Figure 6b: Cross- fibre frictional massage using finger pads

Figure 7a: Sustained myofascial tension to the Iliotibial Band applied, usually applied by elbow or forearm

Figure 7b: Sustained myofascial tension combined with passive knee extension. The hand forearm is kept stationary and the release is performed by passively extending the knee

Treatment in chronic phase Treatment aims are to address functional deficits and to prepare the patient for work or sport. Restoring muscle strength, normal pain-free range of motion and proprioception represent key areas of rehabilitation. Massage techniques aim to encourage optimum tissue healing and collagen re-alignment and to develop a mobile scar with high tensile strength. Untreated scar tissue is considered a major cause of re-injury, even years later. At this stage, tissue is maturing and has gained good tensile strength and thus is capable of withstanding much higher loading (see Fig. 2). Massage should be vigorous, deeper and stronger. According to Norris, vigorous frictions can induce pain relief (via pain gates) and improve mobility of tissue, all of which are useful in healing (38). It is generally accepted that heat should be applied during the chronic phase to improve tissue pliability. Therefore, hot-packs can be used to preheat tissue before applying (manual therapy) massage, stretching and so on. Wheat packs can be heated in a microwave conveniently located in the clinic. Active and passive stretching should continue, but with increased force and loading. To achieve effective stretching

inflammation stress repair

thickening, loss of pliability

remodelling Figure 8a: Re-occurring inflammatory cycle

during the remodelling phase, the tensile force used should bring the tissue to its end-elastic/early-plastic range (24). Beyond this range, tissue rupture may occur. Lederman (24) suggests that a loading that elicits a “pleasant” stretch sensation that feels “therapeutic” is ideal. Strength deficits should be addressed using various methods of progressive resistance exercise. These may include body resistance, elastic clinibands or more complex methods such as multi-gym systems or even isokinetic equipment. Rehabilitation should include both concentric and eccentric contractions (32). Hamstring muscles and the calf/Achilles complex are typical examples that require eccentric work.

WHEN AIMED AT THE RESORPTION OF INFLAMMATORY EXUDATE

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EARLY INTERVENTION OF EFFLEURAGE AND PETRISSAGE CAN BE EFFECTIVE

Chronic inflammation Chronic inflammation must not be confused with the normal chronic phase of healing, as described above. Inflammation that persists for months or more is termed “chronic” and is due to a breakdown in the normal healing process.

Chronic inflammation occurs when the acute inflammatory response fails to eliminate the injury and thus restore the tissues to their normal physiological state. Recurring cycles of acute inflammation and healing lay down extra fibrous tissue; this fibrotic build-up eventually causes stiffness. This is known as the “inflammatory cycle” (Fig. 8a). Failure to identify the cause and break the inflammatory cycle leads to chronic scarring, tissue adhesions, permanent stiffness, and loss of range of movement of the affected joints. The classic characteristics of chronic inflammation include fibrous stringy tissue, thickened tissue (Fig. 8b), stiffness after rest in the morning, swelling without heat or redness, and a dull nagging ache. Generally, pain levels are low but persistent, compared with acute conditions. Treatment of a chronic inflammatory condition relies on breaking the inflammatory cycle. This often involves identifying and removing causative factors. With regard to chronic inflammatory conditions caused by, for example, overuse, treatment protocols are very similar to those discussed above for the chronic phase – for example, heat, vigorous massage techniques, myofascial release and stretching, including PNF and MET.

CONCLUSION Despite the dearth of robust evidence to support its efficacy, massage continues to be used by a wide range of therapists, in many countries, in many sports, and is recognised as one of the most popular and established manual therapy techniques. However, its delivery, similar to other interventions, must be safe and ideally effective. This can be achieved by applying sound clinical reasoning, ongoing assessment, patient education and adherence strategies, and cognitive and meta-cognitive skills, all embraced within the scientific principles underlying tissue healing.

sportEX dynamics 2009;22(Oct):12-17