The use of massage therapy has been shown to improve outcomes in post-operative patients.
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.
A comprehensive complementary post-operative treatment should incorporate a number of rehabilitation strategies based on patient-specific assessment findings including, but not limited to:
• Manual Therapy (neurodynamic mobilization, classic massage, joint mobilization)
• 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)
Postoperative Pain Management
Massage therapy has a modulatory affect 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. 2015, Vigotsky et al. 2015). This anti-nociceptive effect of massage therapy can help ease discomfort in post surgical patients (Mitchinson et al. 2007) .
Postoperative Range of Motion
A 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.
Postoperative Scar Management
Research is still in its infancy but there is evidence to suggest that in addition to managing pain 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).
Massage therapy is a promising strategy that is used to attenuate adhesion formation and minimize the loss of mobility due to fibrosis.
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.
Recent studies have looked at the effect of modeled massage therapy on tissue levels of TGF-β1 (Bove et al. 2016). In this study it was demonstrated manual therapy attenuated the increase of fibrosis and tissue levels of TGF-β1, this may play a role in scar development by reducing the contractile activity of myofibroblasts.
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 treatment, treatments includes recommendations for activity modification, info on natural history, remedial exercise and self-care.
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-pharmacological approach.
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
Ali, A., Rosenberger, L., Weiss, T.R., Milak, C., Perlman, A.I. (2017). Massage Therapy and Quality of Life in Osteoarthritis of the Knee: A Qualitative Study. Pain Med.
Alvira-Lechuz, J., Espiau, M. R., & Alvira-Lechuz, E. (2017). Treatment Of The Scar After Arthroscopic Surgery On A Knee: A Case Study. Journal of Bodywork and Movement Therapies.
Aresti, N., Kassam, J., Bartlett, D., Kutty, S. (2017). Primary care management of postoperative shoulder, hip, and knee arthroplasty. BMJ.
Begovic, H., Zhou, G., Schuster, S., & Zheng, Y. (2016). The neuromotor effects of transverse friction massage. Manual Therapy.
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.
Bijlard, E., Uiterwaal, L., ... Huygen, F.J. (2017). A Systematic Review on the Prevalence, Etiology, and Pathophysiology of Intrinsic Pain in Dermal Scar Tissue. Pain Physician.
https://www.ncbi.nlm.nih.gov/pubmed/28158149 (OPEN ACCESS)
Bishop, M. D., Torres-Cueco, R., Gay, C. W., Lluch-Girbés, E., Beneciuk, J. M., & Bialosky, J. E. (2015). What effect can manual therapy have on a patient's pain experience? Pain Management.
https://www.ncbi.nlm.nih.gov/pubmed/26401979 (OPEN ACCESS)
Bochaton-Piallat, M., Gabbiani, G., & Hinz, B. (2016). The myofibroblast in wound healing and fibrosis: Answered and unanswered questions. F1000Research.
https://www.ncbi.nlm.nih.gov/pubmed/27158462 (OPEN ACCESS)
Bove, G., & Chapelle, S. (2012). Visceral mobilization can lyse and prevent peritoneal adhesions in a rat model. Journal of Bodywork and Movement Therapies.
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.
http://www.ncbi.nlm.nih.gov/pubmed/26810536 (OPEN ACCESS)
Busse, J.W., Craigie, S., Juurlink, D.N, ... Guyatt GH. (2017). Guideline for opioid therapy and chronic noncancer pain. CMAJ.
Cezar, C.A., Roche, E.T., Vandenburgh, H.H., Duda, G.N., Walsh, C.J., Mooney, D.J. (2016). Biologic-free mechanically induced muscle regeneration. Proc Natl Acad Sci U S A.
https://www.ncbi.nlm.nih.gov/pubmed/26811474 (OPEN ACCESS)
Cheatham, S.W., Lee, M., Cain, M., Baker, R. (2016). The efficacy of instrument assisted soft tissue mobilization: a systematic review. J Can Chiropr Assoc.
https://www.ncbi.nlm.nih.gov/pubmed/27713575 (OPEN ACCESS)
Chaudhry, H., Bukiet, B., Ji, Z., Stecco, A., Findley, T.W. (2014). Deformations experienced in the human skin, adipose tissue, and fascia in osteopathic manipulative medicine. J Am Osteopath Assoc.
Chaitow, L. (2016). Dosage and manual therapies – Can we translate science into practice? Journal of Bodywork and Movement Therapies.
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, V.A., Foran, J.R., Paxton, R.J., Bade, M.J., Zeni, J.A., Stevens-Lapsley, J.E. (2017). Arthrofibrosis Associated With Total Knee Arthroplasty. J Arthroplasty.
Cholok, D., Lee, E., Lisiecki, J., Agarwal, S., Loder, S., Ranganathan, K., Qureshi, A.T., Davis, T.A., Levi, B. (2017). Traumatic muscle fibrosis: From pathway to prevention. J Trauma Acute Care Surg.
Chughtai, M., Mont, M.A., Cherian, C., Cherian, J.J., Elmallah, R.D., Naziri, Q., Harwin, S.F., Bhave, A. (2016). A Novel, Nonoperative Treatment Demonstrates Success for Stiff Total Knee Arthroplasty after Failure of Conventional Therapy. J Knee Surg.
Comesaña, A. C., Vicente, M. D., Ferreira, T. D., Ma Del Mar Pérez-La Fuente Varela, Quintáns, M. M., & Pilat, A. (2017). Effect of myofascial induction therapy on post-c-section scars of more than one and a half years old. Pilot study. Journal of Bodywork and Movement Therapies.
Cook, C.E., Rhon, D.I., Lewis, B.D., George, S.Z. (2017). Post-operative opioid pain management patterns for patients who receive hip surgery.
Crespin, D.J., Griffin, K.H., ..., Dusek, J.A. (2015). Acupuncture provides short-term pain relief for patients in a total joint replacement program. Pain Med. (OPEN ACCESS)
Duchesne, E., Dufresne, S.S., Dumont, N.A. (2017). Impact of Inflammation and Anti-inflammatory Modalities on Skeletal Muscle Healing: From Fundamental Research to the Clinic. Phys Ther.
Ebert, J.R., Joss, B., Jardine, B., Wood, D.J. (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.
Ekhtiari, S., Horner, N.S., de Sa, D., ... Ayeni, O.R. (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.
Filardo, G., Roffi, A., ... Marcacci, M. (2016). Patient kinesiophobia affects both recovery time and final outcome after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc.
Fisher, P., Zhao, Y., Rico, M., Massicotte, V., Wade, C., Litvin, J., . . . Barbe, M. (2015). Increased CCN2, substance P and tissue fibrosis are associated with sensorimotor declines in a rat model of repetitive overuse injury. Journal of Cell Communication and Signaling.
https://www.ncbi.nlm.nih.gov/pubmed/25617052 (OPEN ACCESS)
Freitas, S.R., Mendes, B., ... Milanovic, Z. (2017). Can chronic stretching change the muscle-tendon mechanical properties? A review. Scand J Med Sci Sports.
Fry, C.S., Johnson, D.L., Ireland, M.L., Noehren, B. (2017). ACL injury reduces satellite cell abundance and promotes fibrogenic cell expansion within skeletal muscle. J Orthop Res.
Kalson, N.S., Borthwick, L.A., Mann, D.A. ...Krenn, V. (2016). International consensus on the definition and classification of fibrosis of the knee joint. Bone Joint J.
LaPrade, R.F., Morgan, P.M., Wentorf, F.A., Johansen, S., Engebretsen, L. (2007). The anatomy of the posterior aspect of the knee. An anatomic study. J Bone Joint Surg Am.
Laumonier, T., & Menetrey, J. (2016). Muscle injuries and strategies for improving their repair. Journal of Experimental Orthopaedics.
https://www.ncbi.nlm.nih.gov/pubmed/27447481 (OPEN ACCESS)
Loskotová, A., Loskotová, J., Suchanek, I., Brychta, P., Lipový, B. (2017). Myofascial-manual lymphatic drainage for burn trauma: a service evaluation. Br J Community Nurs.
Miller, B.F., Hamilton, K.L., ... Butterfield, T.A., Dupont-Versteegden, E.E. (2017). Enhanced skeletal muscle regrowth and remodelling in massaged and contralateral non-massaged hind limb. J Physiol.
Mitchinson, A.R., Kim, H.M., ... Hinshaw, D.B. (2007) Acute postoperative pain management using massage as an adjuvant therapy: a randomized trial. Arch Surg.
Murakami, M., Fox, L., Dijkers, M.P. (2017). Ear Acupuncture for Immediate Pain Relief-A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Med.
Nahin, R. L., Boineau, R., Khalsa, P. S., Stussman, B. J., & Weber, W. J. (2016). Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States. Mayo Clinic Proceedings.
Nanchahal, J., Hinz, B. (2016). Strategies to overcome the hurdles to treat fibrosis, a major unmet clinical need. Proc Natl Acad Sci U S A.
https://www.ncbi.nlm.nih.gov/pubmed/27342865 (OPEN ACCESS)
Ng, J.L., Kersh, M.E., Kilbreath, S., Knothe Tate, M. (2017). Establishing the Basis for Mechanobiology-Based Physical Therapy Protocols to Potentiate Cellular Healing and Tissue Regeneration. Front Physiol. (OPEN ACCESS)
Noehren, B., Andersen, A., Hardy, P., Johnson, D. L., Ireland, M. L., Thompson, K. L., & Damon, B. (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, A., Gross, R., Andrade, R., Le Sant, G., Freitas, S., Ellis, R., McNair, P.J., Hug, F. (2017). Non-Muscular Structures Can Limit the Maximal Joint Range of Motion during Stretching. Sports Med.
Rand, E., Gellhorn, A.C. The Healing Cascade: Facilitating and Optimizing the System. Phys Med Rehabil Clin N Am.
Salamh, P., Cook, C., Reiman, M.P., Sheets, C. (2017). Treatment effectiveness and fidelity of manual therapy to the knee: A systematic review and meta-analysis. Musculoskeletal Care.
Scholtes, S.A., Khoo-Summers, L., Damico, K.J. (2017). Presentation and management of arthrofibrosis of the knee: A case report. Physiother Theory Pract.
Stecco, A., Stern, R., Fantoni, I., Caro, R., & Stecco, C. (2016). Fascial Disorders: Implications for Treatment. Pm&r.
Tedesco, D., Gori, D., Hernandez-Boussard, T. (2017). Drug-Free Interventions to Reduce Pain or Opioid Consumption After Total Knee Arthroplasty: A Systematic Review and Meta-analysis. JAMA Surg.
Thompson, W. R., Scott, A., Loghmani, M. T., Ward, S. R., & Warden, S. J. (2016). Understanding Mechanobiology: Physical Therapists as a Force in Mechanotherapy and Musculoskeletal Regenerative Rehabilitation. Physical Therapy.
https://www.ncbi.nlm.nih.gov/pubmed/26637643 (OPEN ACCESS)
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.
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)
Williams, G., Howard, R., Liossi, C. (2017). Persistent postsurgical pain in children and young people: prediction, prevention, and management. PAIN Reports. http://journals.lww.com/painrpts/Citation/latest/Persistent_postsurgical_pain_in_children_and_young.99959.aspx
Wong, R., Geyer, S., Weninger, W., Guimberteau, J., & Wong, J. K. (2016). The dynamic anatomy and patterning of skin. Experimental Dermatology.
Wu, M., Chen, K., Chen, I., Huang, S. K., Tzeng, P., Yeh, M., . . . Chen, C. (2016). The Efficacy of Acupuncture in Post-Operative Pain Management: A Systematic Review and Meta-Analysis. PLOS ONE.
Zajonz, D., Fakler, J.K.M., Dahse, ... Roth, A. (2017). Evaluation of a multimodal pain therapy concept for chronic pain after total knee arthroplasty: a pilot study in 21 patients. Patient Saf Surg. (OPEN ACCESS)