Let's Talk About ART

[Jason Silvernail]

dswayze-

I wasn't aware that it's impossible for manual therapies to break up fibrotic adhesions. What's your source/reference for this?

Not exactly impossible, but you've got to push pretty hard, if you read Threlkeld's 1992 paper you'll see that:
Manual Therapy and Connective Tissue - Threlkeld

Unless of course you are placing between 24 and 115kg of force (at bare minimum) on the patient - in which case of course it's possible. But how hard are we pushing with our little ASTYM tools today?
One word for that kind of "therapy" - ouch.

[EricM]

Unless of course you are placing between 24 and 115kg of force

...and assuming that: a) none of the force is dispersed (via various layers of connective tissue) and b) the force is transmitted precisely to the specific target in such a way as to deform it as intended.

[Kim LeMoon]

Originally Posted by Jason Silvernail

Unless of course you are placing between 24 and 115kg of force (at bare minimum) on the patient - in which case of course it's possible. But how hard are we pushing with our little ASTYM tools today?
One word for that kind of "therapy" - ouch.

Ditto regarding the "ouch". The most intense form of instrument-assisted manual therapy I know of is Roptrotherapy, in which studies using a pressure algometer have demonstrated the degree of force that is employed:

"It is applied with a greater pressure, starting with 5-10 Kg/cm², specifically on the deeper layers of the muscle. We called this method “roptrotherapy”. It usually takes 5 to 20 minutes to treat one single “knot-like” hardening with deep friction and it is usually applied in Japan on the musculoskeletal structures of the whole body for at least 90 minutes in total."

[Luke Rickards]

...and c) the target (fibrotic CT) can be reliably identified and is clinically relevant.

[Jason Silvernail]

Eric, Luke-
Thanks for the clarifications - you're both right.

I'd like to amend my statement to make it more accurate.
Connective tissue (CT) can be plastically deformed (permanently changed) by forces from 24 to 115kg, assuming that such force is not dispersed via layers of CT, transmitted exactly to the particular target tissue, and that the target can be reliably identified.
You would want to do this for therapeutic purpose only if you could reliably identify the exact location of the particular CT you wanted to deform, you could be sure it was relevant to the patient's complaint, and you were able to exactly deliver the precise amount of force needed.

Sounds VERY unlikely to most of us here.

[dswayze]

Originally Posted by Jason Silvernail

dswayze-

Not exactly impossible, but you've got to push pretty hard, if you read Threlkeld's 1992 paper you'll see that:
Manual Therapy and Connective Tissue - Threlkeld

Unless of course you are placing between 24 and 115kg of force (at bare minimum) on the patient - in which case of course it's possible. But how hard are we pushing with our little ASTYM tools today?
One word for that kind of "therapy" - ouch.

Hi Jason,

I'm aware of the Threlkeld paper, however, it's getting dated (16 years) and I'm not aware that any significant amount of evidence that would make this definitive in one way or another.

Do you k(not) (hehehe) see any inherent value in tissue remodelling as a desired therapeutic effect to increase clinical outcomes?

DS

[Jon Newman]

Hi ds,

These sorts of questions and comments (a sampling from thread so far) are fine to ask but consider starting a new thread (or chime in on the link BB provided in post #30) simply because the list (10 steps to understanding pain) posted in this thread has little to no relevance to your points in my opinion.

Do you k(not) (hehehe) see any inherent value in tissue remodelling as a desired therapeutic effect to increase clinical outcomes?

Even a better question still, is why wait until "pain" arises when you can prevent, correct and maintain better function?

I guess you're not into prevention and SCREENING for NMS disorders.

Just so I'm clear here does the panel:

1) reject the theory behind of IASTM and its intended outcomes?

2) See's no theoretical/practical value in addressing fibrotic tissue in movement dysfunctions and pain syndromes?

[dswayze]

Originally Posted by Jon Newman

Hi ds,

These sorts of questions and comments (a sampling from thread so far) are fine to ask but consider starting a new thread (or chime in on the link BB provided in post #30) simply because the list (10 steps to understanding pain) posted in this thread has little to no relevance to your points in my opinion.

Ouch.

[Jason Silvernail]

DS-
Jon's right - we are talking about a topic separate from the consensus. There's an ART thread here. I'd be happy to move some of our posts about connective tissue and manual therapy and continue our discussion if you'd like. Please post there if you'd like to keep going. I certainly have more to say - starting with the fact that the age of a paper in basic science says little about the strength of it's conclusions. Especially since I'm not aware of the work being updated - but I'd love to be proven wrong.

[Diane]

I can cut off the thread at some take off point and paste the cut part into a separate thread. Let me know if you'd like me to do that..

[dswayze]

Originally Posted by Jason Silvernail

DS-
Jon's right - we are talking about a topic separate from the consensus. There's an ART thread here. I'd be happy to move some of our posts about connective tissue and manual therapy and continue our discussion if you'd like. Please post there if you'd like to keep going. I certainly have more to say - starting with the fact that the age of a paper in basic science says little about the strength of it's conclusions. Especially since I'm not aware of the work being updated - but I'd love to be proven wrong.

Sounds good. I also realize that old papers can see be good; Watson and Crick comes to mind. But unless you somehow suggest that the paper you presented is in that league, then I doubt very much that those conclusions are irrefutable.

[bernard]

I can cut off the thread

Moved to the ART thread.

[oljoha]

These posts that have been moved on to here have nothing to do with ART. There is talk of remodelling connective tissue and breaking connective tissue which is not what ART is adressing.

It has been shown several times and I think I have posted links to the articles on PubMed - that with repetitive strain you will see adhesions in the tissue - which is nothing like severe scarring - but IMO they could cause restriction of motion and contribute to some sort of entrapment of neural tissue in the muscle or atleast increased mechanical stress on this tissue.

Again - that pain will probably in some individuals lead to a chronic pain problem. And I suspect chronic pain will contribute to a decline in the intramuscular environment as well - causing more of those adhesions.

[BB]

Hi Ole,

DSwayze made this comment:

Kim, if you've ever done active soft tissue manual therapy techniques, such as ART, the practitioner and the patient feels and knows when they are breaking up fibrous adhesions.

which is I believe why the posts landed on this thread.

Do you feel there is a similarity between the instrument assisted STM interventions and ART or 2 separate mechanisms at work?

[oljoha]

Originally Posted by BB

Do you feel there is a similarity between the instrument assisted STM interventions and ART or 2 separate mechanisms at work?

Instrument assisted STM usually try to really break tissue, create bleeding and inflammation. With ART you don't want that.

Naturally there is a lot of other stuff going on: there's the skin stretch (I've come to agree with Diane - but I think it's OK to inflict some discomfort / pain in patients because it's in a different context and non threatening to the patient). There's the movement the patient does - there is usually a great deal of learning in that. There's a lot of nerve gliding - there are separate protocols for treating nerves which are similar yet different.

[Kriskul]

May 10th I am going to Stomennano,italy to see what ART is all about )http://www.activerelease.com/seminar...tSeminarId=198. To me ART looks like a great form of manual care, though the quality of the course will depend a great deal on the theoretical framework being presented. I m guessing it will be slightly too mesodermal for the average somasimpler, though absolutely edible.


I love Dianes theoretical framework, though my soul is just too restless for those prolonged lateral stretches.

[oljoha]

Birger told me I'll only be there on the 18th for the neural entrapments. As for theoretical framework - not much it's 90% practical - which should put you back in touch with some forgotten anatomy.

Originally Posted by Kriskul

I love Dianes theoretical framework, though my soul is just too restless for those prolonged lateral stretches.

I'm also a bit too restless for prolonged stretches - however I suspect that doing some repetitions of shorter durations will be equally - perhaps even more effective. Why? Most of our senses are phasic and they'll adapt to what ever you throw at it. Taking a short break and coming back in will "force" the brain to sit up and pay attention.

[BB]

Most of our senses are phasic and they'll adapt to what ever you throw at it.

This is why skin stretch must not be viewed or practiced as a static stretch. Constant movement, variation in pressure is crucial. This is also of the tougher technical aspects to "get." If you were to have me do DNM on you and then Diane that would likely be a notable difference. Her constant movement is very perceptible if minute.

[Luke Rickards]

Her constant movement is very perceptible if minute.

Yes. It wouldn't be a very interesting kinesthetic conversation if it consisted of the same word over and over.

[oljoha]

Ok - I didn't gather that from the manual she wrote. Good stuff.

[Diane]

Yes, sorry if it comes off sounding static. One has to track/adapt to whatever the patient's nervous system is busy doing. Two-way conversation/adaptation.

[BB]

I should add to my statement below that the difference likely to be felt between my application of treatment and Diane's is one of technical skill/attention and not of approach. In other words, I don't mean for there to be a difference.

Also, as an example for this discussion: I've got a girl coming in now with UE CRPS. At one session with simple contact she pointed out that her ability to become aware of and therefore express the movement was dependent upon her ability to feel my hands. Her ability to feel my hands was dependent upon a continual variation in pressure.

This was very instructive to me and once again demonstrates what our patients have to offer us.

[Jason Silvernail]

DS-
I don't think the "league" of the paper matters that much. If it was a summary of evidence or a theoretical perspective that had been left behind by data, that would be one thing. I'm not aware of the basic science in Threlkeld's paper being refuted. Of course, I'm not much for biomechanics, so I'm willing to believe this sort of work has been repeated and there might be more recent and possibly more accurate data. I'd love to read about it if anyone has it. I don't consider the conclusions "irrefutable", I'm just not aware of them being refuted. If they have been, I'd like to update my knowledge base.

This paper and it's references really make the position of being able to remodel connective tissue very untenable.

Ole-
I see that (in rereading the thread) you've explained why ART is different and not considered to be all about breaking up adhesions. However, I felt that this was the most appropriate thread considering these issues were explored here further.

[dswayze]

Originally Posted by Jason Silvernail

DS-
I don't think the "league" of the paper matters that much. If it was a summary of evidence or a theoretical perspective that had been left behind by data, that would be one thing. I'm not aware of the basic science in Threlkeld's paper being refuted. Of course, I'm not much for biomechanics, so I'm willing to believe this sort of work has been repeated and there might be more recent and possibly more accurate data. I'd love to read about it if anyone has it. I don't consider the conclusions "irrefutable", I'm just not aware of them being refuted. If they have been, I'd like to update my knowledge base.

I'm under the impression that IASTM manual suggested otherwise (it is referenced) and I will ask the PT at work to borrow it. Still, it seems that you're putting a lot of weight behind one paper which would hardly classify as 1A evidence, but appreciate your viewpoint.

Regarding ART, it's my understanding that it's mainly for peripheral nerve entrapments and fascial irritation. Though I can easily see neural gliding, lymphatic drainage, DNM and other concepts explaining the success behind it. The DC in the office has taken these courses and I was impressed with the anatomy covered although am quite skeptical of some of the protocols (for example the psoas attached at the lumbar spine, YEAH RIGHT!)

[oljoha]

Originally Posted by dswayze

(for example the psoas attached at the lumbar spine, YEAH RIGHT!)

It does attach to the lumbar spine...
http://www.yogaatwork.co.uk/images/Image14.gif

[Luke Rickards]

It does attach to the lumbar spine...

I thought that point was relating to the likelihood of getting to those attchments directly with your hands.

[Baecker]

Would you consider ART with patients in chronic pain, those which you just touch from far and they perceive pain?

[oljoha]

Originally Posted by Baecker

Would you consider ART with patients in chronic pain, those which you just touch from far and they perceive pain?

Yes. ART is after all "just" a technique. It does have a theoretical framework that addresses repetitive strain injuries mainly. People who have RSIs have tissue changes long before they have pain. With ART you're working on the health of the tissues. Patients will usually not come to see us before they have pain as a symptom - with these patients I think it's pertinent to address the tissues. Chronic pain is a different category of patients.

I saw a patient a few weeks back where the entire upper back was hyperalgesic - touch was painful. I used the same techniques as usual - inflicting a little bit of pain / discomfort but not so much the patient starts moving away from me. Basically with this patient I could not go any deeper than skin - so I didn't. Hyperalgesia was down to 25% percent after the first treatment and gone after the second so now I can get into the muscles -like I do with most people.

After reading Diane's manual, speaking with Kriskul, reading Matthias' blog and a couple of books he recommended I've changed the way I use ART a bit and I'm backing off more on tension with chronic patients - fibromyalgia and such.

Now I know what I do achieve changes in the brains of these people. I feel using the ART protocols is a good way to do it since there is tactile input, non threatening nociception (that is one of the "rules" - not to go so hard your patient is beginning to contract other muscles and move away from you), there is proprioceptive feedback (with the movements which the patient controls most of the time) etc. There is learning going on.

[Barrett Dorko]

Ole,

I really appreciate what you've said here and your rationale for changing.

Who exactly is that quote from in your signature?

[oljoha]

Originally Posted by Barrett Dorko

Who exactly is that quote from in your signature?

Friedrich Wilhelm Nietzsche

[Kim LeMoon]

Originally Posted by oljoha

...tactile input, non threatening nociception (that is one of the "rules" - not to go so hard your patient is beginning to contract other muscles and move away from you),

Ole, is patient recoil really the gauge that ART practitioners use to determine non threatening nociception? How do you know that other handling is not perceived as threatening? Many people can endure nociception and talk themselves into not recoiling if they believe that this approach will result in pain relief. Is there anything else that ART practitioners do to ensure that their touch is non threatening?

[oljoha]

Originally Posted by Kim LeMoon

Ole, is patient recoil really the gauge that ART practitioners use to determine non threatening nociception? How do you know that other handling is not perceived as threatening? Many people can endure nociception and talk themselves into not recoiling if they believe that this approach will result in pain relief. Is there anything else that ART practitioners do to ensure that their touch is non threatening?

Well, no - naturally you talk to the patient as well.

I'd say being an ART provider is a certification that you know the technique well. How well one applies it depends on a lot of other variables. As with everything else I guess. Being a physical therapist
is the same isn't it? Just a stamp of approval that you actually know a certain amount of information and that you're reasonably well behaved. How you choose to apply your knowledge will vary - pretty wildly IMHO.

Just to make sure everyone gets this - I don't represent ART in any way - I only speak on behalf of me, myself and I. I'm a provider and I love what I do - I think it has made me a much better physio ... (always looking to get better though).

[Diane]

After reading Diane's manual, speaking with Kriskul, reading Matthias' blog and a couple of books he recommended I've changed the way I use ART a bit and I'm backing off more on tension with chronic patients - fibromyalgia and such.

Ole, I really appreciate your change also ... it makes more difference (to the patient) having a different "understanding" of what you are doing (applying a different theory) than it matters what you are doing (technique or what its name might be).

[Jason Silvernail]

Ole-
I can appreciate also this evolution - this has happened to me several times in my practice as well - it's always accompanied by a degree of discomfort but the payoff is worth it in the end.

DS-
If you've got more recent data regarding the forces required to plastically deform connective tissue, I'd love to read it. The Threlkeld paper is far from one source - check the reference list for more things to research. The conclusions and calculations are based on solid data - but as I said I'd be open to newer data if it's out there. Please post it if you can - I'd love to see more recent stuff.

[Harold F]

Hello, this is my first post here (which I see has grown into an essay). I signed up to offer these comments after reading the informed, evidence-oriented discussion above.

For context, although I am not a physical therapist, I have a background in engineering and molecular biology, and have had a long-standing interest in some of the therapeutic techniques that I've seen discussed in this forum.

I would like to offer some observations about applied forces, the strength of collagen structures, plastic deformation, and whether it makes sense to think that manual therapies can break up adhesions.

I've examined Threlkeld's 1992 paper, "Manual Therapy and Connective Tissue", and I'm surprised to see it cited above as indicating that "connective tissue" cannot be plastically deformed by forces of less than 24 to 115 kg. On the face of it, this reading of the paper must be mistaken, because deformation depends not on force, but on force per unit area. If a single, slim fiber can be torn by (for example) a 10 kg force, then a bundle of 100 fibers (ten times the diameter) would require a ton, and a fiber 1/10 the diameter could be broken by the weight of just 100 gm.

Turning to Threkeld's paper, the surrounding discussion indicates that the 24 to 115 kg number, like the numbers in the following table, refers to forces applied to ligaments. The forces required to cause plastic deformation in (for example) a strip of a thin, membranous fascia would be much less, even if the collagen (as a material) is equally strong.

Now consider a fibrous adhesion between the surface fascia of two muscles. How does this differ from a ligament?

First, the collagen fibers will be less well aligned. Tension applied along a particular direction will stretch the tension-aligned fibers more than the cross-wise fibers, and these tension-aligned fibers will therefore stretch and break before the others. In a ligament, by contrast, the fibers will be well-aligned and will share the load almost equally. This difference in organization is one reason to expect adhesions to be less strong (per unit area!) than ligaments.

Second, and more important, a fibrous adhesion will be subject to stress concentrations at its edges. Think of peeling adhesive tape: the peeling force is concentrated in a thin strip along the boundary between the struck and freed regions. The force breaks the adhesion a little bit at a time, and is far less than the force that would be required to lift the tape straight off the surface, all at once (if that were even possible). Advertisements for super-strong glues ("One drop lifts a ton!) show the flip side of this trick: the glue forms a thin film between two metal blocks, bonding a large area. Two rigid blocks can't be peeled apart, and so breaking the bond requires a lot of force even if the glue isn't amazingly strong.

Let's go back to our ligament: It will be anchored to bone in a way that distributes the stress over the whole anchor area. There will be no peeling force at the edge, and so it can't be torn by a force much less than what would be required to pull everything apart at one time. So, the ligament is not only stronger as a material, it's much better at applying its strength to resist a force. By comparison, the adhesion doesn't have a chance.

Going back to the adhesive tape, we all know that pulling the tape while wiggling it frmo side-to-side lets it peel with even less force. This works because the stress gets concentrated on one end of the narrow boundary-band, then on the other, and then on the middle of what has become a curved boundary. Anything that makes the boundary non-straight and non-uniform concentrates force on some parts, making smaller forces more effective in causing separation.

Biological adhesions have irregular shapes, and so pulling and shearing forces along the muscle-muscle interface will be concentrated on just parts of the edge. Which parts those are will depend on the direction of pulling, so the forces can be concentrated on one part, and then another, as with the peeling tape.

The result: When an adhesion resembles a layer of glue between muscles, the forces needed to tear it (from some angles, in some directions) can be be small. When an adhesion is more like a stringy band than like a layer of glue (that is, when it is a little bit more like a ligament) the required forces may be much larger. One still wouldn't expect the adhesion to be as strong as a ligament of similar thickness, however, because the collagen in the adhesion will be less well organized and less well anchored, and this subjects it to a degree of stress concentration that facilitates incremental tearing.

Conclusion: Breaking up adhesions by manual therapy should work, and people who say they've done it or experienced it are probably right.

The above is consistent with my experience with my own body, and also consistent with the distinctive tearing sounds that lead up to the occasional sudden release of a stuck place, as indicated by an immediate and sometimes striking increase in mobility. All the biomechanical results are consistent with the restoration of more-normal sliding motion between previously adhered muscle surfaces.

The above also helps explain why I get stuck again soon after, but differently: Tears in old adhesions would be expected to exude fluid containing fibrinogen, resulting in a fibrinous adhesion. This would be expected to be weaker, to cover a different (perhaps larger) area, and to release with less applied force and without a tearing sound (owing to its less fibrous nature). This is all consistent with my experience.

I should perhaps mention that the neural dimension of all this is fascinating, too, though I've stuck to just the biomechanics in this discussion.

(By the way, do physical therapists ever wear earphones linked to a well-separated pair of stethoscopic microphones taped to a patient's body? Doing so would expand the therapist's perceptual abilities in ways that I would expect to be fascinating and extremely valuable. Internal sounds generated by these process are quite variable and rich in information -- some of which can even be interpreted!)

[Bas Asselbergs]

Harold, interesting take on the manual effects on adhesions.

I would like to use your analogy of peeling tape to illustrate that your theory needs work.
Try to peel the tape with little forces, while it is UNDERNEATH a few other layers.
Your analogy falls short because you seem to completely ignore the layers of skin (and sometimes other tissues) between the supposed adhesions and the hands.

So, manually mobilising adhesions with the explanation you present, would result in either: A) tearing of the layers of skin first (weaker than connective tissues), or B) no tearing of anything.

If you hear "tearing sounds" after getting manual therapy, you may have a problem.

Also, there are no reliable tests for adhesions - no way to actually establish many of the adhesions claimed by some practitioners. None.

All biomechanical effects of manual techniques are most easily explained by neurophysiology.

[Jason Silvernail]

Hello, Harold, and welcome to SomaSimple. This was one heck of a good first post, and there's a lot of really interesting things to talk about here.

Originally Posted by Harold F

For context, although I am not a physical therapist, I have a background in engineering and molecular biology, and have had a long-standing interest in some of the therapeutic techniques that I've seen discussed in this forum.

Well, that should be a good perspective from which to discuss this particular line of inquiry.

Originally Posted by Harold F

I've examined Threlkeld's 1992 paper, "Manual Therapy and Connective Tissue", and I'm surprised to see it cited above as indicating that "connective tissue" cannot be plastically deformed by forces of less than 24 to 115 kg....Turning to Threkeld's paper, the surrounding discussion indicates that the 24 to 115 kg number, like the numbers in the following table, refers to forces applied to ligaments. The forces required to cause plastic deformation in (for example) a strip of a thin, membranous fascia would be much less, even if the collagen (as a material) is equally strong.

I'd have to reread the paper to see where you're coming from here, but I don't recall the discussion there to focus on ligaments themselves.

Originally Posted by Harold F

Now consider a fibrous adhesion between the surface fascia of two muscles. How does this differ from a ligament?
First, the collagen fibers will be less well aligned.

Has this been demonstrated?

Originally Posted by Harold F

Second, and more important, a fibrous adhesion will be subject to stress concentrations at its edges. Advertisements for super-strong glues ("One drop lifts a ton!) show the flip side of this trick: the glue forms a thin film between two metal blocks, bonding a large area. Two rigid blocks can't be peeled apart, and so breaking the bond requires a lot of force even if the glue isn't amazingly strong.

I never thought of it like that - so THAT'S what the deal is on those glue commercials.

Originally Posted by Harold F

Let's go back to our ligament: It will be anchored to bone in a way that distributes the stress over the whole anchor area. There will be no peeling force at the edge, and so it can't be torn by a force much less than what would be required to pull everything apart at one time. So, the ligament is not only stronger as a material, it's much better at applying its strength to resist a force. By comparison, the adhesion doesn't have a chance.

While I see why this makes a ligament relatively stronger, that doesn't make a separate case for the plausibility of breaking the adhesion.

Originally Posted by Harold F

The result: When an adhesion resembles a layer of glue between muscles, the forces needed to tear it (from some angles, in some directions) can be be small. When an adhesion is more like a stringy band than like a layer of glue (that is, when it is a little bit more like a ligament) the required forces may be much larger. One still wouldn't expect the adhesion to be as strong as a ligament of similar thickness, however, because the collagen in the adhesion will be less well organized and less well anchored, and this subjects it to a degree of stress concentration that facilitates incremental tearing.

If this is true about irregular shapes and the lack of anchoring as a ligament has, wouldn't these concepts apply equally well to other tissues in and around the supposed adhesion - like blood vessels, nerves, muscle fibers, etc? How can we selectively target just the adhesion?

Originally Posted by Harold F;59008
[I

Conclusion:[/I] Breaking up adhesions by manual therapy should work, and people who say they've done it or experienced it are probably right.

Hold on a second - this is a bit post hoc ergo propter hoc reasoning here. The fact that it might be biologically plausible doesn't mean that people who say they've done it are "probably right". We have learned this many times in medicine - most recently with the specificity of manipulative therapy for spinal pain. Just because the nerve tissue in and around facets could be responsible for some nociceptive drive and manual therapy could affect them, doesn't mean that that paradigm was shown to be successful. Or even useful...

Originally Posted by Harold F

The above is consistent with my experience with my own body, and also consistent with the distinctive tearing sounds that lead up to the occasional sudden release of a stuck place, as indicated by an immediate and sometimes striking increase in mobility. All the biomechanical results are consistent with the restoration of more-normal sliding motion between previously adhered muscle surfaces.

I have to tell you here, that your subjective experience of what is happening doesn't tell you anything about what is actually happening - especially when your sense of that is neurogenic. Your brain has found a compelling story and interprets its experience to conform with that - that doesn't make it wrong, but not necessarily true, either. We're all wired like that.

Originally Posted by Harold F

The above also helps explain why I get stuck again soon after, but differently: Tears in old adhesions would be expected to exude fluid containing fibrinogen, resulting in a fibrinous adhesion. This would be expected to be weaker, to cover a different (perhaps larger) area, and to release with less applied force and without a tearing sound (owing to its less fibrous nature). This is all consistent with my experience.

See above about the compelling nature of story and our tendency to interpret in that light. Also, it would seem that you have quite an adhesion problem, don't you think? Why is it that this seems to keep happening despite the fact that these have been "broken up" with therapy? A connective tissue disorder of some type?

Originally Posted by Harold F

I should perhaps mention that the neural dimension of all this is fascinating, too, though I've stuck to just the biomechanics in this discussion.

I'm glad you're here, and hopeful that you can help us navigate the biomechanics and Threlkeld's paper a bit better. But you're right to realize that the biomechanics are probably a small part of the whole discussion - especially if its pain we're talking about.

Again, welcome, and consider an introduction in the Welcome forum.

[oljoha]

Originally Posted by Bas

So, manually mobilising adhesions with the explanation you present, would result in either: A) tearing of the layers of skin first (weaker than connective tissues), or B) no tearing of anything.

No - you can selectively add force to the muscle. If you first stretch a muscle and then add manual pressure with a vector you will be adding to the forces already in the muscle.

Originally Posted by Bas

Also, there are no reliable tests for adhesions - no way to actually establish many of the adhesions claimed by some practitioners. None.

Adhesions has been established. I have in this thread provided links to papers that demonstrate them. Whether or not they contribute to the pain experienced by our patients is another story. Following inflammation of the chest cavity for instance you can have adhesions forming that literally glues the lung to the chest wall. I have also provided a link to a site where there are endoscopic pictures from inside the dural sleeve showing adhesions linking the nerve to the sleeve. Surgery to free the nerve from these adhesions has been successful in eliminating pain (don't know of any placebo controlled studies on that though).

Is that ok? Or are we misunderstanding each other?

Originally Posted by Bas

All biomechanical effects of manual techniques are most easily explained by neurophysiology.

No argument there.

[Jon Newman]

To anyone: Aren't there adhesions between most cells in the body (cells have to stick together to form a tissue)? Perhaps it would be helpful to clarify the type of adhesions under consideration. Is there a way to classify adhesions?

[Barrett Dorko]

Ole says:

... you can selectively add force to the muscle. If you first stretch a muscle and then add manual pressure with a vector you will be adding to the forces already in the muscle.

I'm troubled by the word "selective" here because the implication seems to be that this "selection" is of the muscle alone. How so?

The short hand I use when speaking of Threlkeld's conclusions is this: Yes, we're strong enough to permanently elongate connective tissue, but we're not smart enough.

Perhaps for some this is too short and too simple a statement, but whatever might possibly be done to "break adhesions" via manual technique, the very real problem of directing those outside forces safely and appropriately must be addressed. This is to say nothing of what the skin (read brain) has to say about it.

I must say that a clinician would concern themselves with this. An engineer might not.

This is a great conversation.

[oljoha]

Originally Posted by Barrett Dorko

I'm troubled by the word "selective" here because the implication seems to be that this "selection" is of the muscle alone.

Selectively - not selective. Jeez.

Originally Posted by Barrett Dorko

I must say that a clinician would concern themselves with this. An engineer might not.

Leahy, the chiropractor that developed ART was an engineer first.

If you stretch a muscle and then press straight on to it you WILL selectively increase the forces on the tissues that are already stretched. The force on the skin will be much much less since it moves rather freely on top and is mostly just compressed. Try it on yourself. Many of my patients develop DOMS after this procedure - yet their skin is not even bruised (and that even goes for those who are on bloodthinners (warfarin) and they usually bruise quite easily.

Another method I think breaks adhesions quite effectively is eccentric exercise. The asynchronous lengthening of the muscle fibers cause a lot of relative motion between the fibers. Not very specific though. As we know eccentric exercise causes a lot more DOMS than concentric.

[Diane]

What is DOMS?

[Bas Asselbergs]

Ole, since when can you selectively stretch a muscle WITHOUT stretching everything over top of it? Skin for instance. I love to see you add selective pressure to a muscle WITHOUT pressuring the skin - which IS a stretch - a deformation of some kind.

"Mostly just" compressed......jeez. So, all the pressure on the sensor bodies in the skin have NO impact? Yet, you are willing to assume that somehow, the pressure reduces the "adhesions".

Other points: DOMS is a description of soreness - NOT a testable phenomenon. Thus, ALL you are seeing is soreness after your technique. You have NO idea where that comes from. Except that it is neurophysiological. And likely from ONE of the many layers you have just squeezed the blood out of. BTW, what does DOMS have to do with bruising?

Again, WHERE is the testing for those adhesions? Do not show me pleural adhesion or skin scars or dural adhesions - show me some reliable manual tests for these muscular adhesions. And then show me the studies for non-surgical reduction of adhesions.

This

no way to actually establish many of the adhesions claimed by some practitioners

still stands.

[Bas Asselbergs]

Delayed Onset Muscle Soreness.

[Jason Silvernail]

DOMS

Ole-
Whether the word is "selective" or "selectively" - how do we know that the muscle is a special case for this sort of effect and not the skin, or nerve tissue, or blood vessels?

[Jason Silvernail]

Originally Posted by Bas

Again, WHERE is the testing for those adhesions? Do not show me pleural adhesion or skin scars or dural adhesions - show me some reliable manual tests for these muscular adhesions. And then show me the studies for non-surgical reduction of adhesions.

Bas-
I think we may not need to have reliable manual tests for these adhesions if we can show: 1. that they exist (which Ole says he has shown - I'll look further upstream for that to refresh my memory), 2. that they are related to a pain state, 3. that they no longer exist after treatment, and 4. the pain state is positively changed by this treatment.
Then we might begin to start talking about these being relevant - though we'd still have the correlation/causation issue to deal with.

I think if Ole was proposing to specifically diagnose the location of these adhesions, then we could press him to show us the manual examination, but that's not what I'm reading. Ole, is this correct? I appreciate your willingness to continue the discussion on this issue.

[Bas Asselbergs]

Jason, I do take into account the ART practitioner's contention that s/he is treating adhesions. I have seen them at work, and there is NO other testing for those adhesions than manual (palpation mostly) tests. No imaging, no surgical, no MRI. So what is left - manual testing.

So, to point #1: adhesions will likely exist, but are very hard to reliably test in a clinical practice, if manual testing is all there is - and ROM.
#2 and #3 are going to be just as hard to demonstrate, since pre- and post Rx testing is supposed to show specificity - that they were there to contribute to the painstate, and that it was the actual adhesion being treated, and NOT: skin nerves, brain, and circulatory aspects.
#4 is a simple outcome study, and likely the most common positive factor of any manual technique.

[oljoha]

@Diane: Delayed Onset Muscle Soreness

It occurs with exercise. Especially forceful eccentric exercise. I disagree with Bas that it is "just a description of soreness". The amount of soreness is proportional to the stress induced on the muscle. If that were to be due to another structure than muscle then you should get it with just movement - resistance should not matter.

@Bas: I never said you can add selective pressure to a muscle without pressuring the skin. Did you actually read the post? And I never said all the pressure on the sensor bodies in the skin have no impact. And I never ever said anything about testing for adhesions. Where do you get this information?!

Your ideas on DOMS are intriguing. What is your best bet on the cause of DOMS?

How it relates to bruising. Again it doesn't - I never said it did. But when my patients experience DOMS (which I think is caused by microtrauma to the muscle) and not bruising (which I think is caused by damage to bloodvessels in the skin) then I suspect I've had quite an impact on the muscle.

I want to say that I just wanted to argue the possibility of being able to affect adhesions in the muscle. But then I expect you'll just come back and say that there is so much else going on and that you cannot disregard the nervous system. Fine you're right - but for the sake of discussing adhesions NOT pain I will disregard the nervous system for now.

[oljoha]

Oh and I should have posted links to studies where they have demonstrated an increase in adhesions in chronically stressed trapezius muscles. Adhesions are a fact of life.

AND AGAIN - WHETHER THEY ARE A CAUSE OF PAIN IS A DIFFERENT STORY

[Barrett Dorko]

I'm pretty sure that microtrauma has been completely ruled out as concurrent with DOMS.

Though I recently read on the Supertraining listserve that DOMS may reasonably considered an appropriate adaptive response to repetitive and sufficiently forceful contraction, its underlying deep model within the muscle remains a mystery.

Ole,

Any thoughts on ruling the skin in or out? Isn't this kind of important when describing the supposed effect of a technique that impacts it?