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
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mobility vs. stability
Tape
Tape
Tape
Tape
mobilize
mobilize
mobilize
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Body Maps
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