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MASSAGE EVIDENCE BASED PRACTICE
Figure 5a: Free movement of normal healthy fibres under tension with good extensibility
Free movement of normal healthy fibres under tension with good extensibility
Restricted movement of collagen fibres under tension due to abnormal cross- links/adhesions; this limits extensibility
Treatment in subacute phase Treatment aims of the subacute phase are to: n control activity in order to protect the new fragile tissue n the removal of swelling and oedema n to encourage proliferation and healing n to avoid formation of abnormal cross-links/adhesions that restrict normal movement n to break down existing cross-links/ adhesions (Figs 4 and 5) n to encourage commencement of remodelling and realignment of the newly formed collagen fibres n to progressively improve the range of joint movement n to educate the patient.
The main risk is re-rupturing the newly formed fragile tissue posed by the patient wanting to do too much too soon. With regard to treatment, the
removal of oedema should continue by using the same protocols from the acute phase. Gentle circular frictions can be introduced to break up thickened oedema, particularly around joints. Although lacking evidence, contrast bathing is considered to be effective during the subacute phase. Contrast baths decrease swelling and inflammatory exudate by alternating heat and cold to create an alternating mechanical force due to vasodilation and vasoconstriction. Within the literature, different treatment durations are often cited; however, 3 minutes of cold followed by 3 minutes of heat, repeated three times, is fairly typical. Meanwhile, the repair process and
remodelling of tissue that follow are highly responsive to mechanical signals such as manual therapy (24,29,30,32). Holey and Cook (15) suggest that vigorous petrissage techniques stretch and pull the tissues in various directions, thus mobilising adjacent connective tissue fibres. Cross-fibre frictional massage, developed by Cyriax, can be applied to break up adhesions, increase the mobility of the new scar tissue as it heals (32), and promote remodelling and realignment (15). As a guide, gentle cross-fibre frictional massage can commence directly to the site approximately 7 days post-injury. The level of pressure and intensity should not elicit pain.
As the healing tissue gains tensile
strength over the following days and weeks, the pressure, intensity and duration of frictions should gradually increase, within low to moderate pain levels. Cross-fibre frictional massage can be applied with the pads of the thumb or fingertips (Fig. 6) at 90° to the targeted fibres, taking the tissues through their full sweep, to their end-feel (15). Purportedly this has the desired effect of mobilising scar tissue by separating the individual fibres (15) and restoring inter-fibre mobility (24). Frictional massage should commence at 1–2 minutes duration, progressing to 5 minutes or more over the following weeks (15). For more chronic thickened scar, Hammer and Levy (33) suggest a treatment duration of up to 15 minutes. Collagen fibres align along the lines of stress, which can be facilitated through stretching (15,29,31). Stretching exercises are important; however, they
Figure 5b: Restricted movement of collagen fibres under tension due abnormal cross-links/ adhesions; this limits extensibility
should be performed with caution and typically not before 7–10 days post-injury. The stretch must be controlled otherwise the newly formed tissue will be disrupted. The effects, duration, force-loading and frequency of stretching remain controversial. Evidence demonstrates that stretching should be performed slowly rather than rapidly, allowing the tissue to undergo viscous changes. During the vulnerable subacute phase, pain levels should determine the force of loading in order to avoid re-traumatising the fragile tissue (24). Based on research from various trials, stretching should be performed daily, with four 30-second repetitions repeated four times spread over the day (34,35). Sustained myofascial release is a form of massage and is performed by applying a tensile force with the thumb, braced fingers or foreman, usually in a longitudinal direction. The aim is to rupture abnormal cross-linkages and adhesions between collagen fibres formed as a result of the inflammatory response. During the subacute phase, the pressure applied must be regulated to reflect the tensile capabilities of new tissue (36).
3) Chronic phase (remodelling) After approximately 2–3 weeks post-injury, collagen maturation and remodelling initiate (21,37), continuing for months or even years. With maturity, the collagen remodels becoming more obviously oriented in line with local stresses (29,31). A portion of the type III collagen is reabsorbed and is replaced by type I collagen with greater tensile strength.
Figure 6a: Cross- fibre frictional
massage using thumb
RANGE OF THERAPISTS, IN MANY COUNTRIES, IN MANY SPORTS
MASSAGE CONTINUES TO BE USED BY A WIDE
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