Last resort

Dissecting the evidence for ligamentous articular strain techniques
Robert Libbey
January 05, 2016
By Robert Libbey
Annular ligament and radial collateral ligament
Annular ligament and radial collateral ligament
Today’s massage therapy profession is committed to utilizing techniques informed from research and evidence.


In an evidence-informed practice, clinicians are aware of emerging evidence, and rationally integrate new information into their clinical reasoning, keeping the best interests and goals of their patients in mind at all times

Practicing in this manner has the potential to transform your practice and improve the quality of life of your patients – it has for mine.

In this first of two articles, I explore the research supporting the theory for ligamentous articular strain technique (LAST). In the second article, I’ll provide case studies documenting the use of LAST in treatment.

What we know now
For many years we have been taught that ligaments and muscles were separate structures. Many anatomy texts portray ligaments, cartilage, joint capsules and muscles as separate tissues, which are not connected to the surrounding tissues. However, in actual fact, these and the surrounding tissues are inseparable.

In 2009, Jaap van der Wal published a paper in which he stated that ligaments are mostly arranged in series with the muscles, not parallel. There is a joint stability system in which muscular tissue and regular dense collagenous connective tissue (RDCT) interweave and function mainly in an “in-series” situation rather than an “in-parallel” situation.

Van der Wal’s paper titled, “The architecture of the connective tissue in the musculoskeletal system – an often overlooked functional parameter as to proprioception in the locomotor apparatus,” was published in the International Journal of Therapeutic Massage and Bodywork.

Thus, in vivo, the periarticular connective tissue is loaded and stretched both by the movement of related skeletal parts and by the tension of the muscle tissue inserting to this connective tissue. Ligaments are considered RDCTs.

When you contract a muscle, the ligaments are automatically engaged. Like the reins on a horse, ligaments constantly assist in the stabilization of a joint, regardless of its position, during both concentric and eccentric muscular contractions.

Afferent mechanoreceptors in ligaments provide significant input to sensation and contribute to the synergistic activation of muscles. They are responsible for kinesthetic and proprioceptive sensation. These mechanoreceptors are everywhere throughout our connective tissues. They are in especially high concentrations at the tenoperiosteal and ligamentoperiosteal enthuses.

Ligaments are highly dynamic and non-stationary organs. Mechanoreceptors in ligaments trigger a ligamentomuscular reflex activation of associated muscles. This reflex has been shown to exist in most joints of the extremities and in the spine.

Muscular activity elicited by this reflex allows muscles and ligaments to work together as a unit, inhibiting muscles that destabilize the joint and increasing antagonist co-activation to maintain joint stability.

In the DVD, “Fascia and Sports Medicine,” Robert Schleip states, “Ligaments and joint capsules are now seen not as completely separate structures but they are embedded, local densifications, local specifications of a body-wide collagenous, fibrous mostly tension driven interconnected system.”

This ligamentous system is part of the fascial connective tissue referred to as the multimicrovacular collagenic dynamic absorbing system.

In the DVD, “Strolling Under the Skin,” Guimberteau, J. C., states that “the role of this rubbery elastic shock absorbing system, found everywhere in our organism, is to prevent a level of resistance that would permit the collagen to shear, leading to injury.”

In the book, Movement, Stability & Lumbopelvic Pain, Andry Vleeming uses the term “ligamentous stocking” to describe the connectedness of fibrous soft-tissue structures of the lumbar vertebrae to the sacrum.

I see this “ligamentous stocking” as being organism-wide, connecting not just the vertebral column to the sacrum, but also connecting the various appendicular interdigitations of membranous, capsular, ligamentous and periosteal fibrous tissues to the axial fibrous tissues.



Mechanoreceptor-specific techniques
LAST affects the connective tissues of the body, mainly ligaments, joint capsules, fascia, muscles, tendons and indirectly, lymphatic and blood flow, and the autonomic nervous system.

Manual techniques that target mechanoreceptors have been proven to affect autonomic functions, such as lowering sympathetic nervous system activity, increasing local proprioceptive attention, causing a decrease in active muscle tone and affecting both the local blood supply and the local tissue viscosity.

In a study presented at the Third International Fascia Research Congress, Viklund, et al., concluded that specific myofascial receptor techniques might not only improve ROM but also have a longer lasting effect than classical (Swedish) massage techniques. They suggested that “therapists might be encouraged to aim their soft tissue techniques to a lesser area where there is known to be high density of mechanoreceptors.”

HM Langevin and his colleagues proposed that therapies which briefly stretch tissues beyond the habitual range of motion (massage) locally inhibit new collagen formation for several days, and thus, prevent and/or ameliorate soft tissue adhesions.

Manual therapy has been shown to affect the fibrosis and densification of fascia by changing its tensile status and sliding components.

In 2014, Min-yeong Kim and colleagues from the Jaseng Spine and Joint Research Institute, published research on the “clinical observation of muscle energy techniques and ligamentous articular strain in two cases of cervical disc herniation with thoracic outlet syndrome.

The authors stated, “Significant improvements were reported in the outcome measures at admission and at discharge for visual analogue scale (VAS) and neck disability index (NDI) scores and physical examinations.

“The successful outcomes suggest that integrative conservative management focused on muscle energy techniques (MET) and ligamentous articular strain (LAS) are effective in contributing to the conservative management of cervical disc herniation (CDH) with thoracic outlet syndrome (TOS).”

Research confirms the common clinical finding that treatment approaches incorporating mechanoreceptor-specific techniques have both local and systemic effects on our physiological environment. This has the potential to positively affect the functionality of the patient, leading to an improved quality of life.

History
In the beginning of my career, I began searching for a more precise and specific technique that targeted the joint tissues. My journey led me to Andrew Taylor Still, a doctor of osteopathy.

Ligamentous articular strain techniques (LAST) originated in the late 1800s, when Still was innovating manual therapy. The majority of the techniques initially developed were called traction methods, known as “indirect techniques.” Several of these were ligamentous articular strain techniques and various myofascial techniques.

In the early 1900s, many of the techniques were modified by therapists that wanted to focus on a quicker, more direct method of treating. These “direct techniques,” became known primarily as high velocity low-amplitude techniques.

Over the course of my career, I have redefined the techniques of LAST to suit the scope of practice for massage therapists.

“Indirect techniques” follow the permitted motions of the dysfunctional tissues into the direction of ease. “Direct techniques” match the reciprocal tension of the dysfunctional tissues taking the tissues to the first tissue resistance barrier.

It has been a passion of mine to research and advance this technique and bring it into today’s evidence-informed practice standards for the massage therapy profession.

New research is continually being published from the fascial community and from leading researchers who focus on the ligamentous articular tissues. All these research directly affect our understanding of all tissues not just the ligamentous articular tissues.

In the next article in this series, I will present case studies that incorporate LAST and evidence-informed research into practice.


Robert Libbey, RMT, practices full time and instructs LAST courses across Canada. Both live and online courses are accredited for CECs by all Canadian provincial massage therapy regulatory bodies and also the NCBTMB in the USA.  For more information on LAST visit lastsite.ca.


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