PART 5 OUT 5: This article discusses scars and adhesions. Most massage research is conducted on post-surgical and burn scars, but massage may also reduce wound scars. Please check previous blogs for bacterial infections, fungal infections, viral infections, and inflammatory infections.
A scar is a mark left on skin after the body repairs wounds caused by surgery, accidents, or diseases. Location of the scar, skin type, and age affect scar formation. Older skin tends to leave less visible scars whereas younger skin tends to over-heal, resulting in larger and thicker scars. Scars can affect mobility and may extend into deeper layers causing adhesions. Adhesions are bands of scar tissue that bind together two or more tissue layers not normally bound. Adhesions may appear as thin sheets similar to plastic wrap, or as thick fibrotic sheets. Adhesions can impair mobility and are more common in surgical scars.
Wound healing, scar formation, and scar maturation occurs in three sequential and overlapping stages.
- Inflammation. This stage is the body’s response to tissue damage and lasts for approximately 2 weeks. During this stage, the scar is swollen, warm, red, and often painful.
- Proliferation. During this stage, the body begins to repair skin by depositing collagen in the wound site; this stage lasts up to 8 weeks. Immature scars are characterized by the 3 R’s: Red, Raised and R
- Remodeling. In this stage, the scar begins to mature and become soft and flat as excess collagen dissipates. The remodeling stage, also called the maturation phase, can last from 12 to 18 months. Mature scars are stronger, but less pliable, compared with normal skin. Mature scars also lack pigment, glands, and hair follicles found in normal skin.
Abnormal scars are elevated and do not flatten like normal scars. Hypertrophic, keloid, and contracture scars are examples of abnormal scars. It is estimated 10% of scars are abnormal.
- Hypertrophic scars. These scars are elevated, but do not spread beyond the boundaries of the original wound. Hypertrophic scars are more common than keloid or contracture scars.
- Keloid scars. Keloids are elevated scars that extend beyond the boundaries of the original wound. Keloids are more common in darker skin types, specifically people of African or Asian descent.
- Contracture scars. These scars are caused by skin tightening or contracting, and are more common in burn scars, especially second or third degree burns.
Scars are the result of collagen production which occurs during the healing process. Scars may occur from surgical procedures, trauma from accidents, burns, injection sites including vaccines, piercing, tattooing, and scarification, scratching, or diseases such as acne, chickenpox, or shingles. Because tissue healing is influenced by genetics, the tendency to develop abnormal scars is hereditary.
Massage and Scars: Scar massage is thought to work by accelerating collagen maturation, influencing scar remodeling by disrupting fibrotic tissue, improving pliability, and reorienting collagen fibers (Shin et al, 2012).
Scar tissue massage. Avoid massage over scars until the wound or incision is clean and dry and well into the remodeling (maturation) phase. Use deep friction and skin-rolling techniques near and directly over the scar with or without lubricant. Massage tissues in several directions (superior, inferior, medial, lateral, clockwise, anticlockwise) because scar tissue is arranged haphazardly. Begin with light pressure and progress to deeper pressure. Inquire about pressure sensitivity and adjust it below the client’s pain tolerance. Discontinue scar tissue massage and refer the client to his or her healthcare provider if massage causes the scar bleed, or if the scar is redder, warmer, or more painful upon subsequent sessions (MCC, 2008). Teach the client how to massage his or her own scars if located in easily accessible areas. Ask the client to follow the same precautions licensed practitioners follow.
Research: Six 45-minute massage sessions administered twice a week for 3 weeks reduced postoperative scar tenderness and pain, facilitated relaxation of shoulder muscles, and improved mood in a case report (Wilk et al, 2015). A 10-minute friction massage over hypertrophic scars combined with pressure garments decreased itching among pediatric patients compared to pressure garments alone (Patiño et al, 1999). Friction massage did not have any positive effects on scar tissue vascularity, pliability, or height. Five sessions of massage combined with therapeutic exercise administered over 3-weeks, followed by 5 additional sessions of therapeutic exercise over 4-weeks substantially decreased pain, improved function, and facilitated a full return to previous levels of physical training in a female solider with postoperative adhesions (Wong et al, 2015). A literature review found some evidence supporting the use of scar massage, and it appears massage is more effective for postsurgical scars compared with scars caused by trauma or burns (Shin et al, 2012).
Burns: Burns are tissue damage from heat, radiation including sun overexposure, chemicals, or electrical contact. Tissue damage depth ranges from superficial to deep, which is used as criteria for burn classification.
- First-degree burn. Also called a superficial partial thickness burn, a first-degree burn damages only the epidermis. An example of a first-degree burn is mild sunburn.
- Second-degree burn. Also called a deep partial-thickness burn, a second-degree burn is deeper and more severe than first-degree burns and involves both the epidermis and upper layers of the dermis. Hair follicles and sweat glands are spared and remain functional. After the burn heals, a scar may remain.
- Third-degree burn. Also called a full-thickness burn, a third-degree burn destroys the epidermis, dermis, hair follicles, and associated glands and possibly extends into the subcutaneous tissue and underlying soft tissue.
- Fourth-degree burn. A fourth-degree burn is a full-thickness burn which extends to the muscle or bone.
Burns can be caused by heat (including fire, hot liquid, steam, and hot objects including metal or glass), extreme cold, radiation (including sunlight exposure, tanning beds, and radiation therapy), chemicals (strong acids, drain openers, toilet bowl cleaners, and paint thinner), electricity, or friction.
In first-degree burns the affected area is red, swollen, and painful. These burns typically heal in 3 to 5 days. Symptoms associated with a second-degree burn are swelling, redness, blistering, and pain, which may be severe (these burns are the most painful). Healing time for this type of burn is 2 to 4 weeks. Deep second-degree burns can cause scarring. In third- and fourth-degree burns, skin becomes leathery, white, or blackened and charred but is numb because of damage to nerve endings. Because of injury to local lymphatics, little swelling is seen. These burns may take several months to heal. Contracture scars may occur after second or third degree burns and affect mobility because of the restrictive effect of scar tissue.
Massage and Burns: Burned areas are a local contraindication until they have completely healed. Healing time depends on many factors, such as degree of severity, and ranges from several days to several months. Massage over unburned areas is permitted while affected areas are healing. Once healed, massage and scar mobilization is permissible. Use moderate pressure and include friction and skin rolling petrissage applied in all directions over affected areas. Consider using cocoa butter or a cocoa butter blend as a massage lubricant.
Before massaging the affected area, obtain verbal consent. Some clients with disfiguring burns or scarring may feel self-conscious. If consent is granted, ask the client how sensitive the affected area is and adjust the pressure accordingly. Large burns can be devastating to the client. Provide positive reinforcement, being aware each client will progress through different states of grief during the recovery processes. Massage may help reduce anxiety and depression in this population.
Teach the client how to massage his or her own scars if located in easily accessible areas. Or teach a caregiver a few massage technique to be used on the person with burn scars. Ask them to follow the same precautions licensed practitioners follow.
Research: A 15-minute massage using moderate pressure applied to unburned areas of body before wound dressing changes reduced distress among hospitalized young children. Children in the control group showed signs of increased facial grimacing, torso movements, crying, leg movements, and reaching out. Nurses reported greater ease in completing the dressing change task in the massage group (Hernandez-Reif et al, 2001). A 20-minute Swedish massage administered to adults once a day to unburned areas of the body for 1 week just before débridement reduced anxiety and cortisol levels as short-term effects; and decreased depression, anger, and pain as long-term effects (Field et al, 1998). Twenty-minutes of Swedish massage, favorite music, or combinations of both interventions administered daily for 3 consecutive days reduced pain and anxiety, and increased relaxation among burn patients (Najafi Ghezeljeh et al, 2017).
Children who received a 20- to 25-minute daily massage applied to their post-burn scars for 5 consecutive days experienced improved mood and increased range of motion (Morien et al, 2008). Techniques included effleurage, petrissage and skin rolling, and friction using cocoa butter as a lubricant. A 30-minute massage using cocoa butter administered twice a week for 5 weeks reduced itching, pain, and anxiety and improved mood in burn victims. Moderate pressure was used to apply circular, transverse, and vertical movements. Skin and scar tissue were then compressed, lifted, the rolled in all directions. Long gliding movements ended the massage (Field et al, 2000). A 30-minute massage administered once a week for 3 months reduced itching and depression, and improved skin status (Roh et al, 2007). In addition, the primary caregiver massaged the burn survivor at home daily for 10 minutes.
A 30-minute massage applied 3 times a week reduced itching, pain, and improved scar characteristics in hypertrophic burn scars. Scar improvements included reductions in tissue thickness, pigmentation, redness, and increases in tissue elasticity (Cho et al, 2014). Nedelec and LaSalle (2018) noted reductions of itching associated with massage may be due to the application of emollients rather than the massage itself.
Ault et al (2018) conducted a systematic review and noted scar massage may be effective to decrease scar height, vascularity, pain, itching, and depression among individuals with hypertrophic burn scars, and that evidence-based guidelines are needed.
Articles and Journals Referenced:
- Cho YS, Jeon JH, Hong A, et al. The effect of burn rehabilitation massage therapy on hypertrophic scar after burn: a randomized controlled trial. Burns. 2014;40(8):1513-1520.
- Field T, et al: Postburn itching pain, and psychological symptoms are reduced with massage therapy, J Burn Care Rehabil 2000 21(3):189–193, 2000.
- Roh YS, Cho H, Oh JO, Yoon CJ. Effects of skin rehabilitation massage therapy on pruritus, skin status, and depression in burn survivors. Taehan Kanho Hakhoe Chi. 2007;37(2):221-226.
- Field T, et al: Burn injuries benefit from massage therapy, J Burn Care Rehabil 19:241–244, 1998.
- Morien A, Garrison D, Smith NK. Range of motion improves after massage in children with burns: a pilot study. J Bodyw Mov Ther. 2008;12(1):67-71.
- Hernandez-Reif M, et al: Children’s distress during burn treatment is reduced by massage therapy, J Burn Care Rehabil 22:191–195, 2001.
- Wilk I, et al: application of tensegrity massage to relive complications after mastectomy: case report, Rehabil Nurs 40(5):294–304, 2015.
- National Pressure Ulcer Advisory Panel: Prevention and treatment of pressure ulcers: quick reference guide, 2014. http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf
- Guy H: Does massage help to prevent pressure ulcers? Nursing Times 107:32–33, 2011. http://www.nursingtimes.net/nursing-practice/specialisms/wound-care/does-massage-help-to-prevent-pressure-ulcers/5033735.article
- Shahin ES, Dassen T, Halfens RJ: Pressure ulcer prevention in intensive care patients: guidelines and practice, J Eval Clin Pract 15(2):370–374, 2009.
Dr. Susan Salvo is a massage therapist, author, educator, researcher, explorer, and perpetual student. To learn more, check out the “About Susan” tab. You can contact Susan at email@example.com.