Conservative Treatment for Dupuytren's Disease
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Image Credit - Frank C. Müller, CC 4.0.
Massage therapy combined with active and passive stretching has been proposed as a potential adjunct treatment for attenuating Dupuytren's disease (DD) progression and recurrence.
Dupuytren's disease is a progressive disorder of the hand that eventually can cause contractures of the affected fingers. The progression of the disease is a complicated process, involving a cascade of molecular and cellular events, in which the cytokine transforming growth factor beta (TGF-β) plays a fundamental role (Tripoli et al. 2016).
Studies have demonstrated that non-operative treatments such as massage therapy may affect progression (Larocerie-Salgado et al. 2012, Christie et al. 2012). These observations support the investigation of massage therapy as an adjunct treatment strategy for Dupuytren's disease. This post is a look at related research, providing massage therapists and researchers some points of considerations.
“The results achieved in our patients demonstrate that in the setting of early onset contracture of the PIPJ [proximal interphalangeal joint] due to DD, a relatively simple splinting regimen, combined with stretching exercises and massage to contracted tissue, can stabilize the progression of contracture and in some cases ameliorate the degree of deformity” — Larocerie-Salgado et al. 2012
Massage Therapy - The Science is Emerging
Based on available evidence the mechanisms by which massage therapy interrupts the sequelae of pathological healing is most likely not in a single unified response, but as a collection of interconnected adaptive responses within the nervous system and soft tissue structures.
Attenuating Tissue Levels of TGF-β1
As a therapeutic intervention massage therapy has the potential to attenuate TGF-β1 induced fibroblast to myofibroblast transformation. Recent studies have looked at the effect of modeled massage therapy and mechanical stretching on tissue levels of TGF-β1 (Bove et al. 2016). In these studies it was demonstrated that mechanical stretching has the potential to attenuate tissue levels of TGF-β1 and the development of fibrosis.
This is potentially impactful in the treatment of DD because TGF-β1 plays a key role in tissue remodeling and fibrosis (Tripoli et al. 2016).
TGF-Β1 PLAYS A ROLE IN TISSUE REMODELING, AS A THERAPEUTIC INTERVENTION MASSAGE THERAPY HAS THE POTENTIAL TO ATTENUATE TGF-Β1 INDUCED FIBROBLAST TO MYOFIBROBLAST TRANSFORMATION
Attenuating Tissue Levels of TNF-α
Researchers have also described the pathogenic role that tumour necrosis factor (TNF) plays during the course of Dupuytren disease (Verjee et al. 2013, Kalliolias et al. 2016). High levels of TNF contribute to the contractile activity of myofibroblasts, which drives disease development, in Dupuytren's patients.
A study looking at the use of massage for exercise induced muscle damage (Crane et al. 2012) indicates that massage attenuates the production of tumour necrosis factor-α (TNF-α). Attenuating tissue levels of TNF-α with massage may play a role in disease development by reducing the contractile activity of myofibroblasts.
Impacting Inflammation
Persistent inflammation has the potential to interfere with the remodeling of tissue (Rand et al. 2016). There has been modeled experiments to demonstrate the the impact of stretching on inflammation-regulation mechanisms within connective tissue (Berrueta et al. 2016). Another study suggest that the application of massage induces a phenotype change, prompting the transition of M1 macrophages into the M2 macrophages (Waters-Banker et al. 2014).
Neurophysiological Responses
Other research papers have looked at the neurophysiological mechanisms elicited by massage therapy treatments. A biopsychosocial model provides a practical framework for investigating the complex interplay between massage therapy and clinical outcomes.
Massage therapy as a adjunct treatment of Dupuytren's disease
Dupuytren's disease is a topic that I follow closely as I have seen second hand the long term effects of this progressive disorder. If these studies are clinically translatable, prophylactic massage treatments may inhibit inflammatory processes and affect the development of fibrosis by mediating differential cytokine production. Consequently this may stabilize the progression of contractures and in some cases ameliorate the degree of deformity.
Massage therapy is simple to carry out, economical, has very few side effects, the next step for researchers is to look into what sort of dosage and duration would be needed to optimize the effects of this non-invasive approach. As an added note I will emphasize that therapists should be familiar with the condition and cross frictioning need not be vigorous and stretching should be a gentle exploration of range of motion.
More to Explore
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https://www.ncbi.nlm.nih.gov/pubmed/27526686
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https://www.ncbi.nlm.nih.gov/pubmed/26588184
Bochaton-Piallat et al. (2016). The myofibroblast in wound healing and fibrosis: Answered and unanswered questions. F1000Research. (OPEN ACCESS)
https://www.ncbi.nlm.nih.gov/pubmed/27158462
Bove et al. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Journal of the Neurological Sciences.
https://www.ncbi.nlm.nih.gov/pubmed/26810536
Bove et al. (2018). Manual therapy prevents onset of nociceptor activity, sensorimotor dysfunction, and neural fibrosis induced by a volitional repetitive task. Pain.
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