Research Article

Comparing the Effectiveness of Instrument-Assisted Soft Tissue Mobilization and Foam Rolling on Knee Range of Motion: A Critically Appraised Topic

Kohei Osumi and Chelsea Kuehner-Boyer*

School of Kinesiology and Recreation, Illinois State University, USA

Corresponding Author

Chelsea Kuehner-Boyer, School of Kinesiology and Recreation, Illinois State University, USA.

Received Date: May 10, 2024;  Published Date: June 13, 2024

Abstract

Joint range of motion (ROM) has been found to decrease, in part due to myofascial restrictions. Myofascial restrictions can be treated through various forms of myofascial release (MFR) techniques. Foam rolling (FR) and instrument-assisted soft tissue mobilization (IASTM) are common MFR techniques that are applied or recommended for the treatment of myofascial adhesions. Currently, literature exists that supports the effectiveness of FR and IASTM intervention on joint ROM improvement separately, however, a limited number of studies exist to assist the clinician in determining if IASTM or FR is the better intervention to increase ROM. This critically appressed topic sought to compare the effect of IASTM and FR on knee ROM in published high-level randomized control trials. Three published studies were found that met the inclusion criteria, and all three studies found that both FR and IASTM showed statistically significant improvement in knee ROM when applied on their own. Two studies found that there was no meaningful difference in knee ROM improvement between IASTM and FR. One study showed that IASTM produced a slightly greater increase in knee ROM than FR. The three studies appraised in this report supported the effectiveness of IASTM and FR MFR techniques on knee ROM. The results suggest that both interventions may produce similar immediate post-treatment effects and clinicians may use them independently and interchangeably to improve ROM without sacrificing results for their patients.

Keywords: Instrument-Assisted Soft Tissue Mobilization, Foam Rolling, Range of Motion, Knee, Myofascial Release

Abbreviations: Instrument-Assisted Soft Tissue Mobilization (IASTM); Foam Rolling (FR); Range of Motion (ROM); myofascial release (MFR)

Introduction

Range of motion (ROM) dysfunction is common for physically active people and may be restricted by various pathological and non-pathological conditions [1]. Factors that contribute to ROM deficits include poor flexibility, injury, poor posture, biomechanics, and immobilization [1-2]. It is common for clinicians to work to improve ROM during injury prevention and rehabilitation programs because a lack of flexibility and inadequate ROM have been found to be common risk factors for both chronic and acute injury [1]. ROM restrictions are multifaceted, but often the fascia contributes to a restricted ROM [2-3]. Fascia is a multilayered and highly innervated form of connective tissue that runs throughout the entirety of the body [2-3]. Healthy fascial layers move smoothly along the other fascia layers, allowing for healthy ROM of the body structures in all directions [2-3]. Healthy ROM is necessary to achieve optimal muscular function and proper biomechanical movement patterns for people at all levels of fitness and physical activity [4]. However, the fascia can become restricted due to poor biomechanics, repetitive movement patterns, poor posture, injury, or immobilization [1-2, 5-6].

Fascial restrictions occur when the layers of the fascia adhere to each other, limiting the normal smooth movement of the independent fascial layers [2, 5-6]. The fascial adhesions, which can include trigger points, then limit normal ROM, and joint mechanics, and create a greater risk for injury [2,4]. Fascial restrictions are often treated through myofascial release (MFR) techniques [2,4]. Many forms of MFR exist currently, some can be applied by a trained clinician, while others can be applied by the patient through a self-myofascial release technique. Two common forms of MFR in both the physically active and general populations include self MFR through the use of a foam roller (FR) and clinician-applied MFR through instrument assisted soft tissue mobilization (IASTM) [2,4,6- 8]. Though the current research supports the effectiveness of using both FR and IASTM intervention on joint ROM separately [1,4,6.9] a limited number of studies exist that compare the effectiveness of the two tools. Through an in-depth search and appraisal of highlevel experimental studies, this study seeks to assist clinicians in determining if clinician applied IASTM or self-applied FR is more effective in improving ROM.

Focused Clinical Question

In an adult population, what is the effect of IASTM on knee ROM compared with FR in randomized control trials?

Sources of Evidence Searched

Consortium of Academic Research Libraries I-Share Library system, which includes the databases of 89 libraries from colleges and universities throughout the state of Illinois

Article Inclusion Criteria

• Studies that compared IASTM intervention with FR intervention

• Studies that were written in the English language

• Studies published between 2012 and 2023

• Studies with the outcome measure of knee ROM

• Randomized control trials and randomized time series

Article Exclusion Criteria

• Studies that scored lower than a 6/10 on the PEDro Scale

Evidence Quality Assessment

The quality of the included studies was assessed using the Physiotherapy Evidence Database (PEDro) scale. The PEDro Scale consists of 11 criteria for evaluation. PEDro Scale scores are most often classified as poor (0-3), fair (4-5), good (6-8), and excellent (9-10) [10]. The average PEDro score for the three included studies was 8.33 indicating a good research quality, results of the quality assessment can be seen in Table 1.

Table 1:Characteristics of Included Studies.

Summary of Search, Best Evidence Appraised, a Key Findings

A search of the Consortium of Academic Research Libraries I-Share Library system using the search string foam roll AND instrument assisted soft tissue mobilization AND knee range of motion was conducted in the fall of 2022 and again in the fall of 2023. Results were limited to peer-reviewed articles, available in English, that were published between 2012-2023. The initial literature search yielded 6 possible studies for inclusion. The studies were screened for article type to ensure that all articles were a form of randomized controlled trials and to ensure that the studies scored as good or better on the PEDro scale. After the screening process was completed three studies were found to meet the inclusion criteria and were retained for full-text review. Key findings from the three retained studies are shown in Table 1.

All three studies found that FR and IASTM showed statistically significant improvement in knee ROM. Sandrey et al. [4] and Cheatham et al. [11] however, conclude that the difference in intervention effects of the two modalities is small and may not be clinically important, suggesting that both interventions may be interchangeable to produce similar effects. On the other hand, Markovic concluded that the effects of IASTM are greater than FR [4].

Clinical Bottom Line

The three studies included in this report supported the effectiveness of IASTM and FR on knee ROM. The results suggest that both interventions may produce similar immediate posttreatment effects and clinicians may use either intervention to improve immediate post-treatment knee ROM.

Discussion and Implications for Practice

Based on the included studies, both IASTM and FR have a positive effect on knee ROM [2,4,11]. It is important to note that these positive outcomes occurred despite the use of different brands and tools for the IASTM and FR interventions. Markovic used FAT for IASTM intervention, and a GRID FR, while Cheatham et al. [11] used the GRID FR and Smart Tools® Crossbar IASTM tool, while Sandrey, Lancellotti, and Hester [2] used a Graston IASTM tool and a generic dense FR. Additionally, the applications of interventions were different across the studies including time of application, length of treatment, and the body areas treated.

Cheatham et al. [11] and Markovic [4] both applied their interventions for a total of 2 minutes each while Sandrey, Lancellotti, and Hester [2] applied their interventions for 8 minutes. Cheatham et al. [11] and Markovic [4] applied their interventions only once before measuring outcomes while Sandrey, Lancellotti, and Hester [2] applied both of their interventions a total of 6 times over 3 weeks. Cheatham et al. [11] only applied their intervention to the quadriceps, Markovic [4] however treated both the hamstrings and the quadriceps, and finally Sandrey, Lancellotti, and Hester [2] treated the quadriceps, hamstring, gluteal/iliotibial band, and adductors. This indicates that there is a wide range of MFR applications through IASTM and FR that will have a positive effect on knee ROM.

Overall, the research found that both modalities can produce similar effects on knee ROM and may be used interchangeably at the clinician’s discretion [2,4,11]. All three studies included in this critically appraised topic demonstrated the immediate effectiveness of IASTM and FR on knee ROM after the intervention. However, one study by Markovic found that IASTM had a greater immediate effect than FR intervention on male soccer players [4]. The Markovic study results revealed that both IASTM and FR groups significantly improved in hip and knee ROM immediately after application (p < 0.05), with a slightly greater gain in the IASTM group (10-19% vs 5-9%) [4]. Markovic was the only study to examine the post-immediate effect of IASTM and FR. The authors concluded that while the knee and hip maintained some of their ROM gains (9° and 10.1°) 24 hours after the application of the IASTM treatment, the FR measures returned to their baseline values [4]. When determining the clinical application of these interventions it is important to consider effect size. Markovic [4] did not report effect size, which means that the meaningfulness of the differences in the interventions found in his study is unclear. The articles by Sandrey, Lancellotti, and Hester [2] as well as Cheatham et al. [11] considered both significance and effect size and supported the interchangeability of IASTM and FR, however, both articles reported only small to moderate effect sizes for their interventions. Sandrey, Lancellotti, and Hester [2] found that knee extension was significantly (p = .001) increased in both IASTM (176.84 ± 4.89 to 178.65 ± 4.89) and FR (177.39 ± 3.58 to 180.14 ± .55). The authors additionally found that the effect of IASTM on knee extension was small (d = 0.03) while the effect of FR on knee extension was moderate (d = 0.77). Cheatham et al. [11] found that knee flexion was significantly (p = .001) increased in both IASTM (2.31 ± 0.81) and FR (2.33 ± 0.40). The authors additionally found that the effect of both IASTM and FR on knee flexion was small (d = 0.26) [11]. Both of these articles concluded that the difference in ROM improvement after IASTM and FR intervention may not be clinically or statistically significant and conclude that based on their findings FR and IASTM may be used interchangeably and still produce similar effects [2,11].

Limitations and Future Research

Three primary limitations exist across the three studies that were appraised in this study. First, the types of IASTM tools and FR used during the intervention varied depending on the studies. Since each brand is designed differently, a true comparison of those interventions may be incomplete because other treatment techniques and intervention times may have produced different results. Second, all included studies had a generally small sample size ranging from 20-30 patients, which may limit the generalizability of their findings. Finally, the target population of the three studies was limited to young healthy populations.

Treatment effects of IASTM and FR on different age populations or individuals with musculoskeletal pathologies were not assessed within the studies. Thus, future research would benefit from determining the effects of FR and IASTM on different age groups and pathological conditions. Future research should examine the effectiveness of IASTM and FR by using the same brand of modalities to maximize the external validity of the search. Furthermore, identifying participants with specific musculoskeletal pathology who may benefit from this intervention would enhance its overall incorporation.

Conclusions

Based on the included studies, the effects of IASTM on knee ROM were not superior to FR immediately after treatment in adult patients. Overall the research found that both modalities can produce similar effects on knee ROM and may be used interchangeably at the clinician’s discretion. This is clinically meaningful for busy clinicians who may not be able to apply a hands-on modality like IASTM treatment to each patient or who are looking for a modality that patients can complete on their own in between treatment sessions.

Acknowledgments

None.

Conflict of interest

None.

References

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