Probably the most effective soft tissue treatment I have used through the years is friction massage. James Cyriax, the English orthopedist, developed a functional examination to determine where the friction should be applied, since most of the time the most tender area was not the source of the pain. His theory was that the effect of friction was based on inducing a traumatic hyperemia, movement of the tissue, increased tissue perfusion and mechanoreceptor stimulation.1 He was very close to the present-day findings based on sophisticated examination of the tissue. Recent studies using light microscopy, electron microscopy and immunoelectron microscopy have shown that after friction massage there is fibroblastic proliferation and realignment of collagen fibers.2
A group called Performance Dynamics, a subsidiary of Ball Memorial Hospital in Muncie, Indiana, has been involved in researching the effects of friction massage. They use what they call augmented soft tissue mobilization, which involves the use of a special instrument in which "controlled microtrauma" leads to regression of fibrosis in various soft tissue structures.3 They believe that friction massage causes a microtrauma to an area of excessive soft tissue fibrosis or scar. They state: "The micro-injury causes microvascular trauma and capillary hemorrhage, resulting in a localized inflammatory response which serves as the stimulus for the body's healing cascade and immune/reparative system." The fibroblastic proliferation is responsible for the repair and regeneration of collagen, since fibroblasts produce fibronectin and synthesize collagen.
While Cyriax preached that friction should be across the fibers, Performance Dynamics states that the friction should be in a longitudinal direction. I feel that a possible barrier should be palpated first, allowing the practitioner to friction toward it, whether the direction is longitudinal, transverse or at an angle. When palpating near the insertion of the supraspinatus, for example, it's very difficult to palpate for a specific direction. I suppose frictioning in any direction will probably work since the force of the mechanical load is probably the primary stimulant.
A study by Gehlsen et al.4 demonstrated that the fibroblastic proliferation was directly dependent upon the magnitude of the applied pressure by their instrument. I have over the years always begun friction with a mild pressure, increasing it until a numbness of the tissue occurred, and then increasing the pressure to the next bearable level. I only use friction at the musculotendinous and insertion points of tendons, relying on fascial methods for use on the muscle bellies. New cadaver studies have helped in developing new locations for friction message where there is less overlying muscle in the way.5
References
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