Professional Documents
Culture Documents
doi: 10.4085/1062-6050-481-17
Ó by the National Athletic Trainers’ Association, Inc Therapeutic Interventions
www.natajournals.org
Objective: To determine the overall effectiveness of instru- Data Extraction: Thirteen articles met the inclusion criteria.
ment-assisted soft tissue mobilization (IASTM) in improving Four independent reviewers assessed study quality using the
range of motion (ROM), pain, strength, and patient-reported PEDro and Centre for Evidence-Based Medicine scales. Twelve
function in order to provide recommendations for use. We also articles were included in the effect-size analysis.
sought to examine the influence of IASTM on injured and Data Synthesis: The average PEDro score for studies of
healthy participants, body part treated, and product used. uninjured participants was 5.83 (range ¼ 5 to 7) and that for
Data Sources: We searched the Academic Search Premier, studies of injured participants was 5.86 (range ¼ 3 to 7). Large
Alt Healthwatch, CINAHL Complete, Cochrane Library, MEDLINE effect sizes were found in outcomes for ROM (uninjured
with full text, NLM PubMed, Physical Education Index, Physio- participants), pain (injured participants), and patient-reported
therapy Evidence Database (PEDro), SPORTDiscus with full text, function (injured participants). The different IASTM tools used in
and Web of Science databases for articles published from 1997 these studies revealed similar effect sizes in the various
through 2016. The Boolean string advantEDGE OR astym OR outcomes.
graston OR iastm OR ‘‘instrument assist* soft tissue mobil*’’ OR Conclusions: The current literature provides support for
‘‘augment* soft tissue mobil*’’ OR ‘‘myofascial release’’ OR IASTM in improving ROM in uninjured individuals as well as pain
‘‘instrument assist* massage’’ OR ‘‘augment* massage’’ OR and patient-reported function (or both) in injured patients. More
‘‘instrument assist* cross fiber massage’’ was used. high-quality research involving a larger variety of patients and
Study Selection: Included articles were randomized con- products is needed to further substantiate and allow for
trolled trials that measured ROM, pain, strength, or patient- generalization of these findings.
reported function and compared IASTM treatment with at least 1 Key Words: soft tissue therapy, critical summary, clinical
other group. meaningfulness
I
nstrument-assisted soft tissue mobilization (IASTM) is tedious for a clinician to sift through the vast array of
the use of hard tools to manipulate soft tissue and was published works to determine best practices. Recently,
derived from the Cyriax1 cross-friction massage.2 It has Cheatham et al18 published an IASTM systematic review;
recently emerged as a popular alternative to traditional however, their search was limited in study selection, and
manual therapy techniques, but the first controlled IASTM the findings were inconclusive because of variability in
study3 was published in 1997. Similar to massage, the study designs. Additionally, Lambert et al19 conducted a
motions used during IASTM treatments vary in direction, systematic review of the effects of IASTM compared with
force, and pattern and allow for pressure to be dispersed to other interventions but only examined the clinical outcomes
the underlying tissues.3 Modern-day IASTM instruments of pain and function. Given these limitations and continued
vary in material (eg, stainless steel, plastic) and design2 and additions to the literature, the purpose of our study was to
are used to improve a variety of musculoskeletal conditions conduct a comprehensive systematic review of the effects
and associated outcomes.4–6 As such, many IASTM of IASTM on range of motion (ROM), pain, strength, and
instruments, companies, and proposed application protocols, patient-reported function. Furthermore, because of the
including ASTYM (Performance Dynamics, Muncie, IN),7 variability in designs reported by Cheatham et al,18 we
Fascial Abrasion Technique (FIT Institute, Niagara Falls, performed an effect-size analysis to further determine
ON, Canada),8 Graston Technique (Indianapolis, IN),9 and IASTM’s effectiveness, provide recommendations for use,
HawkGrips (Conshohocken, PA),10 to name a few, exist. and guide future research.
Despite instrument and protocol variability, all of these
techniques and companies plus others11,12 fall under the METHODS
IASTM umbrella13 and refer to the same studies that have
found IASTM facilitates the healing process through Data Sources and Searches
increased fibroblast proliferation3,14 and increased collagen We conducted the literature search on September 15,
synthesis, maturation, and alignment.15,16 The IASTM 2016, using the following databases: Academic Search
literature has been inundated with successful case studies Premier, Alt Healthwatch, CINAHL Complete, Cochrane
and case series (level 4 research).17 It can therefore be Library, MEDLINE with full text, NLM PubMed, Physical
Education Index, Physiotherapy Evidence Database (PE- The primary reviewer (C.B.S.) conducted the compre-
Dro), SPORTDiscus with full text, and the Web of Science. hensive literature search. All records were exported into
The Boolean string advantEDGE OR astym OR graston OR EndNote (version X7; Clarivate Analytics, Philadelphia,
iastm OR ‘‘instrument assist* soft tissue mobil*’’ OR PA).20 Once all records were imported, duplicates were
‘‘augment* soft tissue mobil*’’ OR ‘‘myofascial release’’ OR removed. Titles and abstracts were then screened for
‘‘instrument assist* massage’’ OR ‘‘augment* massage’’ OR potential eligibility by the primary reviewer. Once
‘‘instrument assist* cross fiber massage’’ was used. We screened, remaining articles were retrieved in full text
used the name brands Graston Technique, ASTYM, and and reassessed for the inclusion and exclusion criteria. The
AdvantEDGE (the original name of ASTYM) as search reference lists of all 26 full-text articles and 3 manufacturer
terms because they were commonly mentioned in articles Web sites were manually searched to identify any
used for the preliminary literature review. The remaining additional articles not located through the electronic
terms were included as they represent the many synonyms database search. If the primary reviewer was unsure
and variations of the term IASTM.
whether a study should be included, a second author
(A.M.G.S.) was consulted. The Figure provides an
Study Selection overview of the study-selection process.
Articles were included if they met all of the following:
(1) the study was a randomized controlled trial; (2) ROM, Data Extraction
pain, strength, or patient-reported function was measured
preintervention and postintervention; (3) the article was Primary data extraction was performed by the lead
written in English; (4) human participants were assessed; researcher (C.B.S.) and the following characteristics were
and (5) IASTM was examined as an intervention and entered into a spreadsheet: author, year, pathology or body
compared with at least 1 other group not receiving IASTM. region treated, study aim, participants, study design,
Articles were excluded if (1) the randomization methods experimental groups, follow-up period, participant with-
were not clear or (2) foam rolling or self-myofascial release drawal, outcome scales, all results, effect size reported (if
was studied as the main intervention. The first controlled provided), power analysis (if conducted a priori), and
study3 on IASTM was published in 1997; therefore, all product used. A second author (A.M.G.S.) confirmed the
articles published before 1997 were excluded. accuracy of the extracted data.
812
Outcome Scales
Body Part/ Range of PEDro Product
Author (Year) Condition Participants Pain Motion Function Strength Groups Results Score Used
Non–injury-based studies
Bailey et al4 (2015) Shoulder 60 collegiate baseball X IASTM and self- Glenohumeral HA, IR 7 SASTM
players stretching compared with control (P ,
Control (self-stretching) .001)
Heinecke et al44 (2014) Shoulder 15 collegiate overhead X IASTM and strength/ Left arm Apley scratch test 5 GT
athletes stretch compared with control (P ¼
Control (strength/ .045)
stretch)
Laudner et al46 (2014) Shoulder 35 collegiate baseball X IASTM Glenohumeral HA and IR after 6 GT
players Rest treatment compared with
control (P , .001)
Markovic6 (2015) Lower extremity 20 regional-level male X IASTM Hip flexion compared with foam 5 FAT
soccer players Foam rolling rolling (P ¼ .039)
the IASTM and comparison-group CIs crossed zero (17 of Patient-Reported Function: Injured Participants.
28 and 20 of 28, respectively). The 5 studies 41–43,47,49 of injured participants that
Pain: Injured Participants. Table 4 displays the effect assessed patient-reported function after IASTM treat-
sizes and CIs of the 5 studies of injured participants41–43,47,49 ments and accompanying comparison-group effect sizes
that evaluated pain in the treatment and comparison groups. and CIs are presented in Table 6. All authors used
Four used the visual analog scale in centimeters43 or different patient-reported functional scales. Effect sizes
millimeters,41,42,49 and 1 group47 used the numeric pain rating varied from a small to a large increase (0.54 to 2.24) in
scale. The IASTM treatment groups had small to large the IASTM groups and from a trivial to a large increase
improvements in pain (0.48 to 2.08), with short-term (0–8 (range ¼ 0.13 to 1.76) in the comparison groups.41–43,47,49
weeks) effect sizes ranging from small to large41–43,47,49 (range Short-term IASTM group effect sizes varied from small
¼ 0.48 to 1.95) and long-term (3 months to 52 weeks) effect to large improvements41–43,47,49 (range ¼ 0.54 to 1.60), as
sizes ranging from moderate to large41–43,47,49 (range ¼ 1.19 to did long-term effect sizes43,47,49 (range ¼ 0.54 to 2.24).
2.08). The comparison-group effect sizes ranged from trivial Comparison-groups’ effect sizes were trivial to moderate
to large (range ¼ 0.20 to 2.52) in the short term,41–43,47,49 with (range ¼ 0.13 to 0.82) in short-term assessments41–43,47,49
only 1 time point reaching the large category42 and moderate and from small to large (range ¼ 0.58 to 1.76) in long-
to large (range ¼ 0.62 to 1.74) category in the long term assessments. 43,47,49 The 4 studies 41,43,47,49 that
term.41–43,47,49 The 4 studies41,43,47,49 in which the IASTM demonstrated at least 1 categorical effect-size improve-
effect sizes were at least 1 Rhea category higher than those of ment in the IASTM versus comparison groups in the
the comparison groups are shown in Table 7. Of note is that short-term assessment and the 3 that did so41,43,47 in the
very few of the IASTM and comparison-group CIs crossed long-term assessment are provided in Table 7.
zero (2 of 18 and 4 of 18, respectively). The IASTM Product Analysis. The IASTM tools used
Strength: Injured Participants. The effect sizes and CIs in each of the studies included in the effect-size analysis are
for IASTM and comparison groups in the 4 studies of indicated in Tables 3 through 6. The standardization offered
injured participants41,42,45,49 that assessed strength are found by effect sizes allows for a comparison of the 4 tools used:
in Table 5. Overall effect sizes for the treatment groups Graston Technique instruments,41–44,46,48,50 Fascial Abra-
ranged from 0.06 to 0.81, indicating a decrease to a sion Technique,6 SASTM,4 and Astym.45,47,49 Graston
moderate increase in strength.41,42,45,49 Comparison-group Technique effect sizes41–44,46,48,50 ranged from 0.28 to
effect sizes ranged from 0.11 to 0.28, indicating a 2.42 and Astym effect sizes45,47,49 from 0.06 to 2.08,
decrease to a trivial improvement.41,42,45,49 Short-term (0– indicating a decrease to a large improvement for both tools.
8 weeks) IASTM group effect sizes ranged from trivial Fascial Abrasion Technique effect sizes6 ranged from 1.52
decreases to moderate increases in strength41,42,45,49 (range to 2.48, indicating a large improvement. The SASTM effect
¼ 0.06 to 0.81), and long-term (12 weeks) effect sizes sizes4 ranged from 0.19 to 1.45. As seen in Table 7, all tools
studied were associated with a larger categorical difference
ranged from small to moderate42 (range ¼ 0.59 to 0.81).
in the IASTM groups in at least 1 observed outcome versus
Comparison-group effect sizes demonstrated a decrease to a
the comparison groups.
trivial improvement in the short term41,42,47,49 (range ¼
0.11 to 0.28), whereas the results were only trivial in the
long-term assessment42 (range ¼ 0.15 to 0.22). For DISCUSSION
comparison purposes, Table 7 cites the 2 studies42,45 in Our primary purpose was to conduct a comprehensive
which the IASTM group values were categorically larger systematic review of IASTM effectiveness, given the
than the comparison groups in short-term assessments and 1 limited scope of previous reviews18,19 and recent growth
study42 that had larger effect sizes in the long-term in the literature. Our systematic review consisted of 6 and 4
assessment. Additionally, all CIs for both comparison and more studies than previously published reviews,18,19
IASTM groups crossed zero. respectively, likely because of more inclusive search terms,
815
Table 4. Effect Sizes of Pain Outcomes of Instrument-Assisted Soft Tissue Mobilization (IASTM) in Injured and Comparison Groups:
Baseline to Time Point Extended on Next Page
Time-Elapsed Effect Size With
95% Confidence Intervals (IASTM Listed First)a
Treatment Time
Short-Term, wk
3 No. of Scale
Author (Product) Condition Treatments Used 0 1
Blanchette and Lateral elbow Unspecified 3 10 VAS, mm
Normand41 (GT) epicondylopathy
Sevier and Lateral elbow Unspecified 3 8 VAS, mm
Stegink-Jansen49 epicondylopathy
(Astym)
Burke et al42 (GT) Carpal tunnel Unspecified 3 10 VAS, mm 1.95 (0.98, 2.92)
syndrome 2.52 (1.35, 3.69)
Crothers et al43 Nonspecific thoracic 10–15 min 3 max VAS, cm 0.48 (0.11, 0.84)b
(GT) pain of 10 0.20 (0.27, 0.67)
McCormack et al47 Achilles tendinopathy 20–30 min 3 12 Numeric pain
(Astym) rating scale
Abbreviations: GT, Graston Technique; N/R, time point measurement but no data reported; VAS, visual analog scale.
a
Effect size of ,0.35 is considered trivial, 0.35–0.79 is considered small, 0.80–1.50 is considered moderate, .1.50 is considered large.29,31
Positive effect size indicates improvement.
b
The IASTM group was at least 1 Rhea effect-size category larger than the listed comparison group.
the criteria and databases searched, and the publication included studies were susceptible to biased results,
dates. We excluded 25 case reports or case series. Though decreasing their validity. Although blinding of the therapist
case reports and case series are critical in developing is impossible because of the nature of the treatment,
evidence-based practice and are often used to assist in blinding of the assessor is easily accomplished, and
clinical decision making, they provide limited generaliz- blinding of the participants can be done with the
ability and carry a high risk of bias.55 Thus, moving appropriate methods, as shown by Kivlan et al.45 Concealed
forward, we implore researchers to consider the dispropor- allocation and adequate follow-up are other criteria that are
tionate number of case reports compared with randomized easily met with prior consideration, yet few researchers
controlled trials. included these in their methods.
Table 5. Effect Sizes of Strength Outcomes of Instrument-Assisted Soft Tissue Mobilization (IASTM) in Injured and Comparison Groups:
Baseline to Time Point Extended on Next Page
Treatment Time
Author (Product) Condition 3 No. of Treatments Scale Used
41
Blanchette and Normand (GT) Lateral elbow epicondylopathy Unspecified 3 10 Grip in kg
Sevier and Stegink-Jansen49 (Astym) Lateral elbow epicondylopathy Unspecified 3 8 Grip in pounds
Pinch in kg
Abbreviations: GT, Graston Technique; N/R, time point measurement but no data reported.
a
Effect size of ,0.35 is considered trivial, 0.35–0.79 is considered small, 0.80–1.50 is considered moderate, .1.50 is considered large.29,31
A positive effect size indicates a gain in strength.
b
The IASTM group was at least 1 Rhea effect size category larger than the listed comparison group.
As such, we calculated effect sizes using pretest-posttest Only 1 author6 assessed hip ROM, yet the results are very
results. This approach allows for a greater appreciation of promising. Markovic6 compared IASTM with foam rolling
IASTM’s clinical ability to improve outcomes in injured to determine the short-term effects (24 hours) on hip and
and uninjured participants and in short- and long-term knee ROM in regional male soccer players. The IASTM
ranges. group had immediate ROM gains, which were twice as
Range of Motion: Uninjured Participants. The studies large as those of the foam-rolling group.6 Additionally,
of uninjured participants in this review assessed ROM, with these improvements were maintained at 24 hours post-
a majority examining the shoulder-joint complex.4,44,46 intervention, whereas the foam-rolling group returned to
When we take into consideration study quality, statistical baseline ROM.6 The ROM gains reported by Markovic6
significance, the comparative effect-size analysis, and CIs, appeared to have been retained longer than those reported
in recent systematic reviews59,60 of foam rolling and
IASTM appeared to be effective in yielding short-term
proprioceptive neuromuscular facilitation (PNF) stretching.
improvements in shoulder horizontal adduction and internal Specifically, the IASTM-treated participants in the Mar-
rotation among uninjured participants.4,46 The findings of kovic6 study maintained their ROM gains for longer
Heinecke et al44 appeared to contradict those results, but durations (up to 24 hours) compared with those in the
this is likely due to the low quality score (PEDro score ¼ 5) PNF-stretching (less than 6 minutes)59 and foam-rolling
and large SDs resulting in wide CIs. Bailey et al4 credited (less than 30 minutes)60 studies. In support of Markovic’s
the glenohumeral-joint ROM improvements found in their results,6 we found the effect sizes and strong CIs after
healthy overhead athletes to decreases in posterior rotator IASTM were large and greater than those in the comparison
cuff muscle stiffness. For clinicians, this observation is groups. Although we recognize that this single study should
highly relevant, as investigators56–58 have linked deficits in not be interpreted to mean that IASTM is superior to foam
shoulder ROM in particular to higher incidences of injury rolling or PNF stretching, the substantial gains Markovic6
during a season. demonstrated indicate that further research is needed.
Time-Elapsed Effect Size With 95% Confidence Intervals (IASTM Listed First)a
Short-Term, wk Long-Term, wk
0 4 6 8 12
0.14 (0.57, 0.86)
0.13 (0.67, 0.93)
0.28 (0.12, 0.68) 0.06 (0.66, 0.54) N/R
0.06 (0.35, 0.48) 0.01 (0.48, 0.46) 0.15 (0.40, 0.70)
0.63 (0.19, 1.45)b 0.59 (0.23, 1.41)b
0.28 (0.60, 1.16) 0.21 (0.67, 1.09)
0.81 (0.03, 1.63)b 0.81 (0.03, 1.63)b
0.22 (0.66, 1.10) 0.22 (0.66, 1.10)
0.30 (0.42, 1.02)b
0.11 (0.83, 0.61)
Burke et al42 (GT) Carpal tunnel Unspecified 3 10 Function 0.54 (0.28, 1.35)
syndrome scale 0.82 (0.09, 1.74)
Crothers et al43 Nonspecific thoracic 10–15 min 3 max ODI 0.64 (0.27, 1.00)
(GT) pain of 10 0.49 (0.01, 0.97)
McCormack et al47 Achilles tendinopathy 20–30 min 3 12 VISA-A
(Astym)
Abbreviations: DASH, Disability of the Arm, Shoulder and Hand scale; GT, Graston Technique; N/R, time point measurement but no data
reported; ODI, Oswestry Disability Index; PRTEE, Patient-Rated Tennis Elbow Evaluation; VAS, visual analog scale; VISA-A, Victorian
Institute of Sport Assessment Achilles-Specific Questionnaire.
a
Effect size of ,0.35 is considered trivial, 0.35–0.79 is considered small, 0.80–1.50 is considered moderate, .1.50 is considered large.29,31
A positive effect size in measurements indicates an improvement in function.
b
The IASTM group was at least 1 Rhea effect size category larger than the listed comparison group.
Pain: Injured Participants. The researchers whose work er, more research is needed before strong recommendations
was included in this systematic review used IASTM to can be made.
improve pain among participants with elbow epicondylop- Strength: Injured Participants. Based on the inconsis-
athy,41,49 carpal tunnel syndrome,42 thoracic back pain,43 tent findings, small effect sizes, and wide CIs, IASTM does
patellar tendinopathy,51 and Achilles tendinopathy.47 Wil- not yet appear to be indicated for improving strength in
son et al51 were the only authors to find significant those with an injury.41,42,45,49 This result is unlike the other
improvements in pain; however, we did not include this outcomes examined in this review and yet consistent with
variable in the effect-size analysis because of a lack of data. the mixed literature on other manual therapy techniques.
Interestingly, although the studies included in the compar- Direct techniques such as mobilization with movement64
ative effect-size analysis showed no differences between and general osteopathic manipulation65 show promise for
the IASTM and comparison groups, 4 of the 5 investiga- improving grip and neck muscle strength, respectively, but
tions41,43,47,49 revealed moderate to large improvements that support for indirect techniques such as foam rolling60 does
were larger than those of the comparison groups at the not currently exist.
short- and long-term time points. Thus, IASTM may be Patient-Reported Function: Injured Participants. Of
clinically effective in decreasing pain among populations the studies of injured participants that assessed patient-
with tendinopathy and when treating nonspecific thoracic reported function, IASTM appeared to be most beneficial
pain in adults. Additionally, pain has adverse effects on for treating tendinopathies. Three groups assessed partic-
patient compliance61–63; therefore, the use of IASTM to ipants with patellar,51 elbow,49 or Achilles47 tendinopathy
decrease pain may improve treatment compliance. Howev- and noted improvements after IASTM treatment. Blanch-
Table 7. Studies With Instrument-Assisted Soft Tissue Mobilization Effect Sizes Over Time at Least 1 Rhea Category Greater Than the
Comparison Group in Outcome Assesseda
Range of Motion: Pain: Strength: Patient-Reported Function:
Time Period Uninjured Group (Specific) Injured Group Injured Group Injured Group
Short term Bailey et al4 (IR, HA)b Blanchette and Normand41 Burke et al42 Blanchette and Normand41
Heinecke et al44 (IR, ER, HA) Crothers et al43 Kivlan et al45,b Crothers et al43
Laudner et al46 (IR, ER, HA)b McCormack et al47 McCormack et al47
Markovic6 (Hip and knee flexion)b Sevier and Stegink-Jansen49 Sevier and Stegink-Jansen49,b
Schaefer and Sandrey48 (dorsiflexion
and plantar flexion only)
Long term Blanchette and Normand41 Burke et al42 Blanchette and Normand41
Crothers et al43 Crothers et al43
McCormack et al47 McCormack et al47,b
Sevier and Stegink-Jansen49
Abbreviations: ER, external rotation; HA, horizontal adduction; IR, internal rotation.
a
See Table 1 for specifics.
b
Difference between groups.
ette and Normand,41 who examined patients with lateral pretreatment to posttreatment, rather than the traditional
epicondylopathy, observed no group differences, but the comparison with a control, because the groups were not
IASTM group improved more quickly than the comparison consistent. As a result, the effect sizes we calculated should
group. The researchers speculated this finding was the be compared only with others calculated using the same
result of a small sample size,41 further highlighting the methods and cannot be compared directly with significant
value of evaluating effect sizes.29 Taken together, the findings for treatment and control groups. Lastly, the
studies on tendinopathy had moderate to large effect sizes, inclusion of injured and uninjured populations limits the
larger effect sizes versus the comparison groups, and generalizability of the findings. As such, the clinical
narrow CIs, indicating improved patient-reported function recommendations provided in this systematic review are
after IASTM treatment.41,47,49,51 Because improved patient- based on the populations examined and should not be
reported outcomes have been linked to therapy compli- applied to other types of healthy or injured participants.
ance,66 the magnitude of effect sizes on patient-reported
function in this systematic review supports the role of DIRECTIONS FOR FUTURE RESEARCH
patient compliance in managing tendinopathy.
It is not uncommon for a study of this nature to raise a
significant number of suggestions for future research. The
Instrument-Assisted Soft Tissue Mobilization Product first and perhaps most important recommendation is related
Choices to study design and methods. Future researchers should take
Once a systematic review demonstrates the effectiveness into consideration the variable characteristics of the studies
of a particular therapy, clinicians are left with the daunting included in this systematic review. Control groups, follow-
task of trying to decide which product to purchase. Our up periods, and IASTM protocols varied greatly, which
effect-size analysis revealed that all products studied fell in makes generalizability and comparisons difficult. Instru-
roughly the same categories for the various outcomes ment-assisted soft tissue mobilization protocols differ based
assessed. The Fascial Abrasion Technique tool was the only on the educational programs created by the manufacturers
product to not range out of the large category; however, it of IASTM tools; however, protocols need to be more
was used in only 1 study6 and ROM was the only outcome. consistent in future work if we are to determine the optimal
Although these investigations did not involve all of the treatment prescription. In addition to more consistent
IASTM products on the market, the tools used varied greatly methods, limiting potential bias and dropouts should be
in material, edges, and surface texture; therefore, it may be considered before beginning a study. The current literature
that any tool used to assist tissue mobilization is beneficial. shows only moderate PEDro scores, which could be
Wagner and Olson67 instructed clinicians on how to make improved by blinding, concealment, and possibly providing
their own IASTM tool and contended that the results should incentives for participants to continue through follow-ups.
be similar. Though this prediction has been substantiated Finally, authors should calculate effect sizes (including, but
only by anecdotal outcomes to date, it may be an option for not limited to, Cohen d and numbers need to treat) and
clinicians on a tighter budget and warrants investigation. minimal clinically important differences and report all
statistics. Effect sizes and corresponding CIs, as seen in this
review, can assist in determining meaningfulness beyond
LIMITATIONS
statistical significance and should be included in published
The variety of treatment times, comparison groups, and articles.24,26,29 For studies assessing injured participants,
populations in the included studies presented several resolution rates (see Sevier and Stegink-Jansen49 and
challenges and therefore limitations to our review. Effect- Wilson et al51) should be reported, as these can have large
size calculations were performed for only 12 of the 13 influences on clinical decision making.
articles because we could not obtain usable data for all. The The next suggestion for future research concerns the
various study designs forced us to calculate effect sizes from ability to effectively search for and obtain IASTM
Address correspondence to Alison M. Gardiner-Shires, PhD, LAT, ATC, West Chester University, 855 South New Street, Sturzebecker
HSC Office 222M, West Chester, PA 19383. Address e-mail to agardiner@wcupa.edu.