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Let's Talk About ART

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  • #46
    Originally posted by Jon Newman View Post
    Hi Steve,

    Can you expand on this?

    Is this in addition to the release or while the release is happening?
    First the muscle is brought to a shortened state. For example for the biceps muscle the elbow would be flexed. Then the tissue at the distal end of the biceps would be contacted and taken to tension with a proximal tissue pull. The emphesis of the tissue pull would be from a distal to proximal direction using only light compression. The elbow would then be extended by the patient to lengthen the muscle. If the discomfort level is more than mild to moderate the patient slows down the speed of the movement. The tissue pull is increased slightly as the patient does this ending with a glide over the tissue.

    This would be repeated several times with the contact point being gradually moved more proximally so as to cover the entire muscle. If a deeper muscle was to be treated the superficial muscle is typically treated first. Then the deeper muscle is treated with more compression.

    This is the basic application of ART for all tissue it treats. The technique can be used for muscles, tendons, ligaments, fascia, and occasionally joint capsules. Sometimes the emphisis is between two different muscles rather than along the belly of the muscle, (between the biceps and brachialis for instance). Sometimes it is focused a releasing adhesions between a nerve and a muscle (the pronator teres and median nerve for example).

    There are many times when the movement must be done passively because the movement is to complex for the patient to remember, or it is more convenient in a paticular situation. But whenever it is possible active motion is prefered.
    Last edited by Steven; 21-11-2006, 07:28 AM.


    • #47

      No doubt you're thinking hard about the theory and practice of what you do in the context of pain science. I respect that, and this is just the sort of thing many of us wished we saw in more therapists. We ARE a tough crowd, but you're a smart guy, you can handle it. :teeth:

      I understand a lot more about ART from your and Steven's posts. The practice of it, I mean, not the theory.

      You mentioned that you're not truly breaking down collagen fibers in the muscle. As Cory notes, this is known to frequently (if not always) produce an inflammatory response.
      You did state that it was Fibrin you were breaking down with the technique. How does fibrin get in muscle tissue? Aside from a hematoma from a direct blow and lysis of fibers, I mean.
      Have these fibrin "adhesions" ever been demonstrated?

      Jason Silvernail DPT, DSc, FAAOMPT
      Board-Certified in Orthopedic Physical Therapy
      Fellowship-Trained in Orthopedic Manual Therapy

      Certified Strength and Conditioning Specialist

      The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.


      • #48
        Hi Ole and Steven,

        I did a lit review on this subject of couple of years ago. The most useful article starting off, is too old to be included in full text in the apta website. Here is the abstract however.

        I've got a copy in my hand, and here is what it has to say about fibrin:

        migratory fibroblasts follow the fibrin meshwork created earlier in the wound fluid milieu.
        This is written in the context of wound formation, but the process is consistent. It goes on:

        Once in place, the fibroblast is ready to begin its synthesis of the collagen molecule.
        So, it seems that fibrin is a precursor to collogen formation.

        This link
        is to an excellent article on tissue changes that result from repetitive use.

        Here are some highlights from my notes:
        -Anoxia stimulates events that lead to collogen deposition.
        -Collogen depostion can directly contribute to median nerve compression, which can lead to anoxia
        -Histologic study of chronic overuse syndrome involved muscles showed
        1) denerved or ischemic loss of type 2 collogen fibers
        2) local hypoxia related to static shoulder postures in upper trapezius
        -Damage to sarcomere or sarcolema result in leakage of components into extracellular matrix and around myofibrils, repeated injury causes expansion of extracellular matrix, this all leads to depostion of collagen around myfibrils.

        So, it appears that situations likely to create an environment that would lead to formation of these adhesions and thier pre-cursors would be anoxia, and tissue stress beyond threshold. See this paper for an excellent discussion on that topic.

        So, the questions I am left with mechanically is, what do we know about fibrin as a pre-adhesion? How can it change fast enough to account for the changes seen in pain if they are not in fact neuromodulatory?

        Also, what is DOMS?

        Thanks for this discussion.
        Cory Blickenstaff, PT, OCS

        Pain Science and Sensibility Podcast
        Leaps and Bounds Blog
        My youtube channel


        • #49
          Hi Steve, Ole

          Thanks for the responses. Would it be accurate to say that the ART practitioner should press on the pain or within the muscle where the patient is sore?

          How does ART compare to Total Motion Release or myofascial release?

          I picked the above comparisons because of their use of the word release. Do you suppose the word release is being used to describe the same thing in each technique?

          Lastly, the treatment details described are quite similar to "strain-counterstrain" techniques. Not the same, but similar. Is there any connection in reasoning between the two?
          Last edited by Jon Newman; 21-11-2006, 03:30 PM.
          "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris


          • #50
            I wanted to clarify my question a bit. If fibrin is pre-adhesion and is present in the various levels of the CT, can it be released? Since it would seem to be more anomalous in structure, it would seem to be more of a stickyness creator, vs. adherent. So, how does moving one structure in relation to another decrease the stickyness/friction created by fibrin. And can it happen fast enough to account for the fast reponse in pain?

            The second mechanism, re-establishing normal friction between adjacent structures by changing the interstitial content, sounds like the "stickiness" that Nari describes. Mechanically speaking, this sounds more feasible to me. What causes these interstitual fluid changes?
            This is actually what I was thinking about when I posted this.
            Cory Blickenstaff, PT, OCS

            Pain Science and Sensibility Podcast
            Leaps and Bounds Blog
            My youtube channel


            • #51

              You are correct that the muscle that should be addressed is the muscle that is painful or the muscles around a joint that is restricted in motion. In addition other mucles along the kinetic chain are also evaluated. For example if the rhomboid muscle is painful or tight, the infraspinatus, trapezius, seratus posterior superior, and levator scaplae would also be examined.

              As to your question about Total Motion Release, I am not familiar enough with this method to comment.

              As for the myofascial release, it is very similar. The thought in active release is that by incorporating motion into the treatment the release is greater. By first shortening the muscle, then passively lengthening the tissue via tissue pull, then finally actively lengthening the tissue even more, a deeper release is acheived than by only using a more passive myofascial release.

              In addition Dr. Leahy estimates that 50% of the benifit of ART is with peripheral nerve entrapment, not just with myofascia.

              Strain-counterstrain technique seeks to find a position that eases the tension/pain, and is then held in this position as part of the release. ART does not seek a position of diminished pain. To the contray the pain will sometimes elevate as the movement is performed (although after a few passes it typically eases). The focus is on bringing the muscle from its shortened state (the postion when it is contracted), to a lengthened position.
              Last edited by Steven; 21-11-2006, 10:38 PM.


              • #52
                Hi Steve,

                Thanks for answering my questions. In your response you used the phrase "deeper release". What is the the deeper referring to? Is it adhesions in the muscle that are closer to the bone than the skin?
                "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris


                • #53

                  I suppose that by deeper I mean more complete. A good way to understand would probably be to try on yourself the method I described for the biceps muscle. You should experience a stretching sensation in a muscle that could otherwise not be passively stretched. Compare that sensation with myofascial release. The feeling you get from ART is a stronger sensation of stretch and of release.

                  By lengthening the tissue as the release is performed, a larger degree of release is theorized to occur. This also occurs throughout the length of the entire muscle. I suppose one might feel that it is also deeper in terms of tissue depth for certain muscles.


                  • #54

                    Simple question: When you say a muscle is "tight," what do you mean?
                    Barrett L. Dorko


                    • #55
                      Hi Steve,

                      I'm not sure why it isn't possible to stretch the biceps (or any muscle) passively but I tried what you suggested.

                      Should I feel a release if I don't have adhesions? I felt something.

                      Maybe I should ask what a release feels like so I know I released something.
                      Last edited by Jon Newman; 22-11-2006, 02:29 AM.
                      "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris


                      • #56

                        Having tried the demo I believe what he means is that in the ROM where a stretch isn't normally felt you are inducing the feeling by applying pressure to the muscle belly. Kind of like tightening a drive belt by pushing on it. The feeling is a different one than applying pressure and then trying to move the muscle and I notice the effect is more pronounced as you move distally. So I guess the questions I need to figure out are: Are there these adhesions in normal soft tissue, particularly muscle, do they cause pain and can they be released through this type of manual pressure.

                        DOMS is Delayed Onset of Muscle Soreness, I think someone asked.


                        • #57

                          Thanks for the eg. I have tried this several times and carefully observed the sensations it produces. It seems quite obvious to me that the sensation of stretch from this technique is clearly coming from the skin as the slack is taken up by the increasing angle of the elbow. This is easy to prove. If you get someone to simultaneously contact the skin just distal to your elbow (beyond the attachment of biceps) and drag it distally you can easily produce the same intensity of stretch at a decreased elbow angle as you feel at an increased angle with only proximal drag above the elbow. The stretch sensation is not coming from the biceps muscle.

                          The other sensation is simply the digital pressure into the muscle. As I tried to point out to Ole, no matter what angle to you direct downward pressure, because the skin and superficial CT layers are so slidey most of the force at the deeper layers will still be perpendicular to the tissue. Try this: Place heavy digital pressure into the distal belly of biceps as per your technique. Feel exactly where in the muscle the sensation is located. Now very slowly drag your thumb proximally. You will notice that the your thumb slides along the muscle and the area in which the pressure sensation is located changes. If you were actually gaining enough purchase on the muscle tissue to strecth it directly then this would not occur. The same thing happens when you straighten the elbow but the added sensation of the skin being strongly stretched leads to a false impression.

                          Still, the technique does seem to combine several elements that many people find effective used in isolation.

                          I am fascinated that this is now a patented technique with ongoing recertification. I actually learned this stuff in my osteopathy degree and similar techniques (more often passive movement though) are to be found in Foundations of Osteopathic Medicine, our seminal text. Once again (see craniosacral, myofascial release, positional release etc) it seems a guru has turned a standard osteopathic approach into a money making machine.
                          Luke Rickards


                          • #58
                            Originally posted by Barrett Dorko View Post

                            Simple question: When you say a muscle is "tight," what do you mean?
                            By tight I mean restriction motion of the joint or causing discomfort due to hypertonicity. For example the hamstrings limitting hip flexion, or the wrist extensors limiting wrist flexion. This would be a muscle that would be targeted for treatment with ART.


                            • #59
                              Steven, what would make a muscle 'tight" or "hypertonic"?
                              We don't see things as they are, we see things as WE are - Anais Nin

                              I suppose it's easier to believe something than it is to understand it.
                              Cmdr. Chris Hadfield on rise of poor / pseudo science

                              Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                              We don't need a body to feel a body. Ronald Melzack


                              • #60
                                A :thumbs_up:thumbs_up:thumbs_up
                                Last edited by bernard; 22-11-2006, 06:57 PM.
                                Simplicity is the ultimate sophistication. L VINCI
                                We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances. I NEWTON

                                Everything should be made as simple as possible, but not a bit simpler.
                                If you can't explain it simply, you don't understand it well enough. Albert Einstein