Massage for Medically Complex People

Pain in the sub-acute stages of inflammation is less widespread than acute pain. There are two stages of sub-acute inflammation;

1. fibroblastic repair (Early sub-acute) phase
2. maturation-remodeling (Late sub-acute) phase

Late Sub-acute injuries feel even less red, hot, swollen and painful than in the Early Sub-acute phase.
During this phase, the scar begins to modify into its mature form with steady increases in tensile strength and a decrease in capillaries. Additional collagen fibers are laid down and realigned according to tensions placed on the tissues by normal pressure and movement  At this stage, massage and joint mobilization can align scars to allow for optimal range of motion and functionality. Although scar tissue gradually approximates normal appearance and function, typically the tensile strength of a scar is less than 80% of a functional tissue. Besides vascularity, it lacks elastin, and appears stiff compared to normal, noninjured tissue.  After approximately 3, weeks a firm, strong, nonvascular scar exists but the entire maturation phase can take several years to complete.

The goals of Late Sub -acute inflammation are:

• to fill the area and make the scar more durable
• more collagen – to anchor scars to stable tissue and to remodel the scar according to stresses and pulls

Physiology – In order to reinforce the damaged area with collagen, the following physiological processes happen:

• Scar remodelling –  collagen cross links are being laid down to further fill in the scaffolding established in the Early subacute phase
• Wound contraction – scars try to anchor to the most stable tissue (usually bone) Myofibroblasts make contractile fibers that attach to bone or other fascial planes and pull the healing tissue down and together.  Thus, less tissue is needed to fill the space, but the result is less mobility

Therefore, Pain treatment in the Late Sub -Acute SOI  focuses on continuing to decrease any remaining edema and spasm, and working with the scar as it forms to decrease fascial adhesions, and to decrease its magnitude, so as to maintain optimal range of motion and strength of the muscles.

The Symptom Picture is :

• even more decreased SHARP signs (Swelling, Heat, A loss of function, Redness and Pain)
• There is some possible remaining edema
• If bruising occurred, it is now turning yellow or brownish.
• Pain is more pinpoint and only felt with over pressure
• There may be muscle weakness

Treatment Plan  works to decrease the symptoms. Therefore

• Continue to Decrease remaining edema and spasm
• Maintain available ROM (range of motion) and strength
• Decrease fascial adhesions and scar tissue

Treatment follows directly from the Plan, So in addition to treatments for Acute and Early Subacute SOI, add in:

• MFR (myofascial release) and XFF (cross fiber friction) are best to reorient scar fibers in the direction of muscles, for optimal function and strength
• Continue to Use PIR (post isometric relaxation) and RI (reciprocal inhibition) to maintain AROM and PROM without putting excessive stress on developing scar tissue
• Continue to Address trigger points that refer into the area
• Continue to massaging the opposite side to decrease the stress on compensatory structures, and proximal to the injury to push circulation back to the heart, speeding the removal of toxins from the injury

Self Care Recommendations follow the Plan too, so good recommendations include

• Continue to Educate the client on the importance of not overdoing/ re-injuring the area, as they are feeling
• Do encourage Pain-free movement of the area
• PIR/RI exercises that you have identified on the table and practiced with client to strengthen the area, progressing to gentle active stretches that do not cause pain
• Tell clients to warm up the area with Heat prior to exercise and to ward away any areas of acute inflammation that have been flared by exercise with cool (or ice) applications after

Hydrotherapy : Mild contrast, beginning and ending with Heat

Contraindications include:

• Do not overwork the area with massage or stretch (if it is painful, it is too much)
• If client experiences Pain or Spasm with massage or stretches or exercise, reduce or eliminate the process causing the Pain
• recognize that Pain Medications can affect the patient’s perceptions of pressure that may be causing more damage, so try to get clients to space these out and take the next dose after, rather than right before a session