Graston technique

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clubdeac

clubdeac

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Any of you PTs use this and if so what are its indications and more importantly does it work??
 
I had an athletic training clinical instructor who uses graston on athletes often at the olympic training center he works at. His supervising sports med. physician would refer patients to him for graston treatments and sometimes have him come to his office to treat multiple patients in an afternoon. Can't speak to its efficacy though.
 
I know a few PTs who have used this technique, and I've had the opportunity to feel how it works. It's basically a form of instrument assisted soft tissue mobilization, and rooted in the Cyriax model. The instrument you use actually amplifies what the PT feels in the tissues, meaning you can literally feel tissue adhesions, scar tissue formation, fibrotic tissue, and restrictions. When you glide the instrument firmly against the adhesive soft tissue, you can feel the catches, bumps, and irregularity in the tissues through the metal instrument. Then with the same instrument, you are able to mobilize the tissue. There have been a few studies, and there are more emerging showing the clinical meaningfulness of the technique.
 
Is there a gold standard for the instrument used or technique used in instrument assisted soft tissue techniques?
 
I'm an ATC on my way to PT school and am certified in Graston Technique. While working at the university level we often used Graston and I even use it occasionally in the PT clinic. If used properly you can observe noticeable increased soft tissue extensibility after just one treatment.

az- I'm not sure there is a defined gold standard. Graston really emphasized their superior instrument design, but I'm sure so does every other corporate producer of such product. As far as technique, I think most IASTM involves very similar approaches.
 
I have been trained in Graston Technique for about 18 months. I love it. We use it in the PT clinic with a lot of our patients. We have GT instruments in every clinic. And then we also have a set of knock-off tools in one clinic and I have two of the Edge tools that I use at the high school.

There is another company called Hawk Grips or something like that who have a set of instruments that are nearly identical to the GT set.
 
Is there reliable scientific evidence for this technique? I am busy studying for a couple of exams so do not have time to sift through PubMed, but I did find this article:
http://www.sciencebasedmedicine.org...hnique-inducing-microtrauma-with-instruments/

The GT website (grastontechnique.com) seems to be down right now. However, two items from the above article are interesting:
- "the Graston Technique instruments, much like a tuning fork, resonate in the clinician’s hands allowing the clinician to isolate adhesions and restrictions": resonate with what? I am skeptical about claims that the human body has a resonant frequency. It has too many interconnected organs and structures and computing a resonant frequency for it would be a computational nightmare. And even if you accept some of the numbers that have been published, there is no way a PT can match even the lowest frequency shown, 5 Hz (BTW I have 2 degrees in mechanical engineering and determining a resonant frequency for a system is quite complicated - I don't know how they got the numbers in the link below):
http://physics.stackexchange.com/qu...ve-a-resonant-fequency-if-so-how-strong-is-it

- Do the instruments really cost $3K??
 
Just being recently researched. It'll take a few years to get RCTs, then high-quality RCTs, then a bit longer for systematic review/meta-analyses.
 
goyo1010 said:
Just being recently researched. It'll take a few years to get RCTs, then high-quality RCTs, then a bit longer for systematic review/meta-analyses.
Click to expand...

How about starting with a plausible hypothesis based upon known science?
 
How does one get "ITB Tendinitis" (as described on Graston outcome data)?

Any type of tool assisted massage is great for clinicians and patients, but paying 2-3k on tools is just a scam in my eyes.

There are newer tools called sastm and are ceramic. From what I have read, Graston sold his company and started a new one (sastm). There is also ASTYM, which is pretty cool as well.

I think the moral of the story is you don't have to have a specific name to get good results. You could do gua sha (the original) with spoons and coins, or make your own instruments from orthoplast, and still get the benefits of tool assisted massage.
 
I think one of the benefits of using the Graston instruments (they are very big on not calling them tools) is that they are made of a non-porous stainless steel. For sanitary reasons a non-porous material is much better than say orthoplast or ceramic material which, if used on numerous patients/clients, may transfer harmful bacteria even if cleaned after each use. I'm not saying that everyone should go out and pay $2000-$3000 on the instruments, just a point to consider.
 
Ewozob

That is a very good point, and I had no idea! Thanks for that contribution to this discussion.
 
Good discussion. Thanks for all the comments, much appreciated. I think I'll refer my patient and see what kind of outcome he gets. Thanks
 
I think this bandwagon of praising Graston technique based on anecdotal experiences is ludicrous. If you read the research objectively, there is nothing remotely convincing enough to convince a medical professional to use the treatment. It is irresponsible to use a treatment approach without sufficient evidence of safety and efficacy. The treatment may not work, in which case you are foregoing other treatments that would be helping the patient, and wasting time and money. The treatment may also be harmful, in which case you are actively causing damage to the patient. Or, the treatment could be effective: well constructed clinical trials would demonstrate this. You cannot just assume a fancy treatment works for any reason. Doing so, in my opinion, is morally wrong and unfair to your patients.

Here is a short article by a physician on the evidence for Graston

Here is another article on tissue provocation in general that also discusses Graston
 
RamonyCajal said:
I think this bandwagon of praising Graston technique based on anecdotal experiences is ludicrous. If you read the research objectively, there is nothing remotely convincing enough to convince a medical professional to use the treatment. It is irresponsible to use a treatment approach without sufficient evidence of safety and efficacy. The treatment may not work, in which case you are foregoing other treatments that would be helping the patient, and wasting time and money. The treatment may also be harmful, in which case you are actively causing damage to the patient. Or, the treatment could be effective: well constructed clinical trials would demonstrate this. You cannot just assume a fancy treatment works for any reason. Doing so, in my opinion, is morally wrong and unfair to your patients.
Click to expand...

Gee, this never happens in other areas of medicine. 🙄
 
RamonyCajal said:
I think this bandwagon of praising Graston technique based on anecdotal experiences is ludicrous. If you read the research objectively, there is nothing remotely convincing enough to convince a medical professional to use the treatment. It is irresponsible to use a treatment approach without sufficient evidence of safety and efficacy. The treatment may not work, in which case you are foregoing other treatments that would be helping the patient, and wasting time and money. The treatment may also be harmful, in which case you are actively causing damage to the patient. Or, the treatment could be effective: well constructed clinical trials would demonstrate this. You cannot just assume a fancy treatment works for any reason. Doing so, in my opinion, is morally wrong and unfair to your patients.

Here is a short article by a physician on the evidence for Graston

Here is another article on tissue provocation in general that also discusses Graston
Click to expand...

Yeah. Opiods, muscle relaxers, NSAID's, x-rays and MRI's are the way to go in addition to the "wait and see approach." Percocet is the number one prescribed medication in the US is it not? Please enlighten me about the relative safety of "graston" vs NSAID's and opiods, and cite me some evidence that justifies their excessive use. Enlighten me how boob jobs are ok. How about lumbar fusions, tell me about that as well. Oh, and how about you fork over a few billion dollars that goes into the research for the interventions that you use. It's not exactly easy to do exaustive research to the level that everyone will smile about when there isn't millions of dollars left and right like there is in medicine.
 
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Fiveoboy11 said:
Yeah. Opiods, muscle relaxers, NSAID's, x-rays and MRI's are the way to go in addition to the "wait and see approach." Percocet is the number one prescribed medication in the US is it not? Please enlighten me about the relative safety of "graston" vs NSAID's and opiods, and cite me some evidence that justifies their excessive use. Enlighten me how boob jobs are ok. How about lumbar fusions, tell me about that as well. Oh, and how about you fork over a few billion dollars that goes into the research for the interventions that you use. It's not exactly easy to do exaustive research to the level that everyone will smile about when there isn't millions of dollars left and right like there is in medicine.
Click to expand...

I am not going to "tell you about" all the research supporting treatment strategies for different ailments for different conditions. Do a quick literature search yourself, there is a lot out there. But your examples illustrate a key point: drugs like NSAIDs and opiates undergo extensive double-blinded clinical testing to assess efficacy and safety for specific conditions (pain, inflammation, etc). There are volumes of research on many aspects of x-rays, MRI, etc., as there should be. This is what should happen for all treatments. Surely you're not implying that painkillers like percocet aren't effective at reducing pain? That is their intended use, and at proper dosages under appropriate circumstances they are incredibly effective. This is unrelated to the fact that many physicians overprescribe them in inappropriate circumstances.
Just because a treatment is not pharmaceutical in nature does not mean it is without risks. For a patient and caregiver to do an appropriate cost-benefit analysis you need adequate research. Are you suggesting that treatments should be employed without assessing safety and efficacy?? That is ridiculous and irresponsible. You don't necessarily need exhaustive research, but adequate enough to demonstrate a clear benefit, yes of course. Well designed clinical trials with a technique like Graston would not be very expensive to conduct, so I'm not sure what you're getting at there. Have you read the supporting research for this treatment? It is woefully inadequate. There is essentially a plausible biological mechanism demonstrated in one small mouse study and some very unconvincing case studies. What do boob jobs have to do with this? Do you not think research went into determining the proper procedures and safety precautions of breast enhancement/reduction? I do not understand your argument at all. I think we have a fundamental misunderstanding in that you don't seem to believe treatments need evidence before being employed, which is a strange position to take in a profession that should be about treating problems in the safest and most effective manner possible.
 
RamonyCajal said:
I am not going to "tell you about" all the research supporting treatment strategies for different ailments for different conditions. Do a quick literature search yourself, there is a lot out there. But your examples illustrate a key point: drugs like NSAIDs and opiates undergo extensive double-blinded clinical testing to assess efficacy and safety for specific conditions (pain, inflammation, etc).

There's about 30k deaths/year from opiods, and about 3500/year from NSAIDs. Vicodin alone is prescribed 150 million times per year in the US alone and is the #1 prescription. That is not justified. Canada and the UK do not have a single opiod on the top ten prescription medications, so I'm guessing it's really not necessary Sure they have their place, but the utilization of them is excessive. .

There are volumes of research on many aspects of x-rays, MRI, etc., as there should be. This is what should happen for all treatments.

There's lots of research showing the over utilization of x-rays and MRi's as well for NMSK conditions. This equates to increast cost and delayed appropriate care. These have their place as well, but they're not indicated as much as they're utilized.

Surely you're not implying that painkillers like percocet aren't effective at reducing pain? That is their intended use, and at proper dosages under appropriate circumstances they are incredibly effective. This is unrelated to the fact that many physicians overprescribe them in inappropriate circumstances.

Prescribing in inappropriate circumstances, when there's guidelines and clear danger and strong research/evidence, is far worse than using a benign intervention (i.e. Graston) when it's a form of commonly used intervention anyway.

Just because a treatment is not pharmaceutical in nature does not mean it is without risks. For a patient and caregiver to do an appropriate cost-benefit analysis you need adequate research. Are you suggesting that treatments should be employed without assessing safety and efficacy??

In a perfect world every intervention utilized by healthcare providers would have exhaustive research. Sadly, the world is not perfect, let alone healthcare, let alone healthcare in the US. Use of conservative measures such as Graston as indicated despite lack of research to the satisfaction of physician's who are accustomed to FDA regulated and Pharmaceutical sponsored research does not make it inappropriate or suspect of danger. There's a reason why medications are held to such high standards and strict study, because even after all that they can kill people left and right. And there's a reason why it's not required to study many conservative measures for NMSK conditions, because there's little to no danger.

Keep in mind that Graston/ASTYM are performed on patient's who are often non medicated, non sedated, non anesthatized. There's feedback between the clinician and patient prn. They can feel what's going on. It's not done on peripheral neuropathy, or quadriplegics. If it was dangerous, it would be better regulated.

That is ridiculous and irresponsible. You don't necessarily need exhaustive research, but adequate enough to demonstrate a clear benefit, yes of course. Well designed clinical trials with a technique like Graston would not be very expensive to conduct, so I'm not sure what you're getting at there. Have you read the supporting research for this treatment? It is woefully inadequate. There is essentially a plausible biological mechanism demonstrated in one small mouse study and some very unconvincing case studies.


Looks like ASTYM has done 1 RCT.
http://www.astym.com/Content/documents/ASTYM Research Summary.pdf

Lots of pilot studies, case reports, case series, histological studies on rats. Is there any evidence, even at the lowest level, of danger? Not beyond minor temporary side effects (i.e. bruising, swelling, tenderness). The above "studies" do indeed show benefit. Should we go off what we have, or dismiss it until 100 years from now when the research is to everyone's satisfaction?

What do boob jobs have to do with this? Do you not think research went into determining the proper procedures and safety precautions of breast enhancement/reduction? I do not understand your argument at all. I think we have a fundamental misunderstanding in that you don't seem to believe treatments need evidence before being employed, which is a strange position to take in a profession that should be about treating problems in the safest and most effective manner possible.
Click to expand...

I think you misunderstand that Graston is just deep tissue massage, or augmented soft tissue mobilization, which is a component of manual therapy that has been practiced by PT's for > 100 years. As far as I know manual therapy as a umbrella term has little high quality study evidence for tendinopathy and soft tissue fibrosis. Should we halt all manual therapy for patellar tendonitis, plantar fasciitis, epicondylalgia, hamstring tendinopathy? Should PT's across the world halt all interventions because the evidence is not to the level of pharmaceuticals and surgeries? I'm all in favor of doing high level research, but perhaps professions should patrol their own as there's plenty of inappropriate practice patterns even in medicine.
 
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You can argue for "evidence-based practice" all day long, but don't you at some point have to actually do it on a patient to get that research evidence?

Graston Technique, along with other forms of IASTM, are plenty safe for most patients. A skilled clinician knows which patients cannot benefit from IASTM or other forms of massage. You can go online and find all sort of videos of awful things that individuals have been able to do with a Graston Instrument, etc but they're doing it WRONG!

I love utilizing IASTM and we do it on a regular basis with our patients. My athletes have seen incredible results in the last 2 years I've used it..
 
I don't believe the cost of the equipment is worth it, but I've spoken with a good number of colleagues that have had success with Graston. I recently purchased an IASTM tool and will be attending a Graston educational course for ceus this weekend.
 
DPTErudition said:
I don't believe the cost of the equipment is worth it, but I've spoken with a good number of colleagues that have had success with Graston. I recently purchased an IASTM tool and will be attending a Graston educational course for ceus this weekend.
Click to expand...

Years ago when Graston was just getting rolling, a friend of mine had registered for their course, which was advertised for a particular price. When he told them he wouldn't be needing to purchase tools because his practice partner already had them, he said they jacked up the price of the seminar on him!
 
facetguy said:
Years ago when Graston was just getting rolling, a friend of mine had registered for their course, which was advertised for a particular price. When he told them he wouldn't be needing to purchase tools because his practice partner already had them, he said they jacked up the price of the seminar on him!
Click to expand...



I can definitely tell you this is not true today... I took the Graston course in December and was charged the same price as those who were buying the instruments.
 
ewozob said:
I can definitely tell you this is not true today... I took the Graston course in December and was charged the same price as those who were buying the instruments.
Click to expand...

Glad to hear it. That story always stuck in my mind, but in fairness it was probably 14 or 15 years ago.
 
Here are a few studies to look at:

http://www.ncbi.nlm.nih.gov/pubmed/21276190

http://www.ncbi.nlm.nih.gov/pubmed/17905355

http://www.ncbi.nlm.nih.gov/pubmed/22928824

http://www.ncbi.nlm.nih.gov/pubmed/23313532

The idea that manual therapy or tool assisted massage isn't supported by the evidence is wrong. It may be conflicting (just like many things in medicine), and its effectiveness may not be explained by the same mechanism advertised, but above are a few studies that show the significance of a tool assisted massage technique, and one looking at MT in OA patients. Also, when used following basic MT principles, there is nothing unsafe about it.

I agree that quackery is present, especially when the cost rises exponentially on the tools and certification, and when they say things like "ITB tendinitis" (*cough* Graston *cough*). However, there are noted benefits ranging from "increasing microcirculation (iffy in my opinion)," to "a powerful placebo effect," and a continual trend of reducing pain when compared to the control.

Obviously, more research is needed, and it is conflicting, but that doesn't mean it should be thrown out quite yet. However, it also doesn't mean we should go spend 8k on Graston, ASTYM, sastym, or joshtym tools and certs anytime soon.
 
I am a PT supervisor who treats patients and have been heavily into manual therapy for 28 years. In my clinic I have 3 PT's who have been through both Graston courses. 2 of the 3 therapists have purchased graston tools and we have a clinic owned set of tools from adhesion breakers. I have been using those adhesion breakers for a few years now and they definitely take stress off my fingers and my patients seem to feel it is at least as effective as my fingers but my hands will tell you that on Saturday they are not as sore as they were when I was not using these metal instruments. I have had 2 therapists work on my ITB with both sets of instruments to see if I felt a difference and there was an obvious difference to me. The graston tools felt better and I have used both tools on patients and the graston tools felt better than the adhesion breakers. We are going to take a look at Hawk grips in the near future. Although not cheaper than Graston they do not require ownership of tools to take the second of the graston courses. (which graston does require) We tried the edge tool and 6 of 6 PT's didn't feel it was something they would want to use again. This is just my experience, your mileage may vary.
So, if you get the chance have someone work on you with both sets of tools and see what you think.
 
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