Over the years as physiotherapy has evolved, new methods of interventions have been created. Many new equipment and techniques have been invented. While a few of these have strong evidence to prove their effectiveness, the same cannot be said for all of them. One such example is the application of Kinesio Taping. Since its conception in the 1970s, it has been used for a variety of health conditions. In recent years, a large number of RCTs and systematic reviews have been published that claim that Kinesio Taping is not effective in the treatment of musculoskeletal conditions (Parreira et al., 2014).
ART® is a technique that has been around since its development in the 1980s. Although I had come across the term quite frequently in the recent days, I realized it wasn’t practiced widely in India. This instilled in me the desire to understand this technique further in detail and study regarding its applicability. Hence, I embarked on this journey to uncover evidence on ART® and share the relevant data in a concise manner.
After sifting through research, I realized that very little data is available on this technique. Studies currently published are of low quality. Very little to no credible data exists to prove its reliability as an intervention for the treatment of musculoskeletal disorders. There is also no concrete proof to explain the mechanism behind ART®. Good quality studies on ART® need to be conducted in the future to comment on its effectiveness.
Many such methods of intervention exist that are yet to be proven by research regarding their efficacy. Are they all as effective as they claim to be? This question can only be answered by performing thorough research.
Another issue I came across while researching content for this blog was the use of manual therapy itself in physiotherapy practice. As I mentioned in one of my earlier posts, research regarding its use and efficacy point in the opposite directions. This can pose a dilemma to any therapist. Studies suggest that manual therapy provides only immediate or short term relief from pain. I believe this window of immediate pain relief can be used to provide an effective treatment protocol. The choice of using manual therapy should be left to the therapist but considering the conflicting evidence that exists currently, it should be used only as an adjunct and not as the sole method of intervention.
Writing this blog made me understand the value and importance of evidence based practice in this day and age. Back in India while studying for my bachelor’s degree we were taught numerous assessment and treatment techniques, some even decades old. But while penning down this blog, I began to question their reliability in current physiotherapy practice.
I strongly believe that it is vital to back the use of any modality or technique with concrete evidence. This can be beneficial in saving resources such as time and money when treating a patient. Evidence based practice should be considered a norm and followed by all clinicians and therapists. It is essential to be informed regarding the efficacy of any method rather than blindly following the crowd.
Now that we are at the end of this expedition, I can say that I have evolved as a physiotherapist myself. Incorporating best available current research into my practice will be my next step forward as a physiotherapist.
To conclude, I would suggest therapists reading this blog that those interested in including ART® in their treatment protocol may do so, but it should be used as an additional therapy and not as the only intervention.
I would like to sincerely thank you for reading my first blog and I hope it provides you with a general idea about ART®. Please do not hesitate to leave your comments or queries below.
Adios!
REFERENCES
Parreira, P., Costa, L., Hespanhol, L. C., Jr, Lopes, A. D., & Costa, L. O. (2014). Current evidence does not support the use of Kinesio Taping in clinical practice: a systematic review. Journal of physiotherapy, 60(1), 31–39.
Let us now have a quick look at more research available. As you may remember, in my last post I mentioned about the hierarchy of evidence. In this post I will be considering case studies and case reports that were published on ART®. Although these are located lower in the hierarchy of evidence, with the limited data on this technique, it is important that we gather the available research before making an informed decision.
A chronic Achilles Tendinopathy patient was treated with active and passive tissue warm-up, Graston Technique (a soft tissue mobilization technique performed by using custom designed stainless steel instruments), ART®, exercise and cryotherapy with static stretching. The patient had recovered almost completely after 9 sessions of therapy (Miners and Bougie, 2011).
A similar treatment protocol was given to a subject with trigger thumb. Intervention consisted of ART®, Graston technique® and mobilization. Results suggested that the patient was relieved of his pain (Howitt et al., 2006).
Various nerve entrapments such as posterior interosseous nerve syndrome in a 62- year old male office worker (Saratsiotis and Myriokefalitakis, 2010), pudendal nerve entrapment in a 41-year old male ironman athelete (Durante and MacIntyre, 2010), saphenous nerve entrapment in a 29-year old female ultra-marathon runner (Settergren, 2013), meralgia parasthetica (entrapment of lateral femoral cutaenous nerve) in a 22-year old pregnant female (Skaggs et al., 2006) were all treated with ART® in combination with other manual therapy techniques, exercises and stretching. All the studies obtained positive results in terms of symptom reduction.
Subjects who underwent physiotherapy for a number of conditions such as costochondiritis (Cubos et al., 2010), acetabular labral tear (Cashman et al., 2014), Little Leaguer’s shoulder (Wasylynko, 2015), snapping hip (Spina, 2007) and posterior tibialis strain (Howitt et al., 2009) all had favourable outcomes after a combination of interventions were given to them, which included ART®.
Hence we can observe that when ART® was used along with other physiotherapy interventions, positive results were obtained. However, we cannot confirm from these case studies if it played any role in the treatment of these various disorders.
A multimodal approach is commonly required in the treatment of several physiotherapeutic disorders. Cuesta-Vargas et al (2013) evaluated the effects of a multimodal physiotherapy program in patients with chronic MSDs and concluded that it boosted their general health and quality of life. After summarizing all the available evidence, we can conclude that ART® may be integrated in a multimodal approach to treat various MSDs.
In my last post, I will provide a concise summation of what I will be taking away after having embarked on this journey to uncover data on ART®.
REFERENCES
Cashman, G. E., Mortenson, W. B. & Gilbart, M. K. (2014). Myofascial Treatment for Patients with Acetabular Labral Tears: A Single-Subject Research Design Study. Journal of Orthopaedic & Sports Physical Therapy, 44(8), 604-614.
Cubos, J., Cubos, A. & Stefano, F. D. (2010). Chronic costochondritis in an adolescent competitive swimmer: a case report. Journal of Canadian Chiropractic Association, 54(4), 271-275.
Durante, J. A. & MacIntyre I. G. (2010). Pudendal nerve entrapment in an Ironman athlete: a case report. Journal of Canadian Chiropractic Association, 54(4), 276-281.
Howitt, S., Wong, J. & Zabukovec, S. (2006). The conservative treatment of Trigger Thumb using Graston Techniques® and Active Release Techniques. Journal of Canadian Chiropractic Association, 50(4), 249-254.
Howitt, S., Jung, S. & Hammonds, N. (2009). Conservative treatment of a tibialis posterior strain in a novice triathlete: a case report. Journal of Canadian Chiropractic Association, 53(1), 23-31.
Miners, A. L. & Bougie, T. L. (2011). Chronic Achilles tendinopathy: a case study of treatment incorporating active and passive tissue warm-up, Graston Technique, ART, eccentric exercise, and cryotherapy. Journal of Canadian Chiropractic Association, 55(4), 269-279.
Saratsiotis, J. & Myriokefalitakis, E. (2010). Diagnosis and treatment of posterior interosseous nerve syndrome using soft tissue manipulation therapy. Journal of Bodywork & Movement Therapies, 14, 397-402.
Settergren, R. (2013). Conservative management of saphenous nerve entrapment in a female ultra-marathon runner. Journal of Bodywork & Movement Therapies, 17, 297-301.
Skaggs, C. D., Winchester, B. A., Vianin, M. & Prather, H. (2006). A manual therapy and exercise approach to meralgia parasthetica in pregnancy: A case report. Journal of Chiropractic Medicine, 5(3), 92-96.
Spina, A. A. (2007). External coxa saltans (snapping hip) treated with active release techniques: a case report. Journal of Canadian Chiropractic Association, 51(1), 23-29.
Wasylynko, D. (2015). Chronic pain due to Little Leaguer’s Shoulder in an adolescent baseball pitcher: a case report. . Journal of Canadian Chiropractic Association, 59(4), 383-389.
As promised, in this post I have set forth information from trials that were conducted on effects of ART®, and what we can conclude from them. I should warn you that the following data is fairly technical. It is a very crucial piece of information, so you may want to grab a cup of coffee before you begin reading!
The hierarchy of evidence aims to assist in identifying the strength of research material. I have divided the upcoming posts according to this hierarchy in order to segregate all the data available in a systematic manner (Evans, 2002).
Only one systematic review studies the effectiveness of myofascial release therapies, which is considered as an umbrella term encompassing common non invasive techniques such as Positional Release Therapy, ART®, trigger point pressure release and self-myofascial release. The authors concluded that myofascial release therapies helped in the improvement of range of motion without having any harmful effects on the muscles (Mauntel et al., 2014).
Now we will move on and read about a few randomized controlled trials on ART®.
Fig. 2
ART® and Muscle Energy Technique were found to be equally effective in subjects who presented with latent myofascial trigger points in the upper trapezius muscle (Golnaz et al., 2017). Another trial showed that subjects with trapezius spasm who were treated with ART® had better outcomes than those treated with Myofascial Release (Mishra et al., 2018).
Kim et al (2015) concluded that ART® was the more effective technique in treating chronic neck pain when compared to joint mobilization.
Considering the fact that hamstring tightness is commonly linked to low back pain, Mistry et al (2015) compared the efficacy of ART® and Proprioceptive Neuromuscular Facilitation (modified hold relax technique) on hamstring flexibility in subjects with low back pain. The researchers concluded that although both techniques were effective in improving hamstrings flexibility, the Proprioceptive Neuromuscular Facilitation technique was more successful. ART® was better at reducing hamstring tightness in healthy subjects as well when compared to Mulligan bent leg raise after a single session (Kage et al., 2014).
Two studies looked at Chronic Lateral Epicondylitis. One compared ART® to Myofascial Release and found that although both techniques were effective, Myofascial Release obtained better results (Trivedi et al., 2014). In the second study, one group was given ART® and conventional treatment (ultrasound, exercises and stretching) while the control group was given only conventional treatment. ART® used in conjunction with conventional interventions was more effective (Harneet et al., 2012).
Fig. 3: Upper Cross Syndrome
Upper Cross Syndrome can be defined as “tightness of the upper trapezius, pectoralis major, and levator scapulae and weakness of the rhomboids, serratus anterior, middle and lower trapezius, and the deep neck flexors, especially the scalene muscles.” Two trials evaluated the effects of ART® on this syndrome. The first trial assessed changes in anterior neck carriage or forward head posture pre- and post-intervention. ART® was given in combination with conventional exercises and stretching. The authors found an improvement in anterior neck carriage compared to the control group, but considered it to be clinically insignificant. In this study, the control group was divided into three smaller groups, each being supervised by one researcher. Towards the end of the study, it was revealed that participants from one control group met the researcher once weekly, while the second control group only met once during the initial stages of the trial when exercises were prescribed to them. This can be considered as a major flaw as there was a lack of uniformity in terms of intervention provided to the subjects, which the authors acknowledged (Thacker et al., 2011). In terms of reduction of pain and disability, a significant improvement was seen in subjects who were given a combination of ART® and conventional treatment in comparison to those who received only conventional physiotherapy (Joshi and Srivastava, 2018).
Pilot studies may sometimes be conducted prior to a randomized clinical trial to evaluate if certain components are feasible. While scanning through all the research databases, I came across a few pilot studies on ART® which are worth sharing.
Nine young ice-hockey players suffering from adductor strains were given one session of ART® and were assessed immediately after the intervention. An increase in pain pressure threshold of the subjects was observed (Robb and Pajaczkowski, 2011).
Five subjects diagnosed with Carpal Tunnel Syndrome showed a significant improvement in their symptoms and functional status after receiving ART® for 6 sessions (George et al., 2006).
Effect of ART® on quadriceps strength and inhibition was checked in nine athletes complaining of unilateral anterior knee pain. Inhibition was evaluated by interpolated twitch technique which assesses activation of skeletal muscles during voluntary contractions. No changes were seen in any of the outcome measures (Drover et al., 2004).
A few distinct problems can be noted in all the studies mentioned above. Researchers could have considered the inclusion of a few more outcome measures such as a disability index, quality of life or by accounting for change in the emotional distress in some of these studies, which were missing in some of the trials. This would have enabled a better understanding of the outcomes.
Majority of these studies have a very small number of participants. A small sample size tends to cause a reduction in the power of a study, and increases the margin of error and chances of bias. These factors may eventually render the entire study meaningless. In a few studies, the sample size is also restricted in terms of the age of the participants. This may not provide us with results that can be applied to the general population.
Another important limitation of all the studies was that no follow-up was performed after the intervention had concluded. Hence, the long term effects of the technique are not known. A 3-month or 6-month follow-up would have further improved our understanding about the true efficacy of ART®.
There is a major gap in existing evidence to confirm if ART® really works. There is a need to conduct high quality trials to prove its efficacy.
I will continue to discuss about additional data that is available on ART® in my next post in order to obtain a clearer perspective.
REFERENCES
Drover, J. M., Forand, D. R. & Herzog, W. (2004). Influence of active release technique on quadriceps inhibition and strength: A pilot study. Journal of Manipulative and Physiological Therapeutics, 27(6), 408-413.
Evans, D. (2002). Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing, 12(1), 77-84.
George, J. W., Tepe, R., Busold, D., Keuss, S., Prather, H. & Skaggs, C. D. The effects of active release technique on carpal tunnel patients: Pilot study. Journal of Chiropractic Medicine, 4(5), 119-122.
Harneet, K. M. & Khatri, S. M. (2012). Efficacy of Active Release Technique in Tennis Elbow- A Randomized Control Trial. Indian Journal of Physiotherapy & Occupational Therapy, 6(3), 132-135.
Joshi, S. & Srivastava, N. (2018). To Compare the Effectiveness of Active Release Technique and Conventional Physical Therapy in the Management of Upper Cross Syndrome. Indian Journal of Physiotherapy & Occupational Therapy, 12(4), 51-54.
Kage V. & Ratnam R. (2014). Immediate effect of active release technique versus Mulligan bent leg raise in subjects with hamstring tightness: A randomized clinical trial. International Journal of Physiotherapy and Research. 2(1), 301-04.
Kim, J. H., Lee, H. S. & Park, S. W. (2015). Effects of the active release technique on pain and range of motion of patients with chronic neck pain. Journal of Physical Therapy Science, 27, 2461-2464.
Mauntel, T. C., Clark, M. A., Padua, D. A. (2014). Effectiveness of Myofascial Release Therapies on Physical Performance Measurements: A systematic review. Athletic Training & Sports Health Care, 6(4), 189-196.
Mishra, D., Prakash, R. H., Mehta, J. & Dhaduk, A. (2018). Comparative Study of Active Release Technique and Myofascial Release Technique in Treatment of Patients with Upper Trapezius Spasm. Journal of Clinical and Diagnostic Research, 12(11), YC01-YC04.
Mistry, G. S., Vyas, N. J. & Sheth, M. S. (2015). Comparison of the Effect of Active Release Technique Versus Proprioceptive Neuromuscular Facilitation Stretching (Modified Hold-Relax) on Hamstring Flexibility in Patients having Chronic Low Back Pain. National Journal of Integrated Research in Medicine, 6(5), 66-70.
Robb, A. & Pajaczkowski, J. (2011). Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study. Journal of Bodywork & Movement Therapies, 15, 57-62.
Sadria, G., Hosseini, M., Rezasoltani, A., Bagheban, A. A., Davari, A., Seifolahi, A. (2017). A comparison of the effect of the active release and muscle energy techniques on the latent trigger points of the upper trapezius. Journal of Bodywork & Movement Therapies, 21, 920-925.
Thacker, D., Jameson, J., Baker, J., Divine, J., & Unfried, A. (2011). 1 Management Of Upper Cross Syndrome Through The Use Of Active Release Technique and Prescribed Exercises.
Trivedi, P., Sathiyavani, D., Nambi, G., Khuman, R., Shah, K., Bhatt, P. (2014). Comparisom of Active Release Technique and Myofascial Release Technique on Pain, Grip Strength & Functional Performance in Patients with Chronic Lateral Epicondylitis. International Journal of Physiotherapy and Research, 2(3), 488-94.
This question does not have a definite answer. The exact mechanism behind how ART® works is still not entirely understood. A few theories may help us understand how it functions, which I have enlisted below.
Fig. 2
Mechanical stimulation (tension or pressure applied with digits in ART®) of mechanoreceptors can cause a physiological response which may bring about a change in pain and nociception. Activation of mechanoreceptors may contribute to an inhibitory effect on the central nervous system further leading to the depression of the Hoffman Reflex (H- Reflex). The H-Reflex is a reflex contraction of muscles that is caused due to stimulation of its afferent fibres. This suggests that a neurophysiologic aspect can explain the therapeutic mechanism of pain alleviation. (Schiepatti 1987, cited in Robb et al 2010, p. 60-61). A reduction in H-Reflex may be caused by the afferent fibres that mediate stimulation of the mechanoreceptors (Goldberg et al., 1992, cited in Robb et al 2010, p. 61).
Ruffini bodies are mechanoreceptors that respond to sustained pressure. Stimulation of some interfascial and Ruffini mechanoreceptors through deep pressure applied manually by the therapist can cause the central nervous system to alter the tonus of some motor units in muscle tissue in the area of contact. Due to an increased vagal activity, there is a change in the local fluid dynamics, tissue metabolism and leads to muscle relaxation (Schleip, 2003).
Reactive hyperemia (increase in blood flow after a short period of arterial occlusion) in the affected region after application of deep pressure may also contribute to reduction in pain (Hou et al., 2002). This suggests that biomechanical processes and mechanical stimulation may exist simultaneously (Robb et al., 2010).
Endocannabinoids are transmitters that have an effect on the presynaptic pathway in order to prevent the transmission of nociception. It is believed that they are released to provide a pain-relieving effect by inhibiting the descending pathway (de Fonseca et al., 2005, cited in Robb et al 2010, p.61). The levels of endocannabinoids rise subsequently after a noxious or painful stimulus (Wilson and Nicol, 2002). In ART®, a noxious stimulus is caused by application of manual pressure over the affected region which further leads to the release of endocannabinoids in order to decrease the nociception (Robb et al., 2010).
All the theories mentioned above may play a role in the effects seen after the use of ART®. Although, we can conclude that evidence explaining the mechanism behind it is vague and no clear explanation is available.
Coming next will be a post on the currently available research on ART®. We will uncover a few studies in which the techniques were used as an intervention and make a note of the results they obtained.
REFERENCES
Hou, C. R., Tsai L. C., Cheng, K. F., Chung, K. C. & Hong, C. Z. (2002). Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigge-point sensitivity. Archives of Physical Medicine and Rehabilitation, 83(10), 1406-1414.
Robb, A. & Pajaczkowski, J. (2011). Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study. Journal of Bodywork & Movement Therapies, 15, 57-62.
Schleip R. (2003). Fascial plasticity – a new neurobiological explanation: Part I. Journal of Bodywork and Movement Therapies, 7(1), 11-19.
Wilson, R. & Nicoll, R. (2002). Endocannibinoid signalling in the brain. Science, 296 (5568), 678e682
Since my blog is based on a manual therapy technique, before I concentrate solely on ART®, I believe it is essential to discuss a bit about the current status and future of manual therapy which is a trending issue.
Fig. 1
Current research on the effectiveness of manual therapy in the treatment of MSDs is fairly debatable. Clinicians are unable to find strong evidence to back the use of manual therapy as an intervention. Contradictory research has been published regarding its effectiveness. While a few systematic reviews and trials suggest that it is beneficial, a few others claim the opposite (Collins et al., 2017).
These conflicting studies may prove to be a hindrance in the ability of therapists to treat their patients efficiently.
Manual therapy can still be considered as a starting point in the treatment of MSDs. It is a stepping stone in obtaining results in impairments related to mobility, pain and motor recruitment (Collins et al., 2017). Manual therapy should be encompassed within a multimodal approach in order to achieve maximal benefits and recovery of the patient (Bishop et al., 2015). Tsertsvadze et al (2014) reported that manual therapy can be considered as a cost-effective method in pain reduction compared to alternative interventions.
Having addressed the need for manual therapy, lets return to our topic.
ART® is a patented soft tissue technique. It is the brainchild of Dr. P. Michael Leahy, DC, CCSP, a Doctor of Chiropractic medicine who introduced it around 30 years ago. It is a ‘movement based massage technique’ that aims to treat musculoskeletal conditions associated with tendons, ligaments, fascia or nerves. Injuries to these structures may be caused due to repetitive strain, lack of oxygen supply to the tissues, adhesions or joint dysfunction (Anon., no date).
Fig. 2: Carpal Tunnel Syndrome- A cumulative trauma disorder
ART® is related to the concept of cumulative trauma disorder, which is a soft tissue injury. Any form of acute injury, repetitive strains, or injury caused due to constant pressure or tension can manifest itself as a cumulative trauma disorder. It is believed that weak and tight tissue structures tend to produce increased internal forces like pressure, friction or tension, on the tissue. This phenomenon gradually causes cumulative trauma disorder (Drover et al., 2004). Carpal tunnel syndrome, a disorder in which there is a compression of median nerve at the wrist, is an example. There may be a relationship between repeated exposure to keyboard strokes and the occurrence of carpal tunnel syndrome (Eleftheriou et al., 2012).
As adhesions continue to form, muscles tend to become shortened and weakened, leading to a modification in the motion of muscles and joints, and compression of nerves. The increased force causes a reduction in circulation, leading to edema of the surrounding structures (Drover et al., 2004).
ART® includes a combination of evaluation as well as intervention. The professional manually assesses the texture, tightness, and movement of tendon, muscles, fascia, ligaments and nerves. Affected tissues are treated with a combination of accurately applied tension along with specific patient actions (Anon., no date).
Fig. 3
ART® is commonly used for treatment of conditions related to adhesions or scar tissue in overused muscles. While performing ART®, pressure is applied over the area of tenderness, with the thumb or two fingers, while the patient is asked to actively perform movements to allow the affected tissue to move from a shortened to a lengthened position, thus breaking adhesions. Active participation of the patient in this technique is considered as an added benefit as those who are actively involved in their own healthcare may yield better results (Anon., no date).
Research has been conducted not only to study its effect in subjects with musculoskeletal disorders, but also in asymptomatic subjects such as those presenting with hamstring tightness (Kage and Ratnam, 2014), indicating that ART® may be applicable in a variety of scenarios.
ART® can not only be used to treat disorders or injuries but also for the prevention of injuries, performance improvement and reduction of recovery time in athletes. An increasing number of athletes are using it to maintain their flexibility and joint range of motion. The improved flexibility allows them to work on muscle stretching and strengthening in an effective manner (Gonzalez, 2019).
Not much is known about the exact mechanism behind ART®. Majority of the evidence currently available is anecdotal. Hence, more extensive research into this technique is required.
In my next post, I will introduce a few theories to you that may explain how ART® works.
REFERENCES
Anon. (no date). Active Release Techniques® (Online). Available at: http://activerelease.com/ (Accessed on 19 November, 2019).
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, 5(6), 455–464.
Collins, C. K., Masaracchio, M. & Brismée, J., (2017) The future of orthopedic manual therapy: what are we missing? Journal of Manual & Manipulative Therapy, 25(4), 169-171.
Drover, J. M., Forand, D.R. & Herzog, W. (2004). Influence of Active Release Technique on Quadriceps Inhibition and Strength: A Pilot Study. Journal of manipulative and physiological therapeutics, 27(6), 408-413.
Eleftheriou, A., Rachiotis, G., Varitimidis, S. E., Koutis, C., Malizos, K. N., & Hadjichristodoulou1, C. (2012). Cumulative keyboard strokes: a possible risk factor for carpal tunnel syndrome. Journal of occupational medicine and toxicology, 7(1), 16.
Kage V. & Ratnam R. (2014). Immediate effect of active release technique versus Mulligan bent leg raise in subjects with hamstring tightness: A randomized clinical trial. International Journal of Physiotherapy and Research. 2(1), 301-304.
Tsertsvadze, A., Clar, C., Court, R., Clarke, A., Mistry, H., & Sutcliffe, P. (2014). Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: a systematic review and narrative synthesis of evidence from randomized controlled trials. Journal ofmanipulative and physiological therapeutics, 37(6), 343–362.
Although Active Release Techniques® (ART ®) have been around for quite a while now, sufficient scientific data does not exist to prove if it actually is effective. I am writing this blog to explain about ART ® as an intervention in various musculoskeletal conditions and to share with you the current evidence available.
Before we begin
this journey, let me introduce myself. My name is Suprita Desai and I am a registered
physiotherapist from India. My interest to specialize in the field of
Musculoskeletal physiotherapy brought me to Nottingham, United Kingdom. I am
currently doing my postgraduate studies from University of Nottingham.
Fig. 1
Although the prevalence of musculoskeletal disorders (MSDs) differs according to age and diagnosis, it is estimated that approximately 20-33% of individuals around the world live with a painful MSD. They are the primary cause of disability in the world. Down the line, MSDs may further lead to individuals retiring early from the job and reduced social life (World Health Organization, 2019). Bevan (2015) concluded that the presence of these disorders among working population leads to a great economic impact in Europe.
Fig. 2
In India, where I completed my bachelor’s degree, electrotherapy has almost always been the first line of intervention in a physiotherapy protocol for any condition or disorder whatsoever. There is a dearth of high quality evidence to prove the effectiveness of electrotherapy as a physiotherapeutic option in MSDs such as neck pain (Kroeling et al., 2013). Rasul et al. (2014) showed that manual therapy had better results than electrotherapy in subjects with chronic low back pain. NICE guidelines also do not suggest the use of electrotherapy for low back pain (The National Institute of Health Care and Excellence, 2016). Hence, evidence does not always support the use of electrotherapeutic modalities to treat these disorders.
In the outpatient physiotherapy department that I worked at in India, Instrument-assisted soft tissue mobilization (IASTM) was another technique that was commonly used to treat MSDs. Cheatham et al. (2016) described IASTM as an intervention used for treating myofascial restrictions. It uses specially designed instruments to treat scar tissues or adhesions. They concluded that insufficient evidence exists to prove its efficacy.
It dawned upon me that even though numerous techniques and methods exist for the treatment of various disorders, not all may actually be effective.
As a physiotherapist back in India, I had come across the term ‘ART ®’ only recently. It wasn’t used commonly in the clinical setting. On further research I found that there are limited trials conducted on ART®. This motivated me to dig deeper and put forth the available evidence to gain a better insight on these techniques.
Although you need to be a certified provider to be eligible to use ART®, I hope that my blog will provide a basic idea about its use and applicability in treating various MSDs.
In my next post, I will provide an introduction and explain in brief about how the techniques work.
Do stay with me on this expedition to explore ART®! Please do leave your queries or comments if you have any below!
REFERENCES
Bevan S. (2015)., Economic impact of musculoskeletal disorders (MSDs) on work in Europe. Best practice & research. Clinical rheumatology, 29(3), 356–373.
Cheatham, S. W., Lee, M., Cain, M., Baker, R., (2016). The efficacy of instrument assisted soft tissue mobilization: a systematic review. The Journal of the Canadian Chiropractic Association, 60(3), 200-211.
Kroeling, P., Gross, A., Graham, N., Burnie, S. J., Szeto, G., Goldsmith, C. H., Haines, T., Forget, M., (2013). Electrotherapy for neck pain. The Cochrane database of systematic reviews, (8), CD004251.
Rasul, A., Shoaib, M., Qamar, M. M., Basharat, A., Islam, A., Munem, H. A., Tariq, M. & Rasheed, M. A. U., (2014). Manual Vs Electrotherapy; Comparative Study for the Treatment of Chronic Low Backache. International Journal of Medicine and Applied Health, 2(1).
Active Release Techniques® 
