MASSAGE EVIDENCE BASED PRACTICE

massage is no exception. For example, a prerequisite for masseurs applying for major sporting events such as the Olympics and Commonwealth Games is a minimum of 500 hours of practical sports massage. In a study by Moraska (20), the level of therapist training was shown to impact on the effectiveness of massage as a post-race recovery tool following a 10km run. A greater reduction in muscle soreness was achieved by therapists with 950 hours of training compared with those with 450 hours of training. Interestingly, Bramah (5) believes the reason why chartered physiotherapists fail to understand “massage” is because they receive approximately only six hours of massage training throughout their entire university degree course (5).

THE ROLE OF MASSAGE IN THE TREATMENT OF SOFT- TISSUE INJURIES The key to delivering safe and effective massage in the treatment of soft-tissue injuries and conditions is to understand what is happening in the body’s soft tissues at each successive phase of healing. Clinically, tissue condition should drive and dictate the type, style and intensity of therapeutic massage delivered. Here, suitable complementary interventions will be considered to optimise tissue healing, recovery and rehabilitation.

Phases of tissue healing With respect to tissue healing, a consensus exists, consisting of four overlapping, interlinked phases (Fig. 1): bleeding, acute inflammation, proliferation and remodelling (11,21). Tissue conditions with respect to the

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2–6 days and prepares the wound for the proliferation (subacute) phase.

bleeding inflammation proliferation remodelling hours acute phase sub-acute phase chronic phase

Figure 1: Basic response to tissue injury, and the subsequent overlapping phases of healing

aforementioned phases of healing are also referred to as “acute”, “subacute” and “chronic”.

1) Acute phase (bleeding and inflammation) Following injury, damaged blood vessels bleed. This triggers a natural but essential inflammatory cascade of events, involving a vascular and cellular response with fluid exudate, resulting in oedema and phagocytic activity. Acute inflammation results from vasodilation and vasopermeability of the blood vessels. Clinically, acute inflammation manifests as swelling, erythema, increased temperature and pain, leading to loss of function. The physical characteristics of acute inflammation were first formulated by Celsius (30BC–AD38) using the Latin words rubor, calor, tumor and dolor. Typically, the acute inflammatory phase lasts

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Treatment in acute phase Prevention, containment and removal of swelling represent the essential hierarchy of care, regardless of cause (15). This approach limits the amount of bleeding, oedema, swelling and pain and therefore promotes optimal healing (17,22). Limiting inflammatory exudate (swelling) reduces the amount of fibrin, and ultimately the amount of excessive scar tissue (23), while limiting adhesions and excessive cross-link formation (24). Consequently, through early and effective control of inflammation, the recovery period is shortened and the quality of the repair enhanced. Conversely, failure to control swelling and oedema, or aid its speedy resorption, can prolong recovery and adversely affect the quality of repair. Excess oedema causes pain as pressure is exerted on nociceptors; this further prevents cells from being nourished in fresh tissue fluid. It is widely accepted that control of the acute inflammatory phase is best achieved by “PRICE” – protect, rest, ice, compress and elevate (15,21–24). For more details, see the Association of Chartered Physiotherapists in Sports Medicine (ACPSM) guidelines (22). According to some authors, massage has a limited use during the acute phase. However, the early intervention of effleurage and petrissage can be effective when aimed at the resorption of inflammatory exudate. Massage should not be applied directly over the injured site; nor should the patient be given stretching or dynamic strengthening

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