|This text is an Abstract of the chapter ' deep transverse friction'
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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.
Indications in Shoulder and Elbow Lesions
The reduction in pain achieved after a few minutes localised transverse friction may be very helpful to define the exact location of the lesion.
In muscular, tendinous or ligamentous lesions, a few minutes of massage on the suspected spot results in diminished pain on testing immediately thereafter, so confirming the diagnosis as accurately as an infiltration with local anaesthesia.
Transverse massage is often applied prior to and in conjunction with other mobilizing techniques.
In muscular lesions, friction is given before active or electrical contractions on an unloaded muscle. The purpose of the latter is to allow broadening of the muscle, so preventing adhesion formation between mutual muscle fibres and/or - bundles.
Deep en thorough friction also proceeds manipulation of the elbow in case of a refractory type 2 tennis elbow. The technique is used for its desentizing and softening effect which makes the manipulation more tolerable
Friction is given to a healing muscle belly after contusion or in minor muscular tears. In minor muscular tears the friction is often part of a combined treatment as it is usually applied after an infiltration with local anaesthesia.
The aim of treatment in muscular tears is to allow the torn fibres to heal in such a way that normal enlargement during contraction remains possible. A muscle belly normally increases in breadth on contraction, a characteristic that can be disturbed by abnormal adhesion formation. Transverse friction aims to achieve a transverse sweeping movement over the longitudinal muscular fibres without pulling on the tear, so preventing (in the early stage) or breaking down (in the chronic stage) adhesion formation between the individual fibres and between individual fibres and the surrounding connective tissue. It is obvious that, to break down crosslinks in a chronic stage the friction can be given forcefully and for a duration of 15-20 minutes, whereas in more recent lesions the technique will be applied more gently and for a shorter duration.
Friction to a muscle belly is always given with the muscle well relaxed.
To avoid early recurrence, friction is given for one week after all clinical tests have become negative. During the period of treatment all movements or activities that bring on pain should be avoided by the patient.
Theoretically, friction can be used for all muscle belly lesions. However, some lesions respond so well to local anaesthetic infiltration that friction is not used. This is the case in a type IV tennis elbow ( lesion at the muscle belly of the extensor carpi radialis) and . On the other hand, sometimes no alternatives exist for treatment with deep transverse friction. A lesion of the sublavius or intercostal muscles for instance can be treated only by deep transverse friction.
It is a common clinical experience that all musculotendinous junctions (containing both muscular and tendinous fibres) throughout the whole body can be treated only by deep transverse friction. It seems that no alternatives for the friction exist: local anaesthetics, so curative for some muscle belly lesion and steroids, so effective at teno-periosteal lesions, have not the slightest effect on musculotendinous lesions, whereas deep transverse frictions usually have.
All over-use tendinitis can be treated by deep massage except for the tenoperiosteal origin of the extensor carpi radialis brevis (type 2 tennis elbow), which is best treated by an infiltration with steroid, in refractory cases sometimes by manipulations.
Lesions at the tenoperiosteal insertion can be treated either with steroid infiltrations or with deep transverse massage. Sometimes the friction, sometimes the infiltration will be the treatment of choice. Steroid suspension converts quickly an inflamed and painful scar into one free of inflammation. However, the recurrence rate is rather high ( between 20% and 25% ). The aim of the massage is to get rid of the self-perpetuating inflammation by breaking up the disorderly organised scar tissue and adhesion formations by converting it into properly arranged longitudinal connective fibres. This takes longer but once cure is achieved there will be fewer tendency to recurrence.
It may therefore be the policy to start treatment with infiltrations and if the trouble recurs after a few months to substitute with massage.
As a rule however, the friction is always choosen as the treatment of choice in athletes or in case the tendon is weakened (partial rupture). It can not be denied that repeated use of steroids, even in small doses and correctly applied, will temporarily weaken the tendinous structure. Steroids also take away inflammation and pain, so giving the patient the false feeling of being cured. The combination of a weakened tendon and abolition of pain can be disastrous for the tendon.
Lesions in the tendinous body (biceps tendon ?) , either traumatic or resulting from over-use are contra-indications for infiltration with steroids. Ruptures have been reported after intralesional infiltrations with steroids of long tendons and therefore deep frictions are the treatment of choice here.(13, 14)
It is obvious that during the whole period of treatment of tendinitis, tenosynovitis or tenovaginitis, the patient must avoid all activities that provoke the pain, especially loading the affected contractile tissue.
Transverse massage is an excellent treatment modality in acutely sprained ligaments ( superior and inferior acromioclavicular ligaments) .
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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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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