PRESSURE PERFECT
By
Vladimir Camurungan, PT, FAAOMPT
Soft tissue mobilization or STM is one of the many tools a manual physical therapist uses to mobilize muscles, fascia, tendons and ligaments. STM is performed for the purpose of achieving beneficial effects on the muscular, nervous and circulatory systems. There are many forms of STM existing today ranging from the use of our extremities such as thumb, knuckles, forearm and elbow to the use of steel, ceramic or plastic instruments such as Graston Tools and the Fibroblaster. The latter technique is referred to as Instrument Assisted Soft Tissue Mobilization or IASTM and has been gaining popularity among physical therapists over the manual ones.
The Chinese developed a form of Instrument Assisted Soft tissue Mobilization called Gua Sha that can be traced back to ancient folk medicine. The ancient Greeks and Romans augmented this practice with supplementary instruments. They used metal tools know as “strigils” to remove dirt and sweat from the body. Thus the first instance of Instrument Assisted Soft Tissue Mobilization (IASTM) started with these civilizations.
The most modern version of IASTM started with the misfortunes of a certain Dave Graston in the 1990’s. He was a machinist who suffered from a persistent knee problem that he sustained from surgical complications. He found out that physical therapy treatment and exercises were tolerable when he performed a cross friction massage using the edge of a number 2 pencil. This paved the way to the development of IASTM tools in the present market.
Because of the success of IASTM in the rehabilitation field, there are now documented studies that chronicle the success of IASTM in the treatment of musculoskeletal disorders. Patients’ symptoms, ROM, strength and functions are but a few of the documented improvements. With the resurgence of this popularity came also questions concerning force usage and the way the tools are used.
The most common rational in using IASTM during treatment is to promote healing, to break down scar tissues (type 3 Collagen Fibers being replaced by Type 1 Collagen Fibers) and realign fascia. This has led clinicians to conclude that the simple application of more force will lead to better clinical outcomes. We had experiences in the clinic where patients that had IASTM from other health practitioners were severely bruised by the treatment. Is this type of aggressive treatment really warranted in this day and age? Are we really producing these proposed effects? What are the studies that refute or support this proposed effect of breaking down or reducing scar tissues?
A study performed by Chaudry and Schleip in 2008 look into the forces it would take to deform the various fascia of the human body. They have calculated thru different mathematical formulae that the forces needed to deform the different fascial systems of the body by 1% ranges from 1,142-lbs/square inch to 2,826-lbs/square inch. Is it humanly possible then during IASTM to produce this much forces? I do not think so. For more information about this journal please go to this website: http://www.jaoa.org/content/108/8/379.full. (Just a word of caution, this journal contains a plethora of mathematical calculations and jargon, and can be overwhelming) The last two pages of the document contain particularly important information concerning the amount pressure it would take to deform human fascia.
A further study published in JOSPT in 2009 by Loghman and Warden looks into the claim of breaking down adhesions, realigning fibers, and accelerating the healing process in general. They look into the effects of IASTM on experimentally induced MCL injuries in rats. The conclusions are as follows: IASTM has minimal to no effect in terms of augmenting the overall outcome of the ligament-healing process. For more information on this journal article please go to this website: http://www.scottsevinsky.com/pt/reference/physiology/jospt_graston_efficacy_ligament_healing.pdf
These previous studies beget another question. Why are we successful when we do the aforesaid technique if we are not able to manually deform the fascia? Dr. Schleip gave a most plausible explanation on his 2003 work,“Fascial Plasticity”. This journal article can be accessed thru the Journal of Bodywork and Movement Therapies. He proposes that, instead of directly affecting the fascia, we in turn stimulate mechanoreceptors such as Ruffini Nerve Endings, Pascinian and Meisner’s Corpuscles that trigger responses to the Central Nervous System (CNS) or the Autonomic Nervous Systems (ANS). The CNS activation will create relaxation of the involved local skeletal muscles. The ANS activation, on the other hand, can create lessened tonicity of the Global Muscle and interfascial smooth muscles. Both of these pathways will create decreased tension in the fascia.
Now comes the question of how much force to use? Again, the way to address this question is looking into the mechanoreceptors that we want to stimulate. Rather than considering the amount of force, it would be beneficial to look into the different characteristics of strokes. Ruffini nerve endings respond to slow and sustained amount of force. Pascinian and Meisner’s corpuscles respond to fast and vibratory inputs. With this in mind, you have to find out with your patients what type of stroke that they will respond to. Remember no two patients are alike and they respond differently to different inputs.
Knowing this information, it would be wise for us to rethink the way we educate our patients in the clinic about soft tissue mobilization. The proposed effects of the IASTM can be best explained thru the perspective of neuroscience as explained by Dr. Schleip. The forces generated by this technique influence mechanoreceptors input, which in turn influence changes in the tone of musculoskeletal muscles or interfascial muscles attached to the fascia. Remember to know your tools and to know them very well.