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[libribook.com] Traumatic Scar Tissue Management 1st Edition
Nerve density in pathophysiological scarsDuring wound healing, scar tissue becomes both vascularized and innervated(Bove & Chapelle 2012). Under, over or aberrant innervation can potentially beproblematic.Example 1: as sensory nerves play a role in modulating immune response,denervated skin exhibits reduced leukocyte infiltration leading to impairedfirst line of defence, constituting a kind of no one minding the storepredicament (Galkowska et al. 2006, Sibbald & Woo 2008).Example 2: it is suggested that increased density of substance P and CGRPresponsive fibers is associated with chronic pain and pruritus (Henderson et al.2006, Scott et al. 2007, Almarestani et al. 2008, Cheng et al. 2011, Hamed etal. 2011, Widgerow 2013).In healing wounds, it appears that regeneration of nerve fibers correlates withepithelialization during healing. Immediately following injury, the wound bed isdevoid of nerves. Gradually, nerve fibers localize to the edges and later to thecenter of the wound beds. By 14 days post-injury, burn wounds displayexcessive numbers of nerve fibers (hyperinnervation) below the advancingepithelium. In normal wound healing, these numbers normalize with time andafter 4 weeks, the distribution of nerve fibers in re-epithelialized areas is similarto that of normal skin (Dunnick et al 1996, Scott et al. 2007).Innervation density is not the exclusive consideration in terms of restoration ofnormal neural responsiveness. It has been suggested that loss of sensory functionin pathophysiological scars is not so much due to diminished re-innervation butmore to do with aberrancies in nerve function within the scar or from changes inthe perception of stimuli (e.g. sensitization and plasticity changes). It has alsobeen suggested that a change in tissue structure (e.g. decrease in pliability in thetissues around, near or associated with the nerve) results in sensory deficits(Anderson et al. 2010).
Clinical ConsiderationSome pathological scars differ neurologically from normal tissue.Neurologically active scars can subtly alter or inhibit spinal motion andabnormal joint motion can contribute to pain. Pain of this nature can berelieved by treating neurologically active scars in the abdominal and pubicregion (Kobesová et al. 2007).Hypertrophic scarsHypertrophy of a scar is accompanied by hypertrophy of noci-responsive nerveswithin the scar. Hypertrophic scars exhibiting a greater number of nociresponsivefibers, presented with more serious pathologies (Derderian et al.2005).Aberrations in the re-innervation of scars may either cause aberrant woundhealing or neural hypertrophy may be a result of disturbed interplay in woundhealing mechanisms such as excessive concentrations of NGF and unduemechanical tension, as noted previously (Zhang & Laato 2001, Xiao et al. 2013).Pruritus associated with hypertrophic scars involves a complex interactionbetween the CNS, PNS and skin. Pruritus not only accompanies hypertrophicscars but is also thought to contribute to the development of hypertrophic scars.In addition to itch being caused by histamine, neurokinin, tachykinins,bradykinin and neuropeptides, peripheral nerve damage may be central to theburn injury itch syndrome and may be a central component contributing tohypertrophic scar development. Various neuropeptides are released in responseto injury activate mast cells, which release kinins, histamine and other agents,which in turn excite nociresponsive-fibers leading to exaggerated neurogenicinflammation. Fourteen days post-injury, a rebound increase in substance Presponsive nerve fibers is observed in pathophysiological scars. It is suggestedthat this exaggerated re-innervation is associated with pruritus and thedevelopment of hypertrophic scars. Therefore, attenuating pruritus not only
- Page 428 and 429: Magee DJ (2008) Orthopedic physical
- Page 430 and 431: Stecco C, Porzionato A, Macchi V et
- Page 432 and 433: CHAPTER 5Wound healing and scarsNev
- Page 434 and 435: Wound HealingWound healing, a compl
- Page 436 and 437: Table 5.1Stages of wound healing
- Page 438: Clinical ConsiderationBecause thera
- Page 441 and 442: fibroblast growth factor (FGF), epi
- Page 443 and 444: Clinical ConsiderationDuring wound
- Page 445 and 446: Clinical ConsiderationAlthough the
- Page 447 and 448: Pathophysiological ScarsPathophysio
- Page 450 and 451: Figure 5.3Adapted from Huang et al.
- Page 452 and 453: Pathophysiological considerationFib
- Page 454 and 455: Table 5.2Important pathophysiologic
- Page 456 and 457: According to Klingler (2012):… pa
- Page 458 and 459: Table 5.3Scar types and related ter
- Page 460 and 461: unyielding or pliable and mobile. R
- Page 462 and 463: Prolonged InflammationInflammation
- Page 464 and 465: ImmobilizationThe impact of immobil
- Page 467 and 468: Figure 5.4The fall-out associated w
- Page 469 and 470: Clinical ConsiderationHere we see t
- Page 471 and 472: Pathophysiological ConsiderationAcc
- Page 473 and 474: Pathophysiological ConsiderationNeu
- Page 475 and 476: The diverse biological effects of N
- Page 477: Clinical ConsiderationCareful appli
- Page 481 and 482: Pathophysiological ConsiderationSom
- Page 483 and 484: compressive effect in the keloidal
- Page 485 and 486: alterations in the mechanical envir
- Page 487 and 488: Clinical ConsiderationMechanical fo
- Page 489 and 490: Table 5.4Role of neuropeptides (NP)
- Page 491 and 492: Fitch P (2005) Scars of life. Journ
- Page 493 and 494: Langevin HM (2006) Connective tissu
- Page 495 and 496: active scars. Journal of Bodywork a
- Page 497 and 498: trauma.
- Page 499 and 500: Clinical ConsiderationPostsurgical
- Page 501 and 502: following burn injury,bacterial col
- Page 503 and 504: Table 6.1Comparison of scars (Ogawa
- Page 505 and 506: Pathophysiological ConsiderationAcc
- Page 507 and 508: BurnsA burn injury to the skin or o
- Page 510 and 511: Figure 6.1Depth of burn trauma and
- Page 512 and 513: • Stimulate ECM formation• Regu
- Page 514 and 515: Clinical ConsiderationIt has been i
- Page 516 and 517: Clinical ConsiderationMT may be a v
- Page 518 and 519: ThermoregulationThermoregulation (t
- Page 520 and 521: from the tissues and taken up by th
- Page 522 and 523: treatment strategies are difficult
- Page 524 and 525: Clinical ConsiderationSkin rolling
- Page 526 and 527: Sequelae and ComplicationsAdvances
Clinical Consideration
Some pathological scars differ neurologically from normal tissue.
Neurologically active scars can subtly alter or inhibit spinal motion and
abnormal joint motion can contribute to pain. Pain of this nature can be
relieved by treating neurologically active scars in the abdominal and pubic
region (Kobesová et al. 2007).
Hypertrophic scars
Hypertrophy of a scar is accompanied by hypertrophy of noci-responsive nerves
within the scar. Hypertrophic scars exhibiting a greater number of nociresponsive
fibers, presented with more serious pathologies (Derderian et al.
2005).
Aberrations in the re-innervation of scars may either cause aberrant wound
healing or neural hypertrophy may be a result of disturbed interplay in wound
healing mechanisms such as excessive concentrations of NGF and undue
mechanical tension, as noted previously (Zhang & Laato 2001, Xiao et al. 2013).
Pruritus associated with hypertrophic scars involves a complex interaction
between the CNS, PNS and skin. Pruritus not only accompanies hypertrophic
scars but is also thought to contribute to the development of hypertrophic scars.
In addition to itch being caused by histamine, neurokinin, tachykinins,
bradykinin and neuropeptides, peripheral nerve damage may be central to the
burn injury itch syndrome and may be a central component contributing to
hypertrophic scar development. Various neuropeptides are released in response
to injury activate mast cells, which release kinins, histamine and other agents,
which in turn excite nociresponsive-fibers leading to exaggerated neurogenic
inflammation. Fourteen days post-injury, a rebound increase in substance P
responsive nerve fibers is observed in pathophysiological scars. It is suggested
that this exaggerated re-innervation is associated with pruritus and the
development of hypertrophic scars. Therefore, attenuating pruritus not only
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