Fascia Insights: Measuring the Effects of Soft Tissue Mobilization of the Cesarean Section Scar

By Lina Amy Hack, Certified Advanced Rolfer®, and Isabelle Gilbert, MSc, Ost. DO
July 2023

ABSTRACT In this interview, osteopath Isabell Gilbert discusses her 2022 peer-reviewed article, “Exploring the Effects of Standardized Soft Tissue Mobilization on the Viscoelastic Properties, Pressure Pain Thresholds, and Tactile Pressure Thresholds of the Cesarean Section Scar” that she also presented at the Fascia Research Congress in Montréal, Canada in September 2022. Gilbert discusses her research design, measuring tools, and results.  

Editor’s note: This interview was held over Zoom on December 16th, 2022. The conversation was conducted in French and translated into English for this article.

Featured Publication


Exploring the Effects of Standardized Soft Tissue Mobilization on the Viscoelastic Properties, Pressure Pain Thresholds, and Tactile Pressure Thresholds of the Cesarean Section Scar.

By Isabelle Gilbert, MSc, Ost. DO, Nathaly Gaudreault, PT, PhD, and Isabelle Gaboury, PhD.

Journal of Integrative and Complementary Medicine

Volume 28, Number 4, pp. 355-362.

Our Conversation

Lina Amy Hack: Hello, Isabelle. Thank you for meeting with me to talk about your research. You presented at the Fascia Research Congress in Montréal, Quebec, in September 2022. When I heard your talk, there were many new elements to me, I knew I wanted to follow up with you. Once I read your paper, I had to feature your research here for my colleagues as I knew they would would also find your research interesting.

So, let’s start at the beginning, you are an osteopath in Montréal, Quebec, how long have you been practicing, and how is it that you also do research like this?  

Isabelle Gilbert: Nice to meet you. Thank you for inviting me to speak about my work. I’m not that familiar with Rolfers, but you have told me a little bit about your profession. Yes, I am an osteopath with a DO since 2011. I returned to Université de Sherbrooke again and finished my master’s of science in 2021. Before that, I was in the biomedical field and I spent time in laboratories working in the healthcare system. I came across osteopathy quite by chance. I liked the human approach to wellness.

I have a general professional practice but over the past few years I have developed expertise in perinatal care, women’s health, and sports medicine. These areas may seem paradoxical, but it is a valuable contrast for me as a practitioner. I have a structural osteopathy practice; I like to be in the material if you will. Within these populations, there are instructive comparisons between the tissues of a baby, an athlete, a pregnant woman, and a so-called normal adult. I am a person who loves to learn and apply this knowledge.

Since 2018, I also teach osteopathy, and I’m involved at the political level of Ostéopathie Québec by being on the Board of Directors. This association has the largest number of osteopaths in Québec. I am currently studying at the University of Montréal in the Department of Management and Evaluation of Health Policy and Health Organization under the School of Public Health to gain skills that will hopefully help my professional development. I collaborate with my various organizations and various colleagues to create university programs in osteopathy and with government institutions to accelerate our professional recognition.

LAH: That is interesting, that is another thing I learned at the Fascia Research Congress in Montréal, there are many osteopaths in Québec. What drew your interest to study Cesarean section (C-section) scars (see Figure 1)?

Figure 1: Low transverse incision scar. Photo credit: Kellyanne Jordan Photography.

IG: From the start of my training, we talked about scars and adhesions but very little understanding about the composition of the scars themselves. That motivated me as a researcher. I saw that we need more studies to understand what a scar is and what implications it can have
for someone.

Moreover, as I had a manual practice focused on women’s health, it was logical that I was interested in researching this subject as well. In osteopathy, we are looking for several changes, especially regarding our ability to mobilize scar tissue and the changes induced by our therapeutic gestures. But according to the current literature, the data remains modest as to our influences on scar tissue and between what would seem to be normal and abnormal scar tissue. In general, practitioners who use manual therapy, of which osteopathy is a part, have an anecdotal appreciation of the changes they perceive in their clients due to their therapeutic gestures. I wanted to know if we could characterize these changes by objectively observable measures. That was one of my main motivations, to reduce the subjectivity of our tissue interventions, specifically with the mobilization of scar tissue.

Then the other question was, could I study this in vivo? We assume that scar tissue differs from normal skin, but at this time, we didn’t have quantified in vivo data on that aspect, so we couldn’t say if it were that different. There are in vitro studies in the literature where researchers tested tissues that had been biopsied. Yet, how scar tissues react and behave, and the behavior at the cellular level, will be changed once cut away from the person.

Why study the C-section scar? When I did my literature review on scar tissue and the implications of scar tissue, there were many surgeries to consider, like joint surgeries and mastectomies. Female subjects were investigated in fewer studies than men. And when I considered the C-section scar and the mastectomy scar, it was the C-section scar that had also been less studied in the literature. It has been studied, yes, for chronic pain for example. Immediately after the C-section, there are interventions, but those inquiries were on the medical level investigating the type of anesthesia affecting the implication of pain afterward, and what kind of suturing to do during the procedure. Whether it is better to suture the peritoneal fascia or leave it loose.

LAH: Your 2022 article mentioned that C-sections are one of the most performed incisional surgeries worldwide, and that scar adhesions and intra-peritoneal adhesions are among the most common complications. The adhesion rate could be as high as 32%. How common is it for women to have pain and discomfort?

IG: After surgery, it is normal to have pain, but the number tends to be reduced in medical studies. We realized during our study that it is a population that does not complain much even when they do have discomfort. And when they go to see their health professionals when they have pain, it takes time before they are: one, taken care of, and two, believed. Patients reported they were told, “It will pass.
It’s normal.”

Up to three months after the C-section, it is quite normal to have some types of pain and discomfort. After six months, the pain should either be completely gone or minimal. About 15% of women will have serious pain and discomfort after a C-section and this will influence the quality of life of these women. Regarding influences other than at the incision site, it has been suggested that the C-section scar may have an influence on the lower back, but there is modest research on this yet. Recently, some authors have characterized differences in muscle function of the pelvic floor and transversus abdominis muscles, but this is not sufficient to establish a causal link between the development of certain lumbar problems and a history of a C-section.

LAH: Your 2022 study was doing two things. It was characterizing the C-section scar tissue, as well as doing a pretest-posttest design about the intervention of manual therapy with women who had C-section scars. Had you already noticed a change in the stiffness and density of the scars of your patients when you were treating them as an osteopath?

IG: Clinically and academically, the terminology that we are taught about scar work is that they become more flexible and that we “break down the adhesions.” When I started my research project, I asked myself the question, “But is it really true that the scar tissue becomes more elastic and that we ‘remove’ adhesions?” My first observation as a manual therapist, what we feel when we palpate and mobilize is a reduction in stiffness and not an increase in elasticity. Considering the parameter elasticity is defined as the return of the tissue to its initial state, it seems more difficult to determine this parameter by palpation. The second observation is that we do not ‘remove’ or ‘break’ adhesions, but rather we influence a local behavior that would favor the prevention of their development. This highlights our preventative role, which may not be emphasized enough. Therefore, what I knew going into my study was that manual therapists are able to qualify the presence or absence of stiffness and the quality of the shear but nothing more.

LAH: In your study you used a measurement tool that I had never heard of before, the MyotonPRO [www.myton.com]. What is the MyotonPRO and how does it work?

IG: The MyotonPRO is a tool that calculates biomechanical and viscoelastic parameters of skeletal muscles. Recently, other anatomical regions have been measured with the MyotonPRO since it is an easy-to-use tool for both research and clinical use. It seems to be a valid and reliable tool in many contexts. It uses an oscillatory wave sent by a small lever arm and then calculates the different parameters (see Figure 2).

Figure 2: Picture of the handheld device called MyotonPRO in the process of measuring brachioradialis. Published with permission.

The advantage of this device is that it is portable; I could carry it to my clinic. It is easy to use. It has been standardized and described in peer-reviewed publications; it is a valid tool that quantifies the tissue. It calculates five parameters: tone, stiffness, elasticity, mechanical stress relaxation time, and creep.

LAH: That is a strange parameter, creep.

IG: Yes, the creep is a ratio between the stiffness and the time it will take to relax.

LAH: Interesting, it is a measure of tissue letting go. The MyotonPRO sounds like a game-changer for manual therapy research. It has a whole world of possibilities.

IG: Yes, but it is a device that has limitations. One of these limitations is that it cannot be used in areas close to the bone, otherwise it will give measurement errors. We must be careful how we analyze the data from this device. Also, it is important to remember that it is a ‘calculation’ tool and that even though it measures those five parameters, only two might be relevant to the question at hand and that some research tends to have a misunderstanding of some parameters.

Of course, other devices exist to calculate these same anatomical components, either the elasticity or the stiffness. These other machines are much more expensive. Sonoelastography for example will give a rate of stiffness and a rate of elasticity, yet the device costs thousands of dollars. Other devices measure tissue quality through other mechanisms and sometimes only measures one parameter at a time. But we liked the idea of having the MyotonPRO because it does a compression action, which is within the same parameters that we were going to use during the intervention.

LAH: You used other measures as well, you had validated questionnaires for both the participants of the study and people in the observer role for the study, and you had these people independently report how the scar looked and how the scar felt.

Plus, when you were doing the scar manipulation intervention, reported as soft tissue mobilization, you had a device on your thumb that measured the exact amount of pressure in Newtons that you were applying to the tissue and the length of time you applied the force [FlexiForce sensor, Tekscan]. Can you tell me more about this tool?

IG: Yes, we chose a Newton average to apply to each participant’s scar tissue. The mobilization consisted of a combination of compression and shear stress forces applied parallel and perpendicular to the C-section scar with the thumb.

We do have results related to applying a variety of different forces during the procedure that have not been published yet. We are looking at how much compressive force is needed to create a change in the scar tissue or even in the superficial fascia.

LAH: Your pretest-posttest design was focused on the short-term effects of the manual intervention. How soon after the manual intervention was the participants’ scar tissue measured?

IG: We did a measurement with the MyotonPRO of the scar before the intervention, then we did the intervention for about ten minutes on the scar, and the post-measurement happened immediately afterward. That being said, each participant had two sessions of manual intervention one week apart. So, when the participant returned for the second treatment, that third measure of the scar was at a time interval of one week after the first intervention. This third set of measures had the objective to evaluate the effects of the first intervention and whether the change measured the week before lasted until then. We found that scar stiffness continuously decreased after each mobilization. It was very useful to know that the effects persist for at least a week after ten minutes of intervention, even if only partially.

LAH: You described in your design that you were thinking about an optimal dosage of manual therapy. This is a stimulating idea for Rolfers, ‘optimal dosage’ is something we intuit. For this study, “The mobilization consisted of a combination of compression and tension forces (shear stress forces), which can be clinically translated as gliding strokes. These were applied parallel and perpendicular to the C-section scar with the thumb” (357). How did you decide on the manual therapy dosage?

IG: Unfortunately, in manual therapy studies, regardless of whether it is physiotherapy, massage therapy, or different complementary approaches, the interventions are very heterogeneous in how they are applied to the participants. How many times is the touch done? How long is the manual intervention? How does the clinician do it?

For my study, several aspects made me choose something really simple. Previous researchers had investigated whether it was better to do an intervention with light compression. They asked, is it best to do a superficial fascia treatment? Or would it be better to do superficial and deep treatment? At the end of their study, basically, there was no difference between the two. So, whether I did a deep intervention or not, there was no significant difference between the two interventions. So, from that, I decided I wouldn’t have to go with a big compression force for something to happen. I am also interested in the minimum therapeutic gesture that has a real effect, so I kept this study design to the basic minimum.

As an osteopath, I apply my results by knowing that when I do more than this basic intervention, I assume that I will have combined effects. If I do more than just the intervention of compression, then shearing of the fascial fabric has an effect. The results are reassuring, giving us the way to say to ourselves, “Even if I don’t do a lot, I’m still going to have something happen.”

LAH: Your study had a blind component, to increase the validity and reliability of the measurements. How was your study blind?

IG: I was the ‘experienced osteopath’ who delivered the gliding strokes, and I was the one who was blind for the measurements with the device and questionnaires. I did the intervention, and I was absent for all measurements.

LAH: That makes sense, you did the intervention, and your team collected the results independently of you. Let’s discuss your results further.

IG: We can start by giving the definitions of the characteristics, the tone of the tissue is the basic tension of the tissue, which is always present at the level of the tissues. It is regulated in large part by the nervous system. Elasticity is related to the capacity of the fabric of the tissue to be able to return to its initial state when stretched or compression is removed. Stiffness is characterized by the resistance of being able to impose a force on the tissue. The mechanical stress relaxation time is the time it takes after applying a compressive force or a stretching force for the tissue to be able to relax. And we talked about the creep, the ratio between that time and the stiffness that causes the tissue to stretch slowly.

Our study was the first to establish quantifiable measures of the viscoelastic properties of the C-section scar in vivo. Scar stiffness and pressure pain thresholds were the most significant variables to change, there was a decrease in stiffness after each mobilization and the scars were tolerant to more pressure before the participant reported pain after the two interventions. We saw a modulation in the tone of the scar, the tone had decreased, and elasticity increased, but to be honest, we saw much heterogeneity of tone from one person to another. So, it is difficult to conclude from this study alone, and more research needs to be done.

LAH: What is the main message for manual therapists about these findings?

IG: It is reassuring to know that our tissue mobilization training is concretely making a difference with slight compression and shear forces when working with C-section scars. The thing we look for as manual therapists are changes in the tissues. Personally, it reassured me to observe objectively that the interaction has a reliable and reproducible effect and I think we don’t yet understand all the elements involved.

The other observation that I found interesting was that there was a concordance between the measures used. What I mean is that there was a triangulation between the decrease in stiffness measured by the MyotonPRO and the perception of decreased stiffness by both the participants and the observers that was reported in their questionnaires.

LAH: That is helpful, and this is exactly why your presentation stood out to me, the quantified information about scar tissue. What else is essential to know about C-section scars in general?

IG: Another aspect is the behavior of the tissues and what the analysis describes. Manual therapy training emphasizes awareness about adhesions between fascial layers that are common with scar tissue. Yet the literature shows that several factors contribute to adhesions, including the number of C-sections the woman has had. Some research reports that a C-section scar is not always adherent and if it is, manual therapy interventions will not change that component.

Manual therapy forces will not change the adhesions. We will not break them, but what are we doing? We modulate the environment to limit the fact that they form. The research has helped me have a better understanding of how C-section scar formation functions in women who seek help with their scars. The question that remains is what happens with the scar over time, two years after the manual intervention for example.

And we don’t know precisely how to modulate tissue behavior, but we could investigate preventative manual therapy. We know that adhesions will form if the surgical incision is in an anatomical region where there are a lot of surrounding forces and an inflammatory system that does not subside following surgery. This should speak to you and your colleagues. You mentioned your focus is on gravitational forces as an integral part of your manual therapy. You could say to yourself, how is my client’s scar being affected by the pull of gravity, and what adhesions would possibly form?

Each anatomical region has its own tone, its own rigidity, with its own surrounding forces. As soon as we apply a physiological change in this normality, we could think that we are influencing the cellular construction of the scar. The idea is that the scar forms its own adhesions built with the surrounding stiffness, a relationship with the forces that were already there before. The more force there was initially, the more likely it is that there will be fascial adhesions between the layers. We could examine when it is best to intervene with manual interventions to prevent these adhesions. Note also that it has been shown that scar tissue is a tissue that has lost
. Scar tissue has 20% less ‘stretch’ than so-called normal skin. This brings us back to the notion of stiffness that we talked about earlier and the qualities that manual therapists perceive with they notice a change in function.

Our role could go beyond treating old scars. That work is going to help people, that’s clear, but wouldn’t our role be more efficient in the role of adhesion prevention? In the beginning when women first have a C-section, not in the first forty-eight hours of course, but perhaps there is an optimal window of time where our work can prevent these painful scars from taking hold so that the scar tissue is as healthy as possible.

If we catch the people who end up with major scarring problems, we could reduce the pain of the C-section scar, and modulate the tissue behavior before it becomes a problem. It is best to do the manual intervention repeatedly to have a lasting effect. But to do so, we need to have a better idea of when to do it since we could also create problems if the dosage is inadequate. Our approach is underutilized as preventative health care, we could be doing this work earlier, at the beginning of adhesion formation, but we lack evidence for that approach.

More work to do, and more studies need to be completed. It is an exciting moment to be doing manual therapy. There is a lot of science that is now possible for my profession of osteopathy, and our profession of manual therapy.

LAH: I agree, an exciting time to be doing manual therapy and studying the science of fascia.

IG: Studies in manual therapy clearly show that even if we apply something ultra-specific, we will have non-specific effects. It can be simple, what we do, if we have a good understanding of what it is that we are doing. We learn a wide variety of tools, but in the end, when we put our hand somewhere on an anatomical region, we are hoping to have an interaction. It doesn’t matter if it’s with the nervous system or at the tissue level, perhaps even a response with the bone.

Sometimes we make our ideas too complex, even in research, and sometimes it’s the simplest thing that we’ll understand better and how we can apply our interventions better.

LAH: That’s a great place to end our article, thank you so much for your insights and your time. Congratulations on your 2022 publication, it’s an excellent contribution to the manual therapy peer-reviewed literature.

IG: It was a pleasure.

Isabelle Gilbert has a master’s degree in health science research from the Université de Sherbrooke and is a clinician as a member of Ostéopathie Québec. Gilbert is interested in the effects of post-surgical mobilizations and women’s health. She has been an instructor and clinical supervisor with ENOSI, a professional school
of osteopathy, since 2018. She also works with a multidisciplinary sports medicine clinic and sits on the Board of Directors of Ostéopathie Québec. She is studying in the Department of Management and Evaluation of Health Policies and Organizations at the School of Public Health of the Université de Montréal.

Lina Amy Hack, BS, BA, SEP, became a Rolfer® in 2004 and is now a Certified Advanced Rolfer (2016) practicing in Canada. She has an honors biochemistry degree from Simon Fraser University (2000) and a high-honors psychology degree from the University of Saskatchewan (2013), as well as a Somatic Experiencing® Practitioner (2015) certification. Hack is the Editor-in-Chief of Structure, Function, Integration.

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March 2023 / Vol. 51, No.1
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