- Email: [email protected]
Treatment of the scar after arthroscopic surgery on a knee
+
MODEL
Journal of Bodywork & Movement Therapies (2016) xx, 1e6
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/jbmt
CASE STUDY
Treatment of the scar after arthroscopic surgery on a knee Jacobo Alvira-Lechuz, Ph, CO a, Mercedes Roca Espiau, MD b, Elena Alvira-Lechuz, D c,* a
Madrid School of Osteopathy, University of Zaragoza, Domingo Miral s/n, 50009 Zaragoza, Spain Dr. Roca Center for Medical Diagnosis, La Carrera del Sa´bado, 4, 50006 Zaragoza, Spain c Department of Physics, University of La Laguna, Avenida Francisco Sa´nchez s/n, 38202 La Laguna, Tenerife, Spain b
Received 21 March 2016; received in revised form 12 July 2016; accepted 26 July 2016
Summary The aim of this paper is to present a treatment for scars based on percutaneous traction. This is a structural technique in which movements are performed against the barriers detected in different planes. The stages of this technique are described in detail along with the results after applying it to a postarthroscopic scar on a knee. The active and passive mobility of femoro-tibial and femoro-patellar articulations improved substantially after the treatment, as verified by signs such as pain relief, greater flexibility, disappearance of inflammation and a major recovery of tissue elasticity. A sonoelastography study of the portals and patellar tendon was carried out before and after therapy, showing semiquantitatively the recovery of the viscoelastic properties of the tissue. ª 2016 Elsevier Ltd. All rights reserved.
Introduction Fascial tissue is organized as a three dimensional network that surrounds, suspends, protects, links and separates the muscular, skeletal and visceral components of the body. It is a dynamic tissue with complex vascularization and innervation, varying in anatomy according to its location (Stecco et al., 2013). Fascia includes contractile
* Corresponding author. Fax: þ34 922318320. E-mail address: [email protected] (E. Alvira-Lechuz).
constituents that allow it to modulate forces and to adjust mechanosensitivity in a precise way. Any imbalance in this mechanism of myofascial tone control or reduction in neuromuscular coordination is revealed by musculoskeletal pathology and pain syndromes (Henry et al., 2012; Alburquerque-Garcı´a et al., 2015). Fascia can undergo strains with the resultant mechanical and physiological effects. In consequence, some fascial therapeutic techniques have been developed to liberate stress, relieve pain and restore functionality. Such approaches are based on studies that have analyzed the plastic, viscoelastic and piezoelectric properties of connective tissues (Tozzi,
http://dx.doi.org/10.1016/j.jbmt.2016.07.013 1360-8592/ª 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Alvira-Lechuz, J., et al., Treatment of the scar after arthroscopic surgery on a knee, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.07.013
+
MODEL
2 2012). These modeling techniques have been tested in some cases by sonoelastography, which is able to discriminate different degrees of tissue density, elasticity and hardness. Sonoelastography (SE) is used nowadays in several health fields to diagnose illnesses or as an instrument to measure changes in tissue viscoelasticity after applying manual fascial therapy (Martı´nez Rodrı´guez and Gala ´n Del Rı´o, 2013; Herna ´ndez Dı´az, 2013).
Treatment of scars From an embryological perspective, both skin and fascia arise from the mesoderm, which also gives rise to connective tissue (Bordoni and Zanier, 2014). One of the most important relationships between skin and the rest of body is through the sympathetic nervous system. Its efferent fibers come from the hypothalamus and descend through the ipsilateral brainstem and medulla to the spinal cord, where they meet other (preganglionic) neurons (Vetrugno et al., 2003; Longmire, 2006). Afferent sensory fibers also convey skin properties such as temperature, proprioceptive control or motor strength pattern to the hypothalamus. In this way, the hypothalamus integrates the received information and orchestrates the most appropriate thermoregulation, endocrine responses and postural changes. In short, the cerebellum is stimulated by skin (Bordoni and Zanier, 2014; Vetrugno et al., 2003; Longmire, 2006). Therefore, the skin facilitates the perception and location of mechanical impulses such as pressure, friction, vibration, temperature or pain via the central and peripheral nervous system, by means of independent nerve endings and specialized receptors (Bordoni and Zanier, 2014; McSweeney et al., 2012; Rodriguez et al., 2011; Tozzi, 2012). Every cell or tissue generates substances that allow it to communicate and relate with other body parts, however distant. Skin is no different, in that when its continuity or healing processes are disturbed, it also gives rise to noncutaneous symptoms (Bordoni and Zanier, 2014). Therefore any skin injury like a scar, even if small, affects the organism and constitutes an active obstacle to its normal functioning. Scars actively influence organs, structures and systems throughout life, besides altering their natural development and functioning (Kobesova et al., 2007; Lewit and Olsanska, 2004). Once formed, scars involve changes, stiffness, loss of mobility, i.e. dysfunctions, which have repercussions on both the zone where the continuity loss is located and more distant zones. There is a proportional relationship between scars and body adaptations with time, and inversely with distance. Thus, the longer the time after the scar appeared, the more body adaptations occur; on the other hand scars affect more distant tissues to a much lesser extent. The new-formed scar tissue has different properties from the replaced connective tissue. A new disordered interlaced network is formed, which generates adherences to organs, vessels, nerves and can even affect whole systems. Mechanotransduction refers to how mechanical forces give rise to biochemical stimuli. This process is strongly related to inflammation, fibrosis and scarring (Duscher et al., 2014). After any type of surgery, even the least invasive, scar tissue should be treated to minimize the loss
J. Alvira-Lechuz et al. of mobility, density change capacity and viscoelasticity due to adherences and fibrosis (Duscher et al., 2014; Pavan et al., 2014; Mayr and Sto ¨hr, 2014; Wong et al., 2012). This loss varies between individuals and body zones subject to surgery; for instance it is known that the abdominopelvic and lumbar zones are among the most liable to suffer adherences and consequent sequels (Lyell et al., 2012; Alpay et al., 2008; Robertson and Lefebvre, 2010; Audebert et al., 2012; Ergul and Korukluoglu, 2008). It is easy to understand that the more scars people develop, the more consequences, especially in the same body area (Mazzocchi et al., 2014; Bates Jr. and Shomento, 2011). Therefore it is necessary to study the possible treatments for this type of dysfunction (Fourie, 2014; Klinger et al., 2014; Chou et al., 2014). For example, those proposed for postsurgical scars based on manual therapy (Marchi-Lipski and Duviau, 1998; Daniel, 1995; Duviau and Robert, 1995), giving them the consideration they deserve. These authors pointed out that the shape and time of healing of scars is fundamental to know when they should be treated, so as to obtain the best results. Skin presents more or less elastic areas, depending on the organization of collagen fibers. The lines formed in these areas, named Langer or ‘least stress’ lines, usually correspond to wrinkles and lie perpendicular to the contraction of local muscles (Gonza ´lez Lo ´pez and Bernal Torres, 2010). These lines must be taken into account when a surgical incision is made, since they determine the final shape of scars. The aim of the present article is to put forward a therapeutic technique to treat postsurgical scars. It is applied in a case study of a knee after inner meniscectomy by arthroscopy. Treatment efficiency is confirmed by a sonoelastographic study and by the increased articular mobility, improvement in tissue elasticity and absence of pain.
Sonoelastography Based on elasticity or Young’s modulus measurements of different tissues by means of ultrasound, this is a useful tool to identify pathological injuries arising from a loss of standard elastic properties of tissues such as atrophy, fat deposition or fibrosis. SE superimposes a parametric colored image (representing the deformation capacity of tissues) over the ultrasound anatomical scan images in a range of grays: soft tissues develop a greater capacity to become distorted, while more rigid tissues obviously present less elasticity. Initially SE was used to identify neoplasic breast tissue, in recent years it has become a useful tool to determine muscular activity in a non-invasive way. It is applied to evaluate traumatic muscular injuries, painful myofascial symptoms, Achilles tendinopathy, epicondylitis, etc. (Herna ´ndez Dı´az, 2013). The resulting image reflects tissue density, elasticity and stiffness by means of software that semiquantitatively correlates a chromatic spectrum (from blue to red) with tissue elasticity. Thus, a blue color corresponds to inelastic areas, red to viscoelastic tissues, and intermediate values of rigidity are represented by other spectral colors (Herna ´ndez Dı´az, 2013). In the present study, SE was used to show the importance of manual therapy in postsurgical scars, even the smallest (Martı´nez Rodrı´guez and Gala ´n Del Rı´o, 2013; Herna ´ndez Dı´az,
Please cite this article in press as: Alvira-Lechuz, J., et al., Treatment of the scar after arthroscopic surgery on a knee, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.07.013
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Treatment of the scar after arthroscopic surgery on a knee
3
2013). The elastography equipment used was a Hitachi EUB8500 system comprising a SonoElastography module and a 13 MHz ultrasound probe. A sonoelastographic study of the portals and patellar tendon was made before and after the therapeutic manual treatment, showing tissue elasticity and fibrosis through real-time imaging (Klinger et al., 2014; Martı´nez Rodrı´guez and Gala ´n Del Rı´o, 2013).
b) Later, the affected zones presenting less mobility, sliding capacity and viscoelasticity were manually detected by low intensity tractions with the first and second finger (Fig. 1a). PTS was applied first to tissues further from the articulation, gradually approaching scars and more fibrotic areas, and persisting in those with greater restriction of movement (Fig. 1b). The technique was limited to each zone in turn until the strain decreased or disappeared. c) Once greater elasticity was observed in tissue near the scar, the traction force was intensified to liberate all the inner structures of the affected zone. d) Finally this technique was applied for 5 sessions during two weeks, concentrating particularly on the portals and fibrotic tissue until they presented greater elasticity.
The method The treatment described in this article was applied to a patient subject to inner meniscectomy by arthroscopy. The access points were the anteromedial and anterolateral portals, which were closed by 2 sutures. Antithrombotic measures were adopted after leaving the operating theater, consisting of a compression stocking from groin to foot and anticoagulant treatment with subcutaneous heparin for 10 days. The patient spent the night at home after the operation and the articulation was not immobilized; this permitted walking with sticks with some weight on the operated leg. Several days later, after the healing period, sutures were removed and replaced by adhesive dressings, the wounds were properly treated and physiotherapy started 21 days after surgery. A stiffened patellar tendon was detected at the first physical examination, as well as loss of kneecap mobility in craneo-caudal and laterolateral directions. Palpation on the postsurgical scar was painful in particular at medial level, detecting limited mobility of newly formed fibrotic tissue. Goniometry of the knee showed an active flexion up to 80 and an active straightening of about 3 .
Results and discussion The active and passive mobility of both femoro-tibial and femoro-patellar articulations substantially improved after the treatment, as shown by several objective measures. Pain: The patient reported a progressive recovery of the symptoms throughout the therapy. In particular, the pain and hypersensibility at the medial arthroscopic portal became detectably milder. On the EVA scale, the patient started with a value of 6 and finished at 2.
Manual therapy (Percutaneous Traction on Scars) The manual therapy presented here is an application of manual techniques previously described (Fourie, 2014). It is based on performing percutaneous traction (Percutaneous Traction on Scars PTS), gently and superficially at the beginning then gradually increasing its intensity, which allows access to deeper tissues and structures. Traction is applied in search of restricted tissue mobility in caudal and craneal directions, then lateral and medial, clockwise and anticlockwise. PTS is characterized by being a structural, not a functional technique, in which movements are made against the barriers detected in various planes. Some articular strokes can be simultaneously carried out with arcs of varying angles. The patient can contribute to increasing the tension by deep inspirations and expirations, depending on the area to be treated. If necessary, muscle stretching or other manual therapy may be carried out during the PTS to complete the treatment. In any case, the therapist can improve the effects of the described technique with the aid of the concept of overall handling. The treatment consisted of the following phases: a) Firstly, lymphatic drainage of the whole affected limb was carried out to reduce the inflammatory reaction to surgery.
Figure 1 a) Low intensity tractions with the first and second finger to detect the affected zones. b) PTS applied to tissues further from the articulation.
Please cite this article in press as: Alvira-Lechuz, J., et al., Treatment of the scar after arthroscopic surgery on a knee, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.07.013
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4 Flexibility: On exploration after treatment, the patient presented a wider active arc on both flexing and straightening the knee. Initially the active flexion was less than 80 (Fig. 2a) while at the end of therapy it reached 140 , as shown in Fig. 2b. Straightening began at 3 and reached 0 (Fig. 3), which is the capacity of movement of a normal functional knee. The tibia was able to rotate over the femur without limits, suggesting that there were no other stiffened periarticular tissues. The kneecap could move freely in every direction (craneo-caudal and latero-lateral), as shown in Fig. 4. Greater elasticity was detected in tissue at the portals, allowing traction on them without the rigidity felt by the therapist’s fingers before starting the treatment. Inflammation: The signs of inflammation and stiffness in other periarticular zones gradually became fewer as the sessions advanced (Fig. 5). Elasticity: Before applying the manual therapy, a sonoelastographic study of the portals and patellar tendon was performed, which showed a blue image (in the web
J. Alvira-Lechuz et al.
Figure 3
Figure 4 direction.
Knee mobility after the treatment.
Movement of the kneecap in the latero-lateral
Figure 5 Inflammatory and stiffened signs after the treatment.
Figure 2 Active flexion of knee a) before treatment b) afterwards.
version) (Fig. 6a) representing tissue with total loss of elasticity. After the treatment, a new sonoelastographic study found a more differentiated and reorganized state of the tissue in scars and stiffened zones (Fig. 6b), a positive result given the previously large amount of blue shown in the SE. This was typical of normal soft tissue, indicating recovery of viscoelastic properties.
Please cite this article in press as: Alvira-Lechuz, J., et al., Treatment of the scar after arthroscopic surgery on a knee, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.07.013
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Treatment of the scar after arthroscopic surgery on a knee
5
References
Figure 6 Sonoelastographic images a) before the treatment b) afterwards.
Conclusions A manual therapy for treatment of postsurgical scars (Percutaneous Traction on Scars) has been developed. It is a useful tool that fulfills a fundamental role in the physiotherapeutic treatment of operated zones. The technique has been applied to a knee subject to an inner meniscectomy by arthroscopy, obtaining good results in the recovery of soft-tissue elasticity and flexibility. After the treatment, both active and passive mobility of femoro-tibial and femoro-patellar articulations were objectively improved, as verified by goniometry and sonoelastographic images. The results presented in this case only correspond to the patient treated, other patients in similar circumstances could undergo a different response as consequence of their particular characteristics. To establish if these results are due to their medical history, the study should be carried out with comparative control groups that received the treatment and did not. To obtain statistical conclusions, this manual therapy must be applied to other patients after arthroscopic surgery on the knee, and to other types of postsurgical scars. A comparative study with patients treated with different manual therapies would also contribute to understanding the advantages and disadvantages of PTS.
Alburquerque-Garcı´a, A., Rodrigues-de-Souza, D.P., Ferna ´ndez-delas-Pen ˜as, C., Alburquerque-Sendı´n, F., 2015. Association between muscle trigger points, ongoing pain, function, and sleep quality in elderly women with bilateral painful knee osteoarthritis. J. Manip. Physiol. Ther. 38 (4), 262e268. Alpay, Z., Saed, G.M., Diamond, M.P., 2008. Postoperative adhesions: from formation to prevention. Semin. Reprod. Med. 26 (4), 313e321. Audebert, A., Darai, E., Be ´nifla, J.-L., Yazbeck, C., De ´chaud, H., Wattiez, A., Crowe, A., Pouly, J.-L., 2012. Adhe ´rences postope ´ratoires et leur pre ´vention en chirurgie gyne ´cologique: I. Ce qu’il faut savoir. Gyne ´col. Obste ´t. Fertil. 40, 365e370. Bates Jr., G.W., Shomento, S., 2011. Adhesion prevention in patients with multiple cesarean deliveries. Am. J. Obstet. Gynecol. 205 (6), S19eS24. Bordoni, B., Zanier, E., 2014. Skin, fascias, and scars: symptoms and systemic connections. J. Multidiscip. Healthc. 7, 11e24. Chou, L., Hsieh, Y., Kuan, T., Hong, C., 2014. Needling therapy for myofascial pain: recommended technique with multiple rapid needle insertion. BioMedicine 4 (2), 39e46. Daniel, F., 1995. Aspects actuels de la cicatrisation cutane ´e. Kine ´sithe ´r. Sci. 346, 21e29. Duscher, D., Maan, Z.N., Wong, V.W., Rennert, R.C., Januszyk, M., Rodrigues, M., Hu, M., Whitmore, A.J., Whittam, A.J., Longaker, M.T., Gurtner, G.C., 27 June 2014. Mechanotransduction and fibrosis. J. Biomech. 47 (9), 1997e2005. Duviau, F., Robert, L., 1995. Les troubles de la cicatrisation. Kine ´sithe ´r. Sci. 345, 46e58. Ergul, E., Korukluoglu, B., 2008. Peritoneal adhesions: facing the enemy. Int. J. Surg. 6, 253e260. Fourie, W., 2014. In: Chaitow, L. (Ed.), Fascial Dysfunction. Manual Therapy Approaches (Chapter 18). Handspring, UK. Gonza ´lez Lo ´pez, F., Bernal Torres, A.B., 2010. Te ´cnicas de sutura para enfermerı´a. Asepeyo, Madrid. Herna ´ndez Dı´az, C., 2013. Elastografı´a como Me ´todo de Evaluacio ´n de la Biomeca ´nica Muscular. Rev. Chil. Reumatol. 29 (3), 125e134. Henry, R., Cahill, C.M., Wood, G., Hroch, J., Wilson, R., Cupido, T., VanDenKerkhof, E., 2012. Myofascial pain in patients waitlisted for total knee arthroplasty. Pain Res. Manag. 17 (5), 321e327. Klinger, W., Velders, M., Hoppe, K., Pedro, M., Schleip, R., 2014. Clinical relevance of fascial tissue and dysfunctions. Curr. Pain Headache Rep. 18, 439e446. Kobesova, A., Morris, C.E., Lewit, K., Safarova, M., 2007. J. Manip. Physiol. Ther. 30, 234e238. Lewit, K., Olsanska, S., 2004. J. Manip. Physiol. Ther. 27, 399e402. Longmire, D.R., 2006. An electrophysiological approach to the evaluation of regional sympathetic dysfunction: a proposed classification. Pain Physician 9 (1), 69e82. Lyell, D.J., Caughey, A.B., Hu, E., Blumenfeld, Y., El-Sayed, Y.Y., Daniels, K., 2012. Rectus muscle and visceral peritoneum closure at cesarean delivery and intraabdominal adhesions. Am. J. Obstet. Gynecol. 206 (6), 515.e1e515.e5. Marchi-Lipski, F., Duviau, F., 1998. Posibilite ´ de la kine ´sithe ´rapie dans les cicatrices. In: Kine ´sithe ´rapie e Me ´decine Physique e Re ´adaptation. Traite ´ EMC. Elsevier, Paris. Martı´nez Rodrı´guez, R., Gala ´n Del Rı´o, F., 2013. Mechanistic basis of manual therapy in myofascial injuries. Sonoelastographic evolution control. J. Bodyw. Mov. Ther. 17 (2), 221e234. Mayr, H.O., Sto ¨hr, A., 2014. Arthroscopic treatment of arthrofibrosis after ACL reconstruction. Local and generalized arthrofibrosis. Oper. Orthop. Traumatol. 26 (1), 7e18. Mazzocchi, M., Dessy, L.A., Di Ronza, S., Iodice, P., Saggini, R., Scuderi, N., 2014. A study of postural changes after abdominal rectus plication abdominoplasty. Hernia 18, 473e480.
Please cite this article in press as: Alvira-Lechuz, J., et al., Treatment of the scar after arthroscopic surgery on a knee, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.07.013
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6 McSweeney, T.P., Thomson, O.P., Johnston, R., 2012. The immediate effects of sigmoid colon manipulation on pressure pain thresholds in the lumbar spine. J. Bodyw. Mov. Ther. 16 (4), 416e423. Pavan, P.G., Stecco, A., Stern, R., Stecco, C., 2014. Painful connections: densification versus fibrosis of fascia. Curr. Pain Headache Rep. 18, 441e446. Robertson, D., Lefebvre, G., 2010. Adhesion prevention in gynaecological surgery. J. Obstet. Gynaecol. Can. 32 (6), 598e602. Rodriguez, H., Espinoza-Navarro, O., Silva, I., Quiroz, P., Arriaza, C., Sanchez, C., Vallejos, R., Castro, M.E., Arias, M., Jimenez, L., Fernandez, E., 2011. Histological description of the interaction between muscle fibers and connective tissue of the fascia of the human trapezius muscle. Int. J. Morphol. 29 (1), 299e303.
J. Alvira-Lechuz et al. Stecco, C., Tiengo, C., Stecco, A., Porzionato, A., Macchi, V., Stern, R., De Caro, R., 2013. Fascia redefined: anatomical features and technical relevance in fascial flap surgery. Surg. Radiol. Anat. 35 (5), 369e376. Tozzi, P., 2012. Selected fascial aspects of osteopathic practice. J. Bodyw. Mov. Ther. 16 (4), 503e519. Vetrugno, R., Liguori, R., Cortelli, P., Montagna, P., 2003. Sympathetic skin response: basic mechanisms and clinical applications. Clin. Aut. Res. 13 (4), 256e270. Wong, V.W., Longaker, M.T., Gurtner, G.C., 2012. Soft tissue mechanotransduction in wound healing and fibrosis. Semin. Cell Dev. Biol. 23 (9), 981e986.
Please cite this article in press as: Alvira-Lechuz, J., et al., Treatment of the scar after arthroscopic surgery on a knee, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.07.013
MODEL
Journal of Bodywork & Movement Therapies (2016) xx, 1e6
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/jbmt
CASE STUDY
Treatment of the scar after arthroscopic surgery on a knee Jacobo Alvira-Lechuz, Ph, CO a, Mercedes Roca Espiau, MD b, Elena Alvira-Lechuz, D c,* a
Madrid School of Osteopathy, University of Zaragoza, Domingo Miral s/n, 50009 Zaragoza, Spain Dr. Roca Center for Medical Diagnosis, La Carrera del Sa´bado, 4, 50006 Zaragoza, Spain c Department of Physics, University of La Laguna, Avenida Francisco Sa´nchez s/n, 38202 La Laguna, Tenerife, Spain b
Received 21 March 2016; received in revised form 12 July 2016; accepted 26 July 2016
Summary The aim of this paper is to present a treatment for scars based on percutaneous traction. This is a structural technique in which movements are performed against the barriers detected in different planes. The stages of this technique are described in detail along with the results after applying it to a postarthroscopic scar on a knee. The active and passive mobility of femoro-tibial and femoro-patellar articulations improved substantially after the treatment, as verified by signs such as pain relief, greater flexibility, disappearance of inflammation and a major recovery of tissue elasticity. A sonoelastography study of the portals and patellar tendon was carried out before and after therapy, showing semiquantitatively the recovery of the viscoelastic properties of the tissue. ª 2016 Elsevier Ltd. All rights reserved.
Introduction Fascial tissue is organized as a three dimensional network that surrounds, suspends, protects, links and separates the muscular, skeletal and visceral components of the body. It is a dynamic tissue with complex vascularization and innervation, varying in anatomy according to its location (Stecco et al., 2013). Fascia includes contractile
* Corresponding author. Fax: þ34 922318320. E-mail address: [email protected] (E. Alvira-Lechuz).
constituents that allow it to modulate forces and to adjust mechanosensitivity in a precise way. Any imbalance in this mechanism of myofascial tone control or reduction in neuromuscular coordination is revealed by musculoskeletal pathology and pain syndromes (Henry et al., 2012; Alburquerque-Garcı´a et al., 2015). Fascia can undergo strains with the resultant mechanical and physiological effects. In consequence, some fascial therapeutic techniques have been developed to liberate stress, relieve pain and restore functionality. Such approaches are based on studies that have analyzed the plastic, viscoelastic and piezoelectric properties of connective tissues (Tozzi,
http://dx.doi.org/10.1016/j.jbmt.2016.07.013 1360-8592/ª 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Alvira-Lechuz, J., et al., Treatment of the scar after arthroscopic surgery on a knee, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.07.013
+
MODEL
2 2012). These modeling techniques have been tested in some cases by sonoelastography, which is able to discriminate different degrees of tissue density, elasticity and hardness. Sonoelastography (SE) is used nowadays in several health fields to diagnose illnesses or as an instrument to measure changes in tissue viscoelasticity after applying manual fascial therapy (Martı´nez Rodrı´guez and Gala ´n Del Rı´o, 2013; Herna ´ndez Dı´az, 2013).
Treatment of scars From an embryological perspective, both skin and fascia arise from the mesoderm, which also gives rise to connective tissue (Bordoni and Zanier, 2014). One of the most important relationships between skin and the rest of body is through the sympathetic nervous system. Its efferent fibers come from the hypothalamus and descend through the ipsilateral brainstem and medulla to the spinal cord, where they meet other (preganglionic) neurons (Vetrugno et al., 2003; Longmire, 2006). Afferent sensory fibers also convey skin properties such as temperature, proprioceptive control or motor strength pattern to the hypothalamus. In this way, the hypothalamus integrates the received information and orchestrates the most appropriate thermoregulation, endocrine responses and postural changes. In short, the cerebellum is stimulated by skin (Bordoni and Zanier, 2014; Vetrugno et al., 2003; Longmire, 2006). Therefore, the skin facilitates the perception and location of mechanical impulses such as pressure, friction, vibration, temperature or pain via the central and peripheral nervous system, by means of independent nerve endings and specialized receptors (Bordoni and Zanier, 2014; McSweeney et al., 2012; Rodriguez et al., 2011; Tozzi, 2012). Every cell or tissue generates substances that allow it to communicate and relate with other body parts, however distant. Skin is no different, in that when its continuity or healing processes are disturbed, it also gives rise to noncutaneous symptoms (Bordoni and Zanier, 2014). Therefore any skin injury like a scar, even if small, affects the organism and constitutes an active obstacle to its normal functioning. Scars actively influence organs, structures and systems throughout life, besides altering their natural development and functioning (Kobesova et al., 2007; Lewit and Olsanska, 2004). Once formed, scars involve changes, stiffness, loss of mobility, i.e. dysfunctions, which have repercussions on both the zone where the continuity loss is located and more distant zones. There is a proportional relationship between scars and body adaptations with time, and inversely with distance. Thus, the longer the time after the scar appeared, the more body adaptations occur; on the other hand scars affect more distant tissues to a much lesser extent. The new-formed scar tissue has different properties from the replaced connective tissue. A new disordered interlaced network is formed, which generates adherences to organs, vessels, nerves and can even affect whole systems. Mechanotransduction refers to how mechanical forces give rise to biochemical stimuli. This process is strongly related to inflammation, fibrosis and scarring (Duscher et al., 2014). After any type of surgery, even the least invasive, scar tissue should be treated to minimize the loss
J. Alvira-Lechuz et al. of mobility, density change capacity and viscoelasticity due to adherences and fibrosis (Duscher et al., 2014; Pavan et al., 2014; Mayr and Sto ¨hr, 2014; Wong et al., 2012). This loss varies between individuals and body zones subject to surgery; for instance it is known that the abdominopelvic and lumbar zones are among the most liable to suffer adherences and consequent sequels (Lyell et al., 2012; Alpay et al., 2008; Robertson and Lefebvre, 2010; Audebert et al., 2012; Ergul and Korukluoglu, 2008). It is easy to understand that the more scars people develop, the more consequences, especially in the same body area (Mazzocchi et al., 2014; Bates Jr. and Shomento, 2011). Therefore it is necessary to study the possible treatments for this type of dysfunction (Fourie, 2014; Klinger et al., 2014; Chou et al., 2014). For example, those proposed for postsurgical scars based on manual therapy (Marchi-Lipski and Duviau, 1998; Daniel, 1995; Duviau and Robert, 1995), giving them the consideration they deserve. These authors pointed out that the shape and time of healing of scars is fundamental to know when they should be treated, so as to obtain the best results. Skin presents more or less elastic areas, depending on the organization of collagen fibers. The lines formed in these areas, named Langer or ‘least stress’ lines, usually correspond to wrinkles and lie perpendicular to the contraction of local muscles (Gonza ´lez Lo ´pez and Bernal Torres, 2010). These lines must be taken into account when a surgical incision is made, since they determine the final shape of scars. The aim of the present article is to put forward a therapeutic technique to treat postsurgical scars. It is applied in a case study of a knee after inner meniscectomy by arthroscopy. Treatment efficiency is confirmed by a sonoelastographic study and by the increased articular mobility, improvement in tissue elasticity and absence of pain.
Sonoelastography Based on elasticity or Young’s modulus measurements of different tissues by means of ultrasound, this is a useful tool to identify pathological injuries arising from a loss of standard elastic properties of tissues such as atrophy, fat deposition or fibrosis. SE superimposes a parametric colored image (representing the deformation capacity of tissues) over the ultrasound anatomical scan images in a range of grays: soft tissues develop a greater capacity to become distorted, while more rigid tissues obviously present less elasticity. Initially SE was used to identify neoplasic breast tissue, in recent years it has become a useful tool to determine muscular activity in a non-invasive way. It is applied to evaluate traumatic muscular injuries, painful myofascial symptoms, Achilles tendinopathy, epicondylitis, etc. (Herna ´ndez Dı´az, 2013). The resulting image reflects tissue density, elasticity and stiffness by means of software that semiquantitatively correlates a chromatic spectrum (from blue to red) with tissue elasticity. Thus, a blue color corresponds to inelastic areas, red to viscoelastic tissues, and intermediate values of rigidity are represented by other spectral colors (Herna ´ndez Dı´az, 2013). In the present study, SE was used to show the importance of manual therapy in postsurgical scars, even the smallest (Martı´nez Rodrı´guez and Gala ´n Del Rı´o, 2013; Herna ´ndez Dı´az,
Please cite this article in press as: Alvira-Lechuz, J., et al., Treatment of the scar after arthroscopic surgery on a knee, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.07.013
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Treatment of the scar after arthroscopic surgery on a knee
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2013). The elastography equipment used was a Hitachi EUB8500 system comprising a SonoElastography module and a 13 MHz ultrasound probe. A sonoelastographic study of the portals and patellar tendon was made before and after the therapeutic manual treatment, showing tissue elasticity and fibrosis through real-time imaging (Klinger et al., 2014; Martı´nez Rodrı´guez and Gala ´n Del Rı´o, 2013).
b) Later, the affected zones presenting less mobility, sliding capacity and viscoelasticity were manually detected by low intensity tractions with the first and second finger (Fig. 1a). PTS was applied first to tissues further from the articulation, gradually approaching scars and more fibrotic areas, and persisting in those with greater restriction of movement (Fig. 1b). The technique was limited to each zone in turn until the strain decreased or disappeared. c) Once greater elasticity was observed in tissue near the scar, the traction force was intensified to liberate all the inner structures of the affected zone. d) Finally this technique was applied for 5 sessions during two weeks, concentrating particularly on the portals and fibrotic tissue until they presented greater elasticity.
The method The treatment described in this article was applied to a patient subject to inner meniscectomy by arthroscopy. The access points were the anteromedial and anterolateral portals, which were closed by 2 sutures. Antithrombotic measures were adopted after leaving the operating theater, consisting of a compression stocking from groin to foot and anticoagulant treatment with subcutaneous heparin for 10 days. The patient spent the night at home after the operation and the articulation was not immobilized; this permitted walking with sticks with some weight on the operated leg. Several days later, after the healing period, sutures were removed and replaced by adhesive dressings, the wounds were properly treated and physiotherapy started 21 days after surgery. A stiffened patellar tendon was detected at the first physical examination, as well as loss of kneecap mobility in craneo-caudal and laterolateral directions. Palpation on the postsurgical scar was painful in particular at medial level, detecting limited mobility of newly formed fibrotic tissue. Goniometry of the knee showed an active flexion up to 80 and an active straightening of about 3 .
Results and discussion The active and passive mobility of both femoro-tibial and femoro-patellar articulations substantially improved after the treatment, as shown by several objective measures. Pain: The patient reported a progressive recovery of the symptoms throughout the therapy. In particular, the pain and hypersensibility at the medial arthroscopic portal became detectably milder. On the EVA scale, the patient started with a value of 6 and finished at 2.
Manual therapy (Percutaneous Traction on Scars) The manual therapy presented here is an application of manual techniques previously described (Fourie, 2014). It is based on performing percutaneous traction (Percutaneous Traction on Scars PTS), gently and superficially at the beginning then gradually increasing its intensity, which allows access to deeper tissues and structures. Traction is applied in search of restricted tissue mobility in caudal and craneal directions, then lateral and medial, clockwise and anticlockwise. PTS is characterized by being a structural, not a functional technique, in which movements are made against the barriers detected in various planes. Some articular strokes can be simultaneously carried out with arcs of varying angles. The patient can contribute to increasing the tension by deep inspirations and expirations, depending on the area to be treated. If necessary, muscle stretching or other manual therapy may be carried out during the PTS to complete the treatment. In any case, the therapist can improve the effects of the described technique with the aid of the concept of overall handling. The treatment consisted of the following phases: a) Firstly, lymphatic drainage of the whole affected limb was carried out to reduce the inflammatory reaction to surgery.
Figure 1 a) Low intensity tractions with the first and second finger to detect the affected zones. b) PTS applied to tissues further from the articulation.
Please cite this article in press as: Alvira-Lechuz, J., et al., Treatment of the scar after arthroscopic surgery on a knee, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.07.013
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4 Flexibility: On exploration after treatment, the patient presented a wider active arc on both flexing and straightening the knee. Initially the active flexion was less than 80 (Fig. 2a) while at the end of therapy it reached 140 , as shown in Fig. 2b. Straightening began at 3 and reached 0 (Fig. 3), which is the capacity of movement of a normal functional knee. The tibia was able to rotate over the femur without limits, suggesting that there were no other stiffened periarticular tissues. The kneecap could move freely in every direction (craneo-caudal and latero-lateral), as shown in Fig. 4. Greater elasticity was detected in tissue at the portals, allowing traction on them without the rigidity felt by the therapist’s fingers before starting the treatment. Inflammation: The signs of inflammation and stiffness in other periarticular zones gradually became fewer as the sessions advanced (Fig. 5). Elasticity: Before applying the manual therapy, a sonoelastographic study of the portals and patellar tendon was performed, which showed a blue image (in the web
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Figure 4 direction.
Knee mobility after the treatment.
Movement of the kneecap in the latero-lateral
Figure 5 Inflammatory and stiffened signs after the treatment.
Figure 2 Active flexion of knee a) before treatment b) afterwards.
version) (Fig. 6a) representing tissue with total loss of elasticity. After the treatment, a new sonoelastographic study found a more differentiated and reorganized state of the tissue in scars and stiffened zones (Fig. 6b), a positive result given the previously large amount of blue shown in the SE. This was typical of normal soft tissue, indicating recovery of viscoelastic properties.
Please cite this article in press as: Alvira-Lechuz, J., et al., Treatment of the scar after arthroscopic surgery on a knee, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.07.013
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References
Figure 6 Sonoelastographic images a) before the treatment b) afterwards.
Conclusions A manual therapy for treatment of postsurgical scars (Percutaneous Traction on Scars) has been developed. It is a useful tool that fulfills a fundamental role in the physiotherapeutic treatment of operated zones. The technique has been applied to a knee subject to an inner meniscectomy by arthroscopy, obtaining good results in the recovery of soft-tissue elasticity and flexibility. After the treatment, both active and passive mobility of femoro-tibial and femoro-patellar articulations were objectively improved, as verified by goniometry and sonoelastographic images. The results presented in this case only correspond to the patient treated, other patients in similar circumstances could undergo a different response as consequence of their particular characteristics. To establish if these results are due to their medical history, the study should be carried out with comparative control groups that received the treatment and did not. To obtain statistical conclusions, this manual therapy must be applied to other patients after arthroscopic surgery on the knee, and to other types of postsurgical scars. A comparative study with patients treated with different manual therapies would also contribute to understanding the advantages and disadvantages of PTS.
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Please cite this article in press as: Alvira-Lechuz, J., et al., Treatment of the scar after arthroscopic surgery on a knee, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.07.013