Athletic Training and Sports Health Care

Clinical Roundtable 

Instrument-Assisted Soft Tissue Mobilization

James R. Scifers, DScPT, PT, SCS, LAT, ATC; Russell Baker, DAT, ATC; Alison Gardiner-Shires, PhD, LAT, ATC; Phillip Vardiman, PhD, LAT, ATC

Abstract

Instrument-assisted soft tissue mobilization (IASTM) is an approach to soft tissue manipulation that uses concave and convex stainless steel instruments to release scar tissue, break soft tissue adhesions, and remove fascial restrictions. The variation in curvatures of the tools allows clinicians to individualize treatments to address specific tissues and anatomical regions. The goal of IASTM is to enhance the healing process by breaking down collagen cross-linkages, increasing blood flow, and increasing cellular regeneration. IASTM has been proposed as a treatment option for a wide variety of soft tissue injuries, ranging from medial and lateral epicondylalgia and rotator cuff tendonopathy to ilio-tibial band syndrome and plantar fasciitis. However, not all soft tissue pathologies can benefit from the use of IASTM.

Evidence regarding the use of IASTM is limited and often mixed with regard to benefits. Although the technique has been found to accelerate ligament healing using an animal model and increase shoulder range of motion in athletes, several studies have demonstrated no therapeutic benefits beyond those of more traditional treatments. This clinical roundtable discussion investigates the benefits and limitations of IASTM.

Scifers: How are you using IASTM in your practice? How do you incorporate IASTM into the overall treatment plan for your patients?

Baker: After my initial training, I probably used IASTM like most clinicians do initially—I focused on treating supposed “overuse” pathologies, range of motion limitations, scar tissue, or other conditions I believed would respond to an intervention promoting mechanical tissue remodeling. As I used IASTM more in clinical practice, and completed training in other rehabilitative techniques/paradigms, my use pattern changed. Often, I would find my patient outcomes, such as increases in range of motion or decreases pain, were happening at a rate and pattern that did not seem to fit the proposed tissue remodeling model often cited in IASTM literature.Additionally, other interventions, such as the Mulligan Concept, Positional Release Therapy, or Total Motion Release, were either immediately changing my IASTM scanning evaluation (eg, I could no longer identify adhesions with the instruments after applying one treatment of another technique) or these other interventions were resolving cases of diagnosed “overuse” pathologies in one to three visits. When something challenges your belief system like that, you have two options: (1) stick your head in the sand or (2) reevaluate your patient care philosophy. I chose reevaluation of my belief system.Now, IASTM intervention tends to be an adjunct therapy I combine within other interventions and it is used far less frequently. If I reflect on my patient care, I would say I tend to use it most often when I am fairly confident that I need to reinitiate the inflammatory process given a specific patient presentation. I also gravitate toward it when patient improvements experienced from other interventions are not being fully maintained between visits and I think IASTM can effectively “reinforce” the other intervention.

Gardiner-Shires: Like Dr. Baker, I most frequently use IASTM on patients with chronic pathologies such as tendinopathies and postural dysfunction, where my goal is to increase range of motion, improve function, and decrease pain. After a dynamic warm-up, I follow a progression of treating the targeted soft tissue structure on slack, followed by treating the targeted tissue on stretch and finally in combination with motion and/or exercise.

Vardiman: I use IASTM primarily for subacute and chronic injury treatment that involves tissue restrictions that inhibit range of motion. I don't incorporate IASTM for all patient care, but rather I use it in combination with other manual therapy and soft tissue mobilization techniques to help improve joint motion and patient function.

Scifers: For which conditions do you find IASTM…

Instrument-assisted soft tissue mobilization (IASTM) is an approach to soft tissue manipulation that uses concave and convex stainless steel instruments to release scar tissue, break soft tissue adhesions, and remove fascial restrictions. The variation in curvatures of the tools allows clinicians to individualize treatments to address specific tissues and anatomical regions. The goal of IASTM is to enhance the healing process by breaking down collagen cross-linkages, increasing blood flow, and increasing cellular regeneration. IASTM has been proposed as a treatment option for a wide variety of soft tissue injuries, ranging from medial and lateral epicondylalgia and rotator cuff tendonopathy to ilio-tibial band syndrome and plantar fasciitis. However, not all soft tissue pathologies can benefit from the use of IASTM.

Evidence regarding the use of IASTM is limited and often mixed with regard to benefits. Although the technique has been found to accelerate ligament healing using an animal model and increase shoulder range of motion in athletes, several studies have demonstrated no therapeutic benefits beyond those of more traditional treatments. This clinical roundtable discussion investigates the benefits and limitations of IASTM.

Scifers: How are you using IASTM in your practice? How do you incorporate IASTM into the overall treatment plan for your patients?

Baker: After my initial training, I probably used IASTM like most clinicians do initially—I focused on treating supposed “overuse” pathologies, range of motion limitations, scar tissue, or other conditions I believed would respond to an intervention promoting mechanical tissue remodeling. As I used IASTM more in clinical practice, and completed training in other rehabilitative techniques/paradigms, my use pattern changed. Often, I would find my patient outcomes, such as increases in range of motion or decreases pain, were happening at a rate and pattern that did not seem to fit the proposed tissue remodeling model often cited in IASTM literature.Additionally, other interventions, such as the Mulligan Concept, Positional Release Therapy, or Total Motion Release, were either immediately changing my IASTM scanning evaluation (eg, I could no longer identify adhesions with the instruments after applying one treatment of another technique) or these other interventions were resolving cases of diagnosed “overuse” pathologies in one to three visits. When something challenges your belief system like that, you have two options: (1) stick your head in the sand or (2) reevaluate your patient care philosophy. I chose reevaluation of my belief system.Now, IASTM intervention tends to be an adjunct therapy I combine within other interventions and it is used far less frequently. If I reflect on my patient care, I would say I tend to use it most often when I am fairly confident that I need to reinitiate the inflammatory process given a specific patient presentation. I also gravitate toward it when patient improvements experienced from other interventions are not being fully maintained between visits and I think IASTM can effectively “reinforce” the other intervention.

Gardiner-Shires: Like Dr. Baker, I most frequently use IASTM on patients with chronic pathologies such as tendinopathies and postural dysfunction, where my goal is to increase range of motion, improve function, and decrease pain. After a dynamic warm-up, I follow a progression of treating the targeted soft tissue structure on slack, followed by treating the targeted tissue on stretch and finally in combination with motion and/or exercise.

Vardiman: I use IASTM primarily for subacute and chronic injury treatment that involves tissue restrictions that inhibit range of motion. I don't incorporate IASTM for all patient care, but rather I use it in combination with other manual therapy and soft tissue mobilization techniques to help improve joint motion and patient function.

Scifers: For which conditions do you find IASTM to be most useful?

Vardiman: In my practice, IASTM has proven most beneficial in treating subacute and chronic injury that involves loss of motion or function due to tissue restriction.

Gardiner-Shires: Most commonly, I use this treatment intervention to treat tendinopathies, such as the Achilles tendon and patellar tendon. For example, in a patient with patellar tendinosis, I apply IASTM to the patella tendon and quadriceps muscle at the same time that the patient performs a provocative activity (up to 3 of 10 on the Visual Analog Scale) such as an overhead squat or lunge.

Baker: If you look in the literature or attend a course, you will definitely find a list of conditions IASTM is recommended to treat. You are welcome to follow that list, but I am more inclined to say it is useful for specific patient presentations as opposed to specific conditions/pathologies. For example, a patient who is diagnosed as having lateral epicondylagia may have his or her condition resolved within one to three visits using the Mulligan Concept alone. In those cases, I don't see the value in using IASTM—it takes longer, has more contraindications, and is more likely to cause an adverse reaction. However, I might have another patient with the same diagnosis but a slightly different clinical presentation. In this case, the patient needs a multimodal intervention and responds well to an approach using the Mulligan Concept, IASTM, and neurodynamics. So, with that frame of reference, I am hesitant to prescribe interventions to pathologies versus recommending we match interventions to the presentations, limitations, or dysfunctions found within a given patient case.

Scifers: IASTM has many proposed benefits, including releasing scar tissue, adhesions, and fascial restrictions, increasing blood flow, and promoting tissue healing. How have you seen IASTM benefit your patients in terms of clinically measurable outcomes, such as improving range of motion, strength, and function?

Vardiman: I have seen it improve range of motion, decrease pain, and increase function. When I teach IASTM, I encourage the clinician to assess the patient's primary complaint of pain, restriction, or both in a functional movement. After the treatment application to the patient, have him or her repeat the functional movement to determine treatment efficacy. The patient's post-treatment movement will tell you a lot about his or her immediate clinical needs, what the home exercise program needs are, and provide you with a new baseline for when the patient returns for more care. Another helpful tip is to get the patient's permission to use an app on a secured mobile device to video record the movements and show the patient the improvements of before and after treatment side by side and day by day.

Baker: The most consistent improved outcome across various patients and conditions is an increase in range of motion. When matched well to patient presentation/dysfunction, I have also found IASTM to be effective for decreasing pain, improving strength and function, and producing meaningful changes on patient-reported outcomes instruments. Based on the available evidence and my patient outcomes, however, I am not convinced these changes are occurring by releasing scar tissue, adhesions, or fascial restrictions. I do think there is the potential to promote healing when used to treat certain pathological conditions, such as subacute ligament sprains, but I cannot say that I have measured these changes objectively in my clinical practice.

Gardiner-Shires: I assess pain (via the Visual Analog Scale) before and after treatment and have found patients to report an immediate, significant decrease in pain after treatment. Most often, those gains are maintained after 24 hours. The same can be said for improvements in range of motion and function. Consistent with the literature on other manual therapy techniques, I have found a multimodal approach to improving range of motion and function to be superior; in other words, using IASTM in conjunction with stretching and corrective exercise to overcome range of motion and functional barriers as opposed to using any one treatment intervention alone.

Scifers: Have you identified any negative effects from the use of IASTM?

Gardiner-Shires: The most common negative effect is bruising if an area is treated too aggressively.

Vardiman: I have identified mild bruising and post-treatment tenderness that typically resolves within days of treatment.

Baker: If a clinician is cognizant and purposeful with what he or she is doing, I think it is easy to avoid negative effects of IASTM application. If you are too aggressive, poorly integrate other therapies with IASTM application, or do not purposefully use IASTM to produce specific effects, then I think you are more likely to produce negative effects in your patient care. Overall, I think the negative effects, such as patient discomfort, patient bruising/petechiae, or a more adverse reaction to treatment, are fairly easy to avoid if you pay attention to treatment precautions and contraindications.

Scifers: There is a limited amount of peer-reviewed, clinical research regarding IASTM. How would you like to see this technique investigated in the future?

Gardiner-Shires: There are numerous challenges with the existing literature. First, to assist clinicians and researchers, authors should consistently use the term IASTM in their title, key words, and abstract. Currently, it takes a complicated Boolean string to locate the randomized controlled trials that exist; this is due to alias and product-specific terms being used instead of the term IASTM. I would also like to see the overall quality of studies be improved; few studies exist that are a 7 of 10 or higher on the PEDro (Physiotherapy Evidence Database) scale. Finally, the literature would benefit greatly from standardized treatment parameters. Currently, there is a great deal of variability in treatment time, patient positioning, region treatment, number of treatments applied, treatment groups (control vs no control), and types of participants (healthy vs unhealthy); this makes comparison and generalizability extremely difficult.

Baker: The obvious first step is to recreate the bench science animal studies as human trials. I do not think we have sufficiently identified the cellular and mechanical responses of IASTM treatment with in vivo human trials. That said, I do not think those studies will fully answer the questions we need answered to truly understand the mechanisms or effectiveness of IASTM as an intervention. Additionally, we need more translational research studies examining both disease and patient-oriented evidence in combination to assess the effectiveness of IASTM in patient care.Like Dr. Shires-Gardiner, I would like to see more consistency of the IASTM application within these studies. I also think we need to examine other potential mechanisms (eg, neurological changes, vascularity changes, and pain perceptions) to determine how IASTM is producing its effects. Currently, I think there is reasonable evidence to refute the theory that the benefits are occurring through observable structural tissue changes.

Vardiman: There is much work to be done regarding producing strong evidence supporting or refuting the use and benefits of IASTM. One area that I am particularly interested in seeing examined in the literature is how IASTM invokes an inflammatory response in restricted tissues.

Scifers: For a clinician who has not used IASTM previously, what advice would you offer for getting started with this treatment intervention?

Vardiman: I would encourage a novice user to take a continuing education course to become better educated in the theory behind and use of IASTM. Purchasing IASTM tools can be a major expense. I would advocate that clinicians try multiple IASTM tools and purchase the tools that they feel most comfortable using in clinical practice.

Baker: First, I would recommend reviewing the literature on IASTM and other related areas to gain an appreciation for what is or isn't known in areas that may guide IASTM application. In many cases, we are lacking evidence to confirm or refute the proposed benefits of IASTM. I would also recommend working with, or at least discussing, IASTM as an intervention with another health care provider who is well versed in IASTM and other rehabilitative paradigms because that may provide the greatest insight on effective use of the technique and may reduce overreliance on IASTM therapy.Finally, I would recommend reviewing the different IASTM educational providers and selecting at least one course to attend to receive formal training. It is not an overly complicated intervention to learn and apply, but having used and taught IASTM for more than a decade, I can tell you there is definitely a learning curve when people first begin to use the technique. Choosing the provider can be difficult because there are so many options, but I would recommend finding a course provider who teaches IASTM as part of a larger rehabilitative protocol and incorporates other techniques, systems, or mechanisms into their training versus learning from a group who takes a dogmatic approach to IASTM application.

Gardiner-Shires: Start small and follow evidence-based practice guidelines—familiarizing yourself with the existing literature will assist you in the clinical decision-making process. As you use IASTM, be sure to assess patient values and document your outcomes before and after treatment.

Suggested Reading

  1. Cheatham, SW, Lee, M, Cain, M & Baker, R. The efficacy of instrument assisted soft tissue mobilization: a systematic review. J Canadian Chiro Assoc. 2016;60:200–211.
  2. Laudner, K, Compton, BD, McLoda, TA & Walters, CM. Acute effects of instrument-assisted soft tissue mobilization for improving posterior shoulder range of motion in collegiate baseball players. Int J Sports Phys Ther. 2014;9:1–7.
  3. Loghmani, MT & Warden, SJ. Instrument-assisted cross-fiber massage accelerates knee ligament healing. J Orthop Sports Phys Ther. 2009;39:506–514. doi:10.2519/jospt.2009.2997 [CrossRef]
  4. Schaefer, JL & Sandrey, MA. Effects of a 4-week dynamic-balance-training program supplemented with Graston instrument-assisted soft-tissue mobilization for chronic ankle instability. J Sport Rehab. 2012;21:313–326. doi:10.1123/jsr.21.4.313 [CrossRef]
  5. Stow, R. Instrument-assisted soft tissue mobilization. Int J Athletic Ther & Train. 2011;16:5–8. doi:10.1123/ijatt.16.3.5 [CrossRef]
  6. Vardiman, JP, Siedlik, J & Herda, T et al. Instrument-assisted soft tissue mobilization: effects on the properties of human plantar flexors. Int J Sports Med. 2015;36:197–203.
Authors

Russell Baker, DAT, ATC, is from the University of Idaho, Moscow, Idaho.

Alison Gardiner-Shires, PhD, LAT, ATC, is from West Chester University, West Chester, Pennsylvania.

Phillip Vardiman, PhD, LAT, ATC, is from Kansas State University, Manhattan, Kansas.

Moderator: James R. Scifers, DScPT, PT, SCS, LAT, ATC

This Clinical Roundtable was conducted February 22, 2017.

The authors have no financial or proprietary interest in the materials presented herein.

10.3928/19425864-20170223-01

Sign up to receive

Journal E-contents