Abnormal Scars as a Cause of Myofascial Pain

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Abnormal Scars as a Cause of Myofascial Pain by Heller, Marc, Dynamic

Chiropractic magazine

I have long believed that the dominant chiropractic view of subluxation is much

too

limited. Most of us limit the scope of our manipulative treatment to spinal

joints.

Once you move away from strictly high-velocity thrusts, enormous areas of the

body

become available to assess and correct via the adjustment. The soft tissues,

including all of the tissues that derive from the mesodermal embryological

layer, can

be clinically significant targets for barrier assessment and correction.

In this light, I was excited to read Karel Lewit and Sarka Olsanska's article,

" Clinical

Importance of Active Scars: Abnormal Scars as a Cause of Myofascial Pain, " in

the

July/August 2004 issue of our own JMPT. I have known and used these ideas for a

long time, but having a description and set of case studies published in a

prominent

peer-reviewed journal is a big step forward. I will review the article for you

and urge

you to read the full text yourself. I appreciate JMPT, but occasionally find it

a bit

dry; this particular article is juicy and full of wonderfully useful clinical

ideas.

Lewit begins by reviewing the history of neural therapy, which began in the

1930s

with injections of Novocain into scar tissue for pain that would be described

today as

myofascial pain. The effect of these injections was so rapid that they described

the

therapy with the German word sekundenphenoman, meaning " effect within a

second. " Lewit traces the evolution of this concept, noting that dry needling,

like

acupuncture, could produce the same effect, and mentioning manual soft-tissue

manipulation as another tool to release scars.

Lewit reviews the importance of the soft tissues: " Every movement of the trunk

or

extremities is accompanied by a corresponding movement (stretch and/or shift) of

the soft tissues surrounding muscles, joints, and bones. This is also true of

visceral

organs. " He notes that impaired mobility of the soft tissues, especially fascia,

can

greatly impair motor function, contributing to trigger points and joint

restrictions.

Lewit then goes on to outline diagnosis and treatment: " The moment the first

resistance is met, the barrier is reached ... For treatment, we engage the

barrier, and

after a short latency, release is obtained. " He says that in the abdomen,

restriction

can occur in several layers, and in several different barrier directions. This

description is very similar to my own version of Engage, Listen, Follow (ELF),

which

I learned from the French osteopaths - particularly Barral. The keys include:

1. Palpate to the soft barrier, not the hard end-feel.

2. Engage the barrier, which means keeping this gentle pressure against the

barrier

and waiting for a tissue response.

3. Allow the tissue to release, an almost passive process. I want to emphasize

that

if you want to release scar tissue in the abdomen, this gentle, respectful

approach to

the tissues is critical for optimal results. I have always hesitated to teach

visceral

manipulation in my writing, as I believe it is best taught in a hands-on manner,

and

needs a deep understanding of the softness of the approach, which is often

lacking

in the chiropractic paradigm.

Lewit talks about two major types of scars. One is near the skeletal structures,

where the scar is close to bone. The second is in the abdomen. He notes that the

internal aspect of the abdominal scar may be far away from the surface incision.

The surface incision is chosen for cosmetic and muscle-sparing reasons, while

the

internal scars need to be searched for. This can be even more of a problem with

recent surgical advances, particularly those carried out through small

arthroscopic

ports.

Lewit uses a palpation for barriers approach in the abdomen, emphasizing the

assessment of the various layers, from the skin down through the various

muscular

and fascial layers. He gives a fascinating protocol (which I heartily agree

with) for

assessing the clinical significance and relevancy of the scar. One must first

assess

the neuromusculoskeletal system in a typical fashion, finding and noting joint

restrictions and myofascial restrictions, without giving treatment. Then, find

and

treat the relevant scar, and recheck the joint and myofascial restrictions.

Lewit

states: " With some exceptions, everything will have reverted to normal. " The

effect

has to be lasting and the patient should still be improved upon exam, two weeks

later. Lewit describes his full protocol for correcting these scar tissue

lesions,

including a series of cases.

This protocol is a beautiful description of a priority-oriented approach. When

you

correct the primary subluxation, the secondary restrictions will often melt on

their

own. Yes, I am defining these scars as subluxations; neurologically significant

soft-

tissue restrictions. If releasing the scar releases the joint restriction in the

spine, it

behooves us to assess and treat in this manner.

One of my remaining questions is, what really happens to the scar when we

" release " it? When I started studying visceral manipulation, I had the

opportunity to

" glove up " and observe an open abdominal operation involving a patient who had

experienced multiple previous abdominal operations. When I saw the abdominal

adhesions and felt them with my own hands, it became obvious that my low-force

manipulation would not completely eliminate these very physical, strong

adhesions.

Yet, in my years of doing visceral manipulation, I have seen profound effects on

multiple conditions. What are we doing to the scar? My suspicion is that part of

the

effect is mechanical, changing mobility to some degree. I believe that another,

probably more significant effect is neurological. According to Feinberg,

" A

more reasonable description is that the introduction of therapeutic manual force

causes a reset of neurological circuits and releases the noxious stimulation to

which

the body was adapting. "

Lewit notes that resistance felt in deep tissues such as the abdominal cavity

can be

due to pathology or to an active scar: " If, after engaging the barrier we obtain

release

after a short latency, the resistance 'melting away' pressure exerted by the

therapist

is no longer painful, and most symptoms have cleared up, we can conclude that an

active scar is the cause. If there is pathology, no such effect is obtained and

the

resistance remains unaltered. We have repeatedly sent patients to surgeons

(gynecologists) after this type of examination. "

I'd like to add that Barrai and Roth both teach that there are many other

sources of

significant visceral restrictions. These would include trauma, whereby the

heavy,

fluid-filled organs can be moved suddenly. Infections can leave adhesions in the

GI

and respiratory tract. Other causes include repetitive daily motions, esophageal

reflux, and the effect of emotional stress on the GI sphincters. All can lead to

correctable restrictions in the chest and abdomen.

I'll quote Lewit again on his impression of the significance of this approach

for our

difficult patients: " If active scars are left untreated, they constitute a

perpetuating

factor which may frustrate all of our therapeutic efforts. "

I hope this article sparks you to continue to learn, and to pay attention to a

broad

variety of soft-tissue restrictions and their effects on your patients. The

international

world of manual medicine has many contributions that can add to our therapeutic

effectiveness.