vary depending upon the stage of healing and client comfort) then slowly glide in to the scar margin and circularly glide back away from the scar (white arrow), making a letter ‘J’. This technique can be applied along the entire length of the scar (yellow arrow). (B) J-stroke – compression, tension and bending. As noted in (A), glide into the scar margin, bending the scar tissue (white line) and then circularly glide back. Figure 9.16 ‘Ss’. Begin by grasping the tissue in an approximation-compression manner, then apply tissue layers. Like J-strokes, gentle circles can pressure into the tissue with the thumbs and fingers in opposing directions, bending the tissue into the be used in the earlier stages of healing, once the letter ‘S’ (begin at pressure grade 1–3 (see Box 9.8), scar is stable (i.e. no risk of dehiscence). Typi- and slowly increase until barrier/bind is felt). cally, pressure grades 1–4 (see Box 9.8) are used when applying this technique. This technique is

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training you have received in trauma-related saying that taking measures to minimize stress- care (Mathieu 2012). ors, develop effective stress coping skills and build solid, personal and professional, support net- When overtaxed by the nature of our work we works are important preventative measures. may begin to show symptoms that are similar to our traumatized clients: difficulty concentrat- The therapist’s way of working with survivors may ing, intrusive imagery, feeling discouraged about contribute to or diminish the incidence of com- the world, hopelessness, exhaustion, irritability, passion fatigue and indirect trauma. For example, high attrition and negative outcomes (dispirit- managing boundaries effectively can help protect edness, cynical outlook, boundary violations) the therapist from compassion fatigue indirect (Mathieu 2012). trauma. The importance of professional bounda- ries for the sake of client safety and therapist well- Indirect Trauma being cannot be emphasized enough. Every scar has a story and there is a high likeli- Care for the care provider hood of massage therapists bearing witness to a client’s story. Their stories can be horrific and It is important to be able to recognize indicators the recounting of them may have lasting impact of compassion fatigue indirect trauma, as aware- on both the client and therapist. ness is the first step toward change. Indirect trauma is the cumulative response to Any professional working with trauma survivors working with many trauma survivors over time. can benefit from identifying specific difficulties, The indicators for indirect trauma resemble those assessing the contributing factors, targeting spe- of direct trauma (e.g. intrusive imagery, SNS cific steps to take, and getting support from friends stimulation, anxiety and feeling overwhelmed) or colleagues in taking those steps (ISTSS 2015). and can impact the therapist’s personal and pro- Compassion fatigue and indirect trauma can be fessional relationships (ISTSS 2015). addressed by attending to basic self care: work- As is the case with trauma survivors, indirect life balance, ensuring quality time for play and trauma will look and feel different for each per- rest. Healthy nutritional practices and regular son. Some of the characteristics that may con- exercise are also essential. tribute to indirect trauma are the therapist’s Additionally, massage therapists can benefit personal history, usual ways of coping with from appropriate professional training, connec- challenge and distress, and current life circum- tion with their colleagues, ongoing consultation stances (e.g., other stressors, lack of support net- for their work, and a place to talk about their work) (ISTSS 2015). experience of indirect trauma and, when neces- sary, professional assistance. Prevention Finally, it is essential to embrace or restore mean- Ways of coping and current life circumstances can ing and hope. Each individual must find ways to contribute to a greater likelihood of compassion connect with whatever in life is meaningful and fatigue and indirect trauma. So it goes without gives purpose for that person (ISTSS 2015). References Ajzen I, Fishbein M (2005) The influence of attitudes on Al-Waili NS, Salom K, Butler G, Al Ghamdi AA (2011) behavior. In: Albarracin D, Johnson BT, Zanna MP, eds. Honey and microbial infections: a review supporting the The handbook of attitudes. Hillsdale NJ: Lawrence Erlbaum use of honey for microbial control. Journal of Medicinal Associates. Food 14: 1079–1096.

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