Exploring Hand Therapy Magazine
Volume 5, Issue 1 APRIL 2005
||FASTER, BETTER, EASIER SOFT-TISSUE MOBILIZATION
By Scott Smith
|In a world of no limits, the ideal soft-tissue mobilization technique would be one that lets you readily and reliably detect and release scar tissue and fascial restriction of the digits, wrist, forearm, elbow, upper arm and even the shoulder. And at the same time, it would reduce or eliminate the wear-and-tear on your own set of hands.
Hand therapist Lori Hiatt, OTR, CHT, who works at OrthoCarolina in Huntersville, N.C., is more specific in her description of the ultimate soft-tissue mobilization process: it would prevent adhesion in postoperative patients by ensuring the tendons glide beneath new scar tissue.
"The problem of adhesion is especially pernicious in those parts where muscle tissue is in short supply, such as on the back of the hand," she says. "There, post-operative scar tissue tends to adhere right down to the bone, thereby preventing the gliding of tendons."
Heretofore, Hiatt, like the majority of hand therapists, has effectively treated upper extremity dysfunctions with the tried and true myofascial release, cross-friction, scar massage and other methods — despite the physical demands on their own extremities. Now, it seems Hiatt and a growing number of therapists across the country are discovering an approach known as instrument-assisted soft-tissue mobilization (ISTM) that comes about as close to ideal as any technique thus far.
ISTM, developed in 1991, entails use of specially designed stainless steel instruments in conjunction with a variety of motions and pressures and a carefully laid-out treatment protocol. It permits soft-tissue mobilization's objectives to be achieved more efficiently and with less physical exertion, according to advocates.
"Instrument-assisted soft tissue mobilization has been very beneficial in my practice," says Gretchen L. Maurer, OTR/L, CHT, owner of Hand Rehabilitation of Hampton Roads, Inc., a four-office enterprise based in Norfolk, Va. "I often use ISTM in place of the manual soft-tissue mobilization techniques I had been relying on previously.
"By working with the instruments, I can accomplish more in less time during each visit”. "Also, the instruments are very easy on my hands and I don't fatigue or experience thumb-joint pain administering therapy as I did in the days when I had only my hands to use." Further, Maurer can see more patients during the course of a day because of the time-efficiencies gained from use of the instruments.
Hiatt echoes Maurer's sentiments: "It's amazing how easy ISTM makes identification of restrictions that cannot be detected with your unaided hands," she says. "Then, when you're performing the actual therapy with the instruments, they let you work down deeper than you can with hands alone.
"I'm amazed too at how people get better quicker when ISTM is used."
SUITED TO MANY INDICATIONS
Therapists find that integrating ISTM with one's regular retinue of manual soft-tissue mobilization techniques proves a simple matter. "I'm using ISTM on virtually every type of case I see: post-operative tendon repairs, hand fractures, wrist fractures, you name it," says Hiatt. "The exception is the patient who is very early post-op and his or her skin has yet to regain sufficient integrity to be worked on."
Hiatt reports excellent results using the ISTM with high risk patients, preventing complications from adhesions. "No matter what you do, scar is still going to form," she says. "However, I can count on ISTM to keep things moving along a lot better."
Mary Sue Tank, OTR, CHT, staff therapist at St. Vincent Physical-Occupational Therapy Center in Carmel, Ind., has been an ISTM fan since 2000. She reports that the technique is useful for ameliorating lateral and medial epicondylitis, lumbrical strain and thumb adductor strain.
Therapists who've adopted ISTM typically don't hesitate to incorporate the tools in as many patient treatment plans as possible — or to begin their usage at the earliest practical juncture.
"I like to start in with ISTM as soon as possible, preferably on the patient's first visit and continuing with each visit afterward," says Hiatt. "I generally stop toward the final few visits in order to focus on postural and ergonomic exercises and function instruction."
DIAGNOSTIC TOOL, TOO
ISTM can be administered in a variety of ways, which is important because not every patient responds to the same maneuvers. "Part of the magic of the tools," says Hiatt, "is that you have so many options for ways to use them. So, if one technique doesn't seem to be having the effect you're looking for, you can try another. And if that doesn't work, you can try another and another and another. Eventually, in all probability, one of them will provide the result you want."
Upon discovering the one approach that works best for the patient in question, Hiatt notes it in her chart and then uses that particular method every visit thereafter.
Intriguingly, ISTM plays a dual role, in that it is as much a diagnostic aid as a therapy tool.
"We know the general location of the problem, and ISTM allows the therapist to identify specific restrictions that may not be felt by the unaided hand," says Maurer.
To illustrate, Maurer describes the steps she takes in preparing to work on a lateral epicondylitis patient.
"Prior to initiating the instrument-assisted technique, moist heat is applied to soften the tissue," she says. "A cream is then applied to allow the ISTM tool to glide more easily over the skin. Then, an ISTM tool known as the half-moon is used to scan below the surface of the skin to assess the presence and extent of fibrosis.
"I sweep the scan tool both proximally and distally to identify adhesions and fibrosis that may be felt in only one direction."
As she scans, Maurer asks the patient questions to elicit feedback that will be helpful in the detection process.
"I ask if pain is felt when I work in a specific area or what it feels like to them; for example, gristly, bumpy, rope-like," she says. "Often times I will scan the noninvolved skin to let them feel the difference."
GETTING DOWN TO BUSINESS
Maurer indicates that several instruments might be used in treating a specific area. "I stroke with fairly light pressure at first, then increase it as I work deeper," she says.
Applying the right amount of pressure, when using the tools, is crucial. Tank relies on feel and patient feedback to gauge whether she's overdoing it, not bearing down hard enough, or right on the money. She instructs the patient to tell her if the pressure causes too much pain. If it does, she immediately backs off.
Pain is most reliably triggered and strongly felt when treating scar tissue, experts assert.
"Given that scar is painful tissue, I may work the area for only a minute or so," says Hiatt, who shares that a very effective method of using ISTM on scar tissue calls for light, short strokes down each side of the restrictive area, then inward with a lifting or scooping motion."
Tank, meanwhile, likes to switch between sweeping and strumming motions for treating lateral epicondylitis. She describes the sweeping motion as one that's used longitudinally on a muscle, whereas strumming is deep and perpendicular — similar to crossfriction massage technique.
The length of each stroke, if varied, causes a considerable difference in effect. Long strokes, according to Hiatt, are used to acquaint the affected area with treatment at the start of intervention, or to soothe it at the conclusion. Short strokes, on the other hand, concentrate the power of the instruments on the area of restriction.
"No matter what type of motion you use, a goal is to first clear away the superficial dysfunction," Hiatt says. "Only then will the deeper dysfunction become apparent."
An ISTM session at Maurer's offices lasts eight to ten minutes; however, it may take several visits before good results emerge. An important element of the treatment protocol, according to Maurer, is to follow each session with a few minutes of stretching exercises.
"Usually, improvement is seen the very first time the tools are used," she says. "I can often count on seeing improved range of motion on the order of 15% to 20% at the end of that initial usage. Pain also will be appreciably reduced."
Maurer says she continues ISTM until either the patient achieves what she deems sufficient flexibility and movement, or is indicating a substantial decrease in pain.
Only in the rarest of circumstances do the instruments yield little or no improvements in patient condition over time. Even so, Tank contends ISTM ranks among the finest innovations she's seen during her nearly 35 years in practice.
"ISTM is a very valuable addition to the toolkit I have at my disposal in working with patients," she says. "And I'm not the only one in this center who thinks that. These tools never sit idle during the day because they're constantly in use from the moment we open up in the morning until the time we close up for the evening. When something works, you stick with it. This works."
Mary Sue Tank's Story
ISTM puts therapists on a new track. Many hand therapists who use instrument-assisted soft-tissue mobilization (ISTM) first learn about it from colleagues. Such was the case for Mary Sue Tank, OTR, CHT, staff therapist at St. Vincent Physical-Occupational Therapy Center in Carmel, Ind.
Actually, the colleague who brought ISTM to Tank's attention also happened to be her physical therapist husband. Back in the mid-1990s, he had become a proponent of the instrument-assisted technique. At home, around the family dinner table, he would discuss with Tank the patients he'd seen earlier in the day and talk about the good results he was obtaining with ISTM.
Tank, eventually became intrigued enough by the concept of ISTM that she asked her employer at the time to consider acquiring a set of tools like those her husband was using where he worked.
Unfortunately, her request was refused on the grounds that it would cost too much from the particular source to which Tank had pointed her bosses.
Several years later, when Tank was hired by St. Vincent, she made a similar request. This time, though, it turned out that her new employer was already considering acquiring ISTM tools, only from a different source, the Graston Technique®, whose offerings were significantly less expensive but equally if not more effective than those Tank had previously sought.
Evidently, Tank's was not a lone voice; St. Vincent administrators had been fielding from other employees unprompted requests for ISTM tools, and that's what got the ball rolling on their decision to at least explore the possibility of buying.
Following an evaluation of the Graston Technique products, administrators became convinced the instruments would make a good investment, so they ordered several sets and also arranged for staff to be properly trained, a requirement by the company, prior to purchasing the instruments. Tank was among the first to step forward when the call for training-course volunteers was issued.
That was in 2000. Since then, she and her colleagues have been using the instruments on a daily basis. Numerous out-patient facilities in the Indianapolis area utilize GT, including Physiotherapy Associates and Community Hospital, which has more than 65 GT-trained clinicians at its five sites.
Lori Hiatt, OTR, CHT, with OrthoCarolina in Huntersville, N.C., discovered Graston Technique instruments for ISTM in October, 2004, while attending an American Society of Hand Therapy conference in Charlotte, N.C.
Impressed by the ISTM demonstration conducted by GT representatives, she volunteered for a demonstration at the convention and came away a believer. A month later, she attended a formal 12-hour training course. ISTM now is a primary intervention in her day-to-day practice.
Research conducted by Graston Technique trained clinicians at Ball Memorial Hospital and Ball State University, Muncie, Indiana, found that the controlled micro trauma induced through the Graston Technique protocol, increased the amount of fibroblasts to the treated area. That amount of inflammation to the scar tissue helps initiate the healing cascade.
The structure of the tissue is rearranged, and damaged tissue is replaced by new tissue. Ice is then applied to reduce the pain and exercise is implemented to increase function and range of motion.
Other clinical studies continue to document the success of the Graston Technique, generally achieving better outcomes when compared to traditional therapies, and resolving injuries that have failed to respond to other therapies.
Research on the Graston Technique is ongoing. The following studies were conducted using the GASTM* Protocol by Graston Technique trained clinicians:
- Davidson CJ, Ganion L, Gehlsen G, Roepke J, Verhoestra B, Sevier TL: Morphologic and functional changes in rat achilles tendon following collagenase injury and GASTM . Journal of the American College of Sports Medicine 27(5) 1995.
This study examined morphologic changes and functional changes in the Achilles tendon of rats following collagenase injury and subsequent intervention with the Graston Technique (GASTM). Animals were randomly assigned to one of four groups (five rats per group): (1.) control; (2.) tendinitis; (3.) tendinitis plus GASTM; and (4.) GASTM alone.
The Achilles tendons were harvested six weeks after injury. Gait analysis was performed using a rat treadmill, high-speed film and computer digitalization. Results indicated a significant therapeutic effect of the GASTM for stride length, stride frequency and knee range of motion (ROM). Electron microscopy found an increased number of fibroblasts in both groups treated with the Graston Technique (GASTM) (groups 3 & 4).
- Sevier TL, Gehlsen GM, Wilson JK, Stover SA, and Helfst RH: Traditional physical therapy vs. Graston Technique Augmented Soft Tissue Mobilization in treatment of lateral epicondylitis . Journal of the American College of Sports Medicine 27 (5), 1995.
Forty patients diagnosed with lateral epicondylitis were randomly assigned to one of two groups; traditional PT protocol; phonophoresis and manual cross-friction; the Graston Technique protocol. Both groups received identical cryotherapy, exercise and stretching programs. Pain level, mechanical finger power and grip strength were measured. There was a statistical difference between groups, in favor of the Graston Technique protocol for the above measures.
Our Clinical Philosophy
Resolve your condition. Our primary treatment objective is to resolve whatever condition you are dealing with. We are not interested in seeing you for the same condition over and over again. Our success rate is over 90% at resolving musculoskeletal conditions.
Provide you with a rehabilitative strategy so your condition does not return. Every patient who is treated at our clinic is given appropriate rehabilitative exercises. These exercises include exercises for the four cornerstones of rehabilitation: flexibility, strength, cardiovascular and balance.
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