2.10: Instrument Assisted Soft Tissue Mobilization

What is Instrument Assisted Soft Tissue Mobilization?

Instrument Assisted Soft Tissue Mobilization (IASTM) is a soft tissue technique that uses handheld tools to stimulate local mechanoreceptors. IASTM devices may be made from different materials (e.g., wood, stone, jade, steel, ceramic, resin).

How can Massage Therapists Incorporate IASTM into Treatments?

IASTM has been shown to improve short term range of motion and improve function for athletes (Cheatham et al., 2016). IASTM is closely related to transverse friction massage which has long been used for tendon pain and sports injuries. The depth of application varies from simple massage based techniques aiming at stimulating mechanoreceptors and improving range of motion to a complex soft-tissue treatment system encompassing the latest research on mechanotherapy.

There are many nuances to using these techniques, with the possibility of bruising and petechiae if treatments are not done with care. Not fully understanding the different aspects and approaches to IASTM is leading to a great deal of confusion about what exactly IASTM is, when it’s appropriate and how to use these techniques.

IASTM Protocols

IASTM techniques are often combined with other techniques, exercises, positions or different types of stretching. First, the treatment area is lubricated with massage lotion, then short sweeping movements are applied using multi-directional assessment and treatment strokes. IASTM techniques are often combined with active and passive stretching. Around 2-3 minutes of light scraping per area should be enough to stimulate local mechanoreceptors.

Post-Operative Care

Treatments depend on the underlying pathology, but IASTM may have a role in post-surgical care. A recent study published in The Journal of Knee Surgery looked at the effect that soft-tissue treatments with hand-held instruments have on post-surgical knee stiffness (Chunghtai et al., 2016). In the study soft-tissue treatments were shown to improve knee flexion deficits by 35° and knee flexion contractures by 12° in a small cohort of individuals who had failed to respond to traditional rehabilitation and manipulation under anesthesia. Hypothetically it may be used to impart a mechanical stimulus that contributes to the breakdown of immature scar tissue and developmental fibrosis. Fibrosis is a potential complication of surgery or trauma characterized by the production of excessive fibrous scar tissue, which may result in decreased movement. Understanding the cellular effectors and signaling pathways that drives the accumulation of fibrotic deposition, helps therapists optimize treatment protocols.

In the normal wound healing response, the cascade of biological responses is tightly regulated. Fibrotic development is characterized by a lack of apoptosis in the proinflammatory phase, resulting in an imbalance between synthesis and degradation. Persistent transforming growth factor-β (TGF-β) secretion and downstream responses are thought to contribute to a sustained inflammatory response (Cheuy et al., 2017). One study published in The Journal of Neurological Sciences showed soft-tissue massage prevented the deposition of collagen and transforming growth factor beta 1 (TGF beta 1) in the nerves and connective tissues of the forearm (Bove et al., 2016). This was recently followed up by a study published in the prestigious journal Pain showing that by attenuating the inflammatory response (with modelled massage) in the initial stages of an injury, they were able to prevent the development of neural fibrosis (Bove et al., 2019). This is potentially impactful in postoperative rehabilitation because TGF-β1 plays a key role in tissue remodeling and fibrosis.

Key Takeaways

The responses to IASTM are complex and multifactorial – biopsychosocial factors interplay in a complex manner. The use of prophylactic IASTM may help patients manage postoperative pain. It may also affect the development of fibrosis by mediating differential cytokine production. The next step for researchers is to look into what sort of dosage and duration would be needed to optimize the effects of this non-pharmacological approach.

References and Sources

Begovic, H., Zhou, G. Q., Schuster, S., & Zheng, Y. P. (2016). The neuromotor effects of transverse friction massage. Manual therapy, 26, 70–76. doi:10.1016/j.math.2016.07.007

Bove, G. M., Harris, M. Y., Zhao, H., & Barbe, M. F. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Journal of the neurological sciences, 361, 168–180. doi:10.1016/j.jns.2015.12.029

Bove, G. M., Delany, S. P., Hobson, L., Cruz, G. E., Harris, M. Y., Amin, M., … Barbe, M. F. (2019). Manual therapy prevents onset of nociceptor activity, sensorimotor dysfunction, and neural fibrosis induced by a volitional repetitive task. Pain, 160(3), 632–644. doi:10.1097/j.pain.0000000000001443

Cadellans-Arróniz, A., Llurda-Almuzara, L., Campos-Laredo, B., Cabanas-Valdés, R., Garcia-Sutil, A., & López-de-Celis, C. (2020). The effectiveness of diacutaneous fibrolysis on pain, range of motion and functionality in musculoskeletal disorders: A systematic review and meta-analysis. Clinical rehabilitation, 269215520968056. Advance online publication. https://doi.org/10.1177/0269215520968056

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.

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.

Cheatham, S. W., Kreiswirth, E., & Baker, R. (2019). Does a light pressure instrument assisted soft tissue mobilization technique modulate tactile discrimination and perceived pain in healthy individuals with DOMS?. The Journal of the Canadian Chiropractic Association, 63(1), 18–25.

Cheuy, V. A., Foran, J., Paxton, R. J., Bade, M. J., Zeni, J. A., & Stevens-Lapsley, J. E. (2017). Arthrofibrosis Associated With Total Knee Arthroplasty. The Journal of arthroplasty, 32(8), 2604–2611. doi:10.1016/j.arth.2017.02.005

Christie, W. S., Puhl, A. A., & Lucaciu, O. C. (2012). Cross-frictional therapy and stretching for the treatment of palmar adhesions due to Dupuytren’s contracture: a prospective case study. Manual therapy, 17(5), 479–482. doi:10.1016/j.math.2011.11.001

Chughtai, M., Mont, M. A., Cherian, C., Cherian, J. J., Elmallah, R. D., Naziri, Q., … Bhave, A. (2016). A Novel, Nonoperative Treatment Demonstrates Success for Stiff Total Knee Arthroplasty after Failure of Conventional Therapy. The journal of knee surgery, 29(3), 188–193. doi:10.1055/s-0035-1569482

Chughtai, M., Newman, J. M., Sultan, A. A., Samuel, L. T., Rabin, J., Khlopas, A., … Mont, M. A. (2019). Astym® therapy: a systematic review. Annals of translational medicine, 7(4), 70. doi:10.21037/atm.2018.11.49

Gunn, L. J., Stewart, J. C., Morgan, B., Metts, S. T., Magnuson, J. M., Iglowski, N. J., … Arnot, C. (2019). Instrument-assisted soft tissue mobilization and proprioceptive neuromuscular facilitation techniques improve hamstring flexibility better than static stretching alone: a randomized clinical trial. The Journal of manual & manipulative therapy, 27(1), 15–23. doi:10.1080/10669817.2018.1475693

Hussey, M. J., Boron-Magulick, A. E., Valovich McLeod, T. C., & Welch Bacon, C. E. (2018). The Comparison of Instrument-Assisted Soft Tissue Mobilization and Self-Stretch Measures to Increase Shoulder Range of Motion in Overhead Athletes: A Critically Appraised Topic. Journal of sport rehabilitation, 27(4), 385–389. doi:10.1123/jsr.2016-0213

Ikeda, N., Otsuka, S., Kawanishi, Y., & Kawakami, Y. (2019). Effects of Instrument-assisted Soft Tissue Mobilization on Musculoskeletal Properties. Medicine and science in sports and exercise, 51(10), 2166–2172. doi:10.1249/MSS.0000000000002035

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. doi:10.12965/jer.1732824.412

Loghmani, T. M., Bayliss, A. J., Clayton, G., & Gundeck, E. (2015). Successful treatment of a guitarist with a finger joint injury using instrument-assisted soft tissue mobilization: a case report. The Journal of manual & manipulative therapy, 23(5), 246–253. doi:10.1179/2042618614Y.0000000089

McCormack, J. R., Underwood, F. B., Slaven, E. J., & Cappaert, T. A. (2016). Eccentric Exercise Versus Eccentric Exercise and Soft Tissue Treatment (Astym) in the Management of Insertional Achilles Tendinopathy. Sports health, 8(3), 230–237. doi:10.1177/1941738116631498

Nazari, G., Bobos, P., MacDermid, J. C., & Birmingham, T. (2019). The Effectiveness of Instrument-Assisted Soft Tissue Mobilization in Athletes, Participants Without Extremity or Spinal Conditions, and Individuals with Upper Extremity, Lower Extremity, and Spinal Conditions: A Systematic Review. Archives of physical medicine and rehabilitation, 100(9), 1726–1751. doi:10.1016/j.apmr.2019.01.017

Stanek, J., Sullivan, T., & Davis, S. (2018). Comparison of Compressive Myofascial Release and the Graston Technique for Improving Ankle-Dorsiflexion Range of Motion. Journal of athletic training, 53(2), 160–167. doi:10.4085/1062-6050-386-16