Terra Rosa e-magazine, No. 13 (December 2013) 15

FFT® Est. Since 1994

Distract Tissue and Apply Load.

FFT® is a rapid and effective way to decrease pain, as-

sist function and allow rehabilitation to commence in a

pain free environment. Clinically, FFT can be used to

determine Soft Tissue Dysfunction in the muscu-

loskeletal conditions with a high degree of accuracy.

This article will discuss the overview and results of a

research project on the effects of FFT on non-specific

low back pain which was the subject of Shu-Mei Chen’s

PhD at Deakin University and was supervised by Pro-

fessors Jill Cook and Sing Ky Lo. Shu-Mei Chen and

Ron Alexander were the clinical investigators and the

outcome assessor was Shu-Mei. This study was pub-

lished in the Journal of Clinical Rehabilitation October

2012(1).

Background

Non-specific Low Back Pain (NSLBP) is a common

musculoskeletal disorder with a high lifetime preva-

lence and high rate of recurrence.(2) Pain can hinder

movement and disturb neuromuscular activity and mo-

tor control and thus affect function.(3) Individuals with

chronic pain can experience further disability due to

psycho-social problems that result in personal and so-

cietal economic burdens.(4) Limiting pain in magnitude

and time is therefore likely to minimize or reverse the

negative consequences of NSLBP. After an acute low

back episode 90% of people will get better after 6 weeks

regardless of treatment, 10% will go on to have pain for

12months. Patients cannot be given a clear diagnosis

and do not present with signs on imaging. Eighty-five

percent of back pain patients fall within this group.

How is FFT different to other taping tech-

niques?

The taping has 2 components - Assessment and Appli-

cation (5). The assessment procedure follows the stan-

dard clinical processes of test, intervene and re-test.

This procedure is guided by the patient’s symptoms

and allows for continual reassessment as symptoms

decrease. This test has pain specific direction variabil-

ity. The assessment intervention is performed in the

pain provocative position and is determined by the op-

timal direction of ease. It is a systematic process dis-

tracting the skin and underlying tissue, with a graded

tangential force directly over the pain. This is similar to

the approach of Andrew Taylor Still (1828-1917), the

founder of Osteopathy. Then whilst still in that range

and with positive change, we observe if an increase in

range is possible. The right direction takes in a number

of factors and multiple vectors can be used.

Tape application aims to create a graded load (tension)

to tissues and employs a gathering technique to directly

tighten the skin and the tissue below to change the tis-

sue slack and to possibly affect the deeper structures.

The rigid tape width is half the standard size of 38mm,

halving it makes the tape tighter. This comes about by

decreasing area, which increases force and creates

more pressure, in this case the pressure is tension. Re-

sulting in greater load on the tissues, this aims to offer

a specific vector force away from the pain, in the direc-

tion predetermined by the assessment. The application

may sound like it may decrease range of motion, how-

ever it does not, and it actually has a fascilitory effect

on range in most cases. After these 2 stages are per-

formed patients/athletes have pain relief and tension/

load to tissues during daily activities or exercise for an

extended and predetermined period of time.

Functional Fascial Taping®

Research By Ron Alexander

Terra Rosa e-magazine, No. 13 (December 2013) 16

Research Methods

This pilot study design was a randomised, placebo-

controlled trial comparing the effect of FFT with Sham

Taping or Control Group during a 2-week intervention

with 2, 6, and 12 week follow-up.

Forty three participants were recruited from the gen-

eral population, with a flexion deficit. All baseline char-

acteristics were similar within and between the groups

FFT (n = 21) and Sham/Control (n = 22). We used what

is considered to be the best prognostic measures for

investigating Low Back Pain (LBP) which was the result

of a systematic review conducted by Shu-Mei and later

confirmed from a presentation by LBP expert Professor

Bogduk at a Melbourne Conference. The study had 2

people in both groups drop out in the first 2 weeks and

a further 2 in the FFT group within 6 weeks.

The treatment procedure was standard between the 2

groups except for how the rigid tape was applied. Lum-

bar flexion exercises were given in the 2nd week and a

manual for skin care was provided to all participants.

Both groups were treated 4 times over a 2 week period.

Patients were to keep the tape on and was tightened

daily. After 2 weeks the tape was removed.

In treatment sessions 2, 3 and 4, the patients in both

groups went into trunk flexion, in the pain provocative

position and the same tape procedures as in session 1

were applied. The results from the study are far too

detailed for this article, so an overview will be provided.

Results

We used a statistical analysis called ANOVA (Analysis

of Variance), to observe the results of a number of the

prognostic indicators for LBP. The analysis looked at 5

repeated measures to detect change in pain and func-

tion, within and between the treatment groups, over

the duration of the study, expressed as an effect size

and compared with baseline (start of the project). The

measures were used so we can confirm our findings/

data a number of times. The results from the study

showed the FFT group demonstrated significantly

greater reduction in worst pain compared to the control

group after the 2 week intervention. The study was set

so that the p-value had to show less than a 0.05 for

clinical significance (meaning that there is less than 5%

probability of getting a no effect). At the end of the trial

the p-value result was 0.02. This number indicates that

2% of the time change may have occurred through

chance with a 98% certainty that it was the interven-

tion (FFT) that had created change. The study was also

set to show a greater than 0.5 effect size (a measure of

the strength of the treatment) for clinical significance.

The result was 0.74 which means that the effect from

FFT is very large and a powerful treatment. There were

an additional 2 measures to test our findings, both of

which confirmed that FFT was clinically significant for

reducing worst pain.

The same ANOVA analysis was applied to the modified

Oswestery disability index questionnaire [mODI] to

observe change in function. Although the data showed

higher numbers in the FFT group, it was not clinically

significant. The results from this data may have been

underpowered at this stage due to the dropouts. If we

had better adherence to treatment or if we had higher

number of participants, we believe that greater change

would have occurred and been detected. There were no

significant differences between the 2 groups in relation

to average pain at any time periods.

The study also looked at pain intensity, function and

used a calculation called Minimal Clinical Important

Difference (MCID). Although the name uses the word

‘minimal’, it’s actually an important calculation and

used in various research projects. For example, if a pa-

tient presents with 7/10 pain and after treatment the

symptoms are reduced by more than 2, so less than

5/10, this means that they have attained MCID, i.e. in-

tense pain reduced to comfortable pain. In order to

confirm clinical relevance the study had to show less

than 0.05 p-value. The data showed that in the FFT

Group, 17 people attained and 4 did not attain MCID.

Within the control group, 9 attained and 11 did not.

Therefore a higher proportion of patients in FFT group

attained MCID in worst pain [0.007 p-value] and func-

tion [0.007 p-value] than did those in the control group

after the 2-week intervention.

FFT Research

Sham/Control, Session 1

- Sit, pain provocative position.

- Measure pain region, sham calculations

performed, patients potentially

thought the procedure looked technical.

- Apply white and rigid tape, by placing

tape over the measured area.

Rigid Tape ½ width wide.

FFT Group, Session 1

- Sit, pain provocative position.

- Assessed tissue directionally specific.

- Apply white and rigid tape ½ width

wide, FFT gathering technique.

- 2nd week flexion exercises.

Terra Rosa e-magazine, No. 13 (December 2013) 17

Why did the 4 dropouts occur in the FFT Group? One

patient had soft tissue pain reduction which revealed

an underlying osseous pathology which required sur-

gery. One person thought they were in the placebo/

sham group and dropped out and 2 patients got better.

These 2 learnt how to apply FFT and dropped out. The

Principal Supervisor Jill Cook, explained that their data

was to be recorded as a nil result and had to stay in the

data. This was because the intention to treat analysis

had been used, which meant that anyone who enters

the study and drops out for any reason must be re-

corded as nil or no result from either taping group. On

the day that the 4th person, dropped out (2nd pain free

patient), I went for a nice long walk.

Taking the focus away from patient compliance for a

moment and looking at those who remained in the

study, we can look at what was truly happening. Of the

people who stayed in the study, we had in the FFT

group 17 people out of 17, or 100% who attained posi-

tive MCID. The result for the control group was 50%.

Even with the dropouts we have still shown an amazing

result at 0.007 p-values for both pain intensity and

function. This score means that if the project was re-

peated 1000 times then a similar result would be

achieved for 993 times. Clinically for practitioners this

indicates that by decreasing pain we increase function.

We can confidently state that this was a real effect and

not simply a matter of chance . Over the following

weeks the patients within the FFT Group continued to

show the same consistent results, however the control

group started to show improvement. This can be the

natural occurring effect due to patient expectation to

treatment. Even with the tape being placed on the body

we would have proprioceptive input and subtle load,

especially when they moved into truck flexion. (For

more information about the role of placebos in re-

search, see an article by Bianca Nogrady, Placebos

more effective than mere sugar pills. www.abc.net.au/

health/features/stories/2013/11/11/3888346.htm)

Discussion

In clinical practice we know that NSLBP is a complex

musculoskeletal condition and that it can be multifac-

torial in nature. As clinicians we need to know if indi-

vidual treatments are effective as well as when to use

these. In this study, we looked at FFT and trunk flex-

ion, in a normal practice, of course, you would be using

other treatments and thus potentially achieve better

results. Numerous reasons can contribute to NSLBP

such as computer set up, smoking and psychosocial

factors etc. Whilst NSLBP evidence based treatments

are lacking(6), massage(7,8) has been shown to be effec-

tive however this is limited to the hands on session.

FFT allows the treatment to work for a longer period of

time. I am definitely not saying that we don’t ever need

to do massage/soft tissue work, however clinicians can

be more effective by incorporating FFT as it can be left

on for hours and reapplied for days or weeks if need be.

The data from this study demonstrates that a window

of opportunity is created by the use of FFT. The patient

experiences a rapid decrease in pain and an increase in

function, the patient is encouraged to go back into the

previous pain range and this potentially creates de-

creased apprehension of pain. This elevates the pa-

tient’s mood and speeds recovery because you can start

rehabilitation earlier than is usually the case. An addi-

tional benefit is that the rehabilitation is being per-

formed in a pain free environment. It may also now

provide an opportunity to refer patients who have other

contributing factors that are out of the scope of Manual

FFT Research

FFT treatment group in session 2. Sham treatment group in session 2.

Terra Rosa e-magazine, No. 13 (December 2013) 18

Therapists, as the patient may be more receptive to

change.

What could be happening to the body?

It is still not a thorough understanding of the mecha-

nism by which any taping technique creates change(9).

Our hypothesis for this study was limited to what could

be taking place physiologically. The FFT assessment

procedure has pain specific direction variability, which

may indicate the Neuro-Fascial Interface. This may

stimulate large-diameter afferent fibres and then

modulate nociceptor input (Gate control mechanism).

The load from tape could potentially change the sliding

of fascial tissues relative to tissues next to them. The

load from the tape may also potentially affect the skin

and/or remodel the internal architecture of connective

tissue(9,10), this may include changing mechanoreceptor

activation(11). This hypothesis was supported by a paper

on Motor Synchronisation that investigated the knee(12), the same principles can be translated to the back.

Further research to investigate the potential mecha-

nisms of how FFT could affect pain perception is re-

quired.

We conducted an interesting experiment this year at

the AAMT conference. Let me explain as some of you

may have taken part and not realized it. I presented

FFT at the AAMT conference in Adelaide, May 2013. I

also presented twice a 3 hr workshop at the Conference

and we had 60 people in each. I presented a lecture,

followed by a demonstration and then taught everyone

the elementary steps of the technique. I then had par-

ticipants do an unbiased neural tension test in the arm,

because not everyone is going to have a positive neural

tension test and I wanted them perform an objective

exercise. Most therapists are Neuro-Fascially tight in

the arms because of the way they work. From experi-

ence I know that this test produces some pretty obvious

Neural-Fascial Symptoms, in asymptomatic people and

we can observe a decrease in pain and an increase in

range. If anyone didn’t have discomfort doing this they

were to choose an area in their hypermobile body (one

or two in every crowd) that either produced pain or was

uncomfortable. Each person had 20 minutes to per-

form the assessment and tape application. After the

second workshop, 120 people had performed the exer-

cise. Of these 120 people, 100% had experienced a de-

crease in symptoms and an increase range of motion.

This exercise was repeated at the World Congress on

Low Back and Pelvic Pain, in Dubai October 2013, on

48 people with 100% result. Our data from our RCT on

FFT for NSLBP supports what we had observed at the 2

Conferences and is confirmed at almost all FFT work-

shops. These consistent results indicate that the effect

from FFT is predictable, in that you can have an effect

in a large number of cases. Although there are situa-

tions where it doesn’t work, it is evidence-based, it is a

relatively simple technique and it provides immediate

results.

References 1. Chen SM, Alexander R, Sing KL,Cook J. Efficacy of Functional Fascial Taping on Pain and Function in Patients with Non-Specific Low Back Pain: A Randomised Controlled Trial. 2012. Pub Clin Re-hab Oct 2012 Vol 26, No. 10. 924-933.

2. Pengel LH, Herbert RD, Maher CG, et al. Acute low back pain: systematic review of its prognosis. BMJ 2003; 327: 323.

3. Swinkels-Meewisse IE, Roelofs J, Verbeek AL, et al. Fear avoid-ance beliefs, disability, and participation in workers and non-workers with acute low back pain. Clin J Pain2006; 22: 45–54.

4. Penny KI, Purves AM, Smith BH, et al. Relationship between the chronic pain grade and measures of physical, social and psychological well-being. Pain 1999; 79: 275–279.

5. Alexander R. Functional Fascial Taping. 5th International Olympic Committee World Congress on Sport Sciences with the Annual Con-ference of Science and Medicine in Sport 1999 Sydney. Book of Ab-stracts P 36.

6. Beurskens A.J, De Vet HC, Van der Heijden GJ, Knipschild PG, Köke A.J, Lindeman E, Regtop W. Efficacy of traction for non-specific low back pain: a randomised clinical trial. The Lancet 1995 Vol 346, Iss 8990, 1596–1600.

7. Tsao JCI. Effectiveness of massage therapy for chronic, non-malignant pain: A review. 2007. Vol 04,2,165-179.

8. Kumar S, Beaton K, Hughes T. The effectiveness of massage ther-apy for the treatment of nonspecific low back pain: A systematic re-view of systematic reviews. 2013, Int J Gen Med. Sep 4;6:733-741.

9. Ingber DE. 2008. Tensegrity-based mechanosensing from macro to micro. Prog Biophys Mol Biol. 97:163-179.

10. Langevin HM, Storch KN, Snapp RR, et al. Tissue stretch induces nuclear remodeling in connective tissue fibroblasts. Histochem Cell Biol 2010; 133: 405–415.

11. Grigg P and Del Prete Z. Stretch sensitivity of cutaneous afferent neurons. Behav Brain Res 2002; 135: 35–41.

12. Macgregor K, Gerlach S, Mellor R, Hodges PW. 2005. Motor syn-chronisation. Cutaneous stimulation from patella tape causes a dif-ferential increase in vasti muscle activity in people with patel-lofemoral pain. J Orthopaed Res. 23:351-358.

Ron Alexander is the Director/Founder

of the Functional Fascial Taping Insti-

tute. FFT was refined over eight years

service as the Principal Soft Tissue

Therapist [Musculoskeletal] for The

Australian Ballet. During this time he

was awarded the Lady Southey Schol-

arship for Excellence from the Austra-

lian Ballet Foundation. More recently he was a co-

investigator of Randomised Double Blind Placebo

Controlled Trial of FFT for Non-Specific Low Back

Pain (PhD) Deakin University, Melbourne, Australia.

Ron has an interest in chronic pathologies, continues

to research the effects of FFT.

Read 6 Questions to Ron on page 50.

FFT Research

Terra Rosa e-magazine, No. 13 (December 2013) 50

1. When and how did you decide to become a bodyworker?

In my early 20's I had back pain from playing Aussie Rules

Football [Country League] so 'running it out' was the treat-

ment of choice by the coach but now I know that this was not

the answer and my posture needed attention. I saw a Doctor

and he recommend NSAID's and I knew that other older guys

at the club were using them for a long time and they still had

their pain condition. My mother suggested a Naturopath who

worked out of a caboose in Tarnagulla Central Victoria and

had legendary stories of amazing results. She treated my back

and neck, with techniques that were similar to what I later

learnt to be like Bowen Techniques. This completely changed

my discomfort and I was light headed from the treatment or

from the painful experience. She was talking about massage,

that you can make a career out of helping people, athletes and

work with sports clubs. It sounded really interesting and after

doing more research, I enrolled 3 months later in a two year

course at the Southern School of Natural Therapies.

2. What do you find most exciting about bodywork therapy?

There are numerous things. One of them is the various ex-

periences that you can have in this profession such as work-

ing for athletes and performers. When I worked for the Aus-

tralian Ballet, I got to travel and was part of an excellent

Sports Medical Team. This was a great learning experience as

knowledge was shared so I was exposed to a world bigger

than massage, which gave me a much greater understanding

of the body and how to treat it. The sheer volume of dancers

and the environment provided the impetus to experiment

with treatments to get the dancers out on stage and this

where FFT came from. So being able to develop something

new was very exciting and I am still excited by that today. A

patient can present with something that sounds very compli-

cated and has been there for a long time and no-one else has

changed the condition that I am able to affect it with FFT.

This still excites after all these years and it keeps me moti-

vated.

3. What is your most favourite bodywork book?

Sorry I cannot choose just one, but I can limit it to two. Years

ago Job’s Body by Juhan. It gave me a great understanding of

how the fascia has a big role to play in the body and should be

used as one of the basic texts for all Bodywork courses. In

more recent years Explain Pain, by Butler and Mosely. It is

written in simple language, although it discusses quite com-

plicated concepts and can even be given to chronic pain pa-

tients. So you should have more than 1 copy!

4. What is the most challenging part of your work?

Long flights to present FFT.

5. What advise you can give to fresh massage therapists who

wish to make a career out of it?

Be good to your patients, be good to your referrals and you

will do alright. Dream, believe, achieve, and succeed. It

works.

6. How do you see the future of massage therapy?

Where we have come from and where we are at now, the

transformation is amazing. The Australian Bureau of Statistcs

has identified massage as a growing industry. Over time it

will become an even greater part of mainstream medicine.

This translates to more people being able to make good ca-

reers within the industry. I think we have started to evolve

into the medical model and thank God away from the sex

industry. I think the Medical model is also changing and

some accepted that they are not able to provide all the an-

swers and are willing to try alternatives. I think people in this

digital world are exposed to so much information and so

quickly, that not only are we more informed as practitioners

but so are the public and that can have great benefits. For

example making more insurance companies change policy to

suit customer preferences. This combined with pressure from

Massage Associations has had a big influence on us as an in-

dustry.

I also see evidence based massage becoming the way forward.

I think as we increasingly value education and make efforts to

improve the quality of education, research will follow. We

need to more closely align ourselves with Universities in or-

der for this to happen. As the Quality research is very impor-

tant for our industry as it will give credibility to what we

know clinically to be true. This will translate to publishing

findings, not just in peer review journals but ones widely read

by other industries. This will be one of our greatest ways of

having the biggest impact. However as far as research goes if

we stay doing what we are currently doing we will still be at

the same place in 10 years. Our RCT is only the 2nd in Austra-

lia's history within our industry to be completed and pub-

lished. I find this very surprising in such a progressive coun-

try as Australia.

6 Questions to 6 Questions to 6 Questions to

Ron AlexanderRon AlexanderRon Alexander