massage therapy journal

keeping you in touch.

  

Q&A
with Annie Morien, PhD, PA-C,LMT, Nancy Keeney Smith, NCTMB &
Diane Garrison, BA, LMT

1. When working with a burn survivor client, how should therapists approach the scars?

First, approach the person, not the scar. If you understand the person, the emotional and physical being, you will have greater understanding of the scars.

Second, go slowly. People with burns have emotional scars, in addition to physical scars. The psychological component can be entrenched for years, producing behaviors such as hiding scars, avoiding touch and inability to discuss their scars. Also, go slowly with making physical contact with your client. Touching scars may be painful.

Third, listen to your clients. They must direct the massage. Encourage them to express their feelings and goals for each session.

Fourth, be patient. Some sessions may consist of very little massage and more conversation. Both you and the client can explore the depth and meaning of the scar—each client is different. Again, sessions should be tailored to the individual, not the scar.

2. How is burn scar tissue different than regular tissue, in terms of pliability, feeling, sensation, etc.?

We’ve all touched non-burned tissue—typically it’s soft, elastic, smooth in texture and has a nice pink color. Burn scars “feel” different—the temperature, color, texture and elasticity is different. These characteristics vary depending on the type of burn (chemical, thermal, etc.), depth of the scar (surface versus deeper loss of muscle and fat), location of scar (contracture over a joint) and age of the client (older people take longer to heal). New scars feel different from old scars.

3. What is the difference between working with new scars versus older scars?

In general, new scars go through a cellular maturation process for approximately 6 to 18 months, perhaps up

to two years. New scars tend to be extremely sensitive, itchy (pruritic) and have greater pigmentation (a purple or blue hue). When touching a new scar, you may feel extreme coolness or warmth. Scars can feel “stiff.” This varies depending on the thickness of the graft, depth of the scar, whether underlying fascia and muscle was destroyed, etc.

Older scars tend to be less flexible, less pigmented and less itchy, but this is variable also. The sensitivity can range from complete lack of feeling to extremely sensitive. A colleague of mine describes old scars as “feeling like a rubber tire under [her] fingers.” The scars tend to feel thick and non-elastic, but again, this varies depending on the graft, thickness and underlying tissue.

Edema (swelling) can occur with new or old scars. The tissue feels puffy or fluid-filled under the scar, or downstream from the scar tissue. Also, new and old scars vary in dryness. Clients who apply moisturizers daily to their scars make our job easier. A soft lubricated scar is easier to work than a dry scar. And finally, new or old scars may change within the massage session—the texture may soften, the color changes and you feel more warmth in the scar.

4. Which skin characteristics do massage therapists need to be most aware of ?

I wish it were that simple. All characteristics must be monitored closely during each massage session: sensation, elasticity, pruritis, vascularity, contractures and edema.

5. What strokes or massage techniques work especially well with scar tissue? Which ones should be avoided?

To my knowledge, no empirical research has determined the type of massage or stroke that is most appropriate for burn scars. Published studies have used various strokes and techniques on burn patients, such as friction, light massage or others.

The type of massage stroke used is dependent upon the scar. In general, lymphatic drainage assists in areas of swelling and fluid accumulation (edema), passive range of motion and stretching helps contractures and taut tissue, and light massage increases circulation, decreases pruritis, and may alter sensation. Energy work is appropriate at any stage of wound healing, provided the client can handle it. I have heard of some massage therapists using deeper work (myofacial release); however I advise caution—only very skilled and experienced massage therapists should use this technique on burn scars.

Avoid touching open wounds or skin due to increased risk of infection. Also, be aware of your client’s level of sensation. Massage can cause pain or increased sensation in scars. There is a potential to damage the skin and produce additional skin defects if the therapist is overzealous in the treatment.

Keep in mind that the characteristics of the scar (depth, amount of tissue involved, location, level of  sensation) as well as the age of the scar indicate the type of massage that is appropriate. And sometimes, just letting the client talk about the scar is the best therapy.

6. What are some other conditions that may produce scar tissue?

Any time you open the skin you will produce a scar. One example is trauma to the skin. We see this on a daily basis when clients point to their childhood (or adult) injuries such as skinned knees and elbows. Also, surgical cuts produce scars. For example, mastectomies, open-heart operations and abdominal incisions produce scars.

7. Is there a different approach to other types of (non-burn) scar tissue?

Yes and no. Yes—each scar is unique, whether it is a surgical scar or burn scar. The therapist must tailor the session according to the client’s goals and the type of scar. No—damage to the skin is damage to the skin. The client will have some degree of altered sensation, circulation and function, regardless of the type of scar.

8. What are the differences in approach, if any, when working with children who have scar tissue?

Young children are extremely sensitive. While in the hospital, they learn quickly to associate a white coat or hospital scrubs with pain. Therefore, when approaching a child with healed burn scars, go slowly. Let them lead you. Approach their feet, rather than their head. Massage non-burned skin rather than scars. Get them to laugh, be relaxed. Once a child trusts you, you can start working with his or her scars.

Adults are also sensitive, but have the maturity to rationalize their feelings. However, I advise the same: go slowly, listen, be patient. Remember, adults can have years of psychological scarring.

9. What kind of training do therapists need to work with burn survivors, or those with scar tissue?

Volunteer and work with experienced massage therapists who are currently working with clients with scars. Touching a variety of scars gives you experience with the tissue and increases your comfort level in working with this type of population. Also, get training from certified workshops. Nancy Keeney Smith at the Florida School of Massage offers a continuing education workshop on massage and burns. Rena Margulis in New Jersey teaches acupressure for scars in her workshops. And finally, align yourself with people who work with scars: surgeons, nurses, etc. They can give you good information and possibly send you clients.

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