February 26, 2024 • 54 mins
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.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:07):
Hello and welcome to another episode of Purvis Versus
.
My name is Eric Purvis.
I'm a massage therapist coursecreator, continuing education
provider, curriculum advisor andadvocate for evidence-based
massage therapy.
In this episode, we welcomeback Susan Shipton, who is an
RMT in Toronto, ontario.
Susan and I have a discussionon scar tissue massage, treating
people post-surgery and theimportance of being comfortable
(00:29):
without having all the answers.
If you enjoyed this episode,please rate it and share it on
your favourite social mediaplatforms.
You can also support my podcastby making a donation by
visiting buymeacoffeecom.
Purvis Versus can also be foundon YouTube, so please check us
out there and subscribe.
Thanks for being here and Ihope you enjoyed this episode.
(00:50):
Hello everyone, and welcome toanother episode of Purvis Versus
.
I'm so excited to have my goodfriend, susan Shipton back.
She was here on an episode anumber of months ago where we
talked about cancer and oncologymassage, which is her area of
interest, but today what we'regoing to do is we're going to
continue a conversation that wehad on Facebook Live back in the
(01:12):
middle of January, which kindof went viral, I guess, so to
speak, for in our industryanyway, you get a few thousand
people watching something.
That's a lot.
So I'm hoping that thisconversation we have today will
be a continuation of that andalso for those people that
aren't on Facebook, it might bea good opportunity to listen to
us discuss the topic of scartissue and the role of massage
(01:35):
therapy and scar tissue.
This is such an interestingtopic and one that we hear a lot
of people talk about, but Ithink it's important for us to
really unpack, kind of what weknow and what we don't know, and
so today we're going to talkabout some of the research and
what this means, and we'llprobably leave this conversation
today with a lot of well, itdepends, and well, we don't
(01:56):
really know.
But it's better than saying,yes, we know for sure when we're
just making, so we're not justmaking stuff up.
Welcome, susan.
Speaker 2 (02:03):
Thank you.
Thanks for having me again,eric.
Glad to be here, yeah.
Speaker 1 (02:08):
So why don't you just fill us in a little bit about
what you've been up to sinceyour last episode that you're on
with me?
Why don't you tell a little bitabout your course that you just
finished running?
Speaker 2 (02:18):
Thank you.
I launched my online continuingeducation course for RMTs on
oncology massage.
It went really well.
I'm so happy to say that thefirst time through, I think, was
a success.
Obviously, there are somethings I'm going to change and
tweak a little bit, but I had 14RMTs from Nova Scotia to
(02:41):
British Columbia join me forfour evenings and the feedback
was really good.
And it was, I think, good forall of us also to get together
and to have an opportunity toconnect and to share some
stories about our clinicalexperiences working with people
with cancer.
And that's important because sooften the job of an RMT can be
(03:03):
kind of isolating.
We're working in our treatmentrooms and we're not necessarily
having an opportunity to talkwith other therapists who are in
a similar kind of work Not justabout clinical advances or
research advances, but also theimpact of this kind of work on
us.
And we do need to acknowledgethat sometimes it can be hard to
(03:25):
work with people who aresuffering and who are ill and
who may sometimes be near theend of life because of their
health condition.
So I think it went really well.
I'm offering it again in Mayfour evenings in May and hoping
to get a similar crowd this time.
Speaker 1 (03:44):
Amazing, amazing.
Well, yeah, you might be too,too humble to share, but you did
share with me off air, some ofthe lovely feedback that you had
.
So why don't you just telleverybody this, because I asked
you to you don't have to, but Ithink you should why don't you
tell everybody what that onequote was that you got from one
of the learners?
Speaker 2 (04:05):
One of the learners said that the course was
grounded in evidence, guided bycompassion, and I was so touched
by that and I think really Ican't aspire to offer anything
greater than that.
So whoever that was thefeedback was all anonymous I
honestly don't know who thatcame from, but thank you very
(04:25):
much.
That warmed my heart and isalso going to continue to be a
guiding principle for me as I goforward and create this
continuing education for othertherapists that it has to be
grounded in the evidence andthen guided by our humanity and
our compassion as we share, howwe, how we interact with other
humans.
Speaker 1 (04:47):
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 kindof segues nicely into our
conversation about scar tissueand that there's a lot of.
The term that I like to use iskind of evidence, adjacent kind
of stuff that's out there wherethere's, you know there's.
(05:07):
You see a lot of courses andwebinars and workshops, whatever
you want to call them wherepeople are often quoting
research or using research tokind of support a premise, but
then when you actually look atthe research in depth, it
doesn't actually support what itis that they're saying or might
even contradict it, and we seethat a lot.
And this is obviously a biggerissue than just the C industry.
(05:28):
I think it's an issue with theresearch literacy and critical
thinking in our profession, andthat is just something that is
not part of our entry levelpractice and something that you
know.
Obviously, people like you and Iare heavily biased and wanting
it to be more prevalent with theresearch evidence.
But that's why we have theseconversations today, so we can
(05:50):
try to disseminate ourinterpretation of evidence in a
way that is hopefully meaningfuland hopefully not using it in I
don't want to say in abusiveway, because hopefully not using
it in a way that bends thetruth about what it really says.
That's that's important.
So let's just start off thisconversation, because this this
(06:13):
is on scar tissue and then therole of massage and scar tissue
management.
What do you think are some ofthe biggest beliefs about scar
tissue and massage?
Speaker 2 (06:27):
Well, we're all taught that with our hands we
can break down scar tissue,release adhesions and thereby
release the patient from thepain and restriction and
dysfunction that they'veincurred as a result of the scar
tissue.
And the evidence isindisputable that we cannot
change the scar tissue.
(06:47):
So that's a myth and anarrative that I'd really like
to see go.
I think that it can be harmfulif people are coming to us and
we're saying well, this isbecause of the scar tissue from
your surgery or from this biginjury that you incurred, but
don't worry, because we, withour hands, can change the scar
tissue.
We really need to drop thatnarrative from our, from our
(07:10):
vocabulary.
Speaker 1 (07:12):
Yeah, I guess the question I have too is I mean, I
haven't taught in a school, orin a long time since I've been
involved with a specific schoolhere in BC where I am.
But as far as what I, when Iencounter 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
(07:32):
frictions and they learn about,you know, any little kind of
lump or bump that you feel whenyou put your hands on people.
That is probably like a mildfascial adhesion and these are
kind of terms that are so.
They're used so many times, sooften our profession.
They become like a truthism.
You know it's like you say itenough times.
It becomes reality even thoughwe know that that might not be
(07:54):
reality.
What are your thoughts on whythese myths are so prevalent in
our profession?
Speaker 2 (08:04):
Well, I think because unfortunately our profession
historically has not beengrounded in scientific research,
and so a lot of there's been alot of surmising of what we
think is happening inside thebody and what we think is
happening with our manualtechniques and our interaction
(08:25):
with our patient, and then thesemyths just get perpetuated and
they go on and on and on.
And then, unfortunately, withinour profession, the science
literacy is not a big part ofour education.
We're not taught how to readscientific literature, how to
evaluate it for its strengthsand its weaknesses.
We don't know how to go andcheck if what we think we're
(08:50):
doing is actually supported bythe evidence, and so that's
another reason why these thingsget perpetuated, because we're
just not equipping RMTs with theskills to actually examine
critically what we're hearing.
Speaker 1 (09:04):
Yeah, I agree with that.
I think one thing that we seetoo is there's just obviously
not a lot of massage therapyspecific research.
And this is something Iencounter all the time where
people like, oh, there's no,nobody wants to research this
stuff.
There's no one wants to putmoney into this thing because
it's not pharmaceuticals.
There's a lot of excuses thatpeople make why there's not a
(09:26):
lot of massage therapy specificresearch on stuff that they
think is important.
And I would say let's remove thebig pharma out of the
conversation and let's look at,say well, maybe there's a reason
why science isn't doing a lotof research on breaking down
scar tissue with our hands orthat kind of thing, because I
(09:47):
think what ends up happening isthat most of the scientists know
that we can't change it anyway.
So why would we try to do itwith research?
And what's the purpose of that?
You know, I think if you lookat a lot of the biological
plausibility of the stuff thatpeople in our profession want to
study, if you just look at thebasic science of it, it says a
(10:08):
lot of stuff can't happen anyway.
So I think a lot of theresearchers are like well, we
can't change fascia, we can'tchange scar tissue, we can't,
you know, increase the length ofa muscle, so to speak, with
these techniques.
So why bother studying it?
Because we know that can'thappen.
But people in our professionsay, 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 thescience says.
Speaker 1 (10:36):
I think a lot of that .
I see that a lot and obviouslywe're all biased and this is my
own anecdotal experiences.
But from teaching courses andhaving conversations with people
and speaking at schools andconferences and all the people I
interact with, I think thatthat's the biggest thing that I
come across is that people justdon't want to accept the science
(10:56):
.
And I think it's wellunderstood that when we you
can't change people's minds withevidence, 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 myhands on people, I feel things
soft and I think feel thingsmove, the person has more range
of motion, they have less pain.
(11:18):
So they just dismiss thescientific explanation for it
and they just kind of go withwhat they've always thought.
And I think the thing that weneed to really understand is
that when you're questioning thescience, you're never
questioning the person'sindividual experience.
Those are two totally separatethings.
So we can question the scienceall day and we can say the
science doesn't support changingscar tissue, for example, but
(11:43):
if someone has a clinicalexperience that they treated
somebody and there was anoticeable change in the
experience of the person's scartissue.
Well, we're not saying thatdidn't happen.
We're saying, well, maybe thereasons why those things
happened are different and maybethat is a one that just
happened with that one person.
Can we say that isgeneralizable across the
population?
I would say probably not, andthat's a big thing that.
(12:07):
I don't know if you found thatin your course, but some people
will often question the sciencebecause it contradicts their
experience and I always want tobring it back to say I'm not
saying what you're experiencingis wrong, but maybe the
understanding behind it isincomplete.
Speaker 2 (12:24):
Or somebody might be attributing the effect to a
cause other than what itactually is.
We know there are so manythings going on physiologically,
environmentally,psychologically, emotionally.
There are so many things thatare contributing to the overall
experience.
How can we pin down forcertainty that something was
(12:46):
caused by one thing?
We can't.
Speaker 1 (12:50):
And that's a great point.
And this goes to the differencebetween outcome based massage
and mechanism based sorry,science that produces outcomes
and science that producesmechanisms of outcomes.
So if you put your hands onsomebody and you do something to
them and there's an outcomethat doesn't prove the mechanism
(13:11):
of the outcome, it just provesor 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'slots of that stuff out there
where people do a specifictechnique or techniques on
someone and then the peoplebeing studied the experimental
group reported less little backpain, less disability whatever
and they're like aha, it'sbecause I changed the fascia.
Well, no, your research didn'tshow that you did anything to
(13:37):
the fascia.
It showed that these techniquesor this approach helped this
person feel better.
All we know is that manualtherapy that looks something
like that might help.
People doesn't say that youchanged fascia, and we see that
a lot.
At least I see that a lot and Ihave those conversations often
with people in courses.
Speaker 2 (13:58):
Yeah.
To go back to your originalquestion about why these myths
are so they have such long lives, it's not that we're
egotistical, but in a way it'snot that we're egotistical and
we want to feel all powerful.
I think it's more that we allreally want to believe that we
can offer somebody somelegitimate help.
(14:18):
So it does come from a goodplace in us.
We genuinely want to be able tohelp somebody and we think that
we can and we're eager to try,and then we're eager to have
that really positive effect andthat positive outcome.
But, as we said earlier, we canalso cause some harm in leading
(14:40):
people down the wrong path andmaking them believe that we can
do something that we can't, andthen how we extrapolate from
that as well.
Speaker 1 (14:47):
Yeah, that's a really good point, susan.
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 themehere for today.
What does it say to the personwho's experiencing pain after
surgery?
Say they've had I don't knowwhatever, it doesn't matter.
(15:08):
Say they've had mastectomy orsomething, cause I know cancer.
You probably have a lot ofexperience, I know you have a
lot of experience working inthese populations and say
they've got significant scarringafter the surgery.
Well, what does it say to thatperson when they come in and say
they're therapists who's verywell meaning and, like you said,
probably compassionate,understanding but they say, yeah
(15:30):
, you know, you've got the scartissue here.
If we can mobilize this andbreak this down, then that'll
help with your courting orthat'll help with your shoulder
range motion and say the persongets these treatments and they
get a series of treatments andthere's nothing there and
nothing happens.
It doesn't work.
Then what's the person leftwith?
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 peopleare paying out of pocket and
cancer doesn't choose accordingto socioeconomic status.
So for some people seeking helpduring or after their cancer
treatment can actually be quitean economic, quite a financial
burden on them.
And so if you don't actuallydeliver on what you say you're
(16:13):
going to deliver, or yourtreatment doesn't produce the
results that you say it's goingto produce, it can have an even
broader impact on somebody wherethey think, oh, but I've put a
few hundred dollars into comingto see you several times and I
can't really afford this, andthen obviously disappointed
because they're not getting theresults that they have been
(16:34):
promised.
So I think we have to becareful.
Speaking of mastectomy, thereare common side effects to the
cancer treatment that a lot ofpeople experience and I'm often
honest and say this is notreally well understood.
For example, courting thosevisible, palpable lines that
(17:02):
appear in and out of the axilla,down the arm, sometimes down
the trunk.
That is not well medicallyunderstood.
We don't really know what'sgoing on physiologically.
It was really striking to me.
One of my patients told me thatshe had been talking with her
surgeon about having a revisionsurgery, which is quite common.
We're just little things areaddressed.
(17:22):
And when she was talking aboutpossibly having a revision
surgery, she said to the surgeonwell, can you cut the cords as
well?
And the surgeon said we can'tactually see the courting.
So when they open up somebody'sbody, they don't see anything.
That looks any different withsomebody who has courting than
in somebody who doesn't havecourting.
(17:43):
Courting is not actually athing like a new anatomical
structure or a change in theanatomy of that person that is
visible to the surgeon's eyes.
That was really striking to me.
Having said that, though, whileI can't explain what's
happening when somebodyexperiences courting and equally
(18:03):
I can't explain why manualtherapy can often help with the
courting.
Very often not always, but veryoften we do see an improvement
in the person's courting as aresult of the manual therapy and
as a result of passive movementand active movement that we
suggest that the patient use inbetween appointments, engage
(18:27):
with in between appointments.
It probably does have somethingto do with scar tissue, because
it is always the result ofsurgery.
It always comes after surgery.
You don't see it in somebodywho hasn't had surgery.
It's associated with lymph noderemoval, and the lymph nodes
are removed from the axilla.
(18:48):
That is where usually thecourting is, but sometimes it
can be on the trunk.
For example, if somebody's hada mastectomy and a breast
reconstruction, sometimes youcan see and feel courting
running down the front of thetrunk from the inferior aspect
of the breast.
So it does seem to be related tosurgery but, as I said, I can't
(19:09):
say with any certainty that Ican explain what it is that's
happening inside their body andI'm quite clear about that and
people seem to accept that.
Actually I've never hadsomebody express frustration or
anger that the medical communitycan't explain to them what it
is that's happening.
I think perhaps it's evenbetter if we're honest and just
say we don't really understandthis, we don't really know
(19:29):
what's going on.
Why don't we try this?
We know that in a lot of peoplewhen we do this kind of manual
therapy and blah, blah, blah,blah.
Why don't we try it and see ifwe 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'tmake any claims and we can try
this.
And you know what my clinicalexperience, which is part of
evidence face practice, is.
Your clinical experience saysthis helps to some people.
We can just leave it at thatright Rather than making
promises, and you know everytime we make these kinds of,
(20:02):
have these types ofconversations, almost always get
feedback from somebody who'slike, well, I've never once
heard somebody ever say that.
I'm like, okay, well, maybe youhaven't, I don't know, but it
doesn't mean it's not true.
It doesn't mean people don'tbelieve in say these things.
And was it an absence of nothearing?
That doesn't mean it's not true.
(20:24):
Yeah, I think one thing I readas we were preparing for this.
I read a paper on axillary websyndrome.
According, I think I didn'tknow that it was actually called
axillary web syndrome, but Ilearned something which is great
and they were saying that theythought, and it was again.
It was kind of like this iswhat we think it might be, and
(20:45):
this was a research paperwritten in the last probably six
or seven years.
I'll try, if I find it.
I'll try and remember to put itin the show notes, so if I can
find it again.
But to paraphrase, theybasically said that after
surgery with the removal oflymph nodes, they think that it
might be doing due to increasedinflammatory products within the
lymphatic system, whichbasically caused the swelling of
(21:06):
the lymph vessels.
Speaker 2 (21:08):
I have heard that too , that some people think that it
might have to do with thelymphatic vessels.
I also was very surprised tohear a very experienced,
well-regarded therapist say thatit was neural tissue.
That sort of gets involved inan inflammatory response and the
(21:31):
creation of scar tissue.
I don't think that that's true.
I think that if it were neuraltissue, 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 isnerves.
I think it is more likely thelymphatic vessels.
Speaker 1 (21:55):
I would tend to agree that that lymphatic vessel
sounds like the less wrongunderstanding the neural stuff.
Yeah, you're spot on there, youwould see.
Probably you should see sometype 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 someof these papers which we
discussed in the Facebook liveand just kind of just bring some
of the information of what theysaid in them.
And the first one is called therole of massage and scar
management.
So this is probably one of theonly ones I could find that
(22:30):
actually talked about massage,doing massage and scar.
It's from 2012 and waspublished in the American
Society for DermatologicalSurgery.
Dermatological Surgery it's ahard word to say for me,
apparently and some things thatwe look at in this here is the
questions we want to answer, andthat's why we look at the
research is does scar tissueplay a role in pain?
(22:52):
That's the one thing we want tolook at.
Another thing I think we shouldtry and answer is can scar
tissue be changed?
We kind of talked about italready Can't really change scar
tissue Once it's been formed.
There is some evidence thatsays you might be able to impact
it, but maybe it might notalways be positively in the
early stages.
And the other thing, too, Ithink is really important for us
(23:14):
to understand is does scartissue need to be altered to
return to function Like doesscar tissue actually need to
change?
Right?
And so when we look at theresearch so this one here and
then so to answer the first oneabout pain we would say does
scar tissue play a role in pain?
It does, because any type ofprotocol, surgery or tissue
damage, there's gonna be damageto the axons, there's gonna be
(23:38):
damage to neurons which cancreate an increased nociceptive
firing.
So, yeah, we could say thatmakes sense.
But just to look at some of thequotes from this paper, we're
not gonna go into too muchdetail.
But it says this it sayspossible negative aspects of
this therapy.
So massage therapy include thisis a very bold statement
(23:59):
wasting the patient's time.
If massage is not anefficacious treatment, which is
important to think what we justsaid but people being told that
there might, maybe we can dosomething that we can't.
So we have to be honest, right?
Because otherwise it is justtaking your money and that's not
really informed consent.
I don't think it said there'salso could be irritation from
(24:20):
friction.
And it says too that earlymassage should be avoided, in
light of evidence thatmechanical pressure during early
phases of wound healingpromoted hypertrophic scar
formation in a mouse model.
And that's the thing I think weneed to be really mindful of
when we look at theextrapolating scar tissue
(24:43):
research and then saying this isapplicable to humans, Cause
it's most of us have just doneon animals and we can't just say
that it's like if we seesomething 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 Iwould say, and it's something
like this one you say, well, toomuch pressure in and around the
(25:06):
wound early on actuallyincreases more scar tissue
formation, Even though it wouldhave to ask that should be
something we should be mindfulof, that we don't want to
facilitate.
Speaker 2 (25:17):
Yes.
But there I have to ask they'reusing the term massage therapy
very broadly and I'd like tothink that any massage therapy
would have the common sense notto do really deep, aggressive,
vigorous, shearing type massagetechniques around a surgical
(25:38):
site early in the healing stages.
That if any work is gonna bedone around the surgical site it
would be light pressure, itwould be gentle.
You absolutely don't want todisrupt the healing that has to
take place not just on thesurface of the skin that we can
see the surgical incision, butall of the healing that's taking
place underneath the skin, inthe tissue.
(26:01):
I think it's.
I always like to think thesurgical incision that we can
see is just the doorway into thebody and remember that a whole
lot of tissue and we might betalking about only a few
centimeters or we might betalking about a much larger
measurable area, but that theincision is small compared to
(26:23):
the area within the body, thesurgical field underneath the
skin that we can't see.
But to go back to my originalpoint, I think we also need to
think what do they mean?
Does the research paperdescribe the massage that was
employed, the type of techniques, the pressure, the amount of
(26:45):
movement within the tissue thatwas incurred through the massage
techniques.
The duration of the massageobviously, if it's on animals,
then you can't really getfeedback about how comfortable
it is and use that as some kindof 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 kindof take this information that we
look at on the role of scartissue and massage or just the
physical management of scartissue in general, is because
when they use the word massage,like what does that mean?
Like it hasn't been qualified atall right, like you made some
great points there.
So it's like okay, so it saysthat we shouldn't probably use
(27:26):
it because this might result inmore scar formation.
But it doesn't say like doesthat mean?
Like could you put your handsover it and just kind of just
like hold the skin a little bitmaybe 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 paperhere it says that, you know,
(27:48):
through endogenous opioidpeptides and neurotransmitters,
we know the massage can help inpain reduction.
That's great, but I think thatit's In order to really say what
massage can do for scar tissue,I think we need to have
research that is a little morespecific.
Speaker 2 (28:09):
I agree, you make a great point there.
Well, as you said, there's beenvery little research into
massage therapy and scar tissue.
In my VODER training, of course, we did talk about utilizing
manual lymph drainagepost-surgically, but manual
lymph drainage by definition isa light pressure, superficial,
(28:31):
low velocity technique.
I wondered when you read thequotation out and they talked
about avoiding massage therapybecause it might create
hypertrophic scarringpost-surgically in the early
acute stages or the subacutestages.
I wondered if they werethinking of the more vigorous
frictions and, as I said, I hopethat no massage therapist would
(28:53):
do that on somebody early inthe 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 thewhat do we do with people acute
injuries, post-surgical, forexample or say it's a muscle,
tear, ligament where there'sgoing to be scarring, that's
going to be formed, but we can'tsee it.
If it's a tissue internal orinternal, but I guess it's
(29:22):
internal, I'm sure why not Belowthe skin that we can't see.
If there's a tissue injurythere and for sure we know that
there's going to be aninflammatory 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 increasingmore information.
(29:43):
And when we look at some of theother research here this one
other paper called PhysicalManagement of Scar Tissue with
Systematic Review and MetaAnalysis from 2020, we look at
like when you, if you put morestrain and load into tissue that
is acutely healing, it canactually result in more fibrosis
Because you're disrupting thehealing process, potentially
(30:07):
like tissue stretch.
You know, gentle range ofmotion stuff, which is in our
scuba practice, probably not.
But I think the one thing thatwe that we probably see more of
in our profession and I'llcorrect me if my thoughts are or
might be off here, but what wedo see is we see these people,
these longstanding painsyndromes, people that suffer
(30:30):
with, say, chronic low back painor shoulder or neck pain or hip
pain, whatever you choose yourbody part.
Those people are often told thatthey are full of adhesions or
it's because of a scar, becauseof an injury they had.
You know, oh, you have low backpain.
Well, it's because you, you,you, you, you strain your
hamstring, you know playing, youknow running track or whatever,
and that's that scar tissue ispulling on your low back and
(30:54):
that's creating this wholeseries of, you know,
biomechanical dysfunctions, soto speak, and then all we need
to do is we need to break downthe scar tissue.
So some people are subjected tosome seriously aggressive stuff
to try and break down scartissue.
That is like in a muscle orperceived to be in a muscle, and
we know there's no evidence forthat, but that is something
(31:14):
that people are subjected to allthe time.
Have you seen that a lot inyour practice too, susan?
Speaker 2 (31:19):
I haven't seen that a lot.
I do have people who come to mespecifically to have the scar
tissue worked on, because theyhave also heard that narrative
and they think that that'ssomething that massage therapy
can can offer.
And it can sometimes be hardtalking about being honest.
It can sometimes be hard tocounter somebody's expectations
(31:41):
If they've come with a specificthing and then either they're
disappointed because they thinkthe problem is scar tissue, they
think massage therapy is goingto get rid of the scar tissue
and they think then they won'thave any problems anymore, or
they think, well, you just don'tknow what you're talking about,
because this other therapisttold me that you can break down
scar tissue.
(32:01):
So I'm going to go back to theseven massage therapist and, of
course, everybody can make theirown choices.
Speaker 1 (32:07):
Yeah, and that's a thing too, that's just your good
point you brought up is becauseif we are the person that's
telling a different narrative ora different story than what the
person has been told by otherwell-meaning health care
providers or something they'vemaybe 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'thelp you.
(32:27):
But if you, if you, if you kindof dismantle that, that belief,
and you know, I would say, dowe need to change those beliefs?
Maybe only if they're negativeand an impact in behavior Do we
want to maybe have aconversation about it.
We should ever try and forcethose chains.
But if someone's like you needto break down my scar tissue,
that's the only thing I need,and you're like well, I can work
(32:49):
on your hamstring, I can workon this body part, but I can't
change that scar tissue, butmaybe we can do some stuff to
make it feel better.
If they think you're crazy andbecause you're saying something
different everybody else, Ithink it can make a lot of us
uneasy because we're worriedabout losing that client, we
want to please them and thatbecomes a, that becomes a
(33:13):
delicate balancing act, I feelwhere 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 agood trusting relationship
before you start to challengesomebody's beliefs too deeply.
So to come right out of thegate, challenging somebody's
beliefs is not going to beproductive in the long run.
I think, though, another thingto mention in this discussion is
that believing that a problemis only because of scar tissue
(33:47):
or only because of one thing israther myopic.
As we talked about earlier,there are so many things that
are going on in somebody'sexperience of pain and
dysfunction, and so, as you said, why don't we talk about some
other things that might help youfeel better and that brings in
that makes the conversationwider where we can talk about?
(34:08):
So, if somebody has an injurythen and they're experiencing
pain, maybe there's somesecondary muscle tension that is
a normal reaction toexperiencing pain, and so maybe
we can, we can help relax someof those muscles.
We can help calm yoursympathetic nervous system.
Maybe it's sort of in aheightened state of guarding and
(34:29):
protection because of the painor because of a history of
injury in that area, and maybe,if we can calm your sympathetic
nervous system, you'll be lesssensitive to pain.
If you're feeling less pain,you might find that you can,
that the muscles are a littlebit softer and more relaxed, you
might find that you can move alittle bit better and that your
function improves.
That there's.
There are these other thingsthat sort of surround the
(34:51):
central issue in someone's mindthat they might not be aware of,
and there can be a cascadeeffect.
If we can, if we can interactwith something, with one part of
this person's overallexperience, then there can be a
follow, in effect, to the otherthings that are happening at the
same time, and so we can engageour clients in a conversation
(35:11):
in that way that that hopefullyhelps enlighten them to the many
other issues, or the multifactorial to draw on a buzzword
the many things that are thatare 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 thecomplexity of the multi
factorial and yeah, it's, it's aword that gets thrown around a
lot, but it's, it's true and the, the simplistic approach of you
know, you have pain becausecartoon, you just break that
down and you'll feel better is Ithink 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
(35:52):
know, we know.
I think what we can say is, ifsomeone has Pain around a scar,
we can say, ok, it hurts becausethere's some type of activation
of the, the no receptors inthis area and that's
contributing to creating thesenoxious stimuli, which is part
of your pain.
But you know, do we do we needto?
When it was air quotes, eventhose kind of podcasts, and I
(36:12):
can see it and you know, do weneed 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 thesensation in that area.
And when we look at the researchand and you know this I'm going
to make I'm going to read aquote here from this other paper
, the physical management ofscar tissue paper.
It says that a meta analysisshows that physical scar
(36:33):
management has a significantpositive effect to influence
pain, pigmentation, pliability,puritis, surface area and scar
thickness, compared with controlor no treatment.
Unfortunately, massage on itsown is not shown to be very
effective.
It should be used as part of anoverall treatment plan so we
(36:54):
can have an influence on pain,we can help with the,
potentially with the overallpresentation of the scar.
But that's only one, it's onlyone piece right.
Another thing that one of thispaper I think it's this paper
when the other one said is thatthat the silicone strips are
(37:15):
just as effective as massage andcheaper.
So you know, it's not just amassage and that's, you know.
The evidence I think is quitestrong in saying that a lot of
the things that we believe arejust 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 toalmost immediately start doing
some gentle massage, some gentlemanipulation of the tissue
Remember, people are going to be, they're going to have bandages
(37:58):
and wound care over thesurgical incision for, you know,
possibly a couple of weeks butto gently, gently start moving
the tissue.
And of course they'reencouraged to get up and start
moving around again.
Nobody's told to lie perfectlystill and all of this
contributes to a good healing ofthe surgical field, I think,
(38:21):
because it can help maintaingood circulation.
Obviously there's going to bepost-surgical inflammation
that's part of the healingprocess and that needs to be
there.
But you don't want to haveexcessive swelling because that
can cause some problems initself.
And I think moving around helpsthe body just keep the fluid
moving in and out and in and outand sort of control excessive
(38:44):
fluid buildup.
I think something that we don'ttalk about enough, and this is
my speculation.
I doubt very much there's anyresearch on this, but in my
experience I think another thingthat the touch provides,
whether it's the patienttouching the surgical site or a
(39:08):
therapist touching the surgicalsite, the surgical field, the
area around is it helps thepatient integrate how their body
has been changed into theirsense, their overall sense of
themself.
So obviously there might besome numbness following the
surgery, so they're not going tohave full sensation but
hopefully will come backgradually.
(39:29):
Sometimes it doesn't come backfully.
It's common after mastectomyfor women not to have feeling on
their chest, particularly witha breast reconstruction, an
autologous breast reconstruction.
But I think psychologically aswell, they've gone through a lot
of trauma with the wholepsychology around the disease of
(39:53):
cancer, the physiologicaltrauma of the surgery and their
body has been changed and theirsense of their body and how it
represents themself, theirfemininity, their sexuality
possibly not always, but I thinkthat because we are on a
continuum, we're not twoseparate spheres of physiology
(40:16):
in one sphere andpsycho-emotional experience in
the different sphere.
We are in a continuum and Ithink that incorporating some
kind and gentle and sensitiveand intelligent touch helps
integrate all of these differentaspects into someone's overall
sense of themself and I can'tstress enough how important I
(40:40):
think that is for someone'slong-term well-being.
It's not healthy to go throughlife feeling that a part of your
body is diseased or off limitsor shameful because of how it
looks, or you know, damaged orugly or scary.
(41:03):
We have to have overall a senseof living in our bodies and
living well in our bodies andhaving a good relationship with
our bodies.
Speaker 1 (41:16):
So powerful.
What you just said there and ifwe look at so bring in some
research to what you said spoton is the, that sense of
ownership and that sense of Ithink the word is it
somatoprecious organization.
I think it is a term that theyuse in in the one paper on the
(41:39):
science of touch, I think iswhat it's called.
They talk about the touch.
Basically bring that sense ofownership and that awareness of
like your body part and helpingto like, recognize it as part of
you again.
Somebody can tell me if I'mwrong.
I can find me to say thatcorrectly and appropriately.
But anyway, what you said thereis so true and it's really
important as part of the wholehealing or recovery process.
Speaker 2 (42:01):
It is and, eric, you've just reminded me.
Several years ago, when I wasdoing research for a paper that
I wrote, I came across somehowthat the somewhere I found the
old English word for healing,which is Halen.
H, a, e, l A N.
(42:22):
I think the old English wordfor healing, halen, meant not
just to cure but to make wholeagain, and I have always loved
that because I think itreinforces that what we are
doing as manual therapists ishelping people become whole
again, and how absolutelyimportant that is in their
(42:47):
healing process and in theirrecovery.
Wow.
On a different note, one thingI'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 sopart of their body is
surgically removed, does thehomunculus change and does the
(43:14):
manual therapy that we provideand the sensation that the
person feels in response to ourmanual therapy, does that help
the humunculus adapt to thechanged body?
What kind of sensory input isthe brain receiving from this
post-surgical body?
I have no idea.
(43:37):
I've never looked into theresearch.
Speaker 1 (43:39):
Yeah, that's a good point.
I don't know how it stands upto newer research but I know as
last time at Ramos Chondron inthe late 90s did a bunch of
research on phantom pain andchanges in the homunculus and
(44:01):
they made some.
I know some of the early painscience.
I don't know early, but painscience stuff around that time,
the early 2000s I think, evenexplain pain and their first two
editions they may have talkedabout that kind of
reorganization.
I don't know if it's, if thatstill stands up.
I don't know if that's ever, ifthat was just a hypothesis and
(44:24):
then it's never improved, or ifthere's actually evidence to
support.
I'm not really sure.
Speaker 2 (44:30):
That's a good question.
I think I have heard recentlythat the humunculus doesn't
reorganize itself after a limbamputation.
For example, there's a recentpaper that was just published
last year, I think, 2023 oncommon shoulder impairments
following mastectomy and, to mysurprise, they included phantom
(44:54):
pain as one of the commonexperiences that women might
experience following amastectomy.
So the same thing a part of thebody is amputated.
I've never heard of this before.
I've never encountered anybodywho who experiences this.
Interestingly also, they notedthat the number of people
(45:14):
experiencing phantom pain aftermastectomy has been diminishing
over recent years, which theyattributed 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 thatmakes me wonder if phantom pain
was a bigger topic of discussionjust in the zeitgeist, say 20
years ago then.
Did women following amastectomy, were they somehow
(45:48):
primed to feel phantom pain orwhat they thought was phantom
pain and what they mightdescribe as phantom pain?
More so than now where, as Isaid, I've never heard somebody
even suggest that this would besomething that would happen.
Speaker 1 (46:05):
Yeah, yeah, yeah, that's a good point.
And I think when we look atsome of that, a lot of the
research like the earlier painresearch, the stuff that was
really kind of you know I jumpedheadfirst into a lot of it.
I'll admit that and I'm sure Iknow hopefully I'm not the only
one, I'm sure I'm not there's alot of priming that's done in
(46:27):
that type of research.
Oh, do you feel this, does thishurt more?
Do you feel like, oh, does itfeel like that limb should be
there, like you're kind ofasking a very loaded question.
So people often kind of theycan be primed to responding in a
way that might be favorable tothe examiner.
(46:50):
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 sayto people that are listening is
if you want to read more aboutscar tissue and the role of
manual therapy, if you just gointo scholargoogleca orcom if
(47:18):
you're not in Canada and you goand you look for understanding
and approach to treatment ofscars and adhesions by Susan
Chappelle.
She's a massage therapist basedhere in BC and she's got a book
chapter.
It's free and you can justdownload it or just click
there's a website for it and shetalks all about scars and
(47:38):
adhesions and kind of goes into.
You know, what do we know?
What do we not know?
For those of you that don't knowSusan Chappelle, she's the one
that did a paper well over adecade ago on doing mobilization
and little massage on ratsafter they'd had their abdomens
cut open and her stuff has oftenbeen used to support the role
(48:03):
of visceral massage and scarmassage and her research doesn't
find that even in this bookchapter she says that's not what
it says, but it's often again,there's that kind of use and
abuse of the information tosupport a narrative that people
want.
You know, just before we leavejust a couple little quotes I
(48:24):
wanted to read from this, whichI thought kind of fits in this
whole idea of, like you know,scar massage just being
something that I think is madebigger than it really should be.
She says, as a perfection,manual therapists have long held
the belief that localrestrictions and tissue
movements can result in moreglobal dysfunction.
There's little support for thisconcept.
That's something we see all thetime.
(48:45):
Right, oh, you've got thisinjury over here and that's
going to cause this pain wayover here.
It's a belief.
Again, there's no research.
She does also say that thetissue that has been mobilized
early was much more prone tore-injury.
Oh, that's so interesting.
But that goes back to what wesaid earlier too is like how
much mobilization, how much weneed people to move.
(49:07):
But I guess again it's thatthere's probably that sliding
scale of what is too much or not.
One thing she says too.
She said procedures used toreduce the burden of adhesions
so they don't go to adhesions ofthings that are occurring, like
they're talking about, in theabdomen, usually after surgery,
(49:28):
not like the ISTM and grass inadhesions where every little
bump thing is supposed to besomething you can break down
with a tool.
That's not how adhesions isused in the medical community.
It's something that we have inthe manual therapy community.
We've kind of taken on.
She says that anyway,procedures used to reduce the
burden of adhesions and clinicalpractice have not shown
clinical effectiveness and havelacked scientific validity.
Goes on to say in her chapterthat the only way that you can
(49:51):
actually break down an internaladhesion 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 interferedwith the formation of a
post-operative adhesions butfailed to significantly reduce
already formed adhesions afterone week.
So doing something might, itsays, interferes with formation
of post-operative adhesions.
(50:19):
We don't necessarily know ifthat's good or bad.
Did you delay the healingprocess?
Did you make the adhesions thatmaybe they didn't heal as
strong?
We don't know.
So we have to be very carefulof extrapolating that research
to the bigger world of scarringadhesion massage, because her
(50:42):
paper doesn't say that itdoesn't support the law of the
claims that people make from it.
Lastly, as I want to read thisquote here and I think this is
great, it says for the most partpeople seek care for manual
therapists for pain relief.
When a link is made between atreatment and pathology, such as
scar or an adhesion, it may bepresumed that there is also some
connection between thepathology and the symptoms, and
(51:04):
that's neurology.
Every injury also involvesnerves of some caliber.
Kidney surgery involves cuttingmany intercostal nerve branches
and even a small cut in theskin damages a few axons.
These damaged axons remainalive and immediately start to
regenerate.
For the most part, nervesregrow appropriately, but in
(51:25):
many cases they do not and canlead to persistent pain.
I think we just take this backto what we do as massages in
manual therapists is that wehelp people that hurt.
We help them hopefullyexperience less pain.
If our focus is on trying tochange scar tissue, then we are
probably removing that focus on.
(51:45):
What matters most is the personand their experience of pain.
If we can just flip that scripta little bit to focus more on
the person and not on the tissuelike you said earlier, it's
multifactorial and we'llprobably have better.
The person that comes to seekour care will probably have
better, more meaningful outcomes.
Speaker 2 (52:06):
Completely.
I completely believe that In mycourse, my online course on
oncology massage, I invited someof my patients to contribute
reflections for me to share withthe learners.
I asked them what did they wantRMTs to know about working with
(52:30):
people with cancer?
One of my patients sent mesomething that said I'm
paraphrasing, obviously, but shesaid although I had surgery in
one part of my body, the rest ofmy body felt beat up and
bruised and sore.
I really appreciated that.
You asked what I wanted tofocus on today.
That's such a good reminderthat we are dealing with a whole
(52:52):
person.
We're not just dealing with onesite of injury or surgery or
dysfunction.
We need to look at the wholeperson and how they're feeling
and what they're hoping to getout of their massage interaction
with us.
We should ask them we can'tpresume to know on their behalf
what it is that they need thatday.
Speaker 1 (53:14):
I think that's perfect way to end this, Susan.
Excellent Thank you for beinghere, until next time.
Speaker 2 (53:21):
Thanks so much, Eric.
As always, it was a pleasurechatting with you and my brain
is stirring and moving with allkinds 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 socialmedia.
You can follow me on Instagramor Facebook by searching at
ericprivicermt.
Now please head over to mywebsite, ericprivicecom, to see
a full listing of all my livecourses, webinars and
self-directed course options.
If you'd like to connect withSusan, she can be reached via
(53:52):
her website, which iswwwsusanshiptinrmtcom.
Until next time, thanks forlistening.
Hello and welcome to another episode of Purvis Versus
.
My name is Eric Purvis.
I'm a massage therapist coursecreator, continuing education
provider, curriculum advisor andadvocate for evidence-based
massage therapy.
In this episode, we welcomeback Susan Shipton, who is an
RMT in Toronto, ontario.
Susan and I have a discussionon scar tissue massage, treating
people post-surgery and theimportance of being comfortable
(00:29):
without having all the answers.
If you enjoyed this episode,please rate it and share it on
your favourite social mediaplatforms.
You can also support my podcastby making a donation by
visiting buymeacoffeecom.
Purvis Versus can also be foundon YouTube, so please check us
out there and subscribe.
Thanks for being here and Ihope you enjoyed this episode.
(00:50):
Hello everyone, and welcome toanother episode of Purvis Versus
.
I'm so excited to have my goodfriend, susan Shipton back.
She was here on an episode anumber of months ago where we
talked about cancer and oncologymassage, which is her area of
interest, but today what we'regoing to do is we're going to
continue a conversation that wehad on Facebook Live back in the
(01:12):
middle of January, which kindof went viral, I guess, so to
speak, for in our industryanyway, you get a few thousand
people watching something.
That's a lot.
So I'm hoping that thisconversation we have today will
be a continuation of that andalso for those people that
aren't on Facebook, it might bea good opportunity to listen to
us discuss the topic of scartissue and the role of massage
(01:35):
therapy and scar tissue.
This is such an interestingtopic and one that we hear a lot
of people talk about, but Ithink it's important for us to
really unpack, kind of what weknow and what we don't know, and
so today we're going to talkabout some of the research and
what this means, and we'llprobably leave this conversation
today with a lot of well, itdepends, and well, we don't
(01:56):
really know.
But it's better than saying,yes, we know for sure when we're
just making, so we're not justmaking stuff up.
Welcome, susan.
Speaker 2 (02:03):
Thank you.
Thanks for having me again,eric.
Glad to be here, yeah.
Speaker 1 (02:08):
So why don't you just fill us in a little bit about
what you've been up to sinceyour last episode that you're on
with me?
Why don't you tell a little bitabout your course that you just
finished running?
Speaker 2 (02:18):
Thank you.
I launched my online continuingeducation course for RMTs on
oncology massage.
It went really well.
I'm so happy to say that thefirst time through, I think, was
a success.
Obviously, there are somethings I'm going to change and
tweak a little bit, but I had 14RMTs from Nova Scotia to
(02:41):
British Columbia join me forfour evenings and the feedback
was really good.
And it was, I think, good forall of us also to get together
and to have an opportunity toconnect and to share some
stories about our clinicalexperiences working with people
with cancer.
And that's important because sooften the job of an RMT can be
(03:03):
kind of isolating.
We're working in our treatmentrooms and we're not necessarily
having an opportunity to talkwith other therapists who are in
a similar kind of work Not justabout clinical advances or
research advances, but also theimpact of this kind of work on
us.
And we do need to acknowledgethat sometimes it can be hard to
(03:25):
work with people who aresuffering and who are ill and
who may sometimes be near theend of life because of their
health condition.
So I think it went really well.
I'm offering it again in Mayfour evenings in May and hoping
to get a similar crowd this time.
Speaker 1 (03:44):
Amazing, amazing.
Well, yeah, you might be too,too humble to share, but you did
share with me off air, some ofthe lovely feedback that you had
.
So why don't you just telleverybody this, because I asked
you to you don't have to, but Ithink you should why don't you
tell everybody what that onequote was that you got from one
of the learners?
Speaker 2 (04:05):
One of the learners said that the course was
grounded in evidence, guided bycompassion, and I was so touched
by that and I think really Ican't aspire to offer anything
greater than that.
So whoever that was thefeedback was all anonymous I
honestly don't know who thatcame from, but thank you very
(04:25):
much.
That warmed my heart and isalso going to continue to be a
guiding principle for me as I goforward and create this
continuing education for othertherapists that it has to be
grounded in the evidence andthen guided by our humanity and
our compassion as we share, howwe, how we interact with other
humans.
Speaker 1 (04:47):
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 kindof segues nicely into our
conversation about scar tissueand that there's a lot of.
The term that I like to use iskind of evidence, adjacent kind
of stuff that's out there wherethere's, you know there's.
(05:07):
You see a lot of courses andwebinars and workshops, whatever
you want to call them wherepeople are often quoting
research or using research tokind of support a premise, but
then when you actually look atthe research in depth, it
doesn't actually support what itis that they're saying or might
even contradict it, and we seethat a lot.
And this is obviously a biggerissue than just the C industry.
(05:28):
I think it's an issue with theresearch literacy and critical
thinking in our profession, andthat is just something that is
not part of our entry levelpractice and something that you
know.
Obviously, people like you and Iare heavily biased and wanting
it to be more prevalent with theresearch evidence.
But that's why we have theseconversations today, so we can
(05:50):
try to disseminate ourinterpretation of evidence in a
way that is hopefully meaningfuland hopefully not using it in I
don't want to say in abusiveway, because hopefully not using
it in a way that bends thetruth about what it really says.
That's that's important.
So let's just start off thisconversation, because this this
(06:13):
is on scar tissue and then therole of massage and scar tissue
management.
What do you think are some ofthe biggest beliefs about scar
tissue and massage?
Speaker 2 (06:27):
Well, we're all taught that with our hands we
can break down scar tissue,release adhesions and thereby
release the patient from thepain and restriction and
dysfunction that they'veincurred as a result of the scar
tissue.
And the evidence isindisputable that we cannot
change the scar tissue.
(06:47):
So that's a myth and anarrative that I'd really like
to see go.
I think that it can be harmfulif people are coming to us and
we're saying well, this isbecause of the scar tissue from
your surgery or from this biginjury that you incurred, but
don't worry, because we, withour hands, can change the scar
tissue.
We really need to drop thatnarrative from our, from our
(07:10):
vocabulary.
Speaker 1 (07:12):
Yeah, I guess the question I have too is I mean, I
haven't taught in a school, orin a long time since I've been
involved with a specific schoolhere in BC where I am.
But as far as what I, when Iencounter 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
(07:32):
frictions and they learn about,you know, any little kind of
lump or bump that you feel whenyou put your hands on people.
That is probably like a mildfascial adhesion and these are
kind of terms that are so.
They're used so many times, sooften our profession.
They become like a truthism.
You know it's like you say itenough times.
It becomes reality even thoughwe know that that might not be
(07:54):
reality.
What are your thoughts on whythese myths are so prevalent in
our profession?
Speaker 2 (08:04):
Well, I think because unfortunately our profession
historically has not beengrounded in scientific research,
and so a lot of there's been alot of surmising of what we
think is happening inside thebody and what we think is
happening with our manualtechniques and our interaction
(08:25):
with our patient, and then thesemyths just get perpetuated and
they go on and on and on.
And then, unfortunately, withinour profession, the science
literacy is not a big part ofour education.
We're not taught how to readscientific literature, how to
evaluate it for its strengthsand its weaknesses.
We don't know how to go andcheck if what we think we're
(08:50):
doing is actually supported bythe evidence, and so that's
another reason why these thingsget perpetuated, because we're
just not equipping RMTs with theskills to actually examine
critically what we're hearing.
Speaker 1 (09:04):
Yeah, I agree with that.
I think one thing that we seetoo is there's just obviously
not a lot of massage therapyspecific research.
And this is something Iencounter all the time where
people like, oh, there's no,nobody wants to research this
stuff.
There's no one wants to putmoney into this thing because
it's not pharmaceuticals.
There's a lot of excuses thatpeople make why there's not a
(09:26):
lot of massage therapy specificresearch on stuff that they
think is important.
And I would say let's remove thebig pharma out of the
conversation and let's look at,say well, maybe there's a reason
why science isn't doing a lotof research on breaking down
scar tissue with our hands orthat kind of thing, because I
(09:47):
think what ends up happening isthat most of the scientists know
that we can't change it anyway.
So why would we try to do itwith research?
And what's the purpose of that?
You know, I think if you lookat a lot of the biological
plausibility of the stuff thatpeople in our profession want to
study, if you just look at thebasic science of it, it says a
(10:08):
lot of stuff can't happen anyway.
So I think a lot of theresearchers are like well, we
can't change fascia, we can'tchange scar tissue, we can't,
you know, increase the length ofa muscle, so to speak, with
these techniques.
So why bother studying it?
Because we know that can'thappen.
But people in our professionsay, 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 thescience says.
Speaker 1 (10:36):
I think a lot of that .
I see that a lot and obviouslywe're all biased and this is my
own anecdotal experiences.
But from teaching courses andhaving conversations with people
and speaking at schools andconferences and all the people I
interact with, I think thatthat's the biggest thing that I
come across is that people justdon't want to accept the science
(10:56):
.
And I think it's wellunderstood that when we you
can't change people's minds withevidence, 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 myhands on people, I feel things
soft and I think feel thingsmove, the person has more range
of motion, they have less pain.
(11:18):
So they just dismiss thescientific explanation for it
and they just kind of go withwhat they've always thought.
And I think the thing that weneed to really understand is
that when you're questioning thescience, you're never
questioning the person'sindividual experience.
Those are two totally separatethings.
So we can question the scienceall day and we can say the
science doesn't support changingscar tissue, for example, but
(11:43):
if someone has a clinicalexperience that they treated
somebody and there was anoticeable change in the
experience of the person's scartissue.
Well, we're not saying thatdidn't happen.
We're saying, well, maybe thereasons why those things
happened are different and maybethat is a one that just
happened with that one person.
Can we say that isgeneralizable across the
population?
I would say probably not, andthat's a big thing that.
(12:07):
I don't know if you found thatin your course, but some people
will often question the sciencebecause it contradicts their
experience and I always want tobring it back to say I'm not
saying what you're experiencingis wrong, but maybe the
understanding behind it isincomplete.
Speaker 2 (12:24):
Or somebody might be attributing the effect to a
cause other than what itactually is.
We know there are so manythings going on physiologically,
environmentally,psychologically, emotionally.
There are so many things thatare contributing to the overall
experience.
How can we pin down forcertainty that something was
(12:46):
caused by one thing?
We can't.
Speaker 1 (12:50):
And that's a great point.
And this goes to the differencebetween outcome based massage
and mechanism based sorry,science that produces outcomes
and science that producesmechanisms of outcomes.
So if you put your hands onsomebody and you do something to
them and there's an outcomethat doesn't prove the mechanism
(13:11):
of the outcome, it just provesor 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'slots of that stuff out there
where people do a specifictechnique or techniques on
someone and then the peoplebeing studied the experimental
group reported less little backpain, less disability whatever
and they're like aha, it'sbecause I changed the fascia.
Well, no, your research didn'tshow that you did anything to
(13:37):
the fascia.
It showed that these techniquesor this approach helped this
person feel better.
All we know is that manualtherapy that looks something
like that might help.
People doesn't say that youchanged fascia, and we see that
a lot.
At least I see that a lot and Ihave those conversations often
with people in courses.
Speaker 2 (13:58):
Yeah.
To go back to your originalquestion about why these myths
are so they have such long lives, it's not that we're
egotistical, but in a way it'snot that we're egotistical and
we want to feel all powerful.
I think it's more that we allreally want to believe that we
can offer somebody somelegitimate help.
(14:18):
So it does come from a goodplace in us.
We genuinely want to be able tohelp somebody and we think that
we can and we're eager to try,and then we're eager to have
that really positive effect andthat positive outcome.
But, as we said earlier, we canalso cause some harm in leading
(14:40):
people down the wrong path andmaking them believe that we can
do something that we can't, andthen how we extrapolate from
that as well.
Speaker 1 (14:47):
Yeah, that's a really good point, susan.
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 themehere for today.
What does it say to the personwho's experiencing pain after
surgery?
Say they've had I don't knowwhatever, it doesn't matter.
(15:08):
Say they've had mastectomy orsomething, cause I know cancer.
You probably have a lot ofexperience, I know you have a
lot of experience working inthese populations and say
they've got significant scarringafter the surgery.
Well, what does it say to thatperson when they come in and say
they're therapists who's verywell meaning and, like you said,
probably compassionate,understanding but they say, yeah
(15:30):
, you know, you've got the scartissue here.
If we can mobilize this andbreak this down, then that'll
help with your courting orthat'll help with your shoulder
range motion and say the persongets these treatments and they
get a series of treatments andthere's nothing there and
nothing happens.
It doesn't work.
Then what's the person leftwith?
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 peopleare paying out of pocket and
cancer doesn't choose accordingto socioeconomic status.
So for some people seeking helpduring or after their cancer
treatment can actually be quitean economic, quite a financial
burden on them.
And so if you don't actuallydeliver on what you say you're
(16:13):
going to deliver, or yourtreatment doesn't produce the
results that you say it's goingto produce, it can have an even
broader impact on somebody wherethey think, oh, but I've put a
few hundred dollars into comingto see you several times and I
can't really afford this, andthen obviously disappointed
because they're not getting theresults that they have been
(16:34):
promised.
So I think we have to becareful.
Speaking of mastectomy, thereare common side effects to the
cancer treatment that a lot ofpeople experience and I'm often
honest and say this is notreally well understood.
For example, courting thosevisible, palpable lines that
(17:02):
appear in and out of the axilla,down the arm, sometimes down
the trunk.
That is not well medicallyunderstood.
We don't really know what'sgoing on physiologically.
It was really striking to me.
One of my patients told me thatshe had been talking with her
surgeon about having a revisionsurgery, which is quite common.
We're just little things areaddressed.
(17:22):
And when she was talking aboutpossibly having a revision
surgery, she said to the surgeonwell, can you cut the cords as
well?
And the surgeon said we can'tactually see the courting.
So when they open up somebody'sbody, they don't see anything.
That looks any different withsomebody who has courting than
in somebody who doesn't havecourting.
(17:43):
Courting is not actually athing like a new anatomical
structure or a change in theanatomy of that person that is
visible to the surgeon's eyes.
That was really striking to me.
Having said that, though, whileI can't explain what's
happening when somebodyexperiences courting and equally
(18:03):
I can't explain why manualtherapy can often help with the
courting.
Very often not always, but veryoften we do see an improvement
in the person's courting as aresult of the manual therapy and
as a result of passive movementand active movement that we
suggest that the patient use inbetween appointments, engage
(18:27):
with in between appointments.
It probably does have somethingto do with scar tissue, because
it is always the result ofsurgery.
It always comes after surgery.
You don't see it in somebodywho hasn't had surgery.
It's associated with lymph noderemoval, and the lymph nodes
are removed from the axilla.
(18:48):
That is where usually thecourting is, but sometimes it
can be on the trunk.
For example, if somebody's hada mastectomy and a breast
reconstruction, sometimes youcan see and feel courting
running down the front of thetrunk from the inferior aspect
of the breast.
So it does seem to be related tosurgery but, as I said, I can't
(19:09):
say with any certainty that Ican explain what it is that's
happening inside their body andI'm quite clear about that and
people seem to accept that.
Actually I've never hadsomebody express frustration or
anger that the medical communitycan't explain to them what it
is that's happening.
I think perhaps it's evenbetter if we're honest and just
say we don't really understandthis, we don't really know
(19:29):
what's going on.
Why don't we try this?
We know that in a lot of peoplewhen we do this kind of manual
therapy and blah, blah, blah,blah.
Why don't we try it and see ifwe 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'tmake any claims and we can try
this.
And you know what my clinicalexperience, which is part of
evidence face practice, is.
Your clinical experience saysthis helps to some people.
We can just leave it at thatright Rather than making
promises, and you know everytime we make these kinds of,
(20:02):
have these types ofconversations, almost always get
feedback from somebody who'slike, well, I've never once
heard somebody ever say that.
I'm like, okay, well, maybe youhaven't, I don't know, but it
doesn't mean it's not true.
It doesn't mean people don'tbelieve in say these things.
And was it an absence of nothearing?
That doesn't mean it's not true.
(20:24):
Yeah, I think one thing I readas we were preparing for this.
I read a paper on axillary websyndrome.
According, I think I didn'tknow that it was actually called
axillary web syndrome, but Ilearned something which is great
and they were saying that theythought, and it was again.
It was kind of like this iswhat we think it might be, and
(20:45):
this was a research paperwritten in the last probably six
or seven years.
I'll try, if I find it.
I'll try and remember to put itin the show notes, so if I can
find it again.
But to paraphrase, theybasically said that after
surgery with the removal oflymph nodes, they think that it
might be doing due to increasedinflammatory products within the
lymphatic system, whichbasically caused the swelling of
(21:06):
the lymph vessels.
Speaker 2 (21:08):
I have heard that too , that some people think that it
might have to do with thelymphatic vessels.
I also was very surprised tohear a very experienced,
well-regarded therapist say thatit was neural tissue.
That sort of gets involved inan inflammatory response and the
(21:31):
creation of scar tissue.
I don't think that that's true.
I think that if it were neuraltissue, 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 isnerves.
I think it is more likely thelymphatic vessels.
Speaker 1 (21:55):
I would tend to agree that that lymphatic vessel
sounds like the less wrongunderstanding the neural stuff.
Yeah, you're spot on there, youwould see.
Probably you should see sometype 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 someof these papers which we
discussed in the Facebook liveand just kind of just bring some
of the information of what theysaid in them.
And the first one is called therole of massage and scar
management.
So this is probably one of theonly ones I could find that
(22:30):
actually talked about massage,doing massage and scar.
It's from 2012 and waspublished in the American
Society for DermatologicalSurgery.
Dermatological Surgery it's ahard word to say for me,
apparently and some things thatwe look at in this here is the
questions we want to answer, andthat's why we look at the
research is does scar tissueplay a role in pain?
(22:52):
That's the one thing we want tolook at.
Another thing I think we shouldtry and answer is can scar
tissue be changed?
We kind of talked about italready Can't really change scar
tissue Once it's been formed.
There is some evidence thatsays you might be able to impact
it, but maybe it might notalways be positively in the
early stages.
And the other thing, too, Ithink is really important for us
(23:14):
to understand is does scartissue need to be altered to
return to function Like doesscar tissue actually need to
change?
Right?
And so when we look at theresearch so this one here and
then so to answer the first oneabout pain we would say does
scar tissue play a role in pain?
It does, because any type ofprotocol, surgery or tissue
damage, there's gonna be damageto the axons, there's gonna be
(23:38):
damage to neurons which cancreate an increased nociceptive
firing.
So, yeah, we could say thatmakes sense.
But just to look at some of thequotes from this paper, we're
not gonna go into too muchdetail.
But it says this it sayspossible negative aspects of
this therapy.
So massage therapy include thisis a very bold statement
(23:59):
wasting the patient's time.
If massage is not anefficacious treatment, which is
important to think what we justsaid but people being told that
there might, maybe we can dosomething that we can't.
So we have to be honest, right?
Because otherwise it is justtaking your money and that's not
really informed consent.
I don't think it said there'salso could be irritation from
(24:20):
friction.
And it says too that earlymassage should be avoided, in
light of evidence thatmechanical pressure during early
phases of wound healingpromoted hypertrophic scar
formation in a mouse model.
And that's the thing I think weneed to be really mindful of
when we look at theextrapolating scar tissue
(24:43):
research and then saying this isapplicable to humans, Cause
it's most of us have just doneon animals and we can't just say
that it's like if we seesomething 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 Iwould say, and it's something
like this one you say, well, toomuch pressure in and around the
(25:06):
wound early on actuallyincreases more scar tissue
formation, Even though it wouldhave to ask that should be
something we should be mindfulof, that we don't want to
facilitate.
Speaker 2 (25:17):
Yes.
But there I have to ask they'reusing the term massage therapy
very broadly and I'd like tothink that any massage therapy
would have the common sense notto do really deep, aggressive,
vigorous, shearing type massagetechniques around a surgical
(25:38):
site early in the healing stages.
That if any work is gonna bedone around the surgical site it
would be light pressure, itwould be gentle.
You absolutely don't want todisrupt the healing that has to
take place not just on thesurface of the skin that we can
see the surgical incision, butall of the healing that's taking
place underneath the skin, inthe tissue.
(26:01):
I think it's.
I always like to think thesurgical incision that we can
see is just the doorway into thebody and remember that a whole
lot of tissue and we might betalking about only a few
centimeters or we might betalking about a much larger
measurable area, but that theincision is small compared to
(26:23):
the area within the body, thesurgical field underneath the
skin that we can't see.
But to go back to my originalpoint, I think we also need to
think what do they mean?
Does the research paperdescribe the massage that was
employed, the type of techniques, the pressure, the amount of
(26:45):
movement within the tissue thatwas incurred through the massage
techniques.
The duration of the massageobviously, if it's on animals,
then you can't really getfeedback about how comfortable
it is and use that as some kindof 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 kindof take this information that we
look at on the role of scartissue and massage or just the
physical management of scartissue in general, is because
when they use the word massage,like what does that mean?
Like it hasn't been qualified atall right, like you made some
great points there.
So it's like okay, so it saysthat we shouldn't probably use
(27:26):
it because this might result inmore scar formation.
But it doesn't say like doesthat mean?
Like could you put your handsover it and just kind of just
like hold the skin a little bitmaybe 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 paperhere it says that, you know,
(27:48):
through endogenous opioidpeptides and neurotransmitters,
we know the massage can help inpain reduction.
That's great, but I think thatit's In order to really say what
massage can do for scar tissue,I think we need to have
research that is a little morespecific.
Speaker 2 (28:09):
I agree, you make a great point there.
Well, as you said, there's beenvery little research into
massage therapy and scar tissue.
In my VODER training, of course, we did talk about utilizing
manual lymph drainagepost-surgically, but manual
lymph drainage by definition isa light pressure, superficial,
(28:31):
low velocity technique.
I wondered when you read thequotation out and they talked
about avoiding massage therapybecause it might create
hypertrophic scarringpost-surgically in the early
acute stages or the subacutestages.
I wondered if they werethinking of the more vigorous
frictions and, as I said, I hopethat no massage therapist would
(28:53):
do that on somebody early inthe 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 thewhat do we do with people acute
injuries, post-surgical, forexample or say it's a muscle,
tear, ligament where there'sgoing to be scarring, that's
going to be formed, but we can'tsee it.
If it's a tissue internal orinternal, but I guess it's
(29:22):
internal, I'm sure why not Belowthe skin that we can't see.
If there's a tissue injurythere and for sure we know that
there's going to be aninflammatory 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 increasingmore information.
(29:43):
And when we look at some of theother research here this one
other paper called PhysicalManagement of Scar Tissue with
Systematic Review and MetaAnalysis from 2020, we look at
like when you, if you put morestrain and load into tissue that
is acutely healing, it canactually result in more fibrosis
Because you're disrupting thehealing process, potentially
(30:07):
like tissue stretch.
You know, gentle range ofmotion stuff, which is in our
scuba practice, probably not.
But I think the one thing thatwe that we probably see more of
in our profession and I'llcorrect me if my thoughts are or
might be off here, but what wedo see is we see these people,
these longstanding painsyndromes, people that suffer
(30:30):
with, say, chronic low back painor shoulder or neck pain or hip
pain, whatever you choose yourbody part.
Those people are often told thatthey are full of adhesions or
it's because of a scar, becauseof an injury they had.
You know, oh, you have low backpain.
Well, it's because you, you,you, you, you strain your
hamstring, you know playing, youknow running track or whatever,
and that's that scar tissue ispulling on your low back and
(30:54):
that's creating this wholeseries of, you know,
biomechanical dysfunctions, soto speak, and then all we need
to do is we need to break downthe scar tissue.
So some people are subjected tosome seriously aggressive stuff
to try and break down scartissue.
That is like in a muscle orperceived to be in a muscle, and
we know there's no evidence forthat, but that is something
(31:14):
that people are subjected to allthe time.
Have you seen that a lot inyour practice too, susan?
Speaker 2 (31:19):
I haven't seen that a lot.
I do have people who come to mespecifically to have the scar
tissue worked on, because theyhave also heard that narrative
and they think that that'ssomething that massage therapy
can can offer.
And it can sometimes be hardtalking about being honest.
It can sometimes be hard tocounter somebody's expectations
(31:41):
If they've come with a specificthing and then either they're
disappointed because they thinkthe problem is scar tissue, they
think massage therapy is goingto get rid of the scar tissue
and they think then they won'thave any problems anymore, or
they think, well, you just don'tknow what you're talking about,
because this other therapisttold me that you can break down
scar tissue.
(32:01):
So I'm going to go back to theseven massage therapist and, of
course, everybody can make theirown choices.
Speaker 1 (32:07):
Yeah, and that's a thing too, that's just your good
point you brought up is becauseif we are the person that's
telling a different narrative ora different story than what the
person has been told by otherwell-meaning health care
providers or something they'vemaybe 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'thelp you.
(32:27):
But if you, if you, if you kindof dismantle that, that belief,
and you know, I would say, dowe need to change those beliefs?
Maybe only if they're negativeand an impact in behavior Do we
want to maybe have aconversation about it.
We should ever try and forcethose chains.
But if someone's like you needto break down my scar tissue,
that's the only thing I need,and you're like well, I can work
(32:49):
on your hamstring, I can workon this body part, but I can't
change that scar tissue, butmaybe we can do some stuff to
make it feel better.
If they think you're crazy andbecause you're saying something
different everybody else, Ithink it can make a lot of us
uneasy because we're worriedabout losing that client, we
want to please them and thatbecomes a, that becomes a
(33:13):
delicate balancing act, I feelwhere 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 agood trusting relationship
before you start to challengesomebody's beliefs too deeply.
So to come right out of thegate, challenging somebody's
beliefs is not going to beproductive in the long run.
I think, though, another thingto mention in this discussion is
that believing that a problemis only because of scar tissue
(33:47):
or only because of one thing israther myopic.
As we talked about earlier,there are so many things that
are going on in somebody'sexperience of pain and
dysfunction, and so, as you said, why don't we talk about some
other things that might help youfeel better and that brings in
that makes the conversationwider where we can talk about?
(34:08):
So, if somebody has an injurythen and they're experiencing
pain, maybe there's somesecondary muscle tension that is
a normal reaction toexperiencing pain, and so maybe
we can, we can help relax someof those muscles.
We can help calm yoursympathetic nervous system.
Maybe it's sort of in aheightened state of guarding and
(34:29):
protection because of the painor because of a history of
injury in that area, and maybe,if we can calm your sympathetic
nervous system, you'll be lesssensitive to pain.
If you're feeling less pain,you might find that you can,
that the muscles are a littlebit softer and more relaxed, you
might find that you can move alittle bit better and that your
function improves.
That there's.
There are these other thingsthat sort of surround the
(34:51):
central issue in someone's mindthat they might not be aware of,
and there can be a cascadeeffect.
If we can, if we can interactwith something, with one part of
this person's overallexperience, then there can be a
follow, in effect, to the otherthings that are happening at the
same time, and so we can engageour clients in a conversation
(35:11):
in that way that that hopefullyhelps enlighten them to the many
other issues, or the multifactorial to draw on a buzzword
the many things that are thatare 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 thecomplexity of the multi
factorial and yeah, it's, it's aword that gets thrown around a
lot, but it's, it's true and the, the simplistic approach of you
know, you have pain becausecartoon, you just break that
down and you'll feel better is Ithink 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
(35:52):
know, we know.
I think what we can say is, ifsomeone has Pain around a scar,
we can say, ok, it hurts becausethere's some type of activation
of the, the no receptors inthis area and that's
contributing to creating thesenoxious stimuli, which is part
of your pain.
But you know, do we do we needto?
When it was air quotes, eventhose kind of podcasts, and I
(36:12):
can see it and you know, do weneed 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 thesensation in that area.
And when we look at the researchand and you know this I'm going
to make I'm going to read aquote here from this other paper
, the physical management ofscar tissue paper.
It says that a meta analysisshows that physical scar
(36:33):
management has a significantpositive effect to influence
pain, pigmentation, pliability,puritis, surface area and scar
thickness, compared with controlor no treatment.
Unfortunately, massage on itsown is not shown to be very
effective.
It should be used as part of anoverall treatment plan so we
(36:54):
can have an influence on pain,we can help with the,
potentially with the overallpresentation of the scar.
But that's only one, it's onlyone piece right.
Another thing that one of thispaper I think it's this paper
when the other one said is thatthat the silicone strips are
(37:15):
just as effective as massage andcheaper.
So you know, it's not just amassage and that's, you know.
The evidence I think is quitestrong in saying that a lot of
the things that we believe arejust 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 toalmost immediately start doing
some gentle massage, some gentlemanipulation of the tissue
Remember, people are going to be, they're going to have bandages
(37:58):
and wound care over thesurgical incision for, you know,
possibly a couple of weeks butto gently, gently start moving
the tissue.
And of course they'reencouraged to get up and start
moving around again.
Nobody's told to lie perfectlystill and all of this
contributes to a good healing ofthe surgical field, I think,
(38:21):
because it can help maintaingood circulation.
Obviously there's going to bepost-surgical inflammation
that's part of the healingprocess and that needs to be
there.
But you don't want to haveexcessive swelling because that
can cause some problems initself.
And I think moving around helpsthe body just keep the fluid
moving in and out and in and outand sort of control excessive
(38:44):
fluid buildup.
I think something that we don'ttalk about enough, and this is
my speculation.
I doubt very much there's anyresearch on this, but in my
experience I think another thingthat the touch provides,
whether it's the patienttouching the surgical site or a
(39:08):
therapist touching the surgicalsite, the surgical field, the
area around is it helps thepatient integrate how their body
has been changed into theirsense, their overall sense of
themself.
So obviously there might besome numbness following the
surgery, so they're not going tohave full sensation but
hopefully will come backgradually.
(39:29):
Sometimes it doesn't come backfully.
It's common after mastectomyfor women not to have feeling on
their chest, particularly witha breast reconstruction, an
autologous breast reconstruction.
But I think psychologically aswell, they've gone through a lot
of trauma with the wholepsychology around the disease of
(39:53):
cancer, the physiologicaltrauma of the surgery and their
body has been changed and theirsense of their body and how it
represents themself, theirfemininity, their sexuality
possibly not always, but I thinkthat because we are on a
continuum, we're not twoseparate spheres of physiology
(40:16):
in one sphere andpsycho-emotional experience in
the different sphere.
We are in a continuum and Ithink that incorporating some
kind and gentle and sensitiveand intelligent touch helps
integrate all of these differentaspects into someone's overall
sense of themself and I can'tstress enough how important I
(40:40):
think that is for someone'slong-term well-being.
It's not healthy to go throughlife feeling that a part of your
body is diseased or off limitsor shameful because of how it
looks, or you know, damaged orugly or scary.
(41:03):
We have to have overall a senseof living in our bodies and
living well in our bodies andhaving a good relationship with
our bodies.
Speaker 1 (41:16):
So powerful.
What you just said there and ifwe look at so bring in some
research to what you said spoton is the, that sense of
ownership and that sense of Ithink the word is it
somatoprecious organization.
I think it is a term that theyuse in in the one paper on the
(41:39):
science of touch, I think iswhat it's called.
They talk about the touch.
Basically bring that sense ofownership and that awareness of
like your body part and helpingto like, recognize it as part of
you again.
Somebody can tell me if I'mwrong.
I can find me to say thatcorrectly and appropriately.
But anyway, what you said thereis so true and it's really
important as part of the wholehealing or recovery process.
Speaker 2 (42:01):
It is and, eric, you've just reminded me.
Several years ago, when I wasdoing research for a paper that
I wrote, I came across somehowthat the somewhere I found the
old English word for healing,which is Halen.
H, a, e, l A N.
(42:22):
I think the old English wordfor healing, halen, meant not
just to cure but to make wholeagain, and I have always loved
that because I think itreinforces that what we are
doing as manual therapists ishelping people become whole
again, and how absolutelyimportant that is in their
(42:47):
healing process and in theirrecovery.
Wow.
On a different note, one thingI'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 sopart of their body is
surgically removed, does thehomunculus change and does the
(43:14):
manual therapy that we provideand the sensation that the
person feels in response to ourmanual therapy, does that help
the humunculus adapt to thechanged body?
What kind of sensory input isthe brain receiving from this
post-surgical body?
I have no idea.
(43:37):
I've never looked into theresearch.
Speaker 1 (43:39):
Yeah, that's a good point.
I don't know how it stands upto newer research but I know as
last time at Ramos Chondron inthe late 90s did a bunch of
research on phantom pain andchanges in the homunculus and
(44:01):
they made some.
I know some of the early painscience.
I don't know early, but painscience stuff around that time,
the early 2000s I think, evenexplain pain and their first two
editions they may have talkedabout that kind of
reorganization.
I don't know if it's, if thatstill stands up.
I don't know if that's ever, ifthat was just a hypothesis and
(44:24):
then it's never improved, or ifthere's actually evidence to
support.
I'm not really sure.
Speaker 2 (44:30):
That's a good question.
I think I have heard recentlythat the humunculus doesn't
reorganize itself after a limbamputation.
For example, there's a recentpaper that was just published
last year, I think, 2023 oncommon shoulder impairments
following mastectomy and, to mysurprise, they included phantom
(44:54):
pain as one of the commonexperiences that women might
experience following amastectomy.
So the same thing a part of thebody is amputated.
I've never heard of this before.
I've never encountered anybodywho who experiences this.
Interestingly also, they notedthat the number of people
(45:14):
experiencing phantom pain aftermastectomy has been diminishing
over recent years, which theyattributed 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 thatmakes me wonder if phantom pain
was a bigger topic of discussionjust in the zeitgeist, say 20
years ago then.
Did women following amastectomy, were they somehow
(45:48):
primed to feel phantom pain orwhat they thought was phantom
pain and what they mightdescribe as phantom pain?
More so than now where, as Isaid, I've never heard somebody
even suggest that this would besomething that would happen.
Speaker 1 (46:05):
Yeah, yeah, yeah, that's a good point.
And I think when we look atsome of that, a lot of the
research like the earlier painresearch, the stuff that was
really kind of you know I jumpedheadfirst into a lot of it.
I'll admit that and I'm sure Iknow hopefully I'm not the only
one, I'm sure I'm not there's alot of priming that's done in
(46:27):
that type of research.
Oh, do you feel this, does thishurt more?
Do you feel like, oh, does itfeel like that limb should be
there, like you're kind ofasking a very loaded question.
So people often kind of theycan be primed to responding in a
way that might be favorable tothe examiner.
(46:50):
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 sayto people that are listening is
if you want to read more aboutscar tissue and the role of
manual therapy, if you just gointo scholargoogleca orcom if
(47:18):
you're not in Canada and you goand you look for understanding
and approach to treatment ofscars and adhesions by Susan
Chappelle.
She's a massage therapist basedhere in BC and she's got a book
chapter.
It's free and you can justdownload it or just click
there's a website for it and shetalks all about scars and
(47:38):
adhesions and kind of goes into.
You know, what do we know?
What do we not know?
For those of you that don't knowSusan Chappelle, she's the one
that did a paper well over adecade ago on doing mobilization
and little massage on ratsafter they'd had their abdomens
cut open and her stuff has oftenbeen used to support the role
(48:03):
of visceral massage and scarmassage and her research doesn't
find that even in this bookchapter she says that's not what
it says, but it's often again,there's that kind of use and
abuse of the information tosupport a narrative that people
want.
You know, just before we leavejust a couple little quotes I
(48:24):
wanted to read from this, whichI thought kind of fits in this
whole idea of, like you know,scar massage just being
something that I think is madebigger than it really should be.
She says, as a perfection,manual therapists have long held
the belief that localrestrictions and tissue
movements can result in moreglobal dysfunction.
There's little support for thisconcept.
That's something we see all thetime.
(48:45):
Right, oh, you've got thisinjury over here and that's
going to cause this pain wayover here.
It's a belief.
Again, there's no research.
She does also say that thetissue that has been mobilized
early was much more prone tore-injury.
Oh, that's so interesting.
But that goes back to what wesaid earlier too is like how
much mobilization, how much weneed people to move.
(49:07):
But I guess again it's thatthere's probably that sliding
scale of what is too much or not.
One thing she says too.
She said procedures used toreduce the burden of adhesions
so they don't go to adhesions ofthings that are occurring, like
they're talking about, in theabdomen, usually after surgery,
(49:28):
not like the ISTM and grass inadhesions where every little
bump thing is supposed to besomething you can break down
with a tool.
That's not how adhesions isused in the medical community.
It's something that we have inthe manual therapy community.
We've kind of taken on.
She says that anyway,procedures used to reduce the
burden of adhesions and clinicalpractice have not shown
clinical effectiveness and havelacked scientific validity.
Goes on to say in her chapterthat the only way that you can
(49:51):
actually break down an internaladhesion 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 interferedwith the formation of a
post-operative adhesions butfailed to significantly reduce
already formed adhesions afterone week.
So doing something might, itsays, interferes with formation
of post-operative adhesions.
(50:19):
We don't necessarily know ifthat's good or bad.
Did you delay the healingprocess?
Did you make the adhesions thatmaybe they didn't heal as
strong?
We don't know.
So we have to be very carefulof extrapolating that research
to the bigger world of scarringadhesion massage, because her
(50:42):
paper doesn't say that itdoesn't support the law of the
claims that people make from it.
Lastly, as I want to read thisquote here and I think this is
great, it says for the most partpeople seek care for manual
therapists for pain relief.
When a link is made between atreatment and pathology, such as
scar or an adhesion, it may bepresumed that there is also some
connection between thepathology and the symptoms, and
(51:04):
that's neurology.
Every injury also involvesnerves of some caliber.
Kidney surgery involves cuttingmany intercostal nerve branches
and even a small cut in theskin damages a few axons.
These damaged axons remainalive and immediately start to
regenerate.
For the most part, nervesregrow appropriately, but in
(51:25):
many cases they do not and canlead to persistent pain.
I think we just take this backto what we do as massages in
manual therapists is that wehelp people that hurt.
We help them hopefullyexperience less pain.
If our focus is on trying tochange scar tissue, then we are
probably removing that focus on.
(51:45):
What matters most is the personand their experience of pain.
If we can just flip that scripta little bit to focus more on
the person and not on the tissuelike you said earlier, it's
multifactorial and we'llprobably have better.
The person that comes to seekour care will probably have
better, more meaningful outcomes.
Speaker 2 (52:06):
Completely.
I completely believe that In mycourse, my online course on
oncology massage, I invited someof my patients to contribute
reflections for me to share withthe learners.
I asked them what did they wantRMTs to know about working with
(52:30):
people with cancer?
One of my patients sent mesomething that said I'm
paraphrasing, obviously, but shesaid although I had surgery in
one part of my body, the rest ofmy body felt beat up and
bruised and sore.
I really appreciated that.
You asked what I wanted tofocus on today.
That's such a good reminderthat we are dealing with a whole
(52:52):
person.
We're not just dealing with onesite of injury or surgery or
dysfunction.
We need to look at the wholeperson and how they're feeling
and what they're hoping to getout of their massage interaction
with us.
We should ask them we can'tpresume to know on their behalf
what it is that they need thatday.
Speaker 1 (53:14):
I think that's perfect way to end this, Susan.
Excellent Thank you for beinghere, until next time.
Speaker 2 (53:21):
Thanks so much, Eric.
As always, it was a pleasurechatting with you and my brain
is stirring and moving with allkinds 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 socialmedia.
You can follow me on Instagramor Facebook by searching at
ericprivicermt.
Now please head over to mywebsite, ericprivicecom, to see
a full listing of all my livecourses, webinars and
self-directed course options.
If you'd like to connect withSusan, she can be reached via
(53:52):
her website, which iswwwsusanshiptinrmtcom.
Until next time, thanks forlistening.
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