CONNECTIVE TISSUE MASSAGE Page 4 P H Y S I O T H E R A P Y September, 1965 By M A R IA E B N E R , m .c .s .p . (Teacher’s Certificate). D iplom a in Physical Education (Vienna University), form er Principal o f School and D epartm ent o f Physiotherapy o f the U nited Leeds H ospital, England. C onnective Tissue Massage represents a type o f Physio­ therapy T reatm ent o f which I became aw are soon after the second world w ar when the C hartered Society o f Physio­ therapy invited a num ber o f G erm an Physiotherapists to its A nnual Congress in L ondon. One o f these Physiotherapists followed my invitation to Leeds where he dem onstrated the technique on a mem ber o f my staff who suffered from severe an d very acute “ fibrositis” o f the neck. T he result o f two treatm ents was amazing in giving alm ost im m ediate relief o f a condition w hich had existed fo r a long tim e and had been treated by various form s o f conventional physiotherapy. Some o f the events during the treatm ent such as the general feeling o f w arm th arising in a fairly cold room were to say the least o f it, puzzling. My interest in this form of treatm ent was very m uch aroused, b u t the difficult conditions o f organ­ ising a big departm ent an d running a school prevalent in the years after the war, prevented me from going to G erm any an d study the m ethod. This was at last possible in 1954. Since then I have not only learned to appreciate the value o f this form o f treatm ent in a variety o f conditions for which there was little other help available but it has contributed to the developm ent o f a different outlook on “ therapy” in myself. T he unsatisfactory assessment o f a patient as a “ shoulder-syndrom e” o r a case o f “vascular insufficiency” an d m any other sim ilar descriptions o f p atient’s symptoms, has given place to an appreciation o f a patient where certain sym ptom s are only the obvious signs o f a dysfunction o f the whole organism. O n my return from G erm any I treated personally o r thro u g h mem bers o f my staff under my super­ vision several h undred patients w ith very satisfactory and sometimes amazing results. In the beginning the patients referred by consultants were usually patients in which more conventional form s o f therapy h ad failed, later on patients were selected, taking into account the results previously achieved. A second visit to G erm any in 1958, this time to Frieburg im Breisgau, produced some new aspects o f this form o f therapy. I m entioned previously my changing attitude in the physiotherapeutic approach to the patient an d should like to enlarge on this statem ent. M any o f the patients to be found in Physiotherapy D epartm ents are suffering from a variety of “ soft tissue lesions” . Two com ponents are there­ fore always involved even if the condition is originally due to injury o f boney o r nervous tissue. T he tw o com ponents involved are the connective tissue and th e circulatory system. T he circulatory system in its widest sense consists o f a system of tubes dealing with an am ount o f fluid, the quantity o f which only alters w ithin small limits, provided the heart and kidneys are w orking norm ally. Accumulation o f fluid, due to inflam m atory processes anywhere in the body o r lack o f fluid due to interference w ith the vascular nerve supply, m ust therefore cause alterations in the fluid contents o f the tissues in other parts. The tissue which is prim arily affected by alterations in fluid contents is con­ nective tissue. L ack o f fluid o r alterations in th e consistency o f the fluid will not only affect the consistency o f connective tissue by also its extensibility. Connective tissue form s the body surface an d also form s an integral p a rt o f all body structures. It is continuous throughout the body. Alterations in its tension anywhere in the body m ust therefore be reflected in other parts o f the body and interfere w ith func­ tion. Loose connective tissue alm ost assumes the function o f an organ o f m etabolism , acid-base equilibrium , water and salt balance, osm otic pressure regulation all take place through the medium o f connective tissue. Sometimes there is active participation o f connective tissue cells in these processes. Circulation plays a decisive p art in the form ation of connective tissue. C irculation is partly under nervous control (as m entioned) partly under chemical control such as endocrine secretions and release o f substances such as histam ine and heparin from the M ast cells which are one of the cellular elements o f connective tissue. These thoughts offer an explanation why we find extensive connective tissue changes in a variety of conditions which are not associated w ith injury such as states o f mental tension in m any people who have lost the art o f relaxation. Results o f this tension such as frequent headaches, backache, shoulder-syndrom e are often only treated w ith drug therapy and therefore the changes which occur as a result o f circu­ latory changes in the connective tissue are not cleared up. The pain and functional im pairm ent due to these tissue changes form p art o f a vicious circle increasing the mental tension. These connective tissue changes can often be observed in the body conture in the back. (See literature.) I t is therefore essential to consider the patient as a whole, norm alize the connective tissue tension over the whole body by influencing the circulation on the body surface. This can be achieved by connective tissue massage in the back. W idespread connections along circulatory pathways and segmental nerve supply will influence the circulation not only over the body surface b u t in som atic and visceral structures associated with the areas under treatm ent. Almost I all treatm ents start in the sacral area for various reasons. T he sacral area gives rise to p art o f the parasym pathetic outflow and the connective tissue covering it is continuous with the connective tissue covering the upper p art o f the tru n k and arm s and with the connective tissue covering the buttocks and the legs. Em pirically it has been found that this increase in peripheral circulation prom otes a condition o f general relaxation and a feeling o f wellbeing. Patients sleep better which helps to break the vicious circle of tension buildup. In o rder to m ake this article more useful, I am not gener­ ally referring to facts which have been discussed in detail in th e b oo k “ Connective Tissue M assage” but I am trying to concentrate on conditions present in patients who have been presented to me during the courses which I have been able to hold in South Africa. I have been particularly im pressed by th e prevalence and frequency o f peripheral vascular lesions b o th in Whites and non-W hites fo r which I could not obtain an explanation related to either climatic o r nutritional factors. I should be very grateful if any research o r literature existing on this subject could be brought to my notice. Since the publication o f the book on this subject I have had fu rth er opportunity to treat patients R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Se p te m b e r, 1965 P H Y S I O T H E R A P Y Page 5 suffering from the conditions mentioned and I therefore proposed to discuss in m ore detail than was possible pre­ viously, migraine and interm ittent claudication. M igraine The diagnosis o f migraine is often applied to various forms o f headache, which need not necessarily produce the more specific sym ptom s o f true migraine, i.e. visual dis­ turbances a n d /o r nausea. All forms o f headache benefit from the application o f C.T. massage but as headache is a symptom which be due to a variety o f causes, it will lead to a m ore successful approach if some o f these causes and their symptoms will be discussed. Causes: H eadache m ay be a sym ptom in post-concussional syndrome and during the inspection o f the back the zones between the scapulae, along the cervical spine and along the occipital curved line will be particularly pronounced. Changes may be palpated along the border o f the upper fibres of trapezius and along the borders o f sterno-m astoid. In the presence o f generalized rheum atism , headaches may be a troublesom e additional sym ptom and are often asso­ ciated with paraesthesia in the upper limbs particularly noticeable in the m orning on waking up. The m ain headache zone between the scapulae will again be present b u t addi­ tional pronounced zones may be noticed over the posterior aspect o f deltoid. H eadaches w ith additional symptoms o f nausea which often m ay lead to vomiting will often produce distinctly visible an d palpable liver o r intestinal zones in addition to the always-present interscapular zone. In these cases it will be useful to direct some investigation and the patient’s attention to the occasions when these headaches appear. It will be possible to find frequently an association between headache periods and some food allergy. In other patients it m ay be possible to detect a n association between headache periods and the m enstrual cycle. In these patients the lower headache zones (see book chart) will be frequently found. In patients suffering from a condition which is often diagnosed as tension headaches all the upper headache zones will be very pronounced but the whole back may show conture alterations w ith special liver or intestinal zones present. The above rem arks will m ake it clear how im portant the first investigation is in order to assess the p atient’s condition. It is often helpful if the patient has a headache when they come for their first treatm ent. Visual investigation according to the back-chart will reveal the presence o f headache zones and the additional presence o f e.g. liver zones o r m enstrual zones o r special zones o f tension in the cervical region may provide a guide to the underlying cause o f the headaches. Manual investigation will reveal changes in tissue consis­ tency o r tissue sensitivity in certain areas. All these findings will help to plan the treatm ent m ore intelligently. I t is most im portant to have an open m ind and n ot expect “ typical” symptoms in patients who suffer from headaches. Some patients who suffer from severe migraine attacks with continuous vomiting may be perfectly well the next day and other m ay feel off colour fo r several days. It is always im portant to treat thoroughly the sacral area, as in all types of headache there seems to exist a relationship between the sacral area and the head. F o r the rest o f the treatm ent the importance o f emphasis on other areas varies. A general easing of the condition can alm ost invariably be observed after 1-3 treatm ents o f the sacral area in all patients. In some patients the final im provem ent occurs when the latissimus dorsi and the area between the scapulae is treated, |n others the final clearance occurs when treatm ent is given in the cervical region and along the borders o f trapezius. In other patients the liver zone represents the crucial treat­ ment area. To give a general guide I shall attem pt to discuss these patients falling into three main groups. I should however like to stress again th at a clear division is often not possible and various underlying causes may combine to give the p atien t’s symptoms. Headaches after Trauma As far as possible the treatm ent should be carried out in sitting and concentrated on the basic section fo r 2-3 sessions w ith the addition o f the latissimus dorsi border. F u rth er progression tow ards the cranium will have to be guided by the p atien t’s condition. T he patient should however not be discharged until the occipital curved line shows norm al tension and absence of special pain sensitivity. Headaches Associated with M enstrual or Digestive Disturbances LIV ER -STR O K E The patient should be in lying and the Physiotherapist should be sitting on the right side o f the patient. The stroke can be carried out with the right or the left hand, at first with very little depth, gradually increasing in depth. These patients usually show a distinct headache zone between the scapulae an d additional zones over the liver area and the sacrum. F o r a num ber o f treatm ents it is essential to concentrate on the basic section, carrying out th e treatm ent in sitting. Long strokes will not be possible in m any cases as the p atient’s response is often only a “ tickling” sensation in response to the stroke instead o f the scratching or cutting sensation. Short strokes m ust therefore only be applied until the response alters. It may often be necessary to include the great trochanter area in the early treatm ents. This treatm ent is best carried out in half lying o r lying. As soon as the progress o f the treatm ent permits the liver area m ust be included in the treatm ent, concen­ trating at first with short strokes on the angle between the last rib and the vertebral colum n, including latissimus dorsi into the treatm ent an d gradually attem pting to apply the subcostal stroke with the patient in the lying position. This “liverstroke” m ust be applied with no depth in the beginning as the area is often very sensitive. T he feeling o f nausea or sickness may often be abolished w ith this stroke. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) I f the headaches are definitely associated with the m en­ strual cycle, treatm ent as described in “ Connective Tissue M assage” must be applied. Headaches associated with Hypertension B ack investigation in these patients often produces acute cutting sensation in the sacral areas, distinct zones between the scapulae and very m uch increased sensitivity to palpation in the whole cervical an d shoulder areas up to the occipital curved line. E arly treatm ents m ust be concentrated on the basic section an d the latissimus dorsi, carried out in sitting if possible. G radual progression must include the whole back and cervical region, scapulae and clavicles. It is very im portant to abandon the treatm ent o f the paravertebral thoracic area until a clear cutting sensation can be obtained. Frequent strokes over th e clavicles and an terio r release strokes are very im portant as the autonom ic balance in these patients is often very labile. It is also im portant that these patients rest fo r 20-30 m inutes after the treatm ent. T o teach general relaxation to these patients proves often o f additional benefit. In order to illustrate some o f the points, previously discussed, the following case history may prove useful. P atient: Female, aged 55. O ccupation: Housewife. 7/7/1962. This p atient’s case history revealed that migraines started in 1948 after her h usband’s death, having one o r two attacks per week. (There is a family history o f m igraine— grandm other and niece suffer from it). The num ber o f attacks has decreased during th e last two years. A t present she has one at intervals o f approxim ately 10 days. She sleeps badly and usually gets up during the night to make some tea. She always wakes with a headache which usually lasts until midday. W hen she has a migraine attack, she usually wakes a t about 6 a.m . The headache increases in intensity for approxim ately 3-4 hours when she starts attacks of vomiting. This stage passes after another 3-4 hours, when the patient is able to go to sleep for 3-4 hours w ith the help of “ m igral” . T he pain usually starts in the frontal area an d passes later to the back o f the skull. She avoids long car journeys or visits to the city as it brings on an attack o f migraine. She cannot tolerate bright light o r sitting in the sun. Treatment: 1. Basic S ection: T he back was very tense and all strokes very cutting. ’■ 2. Back to C7 and anterior pelvic strokes. 3. The patient reported th a t the m orning headaches cleared up m uch m ore quickly. Back treated to C l. 4. Patient arrived w ith ordinary headache. Back treated to C l, Latissimus dorsi, clavicles an d trapezius. The pain im proved after the ribstrokes and completely disappeared after the treatm ent o f Latissimus dorsi. 5. Two days ago th e patient woke w ith migraine, but less severe than before and did n o t vom it. The migraine lasted until 6 p.m. O n arrival th e patient reported th at fo r the first time she did no t wake with a headache today. T reatm ent as last time. T he patient is now sleeping well and has not found it necessary to get up during the night to m ake tea since th e second treat­ ment. 6. T he patient reported that she had been to the city until 4 p.m ., th e first time for m any years and h ad no headache in the evening. 7. On arrival the p atient reported th at she had a slight migraine, suffered from nausea, b u t had not been sick. Treatm ent as before. T he feeling o f nausea cleared after the rib-strokes and the headache com ­ pletely disappeared after the an terio r pelvic strokes. Page 6 P H Y S I O T H E R A P Y September, 1965 Six further treatm ents were given at the ra te o f three times per week. T he patient reported th a t she had been headache- free fo r one week, could w ork in the garden, tolerate bright light and could sit in the garden in the sun. T he patient continued treatm ent at the sam e rate and had only short episodes o f ordinary slight headaches. 24/8/1962. T he patient reported th at she had been m otoring all day on the previous day and felt delighted as she had not risked such a journey for m any years. She returned w ithout headache. The patient continued with treatm ent three times per week until the end o f September 1962. She had now resumed an ordinary social life, went to the theatre, had visitors and w orked with the “ W om en’s G uild” w ithout feeling any ill-effects. Two further treatm ents were given, one in O ctober and one in Novem ber. The patient reported th at “ she felt like a new w oman, 10 years younger” . She had no ordinary headaches or migraines during these two m onths and dis­ continued treatm ent in D ecem ber 1962. She reported a year later th at she was still feeling very well. Intermittent Claudication T his condition has been previously discussed (Ebner C .T.M ., pages 150-154). F u rth er experience has shown that the effect o f treatm ent can often be enhanced if the patients are encouraged to rest in the recum bent position for h alf an h o u r to one h o u r after treatm ent. W here possible the treat­ m ent should therefore be carried out in the p atien t’s home or arrangem ents m ade that the patient can have undisturbed rest in the departm ent before em barking on the homeward journey. It is claimed by G erm an investigators that the autonom ic tone swings over to the parasym pathetic side after C.T. massage which proves beneficial to these patients, who very often are tense and find it difficult to relax. The condition o f these patients is often aggravated by additional pathology affecting other organs. G astric or duodenal ulcers or heart conditions m ay be present an d the rest period in all these cases is therefore very im portant, in order to allow the circulatory system to a d a p t itself to the altered situation produced by the C.T. massage treatm ent. It is also often im portant to teach these patients general relaxation and draw their attention to the fact that a more tolerant approach to difficulties arising in daily life would help their condition. M any o f these patients are used to m anaging a great deal o f work in their life an d have therefore adopted very quick walking habits. It is often helpful to ad­ vise them to walk a little bit m ore slowly and avoid a situa­ tion where they have to take definite rest periods. In som e cases additional benefit can be derived if the back is treated to the level o f T7 and special attention is given to the liver zone. Should the patient suffer additionally from headaches, the treatm ent m ust be gradually extended over the whole back. Fairly long intervals w ithout treatm ent are possible once the condition has resolved itself to the extent that the patient can follow his ordinary working routine at a slightly reduced speed. This m ay dem and initially 20-30 treatm ent sessions and it is advisable in m any cases to repeat yearly a short course o f treatm ent. T he following case history m ay illustrate som e o f the points m ade: P atien t: M ale. Age, 60 years. D iagnosis: H ardening o f arteries, interm ittent claudication. 19/4/1964. O n investigation the p atient reported th at he had felt som e leg pain after walking longer distances but the condition had become m uch aggravated after return from a pilgrimage when he had been on his feet for many hours w ithout rest. A t present pain occurs after very short distance walking—he has to slow dow n b u t does not have R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Se p te m b e r, 1965 P H Y S I O T H E R A P Y Page 7 to stop completely. There is no pain after a night’s rest but it soon returns after resuming the tasks o f a daily routine which involved a great deal of walking and standing. The patient’s norm al walking pace was very quick. There was a positive arterial zone over both buttocks, more pronounced on the left. Treatment: 1 . Forw ard lying basic section, two thighs as far as the popliteal space, including the two heads o f gastroc- nemeus. A slight cutting reaction over the buttocks could only be obtained after stim ulation o f the trigonum lum borum . First stroke reaction was only “ tickling” . A fter the treatm ent the patient reported that he felt fine and the legs much more alive. 2. Patient reported that he felt fine and had mowed the lawn for 1J hours w ithout ill effects. Treatment: Basic section and both legs including the feet. T he stroke reaction was much sharper except over the feet which only gave a “ tickling” reaction. The lower legs were only treated with short strokes. G eneral relaxation taught. 3. Patient reported he was walking with much greater ease. The sam e areas were treated. A much better erythem a was obtained, the short strokes along the medial and lateral border o f the feet were felt as very sharp. 4. Felt very well after the last treatm ent for two days when some discom fort was felt in the right ilio-tibial tract and the right calf. T reatm ent of back extended to T7 in the forw ard lying position. The two legs were treated in the lying position and treatm ent specially concentrated with short strokes on the ilio-tibial tracts and the popliteal space. These four treatm ents were carried out at 3-4 days interval. A necessary journey caused interruption in the course of treatm ent fo r one m onth. 5. The patient could carry out all necessary walking w ithout having to stop, discom fort in the calves, however, after quick walking necessitated sometimes slowing down o f pace. Treatment: Back to T7, both lower extremities. C utting reaction obtained everywhere. 6. Patient reports th at he can do everything, only slight discom fort in calves on quick walking. Fourteen further treatm ents were given at weekly intervals. The walking pace could gradually be increased. The patient went for a three-week holiday. D uring the holiday he had a slight flareup o f his gastric ulcer. A fter long walks he felt tired but had no acute pain. 26/11/1964. T he treatm ent was resumed. Areas treated were the back to T7, latissimuus dorsi and both legs in­ cluding the feet. A fter the first treatm ent the gastric ulcer gave no further trouble. Seven more treatm ents were given to the same areas at weekly intervals. T he patient only experienced discom fort in the calves on quick uphill walking and the left hallux felt less alive than the rest of the foot. D uring this period the patient had a great deal o f work which involved walking and standing and this could be carried out w ithout discomfort. A fter my return from South Africa I saw the patient again on A pril 21st 1965. D uring the period o f 3 i m onths without treatm ent the patient had no ulcer trouble and no leg discomfort except on quick uphill walking. L iterature: Connective Tissue Massage, Theory and Therapeutic Application. M aria Ebner, 1962. E. and S. Livingstone L td., E dinburgh. SOFT TISSUE INJURIES OF ANKLE AND CALF By M A R IA E B N E R , m .c .s . p . (Teacher’s Certificate). (L ecture-D em onstration given to Physiotherapy Students) These injuries are often considered trivial but may incapacitate the patient fo r a long time. If the treatm ent is not planned on physiological lines, these injuries may recur again at frequent intervals and eventually force the patient to discontinue with athletic activities. I have chosen for illustration of the underlying principles o f treatm ent two frequently-occurring injuries, i.e., “ sprained ankle” and “ partial tear of gastrocnemeus fibres” . The cause o f these injuries is always the use o f tissue beyond physiological limits, resulting in a tear o r stretch o f formed or unformed connective tissue. As a result o f the tear, blood vessels are injured, haem orrhage occurs, exuda­ tion o f tissue fluid takes place and a haem atom a forms. The haem atom a gradually becomes organised into scar tissue which has a tendency to contract and shorten, very often including some nerve fibres into the scar tissue. If the scar tissue is part o f a muscular structure a different coefficient o f expansion is present between the muscle fibres and the scar tissue. Future functional use o f the muscle will often cause pain due to the caught nerve fibres and future tears will often result due to the different coefficient of expansion between the two tissues. A physiological approach to these problem s will have to follow the principles o f tissue rep air and assist them with physiotherapeutic measures as far as possible. The first principle o f treatm ent in these injuries is therefore to limit the am ount o f haem orrhage and exudation and encourage absorption as far as possible in order to limit the am ount o f unavoidable scar tissue. Static hyperaemia as a result of the injury must therefore be changed into active hyperaem ia so that inflam matory products can be carried away in the blood and lym phstream. The second principle o f treatm ent applies to the norm al use o f the p art within physiological limits in order to avoid alienation occuring in the cortical pathway. The two examples chosen may help to illustrate the above- mentioned principles. Sprained Ankle I t is comm only taught that a sprained ankle is a lesion o f the lateral.ligam ent o f the ankle jo in t due to an inversion strain. This explanation assumes th at a ligament is the first line o f defence if unphysiological force is applied to a joint. This is incorrect. Ligaments as well as muscles possess as part o f their structure stretch receptors which record applied stretching strains beyond their physiological stretching ability. As a result of this stretch stimulus muscles reflexly contract to protect structures such as capsules and ligaments which have very little extensibility. If the applied force is too great, inextensible structures such as the periosteal attachm ents o f muscles or fibres at the junction of tendon and muscle o r ligaments passing over a jo in t o r forming part o f the jo in t capsule, will tear. I f the inversion strain is too suddenly o r too forcefully applied and injury occurs, it is therefore reasonable to look for injury in the above-m en­ tioned structures. The muscles affected in an inversion strain which is not strong enough to produce a fracture will be the evertors, i.e., peroneus longus, peroneus brevis and peroneus tertius. I f it is accepted that the weakness and pain after a sprained ankle is due to a muscle lesion rather than a ligamentous lesion the com m on sites of pain and swelling can easily be explained. Pain is often present at the base o f the fifth m etatarsal which represents the insertion o f peroneus brevis which is torn off partially from its insertion. Pain and swelling in front o f the lateral malleolus represents an injury to Dernneus R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )