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To comply with professional boards/associations standards:• I declare that I (or my family) do have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship.•Requirements for successful completion are attendance for the full session along with a completed session evaluation.•Vyne Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.
Session 403: IASTM Redefined: Basic, Gentle Soft Tissue Techniques for Patient Care
Shante Cofield, PT, DPT, OCS, CSCS, CF‐L1
Leading the Way in Continuing Education and Professional Development. www.Vyne.com
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Take Home
Messages
Human Navigation
Sensory system
Mechanical vs. Neurological models
Stroke rate, depth, dosage
Fascial Glide – Dry Technique
Fascial Glide – Dry Technique
Risk Management
Why?
“Never be sure of what you think”
“You think, but are you sure of what
you think?”
Dr. Jean-Claude Guimberteau
Personal and professional reflection
What I Think We Are Doing
Feeding the Sensory System to
Improve Motor Output
Sensori-Motor Re-Training
Limits exist only in the mind
Pain Science – Paradigm Shift in Rehab
SIMPLE SOLUTIONS TO COMPLEX PROBLEMS IS NOT
WORKING
Biomedical
SocialPsychological
We are fearfully and wonderfully complex
Lorimer Moseley
IANSM
Instrument Assisted Neuro-Sensory Modulation
How to make chronic changes in tissues?
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Compliant+
mobile
Stiff+
Springy
+
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Chronic Changes
compliant REACTIVE efficiency+ =
mobility motor control
+ stiff
STABILITY
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corrective exercise - Used to normalize human movement before increasing training or exercise demands
kinesiology tape- A special sports tape that provides support while allowing full range of motion. Tape is used to decrease pain, unload tissue via decompression, and provide a novel stimulus that improves body awareness.
iastm - Instrument - Assisted Soft Tissue Massage - A manual therapy technique designed to provide direct, mechanical manipulation of irregular tissue.
rolling/balls/bands - A collection of tools used by athletes for manipulation of the myofascial system to normalize muscle tone.
assessment- The act of making a judgment about the quality of human movement
screening- The act of examining people to decide if they are suitable for a particular movement or exercise
Movement Pyramid
Mechanical Neurological
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Mechanical Effects
Dr. Robert Schleip • Debunked the idea of fascial release
(mechanical deformation of fascia)
• Dismisses the traditional explanations of thixotropy and peizoelectric-effect-mediated adaptation, and thoroughly describes fascial toughness.
• Concludes that plastic fascial change in response to moderate loading is “impossible to conceive.”
Superhuman
How much pressure necessary to distort tissue?
2000 LBS/SQ”
Dr. Geoffrey Bove • “It’s all about the interfaces”• Interfaces are essentially the fascial planes between
muscles, nerves, fascia, etc..• Lack of gliding is the enemy • Positive treatment effects are at the loose connective
tissue and not in the fascia • Early intervention is the key
Bove GM, Chapelle SL. Visceral mobilization can lyse and prevent post-surgical adhesions. Journal of Bodywork and Movement Therapies, 16, 76-82, 2012 doi: 10.1016/j.jbmt.2011.02.004
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www.mindray.com
Beneath the SkinSkin
Superficial Fascia
Deep Fascia
Muscle
Bone
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Langevin study : thoraco-lumbar fascial movement
Wet Dry
• Allows for Skin Glide • Stimulation of Sensory
Nerves
• Improves tangential forces• Improves gliding between
layers
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Dry Method
Pathological Adhesion?
Pre Blades Post Blades
Old School
Aggressive and intense manual therapy with no regard for the state of the patient’s nervous system is problematic
No Pain, No Gain
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NeurologicalEffects
Peripheral Effects
Central Effects
Body Maps
Connect the Dots• Redefining the maps
• Modern rehabilitation will be via normalization of sensation, motor control and the congruence of these factors
Smudging
Tactile Acuity and Pain
Science of touch
Making the Invisible Visible
Kinesthetic Cueing
Autonomic Nervous System -
Brain
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hypothalamic tuning
global muscle tone
intra-fascial smooth muscles
palpable tissue response
tissue manipulation
stimulation of mechanoreceptors
Robert Schleip
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1golgi receptors
(type Ib)
2
3
pacinian corpuscles (type
II)
ruffini endings(type II)
interstitial (type Iii/iv)
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4 types of fascial receptors
Fascial Tone Modulation
Pain Mitigation
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How to Navigate the Human Body
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Fascia Joint by Joint
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fascia as our roadmap
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Via the ectoderm
connected both mechanically and
neurologically
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it’s alive
fascia sensesrichest sensory organ
fascia transmits force globallycommon myofascial pathways for transmitting stability, strain, and responsedistributes strain
continuous interconnected weba GPS system of strain distribution
what is fascia
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mobility - ripple effect
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where you think it is, it ain’t.
Ida Rolf
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ankle restriction
• ripple:• calf/shin/hamstrings
• target tissue – ankle• ripple:
• foot
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Wainner, RS, et al. Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. J Orthop Sports Phys Ther 2007;37(11):658-660
“when the assessment is initiated from the perspective of a movement
pattern, the clinician is able to identify meaningful impairments that may
seem unrelated to the main complaint”
regional interdependence
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mobility vs. stability
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Foot StableAnkle** MobileKnee Stable (control)Hip** MobilePelvis/Sacrum/L-Spine Stable (Control)Thoracic Spine** MobileCervical Spine Stable (Control) Shoulder complex MobileElbow Stable (Control) Wrist Mobile
** key mobility centers
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movement screening methods
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all movement is a screen
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multi-planar approach
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1joint restriction:• Banded
distractions • Joint Mobilizations• Joint Adjustments 2
soft tissue shortening:
• Foam rolling• Ball release• Instrument assisted• Hands on release
Mobility Restrictions
ProtectiveBarrier
TissueGlide
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corrective exercise - Used to normalize human movement before increasing training or exercise demands
kinesiology tape - A special sports tape that provides support while allowing full range of motion. Tape is used to decrease pain, unload tissue via decompression, and provide a novel stimulus that improves body awareness.
iastm - Instrument - Assisted Soft Tissue Massage - A manual therapy technique designed to provide direct, mechanical manipulation of irregular tissue.
rolling/balls/bands - A collection of tools used by athletes for manipulation of the myofascial system to normalize muscle tone.
assessment- The act of making a judgment about the quality of human movement
screening- The act of examining people to decide if they are suitable for a particular movement or exercise
Movement Pyramid
1. Driver’s Education
2. The Method
– Graded Exposure Model
3. Treatment Strokes
– Pain Mitigation
– Movement Priming
– Relaxation
– Gliding (Dry)
4. Fascial Case Study
How?
Pain Science Community
To start: Have a Plan1. What do you WANT?
2. Find your BASELINE
3. PLAN your progression
4. Be PERSISTENT
5. Educate
Graded Myofascial Release
1. Slow Progressions
2. Avoid Flare Ups – Reduce the risk of undue trauma
3. Improve Tissue Tolerance
4. Distraction Therapy
Graded Exposure TherapySystematic desensitization, also known as graduated exposure therapy is a type of behavior therapy used in the field of psychology
Recently adopted to address Musculoskeletal conditions
Distraction Method
Driver’s Education
Treatment Edges
Hard Rock
Groovy Rock
Bottle Opener
Soft Rock
Alternative Rock
NarrowEdge
BluntEdge
Fine Tuning Edge
Finger Pads
Grip
Indications • Limited motion
• Pain during motion
• Motor dysfunction (poor motor patterns)
• Lack of tissue glide
• Poor body representation
Contraindications • Compromised tissue integrity (open wound, infection,
tumor)
• Active implants (pacemaker, internal defibrillator, picc/pump lines)
• DVT (Deep Vein Thrombosis)
• Cervical carotid sinus
• Inability to communicate
Disclaimer
Not necessary
5 Treatment Strokes:
1. Feathering = Pain Control 2. Rapid = Stimulation 3. Slow = Relaxation 4. Dry = Tissue Glide 5. Fluid Capture = Fluid Management
Treatment Strokes
SUPERFICIAL
DEEP
Depth
Interoception/Pain Relief
Pain = FeatheringInterstitial Stimulation
Manual Therapy myofascial therapists are usually concerned with direct biomechanical effects
ORwith the stimulation of specific proprioceptive nerve endings such as muscle spindles, golgi receptors
• Advisable that manual therapists target the interoceptive receptors (Interstitial Fibers) and their related upstream effects
Interstitial receptors
• Free Nerve Endings (Unmyelinated C-Fiber afferents)
• Low Mechanical Threshold
• Present in human hairy skin
• Project to the insular cortex
– Trigger a general sense of well-being/Pain Relief
– Increase vagal tone – Global relaxation
Pain – Feathering1. SCAN tissues targeted within
workout.2. IDENTIFY areas of
tenderness/tightness = TARGET TISSUE
3. SUPERFICIALLY FEATHER pressure on target tissue for 30 seconds to tolerance
4. ADDRESS tissues up/down stream to target tissue = RIPPLE
SCAN + IDENTIFY + FEATHER STROKE + RIPPLE
Pre Tension Model
Rate
Pacinian Receptors = FAST
Ruffini Receptors = SLOW
Contractile Properties of Fascia• Sensory and motor dimension• Dr. Staubesand:
– Network of smooth muscle-like cells (Myofibroblasts)
– Rich intra-fascial supply of sympathetic nerve tissue and sensory nerve endings
PRIMING= FASTPacinian Stimulation
Increasing Tone
Tactile AcuityBody
Representation
Smudging
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pacini mechanoreceptors:
• these receptors are primarily responsive to rapid pressure changes.
• Stimulating these receptors can result in improved proprioceptive feedback and controlled motor movement.
Body Map receptors
Tactile Acuity
PRIMING – FAST/Oscillating
1.SCAN tissues that will be targeted in specific workout out.
2.IDENTIFY areas of tightness/tenderness = TARGET TISSUE
3.QUICKLY oscillate over the area for 30 SECONDS = RAPID RELEASE
4.ADDRESS tissue up/down stream to target tissue = RIPPLE
SCAN + IDENTIFY + RAPID STROKES + RIPPLE
Beneath the SkinSkin
Superfiscial Fascia
Deep Fascia
Muscle
Bone
relaxation
Relaxation = SLOW
Ruffini Stimulation
decreasing Tone
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ruffini mechanoreceptors:stimulation of ruffini corpuscles is assumed toresult in a lowering of sympatheticnervous system activity (van den Berg & Capri1999).
slow deep tissue techniques tend to have arelaxing effect on local tissues as well as on thewhole organism.
It therefore appears that deep manual pressure– specifically if it is slow or steady- stimulatesinterstitial and Ruffini resulting in global musclerelaxation, as well as a more peaceful mind andless emotional arousal.
inhibitory receptors
Relaxation
Relaxation – SLOW/Deep1. SCAN tissues targeted within
workout.2. IDENTIFY areas of
tenderness/tightness = TARGET TISSUE
3. Deep/Slow pressure on target tissue for 30 seconds to tolerance
4. ADDRESS tissues up/down stream to target tissue = RIPPLE
SCAN + IDENTIFY + RECOVERY RELEASE + RIPPLE
gliding
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interlayer gliding
Dr. Geoffrey Bove • “It’s all about the interfaces”• Interfaces are essentially the fascial planes between
muscles, nerves, fascia, etc..• Lack of gliding is the enemy • Positive treatment effects are at the loose connective
tissue and not in the fascia • Early intervention is the key
Bove GM, Chapelle SL. Visceral mobilization can lyse and prevent post-surgical adhesions. Journal of Bodywork and Movement Therapies, 16, 76-82, 2012 doi: 10.1016/j.jbmt.2011.02.004
136
137
www.mindray.com
138
139
Langevin study : thoraco-lumbar fascial movement
Wet vs. Dry Treatment Dry Treatment – Improve Skin Drag to
create tangential load to skin/fascia
– Stimulating RuffiniEndings that respond best to skin shear
– Improved gliding effect (fascial interface)
Wet Treatment – Allow for superficial
skin/fascial stimulation at a faster rate (Pacinian Corpuscle)
– Allow for feathering effect on interstitial fibers (interoception)
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Rx
Tool Assisted Mobilization:
Target Tissue Tx = 10-30 secsRipple above and below = 10-30 secs90 secs (approx) region
90 Seconds – Curative Dosage
Goals:
ScreenPain ReliefprimingrelaxationROM – gliderippleFascial/jxjre-screen
Case Study
PerformanceBackChain
Sagittal Plane Correction
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Sagittal planar dysfunction
In Summary • New perspective of manual therapy
• Neurological tweaking of the brain
• Navigating the human body
• Fascial IANSM
• Dry Instrument assisted method
• Scrape, tape, train model (movability)
• LESS IS MORE (limits flair ups)