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  • CT Let's Talk About ART

    Over in another thread, the topic of ART came up. This is a system that many of us have heard of, and for which I read a lot of interest and dedication in the practitioners.

    Ole Johanson posted about it in the "Your Approach..." thread, #51, and I thought we could bring the discussion here to keep topics separate. Also so I could come back here and use the discussion the next time I have someone ask me about ART.

    First of all, I don't think anyone will doubt that some people treated with ART improve. There seems to be no published research on this approach, so it's logical then to ask whether the mechanisms of relief proposed by the instructors of the technique make sense.
    Perhaps that's where we should start...
    Last edited by bernard; 16-11-2006, 06:39 AM. Reason: area 51!
    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.

  • #2
    Ole posted this about ART in the previous thread:
    Originally posted by Ole
    Here you find images of spinal nerves adhesed to the dura as they exit the spine : http://www.ipmt.net/ (I've presented these to you before on the noigroup)

    This is due to injury: http://www.ncbi.nlm.nih.gov/entrez/q...st_uids=912984

    I never said without injury - repetitive strain is injury:

    Pathophysiological Tissue Changes Associated With Repetitive Movement: A Review of the Evidence
    Chronic repetitive reaching and grasping results in decreased motor performance and widespread tissue responses in a rat model of MSD

    Another interesting one on adhesions forming in various tissues:
    Presence and Distribution of Sensory Nerve Fibers in Human Peritoneal Adhesions
    Last edited by bernard; 16-11-2006, 06:40 AM. Reason: quote
    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.

    Comment


    • #3
      There are some research but it's sparse and it doesn't discuss the proposed mechanisms of relief.

      The effects of active release technique on carpal tunnel patients: a pilot study
      Influence of active release technique on quadriceps inhibition and strength: a pilot study

      These are the same:
      Comparison of active release technique and proprioceptive neuromuscular facilitation for improving hamstring flexibility
      The effects of active release technique on hamstring flexibility: a pilot study

      The latter write this in their discussion: "At the 10-day follow-up the PNF group had significantly greater flexibility compared with ART. This may indicate that ART's effectiveness is dependent on mechanical deformations or tension within the musculoskeletal system not typically found in normal asymptomatic populations. It may also represent PNF's ability to impact contractile functions of the muscle that may not contain mechanical pathologies such as connective tissue changes."

      There is a study that showed that decreasing oxygen levels in a muscle will start an inflammatory process and thus cause the process where scar tissue (adhesions) are being formed. I cannot find it indexed anywhere though. This relates to repetitive strain injuries. This study was what sparked the development of ART.

      I also have another article which states that pretty much every tissue in the body can become adhesed to another - it's somewhere I haven't found it yet.

      Naturally - scar tissue cannot be painful. No tissues can. But they can cause mechanical and chemical deformation of nervendings in the tissues leading to tenderness and pain. Does this make sense to people here? Does it make sense for others to target the scar tissue with treatment?

      I cannot and do not deny that ART works in other neuralmodulatory ways as well.

      And please: let's stay focused on the issue of mechanisms.
      Ole Reidar Johansen, Musculoskeletal Physiotherapist
      "And if you gaze for long into an abyss, the abyss gazes also into you." - Nietzsche

      Comment


      • #4
        Hi Ole,

        Naturally - scar tissue cannot be painful. No tissues can. But they can cause mechanical and chemical deformation of nervendings in the tissues leading to tenderness and pain. Does this make sense to people here? Does it make sense for others to target the scar tissue with treatment?
        It would make sense to me that nervous system that is adhered to/or lies within an environment of adhered tissue would have decreased adaptive potential. It would therefore make sense that changing this would increase the adaptive potential.

        However, remodeling of scar tissue is a relatively slow process that would not likely explain the fast changes seen in pain (I assume they are fast). Additionally, the process stimulating the remodeling of the scar tissue is the inflammatory process. It would stand to reason that, initially an increase in nociception would occur as a result.

        From an orthopedic stand point, strictly tissue based, re-initiating the inflammatory process in a degenerative tissue would seem to be very benificial as it would jump start a healing process in a tissue that had stopped responding in this way. This of course can all happen and be present in the absence of pain.

        So, although the long term changes in pain could be a result of a increased adaptive potential, I don't feel the immediate responses seen could be anything other than neuromodulatory.

        I've some questions about the technique. You speak of break down of adhesions. Does ART function through a trauma to the tissue in the way of the tool assisted techniques such as ASTYM, graston, gua sha? My understanding (which is limited) is that it is a relatively gentle technique. I'm curious because, if it is gentle and does not bring about an inflammatory response, I would have to wonder if scar tissue change is even happening.
        Cory Blickenstaff, PT, OCS

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        • #5
          Originally posted by BB View Post
          It would make sense to me that nervous system that is adhered to/or lies within an environment of adhered tissue would have decreased adaptive potential. It would therefore make sense that changing this would increase the adaptive potential.
          Originally posted by BB View Post
          However, remodeling of scar tissue is a relatively slow process that would not likely explain the fast changes seen in pain (I assume they are fast). Additionally, the process stimulating the remodeling of the scar tissue is the inflammatory process. It would stand to reason that, initially an increase in nociception would occur as a result.
          I agree with you. But we are not trying to remodel scar tissue. These adhesions are scars that make fibers stick to eachother - i.e. they are between the fibers and restrict movement.

          Originally posted by BB View Post
          From an orthopedic stand point, strictly tissue based, re-initiating the inflammatory process in a degenerative tissue would seem to be very benificial as it would jump start a healing process in a tissue that had stopped responding in this way. This of course can all happen and be present in the absence of pain.
          While some techniques aim to re-initiate an inflammatory process ART is designed to avoid inflaming the tissues.

          Originally posted by BB View Post
          So, although the long term changes in pain could be a result of a increased adaptive potential, I don't feel the immediate responses seen could be anything other than neuromodulatory.
          There are two scenarios here. It is the patient who gets pain somewhere in the ROM. Then there is the patient where there is a constant ache / tingling / numbness. ART can be used for both. In the first case I'd say it is the breaking down of adhesions which lead to an increase in ROM - DOMS is not an unusual side effect either. In the second case - I agree it is likely more a result of neuromodulation. Or a little bit of both in both cases. Usually we address tissues directly adjacent to the nerves - theory being that we free the nerve. Naturally I think this can be neuromodulatory - Butler mentioned neurogenic massage in the sensitive nervous system. With ART it's more a stretch to the adjacent tissues rather than a massage.

          Originally posted by BB View Post
          I've some questions about the technique. You speak of break down of adhesions. Does ART function through a trauma to the tissue in the way of the tool assisted techniques such as ASTYM, graston, gua sha? My understanding (which is limited) is that it is a relatively gentle technique. I'm curious because, if it is gentle and does not bring about an inflammatory response, I would have to wonder if scar tissue change is even happening.
          It's basically a lengthening of a tissue while one applies pressure to it. The pressure is specific and almost always in the direction of the fibers (you don't want to break the fibers - the direction they run is where they are designed to handle load so they shouldn't be affected too much) so that the adhesions in between them will break. It's simple. But IMHO the seminars are essential to get the touch right and to learn all the protocols. Even with the spine and upper extremity courses done I was nowhere near competent with the lower extremity and I did have to study and practice quite a bit to pass the lower seminar. If you do the seminar on the weekend you'll be able to use the techniques quite successfully on monday - but your proficiency with it will grow over the next couple of years. I've been doing it for 2 1/2 year and I'm looking forward to the recert in May as I will get to practice all the techniques with other providers.
          Ole Reidar Johansen, Musculoskeletal Physiotherapist
          "And if you gaze for long into an abyss, the abyss gazes also into you." - Nietzsche

          Comment


          • #6
            Originally posted by Ole
            While some techniques aim to re-initiate an inflammatory process ART is designed to avoid inflaming the tissues.
            How does it work?
            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
            bernard

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            • #7
              Ole,

              Can I add to Bernard's question- How can adhesions be changed without remodeling the connective tissue in some way?

              How would one approach an acute condition using ART, ie where there hasn't even been enough time for scar tissue/adhesions to form? Or don't you use it for acute presentations?

              How can you put pressure in the direction of muscle fibers only? Surely any pressure from the outside will always be mostly perpendicular to the muscle.
              Luke Rickards
              Osteopath

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              • #8
                I think this is where the R in ART comes into play.
                "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                Comment


                • #9
                  The example that came to me as I read that small article is this, A piece of raw steak. Massaging it doesn't really make it any more tender. Now pounding it with a hammer and spikes breaks down some of the tissue, a little, but I don't think anyone really wants to do that to their patient. Ok, some patients you do. Any change in the quality of muscle as a result of manual pressure seems to be more likely an effect of a neurological response than a change to the tissue itself. On the other hand, using the example of a steak, I can see how some relative change in position could be induced.

                  Comment


                  • #10
                    Originally posted by Randy
                    On the other hand, using the example of a steak
                    The steak isn't connected to a brain. That is a major difference! :angel:
                    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
                    bernard

                    Comment


                    • #11
                      Tenderness of a steak comes around by the degradation of collagen by enzymes leaking from the cells.

                      I don't disagree that much of an effect comes from interacting with the nervous system - especially on the pain. But there is also a major change in tissue texture and ROM.

                      Bernard - I wrote how it works. By freeing the fibers from eachother you increase the relative motion between the fibers. This is the change in tissue texture - from leathery to normal which is also accompanied by DOMS most of the time. If the tissues are of normal texture there is rarely any DOMS.
                      Ole Reidar Johansen, Musculoskeletal Physiotherapist
                      "And if you gaze for long into an abyss, the abyss gazes also into you." - Nietzsche

                      Comment


                      • #12
                        Originally posted by Luke Rickards View Post
                        Can I add to Bernard's question- How can adhesions be changed without remodeling the connective tissue in some way?
                        These adhesions are between the fibers. They are "left overs" from a repair. The one thing you do need when tissue is remodelling is movement and load on the tissue so that it becomes aligned. Imagine some bits are stuck between the fibers causing a decrease in ROM and the feeling of a knot in the muscle. One just wants to break up these adhesions to remove them. I think when they are broken down they will often cause DOMS.

                        Originally posted by Luke Rickards View Post
                        How would one approach an acute condition using ART, ie where there hasn't even been enough time for scar tissue/adhesions to form? Or don't you use it for acute presentations?
                        You can use it for acute - but it's different - you don't adress the injury itself - rather you can address the uninjured area. Adding tension to an acute injury would surely make it worse. Let's not go there now.

                        Originally posted by Luke Rickards View Post
                        How can you put pressure in the direction of muscle fibers only? Surely any pressure from the outside will always be mostly perpendicular to the muscle.
                        No. If you press straight down it will be perpendicular - but if you angle it and just go to the depth you wish to reach you create a vector of force.
                        Ole Reidar Johansen, Musculoskeletal Physiotherapist
                        "And if you gaze for long into an abyss, the abyss gazes also into you." - Nietzsche

                        Comment


                        • #13
                          Originally posted by Jon Newman View Post
                          I think this is where the R in ART comes into play.
                          "Any softening or increased range of motion within the body that follows the kind of pressure I can exert with my hands cannot be said to be due to connective tissue changes. It is incapable of changing in response to my pressure in so rapid or radical a fashion. Period."

                          This is exactly where we're at in this discussion right now. I disagree with the statement Barrett made there.

                          Gotta go.
                          Ole Reidar Johansen, Musculoskeletal Physiotherapist
                          "And if you gaze for long into an abyss, the abyss gazes also into you." - Nietzsche

                          Comment


                          • #14
                            Ole-

                            But Barrett's quote, about the tissue change is backed by a peer-reviewed research paper and basic science that is not in dispute. By this I'm talking about Threlkeld's 1992 article I've posted here.

                            We simply cannot change connective tissue this quickly. After reading the article, don't you agree?

                            BTW, I think this is entirely different from the effects of the treatment - I've hear both practitioners and patients rave about ART. So I'm sure it works sometimes for some people. But not for the reason we have been told it works, you know what I mean?

                            Jason.
                            Attached Files
                            Last edited by Jason Silvernail; 19-11-2006, 01:03 PM.
                            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.

                            Comment


                            • #15
                              So, Ole, you do not agree that the skin overlying the tissue you think you are directly affecting has anything to do with autonomics or their outflow, or fast sensing by the cortex, or changes in the stuff you think you are directly effecting through your contact? Do you regard the nervous system as being the change agent, or yourself and your probings? How about a combination of yourself and the sensory nervous system of the patient in the form of a kinesthetic conversation?

                              Sounds like you regard skin as just a convenient passive holder in of tissue leakage.

                              I would call the neural effects from skin a "confounding factor" to your theory; to disprove any effects deriving from skin is a necessary step, at least mentally, to help your hypothesis along, or it can't fly. If you were able to remove the skin from your patients, then treat them and get your results, then put the skin back on after, I would believe your theory without hesitation. But, in that this is impossible to do in living conscious outpatients, I assert that you must take skin/sensory input through it into account in any kind of manul therapy. Once your mind does take it into account, it becomes simpler/less complicated/more creative to get the effects you want just by handling the outer layer. Given a chance, the patient's system will paradoxically do much more with way less.

                              Jason, "By this I'm talking about Threlkeld's 1992 article I've posted here." Would you please repost that? Or post a link to the post where you posted that? I tracked back but couldn't find where you had posted it. Thanks.
                              Last edited by Diane; 19-11-2006, 01:17 PM.
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