Therapeutic Touch - Aims, Outline, and Evidence

Therapeutic Touch ----------------- ###### Aims - Understand the controversy & research difficulties related to TT in physiotherapy - Understand the targeted tissues and theoretical mechanisms underpinning TT - Introduced to key techniques used by physiotherapists ###### Outline...

Therapeutic Touch ----------------- ###### Aims - Understand the controversy & research difficulties related to TT in physiotherapy - Understand the targeted tissues and theoretical mechanisms underpinning TT - Introduced to key techniques used by physiotherapists ###### Outline - Research challenges - Pain - Possible tissues & mechanisms - Fascia - Trigger points - Pain systems - Somatosensory system - Techniques Therapeutic Touch ----------------- - Manual techniques applied to **soft tissues** (often called '**massage therapy**') - Manual techniques applied to **joints** - **Lymphatic** techniques - **Empathetic**, **relational** touch - **Desensitization** techniques - **Proprioceptive** feedback - Movement & breathing **facilitation** Evidence -------- - Reducing **pain** - Reducing **anxiety** - Improving **function** - Improving health-related **QoL** - Technique parameters - - Type of massage - Frequency - Duration - Intensity - **Inconsistent & unclear descriptions** of techniques used - **Practitioner** differences - - Specific profession - Years of experience - Variety of **conditions treated** - Comparisons with **no treatment, sham treatment, or in addition to another treatment** - Clinical **setting and context** Tissues & --------- muscles -- - Restore tissue extensibility and range of motion - Muscle **relaxation** - Reduce **pain** - Reduce **swelling/edema** - **Scar tissue** - **Adhesions** - **Trigger points** - **Spasm** mechanical changes -- - Breaking down scar tissue - Releasing 'knots' and adhesions - Deactivating 'trigger points' Tissues & --------- - Addition of **fascia** as a potential affected tissue - New research on the physiology of **trigger points** - Addition **of pain, emotional and psychological** - Addition of **proprioception and somatosensory** Tissues & Mechanisms -------------------- Tissues & Mechanisms -------------------- - Pain review - Possible tissues & mechanisms 1. Fascia 2. Trigger points 3. Somatosensory system 4. Pain & placebo Pain ---- Nociception ----------- - Signal of injury or threat sent (nociception) - Signal travels to SC, then the brain - The brain and SC can increase or decrease this signal depending on context & beliefs about the extent of danger, damage and other priorities Pain ---- **Yes!! Pay attention!!** Pain ----  - Nociceptive signal is **repetitive/prolonged** - The person **feels in danger & under threat** in any way - The person experiences **fear/lack of safety** in relation to the pain (e.g. trauma, shame, guilt) - The person has **negative beliefs** about the pain (e.g. it will never get better, they cannot cope, it will interfere with Pain ---- - Fear of **movement** - **Rigid** movement patterns - **Avoiding** particular positions/actions - **Somatosensory** and **motor control** changes - **Stopping activities** which used to be important, joyful, meaningful - **Mental health** challenges Pain ---- - Neurological relaxation - Somatosensory reorganization - Changes to motor control - Changes to sensitivity, fear and movement avoidance - Mechanical changes to the muscle 1: Fascia ========= ### Tissues & Mechanisms ### Tissues & Mechanisms Fascia includes -- - Neurovascular sheaths - Aponeuroses - Deep and superficial fasciae - Joint capsules - Ligaments - Membranes - Periostea - Retinacula - Tendons and tendon sheaths - Visceral fasciae - Endomysium, perimysium, epimysium ### Tissues & Mechanisms  - Contain a substantial number of **proprioceptors** - Contain **nociceptors** - Contain **myofibroblasts** -- cells which can contract - **Connect** in a continuous manner to muscles and other fascial tissues, allowing for **direct force transmission between distant structures** ### Tissues & Mechanisms Contraction of myofibroblasts -- - Not well understood yet - Some evidence of greater MFB contraction with sympathetic excitation - Some evidence for temporarily reduced contraction with **stretching** Fluid content (water and hyaluronic acid) -- - Changes in the **balance of HA and water** (e.g. following injury, exercise, mechanical loading) can change fascia stiffness #### Tissues & Mechanisms Fascia -- Myofascial Chains However, fascial tissues also provide a pathway for force transmission through myofascial connections e.g. - - Proximal medial **gastrocnemius** is continuous with **semitendinosus** via a fascial band - **Gluteus maximus** and **TFL** exert force on the knee joint **capsule** via the **ITB** #### Tissues & Mechanisms Fascia -- Myofascial Chains ### Tissues & Mechanisms - Increased **stiffness** - **Adhesions** tethering structures together - Chemical cascade contributing to 2: Myofascial pain & Trigger points =================================== #### Tissues & Mechanisms Myofascial Pain, Trigger Points #### Tissues & Mechanisms Myofascial Pain, Trigger Points #### Tissues & Mechanisms Myofascial Pain, Trigger Points #### Tissues & Mechanisms Myofascial Pain, Trigger Points - a **taut** band - a **hypersensitive** spot - **referred** pain #### Tissues & Mechanisms Myofascial Pain, Trigger Points #### Tissues & Mechanisms Myofascial Pain, Trigger Points #### Tissues & Mechanisms Myofascial Pain, Trigger Points - Deep tissue massage techniques - Dry needling - Joint mobilization/manipulation - Cupping - Increased **blood flow, oxygen and nutrient** - Centrally mediated **pain inhibition/desensitization** - **Relaxation**, reduced **sympathetic** activation - **Unclear** technique descriptions - Multitude of **different techniques** used in different - Techniques used as **standalone interventions with no clinical reasoning** or shared decision-making 3: Somatosensory ================ **changes** Mechanisms -------------------------------- - Improved positional/movement control - Understanding of the body as whole and perceptual effects of visual feedback (e.g. 4: Pain & Placebo ================= ###### Pain systems Safety and care Beliefs & expectations Mechanisms ---------- - Activation of pain inhibitory pathways - Changes in emotional processing regions of - Reduced hypervigilance, fear & anxiety - Psychological relaxation - Muscle relaxation Is this a placebo effect? What is the placebo effect? Mechanisms ---------- Mechanisms ---------- - **Patients feel safe**, understood and cared for - **Patients believes** the treatment will be effective - **Clinician believes** the treatment will be effective Mechanisms ---------- Mechanisms ---------- - Previous experience with a given intervention - Previous experience with medical - Beliefs about the cause(s) of their pain - Interactions with the treating clinician - Social and cultural context - Understanding of what is happening - Mental health influenced by beliefs -- Mechanisms ---------- Mechanisms ---------- Mechanisms ---------- Bialosky et al (2018) - Consideration of **patient preferences and** - Empathetic, reassuring, culturally - Shared decision-making - Utilisation of a manual technique in a caring context which **directly addresses emotional and pain processing** Techniques ---------- \ Common types -- - Myofascial Release - Fascial Manipulation - Trigger Point Release  - Swedish - Thai - Acupressure - Sports Techniques ---------- ##### Deep Tissue Massage - Long, Swedish massage strokes with - Slow, diagonal strokes (cross-fiber) maintaining deep pressure using body weight Techniques ---------- ##### Deep Tissue Massage  Techniques ---------- ##### Deep Tissue Massage Techniques ---------- ##### Myofascial Release Techniques ---------- ##### Myofascial Release Techniques ---------- ##### Myofascial Release Techniques ---------- ##### Fascial Manipulation - Increased fascial stiffness - Altered proprioception - Altered coordination - Non-physiological joint movement - Myofascial pain Techniques ---------- ##### Fascial Manipulation 6 myofascial units Techniques ---------- ##### Fascial Manipulation Techniques ---------- ##### Fascial Manipulation Techniques ---------- - Compression techniques (most commonly - Spray and stretch - Frictions - Dry needling - Cupping - Joint mobilizations & manipulations - Small number of studies - Low quality of many studies - Variety of treatment protocols and patient presentations - Short follow-up times research is needed" Techniques ---------- ##### Sports Massage Techniques ---------- ##### Sports Massage - **Effleurage** (long strokes in the direction of lymphatic drainage - **Petrissage** (lifting tissue away from underlying - **Wringing** (tissues grasped in both hands and twisted in opposite directions) - **Tapotement** (repeated light strikes) - Vibrations & shaking - **Frictions** (brisk, deep stroke transversely across fibres) - **Compressions** (hard, constant pressure through Techniques ---------- ##### Sports Massage - No evidence for improved performance - Two studies suggested a possible detrimental effect on performance - Small but significant **increase in flexibility** (though no studies investigated whether the effect was any better than stretching) - Small but significant **reduction of DOMS** Techniques ---------- ##### Lymphatic Drainage - Post-surgical (particularly - Cardiac patients Techniques ---------- ##### Lymphatic Drainage - Direct pumping effect of the technique - Stimulation of lymphatic pumps Self-Release ------------ - Trigger point release - Reduction of MFP - Increase myofascial extensibility - Increase ROM - A short-term **ROM increase** following 30-60s of - No **negative impact on performance** (unlike static stretching) - Limited evidence for **reduced TrP sensitivity** - Reduced pain Risks ----- - Deep vein **thrombosis**/thromboembolism - Neuropathies - Severe **bruising** following forceful techniques - **Autonomic effects** (e.g. nausea, sweating, BP changes) - **Skin reactions** to oils/creams - Skin breakdown - **Psychological** distress/panic/dissociation \ Precautions - - History of or current **DVT** - Inflammation, recent injury - **Clotting dysfunction** (e.g. hemophilia, anticoagulant medications) - **Neurological** signs - **Frail skin** (particularly in older people) - Open wounds, inflammation, infection - History of trauma, neurodiversity or other potential causes of **touch aversion**  Summary ------- mechanical, neurophysiological and/or psychological effects References ---------- References ---------- References ---------- References ----------