Posts Tagged ‘scarring’

International Fascia Research Congress, Vancouver, BC – Day 2, the night

| March 29th, 2012 | No Comments »

Tonight I watched a prophet perform. Not what I expected to see at a Fascial Congress but I am not sure what other words to use. Gil Hedley was the final act in our multimedia night. After three amazing, room-stilling videos that were highly anticipated, onto the stage came a wiry, kinetically unstable bundle of poetry reading anatomist.

Perhaps I have had too much coffee, not enough sleep or entirely too much mental stimulation but Gil Hedley’s presentation on his new thinking around fascia makes me what to sign up to join whatever cult he’s leading or drink whatever kool-aid he’s pouring. He brings an inspiring combination of respect, enthusiasm, joy and intellect into the world of fascial dissection.

I am someone who loves my words and concepts and rather resent having to give up a perfectly good story for a new idea. Even though Hedley’s whole presentation was a debunking of his own, infamous “fascial fuzz” speech that has become an easy, u-tube click away, introduction to fascia for the uniformed, I loved it. I now have to discover a new story to tell myself about the development of adhesions and what I am doing in my work. Daunting. I am inspired though by the enthusiasm, dance, poetry and joy that was displayed on the stage of the grand ballroom of the Sheraton Wall Centre tonight in Vancouver, BC

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International Fascia Research Congress 3 – Vancouver, BC, Day 1

| March 28th, 2012 | No Comments »

***Beware – this post is a total fascia geekfest, if you are not prepared to deal with that, read a different post!  Also, any factual errors are my faulty memory, not faulty presentations.***

 

Today I had the absolute pleasure of beginning my time at the 3rd gathering on scientists and clinicians who have an abiding interest in fascia in all its varied and wonderous forms.  I began the day with a flight to Vancouver and a slightly late arrival – but I got before the real geek-out stuff began, so it is all good.  

After some general introductory speeches we dove right into the first keynote speaker.  A anatomist from Temple University, Mary Barbe spoke to us about her research in duplicating repetitive stress injuries (RSI’s) in rats and the tissue changes that occurred in response to various types (high, low and negligable intensities) of work.  How could this possibly relate to massage therapy you ask? Well the road hasn’t fully been built, but knowing that rest doesn’t always fix the problem and that inflammatory processes have likely come and gone prior to anyone presenting at my office (they peak between week 4 and 8 of performing the task) after months or years of a repetitive task, provides me with insight into what interventions and homecare might best benefit my clients.  simply knowing that there are significant connective tissue changes that occur within weeks of undertaking an repetitive task shouts loud and clear about the importance of the fascial work that I am a huge advocate for.

After a quick break we moved our second speaker, Michael Kjaer, whose topic was the impact of exercise on tendon tissues.  We discovered that exercise (and not a lot, 1x creates 72 hours of increased collagen production which is what builds your tendons) increases the density of tendons.  Interestingly, there seems to be little issue with maladaptive changes in the tissue to repetitive exercise as there is to repetitive work activity (there’s a thinker).  More surprisingly, it turns out men exhibit greater tendon density increase than women, and that within the female population women taking oral contraceptive exhibit even lower levels of tendon response than the general population.  Further interest in gender issues came when it was revealed that in post-menopausal women being on hormone replacement heightened tendon response.  Hmmm, that estrogen, funny stuff.  

 

After a break for lunch we broke into three groups for presentations on specific areas of fascial research.  I chose the “biomechanics” room and got to learn about different means of trying to empirically measure different types of mechanical interventions.  From pressure sensitive pads on fingers to rather medieval looking table devices this part of the afternoon was an interesting insight into the various ways we can try to research the interventions we apply with our hands and their outcomes.  I also gained an interesting insight into the world of research.  Failure, or rather, not proving your hypothesis fully or at all.  Even in those cases it was interesting to see how that research could be used to launch into better studies.

Our next keynote speaker, Albert Banes, was a doozy.  I am pretty sure I learned so interesting things, but they went by so fast I think I might be lucky to catch up with them sometime next week – after reading the paper a few times!  He seemed to be summarizing quite an extensive array of studies in the field of fascia research and had some very interesting things to say – and showed us pictures of some lab grow tendons, but it was a lot in just a little time

The final event of the afternoon, academically, was a panel of  four clinicians presenting of “scars and adhesions”.  One of the exciting bits of us BC RMT’s was having one of our own on the panel – Susan Chapelle of Squamish, BC who talked about the benefits of integretive treatment and the need for increased research that included a manual therapy aspect.  She was preceeded by a surgeon, Dr. Michael Diamond, who discussed post-surgical adhesions (things sticking together that shouldn’t after surgery) which I was surprised to find has a 65-100% incidence rate in abdominal surgeries (though they are not limited to those surgeries).  We were then treated to a new movie by Jean Claude Guimberteau, a French physician, who has now produced several in vivo movies of fascia using endoscopic techniques (his first being “Strolling Under the Skin”, presented at the first fascial congress).  We also had a naturopathic doctor, Hal Brown, present some of his case studies of the impact of the injection of aenasthetic under the skin into scars to improve function in both near and far tissues. 

The day finished with a welcome reception that was very well attended that allowed us all to review and discuss our reactions and thoughts regarding the days flood of knowledge.  I can hardly wait for day two….

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Willem Fourie, again…

| May 5th, 2011 | No Comments »

Last week I spent two wonderful days in Vancouver. With hardly any shopping to enhance the experience. I attended an advanced seminar on post-mastectomy care with Willem Fourie, a leader in the world of fascia. Willem is a physiotherapist from South Africa and has made a study of the specific impacts of breast cancer treatment, due to lump- and mast-ectomies, radiation and reconstructions.

I wrote, glowingly, about my introductory course last June. When the opportunity to attend a more advanced course arose I was quick to sign up. Out of the 75 of us who attended last year’s introductory course 11 of us returned this year to broaden our understanding of approaches to care for breast cancer patients.

One of the things that quickly became clear was that we had all, myself included, found uses for the approaches taught by Willem in the 11 month since the first course. We opened the course with each attendee describing how they had employed the techniques and what they sought to learn. Some had very emotional stories to tell of breast cancer patients who they had been able to help and who had inspired them with their strength and courage. Others, myself included, had taken the approaches and been able to apply them with great results to a number of other conditions, from abdominal surgeries to burn victims. The scope of application and success from these fascial techniques was impressive.

The intensity and integrity expressed in the opening of the course set the tone for the whole two days. Often at this type of course there is a very chatty, social atmosphere as the attendees enjoy a break from their regular routines. Schedules are often quick paced and hands on time limited. None of these was the case for this course. There was chatting for certain, but never disruptive to the course. The tone was quiet and the schedule was full of hands on time and quiet diligence. Where hands on time in other courses might become a bit raucous and unfocused in this instance it was very much about applying the techniques and learning to treat what you found in the connective tissue. Though we had no actual breast cancer survivors, we did apply the techniques to the variety of injuries and old surgeries we collectively brought to the occasion. We addressed armpits, abdomens and breasts without giggles or discomfort.

I came away with a deeper understanding of the anatomy, physiology, surgery and the humanity that are all part of treating any patient, most especially those who have faced such monumental challenges as breast cancer. I am continuing diligence of the course having already found several patients who could benefit from these techniques. I hope that they have found some benefit from those two days I spent in thoughtful pursuit of new information and new ideas.

Willem Fourie’s website

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Healing Series #4 – Sprains

| February 14th, 2011 | No Comments »

I was trying to stop my toddler from running about the parking lot while coaxing my slightly lame dog into the back of the minivan. In frustration, I bent forward, wrapped my arms around the dog’s middle and lifted him into the back of the vehicle. I felt a funny twinge in your back but nothing seems to come of it – until later. Stiffness and pain began in my low back and radiated down into my butt.  I had sprained my ilio-lumbar ligament (it is right at the base of the spine and goes from the ilium to the 5th lumbar vertebrae). It was a mild injury, a moderate grade one. The grading for sprains is similar to strains, which were roughly outlined in the my muscle strains post.

As with all the other healing processes we have looked at there will be the clearing out of damage and the repairing of the tissue. In a ligament we see scar tissue fill in the ruptured area, restoring the continuity of the ligament. The differences comes from the fact that this is the first avascular, poorly innervated structure we will be looking at.

First, let’s look at what a ligament is and what it is supposed to do. Ligaments are sheets of tightly packed, closely aligned collagen cells.  Structures with little elasticity or extensibility, they are the brakes on the engine of muscular motion.

Without direct circulation, ligaments will be slower to send out the chemicals that signal the need for healing. The exchange of healing materials for waste products will be slow and inefficient. This slow fluid exchange will create and prolong irritation and inflammation. The lack of innervation will further slow healing.  The body’s ability to know when it is being re-injured is be limited. Most of the pain will come when surrounding tissues become over-taxed, irritated and inflamed.  The ankle and low back, two of the most frequently sprained regions, also have the highest rates of re-injury and chronic acute conditions (basically when the area is so regularly being injured it never truly heals and is always painful).

the ligament fibers end up looking as messy as these twigs

How long is slow? A year. It takes a year for a ligament to fully restore itself. If there is no intervention you will be lucky to get 50% functional integrity at the injury site.

For the first three months you are especially vulnerable to re-damaging the healing ligament. After three months most of the basic repair is done and the new scar is in place. We are entering that retraining period I talked about in the muscle strains blog. This is one of the most tricky times, you need to be active, you are generally pain free, but your ligament is just not capable of what it once was. Directional stress tells scar tissue fibres what direction they need to line up and be strong in. To be functional, ligaments need proper structure, something that can only be achieved through safe movement. By six months or so you might be okay in most activity but be aware that you are still at risk. The wrong move at the wrong time can spell a reversal back to the beginning.

 

How much of a difference can proper care make? Immensely, think 98% integrity vs the aforementioned 50%. What is proper care? In

with good healing the fibers flow together smoothly in line

the early stages RICE is the answer. If an activity brings on pain, stop it. Get help or modify for safety activities you need to do. Once you are moving without pain through normal activity, return to more vigorous pursuits. If the activity creates similar risks to the injury, tape the injured area. Tape creates some small physical stability, and, more importantly, it brings your brain’s attention to the area.

The other aspect of proper care is some professional assistance. Help to keep compensating structures healthy and ensure optimal circulation using massage therapy, physiotherapy, or acupuncture. The first two, along with a kinesiologist can help with rehabilitation exercises. The kinesiologist can help with bad movement patterns too, as can Alexander technique instructors or Feldenkrais practitioners. You do not have to use the whole spectrum of care, but think about what you need help with and what you have to invest in your health and match that to the practitioner best suited to assist you.

Finally – be patient. This is a long haul situation, if you try to shortcut it you will make it worse.

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Healing Series #3 – Muscle Strains

| February 4th, 2011 | No Comments »

Trying out skates for the first time in over a decade, sticking close to the wall, wobbling along. You come up on someone even slower than you (shocking!) and decide to brave open ice and go around. You start your big move, its going well, you glance away for a moment…toe pick…crap! Your knee is throbbing, your hand is sore where the ice scraped it, and your shoulder is a bit achy. You are on your belly, on the ice, feeling like an idiot.

The next morning, with a bruise as big as a salad plate on your knee, you think the limp will be your biggest problem, until you try to take off your sleep shirt. That achy shoulder from yesterday is not interested in heading up over your head. You have to take your shirt off like a 2 year old – one arm at a time, then over the head. You suck it up and head on about your day but quickly realize that every time you try to reach out in front of yourself, or up over your head your shoulder protests – bitterly. You haven’t thought about your knee all day.

What has happened? You have a first degree strain of your subscapularis muscle (it is in you armpit). Strain not sprain (strain = muscle, sprain = ligament), and only first degree (they go from a few torn fibers at 1st, a small to large gap at 2nd or a complete rupture at 3rd). What now?

As I have previously stated the first major stage is inflammation, you can read about it in its own blog. The rest of the steps are not radically different from deep wound healing. The body sends cells and microscopic nutrients and components to the wound that clean it, keep infection out and rebuild. The difference comes in the result.

Almost no regrowth of muscle is possible. Occasionally muscle cells with extra nuclei can divide to replace damaged tissue on a very small scale. The intact muscle cells can enlarge. The majority of the healing though will be the laying down of scar tissue. Fibrous collagenous tissue with limited blood flow, minimal extensibility, no contractility and little elastic recoil, all contrary to the nature of muscle. A muscle is designed to move, to get longer and shorter and to return to its starting length. And most importantly muscle is expected to generate force through contraction. Scar tissue can not do any of this.

Creating a mobile scar in dermal tissue is a good thing both functionally and esthetically, in muscle a healthy scar is essential. A healthy scar ensures that you are able to continue unrestricted activity and that you will not re-injury yourself. How you treat your body during this healing phase is critical. For the first 24-72 hours you should RICE (Rest, Ice, Compress and Elevate). Light daily life activity is okay, just try to avoid doing more damage. After that, provided you have no resting pain, you need to start moving that muscle, right to its pain barrier, and in all the directions you want to use it for the rest of your life. Do not use weights or resistance at this point, just want move it (you are doing ROM exercise). By educating the emerging tissue as to it responsibilities you encourage the scar to be of sufficient size to fill the space without shortening the muscle, you also encourage all the little collagen fibres to lie down in alignment with the stretch you place on the muscle (meaning you will have a scar of maximum strength) , and your uninjured muscle, your proprioceptors, and your brain are all learning how to deal with their new situation.

Realistically, for a first degree sprain you shouldn’t have any trouble doing this. There is minimal pain and you should be comfortable moving it quite quickly. The scar will be very small and change the way your muscle behaves minimally. You will likely be unaware of the alteration and re-injury is a small risk. The principles though hold all the way up to a full rupture.

With a rupture the time before safe movement is longer and you would need to have the structure repaired before ROM could make a difference. There would also be a need to progress from ROM to resistance exercise in order to gain back the strength that would be lost through the period of inactivity and the loss of contractile fibres. The key is that you want to retrain your body to deal with the new state of affairs. You can not just “rest” it for three weeks, using only 25% of your regular movement, and have your body know how to behave. You will have a very short, poor quality scar. You will be more likely to have tiny little tears occurring all around it as you try to expand your usage of the muscle. Basically, you will be causing small injuries over and over again, creating more and more scarring.

The issue with muscle healing is that you need your muscles to move, that is their job. If you do not ensure that they learn how to move in their post-injury state they will keep trying to move the way they used to, with poor results. Remember, for injuries the intervention of a health professional can speed the healing process and provide guidance on safe ways to rehabilitate. For mild strains a registered massage therapist or a physiotherapist would be your best choices. If you believe your have a more significant injury a visit to your physician is a must. A reputable RMT or physio will assess your injury and let you know if a doctor’s help is needed. A good doctor will send you to a RMT or physio when it is safe.

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A healing sidebar – Inflammation

| November 22nd, 2010 | No Comments »

I want to elaborate on an important process that is essential to healing in the human body – inflammation. As I have moved further into my healing series I realized that it would be beneficial to take the time to fully describe the process and its role in healing.

First, why is inflammation important? Lack of inflammation leads to slow or absent healing, too much leads to poor tissue nutrition and pain. As with so many physical process, balance is a key factor in good function. In the proper degree and duration inflammation is an essential for healing. However, the constant tax on our system from chronic inflammation, and the changes it creates inside our bodies’, appears to increase our risk of cancer, heart disease, clogged arteries and autoimmune disorders.

Now, into the meat of things. What is inflammation? What trigger it? What causes its visible signs – heat, redness, swelling and pain?

Any event that the body perceives as potentially harmful is the trigger of inflammation. Local cells begin secreting chemicals that create the inflammatory process. Theses substances sensitize tissues, creating more pain and trigger vasodilation, the enlargement of blood vessels, which does two things. One, increases the amount of blood that can arrive at the area by increasing the diameter of the carrying vessels. Two, increases the size of the gaps in your vessel wall, allowing substances that are not usually able to pass out of the blood to enter the tissue. This ensures the nutrition, oxygen and immune components that the body requires to heal can enter the tissue. Vasodilation will lead to redness, heat and swelling common with inflammation.

As the blood cells, plasma proteins, platelets, fluid and healing substances flow out of the enlarged vessels swelling will occur. This is a simple physical requirement of all that extra material in the tissue. Clinically, we call this edema. Before we can see edema there is, on average, 30% more fluid in our tissue than is normal. The problem with extreme increases in the amount of fluid is that our cells are fed by diffusion and the farther apart our cells the longer energy takes to get to them. This chain reaction leads to the possibility for tissue injury or death from excess swelling. Concern over the risk of exaggerated swelling is one of the reasons ice and anti-inflammatories are often recommended post injury. Both decreased nutrition and increased pressure on surrounding structures can create pain. Occasionally the pain can be severe enough to inhibit function in the area.

The process of inflammation is generally self-limiting and usually resolves within 72 hours of the injury. Infection, re-injury, or chronic conditions in the body, may elongate this process.

There is the process of inflammation in the body. As we move forward with this healing series hopefully this helps you understand this vital portion of healing.

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Healing Series #2 – Deep Wounds

| November 1st, 2010 | 2 Comments »

You are chopping onions and your knife slips a bit and you cut your finger tip. As fingers, with there plentiful supply of blood, are prone to, it bleeds, a lot. You put some pressure on the wound, lift your arm over your head and it’s off to the band aids. When you take away your pressure the blood is still flowing but has slowed, and a quick look shows you have cut through so the length of the wound is bleeding but you haven’t really gotten into the meat of the finger. No stitches required, a tightly wrapped band-aid squishes the edges together and reduces the blood flow. Unlike that wee scratch you got on your walk last week, this cut will be there for a while, and for the next few hours the finger will throb and pulse and hurt. Within a couple weeks you will be healed, but there will be a scar. What is different inside your body for this injury compared to that scrape?

In medical-ese you have given yourself a deep wound, a wound that extends through the hard, dry (keratinized) epidermis and into, not just to, the living portion of the skin, the dermis. This is an important distinction, in the previous example the damage was able to be repaired easily in part because there was no real impingement on living tissue with extensive blood supply. Once you are into the structural part of the skin and the physical protective capacity of the skin has been broached, your body must mobilize its other protections and staunch the escape of the blood while working to restore integrity to its tissue.

There are four stages that this type of wound will pass through on its way back to normal function. These phases overlap but begin sequentially. First, the clotting phase, then the inflammatory phase (some meld these two together), then comes the migratory phase and healing finishes with the maturation phase. Different activities, chemicals and processes dominate these phases and all are necessary to restore proper function.

The cut happens and within moments, reacting to the damage of their lining cells (endothelial cells), the damaged blood vessels go into spasm to reduce their diameter (vasoconstriction), which also has the added benefit of bringing the wound edges closer together. The damaged lining cells also cease to release the chemicals they usually secrete to prevent coagulation of the blood and begin to secrete chemicals that encourage clotting (von Willebrand Factor and thromboplastin), as well as proteins (cytokines) that jump starts the immune responses of the body. Within the hour the clotting factors encourage small cell fragments in the blood (platlets) to stick to the damaged areas of the blood vessels, holding the edges together and stopping the flow of blood. Once this plug is in place a protein (fibrinogen) is converted into a non-soluble protein (fibrin) and forms a web-like framework for blood to coagulate around. Once sufficient blood coagulates around this framework the plug becomes a clot.

As clotting occurs another process, inflammation, is beginning to help clean and protect the wound and to ensure that all the other chemicals and cells needed for healing are able to reach the wound site. The first event in inflammation is the enlargement of the blood vessels around the injury (vasodilation) which both increases the volume of blood flow to and from the area and enhances movement of material through the walls of the blood vessels. The first new cells to arrive are White blood cells (specifically neutrophils and macrophages) and cells (mesenchymal cells) that transform into tissue building cells (fibroblasts). This is also the process that will cause the throbbing in your finger. More and more fluid, chemicals and cells crowd the limited space of the fingertip until you can literally feel the surge of your pulse pushing more into the constricted space. Fingertips, or any constricted space that swells will manifest this throbbing. In more spacious areas swelling of the tissue over a larger area allows these materials to disperse into a larger area and you rarely feel the pulsing. Within about 24 hours the inflammation has subsided to the point that the throbbing isn’t evident, you may not even note any swelling.

At around the 3 day mark the migratory phase becomes dominant. At this point the clot has become a scab and under that the epithelial cells are migrating across the gap (see “Healing Scrapes”). The fibroblasts migrate on the fibrin threads producing scar tissue (primarily collagen and glycoprotein, this tissue also secretes a antibiotic-like fluid) as they move. At the same time the damaged blood vessels are healing. This phase can take up to about 3 weeks.

By the 3 week mark healing moves into the maturation phase. This is when the wound undergoes its remodelling. In a house remodel this would be the painting stage, in the body this is when the new structures attain more organization, when the cells involved in healing begin to disperse or die off, and the blood vessels are fully restored. Depending on the severity of the injury this phase can be ongoing for up to 2 years. You would see this as the slow fading of the visible scar. For you body the tissue would be slightly less sturdy and perhaps have slightly altered blood flow until this process completed.

Nutritionally speaking your body will be using more Vitamin C (connective tissue production and blood vessel healing) and more Vitamin E (to decrease scarring and speed the process). In the early stage Vitamin K would be used heavily in clot production.

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