A CASE STUDY
SET TALK
By Don McCann, MA, LMT, LMHC
MA3267 MH705 MM3717
Weekly I receive inquiries from massage therapists and potential clients asking for help with the pain they are experiencing from surgical scar tissue and adhesions. So, this column will present a case study of one of my clients detailing the treatment process with explanations of why it was successful. I hope this will answer some of your questions and give you some helpful suggestions for treating surgical adhesions and scar tissue. The name has been changed to protect confidentiality.
Sarah, a 63-year-old disabled office worker, was referred to me by her daughter. Sara’s problems started 20 years ago when she donated a kidney for her daughter. The surgical incision was half way around her body. Six months after the removal of the kidney Sara had an additional surgery for the removal of surgical adhesions that had resulted from the initial surgery. These adhesions had produced significant pain and prevented her from returning to work. The second surgery was followed by a third surgery four months later, again for surgical adhesions. Sara still had not been able to return to work and her pain had worsened.
By the time she was referred to me she had undergone a total of seven surgeries for adhesions and was still unable to work. This disability had lasted approximately 20 years and by the time she came to me her overall vitality and health reflected the 20 years of medication and pain, and she appeared older than her 63 years.
Upon evaluation she was severely bent over on her right side in an acute collapse of the core distortion pattern and could not rotate her upper body to the right. She was not able to fully straighten up due to the restrictions deep in her abdomen from the surgical adhesions. When I palpated the surgical adhesions and scar tissue, I found them to be fibrous, thick and hypersensitive from the surface tissues in the rectus abdominus, obliques, and latissimus dorsi all the way through the soft muscle of the intestines, and into the psoas and quadratus lumborum of the deep intrinsic stabilizing muscles. In addition, she had significant pain in the lower lumbar region of the spine, hip, neck and shoulders as a result of the structural collapse. She was also depressed due to the fact that she had not been able to work or take part in activities that she enjoyed.
Sara was a challenge. It was obvious that surgery was not the answer for removing scar tissue – in fact, all the surgeries compounded the amount of adhesion and scar tissue which resulted in the degeneration of her structure. Pain medication had only created additional problems, and obviously had not allowed her to resume a normal life. What was amazing was that she still had hope and ambition and dreams for her future.
To effectively treat Sara it was necessary to determine long term, intermediate and specific session goals. The long term goal was simple – a return to normal life activities pain free. The intermediate goals would be the steps to accomplish the long term goal. These included a reduction of pain, a balancing of the structure, lengthening and normalizing the scar tissue and surgical adhesions, and an increased range of motion. Each of these would be accomplished through a series of treatment sessions with Sara. To accomplish the intermediate goals, there needed to be specific goals for each session. I discussed this with Sara, and let her know that I would be applying different techniques in the process of accomplishing the ultimate goal of total rehabilitation. I also explained that, since she had been in this condition for so long, it was going to take some time, but that we would measure her progress by the small successes along the way which would accomplish the intermediate goals leading to the long term goal – her rehabilitation.
The goals for the initial treatment sessions for Sara were to lessen the sensation in and around the surgical adhesions and scar tissue, to release the build up of fluid and toxins associated with the pain and inflammation, clear the trigger points and soften the surface layers of the scar tissue which would prepare the areas for the deeper treatments as therapy progressed.
These initial sessions also supported the intermediate goal of balancing the structure. The strokes were applied in specific sequences and directions that would facilitate the release of the structural distortion to initiate the structural balancing. These initial strokes were lighter milking strokes which were applied very slowly to allow more change in the tissue with less threat and less sensation for a client who is in severe pain.
After three sessions my palpation of the scar tissue was less painful for Sara, and the surface of the tissue was less fibrous and rigid. I was now able to feel the deeper fibrous edges of the surgical adhesions that went through and around the soft tissue muscle of the intestines, and into and around the deep stabilizer muscles of the spine – the psoas and quadratus lumborum. The trigger points in the surface tissue of the rectus abdominus, the obliques and latissimus dorsi were cleared, and the fluid, toxins and ischemia that had built up in these tissues were greatly reduced. Thus, Sara was now ready for deeper work into the surgical adhesions and fibrous tissue.
In the next phase of treatment one of the goals was to unwind the myofascial holding patterns that had been pulling her structure further into structural collapse. To further enhance the effectiveness of this stage of the work, it was necessary to work beyond the actual surgical adhesions and release the myofascial holding pattern that supported the structural collapse of her spine and the full structure. This included balancing the pelvis to address the pain that was associated with her hip and low back. Thus, the session goals for this phase included unwinding the myofascial holding pattern of the structural collapse, not only in the adhesions of the scar tissue, but also in the restrictions throughout the rest of her structure. This would also help reduce the pain in her hip and lower back due to the structural collapse. We were also going to start releasing some of the hardened fibrous adhesions and their compression on nerve tissue which was one of the significant causes of her pain. Another goal in this phase was to increase her range of motion as the fascia and scar tissue restrictions were released and mobilized.
This was a very important phase of Sara’s treatment, and it was necessary to accomplish those goals for her to continue on her journey to rehabilitation. They were accomplished over seven treatment sessions. Each session achieved more unwinding of the myofascial holding pattern, a softening of the surgical adhesions in the smooth muscle organs allowing deeper work, and releasing the myofascial holding pattern of the low back that was found in other muscles associated with the pelvis. All of this also increased her range of motion.
After the seven sessions Sara was standing straighter with a significant reduction of the structural collapse. She was more mobile and was able to participate more freely in her daily life activities. Her energy was better, and her spirits were high because she was finally feeling and seeing the improvement, was able be more active, was having more fun, and feeling more satisfaction in her accomplishments. The pain was reduced both from the release of the direct pressure of the surgical adhesions on nerves, and from the release of the structural collapse which had caused the low back pain. She was also experiencing less pain in her neck and shoulders due to the fact that she was no longer bent over, and her neck and shoulders were now more supported by a straighter spine.
Sara was now ready for the release of the deep surgical adhesions that surrounded the psoas and quadratus lumborum. These deep adhesions were responsible for maintaining the remaining collapse of the structure, and were still compressing some of the nerves close to the lumbar spine creating some radiating pain. In addition, there were deep fibers of adhesions in the other muscles of the pelvis that had supported the structural collapse that had not released with directed myofascial unwinding. All of these deeper tightened fibers needed to be release with deeper more individualized and specific strokes to release the core of the structural collapse. If we view these adhesions like an onion, we were now ready to work on the core after having taken off the surface and intermediate levels.
The goals here were going to be specific release of the fibrous tension of the surgical adhesions, release of the shortened fibers and adhesions in the psoas and quadratus lumborum to release nerve entrapment and allow structural balance, release other fibers in pelvis that supported the structural collapse, and increase range of motion back to normal function. After seven more sessions that incorporated the deep individual fiber release to sufficiently lengthen and balance Sara’s structure, take the pressure off the nerve entrapments, and return range of motion to normal ranges, we were able to accomplish the long term goal of pain free living. It was only by setting goals, using them as observable and obtainable measurements which allowed us to track improvements along the way, that we were able to achieve successful resolution of Sara’s acute condition.
The Three-step Approach of first releasing ischemia, fluids and toxins, then applying directed myofascial unwinding strokes, and finally releasing individual fibers allowed me to work with Sara staying within her pain thresholds even during the most acute phase of her rehabilitation. Using this three-step approach, I was able to finally release the deepest of the surgical adhesions, and ultimately, release her structure in to balance. Sara has gone back to work, and is finally happily participating in activities that had given her such enjoyment before the kidney donation.