0:04 This is Brenda the brook Bush Institute in this video. We're going 0:07 over manual therapy techniques specifically instrument assisted soft 0:10 tissue mobilization. Now, if you're watching this video, I'm assuming 0:13 that you are a licensed Medical Professional with instrument assisted 0:16 soft tissue mobilization within your scope 0:19 of practice. Now, there's some gray area here not every 0:22 state has legislation around these tools. If you're not sure 0:25 check, I would hate to see somebody getting in trouble because 0:28 they watch one of our videos and used 0:31 it on a patient or client when things did not fall 0:34 within their scope of practice act. Now these tools 0:37 just like all of our other techniques fall within 0:40 a model of practice and we are very 0:43 big on assess a dress reassess. So 0:47 even though these tools are specific to 0:50 perhaps fossil tissue. We're still 0:53 going to base their use on reliable assessments. 0:56 We're going to use these techniques 0:59 and then we're going to reassess and if they're not 1:02 effective we're not going to use them again for 1:04 That particular patient or problem in this 1:07 video. We're going to do istm instrument assisted soft tissue mobilization 1:10 for the thoracolumbar. Fascia of the low back. I'm 1:13 gonna have my friend Lisa come out. She's gonna help me demonstrate now if 1:16 we're talking about how I do rehab I'm always going after some sort of 1:19 change in an objective measure some sort of change. I 1:22 can note in a movement assessment because I know that if I 1:25 improve the quality of movement somebody's symptoms will get 1:28 better. I'm not one to chase diagnosis. I'm not 1:31 one to chase pain. I know a lot of people use what I'm 1:34 about to show you just for low back pain in general. 1:37 I wouldn't suggest that but if low back 1:40 pain leads to impairments 1:42 Great, just make sure you're assessing now with 1:45 that being said since I know these two things can be tied low 1:48 back pain and what I'm about to show you. 1:51 We need to talk about position. My preferred position for this technique 1:54 is in child's pose so that we have a little tension on 1:57 the thoracolumbar fascia iastm techniques work a lot 2:00 better when there's a little tension in the fossil tissue so that 2:03 you could actually grab some tissue if 2:06 it's slack. You just kind of like run 2:09 the tool through and you get no purchase on any 2:12 fossil layer. 2:14 Now sometimes for low back pain patients child's 2:17 pose isn't an easy position to get into or somebody 2:20 has knee issues and 2:22 Child's poses an easy position to get into so one 2:25 modification that I will often use is I'll 2:28 just have somebody like Lisa. Let's say she she 2:31 had some some pretty rough low back pain. All right. 2:34 Well, I'll be like do you think you could you could do one of these for me 2:37 like just kind of rest down on your elbows and since we're gonna be there 2:40 a little bit I'll even make it a little easier for her, but putting a pillow 2:43 to support some of our torso now, I 2:46 have some of that flexion that I need here to get some tension and 2:49 I can do 2:51 My iastm techniques now if that 2:54 didn't work, I'd probably put her in 2:57 sitting that's not a deal for me because now I'm behind her 3:00 and obviously my biomechanics are 3:03 not great. What I would try to stay away from guys with this, although 3:06 if you have to you have to is supine 3:09 on a table. I find that supine 3:12 puts people into extension all the sudden there's a lot of slack in 3:15 the tissue. And again, it's really hard to get purchase on any 3:18 of the fascia to try to do any of 3:21 this Shear force that we think we're affecting so 3:24 I'm gonna have Lisa go ahead and get up. 3:27 On the table in child's pose because her low 3:30 back pain certainly is an irritable. 3:33 She volunteered for videos today. She's in good health. 3:36 All right. So what I'm gonna do is go ahead and pull her shirt up 3:39 and I'm just gonna tuck it underneath her sports 3:42 bra. 3:44 And so it stays out of our way. 3:47 Good. All right. And so you guys can imagine the thoracolumbar? Fascia 3:50 is the origin of the latissimus dorsai. 3:53 So it's it's gonna go up this way, right? It 3:56 actually connects all the way into the lower traps, right? 3:59 So we're up into the thoracic spine here. And then 4:02 as far as how low we're gonna go if I 4:05 find her pelvic crest 4:08 and I just put her pants right up against her pelvic Crest 4:11 now. I have a good little border. 4:14 for the area that I should probably scan and 4:17 treat any dysfunctional tissue in 4:20 so we're going to use the same protocol. We've been using for all 4:23 of our techniques. 4:28 A little bit of cream to make sure that we don't abrade the 4:31 skin. Remember our goal is to affect the 4:34 layers of fascial tissue. In fact, there's a 4:37 study that shows low back pain results in 4:40 a reduction in Shear between layers of 4:43 the thoracolumbar fascia in low back pain patients really 4:46 interesting stuff. 4:48 The thoracal lumbar fascia is actually probably the most well researched 4:51 fossil tissue. 4:55 So I'll try to lay out some facts here as we go through this, 4:58 but I'm just rubbing in that. 5:01 That cream again. I know some people get all bent out 5:05 of shape about how much cream they use. It doesn't matter that 5:08 much. You might make a bit of a mess, but 5:12 it's okay. You can wipe it off with the towel pretty easy. 5:16 or you can just 5:18 Moisturize the other side of leases back here. 5:21 You see you mind if I moisturize the other side of your back too. Okay. 5:24 Yeah, she doesn't mind. 5:27 All right. So as I'm going through here, I could also just kind of 5:30 use my palpation skills to notice any areas 5:33 that I thought were a little bit more. 5:36 Dense, or maybe not dense, right? We know that we get atrophy of 5:39 the multifidae and the erector spinae. 5:42 around areas of dysfunction like hernia herniations 5:47 Maybe I'll note some of that with my hands. All right, then once 5:50 I get all that. 5:53 That nice and rubbed in and the skin is 5:56 lubricated. Now. I can use my scanning strokes and I'm gonna 5:59 start at her posterior iliac spine here. 6:02 And just kind of work my way up. 6:06 for really her erector 6:11 kind of bump here 6:14 see if I notice anything unusual like I 6:17 do notice like right here. I can feel like 6:20 a little bit more bumpiness in the tissue. So I'm gonna take note of that. I'm just 6:23 scanning through. 6:25 20 degree angle on the tool pulling through 6:28 the tissue. Let's do the other side compare sides 6:32 a little bit again scanning through the tissue noting 6:35 any differences. 6:39 Kind of using kind of a lawnmower sort of pattern right 6:42 one strip of skin at a time. 6:46 I can go back down this way. 6:48 If I wasn't totally sure and yeah, I'm get definitely getting a 6:51 lot more in here. 6:56 All right, so I'm getting a lot more tissue 6:59 texture right a difference 7:02 something that's not uniform kind of in this 7:05 area. 7:06 So now we're going to use those multiple directions Strokes. 7:11 to try to 7:15 Unbind these tissues and get some Shear back 7:18 between tissue layers. There are a lot of layers. There's 7:21 actually like four layers to the thoracco lumbar fascia, right? 7:24 So your thoracolumbar fascia has a superficial posterior 7:27 lamina, it has a deep posterior. Lamina 7:30 has a middle layer and an anterior layer, you know, 7:33 I think up till the middle layer. We're probably affecting a little bit with 7:36 these tools. So that's something to think about and if 7:39 you guys look up the work of leaming you can actually see how complex 7:42 the direction 7:45 Of all of those layers, it's it's really interesting stuff. 7:48 Now all we need to know is that 7:51 the layers don't necessarily follow the erector 7:54 spinae. It's not straight up and down and disorderly collagen 7:57 binding isn't going 8:00 to be in any One Direction either. 8:02 So again, I'm gonna try to go in a bunch of different directions. 8:06 Generally, I do six. I don't know where I got that from but I'll 8:09 go up down and then I'll do. 8:12 Down Arch this way up Arch this 8:15 way and then come from the other side and do the same thing, right? So 8:18 that gives me kind of like six angles. 8:21 I think that's probably a pretty good. 8:24 way to get 8:26 a lot of 8:28 angles going 8:32 usually do three to six Strokes in each 8:35 Direction. 8:37 And that's just based on the amount of 8:40 redness. I get I think if you go much past three to six Strokes, 8:43 which if you think about it, we just do our math that's 18 to 36 8:46 Strokes in one area. That's a 8:49 lot of therapy actually. 8:52 Definitely doesn't take very long. 8:57 She's getting pretty red already. 8:59 I'm even getting a little bit of that petechiae because it 9:02 probably heard that term before but that's a little redness that you like. 9:05 Looks like a hickey or like a rug burn when we 9:08 know we've we've broken up some capillary beds 9:11 a little bit. 9:12 I can go ahead and do the other side. 9:15 Start with these strokes and then these Strokes. 9:20 these Strokes 9:30 good stuff. And again, 9:33 she's getting pretty red here. 9:36 Just double check the rest of this tissue. 9:38 All right, so I got those now. Let's say I found a 9:41 trigger point. Let's say that I found a trigger 9:44 point in a Rector spinae. We know that's pretty common and I during 9:47 my static manual release techniques, I'd 9:50 noticed it. So now I'm going to come back and I'm gonna try to break up. Any 9:53 adhesion that's been caused around that trigger 9:56 point. I have found a little Improvement in carry over. 10:00 So now our protocol so far. 10:03 is scan 10:06 disrupt any areas of non-uniformity 10:11 with those multi-directional scope Strokes, then we're 10:14 going to attack these trigger points by going 10:17 in all directions around the trigger point and kind of like a cross friction 10:20 massage sort of way. 10:23 and then of course the way to 10:27 finish off any of these istm techniques is probably 10:30 with some sort of like pin and 10:33 stretch technique now that is pretty tough in the 10:36 low back. 10:37 What we probably have to do is either have 10:41 her start a little a little up. 10:44 pin the technique down 10:47 Right now go ahead and reach forward for me all the 10:50 way into like a lat stretch. 10:54 Good, right, we get a little bit of tension developed 10:57 here. Alright, so come up a little bit. 11:01 All right pin and then reach out for me. 11:04 And then if I was doing this side, I wanted to 11:07 get a little bit more. I'm actually gonna have you reach this towards the 11:10 end of the table. Okay. All right, so back 11:13 up again. 11:14 All right, last one and reach. 11:17 Good stuff. All right, let's do the other 11:20 side a little bit. All right, same thing. 11:23 Pin some tissue, right? So I'm just grabbing some tissue holding and 11:26 then reach. 11:29 Good. 11:30 And she started with the side reach she likes she likes 11:33 to get intense quick. 11:35 kettlebell champ 11:37 She likes intense workouts. 11:39 All right, go ahead and reach. 11:41 Good stuff. All right, let's keep let's 11:44 keep going to that opposite side since you started that way and one 11:47 more and this is a really 11:50 intense technique like I'm kind of repeating myself now, 11:53 but you know, I wouldn't do much more than three to five 11:56 of those pin and stretch Strokes. 12:00 All right guys, so the next thing I'll show you is a close-up 12:03 recap. So you get a good look at some of 12:06 the redness that appeared and how some of that technique looks 12:09 close up. All right guys for a close-up recap. I'm 12:12 gonna go ahead and add a little bit of this. 12:15 Smart Tools cream here. Of course. There's a lot of different creams out 12:18 there guys. Use what's comfortable for you. I'm gonna 12:21 go through and make sure the Skin's well 12:24 lubricated. I'm gonna take this chance to kind of 12:27 feel through and use my palpation skills to 12:30 get as much information as I can about what's going 12:33 on. Do I feel like some atrophy 12:36 or maybe some hypertrophy on 12:39 only one side. Do I feel any denseness 12:42 in the tissue any trigger points? It's all 12:45 information. I'm keeping track of but what I'm gonna do is 12:48 I'm gonna take this scanner tool. 12:50 The scanner tool is single bevel pretty sharp and 12:53 I'm gonna go ahead and go from posterior iliac 12:56 spine all the way up into 12:59 the thoracic spine, right? My thoracolumbar fascia comes 13:02 up like this. 13:03 And it goes all the way up and inserts into the 13:06 lower trapezius actually. 13:08 So if I go this way? 13:12 Just kind of pull through the tissue. I'm going to note any 13:15 sort of dysfunction. 13:18 And as I kind of mentioned in the further away shot, she's 13:21 got a little bit more dysfunction in here. 13:25 And I felt something right there. 13:30 And The Superficial lamina of the thoracolumbar fascia. 13:35 is actually partly created by The Superficial flash 13:38 of the latissimus Dorsey, so 13:41 If you wanted to go out this way a little bit you could I did feel 13:44 a little bit of something right there. 13:47 Same thing you guys can see I just have like a mowing the 13:50 lawn pattern. 13:52 Just taking one strip of tissue at a time and all I'm doing 13:55 right now is kind of making notes of things. I want to go back over with my 13:58 multidirectional Strokes. So let's say here 14:01 and then maybe here 14:03 now the tool tools that seem to work best for me. 14:06 On the low back or this tool? 14:08 the battering tool 14:11 or 14:12 the shark tool 14:14 I tend to want a convex Edge 14:17 for the low back. I find the concave 14:20 edges. 14:21 It's a little hard to not end 14:24 up hitting the spinous process to not end 14:27 up hitting some of the Bony protuberances. 14:33 All right. So all I'm going to do guys. 14:36 Is my multidirectional Strokes so you can see here. 14:39 I'm going to start. 14:42 fulcrum 14:43 pivot fulcrum pivot that's One Direction 14:47 fulcrum pivot fulcrum pivot, that's 14:50 the other direction. 14:51 fulcrum pivot fulcrum pivot 14:56 fulcrum pivot fulcrum pivot and then I'll 14:59 go up. 15:02 Down and it doesn't really matter what order you do things 15:05 in remember this tissue the thoracle number 15:08 Flash in particular has a very complicated fiber arrangement 15:11 with multiple layers moving in various different directions, and 15:14 then The Binding between layers happens with disorderly collagen 15:17 kind of binding in all 15:20 sorts of different directions. So we don't need to necessarily worry about only going up 15:23 or only going down. 15:26 All right. We're just going to kind of go in a bunch of different directions here. 15:30 You guys can see a little redness coming on there this of 15:33 course is the second time. I'm going over this part of her low back. So I'm gonna leave this alone 15:36 if I did it here again. 15:38 Three four five six you can 15:41 see I'm about a 30 degree angle. I'm just going 15:44 through my Different Strokes. 15:48 Notice that redness coming in that's that histamine response. Now, 15:51 the redness is not necessarily therapeutic. 15:55 I don't actually think that like petechiae and 15:58 histamine responders really have much to do with the 16:01 effect we get. I think it's a lot more. 16:05 Of if you guys look up the Sleep model. 16:09 You know fascia response to tissue manipulation. 16:13 I think that is a much better explanation of what's happening. 16:16 I think the histamine response and some of the petechiae is 16:19 more coincidental having to do with increased inflammation 16:22 at one point that led to some of the tissue stuff 16:25 that we're feeling. 16:27 Now, of course the last thing we need to do or I'm sorry, the two last 16:30 things we need to do is go after any trigger points. 16:33 Break those puppies up say this was a trigger 16:36 point. I just 16:37 do one of these things right do some cross friction all 16:40 the way around. 16:42 Really try to break up any adhesive tissue. 16:45 That had been created by that trigger point and then always 16:48 remember. 16:50 To get a little bit of that. 16:52 Dynamic instrument assisted soft tissue 16:55 mobilization in to really get some change in 16:58 how these layers move. 17:02 All right. So what I'm gonna do is I'm gonna have Lisa go 17:05 ahead and kind of 17:06 Arch up a little bit for me here, and she she actually just 17:09 kind of pushed up from this position. Like she did a Mckenzie, press 17:12 up almost now. I'm gonna pin down the 17:15 tissue right right where she had that dysfunction. So right 17:18 where she had the dysfunction I'm pinning down. And now 17:21 what I'm gonna have her do is reach out into a lat stretch and 17:24 then side Bend away from the tool. 17:28 Good. 17:30 Alright, and that is a pretty intense technique. So we're gonna do it 17:33 again. 17:34 We're only going to do it like three to five times. 17:37 All right do it again? 17:39 Especially on the first session after the first session let's 17:42 reassess. Let's find out how much 17:45 of a response we got. Let's see how she feels the next 17:48 day. Let's see that one more time. 17:52 and reach 17:54 Alright guys. Remember this is not just a low 17:57 back pain technique. We're trying to change 18:00 Mobility. I would say that the most reliable assessment 18:03 here is probably rotation. 18:08 I think we can get see the biggest changes in rotation. Especially 18:12 if somebody is restricted in rotation after we try this 18:15 technique you want to try the other side. 18:17 Go ahead and go up. 18:20 and stretch over 18:23 good back up. 18:26 Back over there is reason to believe that if somebody 18:29 was really irritable with low back pain. It was really generalized. 18:32 They had that like band of pain this way. 18:35 Go ahead and do it again. This may not be 18:38 something we want to do. 18:39 A lot of The receptors in the thoracolumbar. Fascia. 18:42 I know we see a lot of talk about 18:46 Receptors in fossil tissue a lot of them in 18:49 the thoracolumbar fascia are actually pain receptors. So that's that's something 18:52 to keep in mind. We might not want to attack this stuff in somebody 18:55 who's very irritable guys. I hope 18:58 you enjoyed the video. I hope you'll give the technique a try 19:01 instrument assisted soft tissue mobilization is a wonderful amendment 19:04 to an integrated program. And I 19:07 think you guys will get some great carry over from session 19:10 to session. If you have any questions leave them in 19:13 the comments box below. So there you have it instrument assisted soft 19:16 tissue mobilization, make sure to assess 19:20 Address using the intervention and then of 19:23 course reassess and if you get the chance these 19:26 videos are not a replacement for 19:29 live education. Of course, if you 19:32 get the chance, you should take live workshops or find 19:35 a mentor who's experienced using these tools or maybe 19:38 a friend that wants to learn them too. So 19:41 at least you can practice on each other and give each other 19:44 some tactile feedback of what you feel how you 19:47 felt the next day what results you felt that you 19:50 got. 19:51 I hope you guys enjoyed this video. Please. Feel free to leave your 19:54 questions below.
