IASTM: Taking the sore thumb out of manual therapy

Transcription

1 IASTM: Taking the sore thumb out of manual therapy Disclosures UCSF Assistant Clinical Professor Outpatient Sports-Ortho perspective Created the approach Myofascial Decompression Techniques Vital Importance of the Connective Tissue System DaPrato, DPT, SCS 2015 Objectives: Describe the layers and subunits of the connective tissue system. (CT) Summarize the role collagen, ground substance, and other CT elements may be affecting movement patterns Define the terms tensegrity, thixotropy, as they relate to stress-strain curves Distinguish the effect of stretching on length-tension vs. CT elements Describe common IASTM interventions to improve mobility of the CT system Integument Skin layers Epidermis: thin skin 1

2 Epidermis: thick skin Dermis Connective tissue development Ectoderm and Mesoderm gives rise to the CT of skin and fascia above and around muscle tissue. Fascial Layers Superficial Deep = Aponerotic & Epimysial TLF, TFL, rectus sheath Intermuscular Visceral analogous Living tissue is hydrated and dynamic 2

3 Dynamic nature of living tissue The way we think about movement in the human body is clouded by the way we learned anatomy Cadaver tissue, hard muscles, web like fascia Surgery observation; as soon as you cut into it you have changed it. AND what we observe in surgery = tourniquets used; even though living tissue, not the same Functions of muscles We learn action but as we move in real world multiple ERs become IRs past 90 degrees Skin: more complex that we learned Jean-Claude GUIMBERTEAU, MD: strolling under the skin Retinacula Cutis 4 th International Fascia Congress Benchmark sciences filling in the gaps of traditional anatomy 3

4 Skin layers What is understood in radiology? Fascial herniations Morelle-Lavale lesions Compartment syndrome; fasciotomy Gr 4 AC joint Kumar 2014 Weiss 2015 Fascial Components Fibroblasts Make and secrete all fibers of areolar connective tissue Collagen fibers Strongest and most abundant; cross linking leads to immense tensile strength Elastic fibers Rubber like proteins which allow tissue to return to original shape Reticular fibers Connect vessels and nerves; have more give than collagen Ground substance Extracellular matrix that holds interstitial fluid via sugar-protein molecules that soak fluid like a sponge; with increased inflammatory response it becomes more viscous The Colloidal Matrix Viscoelastic properties of skin Fascial Contributions Support structure, tension, and suspension for tissues; scaffolding Fluid mobility; high amount of plasticity Connecting multiple muscles = functional kinetic chain Has been shown to have myofibroblasts Contraction of myofibroblasts influences movement? 4

5 Muscles within the Fascial layers Twitch of skin horse, cow, pig Hair stand up - Arrector Pili Myofibroblasts Viscoelastic properties: Collagen Dermis is made up of 80% collagen, dry weight, and of that collagen, 85% is type I Type 3 collagen is ~15% of dermal collagen, but is higher in immature tissue With age, ratio of type 1:3 collagen increases Increased collagen fiber density with age= decreased ground substance space Viscoelastic properties Viscoelastic properties: Ground substance with GAGs Glycosaminoglycans Proteoglycans and repeating disaccharide units Commonly hyaluronan and chontratin sulfate; including dermatan sulfate Bind water in normal healthy tissue and proteins In aged skin, less binding to water and bind more to elastoic material= thickened Viscoelastic properties: Thixotropic Effect Thixotropy is the property of certain gels or fluids that are thick (viscous) under normal conditions, but flow (become thin, less viscous) over time when shaken, agitated, or otherwise stressed. Viscoelastic properties: Creep and Hysteresis In relation to manual therapy, creep is the distortion of tissues as a function of pressure over time Hysteresis is the exchange of heat and energy as tissues are distorted; permanent deformation. Microtrauma. With MFR seconds is the time for generally the first barrier (R1) to release and push into new range of extensibility. Tendon Hysteresis in 5-10 minutes(kubo 2001) 5

6 Stress-strain curves; human tissue What really happens when we stretch? Sensory endpoint theory (Weppler & Magnusson 2010) Very little evidence that Torque/angle curves shift; even w/ 8 weeks More likely that the perception of the stretch sensation occurs later in the application of similar force PF stretch doesn t change relfex pathway (Hayes 2012) Stretching Soft tissue mobility: Folding CT ability to compress upon itself Shoulder Elevation= inferior capsule and axillary fold stretched, but also superior and anterior structures need to fold End Range hip flexion in supine = hams and glute flexibility, but also anterior hip folding Fascia encapsulates and supports Fascia encapsulates and supports 6

7 Tensegrity Tensegrity Tensional integrity Fuller 1950 s first visualized by the sculptor Kenneth Snelson (Snelson, 1996).Fuller defines tensegrity systems as structures that stabilize their shape by continuous tension rather than by continuous compression Micro: studies of both cultured cells and whole tissues indicate that cell shape stability depends on a balance between microtubules and opposing contractile microfilaments Tensegrity Mechanical CT Changes Inflammation or Trauma Secondary movement dysfunctions ECM response Tensegrity affected Collagen crosslinkingcollagen cross-linking Ground substance viscosity Cascade of events: Ge et al studied involvement of central sensitization mechanisms in local pain syndromes pain perception may result from a deregulation in peripheral afferent and central nervous system pathways- chronic excitability Trigger Points Lower levels of oxygen, nutrients, blood perfusion Increased calcium levels, leading to excessive chronic muscle contracture, spasms Stress can lead to abnormal excess afferent stimulation Can have shortening of sarcomeres 7

8 Fascial mechanics Translating forces = Slings Lats to TLF to contra glute max and down lateral thigh =ITB Tx Myofascial Lines Work of Thomas Myers Myofascial Tracks= muscles, tendons, ligaments and fascia Bony Stations= joints or insertional sites at bony landmark Can be static or motion driven Picture: Pec minor, biceps, coracobrachialis, rectus abdominis Or ab scar restricting shoulder or lumbar motion Superficial Back Line Superficial Back Line Includes: Plantar fascia Achilles tendon and Gastrocnemius Hamstings Sacrotuberous ligament Thoracolumbar fascia Erector spinae Scalp fascia Lateral Line Lateral Line Often involved with leg length differences and pelvic obliquities Includes: Peroneals Anterior ligament of the head of fibula ITB and TFL Superior fibers of glute max, medius External and internal obliques Splenius capitis and SCM 8

9 The Spiral Line The Serape=double spiral Includes: Splenius capitis and cervicis Rhomboids Serratus anterior Ext/Int obl. & ab aponerosis TFL and ITB Tib anterior Peroneals Bicep femoris to sacrotuberous ligament Lumbar fascia and erector spinae Myofascial Lines Fascial planes and CT restrictions affect dynamic movement scar adhesions Body takes the path of least resistance Interventions with traditional manual therapy Interventions with negative pressure applications: Interventions with IASTM Manual therapy for lymphatic flow Both picture thoracic extension; but may be restricted for different reasons Compensations and Adaptations A best-practice model for managing patients with musculoskeletal complaints has yet to be identified. -Tim Flynn (JOSPT 2007) Consider hip strength for runners with foot pain, or Use of foot othosis as a method of treating PFPS Why does IASTM work? Pain generating mechanisms Bridge to the IASTM picture Mechanical connective tissue change Fascial plane restriction and scar adhesions Trigger points and metabolic exchange Fluid mobility Counterirritant; C fiber instead of A fiber; Gated Receptors in TL Fascia (Schilder 2014 Pain) Muscle pain could be more akin to projection hyperalglesia, and not an issue in the tissue. IE: PF pain likely cartilage or other soft tissue restrictions? Grooves in PF joint in cadavers OR IE: THR patients that have the same hip pain come back 6 months later 9

10 IASTM = Instrument Assisted STM Mostly a Pro-inflammatory approach Some techniques are for flushing in acute phases Effect at the superficial fascia level, deep fascial membrane, epimyseum mechanoreceptors Where are the Pacinian corpuscles? = Where are the Meisner corpuscles? = Where are the Ruffini corpuscles? = IASTM ASTYM Graston SASTM FAKTR Iamtools GuaSha Orthopedic Target Point Fuzion Tool BioEdge = GuaSha IASTM Self trigger point tools theracane, TrP tools Snowman with a hat, PAs Belt techniques for hip and shoulder Are you just moving the joint? Or are you also with an inferior hip glide pushing through RF trigger point region, and other contractile tissue that may reset sensitivity thresholds Negative pressure devices Negative Pressure Ultrasound With Myofascial Decompression 10

11 MFD Techniques Negative Pressure Negative Pressure Negative Pressure Proof of Concept Study Proof of Concept Study 11

12 GuaSha and IASTM Basic Steps: Watch the area with movement patterns Sweep area with hands/fingers Trace and isolate with Vectoring 4 directions, find most limited. Compare contralateral Add in rotational vector as well IASTM techniques Superficial scrape Sense percussive info from tool Scrape parallel fibers Into the motion barrier = direct = subacute and chronic Away from motion barrier =indirect = acute or irritable Diagonal and perpendicular Add movement Contraindications Eyes; genitalia? Unhealed wounds Hemophilia, leukemia, active TB Thrombocytopenia Later stages of pregnancy Influenza of fever Moderate/severe anemia Moderate/severe cardiac conditions, high BP Vasculitis Cancer active Skin elasticity disorders-eds?? Precautions -Patients that are over eager - addictive personalities, chronic pain? -Blood thinners -Healing or thin skin Elderly, Psoriasis -Pregnancy -Areas of ecchymosis Previous STM -Venous stasis and varicose veins -DM; tissue healing and neuropathy -Swollen tissue especially pitting edema Results? Outcomes? 12

13 Future Studies Perfusion and Diffusion MRI with MFD vs Graston vs ASTYM vs other tools/techniques/modalities Pre, during, and 8-48 hrs after for different Tx Fascial changes on magnified MRI Local metabolic change; on a nano level IE: why does US work in some patients? References Books: Functional Atlas of the Human Fascial System, Carla Stecco MD, 2015, 1 st Edition The Endless Web. Fascial Anatomy and Physical Reality. L. Schultz, R. Feitis, North Atlantic Books. Anatomy Trains. Thomas Myers, 2008, 3 rd edition Journals: Abbott RD, et. Al. Stress and matrix-responsive cytoskeletal remodeling in fibroblasts. J Cell Physiol Jan; 228(1):50-7 Ates, F, et al. Muscle lengthening surgery causes differential acute mechanical effects in both targeted and non-targeted synergistic muscles. Journal of Electromyography and Kinesiology, 23, , 2013 Ballyns, Jet al., Objective ultrasonic measures for characterizing myofascial trigger points associated with cervical pain. J. Ultrasound Med., vol. 30, pp , 2011 Bhattacharya V, et. Al. Detail microscopic analysis of deep fascia of lower limb and its surgical implication. Indian J Plast Surg Jul;43(2): Bonilla-Yoon, et al. The Morel-Lavallée lesion: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol Feb;21(1): Borgini E, Stecco A, Day J. A., Stecco, C. How much time is required to modify a fascial fibrosis? J BodywMovTher, 2010 Vol 14(4): Cao TV, Hicks MR, Standley PR. In vitro biomechanical strain regulation of fibroblast wound healing. The Journal of the American Osteopathic Association. Nov 2013;113(11): References Ge HY,et al. Topographical mapping and mechanical pain sensitivity of myofascial trigger points in the infraspinatus muscle. Eur J Pain Oct;12(7): Findley, T., Chaudhry, H., & Dhar, S. (2014). Transmission of muscle force to fascia during exercise. Journal of Bodywork and Movement Therapies. In press 2014 Holm L, et al. Contraction intensity and feeding affect collagen and myofibrillar synthesis rates differently in human skeletal muscle.amj Physiol (Endo), 298: E257-E269, 2010 Kim KT, Kim YJ, Lee JW, et al.. Can necrotizing infectious fasciitis be differentiated from nonnecrotizing infectious fasciitis with MR imaging? Radiology 2011;259(3): Kubo K, et. al. Is passive stiffness in human muscles related to the elasticity of tendon structures? Eur J Appl Physiol Aug;85(3-4): Kumar S, Kumar S. Morel-Lavallee lesion in distal thigh: A case report. J Clin Orthop Trauma Sep;5(3):161-6 Langevin HM, Nedergaard M, Howe AK. Cellular control of connective tissue matrix tension. J Cell Biochem Aug; 114(8): May DA, et. al. Abnormal signal intensity in skeletal muscle at MR imaging: patterns, pearls, and pitfalls. Radiographics Oct;20 Spec No:S Schilder A, et al. Sensory findings after stimulation of the thoracolumbar fascia with hypertonic saline suggest its contribution to low back pain. Pain 155: , 2014 Schleip R. et al. Passive muscle stiffness may be influenced by active contractility of intramuscular connective tissue. Medical Hypotheses 2006; 66(1): Weppler CH, Magnusson SP. Increasing muscle extensibility: a matter of increasing length or modifying sensation? Phys Ther Mar;90(3): Willard FH,et al. The thoracolumbar fascia: anatomy, function and clinical considerations.. J Anat 2012; 221(6): Other recommended CE work Janda courses or Movement Links MyofascialDecompression.com Kaiser Residency and fellowship IPA PNF and FM Great Lakes MFR course Kinetacore.com Spinalmanipulation.org Myopain seminars Systemicdryneedling.com Thank You!! 13