Soft tissue techniques to treat scars and adhesions

Internal or external, they share the same faith... The days of scars and adhesions are numbered under the hands of a capable body worker. 

What are scars and adhesions
 
Scar tissues and adhesions are a part of the body’s natural healing cycle. They can be internal or external and in an ideal scenario, the body itself would eliminate them as the trauma heals. Often the redundant adhered tissues, however, are not broken down. They may even continue spreading which triggers a cascade of compensations.
 
It is useful to distinguish between scars and adhesions.

• Scars appear after an injury as collagen fibres that have replaced normal skin or other tissues. They are a natural occurrence as part of wound repair but are never as functional as the tissue they replace. Every wound results in some scar tissue formation except for very minor lesions.

 

• Adhesions are anchored bands of scar tissue supporting the wound. They form when collagen fibres lay chaotically across fascia and muscle fibres. Adhesions can be seen as internal scars and they bind all tissues they contact. They increase the stress on the body by restricting movement and increasing pain.

 
Scar tissue can be further classified as external or internal. External, as the name suggests, can be found on the surface of the skin. Internal, on the other hand, is situated below the skin and can form patch-like adhesions affecting and pulling the surrounding soft tissues.
 
There are some distinguishing characteristics that help recognise scars. The skin and sometimes the underlying tissues can become hard and non-pliable and the bands of fibres can be palpated. The skin usually becomes tight and short, which can compromise the joint integrity and function and limit its range of motion.
 
There are numerous long-term detriments that can come from scar tissue formation. These collagenous formations can prohibit adequate circulation. This limits lymph drainage, blood flow and oxygen delivery in the area. This is not only dysfunctional but also makes the area slower to heal. The resulting stress can lead to impinged nerves, numbness, pins and needles. Postural misalignment and reduced flexibility are likely to occur as well. This also increases the risk of future injuries.
 
It is important to consider what is the phase of scar healing as one considers the most appropriate tools to use.

• In the immature phase, immediately after a wound heals, the area may be itchy, painful or sensitive. It may be red initially but over time it will return to normal flesh colour. Immature scarring responds best to heat application, exercise and massage.

 

• The mature phase is when production of scar tissue stops. This can take anything from three to eighteen months depending on the trauma. More disciplined and structured approach is required to reduce scar tissue that has matured.

​How to release scars and adhesions
 
By addressing scar tissue early in its development, a body worker can help minimise the related problems and prevent future ones. Some of the following interventions can be applied as soon as the wound is closed. It is important to emphasise that the approach needs to be gentle in the immature phase.
 
It is important always warm up the tissue with effleurage and petrissage before applying any of the more invasive tools we’ll discuss. It is essential to alternate the tools you use in a way that varies the intensity. This ensures the client’s body and nervous system are not excessively stressed. 

A soft tissue therapist has a variety of tools that work well:
 

• Frictions. Deep transverse frictions can help break down scarring and adhesions and prevent the formation of new ones. This technique can be very effective both in mature and immature scar tissue. Deep pressure is applied with the fingers directly perpendicular to the direction of the fibres. Client communication is essential to ensure pressure stays within their comfort zone.

• Myofascial / Soft Tissue Release (STR). This is an effective technique to treat areas of constricted tissue. The fingers of one hand are placed and apply some pressure at the beginning of a scar, then the other hand is used to stretch the skin above with. This can be done with a gliding stroke along the scar or but just applying pressure and gently stretching the tissue usually works better. Then the fingers of the first hand are moved further along the area and the procedure is repeated. The same pattern can be applied by massaging with a circular motion. 

• Acupressure. Pressure can be applied to acupressure and trigger points using the finger tips and thumbs. This compression temporarily restricts blood flow to the area. When the pressure is eased an ischemic reaction occurs. Where blood flow was restricted, now it is significantly increased. This helps to soften, break down and improve muscle condition and heal the damaged tissue. 

• Neuro Muscular Techniques (NMTs). There are small, localised, sensitive areas of the body causing pain when irritated. These trigger points are located in the centre of a muscle fibre. They are called neuromuscular because muscle and nerve meet there and can be painful when compressed. When compression is applied after an initial discomfort a numbing occurs and the pressure can be increased. The mechanics of the effect are similar to acupressure with the added effect of rewiring the response of the nervous system. When pressure is released the result is an inflow of fresh blood and reduction in neuromuscular pain in the area.

• Manual Lymph Drainage helps by promoting lymphatic circulation in the area. Gentle, draining strokes can be applied in the area either with circular motions or in accord with the anatomy of the area. Pumping motions applied along the scar also assist with draining congested lymph. The tissue usually feels somewhat softer after such treatment. This gentle intervention can be used daily. It is especially beneficial for accelerating the healing of scars post-surgery.

• Stretching scars that cover or cross joints is very important and very beneficial. This would ensure that restrictions in the superficial tissue will not translate into a reduced range of motion. Stretching can be performed during a session with the therapist’s help, prescribed as an aftercare or both. Doing some stretching for the client during the session accomplishes several important goals. It demonstrates the correct technique. It establishes stretching as an important part of the healing process. It begins the process of forming a habit for stretching.

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• Cupping can be a powerful tool for releasing scar tissue. For maximum effectiveness, a cupping device can be used. These devices have endings resembling cups of various sizes connected to a hose that creates a vacuum by sucking air. Usually, they work by pulsing the vacuum as opposed to keeping it constant like in a hoover. The vacuum of the suction cup lifts the tissue above and below the skin. This gently pulls the scar tissue apart and invites fresh lymph and blood in the area. This improved circulation accelerates healing and makes movement easier. Gliding or massage cupping is usually the best approach to apply on scars. After applying some lubrication to the scar, the therapist works along the length of the scar and in parallel on each side. It is important to maintain communication with the client to ensure the less sensitive scar tissues is not overly stretched. Five to ten minutes for a single scar is usually the upper limit on duration. The procedure can be applied daily with visible and rapid results.

• Eccentric contractions lengthen the muscle while it exerts force. This lengthening accompanied by tension can help break down adhesions. The client shortens a muscle and is asked to gently resist while the therapist lengthens the muscle to its full or achievable at the time range of movement. The client need not exert a lot of force as this may lead to excessive micro-trauma and muscle soreness. Ideally, such eccentrics would be alternated with a gliding stroke over the muscle to promote the elimination of the microtrauma by-products. Another important benefit of this approach is that it is also functional as it develops muscle strength. 
• Heat applied in the area helps with keeping the scar flexible and pliable. Heat packs, ultrasound, paraffin wax and various devices can be used.
• Applying oils in the area lubricates the skin making it more pliable and softer. Lotions and nutrient rich oils hydrate the scar and promote healing while preventing drying and re-opening. 

This list is by no means exhaustive and aims to suggest a range of possible options. In reality, the individual case needs to be carefully evaluated. Then the best approach given the circumstances and the therapist’s knowledge is applied.
 
For example, a client presented himself with some deeper muscular adhesions and superficial scarring following a recent knee surgery. First, I warmed up the muscles above and below the knee. Next, I applied some deep frictions to adhesions I identified. I followed up with some STR techniques on the quads. This was followed by some passive stretching and eccentrics. Finally, I performed some gentle stretching and draining strokes over the superficial scarring. The deeper techniques were alternated with effleurage to avoid overstressing the client’s nervous system and promote elimination of waste.

​The physiology of scar tissue removal techniques
 
Understanding what actually happens in the body not only makes us educated but also more confident in the technique that we are applying. And belief is a fundamental aspect of healing.
 
Without going into detail of how every single tool works, the following effects are worth mentioning:

• Increasing temperature helps break down scar tissue. This is accomplished either through increased circulation or by the application of external heat. Both muscle fibres and bodily fluids move more freely and more quickly when the temperature is higher. This promotes healing.
• Increasing oxygenation is a by-product of increased circulation combined with a superior oxygen hunger. Alternating eccentrics with somewhat quicker effleurage strokes can do this quickly and efficiently. Vasodilation (blood vessel widening) and capillarisation (increase in the number of surrounding capillaries) increase the availability of nutrients and oxygen. This helps to break down scar tissue, repair damaged cells and provide the muscle with more energy for healing.
• Increased breakdown and realignment of fibres occurs as a result of techniques targeting scarring and adhesions. During the healing process, some collagen fibres are laid randomly across muscle fibres and fascia. This creates adhesions, restricts movement and causes pain. Some of the previously described techniques efficiently break down these cross-links. The strokes along the muscle length help realign them. 

Considerations 
Providing high-quality massage during the immature phase of a scar prevents further formation and can speed up healing. This is also a time of great vulnerability, however. So, the practitioner needs to use their educated judgment and consult a higher medical professional if necessary.

Additionally, it is advisable to discontinue the technique, except for deep frictions, if it causes pain or redness to the client. Open lesions should never be treated and extreme caution is recommended when working with radiated tissues. With the techniques that do not involve gliding, it is recommended to perform them without lubrication. This prevents unnecessary sliding of the hands and fingers.

The principle to always keep in mind is ‘do no harm’. At the same time, a targeted and well-executed massage can do a lot of good for the client’s body both locally and systemically.

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