The purpose of this essay is to consider the merits of deep transverse frictions in the treatment of acute and chronic soft tissue injuries. To facilitate this I have considered a wide range of research that has been conducted into the use of frictions. I have also considered the use of alternative therapies in the treatment of similar conditions in order to evaluate the effectiveness of deep transverse frictions in comparison to each of the other treatment methods.
What is deep transverse friction?
Deep transverse friction was developed for the treatment of soft tissue lesions by the British osteopath Dr. James Cyriax who postulates that deep transverse friction is effective in the reduction of fibrosis and facilitates the formation of strong, pliable scar tissue at the site of healing injuries. Deep transverse friction, which is also known as cross-fibre frictioning (CFF), can help to alleviate build up of the crystalline deposits that can form between tendons and their sheaths and result in painful tendonitis. It can also help to offset the development of myofascial adhesions and soften those that are already present.
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Deep transverse frictions should be administered with a braced finger or thumb moving across the grain of the muscle, tendon or ligament with a deep, non-gliding, friction stroke. It is not necessary to use a lubricant as this reduces friction. The therapist's thumb and the client's skin should move as one over the exact site of the lesion to create a mechanical effect on the tissue being treated. The massage must be applied directly over the site of the lesion and at right angles to the fibres, the stroke must also be wide enough to divide the fibres without 'skipping' over them. The treatment can be painful, but should always be conducted within the pain tolerance threshold of the recipient, and should be started only with the informed consent of the client. It is contraindicated during the initial inflammatory stage of an acute injury.
Deep transverse friction may be utilised in the treatment of both acute and chronic conditions. Its uses include;
â€¢ mobilisation of interstial fluid
â€¢ reduction or modification of oedema
â€¢ increase of local blood flow
â€¢ decrease of muscle soreness and stiffness
â€¢ moderation of pain
â€¢ facilitation of relaxation
â€¢ prevention or elimination of adhesions (Wieting 2004).
There are a variety of massage techniques that can have physiological, neurological and psychological effects. These can be used to reduce pain and the formation of adhesion, mobilise fluids, increase muscular relaxation, and increase vasodilatation (Wieting 2004).
Mechanical pressure on soft tissues displaces fluid which then moves in the direction
of least resistance. Movement of the practitioners hand creates a pressure gradient
resulting in small amounts of fluid leaving the soft tissues and entering the venous or
lymphatic systems, improving lymphatic flow (Wieting 2004).
In addition to its mechanical effects, deep transverse friction (and other massage techniques) causes the release of histamine which has a superficial vasodilatory effect that assists in the washing out of metabolic waste products. A noticeable decrease in lactate occurs in massaged muscles which can be associated with reduced muscle spasm, increased endurance and force of contraction. (Cox, 2007)
Other beneficial effects of massage include decreased blood viscosity and increased hematocrit levels. There is also an increase in circulating fibrinolytic compounds
along with substances such as myoglobin, creatine kinase, dehydrogenase, and
glutamic oxaloacetic transaminase which probably represent local muscle cell leakage
from the applied pressure. There is also release of endorphins and enkaphalin
production (Wieting 2004).
Impulses from the stimulation of superficial skeletal muscle fibres, cutaneous and spindle receptors reach the spinal cord and may produce segmental moderation and even somatovisceral reflex changes (Wieting 2004).
The normal healing process may also be improved by the breaking of cross bridges, which will help to prevent abnormal scarring. The mechanical action of the technique causes hyperaemia and increased blood flow to the area (Brosseau et al 2002). In addition shearing stresses are created at tissue interfaces below the skin. e.g.dermis-fascia, fascia-muscle, muscle-bone interfaces, the deep pressure prevents shearing of superficial tissues and the shear force is directed at the deeper tissue surface interface (Wieting 2004). This helps release underlying adhesions and promotes improved circulation to the area (Lorenzo 2004).
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Sevier and Wilson (1999) describe vigorous cross friction massage for 5-10 minutes
over the common extensor tendon perpendicular to underlying soft tissue structures in
the treatment of lateral epicondylitis. Point friction may also be performed directly over the lateral eipcondyle and over the radial tunnel where it can be used in an attempt to reduce venous congestion at the extensor carpi radialis origin. This is a purely descriptive article of commonly used treatments for tennis elbow. No analysis of any evidence regarding the efficacy of any of these treatments is given.
Disabella (2004) describes the use of friction massage in conjunction with ultrasound
and/or electrical stimulation in the treatment of elbow and forearm overuse injuries.
In a systematic review of the use of deep transverse friction massage in the treatment
of tendonitis Brosseau et al (2002) found only 2 randomised controlled trials of
sufficient quality. One of which looked at patients receiving treatment for iliotibial
band friction syndrome and the other at tennis elbow.
The outcomes of both studies suggest that transverse friction massage combined with other physiotherapy modalities does not significantly reduce tendonitis symptoms when compared to a control. However these studies were of small sample size making it difficult to draw conclusions regarding the benefits or not of treatment of iliotibial band friction syndrome or tennis elbow with transverse friction massage.
The tennis elbow study looked at 9 sessions of transverse friction massage given over
5 weeks in combination with other physiotherapy modalities and in isolation. The
comparison groups were as follows;
â€¢ deep transverse friction massage with therapeutic ultrasound and placebo ointment compared with therapeutic ultrasound and placebo ointment
â€¢ deep transverse friction massage compared with phonophoresis alone
No difference was found in pain relief, grip strength and functional status between the
groups. This study used double blinding and a sound randomisation procedure but did
not report withdrawals and dropouts (Brosseau et al 2002).
Another study of lateral epicondylitis was carried out by Smidt et al (2002). 185
patients with lateral epicondylitis of at least 6 weeks were randomised using computer
generated block randomisation to 6 weeks of treatment with steroid injection,
physiotherapy or wait and see policy. The physiotherapy arm of the study consisted of
9 sessions of pulsed ultrasound, deep friction massage and an exercise program over 6
Outcome measures were general improvement, severity of main complaint, elbow
disability, grip strength and pressure pain threshold. Prior to the main study a
reproducibility study on 50 patients was carried out that demonstrated good intertester
reliability for the research physiotherapists carrying out the outcome measures.
Intention to treat analysis was used and at 6 weeks injection was significantly better
than all other options on all outcome measures. There was a high recurrence rate in
the injection group. The physiotherapy package (which included frictions) gave better
long term outcomes than injection but was no better than wait and see policy.
Interestingly the wait and see policy had better long term outcomes than injection and
physiotherapy that included transverse friction.
In a review article containing a summary of the evidence for the effectiveness of interventions for the management of tennis elbow Nimgade et. al (2005) used the Cochrane Collaboration guidelines to assess the quality of the evidence reviewed. The Cochrane guidelines have 11 score items for internal validity, 6 for external validity and 2 for statistical criteria. Thirty studies were reviewed and the quality scores awarded to each study varied between 2 and 9 (out of a possible 11). Eighteen of the studies scored between 6 and 11 points giving an indication of good quality.
It appears that relative rest will eventually improve function but the use of early
active interventions including steroid injection and physiotherapy modalities may
speed up recovery. The physiotherapy interventions reviewed included exercise and
ultrasound alone and in combination with friction massage.
These authors concluded that, patients who need a rapid return to work or usual
activities, may benefit from one or two steroid injections for pain relief in the first few
weeks or months and physiotherapy (which may include friction massage) at any
Smidt et al (2003) carried out a review to evaluate physiotherapy interventions for
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lateral epicondylitis. This was a well conducted review that found only one RCT with
acceptable validity showing exercises were significantly better than ultrasound plus
friction massage. The authors therefore concluded there was insufficient evidence for
the effectiveness for most interventions and there was weak evidence that ultrasound
may have a beneficial effect.
For the treatment of sub acute bicipital tendonitis Gonzalez (2004) recommended
physical therapy involving soft tissue therapy with transverse gliding of the tendon
and cross-friction massage.
In the trial reviewed by Brosseeau et al (2002) involving patients with iliotibial band
friction syndrome deep transverse friction massage was used in combination with rest,
ice, stretching exercises and ultrasound and this was compared to a control group
receiving rest, ice, stretching exercises and ultrasound only. No statistically
significant difference was demonstrated in pain relief after 4 sessions of friction
massage combined with the other modalities. There was however a clinically
important difference in pain when running.
This study was not double blinded but this is difficult to do where rehabilitation
interventions are concerned and can result in trials of such modalities having
consistently low methodological scores. However withdrawals and dropouts were
reported which is good practice but there were problems with the randomisation
procedure (Brosseau et al 2002).
In a summary of aetiology, pathology and treatment of temporomandibular joint
syndrome Berman (2004) suggest friction massage may help inactivate trigger points
due to temporary ischemia and resultant hyperaemia produced by a firm cutaneous
pressure. In addition small fibrous adhesions in the muscle formed as a result of
surgery, injury, or prolonged restricted motion may be disrupted.
Many studies have used subjective and non validated scales for pain measurement and
the use of combined treatments causes difficulties when trying to evaluate treatment
efficacy (Brosseau et al 2002). This can make comparison of outcomes between
different trials particularly difficult.
In studies where a lack of effect is demonstrated there are a number of variables that can contribute to this. These include characteristics of therapeutic application (experience of therapist, rate, rhythm and depth of technique application), population (age, sex, occupation, sports), disease (acute/chronic) and methodology
(blinding, randomisation, validated outcome measures, sample sizes, comparison groups, 'massage only' group to assess specific effects) (Brosseau et al 2002).
Comments & Conclusions
Despite a lack of good quality evidence to recommend either its inclusion or
exclusion transverse friction massage is a widely taught, and used, physiotherapy
treatment in the management of muscle, ligament, tendon injury and pain.
The majority of the literature found seems to review the usage of transverse friction massage in the treatment of tennis elbow. There is a lack of good quality,
randomised, controlled trials testing the efficacy of transverse friction massage either
in isolation or as part of management package. Many papers are descriptive in nature
of transverse friction massage being used in conjunction with other modalities. The
literature regarding mechanical, physiological, neurological effects and possible
mechanisms of action is speculative which could be due to such trials being difficult