Clinical Review

© 2015 Human Kinetics - IJATT 20(5), pp. 29-34

http://dx.doi.org/10.1123/ijatt.2015-0009

A Comparison and Review of Indirect

Myofascial Release Therapy, Instrument-
Assisted Soft Tissue Mobilization,
and Active Release Techniques
to Inform Clinical Decision Making
Janet McMurray, ATC, LAT, MEd • McMurry University and University of Idaho; Scott
Landis, ATC, LAT, MA, LMT • King University and University of Idaho; Kris Lininger, ATC,
MS • College of the Siskiyous and University of Idaho; Russell T. Baker, DAT, ATC, LAT,
Alan Nasypany, EdD, ATC, LAT, and Jeff Seegmiller, EdD, AT • University of Idaho

M anual therapies are commonly used by

clinicians in patient care to decrease pain
The purpose of this article is to elucidate
similarities and differences while exploring
and increase range of current research, theoretical mechanisms of
motion (ROM).1 Instru- action, and reported clinical effectiveness
Key Points ment-assisted soft tissue of IASTM, MFR, and ART. Clinicians who
Delineating the most effective manual mobilization (IASTM), understand these concepts may make more
therapies may be possible by utilizing indirect myofascial informed decisions regarding manual ther-
patient presentation criteria. release therapy (MFR), apy options.
and active release tech-
Treatment time and application of force niques (ART) are manual
Myofascial Release Therapy
may influence manual therapy choice. therapy methods sim-
ilar in mechanism MFR therapy is defined as “…the facilitation
Similarities and differences of indirect of action, theoretical of neural, mechanical, and psychophysio-
myofascial release therapy, instrument-as- bases, and proposed logical adaptive potential as interfaced via
sisted soft tissue mobilization, and active fascial effects.2–4 Since the myofascial system.” 6 The therapy is
release techniques impact clinical decision the therapies are related based on theories postulated by John Barnes,
making. in several respects 2,3,5 which propose that morphological changes
and often lack research occur in both connective tissue (fascia) and
support of the proposed benefits, choosing the neuromuscular system.2 These changes
the most effective course of treatment in an are believed to influence plastic, elastic,
individual patient context may be difficult. viscoelastic, and piezoelectric properties of

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connective tissues.2 Viscoelasticity possesses attri-
butes of viscosity and elasticity (i.e., connective tissue)
during deformation.7 Piezoelectricity is produced by
mechanical pressure on mineralized and nonminer-
alized structures.8 Meltzer et al.9 investigated Barnes’
theory of cellular and molecular effects and discovered
strained fibroblasts treated with indirect MFR exhibited
improved attenuation of programmed cell death com-
pared with untreated fibroblasts.9 Researchers have
also used the spring and dashpot model to determine
the stress–strain behavior of tissues and found evi-
dence that supports viscoelastic property change due
to tissue deformation.10,11 Indirect MFR applies minimal
(i.e., a few grams) pressure to myofascial tissue while
moving through the path of least tissue resistance in a
three-dimensional setting12 to ‘meet the barrier’ in all
three planes.12 Low mechanical force combined with
long hold duration (90 s to several minutes) provides
tissue deformation.12 The clinician and patient mutually
provide feedback during indirect MFR treatment.13
Researchers examining the clinical application of
indirect MFR found positive outcomes for headaches,14
chronic low back pain,15 lateral epicondylitis,16 fibro-
myalgia symptoms,17 and limited shoulder ROM.18
Contraindications to MFR include: malignancy, acute
rheumatoid arthritis, severe osteoarthritis, healing
fractures, advanced diabetes, open wounds, aneurysm,
and highly-sensitive skin.19,20
The clinical effectiveness of indirect MFR is difficult
to validate in the literature due to a broad variety of
application methods and treatment parameters that
include: force applied, length of treatment time, move-
ment across intended tissue, use of external tools, and
inclusion of complementary modalities.20 Despite the
varied parameters, researchers have demonstrated that
indirect MFR produced positive outcomes in patient
pain and pelvic girdle, foot, and hip function.21–24
Instrument-Assisted
Soft Tissue Mobilization
IASTM therapy is based on Cyriax’s theories that deep
friction tissue massage improves tissue movement,
prevents scar tissue formation, and produces local
inflammatory response.25–29 The method differs from
other massage techniques by using specially-designed
instruments to apply multidirectional pressure to soft
tissues.27,30 The instruments theoretically provide a
mechanical advantage by allowing clinicians greater
force transmission than with hands alone.5,29,31 The
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advantage may facilitate a clinician’s ability to detect
altered tissue properties.5 Silbaugh32 found moder-
ate evidence to support the notion that instruments
improved a clinician’s ability to locate myofascial
restrictions and adhesions.
External mechanical load affects the extracellular
matrix (ECM) of connective tissue and is responsible
for fibroblast proliferation and orderly collagen fiber
arrangement.33–35 Soft tissue healing after injury or
immobilization results in irregular collagen fiber
arrangement with increased random cross-links
between fibers and fiber bundles.34 Weaker collagen
proteins in healing connective tissue are substituted
for the original collagen.34 Lower water content in
the tissues diminishes movement between fibers.34
Hammer5 theorized that altered collagen fiber compo-
sition produces tissue adhesions, and instrument use
allows better detection of these soft tissue restrictions.
Instrument-induced mechanical load produces
microfailure and realignment of the collagen fibers.5
Increased stimulation of fibroblast production initiates
earlier healing and return of function.36 The inflamma-
tory process appears to be facilitated by introducing
a controlled amount of microtrauma to the affected
area, resulting in a healing cascade that causes optimal
collagen deposition and maturation.5,37
Contraindications to using IASTM include, but
are not limited to: open wounds, thrombophlebitis,
uncontrolled hypertension, kidney dysfunction, hema-
toma, and myositis ossificans.38 Patient tolerance, skin
conditions, and certain medications are considered
cautionary factors for IASTM use. Treatment can also
cause hyperemia with petechiae formation.38
The definitive efficacy and long-term effects of
IASTM have not been firmly established, due to a lack
of research examining lasting fascia structural changes
and patient outcomes.1,5,29,39–41 Treatment protocols
for IASTM are also not universally defined and vary
between clinicians.5,29,42,43 A variety of case studies
and series do support IASTM use through positive out-
comes in clinical practice (e.g., improvement in pain,
ROM, and function).5,29,39,42,44 Perle et al.42 conducted
a prospective case study with 1,004 patients treated
with IASTM and found statistically and clinically signif-
icant improvements in pain, numbness, and function
for (but not limited to): plantar fasciitis, carpal tunnel,
and fibromyalgia.42 Hammer and Pfefer29 observed
favorable results treating lumbar compartment syn-
drome, and Hammer5 reported positive outcomes
on degenerated tissue using IASTM for supraspinatus
tendinosis, Achilles tendinosis, and plantar fasciosis.
More recently, researchers have focused on tissue
extensibility dysfunction and perception of functional
ability, and successful results demonstrated pain
reduction and improved function.39,43,45 One benefit
for the clinician in using an instrument resides in
the reports of decreased strain on the hands.5,43,44 No
differences were reported in patient satisfaction or
clinical improvements between manual soft tissue
mobilization and IASTM.44
Active Release Techniques
ART consist of soft tissue treatment methods intended
to treat injuries to fascia, ligaments, joint capsules,
muscles, tendons, and nerves.3 Soft tissue adhesions
resulting from strain, cumulative trauma, and constant
pressure are released using compression, tension,
and shearing forces during active patient movement.3
Shearing forces are achieved through active or passive
tissue shortening followed by manual pressure from the
clinician.3 The pressure between clinician and patient is
maintained as the patient actively elongates the tissue.3
The ART paradigm is grounded in foundational soft
tissue methods, such as muscle pressure,46,47 stretch-
ing,48 and friction massage,23 that have been indicated
to result in pain modulation.
Clinical efficacy has been mixed in studies using
one of the foundational forms of soft tissue mobi-
lization for ART.41,47,49,50 Chaudhry et al.41 explored
the effects of ischemic compression on active ROM,
surface electromyography, and pain threshold, with
improvement in all measures.41 Fryer and Hodgson47
reported muscle pressure release technique pro-
duced less sensitivity to painful pressure, while other
researchers found no significant difference in ischemic
compression and transverse friction massage used in
ART for trigger points.49 Hanten et al.50 observed that
ischemic compression followed by stretching resulted
in decreased patient-reported pain. Further research
on the combined effects of compression, tension,
and shearing forces with muscle activation under the
ART paradigm is needed. A lack of research in these
areas limits the understanding of potential benefits of
combined soft tissue mobilization methods compared
with others. Current contraindications for ART include
blunt trauma and active inflammation.46
Recent theories may explain how ART produces
a therapeutic effect.46–48,50 Neurophysiologic theory
claims mechanical forces can elicit physiological
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changes in patients via mechanoreceptors.49 Robb
and Pajaczkowski51 hypothesized physical contact
between the clinician and the patient stimulates
cutaneous and intramuscular mechanoreceptors;
the stimulation may alter nociception and patient
pain or result in Hoffmann reflex inhibition due
to stimulation of afferent fibers. 49 Ruffini endings
and type IV mechanoreceptors modulate pain with
sustained deep pressure consistent with ART.52 The
compressive action applied during ART can elicit a
noxious stimulus to release endocannabinoids that
inhibit nociceptive transmission.53,54 The literature
does not fully support the neurophysiologic theory,
but it provides insight into how ART may provide a
positive therapeutic outcome. To firmly establish the
rationale for clinical use, future research is needed on
how ART influences histological function of the body
and fundamental changes in tissue structure.
Comparing and Contrasting Therapies
MFR therapy, IASTM, and ART all intend to improve
pain and/or ROM. 14–17,39,42,43,55,56 Distinctions exist
between IASTM, ART, and indirect MFR regarding the
amount of suggested mechanical force applied (Table
1).12,35,57 Only a few grams of pressure are applied
using indirect MFR, while IASTM and ART do not have
suggested applications of force.12 Researchers have
demonstrated that increased force (i.e., 0.5 N/mm2 to
1.5 N/mm2) increased fibroblast proliferation as the
force increased,58 while others found that 250–300g
of downward force was enough to promote healing in
laboratory animals when using isntruments.59 Patients
displaying higher sensitivity to mechanical force and
lower application tolerance may respond better to
MFR considering the fact that IASTM often results in
bruising and petechiae.60
Differences in total treatment time between ART,
IASTM, and MFR may favor one intervention over
another.5,12,15,43,56,61 Indirect MFR often requires 90 s
to 5 min at multiple sites of fascial dysfunction.12,14–16
IASTM treatment time has not been fully and consis-
tently established and has ranged in previous research
from 40 s to 18 min to produce positive patient out-
comes.5,39,42,45 Treatment time recommendations in
IASTM do not exist for specific conditions or dysfunc-
tions, but generally are approximately 5–6 min. ART
methods are directed using repetitions and patient
perceptions of symptoms instead of defined time
intervals.56,61
 Table 1.  Comparison of Associated Characteristic Variables
of ART, IASTM, and Indirect MFR
ART IASTM Indirect MFR Therapy
Theoretical basis Connective tissue remodel- Connective tissue remodel- Connective tissue remodel-
ing through ischemic com- ing; initiation of inflamma- ing through fascial unwind-
pression and active move- tory process ing
ment
Specialized skills
1. Evaluation Palpation of affected tissue Detection of tissue restric- Observation, sensing tissue
before treatment tions/adhesions with instru- tension, and movement
ment during treatment restriction before treatment
2. Therapeutic action Fascial release through Initiation of inflamma- Fascial release through
shearing effect tory process and collagen tissue deformation
realignment
Therapeutic touch/movement
1. Type Clinician’s hands Instrument Clinician’s hands
2. Amount of force Variable based on presen- Variable based on presen- A few grams
tation tation
Acute/chronic condition Chronic Chronic Acute and chronic
treated
Certification/training needed Yes, course attendance Dependent on particular No, but courses are recom-
instruments mended
Length of treatment time (1 5–15 min 5–6 min average 5–30 min
session at 1 region)
Number of sessions 3–5 per week Optimal amount not deter- Optimal amount not deter-
mined mined
Abbreviations: ART = active release techniques; IASTM = instrument-assisted soft tissue mobilization; MFR = myofascial release.

Therapeutic effects differ between MFR and
IASTM.13,43 Controlled inflammatory responses are
activated using IASTM.5 Indirect MFR and ART do not
intend to elicit an inflammatory response.4 All three
interventions use similar application directions in a
multidimensional plane to correct fascial disfigure-
ment.2,3,5,12,61 Certification and training programs for
MFR, IASTM, and ART differ slightly and are encour-
aged for clinicians to apply these therapies correctly.
MFR therapy training is recommended, although not
required, for clinicians. IASTM certification is required
by certain IASTM companies (i.e., Graston Technique),38
while others recommend but do not require it. ART
certification requires potential clinicians to be licensed
health care professionals with malpractice insurance
and within the appropriate scope of practice to perform
soft tissue treatment.5
The outcome measures most commonly used with
each therapy demonstrate improvements in pain and
ROM (Table 1).4,5,14–17,39,43,56 Immediate improvements
in ROM were found after treatment using IASTM and
MFR.5,18,39,43,55 There is evidence to support the short-
term outcomes of MFR14–16 and IASTM,29,39,42,45 but
limited evidence exists for the long-term benefits of
these treatment protocols. Future research must be
conducted to track long-term patient outcomes and
generate evidence to support or refute long-term use
of these interventions in particular clinical scenarios.
Indirect MFR, IASTM, and ART share similarities
and have differences in theoretical bases. ART requires
active movement from the patient to achieve releases
of soft tissue adhesions.3 IASTM offers a mechanical
advantage through external instrumentation use to
initiate a local inflammatory response to promote
new collagen formation and fibroblast formation in
tissues.5,34 Indirect MFR is believed to offer morpholog-
ical changes in connective and neuromuscular tissue
and may optimize fibroblast activity through force
application in ways similar to IASTM.2,9 Randomized
control trials are limited, but current research indicates

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clinical effectiveness using indirect MFR for particular
anatomic pathologies.14,16,21,58
Conclusion
The choice of a specific myofascial therapy should be
primarily directed by a patient’s individual presenta-
tion (e.g., root cause of dysfunction) and include the
patient’s sensitivity to pressure, pain threshold, and
available treatment time. Evidence exists to suggest
MFR, IASTM, and ART can be used to decrease pain and
dysfunction associated with a variety of pathologies.
Based on the available literature evidence, IASTM can
produce a positive impact on degraded tissue and is
more likely to produce favorable outcomes in shorter
treatment times. MFR would likely produce better
patient outcomes for general myofascial restrictions.
The lack of research evidence on ART prevents defin-
itive recommendations at this time. Clinicians should
use patient outcomes analysis and a systematic classi-
fication approach to better match myofascial therapy
interventions to patient presentations. 
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Janet McMurray is head athletic trainer and an instructor in the
Kinesiology Department, McMurry University, Abilene, TX; and is
also currently a doctoral student of athletic training, Department of
Movement Sciences, University of Idaho, Moscow, ID.
Scott Landis is with the School of Behavioral and Health Sciences,
King University, Bristol, TN; and is also currently a doctoral student
of athletic training, Department of Movement Sciences, University of
Idaho, Moscow, ID.
Kris Lininger is with the Department of Kinesiology, Health, and
Athletics, College of the Siskiyous, Weed, CA; and is also currently a
doctoral student of athletic training, Department of Movement Sci-
ences, University of Idaho, Moscow, ID.
Russell T. Baker and Jeff Seegmiller are with the Department of
Movement Sciences, University of Idaho, Moscow, ID.
Alan Nasypany is with the Division of Health, Physical Education,
Recreation & Dance, University of Idaho, Moscow, ID.
Trent Nessler, PT, DPT, MPT, Champion Sports Medicine/Physiotherapy
Associates, is the report editor for this article.