Summary:

This article is written for RMTs who are interested in understanding current research on massage and scar tissue management. The article reviews outdated concepts of ‘releasing adhesions’ and ‘breaking-down scar tissue’ and explores patient-centred considerations for treatment planning including: the patient’s relationship with their scar, their physical and emotional experiences, and their treatment goals and preferences. The importance of providing patients with up-to-date information about what massage can help with is emphasised in the context of obtaining informed consent.

Background

The reality is, many manual therapists learn outdated information in school. It’s commonly taught that certain techniques can 'release adhesions' and ‘break down scar tissue'. In massage school we learned how to do painful and intense techniques like ‘cross-fibre frictions’ on scar tissue - ouch! Since current evidence indicates that we can’t say with certainty that we are changing the state of the tissues (more on that later), how does this impact our approach to treatment?

If we aren’t changing the tissue, what could our treatment goals be? What other considerations are important when working with people who have scars? These questions can only be answered by asking the patient in front of us what their relationship with their scar is, and what they hope to achieve with massage therapy. If this intrigues you, please read on…

“I’ll always remember an experience I had in the student clinic. A person came in for a relaxation massage and the clinic supervisor came in during the massage and immediately began touching the scars on the person’s head that were from a traumatic brain surgery. The patient was clearly uncomfortable with having that area touched; it wasn’t what they requested or had consented to.”

— RMT

“I went for a massage because I was experiencing back pain and I really needed to de-stress. The RMT told me we should work on old scars I had from a breast reduction surgery. They said it would help with my back pain but the massage hurt and I didn’t feel better afterwards. I’ve had those scars for 20 years and my back pain just started this week - it didn’t make sense.”

— Patient

The two quotes above raise some important questions for us to consider as therapists:

Does the patient want their scar tissue worked on? Are they experiencing any concerns that they perceive as being connected to their scar tissue, or is this a scar they have no concerns about? Are we pathologizing healthy scars and creating fear in our patients? Are we promising non-evidence based outcomes to folks who are vulnerable and/or have limited funds for therapeutic treatments? Are we discussing the most current evidence for treatment of scar tissue with our patients so that they can make an informed decision about their treatment?

Current Evidence for Massage and Scar Tissue Management

Manual therapy education often teaches that scar tissue in one area can impact another part of the body and that ‘breaking down’ the scar tissue will help. This incorrect information may encourage practitioners to perform aggressive treatments on scar tissue, with the false belief that doing so will relieve pain or improve range of motion elsewhere in the body. Researcher Susan Chapelle shares a wealth of research findings in her Chapter: Understanding and Approach to Treatment of Scars and Adhesions. She reflects that “as a profession, manual therapists have long held the belief that local restrictions in tissue movements can result in larger global dysfunction. There is little support for this concept.” (Chapelle, 2016)

The Role of Massage in Scar Management: A Literature Review concluded that:

“The evidence for the use of scar massage is weak, regimens used are varied, and outcomes measured are neither standardised nor reliably objective, although its efficacy appears to be greater in postsurgical scars than traumatic or postburn scars. Although scar massage is anecdotally effective, there is scarce scientific data in the literature to support it.”

— Shin, 2012.

“The remodeling phase can last from months to years, during which time the scar matures and improves in appearance and pliability. This process occurs in the absence of any intervention.”

— Shin, 2012

Physical Management of Scar Tissue: A Systematic Review and Meta-Analysis analyzed research done to date on various forms of treatment for scar tissue including mechanotherapy (massage and extracorporeal shockwave therapy/acoustic pulses); occlusive and hydrogenic therapies and light therapy (Deflorin et al, 2020).
Four of the studies looked at massage and scar thickness, however most studies had small sample sizes which limits the translation of these results into practice.
A moderate to strong effect on pain reduction was observed in two studies, where scar tissue from burns was treated with massage therapy for 30 minutes. Both studies used massage in combination with other standard therapy for burn scars. Massage was also observed to have a moderate effect on reducing itchiness in burn scars.
“Only one study investigated the effects of skin rehabilitation massage therapy on the pliability of burn scars, showing a large and significant effect.” This could be due to the mechanical disruption of the fibrotic tissue. “The application of mechanical stimuli can lead to changes in the expression of the extracellular matrix proteins and proteases, and therefore may change the structural and signaling milieu.”
Two studies showed that massage was effective in reducing scar thickening in hypertrophic and burn scars, while two other studies showed no effects in reducing scar thickening. Treatment frequency and duration may have an impact.

When it comes to applying manual therapy to scar tissue we don’t have clear evidence for what kind of pressure, technique, or length of treatment is best, or at what stage in the healing process to apply it. This information inspires a sense of humility and curiosity.

So what’s an RMT to do?

Let’s update our knowledge and get comfortable with uncertainty. Let’s get curious about the patient’s experience and treatment goals and what feels best for them - those details can only be discovered through skillful communication...

What Does the Scar Represent?

Educator Pamela Fitch asks an important question: ‘what does the scar represent’ to the patient?

Does it represent triumph through adversity or challenge? Changes in ability to work and support themselves financially? Changes in comfort socialising or connecting with others? Is it a reminder of a difficult or scary time?

Did the scar tissue result from an elective surgery with a positive outcome? Or an elective surgery with associated negative experiences (lack of support during healing, or infection complications)? Did the person feel they had control and choice through the process? Did they feel supported as they integrated the changes to their body?

By considering these possibilities we get a sense of some of the potential challenges and impacts and ways that we could help as Registered Massage Therapists.

Potential Treatment Goals

Patients often come into our clinic for post-mastectomy or post top-surgery care. In order to best support them, our team of RMTs hosted a discussion night and brainstormed a list of possible treatment goals when working with folks who have scar tissue.

As Registered Massage Therapists we could potentially help with:

Managing the impacts of stress, anxiety and/or depression.
Co-creating pain management and self-care strategies.
Improving sleep quality and duration.

Encouraging beneficial movement during the healing phase / (the right dose is variable for each person: aim for the middle path of ‘not too much and not too little movement’.)
Decreasing fear-avoidance of movement through reassurance and exploring gentle movement together (gently approach the edge of discomfort with movement that feels safe, don’t push through).
Improving pain-free functional capabilities that are important/meaningful to the patient - start with passive movements; then progress to assisted active movements; non assisted movements; and then gradually add resistance or weights.

An improved sense of social connection (depending on the location, severity and circumstances surrounding the scar tissue, the person may be experiencing a sense of isolation or shame).
An enhanced sense of interoception and body awareness.
Bearing witness/facilitating reintegration: Witnessing changes in returning sensation; coming into relationship with that area of the body.

Other notes from our clinic discussion:

Not everyone wants their scar tissue worked on.
Even when a person has provided consent during the intake process, always ask permission before touching someone’s scar.
Have the person place their hand on the scar tissue first, then the RMT places their hand on top. The person can then remove their hand when/if they feel ready.
Treatment frequency depends on the treatment goals and patient preferences.
Avoid over treating - there is a risk of harm.
Incorporate other enjoyable areas of treatment as appropriate.
Remember: as scars mature, their appearance and pliability improve in the absence of any intervention (Shin, 2012)
Patient’s cannot give informed consent to the proposed treatment plan unless they have been provided the most up to date evidence-based information and the risks and benefits of massage for scar tissue management.

On that note, let’s be mindful of the claims we are making about what massage therapy can do. Let’s look more closely….

Tracy Walton examines this claim in 5 Myths and Truths about Massage Therapy: Letting Go Without Losing Heart:
“There are a handful of studies on massage and circulation, but they are inconclusive. It’s too early to say whether or not massage increases circulation at the site of massage, overall throughout the body, or whether it’s clinically important if it does. Since we don’t know the answer to this question, in my practice, I focus on helping my clients in other ways.” (Walton, 2016).
This is not a claim we can make. We know that scars and adhesions can become innervated with nociceptors.
“Nerve regrowth into muscle fibres does not seem to be inhibited by scarring; axon sprouts are able to penetrate scar tissue and are able to form new, functional neuromuscular junctions.” (Kaariainen et al., 2000).
Shin's literature review notes that massage may be effective through affecting matrix remodelling and fibroblast apoptosis, although the exact mechanism remains to be determined. (Shin, 2012)
*Studies on fibroblasts are commonly done in vitro (observing cells in a petri dish) - so their application to manual therapy may have limitations.
“Adhesion” is a word that gets tossed around a lot by manual therapists. An RMT may believe that they can feel or sense ‘adhesions’ in a clients tissues, but the scientific definition of an adhesion calls this super-power into question. When an RMT tells a patient they have adhesions, it can sound scary and create a perception that there is something ‘wrong’ where there may not actually be cause for concern.
So what is an adhesion exactly?
- An adhesion is an attachment of tissues at unusual non-anatomical site [... whereas] a scar is a mark left on the skin or within body tissues where a wound, burn or sore has been healed completely by primary intention, and fibrous connective tissue has developed (Chapelle, 2016).
- Adhesions are most often as a result of surgery, but can be formed from any defect that causes inflammatory exudate (Chapelle, 2016).
- Peritoneal adhesions are almost ubiquitous after surgery [...] fibrous bands of tissue that have connected viscera together or attached organs to the abdominal wall (Chapelle, 2016).
- Adhesions cannot be imaged accurately and can only be diagnosed upon reoperation by laparoscopy, which often leads to a reformation of adhesions (Chapelle, 2016).
- Many approaches have been taken to resolve adhesion formation in the abdomen, but none offer reliable results (Chapelle, 2016).
With this information in mind, we realise that manual therapists are using the word ‘adhesion’ far too loosely. And even in the case of probable post-surgical abdominal adhesions, there is no treatment protocol that offers reliable results.
(The phenomenon of ‘palpatory pareidolia’ should also make us question whether what we think we are feeling in people’s tissues is 100% accurate.)

An RMT’s reflections on scar tissue work in their practice:

An RMT's reflections on massage and scar tissue in practice

“What I generally tell folks who want to work on their scars is: although there's little evidence to support significant changes in the scar tissue itself, it can still be illustrative and beneficial to explore and work on the affected and surrounding areas. It can be helpful to get a sense of what their body and skin feels like now, which areas have sensation and which don't, and what it feels like to have an altered sense of touch in those areas.”

“Often people come saying, ‘I was told it is good to massage my scar but I was given no resources - what should I do?’ - in which case I like to show gentle mobilization techniques with principles from fascial work, and I'll often demonstrate torsions/shearing/stack and load type-stuff. Usually not for the purpose of addressing the superficial scar tissue, but it can feel really good and illuminating for the person to do that sort of work on the underlying tissues, as well as to just get a sense that it's okay to move all this stuff around.”

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“I've witnessed moderate to significant changes in the characteristics of people's scars over the course of months-years. I don't think it had anything to do with my work on/around their scars, as these people also experimented with other things that are touted as beneficial, such as silicon tape, but I've seen shifts and variations in the thickness, depth, and sensation. Almost like there is a fluidity to the tissue, it can develop whirls and I often think that portions look like soundwaves. It's super neat, and I don't know what to make of it, but I consider it sort of beautiful and heartening that there's so much permutation to the process.”

“Post mastectomy or top-surgery, often what I see is that over the course of a several-month healing process, is that people are accustomed to protecting those areas (and are sometimes told to keep those areas/surrounding joints relatively immobilized for way too long), and so what may manifest as feelings of weakness/restriction can be connected to postural changes associated with guarding/prolonged protective postures and disuse. It can be super beneficial to explore light mobility and gentle load exercises like window washers/dowel ROM/rolling a ball on a surface to get people used to engaging with their new normals.”

In conclusion, the evolving understanding of scar tissue and its treatment highlights the necessity for massage therapists to adapt their practices based on the best quality evidence. When creating a treatment plan, RMTs should consider the patient’s relationship with their scar, their physical and emotional experiences, and their treatment preferences and goals. We can let go of ideas that massage can ‘break up scar tissue’ or ‘release adhesions’ and provide our patients with updated explanations for ‘how massage works’. By prioritising informed consent, individualised treatment goals, and evidence-based practices, massage therapists can offer meaningful and ethical support for people with scar tissue.

If you’re interested in learning more about how all massage techniques work check out our blog post.