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.