Massage Therapy for Postoperative Patients

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Massage therapy early on could lead to improved outcomes in post-operative patients

Massage therapy early on could lead to improved 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.

The Goal of Rehabilitation is to Improve Physical Function and Manage Pain.

Following surgery there may be a number of pathophysiological responses (ie. fibrosis, postoperative pain) that may ultimately limit rehabilitation. In an interdisciplinary rehabilitation program massage therapy is used as a specific hands-on technique to expedite tissue healing, leading to improved outcomes.

The use of massage therapy has been shown to improve outcomes in post-operative patients.

One recent 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. 

Post-Operative Pain Management: Why Does Massage Therapy Make 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 framework for investigating the complex interplay between massage therapy and clinical outcomes.

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 - Therapeutic stimulation of somatosensory nerves (C-tactile afferent) mediates the release of oxytocin. Which can result in reduce physiological and behavioural reactivity to stressors and improved mood/affect.
  2. Neuroplasticity - Input from low-threshold Aβ fibers inhibits nociceptive processing and contributes to the activation of endogenous pain inhibitory mechanisms (endocannabinoids, and endogenous opioids). 
  3. Contextual Effects - A positive therapeutic encounter is tied to clinical outcomes, the magnitude of a response may be influenced by mood, expectation, and conditioning.
  4. Mechanical Effects - Gentle stretching of neurovascular structures and muscles induces a molecular response that helps blunt edema and expedite clearance of noxious biochemical by-products of inflammation and muscle damage (cytokines, prostaglandins and creatine kinase).

Massage Therapy in Various Forms May Influence Tissue and Cell Physiology

Additionally, massage therapy may improve healing after trauma and in some cases ameliorate the degree of postoperative fibrosis. 

Fibrosis is a potential complication of surgery or trauma, 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.

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

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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.

Manual mobilization is a promising strategy that is used to attenuate adhesion formation and minimize the loss of mobility due to fibrosis. 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). 

Summary Points

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 may play a role in promoting enhanced muscle regrowth and reducing postoperative fibrosis. Which may improve outcomes later in the rehabilitation process as therapy shifts towards regaining strength.

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

Research Links

Aresti, N., Kassam, J., Bartlett, D., Kutty, S. (2017). Primary care management of postoperative shoulder, hip, and knee arthroplasty. BMJ.
https://www.ncbi.nlm.nih.gov/pubmed/29046286

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

Boitor, M., Martorella, G., Maheu, C., Laizner, A.M., Gélinas, C. (2018). Effects of Massage in Reducing the Pain and Anxiety of the Cardiac Surgery Critically Ill-a Randomized Controlled Trial. Pain Med.
https://www.ncbi.nlm.nih.gov/pubmed/29618079

Boitor, M., Gélinas, C., Richard-Lalonde, M., Thombs, B.D. (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.
https://www.ncbi.nlm.nih.gov/pubmed/28619390

Bove, G.M., Harris, M.Y., Zhao, H., Barbe, M.F. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. J Neurol Sci. 
https://www.ncbi.nlm.nih.gov/pubmed/26810536

Busato, M., Quagliati, C.,...Stecco, A. (2016). Fascial Manipulation Associated With Standard Care Compared to Only Standard Postsurgical Care for Total Hip Arthroplasty: A Randomized Controlled Trial. PM R.
https://www.ncbi.nlm.nih.gov/pubmed/27210234

Capogna, B.M., Shenoy, K., Youm, T., Stuchin, S.A. (2017). Tendon Disorders After Total Hip Arthroplasty: Evaluation and Management. J Arthroplasty.
https://www.ncbi.nlm.nih.gov/pubmed/28688837/

Chan, M.C., Wee, J.W., Lim, M.H. (2017). Does Kinesiology Taping Improve the Early Postoperative Outcomes in Anterior Cruciate Ligament Reconstruction? A Randomized Controlled Study. Clin J Sport Med.
https://www.ncbi.nlm.nih.gov/pubmed/27428680

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.
https://www.ncbi.nlm.nih.gov/pubmed/27908839

Cholok, D., Lee, E., ... Levi, B. (2017). Traumatic muscle fibrosis: From pathway to prevention. J Trauma Acute Care Surg.
https://www.ncbi.nlm.nih.gov/pubmed/27787441

Chughtai, M., Mont, M.A., ..., Bhave, A. (2016). A Novel, Nonoperative Treatment Demonstrates Success for Stiff Total Knee Arthroplasty after Failure of Conventional Therapy. J Knee Surg.
https://www.ncbi.nlm.nih.gov/pubmed/26713596

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. 
https://www.ncbi.nlm.nih.gov/pubmed/28789470

Fisher, P., Zhao, Y., Rico, M., . . . 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. (OPEN ACCESS)
https://www.ncbi.nlm.nih.gov/pubmed/25617052 

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.
https://www.ncbi.nlm.nih.gov/pubmed/27935172

Gigliotti, D., Leiter, J.R., ... Anderson, J.E. (2015). Atrophy, inducible satellite cell activation, and possible denervation of supraspinatus muscle in injured human rotator-cuff muscle. Am J Physiol Cell Physiol. (OPEN ACCESS)
https://www.ncbi.nlm.nih.gov/pubmed/26135801

Gigliotti, D., Leiter, J.R., MacDonald, P.B., Peeler, J., Anderson, J.E. (2016). Altered Satellite Cell Responsiveness and Denervation Implicated in Progression of Rotator-Cuff Injury. PLoS One. (OPEN ACCESS)
https://www.ncbi.nlm.nih.gov/pubmed/27668864

Gigliotti, D., Xu, M.C., Davidson, M.J., Macdonald, P.B., Leiter, J.R., Anderson, J.E. (2017). Fibrosis, low vascularity, and fewer slow fibers after rotator-cuff injury. Muscle Nerve.
https://www.ncbi.nlm.nih.gov/pubmed/2757128

Kukimoto, Y., Ooe, N., Ideguchi, N. (2017). The Effects of Massage Therapy on Pain and Anxiety after Surgery: A Systematic Review and Meta-Analysis. Pain Manag Nurs.
https://www.ncbi.nlm.nih.gov/pubmed/29173797

Lampi, M.C., Reinhart-King, C.A. (2018) Targeting extracellular matrix stiffness to attenuate disease: From molecular mechanisms to clinical trials. Sci Transl Med.
https://www.ncbi.nlm.nih.gov/pubmed/29298864

Laumonier, T., & Menetrey, J. (2016). Muscle injuries and strategies for improving their repair. Journal of Experimental Orthopaedics. (Open Access)
https://www.ncbi.nlm.nih.gov/pubmed/27447481

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.
https://www.ncbi.nlm.nih.gov/pubmed/29090454

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. 
https://www.ncbi.nlm.nih.gov/pubmed/18086982

Noehren, B., Andersen, A., ... Damon, B. (2016). Cellular and Morphological Alterations in the Vastus Lateralis Muscle as the Result of ACL Injury and Reconstruction. J Bone Joint Surg Am.
https://www.ncbi.nlm.nih.gov/pubmed/27655981 

Salamh, P.A., Kolber, M.J., Hegedus, E.J., Cook, C.E. (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.
https://www.ncbi.nlm.nih.gov/pubmed/28901811

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.
https://www.ncbi.nlm.nih.gov/pubmed/28813550

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. (OPEN ACCESS)
https://www.ncbi.nlm.nih.gov/pubmed/26637643 

Vercelli, S., Ferriero, G., Sartorio, F., Stissi, V., & Franchignoni, F. (2009). How to assess postsurgical scars: A review of outcome measures. Disability and Rehabilitation.
http://www.ncbi.nlm.nih.gov/pubmed/19888834

Vining, K.H., Mooney, D.J. (2017). Mechanical forces direct stem cell behaviour in development and regeneration. Nat Rev Mol Cell Biol.
https://www.ncbi.nlm.nih.gov/pubmed/29115301

Williams, G., Howard, R.F., Liossi, C. (2017). Persistent postsurgical pain in children and young people: prediction, prevention, and management. Pain Rep. (OPEN ACCESS)
https://www.ncbi.nlm.nih.gov/pubmed/29392231