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Instrument-Assisted Soft-Tissue Mobilization: New Research and

Updated Clinical Standards

Speaker Bio

Scott Cheatham PhD, DPT, PT, ATC  

• Educator/Researcher 

• Several related studies and publications

• Credentials 

• Graston® Technique

• RockTape® 

• Tecnica Gavilan® 

• Other related CE courses

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• Permission provided for images of products used in this presentation.

• There are no conflicts of interest with this presentation.

• We are still learning about IASTM. This presentation share’s the latest theories, research, and clinical knowledge.

Disclaimer Learning Outcomes

Participants will be able to:

• Discuss the latest scientific theories and best practices for IASTM.

• Describe updated evidence based clinical standards for IASTM.

• Discuss strategies for including IASTM as part of a comprehensive treatment strategy for various musculoskeletal conditions.

Learning Modules

• Module I: Myofascial Science

• Module II: Clinical Practice Patterns

• Module III: IASTM Research Review

• Module IV: IASTM Treatment Patterns

Levels of EvidenceEvidence Levels

Grading Criteria 

Level 1A: Systematic Review of RCT’sB: Individual RCT with narrow CIC: Series of cases (all or none)

Level 2A: Systematic review of cohort studiesB: Individual cohort study, RCT with dropouts >20%C: “Outcomes” Research or ecologic studies

Level 3 A: Systematic Review (case‐controls)B: Individual case‐control

Level 4 Case Series

Level 5 Expert’s opinion

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Module I: Myofascial Science

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What is the basic science of the myofascial system?

Defining the Myofascial System

• Definition: • Fascia is connective tissue fibers, primarily

collagen, that form sheets or bands beneath the skin to attach, stabilize, enclose, and separate muscles and other internal organs.

• Fasciae are classified according to their distinct layers, their functions and their anatomical location.

Training principles for fascial connective tissues:  Scientific foundation and suggested practical applications               Schleip & Muller J. of Bodywork and Movement Therapies (2012)

Superficial Fascia

Deep Fascia

Epimysium

Classification

Sensory Receptors

Image: Cheatham SW, Kolber MJ. Orthopedic Management of the Hip and Pelvis ‐ E‐Book. Elsevier Health Sciences; 2015.

Afferent Receptors

Muscle

Muscle spindle GTO

Skin/Myofascia

Merkel discs      Pacinian corpuscles Ruffini corpuscles 

Meissner corpuscles  

Myofascia Layers

Aδ fibers Nociceptors          

Free nerve endings Mechanoreceptors 

C‐fibers 

Merkel Discs (Type II) 

(mechanoreceptor)

Location: Epidermis/dermis (hands/fingers)

Adapt: Slow response 

Receptor: Small/defined area

Stimulus: Light pressure/vibration (5‐15 Hz)

Pacinian Corpuscles (Type I)

Location: Subcutaneous, deep dermis, joint capsule, periosteum, organs

Adapt: Rapid response

Receptor: Large area

Stimulus: Deep pressure/ vibration (250‐300 Hz) 

Meissner Corpuscles (Type II)

Location: Epidermis/dermis (hands, sole)

Adapt: Rapid response 

Receptor: Small/defined area

Stimulus: Light touch/pressure, vibration (30‐50 Hz)

Ruffini Corpuscle (Type I)

Location: Deep epidermis, ligaments, tendons

Adapt: Slow response

Receptor: Large area

Stimulus: Sustained pressure, skin (tangential) stretch, joint movement (gripping) 

Skin Receptors

* Cutaneous free nerve endings: nociception, hot and cold, and light touch

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Fascia and Movement

F.  Promotes sliding and reduces compartment friction during motion

E. Adapts its fiber arrangement, length, and density according to local demand

D. Interconnected tensional network for stability and communication

C. Rich in contractile cells, proprioceptors and nociceptors 

B.  Pre‐tension

A.  Force transmission

What are the current scientific theories behind myofascial

dysfunction?

Cumulative Injury CycleCumulative injury cycle

Repetitive pattern

overload

Tissue trauma

Inflammation

Muscle spasm

Myofascial restriction

Trigger points

Altered neuromotor

control

Muscle imbalances

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What are the scientific theories behind myofascial

interventions?

Thixotropy

Myofascial Intervention Soup Bowl

Three main levels of the somatosensory system

1. Receptor level

2. Circuit level (ascending)

3. Perceptual level (cortex)

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Mechanical Compression of the Myofascia

Myofascial Compression

Stimulation of local tissues and afferent

receptors

CNS process information

CNS responds with a local and global efferent response

Observable changes

1. Joint ROM

2. Pain modulation

3. Movement efficiency

4. Performance

Scientific TheoriesScientific Theories

Neuro-PhysiologicalNeuro-Physiological

Mechanical compression influences tissue relaxation and pain reduction in the local

and surrounding tissues through CNS afferent input from the golgi tendon reflex, mechanoreceptors, nociceptors, and other

CNS pathways.

Parasympathetic Effect?

Mechanical compression influences tissue relaxation and pain reduction in the local

and surrounding tissues through CNS afferent input from the golgi tendon reflex, mechanoreceptors, nociceptors, and other

CNS pathways.

Parasympathetic Effect?

MechanicalMechanical

Mechanical compression to the local myofascia effects the tissue viscoelastic properties. Other mechanisms involved

may include changes in thixotropy, reduced MF restriction, trigger points, fluid changes,

cellular responses, and fascial inflammation.

Mechanical compression to the local myofascia effects the tissue viscoelastic properties. Other mechanisms involved

may include changes in thixotropy, reduced MF restriction, trigger points, fluid changes,

cellular responses, and fascial inflammation.

Summary

MF compression

Activation of group III/IV afferents via   

mechanoreceptors, metaboreceptors, proprioceptors

Global pain modulation: gate control theory, diffuse noxious inhibition, PNS

Pain Modulation

MF  compression 

Changes in tissue  viscoelasticity, thixotropy, MF restriction, trigger 

points, cellular fluids, and fascial inflammation.

Changes in local tissue stiffness, stretch tolerance, 

ROM

MF compression

Ruffini/Pacinian modulate SNS 

Group III/IV modulate SNS/PNS

GTO/alpha motor modulated

Non‐local effects

Crossover

Recip. inhibition 

Local Effects

Global Effects

Bottom Line

• The scientific research suggests two theories: • Mechanical • Neurophysiological

• Based on the evidence, the myofascial compression interventions may or may not:

• Release myofascia• Break up adhesions• Promote tissue healing• Etc.

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Module II: IASTMClinical Practice Patterns

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What are the common IASTM terms?

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Background

• Common Terms in the Literature

• Instrument assisted soft-tissue mobilization (IASTM)

• Instrument assisted soft-tissue treatment

• Instrument assisted cross fiber massage

• Instrument assisted neuromobilization

• ASTYM®

• Graston®

Bottom Line

• Issue: Researchers and clinicians often describe the specific paradigm (e.g. Graston®) but only do the IASTM tool technique.

• Solution: Describe either the instrument technique or paradigm

• Proposed tool technique description:

• “Instrument assisted soft-tissue mobilization is a skilled intervention that includes the use of specialized tools to manipulate the skin, myofascia, muscles, and tendons by various direct compressive stroke techniques”.

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How are professionals using IASTM in their clinical practice?

IASTM Survey Research• Cheatham SW, Baker RT, Larkin L, Baker J, Casanova M. Instrument assisted

soft-tissue mobilization: a survey of practice patterns among health care professionals. J Athl Train. 2021 [In print]

N=853

Education

86% report formal and informal

trainingTreatment

recommendations

66% followed professional

recommendations

19% rarely or never followed

Tool pressure

71% reported not knowing amount of applied pressure

IASTM treatment time

Local region (1-5 min)

Average time (14 min)

Combined interventions

31 different pre & post IASTM interventions

Clinical outcomes

94% reported using some type of measure

What are common IASTM tools being used by clinicians?

Instruments

• Stainless Steel • (+) Hypoallergenic• (+) Smooth surface• (-) May not grip skin when

used with emollient

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Instruments

• Stainless Steel/Rubber• (+) Hypoallergenic• (+) Smooth surface• (-) May not grip skin when used

with emollient

• Jade/Stone/Plastic • (�) Hypoallergenic?? • (-) Mainly for Gua Sha not IASTM

Instruments

• Stainless Steel + NMES • (+) Hypoallergenic• (+) Smooth surface• (+) Neurophysiological effect?• (-) May not grip skin when used

with emollient

• Textured Surface • (+) Hypoallergenic?• (+) Rough surface• (-) May grip the skin and feel

rough to the patient

Bottom Line

• Professional should consider the following for instruments:

• Material

• Hand grip

• Ability to clean

• Instrument weight, shape, and size

• Edge radius and type of bevel (single/double) ��

Hajzl M. IASTM Primer. Available at www.myobar.com

What are IASTM precautions and contraindications?

Precautions Petechiae, bony landmarks Patient intolerance, hypersensitivity, 

high pain sensation

NSAIDS, steroids, narcotics Anti‐coagulants, hormone replacement, fluoroquinolone antibiotics

Herbal supplements Lymphadema

Patient age, flu or flu like symptoms Osteoporosis

Cancer, pregnancy, Diabetes Vericose veins, polyneuropathy

Hypertension, kidney dysfunction Burn scars, body art 

Acute inflammatory conditions RA, ankylosing spondylitis

Post injection (e.g. steroid) Allergies to metals, emollients, latex

Unhealed closed factures Autoimmune disorders, RSD/CRPS

Congestive heart disease, circulatory disorders 

Pacemaker or insulin pumps (treatment around devices)

Contraindications Acute or recent injury, infection or 

fever Petechiae (severe) or ecchymosis

Skin rash, open wounds, blisters, local tissue inflammation, or tumors

Treatment over surgical hardware

Recent surgery or Osteoporosis Cancer or malignancy

Unhealed bone fracture or myositis ossificans

Hypertension (uncontrolled)

Acute/ severe cardiac, liver, or kidney disease

Congestive heart disease/circulatory disorders

Neurologic conditions Bleeding disorders 

Metabolic conditions (e.g. diabetes) Unhealed surgical site

Connective tissue disorders  Peripheral vascular disease 

Blood thinners or narcotics Thrombophlebitis or osteomyelitis

Chronic pain conditions Direct pressure over face, eyes, arteries, vessels, or body regions 

Severe pain felt by patient  Epilepsy

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Most Obvious Concerns

Precautions

• Petechiae

• Patient intolerance

• Bones/nerves/vessels

• Healing skin (scars/wounds)

• Skin allergies

• Meds effecting sensation

• Diabetes/neuropathy

• Etc.

Contraindications

• Severe petechiae

• Skin rash/open wounds

• Blisters/tissue inflammation

• Cancer/malignancy

• Over eyes/sensitive areas

• Healing surgical/injury site

• Severe pain

• Neurological conditions

• Etc.

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The medical literature is beginning to document injuries from aggressive IASTM treatments

2016- Buntinx & Greenwald , 2015- Aprile A et al., 2013- Odhav et al, 2000- Amshel & Caruso

Bottom Line

•We need to educate patients prior to TX•Potential side effects•Pain during or after treatment•Precautions/contraindications

•*Respect cultural beliefs but educate

What are the current recommendations for instrument

hygiene?

Instrument Hygiene • Instrument disinfecting:

• Use intermediate-level disinfectant.

• Flush instrument with soap and water before treatment.

• If the tool contacts blood, bodily fluids, etc. then a high-level disinfectant or sterilization should be done.

Center for Disease Control Levels of Disinfection

High‐level disinfection These disinfectants kill all organisms, except high levels of bacterial 

spores, and is effected with a chemical germicide cleared for marketing 

as a sterilant by FDA. Typically, they are not used for generalized 

disinfecting.

Intermediate‐level disinfection These disinfectants kill mycobacterium, most viruses, and bacteria with 

a chemical germicide registered as a "tuberculocide" by EPA.

Low‐level disinfection These disinfectants kill some viruses and bacteria such as HIV and HBV 

with a chemical germicide registered as a hospital disinfectant by the 

EPA.

EPA: Environmental Protective Agency

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Bottom Line

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• Professionals should develop standard cleaning procedures.

• Use an intermediate-level disinfectant to clean instruments.

• Clorox® and Lysol® brand wipes, 70% isopropyl alcohol

• Follow the recommended “wet time” (e.g. 4 min to disinfect)

• Wear proper PPE per the product recommendations • At minimum, gloves and maybe a mask (e.g. harmful odor)

Module III: IASTMResearch Review

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Literature Reviews

20002000 20182018

Systematic/Literature Reviews

Reviews:

• 2018- Hussey et al. J Sport Rehabil

• 2017- Kim et al. J Exerc Rehabil

• 2016- Cheatham et al. J Can Chiropr Assoc

Consensus:

• Mixed methods = mixed results

• Named paradigm (e.g. Graston®) but didn’t do it

• Weak evidence for therapeutic benefits

• 25+ case studies

Evidence Grade = 1

Literature Reviews

20192019 20212021

Systematic/Literature Reviews

Reviews:

• 2019- Seffrin et al. J Athl Training• (+) outcomes: ROM (uninjured), pain (injured), function (injured)

• 2019- Nazari et al. Arch Phys Med Rehabil• (-) outcomes: ROM, Pain, and Function

• 2019- Cheatham et al. Int J Sports Phys Ther

Consensus:

• Reviews used diverse search criteria

• Found mixed methods = mixed results

• Still weak evidence for therapeutic benefits

Evidence Grade = 1

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Module IV: IASTMTreatment Patterns

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Literature Reviews

20152015 20212021

Treatment Categories

ROM, pain, muscle performance,

& functional movements

Musculoskeletal pathologies

Tissue healing & blood flow

Neurophysiological effects

What are the latest IASTM studies on ROM, muscle performance, and

functional movements?

Range of Motion: (+ outcomes)

• 2020‐ Lee et al. J Allied Health• 2020‐ Simatou et al. J Phys Ther Sci• 2019‐ Rowlett et al. J Bodyw Mov Ther• 2019‐ Ikeda et al. Med Sci Sports Exerc• 2018‐ Stanek et al. J Athl Train• 2017‐ Kim et al. J Back Musculoskelet Rehabil

Muscle Performance/Functional Movements: (+ outcomes)

• 2020‐ Stroiney et al. J Strength Cond Res• 2019‐ Gamboa et al. Int J Exerc Sci• 2018‐ Rhyu et al. Technol Health Care• 2017‐ Kim et al. J Back Musculoskelet Rehabil

Evidence Grade = 2

Related Studies

What are the latest IASTM studies on treating different MSK

conditions?

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MSK Pathology: (+ outcomes)

• 2020‐ Park et al. J Exerc Rehabil (Chronic ankle instability)

• 2019‐ Jones et al. J Am Podiatr Med Assoc (Plantar heel pain)

• 2018‐ Crane et al. Physiother Theory Pract. (Axillary Web Syndrome)

• 2018‐ Gulick. J Bodyw Mov Ther (Myofascial trigger points)

• 2017‐ Coviello et al. J Sports Med Phys Fitness (Shld. Impingement)

• 2016‐ Hoon Lee et al. J Allied Health (LBP)

Evidence Grade = 2

Related Studies

What is the evidence that IASTM produces a local mechanical effect

to promotes tissue healing and blood flow?

Laboratory studies: (rat models)

• IASTM: Increased fibroblast proliferation and collagen repair in cases of enzyme-induced tendinitis.

• IASTM: Increased damaged ligament healing via healing factor and vascular changes.

Research• 2013‐ Loghmani et al. BMC Complement Altern Med

• 2009‐ Loghmani et al. J Orthop Sports Phys Ther

• 1999‐ Gehlsen et al. Med Sci Sports Exerc

• 1997‐ Davidson et al. Med Sci Sports Exerc

��2013‐ Loghmani et al. BMC Complement Altern MedEvidence Grade = ?

Local Blood Flow: (+ outcomes)

• 2020‐ Fousekis et al. J Phys Ther Sci (Human‐hamstrings) 

• 2014‐ Portillo‐Soto et al. J Altern Complement Med (Humans)

Evidence Grade = 2

Related Studies

What is the evidence that IASTM produces neurophysiological effects

such as PPT & TPD?

Does a light pressure instrument assisted soft tissue mobilization technique modulate tactile discrimination

and perceived pain in healthy individuals after strenuous exercise?

Cheatham, Kreiswirth (2019)

• Purpose: To measure the effects of light pressure IASTM on TPD and PPT in healthy individuals after strenuous exercise.

• Design: Pretest, posttest observations study

• Subjects: 23 healthy, active adults(M=14,W=9) (24.22 � 3.07 yrs)

• IASTM Tool: RockTape® Mohawk

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Study Protocol Methods• DOMS protocol:

• 5-min warm-up

• 100 drop jumps from 0.5m box

• IASTM (90 sec):

• Quadriceps (pre-marked)

• Light pressure (wt. of tool 208 g), stroke (120 bpm), 30◦angle

• Stimulate Pacinian receptors

• Outcomes:• NRS to confirm DOMS• PPT (algometry)• TPD

Subjects (N=23)

Day I

Baseline MeasuresDOMS Protocol

Day II (24-hrs post)

IASTM TXPost measures

Day III (48-hrs post)

IASTM TXPost measures

• Results

• TPD- Significant difference between all time points (p <.001). • Baseline to 24 hours post (p <.001) and 48 hours post (p <.001).

• PPT- Significant difference between all time points (p <.001). • Baseline to 24 hours post (p=.005) and 48 hours post (p=.003).

• No significant change between 24 to 48 hours post for TPD and PPT (p=1.00).

Baseline and post‐intervention descriptive results (N=23)

Baseline 24 hours  P‐value Baseline 48 hours P‐value

Two Point 

Discrimination 

(cm)

4.33 ± 1.12 2.98 ± 1.28 *p<.001 4.33 ± 1.12 2.83 ± 1.57 *p<.001

Pressure Pain 

Threshold (kPa)

1132.08 ±

244.26

1214.91 ±

261.25

*p=.005 1132.08 ±

244.26

1207.22 ±

248.80

*p=.004

*IR: inter Data reported as mean ± SD, kPa= kilopascals; cm: centimeters

• Limitations• Healthy subjects, no control group

• One specific DOMS protocol and IASTM technique

• Pre-determined body region and a small area

• *Study considered preliminary

• Conclusions• A light IASTM technique may produce a short-term

neuromodulation effect on local TPD and PPT after DOMS.

• Future research needs to focus on the neurophysiological effects of different instruments, treatment protocols, and on different body regions (different receptor geography)

Evidence Grade = 2

PPT/TPD:(* insignificant outcomes)

• *2018‐ Gulick. J Bodyw Mov Ther (PPT)

• *2017‐ Ge et al. J Phys Ther Sci (TPD)• 2017‐ Kim et al. J Back Musculoskelet Rehabil (PPT)

• Limitations: • *Researchers reported using the Graston® concept but did

not follow the protocol• Researchers did not report any specific treatment

parameters such as: tool angle, stroke rate, predetermined area, and pressure.

Evidence Grade = 2

Related Studies

Is IASTM Interchangeable with other myofascial interventions?

Myofascial compression interventions: comparison of roller massage, instrument assisted soft‐tissue mobilization, and floss band on passive knee 

range of motion among non‐experienced individuals Cheatham SW, Martinez RE, Montalvo A, Odai M, Echeverry S, 

Robinson B, Bailum E, Viecco, K. Clin Pract Athl Train. 2020;3(3):24‐36. 

Subjects (N=40)

Roller Massage

N=15

2‐min intervention

ROM: Left knee flexion

IASTM

N=10

2‐min intervention 

ROM: Left knee flexion

Floss Bands N=15

2‐min intervention

ROM: Left knee flexion

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Results: (pretest, posttest)

• ROM: Gains in ROM were made• RM (Foam Rolling): 2° (p<.001)• IASTM: 3.5° (p<.001) • Floss Band: 4° (p<.001)

• The three MF compression interventions may be interchangeable by producing similar immediate effects.

Evidence Grade = 2

IASTM vs. Tissue Flossing vs. KT: (+ outcomes)

• 2021‐Mylonas et al. J Sport Rehabil

IASTM vs. Self‐Myofascial Rolling:(+ outcomes)

• 2020‐ Lee et al. J Allied Health • 2020‐ Stroiney et al. J Strength Cond Res • 2020‐ Lee et al. J Allied Health• 2020‐ Sandrey et al. J Sport Rehabil

IASTM vs. Static/PNF/Active Stretching: (+ outcomes)

• 2019‐ Rowlett et al. J Bodw Mov Ther• 2019‐ Gunn et al. J Man Manip Ther• 2018‐Myburgh et al. J Rehabil Med Clin Commun

IASTM vs. Massage: (+ outcomes)

• 2020‐ El‐Hafez et al. J Taibah Univ Med Sci• 2020‐ Koumantakis et al. J Bodw Mov Ther

• 2021‐Mylonas et al. JBMC Musculoskelet Disord (IASTM + Therex) 

Evidence Grade = 2

Related Studies

What are some of the emerging IASTM research?

Quantification of IASTM Force:• Stevenson et al. J Athl Training. 2021 [In‐review] (2‐handed)• Duffy S et al. J Athl Training. 2021 [In‐review] (1‐handed)• Martonick et al. J Sport Rehab. 2021 [In‐press] (Simulated treatment)

Evidence Grade = 2

Related Studies

Research Recommendation

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Instrument Assisted Soft-Tissue Mobilization: A Commentary on Clinical Practice Guidelines for Rehabilitation Professionals.

Cheatham, Baker, Kreiswirth (2019)

• PubMed Link: IASTM Studies (2015-2021)• https://pubmed.ncbi.nlm.nih.gov/?term=IASTM&filter=years.2015-

2021&show_snippets=off&sort=pubdate&size=100

Suggestions: Future Research

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• Compare the therapeutic effects of different instruments:• Graston®

• HawkGrips®

• Fascial Abrasion Technique®

• RockBlades®

• Instrument hygiene/cleaning standards

• Myofascial interchangeable interventions

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Bottom Line

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Known Effects • IASTM improves:

• Joint ROM• Pain modulation• Tissue temp change• Muscle performance • Functional movement

Unknown Effects• IASTM may (humans):

• Release myofascia• Breaks-up adhesions • Promote healing

Final Thoughts: IASTM

�

• Researcher and clinicians both need to described either the instrument technique or paradigm.

• IASTM research continue to produce human studies with mixed methods which produces mixed results.

• Standard research and practice guidelines are needed.

• Interchangeable: IASTM may produce similar effects as other interventions.

Final Evidence Grade =

Thanks!!!

Scott Cheathamscheatham@csudh.edu

• Cheatham SW, Baker R. Gender differences in pressure pain thresholds of the ipsilateral agonist, antagonist, and contralateral muscle groups after a bout of foam rolling: A comparison study. J Bodywork Mov Ther [In Review]

• Cheatham SW, Kolber MJ, Hanney WH, Mokha GM. Concurrent Validation of a Pressure Pain Threshold Scale for individuals with Myofascial Pain Syndrome and Fibromyalgia. JMMT [In Review]

• Cheatham SW, Kolber MJ, Mokha GM, Hanney WJ. Concurrent Validity of Pain Scales in Individuals with Myofascial Pain and Fibromyalgia. J Bodywork Mov Ther. 2017 [Accepted]

• Cheatham SW, Kolber MJ, Cain M. Comparison of a video‐guided, live‐instructed, and self‐guided foam roll intervention on knee joint range of motion and pressure pain threshold: A randomized controlled trial. Int J Sports Phys Ther. 2017;12(2):1‐8

• Cheatham SW, Kolber MJ. Does self‐myofascial release with a foam roll change pressure pain threshold of the ipsilateral lower extremity antagonist and contralateral muscle groups? An exploratory study. J Sports Rehab. 2017 [Epub Ahead of Print]

• Cheatham SW, Lee MD, Cain M, Baker RT. The Effects of Instrument Assisted Soft Tissue Mobilization: A Systematic Review. J of Can Chiropr Assoc.2016; 60 (3): 200‐211

• Cheatham SW, Kolber MJ, Cain M, Lee MD. The Effects of Self‐Myofascial Release on Joint Range of Motion, Muscle Recovery, and Performance: A Systematic Review. Int J Sports Phys Ther. 2015, 1(6);827‐838

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