T-bars made of wood and with rubber tips have been used for years to penetrate deep areas that are difficult to reach with the hands. Ancient East Asian methods, like gua sha, make use of any smooth edge, such as buffalo horn or even the metal lid from a jar.1 Lucite, acrylic, ceramics and stainless steel instruments are in use today. Gua sha explains its effect by scraping the skin and attracting blood from the tissue, causing small petechiae or ecchymotic patches. The theory is based on promoting blood production and improving the disseminaton of fluids.1 Graston Technique (GT) makes use of six specially designed stainless steel instruments with beveled edges2 for the purpose of diagnosis and treatment.
GT, however, has based its methods and outcomes on the scientific literature describing the effects of manual loading on soft tissue. One of the most important findings regarding the effect of instrumentation on soft tissue is the stimulation of fibroblasts and their synthesis of proteoglycan and collagen. In discussing the healing of tendinosis, Nirschl3 states that the goal of healing is to enhance the proliferative invasion of vascular elements and fibroblasts, followed by collagen deposition and ultimate maturation. The reality is that mechanical load literally creates new tissue and helps it mature, when followed by specific stretching and strengthening. "Dynamic strain is integral to fibroblast stimulation and in the organization of the overall extracellular matrix of connective tissues."4,5
Davidson, et al.,6 used augmented soft-tissue mobilization (ASTM-instrument-assisted) and demonstrated tendon healing by activating fibroblasts. Gehlsen, et al.,7 found that the use of instruments increased the number and size of fibroblasts, as assessed by light microscopy and the electron microscope. They found that heavy pressure promoted the healing process to a greater degree than light or moderate pressure. Surely, friction massage by hand increases circulation and fibroblastic proliferation, and clinically, it is recommended that friction be applied for 20 minutes or more.8 With instrumentation, the friction time is reduced to one minute and is obviously more penetrating and specific.
It is thought that the controlled microtrauma caused by instrumentation causes microvascular trauma and capillary hemorrhage, creating a localized inflammatory response that stimulates the body's healing cascade and immune/reparative system.9-11 Prentice12 states that tendon healing is facilitated by accelerating the inflammatory process. In addition to the benefits of enhanced mechanical load, the GT instruments have shown promise in their capacity to magnify the sensation resulting from palpation of soft-tissue adhesions. Clinicians report that they feel blockages more precisely, both in terms of location and barrier direction.
A major reason why instrumentation is important is preservation of the joints of the practitioner. Snodgrass13 surveyed physical therapists and found that after spinal pain, the second most common cause for absenteeism from work was overuse of the thumb. Ninety-one percent of physiotherapists using some sort of massage had to modify their treatment techniques because of thumb pain. This fact is obvious to many DCs.
There are, at present, numerous case studies and outcome studies demonstrating the benefits of instrument-assisted soft-tissue methods. (See references for a partial list.)14-18 Graston has led the way in the chiropractic profession regarding the use of instrument-assisted soft-tissue mobilization. It is already part of the core curriculum at Bridgeport, NUHS, and Northwestern; is being taught at CMCC; and is in varying stages of inclusion at other chiropractic colleges. It is also taught in the graduate kinesiology program for athletic trainers at Indiana University of Health Sciences. The owners of the technique are funding a study at NYCC on carpal tunnel syndrome (DC, April 4 issue, News in Brief) and a study at the Texas Back Institute on post-fusion lumbar spine range of motion. A very important aspect of the technique is its training program, emphasizing the use of instruments based on a functional evaluation of the involved soft tissues.
In summary, instrumentation is increasingly proving valuable to chiropractors in its capacity to heighten the effectiveness of human touch in diagnosing and treating soft-tissue lesions.
- Nielsen A. Gua Sha: A Traditional Technique for Modern Practice. Edinburgh, Eng. Churchill Livingstone, 2000.
- Nirschl RP, Ashman ES. Elbow tendinopathy:tennis elbow. Clin Sports Med 22(4);2003:813-836.
- Lundon K. Orthopedic Rehabilitation Science: Principles for Clinical Management of Nonmineralized Connective Tissue. St Louis, Missouri, Elsevier Science, 2003:121.
- Eastwood M, et al. Fibroblast responses to mechanical forces. Proc Istin Mech Engrs 1998;20(1):55-62.
- Davidson CJ, Ganion LR, Gehlsen GM, et al. Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Med Sci Sports Exer 1997;29(3):313-319.
- Gehlsen GM, Ganion LR, Helfst R. Fibroblast responses to variation in soft tissue mobilization pressure. Med Sci Sports Exer 1999;31(4):531-535.
- Cyriax J. Textbook of Orthopaedic Medicine: Treatment by Manipulation, Massage and Injection vol. 2, 11th ed. London, Bailliere Tindall, 1984.
- Roush MB, Sevier TL, Miller KW, Augmented soft tissue mobilization in the treatment of chronic achilles tendinitis: a case study. 1998 Performance Dynamics, Muncie, Ind.
- Gross MT. Chronic tendititis: Pathomechanics of injury factors affecting the healing response and treatment. J Orthp Sports Phys Ther 16(6);1992:248-261.
- Leadbetter WB. Cell-matrix response in tendon injury. Clin Sports Med 1992;11:533-577.
- Prentice W. Therapeutic Modalities in Sports Medicine, 3rd ed., St. Louis. Mosby, 1994:336-339.
- Snodgrass SJ. Thumb pain in physiotherapists: potential risk factors and proposed prevention strategies. J of Manual and Manipulative Therapy 2002;10(4):206-217.
- Sevier TL, Gehlsen GM, Wilson JK, Stover SA, and Helfst RH: Traditional physical therapy vs. Graston augmented soft tissue mobilization in treatment of lateral epicondylitis. Journal of the American College of Sports Medicine 1995;27(5).
- Henry P, Panwitz B, Wilson JK. Treatment of a bilateral total knee replacement using augmented soft tissue mobilization. Physical Therapy Case Reports 1999;2(1):27-30.
- Henry P, Panawitz B, Wilson JK. Rehabilitation of a post-surgical patella fracture: A case study. Physiotherapy 2000;86(3):139-142.
- Melham TJ, Sevier TL, Malnofski MJ, Wilson JK, Helfst RH. Chronic ankle pain and fibrosis successfully treated with a new noninvasive augmented soft tissue mobilization (ASTM): A case report. Medicine and Science in Sports and Exercise 1998;30(6):801-804.
- Perle S, Perry D, Carey-Loghmani M. Effects of Graston Technique on Soft Tissue Conditions: A Prospective Case Series. Poster Presentation, WFC Exposition, 2003.
Warren Hammer, MS, DC, DABCO
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