Deep Transverse Friction
Deep transverse friction (although the word friction is technically incorrect and would be better replaced by 'massage') is a specific type of connective tissue massage (new reference) developed in an empirical way by Cyriax. ( 1)
Transverse massage is applied by the finger(s) directly to the lesion and transverse to the direction of the fibres. It can be used after an injury and for mechanical overuse in muscular, tendinous and ligamentous structures (old references 2-4) In many instances the friction massage is an alternative to infiltrations with steroids. Friction is usually slower in effect than injections but leads to a physically more fundamental resolution, resulting in more permanent cure and less recurrence. Whereas steroid injection is usually successful in 1- 2 weeks, deep friction may require up to 6 weeks to have its full effect.
The technique is often used prior to and in conjuction with mobilisation 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 movements until full resolution has been achieved.
It is vital that transverse massage be performed only at the site of the lesion. The effect is so local that, unless the finger is applied to the exact site and friction given in the right direction, relief cannot be expected.
Over the years, and unfortunately enough, the technique has been developed a reputation for being very painful for the patient. (2)
However, pain during friction massage is usually the result of either a wrong indication, a wrong technique or an unaccustomed amount of pressure. Friction massage applied correctly will quickly result in an analgesic effect over the treated area and is not at all a painful experience to the patient.
Mode of action
Transverse massage should be taken for what it is: no scientific proof (yet) but banking on empiry.
So far there is very little scientific evidence on mode of action and on effectiveness of friction. Only a few studies exist and more research is urgently needed. However, experienced therapists know in what kind of soft tissues they can expect good results with transverse massage and where the technique doesnt work. Transverse massage either works quickly ( after 6 to 10 session) or not at all. Advices on indications, contra-indications and modalities of the technique that are given in this book rely solely on the expiences of its authors and not on scientific research.
However although the exact mode of action is not known, some theoretical explanations have been put forward. It has been hypothesised that friction has a local pain diminishing effect and results in better alignment of connective tissue fibrils.
Relief of pain
It is a common clinical observation that application of local tansverse friction leads to immediate pain relief - the patient experiences a numbing effect during the friction and reassessment immediately after the session shows reduction in pain and increase in strength and mobility. The time to produce analgesia during the application of transverse friction is a few minutes and the post-massage analgesic effect may last more than 24 hours. (3)
The temporary relief at the end of a session prepares the patient for treatment with mobilisation not otherwise possible, such as selective rupture of unwanted adhesions.
A number of hypotheses to explain the pain relieving effect of transverse massage have been put forwards:
Pain relief during and after friction massage may be due to modulation of the nociceptive impulses at spinal cord level: the "gate control theory" . The centripetal projection into the dorsal horn of the spinal cord from the nociceptive receptor system is inhibited by the concurrent activity of the mechanoreceptors located in the same tissues. Selective stimulation of the mechanorecptors by rhythmical movements over the affected area thus closes the gate for pain afference.
According to Cyriax, friction also leads to increased destruction of painprovoking metabolites, such as Lewis's substances. This metabolite, if present in too high a concentration, provokes ischaemia and pain.
It has also been suggested that prolonged deep friction of a localised area may give rise to a lasting peripheral disturbance of nerve tissue, with local anaesthetic effect.
Another mechanism through which reduction in pain may be achieved is through diffuse noxious inhibitory controls, a pain suppression mechanism that releases endogenous opiates. The latter are inhibitory neurotransmitters which diminish the intensity of the pain transmitted to higher centres. (4,5,6)
Effect on connective tissue repair
Connective tissue regenerates largely as a consequence of the action of inflammatory cells, vascular and lymphatic endothelial cells, and fibroblasts. Regeneration comprises three main phases : Inflammation; proliferation (granulation) and remodelling. These events do not occur separately but form a continuous sequence of changes (cell, matrix and vascular changes) that begins with the release of inflammatory mediators and end with the remodelling of the repaired tissue.
Friction massage may have a beneficial effect on all three phases of repair.
It has been suggested that gentle transverse friction, applied in the early inflammatory phase enhances the mobilisation of tissue fluid and therefore increases the rate of phagocytosis. (7)
During the maturation, the scar tissue is reshaped and strengthened by removing, reorganising and replacing cells and matrix . (8) It is now generally recognised that internal and external mechanical stress applied to the repair tissue is the main stimulus for remodelling immature and weak scar tissue with fibres oriented in all directions and through several planes into linearly rearranged bundles of connective tissue. (9) 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. This problem can be solved by friction. Transverse friction massage imposes rhytmical stress transversely to the remodelling collagenous structures of the connective tissue and thus reorients the collagen in a longitudinal ashion. Friction is thus an useful treatment to apply at the beginning of the repair cycle (granulation and beginning of remodelling stage): The cyclic loading on and motion of the healing connective tissues stimulates formation and remodelling of the collagen (10).
As transverse friction aims basically to achieve transverse movement of the collagen structure of the connective tissue, crosslinks and adhesion formation are prevented . In the early stages of proliferation when crosslinks are absent or still weak, friction must be very light so as to cause only minimal discomfort. Therefore, in the first day or two following an injury, friction is given with slight pressure only and over a short duration, say one minute.
At a later stage when strong crosslinks or adhesions have formed, more intense friction is needed to break these down.( 11, 12). The technique is then used to soften the scar tissue and to mobilize the cross links between the mutual collagen fibres and the adhesions between repairing connective tissue and surrounding tissues . This, together with the produced local anaesthesia, prepares the structures for the mobilizations that apply longitudinal stress to the structures and rupture the larger adhesions.
Forceful deep friction produces vasodilatation and increased bloodflow to the area. It may be hypothesised that this facilitates the removal of chemical irritants and increases the transportation of endogenous opiates resulting in a decrease in pain. Such a forceful friction, resulting in traumatic hyperemia is only desirable in chronic, self perpetuating lesions.
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2- Woodman RM, Pare L. (1982) Evaluation and treatment of soft tissue lesions of the ankle and forefoot using the Cyriax approach. Physical Therapy 62:1144-1147
3- De Bruijn R. 1984 Deep transverse friction: its analgesic effect. International Journal of Sports medicine 5:35-36
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5- Field TM (1998) Massage therapy effects. Am Psychol Dec;53(12):1270-81
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7- Evans P. 1980 The healing process at cellular level, a review. Physiotherapy 66:256-259
8- Bulckwater JA, Crues R. (1991) Healing of musculoskeletal tissues. In : Rockwood CA, Green DP (Eds) Fractures JP Lipincott Philadelphia
9- Hardy MA 1989 The Biology of scar formation. Physical therapy 69:1014-1023
10- Buckwalter JA (1996) Effects of early motion on healing of musculoskeletal tissues. Hand Clin Feb;12(1):13-24
11- Walker H. (1984) Deep transverse frictions in ligament healing. J Orthop Sports Phys Ther 6(2): 89-94
12- Chamberlain G. (1982) Cyriax's friction massage: A review. J. Orthop Sports Phys Ther 4:16-22
13- Stannard JP, Bucknell AL (1993) Rupture of the triceps tendon associated with steroid injections. Am J Sports Med May-Jun;21(3):482-5
14- Clark SC, Jones MW, Choudhury RR, Smith En(1995) : Bilateral patellar tendon rupture secondary to repeated local steroid injections.J Accid Emerg Med Dec;12(4):300-1