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Principles of Treatment 5 Principles of treatment 5 CHAPTER CONTENTS • All pain arises from a source Introduction . 83 • All treatment must reach the source • All treatment must exert a beneficial effect on it. Techniques . 84 It is obvious that the method of treatment will depend largely Deep .transverse .friction . 84 on the existing type of disorder. Mode of action. 84 In orthopaedic medicine, disorders may be grossly catego- Relief of pain. 84 rized as follows: Effect on connective tissue repair. 85 • Traumatic – an injury resulting either from one single Indications . 86 trauma or from multiple small traumas, the so-called overuse injuries Contraindications . 87 • Inflammatory – rheumatoid: poly- or monoarticular, Technique . 88 infectious, traumatic Passive .movements . 91 • Degenerative Indications . 92 • Internal derangement – loose bodies and displaced menisci Manipulation of the spine . 95 in peripheral joints and intervertebral disc displacements Active .movements . 102 in the spine • – instability, weakness, proprioceptive Simple active movements to gain or preserve Functional disorders normal range in a joint . 102 disturbances Isometric contractions . 102 • Psychogenic pain – there is no existing functional or anatomical explanation for the pain. Isotonic contractions . 103 However, most ‘disorders’ have a combined aetiology: trau- Electrical contractions . 103 matic inflammation or repetitive internal derangement may Coordination exercises . 103 lead to functional instability or to weakening of the propriocep- Injection .and .infiltration . 104 tive reflexes; long-standing functional disorders may lead to General principles . 104 psychogenic decompensation. Before any form of treatment is undertaken, precise diag- Local anaesthetics . 106 nosis is mandatory; it is the type, extent and position of the Corticosteroids . 110 disorder present which determines treatment. Therefore train- Sclerosing agents . 114 ing in orthopaedic medicine must put great emphasis on how to reach a proper diagnosis. It is more difficult and requires considerable delicacy of approach to teach and learn how to diagnose and so to propose therapy chosen on logical grounds, Introduction than it is to instruct and learn treatment techniques. Other aspects must also be taken into account: how much pain can Cyriax had a straightforward opinion about treating orthopae- the patient bear? To what extent does the lesion interfere with dic problems: normal activities? How eager is the patient to receive a quick © Copyright 2013 Elsevier, Ltd. All rights reserved. General Principles cure? And what is the patient’s attitude towards certain thera- Deep transverse friction peutic methods such as corticosteroids and manipulation? Orthopaedic medicine based on a detailed functional exami- Deep transverse friction (although the word friction is techni- nation requires more knowledge, skill, time and effort from cally incorrect and would be better replaced by ‘massage’) is a the physician than just to order technical investigations, but specific type of connective tissue massage2 developed in an leads to greater professional interest, more appropriate diagno- empirical way by Cyriax.3 sis and a higher degree of patient satisfaction. Clear diagnosis Transverse massage is applied by the finger(s) directly to the and consequent selection of treatment on logical grounds also lesion and transverse to the direction of the fibres. It can be leads to better understanding between doctors and therapists. used after an injury and for mechanical overuse in muscular, Because the two groups work with the same types of patient, tendinous and ligamentous structures.4–6 In many instances the they must share a common approach. Therapists should no friction massage is an alternative to infiltrations with steroids. longer be regarded purely as technicians who listen to the Friction is usually slower in effect than injections but leads to physician and carry out orders. On the contrary, they should a physically more fundamental resolution, resulting in more be aware that they have diagnostic and therapeutic responsi- permanent cure and less recurrence. Whereas steroid injection bilities. Their opinion must be taken seriously and is important is usually successful in 1–2 weeks, deep friction may require to avoid unnecessary delay in achieving a satisfactory outcome. up to 6 weeks to have its full effect. The technique is often used before and in conjunction with Techniques mobilization techniques. In minor muscular tears, friction is usually followed by active movement, in ligamentous tears by passive movement and in tendinous lesions by active unloaded The treatment techniques used in orthopaedic medicine thus movements until full resolution has been achieved. depend entirely on the type of disorder. The different types It is vital that transverse massage is performed only at the of treatment we describe are: site of the lesion. The effect is so local that, unless the finger • Manipulation techniques (rapid, small-amplitude, thrusting is applied to the exact site and friction given in the right direc- passive movement – also called ‘grade C mobilization’) are tion, relief cannot be expected. used to reduce small cartilaginous displaced fragments Over the years, and unfortunately enough, the technique both in the spine and in peripheral joints (loose bodies). has developed a reputation for being very painful for the Manipulation is also called for to restore normal mobility patient. However, pain during friction massage is usually the in a joint restricted by ligamentous adhesion and in result of a wrong indication, a wrong technique or an unac- subluxation of bones. customed amount of pressure. Friction massage applied cor- • Gentle passive mobilizations (grade A and B rectly will quickly result in an analgesic effect over the treated mobilizations) are used to stretch capsular adhesions and area and is seldom a painful experience for the patient. to improve the function of ligaments and tendons. In the treatment of traumatic injuries they are often used in combination with deep transverse massage. Mode of action • Active movements and proprioceptive training are needed in the treatment of functional disorders and instability. Transverse massage should be used empirically for what it is In the treatment of minor muscular tears they are very and what it achieves; there is no scientific proof for any pos- useful in avoiding the formation of abnormal intralesional tulates about the underlying mechanism of action. 7,8,9 adhesion formation. Only a few studies exist, and more research is urgently • Injection and infiltration techniques are used to reduce needed. However, experienced therapists know in what traumatic or rheumatoid inflammation. They are most kind of soft tissues they can expect good results with trans- valuable in arthritis, bursitis, ligamentous and tendinous verse massage and where the technique does not work. Trans- lesions and in neurocompression syndromes. verse massage either is effective quickly (after 6–10 sessions) or not at all. Advice on indications, contraindications and • Deep friction is a very useful technique in treating modalities of the technique that are given in this book rely traumatic and overuse soft tissue lesions. The rationale for solely on the experiences of the authors and not on scientific using deep friction (which is in fact a form of soft tissue research. mobilization) is supported by experimental studies of However, although the exact mode of action is not known, the past several decades that confirm and explain the some theoretical explanations have been put forward. It has beneficial effects of activity on the healing musculoskeletal been hypothesized that friction has a local pain-diminishing tissues (see Connective tissue). effect and results in better alignment of connective tissue Repair and remodelling of healing tissues respond to cyclic fibrils. loading and motion.1 Early motion and loading of injured tissues is not without risk, however, and excessive loading can inhibit or stop healing. Deep transverse friction imposes cyclic Relief of pain loading without bringing too much tension on the healing lon- gitudinal structures of tendon or ligament and can therefore It is a common clinical observation that application of local be considered as beneficial. transverse friction leads to immediate pain relief – the patient 84 Principles of treatment C H A P T E R 5 experiences a numbing effect during the friction and reassess- It is now generally recognized that internal and external ment immediately after the session shows reduction in pain mechanical stress applied to the repair tissue is the main stimu- and increase in strength and mobility. The time to produce lus for remodelling immature and weak scar tissue – with fibres analgesia during the application of transverse friction is a few that are oriented in all directions and through several planes minutes and the post-massage analgesic effect may last more – into linearly rearranged bundles of connective tissues.16 than 24 hours.10 The temporary relief at the end of a session Therefore, during the healing period, the affected structures may prepare the patient for treatment with mobilization not should be kept mobile by normal use. However, because of otherwise possible, such as selective rupture of unwanted pain, the tissues cannot be moved to their full extent. This adhesions. problem can be solved by friction. Transverse friction massage A number of hypotheses to explain the pain-relieving effect
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