Barrett L. Dorko, P.T.

Part I - Technique

          Perhaps nothing reveals as much about a therapists's philosophy of manual care as the way they approach scars.

          I've seen people who ordinarily handle their patients with gentleness and respect suddenly go into some kind of attack mode as the scar looms before them. They seem convinced that only the strongest, most painful pressure will have any hope of defeating this enemy.

          Evidently they think that the rigidity of the skin at this site cannot be reduced with anything less powerful than its own adherence to adjoining tissue. To me, this implies a massive misunderstanding of the materials we're dealing with.

          Let me explain: While reduced mobility of the connective tissue elements within the scarring is a fact, manual pressure on the skin will be dispersed throughout the region, and it will have little if any chance of reaching its target with appropriate force or direction. In addition to this, any threatening or painful pressure will always lead to a rise in sympathetic and muscle tone. This begins in the brain, and it will never be overcome by more pressure from the periphery.

          This dilemma would never be resolved were it not for the nature of the cellular mechanics of sensation and the self- corrective tendency of the body. We know that increased membranous tension in the cell enhances its permeability when deformed, thus increasing sensation and reflexive effect at the site of any scar, as long as the pressure does not also increase sympathetic tone.

          If we follow this reasoning, the best technique of handling at the site of the scar would be that which leads to increased blood flow and a decrease in local muscle tone. Simple contact; the sort of handling that enhances another's sense of already ongoing processes, customarily elicits precisely this reaction and it always begins gently; the therapist landing as if a bird on the ocean.

          Deformation of the skin at a cellular level opens the stretch activated ion channels responsible for the influx of chemicals leading to mechanoreceptor firing and thus sensation and reflexive effect will occur. Although it is a fact that this opening occurs in the tympanic membrane when sound waves vibrate the organ, waving the hands near the skin will not have a similar effect, and anyone employing such a technique has some explaining to do.

          For my part, the fact that increased membranous tension of the cell enhances stretch activated ion channel activity means that the site of scarring is an ideal entryway into the neural network where reflexive reaction is propagated. Ultimately, understanding cellular mechanics reveals that the scar is not a barrier to normal function, but a doorway leading toward deep and profound change.

Part II - Attitude

          To a craftsman, nothing is more important than his knowledge of the materials. When we work with other people we are trying to change something animated that might all at once or in various sequences be resistant, pliable, unaware, sensitive, tender, hard, soft, angry or longing to be touched. Please remember that all of these attributes can be assigned to the therapist or their hands as well. Fortunately, the nature of our presence and touch is at least to some extent under our control, and when we bring our knowledge and acquired skill to the surface of the patient much is said non-verbally that will influence the response.

          If we begin with the attitude that scars are opportunities for respectful entry to an important process, that patient will not be threatened and will not respond with an increase in sympathetic or muscle tone.

          Aside from the obvious anatomic and physiologic reasons to consider scars as opportunities, there is often a more subtle psychological significance present when scars are exposed to our awareness.

          I know of no more powerful way to express this then through a portion of a poem entitled "Scars" by William Stafford.

...They tell
the slant life takes when it turns
and slashes your face as a friend.

Any wound is real. In church
a woman lets the sun find
her cheek, and we see the lesson:
there are years in that book; there are sorrows
a choir can't reach when they sing.

Rows of children lift their faces of promise,
places where the scars will be.

          It seems to me that Stafford has come to understand that scars are never requested or initially welcomed, but that they will inevitably occur. Maturity helps us understand that they contain lessons we dare not ignore and cannot, perhaps should not, share with others. As long as they are handled with acceptance, the learning will remain and, over time, lead to more self-knowledge.

          When the therapist approaches the scar with a similar understanding, this acceptance is transmitted on a non-verbal level. Such resonance may lead to change in profound and long- lasting ways.

          For more on this see "Simple Contact and Distant Change" also on this page of the website.