SCAR TISSUE OR FIBROSIS?
(THE MICROSCOPIC STRUCTURE OF THE SCAR)
"Scar tissue is composed of the same protein (collagen) as the tissue that it replaces, but the fiber composition of the protein is different; instead of a random basketweave formation of the collagen fibers found in normal tissue, in fibrosis the collagen cross-links and forms a pronounced alignment in a single direction. This collagen scar tissue alignment is usually of inferior functional quality to the normal collagen randomized alignment."
The first thing I want to do is discuss the word 'random'. When I look at Webster's 1828, I see that the word's definition is, "A roving motion or course without direction; hence, want of direction, rule or method; hazard; chance; used in the phrase, at random that is, without a settled point of direction; at hazard. Done at hazard or without settled aim or purpose; left to chance; as a random blow. Without previous calculation...." Wikipedia itself defines randomness as, "the lack of pattern or predictability in events. A random sequence of events, symbols or steps has no order and does not follow an intelligible pattern or combination. Individual random events are by definition unpredictable."
Now; take a good look at the pictures of baskets found both above and below and tell me what you see. Are these baskets woven in a manner that could, in any rational sense of the word, be considered "random"? Absolutely not. And not only are they not random, they are highly ordered / organized. I would argue that rather than the purposeless of randomness when healthy, soft tissues become random after injury and / or insult. But.........
A perfect example of this is Scar Tissue itself. Although you might debate, I would argue that the model I use to explain SCAR TISSUE to my patients, whether right or wrong, has no real bearing on the results of their treatment. The proof? Take a look at our TESTIMONIAL PAGE. But because testimonials are anecdotal and I don't blame you for wanting cold hard facts, allow me to give you just a few.
- Active Recovery Boston has a fantastic primer on Scar Tissue and the harm it's capable of. "Scar tissue. Adhesion. Fibrosis. The words are different, but the concepts are the same. This dense, fibrous tissue affects us all and is an underlying factor in many injuries. Scar tissue binds up and ties down tissues that need to move freely. As scar tissue builds up, muscles become shorter and weaker. Tension on tendons causes tendinosis. Nerves can become trapped. All these problems can cause reduced range of motion, loss of strength, and pain as well as tingling, numbness, and weakness."
- Physical Therapist Brett Sears wrote a piece called Scar Tissue: Physical Therapy Management. In it he presented an excellent overview of the entire process (cherry-picked of course). "The cellular makeup of collagen makes it very strong due to the alignment of collagen cells. It can resist tensile forces, such as stretching and pulling, without tearing or breaking. After injury to a muscle, tendon, skin, or ligaments in the body, the inflammatory process starts to heal the injury site. Unfortunately, the body does not know exactly how to arrange the collagen cells so that they become healthy tissue that can resist tensile and stretching forces. The collagen cells become a balled-up clump of tissue called scar tissue. The scar tissue can become stronger and better able to tolerate stretching forces through a process called remodeling. Remodeling scar tissue is a must to ensure that the muscle, tendon, skin, bone, or ligament becomes normal, healthy tissue again. Scar tissue remodeling occurs as you start to stretch and pull on it. The stretching of the scar tissue helps to align the collagen fibers to allow them to return to normal. This realignment of the collagen fibers makes the tissue better able to tolerate the forces that are placed on it during the day."
- When we look at pictures of Scar Tissue that were taken under a microscope, they always seem to look more random than normal tissue. Case in point, HERE.
- The website Microscopy U carries a picture of Scar Tissue that was taken at a magnification of 10X. The caption states, "The most familiar scars appear on the surface of the skin, though they also can develop on tissues located inside the body. Scar formation is a natural process that results from replacement tissue being somewhat structurally and functionally different than the original tissue that was injured. The poor elasticity of scar tissue can limit movement in areas of the body that were extensively damaged."
- Writing for the April, 2003 edition of a magazine for HORSE ENTHUSIASTS, Equus, Ruth Ann Mosby wrote, "Only a never-injured horse is an unscarred horse, for the inalterable reality of mammalian life is that repaired tissue is inferior to the original."
- Plastic surgeon David Sherris wrote in an article called Management Of Scar Contractures, Hypertrophic Scars, and Keloids that, "Wound contraction is a normal phase in cutaneous wound healing by which the edges of a wound are pulled toward the center of the wound itself." I extensively dealt with this phenomenon HERE.
- Another plastic surgeon, Dr. Mark Gold, writes in Scars: Why They Form and How to Treat Them, "Every wound takes up to two years to heal. The process is the same for a scratch and a tummy tuck. The wound seals it self in 24-48 hours... From six moths to two years the final collagen organization is taking place". This is critical to understand if you have been injured in an MVA, as insurance companies will tell you that these sorts of injuries should be healed in 6-8 weeks. The truth is, they should be --- all but the final and most important of the phases' the 'Remodeling Phase'. CLICK HERE for information about the various stages of the healing process for soft tissues.
- Breast Cancer dot org (Scar Tissue Formation) said on their site that, "Scar tissue can cause its own side effects. Nerve pain or numbness if scar tissue forms around nerves. A lump of scar tissue forms in the hole left after breast tissue is removed. If scar tissue forms around a stitch from surgery it's called a suture granuloma and also feels like a lump." I have seen any number of THESE over the years in any number of anatomical places. The article above, however, was geared specifically at those who have had BREAST SURGERY.
The bottom line is that no matter what it actually looks like under a microscope, Scar Tissue does not function as well as normal tissue on any level. It is essentially the body doing the best it can with what it's got to work with. The problem is, there will always be, at least to some degree, consequences. For one, there will always be a loss of ROM. Often this is obvious to the patient, but in almost as many cases, they have no idea they have lost as much range of motion as they have (and some people --- particularly younger women or girls, can have scar tissue building up with a normal ROM --- HERE).
In similar fashion to the way that Scar Tissue "blocks off cell communication and regeneration," it hinders the flow of oxygen as well. A failure to oxygenate is known as hypoxia and because it causes ACIDITY, is a known cause of tissue damage and subsequent Scar Tissue (not to mention NUMEROUS DISEASE STATES). As you can see, a very vicious cycle. Furthermore, hypoxia promotes the accumulation of FREE RADICALS in the soft tissues themselves. But not even this is where it ends.
The loss of function (the fifth sign of Inflammation known as "Functio Laesa") promotes even more injury. Because much of said injury is relatively quiet (mechanical stresses over time), it can slowly accumulate until it is as significant as a traumatic injury. I like to describe this phenomenon in terms of splitting a piece of wood by hand. To split said piece of wood you can pick up your 15 lb Monster Maul and take one massive lick, blowing the one piece apart into two pieces with a violent force. Or you can use wedges that you gently tap with a three pound hammer for weeks on end. The end result is the same. The only difference is that the first piece of wood split instantly.
Finally, according to Dr. Chan Gunn, the famed neurologist and clinical professor at University of Washington, the result can be extreme hypersensitivity to pain (HERE). "The definition used by the International Association for the Study of Pain is: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described by the patient in terms of such damage”. But this definition can be misleading because pain, the central perception of noxious input, is not just one, but at least three distinct entities, and pain can also arise when there is no apparent tissue damage." If you are struggling with Chronic Pain, I would suggest you read his article in its entirety (WHAT IS PAIN?). BTW, Gunn is an expert in acupuncture and widely considered the father of modern DRY NEEDLING.
What does pain, inflammation, altered reflexes, loss of motion, and loss of function always lead to? Degeneration (HERE). This degeneration is multifaceted. I showed you right at a year ago that the number one way to stimulate your nervous system is via exercise (HERE). Although Gunn talks about neurodegeneration in his article above, a loss of function is also going to cause bony / joint degeneration (HERE). The problem is, degeneration, no matter where its found, always leads to diminished function, which in turn causes more degeneration. The secret is finding the right monkey wrench to throw in the right gears that will stop the machine from turning.
There are any number of ways to help beat this process. EXERCISE, TISSUE REMODELING, DRY NEEDLING, CHIROPRACTIC ADJUSTMENTS, THERAPY, ACUPUNCTURE, LASER THERAPY, FUNCTIONAL NEUROLOGY, NUTRITIONAL SUPPLEMENTS, etc, etc, etc. However, I tend to think that there is one area that is overlooked the majority of the time --- probably because it is the most difficult on the list. To truly have a prayer at getting better, you are probably going to have to address the Chronic Inflammation in your life (HERE).
The crazy thing is, this Inflammation might be coming at you in any number of ways, as it can take the form of PARASITES, BLACK MOLD, CHEMICAL EXPOSURE, SUBCLINICAL INFECTIONS, DENTAL ISSUES, GUT HEALTH ISSUES, HEAVY METAL TOXICITY, etc, etc, etc. However, besides studying and learning everything you can about your condition, the first thing you can do for yourself is to radically change your diet (HERE). Fortunately, this alone will solve huge numbers of cases (HERE is an example).
As you are starting to learn, Scar Tissue and Fibrosis are a huge deal --- especially considering that they frequently don't show up on MRI's, CT, or other forms of advanced imaging (see yesterday's post). If you want to share this info with others, the easiest way is simply by using FACEBOOK.