Deep skin defects resulting from burns, necrosis or severe soft tissue trauma can significantly restrict patients’ overall mobility. Fibers and cells responsible for elasticity and mobility are mainly located in the dermis. For that reason, a loss of this layer leads to massive limitations (scar contractures). Appropriate mechanical stimuli can have a positive influence on the scar tissue. Thus, manual scar treatment requires a dosage adapted to the tissue physiology and to the healing phases. There isn’t an easy answer to the following questions: which dosage should be applied in which phase of healing and when? An article published in 2020 by a specialist in the rehabilitation and reintegration of accident victims attempts to answer those questions.

THE HEALING PROCESS

The healing process helps to restore the integrity of the skin as quickly as possible. This is essential for survival as the skin protects against infection and prevents fluid loss.
Wound healing can be divided into 3 stages:

Inflammatory phase: until day 6

Proliferation phase: until day 21

Remodeling phase: until day 21

In patients with deep dermal and large-area defects such as burns, the healing phases last much longer. Furthermore, depending on the depth and size of the defect, scar areas are never in the same healing phase. In this process, fibroblasts are key players: they will transform into myofibroblasts whose task is to close the wound. Morphologically, myofibroblasts are characterised by the presence of a fibrous protein, alpha-SM actin, allowing them to contract four times more than normal fibroblasts. After wound closure, myofibroblasts die. This phenomenon is not yet fully explained. What is certain is that myofibroblasts do not die during pathological scarring (hypertrophic or keloid scars).

 

Fibroblasts have the ability to respond to mechanical stimuli. This is known as mechanotransduction or the transformation of a mechanical signal into a biological response. Mechanical stimulation applied by physiological movement or manual therapy is detected by mechanosensors on the cell surface. The signal is transmitted inside the cell via its skeleton (cytoskeleton) to reach the nucleus and trigger the production of proteins necessary for healing, in particular collagen. The aim of manual therapy is to apply physiological stimuli as appropriately as possible in each phase of healing process.

 

Tissue reactions are different depending on the dose
of mechanical stimulation:

1. A deep skin lesion causes a defective site in the collagen network, the extracellular matrix is torn and repair processes take place.

2. In the proliferation phase, the fibroblast synthesises type III collagen. Without mechanical stimulation from the outside, this collagen is not functionally aligned in the extracellular matrix.

3. With adequate and functional external mechanical stimulation, the collagen aligns itself. This has a decisive advantage, because in the remodeling phase type I collagen is aligned in exactly the same way as the existing collagen.

4. If too much mechanical stimulation is applied during the proliferation or remodeling phase, damage occurs at the cellular level. A new unwanted inflammatory reaction with overproduction of tissue occurs.

In the end, an adequate dosage of manual therapy is a basic requirement in order to be able to initiate the correct healing processes at the cellular level. Overstimulation inevitably leads to cellular damage and triggers a new inflammatory reaction with all the deleterious consequences.

WHAT IS THE RIGHT DOSAGE FOR AN OPTIMAL STIMULATION?

 

In order to apply adequate stimulation, amplitude, duration and frequency are important parameters that must be taken into account in relation to the healing phase. Given that mechanotransduction cellular responses are already initiated by minimal forces, functional alignment of the extracellular matrix is already achieved with very gentle manual therapies. In terms of frequency, a slight stretch is recommended with an intermittent oscillation of 0.2 cycles per second. Regarding duration, good results can be obtained with application times of one minute per location, once or twice a day.

 

GIVEN THAT, WHAT ABOUT  medical endermologie® TREATMENTS?

 

LPG Systems is the world leader in cellular stimulation and has been studying mechanotransduction on the whole body for more than 35 years (circulatory, trophic, anti-fibrosis and analgesic effects). A study on the fibroblast carried out with Pr. Philippe HUMBERT, has shown that medical endermologie® sessions activated the fibroblast with evidence in the papillary dermis of the protein that characterises myofibroblasts, alpha SM actin. LPG Systems is also a precursor in the mechanical treatment of scars with a collaboration of more than 35 years with the Ster Center in Lamalou Les Bains, which has become the European reference center for the treatment of severe burns.

A wide range of extremely fine and precise settings, allows constant adaptation to the healing phases and provides the right dosage for an optimal stimulation.

 


SOURCES:
  • Koller T. Mechanosensitive Aspects of Cell Biology in Manual Scar Therapy for Deep Dermal Defects. Int J Mol Sci. 2020 Mar 17;21(6):2055 https://pubmed.ncbi.nlm.nih.gov/32192136
  • Scar Management. Practical guidelines. Coordinating Editors: Esther Middelkoop, Stan Monstrey, Luc Téot, Jan-Jeroen Vranckx.
  • Humbert P et al. Mécano-Stimulation™ of the skin improves sagging score and induces beneficial functional modification of the fibroblasts: clinical, biological, and histological evaluations. Clin Interv Aging. 2015 Feb 2;10:387-403.

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