Dr. Konin: The Graston Technique® (GT) utilizes instruments to mobilize soft tissue in an effort to treat functionally limiting scar tissue. How effective is this technique in your opinion?
Dr. Greenstein: The utilization of the GT instruments has been very effective. We’ve found the instruments and technique to be effective among patients in the acute, subacute, and chronic neuromusculoskeletal condition populations. Of course, patient selection criteria, contraindications, and application of the various techniques all play a significant role in the overall outcome for the patients we treat.
Dr. Schrader: In my opinion, it is very effective. When I was introduced to the technique 14 years ago, I was the only clinician trained in the area [who] could treat non-athletes and [I was] still reasonably skeptical of its benefits. A young physician, familiar with instrument-assisted soft tissue mobilization, had recently moved into town and asked me to see some of his patients. As a relative novice with the technique at that point, I reluctantly agreed. I maintained my own personal log of the individuals he sent to me, monitoring their pain and function ratings with each visit.Over a sequence of 23 patients, virtually all except for 1 demonstrated significant improvement of their condition. Of course, I was a poor researcher and didn’t structure my independent project so that it was publishable in any way. However, I was quite surprised by the benefits to some patients—patients whose conditions I did not believe I would be able to improve because of lengthy histories of failed courses of formal physical therapy and the chronicity of their conditions.
Dr. Konin: What is the trick behind the patented GT instruments?
Dr. Greenstein: Based on the experience of using other instruments, I prefer the GT instruments because they are stainless steel, which really helps me “feel” the adhesions in the muscular and fascial tissue, and because their various shapes and sizes allow me to treat virtually all musculoskeletal structures easily and efficiently.
Dr. Schrader: I don’t know if the word “trick” fits the question concerning the instruments. The original research on instrument-assisted soft tissue mobilization was conducted utilizing stainless steel instruments. A great deal of time was spent by the inventors developing a compact set of instruments that were adaptable to virtually any body part and were capable of accessing soft tissue regions more effectively than some manual techniques. A great deal of time was spent developing edges that would engage the soft tissues and appropriately impart a mechanical advantage to mobilize them better than you could with your hands. In addition, the weight of the instruments helps the clinician with better consistency of pressure because you do not need to apply as much force.The traditional approach for instrument-assisted soft tissue mobilization has been to release identified soft tissue restrictions in chronically injured structures and contributing structures. I would consider GT an enhancement of Dr. James Cyriax’s cross friction massage (CFM) protocol. Dr. Cyriax’s approach was to create friction massage in a perpendicular direction to the tissue fiber alignment. This approach [CFM] is an important part of a GT treatment; however, the therapeutic approach is designed to treat in more of a 3-dimensional fashion. Treatments are designed to look more globally at a functional unit and not at singular structures given that the body is such a highly integrated system.As far as the GT technique [is concerned], the recommended sequence is started with a good soft tissue warm-up, a recommended sequence of strokes to address the identified pathology, targeted stretching to structures treated with the instruments, and low-load and high-repetition exercise initially followed by cryotherapy. Of course, this happens to be for chronic myofascial problems. Currently, many clinicians have been using the instruments in what would be classified as a “non-inflammatory” treatment to assist with edema removal or for soft tissue warm-up. We are currently attempting to collect sufficient subjects to measure the impact of a non-inflammatory GT approach on acute ankle sprains.
Dr. Konin: How long does it take you to become proficient in the technique after you have completed the training courses?
Dr. Greenstein: As clinicians, the more we do, the better we get. I felt very comfortable treating patients after my certification course. I had outstanding instructors who clearly explained the pathophysiology of the conditions we treat, the methodology behind the components of comprehensive care inclusive of other forms of treatment (cryotherapy, stretching, exercise) in conjunction with GT, and the application of GT specifically for different conditions and patient populations. The key for practitioners is to “just do it.” Get in there and start achieving good outcomes for your patients.
Dr. Schrader: There are 2 courses, each of which is approximately 12 hours. The initial course is designed to teach indications, contraindications, strokes, handholds, patient positioning, and treatment sequences. The second course is more diagnosis specific and involves more advanced treatments with motion. My personal opinion is that this is a skill like many other manual techniques. Some people will become proficient relatively quickly, whereas others may struggle for a period of time.
Dr. Konin: What is a typical treatment like in terms of length of time and patient expectations?
Dr. Greenstein: So much of the application is related to specific patient biomechanical and functional issues. A patient with shoulder pathomechanics and pain may have multiple tissues that need to be addressed. I would say 30 to 60 seconds, maximum, per tissue location. Further, depending on how acute the problem is may determine the length of treatment.Patient expectations are about as individual as snowflakes if you really do a thorough history and assess the patient’s true goals. We are very clear in our communication to patients about what to expect from GT in terms of pain during treatment, soreness after treatment (which we try to ameliorate via modalities and cryotherapy-ice/Biofreeze [Hygenic Corporation, Akron, Ohio]) and prognosis. The key is to encourage regular feedback from the patients so communication is flowing not just from provider to patient, but also from patient to provider.
Dr. Schrader: This is a little difficult to answer because it depends on the diagnosis and what areas along a myofascial system may be involved in the condition. If there are multiple areas and a protracted history, the length of a visit many not necessarily be abnormal, but the areas to be treated may have to be broken up by days. This is easily accomplished in that the protocol for chronic conditions recommends 48 to 72 hours between visits; therefore, you can still see someone 3 times per week, but you may be addressing alternate sites each visit. Total treatment time with the instruments is typically no more than 8 to 20 minutes. The other components will vary depending on treatment environment, equipment, and so on. Highly compliant patients can do a substantial amount of the protocol as a home exercise program.I usually explain to my patients that the treatment is to tolerance and therefore may be uncomfortable but should not be painful. They can anticipate the possibility of some bruising (if pro-inflammatory approach) and it may be tender to touch the treated area. They may have mild discomfort posttreatment, and if they do, they should use over-the-counter pain relievers as they would for a headache. In addition, I will explain to them to not anticipate immediate improvement, as it will generally take 4 to 6 treatments before significant changes occur.
Dr. Konin: Is the technique typically combined with other therapeutic approaches, or is it best performed in isolation to achieve successful results?
Dr. Greenstein: YES! It MUST be performed with other approaches. In my 18+ years of clinical experience, there is no magic bullet. Evidenced-based clinicians use a multi-modal approach to neuro-musculoskeletal health. The GT training program specifically discusses the importance of controlling pain through modalities and cryotherapy and the importance of dynamic/functional and static stretching and appropriate exercise prescription that includes, but is not limited to, proprioceptive training, endurance, muscle activation timing and sequencing enhancement, and strength.
Dr. Schrader: The GT can be combined with other approaches as long as the clinician considers the cumulative effects. As an example, many hand therapists incorporate iontophoresis into their treatment paradigm. The GT can be incorporated into other protocols easily. A number of manual therapists and chiropractors will use GT prior to mobilization or manipulation. It is a soft tissue mobilization technique that can be incorporated like other soft tissue techniques.
Dr. Konin: How do you see the GT becoming more utilized in the future?
Dr. Greenstein: As the demand for advanced soft tissue treatment increases, providers will recognize the need to have as many “instruments in the instrument box” as possible to treat the vast range of conditions that our patients present with. More clinical trials need to occur to develop a better understanding of which conditions have the best outcome with GT being part of the multi-modal approach. I think that this technique, which seems to be mainly utilized in the clinic setting, will also start to expand to sport venue settings to get athletes back into competition sooner.
Dr. Schrader: I have found this to be an incredibly fascinating technique with very good outcomes. I have treated patients who did have a soft tissue component to their problem whom I honestly didn’t think would get much benefit from the treatment. Much to my surprise, they frequently identified GT as helping decrease their pain.As the technique has grown in usage, I think it will be utilized in a variety of ways. Muscle facilitation, acute injury noninflammatory approaches, and scar management are a few of the uses that are currently beginning to be reported.
This Clinical Roundtable was conducted January 10, 2011.