Download Taking the sore thumb out of manual therapy

9/5/2015
IASTM:
Taking the sore thumb
out of manual therapy
Disclosures
• UCSF Assistant Clinical Professor
• Outpatient Sports-Ortho perspective
• Created the approach Myofascial
Decompression Techniques
Vital Importance of the
Connective Tissue System
DaPrato, DPT, SCS 2015
Objectives:
Integument
• Describe the layers and subunits of the
connective tissue system. (CT)
• Summarize the role collagen, ground
substance, and other CT elements may be
affecting movement patterns
• Define the terms tensegrity, thixotropy,
as they relate to stress-strain curves
• Distinguish the effect of stretching on
length-tension vs. CT elements
• Describe common IASTM interventions to
improve mobility of the CT system
Skin layers
Epidermis: thin skin
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Epidermis: thick skin
Connective tissue development
Dermis
Fascial Layers
• Superficial
• Ectoderm and Mesoderm gives rise to the
CT of skin and fascia above and around
muscle tissue.
• Deep = Aponerotic & Epimysial
 TLF, TFL, rectus sheath…
• Intermuscular
• Visceral
analogous…
Living tissue is hydrated and dynamic
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Dynamic nature of living tissue
• The way we think about movement in the human
body is clouded by the way we learned anatomy
Functions of muscles
• We learn action but as we move in real world
multiple
▫ ERs become IRs past 90 degrees
▫ Cadaver tissue, hard muscles, web like fascia
▫ Surgery observation; as soon as you cut into it you
have changed it.
▫ AND what we observe in surgery = tourniquets
used; even though living tissue, not the same
Skin: more complex that we learned
Jean-Claude GUIMBERTEAU, MD: strolling under the skin
Retinacula Cutis
4th International Fascia Congress
• Benchmark sciences filling in the gaps of
traditional anatomy
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Skin layers
What is understood in radiology?
▫ Fascial herniations
▫ Morelle-Lavale lesions
▫ Compartment
syndrome; fasciotomy
▫ Gr 4 AC joint
Kumar 2014
Weiss 2015
Fascial Components
The Colloidal Matrix
• Fibroblasts
▫ Make and secrete all fibers of areolar connective tissue
• Collagen fibers
▫ Strongest and most abundant; cross linking leads to immense
tensile strength
• Elastic fibers
▫ Rubber like proteins which allow tissue to return to original shape
• Reticular fibers
▫ Connect vessels and nerves; have more give than collagen
• Ground substance
▫ Extracellular matrix that holds interstitial fluid via sugar-protein
molecules that soak fluid like a sponge; with increased
inflammatory response it becomes more viscous
Viscoelastic properties of skin
Fascial Contributions
• Support structure, tension, and suspension for
tissues; “scaffolding”
• Fluid mobility; high amount of plasticity
• Connecting multiple muscles = functional
kinetic chain
• Has been shown to have myofibroblasts
▫ Contraction of myofibroblasts influences
movement?
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Muscles within the Fascial layers
• Twitch of skin – horse, cow, pig…
• Hair stand up - Arrector Pili
• Myofibroblasts
Viscoelastic properties
Viscoelastic properties: Collagen
• Dermis is made up of 80% collagen, dry weight,
and of that collagen, 85% is type I
• Type 3 collagen is ~15% of dermal collagen, but
is higher in immature tissue
• With age, ratio of type 1:3 collagen increases
• Increased collagen fiber density with age=
decreased ground substance space
Viscoelastic properties:
Ground substance – with GAGs
• Glycosaminoglycans
▫ Proteoglycans and repeating disaccharide units
▫ Commonly hyaluronan and chontratin sulfate;
including dermatan sulfate
▫ Bind water in normal healthy tissue and proteins
▫ In aged skin, less binding to water and bind more to
elastoic material= thickened
Viscoelastic properties: Thixotropic
Effect
• Thixotropy is the property of certain gels or
fluids that are thick (viscous) under normal
conditions, but flow (become thin, less viscous)
over time when shaken, agitated, or otherwise
stressed.
Viscoelastic properties:
Creep and Hysteresis
• In relation to manual therapy, creep is the
distortion of tissues as a function of pressure
over time
• Hysteresis is the exchange of heat and energy
as tissues are distorted; permanent
deformation. Microtrauma.
• With MFR 90-120 seconds is the time for
generally the first barrier (R1) to release and
push into new range of extensibility.
• Tendon Hysteresis in 5-10 minutes(Kubo 2001)
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Stress-strain curves; human tissue
What really happens when we
stretch?
• Sensory endpoint theory (Weppler & Magnusson 2010)
▫ Very little evidence that Torque/angle curves shift; even w/ 8
weeks
▫ More likely that the perception of the stretch sensation occurs
later in the application of similar force
▫ PF stretch doesn’t change relfex pathway (Hayes 2012)
Stretching
Soft tissue mobility: Folding
• CT ability to compress upon itself
• Shoulder Elevation= inferior capsule and
axillary fold stretched, but also superior and
anterior structures need to fold
• End Range hip flexion in supine = hams and
glute flexibility, but also anterior hip folding
Fascia encapsulates and supports
Fascia encapsulates and supports
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Tensegrity
Tensegrity
Tensegrity
• “Tensional integrity”
• Fuller 1950’s first visualized by the sculptor
Kenneth Snelson (Snelson, 1996).Fuller
defines tensegrity systems as structures that
stabilize their shape by continuous tension
rather than by continuous compression
• Micro: studies of both cultured cells and
whole tissues indicate that cell shape stability
depends on a balance between microtubules
and opposing contractile microfilaments
Mechanical CT Changes
Inflammation
or Trauma
Secondary
movement
dysfunctions
ECM response
Tensegrity affected
Collagen crosslinkingCollagen
cross-linking
Ground
substance
viscosity
Cascade of events:
• Ge et al. 2008 studied involvement of central
sensitization mechanisms in local pain syndromes
• pain perception may result from a deregulation in
peripheral afferent and central nervous system
pathways- “chronic excitability”
Trigger Points
• Lower levels of oxygen, nutrients, blood
perfusion
• Increased calcium levels, leading to
excessive chronic muscle contracture,
spasms
• Stress can lead to abnormal excess afferent
stimulation
• Can have shortening of sarcomeres
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Fascial mechanics
• Translating forces =“Slings”
• Lats to TLF to contra glute max and down
lateral thigh =ITB Tx
Myofascial Lines
• Work of Thomas Myers
• Myofascial Tracks= muscles,
tendons, ligaments and fascia
• Bony Stations= joints or
insertional sites at bony landmark
• Can be static or motion driven
▫ Picture: Pec minor, biceps,
coracobrachialis, rectus abdominis
▫ Or ab scar restricting shoulder or
lumbar motion
Superficial Back Line
Superficial Back Line
Includes:
Plantar fascia
Achilles tendon and Gastrocnemius
Hamstings
Sacrotuberous ligament
Thoracolumbar fascia
Erector spinae
Scalp fascia
Lateral Line
Lateral Line
• Often involved with leg length differences
and pelvic obliquities
Includes:
Peroneals
Anterior ligament of the head of fibula
ITB and TFL
Superior fibers of glute max, medius
External and internal obliques
Splenius capitis and SCM
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The Spiral Line
The Serape=double spiral
Includes:
 Splenius capitis and cervicis
 Rhomboids
 Serratus anterior
 Ext/Int obl. & ab aponerosis
 TFL and ITB
 Tib anterior
 Peroneals
 Bicep femoris to sacrotuberous
ligament
 Lumbar fascia and erector spinae
Both picture thoracic extension; but may be
restricted for different reasons
Compensations and Adaptations
Why does IASTM work?
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Bridge to the IASTM picture
Mechanical connective tissue change
Fascial plane restriction and scar adhesions
Trigger points and metabolic exchange
Fluid mobility
Counterirritant; C fiber instead of A fiber; Gated
Myofascial Lines
• Fascial planes and CT restrictions affect
dynamic movement – scar adhesions
• Body takes the path of least resistance
• Interventions with traditional manual therapy
• Interventions with negative pressure
applications:
www.MyofascialDecompression.com
• Interventions with IASTM
• Manual therapy for lymphatic flow
“A best-practice model for
managing patients with
musculoskeletal complaints has yet
to be identified.”
-Tim Flynn (JOSPT 2007)
Consider hip strength for
runners with foot pain, or
Use of foot othosis as a
method of treating PFPS
Pain generating mechanisms
• Receptors in TL Fascia (Schilder 2014 Pain)
▫ Muscle pain could be more akin to projection
hyperalglesia, and not an “issue in the tissue.”
• IE: PF pain – likely cartilage or other soft tissue
restrictions?
▫ Grooves in PF joint in cadavers
• OR IE: THR patients that have the same hip
pain come back 6 months later
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IASTM = Instrument Assisted STM
• Mostly a Pro-inflammatory approach
▫ Some techniques are for flushing in acute phases
• Effect at the superficial fascia level, deep fascial
membrane, epimyseum
▫ mechanoreceptors
Where are the Pacinian corpuscles?
=
Where are the Meisner corpuscles?
=
Where are the Ruffini corpuscles?
=
IASTM
• Self trigger point tools – theracane, TrP tools…
• Snowman with a hat, PAs
• Belt techniques for hip and shoulder
IASTM
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ASTYM
Graston
SASTM
FAKTR
Iamtools
GuaSha Orthopedic
Target Point
Fuzion Tool
BioEdge
= GuaSha
Negative Pressure
▫ Are you just moving the joint? Or are you also with
an inferior hip glide pushing through RF trigger
point region, and other contractile tissue that may
reset sensitivity thresholds
• Negative pressure devices
Ultrasound
With Myofascial Decompression
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MFD Techniques
Negative Pressure
Negative Pressure
Negative Pressure
Proof of Concept Study
Proof of Concept Study
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GuaSha and IASTM
Basic Steps:
• Watch the area with movement
patterns
• Sweep area with hands/fingers
• Trace and isolate with Vectoring
▫ 4 directions, find most limited.
▫ Compare contralateral
▫ Add in rotational vector as
well
Contraindications
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Eyes; genitalia?
Unhealed wounds
Hemophilia, leukemia, active TB
Thrombocytopenia
Later stages of pregnancy
Influenza of fever
Moderate/severe anemia
Moderate/severe cardiac
conditions, high BP
• Vasculitis
• Cancer active
• Skin elasticity disorders-EDS??
Results?
IASTM techniques
• Superficial scrape
▫ Sense percussive info from
tool
• Scrape parallel fibers
▫ Into the motion barrier =
direct = subacute and chronic
▫ Away from motion barrier
=indirect = acute or irritable
• Diagonal and perpendicular
• Add movement
Precautions
-Patients that are over eager
- addictive personalities, chronic pain?
-Blood thinners
-Healing or thin skin
▫ Elderly, Psoriasis
-Pregnancy
-Areas of ecchymosis
▫ Previous STM
-Venous stasis and varicose veins
-DM; tissue healing and neuropathy
-Swollen tissue
▫ especially pitting edema
Outcomes?
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Future Studies
• Perfusion and Diffusion MRI with MFD vs Graston
vs ASTYM vs other tools/techniques/modalities
• Pre, during, and 8-48 hrs after for different Tx
• Fascial changes on magnified MRI
• Local metabolic change; on a nano level
▫ IE: why does US work in some patients?
References
• Ge HY,et al. Topographical mapping and mechanical pain sensitivity of myofascial trigger
points in the infraspinatus muscle. Eur J Pain. 2008 Oct;12(7):859-65
• Findley, T., Chaudhry, H., & Dhar, S. (2014). Transmission of muscle force to fascia during
exercise. Journal of Bodywork and Movement Therapies. In press 2014
• Holm L, et al. Contraction intensity and feeding affect collagen and myofibrillar synthesis
rates differently in human skeletal muscle.Am J Physiol (Endo), 298: E257-E269, 2010
• Kim KT, Kim YJ, Lee JW, et al.. Can necrotizing infectious fasciitis be differentiated from
nonnecrotizing infectious fasciitis with MR imaging? Radiology 2011;259(3):816–824
• Kubo K, et. al. Is passive stiffness in human muscles related to the elasticity of tendon
structures? Eur J Appl Physiol. 2001 Aug;85(3-4):226-32
• Kumar S, Kumar S. Morel-Lavallee lesion in distal thigh: A case report. J Clin Orthop Trauma.
2014 Sep;5(3):161-6
• Langevin HM, Nedergaard M, Howe AK. Cellular control of connective tissue matrix tension.
J Cell Biochem. 2013 Aug; 114(8):1714-9
• May DA, et. al. Abnormal signal intensity in skeletal muscle at MR imaging: patterns, pearls,
and pitfalls. Radiographics. 2000 Oct;20 Spec No:S295-315
• Schilder A, et al. Sensory findings after stimulation of the thoracolumbar fascia with
hypertonic saline suggest its contribution to low back pain. Pain 155:222-231, 2014
• Schleip R. et al. Passive muscle stiffness may be influenced by active contractility of
intramuscular connective tissue. Medical Hypotheses 2006; 66(1): 66-71
• Weppler CH, Magnusson SP. Increasing muscle extensibility: a matter of increasing length or
modifying sensation? Phys Ther. 2010 Mar;90(3):438-49
• Willard FH,et al. The thoracolumbar fascia: anatomy, function and clinical considerations. . J
Anat 2012; 221(6):507-36
References
Books:
• Functional Atlas of the Human Fascial System, Carla Stecco MD, 2015, 1st
Edition
• The Endless Web. Fascial Anatomy and Physical Reality. L. Schultz, R.
Feitis, 1996. North Atlantic Books.
• Anatomy Trains. Thomas Myers, 2008, 3rd edition
Journals:
• Abbott RD, et. Al. Stress and matrix-responsive cytoskeletal remodeling in fibroblasts.
J Cell Physiol. 2013 Jan; 228(1):50-7
• Ates, F, et al. Muscle lengthening surgery causes differential acute mechanical effects
in both targeted and non-targeted synergistic muscles. Journal of Electromyography
and Kinesiology, 23, 1198-1205, 2013
• Ballyns, Jet al. , Objective ultrasonic measures for characterizing myofascial trigger
points associated with cervical pain. J. Ultrasound Med., vol. 30, pp. 1331-1340, 2011
• Bhattacharya V, et. Al. Detail microscopic analysis of deep fascia of lower limb and its
surgical implication. Indian J Plast Surg. 2010 Jul;43(2):135-40
• Bonilla-Yoon, et al. The Morel-Lavallée lesion: pathophysiology, clinical presentation,
imaging features, and treatment options. Emerg Radiol. 2014 Feb;21(1):35-43.
• Borgini E, Stecco A, Day J. A., Stecco, C. How much time is required to modify a
fascial fibrosis? J Bodyw MovTher, 2010 Vol 14(4): 318 – 325
• Cao TV, Hicks MR, Standley PR. In vitro biomechanical strain regulation of fibroblast
wound healing. The Journal of the American Osteopathic Association. Nov
2013;113(11):806-818
Other recommended CE work
• www.ptrehab.ucsf.edu/education/continuingeducation
• Janda courses or Movement Links
• MyofascialDecompression.com
• Kaiser Residency and fellowship
• IPA PNF and FM
• Great Lakes MFR course
• Kinetacore.com
• Spinalmanipulation.org
• Myopain seminars
• Systemicdryneedling.com
Thank You!!
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