Instrument Assisted Soft Tissue Mobilization (IASTM) Redefined:

Basic, gentle soft tissue techniques for your patient care

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Outline

New Model in soft tissue manipulation

Neurological effects

Mechanical effects

Treatment vectors/rate/time/Depth

Fascial Chains (Tracing)

Case Study

When you understand a technique, you know a technique.When you understand a concept, you know a thousand techniques.

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corrective exercise - Used to normalize human movement before increasing training or exercise demandskinesiology tape - A special sports tape that provides support while allowing full range of motion. Tape is used to decrease pain, unload tissue via decompression, and provide a novel stimulus that improves body awareness.iastm - Instrument - Assisted Soft Tissue Massage - A manual therapy technique designed to provide direct, mechanical manipulation of irregular tissue.

rolling/balls/bands - A collection of tools used by athletes for manipulation of the myofascial system to normalize muscle tone.

assessment- The act of making a judgment about the quality of human movement

screening- The act of examining people to decide if they are suitable for a particular movement or exercise

Movement Pyramid Limits exist only in the mind

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efficiency

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stiffness compliance

criteria for optimal efficiency

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elastic springy

+

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Chronic Changes

compliant reactive efficiency+ =

mobility motor control

+ stiff

stability

Personal & Professional Reflection

Pain Science Paradigm Shift in Rehab

Simple Solutions for Complex Problems is Not Working

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Mechanical Effects

Dr. Robert Schleip • Debunked the idea of fascial release

(mechanical deformation of fascia) • Dismisses the traditional explanations of

thixotropy and peizoelectric-effect-mediated adaptation, and thoroughly describes fascial toughness.

• Concludes that plastic fascial change in response to moderate loading is “impossible to conceive.”

Superhuman

How much pressure necessary to distort tissue?

2000 LBS/SQ”Three-dimensional mathematical model for deformation of human fasciae in manual therapy.Chaudhry H, Schleip R, Ji Z, Bukiet B, Maney M, Findley T.J Am Osteopath Assoc. 2008 Aug; 108(8):379-90.

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1joint restriction:

• banded distractions • joint mobilizations

2soft tissue shortening:

• foam rolling• ball release• instrument assisted

4 levels of restriction

ProtectiveBarrier

TissueGlide

Beneath the Skin

Skin

Muscle

fascia

LooseConnec)veTissue

Pathological Adhesion?

Pre Blades Post Blades

Densification vs. FibrosisDensification• indicates an increase in

the density of fascia. This is able to modify the mechanical proprieties of fascia, without altering its general structure.... If there is only an alteration of the loose connective tissue, the term fascial densification is preferred

A. Stecco

Fibrosis• is similar to the process of

scarring, with the deposition of excessive amounts of fibrous connective tissue, reflective of a reparative or reactive process. It can obliterate architecture and function of the involved tissue.... If there is alteration of collagen fibrous bundles, the term fascial fibrosis is the term of choice

A. Birbrair 20

normal tissue

Mechanical densification

Neurological Barriers

lack of glideOld School

Aggressive and intense manual therapy with no regard for the state of the patient’s nervous system is problematic

No Pain, No Gain www.noigroup.org

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NeurologicalEffects

Feed the Brain

Feed the brain when you treat a patient with instruments it’s the nervous system that you have influenced. It is unlikely that any changes in the mechanical properties of tissues have occurred.

you have convinced the nervous system to let you move farther, with greater ease or with greater strength.

thought to stimulate intra-fascial mechanoreceptors which cause alterations in the afferent input to the CNS, leading to a reduction in the activation of specific groups of motor units

more widely accepted than the older mechanical models.

Hilton’s Law (1863)

“The same trunks of nerves whose branches supply the groups of muscles moving a joint furnish also a distribution of nerves to the skin over the insertions of the same muscles; and - what at this moment more especially merits our attention - the interior of the joint receives its nerves from the same source.” 26

Good Moveme

ntRequires Good

Perception

www.bettermovement.org

Body Maps

• Body Mapping is the conscious correcting and refining of one's body map to produce efficient, graceful, and coordinated movement.

• The body map is one's self-representation in one's own brain. If our representation is accurate, movement is good.

• If our representation is faulty, movement suffers. When our map is corrected, the movement improves.

Movement + Faulty Maps

Precision training Improving the Cortical map

Satellite Systems

Visual

ProprioceptionVestibular

Exteroceptive Interoceptive

Sensory Receptor Classification Proprioception: • is the kinesthetic sense that enables us to sense the relative position of the

parts of the body, posture, balance, and motion. • Located in Muscles, tendons, joints, internal ear

Exteroception:• pertains to the stimuli that originates from outside the body• Located at or near the body surface

Interoception: • is defined as sensitivity to stimuli originating inside of the body.

• Interoceptors: Free nerve endings • Located in blood vessels, organs, and connective tissue (skin/Fascia)

Connect the Dots

Tactile Acuity and Pain

Making the Invisible Visible

Kinesthetic Cueing

What are we treating?“the nervous system is the most important target for influencing posture and movement”

– Feldenkrais

“fascia is the most important tissue for posture and movement”

–Rolf

Both are correct

Autonomic Nervous System -

Brain

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hypothalamic tuning

global muscle tone

intra-fascial smooth muscles

palpable tissue response

tissue manipulation

stimulation of mechanoreceptors

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1golgi

receptors

2

3pacinian

corpuscles (type II)

ruffini endings(type II)

sustained pressure

Shear

interceptorslight touch

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4 types of fascial receptors

IANSMInstrument Assisted

Neuro-Sensory Modulation

How?

Pain Science Community

The Method

Bio-psycho-social Model

To start: Have a Plan1. What do you WANT?2. Find your BASELINE3. PLAN your progression4. Be PERSISTENT5. Educate

www.noigroup.org

Graded Exposure TherapySystematic desensitization, also known as graduated exposure therapy is a type of behavior therapy used in the field of psychology

Recently adopted to address Musculoskeletal conditions

Graded Myofascial Release1. Slow Progressions2. Avoid Flare Ups 3. Improve Tissue Tolerance4. Distraction Therapy

Decrease the The Threat ☑

Distraction Method TT

TT

Tissue Tolerance

Explain Pain - Moseley/Butler

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=

chemical Stimuli

Chemical Distraction

Laing RJ, Dhaka A. ThermoTRPs and Pain. The Neuroscientist : a review journal bringing neurobiology, neurology and psychiatry.2016;22(2):171-187.

Driver’s Education

Drivers EducationGrip:

• Standard• Thumb• Edge

Skin Prep:

• Wet – Emollient• Dry – No lubricant

Treatment Rate:• Fast / Feathering • Slow• Fluid Capture• Shearing – Tangential

Treatment Vector:• Myofascial Chains• Linear• Non - linear

Treatment Depth:• Angle of Approach• Pressure (Grading of Touch) Treatment Edges

Hard Rock

Groovy Rock

Bottle Opener Soft Rock

Alternative Rock

Narrow Edge

Blunt Edge

Fine Tuning Edge

Grip

Finger PadsG

rip

Grip

Depth grading scale

grading scale:

grade 1-3: very light (eye lid analogy) grade 4-6: moderate/firmgrade 7-8: firmgrade 9-10: deep

Indications • Limited motion• Pain during motion• Motor dysfunction (poor motor patterns) • Lack of tissue glide • Poor body representation

Contraindications • Compromised tissue integrity (open

wound, infection, tumor)• Active implants (pacemaker, internal

defibrillator, picc/pump lines)• DVT (Deep Vein Thrombosis) • Cervical carotid sinus• Inability to communicate

Its easy to be heavy; hard to be

light.

G.K. Chesterton

Disclaimer

Not necessary

Interoception/Pain Relief

Manual Therapy • When treating muscular tissues, manual therapists

are usually concerned with direct bio-mechanical effects on non-neural tissues

OR• with the stimulation of specific proprioceptive nerve

endings such as muscle spindles, golgi receptors

• Advisable that manual therapists target the interoceptive receptors and their related upstream effects to a much larger degree.

Sensory Receptor Classification Proprioception: • is the kinesthetic sense that enables us to sense the relative position of the

parts of the body, posture, balance, and motion. • Located in Muscles, tendons, joints, internal ear

Exteroception:• pertains to the stimuli that originates from outside the body• Located at or near the body surface

Interoception: • is defined as sensitivity to stimuli originating inside of the body.

• Interoceptors: Free nerve endings • Located in blood vessels, organs, and connective tissue (skin/Fascia)

Fascia as an Interoceptive Organ• Only a minority of the sensory nerve endings in MSK

fascia are myelinated mechanoreceptors concerned with proprioception

– Golgi Receptors, Paccini Corpuscles, or Ruffini Endings.

• 7 x more interoceptors than other mechanoreceptors • Higher concentration in hairy skin • Stimulation of these receptors result in activation of an

area of the brain (Insula) associated with pain relief and sense of well being

• 40% of these receptors are low threshold receptors which are responsive to light touch,

– Painter’s Brush – Cotton Ball– Feather stroke

Insula

Mind and Body are Integration

– Sense of Wellbeing– Anticipation of Pain– Perception of Pain – Empathy– Affective Touch – more……

InteroceptivePathway

Insula

Thalamus

Prebrachial Nucleus

Lamina I of Spinal Cord

Free Nerve Endings

Interoceptive C-Fiber Endings

Wellbeing Center of Brain

FasciaHairy Skin

Pain = FeatheringInteroceptor Stimulation(Free Nerve Endings)

Autonomic Responses to TxUseful to pay attention to the autonomic responses of each treatment Variable:

Neurological cues: – Warmth– lightheadedness – nausea – pulsation – sense of wellbeing – facial expression– breathing – pupil dilation/constriction – skin color changes – temperature changes

Pain – Feathering1. SCAN tissues targeted within

workout.2. IDENTIFY areas of tenderness/

tightness = TARGET TISSUE 3. SUPERFICIALLY FEATHER

pressure on target tissue for 30 seconds to tolerance

4. ADDRESS tissues up/down stream to target tissue = RIPPLE

SCAN + IDENTIFY + FEATHER STROKES + RIPPLE

Rate

up regulation = FASTPacinian Stimulation

Tactile AcuityBody

Representationup regulation

Satellite Systems

Visual

ProprioceptionVestibular

Exteroceptive Interoceptive

Smudging

Explain Pain - Moseley/Butler

Discriminative Treatment StrokeGraphesthesia:

• Letter/Number Recognition • Shape Recognition • Progress:

– By Size – By Speed– By Location (target

area)– Add Localization – Add Gaze Tracking

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pacini mechanoreceptors:

these receptors are primarily responsive to rapid pressure changes. Stimulating these receptors can result in improved proprioceptive feedback and controlled motor movement.

Body Map receptors

Tactile Acuity

up regulation – FAST/Oscillating 1.SCAN tissues that will be targeted

in specific workout out. 2. IDENTIFY areas of tightness/

tenderness = TARGET TISSUE3.QUICKLY oscillate over the area

for 10 seconds = RAPID STROKES

4.ADDRESS tissue up/down stream to target tissue = RIPPLE

SCAN + IDENTIFY + RAPID STROKES + RIPPLE Rate of Oscillation: 2-6 Hz Level - 200-300 BPM

To the Beat

Metronome Apps Available

Rate Rx:

120-300 BPM (Approx 2-6Hz)

down regulationdown regulation =

SLOWRuffini Stimulation

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ruffini mechanoreceptors:stimulation of ruffini corpuscles is assumed toresult in a lowering of sympatheticnervous system activity (van den Berg & Capri1999). slow deep tissue techniques tend to have arelaxing effect on local tissues as well as on thewhole organism.It therefore appears that deep manual pressure – specifically if it is slow or steady- stimulates interstitial and Ruffini resulting in global muscle relaxation, as well as a more peaceful mind and less emotional arousal.

inhibitory receptors

down regulation

Fascia can contract• Fascia has both a sensory and motor dimension • Fascia has the ability to change its tonus autonomously,

independent of outside muscular forces. • Dr. Jochen Staubesand found, using electron

photomicroscopy, smooth muscle-like cells embedded within this fascia’s collagen fibers.

• Staubesand also found a rich intrafascial supply of sympathetic nerve tissue and sensory nerve endings.

• Based on these findings he concluded that it is likely that these fascial smooth muscle cells enable the sympathetic NS to regulate a fascial pre-tension independent of the muscular tonus.

Staubesand, J., & Li, Y. (1996). Zum Feinbau der fascia cruris mit besonder Berucksichtigung epi – und intrafaszialer nerven. Manuelle Medizin, 34, 196-200.

down regulation – Slow/Deep1. SCAN tissues targeted within

workout.2. IDENTIFY areas of tenderness/

tightness = TARGET TISSUE 3. Deep/Slow pressure on target

tissue for 30 seconds to tolerance

4. ADDRESS tissues up/down stream to target tissue = RIPPLE

SCAN + IDENTIFY + SLOW STROKE + RIPPLE

gliding

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interlayer gliding Dr. Geoffrey Bove • “It’s all about the interfaces”• Interfaces are essentially the fascial planes

between muscles, nerves, fascia, etc..• Lack of gliding is the enemy • Positive treatment effects are at the loose

connective tissue and not in the fascia • Early intervention is the key

Bove GM, Chapelle SL. Visceral mobilization can lyse and prevent post-surgical adhesions. Journal of Bodywork and Movement Therapies, 16, 76-82, 2012 doi: 10.1016/j.jbmt.2011.02.004

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Designed to MOVESLIDE

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A Deeper PerspectiveDynamic view of tissue

manipulation via musculoskeletal ultrasound imaging

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www.mindray.com114

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Langevin study: T/L fascial movement

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Wet vs. Dry Treatment Dry Treatment:

– Improve Skin Drag to create tangential load to skin/fascia

– Stimulating Ruffini Endings that respond best to skin shear

– Improved gliding effect (fascial interface)

Wet Treatment: – Allow for superficial

skin/fascial stimulation at a faster rate (Pacinian Corpuscle)

– Allow for feathering effect on interstitial fibers (interoception)

Wet Release Dry Release

Glide – Wet/Dry1. SCAN tissues targeted within

workout.2. IDENTIFY areas of tenderness/

tightness = TARGET TISSUE 3. TENSION TO END RANGE +

CHOPPING strokes on target tissue for 30 seconds to tolerance

4. ADDRESS tissues up/down stream to target tissue = RIPPLE

SCAN + IDENTIFY + CHOP STROKES + RIPPLE

No Emollient

Fluid capture

Take Home: Treatment Strokes

1. Feather = Pain 2. Rapid = Up-Regulate 3. Slow = Down-Regulate 4. Dry = Glide/Shear 5. Fluid capture

TissueResponse

UpRegulate

DownRegulate

PainMitigation

Shear129

Rx

Dosage:Target Tissue Tx = 10-30 secsRipple above and below = 10-30 secsTotal = 90 Seconds

Sweet Spot:

Min = 90 Secs Max = 5 Mins

System1.Screen 2.Mobilize 3.Motor Control 4.Stabilize 5.Re-Screen

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How to Navigate the Human Body

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Fascia Joint by Joint

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fascia as our roadmap it’s all connected

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connected both mechanically and

neurologically

nervous system

painperformance

movement articular

muscularfascia

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past

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future

future

139

it’s alive

fascia senses

richest sensory organ

fascia transmits force globallycommon myofascial pathways for transmitting stability, strain, and response distributes strain

continuous interconnected web

a GPS system of strain distribution

what is fascia

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Wainner, RS, et al. Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. J Orthop Sports Phys Ther 2007;37(11):658-660

“when the assessment is initiated from the perspective of a movement

pattern, the clinician is able to identify meaningful impairments that may

seem unrelated to the main complaint”

regional interdependence

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mobility vs. stability

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Foot Stable (control)Ankle** MobileKnee Stable

(control) Hip** Mobile Pelvis/Sacrum/L-Spine Stable (Control) Thoracic Spine** Mobile Cervical Spine Stable (Control) Shoulder complex Mobile Elbow Stable (Control) Wrist Mobile** key mobility centers

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movement screening methods

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corrective exercise - Used to normalize human movement before increasing training or exercise demandskinesiology tape- A special tape that provides support while allowing full range of motion. Tape is used to decrease pain, unload tissue via decompression, and provide a novel stimulus that improves body awareness.

iastm - Instrument - Assisted Soft Tissue Massage - A manual therapy technique designed to provide direct, mechanical manipulation of irregular tissue.

rolling/balls/bands - A collection of tools used by athletes for manipulation of the myofascial system to normalize muscle tone.

assessment- The act of making a judgment about the quality of human movement

screening- The act of examining people to decide if they are suitable for a particular movement or exercise

Movement Pyramid

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all movement is a screen

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multi-planar approach Planar Dysfunction Screen

Sagittal Frontal Transverse

Treatment Vectors

3 vectors/planes

1. Sagittal Vector

2. Frontal Vector

3. Transverse Vector

Sagittal Plane Correction

Anatomy Trains

Performance Front/Back Chains

sagittal flexion sagittal extension

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Sagittal PlanE Dysfunction

Flexion extension

Frontal Plane Correction performance lateral chain

frontal- Lateral Flexion

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Frontal Plane Dysfunction Transverse Plane Correction performance functional chains

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Transverse Plane Dysfunction

Fascial Chains

1.Performance Front Chain2.Performance Back Chain 3.Performance Lateral Chain4.Performance Functional Chain5.Performance Arm Chains

Performance

BackChain

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Sagittal PlanE Dysfunction

Flexion extension 164

mobility vs. stability

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Tape - Mechanical Effect

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Tape - Neurological Effect

173 174

mobility vs. stability

Tape

Tape

Tape

Tape

mobilize

mobilize

mobilize

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Body Maps

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