Instrument Assisted Soft Tissue Mobilization (IASTM): The What, the Why, and the How
Instrument assisted soft tissue mobilization (IASTM) goes by many names in the sports medicine and rehabilitation world. Graston, FAKTR, Rock Blade, Gua Sha, Fascial Abrasion Technique (FAT), ASTYM, the list goes on and on… With the huge variety in programs and protocols available, there is not one agreed upon method of application of this therapeutic technique. However, they all have a few things in common that the program agnostic practitioner can apply to their patients.
A 2019 paper (3) attempted to generalize these principles into Clinical Practice Guidelines so sports medicine and rehabilitation practitioners could come under the same umbrella to use IASTM in an agreed upon manner. My favorite, concise explanation of IASTM is as follows:
“Instrument assisted soft-tissue mobilization is a skilled intervention that includes the use of specialized tools to manipulate the skin, myofascia, muscles, and tendons by various direct compressive stroke techniques.” (1)
IASTM is used by Chiropractors (DC), Physical Therapists (DPT), Athletic Trainers (ATC), and other Sports Medicine/Health professionals to treat their patients' soft tissue injuries and biomechanical dysfunctions. While the body of research supporting IASTM consists mostly of lower level evidence including case studies/series, there are a handful of RCTs and systematic reviews evaluating its efficacy in treating a vast number of conditions and cases including:
Calf pain, patellar tendinopathy, knee arthrofibrosis post patellar tendon repair, achilles tendinopathy, Dupuytren's contracture, axillary web syndrome, chronic costochondritis, plantar fasciitis/heel pain, lumbar compartment syndrome, de Quervain's tenosynovitis, tibialis posterior strain, medial epicondylitis, lateral epicondylitis, hyperactive gastrocnemius in hemiparetic stroke patient, pseudo angina pectoris, post-operative ACL repair, benign joint hypermobility syndrome, shoulder impingement, hamstring tendinopathy, individuals with cerebral palsy, tissue extensibility dysfunction, carpal tunnel syndrome, myofascial trigger points, chronic low back pain, non-specific thoracic spine pain, ankle instability, post mastectomy, post total joint arthroplasty, posterior shoulder range of motion, hip and knee ROM, ankle instability, ankle ROM, and a few others (1).
So, a lot of musculoskeletal conditions may be helped with IASTM.
There are a number of proposed mechanisms for how IASTM can help soft tissue injuries heal, how it can manage a patient’s pain response, and how it can improve range of motion. The majority of the observed changes are actually seen in the soft tissue physiology which eventually affects the anatomy, biomechanics, and peripheral neurology. These mechanisms include:
Changes in local temperature (1)
Stimulation of connective tissue remodeling through resorption of excessive fibrosis (1)
Inducing repair and regeneration of collagen secondary to fibroblast recruitment (1)
Stimulation of the natural inflammatory response to accelerate soft tissue healing (3)
Increased blood and nutrient supply to the area treated (3)
Increased fibronectin levels, a glycoprotein synthesized by fibroblasts used in tissue healing and repair (3)
These physiological responses in the soft tissue then manifest anatomically, biomechanically, and neurologically in a number of ways based on the injury or dysfunction being treated. Some of the observed effects in the literature include:
Increased fascial mobility (3)
Increased Young’s Modulus, a measure of elasticity, and increased in stiffness in the Achilles Tendon (3)
Improved LEFS scores after patellar tendon repairs in basketball players (3)
Decreased DASH scores in patient with lateral elbow tendinopathy (3)
Increased walking distance in hospitalized patients for Achilles tendon injuries (3)
Accelerated healing of muscle injuries (3)
Increased muscle performance in patients with muscular weakness from injury (3)
Improved ROM in joints following injury (3)
Improved ROM in healthy athletes (3)
A way to communicate these effects to a patient may be:
“IASTM may result in the release and breakdown of scar tissue, adhesions, and fascial restrictions in order to accelerate healing, decrease pain, and improve range of motion.” (1,2)
Finally, most patients that seek care are in pain. IASTM has been shown to reduce pain in some studies of MSK disease in several locations in the body like the lumbar spine, thumb, ribcage (costochondritis), plantar fascia, hamstrings, etc (3). The theoretical mechanism for short term reduction in pain is similar to other passive therapies; pain gating. Simply put, pain gating is the override of a pain stimulus with a powerful mechanoreceptor stimulus that “overshadows the pain.” The lasting pain management effects of IASTM are still debated upon in the literature. Some theories include reducing excess inflammation, increased blood flow removing pain substrates, reducing swelling around injured tissues, or treating a condition before it achieves chronicity. (3) More research is needed to properly elucidate the pain relieving mechanisms of IASTM.
As with any therapy aimed at changing your physiology, biomechanics, and neurology there can be side effects, precautions, or contraindications to its application. This is why it is crucial that you see a qualified health professional (Chiropractor, Physical Therapist, etc) who is trained to identify these contraindications, identify if your case can be helped with IASTM, and apply the protocol properly. These precautions/contraindications include:
Petechiae, pain sensation altering medications, patient age, certain herbal supplements, cancer, patient intolerance, anti-coagulant medications, lymphedema, osteoporosis, varicose veins, burn scars, RA/AS, acute inflammatory conditions, hypertension, immediately post-injection,polyneuropathy, autoimmune disorders, unhealed fractures, CHF, kidney dysfunction, diabetes, abnormal sensation, pregnancy, allergies to metals, emmolient, or gloves that may be used, acute infection, skin rash/open wounds, surgical hardware, hematoma, myositis ossificans, insect bites, CT disorders like Ehlars-Danlos, Marfans, etc, peripheral vascular disease, chronic pain conditions, epilepsy (1).
While many of these are simply precautions that need to be investigated prior to attempting a therapy, some may totally rule out IASTM as a treatment option. As always, consult with a qualified health care provider trained in the proper evaluation, assessment, and application of this technique.
As far as side effects go, as long as precautions/contraindications are ruled out there are few. A little redness in the immediate post-treatment window is probably okay, some soreness is probably okay, but severe bruising and redness that lasts following the treatment should be a cause of concern and potentially indicates iatrogenic soft tissue injury.
Interesting note on the commonly seen bruising following IASTM:
The authors of this commentary suggest that bruising or ecchymosis at the site of treatment should be considered a contraindication. Traditionally, professionals may have considered both petechiae and ecchymosis as a necessary part of the treatment for different paradigms including Gua sha and IASTM. Currently, it appears that sports medicine professionals and educators are also moving away from the philosophy of creating ecchymosis due to the potential iatrogenic tissue damage that can occur with treatment. In the presence of posttreatment ecchymosis, the clinician should likely refrain from further IASTM treatment and manage the region accordingly to ensure proper healing (1).
WRAP UP SUMMARY (TL;DR)
IASTM is a relatively new protocol utilized by sports rehabilitation practitioners to help soft tissue injuries heal, to manage pain from soft tissue injuries, and improve movement. While there are many proposed mechanisms for how this happens, the literature is confirming and debating exactly what happens and which effects are significant and which effects are just interesting physiological responses. Because there is the huge variability in patient presentations for the same injury, studying IASTM in RCTs or Systematic Reviews is difficult and leads to some seemingly unfavorable or insignificant outcomes. However, Individual experience, case reports, case series, and a few RCTs have shown very promising and clinically significant improvements in patient conditions with using IASTM either on its own or in conjunction with other treatments. More research is needed to homogenize this extremely heterogeneous evidence body and to establish clinical practice guidelines that professionals can abide by regardless of which certification or training they received.
Primary References
(1) Cheatham, S. W., Baker, R., & Kreiswirth, E. (2019). Instrument assisted soft tissue mobilization: a commentary on clinical practice guidelines for rehabilitation professionals. International journal of sports physical therapy, 14(4), 670–682.
(2) Cheatham, S. W., Lee, M., Cain, M., & Baker, R. (2016). The efficacy of instrument assisted soft tissue mobilization: a systematic review. The Journal of the Canadian Chiropractic Association, 60(3), 200–211.
(3) Kim, J., Sung, D. J., & Lee, J. (2017). Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. Journal of exercise rehabilitation, 13(1), 12–22. https://doi.org/10.12965/jer.1732824.412
This article is not meant to be medical advice or a guide for self treatment; if you are in pain or suffering from an injury please seek advice and help from a qualified health professional.