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. The hope is 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.

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.

For instance, Graston is often recommended for a kind of knee tendonitis, IT band syndrome. Even if ilitobial band syndrome really is caused by fibrosis/adhesions — which is not a safe assumption — it seems like Graston technique might be just as likely to make it worse as better!

Graston 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.

Graston inPubMed

A PubMed search for “Graston” brought up seven articles. Five 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®, ultrasound therapy with Traumeel (a mixture of homeopathic doses of herbs, primarily Arnica), 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 “for” Graston

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! 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.