*2.2.5 Effects of ERGON IASTM on pain reduction*

Myofascial pain reduction after IASTM application has long been theoretically connected to the following three mechanisms: (a) local temperature and blood flow increase, (b) localised tissue manipulation and stretching, and (c) reduction of fascial adhesions and restrictions [111–114].

The importance of ERGON techniques for reducing pain has been investigated by Fousekis et al. in 2016, who reported an immediate reduction in pain and pressure sensitivity in soccer players with trigger points in the lumbar area [98].

Furthermore, deep pressure may mask the perception of pain, possibly in connection with endorphins [115, 116]. Using IASTM, applying deep pressure becomes easier as the tools' edges are harder than the tips of a therapist's fingers.

### *2.2.6 Effects of ERGON IASTM on increasing skin temperature*

In sports rehabilitation, increasing blood circulation and tissue temperature are strategic goals for the proper preparation of athletes before a game or a practice session.

The tool angle used when treating tissue should be considered for a more targeted treatment of specific pathologies. Research shows that a greater angle of application results in higher tissue temperature for longer periods of time. More specifically, temperature value and permanence have been examined at 20o , 60o , and 90o application angles. The temperature increased with each application angle but was higher at the 60o and 90o angles. It is worth noting that at 60o and 90o angles, the temperature rise was almost the same. In conclusion, if the goal of the treatment is to maintain increased temperature for a long time, a greater angle, such as a 90o angle, is advisable [79].

In addition, soft tissue techniques using IASTM have been shown to be more effective at raising temperature in basketball players after 15 minutes of application compared to the use of massage and foam rollers [15].

#### *2.2.7 Effects of ERGON IASTM on increasing elasticity*

One of the most noteworthy outcomes of ERGON IASTM techniques is the effect that such techniques have in the therapy of remote areas – that is, when techniques are applied in one anatomical area to induce adaptations in a different one.

This therapeutic approach is based on the existence of 12 specific myofascial meridians (fascia lines) that control the human body, as proposed by Thomas W. Myers [116]. Fibres are interconnected along each myofascial meridian collagen, resulting in the continuity of many functions, such as muscle relaxation.

Myofascial release techniques that use the ERGON IASTM TECHNIQUE improve the elasticity of muscles in adjacent areas. Two studies showed improved elasticity in hamstrings and hip abductors following treatments in the trunk and the upper part of the lateral line (ribs and quantratus lumborum), respectively.

One study showed improved elasticity in hamstrings following treatment aimed at the trunk area of the body. More specifically, 60 university students with shortened hind thighs performed the "sit and reach test" once a week for one month. Participants were divided into three groups: in the first treatment group, manipulations were performed on the hamstrings; in the second treatment group, on the trunk; finally, the third group was the control group, with participants receiving no treatment. In each session, the participants from all groups were evaluated in terms of hamstring elasticity using an angle meter in the straight leg raise (SLR) test. Statistical analysis showed that both treatment groups improved hamstring elasticity in four weeks [117].

A second study showed improved hip-abductor elasticity following treatment in the upper part of the lateral line (ribs and quantratus lumborum). Participants received one treatment per week for six weeks to increase the elasticity of hip abductors. The techniques were applied to the upper part of the lateral line (ribs and quantratus lumborum), to the lower part of the lateral line (the iliotibial band), and, finally, to the entire lateral line. Elasticity improved almost to the same degree in all three groups [118].

Furthermore, the effect of soft tissue mobilisation on the remote parts of the myofascial meridian can extend to the interconnection of non-adjacent anatomical areas. As shown in a study conducted by the Laboratory of Therapeutic Exercise and Sports Rehabilitation at the Department of Physiotherapy at the University of Patras, Greece, there was a significant improvement in hip abductor elasticity and an increase in the hip abduction ROM following applications on scalene muscles [111].

Therefore, in their clinical practice, therapists should include the IASTM treatment of remote areas and points that connect through the fascia lines during the acute phase of the injury. Such immediate interventions will ensure that the elasticity of the treatment area is improved or maintained without the pain and discomfort that would otherwise be caused by direct treatment of the actual injured area.

### *2.2.8 Effects of ERGON IASTM on the restoration of the biomechanical function of joints*

The ERGON IASTM techniques improved the ROM and athletic performance in in 15 professional volleyball athletes, who underwent ERGON treatment once a week for a total of three weeks. The athletes performed specific tests before and after each intervention, which included measuring the ROM of flexion and the internal and external rotation using an angle meter as well as carrying out shoulder functional assessments using the functional throwing performance Index test (FTPI) and the one-hand shot put performance test (OSP). The results showed that the intervention with the ERGON IASTM TECHNIQUE led to better outcomes in improving the ROM compared to the foam roller and the elastic bandage [119].

ERGON techniques can also be combined with neuromuscular exercises aimed at improving the supraspinatus tendinosis. The study by Fousekis et al. in 2017 provided primary evidence that the mobilisation of soft tissue in combination with specialised therapeutic exercise can offer faster therapeutic results in the ROM and in the reduction of pain [120].

In conclusion, the ERGON IASTM TECHNIQUE is a new technique that, based on the latest research evidence, can contribute significantly to sports rehabilitation. More specifically, it enables therapists to improve the ROM, reduce pain, improve the performance of athletes, increase the temperature of the tissues, and improve blood circulation within a few sessions.

## **2.3 Muscle blood flow occlusion: the kinetic flossing technique**

The elastic ischemic bandage is another popular tool in the rehabilitation and prevention of sports injuries. Initially, applications of the ischemic bandage were aimed at improving the performance of athletes. The technique involves an elastic band, made of rubber-latex material, with which the therapist applies an ischemic pressure to the treated limb. The size of the bandage depends on the size of the anatomical structure. Techniques are usually performed in combination with kinesiotherapy or joint mobilisation techniques.

The technique results in multiple effects that require further research. Seemingly, it produces several hemodynamic and biomechanical adaptations.

Hemodynamically, there is an immediate reduction in local blood flow. The removal of the bandage is followed by sharp hyperaemia that increases fibroblastic activity. These normal hemodynamic adjustments after the application of the bandage contribute to (a) the regeneration and restoration of the injured collagen, (b) the removal of inflammation derivatives and pain metabolites, and (c) the desensitisation of the nerve endings and thus to the reduction of local pain and sensitivity [121, 122].

Biomechanical adaptations include compressing and decompressing tissues and correcting the position of the joints and the posture of patients [123, 124].

Research has shown that ischemic bandaging has positive impacts on improving the ROM. More specifically, researchers have evaluated the use of the ischemic bandage for the dorsal flexion ROM and noted an immediate improvement [123, 125].

Also, two more studies have found a significant increase in the ROM of the humerus joint after using the ischemic bandage [125, 126]. The use of the ischemic bandage has also been shown to have positive impacts on athletic performance. More specifically, the application of 2′ on the ankle joint brought about an improvement in jumping ability and in acceleration in 52 and 69 athletes, respectively, with this improvement being maintained for 45′ [127, 128]. Finally, a study performed in 2018 found that the use of the ischemic bandage had a positive impact on DOMS [129].

In conclusion, the muscle flossing technique seems to be a basic or additional treatment tool for the rehabilitation and prevention of sports injuries. Although it is a new technique that needs to be researched further, the ischemic bandage seems to improve the peripheral joints ROM, DOMS, and athletic performance.

#### **2.4 Cupping therapy**

The negative pressure massage technique involves the use of suction cups, which, when applied to targeted areas of the body, lead to myofascial decompression, in contrast to the adaptation observed during classic massage manipulations, when the soft tissue layers are compressed.

There are various techniques for applying cupping therapy. The most prevalent are the static application, which involves small incisions being made in the skin (wet cupping), and the dynamic application, which involves the suction cups being moved to adjacent tissues after application.

Theoretically, the effectiveness of the technique is based on the decongestion and suction of blood and other components that accumulate in deep tissues, the removal of which leads to increased arterial and lymphatic circulation and relief from painful muscle hypertension. During the application of this technique, the created negative pressure leads to the decompression of the myofascial area and the movement of blood and other components to the superficial tissues. This can help in pathological conditions in which congestion of inflammatory extravasations and toxins, such as deep accumulations of blood and swelling or the presence of myofascial adhesions and fibrosis and the presence of pain trigger points [130, 131].

The main mechanism behind the use of cupping therapy involves vascularblood adaptations. In particular, the decompression of the injured areas and the removal of inflammatory agents and blood can lead to a local increase in blood and lymphatic circulation and thus to better oxygenation and tissue metabolism [130]. Cupping therapy has also been associated with a decrease in pathological conditions, such as migraines [132] fibromyalgia [133], neck pain, arm pain and back pain [131, 133–135], and carpal tunnel syndrome [136]. The reduction of pain observed after the application of cupping therapy is based on the reduced irritation of the pain receptors due to the reduced concentration of edema and hematomas in the tissues [5].

In addition, local vasodilation can lead to increased parasympathetic activity and local muscle relaxation [130, 137]. It should also be noted that no research has shown negative adaptations in the human body due to the use of cupping [131, 138]. A study by Liu et al. to control the skin temperature after cupping therapy at acupuncture points in patients with neck pain showed an immediate rise in temperature after the suction cups were removed from the skin. Afterwards, the temperature decreased gradually, with the temperature returning to pre-treatment levels after 30 minutes [139].

### *2.4.1 Clinical applications of negative pressure massage (cupping therapy)*

#### *2.4.1.1 Static application*

For static application, suction cups are placed on the skin to create negative pressure for a period of 5–15 minutes, depending on the athlete's tolerance. The application is done without using an emollient. The patient will initially feel a superficial discomfort that will gradually change into a feeling of deep heat.

The application can be done for all areas of the human body as there are cups of many sizes.

Cupping therapy can be used either for pain trigger points or for an area of general sensitivity (e.g. back pain).

Local application can help move hematomas-swellings from deeper layers of tissue to the surface and is used in the treatment of muscle strains. This technique is applied in combination with stripping massage (using hands or IASTM tools) and is particularly effective in mobilising post-traumatic edema-hematomas.

Initially, cupping therapy is applied directly to the injured tissues to move the edema-hematomas to the surface. This is followed by deep massage applied from the periphery towards the centre of the body by hand or using special tools, such as the ERGON TOOLS. This step is performed to mobilise accumulations. The research by Fousekis et al. describes in detail the procedure that was used for an athlete with a hamstring strain, which reduced the recovery time by 50% [110].

#### *2.4.1.2 Dynamic application*

In addition, the local application of cupping therapy can be used in combination with stretching to increase elasticity. For example, to increase the elasticity of the

#### *Soft-Tissue Techniques in Sports Injuries Prevention and Rehabilitation DOI: http://dx.doi.org/10.5772/intechopen.96480*

IT band, 4–5 suction cups can be applied along the band, which allows the band to be stretched. Immediately after the removal of the cups, strong circular signs of ecchymosis appear on the body, pointing to the hyper-circulation of the area and a mild skin injury. Depending on the metabolism of each athlete, these signs take 2–7 days to disappear.

Cupping therapy is also used in combination with kinesiotherapy and simultaneous movement of the cups on the tissue. For example, to increase the elasticity of the hamstrings, the cups can be applied to the treated area, and while the athlete performs a self-stretch, the therapist moves the cup in the area.

Dynamic cupping therapy is becoming increasingly known for improving the elasticity of the injured area and improving the range of motion [140].

In the dynamic treatment, while the suction cup is being moved, it is necessary to use a special massage emollient. Immediate vasodilation leads to increased blood flow, which facilitates healing as well as lengthening and improving short muscle movement [139].

Research conducted to evaluate the elasticity of the hamstrings showed a significant increase in motion range of the hip and the knee via the SLR test, although the strength of knee flexion was not increased according to the tests performed on an isokinetic dynamometer [141].

Scholars have reported that cupping therapy is useful in reducing pain. A study by Fousekis et al. in 2016 demonstrated the effectiveness of cupping procedures in reducing pain in soccer players with painful trigger points in the lumbar area of the spine, with the participants showing an immediate reduction in pain and pressure sensitivity [98].

#### *2.4.1.3 Massage using cupping therapy*

Massage that involves the use of cups is gradually becoming more widespread in the treatment of myofascial problems in athletes. In addition, it is used as an aggressive approach to reduce swelling and hematomas. For the application of this type of massage, the use of emollient is required so that the cups can be moved smoothly.

The application is done by initially placing the suction cups upon the treatment area. When it comes to areas of intense spasms, suction cups can remain in static application for a few minutes (5–15) before being moved. The application for the reduction of edema and hematomas and their suction towards the surface of the skin can be done either locally as mentioned earlier or by movement. In the latter case, the application must be carried out in two phases, as is done in muscle stripping massage. The first phase involves placing the cups on the periphery of the injury and the moving the suction cups towards the centre at a very slow pace. The second phase involves applying the cups directly on the injured area and again moving the suction cups towards the centre in an attempt to move the deep hematomas and swellings to the centre and towards the surface.

### **3. Conclusions**

Soft tissue techniques have been used since ancient times for the treatment of various pathologies. Their goal is to promote health and wellness through the body's response to mechanical effects such as compression, sliding and decompression of tissues. Therapists apply various techniques either manually or with the use of tools to achieve therapeutic goals. Techniques are divided, depending on the goal, in appeasing and stimulating. Mechanisms activated during soft tissue techniques as well as the effects of the techniques on different pathological conditions have been

and still are being systematically researched. It is crucial for therapists to select the appropriate technique to evaluate and treat tissues. For this, good knowledge of the parameters of each technique is needed as well as setting specific treatment objectives such as improving elasticity, increasing ROM, reducing pain and spasm, and increasing athletic performance. Massage, ERGON IASTM TECHNIQUE, KINETIC FLOSSING and cupping therapy are commonly used for the rehabilitation of various musculoskeletal conditions. In order to achieve optimal results, these are often part of treatment protocols which include additional techniques and/or therapeutic exercise. All four have been proven to serve well either as basic or secondary treatment options for sports injuries prevention and rehabilitation.

More specifically, sports massage is beneficial before, during and after the game. Before the game, therapists apply specialized techniques to prepare muscles for the intense loads, especially on the limbs, or/and to prepare the central body (trunk) which constitutes the biomechanical basis for the initiation and proper execution of movement. During the game, sports massage mainly serves as psychological support for tackling competitive stress as well as for improving performance at the next phase of the game. Through stimulating aesthetic receptors, it reduces painful muscle tone and muscle excitability while at the same time improving the sense of physical recovery. Massage after the game increases blood circulation, reduces the feeling of fatigue, and muscle pain, reduces the intensity of DOMS in athletes and consequently contributes to faster and fuller recovery. Massage after the game has been found to lead to faster recovery of strength levels compared to passive movement therapy. It can also play an important role in repairing sports injuries through reducing the concentration of edemas caused especially when in combination with cupping therapy, and IASTM techniques. Finally, massage is particularly useful in scar tissue treatment and painful trigger points mobilization.

ERGON IASTM TECHNIQUE allows sports physiotherapists to detect abnormalities of the soft tissue such as scars, adhesions, restrictions, trigger points via the initial scanning procedure. Post injury, ERGON IASTM TECHNIQUE is effective in mobilizing edemas, in combination with aggressive soft tissue techniques, thus speeding up recovery time. It reduces the pain through local increase of the temperature and of tissue elasticity by minimizing adhesions. Its most significant contribution is the increase of elasticity. Research done at the Laboratory of Therapeutic Exercise and Sports Rehabilitation at the Department of Physiotherapy of the University of Patras, Greece, has shown the technique's effect in elasticity increase throughout an entire myofascial line/meridian in cases of application only in one of its parts. Lastly, ERGON contributes to the restoration of biomechanic function in combination with therapeutic exercise.

KINETIC FLOSSING is a relatively new soft tissue mobilization technique showing multiple benefits for musculoskeletal rehabilitation. Therapeutic mechanisms include hemodynamic and biomechanical adaptations. Its effects include increasing ROM, enhancing athletic performance, and reducing DOMS.

Cupping Therapy is a well-known technique used from ancient times in many cultures which utilizes negative pressure for soft tissue decompression as well as mobilizing blood and superficial tissues. Its clinical value lies in drawing hematomas-edemas from deeper layers of tissue towards the surface and removing these in combination with other forms of aggressive soft tissue techniques. In addition, cupping therapy increases elasticity of tissues and improves ROM of injured joints, and contributes to pain reduction.

*Soft-Tissue Techniques in Sports Injuries Prevention and Rehabilitation DOI: http://dx.doi.org/10.5772/intechopen.96480*
