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This course describes instrument assisted soft tissue mobilization (IASTM) of the thoracolumbar fascia (TLF), with a focus on treatment of the posterior superficial layer of the TLF (summary of TLF anatomy below). Additionally, modifications of IASTM techniques are discussed, including specific techniques for addressing trigger points, different treatment positions used to increase tissue tension, and pin-and-stretch techniques with IASTM tools (a.k.a. active or dynamic release).

IASTM: Thoracolumbar Fascia

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Course Summary

This course describes instrument assisted soft tissue mobilization (IASTM) of the thoracolumbar fascia (TLF), with a focus on treatment of the posterior superficial layer of the TLF (summary of TLF anatomy below). Additionally, modifications of IASTM techniques are discussed, including specific techniques for addressing trigger points, different treatment positions used to increase tissue tension, and pin-and-stretch techniques with IASTM tools (a.k.a. active or dynamic release). This course does not assume that IASTM treatment addresses the middle or anterior layers of the TLF, and this course does not include treatment of the gluteal fascia or 

Summary of Thoracolumbar Fascia Anatomy (TLF): 

The TLF can be described as a 3-layer system, with the posterior layer having deep and superficial laminae (layers). The superficial lamina of the posterior layer is continuous with the latissimus dorsi, serratus posterior inferior, gluteus maximus, as well as part of the external obliques and lower trapezius. Medially, the majority of the superficial layer is bordered by the supraspinous ligament and spinous processes cranial to L4, but fibers do cross to attach to the contralateral sacrum, PSIS, and iliac crest. Some fibers of the TLF, arising from the gluteus maximus, also cross the mid-line attaching to the opposite sacrum, PSIS, or lateral raphe. The deep lamina of the posterior layer run continuously from the splenius capitis and cervicis, superficial rhomboids, envelops the erector spinae (acting as a retinaculum) and is continuous with the sacrotuberous ligament and potentially the biceps femoris. The middle layer of the TLF extends from the transverse processes, between the quadratus lumborum and erector spinae, and is continuous with the aponeurosis of the transverse abdominis and internal obliques. The deep laminae of the posterior layer and middle layer fuse to form the lateral raphe, which may be thought of as a thickening of the middle layer to reinforce the attachment of the abdominal tourniquet muscles.

Unfortunately, it is easy to be confused by a large number of synonyms for the techniques in this course. Instrument-assisted soft tissue mobilization (IASTM) is a technique that generally includes the application of shear force (scraping) to skin and superficial fascia using a tool with a rounded, but relatively acute (sharp) edge. IASTM could be viewed as a Western approach to a Traditional Chinese Medicine (TCM) technique called Gua Sha. While the application of IASTM is most commonly based on orthopedic assessment with stainless steel tools, the application of Gua Sha is based on TCM-specific assessments with jade or stone tools. Graston is the most well-known brand of IASTM stainless steel tools; however, we do prefer 

 based on their quality, edge, and price. Note, historically the origin of these techniques is undoubtedly Gua Sha, which is perhaps 1000s of years old, Graston popularized IASTM in the Western world, and now there are many brands and tools to choose from.

The IASTM techniques in this course are recommended as an adjunct mobility technique, included in an integrated program that already includes, or has considered soft-tissue release techniques, joint mobilization and manipulation techniques, and/or stretching techniques. The addition of the techniques described in this course may be especially beneficial for individuals assessed with range of motion (ROM) restriction of the lumbar spine, hip, scapula, and shoulder. Further, they may be included in a program designed to address chronic low back pain, lumbar instability, sacroiliac joint pain, trunk muscle strain (e.g. rectus abdominis strain, external oblique strain, erector spinae strain, etc.), or trunk mobility issues (e.g. a loss of lumbar rotation). Additionally, these techniques may be beneficial for those with assessed impairments including an anterior pelvic tilt, asymmetrical weight shift, sway back posture, excessive lordosis, loss of the lordotic curve, 

lumbo pelvic hip complex dysfunction (LPHCD)

The techniques in this course are recommended for all clinical human movement professionals (physical therapists, physical therapy assistants, athletic trainers, massage therapists, chiropractors, occupational therapists, etc.) with the intent of developing an 

, patient-centered, and outcome-driven approach.

Lumbo Pelvic Hip Complex Dysfunction (LPHCD)

Course Summary: Thoracolumbar Fascia (TLF) Instrument Assisted Soft Tissue Mobilization (IASTM)

Introduction

Instrument assisted soft tissue mobilization (IASTM) including the lumbar region is likely to result in significant improvements in pain intensity and range of motion (ROM), may improve some functional outcome measures (e.g. Oswestry Disability Index, Roland Morris Disability, Beck Depression Inventory, etc.), and may have some effect on skin temperature, bioimpedance, and thoracolumbar fascia (TLF) mobility. Further, the addition of IASTM to conventional therapy, traction, neurombolization, and/or stretching is likely to result in significantly larger improvements. Last, IASTM including the lumbar spine may be more effective than cupping and ischemic compression techniques for improving pain intensity and pain pressure threshold; however, studies investigating IASTM on other body segments suggest ischemic compression is generally more effective than IASTM.

Correlated Postural Dysfunction and Movement Impairment

: Weak or With Compensation (Scapula elevation and/or anterior tipping)

: Weak or With Compensation (Lumbar extension, knee flexion, or hip adduction)

: Weak or With Compensation (Lumbar lateral flexion or hip flexion)

Instrument Assisted Soft Tissue Mobilization

Introduction: Thoracolumbar Fascia IASTM

Research Corner

 Studies including only pre-to-post intervention comparison, suggest that IASTM including the lumbar region may significantly alter skin temperature, bioimpedance, and increase mobility, but may not affect TLF stiffness.

When compared to no intervention or sham control groups, IASTM including the lumbar region is likely to improve pain intensity and range of motion (ROM), and may improve Oswestry Disability Index (ODI) scores, and strength in individuals exhibiting dysfunction prior to treatment.

Comparing Interventions With and Without IASTM:

 For individuals with acute (12 weeks or less) low back pain and/or sciatica, the addition of IASTM to stretching may result in larger increases in ROM, and the addition of IASTM to traction and nerve mobilization may result in larger reductions in pain and ODI scores.

 IASTM of the paraspinals or posterior lower extremity muscles may be equally effective for improving sit-and-reach scores. Further, IASTM addressing the cervical, thoracic spine, or lumbar spine may be similarly beneficial for improving cervical, thoracic, and low back pain intensity; however, only the cervical spine is likely to exhibit significant improvements in pain pressure threshold.

Compared IASTM to other Therapeutic Interventions: 

In summary, these findings suggest that IASTM of the thoracolumbar fascia (TLF) may have a larger influence on TLF mobility and straight leg raise ROM than heat, may result in larger improvements in pain intensity and pain pressure threshold than cupping or ischemic compression, and IASTM or kinesiology tape added to conventional therapy may result in similar improvements in pain intensity, Roland Morris Disability Scores, and Beck Depression inventory scores.

Brandl et al. compared 18 healthy males and females (age:18-75 years) with intact lumbar sensation and no history of systemic disease (e.g. rheumatic disease), acute inflammation, or surgery in the past 3 months. All participants received IASTM for 1 session, performed for 3 min, in a prone position, with a stainless steel tool from Fazer, using superior to inferior strokes, 10 N of pressure, and a slow (3 cm/sec) tempo, over the thoracolumbar fascia. The findings demonstrated that IASTM resulted in statistically significant increases in bioimpedance and skin temperature. IASTM did not result in a significant decrease in thoracolumbar fascia stiffness (1). Gohil et al. compared 30 male and female overhead-throwing athletes (age: 18-30 years) with glenohumeral internal rotation deficits (GIRD), before and after an IASTM intervention for 3 weeks, 3x/week (9 total sessions). IASTM sessions included IASTM for 15 min with the M2T blade stainless steel tooth-shaped tool, performed with an angle to the skin of 45°, in the direction of more tissue resistance for the 1st half of treatment and the opposite direction for the 2nd half of treatment, with pain-free pressure, 30-45 strokes/muscle/session, over the posterior deltoid, latissimus dorsi, infraspinatus, supraspinatus, posterior joint capsule, and medial border of the scapula. The findings demonstrated that IASTM resulted in a significant increase in range of motion (ROM) during the reassessment of shoulder internal rotation, shoulder horizontal adduction, and Apley's scratch 

, and a trend (not statistically significant) toward an increase in shoulder external rotation (2). These studies including only pre-to-post intervention comparison, suggest that IASTM including the lumbar region may significantly alter skin temperature, bioimpedance, and increase mobility, but may not affect TLF stiffness.

Additional studies have compared the efficacy of lumbar IASTM to a control group. An RCT by Saha et al. compared 50 males and females (age: 49.7 ± 10.0 years) with complaints of chronic non-specific low back pain at least 1x/week for the previous 3 months, with at least 4/10 pain intensity, and no history of specific low back issues (e.g. acute injury, herniated disc, recent surgery, etc.), systemic disease (e.g. neoplasm, rheumatic disease, etc.), not currently pregnant, not taking medications, no skin condition in the treatment area, and had not received treatment during the 4 weeks prior to the study. Participants were randomly assigned to a control group (no intervention), or an IASTM group for 2 sessions. IASTM was performed using Gua Sha for 15-20 min, in a prone position, using the inside smooth-edged lip of a standard metal cap from a commercially available canning jar, and emollient, with cranial to caudal strokes, and medial to lateral horizontal strokes, with pressure insufficient to induce pain, over the paravertebral muscles of the cervical spine, thoracic spine, lumbar spine, and gluteus maximus. The findings demonstrated that the IASTM group exhibited statistically significant decreases in pain intensity (measured with the visual analog scale). However, there was no significant difference between the IASTM group and control group for Oswestry Disability Index (ODI) scores, pain pressure threshold, or mechanical and vibration detection threshold (3). Laudner et al. compared 35 healthy male Division I collegiate baseball players (age: 20.3 ± 1.1 years) with no history of upper extremity injuries, and no surgery on the throwing arm within the last 6 months. Participants were randomly assigned to a control group, or an IASTM group for 1 session. The control group received no intervention while lying prone for an equal amount of time as the IASTM group. IASTM was performed for a total of 40 sec, in a prone position, with the stainless steel GT4 tool from Graston, with emollient, at a 45° angle to the skin, using parallel and perpendicular strokes, over the posterior deltoid, latissimus dorsi, teres major, teres minor, and infraspinatus of the dominant throwing arm. The findings demonstrated that the IASTM group exhibited statistically significant increases in glenohumeral horizontal adduction and internal rotation ROM (measured with an inclinometer) when compared to the control group (4). An RCT by Kim et al. compared 32 males (age: 28.63 ± 3.01 years) with low back pain for at least 3 months, at least 4/10 pain intensity, and no history of radiating pain in the legs, spinal surgery, and no TENS and IASTM treatment in the last 3 months. Participants were randomly assigned to a control group (no intervention), or a TENS and IASTM group for 3 weeks, 2 sessions/week for a total of 6 sessions. TENS and IASTM were performed simultaneously for a total of 6 min/session, in a standing position with the participant bent forward with elbows on a table, with the "Famuscle device" which combines TENS and IASTM, a water-based cream as an emollient, using "scratching" strokes, with mild pressure, 1 min/side/muscle over the hamstrings, gluteus maximus, and lumbar region. The intensity of electric stimulation was insufficient to induce pain. The findings demonstrated that when compared to controls, the combination of TENS and IASTM resulted in a significantly larger decrease in pain intensity, a larger increase in hamstring flexibility, a larger increase in core muscle endurance, and more improvement in Oswestry Disability Index (ODI) scores (5). Last, a sham-control RCT by Kivlan et al. compared 45 males and females (age: 40 ± 13 years) with a unilateral musculoskeletal injury to the lower extremity, and no history of lumbar spine or shoulder injury, neuropathy, or previous ASTYM treatment. Participants were randomly assigned to a control group (no intervention), an IASTM group, or a sham IASTM group, for 1 session. IASTM was performed using the ASTYM protocol for 12 min, in the supine and prone positions, with an ASTYM tool, using distal to proximal strokes, over the anterior and lateral lower leg, gastrocnemius, soleus, quadriceps, hamstrings, gluteus maximus, and gluteus medius. Sham IASTM used an identical protocol, but with "very light" pressure. The findings demonstrated that the IASTM group exhibited a statistically significant increase in maximal force output (measured with a unilateral isometric leg press machine equipped with a load cell). No significant changes were exhibited in maximal force output in the sham IASTM or control groups (6). These studies suggest, that when compared to no intervention or sham control groups, IASTM including the lumbar region is likely to improve pain intensity and range of motion (ROM), and may improve Oswestry Disability Index (ODI) scores, and strength in individuals exhibiting dysfunction prior to treatment.

Comparing Interventions With and Without IASTM

Two studies have compared interventions with and without IASTM protocols that include the lumbar region. An RCT by Lee et al. compared 30 males and females (age: 40.6 ± 14.6 years) with chronic low back pain for less than 12 weeks, with no history of back surgery, spinal fracture, or other trauma within the last 6 months. Participants were randomly assigned to an exercise-only group, or an IASTM and exercise group for 4 weeks. Exercise was performed for 10-15 min/session and included stretching exercises (specific exercises were not discussed), for 3 sets, 15 reps/set, with a short (1 min) rest between sets, followed by stationary bicycling. IASTM was performed for ~40 sec/area/session, for a total of ~5 min/session, in a position dictated by the area being treated (i.e. kneeling, prone, and side-lying), with a stainless steel tool from DR. YOUSTM, at a 45° angle to the skin, using strokes parallel and perpendicular to the muscle fibers for 20 sec/session each, over the posterior fascia of the lumbar spine, the sacrum, the lateral rotators of the hip, and the hamstrings bilaterally. The findings demonstrated that both groups exhibited statistically significant increases in lumbar flexion, extension, lateral flexion in both directions and hip flexion ROM (measured using an unnamed smartphone inclinometer application); however, the addition of IASTM resulted in significantly larger increases in all ROM measured. Note, that the exercise-only group exhibited a decrease in pain that failed to reach statistical significance (7). An RCT by Qadree et al. compared 20 males (age: 40.30 ± 3.74 years) with sciatica, radicular pain in the lower back for less than 12 weeks, pain with an active straight leg raise between 30-70° (and no pain outside of this range), positive sacroiliac joint dysfunction tests (compression, distraction, and Gaenslen's tests), and no history of a spinal fracture. Participants were randomly assigned to a lumbar traction and nerve mobilization group with and without IASTM for 4 weeks, 3 sessions/week, for a total of 12 sessions. Lumbar traction was performed for 10 min/session, in a supine position, using 30-45 kg of force. Nerve mobilization of the sciatic nerve was performed in a supine position, with the hip flexed, the knee extended, and the ankle dorsiflexed. IASTM was performed for a total of 4 min/session (40 sec/area), in a kneeling and prone position (depending on the area being treated), with the stainless steel Mallet tool from Rocktape, at a 45° angle to the skin, using perpendicular and parallel strokes, over the posterior fascia of the lumbar region, the sacrum, the lateral rotators of the hips, and the hamstrings bilaterally. The findings demonstrated that the addition of IASTM to lumbar traction and nerve mobilization resulted in significantly larger improvements in pain (measured with the numeric pain rating scale), and Oswestry Disability Index (ODI) scores (8). These studies suggest that for individuals with acute (12 weeks or less) low back pain and/or sciatica, the addition of IASTM to stretching may result in larger increases in ROM, and the addition of IASTM to traction and nerve mobilization may result in larger reductions in pain and ODI scores.

Two interesting studies compared IASTM on different segments that may contribute to positive outcomes. An RCT by Fousekis et al. compared 60 healthy males and females (age: 24.4 ± 4.39) with a score of less than 22 on the Sit-and-Reach test, and no history of injury within the last year. Participants were randomly assigned to a control group (no intervention), an IASTM trunk group, and an IASTM lower body group, for 4 weeks, 1 session/week, for 4 total sessions. The IASTM Trunk group received 15 min of "ERGON method" IASTM, in a prone position, with the Ergon stainless steel handlebar tool, over the trunk portion of the superficial back line including the cervical, thoracic, and lumbar paraspinal muscles. The IASTM lower body group received the same protocol using the Ergon stainless steel shark fin tool over the hamstrings, gastrocnemius, and plantar surface of the foot. The findings demonstrated both experimental groups exhibited statistically significant and similar increases in passive hip flexion (measured with a passive straight leg raise), and the control group did not exhibit a significant change (9). An RCT by Lauche et al. compared 40 males and females (age: 49.23 ± 10.96 years) with complaints of chronic neck and lower back pain, at least 5 days/week, for at least 3 consecutive weeks, and at least 4/10 pain, with no history of spine abnormalities or disease, radiculopathy, or systemic disease (e.g. diabetes, cancer). Participants were randomly assigned to a control group, a Gua Sha on the neck (and thoracic spine) group, or a Gua Sha on the lower back (thoracic spine and gluteal fascia) group for 1 session. The control group received no intervention. Gua Sha was performed for 10-15 min (until petechiae became visible), in a seated position, with the inside smooth-edged lip of a metal cap, and emollient, using inferior and horizontal strokes, with pressure insufficient to induce pain, over the paravertebral muscles from C1-T12 or the paravertebral muscles from C7-L5 and the gluteus maximus (depending on the assigned group). The findings demonstrated that when compared to controls, both Gua Sha groups exhibited significant and similar decreases in pain intensity; however, the neck group exhibited a significant increase (improvement) in pain pressure threshold and the lower back group did not (10). These studies suggest that IASTM of the paraspinals or posterior lower extremity muscles may be equally effective for improving sit-and-reach scores. Further, IASTM addressing the cervical, thoracic spine, or lumbar spine may be similarly beneficial for improving cervical, thoracic, and low back pain intensity; however, only the cervical spine is likely to exhibit significant improvements in pain pressure threshold.

Compared IASTM to other Therapeutic Interventions

Research has also compared the efficacy of lumbar region IASTM to other effective therapeutic interventions. An RCT by Weber et al. compared 67 healthy senior-level female soccer players (age: 20.9 ± 3.9 years) who actively competed, and participated in practice for a minimum of 90 min/session/week, with no history of back pathology within the last 4 weeks, and no acute injuries or chronic illnesses. Participants were randomly assigned to a sham control group, a heat therapy group, or an IASTM group for 1 session. The sham control was performed for 8 min, in a prone position, with an inactivated 5 cm² ultrasound transducer, with ultrasound gel, using circular strokes, at a moderate pace, over the right lumbar region. Heat therapy was applied for 8 min, in a prone position, with a 15cm² hot pack, at a temperature of 55 ± 2.5°C, over the right lumbar region. And, IASTM was performed for 8 min, in a prone position, with a stainless steel handlebar tool from Fazer, at a 90° angle to the skin, with emollient, using cranial, cranio-medial, cranio-lateral, caudal, caudo-medial, and caudo-lateral strokes, with 6.7 to 7.8 ± 1.2 kg of pressure, at a slow to moderate, 2.1 ± 0.1 cm/s to 6.2 ± 0.3 cm/s tempo, over the right lumbar region. The findings demonstrated that the IASTM group exhibited statistically significant reductions in shear mobility of the superficial fascia and the superficial lamina of the thoracolumbar fascia, and absolute mobility of the superficial lamina of the thoracolumbar fascia (measured with ultrasound) when compared to the other groups. Additionally, the IASTM group exhibited significantly larger increases in passive straight leg raise ROM (measured with an inclinometer) (11). An RCT by Cakmak et al. compared 30 males and females (age: 37.33 ± 7.14 years) with chronic non-specific low back pain for at least 12 weeks, 3/10 pain intensity or more, and no history of orthopedic disease, structural spinal deformities (i.e scoliosis, kyphosis, or stenosis), neurological disease, and no treatment in the past 6 months. Participants were randomly assigned to a kinesiology tape and conventional therapy group, or an IASTM and conventional therapy group for 6 total sessions, over 3 weeks, 2 sessions/week. Note, that conventional therapy was performed for 15 sessions, 5 sessions/week. Kinesiology tape was applied using Kinesio Tex Tape by KinesioTape, 5 cm wide, using a "Y" strip and an "I" strip over the lumbar region and a "Y" strip over the hamstrings, with 10-25% stretch. IASTM was performed for 11 min/session, with a stainless steel tool by FizyoTools, at a 45° angle to the skin, using vertical, horizontal, and diagonal strokes, over the lumbar paraspinal muscles and the hamstrings. Conventional therapy included 15 min/session of hot packs over the lumbar region, 7 min/session of TENS, with a frequency of 50-100 Hz, duration of 0.05-0.07 msec, 7 min/session of ultrasound, with an intensity of 1.5 W/cm², and a home exercise program including posterior pelvic tilts, prone trunk hyperextensions, bridges, and the cat/camel stretch for 5 sessions/week, 3 sets/session, and 10 reps/set. The findings demonstrated that both groups exhibited statistically significant and similar decreases in pain intensity, and similar improvements in Roland Morris Disability Index and Beck Depression Inventory score (12). Last, an RCT by Fousekis et al. compared 70 male amateur soccer players (age: 24.76 ± 4.39 years), with active trigger points in the quadratus lumborum and gluteal muscles on the dominant side, and no history of injury to the lumbar region or lower extremities within the last 6 months, no inflammation or infection at the site of the trigger point, and no skin lesions. Participants were randomly assigned to a control group, an ischemic compression group, a cupping group, or an IASTM group, all treatments performed over the gluteal and quadratus lumborum region for 3 weeks, 3 sessions/week, for a total of 9 sessions. The control group received no intervention. Ischemic compression was performed for 90 sec/session, in a prone position, with the tip of the clinician's thumb, with gradually increasing pressure to the point of pain, and pressure maintained until discomfort eased by ~50%. Cupping was performed for 5 min/session, in a prone position, with polycarbonate cupping jars, using a rubber pump to create negative pressure (specific pressure and number of pumps were not discussed). And, IASTM was performed for 6 min/session, in a prone position, with a stainless steel tool from Ergon, using linear, saw-like, shearing, and circular strokes. The findings demonstrated that all 3 intervention groups exhibited statistically significant decreases in pain sensitivity (measured with the visual analog scale), and increases in pain pressure threshold (measured with an algometer). The IASTM group exhibited the largest decreases in pain sensitivity and increases in pain pressure threshold, the cupping and ischemic compression groups exhibited similar improvements in pain sensitivity and pain pressure threshold, and the control group exhibited no significant differences in any measurement parameter (13). In summary, these findings suggest that IASTM of the thoracolumbar fascia (TLF) may have a larger influence on TLF mobility and straight leg raise ROM than heat, may result in larger improvements in pain intensity and pain pressure threshold than cupping or ischemic compression, and IASTM or kinesiology tape added to conventional therapy may result in similar improvements in pain intensity, Roland Morris Disability Scores, and Beck Depression inventory scores.

IASTM: Technique and Emollient Recommendations

Technique: Instrument Assisted Soft Tissue Mobilization (IASTM)

 Pressure should be sufficient to feel resistance from the target tissue; that is, pressure should be applied to the "first resistance barrier".

 It may be beneficial to increase tissue tension by lengthening the target tissue. Pressing a tool into tissue that is in a passively shortened position can result in a lack of tissue resistance, which will result in little if any shear force to the target tissue.

The tool angle to the skin should be approximately 30° - 45°.

 Start with long, slow strokes over the full length of the target tissue to note irregularities in tissue consistency.

 Treatment strokes should be shorter, performed at a moderate tempo, in multiple directions, and over tissue assessed as irregular. The goal is to disrupt connective tissue that may be impeding optimal extensibility.

 10 - 30 strokes per region is likely sufficient, with the total dose dependent on the size of the area and the individual's tissue tolerance. Note, that scanning strokes should be included in total strokes.

 Perform 2-5 strokes in each direction. It can be helpful to visualize a clock or compass face and perform strokes in line with each number or direction (e.g. N, NW, W, SW, S, SE, E, NE).

 The development of petechiae or excessive redness is an indication to stop treatment in that area. Initially, this dosage may feel inadequate; however, petechiae and redness are often signs that bruising and significant soreness may follow (Note, bruising may take 24 - 72 hours to become visible). Although Traditional Chinese Medicine (TCM) and the practice of "Gua Sha" considered petechiae the goal of treatment, IASTM as taught by the Brookbush Institute, is performed with the intent to increase mobility and potentially decrease tissue sensitivity. Patechaie and some bruising are not abnormal, but it is likely an indicator that either pressure or dose (total strokes) should be reduced if IASTM is performed in subsequent sessions.

 Addressing active and latent trigger points with IASTM, which are often areas of assessed irregularity in tissue consistency, may improve carry-over from session to session. That is, the addition of IASTM to an integrated treatment plan may aid in maintaining the reduction in trigger point over-activity and sensitivity that results from a session.

Advanced Technique - IASTM with Pin and Stretch:

 This technique is "more aggressive" and should likely be used in small doses to address "stubborn" mobility issues, with patients/clients who have already exhibited good tolerance to IASTM techniques (tissue tolerance and pain tolerance). Following the identification of an area of altered tissue consistency, the IASTM tool is used to "pin" the tissue in the opposite direction of lengthening (generally, pressure has a distal to proximal vector). This technique may be progressed in intensity with the following additions:  

Static IASTM tool with passive lengthening (manual lengthening by the practitioner)

Dynamic IASTM tool (strokes in the opposing direction) with passive lengthening

Static IASTM tool with active or active-assisted lengthening (lengthening by the client or patient)

Dynamic IASTM tool with active or active-assisted lengthening

Static IASTM tool with active-assisted lengthening and over-pressure (client/patient and practitioner force)

Dynamic IASTM tool with active-assisted lengthening and over-pressure

 As with all techniques, IASTM should only be recommended when indicated by a reliable objective assessment (e.g. goniometry), and continued use should be based on a significant improvement on that assessment (> 5° improvement in ROM). Note, "feelings are not facts".

There are emollients specifically marketed for use during IASTM; however, a variety of emollients and lotions will suffice. Here are a few tips for choosing the best emollient for you and your patients.

Choose an emollient that is hypoallergenic, and/or has as few ingredients as possible. Although a fragrance or "moisturizing agent" may sound like a good idea, it is likely best to reduce the chances of adding an agent that could result in additional skin irritation due to a sensitivity or allergy.

 Once you have found an emollient you prefer, be consistent. Although the choice of emollient likely does not affect outcomes, constantly switching emollients may reduce your reliability. The best method for improving outcomes is through continuous refinement, based on comparison using a reliable objective outcome measure, following the consistent implementation of a technique.

 Different products have different viscosities. For example, lotion-like products tend to be less viscous (less sticky or thick), whereas coconut oil-based products tend to be more viscous (more sticky or thick). Your choice is likely going to depend on the feel you prefer, the amount of emollient you apply, and your ability to clean the emollient from the skin.

If you perform IASTM techniques as part of an integrated intervention plan, you will need a safe and effective way to remove the emollient from the skin. Emollients left on the skin can make it very challenging to perform additional manual techniques, position bands, hold on to weights/handles, and/or apply kinesiology tape. We recommend using a spray bottle to spray rubbing alcohol on a towel to aid in wiping the emollient from the skin. Note, that fatty acids, which are the base of most emollients, are not water-soluble, so a wet towel will not suffice. However, fatty acids are alcohol-soluble which is why rubbing alcohol (or alcohol-based products) will work. Just when you thought you would never use chemistry again, we bring it back.

Thoracolumbar Fascia IASTM

Posterior Layers of the Thoracolumbar Fascia (TLF): 

The TLF can be described as a 3-layer system (posterior, middle, and anterior), with the posterior layer having deep and superficial laminae (layers). The superficial lamina of the posterior layer is continuous with the fascias of the latissimus dorsi, serratus posterior inferior, and gluteus maximus, as well as part of the external obliques, and lower trapezius. Medially, the majority of the superficial layer invests in the supraspinous ligament and spinous processes cranial to L4, but fibers do cross to attach to the contralateral sacrum, PSIS, and iliac crest. Some of the TLF fibers arising from the gluteus maximus also cross the mid-line to attach to the opposite sacrum, PSIS, or lateral raphe. The deep lamina of the posterior layer is continuous with the fascias of the splenius capitis and cervicis, superficial rhomboids, envelops the erector spinae (acting as a retinaculum), and is continuous with the sacrotuberous ligament and potentially the biceps femoris. This video discusses IASTM with the intent to treat the posterior layers, and does not assume that this technique has a significant effect on the middle or anterior layers of the TLF.


 Increased tension in the posterior layers of the TLF may be achieved via flexion, contralateral flexion, and contralateral rotation of the lumbar spine. Further, shoulder flexion may increase TLF tension due to fascial continuity with the latissimus dorsi, and hip flexion may increase TLF tension due to fascial continuity with the gluteal fascia.

IASTM cannot be done over the clothing. It is advised that the client/patient wear clothing that allows access to the lumbar spine, thoracic spine, and sacrum region (e.g. a loose shirt or a sports bra, and shorts or pants with an adjustable waistband, etc.). Although it is never our intent to make a client uncomfortable, we also do not want embarrassment to impede great therapy. Often authentic communication, a little empathy, and some planning can reduce or eliminate potentially embarrassing moments.

It may be possible to address areas of assessed tissue inconsistency with the client/patient on a table in a prone position. However, most often the best position for this technique is in the 

Although it is not a contraindication, performing IASTM with significant pressure over relatively superficial bone can result in significant pain and skin abrasion. Reducing pressure is most often sufficient to continue IASTM over superficial bone.

 Because the erector spinae and multifidus are segmentally innervated, trigger points may occur in any fascicle along their length.

A common site for multifidus trigger points occurs adjacent to the L4/L5 segment, just medial to the posterior superior iliac spine (PSIS).

A common erector spinae trigger point occurs adjacent to the mid-lumbar spine and thoracolumbar junction, perhaps where these fascicles originate on the thoracolumbar fascia.

 occur at the "base" of the muscle, just superior to the sacroiliac joint, and in the middle of the muscle adjacent to the L2 - L4 segments.

Brandl, A., Egner, C., Schwarze, M., Reer, R., Schmidt, T., & Schleip, R. (2023). Immediate Effects of Instrument-Assisted Soft Tissue Mobilization on Hydration Content in Lumbar Myofascial Tissues: A Quasi-Experiment. 

Gohil, D., Swami, A., Baxi, G., Tai, Z., Edgaonkar, R., & Palekar, T. (2020). Effectiveness of Instrument-Assisted Soft Tissue Mobilization in Management of Athletes with Gleno-Humeral Internal Rotation Deficit. 

Indian Journal of Physiotherapy & Occupational Therapy Print-(ISSN 0973-5666) and Electronic–(ISSN 0973-5674)

Saha, F. J., Brummer, G., Lauche, R., Ostermann, T., Choi, K. E., Rampp, T., ... & Cramer, H. (2019). Gua Sha therapy for chronic low back pain: a randomized controlled trial. 

Complementary therapies in clinical practice

Laudner, K., Compton, B. D., McLoda, T. A., & Walters, C. M. (2014). Acute effects of instrument assisted soft tissue mobilization for improving posterior shoulder range of motion in collegiate baseball players. 

International journal of sports physical therapy

Kim, Y. K., Cho, S. Y., & Lee, K. H. (2021). Effects of transcutaneous electrical nerve stimulation and instrument-assisted soft tissue mobilization combined treatment on chronic low back pain: a randomized controlled trial. 

Journal of Back and Musculoskeletal Rehabilitation

Kivlan, B. R., Carcia, C. R., Clemente, F. R., Phelps, A. L., & Martin, R. L. (2015). The effect of Astym® Therapy on muscle strength: a blinded, randomized, clinically controlled trial. 

Lee, J. H., Lee, D. K., & Oh, J. S. (2016). The effect of Graston technique on the pain and range of motion in patients with chronic low back pain. 

Qadree, M. S., Shakil-Ur-Rehman, S., Riaz, M. U., Anees, M., & Rajput, H. (2022). EFFECTS OF GRASTON INSTRUMENT SOFT TISSUE MOBILIZATION IN PATIENTS WITH SCIATIC NERVE ENTRAPMENT. 

Fousekis, K., Eid, K., Tafa, E., Gkrilias, P., Mylonas, K., Angelopoulos, P., ... & Tsepis, E. (2019). Can the application of the Ergon® IASTM treatment on remote parts of the superficial back myofascial line be equally effective with the local application for the improvement of the hamstrings’ flexibility? A randomized control study. 

Lauche, R., Wübbeling, K., Lüdtke, R., Cramer, H., Choi, K. E., Rampp, T., ... & Dobos, G. J. (2012). Randomized controlled pilot study: pain intensity and pressure pain thresholds in patients with neck and low back pain before and after traditional East Asian" gua sha" therapy. 

Comparing IASTM to Other Therapeutic Interventions

Weber, P., Klingler, W., Schleip, R., Weber, N., & Joisten, C. (2022). The Influence of a Single Instrument-Assisted Manual Therapy (IAMT) for the Lower Back on the Structural and Functional Properties of the Dorsal Myofascial Chain in Female Soccer Players: A Randomised, Placebo-Controlled Trial. 

ÇAKMAK, Ö., ATICI, E., & GÜLŞEN, M. THE EFFECTS OF INSTRUMENT-ASSISTED SOFT TISSUE MOBILIZATION AND KINESIO TAPING ON PAIN, FUNCTIONAL DISABILITY AND DEPRESSION IN PATIENTS WITH CHRONIC LOW BACK PAIN: A RANDOMIZED TRIAL. 

Türk Fizyoterapi ve Rehabilitasyon Dergisi

Fousekis, K., Kounavi, E., Doriadis, S., Mylonas, K., & Kallistratos, E. (2016). The effectiveness of instrument-assisted soft tissue mobilization technique (ergonš technique), cupping and ischaemic pressure techniques in the treatment of amateur athletes΄ myofascial trigger points. 

IASTM: Thoracolumbar Fascia

Related Courses:

Course Summary: Thoracolumbar Fascia (TLF) Instrument Assisted Soft Tissue Mobilization (IASTM)

Introduction: Thoracolumbar Fascia IASTM

Research Corner

IASTM: Technique and Emollient Recommendations

Thoracolumbar Fascia IASTM

Bibliography

Related Courses:

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