Scar Tissue Massage employs three basic massage technique concepts: depth, pressure, and movement. Depth refers to progressively deeper layers of soft tissue organized according to fascial or connective tissue planes. These planes, or layers, reflect tissue movement in terms of how the planes serve the range of motion in an area: free or restricted. Fascial planes must slide in relation to each other for free range of motion; any adhering tissue between fascial planes restricts motion. Pressure refers to the amount of downward (into the tissue) force is being exerted on the scar tissue at the chosen depth. Most germane to scar tissue work is the tensional forces that movement creates in scar-adhered tissue. Scar tissue massage uses that tension as a primary remodeling force.

In scar tissue massage, the depth of the pressure is determined based on the state of the scar – its age, location, how much it restricts movement, how much pain it causes. The pressure needed to work at that depth is determined by the state of the scar as well. Next, movement is introduced at that depth and pressure with the intention of mobilizing the scar into functional fascial planes. Mobilizing fresh scar tissue into these planes is fairly easy because the collagen fiber network is, by nature,amenable to change in its orientation.

The primary organizing principle used to get the scar tissue matrix to blend seamlessly with with the client’s natural movements is working adjacent tissue organization (fascial planes) into the scar tissue matrix. Collagenase migrates to movement. Collagenase dissolves collagen fibers.  The tissue structures surrounding the scar tissue matrix are organized according to the client’s movement patterns. These structures are in effect a template for the scar tissue matrix. Feeding the fascial planes surrounding the scar tissue matrix into it with myofascial twists will remodel the matrix according to those fascial planes, and consequently to the client’s movement patterns. Successfully applied, the scar tissue matrix, relative to the client’s movements, becomes ‘transparent’.

Clearly, the sooner the scar is treated with scar tissue massage the easier and more thorough the freedom of tissue movement and function. When the collagen network is less ‘set’, the fibers themselves are thinner and less dense. Tissue chemicals, primarily collagenase, are more active. Still, no matter the scar’s age, it can always be treated with scar tissue massage for more mobility.

The therapist continuously assesses the current status of the scar tissue based on its pliability. That assessment directs the depth, pressure, and movement techniques used. If there is edema present, it is advisable to facilitate movement of the edemetous fluid out of the area early in treatment, prior to and during scar tissue massage. Stretching and opening the fascial planes proximal to the swollen tissue is very effective. The established fascial planes act like a superhighway for fluid drainage when those planes are clear. A common problem is the fascial planes proximal to the edema are usually constricted with sympathetic muscle hypertonicity from the pain of the wounded area.

Myofascial stretching, twisting and holding techniques to free the movement and open the fascial planes often dramatically reduces edema. Size reductions of 25 percent are usually apparent after 30 minutes of massage., with drainage continuing after treatment. After edema is reduced, the work focuses on the superficial fascial layer; specifically, to increase movement between the skin and the underlying tissue to whatever degree is comfortable for the client. As the tissue loosens and pain decreases, the massasge is extended to deeper fascial levels. This movement between levels is constantly assessed and evaluated, and the depth, pressure and movement of the treatment constantly adjusted. Remember that controlling, or at least heavily influencing, collagenase migration is a function of how depth, pressure and movement are employed. This is the key to the effectiveness of scar tissue massage: sensitivity to the conditions of the scar and the surrounding tissue and sensitivity to the timing of the healing changes.

Scar tissue massage includes the combined use of several specific techniques. Those are: myofascial manipulation of fascial planes into the scar tissue matrix from undamaged adjacent tissue; direct scar manipulation; cross fiber friction. All of these are adjusted to the client’s comfort level.

Myofascial manipulation of the fascial planes is approached from the surrounding undamaged tissue. The client’s established movement (expressed in the fascial planes) around the scar is fed, or introduced, into the scar tissue matrix to influence, even control, scar remodeling. As research demonstrates, collagenase, the protein the body produces to dissolve collagen, migrates to the movement induced into the scar matrix. Thus the scar is remodeled to accommodate the movement required of it.

Another technique used during scar tissue massage is direct scar manipulation. This technique uses all eight of the therapist’s fingers to play, or work into the scar directly, almost like playing a piano. the therapist allows the tissue to move on its own accord in any direction it chooses. The movements are usually subtle. The pressure is light, really just touching the scar, although the intention is deep into the totality of the damaged tissue. This, like all scar tissue massage, is patient work, waiting for the tissue to lead the therapist. This it will do, because the tissue is seeking to heal. It will, in effect, ‘come’ to the therapist. Fresh scar tissue (less than three months) will always do this. Middle age (up to a year) will also, though it responds slower in most cases. Old scar tissue (more than a year) must be pushed. Again, this move is most effective when depth and pressure are considered, with sensitivity for the feel of the scar tissue and its age (and this can be said for all these techniques). This means that younger scars are worked more lightly in the early stages and progressively deeper and more aggressively as healing progresses.

While cross-fiber friction is the most common technique used for scar tissue and adhesions, I have found it the least effective overall. In LaFrano Massage Dynamics ScarTissue Massage program it is used as an adjunct to the other techniques. It is most effective when applied in all directions over and around the scar area. Work with, against, and diagonal to the direction of the wound. Work directly on the scar progressing outward to the unaffected areas.

A guiding principle in scar tissue massage is the client’s pain response or comfort level. Scar tissue massage causes pin in the local pressure receptors as well as the sensory nerve endings monitoring the interstitial chemical environment. Scar tissue has nerve endings bound up in its matrix. As the collagen fibers are worked apart, pressure receptor thresholds will be crossed, and various trapped and released toxins will contact chemo-receptors and cause pain. Pain will likely only be significant and sustained when the scar is older than nine months and all other manipulations of the area fail to create improvement. This can be the case with rotator cuff scar tissue from old injuries where, for example, the subscapularis tendon around the gleno-humeral cleft is hydrogen-bonded, resistant to manipulation, and adhered to the cleft. Direct and forceful pressure is sometimes the only effective technique and can be quite painful. Conversely, fresh scar tissue rarely needs to have the local pain threshold crossed. Fresh scar tissue (less than three months old) always responds easily and is receptive to remodeling. Between these two points the pain level can vary, but usually the pain threshold will only be mildly crossed. On a pain scale of 1 – 10, where 10 is excruciating and 7 is where muscles reflexively contract to protect, most scar tissue work on middle age scars is done at 3 – 5, while fresh scar tissue is effected without pain. The scar tissue matrix is very malleable on fresh wounds; if the client experiences pain the therapist uses that information to be aware of a restricted direction, but pursuing that pain is unnecessary and counter-productive. Approach the restriction from other, pain-free directions.

A natural problem with achieving functional scar tissue occurs because the wounded area is usually protected and kept relatively still by the person’s natural reflexes. The massage therapist working effective scar tissue massage counters and re-educates this reflex holding pattern by using these techniques combined with passive movements.

In scar tissue massage, each of these techniques is used and combined in a variety of ways, organized and guided by the ever-changing natures of the scar’s pliability and the client’s pain response. In this way, the manner in which the wound remodels itself is influenced and controlled by the therapist. After scar tissue massage, collagen is reorganized alonf the lines of fascial planes, allowing more independence between and among muscular movements. By relieving affected joints of constriction, scar tissue massage allows more movement through the joint capsule with less pressure on it from hypertonicities. The result is healthier and more functional muscle and connective tissue, and a greater range of motion.

In cases where scar tissue massage has been employed, clients report increased range of motion with less pulling on local structures and, in most instances, full function restored with no restrictions.

This technique effectively reduces adhesions in the scar-tissue matrix resulting in accelerated return to full muscle function and freer range of motion. Research on wound healing supports the efficacy of scar-tissue massage and points toward the benefits of the inclusion of this technique in post-injury and post-surgical situations.

Scar-tissue formation, while absolutely necessary to the healing process, can be a significant impediment to the recovery and rehabilitation of injured muscle and connective tissue. Effective scar-tissue massage can speed up the time it takes the body to regain pre-injury or -surgery range of motion not otherwise attainable. Scar-tissue massage is also gaining recognition as an asset in reducing health-care costs[1].
Scar tissue can inhibit range of motion by adhering connective tissue of the wounded and adjacent structures together. This often affects associated joints and presents a formidable barrier to attaining comfortable body function and useful range of motion. Circulation problems can be caused by reflexive muscle tightness in the wounded area. This often becomes chronic, and the resulting reduction in movement interferes with blood circulation allowing waste to become trapped in the dense collagen network, blocking out nutrients. Add to this the adhesion and circulation problems in referred areas due to the pain reflex response, and scar tissue can indeed be considered a significant clinical problem. Research supports the use of scar tissue massage in resolving these functional problems.
“Analysis of various disorders resulting from abnormal deposition of collagn indicates that it is not the volume or amount of collage that accumulates in the tissue lesion, but rather the physical properties (maturation, polymerization) of the collagenous matrix that are responsible for the dysfunction of the affected tissue organ,” write M. Chvapil and C.F. Koopman. “Once collagen is stabilized, it is more resistant to degradation by tissue collagenases. The dense, rigid scar of mature collagen binds less water.” [2] When collagen binds less water it is more dense and thick, therefore the movement and migration of collagenase to and through the tissue is impeded.
Newer scars are more malleable and more easily affected by scar tissue massage, although any scar can be worked on for greater function. Optimally, best results come from beginning work on scar tissue eight to sixteen days after injury or surgery, at which point the scar is in the maturation/remodeling phase.
Inhibition of free, or at least reasonably functional, range of motion is a particularly insidious problem with scar tissue. To have full range of motion the muscles must be able to slide in relation to each other in order to be independent in their motion. Scarred muscles adhere to and pull adjacent connective tissue and muscle with them when they contract or lengthen. Thus one of the functions of connective tissue, to provide a sliding surface for the muscles, is inhibited. This function is apparent in the separation of muscles by intramuscular septa and into fascicles (fiber bundles). Since every muscle fiber is surrounded by connective tissue, conceivably any motor unit could need to slide in relation to adjacent motor units for dexterity and graceful movement.
Scar tissue can bind muscle and connective tissue together so that they cannot move independently but must pull on each other when muscles move. If the injury or surgical cut is deep, scar tissue can bind many layers of muscle and connective tissue causing varying degrees of limited movement and pain. A physiological problem connected with scar tissue is that the collagen fiber network is reticular in orientation, meaning it goes in all directions and so has limited range of motion in any one direction. Consequently, the surrounding area’s flexibility and circulation are affected. If the collagen network is large and extensive, functional movement will be decreased. The advantage of treating scar tissue is that no matter how thick and tough it is, it maintains some pliability. Collagenase is always present in connective tissue. All scars can be loosened to some degree, and usually to a great degree. Scar tissue massage allows the scar’s collagen fibers to increase movement in a greater and more comfortable range.

In many cases, full use of areas of the body, especially limbs, can be impeded by nerves and muscles bound up by the fibers of scar tissue. Scar tissue massage is a simple and straightforward solution to achieving freer movement.

Scar tissue is connective tissue, and so it has the ability to arrange its fibers in a variety of ways in response to the pressure and movement it is under. When connective tissue is stretched, like elastic its fibers recoil to their original state. However, the fibers incorporate some of the stretch, lengthening the fiber net. If the stretch is applied slowly, steadily and repetitively, the increase in the elastic quality can be effectively controlled. “The permanent changes result from breaking intermolecular and intramolecular bonds between collagen molecules, fibers, and cross links,” write A.J. Grodin and R.I. Cantu. [4]
“All connective tissue seeks metabolic homeostasis – the tendency of chemical reactions involved in cellular metabolism to occur in a manner that leads most efficiently to stability of the cells’ metabolism – equal to the outside stresses applied to it. Carefully controlled stresses may positively change the metabolic and physical homeostasis of the tissue. For example, collaen production is less haphazard, more organized and laid down in a quality and direction more suited to optimal tissue function.” [5]
It is evident that in many cases full use of areas of the body, especially limbs, can be impeded by nerves and muscles bound up by the fibers of scar tissue. Scar tissue massage is a simple and straightforward solution to achieve freer movement. But like most tissue injuries, every scar carries its own special circumstances and skilled, individualized adaptation of technique is required. Effectively worked, the reticular fibrous network of scar tissue can be coaxed into functional movement.

Case Histories
The following two client case histories show the benefits of scar tissue massage.
A 42 year-old lawyer, who plays soccer on weekends, tears an Achilles tendon completely in half about three inches above the heel. Five days after surgery he began receiving our scar tissue massage. Since the wound was so fresh, the massage began with gently moving the skin over the underlying tissue to develop independence of the superficial fascia. As the skin became free of the repaired tendon, the massage went slowly deeper into the underlying layers. The goal of the deeper work was to feel for the integrity of the collagen fiber network, and continue to influence the scar fibers in a longitudinal orientation. Also, getting the Achilles tendon and its tendon sheath independent of each other and the structures deep to them were a subsequent goal. This protocol continued twice weekly for four weeks, for approximately twenty minutes duration. The rest of the hour massage addressed the sacro-iliac joints, neck and shoulders.
At that point the tendon could be stretched into almost full range of motion. Massage treatments were changed to once a week, slowly increasing independence in the tendon sheath and surrounding connective tissue. After three months the client resumed jogging, and at five and a half months post-injury the client was playing soccer at full speed, cutting and pivoting without holding back. The client’s post-operative prognosis was nine to twelve months to regain full functional use of the Achilles tendon excluding participation in sports. This occurred four years ago. Today the client remains active in sports and has had no Achilles tendon problems since.
The second case involves a 52 year-old woman who fell on Thanksgiving Day, 1996. The client fell forward, breaking her fall with her hands, and broke bones in both her forearms, requiring the radius to be pinned twice with a rod inserted. She had two surgeries ten days apart. She wore casts for two months and had 16 weeks of physical therapy. The client stopped PT at that point due to lack of insurance coverage.
Upon completion of physical therapy, the client could not close her fist, could not drive a car, and could not sleep through the night because of the pain. Even light pressure or movement on her shoulders was extremely uncomfortable. Pre-treatment assessment for massage revealed permeating scar tissue networks throughout the houlder girdle, rib cage, neck, and left forearm.
Her massage program began with slowly and gently moving the shoulder girdles, assessing for areas of more movement and independence between shoulders and rib cage (freedom of movement of the rib cage is crucial for sustained change in the range of motion for the shoulders arms and neck). After two scar tissue massage sessions, the client reported her first full night’s sleep since her fall. Treatments began in April 1997 and stopped in February 1998. There were numerous lapses in treatment due to financial constraints. In all, the client had 26 treatments of 45 minutes each. Currently, the client reports less pain, the ability to drive a car and sleep through the night, full range of motion in her left hand, and increased power in her grasp. The client returned to work Jan. 12, 1998. the remaining scar tissue in her left forearm is extensive due the fact that one pin inserted during surgery had to be removed and another reinserted. A significant amount of tissue is bound up in scar tissue in that area, which would require further sessions to release. At the same time, the client has enough integration of scar tissue into her movement to be fully functional in her work and everyday life. The remaining symptom is mild/moderate pain in her left wrist and forearm with certain movements.
These two cases required different uses of the scar tissue massage techniques. The pressure, movement, and rate at which tissue was manipulated, and the levels of movement explored, were quite varied. The application of individualized techniques is of primary importance to the effectiveness of this (and, truly, all) kind of massage.

On Collagen
My personal experience indicates that moving the scar-adhered area along the lines of the fascial planes induces the scar-modeling mechanisms to organize the scar tissue along those lines of movement. This observation is supported by H.P. Ehrlich and T.M. Krummel in an article in Wound Repair and Regeneration.
“The arrangement of collagen fibers is by the resident cells, but they are influenced by the chemical composition of the collagen in terms of quantity and quality, as well as the physical forces generated at the healing site as a consequence of its anatomical location.”[6]
Scar tissue massage works by applying controlled physical forces to the healing site. Effective scar tissue massage also normalizes and balances the chemical composition of the connective tissue matrix and interstitial fluid, and simultaneously and consequently improves the function of muscle, connective tissue and nerves.
“The roles of the intra-molecular and extra-molecular contractures in restricting joint motion following prolonged immobilization were studied by the manipulation of previously immobilized rats. The extra-articular pericapsular and the capsular structures resisted most motion. Intra-articularly, manipulation tore the proliferative connective tissue in a plane different from the original joint cleft. The new cleft was lined on either side by fibro-fatty tissue that, with time, came to resemble a synovial membrane (the membrane lining the capsule of a joint),” write W.F. Enneking and M. Horowitz. “The adhesions not disrupted by the manipulation were not affected by the resumption of motion.” [7] The scar tissue matrix, and indeed all connective tissue, responds to pressure and movement. In their absence, the matrix will remain to its current state: tough fibrous connective tissue.
Massage to the scar increases fluid independent movement of the matrix and adjacent tissue, improves muscle function through increased circulation of nutrients and removal of metabolites, and increases range of motion by influencing the effectiveness of the way the wound healing mechanisms remodel the scar. The less movement the connective tissue has, the thicker and denser it becomes, and the pain associated with scar tissue problems usually discourages movement. A 1972 study of knee immobilization reported that, soon after movement resumes, the connective tissue at the site of movement responds by developing a synovial membrane, which is the variation of connective tissue most conducive to movement [8]. Scar tissue massage uses the inherent responsiveness of connective tissue to control scar tissue remodeling. Further, Ehrlich and
Krummel’s work suggests that manipulating the scar changes the nature of the scar’s anatomical construction from immobility toward synovial quality of independence.
“Although soluble collagen can self-polymerize into filamentous fibrils under physiologic conditions (in this case, those in the wound healing process), the organization of these fibrils requires cellular intervention,” the study concludes. “The cellular organization of collagen fibers is important in terms of scar volume, stability and strength… Although collagen covalent cross-links have been shown to correlate with increasing wound-breaking strength (the amount of physical stress the scar tissue matrix can withstand before tearing itself), the amount of collagen deposited, as well as its degree of organization (the alignment of the collagen fibers in the scar tissue matrix, referring in particular to how they function: how much pressure they can withstand vis-a-vis how much movement they allow) may be of greater importance.” [9]
The response of the local fibroblasts is predicated on local tissue chemistry and on the pressures and movements those fibroblasts encounter. My experience indicates that the chemistry and and tissue tension due to local muscle tone can be effectively influenced and altered by scar tissue massage techniques. Scar tissue massage applies movement and pressure through the fascial planes in the surrounding tissue, feeding that pattern into the scar tissue matrix, thereby influencing the fibers’ organization.
The research done by Pins et al and Steffensen et al further supports the relevance and importance of scar tissue massage. They confirmed something that scar tissue massage’s effectiveness suggested: collagenase migrates to movement.[10] That may be the number one anatomical and physiological factor explaining why scar tissue massage works so well. I have come to describe scar tissue massage in its shortest terms as the control of collagenase migration. In fresh scar tissue (less than three months old), collagenase is present in the scar tissue area in great abundance. As the scar tissue matrix ages, the collagenase concentration diminishes, although it is available to all connective tissue always. Middle age scar tissue (approximately 3 months to a year) takes more time to remodel than fresh, and old scar tissue (more than a year) can be tough and take very firm pressure to mobilize. All scar tissue adhesions can be improved no matter how though and resistant. With fresh scar tissue, full range of motion can be virtually guaranteed.

Footnotes

Witte, M.B.; Barbul, A. “General Principles of Wound Healing”, 1997, The Surgical Clinics of North America, 77, (3), pp. 509-528.

2. Chvapil, M.; Koopman, C.F. “Scar Formation:Physiology and Pathological States” 1984, The Otolaryngologic Clinica of North America, 17, (2), pp. 267-8.

Witte, M.B.; Barbul A., p.516

4. Grodin A. J.; Cantu R. “Myofascial Manipulation Theory and Clinical Application, 1992; Aspen Series in Physical Therapy, p.31

Ibib, p.34

Ehrlich, H.P.; Krummel, T.M. “Regulation of Wound Healing from a Connective Tissue Perspective”, 1996, Wound Repair and Regeneration, 4, (2), p.204.

Enneking, W.F.; Horowitz, M. “The Intra-Articular Effects of Immobilization on the Human Knee,” 1972, Journal of Bone and Joint Surgery American; 54-A, (5), p.983.

Ibid.

Ehrlich, H.P.; Krummel, T.M.; p.205

10. Pins, G.D.; Collins, M.E.; VanDeWater, L.; Yarmush, M.L.; Morgan, J.R. “Plasmin Triggers Rapid Contraction & Degradation of Fibroblast Populated Collagen Lattices”; Journal of Investigative Dermatology

and

Steffensen, B.; Hakkinen, L.; Hannu, L. Proteolytic Events of Wound Healing – Coordinated Interactions Among Matrix Metalloproteinases, Integrins, and Extracellular Matrix Molecules

The function of muscle tone is primarily two-fold: to stabilize the joints both statically and dynamically and to circulate fluids through the body’s tissues, functioning as the ‘return heart’.

‘Statically’ refers to stabilizing the joints with the body at rest: sleeping, sitting, where levels of muscle tone required to stabilize the joints would be relatively low. ‘Dynamically’ refers to stabilizing the joints with the body active: walking, running, dancing, where levels of muscle tone required to stabilize the joints would be relatively high. The main point here is that there will always be a required tone to keep the  joints stabile; without that required tone joints would be vulnerable to dislocation, since the joint capsules and the ligaments surrounding them are not designed to support the joints by themselves. They are designed to support the joints with muscle tone.

Here we have the definition of ‘hypertonicity’: any tonal value in excess of the muscle tone required to keep the body’s joints stabile during rest or activity would be a hypertonicity.

The Major Problematic Health Effects of Hypertonicity

Chronic hypertonicity creates serious health problems. The main issues are:

•   Excess pressure on the associated joints
•   Decreased interstitial space
•   Increased pressure on arteries, veins, lymphatic vessels, and capillary beds
•   Increased pressure on interstitial space
•   Increased energy demands of hypertoned muscles
•   Decreased ability to remove toxins from interstitial space
•   Decreased ability to flow waste through veins and lymphatic vessels routing through hypertoned muscles

[See the LaFrano Massage Dynamics article Viability of the Interstitial Space for a discussion of the effects other than the joints.]

The ‘Work’ That Hypertonicity Does

Hypertonicity is, by definition, too much tone. The discussion above defines what too much tone is. A hypertoned muscle is working too hard – it is doing more work than is necessary to accomplish the task at hand. This leads to the very important question: what is the extra work that hypertonicity is doing? What is being accomplished by that extra work?

First, let’s look at what extra work it is not doing. Whatever task is going on, hypertonicity is not making it happen any faster, nor more efficiently. If I’m washing dishes, and I’m hypertonic in my neck and shoulders, I don’t wash the dishes any faster. I probably would do it slower because I’m in some degree of discomfort or pain. Tight muscles will never make me more efficient; quite the opposite, my movements will be less fluid.

Hypertoned muscles will be distributed more than less all around the joint or joints they cross to minimize distortion of posture. They will certainly distort the posture, but the body’s homeostatic balancing reflexes will seek to minimize it. The work that hypertonic muscles do is compress the joints they cross, as well as any structures within the lines of force they create. This effect must be thoroughly considered and appreciated by bodyworkers, as well as its ramifications.

We know that when fibroblasts, the cells of connective tissue proper, are subjected to pressure they produce more collagen fibers to support that pressure. If the increased pressure is accompanied by less movement, as is usually the case with hypertonicity, they will produce less ground substance. [For a more full description of this, see the LaFrano Massage Dynamics article the Three Main Properties of Connective Tissue] One can see that the consequence of this scenario is loss of range of motion.

That is not the end of it; rather, the beginning. As collagen fibers build up in the joint, the joint becomes thicker and denser. If this progresses, movement will at some point cause pain and then inflammation, eventually morphing into a condition called osteoarthritis. It should become apparent that this is not a disease: it is the unfortunate result of a solution, of the body doing what it has to do given the circumstances it has to operate under. Osteoarthritis is one of the results of the work that hypertonicity does.

If the hypertonic muscles put pressure on a visceral organ, the effect will be to congest that organ by inhibiting circulation within the organ, and it’s function will be negatively affected. Impaired circulation in any structure is the genesis of disease. [Again see Viability of the Interstitial Space]

The solution is straightforward – relieve the muscles of their hypertonicity. If the pressure is relieved and movement reintroduced, the body will, over time, deconstruct the fibrous restrictions in the joint or joints. Every client situation will be unique, and the massage approach that will be successful will also be unique to that client. The time frame to achieve this will also differ. There are plenty of variables including how long the hypertonicity has been there, the age, diet, and fitness of the client to name obvious and common ones. Effective bodywork will always be guided by the client’s response, and will include the client’s body-wide tensegrity organization – no hypertonicity exists as a singular phenomenon. Given that, the situation will always be correctable to some degree, and in many cases completely correctable.

As we established in Part One, selfishness means I want the most for me, or more to the point, I choose the most for me. Furthermore, true selfishness requires that I consider other people and circumstances in order to get the most from them. Now we’ll look at how this plays out physiologically in the body.
When I engage in lying (one of the cornerstones of our culture and society – when in doubt: lie) and its relatives, cheating and stealing, my belief system is based on the fact that my truth is not enough, that my truth does not make me safe. I inherently do not trust myself when I lie.  For my brainstem, all information has an emotional component, and it will organize my body accordingly. In short, all thoughts are interpreted as either suggesting threat or safety. My brainstem will interpret mistrust as a threat, and will engage the sympathetic neural response.

We have discussed the dynamics of the sympathetic response elsewhere, and we’ll summarize the two key aspects relative to bodywork here: the sympathetic response inhibits the immune system, and it engages protective muscle hypertonicity somewhere (and to a degree, everywhere) in the body structure. Together, these provide the setting in the body for dysfunction and disease (see the blog ‘Hypertonicity Defined’ and the article ‘Viability of theInterstitial Space’).

Conversely, true selfishness leads to, and actually requires, self-trust.

In order to truly choose the most for me, I must believe I deserve the most for me, and I therefore must believe and trust in myself. The more thoroughly I trust in myself, the more parasympathetic my nervous system will be operating because I will feel safe within myself. And, the more ideal my muscle tone will be, the more fluid my interstitial space will be (‘Viability of the Interstitial Space’). True selfishness is a key aspect of optimal health. From another perspective, when I enlist others’ help in becoming more abundant by being a part of their becoming more abundant, I am engaging myself and them in a creative process. A creative process always excites the quest for and the sense of satisfaction, which is probably human beings’ most desirable experience. The sense of satisfaction which arises from a creative process is a sublime experience which induces a parasympathetic perspective and a sense of self-trust.

We live in an insane culture and society. That is not my opinion, that is a physiological fact. It is important to understand how and why that statement is true because it affects the health and the structural relationships within our bodies, and thus our clients’ bodies. One of many perspectives to understand this is looking at the concept of selfishness versus the reality of self-sabotage.

Selfishness gets a bad rap. Selfishness means I am looking to get the most for myself. Let’s use money for this discussion, but any desirable human condition – love, advancement, security, all will apply. If I am seeking more money from you, our culture and society suggest that, after I seek honest means of getting more, such as selling you something, that I lie, cheat and/or steal. Our culture and society lead us to believe that is selfishness. I am suggesting that is not selfishness, it is self-sabotage. If I lie, cheat, or steal from you, at some point you will probably figure it out, and then I’m done, I’m finished relative to you. Not only will you not have financial dealings with me, you will warn others if the subjects of money and me come up.

Also, this attitude and perspective comes from a position of lack, of scarcity, of not-enough. No matter how much wealth I accumulate, it will never feel like enough. It inherently cannot, not from that perspective. A sense of satisfaction either cannot be attained, or at most be fleeting, and a sense of satisfaction is a universal human goal and desire.

If I am truly selfish and would like the most money I can get from you, I figure out how I can hook you up with more money. Is there someone I can introduce you to who is good for your business? Is there any advice or resource I know of that may be of financial benefit to you? When I can accomplish this, I probably have you for life. You will hook me up with more money whenever you have the opportunity. That is true selfishness; true selfishness requires that I consider others, be it people or circumstances.

Notice how nicely this fits with the concept of true abundance: to be truly abundant show yourself to be a source of abundance. Many of us have come across that idea. Another way of stating it is, if I am causing others to become more abundant, I must of course be abundant. If I cause others to become more prosperous, I must of course be a source of prosperity. In truth, demonstrating oneself to be the source of anything assures the experience of it. There may be a time lapse between the two, although with commitment and single-mindedness the experience always happens presently. Also, from this perspective and with this experience, a sense of satisfaction is the natural result.

Next: the physiology of these two perspectives, true selfishness vs self-sabotage. Peace and love.

Among the back problems we and our clients experience is a situation allopathic medicine refers to as ‘Degenerative Disc Disease’. From our perspective here at LMD, the only word out of those three that is applicable to the situation is ‘Disc’.

The disc here is of course an intervertebral disc, and it is made of cartilage, which is a type of connective tissue. I have never come across any medical  text or article that describes cartilage as a tissue that ‘degenerates’. Degeneration suggests a condition in which something ‘wrong’ is going on inside the cartilage itself, that the tissue is degenerating. Cartilage does not deteriorate from within. It can, however, be worn down.

Think of intervertebral discs as shock absorbers, which is one of their main functions. The discs’ thickness, strength, and resilience is a function of the forces they were designed to deal with. Remember, ‘ideal muscle tone’ is the tone it takes to support the joints in any action the body is doing, and no more. Any tonal value above ideal muscle tone is a hypertonicity. The discs evolved with ideal muscle tone as their basic design parameter.

When hypertonicity becomes chronic in the para-spinal muscle groups, the discs in between the associated vertebrae experience pressures higher than their design parameters. This, over time, is bound to wear them down. They haven’t ‘degenerated’, and they are far from ‘diseased’. They are simply in a situation beyond their design. Everything will wear out prematurely under these circumstances, from your car to your comb.

When a client presents with ‘degenerative disc disease’, your job is pretty obvious at this point, isn’t it? Solve the root cause of the hypertonicities. Of course, our viewpoint here at LMD would be to approach it from a Three-Lever Theory perspective, assessing the SI joints and the Occiput/C1/C2 dynamic, check out rotator cuff, knees, ankles and feet, and proceed from there. A technique I always include in disc issues is: client supine, knees bent at 90 degrees, therapist on table kneeling at client’s feet facing client. Hold the client’s legs above the knees and apply traction. This should always feel good to the client; the more intense the situation the more gentle the traction. I also float the neck, as it’s always a major player in disc issues.

The hypertonicities wearing the discs down are there for a reason, and the job of quality, effective bodywork is to solve the ‘riddle’ of the pattern that is maintaining those hypertonicities. Every situation is unique, nothing works on everyone, something will work on everyone, and the journey is endlessly fascinating. Please, your thoughts and comments.

Note: We’ve run into a minor glitch on our website and my replies to your comments haven’t posted to the website lately. We’ll have that resolved in the next day or two.

I got an email from one of you and would like to make it today’s subject:

“The whole ‘no expectations of results’ that you mention would also be a much-needed topic sometime to post for all us bodyworkers… I think it’s too easy sometimes to get caught in that trap as a massage therapist (and anyone in the “healing” professions for that matter) and take things personally and too hard. We definitely can’t forget about everyone’s personal responsibility and what they do to help themselves, or not help themselves in their own life.”

I like that this therapist put “healing” in quotes. It is important to establish the ground rules of the meaning here, as it’s much more than semantics. I believe it is without question that we are not healers; the only healer that exists for anyone, both physically and emotionally, is him or herself. What we are is facilitators: ideally, we remove physical circumstances that are currently in the way of the client’s body healing itself. It is simply what we’re good at. To think of ourselves as ‘healers’ puts us on a conceptual plane that is above the one the client is on. It suggests a grandiosity. We then tend to not work so much ‘with’ our clients as ‘at’ them. (By the way, that ‘healer’ way of looking at clients is guaranteed to sap your energy.) The main point here considering our topic: being a healer would of course include serious expectations built-in. If I’m a healer, the client better heal, or I’m not much of a healer. A facilitator helps make things happen, makes goals more achievable. That’s what a competent massage therapist does.

I believe there are two main aspects to this issue of expectations: 1) What is the massage therapist responsible for, and; 2) How does the ‘ego’ function best for the massage therapist?

‘Ego’ – For this discussion, we’ll define ‘ego’ as the totality of the concept one has of oneself, how one sees oneself and how one feels about oneself in the world. Basically, ego does not function well when it requires perceived validation from the world around it. That’s not to say it isn’t nice to get validation from the world; it’s wonderful. It lets one know one is probably on a good course (but not necessarily: ‘they’ could be wrong). Approval by those around us is fine, but it’s not necessary. One way this concept has been put is: be in this world, but not of it. Function in the world by making choices, not by ‘acting accordingly’.
For myself, I’ve come to understand that the ego functions best in massage therapy as a coordinator of information, sort of a mediator between what I’m feeling and sensing, and what I end up doing with my bodywork. It works best to do this with no judgement, not even with an opinion. Some would say this is ‘egoless’, but that’s a different interpretation of the word. In our perspective here, it is impossible to be egoless, just as it is impossible for me to not be me. So you could say the ego functions best as the aspect of me that notices things about the client (from what I’m feeling to what I’m intuiting), notices my technique choices, notices the client’s response to what I do. It coordinates what I feel with what I do.

Responsibility – What is a massage therapist responsible for? A pitfall here would be to think that a bodyworker has the responsibility to be effective with his/her client, that the client should improve as a result of treatment. This inevitably leads to the therapist taking responsibility for the client’s physical complaints. And that, of course, is a recipe for expectations. When you think about it, taking responsibility and having expectations is rude: it’s like the therapist saying, “I can handle your problems better than you can,” and that’s just plain rude. Rather, respect the client and their complaints.

So what is a bodyworker responsible for? I feel number one is show up with, and to, the best of your ability for that session. Be present, pay attention. Show up on time, prepared and clean. That’s pretty much it; if you’re in business for yourself, be able to make change for $100 bill.
In terms of what the client does or does not do with our work or in their whole healing process, that is their business, not ours. Their responsibility is not our responsibility. Again, I’ll make the point that it is rude to judge our clients’ decisions on what to do with our work. I understand clearly how difficult this can be when one feels confident in one’s work and understanding of the situation, and of the client’s circumstances. Remember that it’s about them, so respect their choices.

So, my position is we can forget about the clients’ “…personal responsibility and what they do to help themselves, or not help themselves in their own life.” In fact, I believe it’s best if we do forget about the client’s decisions regarding themselves. To re-emphasize, their decisions are their business, and to recognize them is to have a judgement or opinion of their decisions, which will lead to expectations of them (unfair), and that road leads us to resent the client. I’d like to emphasize that it’s not easy to let go of these thoughts and attitudes, and I face this regularly in my work. But it is worthwhile to be conscious of such thoughts and attitudes, understanding that they are not serving us as massage therapists nor our clients.

Greetings All and Happy Holidays

One of you asked in an email:

“Any chance you can address your take on Pleurisy? (especially not virally caused) And, what a treatment may look like….It’s really frustrating doing research when there’s all this Western medicine point of view – I was trying to look at pleurisy as not the problem, but of course, can’t find any info going down that route.”

Excellent question that leads to many interesting points for our consideration.

This is from The A.D.A.M. Medical Dictionary, and is common to the Western medical viewpoint:

Pleurisy is inflammation of the lining of the lungs and chest (the pleura) that leads to chest pain (usually sharp) when you take a breath or cough.

Causes, incidence, and risk factors

Pleurisy may develop when you have lung inflammation due to infections such as pneumonia or tuberculosis. This inflammation also causes the sharp chest pain of pleurisy.

Symptoms

The main symptom of pleurisy is pain in the chest. This pain often occurs when you take a deep breath in or out, or cough. Some people feel the pain in the shoulder.

Deep breathing, coughing, and chest movement makes the pain worse.

Pleurisy can cause fluid to collect inside the chest cavity.

When you have pleurisy, the normally smooth surfaces lining the lung (the pleura) become rough. They rub together with each breath, and may produce a rough, grating sound called a “friction rub.” 

Treatment depends on what is causing the pleurisy. Bacterial infections are treated with antibiotics. Surgery may be needed to drain infected fluid from the lungs.

Viral infections normally run their course without medications. Patients often can control the pain of pleurisy with acetaminophen or anti-inflammatory drugs such as ibuprofen.

When I read something like the above, I’m looking for: key ideas that suggest the cause, what I’m going to begin treatment with, and how I’m going to proceed at the beginning.

The number one key idea from the dictionary is that pleurisy is an inflammation of the pleural membrane. So I immediately know that the pleural membrane is ‘pissed off’. It’s angry because there are unbalanced forces operating in the body, and their most noticeable current effect is to congest the pleural membrane, and so annoy the hell out of it. And it’s letting everyone know.

Check out the effect in terms of connective tissue dynamics. “…normally smooth surfaces (of the pleura) become rough…” We know what makes smooth connective tissue rough – rhymes with ‘fresher’, and of course it’s PRESSURE. I’ll be looking to solve where that’s coming from in terms of dynamic tensegrity.

The first piece, for me, would probably be to see if I can get the area to drain; open up the lymphatics. I would put the client on the table in their most comfortable position – pillow them up, whatever. I’ll start with the SI joints, look at how forces are feeding into Occiput/C1/C2, don’t overlook rotator cuff scar tissue, thoroughly go through SCM, temporalis and masseter, psoas/iliacus/diaphragm, float the rib cage and head, float anything else that occurs to me.

There are points at the spaces between the ribs next to the sternum called Chapman’s Reflexes, and they are claimed to be neuro-lymphatic reflexes, meaning they narrow the lumen of the lymphatic vessels when fired up. I’ve gotten good results using them. The ones for the lungs will be around the upper sternal area, bilateral. They should be ‘burners’ when you press on them, like very active trigger points. You can work them like trigger points, and/or do small local myofascial stretches to them, anything to bring down their sensitivity. Also see what you can do with pec minor, seratus, everything around the lungs. They will be big players, you can count on it.

Now here’s a key technique concept as I see it: the work can be tricky, because if the pleurisy is fired up, you don’t want to cause pain while addressing these things, and that may be difficult. Do your best to avoid a protective response from the client.

An overall thing you’re looking to get is a parasympathetic response from them. Pay close attention: if they tighten and protect in response to what you’re doing, immediately back off and look for another way ‘in’. Work gently. It’s key that the client can rely on you not to hurt them (or at least not to sustain any work that does), that you won’t further annoy the pleural membrane.

With pleurisy, as with anything connected in any way to the immune system, the sympathetic response is the ‘enemy’; the sympathetic response is certainly part of the true cause, and very well may be the ultimate cause.

In terms of whether it’s viral or bacterial, for us I don’t think that’s much of a factor. The more successful I am in increasing a parasympathetic response, the stronger the immune system becomes, helping the client in either case.

The goal is to increase circulation around the pleural membrane. To repeat, pleurisy is an inflammation, and ‘inflammation’ means ‘pissed off’. If you can figure out what’s pissing the area off, you’ll increase the circulation. This should get the condition to at least improve. Let me know if you have any questions on dealing with the Chapman’s Reflexes, or anything else, and I’ll go into greater detail. Later, Friends

Inflammation is for the most part looked upon by the health care community as an entity more or less unto itself. Inflammation may be accompanied by other conditions, but it is usually seen as its own aspect and exists coincidentally with the other conditions.

I see inflammation as both a result of certain situations and, even more, as an indication that an underlying dynamic exists, an underlying dynamic that will potentially cause more insidious problems in the near future if not addressed and resolved.

Many of you have heard me suggest that a phrase that can be substituted for inflammation is ‘pissed off’. Pardon the crudeness, but I believe the euphemism is appropriate.

When tissue is inflamed it is angry, and it is angry for the same reasons you or I would be angry when we’re on the job – it is being required to do something unreasonable and beyond its job description, and it is being required to do this repeatedly or constantly. Like you or I in these circumstances, the tissue is under excesive pressure. In this case, the pressure is coming from some combination of hyper-tonicities, The focus of the hyper-tonicities, or the most vulnerable tissue within the lines of force of the hyper-tonicities, would be the location of the inflammation. Often, the location of the inflammation has no actual physical malady occurring; it is simply the location of the most ‘pissed off’ tissue under the circumstances.

Let’s take plantar fascitis as an easy example. If that is the client’s complaint, and the therapist thoroughly works the plantar fascia, results will much more than likely be temporary at best. The key to effectively addressing the inflammation is to find where the pressure being placed on the plantar fascia is coming from. In truth, it could be coming from anywhere, even (though it would be very unusual) scar tissue from anywhere in the body. You can see that we are now getting into the investigative or ‘detective’ aspect of massage therapy.

This is where we at LMD believe the tensegrity concept of body organization, and even further adding “Three-Lever Theory”, comes into play. If the plantar fascitis is in one foot, the opposite sacro-iliac joint will be the location to begin your investigation. In the detective analogy, it’s the prime suspect. The cool thing about bodywork is that the SI joints are always the prime suspects, because all the forces generated in the body must flow through them effectively for graceful, purposeful movement. And of course, the dynamic of the arms and the balance of the head, focused on Occiput/C1/C2, are the next suspects. It’s like these guys are always in cahoots, and if they are not the cause of the inflammation, they will practically always point you in the direction of the culprit(s).

If the cause of an inflammation is very unusual, like say scar tissue in one finger actually being the root cause in a pattern that results in plantar fascitis, you can trace the cause by following it backwards. If this were the case, the pattern would have to flow through the arm into the neck, where it would create a compensation through the pelvis, and so the SI joint(s), to create pressure in the plantar fascia. The pattern will be there, follow the hyper-tonicities and fascial thickenings. They will be having an effect on the fluidity of the #1 & #2 levers. In this case, they will lead you to thoroughly investigate the arm, elbow, wrist, and hand, and you have a good shot (detective pun intended) at coming across the guilty scar tissue.

So, I feel the bodywork perspective on the subject is that inflammation is a symptom. It is a warning sign that unbalanced forces are now operating. If they are not addressed, the next phase will probably be worse, and a downward spiral is in the making. Look for clues, figure out what is operating, and solve the mystery. Getting good at this is one of the most intriguing and rewarding aspects of effective, advanced massage therapy.

More on this subject next week in a look at pleurisy.

As the last blog suggested, there is a singularity of thought and purpose that is characteristic of creating effective energy, and it begins as an internal process/phenomenon on the part of the bodyworker. Here we will look at the energetic interaction between the therapist and client, and how to use that for therapeutic effect.

There are two aspects to the therapist’s attitude toward the client that come strongly into play, and they are acknowledgement and respect.

One of the most satisfying feelings we experience as human beings is the deep satisfaction we get from being acknowledged, from being recognized. This should come into play from the very beginning of the client/therapist relationship: the first contact and initial interview. It is a product of becoming intrigued by all of the client’s complaints and comments. Dismiss nothing nor downplay anything the client has to say. Rather, encourage the client to go into detail. Most often, details suggest approach options and possible root causes, and so is at the same time in the therapist’s best interest.

Acknowledgement puts the client at more ease. It honors the client’s circumstances and with that will come some degree of relief for them. This will in turn encourage a parasympathetic response on their part, and that response is essential for a healing energetic field.

Acknowledgement and respect go hand-in-hand. In your attitude toward the client, see him/her as a success story. The client, and their body, has done what they’ve had to to get through life. And so far they’ve made it. I think of everything going on in a client’s body that causes pain, discomfort, or dysfunction as ‘badges of honor’.

Another facet of purposeful energy is that the therapist have no judgment of the client and the client’s experiences, even to the point of having no opinion. Judgment never works: when you think about it, judgment says, “I know everything about you and your circumstances,” and that could not be. Judgment always assumes, and we know where that goes. Worse for the therapist, judgment narrows one’s ‘vision’, one’s perspective, and that impairs the therapeutic potential. Accept the client with an open mind, and heart, and listen with your ears and then with your hands. You are hearing and feeling part of their life story.

I like the way the book Conversations With God put it: ‘life is simple for spirit, but it’s not easy’. No one here is having an easy time of life, not with any consistency anyway. Life is often very difficult and it takes a toll on the body. Addressing that is, of course, our job. Show honor and respect for the client’s experience (you may be one of the few who do) and the stage is set for purposeful, healing energy.