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manual therapy and the types of therapeutic loading that will achieve the desired changes. 8 What is Changing? Fibers and Fluid Simply put, when treating any type of mature (fibrotic) scar or adhesion, manual therapy methods are directed at facilitating collagen (fiber) and ground substance (fluid) changes. Evidence-supported manual therapy-mediated collagen fiber changes include improved hydration and organization; disruption of pathological crosslinks; and promoting favorable features, such as crimp, suppleness, and smoothness. Fluid environment changes include shifts in volume and/or viscosity within and around tissue fibers, including loose connective tissue serving a sliding function. The mechanisms by which various methods facilitate fiber and fluid changes involve interrelated responses within multiple systems. 9 A Scar, is a Scar, is a Scar A significant realization we came to when writing the book is that a scar is a scar. From the manual therapy perspective, whether the scar or adhesion is related to a new knee (arthroplasty), oncology treatment (e.g., mastectomy, radiation induced fibrosis), or an accidental injury, scar management protocols are essentially the same. That said, the severity and stage of injury, the anatomy involved, and the person themselves warrant consideration. Client-Centered Care Getting all science-y is my jam. Reading research has changed the way I use my hands— supporting my evolution over 30 years of practice. Equally, my jam is client-centered care: the harmonious marriage of what my hands can facilitate while being present with the human on my treatment table. A dear friend and massage therapy colleague Pamela Fitch exemplifies the perspective of myself and my Traumatic Scar Tissue Management coauthor Nancy Keeney-Smith: "We are not just treating scars; we are treating people with scars." 58 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 2 0 A Contemporary Framework of Massage Therapy Outcomes Affective Touch Interpersonal touch mediates the release of oxytocin and endogenous opioids, which can result in reduced reactivity to stressors and improved affect. Endogenous Pain Modulation Input from somatosensory nerves can influence neuroimmune processes correlated with experience of pain. Contextual Factors A positive therapeutic encounter is tied to clinical outcomes; the magnitude of a response is influenced by mood, expectation, and conditioning. Mechanical Factors Applied forces induce a response that helps diminish intraneural edema and expedite clearance of noxious by-products of inflammation. Concept from Richard Lebert

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