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Dynamic Chiropractic – May 20, 2008, Vol. 26, Issue 11

New Research Regarding Instrument-Assisted Soft-Tissue Mobilization

By Warren Hammer, MS, DC, DABCO

The effect of mechanical load on soft tissue is receiving increased attention from researchers around the world. This was most evident at the recent Fascial Research Conference held at the Harvard Convention Center (

It was emphasized that all types of soft-tissue mechanical loading including exercise, injury, manual muscle treatments such as fascial release, stretching techniques and instrument-assisted soft-tissue mobilization methods (IASTM), such as the Graston technique (GT), affect the fibroblast.

The fibroblast is considered the most important cell in the extracellular matrix (ECM). The repair, regeneration and maintenance of soft tissue take place in the ECM. The fibroblast synthesizes the ECM, which includes collagen, elastin and proteoglycans, among many other essential substances. Fibroblasts have the ability to react as mechanotranducers, which means they are able to detect biophysical strain (deformation) such as compression, torque, shear and fluid flow, and create a mechanochemical response.

It recently has been discovered that after the use of light, manual fascial methods, stimulation of fibroblasts can respond with anti-inflammatory cytokines, growth factors and vasoactive compounds that underlie positive clinical outcomes.1 Standley has shown that injury strains fibroblasts and fascia in negative ways, while manual muscle treatment strains fibroblasts in curative ways.1 Many questions have to be answered. Could it be possible that a light fascial-release technique would have an anti-inflammatory effect, while a heavier technique would have a pro-inflammatory effect? Studies are needed to determine the effect of manual loading, whether by instrumentation or manually, regarding the amount of pressure and how it affects the status of acute versus chronic tissue.

Standley demonstrated that even the direction of the manual load was important as to the type of chemicals produced. Some of the earlier research by Gehlsen and Davidson demonstrated that increased pressure using instrument-assisted soft-tissue mobilization increased fibroblastic proliferation and the recreation of an inflammatory process facilitated tendon healing.2,3 Davidson, using IASTM, demonstrated how a healing cascade was created by enhancing the proliferative invasion of blood, nutrients and fibroblasts to the region, resulting in collagen deposition and eventual maturation.3 Kraushaar and Nirschl stated that 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.4 Other clinicians and researchers have agreed that increasing fibroblastic proliferation is an essential way of producing clinical results.

A recent study by Loghmani, et al., investigated the use of instrument-assisted cross fiber massage using Graston instruments on acute ligament healing.5 Bilateral medial collateral ligaments were surgically transected on 20 rats. Seven days postoperatively, GT was used for one minute to the left MCL, three times a week for three weeks, for a total of nine sessions. Medium pressure was used. The contralateral limb served as an internal control and was not treated. The ligaments treated with Graston instrument-assisted cross-fiber massage were found to be 31 percent stronger (p<0.01) and 34 percent stiffer (p< 0.001) than the untreated ligaments. While ligament healing was accelerated, the authors stated, "Additional research on the effects of instrument-assisted cross-friction massage on other types of ligament injuries, long-term effects on ligament healing, comparison of treatment interventions and ligament injuries in human subjects is needed." This study dealt with GT on an acute lesion.

At present, according to TherapyCare Resources, Inc. of Indianapolis, there are more than 4,500 clinicians using GT, including more than 550 outpatient physical therapy clinics, chiropractic offices and the medical staff of more than 70 professional and amateur sports organizations. GT currently is in the curriculum of most chiropractic colleges and taught as an elective at the Department of Physical Therapy at Indiana University in Indianapolis.


  1. Standley P. Biomechanical strain regulation of human fibroblast cytokine expression: an in vitro model for myofascial release? Presentation at Fascia Research Congress, Boston, 2007. DVD from
  2. Gehlsen GM, Ganion LR, Helfst R. Fibroblast response to variation in soft-tissue mobilization pressure. Med Sports Exer, 1999;31(4):531-5.
  3. Davidson CJ, Ganion LR, Gehlsen GM, et al. Rat tendon morphologic and functional changes resulting from soft-tissue mobilization. Med Sci Sports Exer, 1997;29:313-9.
  4. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). J Bone Joint Surg, 1999;81-A(2):259-76.
  5. Loghmani MT, Avin K, Burr D, Warden S. Instrument-assisted cross-fiber massage accelerates knee ligament healing. Orthopaedic Section Abstracts: Platform Presentation #17. J Orthop Sports Phys Ther, 2006;36(1):A7.

Click here for previous articles by Warren Hammer, MS, DC, DABCO.

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