Attenuation of postoperative adhesions using a modeled manual therapy

Evaluating massage therapy for radiation-induced fibrosis in rats: preliminary findings and palpation results

Radiation-induced fibrosis (RIF) is a common side effect of cancer treatment, but can manifest into a devastating syndrome for which there is no preventive measure or cure. In rats who perform a repetitive work task, who left untreated develop signs and symptoms that resemble repetitive motion disorders in humans, we have shown that manual therapy prevents the development of fibrosis and other key biomarkers. The fibrosis of RIF and repetitive motion disorders has similar biomarkers. In rats, we sought to determine if manual therapy would alter key biomarkers of post-irradiation fibrosis following X-ray irradiation given to the rat forelimb. One limb of rats was given a damaging dose of X-ray irradiation. Some limbs were massaged using a protocol previously described and characterized. Serum inflammatory markers, histological assays of tissue fibrosis and nerve pathology, and electrophysiology for neuropathic discharge were assayed after 8 weeks. We also tested if an experienced therapist could identify the irradiated limb using blinded palpation at the 8 week end-point. While preliminary assays showed robust changes compared to control limbs, the other assays did not show similar pathology. Our therapist could detect each irradiated limb. Serum inflammatory markers were reduced by massage to the irradiated limb. We conclude that blinded palpation is sensitive to detect subtle changes in tissue following irradiation. In contrast to the preliminary studies, the dose of irradiation used was insufficient to induce long-lasting deep fibrosis or nerve degeneration. We suspect that a difference in housing, and thus physical activity, was the plausible reason for this difference.

Functional and Structural Long-Term Effects of Repetitive Instrument-Assisted Manual Therapy (IAMT) of the Lumbar Back on the Dorsal Myofascial Chain Among Female Soccer Players: A Randomized, Placebo-Controlled Pilot Trial

INTRODUCTION

Instrument-assisted manual therapy (IAMT) is suitable for optimizing movement prerequisites, such as range of motion, flexibility, microcirculation, and pain inhibition along myofascial chains, potentially leading to a reduction in hamstring injuries. To date, however, IAMT's modes of action remain largely unclear. This study aimed to examine the functional and structural effects of repetitive IAMT after 2.5 and five weeks.

METHODS

Sixteen healthy female soccer players (age: 21.4 (±5.1) years) were randomly grouped into an intervention group and a placebo control group. The intervention group received nine IAMT sessions twice weekly at the right lumbar region. The placebo group received a single pressureless "therapy" at baseline. In addition to structural ultrasound analyses (absolute motion and shear motion), functional mobility tests (passive straight leg raise (PSLR) test and lumbar and thoracic double inclinometry) were performed 4.0 (±2.0) days after the fourth IAMT and 3.4 (±1.1) days after the ninth IAMT in both groups.

RESULTS

Hamstring flexibility in the PSLR test improved significantly after the ninth IAMT compared with the placebo group (p < 0.05, effect size: 0.913). No systematic differences were seen at the structural level.

CONCLUSION

Repetitive IAMT can improve hamstring flexibility. Further studies in larger groups and diverse collectives are necessary to additionally test the postulated preventive effect also on hamstring injuries. Whether ultrasound is the right method for detecting structural changes in this context needs to be verified in the future.

Irritable Bowel Syndrome-Like Symptoms in Quiescent Inflammatory Bowel Disease: A Practical Approach to Diagnosis and Treatment of Organic Causes

BACKGROUND

Despite achieving remission in inflammatory bowel disease (IBD), persistent gastrointestinal symptoms are common in quiescent IBD. While irritable bowel syndrome (IBS) is commonly diagnosed in IBD, IBS-like symptoms of recurrent abdominal pain and altered bowel habits can also be attributed to a wide range of overlapping gastrointestinal (GI) etiologies and systemic disorders with GI manifestations that often do not respond to conventional IBS therapies. Delay in diagnosis of these conditions can lead to ongoing patient suffering, reduced quality of life, repetition of invasive testing, increased healthcare utilization, and potentially unnecessary empirical escalation of IBD-related treatments.

AIMS

This review provides a practical approach for the evaluation and diagnosis of IBS mimickers in IBD. We summarize the definition, pathophysiology, diagnosis and treatment of the potential etiologies causing unexplained GI symptoms.

CONCLUSION

Overlapping conditions can co-exist with IBD and explain IBS-like symptoms. The diagnostic work-up in this population should be individualized and tailored to the predominant symptom pattern, associated clinical signs and symptoms and predisposing conditions that can be obtained from a detailed history and physical examination.

Peritoneal Adhesions in Osteopathic Medicine: Theory, Part 1

Peritoneal adhesions form as a result of trauma to the abdomen, injuries resulting from surgery, and infections. These tissutal neoformations are innervated and vascularized, and with lymphatic vessels, adherence becomes a new and independent structure, capable of negatively influencing visceral functions. Adherent neogenesis can be asymptomatic or can be a source of pain, limiting the patient's quality of life. Although adhesiolysis remains the elective approach to eliminate adhesions, this therapeutic route prepares the peritoneal anatomical area to recur. The article reviews information on adhesion formation and peritoneal anatomy, probable subjective predispositions, and pathways that carry nociception. The text aims to be a theoretical basis for making new treatment suggestions for non-invasive osteopathic medicine, through a second part will be discussed in another article.

The Influence of a Single Instrument-Assisted Manual Therapy (IAMT) for the Lower Back on the Structural and Functional Properties of the Dorsal Myofascial Chain in Female Soccer Players: A Randomised, Placebo-Controlled Trial

Background: Instrument-assisted manual therapy (IAMT) is indicated to improve flexibility, reduce pain, and induce hyperaemia locally and along myofascial chains. The underlying effects are largely unclear. This randomised, placebo-controlled pilot study aimed to gain first insights into these effects, primarily on the structural level, through ultrasonography. Methods: 67 healthy female soccer players aged 20.9 (±3.9) years were examined after right lumbar intervention (IAMT: intervention group (IG), heat application: comparison group (CG), pressure-less placebo: placebo group (PG)). Ultrasonography (absolute movement and shear motion), flexibility tests (passive straight leg raise test (PSLR), lumbar and thoracic double inclinometry), and superficial skin temperature were recorded before (t0), immediately (t1) and 45 min after the intervention (t2). Results: IAMT decreased the absolute mobility of the superficial lamina and its shear motion to the superficial fascia compared with the PG (t1; p < 0.05). PSLR improved in the IG compared with the CG (t2) and PG (t1, t2; p < 0.05). The temperature increased in the IG and CG compared with the PG (t1, t2) and in the CG compared with the IG (t1; p < 0.05). Conclusion: IAMT of the lumbar back briefly reduces absolute mobility of the superficial lamina and its shear motion to the superficial fascia, improves flexibility, and increases the temperature.

Chemical Scalpel: An Experimental Collagenase-Based Treatment for Peritoneal Adhesions

(1) Background: Abdominal adhesions are a common disease appearing after any type of abdominal surgery and may prolong surgical time and cause intestinal obstruction, infertility, or chronic pain. We propose the use of intraperitoneal collagenase to perform chemical adhesiolysis based on the pathophysiology and histology of adhesions. (2) Methods: We generated an adhesion model with intraperitoneal polypropylene meshes. Four months later, we evaluated the efficacy of the treatment in blinded form, i.e., 0.05% collagenase vs. placebo at 37 °C for 20 min. Protocol 1: Ten rats with ten mesh fragments, in which an attempt was made to remove the maximum number of meshes in a 5-min period. Protocol 2: Six rats with four mesh fragments in the sides of the abdominal cavity in which adhesiolysis was performed using a device that measures burst pressure. (3) Results: Protocol 1: 42% efficacy in the collagenase group versus 8% in the control group (p < 0.013). Protocol 2: 188.25 mmHg (SD 69.65) in the collagenase group vs. 325.76 mmHg (SD 50.25) in the control group (p < 0.001). (4) Conclusions: Collagenase allows for the safe and effective chemical adhesiolysis in this experimental model of adhesions.

Current Management of Adhesive Small Bowel Obstructions in Children

Adhesive small bowel obstructions are a common cause of morbidity in children who underwent prior abdominal surgery. The concept of partial versus complete bowel obstruction is outdated and lacks precision to be clinically useful. Identifying patients with indications for immediate operative intervention is critical and must be recognized to limit morbidity. Clinical protocols and contrast challenge algorithms have attempted to identify patients that will resolve their bowel obstruction nonoperatively; there has been slow uptake in the pediatric patient population versus adults until recently. Incorporating predictive models and standardized contrast challenge protocols will help reduce interpractitioner variability and improve clinical outcomes.

Manual Therapy Research Methods in Animal Models, Focusing on Soft Tissues

Manual therapies have been practiced for centuries, yet little research has been performed to understand their efficacy and almost no animal research has been performed to inform mechanisms of action. The methods of manual therapy practice are quite varied and present a challenge for scientists to model the treatments and perform research using rodents. In this perspective we present a descriptive analysis of the complexity of the treatments, highlighting the role of tissue mechanics and physics. With these complexities in mind, we compare using manual therapy as clinically practiced, to attempts to develop machinery to model or mimic manual therapy. We propose that because of the complexities of manual therapy as practiced, having therapists perform the treatments on research animals just as they would on humans is the most scientific approach. Our results using this approach have supported its practicality.

Prevention of Peritoneal Adhesions by Non-Thermal Dielectric Barrier Discharge Plasma Treatment on Mouse Model: A Proof of Concept Study

Purposes: Formation of peritoneal adhesions is a common consequence of abdominopelvic surgeries and remarkably increases the mortality and morbidity. Moreover, peritoneal adhesions linked to chronic abdominopelvic pain and infertility in women. Various attempts for prevention of peritoneal adhesions were reported. However, these methods either remain insufficient to prevent formation of peritoneal adhesions or carry some practical limitations and thus, there is a need for novel techniques that could effectively decrease the formation of peritoneal adhesions. The aim of the present prospective, randomized, controlled, and single blinded study was to evaluate the effect of non-thermal atmospheric plasma (NTAP) treatment on prevention of peritoneal adhesions. Materials and Methods: Sixteen male CD-1 mice were randomly divided into two groups: control and plasma. Excisional and abrasion adhesion models were generated on the peritoneal side wall and cecum, respectively. Ten days after creating adhesion models, mice were sacrificed and adhesion formations were evaluated macroscopically using Knightly's and Linsky's grading systems to assess the intensity and extent of adhesions, respectively. Zühlke's grading system was used for microscopic assessment of adhesions. Results: The mean scores for peritoneum and cecum in control group according to Knightly's grading system were determined as 3.3 and 2.6, respectively. In NTAP-treated group, Knightly's score was determined as 1.6 and 0.5 for peritoneum and cecum, respectively. NTAP treatment reduced Linsky's score from 3.8 to 1.3 and 2.1 to 1.1 on peritoneum and cecum. Finally, in microscopic evaluation, NTAP treatment reduced Zühlke's score from 3.4 to 1.5 and 2.6 to 1.3 for peritoneum and cecum, respectively. Conclusions: The results of the present proof of concept study suggest that NTAP could be a novel method to reduce and/or prevent the formation of peritoneal adhesions after abdominopelvic surgeries.

Physiological Responses Induced by Manual Therapy in Animal Models: A Scoping Review

Background: Physiological responses related to manual therapy (MT) treatment have been investigated over decades using various animal models. However, these studies have not been compiled and their collective findings appraised. The purpose of this scoping review was to assess current scientific knowledge on the physiological responses related to MT and/or simulated MT procedures in animal models so as to act as a resource to better inform future mechanistic and clinical research incorporating these therapeutic interventions. Methods: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, and Index of Chiropractic Literature (ICL) were searched from database inception to August 2019. Eligible studies were: (a) published in English; (b) non-cadaveric animal-based; (c) original data studies; (d) included a form of MT or simulated MT as treatment; (e) included quantification of at least one delivery parameter of MT treatment; (f) quantification of at least one physiological measure that could potentially contribute to therapeutic mechanisms of action of the MT. MT studies were categorized according to three main intervention types: (1) mobilization; (2) manipulation; and (3) massage. Two-phase screening procedures were conducted by a pair of independent reviewers, data were extracted from eligible studies and qualitatively reported. Results: The literature search resulted in 231 articles of which 78 met inclusion criteria and were sorted by intervention type. Joint mobilization induced changes in nociceptive response and inflammatory profile, gene expression, receptor activation, neurotransmitter release and enzymatic activity. Spinal manipulation produced changes in muscle spindle response, nocifensive reflex response and neuronal activity, electromyography, and immunologic response. Physiological changes associated with massage therapy included autonomic, circulatory, lymphatic and immunologic functions, visceral response, gene expression, neuroanatomy, function and pathology, and cellular response to in vitro simulated massage. Conclusion: Pre-clinical research supports an association between MT physiological response and multiple potential short-term MT therapeutic mechanisms. Optimization of MT delivery and/or treatment efficacy will require additional preclinical investigation in which MT delivery parameters are controlled and reported using pathological and/or chronic pain models that mimic neuromusculoskeletal conditions for which MT has demonstrated clinical benefit.

Sodium aescinate significantly suppress postoperative peritoneal adhesion by inhibiting the RhoA/ROCK signaling pathway

BACKGROUND

Although mechanical barriers and modern surgical techniques have been developed to prevent postoperative adhesion formation, high incidence of adhesions still represents an important challenge in abdominal surgery. So far, there has been no available therapeutic drug in clinical practice.

PURPOSE

In this study, we explored the efficacy of sodium aescinate (AESS) treatment against postoperative peritoneal adhesions, the potential molecular mechanism was also investigated.

STUDY DESIGN AND METHODS

Sixty male Sprague-Dawley rats were randomly divided into 6 groups for the study: the blank, vehicle, positive control and three AESS administration groups (0.5, 1 and 2 mg/kg/d, intravenous administration for 7 days). Adhesions were induced by discretely ligating peritoneal sidewall. An IL-1β-induced HMrSV5 cell model was also performed to explore possible functional mechanism.

RESULTS

The results indicated that the incidence and severity of peritoneal adhesions were significantly lower in the AESS-treated groups than that in the vehicle and positive control group. AESS-treated groups showed that the secretion, activity, and expression of tPA in rat peritoneum were notably increased. The FIB levels in rat plasma were decreased. The immunohistochemical staining analysis demonstrated that collagen I and α-SMA deposition were significantly attenuated in AESS-treated peritoneal tissues. Besides, we found that AESS treatment reduced the protein levels of p-MYPT1. To further explore the mechanisms of AESS, both activator and inhibitors of RhoA/ROCK pathway were employed in this study. It was found that AESS-induced up-regulation of tPA was reversed by activator of ROCK, but the effects of ROCK inhibitors were consistent with AESS.

CONCLUSION

Taken together, the findings of in vivo and in vitro experiments proved that AESS could significantly suppress postoperative peritoneal adhesion formation through inhibiting the RhoA/ROCK signaling pathway. Our researches provide important pharmacological basis for AESS development as a potential therapeutic agent on peritoneal adhesions.

Battling adhesions: from understanding to prevention

Adhesions represent a major burden in clinical practice, particularly following abdominal, intrauterine, pericardial and tendon surgical procedures. Adhesions are initiated by a disruption in the epithelial or mesothelial layer of tissue, which leads to fibrin adhesion sites due to the downregulation of fibrinolytic activity and an increase in fibrin deposition. Hence, the metabolic events involved in tissue healing, coagulation, inflammation, fibrinolysis and angiogenesis play a pivotal role in adhesion formation. Understanding these events, their interactions and their influence on the development of post-surgical adhesion is crucial for the development of effective therapies to prevent them. Mechanical barriers, antiadhesive agents and combination thereof are customarily used in the battle against adhesions. Although these systems seem to be effective at reducing adhesions in clinical procedures, their prevention remains still elusive, imposing the need for new antiadhesive strategies.

Frontiers in fascia research

Basic sciences are the backbone of every clear understanding of how the body is composed and how different structures and functions are connected with each other. It is obvious that there is a huge variability in human beings - not only in terms of the outer appearance such as measurements of height, weight, muscle mass and other physical properties, but also with respect to metabolic and functional parameters. This article highlights recent developments of research activities in the field of fascia sciences with a special emphasis on assessment strategies as the basis of further studies. Anatomical and histological studies show that fascial tissue is highly variable in terms of density, stiffness, and other parameters such as metabolic and humoral activity. Moreover, it encompasses nerves and harbours a system of micro-channels, also known as the primo vascular system. As ultrasound is a widely available method, its use is appealing not only for imaging of fascial structures, but also for thorough scientific analysis. Unlike most other imaging technologies, US has the advantage of real-time analysis of active or passive movements. In addition, other assessment methods for fascial tissue are discussed. In conclusion, fascial tissue plays an important role not only in functional anatomy, but also in evolutionary and molecular biology, sport, and exercise science as well as in numerous therapeutic approaches. A high density of nerves is found in fascial tissue. Knowledge of individual characteristics, especially by visualizing with ultrasound, leads to personalized therapeutic approaches, such as in pain therapy.

Developmental endothelial locus-1 prevents development of peritoneal adhesions in mice

Postoperative peritoneal adhesions, fibrous bands formed in the peritoneal cavity following surgery, represent a common, challenging and costly problem faced by surgeons and patients, for which effective therapeutic options are lacking. Since aberrant inflammation is one of the key mechanisms underlying peritoneal adhesion formation, here we set out to study the role of developmental endothelial locus-1 (Del-1), which has been recently identified as an endogenous inhibitor of inflammation, in the formation of postoperative peritoneal adhesions using a mouse model of peritoneal adhesions induced by ischemic buttons. Del-1-deficient mice had a higher incidence of adhesions, and their adhesions had higher quality and tenacity scores. Del-1 deficiency also led to enhanced inflammation mediators and collagen production. Finally, Del-1 supplementation decreased the incidence and severity of postoperative peritoneal adhesions. Taken together, these results indicate a protective role for Del-1 in postoperative peritoneal adhesion formation.

Polymer materials for prevention of postoperative adhesion

Postoperative adhesion (POA) is a common complication that often occurs after a variety of surgeries, such as plastic surgery, repair operations of abdominal, pelvic, and tendon, and so forth. Moreover, POA leads to chronic abdominal pain, secondary infertility in women, intestinal obstruction, and other severe complications, which significantly reduce the life quality of patients. In order to prevent the formation of POA, a number of strategies have been developed, among which an emerging method is physical barriers consisting of polymer materials. This review highlights the most commonly used natural and synthetic polymer materials in anti-adhesion physical barriers. The specific features of polymer materials are analyzed and compared, and the possible prospect is also predicted.

STATEMENT OF SIGNIFICANCE

Postoperative adhesion (POA) is a serious complication accompanied with various surgeries. Polymer material-based physical barriers have attracted a large amount of attention in POA prevention. The polymer barriers can effectively avoid the formation of fibrous tissues among normal organs by reducing the interconnection of injured tissues. In this review, specific features of the natural and synthetic polymer materials for application in POA prevention were presented, and the possible prospects were predicted. All in all, our work can provide inspiration for researchers to choose proper polymer materials for preclinical and even clinical anti-adhesion studies.