Which Of The Following Is Used For Scraping Tissue

Scraping, or instrument assisted soft tissue mobilization (those strange metal tools your physical therapist is using), is an interesting manual therapy technique that has gained a significant amount of traction in the last few decades – especially the idea of scraping scar tissue. If you’ve ever been in a physical therapy clinic, you’ve likely seen, or received, this intervention yourself. It can appear quite strange when observing it, and may even look painful. Many clinicians and athletes celebrate the bruises left afterwards as a badge of victory, proud to display their hard work to co-workers and teammates. So, is instrument assisted soft tissue mobilization legitimate? What is the thought process behind this intervention and is it sound? Is it really necessary to leave a session with bruising to reap the benefits? We’ll dive into the weeds together here next: you may be surprised. Read on for more.

The Origins of Instrument Assisted Soft Tissue Mobilization

Instrument assisted soft tissue mobilization (which we’ll refer to as IASTM from here out) is a manual therapy technique where instruments made from stainless steel are used by a clinician to “mobilize” the soft tissue of a patient (1). Typically these instruments have beveled edges and are applied in a variety of stroking patterns, through a variety of directions and for a variety of reasons (2). It’s claimed that the application of IASTM helps to increase blood flow and nutrient supply, aid in the removal or scar tissue, promote collagen synthesis and collagen realignment, but are these claims actually true(3)?

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There are many brands and styles of IASTM and you can expect these to be stainless steel (or some equivalent) with different edges and bevels. Most clinicians typically lean into using a specific brand; this is likely due to a personal preference developed over time, or it may just simply be what the clinician learned to use in the early years of their career.

While the popularity of IASTM has seen a sharp increase recently, the origin of this technique is deeply rooted in the eastern Chinese technique of gua sha, a scraping intervention that leads to light bruising (4). “Gua” literally means to scrape or scratch, while “sha” describes stasis within the tissue as well as the resulting petechiae raised from the technique; more on this later (4). From a western perspective, IASTM has concepts threaded within it through some of the work of famous British physician, Dr. James Cyriax. Dr. Cyriax was well-known for his theories on cross-friction massage, which was originally touted to provide a healing stimulus to muscular, tendinous and ligamentous injury by applying manual friction in a force perpendicular to the fibers of an injured soft tissue structure (5).

For better or worse, IASTM is widely used across a variety of professions including physical therapy, athletic training, chiropractic care, massage therapy and many more. However, it isn’t a protected skillset, meaning anyone can adopt it and provide it without consequence.

So What’s the Big Deal with Scraping Tools?

As with many manual techniques, the benefits of IASTM are questioned and criticized by well-intentioned, modern, evidence-based clinicians. With an increased focus on high-value care sought across our healthcare system, therapists should seek to provide interventions that provide meaningful and long-term improvements. Unfortunately, many of the benefits behind IASTM are unproven and based largely on anecdotal reports and poor-quality research.

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Scraping Scar Tissue – It Does Not Break Up Adhesions

Unfortunately, it’s sometimes the first thing out of your clinician’s mouth as you lay down on the table: “we’re going to use this instrument to scrap scar tissue to help break up myofascial adhesions.” We’ve all heard this before. Whether therapists falsely claim it as a “fascial release,” that this tool “removes scar tissue” or simply “breaks up adhesions,” all of the aforementioned are well-intentioned but entirely false.

READ: MASSAGE: WHERE DOES IT FALL IN THE RECOVERY PROCESS?

Fascia is a dense, stringy, fibrous sheath of connective tissue that surrounds virtually every part of your body. While it provides support to your internal organs, it is most known and celebrated for its musculoskeletal functions (6). While fascia is multi-talented and critical to compartmentalizing numerous anatomical structures, the rehabilitative professions sure tend to criticize it a bunch and blame all their problems on it.

Some extremely helpful biomedical engineers, mechanical engineers and mathematicians published a very well-known publication in The Journal of the American Osteopathic Association examining whether or not manual therapists could exert enough pressure to actually deform fascia (i.e. “release” it). Using a three-dimensional mathematical model, the authors determined the changing amounts of force produced in fascial tissue over the course of 20 seconds of manual therapy (6). The authors found that very large forces, “outside the normal physiologic range” of humans are required to produce even 1% compression and 1% shear in the fascia lata (thick fascia over the side of the hip) and plantar fascia (thick fascia on the bottom of the foot).

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That being said, scraping a tissue with a metal tool certainly does not release fascia.

Unless, the authors humorously noted, that fascia is very thin – like the superficial nasal fascia found in your nose and I don’t know about you, but that could shape up to be a very weird day in physical therapy (6).

LISTEN: SHOULD YOU BE FOAM ROLLING?

Scraping Tools May Improve Blood Flow

Improving blood flow to an area of dysfunction is a touted benefit of many manual therapies, IASTM included. However, improved blood flow is fairly difficult to objectively measure, and in the rehabilitative literature it’s usually assumed secondary to another indicator like increased skin temperature or changes in skin color (7,8). A common occurrence with IASTM is the observation of petechiae, which is the appearance of red and purple spots due to bleeding from broken capillaries (very tiny blood vessels) near the skin’s surface (8).

Petechiae is the medical term for the appearance of red and purple spots due to bleeding capillaries.8 It typically resolves over the next several days if they’ve appeared after a bout of IASTM.

Traditionally, petechiae were a designed effect of gua sha, theorized to relieve blood stagnation and reduce pain (9). To an observer, the reddening of the skin would likely suggest increased blood flow. However, modernized practitioners now recognize this as unintended tissue damage produced by a medical provider (8). The reddening of the skin is microtrauma to the capillaries of your circulatory system. Regardless, it’s often worn as a badge of honor by clinicians providing IASTM.

One study commonly cited to demonstrate the effects of increased blood flow simply looked at skin temperature of the calf pre and post application of IASTM (7). While this is an indirect measure of peripheral blood flow, it certainly provides some limited insight to this claim. However, these authors acknowledge that the depth of tissue temperature change is unknown. In summary, claims that IASTM improve blood flow are shaky at best.

Scraping Tools Provide Transient Improvements in Range of Motion

Physical therapists are generally always looking for another way to improve range of motion (ROM) for their patients. In some populations, I can personally appreciate the incentive to find an alternative to aggressive end-range stretching. Take pitchers for instance: at the professional level, these shoulders are often worth millions of dollars. While end-range passive range of motion exercises and stretches can help preserve the deep amounts of external rotation needed to throw 95+ mph, there are consequences that accompany this approach (anterior shoulder laxity, biceps tendinopathy, etc). Wouldn’t it be nice to apply a soft tissue intervention at mid-range, help preserve a full ROM and bypass any unintended effects of deep stretching?

This is what Laudner et. al. set out to find in their 2014 publication in the International Journal of Sports Physical Therapy. These researchers took 35 healthy collegiate baseball players and randomly assigned them to one of two groups: 1.) IASTM to the posterior shoulder in-between pre and post test measurements and 2.) no treatment to the posterior shoulder in-between pre and post test measurements (control). They ultimately found that IASTM applied to the posterior shoulder significantly improved shoulder horizontal adduction (11.1 degrees) and shoulder internal rotation (4.8 degrees), although they described the effects as “acute (10).” In other words, IASTM only creates a brief window of ROM improvement. While this can be a fun party trick (quick improvements from a quick intervention), a skilled clinician should prioritize their order of interventions to use this window intentionally.

IASTM being applied to the posterior shoulder of an athlete from Laudner et al, 2014.10

Limited research exists specifically examining the effects on ROM outside of the aforementioned study. However, it’s worth nothing that similar findings were found in a chiropractic case study examining IASTM effects on low back pain; prolonged lumbar flexion posturing was gradually addressed in a single patient over the course of 6 appointments (11). Again, while I don’t question the transient effects of this intervention, I certainly challenge the narratives behind it. It doesn’t release fascia, but it does provide short-term improvements through another mechanism we don’t fully yet understand (6).

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Looking for more ways to improve your shoulder tissue mobility? Our [P]Rehab Overhead Mobility Program is just what you are looking for! This 8-week program is designed to improve your overhead mobility for all of life’s needs!

Exercises to Improve Shoulder & Mid Back Motion

Interventions that we are aware help to improve circulation to a muscle or area of the body include simply moving and causing contraction or muscle tissue! If looking to improve shoulder and mid back mobility, trying the below exercises as a dynamic mobility drill may be just the ticket!

Kneeling Thoracic Spine Extension Mobilization:

A great exercise to improve overhead work as well as shoulder mobility. The mid back plays a large role in how our shoulders move overhead, to learn more dive into the program HERE.

Standing Shoulder Cross Body Stretch- Posterior Cuff:

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This is a solid exercise to improve the mobility through the posterior cuff and can be crucial for improving range of motion for reaching across your body!

Scraping Tools Provide Transient Reductions in Pain

As with many manual therapy interventions, I don’t doubt that IASTM provides real, short-term relief immediately following its application. I admittedly will provide IASTM without much hesitation to my athletes if they request it, with many hopping off the table feeling better than they started. But does this effect last hours into the remainder of the day? Does IASTM change pain with sustained, long-term improvements that change the slope of a patient’s recovery over time?

READ: WHAT IS PAIN? PART 1

The thought is that IASTM is effective in mobilizing exercise-induced inflammation, but one can quickly “cherry-pick” the literature to defend their personal stance on pain reduction (12). Vardiman et al in 2014 found IASTM to have no effect on changes in inflammation-related factors, and actually found that pain increased after its application (13). Looking on the other end, you have several authors that had different results: Lee et al in 2006 found IASTM helped decrease pain in 30 patients with chronic low back pain over the course of 4 weeks (14). Daniels and Morrell in 2012 found pain was reduced in youth football players with plantar fasciitis through the application of IASTM once a week over 6 weeks (15). Howitt et al found IASTM to be helpful in tri-athletes with tibialis posterior sprains and claim that after 6 weeks pain had dissipated enough to allow these athletes to begin training again (16).

I’ll admit it – there’s likely no landmark publication that is going to have me leaning deep into the claims that IASTM changes a patient’s recovery. However, I see how it can serve a role. I work in elite level athletics, and see the small, transient window of pain reduction IASTM provides as useful. While this is my anecdotal predisposition (bias), I believe that all our manual therapy interventions ultimately help desensitize a sensitive area, which in itself is entirely noble. However, we start to inflict harm with our narratives through making false claims, building patient reliance on passive, and generally unproven, musculoskeletal interventions.

READ: WHAT MODALITIES PLAY A ROLE IN RECOVERY AND PERFORMANCE

You have likely heard of the placebo effect, where positive clinical results are found resulting from the psychosocial contexts surrounding an intervention (17). Placebo analgesia is a term in research that describes real pain reduction, despite the fact that subjects within the study appreciate the likelihood of receiving a sham treatment (18). Placebo analgesia is enhanced when the patient believes they have received an effective intervention, the patient is conditioned to expect the intervention is effective and the patient has had successful prior experiences with the intervention or they see others in their environment benefiting from the treatment (17.) I argue that the majority of pain reduction found after IASTM application occur from conditioning such as the aforementioned. Anecdotally, patients I treat that find the best results with this intervention are typically the ones who have responded well to it in the past.

Many of the IASTM studies that find reductions in pain lack well-designed control and experiment groups. The overwhelming majority of articles on IASTM are case studies – which in itself, case studies aren’t a bad thing – but the greater piece of your research pie chart shouldn’t belong to this type of study alone.

And my last final thought – have you considered the improvements in pain across these aforementioned studies occur just due to the natural course of history (14,15,16)? Meaning, do you think these patients were experiencing pain reduction due to just naturally getting better with time?

The Majority of Claims in the Scraping World are Based on Poor Science

Just this year (at the time I’m writing this article in 2022), an excellent systematic review with meta-analyses was published in the journal of Disability and Rehabilitation by Dr. Goris Nazari (19). For those not familiar, a systematic review is a summary of the medical literature on a specific topic. In other words, it synthesizes the results of multiple studies while attempted to reduce biases and random errors. A meta-analysis is usually performed in conjunction, where a statistical analysis is performed that combines the results of the multiple studies being examined. Together, this is considered the highest-level of evidence.

Nazari and his team examined 46 separate studies on the effects of IASTM from 1999 to 2022. They found that IASTM, when coupled with other treatments, did not produce statistically significant differences in function, pain intensity or range of motion (19). Furthermore, Nazari warned that the majority of the included studies were at high risk of bias and were generally very low quality pieces of literature (19). Ultimately, publications with low quality pieces of literature can make long-term, negative impacts on the academic world, which eventually then impacts the clinical world.

And no one wants to be giving silly interventions in physical therapy if something else better exists.

In Summary:

• The use of scraping tools (IASTM) is an intervention based off of eastern beliefs originally founded in Chinese medicine from thousands of years ago (4). Overtime, we’ve threaded in some western beliefs to make this intervention what you’d find in a PT clinic today.
• The majority of scholarly literature on IASTM is weak, subject to bias and many publications on this subject are found in predatory journals (19,20).
• As a whole, high-quality literature affirms that IASTM doesn’t provide statistically meaningful differences in function, pain intensity or range of motion (19,20).
• IASTM does not release fascia or break-up adhesions (6).
• IASTM may improve blood-flow, but the science here is extremely weak as increased blood flow is measured through secondary markers (7).
• Anecdotally, IASTM can provide some brief improvement in ROM or brief reductions in pain – but then again, so does the majority of interventions provided in physical therapy – but researchers as a whole don’t deem this to be entirely too relevant in the bigger picture.
• At the end of the day, IASTM likely isn’t going to hurt anyone, and you may find it beneficial threaded into your treatment plan appropriately (8). As usual, the narrative behind this intervention is where the real damage is done. Any other benefit you find in IASTM is yours to decide. And if it provides meaningful improvements for you – do it.

References

1. Looney B, Srokose T, Fernández-de-las-Peñas C, Cleland JA. Graston instrument soft tissue mobilization and home stretching for the management of plantar heel pain: a case series. J Manipulative Physiol Ther. 2011;34(2):138-142.
2. Howitt S, Wong J, Zabukovec S. The conservative treatment of Trigger Thumb using Graston Techniques and Active Release Techniques®. J Can Chiropr Assoc. 2006;50(4):249-254.
3. Kim J, Sung DJ, Lee J. Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. J Exerc Rehabil. 2017;13(1):12-22.
4. Nielsen A. Gua Sha: A Clinical Overview. Chinese Medicine Times. 2008;3.
5. Chamberlain GJ. Cyriax’s Friction Massage: A Review. J Orthop Sports Phys Ther. 1982;4(1):16-22.
6. Chaudhry H, Schleip R, Ji Z, Bukiet B, Maney M, Findley T. Three-dimensional mathematical model for deformation of human fasciae in manual therapy. J Am Osteopath Assoc. 2008;108(8):379-390.
7. Portillo-Soto A, Eberman LE, Demchak TJ, Peebles C. Comparison of blood flow changes with soft tissue mobilization and massage therapy. J Altern Complement Med. 2014;20(12):932-936.
8. Cheatham SW, Baker R, Kreiswirth E. Instrument assisted soft-tissue mobilization: A commentary on clinical practice guidelines for rehabilitation professionals. Int J Sports Phys Ther. 2019;14(4):670-682.
9. Lee MS, Choi TY, Kim JI, Choi SM. Using Guasha to treat musculoskeletal pain: a systematic review of controlled clinical trials. Chin Med. 2010;5:5.
10. 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.
11. Hammer WI, Pfefer MT. Treatment of a case of subacute lumbar compartment syndrome using the Graston technique. J Manipulative Physiol Ther. 2005;28(3):199-204.
12. Crane JD, Ogborn DI, Cupido C, et al. Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. Sci Transl Med. 2012;4(119):119ra13.
13. Vardiman JP, Siedlik J, Herda T, et al. Instrument-assisted Soft Tissue Mobilization: Effects on the Properties of Human Plantar Flexors. Int J Sports Med. 2015;36(03):197-203.
14. 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 Therapy Sci. 2016;28(6):1852-1855.
15. Daniels CJ, Morrell AP. Chiropractic management of pediatric plantar fasciitis: a case report. J Chiropr Med. 2012;11(1):58-63.
16. Howitt S, Jung S, Hammonds N. Conservative treatment of a tibialis posterior strain in a novice triathlete: a case report. J Can Chiropr Assoc. 2009;53(1):23-31.
17. Bialosky JE, Bishop MD, Penza CW. Placebo Mechanisms of Manual Therapy: A Sheep in Wolf’s Clothing? J Orthop Sports Phys Ther. 2017;47(5):301-304.
18. Vase L, Petersen GL, Riley JL 3rd, Price DD. Factors contributing to large analgesic effects in placebo mechanism studies conducted between 2002 and 2007. Pain. 2009;145(1-2):36-44.
19. Nazari G, Bobos P, Lu SZ, et al. Effectiveness of instrument-assisted soft tissue mobilization for the management of upper body, lower body, and spinal conditions. An updated systematic review with meta-analyses. Disabil Rehabil. Published online May 25, 2022:1-11.
20. Nazari G, Bobos P, MacDermid JC, Birmingham T. The Effectiveness of Instrument-Assisted Soft Tissue Mobilization in Athletes, Participants Without Extremity or Spinal Conditions, and Individuals with Upper Extremity, Lower Extremity, and Spinal Conditions: A Systematic Review. Arch Phys Med Rehabil. 2019;100(9):1726-1751.

About The Author

Christopher Lefever, PT, DPT, SCS, CSCS, USAW

[P]Rehab Writer & Content Creator

Originally from Reading, Pennsylvania, Chris graduated with his bachelor’s degree in exercise science and a doctorate of physical therapy from Slippery Rock University. He afterwards completed a sports physical therapy residency at the Memorial Hermann IRONMAN Sports Medicine Institute. He later completed a division 1 sports physical therapy fellowship at Duke University where he worked closely with Duke football, basketball and lacrosse. He returned to Houston afterwards with Memorial Hermann to help develop an emerging division 1 sports physical therapy fellowship. Present day, he practices with the sports medicine team at the United States Olympic and Paralympic Committee in Colorado Springs, CO. Chris is a board certified sports clinical specialist (SCS), certified strength and conditioning specialist (CSCS) and certified in dry needling. He has a particular interest in post-operative rehabilitation of the athletic knee, shoulder, hip and elbow.

Disclaimer – The content here is designed for information & education purposes only and is not intended for medical advice.

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