Deep Friction Massage

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Description

Deep friction massage (DFM), also known as cross friction massage, is a specific connective tissue massage that was developed by James Cyriax. The purpose of DFM is to: maintain the mobility within the soft tissue structures of ligament, tendon, and muscle, and prevent adherent scars from forming. The massage is deep, as the name implies, and must be applied transversely to the specific tissue involved unlike the superficial massage given in the longitudinal direction parallel to the vessels which enhances circulation and return of fluids. Before DFM can be performed successfully, the correct structure must be found through proper evaluation procedures. The distinction must be made between contractile structures such as the muscle belly, musculotendinous junction, tendon, and tendon-periosteal junction and non-contractile structures such as the joint capsule, bursae, fascia, dura mater, and ligament.

In addition to finding the right spot, the massage must also be given the most effective way by following these basic principles:

1. The proper location must be found through proper evaluation procedures and palpation of the specific tendon, ligament, or muscle.
2. Friction massage must be given across the affected fibers. The thicker and stronger a normal structure, the more important friction is given strictly across the grain.
3. The therapist's fingers and patient's skin must move as one, otherwise moving subcutaneous fascia against muscle or ligament could lead to blister formation or subcutaneous bruising.
4. The friction massage must have sufficient sweep and be deep enough.
5. The patient must be in a comfortable position.
   
   

The frequency and duration of treatment varies with the severity and type of the injury. In a recent injury, i.e. ligament sprain, start daily with gentle massage to keep mobility. It is important for the therapist to distinguish between tenderness and pain. Tenderness can be due to deep friction and can persist long after the pain disappears. Pain is elicited by clinical assessment and reassessment. Deep friction massage may be given every other day or when the excess tenderness has worn off. The duration of the treatment varies; for example, with an acute ligamentous injury, the gentle massage performed may last only 1-2 minutes. However, it may well take several minutes to be able to get your fingers on the structure depending on the severity of pain. With DFM, the treatment will last 10-15 minutes.

Intensity of the pressure applied during DFM is important to effect pain relief. Mean pressure used by physiotherapists have been estimated to be 2.3kg/cm2, and the application of higher pressures have been shown to shorten the time to the onset of analgesia.

Effects of Deep Friction Massage

• Pain relief
  • DFM is posited to cause analgesia via the gate control theory and the effect can last up to 24 hours.

• Stimulation of fiber orientation in regenerating connective tissue
  • Transverse friction when applied in early repair cycle enhances remodeling and hence reorientation of the collagen fibers in a longitudinal manner.

• Prevention of adhesion formation
  • As friction massage causes a transverse movement of the collagen fibers, it helps in preventing adhesion formation. In situations where adhesions are already formed a more intense friction can help to break them as well. In such cases friction is used to mobilize the scar tissue and break the cross linkages between the connective tissues and the surrounding structures.

• Traumatic hyperaemia
  • As it is a forceful and deep movement it effectively causes increased blood flow to the local area of application through vasodilatation. This assists in removal of chemical irritants and allows the transportation of endogenous opiates, thus causing pain relief.

Indications

Deep friction massage is widely known for its use in the treatment of tendinopathies. However, there is a paucity of evidence showing the effectiveness of DFM alone, but a number of research report positive results when it is used in combination with other forms of therapy.

Also known to be used widely in the management of chronic pain

• Chronic low back pain
• Spasticity in children with cerebral palsy

Contraindications

• Ossification and calcification of soft tissues
• Rheumatoid tendinous lesions
• Ulcers, blisters or psoriasis
• Bacterial infections
• Large haematomas in the area
• Bursitis
• Local sepsis
• Any local skin diseases
  

Key Evidence

Although there is presently no definitive research relative to friction massage and connective tissue, there certainly have been many cases of patients treated by therapists with positive results. Additional rationale for using friction massage could well be the expansion of Stearn's connective tissue theory through the understanding of the anatomy, physiology, and repair process which exist. A discussion of relevant literature is presented so that a physiotherapist can achieve an understanding of connective tissue in order to effectively and appropriately use friction massage.

The use of movement in the treatment of soft tissue injuries to muscle, ligament, and tendon is based upon the work of Stearn. She observed the fibroblastic activity in the healing of connective tissue as well as possible scar formation, as related to the effect of movement. Her conclusions were that fibrils form almost immediately and that external factors were responsible for the development of an orderly arrangement of the fibrils. Cyriax and Russell contend that "gentle passive movements do not detach fibrils from their proper formation at the healing breach, but prevent their continued adherence at abnormal sites.