Instrument-assisted soft-tissue mobilization helps therapists work smarter, not harder.
Physical therapists, for all their fervor to provide the best treatment for their patients, have a tendency to fall behind the technology curve. As a result, they end up working harder than necessary, only to achieve less than optimal results for their trouble. Respected clinicians within the profession blame it on two reasons: An unwillingness to spend money on innovative and demonstrably useful products, and the inclination to not step outside the comfort zone of the old and familiar.
There is no finer example of this technology dilemma than the burgeoning interest in instrument-assisted soft-tissue mobilization (ISTM) techniques, particularly among those employing stainless-steel tools.
“A growing number of therapists are discovering that soft-tissue mobilization using their hands alone is less effective than the instrumented form, and so they're switching over,” says Lynn A. Wallace, PhD, PT, ATC, a past president of the American Physical Therapy Association's (APTA) Sports Physical Therapy Section, and the practitioner after whom the APTA's Lynn Wallace Education Award is named. “However, those who are slowest to invest and acquire the specialized stainless-steel tools seem to be therapists employed at hospitals or working in settings where they do not control the purse strings. They either have minimal influence when it comes to making purchase decisions, or else are subject to budget processes that take a very long time to complete.”
SKEPTICS NO MORE
Conversely, the PT in private practice has control over the funds to purchase instruments at the drop of a hat, but may not be willing to do so if he or she is well-satisfied with the status quo or isn't convinced the technology is valid. The latter is precisely what gives many therapists pause about ISTM, even though the technique has been around for nearly 20 years in one form or another, and has since then accrued a small but impressive body of scientific evidence in support of it.
“Some therapists just find it difficult to believe that a set of curved stainless-steel tools can actually detect and treat below-skin adhesions better than their hands can,” says Mike Ploski, PT, ATC, OCS, a group director of Memphis-based Physiotherapy Associates, a leader in outpatient orthopedics with 41.5 clinics nationwide and a reputation for delivering high-level care. “ISTM is something you have to experience firsthand. I know, because I myself was somewhat of a skeptic at first. I'd heard of the technique, but didn't know a whole lot about it. My interest in learning more was piqued by an encounter with a PGA golfer who was being treated with ISTM and seeing impressive results. I had worked with this golfer previously and was not getting results as good as those of his new therapist using the instruments.”
Tammara Moore, PT, founder and director of Sports & Orthopedic Leaders PT in Oakland, Calif, was even more skeptical. “At first, I thought there's no way instruments could replace my hands for soft-tissue mobilization. But I quickly became a believer; the instruments were demonstrated on me, and I could feel how sensitive they were,” says Moore, a 15-year veteran. The clinic, which employs five therapists and three athletic trainers, focuses on treating unusually difficult chronic musculoskeletal dysfunction.
Interesting, too, about Moore is that she's a teacher of Active Release Technique® (ART), a soft-tissue-mobilization method in which muscle is assessed in a shortened position and tension is introduced to elongate the structure. She was shown ISTM by a colleague who, like her, is a continuing-education instructor with a focus on active release.
“Today, I still use and advocate ART, but I have also integrated ISTM into my practice,” she says. “ISTM isn't the first tool I'll grab if the patient has a very acute condition or a very low pain threshold. But I do reach for it first, or very early on, if the patient hasn't been responding adequately to other therapies. In my opinion, ISTM utilization is warranted in cases where there is restricted soft-tissue mobility involving a fascial barrier or some form of chronic changes in the tissue, such as fibrotic changes, adaptive shortening, or chemical holding. We've also used it successfully on chronic spinal conditions where a patient may have degenerative changes in the spine and have associated muscular or fascial restrictions.”
NOW STANDARD PRACTICE
Spine and industrial medicine specialist Tom Lorren, PT, partner in the Centre for Rehabilitation Excellence, Longview, Tex, is numbered among those therapists who haven't hesitated to adopt ISTM. He recognized the technique's value immediately, and so he decided to make it a standard of practice at each of his four offices. The practice was established in 1992.
“I get the most dramatic results using ISTM on knees, ankles, shoulders, backs, and in dealing with plantar fasciitis,” he says. “I've even gotten good results with some burns.”
Lorren tells of one patient, a woman recovering from a mastectomy and radiation therapy, whose upper arm had become so profoundly adhered, that it was almost completely immobilized. Treating with ISTM, he was able to achieve 130 degrees of motion range in her shoulder.
Physical therapists aren't the only ones embracing ISTM. Rehabilitation-medicine providers of all stripes are enthusiastically welcoming it in their practices. Warren Hammer, DC, MS, DABCO, has employed soft-tissue-mobilization methods at his Norwalk, Conn-based chiropractice office since he first started seeing patients some 30 years ago. However, it's only been in the last 3 years that Hammer, author of the widely circulated textbook, Functional Soft Tissue Examination and Treatment by Manual Methods, New Perspectives, has incorporated instrumented procedures.
“I still use my older soft-tissue-mobilization techniques such as strain-counterstrain and some [proprioreceptive neuromuscular facilitation (PNF] methods for severe acute injuries,” says Hammer, whose clinic goes by the name Hands-On Therapeutics. “For the majority of subacute and chronic conditions, ISTM is now my treatment of choice. It has become a complete treatment source for the majority of soft-tissue lesions.”
In fact, the success he has attained with ISTM is responsible for a whole new aspect of his business. Because of his treatment outcomes with plantar fasciitis, Hammer says, one local podiatrist has referred all of the troublesome cases to him.
FASTER RESULTS
Physical therapists who adopt ISTM techniques find they can treat patients in a fraction of the time it normally takes using other means, experts observe.
“For most of the patients I work on, regardless of the problem, instruments allow you to deliver the therapy twice as rapidly as can be achieved bare-handed,” says Wallace. “Treatment takes as little as 5 minutes per visit, and seldom longer than 15. It's like the difference between driving a Volkswagen and a Ferrari.”
Hammer points out that the time-savings allow a practitioner to see more patients and treat more areas in the course of a day.
In a related turn, patients often express a preference to be treated by PTs who offer ISTM. That's because the technique causes many patients to feel better almost immediately, according to Lorren.
“We live in a world where people want instant everything-the same is true of therapy,” says Lorren. “Chiropractors are popular with patients because the results of a spine adjustment are experienced right away. Nutritionists, on the other hand, they face a harder sell because the effects of what they do won't be felt until days or weeks later. As PTs, we-like chiropractors-need to offer interventions that deliver a fast result for the patient, because that's what today's patients want and expect.”
Speaking of increased income, ISTM helps generate more revenue by giving PTs an additional reimbursable modality to bring to bear during a patient visit.
“It can be used and billed for in conjunction with ultrasound, hot and cold packs, and other equipment routinely covered by most insurances,” says Hammer.
DEEPER FEEL
Another benefit to using ISTM: Therapists tend to be much happier in their work because the tools eliminate wear-and-tear on the hands.
“Delivery of treatment is a lot less stressful with the instruments,” says Wallace.
Admittedly, some therapists who've tried ISTM complain that the implements are fatiguing to use. Wallace, however, asserts that their problem is the consequence of incorrectly holding the tools.
“If you grip them too tightly, then, yes, your hand can grow tired,” he says. “The proper way to hold the instruments, the way I do it, is crosswise and aligned with the extended index finger. They're very comfortable in that position. I can hold them like that all day long.”
Just as important, therapists experienced with ISTM indicate that the stainless-steel tools magnify what the hands can feel during assessment, and allow tissue mobilization to occur at greater depths.
“The technique greatly enhances your palpatory skills,” says Hammer. “It will reveal adhesions you would never be able to detect with your hands alone. After functionally testing for the problem area, ISTM allows you to quickly detect not only the location of the restricted tissue, but also the direction of the barrier, both locally and up the kinetic chain.”
Ploski confides that ISTM has increased his appreciation for the extent to which soft-tissue dysfunction is present in a typical injury.
“In particular, I can feel subtle lesions some distance from the site of pain,” says Ploski, who started using ISTM in 1996. “Once I locate a tissue dysfunction, the instruments make me much more proficient at manipulating the soft tissue. In the assessment stage, I like to start with a generalized, superficial layer palpation technique, working through the different fascial layers in search of deeper lesions.”
For the most part, so does Wallace. Then, “If we see problems of pain, swelling, limitation of movement, lack of muscle-tightening ability, or even problems with balance receptors, we like to begin using ISTM on the very first visit,” Wallace says.
Treatment entails the administration of a series of instrument-aided strokes from distal to proximal or the reverse, and involving appropriate pressure with each sweep.
“Whatever treatable problem the patient has,” Lorren says, “will in most instances be fully resolved with this method in 10 or fewer visits.”
AN EASY SELL
Not every patient tolerates ISTM. It is contraindicated for patients with hematomas, unhealed fractures or suture sites, uncontrolled hypertension, acute inflammation secondary to infection, and cancer, Ploski cautions.
In her experiences with it, Moore lists only one case in which ISTM did more harm than good. It involved a female runner whose sport was ultra-marathon-an event in which competitors race 100 miles at a time. The woman's extreme training regimen produced significant fibrosis in her quadriceps, which Moore attempted to treat with ISTM. However, the patient's pain tolerance was so high that Moore inadvertently applied deeper pressure than was needed. This resulted in substantial inflammation of the treated area.
“It was counterproductive to use the instruments this one time,” she acknowledges. “Otherwise, I've always had good success with it.”
As far as Lorren is concerned, ISTM is simply an outstanding tool-and in no small measure, because it is a tool of outstanding simplicity. He predicts that, with the passage of time, it could emerge as the tool most frequently pulled from the PT's kit.
“At the very least, ISTM will be used far more often than it is now, of that I'm confident,” he says.
As to the economics involved, Lorren believes the costs of the equipment and training are offset-and then some-by the benefits patients gain from ISTM.
“With more and more patients becoming exposed to ISTM, the chorus of consumers insisting on it as the treatment of first choice will be increasingly hard to ignore,” he says. “From the therapist's perspective, ISTM is an easy sell. And, it's an easy sell whether you work in an institution or for yourself in private practice. It's an easy sell because it's technology that makes sense.”
