Instrument Assisted Soft Tissue Mobilization (IASTM) & Graston Techniques
Melissa Carr, SPT & Rachel Labella, SPT
Together, Rachel and I share a passion for orthopedics and intervention techniques that improve the level of care we can provide to our patients. Instrument Assisted Soft Tissue Mobilization (IASTM) has been a huge topic bouncing around the PT world for quite some time, with big names such as Graston, leading the way. While we both have been exposed to a variety of IASTM tools in our graduate and undergraduate careers, we found ourselves wondering about other options that may be available to clinicians, as well as the efficacy behind using instruments for soft tissue mobilization. As part our Evidence Based Practice II course in the Fall of 2020, we individually chose to complete a Critically Appraised Topic (CAT) on the subject of IASTM. It was during this period where we accumulated a copious amount of evidence based literature on the topic at hand. We were gratified to see that one of our professors Jon Hacke, PT, DPT, also wanted to take a closer look into IASTM and its effectiveness, so together we decided that our 3rd year Capstone project would be a collaborative effort. From working with renowned faculty and clinicians, we hoped to shed a greater light on this topic and provide students, and up and coming professionals, with a convenient and detailed resource on IASTM.
Statement of Need
Patients often attend physical therapy for a variety of reasons, including pain, decreased range of motion, or other physical impairments that result in activity limitations. These common impairments are often treated with a variety of manual therapy techniques to enhance soft tissue extensibility and promote pain relief. In the outpatient orthopedic setting, therapists often find themselves using instrument assisted soft tissue massage (IASTM) to address a patient’s pain, soft tissue adhesions, range of motion and functional limitations. This can be used in addition to relying on traditional manual therapy techniques, and other stretching and strengthening exercises. The use of IASTM has been thought to be just as effective at addressing the aforementioned problems, as well as reducing the physical strain on the physical therapist. However, the use of specialized instruments can be costly, and come with additional certification requirements. There is a need to know more about the efficacy and use of IASTM to better determine if these tools produce significant enough results in the patient outcomes to justify their additional cost and time requirements.
The purpose of this capstone project was to gather high-level evidence to conduct a literature review, with the goal of comparing IASTM to a variety of alternative intervention options. It was important to determine if and when IASTM should be implemented into clinical practice to improve the patients functional outcomes. Extensive research was conducted on the histological processes that occur within the body during the application of IASTM to further help the participant understand the physiological process, as well as analyze high-level evidence involving the outcomes of patients who received IASTM as part of their plan of care for a variety of diagnoses commonly seen in outpatient orthopedic clinics. The various products included below will allow the participant to delve deeper into consolidated clinical evidence, as well as have a single-page handout of the key aspects of IASTM for quick reference in the clinic. At the conclusion of the VoiceThread presentation, the participant should understand the histological mechanisms induced during IASTM, as well as be confident using their clinical reasoning to determine which patients would be good candidates for this intervention based on their clinical presentation, and a review of their medical history to identify potential contraindications to IASTM techniques.
We created an evidence table consisting of 10 articles that analyze the efficacy of IASTM by comparing IASTM to alternative interventions. This table outlines the purpose of the study, the subjects involved, the outcome measures and interventions utilized in each group, and the results of the study. These studies were implemented into a VoiceThread to discuss the findings and clinical efficacy of utilizing IASTM for a variety of patient populations and diagnoses. Additionally, the VoiceThread contains health literacy information on the histological progresses induced by IASTM and traditional STM, various types of traditional STM techniques, common IASTM tools seen in the clinic, and the Graston Technique protocol. Video demonstrations are utilized throughout the VoiceThread to augment the learners understanding of each technique. This VoiceThread presentation is targeted toward other healthcare professionals, and uses basic language that should be understood by healthcare professionals from a variety of disciplines. A flyer is also included to highlight the key points from our research and provide a quick reference that can be utilized in the clinic. Participants who take part in this VoiceThread lecture are encouraged to complete the Capstone Evaluation Form following the presentation to identify strengths of the presentation, as well as room for improvement.
I have thoroughly enjoying conducting research on this topic, as I completed my first clinical rotation at an outpatient orthopedic clinic that utilized IASTM tools and traditional STM extensively, but I was very unfamiliar with the efficacy between the two and the training involved in obtaining IASTM certifications. During my first clinical rotation, I often found myself very fatigued after performing traditional STM on patients throughout the day and was interested to try out IASTM to give my hands a break. I would like to give my first clinical instructor, TJ Scott, PT, MPT, OMT-C, credit for peaking my interest in manual therapy techniques during my time at Select Physical Therapy in Mount Pleasant, SC. I was excited to learn that Jon Hacke, PT, DPT, had an interest in starting research on a topic I enjoyed, and I would be able to dig deeper into the world of IASTM. Jon Hacke, PT, DPT and Michael McMorris were two professors who led our manual therapy class, making them ideal members for our committee to provide superior feedback. Additionally, Kristin Somerville, PT, DPT, assisted in our manual therapy class and I thoroughly enjoyed her positive demeanor and she allowed me to further enhance my manual therapy skills with her feedback and helpful tips for us more vertically challenged people. She provided excellent guidance and feedback throughout our research process.
Conducting research on the various diagnoses treated using IASTM has been especially intriguing recently, because my current clinical is in an outpatient clinic with a large neurologic and chronic pain patient population. Throughout my research, I have had the opportunity to perform a variety IASTM techniques on patients in the clinic, many of which have been suffering from lower extremity chronic pain for months, or even years. My current clinical instructor at Brunswick Physical Therapy Associates in Shallotte, NC, Adja Catalano, PT, DPT, has allowed me the opportunity to perform IASTM techniques on patients with varying diagnoses and clinical presentations, and has taken significant interest in the topic as well. I have been encouraged to delve even deeper into the topic in clinic when a question arises or we have a patient who would likely benefit from IASTM treatment but the diagnosis has not come up yet in clinic. In combination with stretching, strengthening, and neuromuscular re-education interventions, I have had significant success so far in the clinic, with patients with plantar fasciitis, decreased DF ROM, and tarsal tunnel symptoms reporting decreased levels of pain and increased ROM that are more prolonged than after prior treatments that did not utilize IASTM. Being a smaller person, it is often difficult to achieve the appropriate pressure required to break up scar tissue and adhesions by hand, but patients have responded positively to the increased pressure achieved with the use of these tools. While I have only had the opportunity to utilize these IASTM techniques on patients with lower extremity involvement, I am excited to continue to implement this research in the clinic to augment patients therapy by promoting increased soft tissue extensibility and pain relief.
Going forward, I plan on obtaining my Graston certification to enhance my professional intervention tool box and be able to provide these interventions to appropriate patients. Prior to this research, I was unaware of the multitude of IASTM companies, each of who have their own specific protocols and tool designs. Upon completion of this project, I have a solid foundation in the histological changes that occur as a result of utilizing IASTM and am confident in using my clinical judgement to know when a patient would likely benefit from this intervention. Additionally, I have gained confidence in explaining to patients the physiological process behind IASTM to provide more detailed patient education.
As an enthusiast of outpatient orthopedics for many years, I was always interested in diving deeper into new interventions or treatment techniques and looking into how effective these may be when working in the clinic. Graston is such a huge name in terms of instrument assisted soft tissue mobilization (IASTM) that I have been exposed to time and again. However, the feedback on Graston itself has varied by clinicians so I was extremely excited when Jon Hacke, PT, DPT and Professor at UNC’s DPT program, proposed a project looking deeper into the efficacy behind IASTM.
At the beginning of this project all I knew was that per clinician report, IASTM provided the advantage that helped to less the load on therapists’ hands when compared to traditional manual therapy techniques. But was it a better treatment option than traditional manual therapy techniques and what other options besides Graston are available? I also had many preconceived notions such as; What if the clinic I work in doesn’t have Graston tools, can I buy them myself without taking a specialized course? Is the cost of licensing and the tool set a necessary investment that will truly better my practice? So with Melissa Carr, my capstone partner, we set out to review or knowledge of specific manual techniques, learn more about Graston and other IASTM tools, and research the efficacy behind these interventions.
Upon researching we found a wealth of knowledge surrounding IASTM and its uses in the clinic. The good news is that for clinicians who have access to tools such as Graston, HawkGrip, EDGE mobility tool, Zuka, etc is that IASTM is an effective intervention. Even better news is that for those clinicians who do not have access to those same tools, they can be assured that they are still delivering an effective and comparable intervention. We had an exceptional team of faculty and clinicians advising us along the way that encouraged us to think critically and further assess the level of evidence we were bringing into this project. Overall, this capstone experience helped to quell any false preconceived notions.
To Dr. Deborah Thorpe, PT, PhD, thank you for taking on the task of organizing the class of 2021’s capstone projects.
To Dr. Jon Hacke, PT, DPT, thank you so much for being our primary capstone advisor. You have been a huge proponent of our success not only during this project, but throughout our education at UNC Chapel Hill. The wealth of knowledge and thoughtful feedback you bring to the table is greatly appreciated and the positive impact you have made on our skill sets will continue to serve us through our professional careers.
To Dr. Michael McMorris, PT, DPT, thank you for agreeing to be one of our capstone committee members. As the Director of the Orthopedic Residency, a Board-certified specialist in orthopedics and Fellow of the American Academy of Orthopedic Manual Physical Therapy, your advice was invaluable. Not only do we appreciate your extensive knowledge, but also your unique humor and patience during this process.
To Dr. Kristin Somerville, PT, DPT thank you for agreeing to be one of our capstone committee members. As a new addition to the UNC PT faculty, your unique perspective into IASTM and the various options besides the Graston tools helped to shape this project and broaden our perspective.