TIMEST H E N E W S L E T T E R O F T H E A M E R I C A N S O C I E T Y O F H A N D T H E R A P I S T S
V O L U M E 2 3 I S S U E 3 • F A L L 2 0 1 6
www.asht.org
Instrument Assisted Soft
Tissue MobilizationBy Jyo Supnekar, OTR/L, CHT, CLT, Clinical Specialist, Johns Hopkins Hospital
6 Editors’ Message
8 President’s Message
10 Member Spotlight
12 Viewpoint
13 Regional Updates
14 Dry Needling for the Upper Extremity
17 Test Your Knowledge
18 Alternative Uses for Iontophoresis in Hand Therapy
22 Test Your Knowledge Answers
23 Education Division Update
CONTENTS Feature
Instrument Assisted Soft Tissue Mobilization
(IASTM) is the use of instruments made of
metal, plastic or ceramic to add shearing
stress to soft tissue in order to enhance the body’s
healing response. The tools are designed not to
replace the clinician’s hands, but to enhance them;
they are designed as an adjunct to palpation and
manual interventions. The complete mechanism
of effect is not yet fully understood. Animal
studies have revealed effect of increased fibroblast
recruitment5 and collagen response. Some animal
studies and patient case studies have shown
positive effects on pain reduction, reduction of
tissue restrictions and adhesions and beneficial
effects on scar remodeling.
The three common brands used in IASTM
are ASTYM, Graston Technique and
HawkGrips. Much of the current
research is with ASTYM and Graston.
HawkGrips describes its technique
as an instrument assisted form
of deep transverse friction soft
tissue mobilization as proposed by
Cyriax. HawkGrips states its origins
are rooted in gua sha, a branch of
traditional Chinese folk medicine
that, loosely translated, means
“scrape or scratch disease.” The goal is
a mechanical breakdown of scar tissue and
fascial restrictions. The HawkGrips technique
involves the utilization of tools to assess soft
tissue dysfunction, including scar tissue, adhesions,
joint contractures, fascial restrictions and neural
mobility restrictions causing range of motion
(ROM) and tissue mobility restrictions in the body.
The HawkGrip tools for IASTM are stainless steel
tools that are ergonomically designed. They assist
the clinician by amplifying the tactile sensation
from myofascial adhesions and tissue. They provide
a mechanical advantage and efficiency of force
transmission to the clinician and prevent overuse
stress on the clinician’s hands and fingers. The
HawkGrips tools are similar in shape and design to
the Graston tools; a key differentiation may be a
patented cross-etching that reduces slip and hand
fatigue when using emollient.
CONTINUED ON PAGE 3
Some studies have
shown positive
effects on pain
reduction, reduction
of tissue restrictions
and adhesions and
beneficial effects on
scar remodeling.
Endorsed by:
Designed specifically for people experiencing
ulnar sided wrist pain and mid-carpal instability.
REV00481t_0616
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ASTYM describes its technique as the use of handheld instrumentation
to topically locate underlying dysfunction of the tissue and then
transfer particular pressure and shear forces to the dysfunctional
tissue.4 Research theorizes it to be a physical treatment method to
potentially regenerate and remodel soft tissue through possible
activation of fibroblasts by means of the endogenous release of
cellular mediators and growth factors. This activation, theorized
to occur from stimulation by physical pressure and shear forces
selectively applied topically and aimed at underlying tissue, would
be strengthened in rehabilitation programs containing specific
tendon loading.4,6 Studies were conducted by ASTYM2,5 to elucidate
physiologically relevant mechanisms and to develop treatment
protocols aimed at stimulating the regeneration of soft tissue and
reabsorption of inappropriate scar tissue and fibrosis.6
Graston Technique utilizes stainless steel tools of various sizes, shapes
and styles of treatment edges.7 Graston Technique describes itself as
an innovative, evidence-based form of instrument assisted soft tissue
mobilization that enables clinicians to detect and effectively break
down scar tissue and fascial restrictions, as well as maintain optimum
range of motion.8 Graston may have popularized the concept of IASTM
and may be the first to market tools and augmented STM technique.
It is often considered a pioneer in the use of IASTM tools. Literature
states that in vivo studies revealed IASTM protocols improve tissue
repair, increase limb function and normalize movement patterns in an
animal model.2,5
The following reviews of some of the literature discussing the use of
instrument assisted soft tissue mobilization will help you to better
understand the theories behind the practice.
According to Norris, the purpose of friction massage is promotion of
local hyperemia, analgesia and reduction of scar tissue.5,10 There are
studies listed in literature on the use of instruments for soft tissue
mobilization and their effects on cell anatomy and physiology with no
definitive answers. Many of the studies are animal studies. The effects
are reported to be analgesic, neuromuscular facilitation/inhibition
and enhanced tissue healing due to enhanced fibroblastic activity. The
theory is that the use of tools during the inflammatory phase helps
to break down immature collagen3,9 followed by exercise and loading,
which realign fibers in the direction of the force.1
Mechanotransduction This is the physiological process in which cells sense and respond
to mechanical load; it is the process by which the body converts
mechanical loading into cellular and biochemical responses.1 It
is broken down into mechanocoupling, which is the mechanical
trigger or catalyst; communication throughout the tissue to
distribute the loading message; and the response at the cellular
level. The communication at each stage occurs via cell signaling —
an information network of messenger proteins, ion channels and
lipids.1 It addresses current scientific knowledge underpinning how
load may be used therapeutically to stimulate tissue repair and
remodeling in tendons, muscle, cartilage and bone. These cellular
responses in turn promote structural change.1 An example is bone
adapting to load. Type III collagen is replaced by Type I collagen. A
small, weaker bone can become larger and stronger in response to
appropriate load.1,12
Tissue Healing EffectBased on the tendon-healing stages of inflammation, proliferation
and remodeling, it is theorized that during the inflammatory stage,
fibroblasts migrate to the injured site and produce fibronectin, which,
together with interstitial collagen, may interact to form the fibrillar
component of extracellular matrix. In the proliferative stage, they
increase in number and synthesize collagen, and during the remodeling
stage there is realignment of the collagen fibers, shifting from
immature Type II collagen to Type I mature collagen.2,5 An animal study
that used Augmented STM (ASTM) on enzyme-induced rat Achilles
tendon injuries demonstrated that IASTM may facilitate the activation
of fibroblasts. In this study, gait analysis indicated earlier restoration
of limb function and tendon repair in tendons treated with ASTM than
was seen in the control group and the Achilles tendinitis group.5
CONTINUED FROM PAGE 1
INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION
Feature
Based on the tendon-healing
stages of inflammation,
proliferation and remodeling,
it is theorized that during the
inflammatory stage, fibroblasts
migrate to the injured site and
produce fibronectin, which,
together with interstitial
collagen, may interact to form
the fibrillar component of
extracellular matrix.
Analgesic EffectThere is a high concentration of mechanoceptors in the fascia and
soft tissue structures. A recent randomized control trial (RCT) study
by Sevier et al on patients with lateral elbow tendinopathy showed
improved disabilities of the arm, shoulder and hand (DASH) scores,
grip strength and pain reduction in the ASTYM group compared to a
group performing eccentric exercise only.6,13 A study by Davies et al
that utilized ASTYM therapy for post-mastectomy patients reported
improved functional outcome scores, improved ROM, decreased
hypersensitivity and decreased pain following ASTYM use.3
Scar Tissue AlterationA controlled lab study by Loghmani et al on the use of cross friction
soft tissue mobilization using IASTM indicated accelerated knee
ligament healing.14
Nerve ConductionA study by Burke et al indicated improved conduction velocity after
the use of STM and IASTM in patients with CTS with symptoms
reduction reported in the group that received STM as well as IASTM
at three-week follow-up.15 Combining this treatment with traditional
neural mobilization treatment techniques may improve patient
outcomes; this needs further investigation.
ROM ImprovementThere are a few studies that indicate an improvement in ROM
immediately following use of IASTM; one study demonstrates acute
effect of IASTM for improving posterior shoulder ROM in collegiate
baseball players.7 A case study reported an improvement in ROM, pain
reduction and function in a guitarist with a PIP joint injury and motion
restriction after the use of IASTM.11
The Tools: Proper Use and Training The tools are designed and contoured specifically for different body
regions. The tools have edges that are designed for treatment and
may be beveled as in the HawkGrips tools. The different organizations
offer educational training in the proper use, the theory behind its
applications, precautions and contraindications. It is recommended
that, prior to using the tools, clinicians receive education and training
in order to ensure client safety and achieve efficacy in their use for
evaluation and treatment of soft tissue disorders.
There are specific strokes that are utilized based on body region, tissue
response and the needs of the client. Some of the common strokes
utilized with use of the HawkGrips IASTM are sweeping, fanning,
brushing, strumming, J stroke and framing. It is not in the scope of
this article to provide instructions in the selection of the proper tool,
application, dosage and principles behind force utilization for different
strokes; a clinician must receive proper training prior to application of
any IASTM tools and techniques.
However, here are brief descriptions of some of the strokes based on
my use of the HawkGrips tools:
Sweeping:
This should be done at a 45-
to 60-degree angle for most
patients; the higher the angle,
the greater the dose. Sweep
using the treatment edge, and
slide back the tool instead of
lifting it.
Fanning:
Keeping one end of the tool
stationary, make a fanning
motion with the tool using
the treatment edge.
Brushing:
Run the treatment edge along
the grain of the muscle.
Strumming:
Closest to cross friction/
transverse friction; tool
perpendicular to the muscle.
J Stroke:
Move the tool along the
muscle and then make a J
curve with it.
Photos courtesy of HawkGrips
Feature
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There are specific recommendations for use of the tools that include
but are not limited to the following: a thorough evaluation including
precautions and contraindications; proper patient education and
explanation of the purpose of the tool; use of an emollient; limited
use of the tools/avoiding overuse of the tools; close monitoring of
skin, tissue and patient response and any adverse reactions; proper
patient positioning; follow-up with the use of appropriate low-load
stretches that are specific to the client’s need; and stress and exercise
to enhance the effects of soft tissue mobilization. A follow-up after a
treatment session to assess effectiveness is essential.
Some of the adverse potential responses after treatment could be
bruising, pain or a regression. Bruising is noted to occur occasionally,
and it is reported that it should resolve within one to three days.
If there is an increase in pain or regression of patient status, the
treatment method has to be modified and, if needed, discontinued
based on patient response.
Common Conditions for Use of IASTM
Tendinopathies, tendinosis, scar adhesions, soft tissue contractures,
nerve entrapment syndromes, postural abnormalities and tissue
restrictions and oncology-related soft tissue restrictions.
Manual therapy precautions and contraindications would apply to
the use of IASTM; some of the contraindications recommended
by HawkGrips are patient intolerance, open wounds, unhealed
suture sites, overmalignancy/neoplastic disease, overinflammatory
skin disease, fracture sites, aneurysm, osteomyelitis, advanced
osteoporosis, advanced DM, myositis ossificans, overlocalized
infection and obstructive edema. Some of the precautions
recommended are anticoagulation medication use, varicose veins,
cancer, burn scars, anemia, RA, kidney disease, pregnancy and
osteomyelitis, fibromyalgia and connective tissue disorder, such as
Ehlers-Danlos.
Soft Tissue Mobilization Considerations
Instrument assisted soft tissue mobilization should be part of a
comprehensive rehabilitation program that includes the use of tools
as an adjunct to clinician palpation and the use of additional manual
therapy techniques for the treatment of soft tissue disorders and
restrictions.
References
1. Khan KM. Scott A. Mechanotherapy: how physical therapists’ prescription
of exercise promotes tissue repair. Br J Sports Med. 2009;43:247-251.
doi:10.1136/bjsm.2008.054239.
2. Gehlsen GM, Ganion LR, Helfst RH. Fibroblast responses to variation in
soft tissue mobilization pressure. Med Sci Sports Exercise. 1999;31(4):531-
535.
3. Davies CC, Brockopp DY. Use of ASTYM® treatment on scar tissue
following surgical treatment for breast cancer: a pilot study. Rehabil
Oncol. 2010:28(3):3-12.
4. Sevier TL, Wilson JK. Treating lateral epicondylitis. Sports Med.
1999;28(5):375-380.
5. Davidson CJ, Ganion LR, Ghelsen GM, Veroestra B, Roepke JE, Sevier TL.
Rat tendon morphologic and functional changes resulting from soft tissue
mobilization. J Am Coll Sports Med. 1997;29(3):313-319.
6. Sevier TL, Stegink Jansen CW. Astym treatment vs. eccentric exercise for
lateral elbow tendinopathy: a randomized controlled clinical trial. PeerJ.
2015;3:e967. doi:10.7717/peerj.967.
7. Laudner K. Int J Sports Phys Ther. 2014;9(1).
8. Graston. http://www.grastontechnique.com/home.
9. Schaefer JL, Sandrey MA. Effect of a 4 week dynamic balance training
program supplemented with Graston instrument assisted soft tissue
mobilization for chronic ankle instability. J Sport Rehabil. 2012;21(4):313-
326.
10. Norris CM. Sports Injuries: Diagnosis and Management. New York, NY:
Butterworth-Heinermann; 1993.
11. Bayliss AJ, Clayton G, Gundeck E, Loghmani MT. Successful treatment of
a guitarist with a finger joint injury using instrument-assisted soft tissue
mobilization: a case report. J Manual Manipulative Ther. 2015;23:5:246-253.
doi: 10.1179/2042618614Y.0000000089.
12. Duncan RL, Turner CH. Mechanotrasduction and the functional response
of bone to mechanical strain. Calcified Tissue International. 1995;57:344-
58.
13. Hidalgo Lozano et al 2011, Toro- Velasco 2009.
14. Loghmani MT1, Warden SJ. Instrument-assisted cross-fiber massage
accelerates knee ligament healing. J Orthop Sports Phys Ther.
2009;39(7):506-14. doi:10.2519/jospt.2009.2997.
15. Burke J1, Buchberger DJ, Carey-Loghmani MT, Dougherty PE, Greco DS,
Dishman JD. A pilot study comparing two manual therapy interventions
for carpal tunnel syndrome. J Manipulative and Physiological Therapeutics.
2007;30(1):50-61.
Some of the adverse potential
responses after treatment
could be bruising, pain or a
regression. Bruising is noted
to occur occasionally, and it is
reported that it should resolve
within one to three days.