We are one of the first Smart Tools-certified chiropractor in Singapore and Australia. Two months ago Nazari et al. published in Archives of Physical Medicine and Rehabilitation that IASTM does not improve pain, function, or range of motion! What happens now?

In all honesty, this does come not as a surprise. In the past two to three years, there was a spike of research heavily emphasising that manual therapy, IASTM inclusive, should be – at best – an adjunctive therapy. Six months ago, Square One moved from being a truly multimodal practice to become Singapore’s first exercise-based chiropractic clinic to keep ourselves congruent with best clinical guideline recommendation. Since the transition, over 80% of our clients leave our care – pain free and with full function – within four to seven visits across a three month period. We do not regret and change and now we deliver results few competitors can match.

What is IASTM … or Graston … or Smart Tools?

IASTM stands for instrument assisted soft tissue mobilisation. It is a technique well-utilised across musculoskeletal pain and sports injuries recovery. The treatment originated from traditional Chinese medicine commonly known as “gua sha” where the scrapping of the skin is used to resolve blood stagnation.

Current IASTM practitioners believe that the technique promotes scar tissue removal and normalisation of tissue function. It was hypothesised that the mechanical of IASTM stimulation promotes blood and nutrient supply, which in turn encourage new collagen synthesis, and, by extension, help with regeneration of the injured tissue.

Ref: Kim J, Sung DJ, Lee J. Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. Journal of Exercise Rehabilitation, 2017; 13(1):12–22.

Effects of IASTM on Pain and Function

This is not the first systematic review on IASTM. There were two earlier systematic reviews on IASTM. The first was published in 2016 in Journal of the Canadian Chiropractic Association which found insufficient evidence for to support IASTM as a treatment for musculoskeletal conditions (Cheatham et al. 2016). A second study was published a year later in Physical Therapy Reviews and it supported IASTM as a viable treatment for reducing pain and improving function in the short term (Lambert, 2017). The current study reached a similar conclusion to the first study stating that the current evidence does not support the use of IASTM for pain, function, or range of motion.

Now let’s look into what each study found:

Cheatham et al. 2016 vs. Lambert et al. 2017 

So we are going to compare these two studies side by side because they are both systematic reviews. Both reviews looked at seven randomised controlled trials, five of which are the exact same studies. So, what are the four studies that gave the authors the polarising conclusions?

The two studies included in Cheatham et al. 2016 but excluded in Lambert et al. 2017 are:

  • Burke et al. (2007): compared Graston vs. hands-on soft tissue mobilisation. Both groups showed improvements but the degree of change was not published in the abstract. It’s unclear if the change is statistically significant or clinically meaningful
  • Brantingham (2009): compared chiropractic manipulative therapy, exercise, and IASTM to knee joints only vs. chiropractic manipulative therapy, exercise, and IASTM to lumbosacral, hip, knee, ankle, and foot. In short, both groups received the same modalities but to different regions. Results? Both groups showed improvements.

I have to admit it’s strange to include feasibility studies or pilot studies into the systematic review since the purpose of these studies are to determine if a full-scale study was possible. The sample size for such studies tend to be under-powered, and, therefore, not generalisable at all.

Moving on to the studies included in only the Lambert et al. 2017 study:

  • Senbursa et al. (2007): compared active range of motion (ROM), stretching and strengthening exercise program vs. 12 sessions of joint and soft tissue mobilization techniques, ice application, stretching and strengthening exercise programs and patient education.”There were statistically differences among the groups in function. Group 2 showed significantly greater improvements in the Neer Questionnaire score and shoulder satisfaction score than Group 1. The patients treated with manual physical therapy applied by experienced physical therapists combined with supervised exercise in a brief clinical trial showed improvement of symptoms including increasing strength, decreasing pain and improving function earlier than with exercise program.”
  • Lauche et al. (2012): compared a single ‘gua sha’ treatment vs. no treatment I believe. Pain sensitivity improved in the treatment group in chronic neck pain, but not in chronic low back pain patients.

This is also strange because the design of Senbursa et al.’s study make it impossible to draw conclusions to if the improvement was from ice application, the mobilisation techniques, or the active range of motion.

To say that the studies cause more confusion than clarity would be an absolute correct statement. All but one of the four studies had poor design where IASTM was not compared against either a control placebo or no treatment. Furthermore, in some of the studies, IASTM was not the variable examined.

Intervention Scientific Study Should Follow A/B Testing

So for those of you who dabble in the marketing side of things, you would be familiar with A/B testing. To design a Facebook ad with the A/B testing methodology, you’d create an initial ad and also a second copy of the same ad with only one variable changed. For example, I may use the picture of a caucasian woman applying IASTM (see what I did there?) for my first ad and a caucasian man applying IASTM in a second ad. Both ads would be shown to the same audience and based on the response, I would – hypothetically – be able to draw conclusions that a picture of a woman convert more sales than the picture of a man. If I were to use a caucasian woman vs. an asian man, it would be impossible to determine if the variable of significance was the gender or the ethnicity. Assuming both had a part to play, it would be impossible to know which of the two variables played a more significant role!

Like wise, scientific studies should follow the same format so we can attribute the change in outcomes to a single intervention. Three out of the four studies were poor quality by study design and it is impossible to attribute change in outcomes to the intervention itself.

Read more about A/B Testing at HubSpot’s How To Do A/B Testing.

Applied A/B Testing in Randomised Controlled Trials

Now let’s revisit the four trials again with the A/B testing methodology in mind.

  • Burke et al. (2007) compared Graston (IASTM) vs. hands-on soft tissue mobilisation with both groups showed improvements. Without going into the magnitude of change, this study only allow us to compare the use of hands vs. the use of instruments.The results will only be relevant if it has been established that hands-on soft tissue mobilisation works to begin with. (It doesn’t.) Furthermore, without a placebo control or a no treatment group, we cannot account for time! Who is to say the improvement is not due to natural history? Natural history refers to how a condition progresses over time and, in some cases, potentially self-resolve without intervention.
  • Brantingham (2009) compared a multimodal treatment to knee joints only vs. multimodal treatment to the lumbosacral, hip, knee, ankle, and foot. In the context of A/B testing, the same ad is shown on Facebook vs. Google. IASTM itself is not even a variable!!
  • Senbursa et al. (2007) … You can scroll up for the details of the comparison groups but in essence this is a A + B + C / D +E + F + C + G situation. Hello?!
  • Lauche et al. (2012) is the most legit by study design. It compared a single ‘gua sha’ treatment vs. no treatment (which is testing time as a self-resolution variable). While it does follow A/B testing, I am not sure how acceptable it is for the authors to include this study since ‘gua sha’ – by definition and practice – isn’t identical. Regardless, the ‘gua sha’ treatment didn’t improve pain sensitivity for patients with chronic low back pain in this study.

How does the Nazari et al. 2019 study perform?

Nazari et al looked at nine trials with 43 reported outcomes (function, pain, range of motion, etc). Six trials reported no clinically important difference between groups. Two trials reported outcomes favouring the non-IASTM group. In one trial, IASTM had a small positive effect on muscle performance when compared against a no treatment group.

We are not going to analyse each of the trials individually because we know how much of a bore that would be. But based on the results collected, it is fair for authors to conclude that there is insufficient evidence to support the use of IASTM.

Reference: Nazari G et al. The Effectiveness of Instrument-Assisted Soft Tissue Mobilization in Athletes, Healthy Participants and Individuals with Upper/Lower Extremity and Spinal Conditions. 2019 Feb 21.

So, does IASTM or Graston work?

chiropractor singapore, singapore chiropractic, sports injuries, back pain, shoulder pain
Published just two weeks ago, the 11 best practice recommendations for care in musculoskeletal pain advocates for the use of manual therapy only as an adjunct!

The short answer is: no. While the naysayers would argue the absence of evidence is not evidence of absence (this is true), there were studies in Nazari’s 2019 study where the comparison group outperformed the IASTM group. Furthermore, two-thirds of the studies reviewed showed no clinical difference between groups.

There is good evidence to suggest that IASTM is not viable treatment option for musculoskeletal pain and injury. So, what now?

The manual therapy, or specifically IASTM, supporters got to deliver more data! At this point in time, there just isn’t enough for us to support IASTM as a treatment option. What to do next? Your best bet is to choose an evidence-based clinician. Some one who focuses on exercises and movement!

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