Jenny is 53 years old. She came to me with chronic low back issues, lack of mobility and constant pain. She also felt depressed and had severe gastrointestinal problems. Jenny had a large scar on her abdomen following removal of part of her bowel.
Raj is 47. He had been diagnosed with a frozen shoulder some months previously following a traumatic incident involving being trampled by some cattle. He had pain and a lack of range of motion his shoulder. He found it difficult to get dressed and to carry out normal activities of daily living. Raj had a large scar on his torso due to the life saving surgery he received after his accident.
Eileen is 27. Following the birth of her daughter by Caesarian section she has experienced extreme SI joint pain and discomfort in the abdomen that cannot be explained by her GP. She finds traditional massage and chiropractic approaches leave her in pain for days afterwards. She told me that she feels labelled as “difficult” and that other practitioners have suggested that the pain is “all in her head”
Three clients, all with different types of presenting pain. Yet there is one common link that lies at the basis of their successful treatment. Yes that’s right – the presence of a scar.
Scars are often the “missing link” when working with tricky cases of ongoing pain or lack of mobility. Therapists are generally not given the skills to work with scars effectively and are often given misleading information about when and how scars should be treated.
I am happy to report that the pain and emotional issues of the above clients (all real people, names changed, who approached me at my pain clinic in Brighton) have all improved dramatically. All received a course of treatments that addressed their particular issues through a combination of advanced soft tissue techniques and, importantly, particular focus on their scar tissue.
Scar tissue techniques can easily be incorporated into your existing massage approaches and can have amazing results in both improving the appearance of scars and helping to get results with tricky pain conditions.
What is a scar?
The dictionary defines a scar as:
1. A mark left on the skin after a wound, burn or sore has healed over
2. A lasting effect on somebody’s mind by a personal misfortune or unpleasant experience
This definition nicely sums up both the physical and emotional factors that are involved in “scarring” – I find with my clients that a physical scar often holds a dramatic emotional component and working on scars can help clients safely release this.
Hidden depths and fascial icebergs!
My favourite definition of a scar comes from the myofascial release expert, John Barnes who states
“ A scar is the tip of a fascial iceberg”
This great quote shows how even a small scar on the surface can be connected to deep fascial restrictions and adhesions. It is important to take into account the possible effect of scars on a client’s pain condition as working a scar can often give fantastic results where other techniques have only been partially effective.
Slugs and snails and puppy dog tails…what are scars made of?
Scar tissue is a collagen- based tissue that develops as a result of the inflammatory process following injury. The inflammatory process and the production of scar tissue are necessary for healing damaged tissue- skin, muscle, tendon, ligament, fascia or nerve. When the collagen used to mend the injury matures it is referred to as scar tissue.
Interestingly, the scar is weaker than the tissue it is replacing. For example, scar tissue replacing damaged dermis will only reach about 80 percent of the strength of the original tissue.
Causes of scar tissue are:
o The inflammatory response that results from wounds, burns, musculo skeletal trauma, or the late stage of osteoarthririts (after cartliage is destroyed)
o Prolonged immoblisation of a structure; for example in a cast following a fracture
o Paralysis of a structure due to a peripheral or central nervous system problem.
Types of scar tissue
There are lots of different types of scar tissue with different fancy names. This can make the subject a little confusing especially if you are dealing with medical diagnoses. Here is a brief run down of a few of the major types of scars you might encounter in your clinic (as listed in the excellent textbook Clinical Massage Therapy: Understanding, Assessing and Treating Over 70 Conditions by Canadian massage therapists Rattray and Ludwig)
• Contracture: the shortening of connective tissue supporting structure over a joint. This includes muscles and other soft tissue structures such as tendons and joint capsules. A contractured muscle or other soft tissue, cannot fully lengthen and results in a reduced ROM in the joint. Soft tissue contractures are subdivided into adhesions and irreversible contractures.
• Adhesion: Here, collagen fibres form cross links due to reduced range of motion (ROM) at a joint. This leads to further reduced ROM. This happens when a limb is left in a shortened position for long periods of time – for example being immobilised after an injury but also the tissue shortening that happens in postural dysfunction.
• Irreversible contracture: When fibrotic tissue or bone replaces muscle and connective tissue. There is a permanent loss of ROM that can only be restored by surgical means
• Scar Tissue adhesion: This occurs within an injury or acute inflammatory process. Collagen fibres form during the tissue repair process that allow adhesions and contractures to form in a random pattern. These adhesions can be within and between skin, muscles, tendons, groups of muscles and joint capsules; also within the joint itself.
• Fibrotic adhesions: These occur with ongoing chronic inflammation and cause moderate to severe restriction in ROM. They can be difficult to eradicate.
• Keloid: Dermal scar tissue that extends beyond the boundaries of the original wound in a tumour like growth. A keloid is thought to contain increased amount of collagen in a more random pattern compared to a hypertrophic scar. It may continue to grow for many years. Both hypertrohpic and keloid scars seem to result from an imbalance between collagen synthesis and collagen breakdown in the wound. Keloids do not respond well to surgical excision and the use of steroids seems to be more effective.
• Young people have increased amounts of scar tissue due to a greater rate of collagen synthesis: 88 percent of keloid and hypertrophic scars are present in people under 30 years old.
Why work a scar?
There are 3 main reasons that it may be useful to address your client’s scar during treatments:
1. To improve appearance: Scar tissue work can dramatically improve the appearance of scars. Ongoing work can help scars to become:
o lighter in colour
o less raised
o blended with surrounding tissue
2. To decrease pain: Scars can be related to pain conditions in many seemingly unlikely ways. I have had cases of clients with hip pain that resolved with treatment of appendectomy scars, knee pain that immediately improved with work on tiny keyhole surgery scars and countless cases of back and SI joint pain that were related to Caesarian scars.
If you are failing to get a result with a client’s pain condition it is always useful to address the scar as it will often make an unanticipated difference
3. To improve range of motion at a joint: Contractures and adhesions around a joint can dramatically affect range of motion as this leads to shortening of muscles and connective tissues. This prevents the joint from being able to lengthen to its full position.
I have had dramatic results through using scar tissue work with clients who have a limited range of motion. The client above who had been trampled on by the herd of cattle was able to fully abduct his arm after one treatment of the scar on his side. The scar was literally acting like a “too tight” teeshirt that was pulling his arm down! My other favourite memory was the 7 year old boy who could not fully extend his elbow following a severe fracture and immobilisation in a cast for several weeks. The surgeon had told his parents that he had to “live with it”. After just a few sessions working on the contractures deep in the soft tissue around the joint he was able to fully extend his arm. Now every time I see him he extends his elbow as a kind of greeting! (he is now 15!)
When is it safe to work a scar?
The million dollar question is always “how soon can you work a scar?”. There is a great deal of conflicting information around this topic in the massage field – I have read professional recommendations that range wildly from 2 days to 2 years! This often leaves the massage therapist fearful of treating scars and clients missing out on much needed helpful work.
Interestingly the medical and plastic surgery professions both advocate that patients self massage their own scars to reduce pain, reduce itching and improve appearance. Patients are generally advised to start self -massage once the scar has healed – in other words when the sutures are fully removed and all scabs have dropped off. This would seem like a good guideline for massage therapists when treating client scars.
As with most things, use your common sense and client feedback as a guide to treatment. If the scar is reasonably new, start with gentle techniques and limit the work to a few minutes. Get feedback from your client at the next session and then increase the time spent in the session on scar work accordingly.
Treat the person not the scar!
It is important to remember that scars can be zinging hubs of raw and unprocessed emotional pain. It can be easy for enthusiastic therapists to become ‘gung ho’ about mechanically treating the scar tissue without paying due attention to emotional issues. It is not uncommon when treating scars to have strong emotional feelings to resurface. In some cases this can be quite dramatic and take the client (and you!) completely unawares.
Take time to ask your client about the scar, how it happened, how old they were and how they felt at the time of the traumatic event. Check in with how they feel about the scar now. I had one client who had not touched or looked at her Caesarian scar for 20 years as it was emotionally associated with a very difficult time for her. In this case our first few sessions consisted of her “getting to know her scar” by putting her hand over the drape and just resting in the area of the scar. Clearly it would have been inappropriate to have gone charging in with some fascial techniques, no matter how effective they might have been!
Techniques for scar tissue release
The technique of choice for scar tissue release would usually be a combination of fascial release techniques, a couple of which are outlined below. As with all bodywork, the skill in these techniques comes from the hands on sensitivity in application that is generally learned best in a classroom situation.
There are many techniques that primarily focus on the fascia. These are often divided into “direct” and “indirect” approaches. Direct approaches are usually derived from Rolfing or other structural integration approaches and involve a clear idea of the direction of the stroke or technique- you could say in this approach the therapist is definitely the leader!
Indirect approaches include MFR; visceral manipulation and craniosacral therapy. In this approach, the practitioner tunes into the tissues using a “listening touch” and follows the fascia to where there is a restriction. So the therapist is more of a facilitator and the body is the leader
In general, to treat scars, I use a combination of all of the above techniques – even if I am doing “direct” work I will be doing this a sense of “listening touch” and tuning into where the body needs me to go. Use broad techniques first (cross hand stretch etc) then more focussed techniques. Work at the periphery of the scar from least restricted to more restricted areas. The goal is to produce a mobile, functional scar.
Myofascial Cross Hand Stretch techniques
o Myofascial cross hand stretches are a great way to start gently working broad areas of scar tissue. Use cross hand stretches over an area before going in with more specific techniques
o Place your crossed hands adjacent to one another in the area to be released – they should be a few inches apart at this point. Sink down until you have a sense of being on the deep fascial layers that run around and through the muscles. This will take around 90 seconds and you should have a sensation of your hands sinking into soft clay until it feels like you are ‘at one’ with the tissues
o Now put a stretch on this tissue so you have a sense of tension between your two hands – like a piece of material being stretched to a barrier.
o If you tune in with your sense of listening touch, after a while you will start to feel the sensation of the tissue starting to move beneath your hands. Make sure you maintain the stretch and “follow” the tissues until you feel the sense of ‘tissue release’ – this whole process takes around 3-5 minutes so you will need to be patient!
o If you are properly tuned into the tissues then the sensation of release will feel like a softening and a melting beneath your hands. This signifies the technique has reached an end point.
o Skin rolling can be used on any area of the body to work on the superficial fascia. In this technique the skin is gently picked up and pulled away from underlying structures.
o Make sure your thumbs are flat on the body (this helps protect the joint from injury) and pick up a “sausage” of skin and superficial fascia between your thumbs and fingers.
o Once the skin is pulled away start to slowly push your thumbs forward, lifting the tissues in a smooth continuous motion while the 2nd and 3rd digits feed into this motion causing a rolling effect.
o Remember to work slowly giving time for restrictions to release.
o When working scars work REALLY slowly with skin rolling. Always keep an eye on your client’s face and continually check in with them about how they feel
Want to learn more?
If you are interested in scar work then check out one of our great hands on workshops. Our next one day scar tissue workshop is on Thursday 7th June – call us on 01273 628942 to book a place.
For those who wish to gain all round proficiency in fascial skills suitable for treating scars and musculoskeletal pain then our 9 day advanced fascial certificate will give you all you need.
About Rachel Fairweather and Jing Advanced Massage
Rachel Fairweather is author of the best selling book for passionate massage therapists – ‘Massage Fusion: The Jing Method for the treatment of chronic pain”.
She is also the dynamic Co-founder and Director of Jing Advanced Massage Training (www.jingmassage.com), a company providing degree level, hands-on and online training for all who are passionate about massage. Come and take part in one of our fun and informative short CPD courses to check out the Jing vibe for yourself!
Rachel has over 25 years experience in the industry working as an advanced therapist and trainer, first in New York and now throughout the UK. Due to her extensive experience, undeniable passion and intense dedication, Rachel is a sought after international guest lecturer, writes regularly for professional trade magazines, and has twice received awards for outstanding achievement in her field.
Rachel holds a degree in Psychology, a Postgraduate Diploma in Social Work, an AOS in Massage Therapy and is a licensed massage therapist.
Tel: 01273 628942