Traumatic Scar Tissue Management Massage Therapy Principles Practice and
Traumatic Scar Tissue Management Massage Therapy Principles Practice and
Traumatic Scar Tissue Management Massage Therapy Principles Practice and
Foreword
Pamela Fitch BA RMT
Foreword
Sandy Fritz BS MS BCTMB
Preface
Acknowledgements
Glossary and key concepts
1 Introduction
2 Skin and fascia
3 The lymphatic system
4 Neurology
5 Wound healing and scars
6 Burns, mastectomies and other traumatic scars
7 Trauma
8 Communication and the therapeutic relationship
9 Assessment and treatment
Comparison of before and after treatment
10 Client and therapist self care
Appendix: Massage therapy research resources
Index
FOREWORD
Everyone has scars: visible and invisible. Every scar contains stories or
secrets about a person’s life. They may even represent specific emotions
associated with the event that caused the wound. When someone shares the
story of their scar or allows the scar to be touched, he or she must recall the
story, feel the emotions and relive the secrets.
Applying massage therapy to manage scars reveals an ancient history.
‘Rubbing’, as the technique was described in antiquity, is mentioned by
Hippocrates. First World War nursing sisters massaged patients with complex
wounds and burns in order to help them gain function and mobility, long
before antibiotics or advanced orthopedic surgical techniques. And yet scar
massage therapy principles and evidence have, at times, been forgotten
within standard massage therapy training. The reasons for this avoidance
seem unclear considering how apt the treatment can be for certain scar
conditions.
Once a therapist has acknowledged a scar, questions immediately surface and
the therapist must connect with the individual’s history and personality. By
asking about a scar, a therapist must engage interpersonally and behave
compassionately. It is possible that the client may feel pride regarding a scar.
Or the individual may feel embarrassed or even ashamed of the scar. It is
impossible to simply touch a scar without considering the story or asking
questions: what does this scar represent? How did it happen? Did it hurt?
Does it hurt now? How does this scar affect the client’s capacity to move or
function? Does this scar affect the client’s self-image negatively or
positively?
Massage therapists commonly encounter client scars when they effleurage
over the body. Many therapists may feel curious about the scar but until
recently, massage therapy training did not include specific knowledge or
clinical considerations about scar tissue. Traumatic Scar Tissue Management:
Massage Therapy Principles, Practice and Protocols addresses this problem
by synthesizing evidence into a comprehensive discussion on massage
therapy principles for scar conditions.
The authors include pathological and clinical considerations to help readers
absorb and apply new-found knowledge. They describe outcomes from a
biopsychosocial perspective rather than adhering to a biomedical model,
reflecting the truth about scars: once they become chronic, clients are the
experts in how the scars feel, move and contribute to or impair function. The
authors wisely emphasize the far-reaching consequences and life-altering
effects of traumatic scarring that may result in clients feeling betrayed by
their bodies. And they stress the importance of professionalism, boundaries
and good communication skills when addressing clients with scars. Clients
often share information about their scars that they may have not told anyone
else. Indeed, many clients are grateful for the opportunity to discuss scar
conditions because they might not have felt free enough to discuss them with
any other person.
In addition, Traumatic Scar Tissue Management: Massage Therapy
Principles, Practice and Protocols recognizes the need for client respect and
choice. Since clients are often protective or concerned about their scars,
therapists must educate the client about the possibilities for treatment and
establish a clear informed consent before proceeding. The authors
demonstrate the need for a transparent therapeutic process and discuss the
complexities of the client–therapist partnership at length.
The authors draw upon decades of clinical experience and perspective. I have
had the privilege of knowing Cathy Ryan for several years as both colleague
and friend. I have read her cogent and thoughtful articles in both Massage
Therapy Canada and Touch U with great interest. Our professional roles have
intersected for many years and when discussions arise regarding how to move
forward on a problem, Cathy’s quiet and articulate presence helps to find
practical and evidence-informed solutions. This book draws upon Cathy’s
passion for writing as well as her considerable knowledge about how fascia
works and how it might impact the development and treatment of scarring.
I first had the pleasure to meet Nancy Keeney Smith after she presented her
research at the 2013 Massage Therapy Foundation Research Conference in
Boston. Nancy shared case reports based on over 10 years’ work at
Children’s Burns Camp of North Florida. She told passionate, compelling
and remarkable stories about how basic massage therapy skills were able to
help camp survivors with a variety of scars and burns. I was fortunate to
continue our conversations when we met again at another seminar in New
Brunswick. Nancy understands the challenges of burn and scar survivors
completely. Her finely tuned clinical and interpersonal skills reflect decades
of hands-on care of this mostly hidden population.
This remarkable resource breaks new ground. It describes the wound healing
process and considers how therapists’ hands can reduce anxiety, pain,
inflammation, and tissue tension. It stitches together the importance of
manual therapies with collaborative therapeutic partnerships and therapist
selfcare. It positions the profession’s capacities to help clients with scars
within an outcomes-based framework that may be employed by educators,
massage therapists and researchers. To my knowledge, no other reference
comprehensively combines the etiology, and factors associated with scars
with massage therapy treatment guidelines and principles.
I hope that Traumatic Scar Tissue Management: Massage Therapy
Principles, Practice and Protocols inspires massage therapists to look
between its covers for answers to their questions and to seek evidence-
informed treatment solutions for client scars.
I am fond of saying that it takes a bushel basket full of knowledge and skill to
intelligently apply a teaspoon of treatment. The more complex a client
situation and story, the more you have to know to gently apply massage. This
textbook, Traumatic Scar Tissue Management: Massage Therapy Principles
Practice and Protocols, created by authors Nancy Keeney-Smith and Cathy
Ryan, reflects these sayings in a logical, intentional and intuitive way. The
text diligently but concisely presents the information and research necessary
to intelligently and intuitively support successful scar tissue formation or to
improve scar tissue function. A scar is a solution to the problem related to
injury. Because the healing process involves scar formation, we need to
respect how the body knits together and reforms the integrity of the body
after tissue damage.
The use of massage and other forms of manual therapy introduces mechanical
force by pushing and pulling on the tissue. Regardless of the style of massage
this is what is done. Skilful pushing and pulling during massage loads soft
tissue to produce a variety of strain patterns in the tissue to challenging the
tissue to respond. Clear intent during the massage sends clear message to the
tissues so the response is therapeutic. Therapeutic loading technique is the
overarching term used by the authors. Readers should be pleased with the
clear descriptions of methods in the assessment and treatment section of the
text.
When working with soft tissue scars, we need to consider many factors and
this book provides the necessary information to make informed decisions to
best interact with the each individual who seeks our help. The authors
skilfully weave together the various approaches used by massage and other
manual therapists without promoting one particular style. Scar tissue
management is an outcome and a process. Scar tissue management is not a
method or a technique or even a modality.
A scar is part of the person and cannot be separated from the experiences
related to the events that resulted in the scar. I have scars as many, if not all
people do. Some scars involve soft tissue. Some scars function well. Some
scars are complex. Some scars bind down and create limits. I had open heart
surgery in 2006. I have a scar on my chest that I massaged using methods
described in this text. It is a visible reminder that I am alive. Those that have
scars have stories. With massage methods we can support and sustain a
mobile and functioning scar. We can respectfully and compassionately listen
to the story. The authors have wisely included content in the book to help us
be therapeutic listeners. We need to understand and acknowledge the solution
the scar provided and we can help the scar evolve as the tissue function
changes and we heal.
If you are drawn to work with individuals and their scars, this book provides
the information needed. You however will need to allow each story the scar
tells teach you how to listen.
More people are surviving traumatic events than ever before and sometimes
survival can come with a price, in the form of detrimental scars.
Scars are not obligated to be problematic. In fact our bodies have an amazing,
innate capacity to heal wounds. However, the process does not always unfold
seamlessly and the end product is not always ideal. And sometimes scars can
be disingenuous, on the surface all may look good however, below the
surface the person’s reality can be a whole other story.
We wrote this book to help the myriad of patients whose journey of healing
and recovery doesn’t stop when their wounds are stitched and healed-over.
Facilitating the healing of wounds and minimizing the aesthetic, emotional
and functional impact of pathophysiological scars on the patient constitutes a
central focus of the authors’ clinical practice.
We have woven client stories, clinical anecdotes and relevant research into
each chapter in an effort to give full credence to the scientific, technical and
empathetic elements of the work.
In this book you will also find a robust chapter on communication and the
therapeutic relationship, because we recognize that as a healing tool,
establishing respectful connection, cultivating our patients’ sense of trust, and
our words can be every bit as therapeutic as our hands.
Whether you have a private practice, practice in a multi-modal clinical
setting, are an urban or rural therapist and no matter where you are on this
planet, the material covered in this book is relevant to your practice, because
wounds and scars are universal. And scar tissue that interferes with structure
and function and adversely impacts quality of life can be safely addressed by
a professional, properly trained massage therapist.
Our aim is to provide other therapists with an evidence-informed guide that
will assist with the development of their clinical expertise, enabling them to
work safely and confidently with patients recovering from trauma of any kind
whether accidental or surgical.
We hope you put this book to good use.
CR
GLOSSARY AND KEY CONCEPTS
All the words defined in this Glossary are highlighted in color the first time
they appear in the text
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.