| Nederlands | English |
Roptrotherapy
INTRODUCTIONDeep cross-friction massage or myotherapy, an integrated manual approach for the treatment of painful muscle pathology, is mostly employed in far eastern countries such as Japan (shiatsu), China, Thailand and India and distinct from traditional western (Swedish) massage. It is applied to release chronic patterns of muscular tension using direct pressure or friction mainly on the central parts of the muscles. The use of deep cross-friction massage, starting with 3-4 kg/cm² is supposed to decrease adhesions and break down the scar tissues.
Tissue micro-injury, inflammation and fibrosis not only can change the biomechanics of soft tissue (e.g. increased stiffness) but also can profoundly alter the sensory input arising from the affected tissues. Connective tissue is richly innervated with mechano-sensory and nociceptive neurons. Modulation of nociceptor activity has been shown to occur in response to changes in the innervated tissue. Tissue levels of protons, inflammatory mediators (prostaglandins, bradykinin), growth factors (NGFs) and hormones (adrenaline), and all have been shown to influence sensory input to the nervous system. Conversely, nociceptor activation has been shown to modify the innervated tissue. Release of Substance P from sensory C-fibers in the skin can enhance the production of histamine and cytokines from mast cells, monocytes and endothelial cells. Increased TGFβ-1 production, stimulated by tissue injury and histamine release, is a powerful driver of fibroblast collagen synthesis and tissue fibrosis. Thus, activation of nociceptors by itself can contribute to the development or worsening of fibrosis and inflammation, causing even more tissue stiffness and movement impairment.
DEEP CROSS FRICTION MYOTHERAPY
In the eighties, Tsujii and colleagues [10,11] developed a specific deep cross-friction massage technique with the aid of a (bronze) myofascial T-bar (weight = 0.80 Kg). It is applied with a greater pressure, starting with 5-10 kg/cm², specifically on the deeper layers of the muscle. We called this method “roptrotherapy” ..
- It usually takes 5 to 20 minutes to treat one single “knot-like” hardening with deep friction and it is usually applied in Japan on the musculoskeletal structures of the whole body for at least 90 minutes in total.
- It is presumed that muscle hardening is the residual effect of an incomplete inflammatory response before the healing processes reach the repair and/or regeneration phases.
- The effect of this friction technique is hypothesized to be able to regenerate connective scar tissues and reduce muscle hardenings as a possible mechanism of pain relief.
ROPTROTHERAPY
The intervention of roptrotherapy consistsof a 30-minute deep cross-friction session, with the aid of a myofascial T-bar made of bronze (neutral material to skin) (Fig.3).
This had the only advantage, compared with wooden or plastic made ones, of being easier to use by hand and to contribute to the compression force by their weight (0.8 Kg), resulting in less fatigue for the therapist when employ in current daily practice. It was performed by the same therapist within the threshold of pain that was tolerable, applying a compressive force of 5-10 kg/cm².
The effect of deep friction technique is supposed in the first place to be beneficial for general body relaxation through the release of endogenous opiates and increasing plasma beta-endorphins and in the second place to be able to regenerate connective scar tissues and reduce muscle hardenings.
1 The word roptrotherapy is combined of “roptron” which means in classic Greek “a knot or pressure bar,” and “therapy”.
Scientific studies concerning ROPTROTHERAPY
Roptrotherapy in Patients with Non-specific Low Back Pain A prospective randomized controlled trial with a 1-week interval evaluating the effect of one deep cross-friction massage with the aid of Japanese-made bronze myofascial T-bars or “roptrotherapy” and applied on the lumbo-pelvic region in patients with subacute non-specific low back pain revealed that the disability and pain related measurements were significantly decreased and a minimum clinical change occurred in the group treated with roptrotherapy at the 1-week interval session, while in the placebo and control group no tendency of improvement was noted.1 The results of this pilot study showed that one roptrotherapy session probably can reduce effectively pain sensitivity and disability in patients with non-specific low back pain.In another study, considering a group of patients with subacute non-specific low back pain starting with roptrotherapy sessions, significant positive changes were found at each weekly reassessment in pain sensitivity, disability, and low back pain related PPTs values.2 In the week following two roptrotherapy sessions, the PPTs increased by more than 2 kg/cm² at the M. Erector spinae L1, L3, and L5 levels. The 3-month follow-up results revealed that the PPT values of the non-treated and not-to-LBP related M. Triceps brachii remained unchanged, while the PPT of the most highly nLBP related M. Erector spinae and M. Gluteus maximus levels increased in such way that the PPT values became similar to those of healthy subjects of those muscle hardenings may desensitize central neural structures involved in pain perception.
According to our interpretation, there are enough clinical and therapeutic elements to assume that there is an explanatory relevance between non-specific low back pain and physiopathologic change in the muscle connective tissue on the level of the thoraco- lumbar erector spinae and postero-lateral muscles of the hip. The cause of subacute low back pain could in fact be rather attributed to the presence of numerous muscle fibroses existing in the M. Erector spinae, which may entrap subcutaneous sensory nerves. In an analogous way the proximally located muscle fibroses in the gluteal compartment may be responsible for low back pain and/or pseudo-ischialgia. By applying simple deep cross-friction to these muscle fibroses (30 minutes in total, 3 x once a week), the connective tissue adhesions in the muscles seem to disappear and the entrapment of the sensory nerves is undone. This method can probably be used as a valid method to treat patients with subacute non-specific low back pain (Fig. 2)..
By explicitly including muscle fibrosis of the thoraco-lumbo-pelvic region as a part of the mechanism, the model incorporates additional factors that have not been linked mechanistically to the pathogenesis of it. Testing this model will require confirming the primary hypothesis that connective tissue fibrosis occurs in non-specific low back pain, then testing the relationship between movement, connective tissue fibrosis and persistent pain.
Nevertheless in the most recent medical literature, it is assumed that chronic low back pain is of a psychosocial nature rather than being caused by purely mechanical factors. The opinion is forwarded that chronic low back pain might not originate as just a consequence of acute low back pain. The attitude towards chronic low back pain is said to evolve by way of a conditioning process.
The results of our study can provide some evidence to show that there is a causal link between muscle fibrosis pathology of the lower part of the lumbar spine and non-specific low back pain and that, since the cause of subacute low back pain cannot be ascertained for the time being, the pain behaviour of the patient is probably not ascribed to conditioning processes alone. The support for the hypothesis that non-specific low back pain is primarily a myofascial pain syndrome is growing and future studies should be focus on local injured muscular structures within the thoracolumbar spine and buttock.
The local tenderness of muscle and the reduction of it by several weekly deep cross-friction therapy sessions (roptrotherapy) at the level of lower part of the thoraco-lumbar region and proximal part of the buttock in patients with subacute non-specific low back pain, is probably due to peripheral desensitization of nociceptors, rather than neuroplastic changes within the spinal dorsal horn and conditioning processes as mentioned in several studies.
Throughout this study, several factors pertaining to non-specific low back pain, the deep cross-friction treatments or “Roptrotherapy” have been evaluated and discussed. In these days of evidence based medicine, physical therapeutic interventions can only gain acceptance and credibility if they are subjected to numerous randomized clinical trials (RCTs) which validate their role and highlights their advantages and safety. On the other hand the complexity of pathophysiology in the patient with subacute non-specific low back pain challenges us to understand the mechanisms underlying the wide variations of muscle tenderness at the level of the thoraco-lumbo-pelvic region and the differences of response to treatment, rather than dismiss our treatment options. Clearly different patients may need different treatment strategies, despite similar or even identical measurement outcomes of pain ratings, questionnaire indexes and/ or pressure pain thresholds.
In the future we need to generate a greater interest in muscle tenderness research and exploring electrographical measurement of peripheral sensitive nerves. Even newer days we still have not an adequate knowledge of the etiopathogenetic role of spinal and hip muscles, physical condition, and (eccentric) postures in the workplace or at home, to which the trunk is subjected. The role of evidence based medicine should allow us to discard treatment proven to be of little benefit and to develop consensus guidelines on the management of a variety of conditions. The ideal performed studies, i.e. double-blinded RCTs, are necessary to minimize the placebo effect, therefore establishing the effect of the treatment above and beyond the natural history of subacute low back pain. Therefore the control treatment in a trial, e.g. endermology massage-like sham treatment, should be as similar as possible to the active treatment, e.g. deep cross-friction on the mean part of muscles and executed on the same bodily region. However, an obvious problem is the extreme difficulty of randomizing treatment interventions. Ethical and practical factors when using placebos can lead to a small number of patients analyzed with short term follow-up.
There is a general consensus that the most important clinical step is the development of clinical guidelines based upon outcome research and less on expert consensus alone. Therefore, there needs to be increased emphasis on adequate, reliable and meaningful outcomes, which could be generally accepted by concerned clinical researchers.
Based on the results of this study, the following recommendations are made for practice with the purpose of physical impairment assessments, pressure pain thresholds measurement, and the treatment of patients with non-specific low back pain:
- that for the exploration of pressure sensitivity, examined at the muscular mass of the thoraco-lumbar spine and postero-lateral muscles of the hip, can be recommended when the purpose is to evaluate the difference in pressure pain thresholds in healthy subjects and patients with subacute non-specific low back pain, especially at the level of L3. Nevertheless, more equivalent studies should be done in case of acute and chronic non-specific low back pain.
- that the deep cross-friction myotherapy or “roptrotherapy” can be applied as a most efficient method, able to reduce pain sensitivity and disability in patients with non-specific low back pain. It should be performed tree times, once a week in order to give satisfying results. In future other RCT studies with the same or other pain measurement methods should be required and mainly focused on the treatment of muscle fibrosis in patients with chronic non-specific low back pain syndromes.
1. Farasyn A., Meeusen R., Nijs J. A pilot randomized placebo-controlled trial of roptrotherapy in patients with subacute non-specific low back pain. Journal of Back and Musculoskeletal Rehabilitation 2007; 15:41-53.
2. Farasyn A., Meeusen R. Effect of Roptrotherapy on Pressure Pain Thresholds in Patients with Non-specific Low Back Pain. Journal of Musculoskeletal Pain 2007;19:111-7.