How I Use Muscle Energy Techniques

Muscle Energy Techniques

The latest webinar recording for Inner Circle members is now available below.

Muscle Energy Techniques

This month’s Inner Circle webinars shifted gears a little bit.  Rather than talk about a specific injury or treatment focus, we discussed a general technique, muscle energy techniques.  I liked this approach as I think there are a lot of immediate clinical implications that will allow you to start using muscle energy techniques right away.  Here is just a few of the things we covered:

  • The history and background of muscle energy techniques from both the physical therapy and osteopathic fields
  • The effects and efficacy of muscle energy techniques
  • A review of some of the various different methods of using muscle energy techniques
  • How I use muscle energy techniques to increase motion, decrease guarding, reduce hypertonicity, perform joint mobilizations, and teach self-stretches
  • How you can start integrating muscle energy techniques into your current skill set.


To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

Frontal Plane Stability, Soft Tissue Duration, and Cash Based Practice

This week’s stuff you should read comes from Chris Johnson, Patrick Ward, and Jarod Carter.


Inner Circle Update

This month’s Inner Circle webinar is actually happening later today!  We will be talking about how I integrate science and evidence into exercise selection.  I love topics like this and feel that little tweaks to exercise can you make you look like a rock star.

Inner Circle members can head over to the dashboard to sign up for the webinar.  I’ll get a recording of the video posted ASAP afterward as well.  Click here to learn more and join the program. Update

There were a few new webinars added to this week!  We have a ton more coming too.  Here is what was new this week:

  • Part 2 of Kevin Wilk’s Current Concepts in ACL Rehabilitation covering several concepts of biomechanics, exercise, and neuromuscular training during the intermediate phase of rehabilitation from week 2 to week 10.
  • Peripheral Neuropathies by Dr. Mike Ellerbusch, who I have collaborated with in past EMG studies
  • Surgical Options for Knee Arthritis in Young Athletes by Dr. Lyle Cain.

And also working on a ton more webinars including kinesiology taping, integrating neuroscience, and more strength and fitness webinars.



Frontal Plane Stability Drill

Chris Johnson shows a nice video of a frontal plane stability drill he uses in runners.  I like the thought and emphasis on the stability of the leg on the ground and the core.  Notice how well Chris performs the exercise and doesn’t allow a hip hike o r



Cash Based Practice Advice 

Jarod Carter includes a nice video of his speech to a group of physical therapy students about cash-based practice.  Nice message and Q&A session.



How Long Should We Spend on Soft Tissue

Patrick Ward answers a question he received regarding how much time we should spend on soft tissue.  To summarize, as long as we need to produce the desired effect!  But how many times in a crazy outpatient setting do we get rushed?



Self Myofascial Release for the Forearm

I wanted to show a quick video of a technique I use for self-myofascial release of the forearm.  Obviously, this is a hard area to get with a foam roll and some of the techniques I have seen using the various trigger point balls don’t seem to apply enough pressure for me.  Here is a quick clip demonstrating:

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The video uses the new Thera-Band Roller Massager+.  Obviously you can use you stick of choice, like the original Massage Stick or Tiger Tail, however I must admit that the Thera-Band stick is my current go-to massage stick device.  I was a little skeptical at first about the ridges, thinking it was just a way to differentiate itself from the competition, but it really does feel better than the other sticks.  The rubber surface with the ridges makes for a nice combination of compression and superficial drag.


Self Myofascial Release for the Forearm

In the video above you’ll notice a few things:

  • I position the stick at an ~45 degree angle and really wedge it into a firm surface.  This gives me a nice rigid platform to roll on.
  • I use this just like a foam roll.  I start with simply rolling back and forth the length of the muscle groups, then stop on any trigger points that I find and hold for a sustained released, then I progress to include multidirection movements that include fascial release techniques.
  • For the flexor and pronator group, I start with the wrist flexed and pronated and as I roll I extend and supinate.
  • This is reverse for the extensor and supinator group, I start with the wrist extended and supinated and as I roll I flex and pronate

This is a great warm-up for the forearm and also a great technique to include in home exercise programs for those with injuries such as medial epicondylitis and lateral epicondylitis.  Try it and let me know what you think about this or if you have any other self-myofascial release techniques for the forearm that you find to be helpful.

Thoracolumbar Fascia – An Area Rich with Activity

Today’s guest post is about the thoracolumbar fascia from Patrick Ward.  I have been reading Patrick’s website for a while now and have always been impressed his content, but he also has the ability to write and communicate in a fashion that fosters thought and learning.  I have been talking with him for months about sending me a guest post, so I am happy to finally have one, thanks Patrick!

Thoracolumbar fascia: An area rich with activity 

The thoracolumbar fascia can be thought of as a transitional area between the lower extremity and the upper extremity where forces are transferred in athletic and sporting movement.  For this reason, the thoracolumbar fascia plays an integral role in the movement system of the body as it connects many joint systems – hips, pelvis, lumbar spine, and thoracic spine.   Also, considering that the latissimus dorsi has attachments onto the thoracolumbar fascia and inserts onto the lesser tubercle of the humerus, the glenohumeral joint can also be thought of as ‘connected’ with the thoracolumbar fascia.  Additionally, the cervical fascia and the thoracolumbar fascia are continuous, so this fascial structures effect can be seen into the cervical and potentially even the cranial regions.

For this reason, the thoracolumbar fascia can be an important area for treatment both in instances of injury/pathology or when developing a recovery/regeneration treatment protocol for certain athletes.


Three layers of Thoracolumbar Fascia

Thoracolumbar FasciaThe thoracolumbar fascia can be thought of as having three layers which help to separate the muscles in this region into compartments:

  • Anterior layer – Attaching to the anterior aspect of the lumbar transverse processes and the anterior surface of the quadratus lumborum.
  • Middle layer – Attaching to the medial tip of the transverse processes and giving rise to the transverse abdominus
  • Posterior layer – Covering all of the muscles from the lumbosacral region through the thoracic region as far up as the splenii attachments.  Additionally, this posterior layer attaches to both the erector spinae and gluteus maximus aponeurosis.  It is in this posterior layer that the gluteus maximus and contralateral latissimus dorsi attach with each other and coordinate together to allow for pendulum like movements between the upper and lower extremity that make walking and running possible.


Together, the muscles that connect into the three layers of the thoracolumbar fascia help to provide both a stabilizing and biomechanical role for the body.  Additionally, the vast amount of mechanoreceptors in this region hint to the importance of the thoracolumbar fascia’s sensory role, making it a potentially rich target for hands on therapy.

Photo from Wikipedia


A Stabilizing Role 

The transverse abdominus, internal oblique, and quadratus lumborum all invest themselves into portions of the thoracolumbar fascia.  According to Neumann (2010), the transverse abdominus provides anticipatory/feed-forward stabilization of the lumbo-pelvic region via a tensioning of the thoracolumbar fascia and an increase in intrabdominal pressure.  The connection that the thoracolumbar fascia has with the posterior ligaments of the lumbar spine allows it to assist in supporting the vertebral column when it is flexed by developing fascial tension that helps control the abdominal wall (Gracovetsky, 1981) and it may also provide some sensory function to the body aid in both postural and protective reflex activity (Yahia, et al., 1992).

The biomechanical role of the thoracolumbar fascia is generally understood by individuals in the strength and conditioning and rehabilitation professions.  Exercise programs or “core training” programs are typically designed to elicit some sort of stabilization activity to the muscles in this region.  However, insight into the myofibroblasts and mechanoreceptors of the thoracolumbar fascia may require us to look a bit deeper if we wish to make larger changes to the function of the human body.



Myofibroblasts are cells that have a sort of dual function, being part fibroblast and part smooth muscle.  It is because of these smooth muscle properties that the myofibroblasts can contract on their own – like other smooth muscles cells – placing them under the control of the autonomic nervous system and allowing the autonomic nervous system to potentially regulate fascial pre-tension independently of muscular tone.  Thus, the fascial system is an adapting organ which almost has a “life of its own.” 

Schleip and colleagues (2006) showed that the lumbar fascia, via its myofibroblasts, has the ability to contract in situations of either chronic tissue contractures, such as tissue remodeling, or during more smooth muscle-like contractions, which may help to influence low-back stability.  Furthermore, Yahia et al. (1993) showed that the thoracolumbar fascia had the ability to spontaneously contract when the tissue was stretched and held at a constant length repeatedly, causing the fascia to slowly begin to increase resistance.  This information could be potentially beneficial in understanding pathologies where increased myofascial stiffness is present.  However, influencing the system to make a change in this stiffness is a more difficult question.


Does it Come Back to Breathing?

Given the smooth muscle properties and the control that the autonomic nervous system may have over the fascial network, perhaps a potential window into effectively dealing with increased myofascial tone can circle around to breathing.

Respiratory function is on aspect of the autonomic nervous system that we actually have direct control over.  We can change our breathing and help to elicit a parasympathetic response to allow for greater relaxation and potentially less overall tissue tone/tension, hopefully leading to more of a comfortable state of being a decreased threat perception.  Additionally, the role of the diaphragm in stabilizing the lumbar region cannot be overlooked and the fact that it shares a fascial connection with the quadratus lumborum (as well as the psoas major) and the transverse abdominus fibers invest themselves into part of the diaphragm means that the diaphragm is in a potentially prime position to have an influence over the thoracolumbar fascia, since both of these muscles invest into layers of that fascial structure.


Manual Therapy of the Thoracolumbar Fascia

The thoracolumbar fascia is richly innervated with mechanoreceptors providing it with a strong sensory role and making it a target for manual therapy.

There are many ways to address the body with manual/touch therapy.  The idea of treating “fascia” has been a hot topic as of late and oftentimes therapists are doing similar things however explaining them in different ways, leading to large semantics debates.  With regard to treating fascia I believe that it is important to not leave out the nervous system, as the goal of any manual hands on treatment is to somehow effect the brain to create an environment that is ripe for healing – one which decreases overall threat perception, decreases fear avoidance, and opens a window for the individual to perform some sort of non-painful movement that increases confidence, and create relaxation (again, helping to achieve a parasympathetic response).

Several types of receptors have been found in connective tissue (not just the thoracolumbar fascia) such as pacini and paciniform corpuscles, ruffini organs, interstitial receptors, and golgi receptors.  Different receptors are responsive to different sorts of techniques and forms of therapy.  For example, pacini receptors are responsive to pressure changes and vibrations, while ruffini receptors are responsive to sustained pressure and tangential forces such as a lateral stretch.


Practical Applications

The thoracolumbar fascia plays an important role in human movement as it not only serves as an attachment site for numerous muscles in the lumbar, thoracic, and sacral regions, but also is an important area of transition between the upper and lower extremities where forces are transferred to allow for coordinated function.

Understanding the implications that the thoracolumbar fascia has over the body will help therapists to develop both exercise programs and manual therapy/hands on treatment programs for either rehabilitation or recovery (to help increase relaxation in this area between competitions and prevent overuse or excessive strain which is common in sport).

The smooth muscle properties of the thoracolumbar fascia (and all fascia of the body) indicate a potential role of the autonomic nervous system in regulating fascial tone.  For this reason, understanding the individual athlete and levels of stress as well as their individual stress resistance can be helpful in managing overall fascial tension.  The pH of the body plays an important role in fascial tension, as greater levels of alkalinity create vasoconstriction and increased muscle tone.  The pH of the body can be influenced by increased levels of threat and changes in breathing, which cause alterations in expired CO2.  Thus, breathing, relaxation, and/or meditation, may be potential ways in which the fascial system can be influenced in a training or therapy session.  Managing stress using a variety of recovery modalities in between competitions can be help to keep athletes healthy and performing well.

Finally, the high number of mechanoreceptors found in the thoracolumbar fascia (and in all fascia) indicate that the fascial system provides an important sensory role for the body.  Various manual/hands on therapies can be utilized to influence the sensory system (and the brain) to help decrease tone/tension, improve proprioception and awareness to the area being treated, decrease threat perception, increase relaxation, and provide a window into the parasympathetic nervous system which can potentially create an optimal environment for healing.

Taking all of this into consideration, when assessing an athlete it is important to look at the entire body and keep in mind that the thoracolumbar fascia shares a connection with many structures and its influence can be seen as far up as the cervical region and into the extremities.  With that in mind the thoracolumbar fascia may be a potential area for therapy when attempting to influence other parts of the body.


About the Author

Patrick WardPatrick Ward, MS, CSCS, LMT is a certified strength and conditioning specialist and licensed massage therapist.  He owns Optimum Sports Performance (, a sports conditioning and soft tissue therapy company which provides training, treatment, and consulting to professional, amateur, and high school athletes.  He writes excellent articles on his website



  • Chaitow L, Delany J. Clinical Application of Neuromuscular Techniques – Volume 2: The Lower Body. Churchill Livingstone. Philadelphia, PA. 2002.
  • Benjamin M.  The fascia of the limbs and back – a review. Journal of Anatomy 2009; 214: 1-18.
  • Neumann D. Kinesiology of the hip: A focus on muscular actions. J Ortho Spors Phys Thera 2010; 40(2): 82-94.
  • Schleip R, Klinger W, Lehmann-Horn F. Fascia is able to contract in a smooth muscle-like manner and therby influence musculoskeletal mechanics. Proceedings of the 5th World Congress of Biomechanics, Munich, Germany. 2006. 51-54.
  • Hammer WI. Functional Soft-Tissue Examination and Treatment by Manual Methods. Jones and Bartlett Publishers. Sudbury, MA.  2007.
  • Schleip R. Fascial Plasticity: A new neurobiological explanation part 1. Journal of Bodywork and Movement Therapies 2003; 7(1): 11-19.
  • Schleip R. Fascial Plasticity: A new neurobiological explanation part 2. Journal of Bodywork and Movement Therapies 2003; 7(2): 104-116.
  • Yahia L, et al. Sensory  innervation of human thoracolumbar fascia: An immunohistochemical study. Acta Orthop Scand 1992; 63(2): 195-197.
  • Hoheisel U, et al. Nociceptive input from the rat thoracolumbar fascia to lumbar dorsal horn neurones. Euro J Pain 2011; 15: 810-815.

The Fibroblaster IASTM Tool

[box type=”note” icon=”none”]UPDATE: There is a new article that discusses my current recommendations for the best IASTM tool.  This newer article contains my updated recommendation for several tool options and information on how to learn how to use IASTM.[/box]


Over the past several months there has been much discussion about instrument assisted soft tissue mobilization (IASTM) techniques and IASTM tools on this website.  I was pleasantly surprised at the amount of people using IASTM.  For those that know me, you know that I am constantly striving to improve and find the best product to use for IASTM.  I have tried almost all of the products on the market and have shared my past thoughts on IASTM tools in a previous post and discussion.

There was a lot of discussion regarding my previous post on the Graston Technique and during the discussion, I was lucky enough to receive a post from Jacob Fey.  Jacob is a physical therapy student at the University of Buffalo and has started to make a pretty good IASTM tool called the Fibroblaster.  Before we talk about the tool, I asked Jacob to write me a brief background into the development of the Fibroblaster, below is Jacob’s story.



How and Why the Fibroblaster Started

IASTM ToolDuring undergrad I first heard of IASTM, from a friend and former classmate that was attending chiropractic college; he talked about Gua Sha, Graston and SASTM.  He went into their use and cost (how he was going to try to even pay for it).  He sparked my curiosity and I started to look into IASTM, particularly the major marketers (Graston, SASTM, and ASTYM) and how it was theorized to work.  Also, during my extremities orthopedic class in DPT, an adjunct clinical professor showed us a tool that he had been using.  This was my first hands on exposure to an instrument.  He also talked about some of the IASTM tools on the market.  Most of us were interested in the tools but not the price.  I joked to a couple of classmates that day in class that I could make them less expensively and they said they would buy one if I could pull it off.

I started talking with the Machine Shop staff in the Engineering Department at the University at Buffalo.  Since I was a student I had access to the university’s facilities to do the project at a substantial savings.  I learned to use CAD software to save money by doing the designing and prototyping myself.  Once I had the design, I also figured out the whole machining process and related costs.  It was pitched to my current and former classmates getting enough interest to move forward.  About 75% of the class pre-ordered to fund the project and the first run of Fibroblasters was made in late Fall ’09 (entire project was not-for-profit).

Over the following year, there was enough interest to pursue another run of Fibroblasters with an updated design. This time the entire project was done off campus with a local company to assist with manufacturing (Made in the USA).  After I collected the pre-orders and borrowed some startup money, I completed the necessary paperwork to form Fibroblaster LLC.  Tools were completed and Fibroblaster sales began Nov. 1st, 2010.

As with all good stories, I have to give a shout out for my mom.  She went online to be the first to purchase a Fibroblaster from the website, at retail price no less.  She proudly displays it next to the clay knickknacks that were made in elementary school.  For the financially strapped graduate student, there is a student discount for those willing to supply me with their advisor’s name, email, contact number, school name and grad date.  Once status is verified, they receive a discount via email.  Since the start sales have been steady and there has been lot of positive feedback from those who have purchased.  The goal of Fibroblaster is to make a quality soft tissue mobilization instrument without the high price tag that is associated with other stainless steel IASTM tools on the market.


My Thoughts on the Fibroblaster IASTM Tool

[box type=”note” icon=”none”]UPDATE: There is a new article that discusses my current recommendations for the best IASTM tool.  This newer article contains my updated recommendation for several tool options and information on how to learn how to use IASTM.[/box]

I thought that was a good story to share and that the product was worthy to promote to my readers (I have no financial interest). I have been using the tool for a couple of weeks now and must say that it is definitely worth looking into.  The design and materials, being stainless steel, are of top quality.

The tool has a great weight to it and resonates well, again thanks to the stainless steel.  The holes in the tool make it real easy to grip, especially when things get a little slippery.  And the sides have good concave and convex edges to them.  It has a single beveled edge but I found that you could using it in either direction to get a slightly different feel that was adequate.  I’m also trying to talk Jacob into working on a second Fibroblaster IASTM tool for more intricate areas of the body like the hand, forearm, foot, and ankle.

Fibroblaster Fibroblaster

I would still advocate that if you are interested in IASTM but worried about cost, that you start with simple Gua Sha tools made of horn, jade, or even bian stone.  I would rather see more people using IASTM with less expensive tools if cost is prohibitive to some.  But if you are ready to make the jump to a more expensive IASTM tool, stainless steel is definitely the way to go.

I have tried almost all of the tools on the market and the Fibroblaster ranks pretty high among them, I would recommend you try it first.  The Fibroblaster is relatively affordable for a stainless steel tool at $125, especially with the huge student discount that Jacob is offering at $75, and you have to respect Jacob’s approach and background story.  Kudos to him for trying to bring a quality IASTM tool to the market without excessive pricing!

For more info visit


Do You Have Interest in Learning More About IASTM?

My new online educational program will teach you everything you need to know to start using IASTM today!  IASTM does not have to be complicated to learn or expensive to start using.  Learn everything about IASTM including the history, efficacy, tool options, different stroke patterns, basic techniques, advanced techniques, and how to integrate IASTM into your current manual therapy skills and treatment programs!

Learn more about how to perform IASTM today!


Graston Technique: A Case Study and Other Thoughts on Instrument Assisted Soft Tissue Mobilization Techniques

[box type=”note” icon=”none”]UPDATE: There is a new article that discusses my current recommendations for the best IASTM tool.  This newer article contains my updated recommendation for several Graston alternatives and information on my online educational programming teaching you how to use IASTM.[/box]

Today’s guest post is quick overview of the Graston technique and it’s application within a case study by Eric Schoenberg, MSPT, CSCS.  I thought Eric did a great job with the post and have will share some of my thoughts on instrument assisted soft tissue techniques, such as Graston technique, at the end of this article.

Graston Technique

graston techniqueRegardless of treatment philosophy, it is difficult to dispute the importance of soft tissue work to help treat pathology, correct muscle imbalance, decrease recovery time, and restore proper muscle recruitment and firing patterns.

While there are many available soft tissue options, in my practice, I have found Graston techniques to be particularly useful in both treatment and evaluation.  Many people don’t realize that the Graston technique can also be a valuable diagnostic tool to quickly “scan” or evaluate a patient’s soft tissue quality and determine its contribution to a patient’s current symptoms or injury risk factor.

The Graston technoique concept is grounded in the works of English orthopedist James Cyriax and the concept of cross fiber treatment. The treatment edge of the Graston instruments allows for improved precision in the treatment of fascial restriction and fibrotic/scar tissue.

I wanted to share my experience and techniques with the Graston technique and will use a case study to illustrate the benefits and specificity of the Graston Technique.

The patient is an 18 year old male who is a 3-sport athlete (football, basketball, baseball) presenting with 9 month history of anterior knee pain consistent with patellar tendinosis. The patient presents with the following objective findings at evaluation:

  • Point tenderness at inferior pole of patella
  • Pain at end-range supine and prone knee flexion
  • Pain with resisted concentric and eccentric knee extension (Kendall MMT position)
  • Decreased hip mobility B
  • Decreased ankle DF ROM B
  • Decreased lumbopelvic/hip and single leg stability
  • Decreased gluteal/core strength B

The patient is participating in pre-season football conditioning with emphasis on sagittal plane squat/split squat/lunge activities, sprinting (including hills), and plyometrics (sagittal plane). He is using foam roller daily on own to improve tissue quality. His symptoms are gradually worsening with increased training intensity.

After evaluating the patient, I decided to include Graston technique treatment focused on the quadriceps, ITB, adductors, hamstring, gastroc/soleus, and tibialis anterior muscle groups.  Here are a couple of examples:

Graston Technique – Seated Quadciceps

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Graston Technique – Seated Patellar Tendon

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One specific application of Graston technique is the ability to effectively treat the injured area in positions of provocation. This patient experiences symptom reproduction in the split squat/forward lunge position:

Graston Technique – 1/2 Kneel Position

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Graston Technique – Dynamic With Squat:

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Treatment Outcomes

The patient was seen for 3 treatments with full resolution of symptoms. Treatments consisted of the following:

  1. 1. Tissue quality: Graston technique, daily lower body foam roller program
  2. 2. Mobility: hip and ankle mobility exercises, active warm-up corrective exercises
  3. 3. Multiplanar strength: frontal and transverse plane strength (emphasized single leg activity, band walks, lateral lunges, lumbopelvic stability- chops/lifts)
  4. 4. Activity Modification: patient educated in proper jump/land technique, limited sagittal plane repetitions, proper muscle firing patterns

Clinical Observations From Using the Graston Technique:

1. The specificity of the treatment edge and the ability to provide uniform pressure is what sets the technique apart from other manual approaches.

2. The instruments truly enhance the clinician’s ability to detect and treat fascial restrictions and adhesions (particularly effective in positions of provocation).

3. Incorporating stretching and strengthening (tendon-loading) exercises with the instrument assisted soft tissue mobilization is the key to promoting re-alignment of the fibers and helping to fully remodel the injured tissue.

4. Coupling Graston in the clinical setting with self myofascial release (SMR) products, such as foam rollers and other similar equipment at home or in an athletic setting (pre/post activity) is an ideal way to achieve maximum success.

Lastly, at least for me, the most exciting part of using Graston Technique in the clinical setting is feeling better suited to treat the more difficult diagnoses (plantar fasciitis, chronic tendonosis, etc) with the expectation of good clinical outcomes.


My goal in writing this article is to present a simple case to allow the reader to appreciate the functionality and ease of use of the Graston Technique. In addition, it is important to note that Graston (along with any soft tissue treatment) should be used in conjunction with skIASTMilled movement evaluation and prescription of corrective exercise to allow for the most effective clinical outcomes.

Eric Schoenberg, MSPT, CSCS is co-owner of Momentum Physical Therapy with offices in Milford, MA and Wellesley, MA.  The owners of Momentum PT are experts in the human movement system. Their mission is to bridge the gap between traditional medicine and fitness with emphasis on patient education and injury prevention.  Visit eric’s blog at


Mike’s Thoughts

[box type=”note” icon=”none”]UPDATE: There is a new article that discusses my current recommendations for the best IASTM tool.  This newer article contains my updated recommendation for several Graston alternatives and information on my online educational programming teaching you how to use IASTM.[/box]

Eric, great article and examples of use of the Graston technique.  I’m sure the patient got better from your very well thought out treatment plan and all of the techniques and exercises you performed in combination with Graston technique.

It is important to note that while this article is specifically about the Graston technique, it also applies to instrumented assisted soft tissue mobilization (IASTM) techniques in general.  Late last year I polled my readers and 20% of you said you used IASTM, including Graston technique, SASTM, and ASTYM.  We could also group in the traditional Gua Sha to this mix as well.

I have used these techniques and do incorporate IASTM in my practice, I have also taken the basic Graston class (though have not taken SASTM and ASYTM classes and have not used their tools).  Here are my thoughts:

  • IASTM is a valuable component of my treatments, but just a component.  Just like everything else, it has its value and it has areas where I would choose another technique.
  • There are a lot of misconceptions here and the internet makes this worse – a huge black and blue down the leg is not what you are trying to achieve using IASTM.  I consider this a sign that you’ve done too much.  This is a misconception.
  • The actual Graston Technique tools and courses are really good.  If you have the budget to go all out for these, great, they will be great to work with. Visit their website for more info, I would be surprised if you were not satisfied with the course and their tools.  They have put a lot of thought and effort into their technique and tools.
  • I do not use the Graston instruments.  I think many more people should learn IASTM techniques.  If you really like the technique and want to learn more or get the better Graston tools, great.  But cost should not be a reason that you don’t learn how to use IASTM.
  • In regard to tools, I go traditional Gua Sha from China.  I have tried other tools, like the Starr Tool, they are good, but more expensive.
  • In regard to Gua Sha tools, you can Google them, there are many shapes and materials for anywhere from $2 to $10.  Horn is a good starting point, but in the grand scheme I would grade them as stone > jade > horn.  Just my opinion.  I have a bunch of horns as they come in a variety of versatile shapes, and a few jades and stones.  So far Bian or Energy stones have felt best for me, but these are closer to $20-$40.  Still cheap in contrast to some of the other instruments.  If you are not sure, start with the horn.


What do you think?  What has been your clinical experience with Graston technique, instruments, and other instrument assisted soft tissue mobilization techniques?

Fascial Manipulation

Today’s guest post is written by Larry Steinbeck, PT.  Larry and I have been talking about Stecco and his Fascial Manipulation book for some time now.  I have both books and must say they are fascinating.  It is a great way to look at the body and to combine the thought process of the kinetic chain and manual therapy.  For those familiar with Anatomy Trains, this is pretty similar.  I find that Anatomy Trains is a bit more geared to the clinical application side, while these books are geared more towards deeper understanding of fascia.  If you have read and enjoyed Anatomy Trains, this is the recommended next book for you.

imageA month ago I had the opportunity to participate in a course presented by the Fascial Manipulation Association in Italy. They present coursework based on the studies and research of Luigi Stecco, PT. This was the first time that the full course was presented in English. Over the past several years this group has presented twice at the the Fascia Research Congress, 2007 in Boston and 2009 in Amsterdam. They have published on fascial research, histology and treatment with 35 indexed articles. I stumbled on their research while continuing my studies on trigger points and myofascial sources of pain. 6 months or so ago I contacted Mike to see if he had read any of Fascial Manipulation. The book describes a unique biomechanical model for movement assessment and treatment of dysfunction.


The Myofascial Unit

imageTheir theoretical concepts have moved away from a strictly muscle insertion and origin viewpoint where a muscle moves a bone/joint, towards a function of a myofascial unit. A myofascial unit is described as group of motor units that activate mono and biarticular fibers that can move a body segment in a specific direction. This includes the joint moved, the nerves and circulatory system and the fascia that connect it all. They look at fascia as more than just a containment vessel, but looking at past and present research, fascia has a role in movement perception and force transmission.

As an example, they cite studies that show that up to 40% of force generated by a muscle contraction is not directed toward the origin and insertion of the muscle, but rather is transmitted to agonistic and antagonistic muscles through endo-, epi- and perimysium. It has been speculated that this force transmission coordinates motor function by stimulation of muscle spindles. Stecco has postulated that the force transmission through the fascia has centers of coordination, where vector forces converge in a given movement pattern. Through his practice and study he noted that many of these centers have commonality with myofascial trigger points as described by Travell, as well as, correlation to acupuncture points.


Fascial Manipulation

clip_image004This method presents an evidence based framework for symptoms associated with myofascial pain, as well as, developing an assessment based on myofascial continuity and centers of coordination.

The assessment and treatment are quite thorough and logically based, and are quite unique. The past several years we have read in PT literature about “regional interdependence”. This model takes that concept to the next level. Movement is looked at locally as well as globally with each assessment. They have demonstrated in their studies the fascial continuity between upper limbs, trunk and lower limbs in a way unique to them. Whether it was their original intent or not, I see how other concept/model can be explained even deeper through the eyes of fascial manipulation biomechanical model-this includes my experience with studying Travell, Elvey/Butler, Lewit/Janda, Mulligan and Knott/Voss. The concepts may take a while to understand and conceptualize. It is definitely worth a look at their texts, articles or even one of their courses. As for me, I am looking forward to be heading back to Italy in September for the second of three courses in the series.


Case Studies

I would like to present 2 recent cases that hopefully will give a more practical representation of the theories presented by Stecco and the Fascial Manipulation Association.

The Fascial Manipulation Association places a great deal of emphasis on history taking. This will include present site of pain, any other present pain (things that I normally would brush off like a patient who comes to the clinic with a diagnosis of cervical arthritis, but also notes knee pain on their intake form). History taking also ask about historical injury/pain-pain that may not be at present, but may have occurred in the past and may have not healed in a normal physiologic time frame,( i.e. a sprained ankle “took months to get over”). There is interest in movements that cause the present pain. History will be taking on past surgeries-anywhere, past fractures, visceral problems, and any parasthesias. (A headache might be considered a parasthesia.) They use this history to develop a hypothesis for segments/myofascial units that might be involved and to establish movement assessment that needs to be undertaken. Below are two recent cases in our clinic that were previously treated in other clinics with no resolution of symptoms.

Case Study 1 – Hip Causing Neck Pain

imageFemale, age in the mid 40’s with 6 month duration right sided cervical pain.  She had received 7 visits over 4 weeks of PT consisting of moist heat, electrical stimulations, cervical, and thoracic manipulations. Symptoms overall had not changed. Primary complained of pain while talking on the phone and turning head to look out rear window in the car. Limitation with cervical sidebend and rotation to the right, but some symptoms to the left as well. No other present pain reported at this time. She had a history of L hip “bursitis” that persisted for 6 months prior to resolution.  Prior treatment had included 2 injections and 6 PT visits. No other history reported.

Fascial manipulation in this case would be directed to look at 2 segments – cervical and hip. Assessment will be made through all planes in both segments. In this case there was a limitation in strength and mobility of the left hip abductors only. The assessment leads one to believe that there is consistent limitation in mobility, either strength or range of movement, in the frontal plane. Based on this finding, treatment would be directed to the myofascial units involved in hip abduction and cervical side bending to the right.  The theory would be that the older injury can quite possibly cause compensation in other areas of the fascia system, and that these compensations may lead to pain/dysfunction. For this reason, the hip was addressed first. Treatment to the hip myofascial units for abduction, resulted in 75% decrease in pain during right cervical sidebend.

Treatment was next direct to the cervical segment for sidebend right. This resulted in 90% decrease in pain with right sidebend.  One week later symptoms were still 75% improved. Each visit a new assessment was made to determine segment and the unit to be treated. Visits were planned for 1 week apart. After 3 visits there was a 95% improvement. Limitation persisted with”tightness” for looking out the car rear window, but no pain with activities.


Case Study 2 – Ankle Cramps and Back Pain

72 year old female with 3 year history of bilateral leg pain,”sciatica”, with a diagnosis of lumbar degenerative disc disease and spinal stenosis. She had been treated medically with NSAIDs, and an epidural injection, as well as traction and HVLA manipulation from a local chiropractor. Primary complaints pain worse at night, “cramps in both my calves.” Also has pain in central lumbar/sacral junction, and in right buttock. Pain is reported as intermittent, worse with activity, primarily with ascending stairs. No other concomitant pain noted. No history of surgeries or fractures.

Based on movements that patient reported as painful and the body areas reported as painful, hypothesis was made to look individually at the lumbar spine, pelvis and both ankles (lower leg). Movement assessment was made for three planes of movement in each segment. Calf pain and low back pain were reproduced with movement test for the posterior myofascial units of the calves.  Low back pain was reproduced with the test for posterior myofascial units. These movements were on the same plane, so treatment was directed to the posterior components. The patient thought that she had the “cramps” in both her calves “years” before she ever had any low back pain.

Treatment was directed to the calves first. Movement assessment following the treatment to the claves resulted in no symptoms present in the lumbar region or pelvis and no pain with the movement reassessment.  The patient was given a home program. At the one week follow up visit, she reported no cramps since initial visit, but still had 1/10 low back pain. No change in ability to ascend stairs without increasing low back pain. Reassessment demonstrated continued problem in the post myofascial unit in the lumbar region, but also in the anterior hip myofascial unit. Treatment was directed toward the posterior lumbar and anterior hip components (the same planes of movement). No symptoms in lumbar region following treatment.

During the follow up one week later, no pain in lumbar region with general activity was noted, no further occurrence of night cramps, but still has pain with ascending stairs. Reassessment revealed limitation in ant hip myofascial unit. Treatment directed here along with progression of home exercises. One week later, no symptoms reported with ascending stairs, no low back pain with general activity, and no night cramps.

With this patient’s history and diagnosis, I would have previously most likely considered traction and unweighted gait training, lumbar “stabilization” program, and maybe another attempt at HVLA manipulation or graded joint mobilization.


More Information

This method provided another means to assess dysfunction through a logical, well thought out, and reproducible method. If this method piques your interest, I would recommend reading both of Luigi Stecco’s books, Fascial Manipulation for Musculoskeletal Pain and Myofascial Manipulation: Practical Part,

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About the Author: Lawrence (Larry) Steinbeck, PT is a physical therapist at the Atlanta Falcons Physical Therapy Center in Jasper, GA.

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