Sports Med U | Educating Minds, Elevating Potential

The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and injuries of the upper and lower extremities: A systematic review by the Ontario Protocol for Traffic Injury management (OPTIMa) collaboration

Piper, S., Shearer, H.M., Côté, P., Wong, J.J., Yu, H., Varatharajan, S., Southerst, D., Randhawa, K.A., Sutton, D.A., Stupar, M. and Nordin, M.C., 2016. The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and injuries of the upper and lower extremities: A systematic review by the Ontario Protocol for Traffic Injury management (OPTIMa) collaboration. Manual therapy, 21, pp.18-34.

In today’s letter

• Overview of Overview of the of how soft tissue techniques affect injuries

• Rapid Results =

1. Soft tissue techniques have shown benefits for relieving pain and increasing function for tennis elbow, carpal tunnel and plantar heel pain.

Thoughts 👇️ 

Other conditions have not been studied, but theres a high possibility that it will have positive affects on most musculoskeletal disorders in the short term at least

• 3 Reads to check out to further you knowledge about soft tissue work

• Meme of the week: This is easy did I hear you say? 😈 

Aim of study

This systematic review aims to assess the effectiveness of soft-tissue therapy, in comparison to other interventions, placebo/sham treatments, or no treatment, in enhancing self-rated recovery, functional recovery and clinical outcomes in patients with musculoskeletal (MSK) injuries

Did you know?

• The CDC (Centers for Disease Control and Prevention) defines MSK disorders as injuries or disorders affecting muscles, nerves, tendons, joints, cartilage, and supporting structures of the upper and lower limbs, neck, and lower back.

In the Netherlands, the most frequently reported sites for MSK pain in adults are:

1. 27% in the low back

2. 21% in the shoulders

3. 21% in the neck

4. 15% in the knee

5. 12.5% in the wrist/hand

6. 7.5% in the elbow

7. 5% in the ankle

• Carpal tunnel syndrome is the most common upper extremity neuropathy, with a prevalence among workers ranging from 2.6% to 14%.

• In Australia, people with shoulder symptoms, including pain and stiffness, have a lower health-related quality of life and are more than 2.5x more likely to experience depressive symptoms compared to those without shoulder complaints.

• Shoulder and knee injuries account for the highest number of lost workdays ( 24 and 15 days)

• In Canada, 18.3% of adults over the age of 20 reported using chiropractic and massage therapy as the primary treatment for musculoskeletal disorders

• Soft-tissue therapy is where soft-tissue structures are pressed and kneaded using hands or a mechanical device.

• Although soft-tissue therapy is a common and often recommended treatment, there is limited literature on its effectiveness for managing MSK issues

• Soft-tissue therapy has various techniques aimed at relieving tension and improving function in muscles and other soft tissues

Results

• 9869 screened articles and critically appraised 7

• Of those, 6 had a low risk of bias and were included in the paper

Study characteristics

• 6 low-risk bias RCTs examined the management of lateral epicondylitis, shoulder impingement syndrome, carpal tunnel syndrome, and plantar fasciitis.

• No relevant studies were found for managing other injuries, including nerve injuries/neuropathies, nor for management in children.

• One study investigated a device-assisted technique, while the others focused on manual soft-tissue therapy

Summary of evidence

Carpal tunnel syndrome

• One RCT suggests that adding self-massage to a program that has exercise protocols provides immediate post-intervention benefits for persistent carpal tunnel syndrome.

• Madenci et al. randomised carpal tunnel syndrome patients to either a 6-week supervised self-massage regimen combined with a multimodal care program (splint + exercises) or to a multimodal care program alone.

• Clinically significant improvements were observed in function and symptom severity favouring the self-massage group immediately post-intervention.

• There were statistically and clinically significant improvements in patient- and physician-rated global pain assessments, grip & strength favouring the self-massage group.

Lateral epicondylitis (Tennis elbow)

• One RCT suggests that muscle energy technique (MET) may provide more long-term benefit than a corticosteroid injection for persistent tennis elbow

• Participants were randomised to receive either 4 weeks of MET or 1 injection of triamcinolone acetonide plus lidocaine.

• The MET involved 5 repetitions twice a week for 4 weeks, focusing on resisted forearm pronation from a maximally supinated position.

• At the 6-week follow-up, corticosteroid injection showed statistically significant improvements in pain-free grip strength.

• In the long term, MET was more effective than corticosteroid injection, with significant improvements in pain-free grip strength, arm function, and disability at 26 and 52 weeks.

• Statistically and clinically significant improvements in pain with hand gripping also favoured MET.

• Another RCT found clinical massage using myofascial release effective for persistent tennis elbow, showing significant improvements in pain and disability compared to sham ultrasound at 4 and 12 weeks

Sub-acromial pain (Rotator cuff related shoulder pain)

• Evidence from 1 RCT suggests that a soft tissue release technique using Diacutaneous Fibrolysis (we will be reffring to this as Graston technique for simplicity), does not provide greater pain relief compared to sham

Sham = Is a type of medical research where some participants get a fake version of the treatment being tested, without knowing it's fake. This helps researchers see if the actual treatment works better than doing nothing.

Barra Lopez et al. randomised participants into 3 groups:

1. Graston technique performed six times over three weeks

2. sham Graston technique with a superficially applied metal hook

3. Care including clinic-based electrotherapy, therapeutic exercises, and cryotherapy.

• Post-intervention, Graston technique showed a statistically significant improvement in function compared to sham Graston technqiue.

• Graston technique and sham Graston technique demonstrated statistically significant improvements in function, shoulder extension, and external rotation compared to multimodal care.

Plantar fasciitis (Plantar heel pain)

• Evidence from 1 RCT suggests that trigger point therapy may not offer additional benefits compared to a self-stretching protocol in the short-term for plantar heel pain.

• Renan-Ordine et al. randomised participants to receive either 16 sessions over 1 month of supervised self-stretching combined with trigger point soft-tissue therapy to the gastrocnemius muscle, or supervised self-stretching alone.

• Post-intervention, trigger point therapy showed statistically significant improvements in physical functioning compared to self-stretching alone.

• However, the difference in bodily pain did not meet the minimum clinically important difference

• Statistically significant improvements were observed favouring trigger point therapy in secondary outcomes such as pressure pain thresholds

• The effect sizes were small, and the clinical significance of these outcomes remains unclear due to unknown minimum clinically important difference

• Evidence from another RCT suggests that myofascial release is effective in managing persistent plantar heel pain.

• Ajimsha et al. randomised adults with single leg plantar heel pain lasting more than 4 months to either 12 sessions over four weeks of myofascial release or sham ultrasound therapy.

• Statistically significant improvements favoring myofascial release were observed in pressure pain thresholds at both follow-up periods, although the minimal clinically important difference remains unknown.

Adverse events

• 4 out of the 6 studies documented adverse events.

• No serious adverse events were noted across these studies.

• In studies focusing on myofascial release therapy for lateral epicondylitis, 14.7% of participants reported increased pain post-treatment (which is pretty normal considering someone has been pressing on your muscles).

• In trials involving corticosteroid injections, 7.3% experienced temporary adverse effects like pain or loss of skin pigment

Top 3 resources

To learn more about soft tissue work

1. Old but gold, check out the soft tissues mobilisation information pack - LINK

2. Instrument assisted soft tissue mobilisation aka “graston technique’ - More information - LINK

3. Muscle tightness explained (VIDEO) - LINK

Thank you for reading this weeks edition!

Have a browse through our articles to sharpen you diagnostic skills