instrument assisted soft tissue mobilization
TRANSCRIPT
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Instrument Assisted Soft Tissue MobilizationBy: Dr. Noah Kubissa, DPT, OCS, FAAOMPT
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About me
● Master’s of Physical Therapy Misericordia University 2011● Transitional Doctorate of Physical Therapy Evidence in
Motion 2014
● Board Certified in Orthopedics
● Fellowship Trained in the American Academy of
Orthopedic Manual Physical Therapy
● Diploma in Osteopractic
● Certified in Dry Needling, Spinal Manipulation, SFMA,
STMT-C
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Review of Evidence
● Cupping Therapy○ Treat anything from infertility to disc herniations
○ What does the evidence say■ Cae et al 2018 Cupping for patients with disc herniations
● Compared cupping and acupuncture and combined
● Found greater than 75% improvement in McGill pain assessment for
combined
● 10 minute fire cupping
■ Teut et al 2018 Pulsatile dry cupping for chronic LBP a RCT● 8 8 minute pulsatile dry cupping sessions of two different intensities
applied
● At 4 weeks, found strong pulsatile dry cupping to be the most effective
● At 12 weeks found no difference
● Lauche et al 2012 The effect of traditional cupping
on chronic non specific neck pain.○ Single session fire cupping 10 - 15 minutes to cervical spine
○ Found significantly decreased pain, higher pain pressure
threshold and quality of life
○ 50 patients, 1 week follow up
● Hong et al 2006 ○ Cupping for 5 minutes in 11 days vs NSAIDs 3 x day for 12
days
○ 70 patients 2 week follow up
○ Significant decrease in pain scores with cupping vs NSAIDs
● Kim et al 2011, Cupping for treating pain○ Dry cupping for cancer pain
○ 60 patients received cupping 3 times a day 5 minutes a time
for 3 days
○ Compared with opiods 3 x a day
○ Found 67% reduction in pain with cupping therapy vs 43%
with opiods
● Ge et al 2017, Dry Cupping for Plantar Fascitis○ 29 patients treated 2 x week for 4 weeks
○ 10 minutes of cupping vs 10 minutes of estim
○ Found cupping to be more effective, but not statistically or
clinically significant
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● Zare et al 2016, Comparison of Dry Cupping and
Acupressure on Perineal Pain○ 150 participants, either received Dry Cupping, Acupressure or nothing
on the back
○ Performed 4-8 hours after delivery and received 10 to 20 minutes of
cupping and acupressure
○ Both Dry Cupping and Acupressure showed statistically significant
changes on McGill Pain Scale, with Dry Cupping being more effective
● Teut et al 2012, Pulsative Dry Cupping in patients with OA
of the knee○ 40 patients with chronic knee OA, either received 8 sessions of
cupping or nothing
○ Found significant improvement at 4 weeks for the WOMAC and 4 and
12 weeks for the VAS and SF-36
○ Cupping for 10 minutes
IASTM Literature Review
● Gulick et al 2018○ Instrument Assisted Soft Tissue Mobilization for treatment of
myofascial trigger points
○ Treated twice a week for 3 weeks for 5 minutes
○ Upper Trapezius region that was treated
○ Statistically significant in pain pressure threshold of myofascial trigger
points after 3 weeks of treatment
● Lee et al 2016○ Effect of Graston Technique on the pain and range of motion in CLBP
patients
○ 30 patients, 4 weeks treatment consisted of 20 seconds parallel to
muscle and 20 seconds perpendicular to muscles
○ Results significant increase in L/S ROM and improvements in the VAS
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● Moon et al 2017○ Immediate effects of graston technique on hamstring flexibility
○ 24 people in split between passive stretching and graston
○ Both groups showed significant increases in hamstring ROM, but an
even larger increase was in the graston group
● Laudner et al 2014○ Acute effects of IASTM on shoulder ROM
○ 35 college baseball players had IASTM to the posterior shoulder
○ Treated once with graston for 90 seconds
○ Results indicated 11 degree increase in shoulder horizontal adduction
and 5 degree increase in shoulder internal rotation
● Markovic et al 2014○ Acute effects of IASTM vs foam rolling on hip and knee rom in soccer
players
○ 2 minutes of foam rolling or IASTM performed over quads and
hamstrings
○ Measured SLR and quad muscle length
○ Found immediate 15% improvement in ROM in IASTM group and 7%
improvement in foam rolling group
○ Followed up 24 hours later and IASTM group still presented with 10%
improvements
● Schaefer et al 2012○ Effects of dynamic balance and IASTM in patients with chronic ankle
instability
○ 36 subjects in dynamic balance training, IASTM, sham or both
○ Patients in DBT, IASTM and both all showed significant improvement
in pain, ROM and star excursion, but group in both demonstrated the
greatest increase
● Wilson et al 2000○ IASTM vs Traditional Rehab for patellar tendonitis
○ Performed same exact protocol, except cross friction massage was
provided with IASTM vs hand
○ Found IASTM to have statistically significant improvements in
patellafemoral joint evaluation scale at 6 weeks and 12 weeks
○ Patient was treated 3 x week for 4 weeks
● Sevier et al 2015○ IASTM vs Eccentric exercise
○ Treated 2 x week for 4 weeks
○ 113 symptomatic elbows
○ Found resolution of symptoms in 78% of patients treated with IASTM
vs 40% with eccentric exercise
○ Gains lasted up to 12 months
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Added Benefit to using tools
● Snodgrass et al 2013○ 91% of physical therapist report using some sort of self
treatment due to thumb pain
○ Key takeaway■ SAVE YOUR HANDS!
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Cupping Mechanisms● The main proposed mechanisms of action were effects of subatmospheric
pressure suction, promoting peripheral blood circulation, and blood vessel formation
● Cupping induced blisters contain several proteins which relate to the
activation of certain immune pathways including anti-oxidation, anti-
apoptosis, tissue repairing and metabolic regulation
● Mechanical effects of cupping include promotion of the skin's blood flow,
changing of the skin's biomechanical properties, increasing pain
thresholds, improving local anaerobic metabolism, and reducing
inflammation
● Guo et al. suggested themmunemodulation theory which states that
changing the microenvironment by skin stimulation could transform into biological signals and activate the neuroendocrine immune system
Continued
● Shaban and Rarvalia proposed the genetic theory, which
suggested that skin's mechanical stress (due to subatmospheric
pressure) and local anaerobic metabolism (partial deprivation of
O2), during cupping suction could produce physiological and
mechanical signals which could activate or inhibit gene
expression.
● Angiogenesis - forming new blood vessels from pre existing
blood vessels
Cupping Contraindications
● Directly over compromised veins, arteries or open wounds
● Fractures
● DVT
● CHF
● Anemic
● Cancer
● Pacemaker
● Varicose veins
● Lymph nodes
● Recent blood donation
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Cupping Spots?
Leu and Chen at al 2018. Is cupping Harmful?
Cupping Techniques
● Reminders○ Lip of Cup compresses, rest of inside distracts tissue
● Static Cupping○ Chronic pathologies, looking to increase number of blood vessels to area
○ Regions with poor blood supply
○ Leave on up to 5 minutes
● Dynamic Cupping○ Areas of swelling, superficial edema
○ Usually use silicone cups
○ Think of trying to pull swelling out of area
● Cupping with Movement○ Similar to ART, cup an area, and move the joint
○ Can be very beneficial if area is too painful to palpate
○ Soft tissue restrictions
Cupping Videos
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IASTM Mechanisms
● Fibroblast formation○ Mechanotransducers respond to changes in biophysical strain, such as
compression, distraction, torque, shear etc and create mechanochemical
responses
○ Increase in tissue temperature, realignment of collagen fibers and
microinflammation
● Gehlsen et al 1999○ fibroblast production is directly proportional to the magnitude of IASTM pressure
used by the clinician
● Davidson et al 1997○ Found significantly increased fibroblast production in rat achilles tendons by using
electron microscopy to analyze tissue samples following IASTM
○ Found morphologic changes in the rough endoplasmic reticulum, indicating micro
trauma to damaged tissues, resulting in an acute fibroblast response
Comparison Study
● Effectiveness of IASTM, Cupping and Ischemic
Compression on MTrPs in L/S○ 70 amateur soccer players were randomly assigned to either IASTM,
Cupping or IC to L/S myofascial trigger points
○ Treated once a week for 3 weeks
○ IC group received 90 seconds of ischemic compression
○ Cupping group received 5 minutes of cupping over trigger points
○ IASTM group received 8 minutes of IASTM with varying strokes
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Results● All three groups significantly decreased VAS and
increased PPT
● IASTM demonstrated the largest improvements
● One of the only high quality studies on IASTM vs
Cupping
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IASTM Contraindications
● Open wound
● Infection
● Tumor
● Active Cancer
● DVT
● Active implants
● Lymphedema
Different Tools
● Graston
● ASTYM
● HawkGrips
● Adhesion Breakers
● Smart Tools
● FRAMs
● Gua Sha
● Edge
Best Tool● Depends on job
● Any tool can work, if you know how to use it
● Best overall to have variety of tools for different
body regions and types
● If too costly, start with one and eventually grow your
tool box
● How to use the different tools?
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Different Tool Designs
● Handle bar
● Multitool
● Boomerang
● Scanner
● Tongue Depressor
Different Strokes
● Parallel
● Perpendicular
● Oblique
● Fast
● Slow
Edges
● Beveled
● Single vs double
● 30-60 degree with single bevel
● 90 degree with double bevel
● Concave
● Convex
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Strokes● Slow with 30-60 degree angulation on beveled edge
○ Detonify muscle
● Fast with 30-60 degree angulation on beveled edge○ Tonify muscle
● Slow with 90 degree angle on beveled edge○ Scan
● Fast with 90 degree angle on beveled edge○ Muscle adhesions
Examples
IASTM Videos
Physiological Response IASTM
● Produce a localized inflammatory response
● Reduce scar tissue
● Break down existing scar tissue
● Break up adhesions
● Improve tissue mobility
● Realign collagen
● Pain reduction
● Increase ROM
● Alters mechanoreceptors with larger axons
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Cupping
● Increase local blood flow
● Local tissue stretch
● Anti inflammatory effects
● Increase lymphatic circulation
● Tissue distraction
Reason for different strokes● Scanning
○ Ability to detect adhesions and tissue tone
○ Sharp edge, slow with medium depth to find adhesions
● Pain○ Reduce nocioception to area
○ Fast paced strokes, parallel to muscle bi-directional, sharp edge of tool, light depth
● Adhesions○ Reduce fascial adhesions
○ Sharp edge of tool, medium pace with medium depth, bi-directional parallel to
muscle
● Inhibit muscle○ Reduce tone of muscle
○ Dull edge of tool, very slow pace with deep depth, single direction, parallel,
perpendicular and oblique to the muscle
Continued
● Muscle activation○ Elicit muscle contraction
○ Dull edge of tool, medium depth and medium speed, bi-
directional
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Combined Treatment
● Cupping and IASTM○ Can cup an area to weigh it down and IASTM away from it
○ Works well for chronic pathologies that is non responsive, as
well as for hypermobile individuals, where additional tension
is required
○ Start with one cup, and can gradually increase number of
cups and add movement
○ Be careful on sensitive skin, elderly, children, blood thinners
Closing● Cupping and IASTM should be complement to already prescribed
exercise, modalities and manual therapy
● Not beneficial to everyone, should get verbal consent before
doing any manual therapy, in particular when skin discoloration
may follow
● Start out with one tool and apply different techniques
● Buy a cupping set, very inexpensive and great for self treatment
● Just get started using it before, after or during exercise
● Most importantly do not be afraid to be creative, lot of theoretical
evidence and case reports, RCTs are lacking, create your own
technique
Questions?
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Bibliography
● Chronic ankle pain and fibrosis successfully treated with a new noninvasive augmented soft tissue
mobilization technique (ASTM): a case report.. Melham TJ, Sevier TL, Malnofski MJ, Wilson JK,
Helfst RH Jr. Med Sci Sports Exerc. 1998 Jun; 30(6):801-4.
● Fibroblast responses to variation in soft tissue mobilization pressure. Gehlsen GM, Ganion LR,
Helfst R. Med Sci Sports Exerc. 1999 Apr; 31(4):531-5.
● Cai C, Gong Y, Dong D, et al. Combined Therapies of Modified Taiyi Miraculous Moxa Roll and
Cupping for Patients with Lumbar Intervertebral Disc Herniation. Evidence-based Complementary
and Alternative Medicine : eCAM. 2018;2018:6754730. doi:10.1155/2018/6754730.
Bibliography● Acute effects of instrument assisted soft tissue mobilization for improving posterior shoulder range
of motion in collegiate baseball players.. Laudner K, Compton BD, McLoda TA, Walters CM. Int J
Sports Phys Ther. 2014 Feb; 9(1):1-7.
● Management of chronic ankle pain using joint mobilization and ASTYM® treatment: a case report.
Slaven EJ, Mathers J J Man Manip Ther. 2011 May; 19(2):108-12.
● Astym treatment vs. eccentric exercise for lateral elbow tendinopathy: a randomized controlled
clinical trial. Sevier TL, Stegink-Jansen CW. PeerJ. 2015; 3():e967.
● Conservative treatment of a tibialis posterior strain in a novice triathlete: a case report. Howitt S,
Jung S, Hammonds N J Can Chiropr Assoc. 2009 Mar; 53(1):23-31.
● Chronic Achilles tendinopathy: a case study of treatment incorporating active and passive tissue
warm-up, Graston Technique, ART, eccentric exercise, and cryotherapy. Miners AL, Bougie TL. J Can
Chiropr Assoc. 2011 Dec; 55(4):269-79.
● Effects of a 4-week dynamic-balance-training program supplemented with Graston instrument-
assisted soft-tissue mobilization for chronic ankle instability. Schaefer JL, Sandrey MA. J Sport
Rehabil. 2012 Nov; 21(4):313-26.
Bibliography● Complementary Therapeutic Clinical Practice. 2017 Nov;29:162-168. doi:
10.1016/j.ctcp.2017.09.008. Epub 2017 Sep 14. Cupping therapy: An analysis of the effects of
suction on skin and the possible influence on human health. Lower D.
● Lauche R, Cramer H, Choi K-E, et al. The influence of a series of five dry cupping treatments on
pain and mechanical thresholds in patients with chronic non-specific neck pain - a randomised
controlled pilot study. BMC Complementary and Alternative Medicine. 2011;11:63.
doi:10.1186/1472-6882-11-63.
● Kim, Jong-In & Lee, Myeong Soo & Lee, Dong-Hyo & Boddy, Kate & Ernst, Edzard. (2009).
Cupping for Treating Pain: A Systematic Review. Evidence-based complementary and alternative
medicine : eCAM. 2011. 467014. 10.1093/ecam/nep035.
● Teut M, Ullmann A, Ortiz M, et al. Pulsatile dry cupping in chronic low back pain – a randomized
three-armed controlled clinical trial. BMC Complementary and Alternative Medicine. 2018;18:115.
doi:10.1186/s12906-018-2187-8.
● Zhidan Liu, Chunlan Chen, Xiaoyan Li, Chuang Zhao, Zunyuan Li, Wei Liang, Yufang Lin, Is
cupping blister harmful?—A proteomical analysis of blister fluid induced by cupping therapy and
scald, Complementary Therapies in Medicine, Volume 36, 2018, Pages 25-29,
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Bibliography
● Tamer S. Aboushanab, Saud AlSanad, Cupping Therapy: An Overview from a Modern Medicine
Perspective, Journal of Acupuncture and Meridian Studies, Volume 11, Issue 3, 2018, Pages 83-87
● Lauche R, Cramer H, Hohmann C, et al. The Effect of Traditional Cupping on Pain and Mechanical
Thresholds in Patients with Chronic Nonspecific Neck Pain: A Randomised Controlled Pilot Study.
Evidence-based Complementary and Alternative Medicine : eCAM. 2012;2012:429718.
doi:10.1155/2012/429718.
● Hong YF, Wu JX, Wang B, Li H, He YC. The effect of moving cupping therapy on non-specific low
back pain. Chinese Journal of Rehabilitation Medicine. 2006;21:340–343.
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Complementary and Alternative Medicine : eCAM. 2011;2011:467014. doi:10.1093/ecam/nep035.
● Zeng, K. and Wang, J.W. Clinical application and research progress of cupping. (Wei, L. I. U.,)J Acupunct
Tuina Sci. 2016 Jul 1; 14: 300–304
● Wei, L.I., Piao, S.A., Meng, X.W., and Wei, L.H. Effects of cupping on blood flow under skin of back in healthy
human. World J Acupunct Moxibustion. 2013 Sep 30; 23: 50–52
● Saha, F.J., Schumann, S., Cramer, H., Hohmann, C., Choi, K.E., Rolke, R. et al. The effects of cupping
massage in patients with chronic neck pain-a randomised controlled trial. Complement Med Res. 2017; 24:
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● Emerich, M., Braeunig, M., Clement, H.W., Lüdtke, R., and Huber, R. Mode of action of cupping—local
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● Lin, M.L., Lin, C.W., Hsieh, Y.H., Wu, H.C., Shih, Y.S., Su, C.T. et al. Evaluating the effectiveness of low level
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● Khalil, A.M., Al-Qaoud, K.M., and Shaqqour, H.M. Investigation of selected immunocytogenetic effects of
wet cupping in healthy men. Spatula DD. 2013 Jul; 3: 51–57
● Guo, Y., Chen, B., Wang, D.Q., Li, M.Y., Lim, C.H., Guo, Y. et al. Cupping regulates local immunomodulation to
activate neural-endocrine-immune worknet. Complement Ther Clin Pract. 2017 Aug 31; 28: 1–3
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Physical Therapy Science. 2017;29(5):859-862. doi:10.1589/jpts.29.859.
● Akbarzade M, Ghaemmaghami M, Yazdanpanahi Z, Zare N, Mohagheghzadeh A, Azizi A. Comparison of
the Effect of Dry Cupping Therapy and Acupressure at BL23 Point on Intensity of Postpartum Perineal
Pain Based on the Short Form of McGill Pain Questionnaire. Journal of Reproduction & Infertility.
2016;17(1):39-46.
● Instrument-assisted soft tissue mobilization increases myofascial trigger point pain threshold. Gulick,
Dawn T. Journal of Bodywork and Movement Therapies , Volume 22 , Issue 2 , 341 - 345
● Lee J-H, Lee D-K, Oh J-S. The effect of Graston technique on the pain and range of motion in patients
with chronic low back pain. Journal of Physical Therapy Science. 2016;28(6):1852-1855.
doi:10.1589/jpts.28.1852.
● Moon JH, Jung J-H, Won YS, Cho H-Y. Immediate effects of Graston Technique on hamstring muscle
extensibility and pain intensity in patients with nonspecific low back pain. Journal of Physical Therapy
Science. 2017;29(2):224-227. doi:10.1589/jpts.29.224.
● Laudner K, Compton BD, McLoda TA, Walters CM. ACUTE EFFECTS OF INSTRUMENT ASSISTED SOFT
TISSUE MOBILIZATION FOR IMPROVING POSTERIOR SHOULDER RANGE OF MOTION IN COLLEGIATE
BASEBALL PLAYERS. International Journal of Sports Physical Therapy. 2014;9(1):1-7.
● Acute effects of instrument assisted soft tissue mobilization vs. foam rolling on knee and hip range of
motion in soccer players. Markovic, Goran. Journal of Bodywork and Movement Therapies , Volume 19 ,
Issue 4 , 690 - 696
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Bibliography● Effects of a 4-Week Dynamic-Balance-Training Program Supplemented With Graston Instrument-
Assisted Soft-Tissue Mobilization for Chronic Ankle Instability. Jessica L. Schaefer and Michelle A.
Sandrey. Journal of Sport Rehabilitation 2012 21:4, 313-326
● Alotaibi AM, Anwar S, Terry Loghmani MM, Chien S. Force Sensing for an Instrument-Assisted Soft
Tissue Manipulation Device. ASME. J. Med. Devices. 2017;11(3):031012-031012-11.
doi:10.1115/1.4036654.
● Fousekis K, Kounavi E, Doriadis S, Mylonas K, Kallistratos E, et al. (2016) The Effectiveness of
Instrument-assisted Soft Tissue Mobilization Technique (Ergon© Technique), Cupping and
Ischaemic Pressure Techniques in the Treatment of Amateur Athletes΄ Myofascial Trigger Points . J Nov Physiother S3:009. doi:10.4172/2165-7025.S3-009
● Gehlsen GM, Ganion LR, Helfst R. Fibroblast responses to variation in soft tissue mobilization
pressure. Med Sci Sports Exerc. 1999;31:531–535.
● Davidson CJ, Ganion LR, Gehlsen GM, Verhoestra B, Roepke JE, Sevier TL.Rat tendon morphologic
and functional changes resulting from soft tissue mobilisation.Medicine and science sport
exercise.1997 Mar;29(3):313-9.
● Julie K. Wilson, Thomas. Sevier, Robert Helfst, Eric W. Honing, and Aly Thomann. Comparison of
rehabilitation methods in the treatment of patellar tendinitis. Journal of sports rehabilitation.2000
Nov; 9(4)304-314.
Bibliography
● Suzanne J. Snodgrass, Darren A. Rivett. Thumb Pain in Physiotherapists: Potential Risk Factors and
Proposed Prevention Strategies. Journal of Manual and Manipulative Therapy. 2013 Jul;10(4):206-
217.
● Sevier TL, Stegink-Jansen CW. Astym treatment vs. eccentric exercise for lateral elbow
tendinopathy: a randomized controlled clinical trial. PeerJ. 2015;3:e967.