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

Volume 23, Issue 3 ASHT TIMES 3

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.