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:

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:

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
patients after hindfoot fractures: a randomized controlled trial. J Man Manip Ther.

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.

Alvira-Lechuz et al. (2017). Treatment Of The Scar After Arthroscopic Surgery On A Knee: A Case Study. Journal of Bodywork and Movement Therapies.

Aresti et al. (2017). Primary care management of postoperative shoulder, hip, and knee arthroplasty. BMJ.

Bijlard et al. (2017). A Systematic Review on the Prevalence, Etiology, and Pathophysiology of Intrinsic Pain in Dermal Scar Tissue. Pain Physician.

Bishop et al. (2015). What effect can manual therapy have on a patient's pain experience? Pain Management. 

Boitor et al. (2017). The Effect of Massage on Acute Postoperative Pain in Critically and Acutely Ill Adults Post-thoracic Surgery: Systematic Review and Meta-analysis of Randomized Controlled Trials. Heart Lung.

Boitor et al. (2018). Effects of Massage in Reducing the Pain and Anxiety of the Cardiac Surgery Critically Ill-a Randomized Controlled Trial. Pain Med.

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. 

Bove et al. (2018). Manual therapy prevents onset of nociceptor activity, sensorimotor dysfunction, and neural fibrosis induced by a volitional repetitive task. Pain.

Boyd et al. (2016). The Impact of Massage Therapy on Function in Pain Populations-A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part III, Surgical Pain Populations. Pain Med.

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.

Busse et al. (2017). Guideline for opioid therapy and chronic noncancer pain. CMAJ.

Capogna et al. (2017). Tendon Disorders After Total Hip Arthroplasty: Evaluation and Management. J Arthroplasty.

Chapman, C.R., & Vierck, C.J. (2017). The Transition of Acute Postoperative Pain to Chronic Pain: An Integrative Overview of Research on Mechanisms. J Pain.

Cheuy et al. (2017). Arthrofibrosis Associated With Total Knee Arthroplasty. J Arthroplasty.

Cholok et al. (2017). Traumatic muscle fibrosis: From pathway to prevention. J Trauma Acute Care Surg.

Chughtai et al. (2016). A Novel, Nonoperative Treatment Demonstrates Success for Stiff Total Knee Arthroplasty after Failure of Conventional Therapy. J Knee Surg.

Cook et al. (2017). Post-operative opioid pain management patterns for patients who receive hip surgery.

Crespin et al. (2015). Acupuncture provides short-term pain relief for patients in a total joint replacement program. Pain Med.

Duchesne et al. (2017). Impact of Inflammation and Anti-inflammatory Modalities on Skeletal Muscle Healing: From Fundamental Research to the Clinic. Phys Ther.

Ebert et al. (2013). Randomized trial investigating the efficacy of manual lymphatic drainage to improve early outcome after total knee arthroplasty. Arch Phys Med Rehabil.

Eckenrode, B.J. (2017). An algorithmic approach to rehabilitation following arthroscopic surgery for arthrofibrosis of the knee: A case series. Physiother Theory Pract.

Eisenach, J.C., & Brennan, T.J. (2018). Pain after surgery. Pain.

Ekhtiari et al. (2017). Arthrofibrosis after ACL reconstruction is best treated in a step-wise approach with early recognition and intervention: a systematic review. Knee Surg Sports Traumatol Arthrosc.

Ferguson et al. (2018). Hip replacement. Lancet.

Filardo et al. (2016). Patient kinesiophobia affects both recovery time and final outcome after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc.

Fry et al. (2017). ACL injury reduces satellite cell abundance and promotes fibrogenic cell expansion within skeletal muscle. J Orthop Res.

Gigliotti et al. (2015). Atrophy, inducible satellite cell activation, and possible denervation of supraspinatus muscle in injured human rotator-cuff muscle. Am J Physiol Cell Physiol.

Gigliotti et al. (2016). Altered Satellite Cell Responsiveness and Denervation Implicated in Progression of Rotator-Cuff Injury. PLoS One.

Gigliotti et al. (2017). Fibrosis, low vascularity, and fewer slow fibers after rotator-cuff injury. Muscle Nerve.

Heerey et al. (2018). Impairment-Based Rehabilitation Following Hip Arthroscopy: Postoperative Protocol for the HIP ARThroscopy International Randomized Controlled Trial. J Orthop Sports Phys Ther.

Jansen et al. (2018). Active controlled motion in early rehabilitation improves outcome after ankle fractures:
a randomized controlled trial. Clin Rehabil.

Kalson et al. (2016). International consensus on the definition and classification of fibrosis of the knee joint. Bone Joint J.

Kukimoto et al. (2017). The Effects of Massage Therapy on Pain and Anxiety after Surgery: A Systematic Review and Meta-Analysis. Pain Manag Nurs.

LaPrade et al. (2007). The anatomy of the posterior aspect of the knee. An anatomic study. J Bone Joint Surg Am.

Lampi, M.C., & Reinhart-King, C.A. (2018) Targeting extracellular matrix stiffness to attenuate disease: From molecular mechanisms to clinical trials. Sci Transl Med.

Laumonier, T., & Menetrey, J. (2016). Muscle injuries and strategies for improving their repair. Journal of Experimental Orthopaedics. 

Loskotová et al. (2017). Myofascial-manual lymphatic drainage for burn trauma: a service evaluation. Br J Community Nurs.

Miller et al. (2018). Enhanced skeletal muscle regrowth and remodelling in massaged and contralateral non-massaged hind limb. J Physiol.

Mitchinson et al. (2007) Acute postoperative pain management using massage as an adjuvant therapy: a randomized trial. Arch Surg.

Ng et al. (2017). Establishing the Basis for Mechanobiology-Based Physical Therapy Protocols to Potentiate Cellular Healing and Tissue Regeneration. Front Physiol.

Noehren et al. (2016). Cellular and Morphological Alterations in the Vastus Lateralis Muscle as the Result of ACL Injury and Reconstruction. The Journal of Bone & Joint Surgery.

Nordez et al. (2017). Non-Muscular Structures Can Limit the Maximal Joint Range of Motion during Stretching. Sports Med. 

Painter et al. (2015). Manual Physical Therapy Following Immobilization for Stable Ankle Fracture: A Case Series. J Orthop Sports Phys Ther.

Price et al. (2018). Knee replacement. Lancet.

Salamh et al. (2018). The efficacy of stretching exercises to reduce posterior shoulder tightness acutely in the postoperative population: a single blinded randomized controlled trial. Physiother Theory Pract.

Scholtes et al. (2017). Presentation and management of arthrofibrosis of the knee: A case report. Physiother Theory Pract.

Tedesco et al. (2017). Drug-Free Interventions to Reduce Pain or Opioid Consumption After Total Knee Arthroplasty: A Systematic Review and Meta-analysis. JAMA Surg.

Thompson et al. (2016). Understanding Mechanobiology: Physical Therapists as a Force in Mechanotherapy and Musculoskeletal Regenerative Rehabilitation. Physical Therapy. 

Vercelli et al. (2009). How to assess postsurgical scars: A review of outcome measures. Disability and Rehabilitation.

Vigotsky, A. D., & Bruhns, R. P. (2015). The Role of Descending Modulation in Manual Therapy and Its Analgesic Implications: A Narrative Review. Pain Research and Treatment. 

Vining, K.H., & Mooney, D.J. (2017). Mechanical forces direct stem cell behaviour in development and regeneration. Nat Rev Mol Cell Biol.

Waters-Banker et al. (2014). Investigating the Mechanisms of Massage Efficacy: The Role of Mechanical Immunomodulation. Journal of Athletic Training. 

Williams et al. (2017). Persistent postsurgical pain in children and young people: prediction, prevention, and management. PAIN Reports.

Wu et al. (2016). The Efficacy of Acupuncture in Post-Operative Pain Management: A Systematic Review and Meta-Analysis. PLOS ONE. 

Zajonz et al. (2017). Evaluation of a multimodal pain therapy concept for chronic pain after total knee arthroplasty: a pilot study in 21 patients. Patient Saf Surg.