Assistant Professor

MPT (Musculoskeletal)

Rama University

Kanpur,  Uttar Pradesh, India 

Instrument Assisted soft tissue mobilization (IASTM) is a simple non –intrusive form of physical therapy to manipulate or deploy soft tissue structures of the human body. IASTM is becoming increasingly Popular these days among both practitioners and patients due its remarkable safety and efficacy profile. The therapy is non-aggressive, yet effective and can be applied either alone or in conjunction with supplementary exercises and additional modalities.(Baker et al.,2013).

What is IASTM?

IASTM is a procedure in which instruments are used to mechanically stimulate soft tissue structures to relieve Musculoskeletal Pain and discomfort and improve overall mobility and function. In other words, Utilization of Instruments to achieve similar effects as soft tissue mobilizations or massage with hands.

These include:                                                                            

1. Facial restrictions
2. Scar tissues
3. Adhesions
4. Thickenings
5. Fibrotic nodules
6. Fibrosis
7. Tissue generation

The IASTM instruments can  either be convex or concave in shape and are made up of different materials, including stainless steel, wood, plastics, ceramics and stone, out of these stainless steel instruments are  most popular ones used frequently in practice.

IASTM instruments are uniquely designed to provide an efficient detection of soft tissue dysfunction and accurate application of evenly applied force during treatment, tools help to apply different strokes at different levels of the body.

Introduction

IASTM is a expert myofascial interfernce used for soft- tissue maneuver. It is based on principle of James Cyriax. It is applied using instrument made up of stainless steel with grooved edges and shape that can verify to unlike body anatomical position and permit for deeper seepage. It is used for detection and treatment of soft tissue disorders. The technique itself is said to be evolved Gua sha which is a method used in Chinese  medicine. Gua sha uses instruments with sooth edges to scrape the skin till red blemishes occur, However Gua sha has different goals and application Method from IASTM.

History

In  many traditional and folk  medicines worldwide, several forms of instrument assisted manipulation that are very similar to IASTM. These  therapies have been around for centuries. Hence, there are quiet few stories on where IASTM originated. The roots can be traced back to ancient Egypt, China, India as well as Greece. However, the  most widely accepted origin of IASTM is Gua sha, is  a form of  traditional Chinese  medicine in which  the skin is scraped with instruments to make light bruising. Today IASTM has its own indications and limitations and practitioner of this therapy can be found in clinics, gyms as well as  sports teams.

Principles

In general IASTM has similar principles as conventional soft tissue mobilization. The purpose of this therapy is to make an ideal environment for the body’s self  maintenance mechanism, by either altering physiologic responses to injury or encouraging normal function in the musculoskeletal system. The approach involves through evaluation of the altered tissue properties and application of specifically directed techniques to encourage normalisation of the soft tissue dysfunctions.

IASTM is based on the concept of deep friction massage as proposed by Cyriax and Russell. The authors manifested a deep massage technique which must be applied transverse to the direction of specific tissue involved, to reach soft tissue structure like muscles, tendons and ligaments, to prevent adhesion of scars and to maintain mobility.

Physiological Mechanism of Iastm

Studies have label the satisfaction of IASTM at the cellular level. The inflammatory response begin through micro trauma to the pretentious tissue result in accelerated fibroblast proliferation, collagen synthesis, maturation and the remodelling of disorganized collagen fibre matrix collagen following IASTM application. Fibroblast is considered the most chief cell in the extracellular matrix (ECM). The repair regeneration and management is all carried takes place in the ECM. The ECM is synthesized by Fibroblast which includes collagen, Elastin and proteoglycans, among many other essential substance. Fibroblast have the quality to pretend as a mechano-transducers, which means they are able to find biophysical strain such as torque, shear, fluidflow, compression and can create mechanochemical response. Gehlson et al concluded that fibroblast production is directly  proportional to the magnitude of IASTM pressure.

IASTM have a neurophysiological effect  as it stimulates mechano-sensitive response through skin deformation by the instrument. Mechanosensitive response include mechanoreceptors which are responsible for two point discrimination and mechanonociceptors which are responsible for pain perception.

IASTM affects the vascular response to the injured soft tissue through increasing the blood flow.

Effects of IASTM

Instrument effectively breaks down facial restrictions and scar tissue. Ergonomic design of these instruments provides ability to locate restrictions to treat affected area with appropriate amount of pressure. The initiation of manage microtrauma to pompus soft tissue structure causes the stimulation of local inflammatory response. Microtrauma initiates reabsorption of inappropriate fibrosis or excessive scar tissue and facilitates healing activities resulting in remodeling of affected soft tissue surgery, Adherence with in soft tissue  may have developed as a result of incision, hold, recurrent strain or other mechanism, shattered down allowing complete repair of function.

Benefits

IASTM provides mechanical advantage, thus preventing over use of hands, provides deeper tissue penetration with less compressive forces to the interphalangeal joints, ninety one percent of the physiotherapist uses his thumb for some sort of physical manipulation and had to modify it due to thumb pain. Also it increases vibratory perception of physical therapist’s hand  while holding the instrument to altered soft tissue properties such as tissue restriction or adhesion.

Features

Instruments can be made of many materials. Polymers, thermoplastics, and aluminum can be acceptable. However, while more expensive, it is the author's opinion (after years of prototyping and listening to clinicians' opinions) that highly polished stainless steel has many advantages for daily clinical practice. These are: • Easily sanitized and cleaned • Durability over a lifetime of daily use •Low coefficient of friction when gliding over the skin • Excellent "feedback" when performing scanning strokes In terms of "shape," instruments forsoft tissue mobilization are generally divided into two categories-Point and Edge. T-Bars, Accuforce®, Jacknobber®, and Asian Medicine "cups" are examples that make point contacts. Runner's Stick, foam rollers, Gua Sha tools, and recent IASTM tools are examples that make Edge contacts. While there are merits in physical therapy for all these sort of tools,  IASTM is most frequently  related with profile edge tools. Tools can be made of numerous materials. Polymers, thermoplastics, and aluminum can be bearable. However, while more costly, it is the writer’s opinion that extremely bright stainless steel has many benefit for daily clinical practice. These are: •  sanitized and made microbefree at ease  • Durability over a lifetime •Low rate of  friction when gliding over the skin • Excellent "response" when scanning performing strokes In terms of "structure," instruments for soft tissue mobilization are generally split into two classifications-Point and Edge. T-Bars, Accuforce®, Jacknobber®, and Asian Medicine "cups" are examples that make point contacts. Runner's Stick, foam rollers, Gua Sha tools, and recent IASTM tools are examples that make Edge attachement. While they excel in physical therapy,  IASTM is most commonly related with profile edge tools. Profiles are described by their convexities, concavities, size/length, thickness, weight, grip, and edge radius. Of these characteristics it is important to note the below images regarding the scale of contact and thickness of edge radius: Profiles are described by their convexities, concavities, size/length, thickness, weight, grip, and edge radius. Of these characteristics it is important to note the below images regarding the scale of contact and thickness of edge radius As a rule, there are sharp radius edges (1/32"), standard radius edges (1/16")edges, and large radius edges (1/8"). Keen edges are little flexible for all around IASTM but are best for the neurological effects (mechanoreceptor stimulation) of graze strokes on the skin, or the origination of blots when a Asian Medicine Gua Sha rationale is deliberate."Calibrated radius edges are what are most commonly available on IASTM tools and, as such, are the commonly adaptable for a variety of treatment strokes. huge Radius edges are useful for bringing out deep Fascial Maneuver® type strokes, bringing out strokes over delicate tissue, or bringing out in depth force blowing without causing the patient pain.

Precautions

Initially one should be at eaze! The equipment focuses on optomated power and use less force than  if one uses one’s thumbs, fingers, etc. The last thing one would would do is to cause more (macro) inflammation to an injured area. The idea of "micro" trauma is exactly which is very clarified and particular supplication to generate connective tissue reproduction only within the enclosure of the tissue lesion. Welts, bruising, blots are an specification an individual treatment was too hostile. Apparently (but definately not all) risk factors are diabetic, recent scars, recent surgery, blood thinners, clotting disorders, steroiduse, open sores, and tattoos. More care to consider regarding IASTM treatment are: • Acute Injuries-many IASTM logical and the blow inconjunct with them are not appropriate for recent injury. However, edema stroking with a concave edge around the tissue-bringing interstitial swelling proximally out of the injured compartment is extremely beneficial. Following that, kinesio-tape can often be used to support the compartment and lessen further edema. • Performance Event/Life Event Timing-it is not a good idea perform an intense treatment (one that requires l-3 days of recovery) right before the championship game, marathon, work commitment, travel, etc. All you have to do communicate with your patient and adjust the treatment accordingly. • Compressive Neuropathy-Nerves are obviously not connective tissue and are extremely sensitive. A radiculopathy or nerve compression is treated by addressing the connective tissue adjacent to the nerve. Acquiring a tool that is effortless  to command along with an fixed apprehension of anatomy will make maneuver victorious. Be concious when handling in depth strokes with a extended edge, that may be by the way register too much pressure over a nerve. • Damage Tendons/Ligaments- Do not apply IASTM to the site of acute tendon or ligament injury. Understand the Kinetic Chain concept enough to know that the point of failure or site of pain is RARELY the primary site of myofascial dysfunction..• Bony eminences-relieve up force during the blow when  waged near or crossing over a bony marker. • Treatment Mark/Social Complications- occasionally subordinate during the correct application of IASTM, reddening, bruising, and capillary damage can be misunderstood as misuse, and either led the patient to make false assumptions, or cause embarrassment to the patient if the mark is in a visible area of the anatomy during social interaction. Case in point-the author left a mark on the levator scapulae the day before a female patient was to stand up in a wedding wearing a strapless dress.

Iastm Application

1. Wash your hands

2.  Position patient

3. Gloves

4. Tools Logistic

5. Ensure patient safety

6. Comfortable atmosphere

7. Sanitized tools

8. Application of cream

9. Choose local or regional area

10. Once identified, choose your treatment integration (Warm up, Scan etc).

11.  Total time should be 10-15 minute  (3 minute for each time).

12.  Approximately 2-3 sessions weekly (alternately).

 

Warm Up

 

Scan Area

 

Find Restriction

 

Treatment

 

Exercises

Indications Of Iastm

·  Carpal Tunnel	· Post surgical and traumatic scars
·  Plantar Fascitis	· Myofacial pain and restrictions
· Patellar Tendinitis	· Ligament sprains
· Patellar Tendenosus	· Medial Epicondylitis
· Heel Pain	· Lateral Epicondylitis
·  Achilles Tendinitis	· Non acute bursitis
· Dequervains Syndrome	· RSD
· Back pain	· Trigger finger
· IT Band Syndrome	·  MTSS
· Musculoskeletal Imbalances	· Chronic Effusion/Edema associated with sprains/strains

Contraindications

1. Open wound

2. Non united fracture

3. Thrombophelibitis

4. Uncontrolled Hypertension

5. Patient intolerance/ Hypersensitivity

6. Severe hematoma

7. Rashes, poor skin, eczema

8. Osteomylitis

9. Myositis Ossificans

10. Hemophilia

References 

1. Chaitow, L (2014) Fascial Dysfunction, Manual Therapy Approaches. Handspring, Edinburgh. (Chapter 12 is dedicated to lASTM, authored by Warren Hammer).

2. Myers, T (2014) Anatomy Trains, Myofascial Meridians for Manual and Movement Therapists, 3rd Ed. Churchill Livingstone, Edinburgh. (Excellent conceptualization of the Kinetic Chain).

3. Stecco, L (2004) Fascial Manipulation for MusculoseletalPain. Piccin, Padova. (An absolute essential for understanding the Kinetic Chain approach and the Hyaluronic Acid Theory of fascial dysfunction). ARTICLES: Available as full articles-P DF' s in a zip file-please request via e-mail.

4. BordoniB, Zanier E (2014) Understanding Fibroblasts in Order to Comprehend the Osteopathic Treatment of the Fascia. Hindawi. Pre-Publication Manuscript article ID 860934. (Great review current with the literature).

5. FarasynA, Meeusen R (2007) Effect of Roptrotherapyon Pressure Pain Thresholds in Patients with Sub acute Non-Specific Low Back Pain. ] Mus Pn15: 41-53. (Highlights a specific lASTMtherapeutic stroke).

6. Hammer, W (2008) The Effect of Mechanical Load on Degenerated Soft Tissue. ] BodywMov Ther12: 246 56. (Specifically related to IASTM technique).

7. Lewit, K (2004) Clinical Importance of Active Scars: Abnormal Scars as a Cause of Myofascial Pain. ] Man Phys Ther27: 399-402. (Listen to what one of the leaders in manual therapy has to say).

8. Langevin H, et. al. (2005) Dynamic Fibroblast Cytoskeletal Response to Subcutaneous Tissue Stretch ex Vivo and in Vivo. Am ] Physiol288: 747-756. Langevin H, et. al. (2010) Tissue Stretch Induces Nuclear Remodelingin Connective Tissue Fibroblasts. HistochemCell Biol133: 405-415. (All manual therapists should have a copy of this).

9. LoghamaniT, Warden S.(2013) Instrument-assisted cross fibermassage increases tissue perfusion and alters microvascular morphology in the vicinity of healing knee ligaments. BMC Complementary and Alternative Medicine 2013, 13:240.

 10. *Cheatham SW, KreiswirthE, Baker R.Does a light pressure instrument assisted soft tissue mobilization technique modulate tactile discrimination and perceived pain in healthy individuals with DOMS?.The Journal of the Canadian Chiropractic Association. 2019 Apr;63(1):18.

11. *↑Jump up to:13.013.1Kim J, Sung DJ, Lee J.Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application.Journal of exercise rehabilitation. 2017 Feb;13(1):12.

12. *↑Melham TJ, SevierTL, MalnofskiMJ, Wilson JK, HelfstJr RH.Chronic ankle pain and fibrosis successfully treated with a new noninvasiveaugmented soft tissue mobilization technique (ASTM): a case report.Medicine and science in sports and exercise. 1998 Jun 1;30(6):801-4.

13. *↑Wilson JK, SevierTL, HelfstR, Honing EW, Thomann A.Comparison of rehabilitation methods in the treatment of patellar tendinitis.Journal of Sport Rehabilitation. 2000 Nov 1;9(4):304-14.

14. *↑Snodgrass SJ, Rivett DA.Thumb pain in physiotherapists: potential risk factors and proposed prevention strategies. Journal of Manual & Manipulative Therapy. 2002 Oct 1;10(4):206