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HISTORY OF MANUAL THERAPY
There is a range of references to manipulation and manual medicine. The first references of manual medicine are ancient and have numerous origins.
Today, soft tissue mobilization is more science-based than ever before. Early theories of some of the pioneers in these fields such as Cyriax, Nimmo, Rolf and others are becoming more scientific than just 'feel good massage.". Many chiropractic and medical physicians, physical therapists, and athletic trainers are not aware of some of these pioneers and just how far back their theories date. Current knowledge supercedes some of the data, but some of their concepts may still have a degree of validity, and certainly contain historical value.
HISTORY OF MANUAL THERAPY
There are many ancient references to manipulation and manual medicine. Even the word massage has numerous origins:
the Arabic verb mass = to touch;
the Greek word massein = to knead;
the East Indian word macer or masser = having oneself massaged
the Sanskrit word makch = to strike or press
the Latin word manus = hand (as in handling or management)
There are Babylonian-Assyrian records of massage being used for cramps.
Hippocrates, Greece (460 BCE) – used to treat kyphosis by having the patient use steam heat, followed by traction from the head and foot while the patient was in a prone position. Several methods of pressure application were utilized including a padded board with a long lever to the kyphosis. (Harris)
Galen, Greece (131-202 CE) – described manual medicine in extremities and cervical spine. (Harris)
Abu’Ali ibn Sina, Saudi Arabia (980-1037 CE) – wrote a textbook on medicine, including manual medicine, and this was utilized until the 17th century. (Harris)
Ambroise Pare, (1510-1590) – described medieval Turkish manipulation during traction. (Harris). He applied massage to surgical patients. (Kamenetz)
There are several mentions of some type of clinical soft tissue mobilization that date back 150-200 years. These references and quotes are included to illustrate that many subjects of debate and of academic questions in the area of manual medicine have been proposed previously. A few of the pioneers include:
P. G. Hensler, MD, Kiel, Germany (died in 1805) believed that massage to the dermatome could affect organs correlating to that area. (Cyriax)
E.D.A. Bartels, MD, Berlin, Germany (1835) continued Henlser’s work. The work was called “bindegewebsmassage” = connective tissue massage. (Cyriax)
Per Henrik Ling, Sweden (1776-1839) – Swedish physical education teacher who brought a system to therapeutic exercises and massage. One of his students (Augustus Georgii) coined the term “kinesitherapy”. Ling’s method of massage received international acclaim and became known as “Swedish massage”. (Kamenetz)
Hooker, MD, 1849 – wrote, “tendons are benefited by a persevering course of friction”. (Cyriax)
Andrew Taylor Still, DO, USA (1828-1917) – founder of osteopathy. Manual medicine had declined during the 17th and 18th centuries.
Johan Georg Mezger, MD, Netherlands (born 1838) – presented his doctoral dissertation on “The treatment of the foot sprain by friction” in 1868. Mezger cited two others: Girard from a paper at the Academy of Medicine in Paris in 1858 entitled “Frictions and massage alone in the treatment of sprains.” He also cited Millet of Tours, France who published his own method in 1864. (Kamenetz)
A collection of physicians described early mobilization for fractures: Norstrom (1884), Just Lucas-Championniere (1843-1913) and was supported by Berne, Leonardon-Lapervenche, Keith. “In 1881 Lucas-Championneiere began to introduce another innovation in the treatment of fractures – the application of massage, not only to the parts in the neighbourhood of a fracture, but actually at the site of the fracture….He claimed that massage allayed almost instantly the pain at the site of the fracture; it accelerated the process of repair; it dissipated inflammatory exudates, reducing swelling and tension in the damaged parts; it maintained muscles, nerves, tendons, ligaments and joints in a state of health. The application of massage to the immediate treatment of fractures and dislocations he counted amongst his chief services to surgery.” (Kamenetz)
James Cyriax, MD, is a British physiatrist who is a pioneer in manual treatment. He certainly deserves significant mention and reference. Cyriax’s text, Deep Massage and Manipulation, was first published in 1944. Later editions were published as Textbook of Orthopaedic Medicine, Volume Two, Treatment by Manipulation, Massage and Injection (11th edition published in 1984 and reprinted in 1990). Cyriax always questioned the underutilization of manipulation. He carefully noted that the usual response to the success of manipulation, particularly after the conventional medical model failed, is to attack the manipulator as opposed to attacking the conventional model for failing. Cyriax was very concerned with specificity of treatment to the lesion. He questioned the manipulation of an asymptomatic area.
Raymond L. Nimmo, DC (1904-1986) was a chiropractic who also was a pioneer in soft tissue therapy. Nimmo was a 1926 graduate of Palmer College of Chiropractic.
Nimmo made the leap of faith that treating the muscles with manual therapy could also improve joint mobility. Nimmo developed neurophysiological theories (receptor-tonus technique) to explain the trigger point phenomenon. He also developed tools for the “Nimmo technique” to reduce the mechanical stress on the provider’s hands, fingers and thumb.
Ida Rolf was a biochemist who developed an aggressive massage technique that became known as “Rolfing”. Rolf addressed fibrosis in myofascial tissues and planes. Rolf developed the theory of “emotional release” through Rolfing. Rolf felt that emotional stress is “remembered or stored” in the muscles. This stress can be released through the Rolfing treatment. The system evolved into a 10-treatment protocol to treat the entire body. John T. Cottingham in Champaign, IL does carry on research based on Rolf’s work. The Rolf Institute is located in Boulder, CO. Brief changes in parasympathetic tone in young adults have been reported with a combination of pelvic lift (Rolf soft tissue manipulation) and moderate pressure over the epigastrium.
Janet Travell, MD – instrumental in promoting and developing the trigger point theories in America. Travell authored texts on trigger point treatment. Travell gained notoriety as the personal physician to John F. Kennedy. Travell expressed her admiration for Nimmo’s work. Personal communication from Travell was most interesting: “I realize what every patient can understand, but many chiropractors seeming cannot, that no bone can move unless a muscle moves it, and no muscle moves a bone unless a nerve impulse reaches it. I decided the lumbar lordosis was due to tight sacrospinalis muscles. I would release them, but the patient would go back into the same position, with return of pain. I looked for muscles that pulled the front of the pelvis, which were of course, the quadriceps” (Cohen, Gibbons 1998).
J Maitland, PT – incorporates Rolf-based soft tissue mobilization to improve posture, Alexander-based guided movement mobilization to improve posture, and pain
modulation procedures consisting of relaxation techniques.
GD Maitland -- not to be confused with J Maitland who has had a major influence in manipulation and mobilization with various techniques that are used today.
Paul Williams – best known for the Williams flexion exercises: pelvic tilt, bridging, and knee to chest. Most common for of basic low back exercises until McKenzie extension exercises became popular.
Robert Salter, MD – performed research, which revealed that continuous passive motion (CPM) promoted healing of articular cartilage vs. immobilized subjects (1980). This is commonly used today in post-op management. This is a landmark study that produced trickle down effects in post-op care as well as rehabilitation. Takai et. al. reported that more cycles of movement per unit of time in CPM resulted in greater tensile properties than in lower cycles. Ahl et. al. found that malleolar fractures that had weight bearing exercise vs. nonweight bearing exercise had better outcomes.
Salter’s research also altered the perception of immobilization vs. early mobilization rehabilitation after injury. Mealy et.al. reported a decrease in pain and increase in range of motion in cervical whiplash patients when they received Maitland-based early mobilization versus traditional immobilization by cervical collar and rest. Maitland techniques included repetitive passive range of motion, low amplitude, and high amplitude motions. Brodin also reports similar findings to Mealy et. al. in cervical cases. Brodin’s study employed Stoddard-osteopathic mobilization techniques – no large amplitude thrusts were used. The general trend appears to be one of increased mobilization and earlier intervention to derive better outcomes.
Respected doctors of chiropractic who have taken a more recent interest in soft tissue mobilization include Griner, Ferrell, Leahy, Hammer, Hannon, Scaringe and Horrigan.
Vladimir Janda, MD – Czech Republic physiatrist who works in the area of muscle recruitment patterns in area such as low back pain. Janda successfully documented tight lumbar paraspinal muscle activity during spine flexion. Janda stretched the tight lumbar paraspinals and repeated the active spinal flexion and found decreased paraspinal activity coupled with increased abdominal muscle activity.
“Bone setting” has been described in numerous cultures. Gypsies of central Europe were known for bone setting. Indians of Mexico had manipulation techniques. The Hawaiian massage of “Lomi-Lomi” is 800 years old. East Africans, Norwegians, Swedes, and Finns have similar descriptions. Whorton Hood gave bone setting its first formal description in the 19th century. Richard Hutton had taught Hood. Sir Herbert Barker was taught bone setting by a relative of Richard Hutton. He was granted Knighthood, but denied an honorary medical degree. The Lancet in 1925 had this to report: “The medical history of the future will have to record that our profession has greatly neglected this important subject…The fact that must be faced, that the bone setters had been curing multitudes of cases by movement…and that by our faulty methods we are largely responsible for their very existence”. (Harris)
Daniel David Palmer, DC (1845-1913) – founder of chiropractic. DD advocated the manipulation of the spine and extremities – origin of “mixers”. This history is well known to those enrolled in this course.
B.J. Palmer, DC – son of DD, advocated manipulation of the spine only – origin of “straights”. This history is also well known to those enrolled in this course.
There were a number of chiropractic treatment methods for soft tissue that have been forgotten, lost or filed in the archives. Some of these methods included “Bio-Engineering”, MacIntosh system of Fascia Release, Chromaffin Synapse Theory which believed treated the sacral ganglia but Nimmo’s opinion was it released muscles (Cohen, Gibbons 1998).
HISTORY OF MANUAL THERAPY
1991 found 73% of the chiropractic profession utilized massage and soft tissue techniques, but by 1998 the percentage increased to 83% (Rupert et. al. 2002). It is not clear if these figures indicate soft tissue mobilization performed by the doctor or is it performed by a massage technician in the office.
Soft tissue adhesions, tendonitis, tendinosus, fascial restrictions and chronic inflammation and dysfunction often respond poorly to conventional treatment (Melham et. al. 1998).
As previously noted, James Cyriax, MD was a pioneer in manual treatment. Cyriax’s manual methods included soft tissue mobilization and joint manipulation (Hutson 1989) (Wright 1988). When we read about the theories Cyriax developed, he could participate in any current academic or scientific discussion regarding soft tissue mobilization today. Cyriax created an extensive clinical model and methodology for treatment of musculoskeletal injuries. His work was based on three principles:
1. 1. All pain arises from a lesion.
2. 2. All treatment must reach the lesion.
3. 3. All treatment must exert a beneficial effect on the lesion.
The efficacy of Cyriax’s work depended upon the performance of a thorough evaluation (Chamberlin 1982). This cannot be emphasized enough. Hammer noted the utilization of post treatment functional testing as a measure of efficacy when using Integrative Fascial Release (Hammer 2000).
Cyriax noted “We attempted direct action on the lesion, ignoring the unaffected muscles. Similarly, we no longer waste time giving quadriceps exercises to a recently sprained ligament at the knee; we treat the ligament itself, thus enabling the patient to use his knee so well that no wasting has time to come about. When contraction of a muscle pulls on a painful scar within itself or in a tendon, we try to rid the inflammation in the scar, or even the excess scar tissue itself” (Cyriax). This is a significant position today, much less in the 1940’s and 1950’s. This train of thought went against the common way of thinking. This is part of what made Cyriax a pioneer, along with Nimmo and Travell, in the field of soft tissue treatment. The terms “transverse friction massage”, “cross-friction massage” and “deep friction massage” were derived from Cyriax’s work.
Cyriax always emphasized the detail of the treatment and the accuracy of the diagnosis. “Throughout, the choice of treatment depends on the diagnosis. Accurate treatment follows as a logical result and requires a high degree of knowledge and skill.” (Cyriax)
There is a definite learning curve and the more cases the provider has seen and treated with a given diagnosis, then usually the better is his/her skill.
“Adequate manipulation demands knowledge of the range of movement at a joint and of the sensations imparted to the hand as each extreme is approached and the ability to estimate that tissue resistance has mounted to the point when the thrust should be applied. The different effects of different techniques must be appreciated, together with the capacity to choose the correct measure different types of lesion. During treatment by deep friction great precision in treating of the patient and of the physiotherapists hand is essential: throughout the session she keeps her mind on her finger-tip. This type of work involves her in much more concentration and care than most of her other work. There is nothing routine about it; each patient and each lesion must be assessed and given expert and individual attention”. (Cyriax)
“When mobility is to be maintained at, or restored to, those moving parts which form their nature or position are apt to develop adhesions or scarring, deep friction is often the method of choice, either alone (as in the case of tendons) or in association with passive movements (for some ligamentous lesions) or with active movements without tension on the healing breach (for minor muscular ruptures)”. (Cyriax)
Cyriax’s theories to support deep friction massage included: “A penetrating technique is required in the treatment by massage of deep-seated lesions. Given properly, deep friction has a four-fold effect. It induces:
(1) traumatic hyperemia,
(2) movement,
(3) increased tissue perfusion,
(4) mechanoreceptor stimulation”.
Traumatic hyperemia – “ …enhancement of blood supply diminishes pain”. Cyriax felt that this increased the destruction of p-substances and this would produce temporary analgesia (although he felt this analgesia was longer than from counter-irritants).
Movement – “By moving the painful structure to and fro, it is freed from adhesions both actually present and in the process of formation”.
Cyriax developed a theory for his method of treatment. Some still follow his idea completely. Others simply view it as the best theory he could develop with the knowledge of his time. There are different points of view today. Cyriax noted the following: “The main function of muscle is to contract. As it does so it broadens. Hence full mobility in broadening muscles that have been the seat of inflammation, whether caused by one or repeated strains. Resolution by fibrosis is occurring or has already occurred. The effect of deep transverse friction clearly consists in mobilizing the muscle, i.e. separating the adhesions between individual muscle fibers that are restricting movement. If passive restoration of full mobility of a muscle is followed by adequate active use, these adhesions do not reform: cure results”.
Cyriax continued “The principle governing the treatment of muscles during the acute or chronic stage is the same. The endeavor must be to prevent the continued adherence of unwanted young fibrous tissue in recent cases, or to rupture adherent scar tissue in long standing cases. To stretch out a muscle does not widen the distance between its fibres; on the contrary, during stretching they lie more closely. Whereas, then, for the rupture of adherent scars about a joint forced movement is required, interfibrillary adhesions in muscle can be broken, not by stretching, but by forcibly broadening the muscle out…Thus, deep transverse frictions restore mobility to muscle in the same way as manipulation frees a joint. Indeed, the action of deep transverse friction may be summed up as affording a mobilization that passive stretching or active exercises cannot achieve”.
Cyriax addressed the acute phase: “In recent cases, after any oedema that may be present has been removed by effleurage, the site of the minor tear in the ligament should receive some minutes’ friction. The purpose is to disperse blood clot or effusion here, to move the ligament to and fro over the subjacent bone in imitation of its normal behaviour (thus maintaining its mobility) and to numb it enough to facilitate movement afterwards. The least strength of friction which achieves these results is called for. Hence, when friction is started during the first day or two after a sprain, the ligament need be moved only a few times. One minute’s treatment thus suffices, since as yet there are no unwanted adhesions to break down. But it may well take ten to twenty minute’s effleurage and gentle friction to enable the patient to accept the one minute’s valid treatment – actually moving the damaged tissue. When the lesion becomes less severe and tenderness is abating, friction maintained with increasing strength for five, ten, then fifteen minutes is called for”. “No scar tissue has yet formed unwanted adherences; hence it is a question of maintaining the capacity of the muscle to broaden fully and to render such active contractions painless. If immediate local anaesthesia is carried out, the massage starts the next day; if not, as soon as the patient is seen. The intention is to prevent scar tissue from matting the muscle fibres together, without interfering with the fibres consolidating themselves in the healing breach. Broadening out in the absence of tension is secured by transverse friction; the massage must reach the right spot but at first need not last long or be really vigorous. It should be followed by active movement of the damaged muscle; this maintains the added excursion towards broadening resulting from the massage”.
Hannon and Scaringe emphasized a few key points about Cyriax’s work:
1. The right spot must be found [Cyriax was noted for a comment that if you are off by
one-quarter of an inch, you may as well be off a mile - Horrigan].
2. The therapist’s fingers and the patient’s skin must move as one.
3. Friction must be given across the fibers composing the
a. affected structures
b. the friction must be given with sufficient sweep
c. the friction must reach deeply enough
d. the patient must be in a suitable position
e. muscles must be kept relaxed during treatment
f. tendons with a sheath must be kept taut.
Hannon and Scaringe also emphasized the hand positions:
1. index finger crossed over the middle finger
2. middle finger crossed over the index finger
3. two finger-tips
4. opposed fingers and thumb
The indications for Cyriax’s transverse friction massage:
1. Muscular lesions
a. recent trauma
b. long standing scars
c. lesions at the musculotendinous junction
2. Tendinous lesions
a. tendons with a sheath
b. tendons without a sheath
3. Ligamentous lesions
a. recent sprain
b. chronic sprain
Contraindications for transverse friction massage:
1. 1. inflammation due to bacterial infection
2. 2. traumatic arthritis of the elbow joiont
3. 3. ossification or calcification of soft tissues
4. 4. bursitis
5. 5. rheumatoid types of arthritis
6. 6. pressure on nerves
Cyriax identified a number of disorders that he thought were curable by transverse friction massage only:
Supraspinatus—musculotendinous junction, biceps tendon—long head, biceps—
distal musculotendinous junction, brachialis belly, supinator belly, ligaments
around the lunate, thenar adductors, interossei belly, interossei tendons,
intercostals muscle belly, oblique muscles of abdomen, psoas major—distal
musculotendinous junction, quadriceps expansion at patella, coronary ligament
of the knee, biceps femoris—distal musculotendinous junction, posterior tibial
musculotendinous junction, anterior musculotendinous junction, peroneal
musculotendinous junction, posterior tibiotalar ligament, anterior fascia of ankle,
and interossei bellies of foot (Hannon, Scaringe, 1992).
Regretfully, as insightful as Cyriax was with regard to the significance of soft tissue injuries, he was certainly no friend to the chiropractic profession. Cyriax spoke out against chiropractic.
Raymond L. Nimmo, DC (1904-1986) was a chiropractic who also was a pioneer in soft tissue therapy. Nimmo made the leap of faith that treating the muscles with manual therapy could also improve joint mobility. Nimmo developed neurophysiological theories known as “receptor-tonus technique (RT) to explain the trigger point phenomenon. He also developed tools for the “Nimmo technique” to reduce the mechanical stress on the provider’s hands, fingers and thumb.
Nimmo coined the phrase “noxious generative points” referring to “spots on the shoulders which when pressed on referred pain to various areas, and these results were spectacular in case after case” (Cohen, Gibbons 1998). Nimmo stated in 1986 “Although it is called the Nimmo Technique, the correct designation is Receptor-Tonus Technique for the reason it deals exclusively with muscle tonus and nerve receptors which initiate pain. The early development of the method was necessarily somewhat experimental and empirical. It was different from anything I had ever been taught but it was the most efficient method and permanent release from pain I had ever used or observed” (Cohen, Gibbons 1998) (Schneider 1994).
Furthermore, Gatterman and Lee noted that “Nimmo found noxious generative points in muscles that referred pain in characteristic patterns. Viewing these hypersensitive areas, the trigger points of Travell, as abnormal reflex arcs he developed a manual technique designed to reduce the irritable loci. He referred to the inter-relationship of muscle tonus and the central nervous system as “reverberating circuits,” whereby the stimulus was self perpetuating until the cycle was broken…This procedure referred to by Travell as ischemic compression offers a noninvasive chiropractic technique instead of common medical practice of injection of the painful trigger points” (Cohen, Gibbons 1998).
Nimmo felt the malfunction of a normal tonus process could be caused by a variety of sources including trauma and the now referred to term of repetitive stress injury. Nimmo relied on the idea that afferent stimulus to the cord produced a ten-fold efferent discharge, a term that Guyton later called “after discharge”. Insults such as trauma and repetitive stress injury result in an increased stream of efferent impulses to the muscles causing a state of abnormal contraction. This then would send additional afferent impulses which produce even more efferent impulses back to the muscle resulting in a viscous, self-perpetuating cycle. There is a reflex spillover to the sympathetic nerves which causes local vasoconstriction trapping metabolites of muscle action. (Cohen, Gibbons 1998).
This latter description matches the current myospasm theory. The focus of the irritability within this abnormal muscle contraction and vasoconstriction becomes the trigger point (Cohen, Gibbons 1998). As the process continues, it spreads to other levels of the cord causing secondary trigger points and also the well known phenomenon known as referred pain (Cohen, Gibbons 1998). It is suggested that Nimmo and Travell developed these concepts concurrently and independently.
Travell was best known for the trigger point injections and spray and stretch to treat the concept of ischemic compression to relax the muscle. Nimmo stated” I have found that a proper degree of pressure, sequentially applied, causes the nervous system to release a hypertonic muscle” (Cohen, Gibbons 1998). Nimmo’s work has been generically referred to as “ischemic compression” and has been used by many fields (Schneider 1994).
Janet Travell, MD – the late Dr. Travell performed a significant amount of work with trigger points, referred pain, myofascial pain, spray and stretch, and trigger point injections. She collaborated with Simons in her textbooks. The work of Dr. Travell is voluminous and I recommend the doctors in this course purchase her text and have it in your reference library.
A variety of equipment have been developed to determine the presence of trigger points. The equipment includes the pressure threshold meter, pressure tolerance meter, and tissue compliance meter. Studies have demonstrated improved pain tolerance in trigger point areas after coolant spray and stretch or trigger point injection (Hou et. al. 2002).
Ida Rolf was a biochemist who developed an aggressive massage technique that became known as “Rolfing”. Rolf addressed fibrosis in myofascial tissues and planes. Rolf developed the theory of “emotional release” through Rolfing. Rolf felt that emotional stress is “remembered or stored” in the muscles. Rolf utilized motion with the soft tissue mobilization. It is not clear if Rolf was the first in recent medical history to incorporate motion with the soft tissue mobilization. This stress can be released through the Rolfing treatment. The system evolved into a 10-treatment protocol to treat the entire body. John T. Cottingham in Champaign, IL does carry on research based on Rolf’s work. The Rolf Institute is located in Boulder, CO. A soft tissue mobilization technique in Rolfing in which moderate pressure is placed over the epigastrum while concurrently receiving posterior tilting and pelvic traction. Cottingham et. al. noted previous osteopathic studies in which lumbosacral decompression and pelvic lift maneuvers have been associated with increased parasympathetic activity and decreased sympathetic activity (Cottingham et. al. 1988).
SOFT TISSUE MOBILIZATION
The definition of manipulation implies that there is a high velocity and high amplitude of the movement//thrust to the joint. Mobilization is defined to have a lower velocity and lower amplitude to the joint movement. A traditional diversified chiropractic adjustment falls into the category of manipulation. The soft tissue manual procedures fall into the category of mobilization.
EXAMPLES OF VARIOUS SOFT TISSUE MOBILIZATION TECHNIQUES IN THE PUBLISHED LITERATURE
A method of soft tissue mobilization using a sold instrument was reported to have key physiologic components (Davidson et. al. 1997). This method was named augmented soft tissue mobilization (ASTM). This method was initially introduced to address the fibrosis of tendon healing. The creators theorize this tool allows the therapist to introduce a more effectively controlled amount of microtrauma to an area of excessive scar or soft tissue fibrosis (Davidson et. al. 1997). A study was performed in which there were four groups: control; tendonitis; tendonitis and ASTM; ASTM without tendininitis. This was performed on rats. The tissue samples were examined by light microscopy, electron microscopy and immunoelectron microscopy and by gait analysis. The ASTM was performed on days 21, 25, 29, and 33 after injection with collagenase into the Achilles tendon unilaterally. The tendonitis group treated by ASTM revealed statistically difference with fibroblast count (Davidson et. al. 1997). The rough endoplasmic reticulum was also highly developed in the ASTM groups. Only the group with tendonitis and ASTM had significantly improved gait on day 21 and the final observation. The ASTM improved gait function and facilitates tendon healing by recruitment and activation of fibroblasts.
Similar results were reported by Gehlsen et. al. (1999). These authors found that augmented soft tissue mobilization did stimulate fibroblast proliferation in an Achilles tendon (rat) and the proliferation was dependent on the amount of pressure utilized (Gehlsen et. al. 1999). Other research has suggested that mechanical stimuli can alter many cellular functions including: ion transport, release of second messengers, protein synthesis, and gene expression (Gehlsen et. al. 1999).
Another study was published using ASTM (Melham et. al. 1998). A case a a 20-year-old junior offensive guard was utilized who had chronic right ankle pain and loss of range of motion. There was a history of five ankle sprains and two arthroscopic procedures to remove bone fragments. The patient received two treatments of ASTM per week for seven consecutive weeks. The results were the subject did not have pain with activity, ROM increased, surgical scar matured and the excessive fibrotic connective tissue around the ankle softened and diminished. The patient was also able to cease taking NSAID’s. Pre and post treatment MRI did not reveal any change (Melham et. al. 1998).
Hou et. al. investigated myofascial release, interferential stimulation, TENS, spray and stretch, hot packs for the treatment of trigger points in cervical myofascial pain. Patients with cervical myofascial pain syndrome have a very high recurrence rate (Hou et. al. 2002). The hypothesis by Simons and Travell for the pathophysiology of myofascial pain is injured or overstressed muscles leads to involuntary shortening and loss of oxygen and nutrient supply with an increased metabolic demand on local tissues. The trigger point is a painful or sensitive spot in a palpable, taut band of skeletal muscle. An active trigger point is one with spontaneous pain or pain in response to movement. A latent trigger point is a sensitive spot that causes pain or discomfort only in response to compression (Hou et. al. 2002). Hou et. al. feel that ischemic compression is a viable treatment method for muscles that are not suitable for spray and stretch and overly bone. Spray and stretch and myofascial release are popular forms of treatment today.
Instruments to measure soft tissue pressure include the pressure threshold meter, the pressure tolerance meter, and the tissue compliance meter. Researchers have found these instruments useful in measuring an increased pain threshold of trigger points after coolant spray, passive stretch or trigger point injection (Hou et. al. 2002). Significant results were found from ischemic compression, spray and stretch, interferential current and myofascial release therapies (Hou et. al. 2002).
The manual methods of Mills, Cyriax, Kaltenborn, Mennell and Stoddard were compared for efficacy in the treatment of tennis elbow (Kushner, Reid 1986). The varus thrust manipulation acts primarily on the capsular structures causing gapping and restoring joint play. Manipulations with the elbow in extension and pronation have the greatest chance of effecting the contractile elements (Kushner, Reid 1986). It was also understood that the success of treatment of tennis elbow includes not only manual procedures, but also exercise, modalities and modification of the activities involved in the etiology (Kushner, Reid 1986).
The Graston technique is gaining popularity in the short time it has been publicized (Wilczewski 2002). The method entails the use of an instrument to cover a large area of skeletal muscle (e.g. hamstring group, upper trapezius, quadriceps) and reduces the strain on the hands of the health care provider.
The description of myofascial release has been used by many practitioners in the field (chiropractic, osteopathic, physical therapy) and the name is currently protected by a physical therapy group. However, it’s loosely used name has been applied by many. Shea and Keyworth noted that myofascial release had been used for many decades but little has been done to document its results. The work and development of myofascial release by osteopathic physicians
This author addressed a case of stride length deficiency in a world class sprinter. The data was tracked by The Athletic Congress (T.A.C. now known as USA Track and Field) during a research project known as The Elite Athlete Project: The Sprints. The subject won the 1986 national championships in the 200m sprint (written permission obtained from patient to discuss findings). The patient had a left hamstring injury earlier in 1986 and this resolved. The left stride length was found to be 4.4 inches shorter than the right stride length at the national championships. The biomechanist performing this project (Ralph Mann, PhD) indicated this discrepancy equated to 0.2 seconds over 200m. An 11cm region of fibrous tissue was palpated in the long head of the biceps femoris. The patient received soft tissue mobilization to the hamstring group, rectus femoris, gluteal group, psoas major, adductor group, and piriformis. The patient entered the 1987 national championships and won again. The Elite Athlete Project was analyzing the top three finishers in each event in 1986 and 1987. The analysis by Mann revealed the patient had not only regained the 4.4 inch deficit, but increased an additional 6 inches for a total left stride length change of 10.4 inches. The right stride length decreased by 1.1 inches. The patient had a personal record in the 200m sprint. The biomechanist and provider were blind to each other. This is unpublished data but has been submitted to a journal and is currently under editorial review (Horrigan, unpublished data).
An investigation was performed with regard to the exposure of physical therapy faculty and program directors (Ehrett 1988). 1% had a single unit of craniosacral therapy. 15% had a unit of myofascial release. 15% had units of both craniosacral and myofascial release. 69% included neither (Ehrett 1988). The lack of exposure in physical therapy, or any other field, may account for the low rate of inclusion in these forms of therapy in practices.
A case presentation indicated myofascial release had a favorable result with failed surgical decompression of the carpal tunnel (Browne et. al. 1999) (Miller 1997). Other authors presented the efficacy of myofascial release with cases of pronator syndrome misdiagnosed as carpal tunnel syndrome (Leahy, Mock 1992).
Shea and Keyworth noted that myofascial release is a complex form of soft tissue work that is highly effective for reducing pain and restoring motion and optimal function on a permanent basis (Shea, Keyworth 1997) (Barnes 1997). These authors noted this method was developed by American osteopathic practitioners and was presented almost exclusively in the osteopathic literature, but only after 1950 (Shea, Keyworth 1997).
An investigation into the efficacy of treatment for various forms of headaches revealed two interesting statistics: 1) multiple forms of modalities produce better outcomes than a single modality; 2) regardless of headache type, myofascial release had the most effective relief of symptoms (Ranieri et. al. 1998).
A case was presented of a trigger point in a well-healed surgical scar that referred pain. The trigger point was treated with transverse friction massage and therapeutic stretching (Updyke 2000).
Hunter described a procedure known as specific soft tissue mobilization (SSTM) which uses specific, graded and progressive application of force to promote collagen synthesis, orientation, and bonding in the early stages of the healing process or to promote viscoelastic response of the tissue in the later stages of healing (Hunter 1998).
---Author Joe Horrigan, DC
