Rethinking Scar Tissue Management in Massage Therapy

Ever wondered if everything you've heard about scar tissue and massage therapy is consistent with the evidence? Prepare to have your beliefs challenged as we're joined by Susan Shipton RMT from Toronto, Ontario. In this episode we discuss the myths and realities of scar tissue management in massage therapy, particularly following surgery. We've all heard the tales of aggressive massage techniques "breaking down" scar tissue, but Susan and I, draw from some current research and our shared experiences to illuminate the path that blends scientific inquiry with the tender compassion necessary in our profession.

Scar tissue isn't just a physical hurdle; it's a complex puzzle that intertwines with our body's pain response, healing mechanisms, and psychological well-being. In this episode, we dissect the multifaceted nature of scar formation and the delicate process of recovery, considering everything from the perplexing axillary web syndrome to the influence of gentle touch post-surgery. Susan's insights from her VODER training on manual lymph drainage reinforce our conversation on the kind of soft, evidence-supported care that respects the body's integrity during such a vulnerable time.

Lastly,  the management of pain and patient expectations. We address the pressing need for honesty and realism when discussing treatment outcomes with patients, exploring how reassessing our approach to scar tissue can lead to more effective healing journeys. Susan and I examine the critical role of movement and touch in not just improving physical symptoms but also in supporting patients' psychological recovery, helping them to embrace and integrate changes to their bodies. Join us as we offer a nuanced perspective that challenges convention and encourages a deeper understanding of the body's response to trauma and therapy.

Transcript

Speaker 1: 0:07

Hello and welcome to another episode of Purvis Versus. My name is Eric Purvis. I'm a massage therapist course creator, continuing education provider, curriculum advisor and advocate for evidence-based massage therapy. In this episode, we welcome back Susan Shipton, who is an RMT in Toronto, ontario. Susan and I have a discussion on scar tissue massage, treating people post-surgery and the importance of being comfortable without having all the answers. If you enjoyed this episode, please rate it and share it on your favourite social media platforms. You can also support my podcast by making a donation by visiting buymeacoffeecom. Purvis Versus can also be found on YouTube, so please check us out there and subscribe. Thanks for being here and I hope you enjoyed this episode.

Speaker 1: 0:50

Hello everyone, and welcome to another episode of Purvis Versus.

Speaker 1: 0:52

I'm so excited to have my good friend, susan Shipton back.

Speaker 1: 0:56

She was here on an episode a number of months ago where we talked about cancer and oncology massage, which is her area of interest, but today what we're going to do is we're going to continue a conversation that we had on Facebook Live back in the middle of January, which kind of went viral, I guess, so to speak, for in our industry anyway, you get a few thousand people watching something.

Speaker 1: 1:19

That's a lot. So I'm hoping that this conversation we have today will be a continuation of that and also for those people that aren't on Facebook, it might be a good opportunity to listen to us discuss the topic of scar tissue and the role of massage therapy and scar tissue. This is such an interesting topic and one that we hear a lot of people talk about, but I think it's important for us to really unpack, kind of what we know and what we don't know, and so today we're going to talk about some of the research and what this means, and we'll probably leave this conversation today with a lot of well, it depends, and well, we don't really know. But it's better than saying, yes, we know for sure when we're just making, so we're not just making stuff up. Welcome, susan.

Speaker 2: 2:03

Thank you. Thanks for having me again, eric. Glad to be here, yeah.

Speaker 1: 2:08

So why don't you just fill us in a little bit about what you've been up to since your last episode that you're on with me? Why don't you tell a little bit about your course that you just finished running?

Speaker 2: 2:18

Thank you. I launched my online continuing education course for RMTs on oncology massage. It went really well. I'm so happy to say that the first time through, I think, was a success. Obviously, there are some things I'm going to change and tweak a little bit, but I had 14 RMTs from Nova Scotia to British Columbia join me for four evenings and the feedback was really good.

Speaker 2: 2:48

And it was, I think, good for all of us also to get together and to have an opportunity to connect and to share some stories about our clinical experiences working with people with cancer. And that's important because so often the job of an RMT can be kind of isolating. We're working in our treatment rooms and we're not necessarily having an opportunity to talk with other therapists who are in a similar kind of work Not just about clinical advances or research advances, but also the impact of this kind of work on us. And we do need to acknowledge that sometimes it can be hard to work with people who are suffering and who are ill and who may sometimes be near the end of life because of their health condition. So I think it went really well. I'm offering it again in May four evenings in May and hoping to get a similar crowd this time.

Speaker 1: 3:44

Amazing, amazing. Well, yeah, you might be too, too humble to share, but you did share with me off air, some of the lovely feedback that you had. So why don't you just tell everybody this, because I asked you to you don't have to, but I think you should why don't you tell everybody what that one quote was that you got from one of the learners?

Speaker 2: 4:05

One of the learners said that the course was grounded in evidence, guided by compassion, and I was so touched by that and I think really I can't aspire to offer anything greater than that. So whoever that was the feedback was all anonymous I honestly don't know who that came from, but thank you very much. That warmed my heart and is also going to continue to be a guiding principle for me as I go forward and create this continuing education for other therapists that it has to be grounded in the evidence and then guided by our humanity and our compassion as we share, how we, how we interact with other humans.

Speaker 1: 4:47

I love that so much and that's such an important thing is the grounded in science, and we'll talk a bit more about that today because it kind of segues nicely into our conversation about scar tissue and that there's a lot of. The term that I like to use is kind of evidence, adjacent kind of stuff that's out there where there's, you know there's. You see a lot of courses and webinars and workshops, whatever you want to call them where people are often quoting research or using research to kind of support a premise, but then when you actually look at the research in depth, it doesn't actually support what it is that they're saying or might even contradict it, and we see that a lot. And this is obviously a bigger issue than just the C industry. I think it's an issue with the research literacy and critical thinking in our profession, and that is just something that is not part of our entry level practice and something that you know.

Speaker 1: 5:40

Obviously, people like you and I are heavily biased and wanting it to be more prevalent with the research evidence. But that's why we have these conversations today, so we can try to disseminate our interpretation of evidence in a way that is hopefully meaningful and hopefully not using it in I don't want to say in abusive way, because hopefully not using it in a way that bends the truth about what it really says. That's that's important. So let's just start off this conversation, because this this is on scar tissue and then the role of massage and scar tissue management. What do you think are some of the biggest beliefs about scar tissue and massage?

Speaker 2: 6:27

Well, we're all taught that with our hands we can break down scar tissue, release adhesions and thereby release the patient from the pain and restriction and dysfunction that they've incurred as a result of the scar tissue. And the evidence is indisputable that we cannot change the scar tissue. So that's a myth and a narrative that I'd really like to see go. I think that it can be harmful if people are coming to us and we're saying well, this is because of the scar tissue from your surgery or from this big injury that you incurred, but don't worry, because we, with our hands, can change the scar tissue. We really need to drop that narrative from our, from our vocabulary.

Speaker 1: 7:12

Yeah, I guess the question I have too is I mean, I haven't taught in a school, or in a long time since I've been involved with a specific school here in BC where I am. But as far as what I, when I encounter people in courses and whether they're new grads or not, they still say that they learn about breaking down scar tissue, they learn about cross fiber frictions and they learn about, you know, any little kind of lump or bump that you feel when you put your hands on people. That is probably like a mild fascial adhesion and these are kind of terms that are so. They're used so many times, so often our profession. They become like a truthism. You know it's like you say it enough times. It becomes reality even though we know that that might not be reality. What are your thoughts on why these myths are so prevalent in our profession?

Speaker 2: 8:04

Well, I think because unfortunately our profession historically has not been grounded in scientific research, and so a lot of there's been a lot of surmising of what we think is happening inside the body and what we think is happening with our manual techniques and our interaction with our patient, and then these myths just get perpetuated and they go on and on and on. And then, unfortunately, within our profession, the science literacy is not a big part of our education. We're not taught how to read scientific literature, how to evaluate it for its strengths and its weaknesses. We don't know how to go and check if what we think we're doing is actually supported by the evidence, and so that's another reason why these things get perpetuated, because we're just not equipping RMTs with the skills to actually examine critically what we're hearing.

Speaker 1: 9:04

Yeah, I agree with that. I think one thing that we see too is there's just obviously not a lot of massage therapy specific research. And this is something I encounter all the time where people like, oh, there's no, nobody wants to research this stuff. There's no one wants to put money into this thing because it's not pharmaceuticals. There's a lot of excuses that people make why there's not a lot of massage therapy specific research on stuff that they think is important.

Speaker 1: 9:30

And I would say let's remove the big pharma out of the conversation and let's look at, say well, maybe there's a reason why science isn't doing a lot of research on breaking down scar tissue with our hands or that kind of thing, because I think what ends up happening is that most of the scientists know that we can't change it anyway. So why would we try to do it with research? And what's the purpose of that? You know, I think if you look at a lot of the biological plausibility of the stuff that people in our profession want to study, if you just look at the basic science of it, it says a lot of stuff can't happen anyway. So I think a lot of the researchers are like well, we can't change fascia, we can't change scar tissue, we can't, you know, increase the length of a muscle, so to speak, with these techniques. So why bother studying it? Because we know that can't happen. But people in our profession say, well, we want to study those things.

Speaker 2: 10:30

So is the problem, then, that, as a profession, we're not accepting what the science says.

Speaker 1: 10:36

I think a lot of that. I see that a lot and obviously we're all biased and this is my own anecdotal experiences. But from teaching courses and having conversations with people and speaking at schools and conferences and all the people I interact with, I think that that's the biggest thing that I come across is that people just don't want to accept the science. And I think it's well understood that when we you can't change people's minds with evidence, you have to change it with experiences. And so when people are like, well, hey, I know what I do works, you know, when I put my hands on people, I feel things soft and I think feel things move, the person has more range of motion, they have less pain. So they just dismiss the scientific explanation for it and they just kind of go with what they've always thought.

Speaker 1: 11:25

And I think the thing that we need to really understand is that when you're questioning the science, you're never questioning the person's individual experience. Those are two totally separate things. So we can question the science all day and we can say the science doesn't support changing scar tissue, for example, but if someone has a clinical experience that they treated somebody and there was a noticeable change in the experience of the person's scar tissue. Well, we're not saying that didn't happen. We're saying, well, maybe the reasons why those things happened are different and maybe that is a one that just happened with that one person. Can we say that is generalizable across the population? I would say probably not, and that's a big thing that. I don't know if you found that in your course, but some people will often question the science because it contradicts their experience and I always want to bring it back to say I'm not saying what you're experiencing is wrong, but maybe the understanding behind it is incomplete.

Speaker 2: 12:24

Or somebody might be attributing the effect to a cause other than what it actually is. We know there are so many things going on physiologically, environmentally, psychologically, emotionally. There are so many things that are contributing to the overall experience. How can we pin down for certainty that something was caused by one thing? We can't.

Speaker 1: 12:50

And that's a great point. And this goes to the difference between outcome based massage and mechanism based sorry, science that produces outcomes and science that produces mechanisms of outcomes. So if you put your hands on somebody and you do something to them and there's an outcome that doesn't prove the mechanism of the outcome, it just proves or shows that this person had this treatment, had this outcome.

Speaker 2: 13:16

Absolutely.

Speaker 1: 13:17

What we see a lot of them is if we pick on the fascial research because there's lots of that stuff out there where people do a specific technique or techniques on someone and then the people being studied the experimental group reported less little back pain, less disability whatever and they're like aha, it's because I changed the fascia. Well, no, your research didn't show that you did anything to the fascia. It showed that these techniques or this approach helped this person feel better. All we know is that manual therapy that looks something like that might help. People doesn't say that you changed fascia, and we see that a lot. At least I see that a lot and I have those conversations often with people in courses.

Speaker 2: 13:58

Yeah. To go back to your original question about why these myths are so they have such long lives, it's not that we're egotistical, but in a way it's not that we're egotistical and we want to feel all powerful. I think it's more that we all really want to believe that we can offer somebody some legitimate help. So it does come from a good place in us. We genuinely want to be able to help somebody and we think that we can and we're eager to try, and then we're eager to have that really positive effect and that positive outcome. But, as we said earlier, we can also cause some harm in leading people down the wrong path and making them believe that we can do something that we can't, and then how we extrapolate from that as well.

Speaker 1: 14:47

Yeah, that's a really good point, susan.

Speaker 1: 14:50

I think, that when we look at it, we look at something like, say, let's use scar tissue. We'll try and keep it on theme here for today. What does it say to the person who's experiencing pain after surgery? Say they've had I don't know whatever, it doesn't matter. Say they've had mastectomy or something, cause I know cancer. You probably have a lot of experience, I know you have a lot of experience working in these populations and say they've got significant scarring after the surgery. Well, what does it say to that person when they come in and say they're therapists who's very well meaning and, like you said, probably compassionate, understanding but they say, yeah, you know, you've got the scar tissue here. If we can mobilize this and break this down, then that'll help with your courting or that'll help with your shoulder range motion and say the person gets these treatments and they get a series of treatments and there's nothing there and nothing happens. It doesn't work. Then what's the person left with?

Speaker 2: 15:47

Well.

Speaker 1: 15:47

I think that they can be Searching for something else.

Speaker 2: 15:50

Yes and I think that they can be left feeling quite angry. And remember too that people are paying out of pocket and cancer doesn't choose according to socioeconomic status. So for some people seeking help during or after their cancer treatment can actually be quite an economic, quite a financial burden on them. And so if you don't actually deliver on what you say you're going to deliver, or your treatment doesn't produce the results that you say it's going to produce, it can have an even broader impact on somebody where they think, oh, but I've put a few hundred dollars into coming to see you several times and I can't really afford this, and then obviously disappointed because they're not getting the results that they have been promised. So I think we have to be careful.

Speaker 2: 16:37

Speaking of mastectomy, there are common side effects to the cancer treatment that a lot of people experience and I'm often honest and say this is not really well understood. For example, courting those visible, palpable lines that appear in and out of the axilla, down the arm, sometimes down the trunk. That is not well medically understood. We don't really know what's going on physiologically. It was really striking to me. One of my patients told me that she had been talking with her surgeon about having a revision surgery, which is quite common. We're just little things are addressed. And when she was talking about possibly having a revision surgery, she said to the surgeon well, can you cut the cords as well? And the surgeon said we can't actually see the courting. So when they open up somebody's body, they don't see anything. That looks any different with somebody who has courting than in somebody who doesn't have courting. Courting is not actually a thing like a new anatomical structure or a change in the anatomy of that person that is visible to the surgeon's eyes. That was really striking to me. Having said that, though, while I can't explain what's happening when somebody experiences courting and equally I can't explain why manual therapy can often help with the courting. Very often not always, but very often we do see an improvement in the person's courting as a result of the manual therapy and as a result of passive movement and active movement that we suggest that the patient use in between appointments, engage with in between appointments.

Speaker 2: 18:30

It probably does have something to do with scar tissue, because it is always the result of surgery. It always comes after surgery. You don't see it in somebody who hasn't had surgery. It's associated with lymph node removal, and the lymph nodes are removed from the axilla. That is where usually the courting is, but sometimes it can be on the trunk. For example, if somebody's had a mastectomy and a breast reconstruction, sometimes you can see and feel courting running down the front of the trunk from the inferior aspect of the breast.

Speaker 2: 19:06

So it does seem to be related to surgery but, as I said, I can't say with any certainty that I can explain what it is that's happening inside their body and I'm quite clear about that and people seem to accept that. Actually I've never had somebody express frustration or anger that the medical community can't explain to them what it is that's happening. I think perhaps it's even better if we're honest and just say we don't really understand this, we don't really know what's going on. Why don't we try this? We know that in a lot of people when we do this kind of manual therapy and blah, blah, blah, blah. Why don't we try it and see if we can get some benefit in you as well?

Speaker 1: 19:41

That just sounds honest and just like so realistic. Be like we don't know, we can't make any claims and we can try this. And you know what my clinical experience, which is part of evidence face practice, is. Your clinical experience says this helps to some people.

Speaker 1: 19:56

We can just leave it at that right Rather than making promises, and you know every time we make these kinds of, have these types of conversations, almost always get feedback from somebody who's like, well, I've never once heard somebody ever say that. I'm like, okay, well, maybe you haven't, I don't know, but it doesn't mean it's not true. It doesn't mean people don't believe in say these things. And was it an absence of not hearing? That doesn't mean it's not true.

Speaker 1: 20:24

Yeah, I think one thing I read as we were preparing for this. I read a paper on axillary web syndrome. According, I think I didn't know that it was actually called axillary web syndrome, but I learned something which is great and they were saying that they thought, and it was again. It was kind of like this is what we think it might be, and this was a research paper written in the last probably six or seven years. I'll try, if I find it. I'll try and remember to put it in the show notes, so if I can find it again. But to paraphrase, they basically said that after surgery with the removal of lymph nodes, they think that it might be doing due to increased inflammatory products within the lymphatic system, which basically caused the swelling of the lymph vessels.

Speaker 2: 21:08

I have heard that too, that some people think that it might have to do with the lymphatic vessels. I also was very surprised to hear a very experienced, well-regarded therapist say that it was neural tissue. That sort of gets involved in an inflammatory response and the creation of scar tissue. I don't think that that's true. I think that if it were neural tissue, people would report neural symptoms. They would report that burning, tingling pins and needles, and nobody reports that. So I don't think that it is nerves. I think it is more likely the lymphatic vessels.

Speaker 1: 21:55

I would tend to agree that that lymphatic vessel sounds like the less wrong understanding the neural stuff. Yeah, you're spot on there, you would see. Probably you should see some type of neuro-symptom.

Speaker 2: 22:08

Yes.

Speaker 1: 22:09

Yeah, that makes sense, yeah, so let's take a little bit of a dive into some of these papers which we discussed in the Facebook live and just kind of just bring some of the information of what they said in them. And the first one is called the role of massage and scar management. So this is probably one of the only ones I could find that actually talked about massage, doing massage and scar. It's from 2012 and was published in the American Society for Dermatological Surgery. Dermatological Surgery it's a hard word to say for me, apparently and some things that we look at in this here is the questions we want to answer, and that's why we look at the research is does scar tissue play a role in pain? That's the one thing we want to look at.

Speaker 1: 22:55

Another thing I think we should try and answer is can scar tissue be changed? We kind of talked about it already Can't really change scar tissue Once it's been formed. There is some evidence that says you might be able to impact it, but maybe it might not always be positively in the early stages. And the other thing, too, I think is really important for us to understand is does scar tissue need to be altered to return to function Like does scar tissue actually need to change? Right?

Speaker 1: 23:22

And so when we look at the research so this one here and then so to answer the first one about pain we would say does scar tissue play a role in pain? It does, because any type of protocol, surgery or tissue damage, there's gonna be damage to the axons, there's gonna be damage to neurons which can create an increased nociceptive firing. So, yeah, we could say that makes sense. But just to look at some of the quotes from this paper, we're not gonna go into too much detail. But it says this it says possible negative aspects of this therapy. So massage therapy include this is a very bold statement wasting the patient's time. If massage is not an efficacious treatment, which is important to think what we just said but people being told that there might, maybe we can do something that we can't. So we have to be honest, right?

Speaker 1: 24:12

Because otherwise it is just taking your money and that's not really informed consent. I don't think it said there's also could be irritation from friction. And it says too that early massage should be avoided, in light of evidence that mechanical pressure during early phases of wound healing promoted hypertrophic scar formation in a mouse model. And that's the thing I think we need to be really mindful of when we look at the extrapolating scar tissue research and then saying this is applicable to humans, Cause it's most of us have just done on animals and we can't just say that it's like if we see something positive in an animal study, we can't just say, ah, this is probably, this is gonna work for humans. We don't know that. We can say possibly, but I would say, and it's something like this one you say, well, too much pressure in and around the wound early on actually increases more scar tissue formation, Even though it would have to ask that should be something we should be mindful of, that we don't want to facilitate.

Speaker 2: 25:17

Yes. But there I have to ask they're using the term massage therapy very broadly and I'd like to think that any massage therapy would have the common sense not to do really deep, aggressive, vigorous, shearing type massage techniques around a surgical site early in the healing stages. That if any work is gonna be done around the surgical site it would be light pressure, it would be gentle. You absolutely don't want to disrupt the healing that has to take place not just on the surface of the skin that we can see the surgical incision, but all of the healing that's taking place underneath the skin, in the tissue.

Speaker 2: 26:01

I think it's. I always like to think the surgical incision that we can see is just the doorway into the body and remember that a whole lot of tissue and we might be talking about only a few centimeters or we might be talking about a much larger measurable area, but that the incision is small compared to the area within the body, the surgical field underneath the skin that we can't see. But to go back to my original point, I think we also need to think what do they mean? Does the research paper describe the massage that was employed, the type of techniques, the pressure, the amount of movement within the tissue that was incurred through the massage techniques. The duration of the massage obviously, if it's on animals, then you can't really get feedback about how comfortable it is and use that as some kind of guideline for what it is that you're working on.

Speaker 1: 27:04

And that's a good point, and that's something that why it's so difficult to kind of take this information that we look at on the role of scar tissue and massage or just the physical management of scar tissue in general, is because when they use the word massage, like what does that mean?

Speaker 1: 27:19

Like it hasn't been qualified at all right, like you made some great points there. So it's like okay, so it says that we shouldn't probably use it because this might result in more scar formation. But it doesn't say like does that mean? Like could you put your hands over it and just kind of just like hold the skin a little bit maybe to make it feel better? Like we know touch is analgesic, so and we know that massage is useful to alleviate pain. And even in this research paper here it says that, you know, through endogenous opioid peptides and neurotransmitters, we know the massage can help in pain reduction. That's great, but I think that it's In order to really say what massage can do for scar tissue, I think we need to have research that is a little more specific.

Speaker 2: 28:09

I agree, you make a great point there. Well, as you said, there's been very little research into massage therapy and scar tissue. In my VODER training, of course, we did talk about utilizing manual lymph drainage post-surgically, but manual lymph drainage by definition is a light pressure, superficial, low velocity technique. I wondered when you read the quotation out and they talked about avoiding massage therapy because it might create hypertrophic scarring post-surgically in the early acute stages or the subacute stages. I wondered if they were thinking of the more vigorous frictions and, as I said, I hope that no massage therapist would do that on somebody early in the post-surgical healing phase.

Speaker 1: 29:01

And this is the thing that we should probably explore a little bit here. But here is that there's the what do we do with people acute injuries, post-surgical, for example or say it's a muscle, tear, ligament where there's going to be scarring, that's going to be formed, but we can't see it. If it's a tissue internal or internal, but I guess it's internal, I'm sure why not Below the skin that we can't see. If there's a tissue injury there and for sure we know that there's going to be an inflammatory process, we know that's going to form scar tissue, but we shouldn't ever try in those early phases to change it, to try to manipulate that, because we might be increasing more information. And when we look at some of the other research here this one other paper called Physical Management of Scar Tissue with Systematic Review and Meta Analysis from 2020, we look at like when you, if you put more strain and load into tissue that is acutely healing, it can actually result in more fibrosis Because you're disrupting the healing process, potentially like tissue stretch. You know, gentle range of motion stuff, which is in our scuba practice, probably not.

Speaker 1: 30:14

But I think the one thing that we that we probably see more of in our profession and I'll correct me if my thoughts are or might be off here, but what we do see is we see these people, these longstanding pain syndromes, people that suffer with, say, chronic low back pain or shoulder or neck pain or hip pain, whatever you choose your body part.

Speaker 1: 30:35

Those people are often told that they are full of adhesions or it's because of a scar, because of an injury they had. You know, oh, you have low back pain. Well, it's because you, you, you, you, you strain your hamstring, you know playing, you know running track or whatever, and that's that scar tissue is pulling on your low back and that's creating this whole series of, you know, biomechanical dysfunctions, so to speak, and then all we need to do is we need to break down the scar tissue. So some people are subjected to some seriously aggressive stuff to try and break down scar tissue. That is like in a muscle or perceived to be in a muscle, and we know there's no evidence for that, but that is something that people are subjected to all the time. Have you seen that a lot in your practice too, susan?

Speaker 2: 31:19

I haven't seen that a lot. I do have people who come to me specifically to have the scar tissue worked on, because they have also heard that narrative and they think that that's something that massage therapy can can offer. And it can sometimes be hard talking about being honest. It can sometimes be hard to counter somebody's expectations If they've come with a specific thing and then either they're disappointed because they think the problem is scar tissue, they think massage therapy is going to get rid of the scar tissue and they think then they won't have any problems anymore, or they think, well, you just don't know what you're talking about, because this other therapist told me that you can break down scar tissue. So I'm going to go back to the seven massage therapist and, of course, everybody can make their own choices.

Speaker 1: 32:07

Yeah, and that's a thing too, that's just your good point you brought up is because if we are the person that's telling a different narrative or a different story than what the person has been told by other well-meaning health care providers or something they've maybe read on the internet, and we're saying, yeah, you know, like we can't change the scar tissue, it doesn't mean we can't help you. But if you, if you, if you kind of dismantle that, that belief, and you know, I would say, do we need to change those beliefs? Maybe only if they're negative and an impact in behavior Do we want to maybe have a conversation about it. We should ever try and force those chains. But if someone's like you need to break down my scar tissue, that's the only thing I need, and you're like well, I can work on your hamstring, I can work on this body part, but I can't change that scar tissue, but maybe we can do some stuff to make it feel better.

Speaker 1: 32:56

If they think you're crazy and because you're saying something different everybody else, I think it can make a lot of us uneasy because we're worried about losing that client, we want to please them and that becomes a, that becomes a delicate balancing act, I feel where you know how much do we challenge their beliefs. You know are they do. We need to.

Speaker 2: 33:24

Well, you need to tread lightly, because you really have to have formed a good trusting relationship before you start to challenge somebody's beliefs too deeply. So to come right out of the gate, challenging somebody's beliefs is not going to be productive in the long run. I think, though, another thing to mention in this discussion is that believing that a problem is only because of scar tissue or only because of one thing is rather myopic. As we talked about earlier, there are so many things that are going on in somebody's experience of pain and dysfunction, and so, as you said, why don't we talk about some other things that might help you feel better and that brings in that makes the conversation wider where we can talk about?

Speaker 2: 34:08

So, if somebody has an injury then and they're experiencing pain, maybe there's some secondary muscle tension that is a normal reaction to experiencing pain, and so maybe we can, we can help relax some of those muscles.

Speaker 2: 34:22

We can help calm your sympathetic nervous system.

Speaker 2: 34:25

Maybe it's sort of in a heightened state of guarding and protection because of the pain or because of a history of injury in that area, and maybe, if we can calm your sympathetic nervous system, you'll be less sensitive to pain. If you're feeling less pain, you might find that you can, that the muscles are a little bit softer and more relaxed, you might find that you can move a little bit better and that your function improves. That there's. There are these other things that sort of surround the central issue in someone's mind that they might not be aware of, and there can be a cascade effect. If we can, if we can interact with something, with one part of this person's overall experience, then there can be a follow, in effect, to the other things that are happening at the same time, and so we can engage our clients in a conversation in that way that that hopefully helps enlighten them to the many other issues, or the multi factorial to draw on a buzzword the many things that are that are happening in this experience contextual, physiological, etc.

Speaker 1: 35:29

And that's a really important thing that we need to kind of embrace is the complexity of the multi factorial and yeah, it's, it's a word that gets thrown around a lot, but it's, it's true and the, the simplistic approach of you know, you have pain because cartoon, you just break that down and you'll feel better is I think it's it was your word to use myopic. I think that's, it's too it's, yeah, it's, it's too small, you know, we know. I think what we can say is, if someone has Pain around a scar, we can say, ok, it hurts because there's some type of activation of the, the no receptors in this area and that's contributing to creating these noxious stimuli, which is part of your pain. But you know, do we do we need to? When it was air quotes, even those kind of podcasts, and I can see it and you know, do we need to break that down to to help you feel better? I would say, well, probably not, because you can't but doesn't mean you can't influence the sensation in that area.

Speaker 1: 36:22

And when we look at the research and and you know this I'm going to make I'm going to read a quote here from this other paper, the physical management of scar tissue paper. It says that a meta analysis shows that physical scar management has a significant positive effect to influence pain, pigmentation, pliability, puritis, surface area and scar thickness, compared with control or no treatment. Unfortunately, massage on its own is not shown to be very effective. It should be used as part of an overall treatment plan so we can have an influence on pain, we can help with the, potentially with the overall presentation of the scar. But that's only one, it's only one piece right. Another thing that one of this paper I think it's this paper when the other one said is that that the silicone strips are just as effective as massage and cheaper. So you know, it's not just a massage and that's, you know. The evidence I think is quite strong in saying that a lot of the things that we believe are just not supported. There are beliefs.

Speaker 2: 37:35

If we look at the advice that patients are given post-surgically in hospital, certainly in the cancer world, they're always encouraged to almost immediately start doing some gentle massage, some gentle manipulation of the tissue Remember, people are going to be, they're going to have bandages and wound care over the surgical incision for, you know, possibly a couple of weeks but to gently, gently start moving the tissue. And of course they're encouraged to get up and start moving around again. Nobody's told to lie perfectly still and all of this contributes to a good healing of the surgical field, I think, because it can help maintain good circulation. Obviously there's going to be post-surgical inflammation that's part of the healing process and that needs to be there. But you don't want to have excessive swelling because that can cause some problems in itself. And I think moving around helps the body just keep the fluid moving in and out and in and out and sort of control excessive fluid buildup.

Speaker 2: 38:45

I think something that we don't talk about enough, and this is my speculation. I doubt very much there's any research on this, but in my experience I think another thing that the touch provides, whether it's the patient touching the surgical site or a therapist touching the surgical site, the surgical field, the area around is it helps the patient integrate how their body has been changed into their sense, their overall sense of themself. So obviously there might be some numbness following the surgery, so they're not going to have full sensation but hopefully will come back gradually. Sometimes it doesn't come back fully. It's common after mastectomy for women not to have feeling on their chest, particularly with a breast reconstruction, an autologous breast reconstruction.

Speaker 2: 39:43

But I think psychologically as well, they've gone through a lot of trauma with the whole psychology around the disease of cancer, the physiological trauma of the surgery and their body has been changed and their sense of their body and how it represents themself, their femininity, their sexuality possibly not always, but I think that because we are on a continuum, we're not two separate spheres of physiology in one sphere and psycho-emotional experience in the different sphere. We are in a continuum and I think that incorporating some kind and gentle and sensitive and intelligent touch helps integrate all of these different aspects into someone's overall sense of themself and I can't stress enough how important I think that is for someone's long-term well-being. It's not healthy to go through life feeling that a part of your body is diseased or off limits or shameful because of how it looks, or you know, damaged or ugly or scary. We have to have overall a sense of living in our bodies and living well in our bodies and having a good relationship with our bodies.

Speaker 1: 41:16

So powerful. What you just said there and if we look at so bring in some research to what you said spot on is the, that sense of ownership and that sense of I think the word is it somatoprecious organization. I think it is a term that they use in in the one paper on the science of touch, I think is what it's called. They talk about the touch. Basically bring that sense of ownership and that awareness of like your body part and helping to like, recognize it as part of you again.

Speaker 1: 41:50

Somebody can tell me if I'm wrong. I can find me to say that correctly and appropriately. But anyway, what you said there is so true and it's really important as part of the whole healing or recovery process.

Speaker 2: 42:01

It is and, eric, you've just reminded me. Several years ago, when I was doing research for a paper that I wrote, I came across somehow that the somewhere I found the old English word for healing, which is Halen. H, a, e, l A N. I think the old English word for healing, halen, meant not just to cure but to make whole again, and I have always loved that because I think it reinforces that what we are doing as manual therapists is helping people become whole again, and how absolutely important that is in their healing process and in their recovery. Wow.

Speaker 2: 42:52

On a different note, one thing I've wondered about and I've never looked into. But as our bodies are changed, let's keep it simple and say somebody has a mastectomy and so part of their body is surgically removed, does the homunculus change and does the manual therapy that we provide and the sensation that the person feels in response to our manual therapy, does that help the humunculus adapt to the changed body? What kind of sensory input is the brain receiving from this post-surgical body? I have no idea. I've never looked into the research.

Speaker 1: 43:39

Yeah, that's a good point. I don't know how it stands up to newer research but I know as last time at Ramos Chondron in the late 90s did a bunch of research on phantom pain and changes in the homunculus and they made some. I know some of the early pain science. I don't know early, but pain science stuff around that time, the early 2000s I think, even explain pain and their first two editions they may have talked about that kind of reorganization. I don't know if it's, if that still stands up. I don't know if that's ever, if that was just a hypothesis and then it's never improved, or if there's actually evidence to support. I'm not really sure.

Speaker 2: 44:30

That's a good question. I think I have heard recently that the humunculus doesn't reorganize itself after a limb amputation. For example, there's a recent paper that was just published last year, I think, 2023 on common shoulder impairments following mastectomy and, to my surprise, they included phantom pain as one of the common experiences that women might experience following a mastectomy. So the same thing a part of the body is amputated. I've never heard of this before. I've never encountered anybody who who experiences this. Interestingly also, they noted that the number of people experiencing phantom pain after mastectomy has been diminishing over recent years, which they attributed to better surgical techniques.

Speaker 1: 45:23

Interesting.

Speaker 2: 45:25

But again, I suspect that there's a lot of supposition happening here. We don't know 100%, and that makes me wonder if phantom pain was a bigger topic of discussion just in the zeitgeist, say 20 years ago then. Did women following a mastectomy, were they somehow primed to feel phantom pain or what they thought was phantom pain and what they might describe as phantom pain? More so than now where, as I said, I've never heard somebody even suggest that this would be something that would happen.

Speaker 1: 46:05

Yeah, yeah, yeah, that's a good point. And I think when we look at some of that, a lot of the research like the earlier pain research, the stuff that was really kind of you know I jumped headfirst into a lot of it. I'll admit that and I'm sure I know hopefully I'm not the only one, I'm sure I'm not there's a lot of priming that's done in that type of research. Oh, do you feel this, does this hurt more? Do you feel like, oh, does it feel like that limb should be there, like you're kind of asking a very loaded question. So people often kind of they can be primed to responding in a way that might be favorable to the examiner. So I think we have to be again, be critical and be mindful of those types of findings for sure.

Speaker 2: 46:55

Yeah.

Speaker 1: 46:57

Yeah, one thing I wasn't sure if we'd get into it or not today. But one thing I did want to say to people that are listening is if you want to read more about scar tissue and the role of manual therapy, if you just go into scholargoogleca orcom if you're not in Canada and you go and you look for understanding and approach to treatment of scars and adhesions by Susan Chappelle. She's a massage therapist based here in BC and she's got a book chapter. It's free and you can just download it or just click there's a website for it and she talks all about scars and adhesions and kind of goes into. You know, what do we know? What do we not know?

Speaker 1: 47:44

For those of you that don't know Susan Chappelle, she's the one that did a paper well over a decade ago on doing mobilization and little massage on rats after they'd had their abdomens cut open and her stuff has often been used to support the role of visceral massage and scar massage and her research doesn't find that even in this book chapter she says that's not what it says, but it's often again, there's that kind of use and abuse of the information to support a narrative that people want.

Speaker 1: 48:21

You know, just before we leave just a couple little quotes I wanted to read from this, which I thought kind of fits in this whole idea of, like you know, scar massage just being something that I think is made bigger than it really should be. She says, as a perfection, manual therapists have long held the belief that local restrictions and tissue movements can result in more global dysfunction. There's little support for this concept. That's something we see all the time. Right, oh, you've got this injury over here and that's going to cause this pain way over here. It's a belief. Again, there's no research. She does also say that the tissue that has been mobilized early was much more prone to re-injury. Oh, that's so interesting.

Speaker 1: 49:02

But that goes back to what we said earlier too is like how much mobilization, how much we need people to move. But I guess again it's that there's probably that sliding scale of what is too much or not. One thing she says too. She said procedures used to reduce the burden of adhesions so they don't go to adhesions of things that are occurring, like they're talking about, in the abdomen, usually after surgery, not like the ISTM and grass in adhesions where every little bump thing is supposed to be something you can break down with a tool. That's not how adhesions is used in the medical community. It's something that we have in the manual therapy community. We've kind of taken on. She says that anyway, procedures used to reduce the burden of adhesions and clinical practice have not shown clinical effectiveness and have lacked scientific validity. Goes on to say in her chapter that the only way that you can actually break down an internal adhesion is through surgery, to go in there and remove it.

Speaker 2: 49:57

Yeah.

Speaker 1: 49:59

So just to quote, she even quotes her rat study. It says in a rat model, visceral massage immediately following surgery interfered with the formation of a post-operative adhesions but failed to significantly reduce already formed adhesions after one week. So doing something might, it says, interferes with formation of post-operative adhesions. We don't necessarily know if that's good or bad. Did you delay the healing process? Did you make the adhesions that maybe they didn't heal as strong? We don't know. So we have to be very careful of extrapolating that research to the bigger world of scarring adhesion massage, because her paper doesn't say that it doesn't support the law of the claims that people make from it. Lastly, as I want to read this quote here and I think this is great, it says for the most part people seek care for manual therapists for pain relief. When a link is made between a treatment and pathology, such as scar or an adhesion, it may be presumed that there is also some connection between the pathology and the symptoms, and that's neurology.

Speaker 1: 51:06

Every injury also involves nerves of some caliber. Kidney surgery involves cutting many intercostal nerve branches and even a small cut in the skin damages a few axons. These damaged axons remain alive and immediately start to regenerate. For the most part, nerves regrow appropriately, but in many cases they do not and can lead to persistent pain. I think we just take this back to what we do as massages in manual therapists is that we help people that hurt. We help them hopefully experience less pain. If our focus is on trying to change scar tissue, then we are probably removing that focus on. What matters most is the person and their experience of pain. If we can just flip that script a little bit to focus more on the person and not on the tissue like you said earlier, it's multifactorial and we'll probably have better. The person that comes to seek our care will probably have better, more meaningful outcomes.

Speaker 2: 52:06

Completely. I completely believe that In my course, my online course on oncology massage, I invited some of my patients to contribute reflections for me to share with the learners. I asked them what did they want RMTs to know about working with people with cancer? One of my patients sent me something that said I'm paraphrasing, obviously, but she said although I had surgery in one part of my body, the rest of my body felt beat up and bruised and sore. I really appreciated that. You asked what I wanted to focus on today. That's such a good reminder that we are dealing with a whole person. We're not just dealing with one site of injury or surgery or dysfunction. We need to look at the whole person and how they're feeling and what they're hoping to get out of their massage interaction with us. We should ask them we can't presume to know on their behalf what it is that they need that day.

Speaker 1: 53:14

I think that's perfect way to end this, Susan. Excellent Thank you for being here, until next time.

Speaker 2: 53:21

Thanks so much, Eric. As always, it was a pleasure chatting with you and my brain is stirring and moving with all kinds of new ideas and questions. Thanks for that.

Speaker 1: 53:29

You're welcome. That's always the goal. Thank you for listening. If you enjoyed this episode, please give it a five star rating and share it on social media. You can follow me on Instagram or Facebook by searching at ericprivicermt. Now please head over to my website, ericprivicecom, to see a full listing of all my live courses, webinars and self-directed course options. If you'd like to connect with Susan, she can be reached via her website, which is wwwsusanshiptinrmtcom. Until next time, thanks for listening.