Introduction
Musculoskeletal diseases and injuries are the second most common group of conditions seen by family practice physicians, exceeded in the number of office visits only by infectious diseases. Many of these conditions arise from the repeated performance of some particular task or activity. As such, many of these musculoskeletal pain conditions are referred to as cumulative trauma disorders (CTDs).

The costs of these conditions is concerning and distressing for the patient, their employers, and the healthcare community. Current treatment modalities are often unsuccessful at treating the problem. Consequently, new and alternative approaches for the treatment of these conditions are appearing.

Recently there has been a dramatic increase in the use of massage therapy as a therapeutic approach to the treatment of pain and injuries. However, some massage methods may be benign, while others may be detrimental and interfere with the patient’s healing process. One must become knowledgeable about various conditions in order to determine when and if massage treatment will be effective. Orthopedic massage is an approach that works quite well for treating cumulative trauma disorders (CTDs).

Cumulative Trauma Disorders
A CTD is an injury to the body that results from repetitive sub-maximal loading. Sub-maximal loading means the amount of force imposed on the tissue is not the maximum load the tissue can withstand. In fact, in most instances it is far below that level. However, if this load is applied to the tissue repeatedly the tissue may begin to break down over time, leading to dysfunction and, ultimately, failure.

There are five tissues primarily affected by CTDs; tendon, muscle, nerve, ligament, and fascia. A closer look at each of these tissues will reveal how CTDs develop.

Tendons:
The most common tendon pathology caused by cumulative trauma is tendinitis. Tendinitis involves collagen degeneration in the tendon fiber that eventually causes long lasting and chronic pain. Once thought to be an inflammatory problem, tendinitis is now understood as a problem with the collagen matrix of the tendon and not the result of an inflammatory response.

Tenosynovitis is another common pathology of the tendon from cumulative trauma. A synovial sheath surrounds many tendons in the distal extremities. The synovial sheath helps to reduce friction between the tendon and other bony or soft tissue structures like the retinaculum, a fibrous band that acts as a pulley for the tendon (see Figure 1). As a result of overuse, adhesions or inflammation may develop between the tendon and its surrounding synovial sheath. This inflammatory reaction is tenosynovitis.

Muscle:
The most common muscle pathologies that result from CTDs are myofascial trigger points, ischemia, muscle hypertonicity, muscle strain, and overuse or fatigue. These problems are likely to occur in conjunction with CTDs that affect other tissues as well.

Another significant problem that may lead to muscle pathology is lack of conditioning and disuse. If an injury involves fiber tearing, such as a muscle strain, immobility following the injury may lead to excess adhesions in the tissue. Deconditioning may also result from prolonged periods of inactivity. The client will usually try to avoid anything that causes increased pain levels. However, pain avoidance causes the tissues to lose a degree of conditioning, which is necessary for withstanding the physical demands of activity. Deconditioning leaves an individual more susceptible to postural and repetitive strains, making recurrent injury more likely.

Nerves:
Nerve tissue is responsible for transmission of sensory information from the periphery of the body to the central nervous system (afferent pathways), as well as motor information from the central nervous system to the periphery (efferent pathways). Cumulative trauma may interfere with both afferent and efferent nerve transmission. The most common type of nerve injuries from CTDs are compression injuries, in which some structure is compressing nerve tissue.

Ligaments:
Ligament tissue adds structural stability to the skeleton by connecting bone to bone. It is designed to withstand strong amounts of stress. The most frequent injuries to ligament tissue involve sudden high force movements that rupture ligament fibers. Ligament tissue does not endure the same amount of mechanical loading from repetitive motion activity as tendons or muscles. Therefore, ligament injuries from cumulative trauma are rare.

However, other structures such as the fibrous joint capsules surrounding the synovial joints are made of ligamentous tissue. These areas may be subject to injury when fibrous adhesion restricts proper motion. An example of this process is when adhesive capsulitis affects the capsule of the glenohumeral joint.

Fascia:
The connective tissues or fascia of the body are rarely considered the primary cause of pain or disability in CTDs. However, the importance of fascial tissue in creating soft tissue pain and injury conditions is gaining the attention of numerous health care professionals. As a result, a number of therapeutic approaches are being developed that focus specifically on fascial restrictions in the soft tissues and how to effectively treat them.

Orthopedic Massage
What sets orthopedic massage apart from the diverse group of massage approaches is the fact that it is not a specific ??technique??. Rather the term ??orthopedic?? is used to refer to the locomotor (movement) system, as it is used in conventional medicine. An analogy can be made with the phrase ??orthopedic medicine??, which describes a conceptual approach to medical practice more than just one particular treatment method. Similarly, the phrase ??orthopedic massage?? is used to refer to a comprehensive system, rather than a particular technique.

There are several underlying principles that are an essential part of the orthopedic massage approach. They include orthopedic assessment, matching the physiology of the tissue injury with the physiological effects of treatment, treatment adaptability, and understanding the rehabilitation protocol.

When working with soft tissue pain and injury conditions like CTDs it is essential for the practitioner to assess the nature of the condition and understand its physiological make-up. Choice of treatment methods should be based on an accurate understanding of the tissue pathology. Therefore, orthopedic assessment skills are necessary to effectively identify the nature of the condition. Assessment skills will also help the practitioner identify conditions that should be referred to other health professionals.

The second component of the orthopedic massage system is to match the physiology of the injury with the physiological effects of the treatment technique. There is no single massage technique that will effectively treat all the diverse types of pain and injury conditions. Rather, in some situations a particular technique will be highly beneficial, yet when used on another condition it may be contraindicated.

This fact reminds us that massage is not necessarily benign ?X it has physiological effects. For the most beneficial treatment, these effects should be matched to the physiological nature of the pain or injury condition. An example would be in the use of massage with carpal tunnel syndrome. Massage is a highly effective treatment, often preventing the need for surgery or other invasive techniques, if the appropriate techniques are chosen. However, a technique like deep transverse friction massage in the carpal tunnel region is especially contraindicated in this condition, as it will aggravate the problem and potentially make it worse. A massage technique that would more effectively match the physiology of the condition would be deep longitudinal stripping to the wrist flexor muscle group, thus leading to a decrease in cumulative tension in those muscles.

The third component of orthopedic massage is treatment adaptability. Clearly, with the different musculoskeletal conditions, the practitioner should not rigidly adhere to one set of massage techniques. In addition, each patient will provide a unique presentation of the pain or injury condition. As such, the practitioner will most effectively treat his/her patient with a protocol that is individually suited to that patient.

Finally, the orthopedic massage system recommends understanding rehabilitation protocols. Rehabilitation protocol is a phrase used to describe the most effective progression through the various stages of soft tissue healing. It includes knowledge of proper tissue healing and injury prevention. While it may not be appropriate for the practitioner to prescribe a rehabilitation plan, the practitioner of orthopedic massage often works in conjunction with other health professionals and it is important that s/he understand these rehabilitation factors. For example, if strength training is being used by another health professional concurrently, the massage practitioner must understand how those exercises may affect the patient and his/her treatment.

Summary
Massage is a treatment that may bring significant relief to individuals suffering from CTDs. Orthopedic massage is an innovative approach to the treatment of numerous musculoskeletal pain and injury conditions previously treated only with conventional methods. Providing a comprehensive system of treatment that incorporates a wide variety of massage treatment techniques, orthopedic massage enables the practitioner to choose the most effective treatment for a particular condition. The orthopedic massage practitioner must be knowledgeable and skilled to identify musculoskeletal pain and injury conditions, and apply the appropriate massage treatment techniques. This combination of expertise provides for the most effective treatment possible using massage therapy

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