Instrument assisted soft tissue mobilization in improving hamstring muscle flexibility: A scoping review

SDCA Journal of Physical Therapy, Volume 3, June 2022 ISSN 2815-164X 12 Instrument assisted soft tissue mobilization in improving hamstring muscle flexibility: A scoping review Ma. Jesusa Mae F. Gaerlan*, Kristian Raelli F. Jaafar, Clarisse June E. Villanueva, Roland L. Sardan Physical Therapy Department, School of Health Science Professions, St. Dominic College of Asia, Bacoor, Cavite, Philippines *Corresponding author: [email protected] Abstract Instrument Assisted Soft Tissue Mobilization (IASTM) is an emerging technique developed by James Cyriax to further improve practices among clinicians under the rehabilitation setting in management of various myofascial and tendinous pathologies. Numerous studies have been conducted to identify its effects on the different regions of the body; however, the effects of this intervention in improving hamstring muscle flexibility remains understudied. This study aims to determine the result of using IASTM in improving hamstring muscle flexibility by analyzing, collating and synthesizing existing studies and provide an overview of the research studies. A systematic literature search was conducted using eight databases: Google Scholar, CORE, ResearchGate, PEDro, PubMEd, British Medical Journal, ScienceDirect, and Cochrane. Specific keywords incorporated with Boolean operators are used in the following database for relevant results. Twelve studies were included after reviewing all 283 studies in the initial research. Screening of qualified studies were also done based on the given inclusion and exclusion criteria provided by the researchers. Studies that were included were collated and comprised of information vital in this study, such as researchers targeted subjects with hamstring tightness, outcome measure procedures, type of tool used, and protocols followed in each experimental group. Traditional managements used as a comparison were outlined. The findings of each studies were emphasized as well. The researchers identified that almost all qualified studies included described the positive effects of IASTM application in the hamstring muscle group, based on the results and conclusion that they derived. Each study concluded that IASTM really does have an effect in treating hamstring muscle tightness, improving one’s knee range of motion and decreasing pain perceived by the patient, which then contributes to overall improvement in quality of life. All studies commended IASTM as an alternative management in treating hamstring muscle tightness and an adjunct to soft tissue mobilization. Keywords: Instrument assisted soft tissue mobilization; Hamstring muscle; Flexibility; Range of motion; Quality of life. To cite this article: Gaerlan, M. J. M. F., Jaafar, K. R. F., Villanueva, C. J. E., & Sardan, R. L. (2022). Work-related musculoskeletal pain among work-from-home employees of a medical billing company. SDCA Journal of Physical Therapy, 3, 12-22. Introduction As the world continues to progress, health-related discoveries continue to escalate. One example of this is the field of rehabilitation medicine towards modern methods of treatment which continuously improves the quality of life of patients with existing conditions. Nevertheless, not everyone in this field nor the civilians in their community are aware of these existing research studies. These researchers can change outdated approaches to a conventional and revolutionized one that is more updated and suitable for its current state. SDCA Journal of Physical Therapy, Volume 3, June 2022 ISSN 2815-164X 13 One of the most recent and advanced interventions is called Instrument Assisted Soft Tissue Mobilization (IASTM) which continues to gain popularity and makes its wave internationally because of its unique approach on a certain technique that was being used traditionally in rehabilitation. IASTM is an adjunct in providing manual application of force in performing soft tissue mobilization. Muscle tightness is a common condition that greatly affects our mobility and function specifically during walking, running or jumping. It is because muscles are a great contributor in carrying out these locomotion activities. Consequences include movements which may be restricted (Koulouris & Connell, 2005) and may affect the quality of produced actions applicable to our daily life (Radwan et al., 2014). Restricted range of motion due to shortening of hamstring muscles specifically, may lead to difficulty in ambulation such as presentation of an antalgic gait that develops to minimize mobilization of the involved muscle mass which shows decreased hip extension and knee flexion (Ernlund & Vieira, 2017). This specific group of muscles is responsible for these actions as well as providing stability in both hip and knee joint needed for the desired action (Kim et al., 2014). According to the study of Van der Horst et al. (2015) and Askling et al. (2013), injuries of hamstring muscles are the most common in sports related field. Athletes who play track & field, football or soccer account for 37% muscular injury stated in this sport alone. Several comorbidities may be acquired as well when there is hamstring tightness or any other pathologies involving this group of muscles including high risk of injury or trauma on other musculature due to developed muscle imbalances, leading to postural deviations that may result in pain and may hinder mobility (Markovic, 2015). Multiple traditional managements are being prescribed to address muscle tightness or decreased flexibility of hamstring muscles, such as passive static stretching, use of modalities like ultrasound and many more (Freitas et al., 2015). Soft tissue mobilization (STM) is also known in rehabilitation medicine for it is used as a manual technique in applying manually lowload forces on a specific muscle area in the body; it also includes tendons, ligaments, joint capsules and other connective tissues such as fascia. STM promotes change and improves tissue healing and adaptive shortening of the structures (Avers & Wong, 2019). According to Cheatham et al. (2016), there is an existing modification of STM based on the discovery of James Cyriax that is continuously emerging, which uses instruments that helps in providing deeper penetration and helps to detect fascial restrictions and treat areas exhibiting inflammation, fibrosis and degeneration to decrease pain and improve range of motion (ROM) and eventually influence muscle performance and function. This tool can also minimize the stress on clinician’s hand in performing numerous manual manipulations unlike STM (Bates, 2016). Instrument assisted soft tissue mobilization (IASTM) became a popular intervention for individuals who suffer from musculoskeletal conditions such as muscle tightness and other soft tissue injuries. IASTM is designed to mobilize scar tissue of those people who overly uses a specific muscle in their body (Hammer, 2008; Crothers et al., 2008). In America, there are already several studies about instrument assisted soft tissue mobilization (IASTM) that is used commonly by athletes who suffer from constant tissue scarring during activities such as playing or training, including those who have muscle strains, ligamentous strains, and excessive tissue.. They use IASTM to improve mobility, decrease pain, and improve recovery. As of now, instrument assisted soft tissue mobilization is still not introduced in the Philippines but there are already seminars scheduled by professional organizations that introduce IASTM as a different approach in the treatment of soft tissue and fascial restrictions and adhesions. These seminars cover the ideas and theories in restoring optimal soft tissue quality and help the body’s natural ability to respond and recover from injuries. They also include how a licensed physical therapist can use instrumentassisted soft tissue mobilization as a method to treat movement problems, pain, and muscle issues in different musculoskeletal conditions. SDCA Journal of Physical Therapy, Volume 3, June 2022 ISSN 2815-164X 14 There are several studies that focuses on the application of IASTM and its effectiveness on different types of musculoskeletal conditions, but the effects of instrument assisted soft tissue mobilization in improving hamstring flexibility specifically remain understudied. The goal of this research is to find out, determine, and summarize information about how instrument-assisted soft tissue mobilization improves hamstring flexibility. Methods Research Question The research question was formulated by using Population, Intervention, Controls and Outcomes (PICO) method (Schiavenato & Chu, 2021). Using this method, the researchers were able to form this question: “Does instrument assisted soft tissue mobilization improve the flexibility of hamstring muscles in patients with hamstring tightness?” Search Strategy A scoping review is a method that uses a structured way to find, examine, and summarize available information, and it also helps to spot areas where more research is needed (Arksey & O’Malley, 2005). Before this review, it was not clear what research had been done on the effects of instrument-assisted soft tissue mobilization on hamstring flexibility or how effective it really is. Using a scoping review method also allows for a broader look at all relevant studies (Munn et al., 2018; Peters et al., 2015) on this topic. Literature search was done using different databases to concisely review the topic of interest which was to determine the effectivity of instrument assisted soft tissue mobilization in improving hamstring flexibility, as to ensure no review had been done before on the subject and done to gain a systematized search strategy. Eight databases were used in the search strategy and included the following: Google Scholar, CORE, ResearchGate, PEDro, PubMed, British Medical Journal, ScienceDirect and Cochrane. Keywords used on the following databases for relevant articles by incorporating of Boolean operators as well are “IASTM” OR “Instrument Assisted Soft Tissue Mobilization” AND “hamstring flexibility” OR “improved hamstring muscle tightness.” Study Selection The included studies consisted of participants with significant limitations of knee flexion and/or musculoskeletal disease affecting the hamstring muscles. The involved studies should examine the use of instrument assisted soft tissue mobilization as the intervention. The studies could use other forms of multimodal interventions, but instrument assisted soft tissue mobilization had to be included. Only studies published in English were included in this research. Studies that had partial English translations or were written in another language were not included. There were no restrictions on the type of setting where the studies were conducted, such as acute care, long-term care, or community-based rehabilitation. Only highquality research methods were used and combined in this study, such as systematic reviews, meta-analyses, randomized controlled trials, and studies with a high level of evidence. Studies with lower levels of evidence (below 3), such as expert opinions, were not included. Commentaries and letters to the editor were also not used as they did not provide much relevant information for the topic being studied. Only research published in 2010 onwards were included. Any study that was relevant but published later the targeted date were excluded. The summarized inclusion and exclusion criteria are listed on Table 1 below. SDCA Journal of Physical Therapy, Volume 3, June 2022 ISSN 2815-164X 15 Table 1. Characteristics of inclusion and exclusion criteria used in this study Inclusion Exclusion • Participants with hamstring muscles tightness • Utilization of instrument assisted soft tissue mobilization as an intervention • Studies published in English language, or studies with complete English translations • Studies published in 2010 up to present • Only high levels of research strategies are included such as systematic reviews, randomized control trial & case studies. • Participants with tightness on other muscle • Absence of instrument assisted soft tissue mobilization as an intervention • Studies published in non-English language, or studies with incomplete English translations • Studies published before 2010 • Studies below 3 on the level of research evidence. A review of the abstracts and full text articles and data extraction was done by the reviewers themselves. Each study will be discussed within the group, while considering the inclusion and exclusion criteria. Data will be extracted pertaining to reference title, author, year, type of research design, instrument assisted soft tissue mobilization, effectiveness of instrument assisted soft tissue mobilization, limitation of motion produced by the hamstring, and significant results regarding hamstring flexibility. Data were charted in a tabular format, which would then be synthesized for the findings. Results and Discussion A total of 283 studies were initially identified from the search, and 14 studies were excluded due to duplication. As a result, 226 articles were excluded for not meeting both the inclusion and exclusion criteria, and a record of 43 articles were screened thoroughly. Research studies that were not available in full text and unable to download were excluded as well. Only 28 studies were downloaded in full text. Researchers reviewed and analyzed each article according to the given inclusion criteria (Table 1). Thus, 16 studies were excluded, making the final record of 12 studies to be included in this scoping review. The summary of the significant data extracted by the researchers from the qualified studies are outlined in Table 2, with a total of two case reports and 10 RCTs (randomized controlled trials). Each study highlighted the type of instrument they used and their application as well as the procedure to address hamstring tightness. Table 2. Summary of qualified studies Author / Year of Citation Research Design Subjects Outcome Measures Technique Intervention Findings Nejo (2014) RCT N=45 (30M, 15F) ROM (goniometer) Graston® (GT1, GT3, GT4) Compared Graston Technique® (GT®) alone vs. GT® with a hot pack, stretching, & strengthening (Whole GT) vs. a sham treatment. GT® was more effective than sham but adding stretching/strengthening ("Whole GT") showed no extra benefit over GT® alone. SDCA Journal of Physical Therapy, Volume 3, June 2022 ISSN 2815-164X 16 Chitamani et al. (2019) RCT N=212 Popliteal angle, AKE Test, Sit & Reach, Lumbar Lordosis Index M2T Compared IASTM (M2T blade) + stretching vs. Bent Leg Raising (BLR) + stretching. Both groups improved significantly in most measures; only the BLR group improved the lumbar lordosis index. Kim et al. (2018) RCT N=45 (21M, 24F) AKE test, Strength, Stiffness, Pain threshold Dr. YOU STM Y1 Compared IASTM vs. Hold-Relax (HR) vs. StrainCounterstrain (SCS) for 2 minutes. The IASTM group showed greater improvements in strength, strength ratio, passive stiffness, and pain threshold. Hoffmeier (2014) RCT N=30 Isokinetic dynamometer GT1 A 5-minute IASTM (GT1) sweeping stroke on the hamstring vs. a control group (sitting). The IASTM group had significantly greater ROM 30 minutes postintervention. Pathania and Muragod (2018) Case Report N=12 Passive Knee extension, Sit & Reach Test M2T (Case Report) IASTM (M2T blade) applied for 60 seconds (30 rubs) from the gluteal line to the popliteal fossa. Hamstring flexibility significantly improved post-treatment. Markovic (2015) RCT N=20M Passive knee flexion test, Passive Straight leg test FAT-tool Pro large Compared IASTM (FATtool) for 2 mins vs. Foam Rolling (FR) for 2 mins on quadriceps and hamstrings. Both improved ROM, but the IASTM group had higher gains (10-19%) vs. the FR group (5-9%), and the effects lasted 24h. Gunn et al. (2018) RCT N=40 (18M, 22F) Passive straight leg raise (PSLR) GTR Compared PNF stretching vs. static stretching with IASTM (GTR) vs. static stretching alone. Both PNF and IASTMassisted stretching resulted in greater hip flexion ROM than static stretching alone. Moon et al. (2017) RCT N=24 Sitting Trunk Flexion Meter, Visual Analog Scale GT® 1 Compared IASTM (GT® 1) for 60 seconds vs. static stretching. The IASTM group showed significantly more improvement in hamstring extensibility. SDCA Journal of Physical Therapy, Volume 3, June 2022 ISSN 2815-164X 17 Fousekis et al. (2019) RCT N=60 (40M, 20F) Passive Straight leg raising (SLR) Ergon® A single 15-min IASTM (Ergon®) treatment applied to A) upper body, B) lower body, or C) Control. Groups A (upper body) and B (lower body) both showed significant increases in SLR performance, while the control group did not. Muragod and Pathania (2019) RCT N=45 Sit and reach test (SRT), Passive knee extension (PKE) M2T (4-week trial) Compared static stretching vs. foam rolling vs. IASTM (M2T blade), all performed thrice a week. All groups improved (P< 0.001), but a betweengroup comparison showed IASTM (M2T) was more effective than the foam roller. Baker et al. (2015) Single case report N=1F Active SLR, Pain scale, Sit & reach test Técnica Gavilán® (Case Report) Week 1: Total Motion Release® (TMR) alone. Week 2: TMR® combined with IASTM. TMR alone improved ROM. Adding IASTM in week 2 provided additional ROM gains and reduced pain to 0/10. Barger (2013) RCT N=20M Passive straight leg raise (SLR) GT®1 Compared a 4minute Graston Technique® (GT®) application vs. Myofascial Decompression (MFD / cupping). While overall improvements were seen, there was no significant difference between the GT® and MFD groups for flexibility or strength. Legend: BLR: Bent Leg Raising; FAT: Fascial Abrasion Technique; F: Female; FR: Foam Rolling; GT: Graston Technique®; HR: Hold-Relax; IASTM: Instrument Assisted Soft Tissue; M: Male; MFD: Myofascial Decompression MTS: Muscuotendinous Stiffness; PNF: Proprioceptive Neuromuscular Facilitation; RCT: Randomized Control Trial; SCS: Strain-Counterstrain; TMR: Total Motion Release® Mobilization Improvement in Hamstring Muscle Flexibility Almost all studies resulted with an improvement in hamstring flexibility between their control and treatment groups emphasizing the application of IASTM intervention, such as in Kim et al. (2018), in which IASTM using Dr. YOU STM Y1 tool was compared to Hold-Relax stretching (HR) and StrainCounterstrain (SCS) groups. The result between these groups showed greater response by using IASTM in enhancing passive knee joint stiffness, the implemented post hoc analysis supported the comparison within the three groups and the IASTM group emerged to exhibit a lower passive knee stiffness data (0.21±0.06 N·deg-1) than the HR group (0.23±0.06 N·deg-1) (p = 0.004) and the SCS group (0.24±0.07 N·deg-1) (p = 0.001). Moreover, IASTM group also showcased significant effects in improving pain threshold, quadriceps and hamstring strength. SDCA Journal of Physical Therapy, Volume 3, June 2022 ISSN 2815-164X 18 Meanwhile, in a study by Muragod and Pathania (2018), only one experimental group was used, and they found a significant and reliable statistical difference between the values before and after treatment. The p-value was less than 5%, which supported their alternative hypothesis that using the M2T blade tool improved hamstring flexibility after treatment. In addition, researchers established another study a year after in which they targeted the same muscle group but this time conducting it with a comparison group. This time, IASTM was identified to be most effective than self-myofascial technique using foam roller in decreasing hamstring tightness in terms of passive knee extension test and sit & reach test. Compared to static stretching, enhancing hamstring extensibility using IASTM in Graston technique shows more potential as described by Moon et al. (2017). On the other hand, both IASTM using M2T blade and Mulligan’s BLR technique, with both groups accompanied by conventional physical therapy, shows a short-term improvement in reducing tightness of hamstring muscle because of the study by Chintamani et al. (2019). Another study by Gunn et al. (2018) shows that IASTM is effective for treating tight hamstrings by targeting and breaking up adhesions in the muscle’s fascia, which can limit how much the muscle can stretch. Fousekis et al. (2019) also found that using Ergon® IASTM on either the upper or lower part of the superficial myofascial back line improved hamstring flexibility using the straight leg raising test. Improvement in Range of Motion of Hamstring Muscle Inclined with hamstring flexibility, the researchers in each study also identified the effect of IASTM in the result range of motion (ROM) of the hamstring muscle group, subsequently grossly affecting one’s quality of movement. In the study of Markovic (2015) which focuses on the acute effects of IASTM compared with foam rolling (FR) in improving ROM of both knee and hip in soccer players, this uses supine passive knee flexion test and passive straight leg test as an outcome measure. The results shown after two minutes of application of both interventions were an increased in knee and hip ROM. However, effects in FAT/IASTM group were higher pre to post-test gains in knee and hip ROM: 13.1˚ and 15.2˚; or 10% and 19%) than FR group (pre to post-test gains in knee and hip ROM: 6.6˚ and 7.0˚; or 5% and 9%). After 24 hours after the overall intervention, FAT group still consistently had a higher ROM result (pre to 24hr posttest gains in knee and hip ROM: 9˚ and 10.1˚ or 7% and 13%). Another study that showed greater impact on increased ROM for hip flexion was described by Gunn et al. (2018), both PNF stretching and the use of IASTM had greater increments in hip flexion ROM than static stretching alone. Post hoc analyses made by Fousekis et al. (2019) showed a significant increase in both groups A and B in terms of SLR performance compared with pre-value of week 1 from 6.2% to 18.2%, and from 6.6% to 17.0%, respectively. Baker et al. (2015) presented an additional increased value of 7.5˚ bilaterally after an application of IASTM a week after undergoing Total Motion Release® (TMR) alone which also shows increased range of motion (ROM) from baseline. Barger (2013), by means of comparing two interventions, IASTM and Myofascial Decompressive Therapy or as described in the study as compressive versus decompressive therapy, found that both treatment groups had a statistically significant difference for an overall improvement in ROM (t=-5.41, p<0.001) as well as in their peak force (t=-3.26, p=0.004), average force (t=-3.47, p=0.003), torque (t=- 3.24, p=0.004) and strength (t=-3.34, p=0.003), however, no significant differences were identified in terms of all aspects in strength and flexibility between two groups as a result of two-way ANOVA. Both interventions were effective in increasing hamstring flexibility, therefore, recommending IASTM as a treatment option in treating hamstring tightness. SDCA Journal of Physical Therapy, Volume 3, June 2022 ISSN 2815-164X 19 Improvement in Functional Outcomes Functional activities may be affected once hamstring flexibility is limited, thus it may be the reason why some studies include functional outcomes to be tested alongside with other outcome measures in patients with hamstring tightness. One specific example that has consistently been used in the study of Pathania and Muragod (2019) was the measurement of hamstring flexibility in elderly population using Sit and Reach Test (SRT). On the pilot study of their research in 2018, it was noted that hamstring flexibility was measured, and pre-post data outlined the improvement in SRT, as well as on their 2019 study in which IASTM was compared with static stretching and foam roller. SRT as well as Passive Knee Extension (PKE) shows improvement in IASTM group higher than the two comparison group. In the case report of Baker et al. (2015), a younger subject was measured with SRT and post application showed additional increase in SRT after second week of treatment using IASTM. Chintamani et al. (2019) also concluded statistically significant changes in all outcome measures namely, popliteal angle test, active knee extension test, sit and reach test except lumbar lordosis index which were all measured pre & post intervention for both IASTM and Mulligan’s bent leg raising (BLR). Decrease in Pain In other studies, they also included an outcome measure for pain which can be correlated because of low back pain associated with hamstring tightness. As described by a study from Kim et al. (2018), an improved pain threshold (p = 0.017) was recorded using visual analog scale (VAS), higher than the HoldRelax and Strain-Counterstrain groups. The result of pain intensity greatly improved after application of IASTM. However, there is no significant difference in pain threshold between IASTM group and static stretching in the study of Moon et al. (2017). According to Baker et al. (2015), the researchers used pain numeric rating scale as an outcome measure and from a pre-test score of 5/10, 0/10 was recorded after all treatment schedules and follow-up were done. Instrument assisted soft tissue mobilization (IASTM) is an emerging intervention that seeks to provide multiple beneficial effects that helps in promoting the integrity of the myofascial and tendinous regions in the human body. Its potential as an alternative for other manual manipulation techniques, that has been used for the longest time in the healthcare setting, mostly in the physical therapy rehabilitation, is slowly making its wave as clinicians and researchers continue to gather enough evidence regarding its effectivity as part of the clinical management. As mentioned, the number of studies including IASTM is still limited and lacking. Many researchers are still determining its short term and long-term effects on different parts of the body. Furthermore, additional local studies must be conducted, which is vital for appealing this modern approach in the progress of the rehabilitation discipline. Having said, the researchers focused on identifying studies that provide necessary information and results that this newly emerging technique offers. The researchers wanted to determine the result of using IASTM in improving hamstring muscle flexibility by analyzing, collating and synthesizing existing studies and providing an overview of the research. Almost all available studies identified by the researchers described the positive effects of IASTM application in the hamstring muscle group. Based on the results and conclusions that they derived, the researchers can conclude that IASTM really does have an effect in treating hamstring muscle tightness and improving one’s knee range of motion, which contributes to overall improvement in quality of life. Pain perceived by the patients, decrease range of motion and affectation in one’s strength and function were also taken into consideration to further analyze the effects of the intervention. As identified by the significant differences in comparison to control and treatment groups, the result in the implementation of IASTM turned out to have a greater effect in enhancing muscle flexibility of the hamstring muscle compared to conventional exercises or treatment protocols. SDCA Journal of Physical Therapy, Volume 3, June 2022 ISSN 2815-164X 20 The traditional managements used as comparisons are static stretching, foam-rolling exercise, holdrelax stretching and strain-counterstrain technique. On the other hand, interventions such as Mulligan’s bent leg raising (Chintamani et al., 2019) and Myofascial decompression (Barger, 2013) have been recorded to present an equal effect like IASTM in improving hamstring muscle stiffness, as it was described statistically that no significant difference was found in comparison. Each study also stresses the application of IASTM in which different kinds of model/brands of instrument and protocol were used, such as M2T blade, Ergon tool, Dr. YOU STM Y1, Fascial Abrasion technique (FAT) and Graston tool (GT), are the most common tools that many researchers use in their practice. Each study, however, follows a different approach in application, such as the number of strokes applied and the length of application, as well as supplementary conventional exercises that were added in unison for the overall protocol of each experiment. Conclusion This review focuses on determining the effect of IASTM as a modern and innovative technique as an adjunct in performing outdated interventions that help improve hamstring flexibility. Although studies regarding IASTM were rampant, research papers that aim to discover the effect of this recent practice concerning hamstring tightness and its effects are still limited up to this date. This scoping review aims to provide necessary information about the influence of IASTM in improving hamstring flexibility. This review summarizes and describes the potential of IASTM as an alternative management for hamstring muscle tightness, which causes increased pain, decreased range of motion and impaired quality of living. The different types of instrument used in the procedure were also highlighted, introducing the completely new form of method in an advanced and revolutionizing way of rehabilitation in different individuals with acquired hamstring pathology. IASTM may be recommended to clinicians as an adjunct to traditional soft tissue mobilization. Recent studies involved in this review revealed to be limited, therefore future researchers may widen their perspective about this evolving intervention, and this research may serve as an overview on the number of studies concerning this subject, providing adequate evidence is required for the imminent use of this technique in the practice of an upgraded soft tissue mobilization. Recommendations This review may be limited to a specific scope of information only, due to the inadequate number of published studies exhausted from available databases that the researchers have access to. To improve this subject matter, future researchers may consider the following aspects and discover further databases that the researchers were not able to access yet. The researchers were not also able to find local studies regarding the implementation of IASTM in the Philippines. Conversely, the studies acquired in this review have differences in terms of the subjects included in each study, such as the range of their age and the characteristics of their symptoms. Different outcome measures were used in each study, as reflected by the method of how they performed IASTM and the type of tool they used. Some studies acquired in this review has only conducted their procedure in single sessions and only monitors the effects in a short-term period, unlike other studies in which they performed pre-post-trial for several sessions they prefer. A limitation of this scoping review is the fact that only research published in English were included. Articles of other languages could also have been beneficial to this review however they were not included.