Articles

The Graston Technique – Inducing Microtrauma with Instruments

The Graston Technique® is a modification of traditional hands-on soft tissue mobilization that uses specifically designed instruments to allow the therapist to introduce a controlled amount of microtrauma into an area of excessive scar and/or soft tissue fibrosis, hoping that this will invoke an inflammatory response that will augment the healing process. It is also intended to reduce the stress on the therapist’s hands.

graston instrumentsGraston treatment

Microtrauma? Hurting people to make them better? I know sometimes an improperly healed bone must be re-broken so it can re-heal in proper alignment, but this is different. It bothers me that they are further injuring already damaged soft tissues and hoping (1) that the new injury will heal, (2) that that will help the older injury heal, and (3) that it can somehow avoid stimulating the deposition of just that much more scar tissue and fibrosis. It seems to violate the “primum non nocere” principle. It is unpalatable. Of course that wouldn’t matter if the evidence showed it was effective. Does it?

Soft tissue mobilization is widely used in physical therapy, although the evidence is sparse. According to one PT website,

Soft tissue mobilization breaks up inelastic or fibrous muscle tissue such as scar tissue, move tissue fluids, and relax muscle tension. This procedure consists of rhythmic stretching and deep pressure.

A related modality is Active Release Techniques® (ART) a patented hands-on treatment. The Graston Technique appears to be just another technique in this family of techniques: one that adds a special instrument to the procedure.

The Graston Technique website tells us it is used by more than 6,500 clinicians worldwide—including athletic trainers, chiropractors, hand therapists, occupational and physical therapists. It tells us the Graston Technique® instruments, much like a tuning fork, resonate in the clinician’s hands allowing the clinician to isolate adhesions and restrictions, and treat them very precisely. It tells us the treatment is clinically proven and it has resolved 87% or more of all conditions treated. (This claim is supported only by this “outcome data” chart with no explanation of what the data mean or where they come from.)

You must pay $495 for 12 hours of training to become qualified to treat and to purchase the set of instruments. The price of the instruments is $2755 — for six curved pieces of steel.

Research listed on Graston Technique Website:

The website lists articles in the popular press, poster presentations, and testimonials, but only 3 citations that appear to be acceptable evidence from peer-reviewed journals. I will call them (1) (2) and (3). A closer look reveals that they are not what they seem.

(1) and (2) are listed as having been published in the “Journal of the American College of Sports Medicine.” There is no such journal. They obviously meant the journal Medicine and Science in Sports and Exercise which is the official journal of the American College of Sports Medicine. Study (2), by Sevier et al., was not listed in the table of contents of that journal for the issue cited (Vol 27, No. 5, 1995) and was not found by searching the journal’s entire website. It was also not listed on PubMed. If such an article exists, it apparently was not published in a peer-reviewed journal, and certainly not in the journal they say it was published in.

(1) is listed as having been published in the “Journal of the American College of Sports Medicine” in 1995. It was indeed published in the journal Medicine and Science in Sports and Exercise, but it was not published in 1995 as the citation indicates, but in 1997. It is, in fact, the same study as (3). The citation for (3) is the only correct one.

So the company’s own website offers us only one scientific article from a 12-year-old peer-reviewed study, and it turns out to be a controlled study of 20 rats. They gave half of them an Achilles tendon “injury” by injecting collagenase and treated half of those with Graston Technique. They found microscopic evidence of increased fibroblast proliferation in those treated with the Graston Technique instruments, and there was also an improvement in the animals’ gait. They killed the rats to do the microscopic studies, so there was no data about long-term outcomes. The authors ended the abstract with this disclaimer:

Although healing in rats may not translate directly to healing in humans, the findings of this study suggest that ASTM [augmented soft tissue mobilization] may promote healing via increased fibroblast recruitment.

Research Found in PubMed

A PubMed search for “Graston” brought up 7 articles. 5 were case reports, one was a description of the design of a proposed trial, and the only one that was a clinical study was a pilot study that was not very informative.

1. A case report of treatment of a tibialis posterior strain in an athlete. I thought this one was really funny. In addition to the Graston technique, the patient received acupuncture, electrical stimulation, Active Release Technique((R)), ultrasound therapy with Traumeel (a mixture of 14 homeopathic remedies), and rehabilitation. So in addition to wondering if the patient would have recovered just as fast with no treatment, we are left wondering which of these modalities or which combination of them was helpful, if any.

2. A report of three case studies.

3. Not a trial, but a description of the design of a proposed trial.

4. Case report of treating trigger thumb with both Graston and ART (active release techniques).

5. Case report of a volleyball player with costochondritis that concluded “This athlete seemed to respond positively to manipulation, soft tissue mobilization, and taping.”

6. This pilot study in patients with carpal tunnel syndrome compared soft tissue mobilization by manual techniques to STM by the Graston Technique and found no difference in clinical improvements. Instead of concluding that the Graston Technique offered no advantage over the other treatment, it concluded that it had substantiated the clinical efficacy of both. The abstract doesn’t mention the number of subjects.

7. Another case report.

There was one other study that my search failed to bring up because the abstract did not mention Graston Technique but it did use GT instruments and has been cited by GT therapists as supporting evidence (that’s how I found out about it). It was a mouse study that instead of showing that GT is clinically effective seems to show the opposite. It found favorable effects on early collagen formation and organization, but minimal to no effect on the final outcome of healing.

Summary of the Evidence

It really all boils down to a handful of mice pro, a handful of mice con, one human pilot study showing no advantage over manual mobilization, and a lot of testimonials. Would you be willing to try a new pharmaceutical treatment on the basis of nothing but one favorable mouse study out of two, and one pilot study? Would you agree to let someone deliberately injure you on such flimsy evidence? I would be very happy if the Graston Technique proves useful, but for the time being it must be considered experimental.

A Media Story that Wasn’t

And now for the rest of the story. A physical therapist approached the editor of her local newspaper asking him to do a story featuring her and this wonderful new treatment. The editor had never heard of it, but amazingly he had heard of me, and he contacted me with questions. I had never heard of it either, but I did some quick research and told him I couldn’t find much in the way of evidence. He told the physical therapist that before he could agree to write about it he needed to see some evidence. She submitted 8 items as supporting evidence. The editor forwarded them to me for comment. I commented, rather impolitely:

This isn’t supporting evidence. It’s bullshit.

1. The cover letter consists of nothing but a protracted logical fallacy: the argument from popularity. The fact that lots of people use it and think it works does not constitute evidence that it actually works. Lots of people used bloodletting and thought it worked. Lots of people believe in astrology.

2. The rat study I referred to, by Loghmani and Warden. The last sentence says “Careful interpretation of this controlled animal study is warranted until its findings are confirmed by clinical studies.” Not even the authors are claiming it is an effective treatment for humans!

3. A testimonial from Golf Digest? Come on!

4. A description of how the Graston Technique is applied.

5. Another copy of the same Loghmani/Warden rat study. Didn’t she even realize she had already provided a copy? Did she hope you wouldn’t notice and would just be impressed by the sheer number of documents?

6. A meaningless table of “outcomes” with no explanation of where the numbers came from and no controls.

7. Something they label a “case report” which does not at all fit the definition of a case report. It is a journalistic report of the preliminary phase of an unfinished 3 part study by the same author, Loghmani, in rats. It does not provide the kind of information one would expect from a scientific paper and does not follow the accepted format. It was not published in a peer-reviewed journal, but in an in-house quarterly publication by Graston Technique. It is 4 years old — by now that study should have been finished and published in a peer-reviewed journal. Why wasn’t it?

8. A description of the technique with a testimonial, published in a popular health magazine. It quotes the same researcher, Loghmani. He says “The approach SEEMS to be effective.” It offers nothing in the way of evidence.

To put this into perspective, the only actual evidence the physical therapist has offered is one study in rats. Would you want to take a pharmaceutical that had only been tested in one rat study?

In summary, there is nothing here that could be considered evidence for clinical benefits to humans. As the Aetna insurance company says, this technique must be considered “experimental and investigational, because there is inadequate evidence in the peer-reviewed published medical literature of… effectiveness.”

In my opinion, experimental treatments like this should be limited to controlled research studies. That way we could learn once and for all if it was effective and safe. To forge ahead beyond the evidence and just treat people as she is doing amounts to using people as guinea pigs in an uncontrolled experiment without informed consent.

If you run an article, you will be giving her free advertising for an unproven treatment that she is misrepresenting as proven and effective.

The editor responded,

Thank you so much. Your assessment is exactly what I needed to keep this story out of the paper.

Posted in: Science and the Media

Leave a Comment (22) ↓

22 thoughts on “The Graston Technique – Inducing Microtrauma with Instruments

  1. DevoutCatalyst says:

    “3. A testimonial from Golf Digest? Come on!”

    As an aside, I’ve noticed in recent years that skepticism is even creeping into golf magazines.

    I would like to see our news media come to view skeptics as the go-to gals and go-to guys that help thwart being carried aloft by the next balloon boy that wasn’t. So bravo to you, Harriet.

  2. Diane Jacobs says:

    Harriet, thank you for turning your skeptical attention to various dubious kinds of human primate social grooming. It’s still amazing to me, a PT who works with manual therapy, how many expensive “systems” there are out there which completely ignore the nervous system and/or the fact that sensitive, neurally dense skin, is (and always will be) between the therapist/therapist’s hands, and the patient’s fibrous ‘whatevers’. I call it mesodermalism. It seems to blind practitioners to ectodermal derivatives and the sorts of changes that the nervous system will make with just some strategic, fairly light kinesthetic coaxing and interaction.

    Diane

  3. colli037 says:

    Another poorly understood “concept” is picked up by a “practitioner” and “THE CURE” is found. We (physicians) are taught that bones get stronger with exercise because of “micro-trauma” which induces additional formation of bone. (apply this to other tissues, modify as needed to get the Graston method. Sell fancy medical device to make it work)

    Magical thinking again, similar to “like causes like”: Fibrous tissue is “bad” and caused by inflammation, so causing “controlled” inflammation in “small amounts” will magically fix the original problem.

    Diane’s comment on “Dubious kinds of human primate social grooming” is perfect.

    tim

    Their device doesn’t use electricity yet, the next version will.

  4. windriven says:

    I win: it was Mr. Graston with the iron bar in the exercise room!

    My trainer is a true believer in a weird device that is apparently made somewhere here in the Pacific Northwest. It is said to break up scar tissue and to promote healing of damaged muscle and connective tissue. I’ve forgotten just what they call the contraption – magnetic oscillator, or something – but it is in fact a high voltage power supply – like a van de Graff generator – coupled with a large clear glass ball. The ball crackles with electrical discharges and I suppose looks very impressive to the average rube. The surface of the ball is placed in contact with the ‘afflicted areas.’ When I pressed on the supposed mechanism of action I was treated to something about how the inventor is a really smart guy.

    Oh my, I’ll start treatments immediately!

  5. Scraping tendonitis … shudder! I don’t even want to brush a hot tendonitis with a feather.

    Although it’s pretty obscure, I think Graston is one of the most egregious of the modality empires (http://SaveYourself.ca/modality_empires). It’s not only implausible, unproven, and expensive, but also so painful that it may be the best example of a physical therapy with a placebo powered by the it-hurts-so-it-must-be-good factor. There are many other good candidates in that category as well, but there’s something special about an intervention that uses gleaming steel tools to inflict agony!

  6. Kimbo Jones says:

    Kudos to that journalist – keep up the good work, buddy!

  7. David Gorski says:

    Wow. I thought I had heard it all, but I had never heard of the Graston technique before. Learn something new every day…

  8. James Fox says:

    Speaking of media contact…, I had an experience with the Golf Channel a year ago when I noticed them giving a well known international golfer air time in an interview to support Age of Autism and the information AoA provided he and his wife when their son was diagnosed with autism. I immediately fired off an e-mail to the show’s producer advising them of the antiscientific anti medicine nature of the organization. When the interview was replayed the next day the portion about AoA was edited out. Not sure if I was responsible but letting media folk know about the difference between suspect advocacy organizations and ones that provide accurate information is worth the effort. A well known local Seattle TV reporter does a lot of medical reporting and she frequently gets e-mails from me pointing to this web site when she heads off to woo land.

  9. beadle says:

    “Your assessment is exactly what I needed to keep this story out of the paper.”

    Maybe you could suggest making sure this story DOES get put in the paper, exposing it for the quackery it is. It could be an example of the ever-so-rare responsible skeptical mainstream article.

  10. @David, the world of manual therapy has a bountiful supply of curious interventions! Fortunately, most are even more obscure than Graston, but there is an effectively endless supply because few of them ever die and therapists are forever coming up with new ones: going into the workshop business and peddling a pet modality is one of the standard ways that manual therapists extend their careers when they get tired of using their hands. Enough therapists go that route that I get a more or less constant flow of inquiries from SaveYourself.ca readers about the new ones.

    An interesting point that almost never gets discussed is the way that these workshops are the nearly universal source of “continuing education” credits for most manual therapists, especially massage therapists and chiropractors. To be eligible for CE credits, workshop sellers basically just submit a curriculum. Thus the concept of continuing education is rendered almost meaningless.

  11. Diane Jacobs says:

    @Paul, “therapists are forever coming up with new ones”

    Chiros are especially inventive, patenting their “tools” and copyrighting their ‘new and improved’ dubious kinds of human primate social grooming, calling ‘same old’ by a new name and altering a tiny detail here or there in the conceptual hallucination and perceptual fantasy packaging of the treatment construct, usually targeted to some mesodermal derivative or other. They long ago figured out how to work the “cont ed” circuit to make better $. By attaching their own name to the construct and method, they can become a famous manual therapy guru. Many PTs are no better. MTs are the usual targets.

    To clone a new income, conceptually take acupuncture needles, make them a lot bigger and blunter, lay them sideways to scrape instead of poke/pierce. Call this by your last name, then teach other practitioners for big bucks, the Newest Best True Way of Getting Fantastic! Results With Your Patients.

  12. cloudskimmer says:

    As someone who has occasionally indulged in therapeutic massage, I have come across people who wanted to massage to the point of inducing pain, explaining that this was necessary to “break down scar tissue,” or relax cramped/knotted muscles. Occasionally this results in a few days of post-massage pain. A friend extolling the virtues of chiropractic indicated that she was black-and-blue after her low back manipulation/massage, but afterwards felt better. It seems to me that there is a subset of the manipulation community–massage and chiropractic–which thinks pain is good. Rolfing seems to fall into this category. And the Graston technique seems similar. I’ve concluded that massage should feel good; any technique that causes pain afterwards is bad (unless clearly indicated–such as post-surgical pain); massage therapists, in my experience, want people to go away happy and ask what their customers want.

    Unfortunately, there seem to be no good modalities for treating back pain, in formal medical practice, or outside of it. This is why back pain is so often treated by personable quacks, and well-meaning doctors who produce indifferent results. Almost everyone has back pain, and it is often self-limiting, which is why many so-called “treatments” seem to work. But there is a subset of those patients who end up with chronic pain, go from doctor to quack again and again without relief, or with only temporary relief. At least that’s my own anecdotal experience in trying to get help for my mother’s back pain, mostly from real medical doctors who say they can help, but after a few weeks of trying their own favorite treatment, give up and blame her for the pain, or even refer to her to quacks (like acupuncturists.) I even met a real M.D. at Cedars Sinai Hospital in Los Angeles–usually considered a top-flight institution–who wanted to inject my mother with a homeopathic substance–another example of how quackery is becoming a part of today’s medical practices. No–we didn’t do it, but I was outraged at the “Doctor” for suggesting it. When Doctors become quacks, how are any of us going to get real medical care?

  13. windriven says:

    I found it!

    The device is called a ‘Molecular Enhancer” and sells for $2500.

    This is from the website under the heading ‘Supporting Science:’

    “Dan Dial’s Molecular Enhancer™ falls under the category of Pulsed Electromagnetic Feild (sic) Therapy and a multiple-wave oscillator. It saturates the cells of the body with the appropriate resonate (sic) energies on which the cells’ electro-chemical systems depend (feed) on (sic).

    This, in turn, maximizes the chemical processes of the cells, which are brought into balance through mutual resonance, allowing proper repair and operation.

    When one uses the Enhancer regularly, it maintains the electrical health of the body on the cellular level by bringing the electrical level in each cell to the same potential, i.e. working in harmony. All chemical processes in the body require energy to take place and the Enhancer feeds the cells’ energy need at the molecular level, energetically assisting the cell in its chemical processes.

    This is accomplished by setting up a high-energy field in and around the body through multiple-wave resonance.

    The Enhancer does not pass current through the body. The transfer of energy is accomplished through induction. All that is used is the oscillating-field voltage and not the current. A person is insulated from the high voltage at either connection by glass. This prevents excess current from getting into the body.

    The resonance process is similar to gently shaking a box of marbles. After a while, the marbles organize themselves into the natural order their shapes dictate. The cells molecular structure (encoded by the persons DNA) has the same way of organizing themselves IF provided sufficient energy. When this is achieved, the cells work at maximum efficiency without causing cellular stress.

    The Enhancer is the vehicle providing the movement in the molecular structure of the cells to their optimum interactive arrangement for normal operations within each cell. And it does this, not by passing current but by providing a resonant state that the bodies cells try and match.

    One scientist explains it this way: A normal cell has an electrical potential of 70 millivolts (mV), an aged cell has 50 mV and the cancer or ill cell has 15 mV. When the cell is in electrical difficulty, the mV and sodium-potassium levels are out of balance causing cellular distress.

    The high-resonate potential provided by the Enhancer brings all of the cells to an equal level, basically natures way of resetting them to their normal state. This provides the potential for healing to occur at an accelerated pace without stressing the cell.

    The additional energy restores cell integrity by reorienting its molecular structure to allow for easier potential movement and interaction. Basically, it bolsters the field of each cell individually, so the cells support each other more easily, thereby helping to create a balanced system. ”

    WTF???

    There are cleverly worded disclaimers scattered about the site noting that the device doesn’t cure anything – though I was told by my trainer that it “breaks up scar tissue.”

    If you want a good laugh: http://www.dansenhancerweb.com

    Klaatu barada nikto. Dude.

  14. keleton says:

    @ cloudskimmer

    Re: massage causing pain –

    Sometimes the only thing that will relieve painful muscle spasms in my mid-to-upper back is massage to the point of bruising. Drugs don’t work, exercises don’t work, heat/ice helps temporarily. It is slightly sore afterwards but better than the cramping pain, and sometimes will last for a few weeks. Usually though to stay comfortable I need to get brutalized at least once a week. Just an anecdote.

    I can see that the science behind this method is not there but why would deep tissue massage be so helpful for some people?

  15. Diane Jacobs says:

    @keleton;
    “I can see that the science behind this method is not there but why would deep tissue massage be so helpful for some people?”

    Helpful? Possibly your (and others’) brain(s) has/have been induced, at both conscious and non-conscious levels, to ‘believe’ (and self-reinforce) that this kind, type, intensity of sensory-discriminatory input is repeatedly necessary to enhance self-regulation.

  16. coryblick says:

    Harriet,

    Thank you for turning your attention to this. This idea of creating microtrauma to facilitate healing or promote redeposition of scar is one that is taking root in physical therapy. I’m curious if you could expand your thoughts a bit more on this. The background theory for this type of method, at least as I’m familiar with it, is that most conditions that traditionally have been labeled as -itis conditions are actually -osis conditions in which the tissue is degrading due to a lack of initiation of the inflammatory response with insult. The theory goes that creating “microtrauma” (which in my mind its trauma or its not) re-initiates the inflammatory process and the aim of therapy is to provide an environment in which the process can proceed to resolution. So, by this theory they are not claiming to further inflame and inflamed tissue, but rather initiate inflammation in a tissue that is failing to inflame.

    Here is an editorial by an author who is driving this thinking and it may be worthwhile to examine his/her claims.
    http://www.ncbi.nlm.nih.gov/pubmed/11895810?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=2

    I think it is important to address this as there are other therapies popping up in the mainstream of PT that also are claiming to act on this theory with and without tools. Another example are exercises focusing on the eccentric phase of motion. There are some studies showing promise in regards to some traditionally stubborn conditions including patellar and achilles tendon area pain. The idea being that eccentrics create more load and initiate process throught this form of “microtrauma.” At least that is my understanding.

    Curious of your thoughts.

  17. Harriet Hall says:

    coryblick,

    The article you cited refers to one specific condition, tendinitis. The Graston technique is used for many other diagnoses, including ankle sprain, fasciitis, neck pain, low back pain, epicondylitis, adhesive capsulitis, carpal tunnel syndrome, and scar pain.

    If the “original insult” didn’t cause inflammation, why not? And how can you be sure a new insult will? Also, there is no way to judge the amount of microtrauma you are causing – how much is necessary and how could you be sure not to overdo it?

    I don’t like the idea of deliberately causing trauma, but I would accept it if there were clear evidence that it works. There isn’t.

  18. coryblick says:

    I agree with you.

    Perhaps this one treatment is not all that is in need of examining, but the entire theoretical construct on which it is based. Especially, since many other treatment techniques that are becoming mainstream are based upon it.

  19. drscottswanson says:

    Interesting article, if all medical treatments were subjected to this much scrutiny there would be none that would pass the test….And unfortunately there are many that are killing and hurting people.

  20. Harriet Hall says:

    drscottswanson,

    What do you mean “this much scrutiny”? Every drug that is approved for marketing is subjected to far more scrutiny than this. Can you name a single medical treatment that is “killing and hurting people” that is based only on two mouse studies, one of which suggests the treatment doesn’t work?

  21. drscottswanson,

    There is no question that bad things happen in the practice of medicine, and stats about iatrogenic problems can seem alarming. However, to simply state that medicine kills and hurts people is misleading fear-mongering. Cars kill and hurt people, too, for pretty much the same reason: it’s risky, but the benefits are worth it, and large numbers of people take the gamble.

    The medical system deals with vastly greater numbers of much more serious cases than manual therapists do, many of them no-win, rarely-win, or sometimes-lose situations with high stakes. It’s just not an apples-to-apples comparison. You should should a little more respect, criticizing that from the outside. Try working in a hospital for a while, try to be perfect, try to never have anything go wrong that matters.

    I assume that you are a chiropractor. If you routinely had to treat huge numbers of people with life-threatening injuries and dire illness, your profession would have scary error rates, too.

    And most medical interventions are subjected to vastly more scrutiny — orders of magnitude more — than Graston has been subjected to here or anywhere.

Comments are closed.