SOFT TISSUE DEEP TRANSVERSE FRICTIONS

and external mechanical stress applied to the repairing tissue is the main catalyst for remodelling immature and weak scar tissue with fibres oriented in all directions and through several planes into linearly rearranged bundles of connective tissue (38). Therefore, during the healing period, the affected structures should be kept mobile by using them normally. However, because of pain, the tissues cannot be moved to their full extent. DTF imposes rhythmical stress transversely to the remodelling collagenous structures of the connective tissue, which rearranges the collagen in a longitudinal fashion. DTF may be a useful treatment to apply at the granulation stage and beginning of remodelling stage due to the loading on and motion of the healing connective tissues stimulating the formation/remodelling of collagen (39).

WHAT IS HAPPENING TO THE TISSUE? The inflammatory chemicals released cause local vasodilation and traumatic hyperaemia. This lasts for some considerable time and may have some beneficial effects. These chemicals also stimulate local nociceptive endings and initially cause pain. After the application of DTF, pain is reduced (40–46). The pain reduction seen with DTF may result from the massage acting as a noxious stimulus (counterirritant) through mechanoreceptor activity. This would explain why DTF used aggressively gives better pain reduction than DTF given lightly, as the more aggressive approach causes greater mechanoreceptor stimulation, which has been shown to increase pain suppression (47).

PAIN RELIEF Pain relief seen clinically is often fairly long-lasting. A study by de Bruijn showed pain relief for up to 48 hours following DTF of a maximum of five minutes (48). The pain relief during and after DTF may be due to

the behaviour of the nociceptive impulses at the spinal cord level, according to the “pain gate control theory”. The centripetal branch of the dorsal horn of the spinal cord from the nociceptive receptor system is inhibited by the simultaneous activity of the mechanoreceptors located in the same tissues. Selective stimulation of the mechanoreceptors by rhythmical movements over the affected area closes the gate for pain afference. The arrival of nociceptive stimuli at certain central inhibitory nuclei in the central nervous system causes release from neurons at the cord level of encephalin. Encephalin blocks the action of neurotransmitters in the pain circuits (substance P) (42,46).

Another mechanism through which reduction in pain may

be achieved is the spreading of noxious inhibitory controls, a pain-suppression mechanism that releases sedatives from within. The latter are inhibitory neurotransmitters that diminish the intensity of the pain transmitted to higher centres (49–51).

FASCIA It is important to consider the role of fascia and how injury affects the fascial system. Research points to a holistic role for the mechanical distribution of strain in the body that goes far beyond dealing with localised tissue pain. Creating an even tone across the myofascial meridians, and further across the entire fascial net, could have profound implications for health, both cellular and general (52).

In the case where an injury to the fascia has not healed completely due to the release of transforming growth factor

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MOVEMENT TO THE DAMAGED TISSUE

DTFS ARE THOUGHT TO APPLY

beta-1 during acute injury, fibrosis begins to take place (10–14 days post-injury), which interferes with regeneration of the perimysium, epimysium and endomysium of muscle. Fibrous scar tissue may have long-lasting and damaging effects on the performance and recovery capability of the soft tissue (52). Applying a force to one area of a tensegrity structure (the property that certain structures possess of maintaining their integrity as a result of continuous tensile integrity) rather than continuous compressive integrity (53) results in restructuring of the whole in order to accommodate. “An increase in tension of one of the member’s results in increased tension in members throughout the structure, even ones on the opposite side” (54). At a later stage, when strong cross-links or adhesions

have formed, more intense friction is needed to break these down (55,56). The technique is then used to soften the scar tissue and to mobilise the cross-links between the collagen fibres and the adhesions between, repairing connective tissue and surrounding tissues.

APPLICATION Therapists must have an accurate knowledge of the structures involved before performing DTF – not only their position but also the direction of their fibres when put under tension. Application of transverse frictions must be accurate in terms of the position of the operator’s fingers, the direction in which the finger is moved, and the tension in the structures to which the technique is applied. Because DTF involves the application of friction and pressure at depth to the culpable lesion that is considered to be the origin of the pain (57), the pressure and movement itself is sufficient enough to disrupt normal tissues, cause minor damage and result in the release of inflammatory chemicals such as histamine and bradykinin (58,59). Mechanical movement of the tissues is a most effective method for either preventing or breaking down adhesions and reducing pain (40,41,60). Movement should be across the fibres making up the tissue, because frictions applied transverse to the long axes tend to move the structure as a whole (ligament, tendon or muscle). This passive manipulative

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