Manual scar therapy on the example of a caesarean section scar

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ABSTRACT

Surgical procedures (including cesarean section) or ac- cidental cuts, may leave marks on the skin in the form of scars and accompanying ailments. There are many methods of scar treatment, including physiotherapeutic techniques.

The aim of the study was to present the issues of manual work with a scar on the example of a scar after a caesarean section.

Soft tissue manipulation techniques allow physiotherapists to be effective in removing the negative effects of poor wound healing, including restoring the aesthetics of visible tissues.

Keywords: scar, manual therapy, cesarean section

STRESZCZENIE

Zabiegi chirurgiczne (w tym cesarskie cięcie) czy przypad- kowe urazy, mogą pozostawiać na skórze ślady w postaci blizn i towarzyszących im dolegliwości. Istnieje wiele me- tod terapii blizn, wśród których wymienia się techniki fizjoterapeutyczne.

Celem pracy było przybliżenie zagadnień manualnej pracy z blizną na przykładzie blizny po wykonanym zabiegu cesarskiego cięcia.

Techniki manipulacji tkankami miękkimi pozwalają fi- zjoterapeutom na skuteczne działanie w zakresie usuwania negatywnych skutków złego gojenia się ran, w tym również przywracania estetyki widocznych tkanek.

Słowa kluczowe: blizna, terapia manualna, cesarskie cięcie Iga Daniszewska-Jarząb¹ 0000-0002-2512-9244

Sławomir Jarząb^1,2 0000-0002-4767-1579

1 Unisono Medica, Stępin 33m, 55-093 Stępin, +48 535 361 104, kontakt@unisono-medica.pl

2 Divison of Rehabilitation in the Movement Disorders, Department of Physiotherapy, Faculty of Health Sciences, Wroclaw Medical University, Grunwaldzka 2, 50-355 Wrocław, +48 71 784 01 85, slawomir.jarzab@umed.wroc.pl Sposób cytowania / Cite Daniszewska-Jarząb I, Jarząb S. Manual scar therapy on the example of a caesarean section scar.

Aesth Cosmetol Med. 2021;10(4):201-204. https://doi.org./10.52336/acm.2021.10.4.05

Manual scar therapy on the example of a caesarean section scar

Terapia manualna blizny na przykładzie blizny po cesarskim cięciu

INTRODUCTION

Surgical procedures or accidents traumatizing the body may leave traces in the form of scars and accompanying ailments, on the one hand, such as pain, tenderness and hy- persensitivity to stimuli, and on the other, limitations, such as contractures or impairment of tissue mobility. All this may have an influence directly on the patient’s quality of life [1, 2]. There is also a significant negative impact on the psychological and social aspect of life, which is caused by the appearance of an unesthetic scar [3-6]. The constant-

ly developed techniques of working with scar support the process of treating this interdisciplinary problem, but the key seems to be the correct integration of the scar tissue with the network of fascial tissue i.e., maintaining or restoring the mobility of these tissues in relation to each other [7].

This goal can be achieved by many methods, such as manual techniques, methods using physical therapy or special methods, which include, among others dynamic taping [8, 9], which turns out to be an highly effective tool in the treatment of scars [10].

Review article / Artykuł przeglądowy

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CAESAREAN SECTION PROCEDURE

The caesarean section surgery leaves a scar that requires special care. During the procedure, a horizontal skin incision approximately 10-15 cm long is usually performed. Apart from the skin, the following: subcutaneous tissue, fascia, peritoneum and uterine muscle are cut. Im- proper wound healing not only affects the area around it, but can also cause a number of abnor- malities manifesting in further parts of the body.

Therefore, it can affect the aesthetic appearance of the abdomen, but also cause, among others, posture asymmetry, gait disturbance, pain in the lumbar spine. Manual procedures can support proper scar formation. The age of the scar does not affect the possibility of its release, but imma- ture scars, due to the greater dynamics of tissue remodelling and healing processes (as is the case here), may be easier to activate [11].

SCAR EVALUATION

The physiotherapist evaluates the appearance and mobility of a healed scar. Mobility is checked by placing the hand or fingertips on or around it. By moving the scar in different directions, the skin’s displacement in relation to the fascia is checked. Apart from the free movement of the scar in all directions in the frontal plane, lifting should also be possible [12]. If the movement of the scar tissue in either direction is limited, scar mobilization techniques can be used. These techniques can also be used for prevention if the tissue maintains its mobility.

MANUAL WORKING TECHNIQUES WITH A SCAR

In the first weeks, gentle techniques are recom- mended - the therapist touches the skin gently, the movements do not encounter resistance on their way and are not unpleasant for the patient. Of- ten patients are afraid of scar therapy, they do not touch it themselves, so the intensity of the movements should be carefully graded. It is worth starting the preparation of the scar with indirect work by moving the tissues lying in the immediate vi- cinity of the scar in different directions [11].

The crucial condition for starting the di- rect work on the scar is complete healing of the wound.

The first stage of the massage is stroking, de- pending on the size of the scar, with one or two hands (fig. 1). Initially, it moves along the fingers placed on both sides of the scar with a slight grad-

Fig. 1 Stroking technique

Source: Authors’ archive based on [13]

Fig. 2 Rolling technique on a caesarean section scar Source: Authors’ archive based on [14]

Fig. 3 Vertical point scar lifting Source: Authors’ archive based on [14]

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ual pressure (with subsequent repetitions, the pressure increases) [13].

A gentle technique is also moving the skin flat at right angles to the scar. Both hands are used, lying flat on the scar. Applying light pressure, the tissue moves across the scar [13].

Another way of scar mobilization is by circular movements. This method involves making circular movements with the tips of the fingers to- wards the scar with two fingers of one hand or al- ternately with both hands. Then, movements are made closer and closer to the scar, and finally along its course. In order to increase the intensity of the action, circular movements are made in opposite directions [13].

Skin rolling - also one of the types of mobilization classified as indirect work - is a safe and gentle form of massage that improves blood circula- tion and mobility of a given area (fig. 2) [11].

Lifting the scar pointwise (fig. 3) and global- ly (fig. 4) enables the release of concave scars.

A fragment of the scar or the entire scar is lifted vertically and held in that position for some time.

This technique can also be performed using as- sistive tools such as a Chinese bubble. A proper- ly formed scar should float as part of the skin, it cannot drag deep tissues behind it.

The “C” grip (fig. 5) involves holding the fold of the skin with the scar in one hand, and with the other hand moving the tissue down through the center of the scar, forming a “C” shape. In this way, it is possible to effectively reduce the limitations in the mobility of the scar [14].

“S” grip - the skin moves in opposite directions (photo 6), with the thumbs of both hands placed perpendicular to the scar, until an “S” shape is formed [14].

The “ram’s horns” technique (fig. 7) is designed to mobilize the ends of the scar by bending the scar into the shape of the letter “U” and addition- ally twisting its distal parts [14].

SUMMARY

Scars may impair the functioning of the fascial network, and thus also other parts of the body. An immobile and inelastic scar may show symptoms of local pain, but also pain that has been trans- ferred to other parts of the body, including inter- nal organs. Disruption of the functioning of the pelvic organs, including among others dysmen- orrhea, may therefore be caused by the patho- logical healing of the caesarean scar, if such surgery has taken place. In order to activate the scar

Fig. 4 Vertical global scar lifting Source: Authors’ archive based on [15]

Fig. 5 The “C” grip

Fig. 6 The “S” grip

Fig. 7 The “ram’s horns” technique Source: Authors’ archive based on [14]

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9. Daniszewska-Jarząb I, Jarząb S. Practical application of kinesio- taping in the case of a cesarean section scar. Aesth Cosmetol Med.

2020;9(6):485-488. https://doi.org/10.52336/acm.2020.9.6.01

10. Deflorin C, Hohenauer E, Stoop R, et al. Physical Management of Scar Tissue: A Systematic Review and Meta-Analysis. J Altern Complement Med. 2020;26(10):854-865. https://doi.org/10.1089/acm.2020.0109

11. Korabiusz K, Torbć A, Lubkowska A, Wawryków P. Blizna skórna po cięciu cesarskim – możliwości fizjoterapeutyczne. Journal of Educa- tion, Health and Sport. 2017;7(7):629-639.

12. Bednarczyk E. Rehabilitacja blizny po cesarskim cięciu. Praktyczna Fi- zjoterapia i Rehabilitacja. 2019;130:68-72.

13. Bringeland NE, Boeger D. Terapia blizn. Wrocław: Wyd. MedPharm; 2020.

14. Chochowska M. Praca z blizną po operacji cesarskiego cięcia ze szcze- gólnym uwzględnieniem technik stosowanych w późnym okresie po- operacyjnym. Rehabilitacja. 2018;5:36-42.

15. Młotek K. Integracyjna terapia blizn. Materiały z kursu. Tarnowskie Góry: Integracyjna; 2021.

16. Wasserman JB, Steele-Thornborrow JL, Yuen JS, et al. Chronic caesa- rian section scar pain treated with fascial scar release techniques:

A case series. J Bodyw Mov Ther. 2016;20(4):906-913.

https://doi.org/10.1016/j.jbmt.2016.02.011

17. Kelly RC, Armstrong M, Bensky A, et al. Soft tissue mobilization techniques in treating chronic abdominal scar tissue: A quasi-experimen- tal single subject design. J Bodyw Mov Ther. 2019;23(4):805-814.

18. Wasserman JB, Copeland M, Upp M, Abraham K. Effect of soft tissue mobilization techniques on adhesion-related pain and function in the abdomen: A systematic review. J Bodyw Mov Ther. 2019;23(2):262-269.

19. Chamorro Comesaña A, Suárez Vicente MD, Docampo Ferreira T, et al. Effect of myofascial induction therapy on post-c-section scars, more than one and a half years old. Pilot study. J Bodyw Mov Ther.

2017;21(1):197-204. https://doi:10.1016/j.jbmt.2016.07.003

“stuck” to the underlying tissues, manual techniques can be used, the effectiveness of which (e.g. in reducing pain) was proved by research studies [16-19]. The possibilities offered by the knowledge of soft tissue manipulation techniques allow physiotherapists to effectively remove the negative effects of poor wound healing, including restoring the aesthetics of visible tissues.

REFERENCES / LITERATURA

1. Bock O, Schmid-Ott G, Malewski P, Mrowietz U. Quality of life of pa- tients with keloid and hypertrophic scarring. Arch Dermatol Res.

2006;297(10):433-438. https://doi.org/10.1007/s00403-006-0651-7

2. Meirte J, van Loey NE, Maertens K, et al. Classification of quality of life subscales within the ICF framework in burn research: identifying overlaps and gaps. Burns. 2014;40(7):1353-1359.

https://doi.org/10.1016/j.burns.2014.01.015

3. Bell L, McAdams T, Morgan R, et al. Pruritus in burns: a descriptive study. J Burn Care Rehabil. 1988;9(3):305-308.

4. Taal L, Faber AW. Posttraumatic stress and maladjustment among adu- lt burn survivors 1 to 2 years postburn. Part II: the interview data. Burns.

1998;24(5):399-405. https://doi.org/10.1016/s0305-4179(98)00053-9

5. Dorfmüller M. Psychological management and after-care of severely burned patients. Unfallchirurg. 1995;98(4):213-217.

6. Robert R, Meyer W, Bishop S, et al. Disfiguring burn scars and adole- scent self-esteem. Burns. 1999;25(7):581-585.

https://doi.org/10.1016/s0305-4179(99)00065-0

7. Wheeler SL, Blessitt KL, Ennis RD. Integrating scar tissue into the fascial web. Journal of Bodywork and Movement Therapies. 2015;19(4):699-670.

8. Anthonissen M, Daly D, Janssens T, Van den Kerckhove E. The effects of conservative treatments on burn scars: A systematic review. Burns.

2016;42(3):508-518. https://doi.org/10.1016/j.burns.2015.12.006

otrzymano / received: 20.05.2021 | poprawiono / corrected: 03.06.2021 | zaakceptowano / accepted: 14.06.2021

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