Heavy Metal Treatment: Using Instruments for Soft

Tissue Mobilization Phillip Vardiman, PhD, LAT, ATC

Assistant Professor University of Kansas

Department of Health, Sport and Exercise Sciences Applied Physiology Laboratory

Background • Assistant Professor University of

Kansas • Graston Technique M1 Instructor to

KU Athletic Training Education Program

• Graston Module 1 and 2 • No funding for research has been

provided by GT or other company

IASTM

Overview

What is Instrument Assisted Soft Tissue Mobilization (IASTM)

History

Clinical Indications

Research Overview

Clinical Applications

Discussion

Questions

Instrument Assisted Soft Tissue Mobilization

A therapeutic modality and manual therapy technique that when combined with rehabilitative exercises improves musculoskeletal function.

History of IASTM

Gua Sha-(Gwah Shah) Gau = Scrape, Scratch and Sha= Sand(the reddening, petechiae that occurs) A.K.A. Coining, Spooning, Scraping

Cao Gio(Vietnam)- (ceow yah) Catch the wind

Kerokan(Indonesia)- coining, spooning, scraping

Traditional East-Asian Alternative Medicine

The use of an instrument to cause friction at the skin surface Transitory Petechiae Ecchymosis Thought to bring the static blood,

“wind”, or bad spirit from the body so that it can be carried away

IASTM

Gua Sha

Fascial Abrasion Technique (FAT)

Hawk Grips

Graston Technique

Fibroblaster

Adhesion Breakers

Ceramic Spoon

Techniques/ Types of IASTM

Clinical Indications

Pain

Soft Tissue Injury

Small and Large Treatment Areas

Decreased Range of Motion

Scar Tissue Restriction of motion Excessive Scarring (Keloid,

Hypertropic)

Fascial Restrictions

Unsuccessful Treatment With Traditional Cross-Fiber Massage or Therapeutic Massage

Tendinopathies Lateral Epicondylosis Medial Epicondylosis Supraspinatus Tendinosis Achilles Tendinosis Dequervains Syndrome Patellar Tendinosis

Fascial Syndromes Plantar fascitis ITB Syndrome Compartment Syndromes Trigger Fingers

Clinical Indications (Cont.)

Relative Contraindications Cancer

Burn Scars (Mature scars 9 months post-healing

Kidney dysfunction

Pregnancy

Medications, Anticoagulants, Steroids, hormone replacements, NSAIDS

Rheumatoid arthritis

Varicose veins

Absolute Contraindications

Open Wounds/ Unhealed suture sites/ sutures

Thrombophlebitis

Uncontrolled Hypertension

Inflammatory conditions due to infection

Contagious or infectious skin conditions

Hematoma/ Myositis Ossificans

Osteomyelitis

Unstable fractures

Research Overview Butterfield (2008) MSSE

Rabbit Model Cyclic Compression improved function, attenuated necrosis and

leukocyte infiltration following EEP

Haas et al. (2013) BJSM Rabbit Model Dose Dependent (N, Hz, Time) MLL aided recovery in active muscle

properties in rabbits

Loghmani and Warden 2009 Rat MCL complete disruption. Found the IASTM accelerated healing

Davidson et al. 1995 Functional assessment of rats after achilles tendon injury Found increased fibroblast proliferation with use of IASTM

1. Haas et al. Br J Sports Med 2013: 47:83-88 2. Cunningham and Butterfield; ASWEB.ORG

Research Overview

Vardiman, Siedlik, Hawkins, Herda, Cooper, and Gallagher (2013) Intramuscular Response to IASTM IASTM to Gastroc/Soleus Complex MTS, EMG, MMG, ROM, PT, PFAQ

Take Home IL-6 and TNF-α(p>0.05) Inflammatory Intramuscular

Myokines Passive and Active Muscle Properties are still being

analyzed (Stay tuned……..)

IASTM vs NO IASTM

0.5

0.6

0.7

0.8

0.9

Baseline 24 Hours 48 Hours 72 Hours

TNF-α

TNF-

α (A

rbitr

ary

Uni

ts)

0.6

0.65

0.7

0.75

0.8

0.85

Baseline 24 Hours 48 Hours 72 Hours

IL-6

IL-6

(Arb

itrar

y U

nits

)

Research Overview

Vardiman, Andre, Maresh, Graham, Gallagher, Moodie, and Moodie (2012) Functional Squat Test Pre/Post IASTM to

Functional Squat Test 3-D Motion Capture Assessment (ROM) and

PFAQ

Take Home No change in Functional Squat Performance No change in perception of functional abiltiy

IASTM, Functional Assessment, Perception of Functional Ability

Vardiman, Graham, Siedlik, Herda, Moodie, & Gallagher (2013) IASTM following SL-EEP Muscle Biopsies at 24 and 48 hours ROM, SL-1RM, Pressure Tolerance Found

SL1RM (P<0.001) PT (P=0.009) ROM (P=0.003) Greater in TL vs. CL and was significantly

greater over time (P<0.001) IL-6 and TNF-α (P>.05)

Take Home IASTM attenuated the decrease in ROM following EEP

Research Overview

IASTM After Eccentric Exercise

Case studies have shown Graston Technique® to relieve symptoms of….

carpal tunnel syndrome (Baker, 1999; Burke, 2007)

lateral epicondylitis (Haller, 1999)

achilles tendonitis (Hammer, 2008)

plantar fasciitis (Hammer, 2008)

Outcome data

60 subjects (20 in each group)

Hip adduction ROM increased 25% in GISTM group 15% in Gua Sha

Holtz BJ, Davey K, Engleman N, Kaeser C, Wood-Vossmer K, Bayliss AJ, Loghmani MT.

3 patients

Patients achieved a mean decrease in pain of 3/10 per the NPRS

Mean improvement of 11.2% LEFS Score 0 Minimum Score Score 80 Maximum score Lower the score greater the disability Minimal Clinically Important Difference = 9 scale points (11%)

Journal of Manipulative and Physiological Therapeutics (JMPT). 2011 Feb; 138-142.

10 patients

Numeric Pain Rating Scale - baseline to follow-up (p=.002)

Lower Extremity Functional Scale – baseline to follow-up (p=.017)

Global Rating of Change Score – 70% improved outcomes

GISTM used in combination with Dynamic Balance Training had the greatest effect on Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS) ankle ROM in 4 directions Star Excursion Balance

Indicates GISTM may be of benefit in treatment of CAI

5 treatment sessions

20% increase in LEFS

Decreased “at worst” pain rating from 7/10 to 3/10

APTA Combined Sections Meeting [poster presentation]. Chicago (IL). 2012 Feb.

Case Study

Warren, AJ. (2013) Effects of Graston Technique IASTM in the Treatment of Chronic Exertional Compartment Syndrome of the Lower Leg: A Case Study. Found

Visual Analogue Pain Scale (100 mm)

p = .013

0

5

10

15

20

25

30

Treat 1 Treat 2 Treat 3

Pre Tx

Post Tx

Short-Form McGill Pain Questionnaire

Questions 1-10 Sensory pain

p = .059

0

2

4

6

8

10

12

Treat 1 Treat 2 Treat 3

Pre Tx

Post Tx

Present Pain Index (PPI)

p = .038

5 = Excruciating 4 = Horrible 3 = Distressing 2 = Discomforting 1 = mild pain 0 = no pain

0

0.5

1

1.5

2

2.5

Treat 1 Treat 2 Treat 3

Pre Tx Post Tx

Global Rating of Change Scale (GROC)

From the time you began treatment until now

p = .03

0

1

2

3

4

5

6

7

8

Treat 1 Treat 2 Treat 3

Pre Tx

Post Tx

Flexibility rating out of 10 max

p = .42

Treat 1 Treat 2 Treat 3

Pre Tx 5 6 5

Post Tx 6 6 5

4.44.64.8

55.25.45.65.8

66.2

Fle

xibi

lity

Chart Title

Perceived Functional Ability Questionnaire (PFAQ)

Perceived Functional Ability Questionnaire (PFAQ)

Strength rating out of 10 max

p = .42

Treat 1 Treat 2 Treat 3

Pre Tx 7 5 5

Post Tx 5 5 5

0

1

2

3

4

5

6

7

8

Stre

ngt

h

Chart Title

IASTM

Musculotindinous Stiffness

EMG / MMG

Electromechanical Delay

Rate of Force Development Slope of the torque-time curve (∆ torque / ∆ time)

Rate of Velocity Development Slope of the velocity-time curve (∆ velocity / ∆ velocity)

Questions?