Dissecting the Evidence Supporting LAST

By Robert Libbey*

Today’s Massage Therapy profession is committed to utilising techniques informed from research and evidence. An “evidence-informed practice” is one in which we as clinicians sensibly integrate research, evidence, information and experience into our clinical reasoning, keeping the best interests and goals of our patients in mind at all times. Practising in this manner has the potential to transform your practice and improve the quality of life of your patients, as I know it has for mine. In this article, I will explore the basic history and provide research supporting Ligamentous Articular Strain Technique (LAST).

A Brief History of LAST

Andrew Taylor Still, MD, DO (1828–1917) was the founder of Osteopathy and Osteopathic Medicine. He was the founder of the American School of Osteopathy (now A. T. Still University), the world’s first osteopathic medical school, in Kirksville, Missouri.

William Garner Sutherland, DO (1873–1954) was a student of Dr. Still and credited the origin of LAST to Dr Still. LAST was derived from General Osteopathic Techniques (GOT).1 In 1947, Dr Sutherland first instructed LAST separate from GOTs to his study group. Ligamentous Articular Strain Techniques were originally published in the 1949 Year Book of the Academy of Applied Osteopathy.2 The article informs the reader that Osteopathic lesions are strains of the tissues of the body and that when they involve joints, it is the ligaments that are primarily affected.”3

In 1982, the Dallas Osteopathic Study Group (DOSG) began an extensive study of the Indirect and Direct methods of Osteopathic Manipulative Treatment. A member of the DOSG, Dr Rollin Becker, DO had been in attendance at Dr Sutherland’s 1947 study group presentation of LAST. Most of the Indirect Osteopathic Manipulative Techniques are referred to as Ligamentous Articular Strain Techniques while several of them also formed the basis of Myofascial Release Techniques. In 2001 and 2009 the DOSG published their manual on Ligamentous Articular Strain Techniques.4

A New Perspective

In the late 1990s, I began researching, studying and practising LAST. I have taken the opportunity to advance and update the original context first put forth by Dr Still, Dr Sutherland and the DOSG.

As science and medicine have advanced from the days of Dr Still and Dr Sutherland, so has our understanding of anatomy and physiology. Advances in our understanding of physiology, neurology, pain science, the biopsychosocial model of patient management, new understandings of fascia from the International Fascial Research Congress and regenerative rehabilitation, demand that we adapt the narratives of our manual therapy applications.

Presented here are the same timeless principles viewed through a modern lens. The techniques are applied with the mindset of providing a simple, precise, principle-based, evidence-informed technique utilised by the manual therapy clinician to improve the quality of life of their patients.

What We Know Now

Ligaments are highly dynamic and non-stationary organs. 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, not connected to the surrounding tissues. However, these structures and the surrounding tissues are inseparable. For those of us who have spent many hours in a cadaver dissection lab, we know that the only way to “create” a separate structure is to carve it away from all the surrounding structures it is connected with.

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.5 There is a joint stability system in which muscular tissue and regular dense collagenous connective tissue (RDCT), such as ligaments, interweave and function mainly in an “in series” situation rather than an “in parallel” situation.6 When you contract a muscle, the ligaments are automatically engaged. Like the reins on a horse, ligaments constantly assist in the stabilisation of a joint, no matter what its position, during both concentric and eccentric muscular contractions.7

Ligamentomuscular Reflex and Neuroplasticity

Today we no longer consider ligamentous injuries as simple musculoskeletal peripheral joint injuries, but recognise them as also being neurophysiological dysfunctions. Changes in fascial plasticity and neuroplasticity have been shown to contribute to the chronicity of injuries and slowing of rehabilitation.

In his articles on fascial plasticity, Dr. Robert Schleip discusses how fascia and the autonomic nervous system are connected and communicate via afferent mechanoreceptors input.8 9 Mechanoreceptors are everywhere throughout our connective tissues. In ligaments and tendons, they are in high concentrations at the tenoperiosteal and ligamentoperiosteal entheses.5 Mechanoreceptors in ligaments provide the CNS with kinaesthetic and proprioceptive information along with contributing to a “Ligamentomuscular Reflex” of associated muscles.10 11

The Ligamentomuscular Reflex has been shown to exist in 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 destabilise the joint and increasing antagonist co-activation to maintain joint stability.12 13

This reflex works quickly as a protective mechanism to attempt to limit damage by stimulating a monosynaptic connection from the ligament to the skeletal motor neuron.14 15 16 For example, when you are about to sprain your ankle, the lateral ligamentous structures and joint capsule recognise that the joint is being taken beyond its structural tolerance. The ligamentous structures and joint capsules very quickly enlist the help of the associated muscles in your lower leg to contract in an attempt to protect and help prevent the joint from being excessively subluxated or dislocated.

This reflex has also been shown to be a contributing factor in chronic neuromuscular tension conditions. Working via a polysynaptic connection, the ligament communicates through multiple regulatory influences to the gamma muscle spindle system to constantly create increased protection of affected areas.11 15 17 18 19 In essence, the CNS recognises that there has been an event that has created structural change or the potential for damage to occur. There could be an instability in one or more joints which require(s) stabilisation in order to provide function. The CNS protects by increasing tension and contraction of muscle groups and by increasing densification of fascia around the affected area.

Injuries to the soft tissues of peripheral joints contribute to chronic neuromuscular adaptations due in part to a loss of effective messaging from mechanoreceptors to the CNS.20 21 22 23 Peripheral joint injuries disrupt the generation and transmission of adequate proprioceptive input from mechanoreceptors, which can lead to significant joint sensorimotor impairment.9 12 20 21 22 24 25 These dysfunctions influence “executive functions” such as processing of somatosensory information by the prefrontal cortex, causing reorganisation of the central nervous system, effecting neural plasticity.6 25 26 27

Neurophysiological and neuroimaging studies provide evidence for CNS reorganisation (neuroplasticity) at both the cortical and spinal levels after peripheral joint injuries.22 25 33 Neuroplastic changes may help to explain the transition from acute to chronic conditions.22 27 These changes may explain why some patients continue to experience pain when no structural cause can be determined, and why some patients fail to respond to conservative interventions.26 27

Schleip8 9 and Pelletier26 27 recommend that clinicians change their perspective of treatment from a purely mechanical perspective to one that also is inclusive of nervous system modulation strategies.

Treatment Influences – Fascia and Neuroplasticity

As clinicians, we have the opportunity to recognise peripheral joint instabilities with increased autonomic protective mechanisms and effectively treat these dysfunctions. No matter if you practice on your own or if you practice in a multidisciplinary clinical setting, it’s important to have a referral network of clinicians that provide therapies that can be used in tandem with your treatments to improve the quality of life of our patients. Referring when medically necessary improves cross-disciplinary mutual therapeutic outcomes.

Focusing on the treatment and management of peripheral joint injuries/conditions, we are primarily concerned with modulating communication from the injured peripheral joint fascial tissues to the CNS to improve function and possibly decrease discomfort/pain. By using both manual/physical based techniques (manual therapy, motor learning, peripheral sensory stimulation) and cognitive based therapy techniques (education, cognitive-behavioural therapy, mindfulness meditation, motor imagery) we and our patients can stimulate CNS neuroplastic changes.26

Langevin and Bouffard reported 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.5 28 29 Manual Therapy can affect connective tissue remodelling, such as modulation of fibrosis and densification of fascia, by changing its tensile status and sliding components.30 31 32

What’s important to remember, is that to accomplish a goal of making a change to fascial tissue and to the CNS, there must be active participation by the patient. Patients can either perform strategic active rehabilitative exercises to accomplish a specific goal of function or play a sport or perform an activity that they enjoy. Not only is it necessary for the patient to be active, but they need to be consistent with that activity for a minimum of at least 6 months to a year in order to see a change.

Why Use Mechanoreceptor Specific Techniques?

LAST is a precise, principle based, mechanoreceptor specific manual therapy technique.

Mechanoreceptor specific techniques that target peripheral joint tissues, affect autonomic nervous system functions which in turn, results in decreased protective myofascial engagement, increased pain pressure sensitivity, normalise kinesthetic and proprioceptive awareness, improving treatment outcomes.

In 2012, we were fortunate to have the Third International Fascia Research Congress in Vancouver, Canada. At the Congress, I attended an informative seminar taught by Dr Peter Viklund. He and his colleagues compared ankle joint dorsiflexion after classical massage and after specific myofascial receptor massage technique on the calf muscle. Their research concluded that specific myofascial receptor massage 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.”32 As you can imagine, I was very happy to see current research confirming what I have been seeing and accomplishing in my practice.

It is a work of passion to research and advance our understanding of the clinical outcomes of LAST and bring it into today’s evidence-informed practice standards for the manual therapy profession. New research is continually being published from the fascial community, from neurophysiological researchers and from researchers who focus on the ligamentous articular tissues. This research directly affects our understanding of function and connectedness of not just the ligamentous articular tissues but all of our tissues.

About the Author

Robert Libbey is a Canadian Registered Massage Therapist and educator who runs workshops and online courses on LAST. Robert will be visiting Australia in October and presenting workshops on LAST in Tweed Heads, Perth and Canberra. Download the workshop flyer for more info. Earlybird prices close on August 1. Robert is also presenting at the AMT National Conference Ocrober 12- 14.  Book your place here – earlybird prices close on 13 August 2018. Learn more about Robert and LAST here.

*This article first appeared in the Massage Therapy Canada Winter 2016 magazine (pages 22-24) with the title “LAST Resort”.

References
  1. DiGiovanna, E. L., Schiowitz, S. & Dowling, D. J. (2004). An Osteopathic Approach to Diagnosis and Treatment: Third Edition. Philadelphia, PA: Lippincott Williams & Wilkins.
  2. Speece CA, et al. (2009). Ligamentous Articular Strain: Osteopathic Manipulative Techniques for the Body (Revised edition). Seattle, WA: Eastland Press.
  3. Sutherland WG. Teachings in the Science of Osteopathy. Wales A (ed.). Portland, OR: Rudra, Press, 1990
  4. Ligamentous Articular Strain – Osteopathic Manipulative Techniques for the Body by Contrad A Speece (2009)
  5. van der Wal J. (2009) The architecture of the connective tissue in the musculoskeletal system—an often overlooked functional parameter as to proprioception in the locomotor apparatus. International Journal of Therapeutic Massage and Bodywork. 2009 Dec;2(4).
  6. Solomonow M. (2009) Ligaments: a source of musculoskeletal disorders. Journal of Bodywork and Movement Therapies, 2009;13(2):136-54
  7. Myers T. (2011). Dynamic Ligaments: Re-visioning the Fascia as a Body-Wide Regulatory System. Massage Magazine.
  8. Schleip R. (2003) Fascial plasticity – a new neurobiological explanation: Part 1. Journal of Bodywork and Movement Therapies, Volume 7, Issue 1, January 2003, Pages 11-19
  9. Schleip R. (2003) Fascial plasticity – a new neurobiological explanation: Part 2. Journal of Bodywork and Movement Therapies, Volume 7, Issue 2, April 2003, Pages 104-116
  10. Solomonow, M. (2006). Sensory-motor Control of Ligaments and Associated Neuromuscular Disorders. Journal of Electromyography and Kinesiology, 16(6), 549-67.
  11. Holm S, Indahl A, Solomonow, M (2002). Sensory-motor Control Sensorimotor control of the spine. Journal of Electomyography and Kinesiology, 12 (3), 219-234
  12. Solomonow, M. (2004). Ligaments: A Source of Work-Related Musculoskeletal Disorders, Journal of Electromyography and Kinesiology, 14, 49-60
  13. Solomonow, M., et al., The ligamento-muscular stabilizing system of the spine. Spine, 1998. 23(23): p. 2552-62
  14. Phillips, D., et al., Ligamentomuscular protective reflex in the elbow. The Journal of Hand Surgery. American volume., 1997. 22(3): p. 473-8
  15. Johansson, H., P. Sjolander, and P. Sojka, A sensory role for the cruciate ligaments. Clin Orthop Relat Res, 1991(268): p. 161-78
  16. Solomonow, M., et al., The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. The American Journal of Sports Medicine, 1987. 15(3): p. 207-13
  17. Raunest, J., M. Sager, and E. Burgener, Proprioceptive mechanisms in the cruciate ligaments: an electromyographic study on reflex activity in the thigh muscles. The Journal of Trauma, 1996. 41(3): p. 488-93
  18. Freeman, M.A. and B. Wyke, Articular reflexes at the ankle joint: an electromyographic study of normal and abnormal influences of ankle-joint mechanoreceptors upon reflex activity in the leg muscles. The British Journal of Surgery, 1967. 54(12): p. 990-1001
  19. Stener, B. and I. Petersen, Electromyographic Investigation of Reflex Effects Upon Stretching the Partially Ruptured Medial Collateral Ligament of the Knee Joint. Acta Chirurgica Scandinavica, 1962. 124 (no free access)
  20. Hildebrand, KA et al., (1998) Scar Formation and Ligament Healing, McCaig Centre for Joint Injury and Arthritis Research, University of Calgary
  21. Nicholas, E. A. (2008) Atlas of Osteopathic Techniques (1st ed.). Baltimore, MD: Lippincott, Williams & Wilkins
  22. Riemann, BL et al. (2002) The Sensorimotor System, Part II: The Role of Proprioception in Motor Control and Functional Joint Stability. Journal of Athletic Training 2002;37(1):80–84
  23. Van Kleef et al. (2010) Pain originating from the Lumbar Facet Joints, Evidence-based Interventional Pain Medicine according to Clinical Diagnosis. 2010 World Institute of Pain, 1530-7085/10
  24. Dreyfuss P et al., Thoracic Zygapophyseal joint pain patterns. A study in normal volunteers. Spine. 1994;19:807-11
  25. Hackett, G. Ligament and Tendon Relaxation Treated by Prolotherapy. Third Edition. Springfield, IL: Charles C. Thomas, Publisher, 1958
  26. Pelletier et al. (2015) Addressing Neuroplastic Changes in Distributed Areas of the Nervous System Associated With Chronic Musculoskeletal Disorders. Phys Ther. 2015 Nov;95(11):1582-91
  27. Pelletier et al. (2015) Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? BMC Musculoskelet Disord. 2015 Feb 12;16:25
  28. Bouffard NA, et al. (2008) Tissue stretch decreases soluble TGF ß1 and Type-1 pro-collagen in mouse subcutaneous connective tissue: evidence from ex vivo and in vivo models. Journal of Cellular Physiology. 2008;214: 389-395.
  29. Langevin HM, et al.(2001) Mechanical signaling through connective tissue: A mechanism for the therapeutic effect of acupuncture. FASEB J. 2001;15:2275–2282
  30. Needle AR (2014) Neuromechanical coupling in the regulation of muscle tone and joint stiffness. Scand J Med Sci Sports. 2014 Oct;24(5):737-48
  31. Stecco et al. (2015) Fibrosis and Densification: Anatomical vs Functional Alteration of the Fascia. Fourth International Fascia Research Congress: Basic Science and Implications for Conventional and Complementary Health Care. Munich, Germany: Elsevier GmbH
  32. Viklund P. (2012) Comparison of ankle joint dorsiflexion after classical massage or specific myofascial receptor massage technique on the calf muscle. Third International Fascia Research Congress: Basic Science and Implications for Conventional and Complementary Health Care. Munich, Germany: Elsevier GmbH (listed under “Manual Therapy”.)
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