Confident Ambiguity

I currently work with a large percentage of patients who experience “complex ” and/or “chronic pain”. Many have multiple surgical intervention histories (most repeat surgeries), every known non-invasive treatment (multiple episodes of PT/chiro/body workers), and every known pharmacological intervention known to man. All of these patients share a similar story, they were all told that “X,Y,Z” would resolve their pain or dysfunction with absolute certainty, everyone told them it was a simple fix. Yet, here they are continuing in pain, or in worse pain, in front of me.

As I sit back and review many of these cases, the most consistent theme I see of why they continue to suffer is that the traditional differential diagnosis has failed them. Many were told they had a specific diagnosis and were given a specific treatment. Differential diagnosis is based in the contemporary utilization of “Occam’s Razor”, which is the principle that “Among competing hypotheses, the one with the fewest assumptions should be selected.” (Side note: Historically it has been argued this  statement is an inaccurate reference to Occam and was created by later philosophers) . Utilization of Occam’s razor is critical to many aspects of healthcare, in particular emergency medicine. However, regarding pain, it is a principle which falls far short. Pain is complex, not simple.

The absolute, “this tissue/disease is the issue”, which is both culturally and healthcare driven, is why we are in a chronic pain epidemic.When it comes to pain and movement, physical medicine and rehabilitation professionals need to come to terms with the complexity of pain. It is never a single factor, even if there is a single predominant source of nociception. This also holds true for acute injury, you must account the environmental factors and the processing, as well as the outputs:

 

Gifford Scrutinise Image

Louis Gifford’s Mature Organism Model – 1998

This understanding makes pain and movement complicated, it makes things a bit gray, there is no absolute. You must make a clinical decision to guide the treatment, you need to be able to identify red flags quickly, you need to identify some important tissue issues, but you also must be able to confidently proceed with fair degree of uncertainty with a great deal of grace and skill.  I call this skill, “Confident Ambiguity”.

Confident ambiguity allows a clinical decision to be made in the absence of an absolute diagnosis, and the absence of absolute certainty. Classically, you would look at it as a list of possible diagnosis, within your differential, but now you are asked to not just identify the possible biomedical diagnosis but also the psycho-social factors and assume for all of them to be present concurrently with a constant dynamic shift, as well as combined presence, in any given moment (Louis Gifford calls it the “Shopping basket”).

Research and clinical prediction rules help, but they need a larger framework to address all the concurrent layers of a biopsychosocial model. Personally, I, as well as many others, have been drawn to Ronald Melzack’s work on the neuromatrix at face value to help with developing a constant confident inventory of inputs/outputs  in the biopsychosocial model. At all times, while interacting, assessing, and treating, in the back of my mind I play the “input/output” game, which at first appears challenging, but over time is very re-assuring both for yourself and your patient based on the dynamic nature of the interaction. This same approach has been beneficial with performance enhancement.

Neuromatrix

Melzack, Ronald and Joel Katz. “Pain in the 21st century: The neuromatrix and beyond.”Psychological knowledge in court. Springer US, 2006, 129-148

Every pain experience and every movement dysfunction cannot simply be broken down to single tissue damage, single disease, length tension relationships, muscular imbalance, tissue restriction, or any other musculoskeletal emphasized diagnosis. You must learn to accept the fact that the tests you delivered ,which you so confidently felt were reproducible to a specific tissue or movement pattern, may at least in part be a “neurotag”, a pain and/or movement memory that is driving everything you see and feel. Furthermore, lumping the patient into a primary “psychosocial” driver of pain is a also problem, one cannot ignore sensory input, regardless of whether it is nociception or any other sensory input perceived as a threat.

Microsoft Word - Figure 5

Confused yet? Frustrated yet? Want to say that you feel that is impossible to treat while this scattered in thinking? I would kindly disagree, and so would my patients who would report that this information has for the first time provided them clarity and understanding of their pain and made them deeply understand the importance of their new treatment plan. Often, this is their first doorway opening toward meaningful lasting pain improvement.  It means the world to them when a clinician can honestly and confidently guide them through a process of explaining they’re not crazy, this is extremely complicated, and how “ambiguous” the pain experience truly is.


Todd Hargrove’s: A Guide to Better Movement

I haven’t updated in a while due to time devoted to opening a new clinic called Generation Care Performance Center.

However, I felt compelled to make a quick, blunt, review of Todd Hargrove’s: A Guide to Better Movement: The Science and Practice of Moving With More Skill And Less Pain. Simply put, this book is the most important book on movement in the last 20 years, possibly in existence up to this point. It will become a required reading for every movement professional to truly understand movement and pain. I have made pitiful attempts to touch on some of the concepts of this book in the past, but Todd has so elegantly written words which convey a clear understanding of the integration of movement in the Neuromatrix, that  I don’t know if I could ever add to it (but will foolish try at some point!). This book is fully accessible to both the clinician and the patient/client. Thank you Todd for your efforts, your clarity, and how incredibly affordable you have made this knowledge in an age of academic inflation. If you don’t buy this book, you are doing a disservice to your patients, and yourself. Buy it now!


Don’t Blame the Structure – The Role of Belief and Movement in Orthopedics

**Updated 2/16/14**

The purpose of this post is to have a central link on this blog which will contain brief summaries of the growing evidence demonstrating a continued need for us to examine the role of belief and movement interventions prior to pursuing surgical interventions for many common orthopedic conditions.

Please let me be clear that there are certainly clear need for surgical intervention for the management of symptoms, even in the absence of medical necessity. In fact, the structure may be involved and may have initiated the output from the brain, but may not necessarily be responsible for continued symptoms. However, the emphasis on structure has resulted in a growing trend towards excessive, unnecessary, expensive, and risky surgical procedures for the management of pain and movement dysfunction. These procedures are occurring despite clear evidence indicating that just because a “damaged” structure innervated with nocioceptors is removed or “repaired” and the patient feels better and/or moves better, the structure itself does not fully explain for the existence of the symptoms, nor does it fully explain for improved symptoms. The advent of placebo surgeries and increased number of true randomized controls for surgical intervention have opened a whole new realm of understanding of the role of structure in the human body.

This post is incomplete as it stands and will be constantly updated. I welcome any and all recommended additions to it, with the hope that it will grow into a stand alone section of the blog itself:

Arthroscopic Debridement for Knee Osteoarthritis
First, the landmark study by Moseley et al. which started it all in 2002 which showed that both  arthroscopic debridement (‘cleaning up”) and lavage (‘washing out’) were no better than placebo surgery for moderate to severe osteoarthritis: http://www.ncbi.nlm.nih.gov/pubmed/12110735

Second, Kirkley et al. addressed some the questions brought about from critics about the pain measures from the Moseley et al. This study compared arthroscopic debridement and lavage to physical therapy and conservative medical therapy and found again that  neither arthroscopic debridement nor lavage provide any additional benefit over physical therapy and conservative medical therapy: http://www.ncbi.nlm.nih.gov/pubmed/18784099

Third, Herrlin et al. found that arthroscopic debridement with physical therapy was no different than physical therapy alone: http://www.ncbi.nlm.nih.gov/pubmed/17216272

Fourth, Katz et al. looked at individuals with a meniscal tear and evidence of mild-to-moderate osteoarthritis on imaging found that arthroscopic partial meniscectomy with physical therapy had no better outcomes that physical therapy alone: http://www.nejm.org/doi/full/10.1056/NEJMoa1301408

Finally, the 2nd edition of the “Treatment for Osteoarthritis of the knee” from the American Academy of Orthopaedic Surgeons officially states “We cannot recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.” and their first recommendation in this association statement was “We recommend that patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engage in physical activity consistent with national guidelines.” with the following clarifying statement written within the recommendation that “The exercise interventions were predominantly conducted under supervision, most often by a physical therapist”.

Arthroscopic Meniscectomy
Most recently (December 2013), Sihvonen et al. compared  arthroscopic partial meniscectomy for patients age 35-65 with degenerative meniscal tears without knee osteoarthritis with placebo surgery and found that their outcomes were no different: http://www.nejm.org/doi/full/10.1056/NEJMoa1305189?query=featured_home

This is in agreement with earlier studies which also showed that arthroscopic partial meniscectomy followed by supervised exercise was no better than supervised exercise alone:
http://www.nejm.org/doi/full/10.1056/NEJMoa1301408 – (May 2013)
http://www.ncbi.nlm.nih.gov/pubmed/17216272 – (2007)

Spinal Fusion for Low Back Pain
A study which followed up on previous randomized controlled trials of spinal fusion versus exercise and behavioral therapy for chronic low back pain found that there no difference in outcome after 10 years and there is no evidence for continued deterioration of symptoms in the absence of surgical intervention. Making strong suggestion for avoiding fusion due to the increased risks of surgical intervention for spinal fusion: http://www.ncbi.nlm.nih.gov/pubmed/24200413

A meta-analysis of  666 patients (402 cases) over 4 randomized control trials demonstrated no benefit of spinal fusion over conservative treatment. The authors concluded the evidence was so strong that no further research was necessary: http://mobile.journals.lww.com/intjrehabilres/_layouts/oaks.journals.mobile/articleviewer.aspx?year=2014&issue=03000&article=00002

No different in outcomes between conservative treatment and lumbar fusion after 10 years:
http://www.ncbi.nlm.nih.gov/pubmed/24200413

Vertebroplasty
Multi-center trial which compared vertebroplasty to a simulated procedure (placebo) without cement for OSTEOPOROTIC SPINAL FRACTURES. The capital letters are for the fact that for the simulated procedure, those vertebrae are still “not secured” or “healed”. Despite this, outcomes between groups for pain and pain related disability were similar at 3 months. The authors did an excellent examination of cross over effects, well worth reading the full text: http://www.nejm.org/doi/full/10.1056/NEJMoa0900563

A similar study design was performed which also confirmed that the fractures were unhealed via MRI and expanded the follow-up to 6 months. Similarly no benefits for vertebroplasty over sham was noted: http://www.nejm.org/doi/full/10.1056/NEJMoa0900429

Miller et al. discuss verbroplasty and the placebo response here: http://pubs.rsna.org/doi/full/10.1148/radiol.11102412

A meta-analysis of these two studies concludes that the hypothesis of the possibility of a specific subgroup benefiting from vertebroplasty is unlikely to have unique benefits from vertebroplasty: http://www.bmj.com/content/343/bmj.d3952

Inappropriate imaging, excessive specialist referral, and lack of physical therapy referral for Low back pain
A recent study on trends in the management of back pain examine the treatment of back pain from January 1, 1999, through December 26, 2010. The researchers found a worsening trend in the management of back pain inappropriately referred for imaging and specialists when they should have been referred to physical therapy first: http://archinte.jamanetwork.com/article.aspx?articleid=1722522

Non-surgical intervention of atraumatic full-thickness rotator cuff tears
A multicenter study of 452 patients who are treated with physical therapy first rather than initiating surgery for full-thickness (complete) rotator cuff tears found that 75% of the patients after 2 years opted not to have surgery due to a satisfactory outcome from physical therapy alone: http://www.ncbi.nlm.nih.gov/pubmed/23540577

Achilles Ruptures treated non-operatively have equivalent outcomes to operative interventions
A randomized study of 144 patients with an average age of 40 revealed that non-operative treatment of achilles ruptures had no difference in functional strength, range of motion, calf circumference, functional scores, or re-rupture rate between groups. In addition, a greater number of soft tissue complications were noted in the operative group: http://www.ncbi.nlm.nih.gov/pubmed/21037028

Is ACL reconstruction the best management strategy for ACL rupture?
A systematic review and meta-analysis of ACL repair versus non-operative repair demonstrates poor available evidence for ACL interventions as a whole, but that current evidence appears to indicate that a non-surgical intervention should be attempted prior to considering surgical intervention. http://www.thekneejournal.com/article/S0968-0160(13)00199-3/abstract

MRI detection of disc herniation has no indication on outcome and is associated with lesser sense of well-being
In a study which examined both surgical and conservative treatment of sciatica and lumbar disc herniation, the presence of disc herniation on MRI after 1 year had no association with the outcome. 85% with the presence of disc herniation after 1 year of treatment still had a favorable outcomes: http://www.ncbi.nlm.nih.gov/pubmed/23484826

This is in agreement with previous research which revealed that not only was MRI findings not representative of the patients symptoms or outcomes, but that knowledge of the MRI findings resulted in a lesser sense of well being: http://www.ncbi.nlm.nih.gov/m/pubmed/16244269/

Surgical Scraping for Achilles Tendinopathy
In a study of patients with bilateral chronic achilles tendinopathy, surgical scraping performed on one side (the most painful side). Despite having expected to need a second surgery for the opposite side, 11 of the 13 patients had full resolution of symptoms bilaterally after unilateral scraping. Many already had full satisfaction bilaterally within the first 6 weeks. The authors make a good discussion why they believe these improvements were centrally mediated, not mechanically oriented: http://www.ncbi.nlm.nih.gov/pubmed/23193327

No difference in outcomes between arthroscopic acromioplasty and supervised exercise for shoulder impingement syndrome
A randomized control trial of 140 patients with shoulder impingement syndrome showed no differences in pain or function at any point over a 5 year follow-up. Furthermore, surgical intervention was not considered cost effective and the recommendation was that structured exercise should be the treatment of choice for shoulder impingement: http://www.ncbi.nlm.nih.gov/pubmed/23836479

Shoulder Impingement Syndrome and Central Sensitization
A trial which compared 17 age matched patients awaiting arthroscopic subacromial decompression to a matching asymptomatic control group and identified a significant proportion of these patients presented with notable central sensitization. Those with the most pronounced levels of central sensitization had significantly worsening outcomes at 3 months post subacromial decompression than those with lower levels: http://www.ncbi.nlm.nih.gov/m/pubmed/21464489/

Examining peripheral and central mechanisms in shoulder pain
Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain: http://www.ncbi.nlm.nih.gov/pubmed/23429268

The pain of tendinopathy: Physiological or Pathophysiological: http://www.bodyinmind.org/wp-content/uploads/Rio2013.pdf

The central nervous system e An additional consideration in ‘rotator cuff tendinopathy’ and a potential basis for understanding response to loaded therapeutic exercise: http://www.ncbi.nlm.nih.gov/pubmed/23932100

Multiple abnormalities of the hip are normal imaging findings in asymptomatic individuals, including labral tears
In a random sampling for 45 volunteers (60% males) with an average age of 37.8 y/o, MRI imaging revealed “Labral tears were identified in 69% of hips, chondral defects in 24%, ligamentum teres tears in 2.2%, labral/paralabral cysts in 13%, acetabular bone edema in 11%, fibrocystic changes of the head/neck junction in 22%, rim fractures in 11%, subchondral cysts in 16%, and osseous bumps in 20%”: http://www.ncbi.nlm.nih.gov/pubmed/23104610

Cervical surgery with physical therapy versus physical therapy alone resulted in similar outcomes after 2 years
Although surgical intervention demonstrated a more rapid improvement in the first year, these differences were no longer present after 2 years. Due to the decreased risks and decreases costs, physical therapy was recommended prior to considering surgical intervention: http://www.ncbi.nlm.nih.gov/m/pubmed/23778373/

MORE TO COME..


Post-Antalgic Patterning – Part 2 – Quick Reference for Manual Therapy and the Nervous System

*Note: This is part of a series of thoughts on the topic of looking at movement and movement related symptoms as influenced by the nervous system. These will be dynamic posts with additional content and references being added as time allows, but the primary purpose of the posts are to share my current thoughts on the influence of manual therapy and exercise on what we see and feel in our patients. I hope others will engage me in these thoughts and provide their perspectives and also criticism into the process.

In part 1, I wanted to provide the definition for post-antalgic patterning which I believe is important to understand before thinking about how we treat it (if it even needs to be treated), for which I lay the ground work here:

Post-Antalgic Patterning – Part 2 – A Quick Reference for Manual Therapy and the Nervous System

A little over a year ago Jason Silvernail released a great video summary on manual therapy and the nervous system called “Crossing the Chasm” which definitely had its intended effect on me. This discussion has been a “hot topic” for at least a decade. As I have attempted to share this same information with other clinicians, I have noted a trend towards wanting more “practical” connection between the techniques we use on a daily basis and the nervous system. As a result, over the last year I have started to formulate a way to bring a little bit of clarity to a very complex topic.

Mechanoreceptors – The elephant in the room

In most of our academic preparatory programs for various rehabilitation disciplines, our afferent and efferent sensory nerve fiber education has focused primarily on severe neurological conditions of the peripheral and central nervous system (stroke, spinal cord injury, CNS disease, etc.). However, when it comes to the role of the nervous system in musculoskeletal conditions, the focus tends to be on nocioception (note of importance: nocioceptors are NOT PAIN RECEPTORS!), chemoreceptors (in particular the relationship to inflammatory mediators), proprioception, muscle spindles, and the golgi tendon reflex. We might touch on some afferents when we talk about gate control, but in general, mechanoreceptors are a very minor part of “most” professional academic programming offerings. This is despite that fact that mechanoreceptors may be one of the bodies most densely dispersed points of interaction with our nervous system, in particularly in the tissues we commonly claim to be treating (joint capsules, fascia, ligaments, muscles, etc.).

I remember vaguely talking about Ruffini Endings, Merkel’s discs, Pacinian and Meisners Corpuscles, but I don’t remember much emphasis on them and I certainly didn’t see any value in even recalling their names at the time. Yet now I realize they are probably some of the most important structures I deal with on a daily basis, in particular when it comes to manual therapy interventions. We get so obsessed with the biomechanical properties of soft tissue and joints and the illusion that we can mechanically alter them through our hands and various tools despite growing evidence that this simply is not the case, or at best, has an extremely small role in the big picture. Yet we choose to ignore, or at the very least downplay, the one basic fundamental pathway, the cascade of neurophysiological events which occur every time skin is compressed. These events can result both in short term and long term tissue and movement quality changes which have the potential to explain every single “change” seen through the use of manual therapy. Furthermore, any inflammatory, fluid dynamics, or thermal responses which potentially could come about from an aggressive intervention could have chemical, thermal, and fluid interactions with mechanoreceptors, chemoreceptors, and thermoreceptors thereby compounding and/or altering an existing externally induced neurological stimulus. If the inflammatory, fluid, or thermal process remains active for hours or days, this could yield a sustained stimulus on mechanoreceptors, thermoreceptors, and chemoreceptors thereby influence the nervous system for an extended period of time (think of a “built-in portal e-stim unit” that already exists in all humans).

Perhaps more important than the external stimulus itself is the ability to modify, enhance, and/or guide the therapeutic outcome of the neurophysiologic response from the stimulus with an educational context provided to the patient, allowing for a profound impact on how they perceive touch and movement.

So what does the pathway for this manual therapy to mechanoreceptor stimulus to tissue quality/movement change look like? Dr. Schleip has perhaps best described this in his work on fascial plasticity, of which this diagram provides perhaps the most concise explanation of the relationship between manual therapy and the nervous system.

Schleip, R. (2003). Fascial plasticity–a new neurobiological explanation Part 2.Journal of Bodywork and movement therapies, 7(2), 104-116.

Schleip, R. (2003). Fascial plasticity–a new neurobiological explanation Part 2.Journal of Bodywork and movement therapies, 7(2), 104-116.

To further help solidify the connection between our commonly utilized manual therapy techniques and the nervous system, I put together a couple of acronyms to show the connection between groups of mechanoreceptors and various manual therapy technique:

“RuffMerks need tender care”

  • Ruffini Endings (End Organs) & Merkel’s discs are slow adapting mechanoreceptors which respond best to slow sustained and deep tension
  • ANS (PNS) & CNS interactions
  • General massage, myofascial release techniques, and possibly even ischemic trigger point releases likely preferentially engage these mechanoreceptors

“PacMeisners need action”

  • Pacinian and Meisners Corpuscles are fast adapting mechanoreceptors which respond best to fast & vibratory inputs and are key to texture discrimination (think edged/textured tools)
  • Predominantly CNS interactions although ANS (PNS) possible
  • Greater concentration subcutaneously are also more frequent on the tendinous site
  • IASTM style, cross friction (hand or tool), and oscillating techniques likely preferentially engage these mechanoreceptors
  • Also thought to play a role in high velocity manipulation

 “Free nerve endings do it all”

  • Some free nerve endings are intermediate adapting mechanoreceptors and can respond to any form of touch, or any modality (chemical, thermal, electrical) for that matter.

 “Ligamentous Mechanoreceptors – I got nothing”

  • 4 types, varying adaptability, primarily stretch mediated, although possibly facilitated through touch if the ligament is superficial enough to be compressed
  • Engaged primarily with mobilization/manipulation

Last but not least, how can so called “inert” soft tissue, or fascia, have tissue tension or “tonus”?

Smooth muscle fascia copy

More regarding the existence of smooth muscle cells within fascia can be found here.

To be continued in part 3..


Post-Antalgic Patterning – Part 1 – A Definition

*Note: This is part of a series of thoughts on the topic of looking at movement and movement related symptoms as influenced by the nervous system. These will be dynamic posts with additional content and references being added as time allows, but the primary purpose of the posts are to share my current thoughts on the influence of manual therapy and exercise on what we see and feel in our patients. I hope others will engage me in these thoughts and provide their perspectives and also criticism into the process.

Post-antalgic Patterning – Part 1 – A Definition
Injury occurs either acutely or cumulatively. A threshold is reached and threat is detected, whether conscious or unconscious, the body wants to protect itself. As a part of the physiologic chemical cascade of events which occurs in an attempt to address the potential structural damage, the nervous system, both central and peripheral, protects the region through numerous responses including localized guarding or splinting. This guarding process involves contractile activation of muscle AND the CONTRACTILE activation of what has previously been defined as inert soft tissue, such as fascia, joint capsules, ligaments (1). As a result, kinematics, arthrokinematics, and tissue dynamics may be altered and movement may change. Some of it is subtle, some of it not (2). Regardless, it appears that occasionally, this alarmed state stays active long after the tissue has healed and the threat removed (3).

Steering away from the complicated matter of pain, better discussed in Explain Pain, I wish to focus on what I call “post-antalgic patterning”. This is the existence of an altered movement pattern that is most often an unconscious behavior that remains long after an injury has been healed, or possibly even perceived injury. It exists anywhere in the body with any movement, not just gait! This pattern is a chronic pattern, which begins as early as 2 weeks after an acute injury and remains a minimum of 6 months or for a multitude of years. It may be associated with patient symptoms through regional interdependence, or it may not. Post-antalgic patterning may resolve spontaneously or it may best respond to touch and/or movement coaching. In this definition, any clinician perceived “dysfunction” of the joint or soft tissue contributing to this movement pattern is propagated by the nervous system, not structural change and is minimally influenced by joint or tissue inflammation or swelling.

This pattern may or may not be mechanically inefficient, and it may, or may not, further propagate future episodes of threat elsewhere in the body. In truth, it may just be what it is. Perhaps changing it makes functional improvements and improved symptoms, perhaps not. This is key, because we really don’t understand it, and we have to know when to just ignore it and have the patient move on with life despite this perceived asymmetry, because in reality, we do not know if it might have always been present. This is important, because you have to put limits on how much you try and attempt to alter, as the concept of a “symmetrical” human is fairly illogical. Rather, the objective is to simply to provide an environment to allow movement in a way that the patient can regain trust in these areas, to become more active, which is where the healing occurs.

Your hands or tools aren’t magic. They may or may not be appropriate to providing that supportive environment for altering this pattern, but if you use them, realize their sole purpose is to get the patient moving, reducing threat and letting the tissue re-accommodate to activity.

To be continued in part 2..

1.) Schleip, R., W. Klingler, and F. Lehmann-Horn. “Active fascial contractility: fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics.” Medical hypotheses 65.2 (2005): 273-277.

2.) Crosbie, Jack, Toni Green, and Kathryn Refshauge. “Effects of reduced ankle dorsiflexion following lateral ligament sprain on temporal and spatial gait parameters.” Gait & posture 9.3 (1999): 167-172.

3.) Gribble, Phillip A., et al. “The effects of fatigue and chronic ankle instability on dynamic postural control.” Journal of athletic training 39.4 (2004): 321.


What IASTM is, is not, and might be

The EDGE series

As indicated in my review of the EDGE series of tools and the fact that I am a re-seller of the EDGE (my disclaimer), I am a huge advocate of Instrument Assisted Soft Tissue Mobilization (IASTM) in terms of providing a different neurophysiological input in comparison to using your hands and reducing the amount of stress you place on your hands with soft tissue treatment techniques. I have found that with practice I can accomplish similar within session changes in ROM, strength, and symptoms as other manual techniques. At the same time, I question the rational of using tools to promote tissue healing and to break down scar tissue. I believe this approach has promoted far too aggressive treatment in the past, and at this time, we really do not have great evidence to support this philosophy of treatment. I hope this post provides some insight into why I have this concern.

What is the evidence for IASTM use?

While I believe IASTM to be a valuable tool in my rehabilitation arsenal with its own indications and limitations of use, there are some who have purported tools as being downright magical in their abilities to “heal” patients. Some major brands claim 80-100% success rates for nearly every musculoskeletal condition under the sun, but record and maintain these records privately, available on request only. From the published experimental study realm, far less data is available.

To date, only one randomized controlled trial in humans has shown a better outcome using a tool over hand based manual therapy intervention.  Wilson et al. (1) compared cross friction (using hands) to IASTM on individuals with patellar tendinitis. 20 subjects (12 men & 8 women) were randomly assigned to either the IASTM group (10 subjects) or the hand cross friction group (10 subjects) with both groups having the same standardized therex and modality interventions. The IASTM group had 8 treatments over 4 weeks and the cross friction group had 12 treatments over 4 weeks. Full resolution was considered having no swelling, no pain upon palpation, and minimal pain (<3/10) performing six single leg hops, squatting to thigh parallel, and performing an eccentric load step down. Clinical evaluation and self-reported questionnaires were completed at 0, 6, and 12 weeks.  Based on their full resolution criteria, at 6 weeks 10/10 subjects in the IASTM group had 100% resolved symptoms  and 6/10 in the cross friction group had full resolution. The remaining 4 from the cross friction group was crossed over to IASTM to be re-assessed at 12 weeks with 2 additional subjects accomplishing the full resolution criteria established by the researchers.

Only two other experimental studies have examined IASTM as an intervention. Burke, et al. (2) compared IASTM to soft tissue mobilization with hands on carpal tunnel syndrome and found that both were equivocal to each other. Blanchette et al. (3) compared IASTM to education, ergonomics, and stretching on lateral epicondylitis, IASTM by itself was found to have no greater or earlier improvements than the control.

Numerous level 2 evidence case reports and case series studies that examined IASTM have demonstrated favorable outcomes in isolation and after other interventions had failed.(4-9) However, as is the nature of these studies, they provide no insight on the mechanism or whether another intervention may have been just as beneficial.

From my personal perspective, I am not looking for magic and I have no concern whether outcomes using a tool may be equivocal to my hands or other interventions(2,3), because at the very least I know it does have a therapeutic effect. This now assures me that I can give my hands a break from time to time and be more willing to experiment a variety of patients using the stimulus of the tool as option, potentially identifying an individual who may be more positively responsive to the tool than you had previously assumed.

Can IASTM help with tissue healing?

Two of the largest names in IASTM make numerous claims regarding the tissue healing and “regenerating” ability of their IASTM tools and techniques. They both have webpages which claim amazing research evidence for their philosophy of treatment. Sadly, little of this “evidence” is available for public consumption. A quick glance at this list shows that only 3 studies on rats provide any insight on the role of IASTM in tissue healing. I will separate many of the popular claims of tissue healing into 3 categories to review the literature: Activate the histamine response and increase local inflammatory response, break down scar tissue and/or re-arrange some nondescript “fibers”, and increasing fibroblasts to the region.

Activate the histamine response and increase local inflammation

Oddly, although erythema is the most obvious effect noted clinically with IASTM, this is not something that is well studied. I have only been able to find one study which utilized Gua Sha to examine micro circulation. (10) The comparison of Gua Sha to IASTM is difficult to make because Gua Sha is significantly more aggressive than most forms of contemporary IASTM.  Gua literally translates “to scrape or scratch” and Sha can best be described as “red, raised,millet-size rash”. As shown below, it is extremely traumatic looking:

Gua Sha Treatment - NOT A GOAL OF IASTM!

I personally would never want to do anything like this one of my patients. With that in mind, the results of the study demonstrate that, shockingly, yes local superficial circulation is increased when you scrape the tissue.  However, this was after 7.5 minutes of aggressive treatment, which is far more than the average IASTM protocol. Furthermore, the circulation increases were noted as superficial, which questions the ability to infer increased nutrient delivery to, or removal of waste from, deeper muscle, tendon, or other soft tissue.

On a side note to those of us that are neurophysiologically minded, this study also examined Gua Sha’s effect on decreasing pain. After treatment, decreased pain was not only noted locally and regionally but also in  areas far distal from the treatment region. This finding made the authors themselves question the relevance of increasing local circulation for the purpose of pain relief. But I digress…

Scar Tissue (Type III collagen) break down and “realigning fibers”

So what about the idea of breaking down scar tissue or realigning fibers? Loghman and Warden examined IASTM on experimentally induced MCL injuries in rats. (11) They did not specifically address the soft tissue breakdown or “fiber realignment” but did note that “There were no grossly observable differences between ‘IASTM’ treated and non-treated ligaments at either 4 or 12 weeks post-injury; however, non-treated ligaments often had more adhesions and granular tissue, and were more difficult to harvest than IASTM-treated ligaments.” which to date is the only experimental discussion of tissue adhesions related to IASTM.

I will note that Dr. E has reported that a colleague of his is completing a ultrasound imaging study which notes changes in the fiber quality after 2-3 minutes of IASTM treatment. Since this study is still being prepared for publication, at this time I have not been able to review the results.

This is one area I would love to see evidence for tissue change, and I believe there is a “slim chance” for us to scrape “adhesions” surrounding superficial paratendons and tendon insertions around our distal extremities (ie: achilles tendon and insertion).  However, it is important to keep in mind that when we feel the “grittiness” or “adhesions” under our tools, we really don’t know what we are feeling. We cannot say with certainty that it is scar tissue we are feeling. We forget that way back in the day during cadaver dissection we used to see a lot of fatty tissue and non-deformable soft tissue adhesions subcutaneously which could easily explain what we are feeling. Further more, often times after several sessions of treatment, these “adhesions” rarely change, only the tissue tension and tonicity we originally aimed for changes. BUT, there are times that these “adhesions” do disappear after treatment, and I would like to know more about that.

Despite all this, I will not deny that secretly in the back of my head I would love to believe that me scraping paratendon sheaths is breaking up longitudinal “scar tissue” (type III collagen) and promoting movement of the sheath and therefore the tendon, but I recognize simple muscle activation and movement probably breaks up as much “scar tissue” as anything I am trying to do to the tendon with the IASTM tool.

Promoting Collagen Synthesis by increasing fibroblasts proliferation

rat

Increased fibroblast proliferation has been the only consistently demonstrated histological property of IASTM. (11,12,13) Although this has only been noted in rats.  Furthermore, Gehlsen et al. demonstrated that increased pressure from the tool resulted in greater fibroblast proliferation. (13) However, what the value of increased fibroblast proliferation is in the long term has not been demonstrated. Loghman and Warden’s rat MCL study showed that although the IASTM group had greater improvements in healing early on, by the 12th week, there were no histological differences in healing between treated and untreated rat MCLs.

And that’s it, that is all we know regarding tissue healing and regeneration related to IASTM. From evidence in rats only, we can promote fibroblast proliferation, but even in the rat studies, when compared to tissue healing without IASTM, no difference is noted after 12 weeks of healing.

Conclusion

Personally, I do not think the tissue healing concepts will pan out any better in future research, nor do I care if it does or not. It is too easy to fall into the “tissue quality” trap, where we chase the make-believe picture of “good quality tissue”, rather than looking at objective measures which are rapidly changeable to meet the patient’s functional goals. As with any manual therapy intervention, I am primarily interested in within and between session improvements which allow me to promote movement to get the patient moving which is ultimately the only thing that will change tissue. If IASTM helps tissue healing, it’s a bonus, but I do not want it to be focus of my treatment or my education.

I want to end this post with reference to a recent study by Alfredson, et al. which examined the most extreme version of tissue scraping, surgical scraping under anesthetic, in the treatment of chronic achilles tendinopathy. (14) In their study, they recruited only individuals with bilateral chronic achilles tendinopathy, and surgical scraping was only performed on one side (the most painful side). Despite having expected to need a second surgery for the opposite side, 11 of the 13 patients had full resolution of symptoms bilaterally after unilateral scraping. Many already had full satisfaction bilaterally within the first 6 weeks. The authors make a good discussion why they believe these improvements were centrally mediated, not mechanically oriented. It is an excellent read and well worth the time locating.

The Sales Pitch

With the understanding that many of the systems out there have little published evidence for the unique benefits of their expensive educational programs that they require you to complete in order for you to be able to purchase their IASTM tools. Why not consider one of the lowest cost options on the market with the best ergonomics, inclusion of all the most popular concavities and convexities (multiple tools in one), and no entry level requirements available in both stainless steel and plastic? Check out the EDGE and EDGEility series of tools!

1.) Wilson JK, Sevier TL, Helfst RH, Honing EW, Thomann AL. 2000. Comparison of rehabilitation methods in the treatment of patellar tendinitis. Journal of Sports Rehabilitation. 2000;9(4): 304-314.

2.) Burke, et al. 2007. A pilot study comparing two manual therapy interventions for carpal tunnel syndrome. Journal of manipulative and physiological therapeutics 30(1):50-61.

3.)Blanchette, Marc-André, and Martin C. Normand. 2011. Augmented soft tissue mobilization vs natural history in the treatment of lateral epicondylitis: a pilot study. Journal of Manipulative and Physiological Therapeutics 34(2):123-130.

4.) Slaven EJ, Mathers J. Management of chronic ankle pain using joint mobilization and ASTYM® treatment: a case report. Journal of Manual and Manipulative Therapy. 2011;19(2):108-112.

5.) Davies CC, Brockopp DY. 2010. Use of ASTYM® Treatment on Scar Tissue Following Surgical Treatment for Breast Cancer: A Pilot Study. Rehabilitation Oncology. 28(3):3-12.

6.) McCrea EC, George SZ. 2010. Outcomes following augmented soft tissue mobilization for patients with knee pain: A case series. Orthopaedic Physical Therapy Practice. 22(2):69-74.

7.) Hammer, W.I., Pfefer, M.T. 2005. Treatment of a case of subacute lumbar compartment syndrome using the Graston technique. J Manipulative and Physiol Ther. 28:199-204.

8.) Hunter, G. 1998. Specific soft tissue mobilization in the management of soft tissue dysfunction. Man Ther. 3: 2-11.

9.) Melham TJ, Sevier TL, Malnofski MJ, Wilson JK, Helfst RH. 1998. Chronic ankle pain and fibrosis successfully treated with a new non-invasive augmented soft tissue mobilization technique (ASTM): A case report. Medicine & Science in Sports & Exercise. 30(6):801- 804.

10.) Nielsen, Arya, et al. 2007. The Effect of Gua Sha Treatment on the Microcirculation of Surface Tissue: A Pilot Study in Healthy Subjects. EXPLORE: The Journal of Science and Healing. 3(5):456-466.

11.) Loghman, M.T., Warden, S.J. 2009. Instrument-Assisted Cross-Fiber Massage Accelerates Knee Ligament Healing. JOSPT. 39(7):506- 514

12.) Davidson, C.J. Ganion, L.R. Gehlsen, G.M., Verhoestra, B. Roepke, J.E., Sevier, T.L. 1997. Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Med Sci Sports Exerc. 29: 313-319.

13.) Gehlsen, G.M., Ganion, L.R., Helfts, R. 1999. Fibroblast responses to variation in soft tissue mobilization pressure. Med Sci Sports Exerc. 31: 531-535.

14.) Alfredson, H., Spang, C., & Forsgren, S. (2012). Unilateral surgical treatment for patients with midportion Achilles tendinopathy may result in bilateral recovery. British Journal of Sports Medicine. Epub Ahead of Print. Nov 28.


Quick Video Link: Furniture Slider Exercises – Multi-Planar Single Leg Squat

Furniture sliders are extremely inexpensive (less than $10 at Lowes) and extremely versatile. I was inspired by Ross from Ross Training to experiment with these tools. One of my favorite exercise progressions is a multi-planar single leg squat. The slider is a great cue to promote mobility and stability as well as adding flow to a sequence of movements. It easily allows progressions and regressions based on the needs of the individual.


EDGE IASTM Video Review

The EDGEility

Dr. E just released the EDGEility plastic (delrin) Instrument Assisted Soft Tissue Mobilization (IASTM) tool. I have been using the stainless steel EDGE tool for over a year now, therefore I thought it was time for another review and to compare both versions of the EDGE side by side. This time I went with a video review. Unfortunately, the choice of this medium once again highlights one of my greatest weaknesses… The ability to speak.

Hope you find it useful regardless:

If you want to have a quick written summary of the video without the fluff, I choose the EDGE series of IASTM tools over other tools based on:

1.) No Education Requirement

2.) Total Cost

3.) Ergonomics

4.) Choice of stainless steel or plastic


Quick Video Link: Maintaining Resistance throughout a Ground Based Rope Climb with Heavy Chain

Ground based rope climbs are great space saving full body pulling exercises. However, the top of the climb ends up being the easiest part of the exercise. Some heavy chain is a great way to maintain resistance throughout the climb. Just be sure to pad the support chain you wear well!

 


Learning about Movement – 2012 – Part 3

This is part 3, the last of a series of posts reflecting on some highlights in learning about movement that I experienced in this last year. In part 1, I addressed my experience with Applied Functional Science / Chain Reaction™ Biomechanics and presented an application of this approach using hip internal rotation. In part 2, I reflected my current thoughts on strength and conditioning. Now in part 3, I discuss my thoughts behind Fascia, Anatomy Trains, and Regional Interdependence.

Much of what we thought we knew about the biomechanical science of fascia and myofascial release is bunk. By saying this, I need to make it clear in advance that this does not change how we treat, rather it changes how we educate our patients and perhaps makes you think more critically about why you might, or might not, want to treat in a certain way. Greg Lehman provides an excellent review of fascial science on his blog.

fascia-man

So what about Anatomy Trains, which I have previously stated may be a beneficial overview for regional interdependence? As Dr. Lehman discussed, it is extremely unlikely that from a manual therapy standpoint we are making biomechanical changes to tissue. If anything, the biomechanical representation of Anatomy Trains better represents fascial adaptation to function and will only respond to progressive overload with daily stresses and exercise. Furthermore, if we look at function and movement, “Form Follows Function” , then the representation presented by Anatomy Trains may vary individually because tissue adapts to the stresses induced on a daily basis.

So we need to throw out the patterns presented by Thomas Meyers, correct? I personally do not think so. This is not the first time we have developed a general map which is not truly accurate of an individual representation. Our good friend the cortical homunculus also is an inaccurate representation of the somatosensory cortex.

Homunculus1

Why? Because the brain is plastic and the somatosensory cortex adapts to how we interact with the world over time, which is most clearly demonstrated by cortical reorganization in phantom limb pain. Yet we still can use the homunculus as a general representation to give us a visual to for understanding sensation. Similarly, I still believe that seeing the patterns in Anatomy Trains can help us better see movement globally and therefore help guide treatment with complex patients representations. From a movement perspective, especially globally, we need to have some way to compartmentalize all the information and how they approximately relate to each other. Joint by joint osteokinematics and arthrokinematics help but can get complex quickly when you combine them with muscles and fascia. Patterns, such as those represented by Anatomy Trains, which encompass both bone and soft tissue, can help compartmentalize and make treatment more efficient if used appropriately. Of course, the reverse is also true, chasing patterns religiously will also take away from the most obvious, efficient, and appropriate treatment approach. Needless to say, these patterns do manifest themselves in our clients and patients from time to time, and to be ignorant of their general representations will cost you and your patient time.

As a side note, we are in a new era of our understanding of pain, with increasing emphasis on a neurophysiological role in this picture. There may be some overlap between the cortical homunculus and fascial adaptation over time. Since fascia is highly innervated with Ruffini and Pacini corpuscles, changes in fascia from physical adaptation to stress and from habituation to particular forms of movement may influence sensory perception and could theoretically be represented in the somatosensory cortex. With some recent evidence regarding the possible existence of a nocioceptive map which overlaps closely with the somatosensory cortex, there is the possibility that sensory rich fascia may be the interface that allows some of our voodoo with regional interdependence to occur, and why sometimes, specificity matters. This is purely hypothetical, but some ground work for the role of fascia and tendon pain (including pain referral) and their related cortical representation  is discussed by Dr. William Gibson (His PhD thesis is available here: Pain sensitivity and referred pain in human tendon, fascia and muscle tissue.) But since we don’t have any other explanation for how manual therapy sometimes requires specificity and sometimes those points of specificity fall in the patterns represented by Anatomy Trains, this is where I am resting my patient education for the time being.

For a better summary than what I wrote above, I highly recommend a post by Alice Sanvito titled:  “If we cannot Stretch Fascia, what are we doing?”.