“Just a minute while I go get my scraper…” my colleague said to his patient. I thought about what might be going through his patient’s mind. What is a scraper? Will I have any skin left when he is done? Is it really as bad as it sounds? My colleague was referring to a small plastic device that was triangular in shape with one side having a slight concavity. He was about to treat his patient with a procedure we call IASTM, or “instrument-assisted soft tissue mobilization.” The “instrument” part of IASTM refers to using a tool to assist with the manual mobilization of muscles and fascia. I suppose the instrument can be anything, but it is most commonly a small, handheld device made of plastic, stainless steel, or jade. You may have also heard IASTM referred to by the brand name of tools, such as Graston® or Fibroblaster®. The term “scraping” can be somewhat intimidating to someone who hasn’t had the treatment before, but the term “instrument-assisted” has a vague nature that leaves too much to the imagination. But I can save my opinions on terminology for a different post…
Inflammation: A necessary or unnecessary evil?
Inflammation after an injury leads to scar tissue build-up. This is absolutely normal, and the purpose of the scar tissue is to reinforce the injured tissues. Instead it ends up making the area weaker and here is why: Scar tissue is laid down in an irregular fashion, creating a physical weak point. Picture this: you are an avid climber and are about to do the most difficult climb of your life. You can pick the rope that is supporting you from the top of a 100-meter cliff. Would you pick a rope that looks like this?
Or would you pick the rope that looks like this?
It is an easy choice! A weaker tendon, muscle, or ligament is more likely to be injured and therefore more likely to have additional scar tissue build-up as a result. Neglecting to treat this leads to a snowball effect that can derail your training or disrupt your quality of life. It is a vicious cycle that IASTM can stop.
The primary focus of IASTM is to create controlled microtrauma to an area of the body to elicit an inflammatory response. Yes, this inflammation is on purpose! Conventional wisdom has led us to believe that inflammation is bad, but that is not always true. You need a little inflammation to heal. IASTM can also help reorganize the direction of the fibers, thus increasing the resilience of your muscle, tendon or ligament. Because scar tissue can inhibit a muscle from lengthening properly, IASTM can help to improve dysfunctional movement patterns that led to the injury in the first place.
The “Pros”
There are many pros to this form of treatment. First, it is less invasive than trigger point injections, dry needling, and acupuncture. Although I am an advocate of these treatments individually for certain patients, I recognize their limitations. Second, it creates more changes at the cellular level than traditional STM. An example of this is more blood-flow, and thus greater nutrition to the individual cells. Third, the list of conditions for which it can be used is very long, and the contraindications list is very short. Fourth, your physiotherapist can provide a deeper and more specific amount of force with an instrument. Additionally, the pads of the fingers cannot detect the subtle differences in soft tissue texture like a firm edge can. And finally, it often works! That is the ultimate “pro” to any treatment! A recent study of collegiate baseball players showed that after 1 treatment subjects showed a significant improvement in two different movements that are instrumental in throwing. In fact, the control group in that study showed a decrease in quantity of both movements tested. Another study showed positive effects of combining dynamic balance training with IASTM. Although in this study both groups improved with some treatment, the treatment effects increase when IASTM is added.
Are there concerns with IASTM? Is it too good to be true?
There is some concern that IASTM will damage healthy tissue. A study was published in 2010 that claimed that when certain types of cells are released in response to inflammation there is damage not to the area of injury but to the healthy tissue around it. This conclusion initially sounds great to those who don’t favor this technique. I am skeptical of jumping to this conclusion, however, because the study investigated hepatic necrosis (death of liver cells) in mice, for which the generalization to injured muscle cells in humans may be a bit of a reach. There can be some post-treatment soreness, and some interpret this as treatment failure. I would argue that because you are re-starting the healing process by causing a small injury, a small amount pain is a necessary evil. If the treatment is performed too aggressively there can be significant pain and bruising; this is not normal or desirable.
If you are a recreational athlete (i.e. your sport is not paying your bills!) it is unrealistic to have a thrice-weekly massage after long, intense training sessions. If you opt for IASTM it becomes more realistic to self-treat with the frequency you need to get better. Many athletes use a foam roller for self myofascial release, but a 2015 study showed that IASTM is superior to foam rolling with improving hip and knee mobility. It is best to have IASTM treatment initially by a physio before you try it at home on yourself. There are a variety of tools available for home use, and you want to make sure you use one that isn’t too sharp and fits your hand well.
Don’t kill the messenger…
One of my favorite quotes when it comes to injury is “Don’t kill the messenger and ignore the message!” I am always an advocate of a multifaceted treatment approach. I have treated many athletes who just want to take some ibuprofen and continue doing their sport. This always keeps them in the injury cycle I mentioned before, and never yields good long-term results. IASTM should be a part of a thorough treatment program including patient education, therapeutic or corrective exercises, and potentially modalities for pain. If you are interested if IASTM is right for you, ask your healthcare provider for more information so you too can break the injury cycle.
Resources:
Markovic G. Acute effects of instrument assisted soft tissue mobilization vs. foam rolling on knee and hip range of motion in soccer players. J Bodyw Mov Ther. 2015;19(4):690-696.
McDonald B, Pittman K, Menezes GB, et al. Intravascular danger signals guide to neutrophils to sites of sterile inflammation. Science. 2010;330:362-366.
Butterfield TA, Best TM, Merrick MA. The dual roles of neutrophils and macrophages in inflammation: a critical balance between tissue damage and repair. J Athl Train. 2006;41(4):457-465.
Laudner K, Compton BD, McLoda TA, Walters CM. Acute effects of instrument assisted soft tissue mobilization for improving posterior shoulder range of motion in collegiate baseball players. Int J Sports Phys Ther. 2014;9(1):1-7.
Hammer Wl. The effect of mechanical load on degenerated soft tissue. JBodyw Mov Ther. 2008; 12:246-256.
Schaefer JL, Sandrey MA. Effects of a 4-week dynamic-balance-training program supplemented with Graston instrument-assisted soft-tissue mobilization for chronic ankle instability. J Sport Rehabil. 2012;21(4):313-326.
Nicole Clark
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