Author Names
Laurianne M Loew, Lucie Brosseau,corresponding author Peter Tugwell, George A Wells, Vivian Welch, Beverley Shea, Stephane Poitras, Gino De Angelis, Prinon Rahman, and Cochrane Musculoskeletal Group
Reviewer Name
Jessica Fritson, SPT, ATC
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Background: Deep transverse friction massage, one of several physical therapy interventions suggested for the management of tendinitis pain, was first demonstrated in the 1930s by Dr James Cyriax, a renowned orthopedic surgeon in England. Its goal is to prevent abnormal fibrous adhesions and abnormal scarring. This is an update of a Cochrane review first published in 2001. Objectives: To assess the benefits and harms of deep transverse friction massage for treating lateral elbow or lateral knee tendinitis. Search methods: We searched the following electronic databases: the specialized central registry of the Cochrane Field of Physical and Related Therapies, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Clinicaltrials.gov, and the Physiotherapy Evidence Database (PEDro), up until July 2014. The reference lists of these trials were consulted for additional studies. Selection criteria: All randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing deep transverse friction massage with control or other active interventions for study participants with two eligible types of tendinitis (ie, extensor carpi radialis tendinitis (lateral elbow tendinitis, tennis elbow or lateral epicondylitis or lateralis epicondylitis humeri) and iliotibial band friction syndrome (lateral knee tendinitis)) were selected. Only studies published in English and French languages were included. Data collection and analysis: Two review authors independently assessed the studies on the basis of inclusion and exclusion criteria. Results of individual trials were extracted from the included study using extraction forms prepared by two independent review authors before the review was begun. Data were cross‐checked by a third review author. Risk of bias of the included studies was assessed using the “Risk of bias” tool of The Cochrane Collaboration. A pooled analysis was performed using mean difference (MD) for continuous outcomes and risk ratio (RR) for dichotomous outcomes with 95% confidence intervals (CIs). Main results: Two RCTs (no new additional studies in this update) with 57 participants met the inclusion criteria. These studies demonstrated high risk of performance and detection bias, and the risk of selection, attrition, and reporting bias was unclear. The first study included 40 participants with lateral elbow tendinitis and compared (1) deep transverse friction massage combined with therapeutic ultrasound and placebo ointment (n = 11) versus therapeutic ultrasound and placebo ointment only (n = 9) and (2) deep transverse friction massage combined with phonophoresis (n = 10) versus phonophoresis only (n = 10). No statistically significant differences were reported within five weeks for mean change in pain on a 0 to 100 visual analog scale (VAS) (MD ‐6.60, 95% CI ‐28.60 to 15.40; 7% absolute improvement), grip strength measured in kilograms of force (MD 0.10, 95% CI ‐0.16 to 0.36) and function on a 0 to 100 VAS (MD ‐1.80, 95% CI ‐0.18.64 to 15.04; 2% improvement), pain‐free function index measured as the number of pain‐free items (MD 1.10, 95% CI ‐1.00 to 3.20) and functional status (RR 3.3, 95% CI 0.4 to 24.3) for deep transverse friction massage, and therapeutic ultrasound and placebo ointment compared with therapeutic ultrasound and placebo ointment only. Likewise for deep transverse friction massage and phonophoresis compared with phonophoresis alone, no statistically significant differences were found for pain (MD ‐1.2, 95% CI ‐20.24 to 17.84; 1% improvement), grip strength (MD ‐0.20, 95% CI ‐0.46 to 0.06) and function (MD 3.70, 95% CI ‐14.13 to 21.53; 4% improvement). In addition, the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to evaluate the quality of evidence for the pain outcome, which received a score of “very low”. Pain relief of 30% or greater, quality of life, patient global assessment, adverse events, and withdrawals due to adverse events were not assessed or reported. The second study included 17 participants with iliotibial band friction syndrome (knee tendinitis) and compared deep transverse friction massage with physical therapy intervention versus physical therapy intervention alone, at two weeks. Deep transverse friction massage with physical therapy intervention showed no statistically significant differences in the three measures of pain relief on a 0 to 10 VAS when compared with physical therapy alone: daily pain (MD ‐0.40, 95% CI ‐0.80 to ‐0.00; absolute improvement 4%), pain while running (scale from 0 to 150) (MD ‐3.00, 95% CI ‐11.08 to 5.08), and percentage of maximum pain while running (MD ‐0.10, 95% CI ‐3.97 to 3.77). For the pain outcome, absolute improvement showed a 4% reduction in pain. However, the quality of the body of evidence received a grade of “very low.” Pain relief of 30% or greater, function, quality of life, patient global assessment of success, adverse events, and withdrawals due to adverse events were not assessed or reported. Authors’ conclusions: We do not have sufficient evidence to determine the effects of deep transverse friction on pain, improvement in grip strength, and functional status for patients with lateral elbow tendinitis or knee tendinitis, as no evidence of clinically important benefits was found. The confidence intervals of the estimate of effects overlapped the null value for deep transverse friction massage in combination with physical therapy compared with physical therapy alone in the treatment of lateral elbow tendinitis and knee tendinitis. These conclusions are limited by the small sample size of the included randomized controlled trials. Future trials, utilizing specific methods and adequate sample sizes, are needed before conclusions can be drawn regarding the specific effects of deep transverse friction massage on lateral elbow tendinitis.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
- Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
- Yes
- Did the literature search strategy use a comprehensive, systematic approach?
- Cannot Determine, Not Reported, Not Applicable
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Cannot Determine, Not Reported, Not Applicable
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Were the included studies listed along with important characteristics and results of each study?
- Yes
- Was publication bias assessed?
- Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
- Cannot Determine, Not Reported, Not Applicable
Key Finding #1
Clear and better designed RCT need to be conducted to support or deny efficacy of deep transverse friction massage for tendinitis.
Key Finding #2
No studies that met the systematic review criteria showed significant pain relief, increase in quality of life, or a successful pain global assessment regarding treatment.
Key Finding #3
More research needs to be conducted to determine the side effects and complications associated with deep transverse friction massage for patients with lateral elbow tendinitis.
Key Finding #4
There was not enough evidence or support to determine deep transverse friction massage influences pain, grip strength, and functional status for lateral elbow tendinitis in patients.
Please provide your summary of the paper
Deep transverse friction massage (DTFM) has been considered for tendonitis pain since the 1930s with the goal of reducing scaring, increasing blood flow, and facilitate healing. This systematic review looks at random control trials and controlled clinical trials that compare DTFM to other active interventions for patients with lateral elbow tendonitis. Two RCT fit the selection criteria. The research study focusing on DTFM on the elbow consisted of 40 participants and looked at DTFM in combination to ultrasound with a placebo ointment in comparison to just ultrasound treatment with the same placebo ointment over a five-week span. The study also looked at DTFM in combination with phonophoresis compared to just phonophoresis for the same duration of the study. The evidence was insufficient for DTFM to demonstrate a clinically significant benefit for patients with lateral elbow tendinitis. There is not sufficient evidence to determine how pain, grip strength, and function status are affected in patients with lateral elbow tendinitis when DTFM is implemented as part of the plan of care. Some limitations of the study include not being able to generalize the results due to the specific study population. Along with this, the two RCTs had difficulty blinding participants and personnel increasing bias risk as it may impact patient-reported outcomes. There were also small sample sizes and a 15% dropout rate within one of the studies. Moving forward, it is necessary for high-quality research with larger randomized samples are conducted to access the effects of deep transverse friction massage to treat tendinitis.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
It is important to consider the research and how we can implement evidence-based practice in our treatment as clinicians. This article gives information that given the RCT referenced in the studies that met the criteria for the systematic review, the research and evidence is poor that deep transverse friction massage is an effective form of treatment for lateral elbow tendinitis. When considering which interventions, specifically manual techniques, it is important to consider what the literature says to have the most informed care. It also reminds clinicians not all studies are conducted in a manner that allows the conclusions to be beneficial to clinical practice. Finally, in healthcare, it is not only important to take into consideration research evidence as a component of evidence-based practice but also clinical expertise and patient values. Given this, the patient values and clinician experience need to be taken into consideration which does not completely negate deep transverse friction massage in lateral elbow tendinitis. Further, better quality research must be explored to gain more understanding of the potential effects and risks.
