Massage therapy for the postoperative population: shoulder, hip, knee, and ankle.

This post is a look at Massage therapy for the postoperative population, specifically as it relates to shoulder, knee, and hip surgery.

This post is a look at Massage therapy for the postoperative population, specifically as it relates to shoulder, knee, and hip surgery.

As the body of knowledge to support the use of massage therapy continues to grow, understanding the basic science behind what we do and the guiding principles of adaptability enable us to apply this work to a number of pathologies.

Massage therapists are uniquely suited to incorporate a number management strategies to help decrease postoperative pain and increase function. In addition to specific hands on soft tissue massage, treatments includes recommendations for activity modification, info on natural history, remedial exercise and self-care. 

A comprehensive complementary post-operative treatment incorporate a number of rehabilitation strategies based on patient-specific assessment findings including, but not limited to:
• Manual Therapy (joint mobilizationnerve mobilizationsoft tissue massageIASTM)
• Acupuncture/electroacupuncture (local, segmental and distal stimulation sites)
• Education on psychosocial factors (eg. BPS framework of pain, fear avoidance)
• Remedial Loading Programs (eg. static stretching, concentric, eccentric, isometric)

The use of massage therapy has been shown to improve outcomes in post-operative patients. Specifically as it relates to postoperative pain management, and postoperative range of motion.

Massage Therapy for postoperative pain management - Massage therapy has a modulating effect on peripheral and central processes via mechanoreceptors. Input from large sensory neurons activate spinal cord interneurons that prevents the spinal cord from amplifying the nociceptive signal (Bishop et al. 2015Vigotsky et al. 2015). This anti-nociceptive effect of massage therapy can help ease discomfort in post surgical patients (Mitchinson et al. 2007) .

Massage Therapy for postoperative range of motion - One research paper published in the journal PM&R, looked at the use of fascial manipulation following total hip arthroplasty (Busato et al. 2016). In this study 2 treatment sessions were are able to significantly improve functional outcomes in patients when used in addition to usual treatment. 

Another recent study published in The Journal of Knee Surgery looked at the effect that soft-tissue treatments with hand-held instruments have on post-surgical knee stiffness (Chunghtai et al. 2016). In the study soft-tissue treatments was shown to improve knee flexion deficits by 35° and knee flexion contractures by 12° in a small cohort of individuals who had failed to respond to traditional rehabilitation and manipulation under anesthesia. 

TGF-Β1 plays a role in tissue remodeling. As a therapeutic intervention massage therapy has the potential to attenuate TGF-Β1 induced fibroblast to myofibroblast transformation.  Davis’s Law, Attribution: www.fascialnet.com

TGF-Β1 plays a role in tissue remodeling. As a therapeutic intervention massage therapy has the potential to attenuate TGF-Β1 induced fibroblast to myofibroblast transformation.

Davis’s Law, Attribution: www.fascialnet.com

Research is still in its infancy but there is evidence to suggest that in addition to managing pain and improving range of motion massage therapy may improve healing after trauma and in some cases affect the development of postoperative fibrosis (Cholok et al. 2017). 

Fibrosis is a potential complication of surgery, it is characterized by the production of excessive fibrous scar tissue, which may result in decreased movement.

Understanding the cellular effectors and signaling pathways that drives the accumulation of fibrotic deposition, helps therapists optimize treatment protocols for patients suffering from post-surgical fibrosis and guide specific prophylactic treatments.

In the normal wound healing response, the cascade of biological responses is tightly regulated. Fibrotic development is characterized by a lack of apoptosis in the proinflammatory phase, resulting in an imbalance between synthesis and degradation. Persistent transforming growth factor-β (TGF-β) secretion and downstream responses are thought to contribute to a sustained inflammatory response (Cheuy et al. 2017).

Following trauma there are often a number of pathological adaptations in the cellular composition of muscle, which may impair the muscle’s ability to respond to subsequent rehabilitation. Massage therapy is a promising strategy that is used to attenuate adhesion formation and minimize the loss of mobility due to fibrosis. Which may improve outcomes later in the rehabilitation process as therapy shifts towards regaining strength.

The mechanisms by which massage therapy interrupt the sequelae of pathological healing is most likely not in a single unified response, but as a collection of interconnected adaptive responses within the neuroimmune system and soft tissue structures.

A study from Geoffrey Bove published in The Journal of Neurological Sciences looked at the effect of modeled massage therapy on TGF-β1 induced fibroblast to myofibroblast transformation (Bove et al. 2016). This is potentially impactful in postoperative rehabilitation because TGF-β1 plays a key role in tissue remodeling and fibrosis.

Another one of these physiological changes following an ACL injury is a decrease in satellite cells. Satellite cells play a large role in muscle repair and regeneration, mitigating the loss of these cells may enhance the muscle’s ability to respond to subsequent rehabilitation. A recent study published in The Journal of Physiology found that compression massage enhanced satellite cell numbers, and protein synthesis (Miller et al. 2018).

The goal of massage therapy is to improve physical function and manage pain. Here are four science backed ways massage therapy helps you feel better.

The responses to massage therapy are multifactorial - physiological and psychological factors interplay in a complex manner. The biopsychosocial model provides a practical reference for investigating the complex interplay between massage therapy and clinical outcomes.

With this goal in mind, an observed favorable outcome may be explained by a number of overlapping mechanism in the periphery, spinal cord, and brain including, but not limited to:

  1. Affective Touch - Interpersonal touch and therapeutic stimulation of somatosensory nerves (C-tactile afferent) mediates the release of oxytocin and endogenous opioids. Which can result in reduce physiological and behavioral reactivity to stressors and improved mood/affect.

  2. Contextual Factors - A positive therapeutic encounter is tied to clinical outcomes; the magnitude of a response is influenced by mood, expectation, and conditioning.

  3. Endogenous Pain Modulation - Input from somatosensory nerves (Aβ, Aδ and C fibers) inhibits nociceptive processing and activate descending inhibitory mechanisms. This influences neuroimmune processes correlated with the experience of pain.

  4. Mechanical Factors - Applied forces induce a molecular response that helps diminish intraneural edema and expedite clearance of noxious biochemical by-products (pro-inflammatory cytokines, and creatine kinase).


More to Explore

As a massage therapist who works with post-surgical patients, this is a topic I am interested in so I will follow closely and keep readers updated as more research comes to light. Here are my current go to resources for post-operative protocols:
• Traumatic scar tissue management: Massage therapy principles, practice and protocols
• Clinical Orthopaedic Rehabilitation: a Team Approach
• Post-Surgical ACL Injuries 

Research Links

Albin et al. (2018). Timing of initiating manual therapy and therapeutic exercises in the management of
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Albin et al. (2019). Short-Term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial. J Orthop Sports Phys Ther.
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Alvira-Lechuz et al. (2017). Treatment Of The Scar After Arthroscopic Surgery On A Knee: A Case Study. Journal of Bodywork and Movement Therapies.
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Aresti et al. (2017). Primary care management of postoperative shoulder, hip, and knee arthroplasty. BMJ.
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Bishop et al. (2015). What effect can manual therapy have on a patient's pain experience? Pain Management.
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Bove et al. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Journal of the Neurological Sciences.
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Bove et al. (2018). Manual therapy prevents onset of nociceptor activity, sensorimotor dysfunction, and neural fibrosis induced by a volitional repetitive task. Pain.
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Busato et al. (2016). Fascial Manipulation Associated With Standard Care Compared to Only Standard Postsurgical Care for Total Hip Arthroplasty: A Randomized Controlled Trial. PM R.
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Cholok et al. (2017). Traumatic muscle fibrosis: From pathway to prevention. J Trauma Acute Care Surg.
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Chughtai et al. (2016). A Novel, Nonoperative Treatment Demonstrates Success for Stiff Total Knee Arthroplasty after Failure of Conventional Therapy. J Knee Surg.
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