The Art of ART

January 29, 2015
Since discovering Active Release Techniques (ART), this author has learned to better assess soft tissue injuries and expedite return to play.
By Bradley Pike

Bradley Pike, ATC, PT, PES, is the Head Athletic Trainer and Director of Rehabilitation Services at Syracuse University. He is also the Owner of Championship Physical Therapy in Syracuse and can be reached at: brpike@syr.edu.


All athletic trainers have been there: An athlete with chronic pain that just won't seem to dissipate completely. For me, it was just last year when a male rower came into our athletic training room at Syracuse University complaining of chronic lower back pain on his right side. Though he was able to complete all required rowing, long sessions were resulting in significant pain.

It wasn't severely affecting his performance in competition, but it had come to the point where the rower's pain was consistently lasting longer into the evening with each successive practice until he had low back pain all the time. I assessed the rower and noted lumbar dysfunction and associated multifidus atrophy.

The next step was figuring out how to get him pain-free and back to full functionality as soon as possible. Conventional care of heat, ice, electrical stimulation, stretching, and re-strengthening exercises provided some relief, but the condition was not remedied. What other modes of care could possibly be used?

Enter Active Release Techniques (ART), a patented soft tissue mobilization system steadily gaining in popularity throughout the sports medicine profession. ART is a treatment approach designed to give clinicians the ability to assess and treat soft tissue injuries. In a nutshell, the technique allows the clinician to identify what is impaired (muscle, nerve, tendon, or fascia) while providing expedited relief of the soft tissue restriction.

In my 25 years as an athletic trainer, I have never used a technique that has had more immediate results and better functional outcomes than ART. This is a treatment system that shows no signs of going anywhere but into more athletic training rooms in the years to come.

DISCOVERING ART
A few years ago, I was seeking different ways to add to my "tool box" of care for the athletes at Syracuse. When speaking about treating athletic injuries with my professional colleagues, ART was becoming a more frequent conversation topic.

For example, Denny Kellington, ATC, Head Athletic Trainer for Football, was a new addition to the Syracuse athletic training staff in 2005. During internships with the Denver Broncos Denny had some firsthand exposure to ART with its creator, Colorado-based chiropractor P. Michael Leahy, DC, CCSP. Denny explained the positive results Dr. Leahy would see after applying the technique to the players on the team, including the resolution of flexibility restrictions due to muscle strain and reduced swelling from various injuries.

Then, during the 2005-06 men's basketball season, I witnessed ART's effects firsthand when our best player suffered a groin strain. I tried many different treatments and was able to reduce his symptoms enough so that he was able to play at 80 percent. This was a huge improvement of course, but I needed something to help resolve the remaining 20 percent.

A local orthopedic surgeon and Syracuse alumnus called and asked me if I had considered ART. He told me he had seen positive functional outcomes by referring some of his patients for ART treatments. I sought out Dale Buchberger, MS, PT, DC, CSCS, DACBSP, a Syracuse area chiropractor and physical therapist who has been certified in ART for many years and served as an ART instructor. Dale assisted me in caring for our basketball athlete by evaluating him, helping me come up with a new outline for his treatment, and performing ART treatments on him.

Following just one ART treatment, we saw the player's functional movement improve. Subsequent ART treatments, along with a core activation and stabilization program, helped the athlete regain that last 20 percent of function. I was immediately impressed and started looking into making ART an additional mode of care I could incorporate into my repertoire.

HOW DOES IT WORK?
ART is a soft tissue management system that has been developed over the past 25 years by Dr. Leahy. He noticed early in his career that many of his chiropractic patients' symptoms seemed to be related to changes in their soft tissue. By experimenting with how his patients' muscles, fascia, tendons, ligaments, and nerves responded to specific soft tissue manipulation techniques, he came up with different muscle, ligament, and nerve entrapment protocols that make up the ART system.

ART can resolve or offer relief from many common conditions in athletes, including tendon strains and ligament sprains, by restoring normal ligament mobility and elasticity. Scar tissue and muscle adhesions that restrict mobility and elasticity are the body's normal response to a soft tissue injury, and through ART, they can be broken down to prevent or reduce hindrance to range of motion, strength, and function. For muscle strains, ART can help with the sliding that occurs between the impaired muscle and its adjacent tissue. Nerve compression injuries, which can become disabling to an athlete and often result in surgery, may be treated through ART as it assists in the reduction of nerve entrapment.

The length of an ART session is dependent on the number of ART protocols a clinician chooses to employ. A typical treatment session lasts an hour. The ART portion typically lasts 10 to 15 minutes, and the rest of the time is spent on the application of moist heat or ice, flexibility and range of motion work, and/or strengthening exercises. I like our athletes to warm up (preferably actively) and work on some flexibility, then I administer the active release protocols. Warming up first allows for the reduction of adhesions and remodeling of the scar tissue before the ART portion so strengthening and functional training can be more efficient.

There are more than 500 ART protocols, including 13 different contact methods. Contacts range from a single thumb--the most common contact--to all five fingers. For more consistent tension, the clinician may use the opposite hand as backup support.

After determining the depth of the tissue, the clinician applies tension to the athlete's muscle, tendon, or ligament, and the athlete either moves through active range of motion or is assisted passively through that motion by another person. This is known as a "pass," and the number of passes is directly correlated to the size of the area. A typical soft tissue injury requires three to fives passes. The degree of tension application is determined by the depth of the tissue and the type of tissue being treated. Fascia requires more tension and nervous tissue requires less. The clinician must be careful to not provide too much tension to the tissue to avoid compressing it, thereby restricting active or passive movement of the muscle.

ART is also used as an assessment tool. In fact, a typical ART session is a combination of assessment and treatment. First, the clinician uses his or her hands to evaluate the texture, tightness, and movement of muscles, fascia, tendons, ligaments, and nerves. When scar tissue or muscle adhesions are detected, the clinician uses specific movements and directs tension accordingly to break it up.

In addition to being used as part of an evaluation and treatment plan, ART can also be used for maintenance or as a performance-enhancing tool. ART tends to be most popular among track and field athletes and triathletes because of their rate of overuse injuries.

For athletes especially, an ART session should be conducted before a workout whenever possible. It is very important that some type of activity, whether it is a strength training session, team practice, or a game, be completed after the ART session because it helps facilitate the improved range of motion realized through treatment.

Positive results can be expected immediately following an athlete's first ART session. Results could range from a reduction in pain to increased range of motion and flexibility. Over time, many athletes also see strength gains as a byproduct of ART. By releasing the muscles of any scar tissue or adhesions, they can be activated more efficiently and strength training is less painful.

CERTIFICATION PROCESS
There are three ART certification courses: spine, upper extremity, and lower extremity. A clinician can be certified in one, two, or all three areas, and the courses can be completed in any order. If you care for your school's track team, it would be prudent to obtain the lower body ART certification first. If you care for your school's baseball team, then perhaps upper body ART is the first course to take.

Each certification course consists of a three- to four-day hands-on module. Dr. Leahy attends every course and participates in the trainings as an instructor and resident expert. All instructors are full body certified (have attended all three ART certification courses). ART courses are held monthly throughout most of the United States, Canada, Europe, and East Asia.

There are many highlights to the certification courses, including the teaching method. The protocols are initially taught to the entire group, which ranges from 45 to 90 people, then the class is broken down into small groups of six to eight students and two instructors. The protocol is reintroduced in this small group setting and the technique is reinforced through repetitive practice.

One of the biggest skills instructed and emphasized in the courses is the palpation skill or "touch" of the clinician. The development of the clinician's touch is paramount in assessing soft tissue and making the correct diagnosis before developing the appropriate treatment outline. Discussions between the different disciplines (chiropractors, athletic trainers, physical therapists, and massage therapists) attending the course are plentiful and helpful in this area.

Certifications last for one year, so each clinician at any level of certification needs to recertify annually. There are special sections available in the spine and extremity courses for clinicians who are recertifying. These clinicians typically only attend 12 hours of the three- to four-day course for recertification.

Full body certified clinicians are afforded the opportunity to enhance their knowledge through additional classes, including a biomechanics course and/or a nerve entrapment course. Though these additional courses are not required, they are extremely helpful in becoming proficient in the assessment and treatment of impaired soft tissue. I have taken the nerve entrapment course, and it changed the way I evaluate upper and lower extremity issues.

If a clinician has full body certification, he or she can recertify through a Master's course or take an online course. I have participated in both courses and found them to be valuable. During a Master's course, the clinician spends a few hours with Dr. Leahy in a small group setting, and the online course is streamed live from corporate headquarters in Colorado and allows time for questions and answers.

The only potential downside to the ART certification courses is the cost, as each one is $2,100. I was fortunate to have the support of Tim Neal, MS, ATC, our Assistant Athletic Director for Sports Medicine, who developed a proposal to get our full-time staff members certified in ART and submitted it to the administration. Our Athletic Director, Dr. Daryl Gross, recognized the added benefit, and our staff began the ART certification process.

GETTING RESULTS
ART has improved my soft tissue assessment and evaluation skills and made me more proficient in anatomy. The technique has allowed me to effectively evaluate injuries and differentiate between tendon pathology and nerve root adherence or compression within the muscle.

Prior to my ART training, I followed standard evaluation protocols and would assess range of motion, ligament integrity, strength, any tenderness, and functionality. But since I have become ART certified, I take much more time evaluating soft tissue. I appreciate the texture of tissue, ligament mobility, and whether the muscles are sliding appropriately. For example, nerve compression injuries frequently mimic muscle strains or overuse injuries, so nerve gliding and nerve root impingement testing are always included in my exams.

My treatment and rehabilitation protocols have become more functionally based and efficient, and time-loss injuries have even been reduced. Overall, my ART certification has assisted me in providing a higher level of hands-on care for our athletes at Syracuse.

Do you remember the rower at the beginning of this article? I implemented ART into his treatment plan and we saw great results. In addition to chiropractic care and a strengthening program, I used ART protocols to work on his flexibility restrictions and the muscle gliding issues he was experiencing in the multifidus, piriformis, hamstrings, psoas, and iliacus. I also used ART on the dorsal sacral ligament and sacrotuberous ligament to address his mobility issues.

With the exception of the psoas and iliacus, which are treated with a broad, soft-finger contact, I mostly treated with a single thumb contact. In this approach, the muscle to be treated is shortened, tension is applied, and the athlete actively moves in the opposite direction to lengthen the muscle.

By the end of the season, about 10 weeks after we started ART, the rower was no longer experiencing lumbar dysfunction or associated multifidus atrophy. He was able to row symmetrically without listing to the side. And most importantly, he was pain-free.

To learn more about Active Release Techniques, visit:
www.activereleasetechniques.com.