Conservative Treatment for Dupuytren's Disease

 Image Credit - By Frank C. Müller, CC BY-SA 4.0.

Image Credit - By Frank C. Müller, CC BY-SA 4.0.

Massage therapy combined with active and passive stretching has been proposed as a potential adjunctive treatment for attenuating Dupuytren's disease (DD) progression and recurrence. Dupuytren's disease is a progressive disorder of the hand that eventually can cause contractures of the affected fingers. The progression of the disease is a complicated process, involving a cascade of molecular and cellular events, in which the cytokine Transforming growth factor beta (TGF-β) plays a fundamental role (Tripoli et al. 2016).

Studies have demonstrated that non-operative treatments such as massage therapy do not cure the condition permanently, but it may affect progression (Larocerie-Salgado et al. 2012 , Christie et al. 2012). These observations support the investigation of massage therapy as an adjunctive treatment strategy for Dupuytren's disease. This post is a brief look at related research, ideally it will serve as a starting point - providing massage therapists and researchers some points of considerations.

“The results achieved in our patients demonstrate that in the setting of early onset contracture of the PIPJ [proximal interphalangeal joint] due to DD, a relatively simple splinting regimen, combined with stretching exercises and massage to contracted tissue, can stabilize the progression of contracture and in some cases ameliorate the degree of deformity”

— Larocerie-Salgado et al. 2012

Massage Therapy - The Science is Emerging
Based on available evidence the mechanisms by which massage therapy interrupts the sequelae of pathological healing is most likely not in a single unified response, but as a collection of interconnected adaptive responses within the nervous system and soft tissue structures. 

Attenuating Tissue Levels of TGF-β1
As a therapeutic intervention massage therapy has the potential to attenuate TGF-β1 induced fibroblast to myofibroblast transformation. Recent studies have looked at the effect of modeled massage therapy and mechanical stretching on tissue levels of TGF-β1 (Bouffard et al. 2008Bove et al. 2016). In these studies it was demonstrated that mechanical stretching has the potential to attenuate tissue levels of TGF-β1 and the development of fibrosis.

This is potentially impactful in the treatment of DD because TGF-β1 plays a key role in tissue remodeling and fibrosis (Tripoli et al. 2016).




Attenuating Tissue Levels of TNF-α
Researchers have also described the pathogenic role that tumour necrosis factor (TNF) plays during the course of Dupuytren disease (Verjee et al. 2013Kalliolias et al. 2016). High levels of TNF contribute to the contractile activity of myofibroblasts, which drives disease development, in Dupuytren's patients.

A study looking at the use of massage for exercise induced muscle damage (Crane et al. 2012) indicates that massage attenuates the production of tumour necrosis factor-α (TNF-α). Attenuating tissue levels of TNF-α with massage may play a role in disease development by reducing the contractile activity of myofibroblasts.

Impacting Inflammation
Persistent inflammation has the potential to interfere with the remodeling of tissue (Rand et al. 2016). There has been modeled experiments to demonstrate the the impact of stretching on inflammation-regulation mechanisms within connective tissue (Berrueta et al. 2016). Another study suggest that the application of massage induces a phenotype change, prompting the transition of M1 macrophages into the M2 macrophages (Waters-Banker et al. 2014).

Neurophysiological Responses
Other research papers have looked at the neurophysiological mechanisms elicited by massage therapy treatments. A biopsychosocial model provides a practical framework for investigating the complex interplay between massage therapy and clinical outcomes.

Massage therapy as a adjunctive treatment of Dupuytren's disease
Dupuytren's disease is a topic that I follow closely as I have seen second hand the long term effects of this progressive disorder. If these studies are clinically translatable, prophylactic massage treatments may inhibit inflammatory processes and affect the development of fibrosis by mediating differential cytokine production. Consequently this may stabilize the progression of contractures and in some cases ameliorate the degree of deformity. 

Massage therapy is simple to carry out, economical, has very few side effects, the next step for researchers is to look into what sort of dosage and duration would be needed to optimize the effects of this non-invasive approach. As an added note I will emphasize that therapists should be familiar with the condition and cross frictioning need not be vigorous and stretching should be a gentle exploration of ROM.

More to Explore

Ball, C., Izadi, D., Verjee, L.S., Chan, J., Nanchahal, J. (2016). Systematic review of non-surgical treatments for early dupuytren's disease. BMC Musculoskelet Disord. (OPEN ACCESS)

Berrueta, L., Muskaj, I., Olenich, S., Butler, T., Badger, G. J., Colas, R. A., . . . Langevin, H. M. (2016). Stretching Impacts Inflammation Resolution in Connective Tissue. Journal of Cellular Physiology.

Bochaton-Piallat, M., Gabbiani, G., & Hinz, B. (2016). The myofibroblast in wound healing and fibrosis: Answered and unanswered questions. F1000Research. (OPEN ACCESS)

Bove, G., Harris, M., Zhao, H., & Barbe, M. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Journal of the Neurological Sciences.

Brauns, A., Van Nuffel, M., De Smet, L., Degreef, I. (2017). A clinical trial of tension and compression orthoses for Dupuytren contractures. J Hand Ther.

Chapman, M.A., Meza, R., Lieber, R.L. (2016). Skeletal muscle fibroblasts in health and disease. Differentiation. (OPEN ACCESS)

Christie, W.S., Puhl, A.A., Lucaciu, O.C. (2012). Cross-frictional therapy and stretching for the treatment of palmar adhesions due to Dupuytren's contracture: a prospective case study. Man Ther.

Crane, J., Ogborn, D., Cupido, C., Melov, S., Hubbard, A., Bourgeois, J., & Tarnopolsky, M. (2012). Massage Therapy Attenuates Inflammatory Signaling After Exercise-Induced Muscle Damage. Science Translational Medicine.

Freitas, S.R., Mendes, B., ... Milanovic, Z. (2017). Can chronic stretching change the muscle-tendon mechanical properties? A review. Scand J Med Sci Sports.

Guimberteau, J., Delage, J., & Wong, J. (2010). The role and mechanical behavior of the connective tissue in tendon sliding. Chirurgie De La Main.

Hicks, M., Cao, T., Campbell, D., & Standley, P. (2012). Mechanical strain applied to human fibroblasts differentially regulates skeletal myoblast differentiation. Journal of Applied Physiology.

Huisstede, B.M., Gladdines S, Randsdorp MS, Koes BW. (2017). Effectiveness of conservative, surgical, and post-surgical interventions for Trigger finger, Dupuytren's disease, and De Quervain's disease. A systematic review. Arch Phys Med Rehabil.

Karkampouna, S., Kreulen, M., Obdeijn, M.C., Kloen, P., ... Kruithof-de Julio, M (2016). Connective Tissue Degeneration: Mechanisms of Palmar Fascia Degeneration (Dupuytren's Disease). Curr Mol Biol Rep. (OPEN ACCESS)

Kay, A.D., Husbands-Beasley, J., Blazevich, A.J. (2015). Effects of Contract-Relax, Static Stretching, and Isometric Contractions on Muscle-Tendon Mechanics. Med Sci Sports Exerc.

Kay, A.D., Richmond, D., Talbot, C., Mina, M., Baross, A.W., Blazevich, A.J. (2016). Stretching of Active Muscle Elicits Chronic Changes in Multiple Strain Risk Factors. Med Sci Sports Exerc.

Kwan, P.O., Tredget, E.E. (2017). Biological Principles of Scar and Contracture. Hand Clin.

Larocerie-Salgado, J., Davidson, J. (2012). Nonoperative treatment of PIPJ flexion contractures associated with Dupuytren's disease. J Hand Surg Eur.

Liu, W., O'Gorman, D.B., Gan, B.S. (2013). Operative trends and physician treatment costs associated with Dupuytren's disease in Canada. Can J Plast Surg.  (OPEN ACCESS)

McMillan, C., Yeung, C., Binhammer, P. (2017). Variation in Treatment Recommendations for Dupuytren Disease. J Hand Surg Am.

Miller, B.F., Hamilton, K.L., ... Butterfield, T.A., Dupont-Versteegden, E.E. (2018). Enhanced skeletal muscle regrowth and remodelling in massaged and contralateral non-massaged hind limb. J Physiol.

Mokos, Z.B., Jović, A., ... Marinović, B. (2017). Current Therapeutic Approach to Hypertrophic Scars. Front Med (Lausanne). (OPEN ACCESS)

Pelletier, R., Higgins, J., Bourbonnais, D. (2017). The relationship of corticospinal excitability with pain, motor performance and disability in subjects with chronic wrist/hand pain. J Electromyogr Kinesiol.

Rand, E., Gellhorn, A.C. (2016). The Healing Cascade: Facilitating and Optimizing the System. Phys Med Rehabil Clin N Am.

Rayan, G.M., Moore, J. (2005). Non-Dupuytren's disease of the palmar fascia. J Hand Surg Br.

Stecco, A., Stern, R., Fantoni, I., Caro, R., & Stecco, C. (2016). Fascial Disorders: Implications for Treatment. Pm&r.

Tripoli, M., Cordova, A., Moschella, F. (2016). Update on the role of molecular factors and fibroblasts in the pathogenesis of Dupuytren's disease. J Cell Commun Signal. (OPEN ACCESS)

Verhoekx, J.S., Mudera, V., Walbeehm, E.T., Hovius, S.E. (2013). Adipose-derived stem cells inhibit the contractile myofibroblast in Dupuytren's disease. Plast Reconstr Surg.

Verjee, L. S., Verhoekx, J. S., Chan, J., . . . Nanchahal, J. (2013). Unraveling the signaling pathways promoting fibrosis in Dupuytren's disease reveals TNF as a therapeutic target. Proceedings of the National Academy of Sciences. (OPEN ACCESS)

Viganò, M., Sansone, V., d'Agostino, M.C., Romeo, P., Perucca Orfei, C., de Girolamo, L. (2016). Mesenchymal stem cells as therapeutic target of biophysical stimulation for the treatment of musculoskeletal disorders. J Orthop Surg Res. (OPEN ACCESS)

Waters-Banker, C., Dupont-Versteegden, E. E., Kitzman, P. H., & Butterfield, T. A. (2014). Investigating the Mechanisms of Massage Efficacy: The Role of Mechanical Immunomodulation.Journal of Athletic Training. (OPEN ACCESS)