Shewail et al.

BMC Musculoskeletal Disorders (2023) 24:457 BMC Musculoskeletal

https://doi.org/10.1186/s12891-023-06540-5
Disorders

RESEARCH Open Access

Instrument–assisted soft tissue mobilization

versus myofascial release therapy in treatment
of chronic neck pain: a randomized clinical
trial
Fatma Shewail1*, Salwa Abdelmajeed2, Mohamed Farouk1 and Mohamed Abdelmegeed2

Abstract
Objective The purpose of this study was to investigate the effect of instrument-assisted soft tissue mobilization
(IASTM) versus myofascial release therapy (MRT) on college students with chronic mechanical neck pain (CMNP).
Methods Thirty-three college students with a mean age of 21.33 ± 0.98 involved in distance learning due to the
Corona Virus 2019 (COVID-19) restriction were randomized to receive either IASTM on the upper trapezius and
levator scapulae muscles or MRT. Researchers measured their pain with a visual analog scale (VAS), function with
neck disability index (NDI), and pain pressure threshold (PPT) with a pressure algometer. The subjects received eight
therapy sessions over four weeks and outcome measures were assessed pre and post-intervention. The study was
registered as a clinical trial on clinicaltrials.gov (registration number: NCT05213871).
Result Unpaired t-test showed no statistical significance between the two groups post-intervention regarding
improvement in pain, function, and PPT (p > 0.05).
Conclusion This study showed insignificant differences between groups. However, we did not use a control group,
indicating that the improvement in outcomes may not have been caused by the intervention.
Study design Quasi-experimental two groups pre-posttest clinical trial.
Level of evidence Therapy, level 2b.
Keywords Neck pain, Manual therapy, Physical therapy

*Correspondence:
Fatma Shewail
fatma.shewail@must.edu.eg
1
Orthopedic physical therapy department, Faculty of physical therapy,
Misr University for Science and Technology, Cairo, Egypt
2
Orthopedic physical therapy department, Faculty of physical therapy,
Cairo University, Cairo, Egypt

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Shewail et al. BMC Musculoskeletal Disorders (2023) 24:457 Page 2 of 8

Introduction Instrument-assisted soft tissue mobilization (IASTM)

Neck pain is one of the most frequently encountered dis- has gained wide attention as a relatively new technique in
orders in clinical settings [1] and is often difficult to diag- the treatment of muscular tightness and pain. Originally
nose and treat [2, 3]. Neck pain continues to increase in described by Cyriax in 1982, this technique can be per-
the general population and specific subgroups worldwide formed using different tools. The IASTM uses the same
[3]. Published data on the prevalence is variable, but it concept by applying an adapted pressure on the tight
is estimated that 22–70% of the general population will structures using different-shaped stainless-steel tools
experience pain at some point in life [4–6]. with beveled edges to conform to different anatomical
Patients with chronic mechanical neck pain (CMNP) structures. Although there is some empirical evidence for
are present with a wide range of symptoms ranging from its use [14], its effect has not yet been investigated in sub-
mild pain and minimal functional limitation to complete jects with CMNP to the authors’ knowledge.
disability [7]. Therefore, it has great socio-economic and Myofascial treatment is an emerging treatment
negative health impacts [1]. in different musculoskeletal conditions although its
Among the identified risk factors for the development clinical benefits is still not clearly understood [15]. Myo-
of CMNP are a long history of neck pain, worrisome atti- fascial release therapy (MRT) aims at restoring the nor-
tude, poor quality of life, and less vitality. The same clini- mal length of a tight structure with the target goal of
cal practice guidelines and its updated revision identified decreasing pain and improving function. Since patients
female gender and prior history of neck pain as predis- with neck pain are usually presented with myofascial
posing factors for the development of a new onset of neck trigger points (MTrPs), MRT can be an effective treat-
pain. In addition, there is low to moderate evidence that ment technique [16].
high job demands, history of smoking, low social/work Since there is a research gap in understanding the effect
support, and history of low back pain are risk factors for of IASTM and myofascial MRT in college students with
the development of neck pain in general [2, 3]. CMNP, the authors of this study were interested in build-
The international classification of functioning, disabil- ing up evidence for their use. During Coronavirus time,
ity, and health (ICF) endorses functional terminologies in college students were ordered to stay at home to stop
describing health conditions. Therefore, the clinical prac- spreading infection and as a mitigation strategy. Thus,
tice guidelines linked to the ICF classify patients with they had to use the computer for long hours. Therefore,
neck pain into four categories: neck pain with mobility the purpose of this study was to compare the effect of the
deficits, neck pain with headache, neck pain with move- IASTM technique and MRT on college students studying
ment coordination deficits, and neck pain with radiated using distance learning and having CMNP. Researchers
upper extremity pain. Each category is presented with hypothesized that there will be no statistically signifi-
clinical findings specific to that category2,3. cant difference between the effect of IASTM and MRT
There is strong evidence that young individual patients on improving pain, function, and/or improving pressure
with a duration of symptoms less than 12 weeks can be pain threshold.
diagnosed with neck pain and mobility deficits when they
are presented with symptoms isolated to the neck and Methods
have a limited cervical range of motion (ROM) [2, 8–11]. Study design and setting
Moreover, the revised clinical practice guidelines of neck This was a prospective quasi-experimental two groups
pain [3] identified the patients with a presentation of the pre-posttest study. Due to the nature of the intervention,
following symptoms as having neck pain with mobility we could not blind the participants or investigators to the
deficits: central and/or unilateral neck pain, limitation in intervention. The participants, however, were randomly
cervical ROM with reproduction of familiar symptoms, assigned to the two experimental groups. Therefore, we
associated referred shoulder or upper extremity pain. followed a quasi-experimental design. The study was con-
College students can be a risk population for develop- ducted at the Faculty of Physical therapy, Misr University
ing CMNP because of the long hours spent studying in for Science and Technology (MUST). It was approved
front of computer screens [12]. This can be also trig- by the institutional review board (IRB) of the Faculty of
gered by sustained posture and abnormal cervical spine Physical Therapy, Cairo University (approval number:
mechanics with tenderness on palpation [1–3]. Addi- PT.REC/012/003381) and was registered on clinicaltrials.
tional clinical examination findings of patients with neck gov (registration number: NCT05213871), registration
pain and mobility deficits include limited cervical ROM, date 28/01/2022.
neck pain reproduced at the end of active and passive
ROM, restricted cervical and thoracic segmental mobil- Participants
ity, associated scapular/thoracic segments pain, and Thirty-three college male and female students were ran-
strength deficits in subacute or chronic neck pain [3]. domized to receive either IASTM on the upper trapezius
Shewail et al. BMC Musculoskeletal Disorders (2023) 24:457 Page 3 of 8

and levator scapulae muscles (group A) or myofascial suggested we need 52 participants (26 in each group) in
release on the same muscles (group B). Both groups an independent sample t-test. We ended up, however,
received postural correction and strengthening exer- with 33 subjects. A flow diagram according to the Con-
cises for neck and scapular stabilizers in addition to their solidated Standards of Reporting Trials (CONSORT)
assigned treatment. The inclusion criteria were college statement is presented in Fig. 1 to illustrate the progres-
students between 18 and 25 years old with CMNP local- sion of this clinical trial [17].
ized to the cervical and periscapular regions, who report
at least one trigger point in the upper trapezius and/or Assessment procedure
levator scapulae muscles, and who use the computer After signing the consent form, subjects were screened
daily for at least two hours and are involved in distance for eligibility to participate. Their demographic data was
learning of at least three months. CMNP was defined as then collected. It was important to us after screening for
having vague, dull, achy pain in the neck for more than eligibility to apply clearing tests to exclude any red flags.
three months with an intensity of at least 30 mm on a We used the Sharp-Purser [18] and alar ligaments [19, 20]
100 mm visual analog scale (VAS) line. Only college stu- tests for ligamentous hyperlaxity/subluxation/dislocation
dents using distant learning during Coronavirus pan- of the proximal cervical spine. They were also screened
demic restriction as stipulated by the school rules were for VBI by putting the subjects’ heads in extension, side
included in the study. bending and rotation for 30 sitting from supine and sit-
Subjects were excluded if they have any specific neck ting positions and assessed VBI signs and symptoms of
pathology, radiculopathy, paresthesia, cervical disc dizziness, vertigo, nystagmus, and nausea. The screening
pathologies, neurological signs, cervical myelopathy, was performed for both sides.
vertebrobasilar insufficiency (VBI), or acute or subacute When the subject was cleared, he/she was asked to
neck pain of any nature. Subjects were also excluded place a mark on the VAS line to indicate the level of pain
if they have any systemic diseases such as rheumatoid intensity. A ruler was then used to measure the distance
arthritis, ankylosing spondylitis, hemorrhage tendency from zero, and the recorded number was rounded to the
and/or anticoagulation treatment, or spinal instability. nearest number. For example, a measure of 5.7 cm was
Subjects who did not meet the inclusion criteria were rounded to 6 cm.
also excluded from participation. Subjects’ functional status was evaluated using the
neck disability index (NDI). The NDI is a widely used
Sample size calculation and reporting of the clinical trial self-reported outcome measure that assesses functional
To detect an effect size of Cohen’s d = 0.80 with 80% limitations in patients with neck pain. It has 10 items
power (alpha = 0.05), G*power software (version 3.1.9.7) answered on a 0–5 Likert scale for each item. The total

Fig. 1 Flow chart outlining the progression of the clinical trial

Shewail et al. BMC Musculoskeletal Disorders (2023) 24:457 Page 4 of 8

raw score is 50 with higher scores indicating greater dis- sweeping technique was used to apply a deep yet com-
ability. Psychometric properties for the NDI are well fortable soft tissue mobilization on the upper trapezius
established in the literature [26–28]. We asked the sub- from origin to insertion for approximately 3 min. The
jects to choose the answer that best described his/her technique was adjusted if needed to allow the subject to
condition for each item of the NDI. Scores were then tal- take a break if a sense of burning was felt or if the treat-
lied, and the total score was calculated. ment was uncomfortable. The skin was then cleaned and
The subjects were then assessed for the presence or wiped with tissues. Subjects were instructed that slight
absence of MTrPs. We used previously published criteria hyperemia on the skin is a normal feeling and should
for evaluation. This includes the presence of a palpable subside before the next session [12, 13, 22]. Treatment
taut band in a muscle, presence of a hypersensitive point was applied bilaterally.
in a taut band, a twitch in a muscle caused by palpation, Subjects in group B received MRT twice a week for four
referred pain produced as a result of compression on a weeks. While the subject was in a supine position with
tender point, and/ or presence of classical referred pain his/her head supported, the subject’s head was rotated
pattern. Four out of five findings classified the trigger away from the side to be treated, and the therapist
point as latent, while the five findings classified the trig- crossed her hands as shown in Fig. 2 to take up the slack
ger point to be active [29]. of the upper trapezius muscle until the tissue barrier was
The pressure algometer (model: FPX 50, S/N: felt. A stretching force was maintained for 30 s at the
2,010,600,173, JTECH Medical, Midvale, Utah, USA) was tissue barrier before moving to a new barrier. The tech-
then applied perpendicular to the trigger point (Fig. 2). nique was repeated until the end range is reached. Lateral
The subject was asked to report when he/she first felt bending of the head was avoided and if more stretching
the first discomfort. The compression was then stopped was needed, the therapist depressed the shoulder more
and the value on the algometer screen was recorded. at the same time the head was rotated. The subjects were
The average of three readings with an interval of 1 min continuously assessed for any discomfort or pain beyond
between the trials was recorded [22, 23]. Assessment of comfortable stretching pain [15, 16]. Both sides of the
pain, function, and pain pressure threshold were per- neck were treated.
formed pre and post-treatment. In addition, both groups received postural correction
and strengthening for neck and scapular stabilizer mus-
Intervention cles following the guidelines of Noormohammadpour
Subjects in group A received the IASTM technique using et al. [31] and Harbut et al. [32] The exercises consisted
an M2T blade twice a week for four weeks. The subject of active cervical retraction with chin tuck and scapu-
assumed a comfortable sitting position leaning on a treat- lar retraction exercises. Also, manual resistance was
ment table with the arm crossed to rest the head (Fig. 2). applied for cervical lateral bending, extension, and rota-
After cleaning the skin of the subject and the blade with tion. All these exercises were performed for 3 sets of 10
alcohol swabs, a lubricant (Vaseline) was applied, and a

Fig. 2 Procedure used in the study. left: assessment of pain pressure threshold, center: application of instrument-assisted soft tissue mobilization (group
A), right: manual soft tissue release (group B)
Shewail et al. BMC Musculoskeletal Disorders (2023) 24:457 Page 5 of 8

Table 1 Demographic data of the two groups

Data Myofascial group IASTM group t-test p-value
n = 15 n = 18
Mean SD Mean SD
Age 21.27 1.16 21.39 0.78 0.36 0.72
Body mass 73.40 19.34 66.56 13.23 1.2 0.23
Stature 162.13 4.97 161.82 6.78 0.14 0.88
BMI 27.61 6.99 25.17 4.57 1.2 0.23
Gender Male 0%, Female 100% Male 12%, Female 88% Chi square = 1.7 0.18

Table 2 Difference between both groups post-measurements

Data Myofascial group* IASTM group* t-value p-value Effect size MD (95%CI)
VAS right 3.40 ± 1.12 3.17 ± 1.38 0.52 0.6 0.18 0.23 (-0.68-1.14)
VAS left 3.60 ± 1.18 3.67 ± 1.41 0.14 0.88 0.05 -0.07
(-1.02-0.88)
Pain pressure right (kg/cm2) 2.85 ± 0.50 2.99 ± 0.68 0.67 0.5 0.24 -0.14
(-0.57-0.29)
Pain pressure left (kg/cm2) 2.76 ± 0.58 2.79 ± 0.57 0.14 0.88 0.05 -0.03
(-0.45-0.39)
NDI 33.15 ± 5.43 31.27 ± 9.62 0.67 0.5 0.18 1.88 (-3.72-7.48)
*Data are presented as mean ± standard deviation
Abbreviations: IASTM: instrument-assisted soft tissue mobilization, VAS: visual analogue scale, NDI: neck disability index, Right/left: data reported for assessment of
each side of the neck, MD: mean difference, CI: confidence interval

repetitions with the same frequency of the treatment for Discussion

each group (twice a week for 4 weeks). The IASTM and MFR techniques appear to have similar
effects on pain and disability on college students studying
Data analysis using distance learning and having CMNP. The partici-
Data were analyzed using the statistical package for pants in group A who received IASTM, however, showed
social sciences (SPSS) computer program version 27 soft- a slight clinical improvement in pain, function, and pain
ware for Windows (IBM SPSS Inc., Chicago, IL, USA). pressure threshold. The lack of statistical significance
Descriptive statistics were expressed as mean ± standard between the two groups may be due to the short dura-
deviation for continuous variables and frequency distri- tion time of the intervention and/or the lack of a control
bution (%) for categorical variables. The normality of the group. Perhaps this short time was not enough to trigger
data was examined using the Kolmogorov Smirnov sta- a statistical significance. It is possible that if the inter-
tistical test. Comparisons between the two groups were vention time was more than four weeks, we could have
performed using unpaired student t-tests pre and post- obtained a different result.
intervention for pain, function, and pressure threshold. The use of valid and reliable outcome measures is
The alpha level was set at p = 0.05. For the effect size, we always important. In this study, we used VAS, NDI, and
used the Cohen’s recommended criteria [24] which is pressure algometry to directly address the purpose of the
as follows: d ≈ 0.2 indicates a small effect and negligible study. It is important to note, however, that the construct
clinical importance, d ≈ 0.5 indicates a medium effect and of the studied outcome measures is different. In some
moderate clinical importance and d ≈ 0.8 indicates a large outcome measures, the lower the scores, the better and
effect and high clinical importance. it is the other way around in the others. For example, the
lower the scores in VAS and NDI, the better the outcome,
Result while the higher scores in the pressure algometry, the
Demographic data are presented in Table 1. There was no better since higher scores indicate higher tolerance for
significant difference between the two groups regarding pain pressure.
subjects’ mean age, body mass, stature, body mass index, In this study, our sample included only college students
or gender (p > 0.05). There was no significant difference involved in distant learning. During Coronavirus disease
between the two groups in all variables measured post- (COVID-19), most of the education changed to become
measurement with p > 0.05 as shown in Table 2; Fig. 3. online. The world has changed since COVID-19 started
and many schools forced students to stay at home and
continue their courses online. This has affected students
and new complaints such as neck pain emerged due
Shewail et al. BMC Musculoskeletal Disorders (2023) 24:457 Page 6 of 8

Fig. 3 Comparison between the two groups post-treatment

to long hours of sitting in front of computers. We were experimental studies should be conducted to compare
intrigued to study how interventions like ours could or intervention with similar constructs, the superiority of
could not help them. Therefore, we delimited the study MFR intervention in their study may be because man-
participants to college students involved in distant ual therapy has superior evidence to passive treatment
learning. modalities in patients with neck pain [2, 3]. This was also
Although there are similar studies that came to simi- the case in another similar study [15, 30] although the
lar results, [21, 22, 25] our study has a population sample treatment provided was shorter than ours. Our study and
with specific characteristics which affected the neck pos- theirs used similar MFR techniques and the three stud-
ture because of the “homeschooling” type of learning. In ies showed significant within-group effects from pre- to
addition, we included a postural correction and strength- post-treatment.
ening exercise program to augment the program assigned This study can be viewed within the context of several
to each group. Although this can limit the generalizabil- limitations. First, the sample size was small, and we had a
ity of our result to the general population, we felt it was large dropout rate, either due to COVID-19 restrictions,
important to address some of the COVID-19 restriction scheduling conflicts, and/or ineligibility criteria to partic-
effects on college students. ipate. We could have obtained a different result if we had
While varieties of MFR techniques exist, the type of a larger sample size. The small sample size also limited
MFR performed on the neck muscles does not seem to the generalizability of the result which affects the exter-
affect the result of pain and pain pressure threshold nal validity of the study. Another factor that may limit the
modulation in subjects with neck pain. In this study, we generalizability of the results is the fact that the age range
used gradual stretching for the upper trapezius and leva- and hence the characteristics of participants are small to
tor scapula muscles while in another study, [22] they extrapolate the findings to the general population. Sec-
used a stripping massage applied using the thumb on the ond, our intervention was for a short time. Again, we
upper trapezius muscle. Neither study found a difference could have obtained a different result with a long time or
between groups in the same outcome measures although with more visits. In addition, we did not follow up with
there was a significant difference within groups pre and participants beyond four weeks and we could not infer
post-treatment. Considering the limitation of both stud- the long-term effect of our intervention.
ies, the type of MFR may not be as important as combin- Third, we assessed trigger points found only in two
ing more than techniques or boosting the sample size to muscles: the upper trapezius and levator scapulae. Dif-
find a different result. ferent muscles have different referral patterns and could
When compared to conventional physical therapy of have been important to study in addition to these two
therapeutic ultrasound, electrical stimulation, and regu- muscles. Fourth, we did not have a control group to bet-
lar massage, MFR was found to be superior in improving ter investigate the effect of our intervention, this lim-
pain, increasing range of motion, and PPT in subjects its the result of this study. We recommend that future
with subacute and chronic neck pain [16]. Although studies include more muscles in their assessment and
Shewail et al. BMC Musculoskeletal Disorders (2023) 24:457 Page 7 of 8

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