DEEP

IMPACT
Targeting restrictions with
instrument-assisted soft-
tissue mobilization
By Mark Butler, PT, DPT, OCS, Cert. MDT
I
nstrument-assisted soft-tissue mobi-
lization, a manual therapy technique
collectively known as IASTM, is rapidly
gaining popularity nationwide. I was
skeptical when rst exposed to the tech-
nique approximately 10 years ago, with
little interest in learning more.
Since having had the opportunity to be for-
mally IASTM trained, using the techniques in
the clinic, and now teaching them myself, I turn
to IASTM frequently in caring for my patients.
Adding this technique to my patients treatment
programs has been extremely valuable in accel-
erating improved outcomes in test, treat, and
re-test clinical applications.
What is IASTM?
IASTM uses a hard-edged instrument made of
metal, plastic or ceramic to add shearing stress to
soft tissue in order to enhance the bodys healing
response. The ability to focus mechanical force
along a small contact surface to your patients
target tissue, and do so with a relatively high
level of comfort for both the patient and treat-
ing therapist, is one of the best features of this
technique.
IASTM tools or instruments are designed
with these basic concepts in mind; and this is
what sets them apart from using items such as
reex hammer handles, spoons or butter knives.
Not only are the instruments useful for trans-
ferring force to the target tissues, theyre very
eective in providing feedback regarding tis-
sue irregularities, since the tool will resonate or
vibrate as if you have driven over a rough patch
of road in a sports car with a sti suspension,
versus a car with underinated tires and a soft
suspension. This quality of the IASTM tools
allows the treating therapist to focus on areas
of tissue restrictions.
History of the Technique
A form of IASTM known as gua sha (gua = to
scrape or scratch, sha = loosely translated as
disease) has its origins in Chinese folk medicine,
with no known starting point.
1
Gua Sha treat-
ments consist of using traditional tools such as
portions of water bualo horns or shaped pieces
of jade, or non-traditional tools such as jar lids
and oriental soup spoons to create friction over
the skin.
The primary goal is to produce a warming
reaction to bring sha to the surface so it leaves
the body.
1
These techniques appeared in the
ADVANCE for Physical Therapy & Rehab Medicine October 28, 2013 www.advanceweb.com/pt
www.advanceweb.com/pt October 28, 2013 ADVANCE for Physical Therapy & Rehab Medicine
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West on a large scale in the mid-to-late
1970s, with Vietnamese refugees prac-
ticing cao gio (coin rubbing), which
prompted school o cials to suspect
child abuse due to these children
showing up with bruising from treat-
ment at home.
2
Gua sha is practiced on
a moderate scale by massage therapists
and practitioners of Eastern medicine.
The most widely known modern
IASTM instruments and techniques
developed independent of gua sha
and can be traced to Dave Graston.
Graston was a machinist and assembly
line worker in the auto industry who
developed chronic knee problems as a
result of a poor surgical outcome from
a waterskiing accident.
Graston discovered that by using
the edge of a No. 2 pencil to perform
friction massage to his sti knee, his workouts
at the gym were more comfortable, and he was
gaining motion and function. He machine-
shaped metal tools to enhance his results, and
modern-day IASTM was born.
Due to increased interest in this modality,
there are now a number of IASTM tools or
instruments on the market. As a result, thera-
pists can nd a system of instruments to match
most budgets and applications of this treatment
technique.
Theres a signicant dierence in how these
instruments feel, both for the treating therapist
and the patient, so I recommend doing some
research before committing to one system. Most
systems oer instructional courses or DVDs to
aid in getting started.
There are no comparative outcome studies to
show dierences between systems. Although
some systems oer certications for completing
their education seminars, this certication isnt
formally recognized by any accrediting body,
and is mainly for marketing purposes and evi-
dence of course completion.
How Does it Work?
Since IASTM is a relatively new modality, theres
no denitive answer to this question. From my
experience, IASTM impacts patient healing on
multiple levels. Analgesia, neuromuscular facili-
tation and/or inhibition, and more rapid tissue
healing are common outcomes of treatment.
The most popular theory discussed in the lit-
erature regarding IASTM is the introduction of
controlled microtrauma, resulting in increased
broblast production and conversion of the
collagen produced from low-quality type III
to high-quality type I collagen.
3-6
IASTM also
appears to aect the quantity of collagen pro-
duced, and facilitate the conversion of collagen
scar tissue to functional tissue with enhanced
ber alignment.
4,7

Recent interest in the link between broblasts,
Substance P (SP), and local and central pain
mechanisms may provide some background
on the analgesic eect of IASTM.
8-10
Substantial
evidence exists that patients pain levels often
correlate poorly with radiological evidence of
tendinopathy and tissue pathology; therefore,
clinically debilitating pain can occur with or
without signs of tissue damage.
11-13
SP, a neuropeptide produced by the small
unmyelinated C-nerve fibers and by fibro-
blasts, aects pain response to stimulus both
on a local (peripheral) and central level.
9
SP
has been shown to be mechanosensitive; that
is, its production and distribution is aected by
mechanical stresses.
Although the effect of IASTM on SP is
unknown, we do know that SP is involved in
tissue healing and pain on a local and central
level. Perhaps theres a mechanical response of
SP to IASTM, and this is one of the mechanisms
through which patients regularly report anal-
gesia and enhanced performance after IASTM
treatment.
6
More research is needed in this area
since many questions remain unanswered.
Current Evidence Base
The majority of articles published on this topic
consist of animal and case studies. The prepon-
derance of case studies have concentrated on
ligamentous injuries and tendinopa-
thies,
14-20
with a few focusing on myo-
fascial and neural components.
21-24
The majority of these, being single
case studies, are level 3b and 4 studies
based on the Levels of Evidence Hier-
archy list per the Centre for Evidence
Based Medicine.
25
This list indicates
the potential for bias in studies, with
level 1A studies having the least and
level 5 studies having the most bias
potential.
Two studies achieved levels 2b
and 2c, respectively, with limited ran-
domization and blinding to minimize
examiner bias.
6,24
A study by Schae-
fer and Sandry looked at the eect of
IASTM and dynamic balance training
(DBT) versus DBT and sham IASTM
or DBT alone on outcomes associated
with chronic ankle instability.
6
For all measures, the group treated with
IASTM and DBT demonstrated the largest
improvement. The study by Burke et al com-
pared IASTM treatment to similar manual inter-
ventions without instruments on patients with
clinical and electrodiagnostic signs and symp-
toms of carpal tunnel syndrome.
24
Both groups demonstrated significant
improvement in outcomes tracked in the study,
with the IASTM group demonstrating greater
scores in symptom reduction at three months
follow-up. However, due to the small sample
size of each group, clinically meaningful dif-
ferences between treatment groups did not
achieve statistical signicance.
Adding to Your Repertoire
IASTM treatment varies somewhat from sys-
tem to system in how regimented the protocols
are. But there is common ground in the systems
that provide treatment guidance.
This includes a warm-up phase, followed
next with a scanning or regional treatment
phase with the tools or instruments, then a
specic treatment phase with tools or instru-
ments that focuses on the target tissue or areas
of restriction/pathology, and nally a move-
ment-based phase that includes stretching and
exercising the target tissues.
Most systems recommend ice after treatment
to help minimize post-treatment soreness and
bruising, which can be a benign side eect. The
warm-up phase can include active aerobic exer-
cises or passive thermal modalities.
The average length of time spent performing
For author Mark Butler, PT, DPT, OCS, Cert. MDT, using IASTM has con-
sistently improved patient outcomes, both within the treatment session
and in carry-over from treatment.
COVER STORY
October 28, 2013 ADVANCE for Physical Therapy & Rehab Medicine
IASTM is between 5 and 10 minutes, with 1-3 minutes spent on spe-
cic lesions in the target tissue. Patients are encouraged to exercise and
stretch the target areas through their home program as well.
As both an educator and clinician whos always looking for ways
to enhance outcomes, IASTM treatment is a regular component of my
patient programs. Of the various continuing education courses I teach
around the country, this is currently the course thats generating the
most interest. My experience with this relatively new modality has been
consistently improved outcomes, both within the treatment session and
in carry-over from treatment.
An added bonus to providing soft-tissue treatments via IASTM has
been decreased stress and fatigue levels to my hands, since the vast
majority of my patients have a soft-tissue component to their treatment
programs. Its not unusual for me to have 12-hour-plus clinic days,
and replacing many pure manual techniques with IASTM treatment
has proven to be a lifesaver hopefully adding years to my ability to
continue practicing manual therapy. Equally as important, if given the
choice, most patients prefer the IASTM tools to comparable manual care.
Taking a Closer Look
Although relatively new to mainstream clinical use, IASTM has roots
dating back thousands of years in Eastern medicine. Research on this
technique is in the early stages, and studies of higher quality are begin-
ning to show up in the literature. By taking a close look at the literature,
I expect you will nd this modality is worth considering as an adjunct
to your manual therapy treatment repertoire.
I started out with a healthy skepticism of the claims of improved
patient outcomes by the IASTM community. But after performing over
a thousand IASTM treatments, it has become a mainstay of my manual
therapy protocols.
References are available at www.advanceweb.com/pt under the
Toolbox tab.
Mark Butler is center manager of the Medford, N.J., NovaCare and adjunct assis-
tant professor at the Rutgers SHRP Doctor of Physical Therapy Program.
COVER STORY
Finally, new and significantly improvea
soIt-tissue therapy instruments.




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Mark Butler PT, DPT, OCS, Cert. MDT
Author of this issues cover story
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An added bonus to providing soft-tissue treatments via IASTM has been
decreased stress and fatigue levels to his hands, noted Butler.

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