Tag Archives: Manual Therapy

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.


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


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?”.


Learning about Movement – 2012 – Part 1

This is part 1 of a series of posts reflecting on some highlights in learning about movement that I experienced in this last year. I hope to be able to do this on an annual basis as a record of self-reflection and hopefully provide some value to others out there on the same journey.

Applied Functional Science / Chain Reaction™ Biomechanics

SKBK_WuShu_Aerial_R

I have previously discussed my interest in going more in depth into multiplanar movement with my posts on 3D stretching as well as regional interdependence. I have used the FMS and SFMA off and on for a few years and felt they were both efficient and useful for their respective purposes, and I love that the research community is actively exploring the validity and reliability of these tests. I will still utilize components of these tests from time to time. However, I have personally found I need to change to a more customized approach to evaluation. In the past, I have found that in the middle of testing, I would break out of the protocols established trying to “tease” out something that did not fit cleanly into any of the tests. Part of this is just my nature, I have a difficult time adhering to standardized procedures and the way I do things just kind of evolves and varies depending by how I perceive something is presented to me. As these breakout sessions grew in complexity, I knew that for me personally I needed to explore some other philosophies which probably have figured out things I have yet to even think to ask about. Gary Gray’s Applied Functional Science (AFS) was the first approach that peaked my interest after that point. Gary Gray arguably pioneered much of the functional training movement, with Gray Cook stating publicly he has been strongly influenced by Gary Gray’s thought process. However, getting to the point of wanting pursue learning about the AFS approach has been a 4 year journey. When I first watched videos of Gary demonstrating and discussing his thought process, I completely disregarded it because my bias at the time of what I was seeing was an awful amount of poor quality movement with no regard for what is currently considered stability, in particular with movement of the spine. But over time, I could not deny that this freedom of motion looked more useful than I had first thought. I finally bit my lip and jumped in, eventually realizing I need to at least give it a try. It was probably one of the best decisions I could have made and now has significantly influenced how I view movement and exercise prescription.

I was given the opportunity to be exposed to the AFS approach through a nine week clinical rotation at Shoreline Sport & Spine in Spring Lake, MI. There are currently 6 Fellows of Applied Functional Science™(FAFS) at this location. A FAFS has completed a 40 week fellowship through Gary Gray’s Applied Functional Science (AFS) approach. The clinicians at Shoreline have integrated AFS with a wide variety of manual therapies and other interventions which was a fantastic eclectic experience that allowed me to explore a number of ways to integrate this philosophy.

Before presenting on this topic, I must first acknowledge that these are my personal reflections on the experience, and if they are in error, they should not reflect upon the excellent clinicians at Shoreline Sport & Spine. I am certain more than one FAFS will perceive I might have missed the boat on key points, and to that, I respond that I plan to formally take a Chain Reaction™ course in the future to see what else I might have missed. Furthermore, I am commenting on but a drop in the ocean of what the AFS system entails. The “Functional Nomenclature” alone requires a 44 page manual to address simply the language and fundamental principles. That being said, here are some key things I learned from this experience:

“Drivers facilitate chain reactions throughout the body”

This was the earliest, most applicable, concept I learned from my exposure to the AFS/Chain Reaction model. It may seem like a simple statement but it is incredibly profound when broken down even a small amount. Rather than simply thinking about one joint moving on another and leaving it at that, the Chain Reaction model demands that every joint be examined from a proximal on distal and distal on proximal perspective, what are the joints above and below doing, and what planes of motion (sagital, frontal, transverse) all of the joints are moving in during any musculoskeletal action. Central to this is the concept that during movement, a driver leads the movement and the joints above and below follow that same movement, but at different speeds as they progressively move in the direction dictated by the driver. This delay in speed/timing of a bone following another bone is the Chain Reaction explanation for much of what we understand about arthrokinematics. When bones move on top of each other in multiple planes of motion in the various representations of roll, glide, spin, etc.,  they are doing so according to the congruencies afforded to them to allow them to follow the next bone and joint as led by the driver.

In most of our manual therapy courses, we examine relative motion of one joint on another and addresses joint movement in various planes of motion based on arthrokinematics. Traditionally, looking at joints this way was left to the manual therapy realm and not the exercise prescription realm. Oddvar Holten likely made the earliest attempt to merge the manual therapy perspective with exercise prescription with his Medical Exercise Therapy (MET – Not to be confused with muscle energy technique) which focused on utilizing various apparatuses to isolate spinal segmental levels and extremities and then focusing on patient induced movement into one or more planes of motion specific to the desired outcome determined in the manual therapy diagnosis. The Chain Reaction approach more broadly addresses this by including concepts more similar to regional interdependence and primarily using the patient’s own body and extremities to control the levels of segmental or joint emphasis through prepositioning such as: Holding on to a stable or unstable support, modifying the weight bearing surface (wedges, angles, instability), conscious prepositioning, etc. It then utilizes another joint or point of the body above or below (could be FAR above or below) to facilitate movement at the joint in the plane, or planes, desired. This approach is both a diagnosis and a treatment, which is the focus of the AFS approach. It integrates extremely well with existing manual therapy interventions, or in Gary’s opinion, independent of traditional manual therapy models, resulting in him developing his own manual therapy system specific to the AFS called Functional Soft Tissue.

Getting back to the idea of a “driver”. A driver is anything which “drives” motor behavior. This could be any part of the upper extremity, lower extremity, trunk, neck, head, eyes, sense organs, and/or even fears and beliefs. The driver itself has numerous variables which can be applied to it: Is it open or closed chain based? What action is performed? What is the direction of movement? What is the speed? What are the force demands? Etc. etc.. This is just a small list amongst many other variables, not even addressing fears and beliefs.  The entire process can get very complex, very quickly, when broken down in the nomenclature which requires looking at every movement from the perspective of:

  • What environment is it occurring in (given available, or specified with certain controls on stability)?
  • What is the beginning position (upright, seated, kneeling, prone, supine, sidelying)?
  • What exactly is the driver (hand, knee, foot, pelvis, trunk, shoulder, etc)?
  • What is the triangulation (direction/target)?
  • What is the action (squat, lunge, reach, pull, etc)?
  • What is the ending position?

I am not qualified to go into that sort of detail, so instead I will provide a broad overview with a contemporary example. Many of us are already applying general versions of this thought process, but do not realize how far we can take it. I will use the example of a kettlebell swing.

 Kettlebell Swing

If you give a new client a kettlebell and only cue them to swing the kettlebell, they will instinctively “drive” the motion using the arms and shoulders, not their hips as you may have originally intended. They do this because you just gave them a cue which facilitates a motor pattern to accomplish the goal in the simplest way the brain understands, which is to swing their arms to swing the kettlebell, rather than to accomplish the exercise prescription goal you had intended, which was likely hip extension. If you change the cue to “Drive the hips forward”, you changed the driver of the motion to the hips, rather than the arms. Now in order to produce the force to swing the kettlebell, the individual will use a hip extension strategy. You just changed the entirety of the neuromuscular patterns utilized, even though you had the exact same exercise setup. Change the driver and the motor behavior changes.  Now, if you expand this to joint by joint, things get really interesting.

Take for example working mobility and stability of hip internal rotation. There are a handful of non-weight bearing activities which involve the femur actively or passively internally rotating on the pelvis.

ch158f14

We may begin with a manual therapy intervention to address mobility, then provide a mobility exercise, then a stretch, then we prescribe an exercise for stability, then we address another joint which may be associated, and we give it a mobility exercise, and a stretch, and a stabilization exercise, on and on we go. We may end up providing a large amount of exercises, all of which take time, with very specific cues and details to remember. Now with AFS, if we apply the concept of a driver along with any number of subtle changes, or “tweaks” as Gary likes to call them (the process is called “tweakology”), we can tailor a custom exercise specific to our patient needs across multiple joints with reduced need for extensive cuing and details. This can be done with fewer exercises overall because we can integrate mobility, stability, and movement across multiple joints, in multiple planes of motion, into simple exercises which require less time for the patient perform. Progression and regression are simple to teach because you are using movement patterns the client/patient already knows, you simply tweak one or two components to make changes towards the movement you want to improve.

As I am already far over my target word count for this post, I will finish with a video in which I discuss some basic strategies to emphasize hip internal rotation in weight bearing and function:


Moving Beyond the “Rest” of RICE in Acute Inversion Ankle Sprains

Back in August, a group of authors, van den Bekerom, et al. published an article in the Journal of Athletic Training which reviewed the evidence for the use of RICE in acute ankle sprains1. The authors concluded that, other than some extremely limited and low quality evidence for ice, there is very little evidence for rest, compression and elevation. The most interesting to me, and purpose of this post, was the discussion of rest, which I felt the was best summarized from the article itself: “All included studies had a similar conclusion: some type of immediate posttraumatic mobilization is beneficial in the treatment of acute ankles sprains“. And curiously, although this was a team of medical doctors writing this article, it appeared that form of mobilization was preferentially (not directly stated) manual therapy.

Although I have not had a chance to do a thorough follow-up lit review myself (always a good practice in reviewing systematic reviews), based on references selected by these authors, it appears there is more published evidence (regardless of quality) towards the use of manual mobilization/manipulation2-6 than activity/exercise7-9. Of particular interest was an examination by Eisenhart, Gaeta, and Yens6, which  examined the use of manipulation (fibula, talocrural, cuboid, and anything else clinically determined), soft tissue techniques (fibularis/peroneals, etc.), and lymphatic techniques combined with RICE (with or without pain meds) in comparison to RICE alone (with or without pain meds) in an emergency department. The group which received manual therapy demonstrated decreased pain, decreased edema, and improved dorsiflexion/plantar ROM (ROM was not statistically significant though) compared to group that received RICE alone. Since it typically does not get more acute than patients showing up at the emergency department, I felt this was a great study to demonstrate the value of manual therapy for acute ankle sprains. Combined with evidence that long term restrictions in posterior talar glide post ankle sprains4, there is clearly evidence for some form of early manual therapy in most inversion ankle sprains.

Despite recognizing the increased risk of compensation injury and general increased risk of injury from deconditioning, RICE, in particular rest and relative immobilization, remains the mainstay for the acute inversion ankle sprain. It is my belief (and I am sure many others) that this treatment philosophy needs to change at every level of patient care, and I believe athletic trainers and physical therapists need to lead the way. Although consideration for the individual patient should be made, as a general guideline, if we are presented with a patient with an acute inversion ankle sprain, our thought process needs to move away from the “rest/immobilization” component unless there is a clear need. Obviously “RELATIVE REST”, ie: not return to full sport participation may be a short term need, but full immobilization and crutches for the purpose of non-weight-bearing is likely unnecessary and potentially harmful. Instead, once a fracture or significant traumatic instability is ruled out, make the foot and ankle move, both actively and passively, and ideally with full weight bearing. Clearly if an excessively antalgic gait is present and cannot be resolved with manual therapy, tape, or other modalities, an assistive device may be necessary to improve the quality of gait, but ambulation with gait training to avoid compensation should occur early.

For those who prefer guidelines towards directing treatment, Whitman, et al. 10 developed a CPR for predicting whether thrust, non-thrust manipulation, and exercise in acute inversion ankle sprains could improve outcomes. They were able to determine that the presence of 3 out of 4 variables: Symptoms worse when standing, symptoms worse in the evening, navicular drop greater than or equal to 5.0 mm, and distal tibiofibular joint hypomobility were present; are predictive of dramatic improvements with a 95% success rate in treatment outcomes if manual therapy and exercise interventions are utilized.

To drive home these points I have 2 recent cases I want to share to demonstrate the clinical value of manual therapy in the management of an ankle sprain. Case 1 involves a 55 year old female who recently experienced an acute ankle sprain after waking up in a recliner and getting up rapidly, not realizing her left lower extremity had “fallen asleep”, resulting in a significant inversion of the left ankle and a “not so graceful” landing onto the floor. Initial evaluation revealed she was positive for 3 of 3 of the Ottawa ankle rules, so she was referred for X-ray. X-ray was cleared, she was provided crutches, and she presented to me 16 hours post injury with significant swelling and difficulty weight bearing. I performed distal fibular head mobilizations and talocrural mobilizations which result in immediate visible decreases with swelling without the involvement of any lymphatic techniques. Furthermore, it allowed the patient to weight bearing with 80% decrease discomfort. Additional soft tissue treatments of the peroneals and lateral aspect of her gastroc allowed her to ambulate without an antalgic gait, and without the crutches she arrived with. Although she still reported some mild discomfort, she was able to be off her crutches from that point on. I was able to see her for 2 sessions before she was sent on her own with 90% improvement within a week after her initial sprain. I would have liked to continue to work on the foot ankle, but she was private pay and she was satisfied with the improvements she already had, I discharged her to HEP with self mobs and progressive strengthening and instructions to keep moving. Clearly I can’t say if these outcomes would have been any different had she been partial-weight bearing for a week or more, but I can say that I was able to produce immediate functional improvements which improved the quality of her life sooner rather than later.

Case 2 is a story of me, jumping for a Chinese flying lantern stuck in a tree, not realizing on return to the earth my ankles would need to accommodate to a muddy ditch with a 75 degree decline in a very short amount of time. Unfortunately, they did not accomplish this goal and I crumpled like a sack of potatoes with the right ankle significantly inverted under my collapsing body. Of course I had just read this article from van den Bekerom, so I got right up and tried to avoid limping for the rest of the evening. Keep moving and it will just resolve itself right? Well nearly 2 months later of working through it, doing occasional self mobs or having someone do a talocrural manips, I still had episodes after training or moving where there were a few minutes that I could not weight bear pain free without significant pain on the lateral plantar surface and partially through the mid-foot  In the back of my mind I kind of thought this may be something cuboid related because this was a typical presentation for it, and I somewhat proved it to myself that I got the most relief when I attempted a self mobs of the cuboid using a small kobble tool, but it never lasted. It was not until I had learned that one of my fellow PT students, Nan Hannum had recently been trained in the Dr. Allyn Peelen (a local podiatrist) method of cuboid mobilization that I finally had it formally treated. Although I always have a hard time believing in a “systematic” or sequential approach to mobilization, I have seen and experienced great results with Dr. Peelen’s method of treating cuboid and all sorts of vague ankle/foot  issues that did not resolve with other manual interventions. So I thought, why not have her try it on me, especially  since it had been consistently problematic and interfering with my activity levels. With one treatment, followed by a foam bolster taped under the cuboid to “hold the treatment”, I was 80% percent improved. We repeated that treatment 2 days later, second bout of tape, this time 90% improvement. I took the tape off 3 days later, and was able to run 2 days later for the first time in 2 months (Thanks Nan!). Furthermore, that specific pain has not been back since (although I did tweak my talocrural recently of course). Needless to say, the purpose of this case study was  that I personally believe that if I had the talocrural and the cuboid (along with anything else clinically relevant) mobilization the first week, I would probably never have to wait 2 months to get full relief and I probably would not have developed subtle hip pain secondary the subtle antalgic gait. Yes, from an evidence based perspective that is a stretch, but when you see the acute benefits (regardless of the mechanism) of manual therapy with numerous patients, it is hard not to make the judgment that earlier treatment may have prevent later complication.

So with my rambling out of the way. I leave you with a slew of videos of my favorite ankle mobs. First off, you can’t go wrong with Dr. E’s collection of eclectic strategies to improve ankle mobility:

Second, don’t forget the cuboid whip, personally I have had good experience with this with patients, but as demonstrated with the Peelen cuboid sequence, we probably don’t need to be this aggressive because this can be painful!

Finally, I was able to track down two videos of Dr. Allyn Peel himself both performing and using a plastic model to explain his approach to cuboid/foot ankle mobilization.

Oh, and one last thing, don’t forget about the other 6-8 hours of an acute ankle sprain..

References

1.) van den Bekerom, Michel PJ, et al. What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults?. J Athl Train 2012;47(4):435-443.

(2.) Bleakley CM, McDonough SM, MacAuley DC. Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review. Aust J Physiother. 2008;54(1):7-20.

(3.) Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Phys Ther. 2001;81(4):984-994.

(4.) Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity. J Orthop Sports Phys Ther. 2002;32(4):166-173.

(5.) van der Wees PJ, Lenssen AF, Hendriks EJM, Stomp DJ, Dekker J, de Bie RA. Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: a systematic review. Aust J Physiother. 2006;52(1):27-37.

(6.) Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc. 2003;103(9):417-421.

(7.) Karlsson J, Eriksson BI, Sward L. Early functional treatment for acute ligament injuries of the ankle joint. Scand J Med Sci Sports. 1996;6(6):341-345.

(8.) Brooks SC, Potter BT, Rainey JB. Treatment for partial tears of the lateral ligament of the ankle: a prospective trial. Br Med J (Clin Res Ed). 1981;21;282(6264):606-607.

(9.) Bleakley CM, O’Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964. doi: 10.1136/bmj.cl964.

10.)Whitman, Julie M., et al. Predicting short-term response to thrust and nonthrust manipulation and exercise in patients post inversion ankle sprain. J Orthop Sports Phys Ther 2009,39(3): 188-200.


Random Tip of the Day: The “Finicky” Rib Torsion

Ever had an external rib torsion which just would not calm down? I had one of these for about 6 months and a fellow student had theirs for several months as well. Addressing the t-spine and the rib itself both through manual and exercise helped a little, but didn’t seem to resolve it completely. Instead, we were both able to treat it successfully with this amazing tool:

Towel

Yes, a towel. We folded a medium sized towel to approximately 1/2 to a 3/4 inch in thickness. This towel was then placed under the painful rib, and slept on. It was positioned in way that whether you slept on your back or on your side it would maintain a constant level of compression on that rib. At first, the intent was just to reduce discomfort of the rib pain at night, but unintentionally, it became the complete treatment and resolved the issue. It took about 4 nights for me and about 10 days for other student. Problem solved. Easy and safe intervention to use concurrently with manual and therex, or possibly try it by itself?


Regional Interdependence: The “Off Label” Treatment

The FDA dictates specific uses and indications of a drug based on pharmaceutical trials. These specific uses and indications are “on the label”. Physicians frequently utilize pharmaceuticals “off label” from their branded purpose based on clinical reasoning. This is a legal and widely accepted practice and necessary to treat conditions which at this time may not have the research evidence available to support the practice but has demonstrated good clinical outcomes. The advent of Clinical Prediction Rules (CPR) and subclassifying of conditions towards specific treatment protocols has been growing in the physical therapy realm5,8,12,13. This is particularly true with manual therapy and CPR for joint mobilizations/manipulations for the cervical, thoracic, and lumbar spine. In general, these guidelines tend to be region specific, IE: a lumbar manipulation for a lumbar condition5,8and cervical spine mobilization/manipulation for neck pain12. Although not as well known, predictive factors for the influence of cervicothoracic manipulation on shoulder pain10 and lumbopelvic manipulation in patellofemoral pain syndrome9 have also been proposed. You could say that the advent of CPRs/classifications is the rehabilitation world’s attempt at providing an “on label” guideline for treatment. However, little other attempt has been made to provide subclassifications for conditions and treatments regarding manual therapy interventions on extremity conditions. Clinically, worldwide, many movement professionals treat extremity conditions one to two joints proximally or distally, in particular through addressing mobility at the spine. This practice is based in the idea of regional interdependence, or “the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint.”18 In an essence, this practice is “off label”, but unlike the pharmaceutical practice, it is not widely accepted and frequently questioned. This is particularly true from a medical billing and, depending on the location, referral/medical prescription level. Even from within our profession itself, it is not terribly uncommon for the concept of regional interdependence to questioned and perceived as a “wild goose chase around the body” 18.  As I have mentioned in previous posts, Thomas Myer’s Anatomy Trains based system KMI, Gray Cook’s SFMA and Gary Gray’s Chain Reaction Biomechanics™/GIFT Fellowship are perhaps the first to develop standardized evaluation and treatment methods of looking at the body globally rather than locally. Although the terminology varies between each, all of these programs have essentially provided a road map towards understanding regional interdependence. I have minimal exposure to all of these programs, so I cannot give justice to any of them trying to give additional details from their models. However, I wanted to share my thoughts on regional interdependence based on the experience I have gained through my mentors, research, and my limited full-time clinical experience thus far.

A JOSPT guest editorial by Wainner, Whitmann, Cleland, and Flynn titled Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come (Freely available directly from JOSPT) written in 2007 probably first popularized the term “Regional Interdependence”, because very little literature prior to this date utilized this term. This editorial presented a great case, both from a clinical and a research perspective, that the practice of examining musculoskeletal conditions beyond the single joint/primarily complaint area is woeful inadequate to address the needs of both common and complicated conditions 18. Research has increasingly been supportive of regional interdependence. Improved pain scores and functional outcomes have been demonstrated painful shoulder conditions as a result of the use of cervicothoracic and rib manipulation 2,4,10,15. Similarly, lumbar and pelvic manipulation has demonstrated improvement in patellofemoral pain syndrome9,16,19. Beyond manual therapy, evidence for the use of foot orthotics for various lower extremity injury as a preventative measure7 and as a method of treating PFPS 17.  However, the role of distal contributions, or more specifically excessive pronation, was recently questioned in a systematic review by Chuter and Janse de Jonge6. In their review, they proposed that a greater influence on lower extremity injury arises proximally from the “core”6. Regardless, what is evident in available research is that proximal and distance regions to the site of injury have some role either as a result of the injury, or as a precursor to the injury1,6,11,14.

Clinically, there are presentations and treatments related to regional interdependence which are a long way (if ever) from being able to be demonstrated or clearly explained in a research design. We are still in the early stages of understanding manual therapy, let alone regional interdependence. Bialosky, et al. (Open access link) provides a great review and proposed a model which encompasses both joint and soft tissue mobilization/manipulation 3.  Although the emphasis of this model and much of the research on manual therapy is based on a neurophysiological, peripheral, spinal, or supraspinal mediated mechanism 3, it is difficult to extrapolate whether these the neurological models also play a key role in regional interdependence. Perhaps now, with the treated “dysfunction” one or more joints away from the injury location, the importance of “movement”, as biomechanically dictated, plays a more important role? Or perhaps still, somewhere in “homunculus land”, a map of regional interdependence is now changed to alter both pain and movement patterns. It is too early to tell, but hopefully this question will soon answered! Whatever the mechanism may be, clinically, there still appears to be a degree of specificity and clinical reasoning necessary in order to provide an optimal outcome. To illustrate this, I want to present a brief clinical case.

This case involves a 23 year old male competitive soccer player who originally presented with posterior left rib pain around T5 region which somehow evolved into some form of left posterior shoulder pain and restricted ROM. Somatic dysfunctions for the thoracic spine, ribs, scapula, glenohumeral capsule, and surrounding tissue(including an incredibly tight latissimus dorsi) were identified. These factors were assumed to be key to recovering the 10-15 degree loss of shoulder flexion with a painful posterior “pinch” at the endrange. A gambit of joint mobilizations and attempts to lengthen the latissimus dorsi, as well as, various techniques for “releasing” other soft tissue restriction was started.  Despite 4 sessions of valiant attempts to regain this loss of shoulder flexion through manual therapy and stretching even up to two joints away, little progress was made. Out of shear randomness, I observed an obscurity in the way the inferior aspect of his rib cage moved when I passively flexed his left shoulder. Perhaps it was an illusion generated by my mind from years of staring at Thomas Meyer’s Anatomy Trains, but something made me believe it was worth looking at his rectus abdominis. Needless to say, simply palpating the rectus abdominis was enough to generate a startle response similar to a typical trigger point presentation. Tension and “restriction” was felt through the lateral band of the rectus abdominis. Much to the patient’s dismay, I spent two minutes “releasing” this restriction and without any other treatment. Immediately afterward, I was able to move him into those last 10-15 degrees of shoulder flexion pain free. One additional treatment was scheduled and the patient was set for a one week recheck, at which point they were still symptom free and discharged.

Looking back now, I could pretend I know what happened and propose a theory to explain it from a biomechanical model utilizing Anatomy trains. I could state that since the rectus abdominis inserts on ribs 5-7, it must then pull on the fascial origins of the pectoralis minor directly or through pulling the rib cage down. Consequently, the pec minor then pulls on the coracoid process of the scapula, which could  result in anterior tilting of the scapula, and therefore give a possible mechanical cause for the “pinching sensation” and  restricting shoulder flexion. The honest truth is, I don’t know why it worked, because it was such a random find. Yet oddly enough, it seemed as though I had to be specific enough in my treatment approach in order to get a positive outcome for this patient. Simply addressing classic restrictions around the shoulder was not enough in this case, I had to go even farther, and I had to use soft tissue! Did I truly decrease the tension in the rectus abdominis and therefore produce the mechanical cascade which lead to this resolution? Could it have been placebo, was the shear randomness of the treatment approach a psychological effect that somehow modulated the pain or ROM changes? I am completely open to any suggestions!

Clearly not every case needs to be this involved or complicated, and sometimes the area of injury is the best place to focus your treatment and leave it at that. At the same time, both clinical and research evidence seems to be paving way the importance of remembering that the leg bone is connected to the knee bone, and the knee bone connected to the thigh bone…

1. Berglund KM, Persson BH, Denison E. Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. Man Ther. 2008;13(4):295-299. doi: 10.1016/j.math.2007.01.015.

2. Bergman GJ, Winters JC, van der Heijden GJ, Postema K, Meyboom-de Jong B. Groningen manipulation study. the effect of manipulation of the structures of the shoulder girdle as additional treatment for symptom relief and for prevention of chronicity or recurrence of shoulder symptoms. design of a randomized controlled trial within a comprehensive prognostic cohort study. J Manipulative Physiol Ther. 2002;25(9):543-549. doi: 10.1067/mmt.2002.128373.

3. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Man Ther. 2009;14(5):531-538. doi: 10.1016/j.math.2008.09.001.

4. Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009;14(4):375-380. doi: 10.1016/j.math.2008.05.005.

5. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: A validation study. Ann Intern Med. 2004;141(12):920-928.

6. Chuter VH, Janse de Jonge XA. Proximal and distal contributions to lower extremity injury: A review of the literature. Gait Posture. 2012. doi: 10.1016/j.gaitpost.2012.02.001.

7. Collins N, Bisset L, McPoil T, Vicenzino B. Foot orthoses in lower limb overuse conditions: A systematic review and meta-analysis. Foot Ankle Int. 2007;28(3):396-412. doi: 10.3113/FAI.2007.0396.

8. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine (Phila Pa 1976). 2002;27(24):2835-2843. doi: 10.1097/01.BRS.0000035681.33747.8D.

9. Iverson CA, Sutlive TG, Crowell MS, et al. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: Development of a clinical prediction rule. J Orthop Sports Phys Ther. 2008;38(6):297-309; discussion 309-12. doi: 10.2519/jospt.2008.2669.

10. Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Keirns M, Whitman JM. Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: A single-arm trial. Phys Ther. 2010;90(1):26-42. doi: 10.2522/ptj.20090095.

11. Reiman MP, Weisbach PC, Glynn PE. The hips influence on low back pain: A distal link to a proximal problem. J Sport Rehabil. 2009;18(1):24-32.

12. Schellingerhout JM, Verhagen AP, Heymans MW, et al. Which subgroups of patients with non-specific neck pain are more likely to benefit from spinal manipulation therapy, physiotherapy, or usual care? Pain. 2008;139(3):670-680. doi: 10.1016/j.pain.2008.07.015.

13. Slater SL, Ford JJ, Richards MC, Taylor NF, Surkitt LD, Hahne AJ. The effectiveness of sub-group specific manual therapy for low back pain: A systematic review. Man Ther. 2012;17(3):201-212. doi: 10.1016/j.math.2012.01.006.

14. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther. 2009;39(1):12-19. doi: 10.2519/jospt.2009.2885.

15. Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther. 2009;17(4):230-236.

16. Vaughn DW. Isolated knee pain: A case report highlighting regional interdependence. J Orthop Sports Phys Ther. 2008;38(10):616-623. doi: 10.2519/jospt.2008.2759.

17. Vicenzino B, Collins N, Cleland J, McPoil T. A clinical prediction rule for identifying patients with patellofemoral pain who are likely to benefit from foot orthoses: A preliminary determination. Br J Sports Med. 2010;44(12):862-866. doi: 10.1136/bjsm.2008.052613.

18. Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: A musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007;37(11):658-660. doi: 10.2519/jospt.2007.0110.

19. Welsh C, Hanney WJ, Podschun L, Kolber MJ. Rehabilitation of a female dancer with patellofemoral pain syndrome: Applying concepts of regional interdependence in practice. N Am J Sports Phys Ther. 2010;5(2):85-97.


The EDGE Review and My Introduction to IASTM

***FULL DISCLOSURE: I am planning on becoming an affiliate for the EDGE. I hope this review stands for itself that monetary reasons have no influence on my perspective or this review, but I wanted to be upfront about my future intentions.

I have been following Dr. E’s Blog off and on for the last year, primarily for the excellent education resource it provides for those with strong interests in manual therapy. I had looked at the EDGE tool a number of times, but never really thought seriously about trying it out because I’ve always had a bias towards the exclusive use of my hands in manual therapy. The whole Graston/ASTYM and the  Instrument Assisted Soft Tissue Mobilization (IASTM) seemed like a fad to me, so I thought I’d wait it out.  However, in January, I mentioned Dr. E in a Twitter reference and was surprised to hear back from the man himself.  We spoke off and on since then, and he mentioned he wanted to get my thoughts on the EDGE as a self-treatment tool for the martial artist. It took me a while, because I was still skeptical, but I finally ordered my own EDGE at the end of February to try it out.  I quickly found out, I really couldn’t do it justice by only speaking from the perspective of a martial artist, but also someone who is completely new to the concept of IASTM and how different it is from traditional soft tissue mobilization (STM).

To start,  I wanted to talk about how oblivious I was to the difference between IASTM and STM. I was fortunate enough to have some great physical therapy mentors introduce me to STM in 2003, prior to even starting school for athletic training or physical therapy. Over time, I began to favor a treatment approach that was biased towards combinations of ischemic pressure based releases and blunt (finger) deep cross friction. This treatment style did not transition well into IASTM , which I believe fits better within  the realm of differentiating and treating based on “dysfunctions” in myofascial tissue layers. I have been historically biased against popular myofascial release techniques because I do not see as rapid of a change as I do when I deal directly with hypertonicity in contractile tissue (trigger points, etc.). In my attempts to transition the EDGE over to this style of treatment, I was frustrated in overlapping these techniques because of the abrasions and skin pinching that resulted from attempting to use the tool in this manner. Over the first few weeks, I was able to get a few individuals willing to subject themselves as gracious guinea pigs for me test the EDGE on, including myself. Our first impressions were that we were uncomfortable with the “abrasive feeling” in comparison to the way I had been treating before, in particular the residual burning skin (not bruising) discomfort for the day following. I also became concerned with some of my deeper treatments possibly breaking the skin because I made that mistake on myself in my first treatment session. I nearly gave up on IASTM two weeks into it because I simply was ignorant to the purpose of it. I decided to step away from the drawing board and started reviewing the EDGE basics videos and a number of ASTYM videos. With paused reflection, I realized I had to come to IASTM with an open mind towards learning a new style of treatment rather than forcing my own idea of how to use it.

The next time I picked up the EDGE, I started working on an old achilles issue of mine and really spent time working superficially before progressing to deeper layers, and this time I actually made a change in the symptoms and the tissue, very quickly. The strokes were now intent on stripping and scraping in a layer approach rather ignoring the superficial layers and going straight for the deep tissue. An e-mail communication with Dr. E. at that point confirmed to me that my early attempts were really rather futile and that the emphasis of IASTM is stripping and scraping technique in order to facilitate the inflammatory process in healing.  Now, six weeks later, not only am I am able to use the stripping and scraping techniques in a manner which is resulting in symptom reduction but I have also slowly been able to adapt my ischemic pressure releases into the EDGE and reduce the dependency of my hands for all my STM treatments.

From my limited experience so far, I can say that the EDGE certainly is not for every condition and does not work well for everyone (I have one volunteer I definitely cannot use it on), but it has found an important place in my developing manual therapy skill set. Nevertheless, the EDGE has dramatically changed the way I think about treating soft tissue dysfunction and I am thankful that I have had the opportunity to start developing IASTM skillset prior to my full time practice as a physical therapist in manual therapy.

One thing that I wanted to comment on was the type of lubricant/medium used as an interface for IASTM.  After a week of trying out Albolene, Dr. E’s favorite medium for IASTM, I switched to Cramer Skin Lube. I was introduced to Skin Lube during one of my clinical rotations in athletic training where we did an extensive amount of STM using a medium (new to me, since again, I didn’t use “massage like” techniques at this point) on track and field athletes. Skin Lube has a much higher melting point, was cheaper than Cocoa Butter which is commonly used in “massage like” techniques. It is odorless similar to Albolene and seems to last longer than Cocoa Butter and Albolene. For me personally, it felt as though I need a significant amount of Albolene before I felt like it was providing a protective layer against excessive early skin abrasion and I felt at times I needed to re-apply it. With Skin Lube, it took only a single application for roughly 1/4th of the amount of medium. Price wise, both products are nearly equal costs on Amazon.com, Skin Lube just barely came in cheaper, 454 grams for $13.41 vs  $13.37 for 340 grams of Albolene. I’m still way new to this whole IASTM thing, but I have to say that my initial experience is that I like the protective feeling of the skin it gives me, but the downside is that it takes quite a bit more work to remove the remaining product in comparison to Albolene. Although perhaps that could be a benefit!

The EDGE for Martial Artists as a self-treatment/preventative tool

Chronic injuries in martial artists are similar to many other sports, although I will highlight a couple of areas I have found the EDGE to be particularly useful.  Hundreds of thousands of hours and repetitions of striking, gripping, pulling, pushing, and chin na/joint locking lends to numerous opportunities to develop overuse injuries in the forearms and hands. The contours of the EDGE are perfectly designed to reach these areas and could possibly play a valuable preventative and treatment intervention for the martial artist’s hands and forearms. Similarly, as martial artists, we are highly susceptible to patellofemoral pain syndromes(PFPS), achilles tendinosis, chronic hamstring, and IT band issues. These areas are also easily accessible with the diverse contours of the EDGE for self-preventative maintenance. Specifically, I found it very effective in addressing problems around tendinous insertions.  I have been able to completely calm down some irritation in my achilles tendon insertion with a single 5 minute session IASTM session allowing me to train pain free for that day. I also had a recent flare-up of PFPS which I have been able to manage symptomatic with a quick session with the EDGE.

When I spoke to Dr. E originally, I mentioned I typically just recommend foam rollers and tennis balls for self-treatment, I was not sure how valuable this tool is going to be to the martial artist. Now 6 weeks into it, I believe I have found a definitive place for the EDGE in self-treatment of areas I didn’t think about treating because I couldn’t really address them with a tennis ball or foam roller.

I would make only one cautionary statement. Our natural instinct as martial artists (and most athletes) is that more is better (“More Chi Train Harder!”), which may make us use the tool more aggressively than it should be utilized, especially if we are used to deep tissue work such as releasing trigger points. I should have known this myself, but my first self-treatment session with the EDGE I actually kept working through the abrasive sensation to the point broke open some skin while I stopped looking at the treatment site. Clearly it’s the users fault, but it was the first time I had to think a intently about being less aggressive and layering my treatment as to avoid making the same mistake. I think with a little instruction and practice, this would be valuable addition to the martial artist’s preventative maintenance program.

“BONUS”: Here is a video clip of a movement based technique I have been using for symptom management of some PFPS that started flaring up for me a few weeks ago. As an update to what I said on the video, not sure if it is coincidence, chance, spontaneous healing, a recent increase in training intensity, or the daily EDGE treatment technique I show here, but my PFPS is pretty much 90% resolved in the last week after only using this technique. Which is surprising to me because I usually have to think more critically about how I was going to treat it “properly” in order for it to get better. Anyway, check it out: