Modern-day practice is embracing Instrument-Assisted Soft Tissue Mobilization, or IASTM therapy for healing intervention
Soft tissue mobilization and manipulation dates to several thousands of years ago with one of the first known techniques in Traditional Chinese Medicine (TCM) known as Gua Sha, to “scrape away illness,” what today is referred to as IASTM therapy
Even during such times, the intent was to improve stagnant blood flow (Gua is the scraping, spooning or coining, and Sha refers to the blood stasis). Although through the years, both TCM and its associated techniques have evolved, Gua Sha’s intent remains as both a local treatment to a body region, and also a more global and multisystemic influence on health such as inflammation, heart rate variability and menopause.1-3
IASTM therapy, modern once again
Overall, modern soft tissue techniques can be associated with a lineage to James Cyriax’s cross (deep) friction massage, itself based on Mennell’s concept from even earlier in the 1900s. 4 The premise was for the use of cross friction massage techniques to provide a controlled “clinical injury” to chronic tendon lesions that had stalled out in the healing process.
The earlier theory suggested that cross friction techniques break down adhesions and re-stimulate the inflammatory response, allowing for tissue healing to occur. We now know that although there is a relationship to the insult energy (pressure), a true “reinjury” is not required to progress through a newly-established tissue regeneration environment (remodeling and resorption).5 In fact, mechanically-applied stress may attenuate the negative inflammatory process (seepage of blood into compartments from damaged cells and tissues) to reduce the effects of injury.6,7
However, these too must be controlled. Although the terminology can be confusing or misleading, the release of “pro-inflammatory” mediators (e.g. IL-6 and IL-8) during this stage of the healing process is often misunderstood and considered to be the same as the edema formation that occurs from damage to vessels. These “pro-inflammatory” mediators are a controlled increase in microcirculation to promote next stages in healing.
Techniques, reported benefits and indications
There are various implements and techniques used in IASTM therapy, including polymers, metals and alloys, natural materials and mechanically generated forces. Some of today’s techniques have extended beyond simply rubbing or scraping an area of concern to include diagnostics, stroking patterns and pressures, and assisted motion of the involved articulation.
Other techniques generating force into the tissue are mechanically generated, and as an alternative to using friction and pressure from an implement, the use of electromechanical, piezoelectric, and pneumatics are used to produce acoustic waves to deliver a pressure or focused shockwave. Although the manual techniques provide most influence to superficial structures, the depth is controlled by pressure force, tissue pull, and potential active or assisted motion of the area being treated. Pressure wave generation has a diverging energy that penetrates up to six centimetres, whereas focused shockwave, also referred to as extracorporeal shockwave therapy (ESWT), has a convergence of energy and can have a therapeutic influence as much as 12.5 cm.
Influencing normal tissue and function again
Much of the literature has focused on outcome measures such as range of motion, strength and pain.8-11 This is through influencing soft and connective tissue such as ligaments, tendons, muscles and fascia, and occasionally articulations. Proposed mechanisms include increasing metabolism, microcirculation, fibroblastic activity and growth factor release, and even apoptosis and other resorption.6,7,12 Overall, the goal is to influence dysfunctional tissue and regions of the body to reestablish, or as close to reestablishing as possible, normal tissue and function.
Given the reported benefits, one may extrapolate that there is a great deal of indication with chronic soft tissue conditions. There seems to be an evolving list — however, generally superficial IASTM therapy is indicated for superficial muscle pain, tendinopathies, ligamentous conditions, acute joint injury, myofascial dysfunction, decreased range of motion, back and neck pain, small joint instability, shoulder impingement and myofascial trigger points. Mechanically-generated pressure, having more control over impact delivery and depth, has previously been mentioned, and has further indications to much deeper tissues, as well as to more acute conditions in men and women.
These are not only common conditions treated in the chiropractic clinic, but are also consistent with commonly-occurring conditions that consume a great deal of health care dollars when managed with more invasive and expensive procedures, including pharmaceuticals and surgical interventions.
Implementing into practice
Integrating instrument-assisted soft tissue mobilization likely has several advantages to a clinic, from patient outcomes to career longevity. The use of implements, compared to hands only, can deliver greater lever force, surface-area contact and depth of penetration while reducing digital and hand effort, potentially reducing work-related injuries for the clinician.
It is also an opportunity to possibly increase the diversity (and volume) of patients, adding billable codes and possibly even cash-based revenue, while enhancing patient outcomes with high satisfaction rates consistent with chiropractic clinics. For manual devices, the implements are a marginal cost, and even for those with more technique-oriented approaches, the investment will likely cover your state license continuing-education requirement. Many payors will cover additional soft tissue mobilization codes, versus adding more techniques associated with articulation manipulation falling under the 98[xxx] procedures.
Electronic- (pressure and focused shockwave) based devices may expand your treatment offerings, e.g. men’s and women’s health, as well as provide high outcome-based cash revenue streams in the former, and for musculoskeletal conditions, as they are not typically covered under third-party payors. These are also less technique-oriented and can be performed by similar staff.
The future of less-invasive treatment
There is a continuous shift in providing less invasive and lower-cost treatment options for not only specific neuromus-culoskeletal issues such as low-back and chronic pain, but also the comorbidities that result from not moving — both of which consume some of the highest health care costs of any society. There may also be an advantage to combining soft tissue mobilization with biologics, as some studies have shown increased efficacy in combining therapies.13-15
Christopher Proulx, DC, PhD(abd), ATC, CSCS, is the founder of Effective Motion Strategies and a clinical education manager at DJO LLC in the Chattanooga division. He is also in private practice and consults as a physical medicine and rehabilitation specialist and performance coordinator for individuals and athletic teams, and is a guest lecturer/researcher at colleges and universities. He holds a Doctor of Chiropractic, PhD(abd) in Exercise Science, Master of Science in Exercise Science, and a Bachelor of Science in Sport Management and Health Fitness. He has over 25 years of experience in sport and clinical sciences, and has personally presented his work across the U.S., Central and South America, China and Europe. Proulx is a licensed chiropractor, certified athletic trainer, and certified strength and conditioning specialist.
- Yuen, J. W. M., Tsang, W. W. N., Tse, S. H. M., et al. (2017, June). The effects of Gua sha on symptoms and inflammatory biomarkers associated with chronic low back pain: A randomized active-controlled crossover pilot study in elderly [Abstract]. Complementary Therapies in Medicine
- Xingze, W., Peijie, C., Xingyu, H., et al. (2017, February 15). Guasha improves the rating of perceived exertion scale score and reduces heart rate variability in male weightlifters: A randomized controlled trial. Journal of Traditional Chinese Medicine, 37(1), 49–56.
- Meng F, Duan PB, Zhu J, et al. (2017). Effect of Gua sha therapy on perimenopausal syndrome: a randomized controlled trial. Menopause. 24(3):299-307.
- Chamberlain, GJ. (1982). Cyriax’s Friction Massage: A Review. JOSPT, 4(1): 16-22.
- Wang CJ, Yang KD, Chen RF, Wang FS, Sheen-Chen SM. (2002b). Extracorporeal shockwave promotes growth and differentiation of bone marrow stromal cells towards osteoprogenitors associated with induction of TGF-beta 1 and VEGF Induction. J Bone Joint Surg Br 84457-461.
- Crane JD, Ogborn DI, Cupido C, et al. (2012). Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. Sci Transl Med;4(119):119ra13.
- Waugh CM, Morrissey D, Jones E, Riley GP, Langberg H, Screen HR. (2015). In vivo biological response to extracorporeal shockwave therapy in human tendinopathy. Eur Cell Mater;29:268-280.
- Kim DH, Kim TH, Jung DY, Weon JH. (2014). Effects of the Graston technique and self-myofacial release on the range of motion of a knee joint. J Korean Soc Phys Med;9:455–463.
- Kivlan BR, Carcia CR, Clemente FR, Phelps AL, Martin RL. (2015). The effect of Astym® Therapy on muscle strength: a blinded, randomized, clinically controlled trial. BMC Musculoskelet Disord.;16:325.
- Laudner K, Compton BD, McLoda TA, Walters CM. (2014). Acute effects of instrument assisted soft tissue mobilization for improving posterior shoulder range of motion in collegiate baseball players. Int J Sports Phys Ther;9:1–7.
- Lee JH, Lee DK, Oh JS. The effect of Graston technique on the pain and range of motion in patients with chronic low back pain. J Phys Ther Sci. 2016;28:1852–1855.
- Baker RT, Nasypany A, Seegmiller JG, Baker JG. (2013). Instrument-assisted soft tissue mobilization treatment for tissue extensibility dysfunction. Int J Athl The Train;18:16–2.
- Sandrey MA. Autologous growth factor injections in chronic tendinopathy. J Athl Train. 2014;49(3):428-430.
- Zhai, L., Ma, X. L., Jiang, C., Zhang, B., Liu, S. T., & Xing, G. Y. (2016). Human autologous mesenchymal stem cells with extracorporeal shock wave therapy for nonunion of long bones. Indian journal of orthopaedics, 50(5), 543–550.
- Hsu, CC, Cheng, JH, Wang, CJ, Ko, JY, Hsu, SL, and Hsu, T.C. (2020). Shockwave Therapy Combined with Autologous Adipose-Derived Mesenchymal Stem Cells Is Better than with Human Umbilical Cord Wharton’s Jelly-Derived Mesenchymal Stem Cells on Knee Osteoarthritis. J. Mol. Sci.2020, 21, 1217.