Fascial Scar Mobilization Techniques in Treating Chronic Caesarian Section Scar Pain

Study Overview
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Brief Summary
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Over 1.37 million Caesarian sections (C-sections) are performed annually in the US . It is estimated that 12-20 % of those will result in chronic scar pain. This pain can lead to functional difficulties performing activities of daily living, pain with bowel movements, and pain with sexual activity . There is anecdotal evidence supporting the use of deep fascial scar mobilization techniques in reducing abdominal surgical scar pain, and yet almost no research has been published. The aims of this randomized clinical trial will be to determine if deep fascial scar mobilization techniques or superficial scar mobilization techniques will improve chronic pain and its resulting functional deficits, threshold pressure discomfort, pressure tolerance and mobility restrictions resulting from C-section surgery and to see if these interventions are more effective than no intervention. A positive result may result in an increase in the use of this intervention and thus the reduction of chronic scar pain for many women; it may provide justification for insurance reimbursement for this approach and it will also pave the way for further investigation into the use of these techniques with other types of painful scars including hysterectomy.

Detailed Description
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Methods: Thirty six subjects will be recruited who have a history of C-section surgery more than three months before entering the study and who report chronic pain in or around the scar stemming from the surgery. Subjects will initially be tested twice four weeks apart, before beginning intervention. This will allow the establishment of a baseline and the subjects will all be part of a baseline control group. They will then be randomly assigned to one of two treatment groups. Group 1 will undergo four, 25 minute sessions of light massage to the trunk followed by superficial skin rolling of the C-section scar. Group 2 will undergo four, 25-minute treatment sessions consisting of multi-planar pelvic and abdominal myofascial mobilization techniques and direct scar mobilization techniques.. Outcomes: Outcome measures will include threshold pressure discomfort and pressure tolerance using a Pressure Algometer, Adheremeter measurements of scar mobility, the numeric pain rating scale (NPRS), the Oswestry Disability Index (ODI), Hip extension and shoulder flexion measured via goniometery, and the Global rating of Change scale. Follow up measures will be collected four weeks following the start of interventions and again at 12 weeks. In addition qualitative data will be collected from the subjects. The treating therapist will be blinded to the results of the outcome measures.

Official Title
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Fascial Scar Mobilization Techniques in Treating Chronic Caesarian Section Scar Pain: A Randomized Clinical Trial

Conditions
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Cesarean Section, Cicatrix, Tissue Adhesions

Intervention / Treatment
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* Procedure: deep fascial mobilization
* Procedure: superficial fascial mobilization


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: well- healed abdominal scar over 3 months old that is resulting in chronic pain pain can be intermittent, at rest or with activity, and must have been present at least at a 3/10 at some point in the month prior to evaluation patient must report the presence of chronic pain. Exclusion Criteria: history of cancer in pelvis or abdomen active infection / infectious disease in pelvis or abdomen pain medications on days of measurements skin irritation/inflammation at site of scar currently pregnant history of radiation to area Age <18 no pain with pressure and mobility is symmetrical in all directions on initial examination.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Deep Fascial Mobilization<br> | Procedure: deep fascial mobilization<br>* Pelvic and abdominal myofascial release techniques as described by Barnes will be performed to facilitate independent mobility between tissue layers as needed following the direction of palpated fascial tension. Following this, direct scar mobilization techniques as described by Manheim will be done, applying a stretch in the direction of palpated restriction . This involves applying deep pressure whose force and direction is dictated by the tightness the therapist palpates and the subject reports. These are each held until a release is felt (defined as a sudden relaxation of tissue tension), usually 60-120 seconds. Total treatment time will last 25 minutes. Treatments will include all the above techniques but the therapist will tailor each treatment to address palpated restrictions. Subjects will be instructed to carry on their normal routines between sessions and will not be given any home interventions. Treatment sessions will total four to occur within a three week time period.<br>|
| Experimental: Superficial Fascial Mobilization<br> | Procedure: superficial fascial mobilization<br>* This group will undergo four 25-minute sessions of gentle superficial effleurage to the abdomen and posterior trunk followed by superficial skin rolling to the scar. Each treatment session will be terminated a) after 25 minutes or 2) when the patient asks to stop due to discomfort. Reasons for termination will be documented. Subjects will be instructed to carry on their normal routines between sessions and will not be given any home interventions. Treatment sessions will total four to occur within a three week time period.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Digital Pressure Algometer | 6 points along the scar will be assessed. Pressure Pain threshold is the force (N) at which pressure turns to pain and Pressure Pain tolerance is the force (N) at which the pain becomes intolerable | Change from 0 weeks to 4 weeks to 8 weeks to 16 weeks | 
| Adheremeter | 6 points along the scar will be assessed. Scar flexibility (mm) in each of 4 directions (superior, right, left, inferior) will be assessed at each point | Change from 0 weeks to 4 weeks to 8 weeks to 16 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Global Rating of Change | patient survey -7= very much worse; 0 = no change; +7= very much better | Change from 4 weeks to 8 weeks to 16 weeks | 
| Goniometery hip extension and shoulder flexion |  | Change from 0 weeks to 4 weeks to 8 weeks to 16 weeks | 
| Qualitative Assessment | subject comments as to response to interventions will be recorded for qualitative assessment | change between 4 and 8 weeks during interventions | 
| Numeric Pain Rating Scale | Subjects are asked to rate their pain in the past 48 hours and their current pain. Pain 0= no pain, 10= maximal pain | Change from 0 weeks to 4 weeks to 8 weeks to 16 weeks | 
| Oswestry Disability Index | Functional Index- patient survey | Change from 0 weeks to 4 weeks to 8 weeks to 16 weeks |