---------- **The Dynamic ArthroMyofascial Translation® Test (DAMT®Test). (4xT®Method the ArthroMyofascial Therapy: Chapter 2)*1*.** ======================================================================== Author: Karl Noten, BSc, Physical Therapist, Fysio Physics Group International, IJsselstein, The Netherlands, karl.noten@fysiophysics.nl ***Background*** In Physiotherapy, fascial tissue interventions are used for treating musculoskeletal pain, such as myofascial release techniques (MFR), myofascial trigger-point interventions, elastic tape interventions, and exercise. During these interventions, it cannot be denied that there is contact with the skin. The skin and fasciae glide in various directions during joint movements. Stiffening of fasciae influences the myofascial force transmission, consequently, this influences muscle-and joint mechanics. Noten developed the 4xT method® (4xT®) based on fascial mechanics, which is a multi-interventional approach using a specific decision tree as main goal to guide the therapist in choosing the best possible interventions, the right location, direction, and intensity of the selected intervention. The four Ts utilized in this decision tree refer to: T1 Testing (DAMT®Test), T2 Triggering (interventions), T3 Taping (Elastic Tape), and T4 Training (exercises) *(2, 3)*. The decision-making in the 4xT® is done by utilizing a Fascial Diagnostic Test: The Dynamic Arthro-Myofascial Translation Test® (DAMT®Test) in a test protocol. The DAMT® Test is a therapeutic diagnostic test, developed and first described by Karl Noten & Marco Schuurman-Stekhoven *(4)*. The DAMT®Test consists of a manual skin-fascia translation (MSFT®Maneuver) during joint motion and evaluates the effect of MSFT® Maneuver on joint range of motion and associated pain level. The DAMT®Test is also described by Noten as a ‘navigation system’ for the therapist: The Fascial Navigation System. Utilizing this test enables the therapist to select the best option for the treatment at this very moment to determine the best: - Intervention (treatment) - Location of this intervention - Direction of this intervention - Intensity of this intervention (in Maitland's Grading Scale *(5)*) Also, the EasyTaping® Method of Fysio Physics *(4, 6)*, a fascial taping method with elastic therapeutical tape, describes a step-by-step treatment plan, using the DAMT®Test. ## The Dynamic ArthroMyofascial Translation® Test ## **What is the characteristic of this test?** The DAMT®Test is a novel diagnostic test to examine the influence of the fascial system on joint/muscle mechanics and kinematics, and pain modulation to determine the interventional location and direction. The test is easy to learn and easy to use. The translation of the fasciae is in specific directions which should result in obtaining the ‘positive direction’. The intensity of the MSFT®Maneuver, vary in the range from ‘into the slack’ (grade 3) till ‘beyond the slack’ (grade 4). This is equivalent to the Maitland's passive tissue stretch grading scale *(7, 8)*. The so-called ’positive direction’ is the direction with a positive impact on the patient’s mobility and pain and is also the direction of the therapeutical interventions on the tested location. **How is the DAMT®Test applied?** The DAMT®Test is described for various musculoskeletal disorders in the 4xT® protocols for low back, pelvis, hip, knee, ankle, neck, shoulder, elbow, and wrist, developed by Noten *(3)*. The DAMT®Test is performed by shifting the fasciae. Herewith several rules are to be observed: - Location: According to the 4xT® Algorithm it starts with the DAMT®Test. The test can be done at any location of the body. In the 4xT® Methods, various specific locations are described in a step-by-step protocol (4xT® Method treatment protocol) like crossroads on a roadmap. - Direction: In principle, the DAMT®Test can be carried out in all directions on the body. Both the protocols of the 4xT® Method and Easy Taping® Method describe specific directions, however, the most frequently used directions are: 1. Horizontally, horizontally to the left and right 2. Vertically, upward, or downward 3. Circularly back or forth 4. Spiral movement: upward + in- or outward; downward + in- or outward - Intensity: The translation during the MSFT®Maneuver is carried out to stretch the fasciae just beyond the first resistance of the fascia (Maitland grade 3) or until the end of the fascial slack (final resistance, Maitland grade 4). The distinction can be made between grade 3 or grade 4 intensity to predict the best intensity of the techniques to be applied. The DAMT®Test is the Fascial Navigation System to know which direction to go in the fasciae: choosing the right way on the crossroads of ‘the body's roadmap’. **How is the DAMT® Test used practically in the 4xT® Method?** **Step 1.** Baseline test: describe and rate the patient’s symptoms at rest (pain, discomfort, stiffness). **Step 2.** Basic functional tests: determine the provocative versus the POSITIVE JOINT-MOVEMENT DIRECTION. The patient makes a movement and the therapist measures, describes, and documents the: - Range of Motion (in objective criteria: grade, cm, inches) - Level of symptoms experienced (pain/discomfort/stiffness NRS) - Location of the experienced symptoms. **Step 3.** DAMT®Test (translational testing): determine the effect of fasciae translation on the movement: repeat the PROVOCATIVE MOVEMENT while performing the MSFT®Maneuver by shifting the fasciae (superficial or deep) in one direction. Repeat the movement while performing the MSFT®Maneuver in another direction. **Step 4.** Conclusion: the translation direction with the most positive effect on the symptoms, is the POSITIVE TRANSLATION DIRECTION (for the tested location). **Treatment plan:** perform the treatment ON the positive tested location IN the positive direction. *Unique in this approach is that not the ‘blockage’ in the joint or muscle tone found by the therapist is the guideline for the therapeutic intervention, but the positive location and direction found by using THE DAMT®Test. In other words: not the therapist decides, but the fascial system.* ---------- ## Example application DAMT®Test utilized in the 4xT® Back Protocol for patients suffering from back pain *(2)* ## ## **4xT® Back protocol** ## Subjects: low back pain (specific, aspecific, acute, and chronic) **Personals :** **Intake** - ***What*** (are the problems) : - ***When*** (do they occur) : - ***Where*** (are the symptoms) : - ***How*** (did they start) : **Basic Reference tests** - Trunk flexion: bend forward with arms hanging in front - Trunk extension: bend backward with hands placed on the pelvic (note: no active pelvic tilt because this makes the test 'false positive'!) **Flexion & Extension reference test**![enter image description here][2] If the basic reference tests do not provoke any pain or discomfort, the spare tests could be utilized instead. **Spare tests** - Lateral-flexion to the Left or Right - Axial rotation Left or Right - Patient-specific motion **Clinimetrics/Assesment** **Table 1.** Trunk movements![enter image description here][3] **Conclusion:** Which reference test causes the biggest problem/discomfort (= provocative direction): - Positive direction o Flexion o Extension o Others - Provocation direction o Flexion o Extension o Others Note (!): The patient decides and not the therapist! The next step is to determine the positive direction of the fascia with the MSFT®Maneuver during the provocative movement (DAMT®Test). The main goal of the treatment is to improve the provocative direction, for example: - Pain experienced during extension, 'release' the extension with Trigger (MFR) and Tape in the positive MSFT®Maneuver direction. - Pain experienced during flexion direction, 'release' the flexion with Trigger (MFR) and Tape in the positive MSFT® direction. **Table 2.** 4xT® treatment workflow![enter image description here][4] > **It's all about results!** **Figure 1.** TEST: Horizontal MSFT maneuver on Extension – Horizontal MSFT maneuver on Flexion![enter image description here][5] **Figure 2.** TRIGGER: Myofascial Release, 'dig out'![enter image description here][1] **Figure 3.** TAPE: EasyTaping® technique![enter image description here][7] (!) Note: this is the first of ten steps of the 4xT® decision-tree Back protocol **Evidence Based Practice** Due to successful treatment results experienced by patients and therapists, the 4xT method® is increasingly used in approaching musculoskeletal disorders like low back pain in clinical practice. Hence, there is a high need for scientific evidence regarding the 4xT method®. At this moment several scientific trials are in progress studying the effects of the 4xT® Method, including PhD. research, from FP Fysio Science in collaboration with VU University Amsterdam (Professor Dr. Annelies Pool-Goudzwaard; Professor Dr. Richard Jaspers). We embrace fellow scientists in investigating this protocolized therapeutic approach by starting with publishing the 4xT® Back protocol in open science. **References** 1. Noten K. 4xT® ArthroMyofascial Therapy. Utrecht: Fysio Physics Media & Publishing, 2020, p.304. 2. Noten K. Orthopedische revalidatie 4xT® Methode. College lecturers. KNGF Accreditatie ID 9673 IJsselstein: Fysio Physics, 2012. 3. Noten K. Orthopedic Rehabilitation: Course description online, https://www.fysiophysics.nl/opleidingen/orthopedische-revalidatie/ (2012, 2021). 4. Noten K and Schuurmans-Stekhoven M. Easytaping Course. Chapter 6: EasyTesting IJsselstein: College lecturers Fysio Physics, 2005, pp.17-21. 5. Petty N. Tribute to Geoffrey Maitland (1924-2010) by the manipulation association of chartered physiotherapists (UK). CHURCHILL LIVINGSTONE JOURNAL PRODUCTION DEPT, ROBERT STEVENSON HOUSE, 1-3 …, 2010. 6. Noten K. Therapeutisch Tapen (4xT Methode®), https://www.fysiophysics.nl/de-4xtmethode/ (2019, accessed 19-12-2019 2019). 7. Lee RY. Kinematics of rotational mobilisation of the lumbar spine. Clinical biomechanics 2001; 16: 481-488. 8. Chester R, Swift L and Watson MJ. An evaluation of therapist's ability to perform graded mobilization on a simulated spine. Physiotherapy Theory and Practice 2003; 19: 23-34. 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