스크랩 Graston Technique: A Case Study and Other Thoughts on Instrument Assistec Soft Tissue Mobilization Techniques

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Today’s guest post is quick overview of the Graston technique and it’s application within a case study by Eric Schoenberg, MSPT, CSCS.  I thought Eric did a great job with the post and have will share some of my thoughts on instrument assisted soft tissue techniques, such as Graston technique, at the end of this article.

Graston Technique

Regardless of treatment philosophy, it is difficult to dispute the importance of soft tissue work to help treat pathology, correct muscle imbalance, decrease recovery time, and restore proper muscle recruitment and firing patterns.

While there are many available soft tissue options, in my practice, I have found Graston techniques to be particularly useful in both treatment and eval‎uation.  Many people don’t realize that the Graston technique can also be a valuable diagnostic tool to quickly “scan” or eval‎uate a patient’s soft tissue quality and determine its contribution to a patient’s current symptoms or injury risk factor.

The Graston technoique concept is grounded in the works of English orthopedist James Cyriax and the concept of cross fiber treatment. The treatment edge of the Graston instruments allows for improved precision in the treatment of fascial restriction and fibrotic/scar tissue.

I wanted to share my experience and techniques with the Graston technique and will use a case study to illustrate the benefits and specificity of the Graston Technique.

The patient is an 18 year old male who is a 3-sport athlete (football, basketball, baseball) presenting with 9 month history of anterior knee pain consistent with patellar tendinosis. The patient presents with the following objective findings at eval‎uation:

• Point tenderness at inferior pole of patella
• Pain at end-range supine and prone knee flexion
• Pain with resisted concentric and eccentric knee extension (Kendall MMT position)
• Decreased hip mobility B
• Decreased ankle DF ROM B
• Decreased lumbopelvic/hip and single leg stability
• Decreased gluteal/core strength B

The patient is participating in pre-season football conditioning with emphasis on sagittal plane squat/split squat/lunge activities, sprinting (including hills), and plyometrics (sagittal plane). He is using foam roller daily on own to improve tissue quality. His symptoms are gradually worsening with increased training intensity.

After eval‎uating the patient, I decided to include Graston technique treatment focused on the quadriceps, ITB, adductors, hamstring, gastroc/soleus, and tibialis anterior muscle groups.  Here are a couple of examples:

Graston Technique – Seated Quadciceps

Graston Technique – Seated Patellar Tendon

One specific application of Graston technique is the ability to effectively treat the injured area in positions of provocation. This patient experiences symptom reproduction in the split squat/forward lunge position:

Graston Technique – 1/2 Kneel Position

Graston Technique – Dynamic With Squat:

Treatment Outcomes

The patient was seen for 3 treatments with full resolution of symptoms. Treatments consisted of the following:

1. 1. Tissue quality: Graston technique, daily lower body foam roller program
2. 2. Mobility: hip and ankle mobility exercises, active warm-up corrective exercises
3. 3. Multiplanar strength: frontal and transverse plane strength (emphasized single leg activity, band walks, lateral lunges, lumbopelvic stability- chops/lifts)
4. 4. Activity Modification: patient educated in proper jump/land technique, limited sagittal plane repetitions, proper muscle firing patterns

Clinical Observations From Using the Graston Technique:

1. The specificity of the treatment edge and the ability to provide uniform pressure is what sets the technique apart from other manual approaches.

2. The instruments truly enhance the clinician’s ability to detect and treat fascial restrictions and adhesions (particularly effective in positions of provocation).

3. Incorporating stretching and strengthening (tendon-loading) exercises with the instrument assisted soft tissue mobilization is the key to promoting re-alignment of the fibers and helping to fully remodel the injured tissue.

4. Coupling Graston in the clinical setting with self myofascial release (SMR) products, such as foam rollers and other similar equipment at home or in an athletic setting (pre/post activity) is an ideal way to achieve maximum success.

Lastly, at least for me, the most exciting part of using Graston Technique in the clinical setting is feeling better suited to treat the more difficult diagnoses (plantar fasciitis, chronic tendonosis, etc) with the expectation of good clinical outcomes.

My goal in writing this article is to present a simple case to allow the reader to appreciate the functionality and ease of use of the Graston Technique. In addition, it is important to note that Graston (along with any soft tissue treatment) should be used in conjunction with skIASTMilled movement eval‎uation and prescription of corrective exercise to allow for the most effective clinical outcomes.

Eric Schoenberg, MSPT, CSCS is co-owner of Momentum Physical Therapy with offices in Milford, MA and Wellesley, MA.  The owners of Momentum PT are experts in the human movement system. Their mission is to bridge the gap between traditional medicine and fitness with emphasis on patient education and injury prevention.  Visit eric’s blog at www.momentumptblog.blogspot.com.

Mike’s Thoughts

Eric, great article and examples of use of the Graston technique.  I’m sure the patient got better from your very well thought out treatment plan and all of the techniques and exercises you performed in combination with Graston technique.

It is important to note that while this article is specifically about the Graston technique, it also applies to instrumented assisted soft tissue mobilization (IASTM) techniques in general.  Late last year I polled my readers and 20% of you said you used IASTM, including Graston technique, SASTM, and ASTYM.  We could also group in the traditional Gua Sha to this mix as well.

I have used these techniques and do incorporate IASTM in my practice, I have also taken the basic Graston class (though have not taken SASTM and ASYTM classes and have not used their tools).  Here are my thoughts:

• IASTM is a valuable component of my treatments, but just a component.  Just like everything else, it has its value and it has areas where I would choose another technique.
• There are a lot of misconceptions here and the internet makes this worse – a huge black and blue down the leg is not what you are trying to achieve using IASTM.  I consider this a sign that you’ve done too much.  This is a misconception.
• The actual Graston Technique tools and courses are really good.  If you have the budget to go all out for these, great, they will be great to work with. Visit their website for more info, I would be surprised if you were not satisfied with the course and their tools.  They have put a lot of thought and effort into their technique and tools.
• I do not use the Graston instruments.  I think many more people should learn IASTM techniques.  If you really like the technique and want to learn more or get the better Graston tools, great.  But cost should not be a reason that you don’t learn how to use IASTM.
• In regard to tools, I go traditional Gua Sha from China.  I have tried other tools, like the Starr Tool, they are good, but more expensive.
• In regard to Gua Sha tools, you can Google them, there are many shapes and materials for anywhere from $2 to $10.  Horn is a good starting point, but in the grand scheme I would grade them as stone > jade > horn.  Just my opinion.  I have a bunch of horns as they come in a variety of versatile shapes, and a few jades and stones.  So far Bian or Energy stones have felt best for me, but these are closer to $20-$40.  Still cheap in contrast to some of the other instruments.  If you are not sure, start with the horn.

What do you think?  What has been your clinical experience with Graston technique, instruments, and other instrument assisted soft tissue mobilization techniques?