Everything I Wish I Knew About IASTM

Well, it was early in my career, and I think it’s safe to say I fell for it hook, line, and sinker. 

I think it was my third continuing education course, and I was entranced by the idea of saving my hands and using these cool-looking tools. I figured I could really dig in and go deeper in treatments without beating my hands up. I’d also stand out as different from all the other therapists I knew around me because I would be offering something “different”. 

So, I jumped in with two feet and headed to Vancouver for the weekend. I believe the course was $500 plus at the end I would invest another $3000 into those cool looking tools. 

I heard some pretty fanciful explanations as to what I would be capable of doing with this new modality, “breaking down scar tissue” and “bringing more inflammation to areas to cause healing.”

While it all didn’t make total sense to me, I went with it. 

The following week people came into the clinic, looked at the tools and said, “what’s with the torture implements”?

Some people loved them; others hated them. 

What Does IASTM Propose?

When I took this course, one of the main things they taught was how going in with these tools and digging in really deep would bring inflammation to the area to promote tissue healing. 

This was the purpose (or the reason) why the skin looked all red and bruised post-treatment. 

Some other proposed mechanisms (1) would be causing greater flexibility compared to doing manual therapy without the tools as they would “reach deeper tissues” to have a more significant effect. Other proposed changes would include improvements in joint range of motion, increased stretch tolerance, and decreasing muscle stiffness by inhibiting muscle activity by modulating the nervous system. 

So this study (1) looked at how IASTM would influence these proposed mechanisms on ankle dorsiflexion. What they found was quite interesting: 

  • there were improvements in dorsiflexion range of motion
  • No input from the central nervous system
  • IASTM had a lesser effect than static stretching
  • less effective in improving flexibility than static stretching
  • IASTM does not change the stiffness of the muscle belly or stretch tolerance 
  • IASTM does not change the perception of pain due to stretch tolerance

Throughout this paper, there was no mention of contextual factors or other things that contribute to successful clinical outcomes, especially since this was done on healthy people. 

Another study (2) compared the effects between a massage roller stick and IASTM on hamstring range of motion and found that neither one was better than the other. Both helped increase ROM after a 3.5-minute treatment, but one was not better than the other. 

However, a significant point in the study is how the massage sticks are probably better for home use and is perhaps a lot more cost-effective for the practitioner; they also pointed out how clinician preference plays a vital role on which to use. 

What about if we compare IASTM to other therapies like spinal manipulation (typical of a chiropractic adjustment)? Well, one study (3) looked at the difference between SMT (spinal manipulation), IASTM, and placebo and found no difference in outcomes when helping with thoracic pain. However, it is essential to remember there is a lot of placebo involved in treatments. 

In most of the studies, patients received over four weeks of treatment and more than eight treatment sessions. Also, the most successful ones were combined with exercise. In fact, they were more successful when combined with a home exercise program, so give good homecare! (3) 

Important to take into account (4) that one IASTM company has a guideline protocol of doing: 

  • assessment
  • warm-up
  • IASTM treatment
  • post-treatment stretching
  • strengthening
  • ice

If we handled every treatment like this, we would have good outcomes with just about any soft tissue treatment (except for the ice, unless a patient really likes that). 

Most research (4) doesn’t use IASTM as a stand-alone intervention; it is always combined with other things to show a positive outcome. However, since most of the case reports reflect more of a subjective outcome, it’s essential to consider this if you’re deciding to put this modality to use. 

Fortunately, the studies also show it is better to move away from the theory of causing increased inflammation with skin redness (ecchymosis, petechiae) due to the potential of iatrogenic tissue damage.

Some research(5) was done in a laboratory setting on rabbits to study the effectiveness of IASTM. They put a surgical injection into the Achilles tendon to induce tendinopathy. Then, after allowing three weeks to heal, they used IASTM on the tendon. 

The results showed that the cross-sectional area of the tendon was larger on the treated tendon than the untreated one. They also found changes in elasticity and viscosity, but not to the point of being statistically significant. 

While the study proposes that the larger cross-sectional area could mean a stronger tendon, they leave something significant out.  

They went in and caused damage to the area with a surgical incision. This would naturally signal the body to send healing properties to the site to help with this. However, the rabbits were also allowed to move freely in their cage between treatments, and they were only comparing their results to “conservative” treatments. 

The most recent research shows us that the best thing for a tendon injury is to load the tissue with movement. Yet, they disregard the contribution of the rabbit’s activities and that loading the tissue is not part of “conservative treatment”. 

Also, none of this has been performed on humans, so it’s hard to say how it would affect our Achilles tendon until this human research is done. 

Disinfecting

As we have seen over the past year and a half (with a pandemic going on), there has been increased awareness of disinfecting our treatment rooms and clinic space for both patient and therapist safety. 

Well, there’s an issue with this modality in this regard too. 

Since there is no best practice guideline in place (4), the therapist’s responsibility is to make sure these tools are properly disinfected after each use. 

While this can be tricky in a clinical setting, IASTM is very popular with therapists involved in sport. 

The recommendations in a clinical setting look something like this(4)

  1. use an intermediate level disinfectant (isopropyl alcohol)
  2. flush with soap and clean water

This is recommended after every patient. If the tool were to contact any bodily fluid (blood, mucous, etc.), we would be required to use a high-level disinfectant as they use with surgical instruments. 

This is obviously a hygiene issue, so the new recommendation is (4)

  1. Before and after treatment clinician washes hands (I hope this is being done regardless of modality). As well as possibly using PPE.
  2. Area of treatment is checked and cleared for treatment. Patients skin is wiped with a sanitizing wipe. 
  3. IASTM treatment delivered. 
  4. Monitor for changes in patients skin colour etc. 
  5. Post-treatment, the body area is inspected and sanitized again. 
  6. Treatment is done, wash hands, dispose of PPE, and clean instruments. 

So in addition to all of the sanitization procedures, we now have to do in our clinic space, with the extra time this would take, could we accomplish it effectively between patients?

Also, if you’re a sports therapist working in the field, is this really practical? I think it would be difficult. 

Another hygiene issue is using a lubricant. When I took the course, we were given a small container filled with something resembling coconut oil. The direction was to take the tool, use the tip and dig out some of the lotion/oil. Then put a small dab on your hand for more use; however, there were still times you would dip the same tool back into the lubricant. 

The new recommendation would be to use a tongue depressor (easily discarded) to scoop the lubricant, then put the amount needed for treatment into a paper cup or another disposable container. 

When it all comes down to it, IASTM is like any other modality. The original narrative needs to change. However, one difference is the importance of discussing the potential consequence of its use (because of petechiae). This is important because, like any other modality, if we aren’t giving patients the most up-to-date information and narrative, we aren’t actually getting proper consent. I still use my tools once in a while because I have some patients who love how it feels and request it. If I decide to use them on another person (because there is still some things I can do with them I can’t do with my hands), then there is a good conversation with them about what I’m doing, explaining why, and letting them know it’s okay to withdraw their consent if they don’t like it. All in all, if you want to learn IASTM, then by all means take the course and use it, just make sure your patients are properly informed when you do. 

References: 

  1. Ikeda N, Otsuka S, Kawanishi Y, Kawakami Y. Effects of instrument-assisted soft tissue mobilization on musculoskeletal properties. Medicine and science in sports and exercise. 2019 Oct;51(10):2166.
  2. Lee J, Young A, Erb NJ, Herzog VW. Acute and Residual Effects of IASTM and Roller Massage Stick on Hamstring Range of Motion. Journal of allied health. 2020 Feb 27;49(1):51E-5E.
  3. McKivigan JM, Tulimero G. An Analysis of Graston Technique® for Soft-Tissue Therapy. Rehabilitation Science. 2020;5(4):31.
  4. Cheatham SW, Baker R, Kreiswirth E. Instrument assisted soft-tissue mobilization: a commentary on clinical practice guidelines for rehabilitation professionals. International journal of sports physical therapy. 2019 Jul;14(4):670.
  5. Imai K, Ikoma K, Chen Q, Zhao C, An KN, Gay RE. Biomechanical and histological effects of augmented soft tissue mobilization therapy on Achilles tendinopathy in a rabbit model. Journal of manipulative and physiological therapeutics. 2015 Feb 1;38(2):112-8.

Articles Of The Week August 29, 2021

I posted something earlier this week about other practitioners questioning what you are doing in practice (specifically to movement). Naturally, this post was a good reminder that we don’t know what is going on in another person’s practice. More specifically we don’t know what’s going on with the person in front of that practitioner and why they’re recommending certain things to their patient. Contextual factors play a large role in what we do, even when it comes to recommending exercise.

What Is Wrong With 3 Sets Of 10 Reps – Marcus Blumensaat

We know how important communication is with our patients so it’s really interesting to see when new research learns new things about this in the brain. After years of research, neuroscientists have discovered a new pathway in the human brain that processes the sounds of language. While we will still need to work on our communication skills, it’s interesting to see how the brain processes this.

Sounds And Words Are Processed Separately And Simultaneously In The Brain – Cell Press

We quite often identify with the techniques we use as therapists. Quite often we hear therapists talking about what they are “doing to a patient”, where a therapist is an ‘operator’. However, this takes the person on your table out of the equation making them a passive recipient. Since we know there are more factors to a successful treatment than just a passive technique, we need to move past the ‘operator’ thinking.

Therapist As Operator Or Interactor? Moving Beyond The Technique – Diane Jacobs & Jason Silvernail

Ever use dad jokes as part of your communication with your patients? Turns out this might be a way to help build a better therapeutic alliance with your patients!

Shop Talk: Therapeutic Alliance – Sheila Schindler-Ivens

I was reading something the other day about how important it is to make tough decisions in life vs. easy decisions and their outcomes. For instance, when working on your business, the easy decision is to sleep in, the tough decision is to get up and get to work. While this post is talking about fitness, the point behind it still rings true; “Easy decisions, tough life. Tough decisions, easy life.”

The Paradox Of Tough Decisions – Eric Bach

Does The Brain Think?

I have discussed in previous posts how scientists often use intentional or psychological metaphors to describe the functions of different body parts. For example, autoimmune disease happens because the immune system for some reason “thinks” that body parts are foreigners; perception depends on how higher levels of the nervous system “predict” incoming sense data from lower levels; visual illusions happen when the brain makes a “mistake” about the meaning of sense data from the eyes. And pain is understood as the product of a system that “wants” to protect you from what it “thinks” is a physical threat to the body. This metaphorical thinking, which Dan Dennett calls the “intentional stance” is ubiquitous in biology, and plays a role in helping scientists to imagine and describe the awesomely complex workings of the body. Of course, metaphors have limits, and therefore using them presents a risk of overreach. Thus, like scientific models, metaphors are always in some sense “wrong” but may be useful.

However, it has been claimed that psychological metaphors in the context of cognitive science are never useful, and represent a fatal flaw called the “mereological fallacy,” which occurs when a part is confused with the whole. Under this view, it is wrong to say that a brain thinks, because only a person can think, and brains by themselves are just gobs of neural goo. This is true in a literal sense, but don’t scientists already know this? When world-renowned neuroscientist VS Ramachandran says that “pain is an opinion” is he confused? It doesn’t seem like it – Ramachandran advanced our understanding of phantom limb pain, which is quite a puzzle without proposing that some unconscious parts of the brain have the wrong “opinions” about the state of the body. But I recently saw arguments on social media that Ramachandran is committing some fundamental philosophical errors that undermine his theories, as well as popular models of pain. I disagree and here’s why.

Some googling reveals that the term “mereological fallacy” does not generate many hits, and most relate more to philosophy than science. Further, nearly all references trace back to a single source of authority – arguments made by Max Bennett and P.M.S. Hacker, who takes the radical view that the entire field of cognitive science is plagued by misunderstandings about the difference between persons and parts of persons. Their arguments are highly technical, and perhaps have some merit in particular contexts, but they do not seem to be widely accepted and have been severely criticized by John Searle and Dan Dennett, two absolute giants in the field of philosophy of mind and cognitive science.

Below is an extended set of quotes from Dennett, explaining why there is nothing inherently wrong with making statements like “the brain thinks.” In fact, the “poetic license” afforded by this language may be “precisely the enabling move that lets us see how on earth to get whole wonderful persons out of brute mechanical parts.” Here’s Dennett:

“The use of psychological predicates in the theorizing of cognitive scientists is indeed a particular patois of English, quite unlike the way of speaking of Oxford philosophy dons…

When I began to spend my time talking with researchers in computer science and cognitive neuroscience, what struck me was that they unselfconsciously, without any nudges or raised eyebrows, spoke of computers (and programs and subroutines and brain parts and so forth) wanting and thinking and concluding and deciding and so forth.

….

It is an empirical fact, and a surprising one, that our brains – more particularly, parts of our brains – engage in processes that are strikingly like guessing, deciding, believing, jumping to conclusions, etc. And it is enough like these personal level behaviors to warrant stretching ordinary usage to cover it. If you don’t study the excellent scientific work that this adoption of the intentional stance has accomplished, you’ll think it’s just crazy to talk this way. It isn’t. … it pays off handsomely, generating hypotheses to test, articulating theories, analyzing distressingly complex phenomena into their more comprehensible parts, and so forth.

It is not just neuroscientists; it is computer scientists (and not just in AI), cognitive ethologists, cell biologists, evolutionary theorists all … teaching their students to think and talk this way … If you asked the average electrical engineer to explain how half the electronic gadgets in your house worked, you’d get an answer bristling with intentional terms that commit the mereological fallacy – if it is a fallacy.

It is not a fallacy. We don’t attribute fully fledged belief (or decision or desire-or pain, heaven knows) to the brain parts – that would be a fallacy. No, we attribute an attenuated sort of belief and desire to these parts, belief and desire stripped of many of their everyday connotations (about responsibility and comprehension, for instance).

… For years I have defended such uses of the intentional stance in characterizing complex systems ranging from chess-playing computers to thermostats and in characterizing the brain’s subsystems at many levels.

The idea is that, when we engineer a complex system (or reverse engineer a biological system like a person or a person’s brain), we can make progress by breaking down the whole wonderful person into subpersons of sorts – agentlike systems that have part of the prowess of a person, and then these homunculi can be broken down further into still simpler, less personlike agents, and so forth – a finite, not infinite, regress that bottoms out when we reach agents so stupid that they can be replaced by a machine.

Far from it being a mistake to attribute hemi, semi, demi, proto, quasi, pseudo intentionality to the mereological parts of persons, it is precisely the enabling move that lets us see how on earth to get whole wonderful persons out of brute mechanical parts. That is a devilishly hard thing to imagine, and the poetic license granted by the intentional stance eases the task substantially.

When [Francis] Crick asserts that “what you see is not what is really there; it is what your brain believes is there,” …[this] is intended by Crick to be understood at the sub-personal level. The interpretation in question is not of (personal level) experience but of, say, data from the ventral stream, and the process of interpretation is of course supposed to be a subpersonal process. …

There are also plenty of times when theorists’ enthusiasm for their intentional interpretations of their models misleads them. For instance, in the imagery debate, there have been missteps of overinterpretation – by Stephen Kosslyn, for instance that need correction. It is not that map talk or image talk is utterly forlorn in neuroscience, but that it has to be very carefully introduced, and it sometimes isn’t. …

In conclusion, what I am telling my colleagues in the neurosciences is that there is no case to answer here. The authors claim that just about everybody in cognitive neuroscience is committing a rather simple conceptual howler. I say dismiss all the charges until the authors come through with some details worth considering.”

Here is a link to the full Dennett paper.

Here is a link to a previous post on Dennett’s intentional stance.

Here is a link to a post on the idea that all models are wrong but some are useful.

Here is a post on the hierarchy of different systems in the body (e.g. organelles, cells, organs, brains, people), all of which have some degree of agency and decision-making ability.

Articles Of The Week August 15, 2021

Unfortunately, cancer is so prevalent in society that it is likely we’ve all been affected by it in one way or another. This article is the story of how one of our colleagues dealt with a breast cancer diagnosis, how she managed it, and what we all need to learn from this in order to help someone who walks through our clinic doors and may need our help.

Lessons From A Massage Therapist Turned Cancer Patient – Meaghan Mounce

Most of us in business are likely trying to generate some consistent content that either gets the attention of new people to book in for appointments or possibly getting some people we haven’t seen for a while to come back to our clinics. Content creation can be tough, but here are some good tools you can put in place to create new content.

My Writing Process: The Mental Tools I Use to Produce Consistent Creative Output – Emily Rudow

Manual therapy is rife with pseudoscience and trying to apply it. This is commonly seen in high-performance sport where an athlete will do just about anything possible to gain an edge over the competition and their favourite therapist applying whatever new modality they can use to gain an edge. Every time the Olympics are on we see a new thing applied to athletes, however, these fads usually come and go, but why?

Olympic Pseudoscience – Tokyo Edition – Steven Novella

This article blends really well with the above one. What does Kinesiotape really do? Well, it kinda depends on if you like it.

Is Kinesiology Tape (KT) A Placebo? – Marc Surdyka

As a profession, we need to keep pushing for evidence-based practice in order to be taken seriously as a health care entity. In order to do that many of the old teachings surrounding the profession either have to be updated or let go of completely, including the myth of healing hands.

The Myth of Healing Hands – Paul Ingraham

Assessment And Reading Your Patient

I think it’s safe to say we’ve all had this happen. 

That person comes in, and as you try to have a chat with them and do an assessment, they’re looking at either the clock on the wall or their watch. 

They give you that look of disdain and just want you to let them get on the table. 

They are basically coming in with an expectation that they booked an hour and expect a FULL hour on the table. 

Well…not so fast, there eager beaver!

I wish I could say experiences like this were isolated incidents, but sadly this happens all too often. 

So, what do WE do and how do WE handle this?

Reading Your Patient

The idea for this blog post stems from a Facebook discussion (why do I keep getting ideas from these?). 

Someone commented that assessment is essential, but hands-on is what they’re paying for. I would say this is true in some instances but not all. 

This is most likely the case in a spa environment. I should preface this by saying I have absolutely no experience working in a spa but have been a customer. When someone is going to a spa for a strictly relaxation massage, and nothing stands out on their intake form that could be a red flag (I’m not sure, do spa’s check for those things?), then by all means, the person should get an hour on the table within reason. 

However, if you’re working in a clinical setting, the rules change. 

Doing some sort of assessment is a necessary part of treatment, and we are responsible for doing this. Now, this doesn’t necessarily have to be a bunch of orthopedic tests, it can simply be a conversation, but it’s still necessary. 

This is part of our responsibility as healthcare practitioners, and it is part of what we should do to protect the public. It’s one of the things that differentiates healthcare from a spa setting. Now don’t get me wrong, I’m not saying there is anything wrong with working in a spa setting and working on strictly relaxation massages. I’m just saying there is a difference, and that difference needs to be taken seriously. And yes, there are people who come into clinics for a relaxation massage, but there should still be some aspect of an assessment. 

Let me lay out a little scenario for you. 

You and I work together with a bunch of other Massage Therapists in a clinical setting. For example, I work with a patient who had been in a car accident for several weeks but never really do any kind of assessment because the patient just wants to get on the table. 

When they try to book their next appointment, I’m full but you have a spot open the following week they can book, so they jump at the opening. 

When they come in you start doing your assessment (cause you’re a rockstar at it) and the patient gets really annoyed because they want to get on the table. 

Then you end the treatment about five minutes early so you can go over some movement and homecare. 

This makes the patient even angrier because they want that entire hour of massage. 

They leave the clinic infuriated and call your regulatory body and file a complaint against you because of your treatment. Then, because their responsibility is to protect the public, the regulatory body HAS to investigate. So you get the dreaded phone call from them and have to talk to investigators over the next month, all while being worried you’ve done something wrong, and your career is in jeopardy. 

Believe it or not, this has happened, and fortunately, it didn’t go anywhere. 

Could you imagine this happening to you? 

Now, don’t get me wrong, I have some patients that I’ve seen for years where it’s a quick conversation and they’re coming in for the usual thing and they say: 

“just the usual thing.” 

I’ll simply ask:

 “nothing new going on?”

This comes after years of seeing the person and having an excellent therapeutic relationship with them, all the while knowing at other times they open up and tell me something new is going on, and that trust is built with them. 

With this is the ability to read your patient. 

This is an important skill to develop and is crucial to building a good therapeutic relationship. 

There may be times when that person who has been in a car accident comes in and is just dealing with too much that day, where the best decision is to get them on the table to help deal with the stress they’re dealing with. However, the next week they come in, their mood is better, their body language has changed, so you can do more assessment and homecare. The ability to read what is going on with someone takes time to develop. Understanding that person’s body language, what they say to you as soon as they walk into your treatment room, and the look on their face as they talk can all be clues as to how today’s treatment will progress. 

However, we cannot take the approach that everyone who comes in is going to get their full hour on the table because we have a responsibility to help these people to the full capacity of our ability. Let’s face it; you’re better than that!

Culture Change

The example we used above probably happens more often than we’d like to admit.

I mean I doubt people are getting reported to their regulatory bodies on a regular basis for doing an assessment, but the patient’s expectation that they should be able to come in and get right on the table is likely quite common.

While this can be partially the patient’s issue, I think we also have to look at ourselves. This isn’t an expectation in the other MSK professions, so why would it be in ours?

If this is commonplace it’s because we have allowed it to happen as a profession.

To truly be accepted as a healthcare profession we must use the tools we have to fullest of our potential in order for the profession to step forward. Quite simply, if it is commonplace where patients expect nothing but purely passive treatment, a culture change is necessary.

And that starts with each of us. We can sit back and blame schools, regulatory bodies, and associations (don’t get me wrong they play a role here too) but the only way we can make this shift is by each of us making this change (if we haven’t already) and OUR patients expecting something different when they come in for treatment. 

The greatest way we can influence a culture change is by starting with ourselves. When other therapists see us doing it, hopefully it will influence them to change. More importantly if a patient is booking in and expects assessment, treatment, homecare because that’s the norm, it’s also what they will expect when they see other therapists.

As Ghandi said “Be the change you wish to see in the world”. For us: “Be the change you wish to see in the profession”.