Scar adhesion, why and how.

Adhesion is like a nightmare to physiotherapists, it is a result of tissue remodeling and is hard to deal with.
We always tell our patients:
“Keep shoulders in mobile to prevent capsule adhesion.”
“Be sure to massage your surgery wound once it is closed up.”
“Light exercise right after surgery is good for wound healing.”

I am sure that some of you may still be confused why it is so important to prevent adhesion. Keep reading to know why.

Where does scar adhesion take place?

To be simple, scar adhesion happens at any wound area. Including surgical wounds and wounds from accidents. Here are some examples:

1. Adhesive capsulitis (ie. frozen shoulder)
2. Adhesion Ileus (adhesion around the intestines, it happens in 93% of people who underwent abdominal operation)
3. Intrauterine adhesions (happens in 37% of women after cesarean section)
4. Post-spinal operation adhesion (the pain is unbearable)
5. Burn wounds adhesion (especially those with large burning areas)
6. Endoscopic wound adhesion (it commonly happens in ACL reconstruction patients)

During the process of scar adhesion, the wound slowly forms a hard block, decreasing blood circulation. In addition, the scar makes the skin, muscles and fascia hard to glide normally, making the circulation even worse.

When the wound is deep, scar adhesion may involve at many dermal layers.

Scar adhesions can cause problems, such as:

＊Decreasing joint range of motion (making daily activities harder).
＊Making the wound area tight and uncomfortable.
＊Decreasing visceral activity (Gastroesophageal reflux, digestive problems)
＊Increasing muscle tone imbalance.
＊Increasing the sensitivity of pain.
＊Impairing the circulation system (cold hands and feet).

If you wonder why it is still uncomfortable after surgery, even the wounds are closed up already, scar adhesion is the reason!

Photo by Ozkan Guner on Unsplash

How does adhesion works?

First, you have to know the correct process of wound healing.

1. Inflammatory phase (2 — 5 days post injury):
   Clotting occurs to obtain hemostasis.
   Enhancing vasodilation to increase healing rate and metabolism.
   Immune system operates to break down bacteria.
2. Proliferative phase (5 days—3 weeks post injury):
   The body provides adequate oxygen and nutrients to continue the healing process.
   The wound contraction begins, fibroblast synthesize collagen type III to resurface the wound.
3. Remodeling phase (3 weeks — 2 years post injury):
   Collagen and degradation are equalized.
   Collagen are remodeled from type III to type I (type I collagen provide more tissue stability)

Scar adhesion occurs at the second and third phase.

There are 2 main reason to scar adhesion

First — hypoxia, insufficient blood supply

During the initial inflammatory process, wound sites are often hypoxic, due to disruption of vasculature surrounding the wound. This enhance the proliferation of dermal fibroblasts, which is essential for wound healing. However, if the situation of hypoxia continues, it can effect the wound.

Normal tissue growth rate are disturbed under long-term hypoxia environment. The rate of tissue growth and breakdown are imbalanced, causing excess tissue proliferation and adhesion.

Second — chronic inflammation

COX-2 enzyme is located at the inflammatory site, which can induce pain, heat, redness and swelling reaction. It has been found that, the expression of COX-2 is significantly increased in adhesion fibroblasts compared with that of the normal fibroblasts.
If inflammation goes into chronic, adhesion is more likely to occur.

Photo by Possessed Photography on Unsplash

How to avoid scar adhesion?

1. Massage and fascia mobilization
   Evidences show that massage and fascia mobilization is beneficial to decrease scar adhesion. It is suggested that massage intervention around the wound can be applied at about 3 weeks post injury.
2. Adequate exercise/ mobility
   This is beneficial for increasing tissue circulation and decreasing inflammation. In addition, mild stretching and range of motion exercises is recommended for scars around joints.
3. Think twice before receiving surgery
   Scar adhesion is a side effect of surgery, thus, it must be taken into consideration.

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References：
Hong WX, Hu MS, Esquivel M, Liang GY, Rennert RC, McArdle A., et al. The Role of Hypoxia-Inducible Factor in Wound Healing. Adv Wound Care (New Rochelle). 2014,1;3(5): 390–9.

Alpay Z, Saed GM, Diamond MP. Postoperative adhesions: from formation to prevention. Semin Reprod Med. 2008;26(4):313–21.

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):262–9.