A Small Scale Study to Establish if an Abdominal Scar is a Factor in Lower Back Pain
Jackie Earl
A dissertation submitted in partial fulfilment of the requirements of Jing Advanced Massage Training for the Professional Diploma in Advanced Clinical
Massage and Sports Massage
July, 2015
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“I certify that this work has not been accepted in substance for any degree, and is not concurrently being submitted for any degree other than that of the Diploma in Advanced Clinical Massage and Sports Massage being studied at Jing Advanced Massage Training. I also declare that this work is the result of my own investigations except where otherwise identified by references and that I have not plagiarised the work of others”.
Jackie Earl: ___________________________________
Date:
Acknowledgments
To my family, friends, clients, classmates and all at Jing
THANK YOU for your unfailing patience, belief, love, humour and support.
The following quote has resonated with me throughout this journey
Our deepest fear is not that we are inadequate.
Our deepest fear is that we are powerful beyond measure.
It is our light, not our darkness that most frightens us.
We ask ourselves, who am I to be brilliant, gorgeous, talented and fabulous?
Actually who are you not to be?
Marianne Williamson
Jackie Earl: ___________________________________
Date:
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ABSTRACT
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TABLE OF CONTENTS
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TABLES
Table 1 Illustration of mode scores of low back pain felt in active ROMS before and after treatment.
Table 2 Illustration of mode scores of restrictions felt in the abdominal scar in active ROMS before and after each treatment.
(Include page nos.)
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FIGURES
Figure 1 Mean results of Quality of Life Questionnaire Page …
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ABBREVIATIONS
Ext - extension
Flex - flexion
LBP - lower back pain
Lat.Flex.L - lateral flexion to the left
Lat.Flex.R - lateral flexion to the right
MFR - myofascial release
ROM - range of motion
Rot. L - rotation to the left
Rot. R - rotation to the right
SFL - superficial front line
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INTRODUCTION
A large and growing number of women in the UK have an abdominal scar following a
caesarean section when giving birth, in 2011-12 C-sections accounted for 25% of total UK
births and increased to 26.2% in 2013-14 (National Childbirth Trust 2015). Hysterectomy
scar in the abdominal area is also common in middle aged women, 55,000 hysterectomies are
carried out in the UK every year and 1.2 million globally (The Hysterectomy Association
2015). This procedure is carried out to ease many gynaecological complaints including
painful and heavy bleeding, endometriosis, fibroids and prolapse of the uterus.
Nikolajsen et al. (2003) concluded that in at least 5.9% of participants, chronic pain was a
significant problem 1 year later after a C-section.
Brandsborg et al. (2007) found that 66.3% of women experienced pain problems elsewhere in
their body (not related to pelvic region or operation) and 83.9% of the pain sites mentioned
were head, neck, shoulders and lower back following an hysterectomy.
In the Oxford dictionary a scar is described as “a mark left on the skin or within body tissue
where a wound, burn or sore has not healed completely and fibrous tissue has developed”.
Scars are commonly seen on the body following injury or surgery, their formation is our
primary method of restoring tissue integrity and is a very effective survival tool (Fourie
2014).
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The body heals deep wounds in an organised and predictable process (Myers 2012) which
consists of three overlapping phases:
1. Inflammation-to control blood loss and fend off bacteria invasion, usually lasts 48
hours to 6 days.
2. Proliferative phase- where new tissue is built to fill the gap left by the damaged tissue
thereby closing the wound, occurs day 5-21.
3. Maturation and remodelling- from day 21 up to 2 years, scar tissue reorganised from
haphazard to laying along lines of tissue stress. Tensile strength and mechanical
behaviour of scar continues to improve (Lederman 1997).
Ideally a scar should close the wound to establish tissue stability and then blend with
surrounding tissue allowing for pre-injury/pre-surgery function. Unfortunately even after the
final stage, scar tissue is less elastic than the original tissue and has approximately only 80%
strength (Myers 2012).
A scar is usually thicker, denser and paler than other tissue, mainly composed of collagen
which is laid down in a sporadic fashion .This may lead to underlying structures adhering
together and improper movement of tissue, thus affecting function commonly leading to
muscle weakness, decreased range of motion (ROM) and pain (McKay 2014). Kobesova et
al. (2007) agree that an active scar in the soft tissue can interfere with the elasticity and
shifting movement of the various layers of the body.
French plastic surgeon Dr. Jean-Claude Guimberteau (2005) created a video of scars and
adhesions observed during his surgeries. This shows below the surface of a scar
demonstrating that the dermis has become fixed, hard and not as mobile as surrounding tissue
indicating less than perfect function.
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It was suggested by Kobesova et al. (2007) that a scar can restrict back flexion which the
patient feels as lower back pain and that this is a common occurrence. Their case study shows
how a patient with persistent low back pain experienced relief after massage of a 20 year old
appendectomy scar.
Tom Myers, author of Anatomy Trains has a slightly different view, he states his theory of
continuous tissue that runs down the front of our body from head to toe forming the
Superficial Front Line (SFL) made up of predominately fast twitch muscles. A common
response to trauma i.e. surgery is the “startle response”, a closing down and contraction of
this frontline, a chronic contraction of this line creates many postural pain conditions e.g. low
back pain ( Myers 2009). He also quotes Feldenkrais as saying “All negative emotion is
expressed as flexion”, showing there could be a link with having an untreated abdominal scar
causing low back pain by the body spending too much time in flexion.
Valouchova & Lewit (2008) agrees with Kobesova et al. (2007) in that back pain is very
frequent in patients with scars in the abdominal region. The researchers state that among the
clinical symptoms caused by these scars, back pain is very frequent. Valouchova & Lewit
(2008) in their study of 13 patients with abdominal scars following surgery, all experienced a
decrease in back pain immediately after massage. Valouchova & Lewit (2008) also agree
with Lewit & Olanska (2004) that impaired mobility of soft tissue can seriously affect the
motor system.
Lewit & Olanska (2004) suggest that scars interfere with movement in the body as they are
found in soft tissue which usually moves and stretches freely with joints and bones, thereby
restricting this freedom and causing pain.
Results stated that in 36 out of 51 cases, massage of the scar proved very relevant with
striking results even after the first treatment, they concluded that the treatment of scars was
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relevant, that soft tissue manipulation may be the most effective type of treatment and that if
left untreated, scars were a cause of therapeutic failure.
Travell and Simons (1998) agree but suggest the cause could be that trigger points can often
develop within scar tissue. They define a trigger point as “a hyperirritable locus within a taut
band of skeletal tissue and/or its associated fascia”. Additionally trigger points are known to
have referral pain patterns. For the rectus abdominal muscle (cut during C-section and
hysterectomy) the referral pattern is pain felt horizontally along the lower back.
Lewit (2010) believes that skin plays an important role in our proprioceptive and tactile
senses, giving us information about where our body is in space. Scars on the outside of the
body can distort our proprioception and potentially create dysfunctions of both muscles and
joints as they pass through several layers of soft tissue.
Although just based on anecdotal evidence of treating patients with scars, Physical Therapist
John F. Barnes believes that scar tissue can put an enormous strain on the fascial system
exerting a “drag” within the whole body not just at the site of injury, so pain can be felt
anywhere “scars you see on the surface are just the tip of the iceberg” (Barnes 2009).
Ajimsha et al. (2013) agree, they hypothesized that fascial restrictions (of which a scar can be
classed as) in one area of the body cause undue stress in other regions due to fascial
continuity. This may result in stress on structures that are enveloped, divided or supported by
fascia.
Fascia has been described as the soft tissue component of the connective tissue system, it
supports, separates, connects, divides, wraps and gives unity to the body (Huijing &
Langevin 2009). Fascia has been described as the largest system of the body because it
touches all other structures, it has ten times more sensory nerve receptors than muscles and is
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seen as a mechanosensitive signalling system with an integrated function similar to that of the
nervous system (Duncan 2014). It is composed of fibrous collagenous tissue that creates a
tensional force transmission system throughout the body (Schleip et al. 2012). After injury it
has been suggested that fascia could become tighter or denser and this alteration could lead to
body misalignment, poor muscular biomechanics, decreased strength and motor co-ordination
(Day et al. 2009).
Topical steroids and vitamin E cream are commonly used in the treatment of post-operative
scars although no beneficial effect on reducing scar formation has been found (Jenkins et al.
1986) Silicone gel sheeting appears to be useful in prevention of hypertrophic scars and has a
20 year history of satisfactory results (Gold et al. 2001). Other methods include
corticosteroid injections, laser therapy, skin needling and radiotherapy with varying levels of
results.
The use of manual therapy techniques to treat scars can be traced back as far the 1500’s, there
is evidence that a French barber surgeon, Ambroise Pare’ (1510-1590) used massage to
relieve joint stiffness and to promote wound healing after surgery on the battlefields (Fourie).
Massage treatment for scars has been found by patients to anecdotally produce positive
results by releasing restrictions in movement, relieving discomfort, sensitivity, improving the
appearance of the scar and helping with swelling. Despite this there is scarce scientific data
evidence to support the use of scar massage (Shin & Bordeaux 2011).
Myofascial Release (MFR) is a widely used form of massage therapy and has its origins in
Osteopathy. In the 1980s the term was adopted by an American Physical Therapist John F.
Barnes to describe his method of freeing up restrictions in the myofascial system
(Fairweather & Mari 2011). This technique involves using hands to address the tissue barrier
of resistance by feeling for restrictions in any place that may be causing tightness or
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restriction. The pressure is gentle and slow and after three to five minutes a feeling of release
is felt. MFR is used to treat patients with a wide variety of conditions but there is little
research to support it.
This present study investigates whether there is a possible link between an abdominal scar
causing restriction which limits full movement of the lumbar spine leading to lower back
pain.
By applying the research previously discussed, it is hypothesised that treating an abdominal
scar with Myofascial Release (MFR) massage techniques, frees fascial restrictions that are
inhibiting full range of movement (ROM) in the lumbar region thereby relieving lower back
pain.
METHOD
Six adult female participants, who suffered with lower back pain since having an abdominal
scar were recruited for the present study. Participants were recruited from the researchers
own massage therapy client base, four presented with hysterectomy and two with C-section
scars.
Each participant received six MFR massage treatments on their abdominal scar only, once a
week over a period of two months. This technique was chosen as it is consistent with the
“barrier phenomenon” used by Kuruma et al. (2012).
Initially, a full client history was taken to ensure the participants were not presenting with any
contra-indications to massage (appendix 1). All participants were fully informed of the
treatment protocol, any risk involved and ethical clearance was provided by Jing Institute of
Advanced Massage Training (appendix 2).
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A treatment protocol was followed for every session, it began with the completion of a
Quality of Life Questionnaire (appendix 3) an amended form of the Orebro Musculoskeletal
Pain Questionnaire (Linton 2003) asking 6 questions related to everyday activities.
To investigate if active scar tissue restrict back flexion (Kobesova et al. 2007) participants
were furthermore required to perform range of movement (ROM) tests for the lumbar region
first to test for restriction felt in the abdominal scar and secondly to test for lower back pain
(appendix 4).
Hot stones were placed over the abdominal scar area whilst lying supine for 5 minutes to aid
relaxation. During this time gentle head holding craniosacral therapy (CST) techniques were
administered.
MFR techniques were applied to the scar area only, for 30 minutes, the goal being to apply a
stretch over and around the scar into any areas of restriction with the intention of softening
this area and making it more pliable. Treatment started with superficial layers then sinking in
to deeper layers as the tissue allows.
The 3 following specific MFR techniques were used:
1.Focussed fascial stretches, to free superficial fascia.
• Using fingers take up all the tissue slack.
• Apply a gentle stretch along the length of the scar.
• Hold, wait for release, follow and stretch again.
• Work along and across scar.
2.Gentle circles, to move the skin over the deep fascia
• Rest fingers next to scar with heal of hand resting on the body.
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• Starting at 6 O’clock position push the skin clockwise in a circle using middle 3
fingers.
• Slowly move the skin towards the scar to engage the tissue barrier in a circular
movement with even pressure and speed.
• Repeat along the line of the scar, repeating several times if necessary.
3.Skin Rolling, to free up restrictions in skin and superficial fascia.
• Pick up skin and superficial fascia between thumb and fingertips.
• Lift the tissue up while maintaining a stretch and roll along the surface in a slow
wave.
• When easing occurs hold the skin roll and pull gently in direction of ease without
rolling.
• Work in all directions over and around scar.
After the massage was complete, a further 5 minutes CST was administered followed by a
repeat of the ROM assessments that were carried out at the beginning. The total treatment
time for each session was one hour.
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RESULTS
Table 1: Illustration of Mode scores of low back pain felt in active ROMS before and after treatments. Zero indicates no increase in pain, 1 a slight increase and 2 a definite increase in pain. In brackets are the number of Participants with the mode value.
Active Movement of lumbar spine
Before Treatment
After Session 1
After Session 2
After Session 3
After Session 4
After Session 5
After Session 6
Extension
2 (3/6)
1 (3/6)
0 (3/6)
0 1 (3/6)
1 (4/6)
0 (4/6)
0 1 (3/6)
Flexion
1 (3/6)
2 (3/6)
0 (3/6)
0 (3/6)
0 (3/6)
0 (4/6)
0 (3/6)
Lat. Flex. Left
1 (3/6)
1 (3/6)
1 (3/6)
0 (3/6)
0 (4/6)
0 1 (3/6)
0 (4/6)
Lat. Flex Right
0 (4/6)
0 (5/6)
1 (4/6)
1 (3/6)
0 (4/6)
0 (3/6)
0 (4/6)
Rotation Left
0 (4/6)
0 (5/6)
0 (4/6)
0 (4/6)
0 (5/6)
0 (6/6)
0 (6/6)
Rotation Right
0 (4/6)
0 (4/6)
1 (4/6)
0 1 (3/6)
0 (4/6)
0 (5/6)
0 (4/6)
Table 1 shows that 3 lumbar ROMS, lateral flexion to the right (Lat.Flex.R), rotation to the
right (Rot.R) and rotation to the left (Rot.L) didn’t cause any pain on average in 4/6
participants before or after the course of treatments.
The other 3 movements did, flexion (Flex.) and lateral flexion to the left (Lat.Flex.L) showed
a slight increase in pain and in extension (Ext.) there was a definite increase in pain at the
start of the course.
After the last treatment all of these movements had shown a decrease in pain, the most
significant being in Ext. where 3/6 had dropped to feeling no increase in pain.
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After 2 treatments the pain levels felt had decreased in both Ext. and Flex. but in Lat.Flex.L
the levels didn’t lower until after session 3.
Table 2: Illustration of Mode scores of restrictions felt in the abdominal scar in active ROMS before and after treatments. Zero indicates no restriction felt, 1 a slight restriction felt and 2 definite restriction felt. In brackets are the number of Participants with the mode value.
Movementof lumbarspine
BeforeTreatment
AfterSession1
AfterSession2
AfterSession3
AfterSession4
AfterSession5
AfterSession6
Extension 1 (3/6)
0(3/6)
0(4/6)
0(4/6)
0(4/6)
0(4/6)
0(4/6)
Flexion
0(6/6)
0(6/6)
0(6/6)
0(6/6)
0(5/6)
0(6/6)
0(6/6)
Lat. Flex.Left
01(3/6)
0(5/6)
0(5/6)
0(5/6)
01(3/6)
0(6/6)
0(6/6)
Lat. FlexRight
0(5/6)
0(4/6)
0(5/6)
0(5/6)
0(4/6)
0(5/6)
0(5/6)
RotationLeft
0(6/6)
0(6/6)
0(5/6)
0(5/6)
0(6/6)
0(5/6)
0(5/6)
RotationRight
0(6/6)
0(6/6)
0(6/6)
0(5/6)
0(6/6)
0(6/6)
0(6/6)
Table 2 shows that there was no change in feelings of restriction felt at the start or after the
last treatment in Flex. Lat.Flex.R. and Rots. R and L.
From these findings it would appear that when carrying out these movements, feelings of
restriction in an abdominal scar was not a problem.
In Ext. and Lat.Flex.L, on average 3/6 felt a slight restriction in their scar at the start and felt
no restriction by the end. The change occurred after the first treatment.
The results in both table 1 and 2 show that Extension was the most painful and restricted
movement. On average at the start 3/6 had a definite increase in pain and felt a slight
restriction in scar, by the end this had dropped to 3/6 experiencing slight increase in pain, 3/6
no increase and 4/6 felt no restriction.
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After the first treatment no scar restriction was felt during extension for the rest of the course,
lower back pain felt also reduced.
Figure 1 Mean results of Quality Of Life Questionnaire. The black bars illustrate the score before the study and the grey bars illustrate the score after the study.
The mean results showed there was an overall improvement of 1.9 in the participants’ ability
to carry out an activity without pain by the end of the study.
0
1
2
3
4
5
6
7
8
9
10
Icandomywork
Icanexercise Icandoordinaryhouseholdchores
IcanlookaQermyfamily
IcanenjoymyleisureSme
Icansleepatnight
Abilityto
parScipateinacSvitywith
outp
ain
(0=UnabletodoacSvity
due
topain)
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DISCUSSION
The purpose of this study was to investigate if there was a possible link between an
abdominal scar which causes ROM restriction, of the lumbar spine and the occurrence of
LBP.
The results of this study show that of all the movements tested, on average extension caused
the most increase in pain at the start of the treatments, and had decreased to slight increase
and no increase (table 1) by the end.
These findings concur with Myers (2009) theory that following trauma i.e. surgery there is a
closing down of SFL and LBP is felt by spending too much time in flexion thereby causing
most discomfort in extension .Valouchova & Lewit (2008) also agree, their study states scars
on the abdomen increase resistance to stretch, thus restricting back bending leading to LBP.
Kobesova et al. (2007) disagree, their study states that an abdominal scar can restrict flexion
and that LBP is felt due to being constantly upright and unable to flex. The present study
demonstrates that participants did experience a slight increase in pain upon flexion at the
start, decreasing to no pain at the end (table 1).
Lewit & Olanska (2004) showed that scars interfere with movement in the body causing pain
and restriction, massage of the scars proved highly relevant with notable results in 36/51
cases even after the first treatment. The results of this study were similar but on a smaller
scale, as the scar restriction eased, after the first treatment, so did the LBP (in extension).
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The present study did not find that feelings of restriction in the scar was a huge problem,
slight restriction was felt only in extension and lateral flexion to the left at the start, dropping
to no restriction after the first treatment (table 2).
The restriction could be in the underlying fascia, when there is a fascial injury (scar) there is
fascial dysfunction, the symptom will arise either in the area altered or in a distal area
(Bordini et.al 2014). This corresponds with Barnes’s theory that a scar exerts a drag within
the whole body not just at the site of injury.
The MFR techniques used in this study proved effective and were similar to other studies
working on scars e.g. Kobesova et al. (2007), Lewit & Olanska (2004) and Valouchova &
Lewit (2008).
In their review on the effectiveness of MFR, Ajimska et al. (2013) found anecdotal evidence
that shows great promise for MFR as a treatment for various conditions, however research to
support this is lacking. Ajimska et al. (2013) concluded that MFR is emerging as a strategy
with tremendous potential. Shah et al (2012) agree, in their study of MFR, they suggest that it
is a very effective, gentle and safe hands on method of soft tissue mobilisation to release
fascial restrictions and restore tissue function.
Kidd (2009) however, believes that MFR is not evidence based medicine as it relies on
practitioner – client interaction, it cannot be a neutral treatment therefore subjectivity of the
interaction cannot be removed when trying to determine outcome. He believes that much of
the effect of MFR relies on the skill of the practitioner in their ability to sense changes in
tissue.
Lewit & Liebenson (1993) agree, their analysis of palpation shows it combines two types of
sensation, that of touch and of motion i.e. proprioception and in addition it causes interaction
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with client resulting in feedback which is a further complication. In summary they believe
that palpation is not very reliable and that there is an urgent need for research which could
provide basic scientific credibility to manipulative techniques.
The present study could be adapted to include MFR as the variable to be measured by having
a control group receiving no MFR, to gather much needed research.
Massage therapy in general remains grossly under-researched, in particular, clinical trials
need to test the effectiveness of defined types of massage for defined conditions. Lack of
research expertise and funds are the two main reasons for the lack of reliable evidence (Ernst
2002).
The human element in the delivery of massage brings up research study issues, despite
similar training each massage therapist develops their own unique method of performing
certain strokes in their own way, dependent on many factors including time of day, mood,
room temperature and interaction with client.
There are also certain intangibles that show the effectiveness of massage, such as the
therapist’s intention, depth of pressure and speed of stroke. These are critical components of
therapy that are difficult to quantify, measure and control therefore if a massage cannot be
precisely duplicated, reliability becomes an issue (Nelson 2013).
The present study solely massaged the abdominal scar, the lower back was not touched so as
there was a reduction in LBP (table 1) this demonstrates that treating an abdominal scar can
reduce LBP.
Further suggestions for these results could be that trigger points were released in the
abdominal muscles when working the scar thereby relieving the referred pain pattern in the
lower back. Heller (2006) considers what happens to a scar when it is “released”, he suggests
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that partly the effect is mechanical i.e. the scar becomes more pliable but more significantly
that the effect is neurological, the therapeutic manual force causes a reset of the neurological
circuit and releases the nociceptive stimulation.
Also, improvements in wellbeing and confidence brought on by the interpersonal relationship
between client and therapist over 6 regular sessions could alter perception of lower back pain.
Scars are a common problem post operatively, in their study on the clinical importance of
active scars Lewit & Olanska (2004) found that the overwhelming majority of scars are due
to an operation i.e. a complication of surgery, yet are completely ignored by surgeons .They
go on to state that untreated, scars are an important cause of therapeutic failure.
Moreover Kobesova et al (2007) require that assessment and treatment of scars should be part
of the routine management of painful conditions of the loco motor system. Their case study
related to a patient who had persistent pain from a 20 year old appendectomy scar that caused
numerous conditions over the years including chronic LBP and had had numerous treatments
and medication. Immediately after a 15 minute MFR type massage treatment his groin and
LBP had disappeared and he was able to straighten up and walk normally.
There are a number of limitations of this study that should be emphasized, firstly the sample
size of six was chosen based on feasibility i.e. time limitations, existing clients that met
criteria, so was an opportunity sample. By using a small sample size there is a risk of
compromising validity and reliability in the findings,” inappropriate, inadequate, or excessive
sample size continue to influence the quality and accuracy of research” (Bartlett, Kotrlik, &
Higgins, 2001). Also, the more representative of the population in general the more results
can be generalised.
A major limitation of this study is the lack of a control or comparison group.
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Another limitation would be that although the sample presented with LBP, according to the
results of the quality of life questionnaire, on average the pain felt at the start didn’t really
affect their daily activities and there was no significant difference after the course of
treatment (figure 1). This would suggest that LBP wasn’t a substantial problem in their life.
Non-specific low back pain is a very common chronic pain disorder affecting 1 in 3 adults in
the UK each year, it is estimated that around 20% will seek help from their GP for the
condition (NICE 2013). In these cases psychological variables are thought to influence the
pain experience including depression, anxiety, sleeplessness, distress and cognitive
functioning (Ajimsha et al.2013). Research has identified the biopsychosocial model to be the
most effective treatment choice for this type of pain and this is the approach used in this
study as massage therapy treats the body, mind and spirit (Suprina 2003).
Other factors to consider would be that two of the participants were on regular pain relief
medication and the others used medication as and when they needed it, this could affect their
answers on the lifestyle questionnaire.
Finally, long term outcomes were not assessed and it is not known whether the improvements
observed at post-treatment can be maintained over a long time.
CONCLUSION
The results from this study demonstrate a possible link between an abdominal scar and LBP.
Results show a decrease in pain felt by 50% of the participants by the end of the treatment,
without having received any massage on their lower back, only on their scar.
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Although these results demonstrate some positive findings results cannot be generalized and a
similar study ideally with a larger sample size and a comparison group can be suggested.
This study has added further evidence concerning the link between scars and pain felt
elsewhere in the body as well as contributing to much needed research on massage therapy
and MFR techniques in particular. So much research on the fascial system is still in its
infancy so it is difficult to say exactly what is taking place and the impact on the body
massage is having, however it is important to remember that as all the body systems work
together so the fascial system is not the only system affected.
If scars were routinely assessed following surgery and if problematic, massage offered as a
quick, effective treatment, this may not only benefit some of the large number of women
suffering after a C-section or hysterectomy but save on long term health care resources. This
highlights the need for well-designed clinical trials that use objective recommendations for or
against the use of manual scar treatments.
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APPENDICES
Appendix 1 - Medical History Form
Appendix 2 - Jing Ethics Form
Appendix 3 - Quality of Life Questionnaire
Appendix 4 - ROM Tests
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APPENDIX 1
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APPENDIX 2
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AAPPENDIX 3
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APPENDIX 4
