Graston technique^®

A contemporary instrument assisted mobilization method for the evaluation and treatment of soft tissue lesions

Introduction

This chapter is intended for manual therapists and clinicians who use their hands directly on the body to achieve therapeutic results. While manual therapists have grown to believe nothing can enhance their manual palpation skills – and, in fact, it is true there are some qualities that cannot be replaced by human touch, there is considerable evidence that the use of instrument-assisted soft tissue mobilization (IASTM) is making a major difference to clinicians and their patients.

IASTM, researched in the early 1990s, was introduced formally in 1994. The original patented technology, Graston Technique^® (GT-IASTM), incorporates the use of stainless steel instruments to effectively treat soft tissue dysfunctions. While it may seem an unusual protocol for a manual therapist to use stainless steel instruments to treat soft tissue dysfunction, incorporating Graston Technique^® instrument-assisted soft tissue mobilization (GT-IASTM) is growing as clinicians and patients become more familiar with its benefits. While no instrument could ever replace all the qualities of human touch, Graston Technique^® (GT) is growing as clinicians and patients become more familiar with its benefits. The protocol is designed to provide an additional modality to the effectiveness of many of our hands-on methods. Actually, adequate manual dexterity is necessary for this method to be applied successfully.

The specially patented contoured beveled edges in the six stainless steel instruments comprising the GT instrument set greatly enhance palpatory skills. The technique is a comprehensive approach that, based on examination findings, integrates IASTM with a rehabilitation program, including targeted stretching and strengthening exercises. Lewit (1993) states that soft tissue techniques in general are applied to treat dysfunction and unless the dysfunction is understood the best of techniques may be used in the wrong place and at the wrong moment. In GT a functional examination is always stressed beforehand to determine the right place to use the instruments.

The use of GT is changing the paradigm of soft tissue methods only being used to restore dysfunction. Recent research is pointing to the additional role of affecting tissue pathology. The effect of mechanical load on degenerated soft tissue (Hammer 2008a) via its effect on fibroblasts and the extracellular matrix has added a new dimension to the treatment of dysfunction.

GT is especially valuable in treatments that rely on palpation of deep fascial fibrotic changes. It is especially effective in determining the direction of fascial barriers. GT’s ability to feel has been compared to the use of a stethoscope for the detection of heart sounds. Graston Technique^® incorporates at a minimum seven different strokes and has a variety of instrument angulations and pressures, depending on the contour of the body and the type of changes desired. The larger instruments can be used over broader areas while the smaller instruments can be used for localized treatment. At present there are thousands of clinicians and about 120 professional and amateur sports teams around the world using GT (Arnolt, personal communication 2009).

A major obstacle in the life of clinicians who use their hands is the development of repetitive trauma injury to their hands and upper extremities over time, adding to the difficulty of practice (Snodgrass et al. 2003). Most clinicians state that the use of these instruments reduces manual stress in their hands and upper extremities.

It is established that “movement and mechanical forces maintain healthy cartilage, bone, muscle and tendons by regulating tissue remodeling. Remodeling is required to remove damaged cells and matrix (catabolic) and to replace damaged tissue (anabolic)” (Ramage et al. 2009). This scenario occurs with ordinary exercise. It appears that methods such as GT could, in effect, be performing a form of localized exercise to a lesion. In the tendon, for example, the fibroblast is considered a key player in tendon maintenance, adaptation to changes in homeostasis, and remodeling in cases of minor or more severe disturbances to tendon tissue (Kjaer et al. 2009). Studies have shown that, with mechanical load, increased fibroblastic proliferation (Davidson et al. 1997; Gehlsen et al. 1999) occurs that is responsible for reproducing the extracellular matrix (ECM), especially collagen 1, elastin, cytokines, and growth factors, among other important proteins. It is hypothesized that for degenerated connective tissue (i.e., tendinosis) GT re-initiates the inflammatory process by introducing a controlled amount of microtrauma to the affected area. A healing cascade is created by enhancing the proliferative invasion of blood, nutrients, and fibroblasts to the region, resulting in collagen deposition and eventual maturation. According to Kraushaar & Nirschl (1999), since tendons have an intrinsic capacity to heal, healing can occur if a fibroblast-driven process integrates old and new collagen in order to contribute to the final stability of the matrix. Khan et al. (2000) state that “The focus of any conservative management program should be to encourage collagen synthesis, maturation, and strength.” But mechanical loading can be used to mechanically mobilize scar tissue, increasing its pliability and loosening it from surrounding healthy tissue without creating inflammation. Standley (2007) demonstrated that manual light myofascial treatment was anti-inflammatory and Yang et al. (2005) hypothesized that repetitive, small magnitude stretching was anti-inflammatory, while large magnitude stretching was proinflammatory.

Clearly, more studies are required to determine the many effects of manual loading, but just as motion and exercise are related to homeostasis, it is now clinically uncontested that positive healing results are occurring with manual loading. Miller et al. (2005) showed that by using acute exercise such as 1 hour of knee extension against resistance to fatigue, the collagen synthesis rate remained elevated for at least 2–3 days. Both a single loading bout as well as long-term habitual loading produced a markedly elevated collagen synthesis response (Langberg et al. 1999). A recent study on the effect of manual loading on soft tissue was conducted by Loghmani & Warden (2009). Bilateral transections of the medial collateral ligaments of rodents were performed. After 1 week, one side was treated with GT for 1 minute three times per week for 3 weeks. The opposite side served as an internal control. The GT-treated ligaments were assessed at 4 weeks and found to be 43.1% stronger, 39.7% stiffer, and could absorb 57.1% more energy before failure. Histological studies showed the treated ligaments had improved collagen fiber bundle formation and orientation within the scar region compared with the nontreated ligaments. Plate 7.14.1(A) shows the nontreated control. Plate 7.14.1(B) shows the GT-treated ligaments showing increased cellularity and more regularly oriented, elongated fibroblasts. At the end of 12 weeks there were minimal differences, although the GT-treated ligaments were 15.4% stiffer. Although the overall long-term effect of healing was similar, the study showed that the earlier return of ligament tissue-level biomechanical properties may allow quicker return to function with less susceptibility to reinjury.

Applications

GT is effective almost everywhere on the body where there are superficial and deep fascia and retinaculum. Listed below are some of the common areas that have responded to IASTM. GT protocol consists initially of tissue warm-up (exercise, moist heat, ultrasound), treatment at least four days apart on the same area, 30 seconds to 1 minute for localized areas and 3–5 minutes for local regions. Immediately after treatment, stretching is performed and eventually, targeted strengthening. Cryotherapy is recommended if necessary. It is important to treat and evaluate areas from both a local and global kinetic perspective. GT is contraindicated for patients with open wounds, nonunion fractures, thrombophlebitis, hematoma, or any other condition contraindicated for soft tissue manipulation, including patient intolerance or noncompliance (Hammer 2007).

Plantar fasciopathy, Achilles tendinopathy, lower extremity disorders

GT protocol is always based on evaluation and treatment of the kinetic chain and might include for the above areas treatment from the plantar fascia to the proximal Achilles tendon (Fig. 7.14.1), triceps surae, hamstrings, anterior and lateral thigh fascial areas. The chain is evaluated by passive stretching, resistive testing, gait analysis, palpation, and scanning with the instrument for restrictive fascial barriers. GT is effective for the treatment of ligamentous ankle sprains, including associated edema and the associated retinacula (Melham et al. 1998).