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The efficacy of instrument assisted soft tissue mobilization: a systematic review

Cheatham, S.W., Lee, M., Cain, M. and Baker, R., 2016. The efficacy of instrument assisted soft tissue mobilization: a systematic review. The Journal of the Canadian Chiropractic Association, 60(3), p.200.

In today’s letter

• Overview of the instrument assisted soft tissue mobilisation & its use in practice

• Rapid Results =

  1. Evidence has poor methadology, however, tissue mobilisation showed no significant change in pathology treated when compared to controls

  2. Tissue mobilisations has a significant improvement in joint range of motion

• 3 resources to check out to further you knowledge about instrument assisted mobilisation

• Meme: Treating the wrong side 🤡

Aim of study

The goal of this systematic review was to appraise the current instrument assisted soft tissue mobilisation (IASTM) literature to provide a current update for the clinician

Did you know?

• Graston tools are widely used to address myofascial restrictions

• Unlike cross friction massage, graston employ specially designed tools to mobilise:

1. Scar tissue

2. Myofascial adhesions

• Which reduces pain and enhancing range of motion and function.

• The instruments provide a mechanical advantage for clinicians, helping to penetration deeper and more precisely, while reducing stress on their hands.

• Graston tools are believed to stimulate connective tissue remodelling by absorbing excessive fibrosis and promoting collagen repair and regeneration through fibroblast recruitment.

• This process is expected to release and break down scar tissue, adhesions, and fascial restrictions.

• Laboratory studies with rat models have shown that instrument use leads to increased fibroblast proliferation and improved collagen repair and maturation in enzyme-induced tendinitis.

• These findings support the notion that these tools stimulate connective tissue remodelling (these physiological changes have yet to be confirmed in human trials)

• The Graston® technique, a specific IASTM method, premotes a protocol with components of warm-up, treatment (e.g., 30-60 seconds per lesion), post-treatment stretching, strengthening, and ice application (if inflammation is present).

• Despite variations in treatment approaches, the primary goal of Graston tools are to enhance myofascial mobility with minimal adverse effects. (e.g discomfort or post-treatment bruising)

• For many years, IASTM's efficacy was supported by case series and reports (level 4 evidence), which are limited due to their subjective nature.

• Most case reports indicated successful treatment outcomes for conditions like tendinopathies and arthrofibrosis.

 Methods

Inclusion Criteria

1. Peer reviewed, English language publications

2. Controlled clinical trials that compared pretest and post-test measurements for an intervention program using IASTM

3. Investigations that compared an intervention program using IASTM

4. Investigations that compared 2 intervention programs using IASTM

Exclusion criteria

1. Studies were excluded if they were:

2. Non-English publications

3. Clinical trials that included IASTM as an intervention but did not directly measure its effects

4. Clinica trials that included Guasha and ASTYM®, case reports, case series, clinical commentary, dissertations, and conference posters or abstracts.

Discussion

Main takeaways

• The body of knowledge regarding graston tools is still developing.

• Current research has shown insignificant results, challenging the efficacy of graston as a treatment, however this is possibly due to methodological variability among studies

Thoughts on its effectiveness on Pathology

• All studies reported using the Graston® technique, but several potential methodological issues may have led to the insignificant results.

• Only 1 study followed the recommended Graston® treatment protocol, which includes

1. Examination

2. Warm-up

3. Treatment

4. Post-treatment stretching

5. Strengthening

6. Ice.

• The other 4 studies either modified or excluded parts of the protocol, making it difficult to determine the effectiveness of the Graston® technique

• The graston tool treatment times varied among studies, with 3 studies reporting different treatment times and 2 studies failing to report any treatment times.

• Some studies had methodological issues with their intervention programs.

• 1 study measured the effects of graston tools for lateral epicondylitis in a group of 27 subjects, randomising them into experimental and control groups.

• The experimental group received treatment only, while the control group received education, forearm stretching, strengthening exercises, ice, and generic anti-inflammatory medication during the intervention phase.

• Both groups improved, but no significant difference in outcomes was found.

• Another study conducted a feasibility study comparing 2 chiropractic protocols in the treatment of patellofemoral pain, with Protocol A including chiropractic manipulative therapy, exercise, and graston tool treatment to the knees only, and Protocol B including additional gratson tool to the lumbosacral, hip, knee, ankle, and foot.

• The study was conducted over a 1-year period with several different treating clinicians and blinded assessors, but the researchers did not report any formal training or reliability measures for these clinicians.

• The subjects were instructed to continue with a prescribed home program until a 2-month follow-up, but no procedure was reported to ensure the subjects followed the home program correctly, which may have influenced the overall outcomes of the study. All groups improved, but no significant difference between groups was found

Thoughts on Range of motion

• Both studies reported favourable outcomes but only applied a one-session treatment with short-term follow-up.

• Both studies had potential methodological issues that may have influenced the results.

• The IASTM treatment times varied between studies. One study reported using the Graston® technique for 40 seconds but did not fully follow the protocol.

• Another study used the FATTM technique without reporting specific IASTM guidelines and based the 2-minute treatment time on the comparison intervention of foam rolling.

• Foam rolling has been found in literature to enhance hip and knee joint ROM with shorter intervention times.

• A more structured graston tool intervention protocol might have improved the outcomes.

• Both studies measured immediate post-intervention outcomes, but only one performed a second ROM assessment 24 hours later, showing that the graston tool group maintained more joint ROM.

• The study that performed the 24-hour follow-up included a comprehensive warm-up, which may have influenced the favourable outcomes.

• A longer post-intervention assessment period with pre-established time points and more stringent guidelines might have better determined the lasting effects of IASTM.

Top 3 resources to check out

1. Case study looking at plantar heel pain - LINK

2. Instrument assisted tissue release explained - LINK

3. Fundamentals of IASTM (VIDEO presentation) - LINK

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