Critical Evaluations of Current Trends

Critical Evaluations of Current Trends: Reflections on Instrument Assisted Soft Tissue Mobilization

If you are a new physical therapy school graduate, transitioning into the professional world can be challenging. Our education never stops and the drive to get the latest certification, learn the newest technique, and better our skills never goes away. This is mostly a good thing. Problems arise however, when we board the hype train a little too quickly. Just look at the the recent court settlement over the claims made about kinesiology taping; many physical therapists have been utilizing taping and getting certified despite underwhelming evidence in support of the treatment. This case highlights the importance of seeking a strong scientific background for our treatments, using the evidence we already have, and translating it for our patients.

Instrument-assisted soft tissue mobilization is another trend that has exploded in popularity. I am constantly seeing new courses, new tools, and new research coming out. But what does the evidence say? Is IASTM as beneficial as some may want you to think? Are these treatments worth our time and our patients’ money? It is vital that members of our profession, and new graduates specifically, stay on top of the science so we can answer these questions.

This article is part of a series, Critical Evaluations of Current Trends: check out the first entry on cryotherapy!

The Basic Claims of Instrument-Assisted Soft Tissue Mobilization

IASTM treatments are diverse in both theory and application, and a variety of companies have offered their own tools, courses, and certifications. These companies include Graston, ASTYM, Rocktape, Hawkgrips, Smart Tools, and more. Each have their own spin on the same basic idea: rubbing one of these tools on a body part has beneficial effects for people who have painful conditions. How these beneficial effects occur depends on who you talk to. The claims are generally broad and bold; IASTM can help with restarting the healing process, eliminating fascial restrictions and adhesions, remodeling scar tissue, improving range of motion and strength, modulating pain or tone, or stimulating the nervous system.

Purveyors contend that IASTM treatments help patients get better, faster. Naturally, the ostensibly appealing promises made make IASTM and attractive choice for new physical therapists. Who wouldn’t want to give our patients the best, most effective treatments available? The research on IASTM however, questions the validity of these claims and ultimately leaves much room for doubt.

Pre-Clinical Research

Some of the foundational research that is often cited in support of IASTM comes from a few studies on rodent tendons. One study from 1997 found that after inducing achilles tendinitis in rodents, those that received IASTM had increased fibroblast counts, thought to be indicative of a jumpstart to the healing process, compared to controls.6 Another study from 1999 echoed these results, and also found that increased pressure resulted in even more fibroblast proliferation.8 A more modern study was performed in 2009 on a group of 51 rodents. The researchers induced bilateral MCL injuries, and for each rat in the experimental group, they treated one side with IASTM and left the other side alone. They found the treated ligaments were stronger and stiffer after four weeks, but there were minimal differences after twelve weeks. They conclude: “in summary, this study suggests that IACFM may accelerate early tissue-level healing following acute capsular/extracapsular ligament injury but it has minimal to no effect in terms of augmenting the overall outcome of the ligament-healing process.”15 A similar study in 2013 by the same authors found that IASTM did not produce increased tissue perfusion in the immediate 20 mins after treatment. However, they did find that increased perfusion and increased vascularity at later time points.16

These studies have provided a plausible, but certainly questionable basis for IASTM. As pointed out by all the researchers, to their credit, we need to be cautious when extrapolating these studies to clinical populations. Studies on rats are clearly different than human studies and we ought to reserve our judgment for now. What does some of the clinical research say?

Clinical Research And Fair Tests

It may be useful to think of what we would consider a fair test for IASTM that would suggest it has benefits above and beyond traditional STM treatments. If companies suggest that IASTM can get patients better, faster, they ought to be able to prove it. A fair test would be a randomized, controlled trial that is adequately powered and with a specific treatment population. This study would have three groups; a control group that received advice and education, and experimental group that received a multi-modal physical therapy program including IASTM, and a comparison group that received a multi-modal physical therapy program including only manual STM. In our ideal study, we would have short and long term follow-up, and multiple outcome measures assessing pain and function at different time points.

Does this ideal study exist? One study from 2007 came close, comparing graston treatment to manual soft tissue mobilization for 24 patients with carpal tunnel syndrome. This study was a small pilot study, but found that for pain, functional status, ROM, and grip strength, there were no differences between groups after the initial study period and the three month follow-up.3 One other study compared five minutes of compressive myofascial release that was performed manually or a graston technique to the calf for improving dorsiflexion in healthy subjects. They found that both techniques were able to improve dorsiflexion by 3-5 degrees after one treatment, with the slight edge to CMR.24 To their credit, the assessors were blinded to group allocation, but there was no long term follow-up. I was unable to find any other study that directly compared an IASTM treatment to a manual STM treatment. Another study from 2011 found that for 27 patients with lateral epicondylitis, both IASTM and advice, ergonomics, and stretching improved outcomes equally after three months.2

Other Thought-Provoking Studies

There are many other interesting studies that have made me question some of the claims regarding IASTM. One study from 2016 compared graston treatments, spinal manipulative therapy, and sham ultrasound therapy for 143 patients with thoracic pain. After a study period of four weeks and a follow-up period of one year, the researchers found no differences in any outcome measure at any time point.5
Another study from 2014 assessed the effects of IASTM on 11 healthy patients’ calf muscles. The researchers found that after an eight minute treatment of IASTM, there were no differences between experimental and control legs in muscle stiffness, PROM, passive resistive torque, maximum voluntary contraction peak torque, interleukin-6 and tumor-necrosis factor.26 The authors write: “the current data indicate that IASTM using appropriate clinical pressure with the instrument held within the accepted treatment angle does not cause muscle damage or initiate the inflammatory process in healthy human muscle tissue.”26

Lastly, a study from 2012 compared dynamic balance training with IASTM or sham light pressure IASTM versus dynamic balance training alone for 36 patients with chronic ankle instability over four weeks. All groups improved on outcome measures equally, despite a statistically insignificant trend of larger effect sizes in the true IASTM group.22

Lower Quality Studies

There are many other studies that do show positive results in favor of IASTM, but their designs leave room for doubt. Many studies followed the (Treatment A + Treatment B) versus (Treatment A only) design, which almost always have positive results in favor of the experimental treatment. These studies show that IASTM can result in positive outcomes for shoulder ROM,1,9 achilles tendinopathy,19 dorsiflexion ROM,21 and lateral epicondylitis.23 Other studies compared IASTM to no treatment and found positive results for pain and decreased flexibility in post-mastectomy patients,7 chronic back or neck pain,12 and shoulder ROM.13

Other study results were mixed. Three studies looked at the effects of IASTM on performance with pre-test/post-test designs. One study compared IASTM to sham IASTM and found that the experimental group had improved lower extremity max force output.10 Another compared IASTM to no treatment, and found no differences in vertical jump height, peak power, or peak velocity.17 The last study compared IASTM to self-myofascial release, and found extremely small differences in vertical jump and a 40 yard sprint.25

One study found one session of IASTM was better than one session of static stretching for improving sitting trunk flexion for patients with low back pain.20 Another found IASTM was better than foam rolling for improving range of motion tests in soccer players.18 Lastly, one study showed that IASTM was better than general exercise over four weeks for improving pain and ROM for patients with back pain.14 However, there was no randomization, no blinding, and the interventions were inadequately described.

Systematic Reviews And Meta-Analyses

A few narrative reviews, systematic reviews and meta-analyses have been undertaken. One review from 2016 found seven randomized controlled trials, five of which were covered above. This review did not include case studies, case reports, Gua Sha therapy, or ASTYM therapy. Each study varied significantly with the protocol used, the population treated and the outcome measures. Statistical and methodological heterogeneity precluded any meta-analyses but the authors noted the evidence does not support the use of IASTM for the treatment of various pathologies, and there is only weak evidence supporting the efficacy of IASTM for improving ROM. The authors conclude by writing “the current evidence seems to lack the methodological rigours necessary to validate the efficacy of IASTM itself or any of the IASTM protocols.”4 In other words, there are no studies of sufficient quality we can point now that show IASTM is effective.

Another review from 2017 looked at seven studies, five of which were covered above. One study included in the review did not feature IASTM in any form, bringing its inclusion in the study into question. For the six remaining studies, the majority either had equivocal outcomes with a control or sham group, or had an inactive control group. One study previously covered above showed that IASTM helped improve ROM tests slightly better than foam rolling. The authors suggest that further research is needed, but go on to say IASTM is effective for reducing pain and improving function in a three month period.11 This is premature, as the methodological quality of the current research and the largely equivocal results should prevent them concluding this.

What Does The Research Really Say?

Based on all of the preclinical research, clinical trials, and systematic reviews, I have to conclude there is not sufficient high-quality evidence to say that IASTM is worth our time. There are no studies that show patients getting better, faster. And there are certainly no studies that compare IASTM to manual soft tissue work with IASTM coming out on top. This certainly could change in the future; as it is not hard to imagine a study coming out with the appropriate statistical and methodological rigour that shows substantial benefits above and beyond traditional therapy. And in fact, I hope one does, because I want a successful and effective treatment just as much as anyone else would. However, right now, there is serious room for skepticism. And to anticipate some objections; I am sure that those of who have used IASTM, myself included, have found success with it. I am sure there are many patients that have benefitted from it, and it may have been the only thing that has helped them. The bar for treatments we include, however, ought to be higher, and IASTM has not yet passed any hard scientific tests.

Conclusions: Should PTs Be Promoting IASTM?

Given the current body of evidence, how should we view the overwhelming enthusiasm and popularity of IASTM? Can Graston, ASTYM, Rocktape and others really say IASTM is backed by science? Should new physical therapists be buying tool sets that cost more than a used car? Should we be seeking to add a few letters after our name and get the latest certification? Should I have to see an advertisement for a new tool every time I log on to my EMR? How much time more time, money, and attention should young physical therapists be giving to IASTM?

As Jarod Hall has pointed out, sex sells in physical therapy. And IASTM certainly is sexy. It seems plausible, sophisticated, and marketable. The hype created by its purveyors makes it seem like a desirable skill, something to set you apart as a new clinician who may be looking for a job. These things can naturally attract new therapists, but I think it might be better to resist the pull. Based on the current evidence, we have no strong reason to believe IASTM is something physical therapists should all be doing, but it is a treatment option. It may in fact be easier on your hands, but this is anecdotal and something difficult to quantify. We should not be investing a great deal of time, money, or attention into the latest tools or courses, given that they haven’t been proven to be more effective than traditional therapeutic approaches by any reasonable, conservative standard. If the evidence improves in quality later on, this balance could change.

It may be a better use of our time to focus our attention on other things. Maybe we should be spending more time learning statistics and research interpretation. Maybe we should be studying concepts from psychology for behavioral change and the psychosocial impact of disease. Perhaps we should be trying to get on the cutting edge of telehealth. Maybe we should be looking to our bosses on how to run a successful physical therapy business. Or maybe we should be working on advocacy for our patients and political issues that impact us.
The physical therapy profession will continue to encounter trends of this nature, and it is up to us to ensure we appropriately investigate them. But more often, we need to take a bird’s eye view of our profession as a whole and the direction it’s going, and not get caught up in the latest and greatest.

References

References

  1. Bailey, Lane B., et al. “Mechanisms of Shoulder Range of Motion Deficits in Asymptomatic Baseball Players.” The American Journal of Sports Medicine, vol. 43, no. 11, 2015, pp. 2783–2793., doi:10.1177/0363546515602446.
  2. Blanchette, Marc-André, and Martin C. Normand. “Augmented Soft Tissue Mobilization vs Natural History in the Treatment of Lateral Epicondylitis: A Pilot Study.” Journal of Manipulative and Physiological Therapeutics, vol. 34, no. 2, 2011, pp. 123–130., doi:10.1016/j.jmpt.2010.12.001.
  3. Burke, Jeanmarie, et al. “A Pilot Study Comparing Two Manual Therapy Interventions for Carpal Tunnel Syndrome.” Journal of Manipulative and Physiological Therapeutics, vol. 30, no. 1, 2007, pp. 50–61., doi:10.1016/j.jmpt.2006.11.014.
  4. Cheatham, Scott, et.al. “The efficacy of instrument assisted soft tissue mobilization: a systematic review.” Journal Of Canadian Chiropractic Association, vol. 60, no. 3, 2016
  5. Crothers, Amy L., et al. “Spinal Manipulative Therapy, Graston Technique® and Placebo for Non-Specific Thoracic Spine Pain: a Randomised Controlled Trial.” Chiropractic & Manual Therapies, vol. 24, no. 1, 2016, doi:10.1186/s12998-016-0096-9.
  6. Davidson, Craig J., et al. “Rat Tendon Morphologic and Functional Changes Resulting from Soft Tissue Mobilization.” Medicine &Amp Science in Sports &Amp Exercise, vol. 29, no. 3, 1997, pp. 313–319., doi:10.1097/00005768-199703000-00005.
  7. Davies, Claire, et.al. “Astym therapy improves function and range of motion following mastectomy.” Breast Cancer: Targets and Therapies, 2016
  8. Gehlsen, Gale M., et al. “Fibroblast Responses to Variation in Soft Tissue Mobilization Pressure.” Medicine & Science in Sports & Exercise, vol. 31, no. 4, 1999, pp. 531–535., doi:10.1097/00005768-199904000-00006.
  9. Heinecke, Michele, et.al. “Graston Technique On Shoulder Motion In Overhead Athletes.” Journal Of Undergraduate Kinesiology Research, vol. 10, no. 1, 2014
  10. Kivlan, Benjamin R., et al. “The Effect of Astym® Therapy on Muscle Strength: a Blinded, Randomized, Clinically Controlled Trial.” BMC Musculoskeletal Disorders, vol. 16, no. 1, 2015, doi:10.1186/s12891-015-0778-9.
  11. Lambert, Matthew, et al. “The Effects of Instrument-Assisted Soft Tissue Mobilization Compared to Other Interventions on Pain and Function: a Systematic Review.” Physical Therapy Reviews, vol. 22, no. 1-2, Apr. 2017, pp. 76–85., doi:10.1080/10833196.2017.1304184.
  12. Lauche, Romy, et al. “Randomized Controlled Pilot Study: Pain Intensity and Pressure Pain Thresholds in Patients with Neck and Low Back Pain Before and After Traditional East Asian ‘Gua Sha’ Therapy.” The American Journal of Chinese Medicine, vol. 40, no. 05, 2012, pp. 905–917., doi:10.1142/s0192415x1250067x.
  13. Laudner, K., et.al. “Acute Effects Of Instrument Assisted Soft Tissue Mobilization For Improving Posterior Shoulder Range Of Motion In Collegiate Baseball Players.” International Journal of Sports Physical Therapy, vol. 9, no. 1, 2014
  14. Lee, Jeong-Hoon, et al. “The Effect of Graston Technique on the Pain and Range of Motion in Patients with Chronic Low Back Pain.” Journal of Physical Therapy Science, vol. 28, no. 6, 2016, pp. 1852–1855., doi:10.1589/jpts.28.1852.
  15. Loghmani, M. Terry, and Stuart J. Warden. “Instrument-Assisted Cross-Fiber Massage Accelerates Knee Ligament Healing.” Journal of Orthopaedic & Sports Physical Therapy, vol. 39, no. 7, 2009, pp. 506–514., doi:10.2519/jospt.2009.2997.
  16. Loghmani, M Terry, and Stuart J Warden. “Instrument-Assisted Cross Fiber Massage Increases Tissue Perfusion and Alters Microvascular Morphology in the Vicinity of Healing Knee Ligaments.” BMC Complementary and Alternative Medicine, vol. 13, no. 1, 2013, doi:10.1186/1472-6882-13-240.
  17. MacDonald, Nicole, et.al. “The Effects of Instrument Assisted Soft tissue Mobilization On Lower Extremity Muscle Performance: A Randomized Controlled Trial.” The International Journal Of Sports Physical Therapy, vol. 11, no. 7, 2016
  18. Markovic, Goran. “Acute Effects of Instrument Assisted Soft Tissue Mobilization vs. Foam Rolling on Knee and Hip Range of Motion in Soccer Players.” Journal of Bodywork and Movement Therapies, vol. 19, no. 4, 2015, pp. 690–696., doi:10.1016/j.jbmt.2015.04.010.
  19. Mccormack, Joshua R., et al. “Eccentric Exercise Versus Eccentric Exercise and Soft Tissue Treatment (Astym) in the Management of Insertional Achilles Tendinopathy.” Sports Health: A Multidisciplinary Approach, vol. 8, no. 3, 2016, pp. 230–237., doi:10.1177/1941738116631498.
  20. Moon, Jong Hoon, et al. “Immediate Effects of Graston Technique on Hamstring Muscle Extensibility and Pain Intensity in Patients with Nonspecific Low Back Pain.” Journal of Physical Therapy Science, vol. 29, no. 2, 2017, pp. 224–227., doi:10.1589/jpts.29.224.
  21. Palmer, Thomas, et.al. “The Effect of Graston Massage Therapy On Talocrural Joint Range of Motion.” International Journal Of Athletic Therapy and Training, 2016
  22. Schaefer, Jessica L., and Michelle A. Sandrey. “Effects of a 4-Week Dynamic-Balance-Training Program Supplemented with Graston Instrument-Assisted Soft-Tissue Mobilization for Chronic Ankle Instability.” Journal of Sport Rehabilitation, vol. 21, no. 4, 2012, pp. 313–326., doi:10.1123/jsr.21.4.313.
  23. Sevier, Thomas L., and Caroline W. Stegink-Jansen. “Astym Treatment vs. Eccentric Exercise for Lateral Elbow Tendinopathy: a Randomized Controlled Clinical Trial.” PeerJ, vol. 3, 2015, doi:10.7717/peerj.967.
  24. Stanek, Justin, et al. “Comparison of Compressive Myofascial Release and the Graston Technique for Improving Ankle-Dorsiflexion Range of Motion.” Journal of Athletic Training, vol. 53, no. 2, 2018, pp. 160–167., doi:10.4085/1062-6050-386-16.
  25. Stroiney, Debra, et al. “An Examination of Self-Myofascial Release vs. Instrument Assisted Soft Tissue Mobilization Techniques on Vertical and Horizontal Power in Recreational Athletes.” Medicine & Science in Sports & Exercise, vol. 49, 2017, p. 1067., doi:10.1249/01.mss.0000519932.05929.d6.
  26. Vardiman, J., et al. “Instrument-Assisted Soft Tissue Mobilization: Effects on the Properties of Human Plantar Flexors.” International Journal of Sports Medicine, vol. 36, no. 03, 2014, pp. 197–203., doi:10.1055/s-0034-1384543.

About Nicolas Ferrara

Nicolas Ferrara
My name is Nicolas Ferrara and I am a physical therapist from Long Island, New York. I graduated with my Bachelor's in Exercise Science in 2012, and my DPT degree in 2016. I currently work in an outpatient clinic specializing in prosthetic, orthopedic, and neurological rehabilitation. I have my own personal blog at factualphysicaltherapy.wordpress.com, where I discuss the role of science and philosophy in physical therapy practice and how it can help us become better clinicians.

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