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Citation: Lucha-López, M.O.;
Hidalgo-García, C.; Monti-Ballano, S.;
Márquez-Gonzalvo, S.; Krauss, J.;
Tricás-Vidal, H.J.; Tricás-Moreno, J.M.
Diacutaneous Fibrolysis: An Update
on Research into Musculoskeletal
and Neural Clinical Entities.
Biomedicines 2023,11, 3122.
https://doi.org/10.3390/
biomedicines11123122
Academic Editor: Juan Antonio
Valera-Calero
Received: 10 November 2023
Revised: 18 November 2023
Accepted: 21 November 2023
Published: 23 November 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
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4.0/).
biomedicines
Review
Diacutaneous Fibrolysis: An Update on Research into
Musculoskeletal and Neural Clinical Entities
María Orosia Lucha-López 1, * , César Hidalgo-García1, * , Sofía Monti-Ballano 1, Sergio Márquez-Gonzalvo 1,
John Krauss 2, Héctor JoséTricás-Vidal 1and JoséMiguel Tricás-Moreno 1
1Unidad de Investigación en Fisioterapia, Spin off Centro Clínico OMT-E Fisioterapia SLP,
Universidad de Zaragoza, Domingo Miral s/n, 50009 Zaragoza, Spain; smonti@unizar.es (S.M.-B.);
724250@unizar.es (S.M.-G.); hjtricas@unizar.es (H.J.T.-V.); jmtricas@unizar.es (J.M.T.-M.)
2School of Health Sciences, Oakland University, Rochester, MI 48309, USA; krauss@oakland.edu
*Correspondence: orolucha@unizar.es (M.O.L.-L.); hidalgo@unizar.es (C.H.-G.);
Tel.: +34-626-480-131 (M.O.L.-L.)
Abstract:
Diacutaneous Fibrolysis (DF) is an instrumentally assisted manual therapy technique
defined as “a specific instrumental intervention for normalizing the musculoskeletal system function
after a precise diagnosis and preserving the skin’s integrity”. The aim of this technique is soft tissue
mobilization with the assistance of specially designed, hook-shaped steel instruments in different
musculoskeletal structures, such as the myofascia, aponeurosis, tendons, ligaments and scar tissues.
Due to discrepant results between previous reviews and the quite abundant new evidence provided
by recently published randomized clinical trials, we propound this narrative review to provide an
update on the scientific evidence related to the fundamentals and clinical efficacy of DF. Current
evidence primarily supports the mechanical effect of DF on connective soft tissues. Diminished deep
tendon reflex and rigidity have been registered after the implementation of DF in healthy subjects.
Though there is still much to uncover, scientific evidence supports the use of the technique for the
clinical treatment of subacromial impingement syndrome, chronic lateral epicondylalgia, chronic
patellofemoral pain syndrome, mild to moderate carpal tunnel syndrome, hamstring shortening,
temporomandibular disorders, tension-type headache and chronic low back pain. Additional data
are essential for better recommendations in the clinical practice of DF.
Keywords: Diacutaneous Fibrolysis; connective tissue; musculoskeletal; neural
1. Introduction
Diacutaneous Fibrolysis (DF) is an instrumentally assisted manual therapy technique
which is defined as “a specific instrumental intervention for normalizing the musculoskele-
tal system function after a precise diagnosis and preserving the skin’s integrity” [
1
]. The
application of this soft tissue mobilization is assisted by specially designed, hook-shaped
steel instruments and applied to different musculoskeletal structures, such as the myofascia,
aponeurosis, tendons, ligaments and scar tissues [1].
Based on deep transversal massage from Cyriax, DF was developed by Kurt Ekman,
a Swedish physiotherapist, who assisted James Cyriax in the 1950s [
2
]. As a technique
eminently based on the manual skills of the therapist who applies it, it has been transmitted
to the present day thanks to the master–disciple model of knowledge transmission. The
disciple of Kurt Ekman, Pierre Duby, a Belgian physiotherapist and professor of anatomy at
the Free University of Brussels, spread the technique internationally, particularly in Europe.
Most of the clinical research on DF has been carried out in Spain, where the technique was
introduced by Pierre Duby in the 1990s at the University of Zaragoza. At the University
of Zaragoza, JoséMiguel Tricás-Moreno and María Orosia Lucha López, two Spanish
physiotherapists, started the diffusion of the technique in Spain.
Biomedicines 2023,11, 3122. https://doi.org/10.3390/biomedicines11123122 https://www.mdpi.com/journal/biomedicines
Biomedicines 2023,11, 3122 2 of 12
The hook-shaped steel instruments are designed to promote a mechanical advantage
by allowing deeper and more precise tissue mobilization and a reduction in stress on the
fingers of the clinician [
2
]. Like deep transversal massage from Cyriax, DF is applied
according to the tissue healing phase and transversal to the longitudinal direction of the
tissue fibers to be treated [
3
], seeking mechanical, circulatory and neurological effects [
4
,
5
].
A systematic review and meta-analysis from 2021, including six randomized con-
trolled trials performed to evaluate the effectiveness of DF on pain, range of motion and
functionality in a variety of musculoskeletal disorders, stated the efficacy of the technique
for pain relief and for the improvement of functionality immediately after treatment and at
follow-ups of at least three weeks [6].
Moreover, there are some systematic reviews that have included DF as a potential
co-adjuvant treatment for the management of a variety of musculoskeletal disorders.
Landesa-Piñeiro and Leirós-Rodríguez performed a systematic review about phys-
iotherapy management in lateral epicondylitis [
7
]. Among the 19 manuscripts analyzed,
one double-blind randomized controlled trial evaluating the effectiveness of DF for the
treatment of chronic lateral epicondylalgia was included [
8
]. The authors stated that inter-
ventions including shock waves, platelet-rich plasma, ultrasounds, friction and stretching
exercises, and bandages obtained better results with less sessions in pain relief. However,
the dosage of the DF intervention that appears in the review is wrong, since it describes 15
sessions of DF [
7
] and the original manuscript specified that the dosage in the DF group
was 6 sessions [8].
Haik et al. performed a systematic review of randomized controlled trials about
the effectiveness of physical therapy in subacromial pain [
9
]. Of the 64 studies included,
one double-blind randomized controlled trial evaluating the effectiveness of DF for the
treatment of subacromial impingement syndrome was included [
10
]. We agree with the
authors about their reflection stating that the effects of DF are not yet well established
and that more studies are needed on the issue, but the review describes the comparing
intervention in the control group of the DF study as an exercise intervention, and this is
not exactly accurate. The control group of the DF study received five sessions per week of
treatment that consisted of therapeutic exercises, analgesic electrotherapy and cryotherapy.
The inclusion of analgesic electrotherapy and cryotherapy in the control group might have
influenced the positive outcomes in pain achieved in the control group that Haik et al.
attributed to supervised exercises alone [9].
Piper et al. performed a systematic review about the effectiveness of soft tissue ther-
apy for the management of musculoskeletal disorders and injuries of the upper and lower
extremities [
11
]. They analyzed six studies due to their low risk of bias, including the
double-blind randomized controlled trial, evaluating the effectiveness of DF for the treat-
ment of subacromial impingement syndrome [
10
]. Regarding DF, Piper et al. stated that
“statistically significant differences favored DF, as well as sham DF over multimodal care
for function, shoulder extension and external rotation” [
11
], but in the original manuscript,
it was stated that “differences between placebo and control groups were statistically signifi-
cant only in extension movement” [
10
], and the other differences were presented between
DF and multimodal care.
Finally, Yu et al., in a review about the noninvasive management of soft tissue disorders
of the shoulder [
12
], recommended that DF should not be offered for soft tissue disorders
of the shoulder after analyzing the results of the previously mentioned double-blind
randomized controlled trial [
10
]. Although the results were similar between the group
treated with DF and the control group after three months, immediately after treatment,
that is, after three weeks, including six DF sessions improved the functionality and the
active extension and external rotation movements compared to the control group and the
differences between the placebo and control groups were statistically significant only in
extension movement.
Thus, due to the debatable results from some of the previous reviews and the quite
abundant new evidence provided by the recently published randomized clinical trials, we
Biomedicines 2023,11, 3122 3 of 12
propound this narrative review to provide an overview of the current evidence related to
fundamentals and clinical efficacy of DF. We have hypothesized that due to the potential
effect of DF in the remodeling process of the connective tissues after injury, intervention
with DF in a variety of clinical entities, including connective tissue dysfunctions, may
ameliorate the clinical course of these entities. Thus, the aim of this narrative review was to
describe the potential mechanisms of action of DF and to assess the effectiveness of DF in
the treatment of different musculoskeletal and neural clinical entities.
2. Materials and Methods
PubMed and Alcorze (search tool of the University of Zaragoza that simultaneously
searches the main databases) were searched for randomized clinical trials, experimental
studies and reviews up to 20 September 2023. Studies were included if they investigated the
mechanisms of fibrinolysis or fibrolysis or massage in collagen and if they investigated the
DF technique. Studies were excluded if they were single-case series or single-case reports,
letters and editorials. No date or article language restriction was applied. Reference lists of
selected articles were manually searched to identify other potential and relevant studies.
The search terms for the first search about the potential mechanisms of action of DF, in
PubMed were (fibrinolysis OR fibrolysis) AND (collagen OR fascia) NOT (“hemo*” OR
venous OR liver OR hepatic OR lung OR arteria) in which all capitalized words represent
the Boolean operators used. A total of 339 results were obtained. After the revision of the
title and/or the abstract, 2 articles were included.
A systematic search was also performed using the key terms Massage AND (collagen
OR fibrolysis OR fibrinolysis). A total of 96 results were obtained. After the revision of the
title and/or the abstract, 8 articles were included.
A systematic search about the effectiveness of DF in the treatment of different muscu-
loskeletal and neural clinical entities was performed in PubMed. The search terms were
fibrolysis AND “*cutaneous”. A total of 175 results were obtained. After the revision of the
title and/or the abstract, 20 articles were included.
A systematic search was also performed in Alcorze using the key term Crochetagem. A
total of 6 results were obtained. After the revision of the title and/or the abstract, 2 articles
were included.
An additional 6 citations were included through the scanning of the reference lists of
the previous studies.
3. Potential Mechanisms of Action of DF
DF, such as Cyriax’s massage, is supposed to accelerate and ameliorate the healing
process in connective tissues, through mechanisms such as hyperemia with consequent
increased blood flow to the tissue and elimination of the augmented cross-linking of
collagen, as well as a decrease in the preponderance of disorganized type III collagen, and
mechanoreceptor stimulation [13].
During the remodeling process of the connective tissues after injury, the proliferation
of fibroblasts may lead to matrix accumulation by increasing the production of collagen
type I and III, unbalanced with the degradation [
14
]. Moreover, fibroblast dysfunction has
been related with hypoxia [15].
In a typical connective tissue disorder such as Dupuytren’s disease [
16
], fibroblasts
proliferate and differentiate into myofibroblasts with an augmented contractile force. This
force is beneficial for physiological tissue remodeling but it can become excessive, leading
to connective tissue contracture with a subsequent deficit for function [
17
]. Tendinopa-
thy, which is understood as maladaptation to mechanical loading, has been related to a
degenerative process more than to an inflammatory one [
13
]. Tendon degeneration has
been characterized by collagen fiber disorganization, disruption and angiogenesis [
18
].
In joint capsules of long-term immobilized joints suffering from hypomobility, increased
disorganization of fibroblasts, high collagen density and irregular collagen fibers, as well
as the disappearance of adipocytes in the synovial membrane, have been found [19].
Biomedicines 2023,11, 3122 4 of 12
Thus, due to these underlying mechanisms related to failed remodeling in the connec-
tive tissue, it might be supposed that a reduction in cross-linking and the disorganization
of collagen and better blood flow will favor adequate tissue healing.
There are no studies in DF supporting the previous mechanisms nor the underlying
mechanism behind them. Nevertheless, some studies developed in animal models have an-
alyzed the tissue effects of other instrumentally assisted soft tissue mobilization approaches.
They shed some light on the issue.
Kami et al. developed a study to highlight the effects of mechanical massage manipu-
lation in the recovering of a blunt muscle injury in the gastrocnemius muscle of the rat. The
blunt muscle injury was induced by a hit with 1.57 joules [
20
]. Massage was performed
for 10 min per day for 25 days [
14
]. Collagenous fiber increased in the non-treated group
with respect to the massage group. Muscle fibrosis is characterized by the accumulation of
extracellular matrix, due to an imbalance between the synthesis and degradation of matrix
components. An excessive number of fibroblasts and myofibroblasts can lead to extracel-
lular matrix augmentation. In the massage group, the apoptosis of myofibroblasts was
increased and showed a more orderly arrangement of sarcomeres within one myofibril [
14
].
Kassolik et al. studied the effects of the spiral friction technique, applied for 6 min per
day, for 60 days, in the middle part of the tail of male rats, on the dense connective tissue of
the tendon [
21
]. The diameter of collagen fibrils was smaller in the massage group with
respect to the non-treated group. Tendon tissue in young rats is characterized by a smaller
fibril diameter [21].
Andrzejewski et al. studied the effects of spiral friction movements on the collagen
fibers of the rear long flexor muscle of the digits tendons from rats subjected to running
training for 5 min per day, for 70 consecutive days [
22
]. In the same way as Kassolok et al.,
they found a higher percentage of the smallest fibers in the tendons [22].
Davidson et al. studied the effects of instrumentally assisted soft tissue mobilization
in the Achilles tendons of rats with collagenase-induced tendinopathy [
23
]. The tendons
received friction in a longitudinal manner from distal to proximal and from proximal to
distal with an aluminum instrument for 3 min, four times, on post-collagenase injection
days 21, 25, 29, and 33 [
23
]. In the tendons that received the soft tissue mobilization
technique, more fibroblasts, stimulated extracellular matrix production and fibronectin
(an extracellular matrix adhesion protein) were found [
23
]. Gehlsen et al., using the same
methodology but with different pressure levels, discovered the largest number of fibroblasts
after six sessions with the heaviest pressure [24].
Again using instrumentally assisted soft tissue mobilization in the collagenase-induced
injured Achilles tendons of rabbits, Imai et al. found better dynamic viscoelasticity and a
larger cross-sectional area in the treated tendons [
18
]. Collagen was better aligned in the
treated tendons and a lower proportion of type III collagen was found, suggesting a better
remodeling phase [18].
In 2009, Loghmani and Warden studied the effects of instrumentally assisted cross-
fiber massage on the healing process of knee medial collateral ligament injuries [
25
]. The
cross-fiber massage (transversal to the longitudinal direction of the ligament) was started
1 week post-injury and three sessions of 1 min per week were performed. Changes were
evaluated at 4 and 12 weeks post-injury. At 4 weeks, the post-injury-treated ligaments had
better orientation and formation of collagen fibers, with minimal differences at 12 weeks
post-injury [
25
]. In 2013, the same authors, with a similar methodology, found enhanced
tissue perfusion due to an increase in the proportion of arteriole-sized blood vessels in the
tibial third of the ligament [26].
Subtle mechanical stretching consisting of 20 to 30% strain for 10 min, twice a day, for
seven days, in mouse subcutaneous connective tissue of the back was related to a lesser
presence of type-1 procollagen (in vivo) [27].
Some studies have been performed in healthy human subjects to study the effects of
DF on the neural underlying mechanisms of muscular relaxation empirically observed with
the technique.
Biomedicines 2023,11, 3122 5 of 12
Lévénez et al. found a reduction in passive tension, with augmentation of the maximal
passive range of motion in ankle dorsiflexion and a reduction in the deep tendon reflex
from the triceps surae, but not in the Hoffmann’s reflex, immediately after 10 min of DF on
the gastrocnemius, the soleus and the Achilles tendon [
28
]. Veszely et al., with a similar
methodology, found similar results but also the maintenance of the changes at the 30 min
follow-up [
29
]. It has been stated that if the experiment was performed with cutaneous
anesthesia of the treated area, the behavior of the Hoffmann’s and deep tendon reflexes did
not change, thus it seems that cutaneous and aponeurotic afferents did not participate in
the neural answer. Moreover, the difference in behavior of reflex responses might be due
more to a change in compliance of the myofascia-tendinous structure transmitting tendon
knock than to a change in neuromuscular spindle sensitivity [30].
López-de-Celis et al. evaluated the immediate effects and the effects at the 30 min
follow-up of a single session of DF on the neuromuscular properties of gastrocnemius in
healthy subjects. A single 10 min session of DF was applied to the same regions as in the
previous studies and was implemented only to one of the lower extremities. The other
extremity acted as a control. After treatment, treated gastrocnemius were less rigid, showed
a more relaxed state, and its contraction velocity was diminished. No differences between
limbs were observed at follow-up [31].
Leite et al. [
32
], conducted research to study the changes in neuromuscular properties
of lateral gastrocnemius immediately after a single 10 min session of DF in one group or
sham DF in the other. The DF group generated a higher force and higher degree of muscle
activation, measured with electromyography after DF [32].
4. Current Status of the Evidence about the Application of DF in Musculoskeletal and
Neural Clinical Entities
Recently, a number of randomized controlled trials and experimental studies have
been performed to highlight the clinical effects of DF in different clinical entities. No
adverse events were reported in any study. All of the studies were subject to a risk of
performance bias due to the fact that the researcher that implemented the DF, placebo or
control intervention had not had the possibility to be blinded.
4.1. Pain in the Shoulder Region
In 2011, Barra et al. performed a double-blind randomized controlled trial in patients
with chronic shoulder pain treated with DF or placebo DF. A single session of about 15 min
long was performed in the muscles from the scapula, the lateral region of the shoulder and
arm and the front part of the shoulder and chest. Immediately after the intervention, the
active range of motion of shoulder flexion, abduction and external rotation in the group
treated with the real technique were better than in the placebo group. No differences
were found in pain intensity, extension or external rotation. The main limitation of the
study was the variety of clinical characteristics of the sample. Chronic shoulder pain is
an imprecise diagnostic, thus the possible different answers to the DF treatment in the
different subgroups of patients remains unclear [33].
In 2013, Barra et al. completed the previous study, with a new study in the shoulder
region, this time in patients with clinically diagnosed subacromial impingement syn-
drome, based on Neer and Kennedy impingement tests. The double-blind randomized
controlled trial included three groups: FD, placebo FD and control. The intervention with
FD or placebo FD was implemented for three weeks, with two sessions per week, non-
consecutively. The three groups also received the usual treatment based on therapeutic
exercises, analgesic electrotherapy and cryotherapy five days a week during the three
weeks. Measurements were taken before and after treatment and at the three-month follow-
up. The intervention group after treatment had better active extension and external rotation
and reported better functionality than the control group. The placebo group showed bet-
ter results than the control group only in extension. A higher proportion of patients in
the DF group reported a feeling of clinical improvement after treatment. No differences
Biomedicines 2023,11, 3122 6 of 12
between groups were found at the three-month follow-up. The main limitation of the
results of this study was that at three months, 20% of the participants were lost. The last
observations carried forward was used to replace the missing values and this conservative
approach may have restricted the detection of statistically significant differences at the final
assessment [10].
Thus, it seems that DF could be used to accelerate the rehabilitation process in subacro-
mial impingement syndrome in the shoulder region. The improvements in functionality in
the short term achieved with the technique might favor the earlier normalization of the
patient’s daily living activities.
4.2. Chronic Lateral Epicondylalgia
In 2018, López-de-Celis et al. published a double-blind randomized controlled trial
with three groups: intervention with real DF, intervention with sham DF and control. The
purpose was to study the effects of DF on chronic lateral epicondylalgia, defined as pain
in the epicondyle region for more than three months and increased pain with gripping
or pressing and with the contraction or elongation of the extensor carpi radialis brevis.
The intervention period was 3 weeks, and measurements were performed at baseline, at
the end of the intervention and at the 3-month follow-up. The three groups received the
habitual treatment, based on ultrasound, transcutaneous electrical nerve stimulation and
muscular stretching, 5 days per week. Real or sham DF were implemented two times per
week, non-consecutively, for around 10 min, in the lateral region of the arm, anterior and
posterior forearm and epicondyle. At the end of the treatment, the DF group had better
general functionality than the control and placebo groups and less pain with more pain-free
grip strength, general functionality and occupational functionality than the sham group.
In the follow-up, the DF group had higher pain-free grip strength than the others groups,
and better general functionality than the control group. No differences between the control
and placebo groups were detected at any time. A higher proportion of patients in the DF
group reported a feeling of clinical improvement after treatment and at follow-up. The
principal limitation of this study was the short period of follow-up, which did not allow
the potential frequent recurrence of the pathology to register [8].
Thus, DF may be recommended along with standard care for the management of
chronic lateral epicondylalgia.
4.3. Chronic Patellofemoral Pain Syndrome
Fanlo et al. studied the effects of DF on patients with chronic patellofemoral pain
syndrome, which is identified as the presence of patellar pain during at least two of
these activities: prolonged sitting, stair climbing, squatting, running, kneeling or jumping.
Patients were treated during one week, with three 30 min sessions of DF on non-consecutive
days. Anterior and lateral myofascias of the thigh were treated together with the soft tissues
around the patellofemoral joint. Measurements were taken at the baseline, at the end of the
treatment and after a one-week follow-up. The patella-lateral condyle distance augmented
from baseline to the end of the treatment period, without changes at follow-up. Pain and
functionality improved after the treatment and at follow-up [
34
]. Pressure pain threshold
from the anterior knee joint, tibialis anterior and contralateral epicondyle of the humerus
(selected as a remote point to measure widespread hyperalgesia) diminished after treatment
and at follow-up. Muscle length from the rectus femoris, hamstrings and iliotibial band
increased after treatment and at follow-up. A total of 97% of patients reported a feeling of
clinical improvement after treatment and at follow-up. The most important limitation of
this study was the short intervention and follow-up period of one week in this pathology
characterized as chronic. A potential placebo effect biasing treatment effects might not be
discarded [35].
These results may encourage the use of DF for the treatment of chronic patellofemoral
pain syndrome, thought medium and long-term follow-up studies are needed.
Biomedicines 2023,11, 3122 7 of 12
4.4. Carpal Tunnel Syndrome
Jiménez del Barrio et al. studied the effectiveness of DF in the treatment of patients
with mild to moderate carpal tunnel syndrome, diagnosed with electroneurogram by
means of a double-blind randomized controlled trial with two groups: DF intervention
and sham DF intervention. The protocol consisted of five sessions of DF or sham DF of
around 20 min, with an interlude of two to five days between each session. The technique
was applied in the myofascias of the ventral forearm and ventral tendons and the fascia
of the hand. Measurements were taken at the baseline, immediately after treatment and
at the one-month follow-up. Intensity of the nocturnal pain, general functionality of the
upper extremity and median nerve distal motor latency and sensory conduction velocity
at the wrist were better in the DF group immediately after treatment [
36
]. The differences
in the intensity of nocturnal pain and the general functionality of the upper extremity
persisted at the one-month follow-up. Electroneurophysiological data are not available on
the follow-up. The main limitation of this study was that possible changes in medication
intake throughout the duration of the study were not recorded [36].
A secondary analysis of the previous study was performed with a selected subgroup
of patients determined to have a result in the standard median nerve neurodynamic test
characterized by achieving the last movement performed in the test, elbow extension,
and with data measured only after treatment and without follow-up [
37
]. Researchers
registered the range of motion of elbow extension (more elbow extension means less
mechano-sensibility in the median nerve), symptom intensity at the end of the range of
motion, the sensory conduction velocity of the median nerve at the wrist, and the symptom
severity and reported functionality registered together, as the outcome obtained in the
Boston Carpal Tunnel Syndrome Questionnaire. All of the variables were better after
treatment in the DF group [37].
Another study from Jiménez del Barrio et al. with a similar methodology found that
after treatment, the DF group, with respect to the sham group, obtained lower numb-
ness intensity and a lower cross-sectional area of the median nerve and thickness of the
transversal carpal ligament, measured with ultrasound [
38
]. The most important limitation
of this study was that patients diagnosed with bilateral pathology were included in the
same group to preserve their blinding. This may have limited the effectiveness of the
randomization to avoid selection bias.
These results may suggest a role for DF in the approach of carpal tunnel syndrome,
though studies on severe cases and with longer follow-up periods are needed.
4.5. Hamstrings Shortening
Cadellans-Arróniz et al. aimed to study the effects of DF on the neuromuscular
properties of shortened hamstrings, diagnosed in athletes with an outcome from a passive
knee extension test of less than 160 degrees. They performed a single-blinded randomized
within participant controlled clinical trial; that is, athletes with hamstrings shortening in
both lower limbs were selected. One limb, randomly selected, was treated, and the other
served as the control. Measurements were taken at the baseline, immediately after treatment
and at the 30 min follow-up. Intervention consisted of the implementation of one session of
DF of around 10 min in the myofascial tissues from the ipsilateral lumbar and gluteal region
and of the dorsal thigh of the lower limb randomly selected for intervention. Immediately
after treatment, stiffness of the gluteus muscle and the stiffness and tone of the biceps
femoris had diminished more in the treated limb. These previous changes did not persist at
follow-up, although the biceps femoris of the treated limb had relaxed more at follow-up.
Other aspects of neuromuscular properties such us contractile properties measured with
tensiomyography and intensity of perceived pain with a pressure of 4 Kg/cm
2
at the
thickest point of the gluteus, biceps femoris and semitendinosus muscles did not show
any difference between the treated and the control limbs [
39
]. Immediately after treatment,
gluteus maximus maximal isometric strength improved more in the treated limb, and this
change persisted at follow-up. At follow-up, hamstring length had improved more in the
Biomedicines 2023,11, 3122 8 of 12
treated limb [
40
]. However, no differences between the treated and control limbs were
detected in the overall flexibility of the hamstring and lower back muscles, the hamstrings’
maximal isometric strength and electrical muscle activity during jumping [
40
]. Jump height
did not change after intervention nor at the follow-up [
40
]. The principal limitation of this
study was that as the subjects acted as their own controls, a neural central effect affecting
the control limb could not be discarded. A potential placebo effect biasing treatment effects
might not be discarded either.
Thus, DF may be recommended to relax and increase the length of shortened ham-
strings, though more studies with higher doses and longer periods of follow-up are needed
in order to facilitate the standardization of protocols for clinical practice.
4.6. Temporomandibular Disorders
Leite et al. performed a sham randomized controlled trial to assess the effects of
DF on temporomandibular disorders in women. The participants were included if they
at least suffered from muscle dysfunction in the temporomandibular region, diagnosed
and classified according to the validated Portuguese version of the Diagnostic Criteria
for Temporomandibular Disorders from the International Network for Orofacial Pain
and Related Disorders Methodology; however, 55% of participants also had disc or joint
implications. Measurements were taken at the baseline and after the 4 weeks of the DF
protocol. The protocol consisted of two 10 min DF or sham technique sessions a week in
the masseter and temporal muscles, bilaterally. The women treated with DF perceived
lower intensity in their usual orofacial pain evoked by mouth opening and had a higher
pressure pain threshold in the right temporal muscle belly than the sham group. No
differences between the groups were detected in active and asymptomatic maximal mouth
opening, although a higher percentage of subjects in the DF group had values of mouth
opening above the average international normal level of pain-free opening (40 mm) after
treatment [
41
]. After treatment, a lower percentage of subjects in the DF group presented
moderate severity in functional limitation related to their temporomandibular disorder,
with the remaining subjects in the DF group showing low levels of severity. The main
limitation of this study was the heterogeneity of the clinical manifestations of the patients.
A total of 55% of the patients included suffered not only from myofascial problems, but also
from disc or joint disorders. Thus, more accurate criteria, excluding patients with disorders
not directly afforded with DF, might favor the clarification of the effects of DF [41].
DF might be indicated to ameliorate the clinical status of patients with temporo-
mandibular disorders, considering the positive short-term results highlighted in the previ-
ous study.
4.7. Tension Type Headache
Cabanillas-Barea et al. performed a single-blinded randomized controlled trial to
study the effects of adding DF to the prescribed pharmacological treatment in patients
with tension-type headaches diagnosed by their physician according to the International
Classification of Headache Disorders criteria. The intervention consisted of three 30 min
DF sessions applied with at least two days of rest between sessions in the dorsal thoracic,
scapular, cervical and occipital regions. Assessments performed by a blind evaluator were
carried out before and after treatment and at a one-month follow-up. The frequency of
headache and the reported impact on daily living caused by the headache ameliorated
more in the DF group compared with the standard care group at the follow-up (after
treatment they were not assessed). The active cervical range of motion in the three planes
ameliorated more in the DF group compared with the standard care group at the end of the
treatment and at the one-month follow-up. The intensity of pain perceived at the moment
of the assessment ameliorated more in the DF group but only after treatment and not at
follow-up [
42
]. The worst and the usual intensity of pain ameliorated more in the DF
group at the one-month follow-up (after treatment they were not assessed) [
43
]. A higher
percentage of subjects said that they felt better in the DF group compared with the standard
Biomedicines 2023,11, 3122 9 of 12
care group at the end of the treatment and at the one-month follow-up [
42
,
43
]. The main
limitation of this study was a follow-up period of only one month in a pathology that might
be chronic. Another limitation was that possible changes in medication intake throughout
the duration of the study were not recorded. A potential placebo effect biasing treatment
effects might not be discarded neither.
It seems that DF may be a promising method to contribute to the management of
symptoms and daily living in patients with tension-type headaches.
4.8. Chronic Low Back Pain
In 2019, Castilho-Alonso et al. performed a randomized controlled trial to analyze the
effects of DF in patients with chronic low back pain. They established two groups. The
kinesiotherapy group, acting as the control group, performed a ball kinesiotherapy protocol
for 50 min, three times a week for 8 weeks. The DF group performed the same protocol and
received a DF treatment on the same days in the sacral region, lumbar spine and piriformis
muscle. Measurements were taken before and after the protocol. Lumbar pain-related
disability was minor after treatment in the DF group. No differences between the groups
were detected after treatment in trunk active range of motion in flexion, extension and side
bending, in abdominal strength and in pain. The main limitation of this study was that
chronic low back pain is an imprecise diagnostic, thus the possible different answers to the
DF treatment in the different subgroups of patients with this diagnostic remains unclear. A
potential placebo effect biasing treatment effects might not be discarded [44].
Thus, DF might be a useful technique in the normalization of daily living activities in
patients with low back pain.
4.9. Scar Treatment
In 2019, Aparecida et al. published an experimental study including 26 women with a
previous cesarean surgery and some type of musculoskeletal pain somewhere. The scar
was treated one time and the subjects were reevaluated 24 h later. Reductions in general
pain and pain on movement, and improvements in pressure pain threshold in the vertebral
spinous process, the level corresponding to the dermatome of the patient’s symptom region,
and general flexibility were observed. The thermography, measured using a thermography
camera in the location of the symptoms, did not change. The main limitation of this study
was the absence of a control group. Another important limitation was the unspecified
assessment performed [45].
The results seem promising, but the methodology of the study does not allow us to
make a recommendation.
5. Conclusions
Current evidence primarily supports a mechanical effect of DF on connective tissue-
based soft tissues. Diminished deep tendon reflex and rigidity have been registered after
the implementation of DF in healthy subjects. An increase in muscle stiffness has been
related to a higher risk of injury, thus, DF might be an adequate technique to prevent and
treat muscular injuries.
Though there is still much to uncover, scientific evidence supports the use of the
technique for the clinical approach of subacromial impingement syndrome, chronic lateral
epicondylalgia, chronic patellofemoral pain syndrome, mild to moderate carpal tunnel
syndrome, hamstrings shortening, temporomandibular disorders, tension-type headache
and chronic low back pain.
DF could be used to accelerate the rehabilitation process in subacromial impinge-
ment syndrome in the shoulder region. The immediate improvements in functionality
achieved with the technique might favor the earlier normalization of the patient’s daily
living activities.
DF may be recommended to ameliorate pain-free grip strength and functionality in
chronic lateral epicondylalgia in the medium term.
Biomedicines 2023,11, 3122 10 of 12
DF may be prescribed for the treatment of chronic patellofemoral pain syndrome due
to its favorable effects on patella position, pain, functionality and muscle length from the
rectus femoris, hamstrings and iliotibial band in the short term.
DF may be suggested for the alleviation of symptoms and the improvement of func-
tionality in patients with mild to moderate carpal tunnel syndrome in the short term.
DF may be prescribed to relax and to increase the length of shortened hamstrings.
DF might be recommended for the treatment of temporomandibular disorders in
women due to its favorable, immediate effects on pain, mouth opening and functionality.
DF may be prescribed for tension-type headache to ameliorate the intensity of pain,
the frequency of headaches, the reported impact on daily living caused by the headache
and the active cervical range of motion in the three planes in the short term.
DF might be suggested for the treatment of chronic low back pain due to its favorable,
immediate effects on lumbar pain related disability.
The patient perspective about the DF treatment was always a feeling of clinical im-
provement when it has been registered.
Future research must afford the inclusion of more specific subgroups of patients in
studies from different clinical entities. Moreover, future research should try to implement
longer periods of treatment and follow-up, in accordance with the natural history of the
pathologies, to establish the most suitable dosage and the effects on the progression of the
pathologies.
In vitro
studies might be developed in the future to highlight the mechanisms
of action of DF.
Additional data are essential for better recommendations in the clinical practice of DF.
Author Contributions: Conceptualization, M.O.L.-L., C.H.-G. and J.M.T.-M.; methodology, S.M.-G.,
S.M.-B. and H.J.T.-V.; formal analysis, M.O.L.-L., J.K. and C.H.-G.; writing—original draft preparation,
M.O.L.-L., J.K. and S.M.-B.; writing—review and editing, J.M.T.-M., S.M.-G. and C.H.-G.; visualization,
H.J.T.-V.; supervision, J.M.T.-M. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement:
No new data were created or analyzed in this study. Data sharing is
not applicable to this article.
Conflicts of Interest: The authors declare no conflict of interest.
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