Therapeutic Techniques – Analyzing Therapeutic Techniques with Current Applied Science

Soft Tissue Massage/Graston/Myofascial Release Treatments

Posted on April 29, 2014April 30, 2014 by Des

There are various modalities of soft tissue augmentation and some are effective for specific things as evidenced by research, and others fail to have sufficient evidence to support the use of the technique. The topics discussed here will include Deep Frictional Massage (DFM), Graston Technique, Myofascial Release, and Soft Tissue Massage.

Deep Frictional Massage:

Deep frictional massage (DFM) is a technique utilizing friction directed transversely across the tissue to break up adhesions, potentially help with collagen alignment to increase range of motion, reduce edema, and essentially function as a healing mechanism, particularly for tendonopathy conditions. There is some evidence to support the efficacy of DFM when used in conjunction with other treatments, but insufficient evidence to support it as a treatment on its own (Joseph et al., 2012).

Bottom Line: The current research combined with anecdotal evidence from practitioners who have experienced positive outcomes is sufficient to support the use of DFM in practice, but the treatment may be most effective when used as an adjunct to other modalities.

Graston Technique:

The Graston technique incorporates the use of six stainless steel instruments to treat various symptoms such as ligament healing after injury. Evidence has shown Graston technique can accelerate ligament healing in the initial stages allowing for earlier rehabilitation and recovery, but that there is no change from controls when looking 12 weeks post treatment. The only major change was an increase in stiffness from Graston treatment, which physiologically is a beneficial thing to improve (Loghmani & Warden, 2009). Graston can also be used as a form of deep frictional massage to ease strain and fatigue on the part of the clinician applying the treatment. The following slide shows some other research findings with regard to the Graston technique. Most of the following research results on the slide were case studies, which are not the best research design when trying to demonstrate effectiveness of a treatment, so the evidence may not be compelling unless reinforced by randomized control trials or similar studies.

Graston technique has also been indicated for treating chronic conditions such as tendinopathies, entrapment syndromes such as carpal tunnel, for breaking up adhesions and scar tissue, for treating ligament pain from MCL/LCL type sprains, and fascial syndromes such as plantar fasciitis, ITB syndrome and chronic compartment syndromes. Graston can also be used for acute conditions in the control of edema, but the technique needs to change to reduce pressure in acute situations.

Bottom Line: The Graston technique is a well-respected technique among practitioners and there is some evidence to show that it can produce desired physiological changes in tissue with the added benefit of less strain on the practitioner to perform the technique.

Myofascial release:

First let’s define what fascia is since people often don’t know. Fascia is the soft tissue component of connective tissue that spans the entire body and provides some structural support. If you were to take out all of the organs, skeleton, muscles, and remove the skin, you would have a whole body outline from head to toe of fascia. This demonstrates the interconnectedness of the whole body and can help us visualize how an injury in the hip could influence mechanics in other parts of the body or how fascia pulling on one side of the body, could affect the other side. Myofascial release has two approaches: one is direct and one is indirect. For the direct technique, the practitioner will use a low force, constant load to the tissues until they feel the tissue release. The release sensation is obvious to a well-practiced clinician and can provide real time feedback to them. The technique is typically held for a short time after the release and then slowly eased off. The picture below is an example of a direct technique.

For the indirect technique, a gentle stretch is added for traction and the force is applied until a barrier is discovered and from there, the pressure allows the tissue to go where it wants to go. The picture below is an example of an indirect technique.

Bottom Line: There is very little research on myofascial release due to the great amount of variability in technique and application, but the treatment makes sense in terms of how it works theoretically and the patient satisfaction is very high, which always counts for something in therapy.

Soft Tissue Massage:

Soft tissue massage is what you most think of as a typical massage. There are many different modalities of massage, but the focus here will be primarily the Swedish type of massage that is seen commonly in sports clinics. Despite how long soft tissue massage has been around, scientists are still not sure what effects, if any, occur physiologically with soft tissue massage. The research that has been done on this therapy does not definitively support the claims that massage can produce physiologically changes at the cellular level. Additionally, the evidence does not support the popular claim that massage can reduce delayed onset muscle soreness. Soft tissue massage for performance recovery is another area that has been heavily investigated by researchers. However, there is insufficient evidence for soft tissue massage benefiting recovery or performance (Best et al., 2008). Part of the problem is the difficulty comparing techniques across practitioners/research when pressure, duration, and technique tend to vary from one therapist to another.

Bottom Line: The use of massage as a therapeutic modality has been around for a very long time so there is ample evidence demonstrating massage as a valuable therapy for patients at least psychologically despite the lack of evidence regarding physiological effects.

References:

1. Best, T. M., Hunter, R., Wilcox, A., & Haq, F. (2008). Effectiveness Of Sports Massage For Recovery Of Skeletal Muscle From Strenuous Exercise. Clinical Journal of Sport Medicine, 18(5), 446-460.

2. Loghmani, M. T., & Warden, J. S. (2009). Instrument-Assisted Cross-Fiber Massage Accelerates Knee Ligament Healing. Journal of Orthopaedic and Sports Physical Therapy, 39(7), 506-514.

3. Joseph, M.F., Taft, K., Moskwa, M., Denegar, C.R. (2012). Deep friction massage to treat tendinopathy: a systematic review of a classic treatment in the face of a new paradigm of understanding. Journal of Sport Rehabilitation, (21), 343-353.

4. http://www.grastontechnique.com/Research_Reports.html

Are ultrasound and other heat application techniques useful as therapeutic treatments?

Posted on April 23, 2014 by Des

You may have heard about ultrasound used as a post-rehabilitation technique after surgery or perhaps you’ve used a heating pad to ease back pain. There are many techniques involving the application of heat, which are purported to treat a variety of symptoms. In this post, I’ll briefly cover the categories of techniques, common physiological effects of thermotherapy according to the literature, and the treatments it could potentially benefit and end by summarizing findings of the research included. As always, sources used for this post are referenced at the end.

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Thermotherapy is defined as the application of a modality with a higher temperature than body temperature to induce changes in tissues, but is the heating of tissues enough to really make therapeutic changes? As usual, the answer depends on the modality and the outcome goals of treatment.

There are two categories of thermotherapy: Superficial and deep.

Superficial thermotherapy is the application of heat to superficial tissues with a depth of penetration equal or less than 1cm. If you think about how big 1cm is you can imagine the problem with this technique for treating things like muscles and deeper tissues. Will a superficial hot pack actually reach a muscle underneath it? Perhaps, if you are heating a hand muscle, or an area of thin skin where the muscle is more superficial, but it’s unlikely that you will have much success reaching deeper tissues with superficial heat using such items as hot packs, and whirlpools. While in certain areas of the body the penetration can be deeper than 1cm, it is not likely to offer therapeutic benefits. Again, this does depend on what you are trying to do therapeutically. To induce mild inflammation (remember, acute inflammation is a good thing) or accelerate metabolic rate, a temperature increase of 1.8 degrees Fahrenheit is necessary. To decrease muscle spasm, reduce pain or increase blood flow, a heat increase of 3.6-5.4 degrees Fahrenheit is necessary. For superficial heat, a hot pack or a whirlpool are referenced by most studies as falling short of a 3.6 degrees Fahrenheit temperature increase on muscles such as the triceps surae and the quadriceps and the depth of penetration is very shallow. If you want to heat up the joint capsule of a shoulder, a hot pack will never be sufficient because it is too deep in body. A modality has to penetrate deeply enough to reach the area needing treatment.

Another modality for superficial heat is a hydrocollator. A hydrocollator is a moist-heat pack that has a typical temperature of 160-170 degrees Fahrenheit, and when applied to quadriceps for 20 minutes, can increase temperature at 1cm depth 6.5 degrees F and at 3cm depth, 1.4 degrees F. These heat packs are so hot they must be applied with a covering pad.

This photo above is from a slide borrowed from my professor summarizing research on depth of penetration and duration of application and their combined effect on temperature increase in the referenced tissues.

Deep thermotherapy is the application of heat modalities, which cause tissue temperatures to rise in deeper tissues (typically 3-4cm). We will focus on ultrasound since it is a common treatment modality in deep thermotherapy. Ultrasound is an acoustic mechanical agent using acoustic vibration to produce heat as a byproduct. Electrical energy is converted to acoustic energy within the sound head of the device and is typically conducted through a water-based gel substance to the body. High frequencies (3MHz) have a high absorption rate and low penetration depth (less than 3cm) and are best for superficial tissues. For superficial tissues, a treatment time of 3-4 minutes is typical though these depend on size of treatment area, intensity etc. Lower frequencies (1MHz) can penetrate deeper (5-7cm), but with less absorption. Clinicians should consider which frequencies to use depending on the treatment area depth. For lower frequencies, 10-12 minutes is therapeutically typical, but depends on various factors surrounding the treatment. A 1MHz frequency might be best for a rotator cuff or the vastus intermedius muscle, whereas the 3MHz output might be better on a patella tendon, MCL or the brachialis muscle. In addition to frequency settings, there is also continuous (100% duty cycle) or pulsed-wave output (chosen by therapist). Pulsed ultrasound has been found effective to decrease pain and increase range of motion as well as accelerating fracture repair. With both modes of ultrasound therapy, there are both thermal and non-thermal effects.

Physiological Effects of Thermotherapy:

As you read the physiological effects of heat below, keep in mind the depth of the various tissues being discussed and the type of modality used and think about whether this treatment could even reach these depths and induce necessary changes in temperature to a therapeutic value. If you are not interested in the physiological effects, just skip down to the “Clinical Applications” section.

Circulation & Fluid Dynamics of Heating:

Applying heat can increase blood flow circulation 1-2 times beyond normal flow and can increase cell metabolism. The increase in cell metabolism can be beneficial during the healing process, but is devastating immediately following an injury because it can induce secondary metabolic injuries in surrounding tissues by increasing the demand for oxygen and increasing waste products. Heat can also increase edema, especially in non-elevated limbs so it is important to not use heat early in an injury. If heating must be used while there is edema, the limb should be elevated. Heat will dilate superficial blood vessels causing relaxation of smooth muscle walls (most vessels have smooth muscle walls). Heat can decrease blood viscosity (thickness), which also increases the rate of flow. Heat is pro-inflammatory and will increase delivery of leukocytes to the heated area. While the inflammatory process is important for healing after an injury, the negative effects of heating early in an injury outweigh the benefits. This is why it’s important to consider the entire picture of injury healing and not focus only on one factor as if it is a separate entity.

Nerve Conduction effects from heating (aka Pain reduction):

Heat is often used to reduce pain and it has both a direct and indirect mechanism for doing so. The direct effect is to increase the pain threshold by increasing the conduction velocity of nerves that can transmit pain information. Indirectly, heat can lessen the mechanical pressure by reducing edema and decreasing muscle spasms, which then can reduce pain. Muscle spasms are reduced by decreasing gamma-motoneuron sensitivity, increasing blood flow, and reducing local muscle metabolites.

Tissue Elasticity effects from heat:

An increase in tissue temperature of 5-7 degrees Fahrenheit for 5 minutes is sufficient to increase tissue extensibility. To achieve plastic deformation, the tissue should be heated to 104-113 degrees Fahrenheit and to deform the tissues, stretching is required during or immediately after heating. Therapeutic temperature ranges of heat are higher than we think and this can be painful or uncomfortable for some people to tolerate.

Proposed Non-thermal effects of ultrasound:

It has been proposed that non-thermal effects of ultrasound can also be beneficial if began 72 hours after injury. Benefits may include: increased calcium ion influx through increased histamine release, increased capillary density in ischemic tissues, increased fibroblastic activity, attraction of immune cells to the area, increased collagen deposition, decreased edema (by liquefying the viscosity), accelerated fracture repair, and formation of stronger collagen tissue.

Clinical Applications:

Both thermal and non-thermal effects can occur in continuous and pulse wave ultrasound treatments and the thermal effects are generally enhanced when the duty cycle approaches 100%. The size of the treatment area should be 2-3 times the size of the sound head and if the area is larger, it should be split into two different sessions. Absorption of ultrasound heat is highest in tendons, ligaments, fascia, joint capsules and scar tissue and has been found effective at accelerating fracture healing.

Thermotherapy can be useful for helping increase blood flow to tissues when a person is unable to do warm up exercises, however, research indicates that doing warm-up exercises is more effective at increasing blood flow, oxygen and nutrient delivery than therapeutic heat so if a person is able to exercise, they should do that instead. If heat is applied for the purpose of stretching, then simultaneous stretching or stretching within 5 minutes of the treatment should occur to be therapeutically useful because there is a very short window of therapeutic effectiveness.

Summary:

Superficial thermotherapy may be useful for soothing and warming tissues, but does not do a lot beyond that. It may help reduce pain, but that also depends on the depth the heat reaches. For therapeutic ultrasound, research shows that it may be useful for soft tissue healing and repair, scar tissue, muscle spasms, trigger point areas, sympathetic nervous system disorders, fracture healing and acute inflammatory conditions (with pulsed-wave ultrasound only). Heat therapy should not occur prior to 73 hours after an injury because of negative effects from increased edema and metabolism. Depth of penetration is an important consideration in thermotherapy and thus the modality selected for treatment should be consistent with the area requiring treatment.

Sources:

Bleakley, C. M., & Costello, J. T. (2013). Do Thermal Agents Affect Range of Movement and Mechanical Properties in Soft Tissues? A Systematic Review. Archives of Physical Medicine and Rehabilitation, 94(1), 149-163.

Knight, K., & Draper, D. (2012). Therapeutic Modalities: The Art and Science [Hardcover] (p. 528). LWW; Second edition.

Robertson, V. J., & Baker, K. G. (2010). A Review of Therapeutic Ultrasound. Journal of Womenʼs Health Physical Therapy, 34(3), 99-110.

Watson, T. (2008). Ultrasound in contemporary physiotherapy practice. Ultrasonics, 48(4), 321-329.

Cryotherapy aka “icing” – Is it really effective?

Posted on April 11, 2014April 12, 2014 by Des

Cryotherapy is a therapeutic technique utilizing the application of a cooling device to the site of injury. Cryotherapy is essentially another way of saying you are “icing” an injury. Most people have heard about the “R.I.C.E.” method: Rest-Ice-Compression-Elevation, but is it truly an effective technique for promoting healing? The answer to this question is complicated and depends on what exactly is meant by “healing”. Recent research and systematic reviews are questioning the effectiveness of the icing method and calling for caution or reevaluation regarding cold therapy. Below, I will describe the effects icing has on various physiological processes and explain what the current views in research are. Sources are cited at the bottom for further reading on the topic.

Metabolic effects: Localized icing decreases tissue metabolism, which decreases the need for oxygen. The potential benefit to this is the reduction of what is called a “secondary hypoxic injury”, which is an indirect form of damage to the cells around the actual injury due to an imbalance in oxygen delivery versus oxygen need. Ice is thought to slow the need for oxygen and reduce the deficit, which ultimately results in a reduction of damage to surrounding tissues. This is only beneficial when ice is applied immediately after injury.

Circulatory effects: Cold therapy induces vasoconstriction of vessels, which means they get narrower, which results in a decrease in blood flow to the area. Icing can also reduce membrane permeability. Both can be helpful in the prevention or reduction of secondary hypoxic injury as described above. Many cold therapy products promote reducing swelling, edema and hemorrhaging. The current research does not support icing have an affect on hemorrhage or reducing edema, but it can help to prevent edema if applied immediately (within a minute) of injury. The ice must be applied before any edema has formed. Once there is edema and subsequent swelling, it is too late, and applying ice will have no effect on edema or swelling. They key here is that it can prevent edema, but it can’t do anything once the edema has occurred so rapid application is necessary.

Inflammation Effects: Acute inflammation is actually a good thing that occurs after an injury. The inflammatory response is essentially your healing response and it is only maladaptive if prolonged beyond the normal healing time. In terms of cryotherapy, more research is warranted on the effects of ice on inflammation. Most research has focused on induced inflammation or the healing of surgical wounds and the results are conflicting. Research seems to support that icing may delay the overall inflammatory response, but does not alter it in the end. The inflammatory process is necessary for healing to occur so there may be some concerns about applying ice if it delays this vital healing response.

Pain Effects: Both A and C fibers are sensitive to temperature changes, and cooling them reduces their conduction velocity, which eventually results in the numbing sensation of the skin. The colder it is, the more the effect of pain reduction. Ice can be an effective method for reducing pain if the cold is well tolerated by the patient. Care must be taken to not apply ice directly over superficial (close to the skin) nerves because very prolonged icing can induce nerve damage.

Sensory and Motor nerves: Similar to above, cooling decreases the velocity of sensory and motor nerve conduction. Sensory nerves are our nerves that conduct information about sensation such as touch and where our body is positioned in space to the brain for processing. Motor nerves are our output for movement, such as contracting muscles to perform some action. At 10 degrees Celsius (referring to nerve temperature not skin temperature), nerve conduction is blocked in many, but not all nerves. The effect on the sensory and motor nerves can alter proprioception and muscle force production respectively, so there is a great concern with icing a player and then sending them right back into the field to keep playing when nerve conduction in the injured area has been reduced.

What about ice baths and full body immersion?

Ice baths should generally be avoided. The main benefit to an ice bath would be to prevent hyperthermia in situations that require immediate cooling of the tissues to save a life. Full body immersion in ice baths has the following effects and all are negative: increases heart rate, blood pressure, oxidation, cortisol and free radicals. Decreases antioxidants and cerebral blood flow (flow of blood to the brain), which can be very dangerous. Some see benefit in the camaraderie of engaging in ice baths for team bonding drills, but one could argue there are better, less damaging ways to do this.

Take home message about cryotherapy:

Cryotherapy can be effective at reducing pain and secondary hypoxic injury as well as preventing (but not reducing) edema and swelling. However, we need to consider whether the benefits outweigh the negatives and whether there is something better we can be doing to promote healing. Research seems to support compression and elevation over icing so we may need to change the “R.I.C.E.” method to the “R.C.E.” method. Icing can be effective at reducing edema only when applied prior to the formation of the edema, but there is little sense in applying ice long after an injury has occurred unless the tissues require cooling for some alternative reason.

Other things to consider:

Applying ice directly over a superficial nerve for a very long time can cause damage to the nerve so do not apply ice for an extended period (such as many hours or a whole day).
Wet crushed ice works better than “dry” cubed ice – the ice should be touching all surfaces so the smaller the ice pieces, the better the effect will be.
The cooler you can get the tissues, the better the effect will be of reducing secondary hypoxic injury so icing for at least 30 minutes in one sitting is necessary for this effect to take place, but keep in mind the duration will vary depending on the location of the injury, the amount of adipose tissue on the individual etc.

Sources:

Bleakley, C. (2004). The Use of Ice in the Treatment of Acute Soft-Tissue Injury: A Systematic Review of Randomized Controlled Trials. American Journal of Sports Medicine, 32(1), 251–261. doi:10.1177/0363546503260757

Bleakley C, McDonough S, Gardner E, Baxter GD, Hopkins JT, Davison GW. (2012, February 15). Cold-water immersion for preventing and treating muscle soreness after exercise. John Wiley and Sons, Ltd. for The Cochrane Collaboration for Systematic Review.

Costello, J. T., & Donnelly, A. E. (2010). Cryotherapy and joint position sense in healthy participants: a systematic review. Journal of Athletic Training, 45(3), 306–316. doi:10.4085/1062-6050-45.3.306

Guilhem, G., Hug, F., Couturier, A., Regnault, S., Bournat, L., Filliard, J.-R., & Dorel, S. (2013). Effects of air-pulsed cryotherapy on neuromuscular recovery subsequent to exercise-induced muscle damage. The American Journal of Sports Medicine, 41(8), 1942–51. doi:10.1177/0363546513490648

Knight, K., & Draper, D. (2012). Therapeutic Modalities: The Art and Science [Hardcover] (p. 528). LWW; Second edition.

Soft Tissue Massage/Graston/Myofascial Release Treatments

Are ultrasound and other heat application techniques useful as therapeutic treatments?

Cryotherapy aka “icing” – Is it really effective?

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