Separating Evidence from Enthusiasm-IASTM and Cupping

As the in-service season picks up, clinicians and students alike are diving into new topics and brushing up on both foundational and fringe interventions. This month’s article features insights from a recent in-service by our colleague Dawson Beeler, SPT, who took on two treatment approaches that continue to stir debate in rehabilitation: Instrument-Assisted Soft Tissue Mobilization (IASTM) and Cupping Therapy.

Both techniques are widely used and heavily marketed, yet their clinical value remains a topic of contention. While some therapists consider them indispensable tools in their practice, others question their validity and underlying mechanisms. This edition examines the proposed roles of each intervention, explores the supporting (and contradicting) evidence, and compares them to traditional manual therapy approaches.

Hype or Helpful?

IASTM and cupping are often viewed as polarizing modalities. Proponents of IASTM highlight its precision and efficiency, citing its ability to reach deeper fascial layers while reducing clinician fatigue. Cupping, on the other hand, is praised for its decompressive effect and historical relevance, though it is frequently critiqued for lacking rigorous scientific validation.

Critics argue that both interventions may rely more on placebo than physiology. Randomized trials and systematic reviews often yield inconsistent or minimal differences in outcomes compared to sham treatments or standard care. Yet anecdotal support remains strong, and many patients report feeling better after treatment. This divide underscores the importance of applying evidence-informed clinical reasoning when deciding whether and how to integrate these techniques.

Instrument-Assisted Soft Tissue Mobilization:

What is it?

IASTM uses rigid tools to apply mechanical pressure to fascia, muscle, and connective tissue. By modifying stroke direction, angle, and depth, clinicians aim to influence tissue quality and mobility beyond what is feasible with manual contact alone¹ .

Reported Benefits and Proposed Mechanisms:

1. Pain Reduction: Mechanical stimulation from IASTM is believed to modulate pain through the gate control theory and mechanoreceptor activation. By applying shear forces to tissue, A-beta fibers are stimulated, inhibiting nociceptive input from A-delta and C fibers^1,2 .

2. Improved Range of Motion: IASTM may enhance ROM by mechanically disrupting cross-linked collagen and myofascial adhesions. Perpendicular strokes can realign scar tissue, while parallel strokes help reduce fascial viscosity and promote tissue extensibility^1,3 .

3. Enhanced Circulation and Edema Reduction: Superficial strokes stimulate cutaneous microcirculation and lymphatic drainage. This effect is attributed to endothelial nitric oxide release, vasodilation, and increased interstitial fluid movement, especially when performed in parallel with lymphatic pathways^1,3 .

4. Cellular Response and Remodeling: Tissue microtrauma from IASTM is hypothesized to initiate a local inflammatory cascade that stimulates fibroblast proliferation, collagen synthesis, and reorganization of extracellular matrix components. This controlled irritation may help remodel chronic or fibrotic tissue, restoring pliability and resilience^3,5 .

Indications: 

• Myofascial pain or trigger points

• Chronic back or neck pain

• Soft tissue adhesions

• Muscle strains or tendinopathies

• Restricted ROM

• Localized swelling or edema^1–4

Contraindications:

Absolute: Open wounds, recent fractures, malignancy, infection, DVT, advanced osteoporosis, anticoagulation, surgical hardware¹ .
Relative: Hypertension, pregnancy (lumbar/abdomen), pacemakers, pediatric/geriatric patients, sensory impairments, allergic reactions to lotions, burn scars¹ .

Cupping Therapy:

What is it?

Cupping therapy applies negative pressure to the skin and underlying tissue through suction. This decompressive force elevates superficial fascia and dermal structures, theoretically relieving tension and stimulating circulation⁶ .

Reported Benefits and Proposed Mechanisms:

1. Pain Relief: Cupping is thought to desensitize nociceptors by reducing tissue stiffness and compressive load on pain-sensitive structures. It may also increase endogenous opioid release and activate descending inhibitory pathways via mechanotransduction and sensory adaptation^6,7 .

2. Tissue Decompression and Fascial Mobility: Unlike compression-based manual therapy, cupping lifts the tissue layers, potentially reducing densification between the superficial fascia and skin. This decompression may help restore fascial glide and improve mobility, especially in regions of superficial stiffness⁶ .

3. Improved Blood Flow and Healing: Suction increases local circulation by dilating capillaries and promoting erythrocyte extravasation. This “therapeutic bruising” is thought to stimulate inflammatory mediators that facilitate healing and tissue regeneration, although the benefit remains debated in literature^6,7 .

4. Scar Remodeling: Through fibroblast activation and matrix remodeling, cupping may improve scar pliability and reduce adhesions. Mechanical stress from suction may help reorganize collagen fibers and stimulate vascularization in fibrotic tissue⁸ .

Indications:

• Chronic low back or neck pain

• Myofascial trigger points

• Soft tissue stiffness

• Scar tissue management^6–8

ContraIndications:

Absolute: Open wounds, burns, skin infections, malignancy, anticoagulation, DVT, nerves/arteries/veins/eyes⁶
Relative: Pregnancy (abdominal/lumbar), recent trauma, pediatric/geriatric patients, hypersensitivity, discomfort with treatment⁶

Brief Comparison to Traditional Manual Therapy

Pain and ROM

IASTM has demonstrated outcomes comparable to or better than manual therapy for pain and ROM in select populations, particularly for chronic soft tissue conditions. Cupping appears to offer short-term symptom relief but often fails to outperform sham treatments in controlled trials^2,4,7 .

Functional Outcomes

Both interventions, when paired with exercise and stretching, yield functional gains. IASTM may reduce the number of required sessions due to its ability to address deep, fibrotic tissue with less clinician fatigue⁵ . Manual therapy continues to outperform in breadth of evidence, particularly where joint mechanics or neuromuscular control are targeted.

Parting Words

IASTM and cupping therapy remain debated, but they can be valuable tools when appropriately integrated. IASTM offers mechanical precision and deep tissue mobilization supported by moderate evidence. Cupping therapy, while less substantiated, may serve as a useful adjunct for patients sensitive to compression or recovering from soft tissue injury.

Both should be viewed not as replacements, but as additions to a multimodal approach grounded in functional rehabilitation, clinical reasoning, and patient-centered care.

Need a Practical Guide for these Modalities in the Clinic?

Looking for quick-reference guides to use with your patients or your team? Click the button below to download clinician-friendly handouts that summarize the indications, contraindications, benefits, and application tips for both IASTM and cupping therapy.

References:

1. Beeler, D. Instrument-Assisted Soft Tissue Mobilization (IASTM) in Physical Therapy: Indications, Contraindications, and Clinical Considerations.

2. Shewail F, Abdelmajeed S, Farouk M, Abdelmegeed M. Instrument-assisted soft tissue mobilization versus myofascial release therapy in treatment of chronic neck pain: a randomized clinical trial. BMC Musculoskelet Disord. 2023;24(1):457. doi:10.1186/s12891-023-06540-5

3. Kim J, Sung DJ, Lee J. Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. J Exerc Rehabil. 2017;13(1):12-22.

4. Agarwal S, Bedekar N, Shyam A, Sancheti P. Comparison between effects of instrument-assisted soft tissue mobilization and manual myofascial release on pain, range of motion and function in myofascial pain syndrome of upper trapezius - A randomized controlled trial. Hong Kong Physiother J. 2024;44(1):57-67. doi:10.1142/S1013702524500069

5. Pianese L, Bordoni B. The Use of Instrument-Assisted Soft-Tissue Mobilization for Manual Medicine: Aiding Hand Health in Clinical Practice. Cureus. 2022;14(8):e28623. doi:10.7759/cureus.28623

6. Beeler, D. Cupping Therapy in Physical Therapy: Indications, Contraindications, and Clinical Considerations.

7. Kim S, Lee SH, Kim MR, et al. Is cupping therapy effective in patients with neck pain? A systematic review and meta-analysis. BMJ Open. 2018;8(11):e021070. Published 2018 Nov 5. doi:10.1136/bmjopen-2017-021070

8. Lubczyńska A, Garncarczyk A, Wcisło-Dziadecka D. Effectiveness of various methods of manual scar therapy. Skin Res Technol. 2023;29(3):e13272. doi:10.1111/srt.13272

Disclaimer:

We are a current Doctor of Physical Therapy (DPT) students sharing information based on my formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While we strive to provide accurate and up-to-date information, our knowledge is based on my current academic and clinical rotations and ongoing learning, not extensive clinical practice.