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Instrument-Assisted Soft Tissue Mobilization (IASTM)
- with specific focus on "The Graston Technique"

By: Carolyn Sobieski, SPT, Tom Bangert, SPT, and John Zegar, SPT



History of IASTM:

History has demonstrated that instruments have assisted with soft-tissue integrity. The history of IASTM has been traced back to ancient Greek and Roman baths, where small metal tools known as “strigils” were used to scrape dirt and sweat from the body.(1)

guasha33.jpg
Reprinted from Borderless News and Views Website, 2012 (2)
“Gua Sha,” another ancient form of IASTM, originated in Asia as a means to move stagnant blood from the tissues without it escaping from the skin. More importantly, “Gua Sha” included palpation and cutaneous stimulation over compressed areas of the body with rounded objects, such as spoons, coins, and pieces of water buffalo horns to promote normal circulation and metabolic processes. The manifestation from this modality was redness of the skin, known as “sha,” believed to have let out bad “chi.” This ancient technique is still used today, and allows for blood flow within and around subcutaneous soft-tissue, enabling circulation and metabolic functioning. This theory and modality has led to more recent, but traditional, approaches to instrument-assisted soft tissue mobilization.(1)

In the early 1980’s physical therapist
graston instruments.jpg
Reprinted from Graston Technique Wikipedia Website, 2012 (3)
, Gail Chamberlin, and orthopaedist, James Cyriax, both published literature expressing the clinical usefulness of transverse friction massage, with its effectiveness in deterring adhesions by evoking local hyperemia (large amounts of blood), shown to assist with blood circulation, tissue metabolism and collagen synthesis, similar to the effects of “Gua Sha.” (1)


The current use of instruments in soft tissue mobilization was developed as an alternative to transverse friction massage.(4) In 1987, David Graston suffered a knee injury, leaving him in need of reconstructive surgery. When traditional rehabilitation failed to help with his post-surgical scar tissue, he developed the first prototypes for what would be the six Graston Technique instruments.(5,6) The Graston Technique, a patented form of IASTM, was further developed at Ball Memorial Hospital and in conjunction with Ball State University in Muncie, IN.(7,8) Initially, these instruments were modeled from wood, then aluminum. However, stainless steel is currently used as the material of choice.(1)



How IASTM Works:

IASTM has several effects on body systems. It helps to restore optimal soft tissue quality by causing controlled microtrauma to the specified area, stimulating increased local inflammation.(9) This stimulation accelerates the body's natural response to soft tissue repair by causing a "cascade effect," in which it increases the amount of blood, nutrients, and fibroblasts to the area. Furthermore, this results in the synthesis of collagen and eventual maturation of the tissue.(1)

effect of mechanical load on degenerated.jpg
Reprinted from Hammer, 2008 (1)

One method of action is influencing the tissue quality of the fascia. Fascia bundles surround the muscles allowing them to move upon each other and prevent muscle fibers from adhering to other. Over time and with age, the fibers can adjoin between layers of fascia causing stiffness which creates faulty movement patterns due to this decreased range of motion. IASTM serves to restore optimal fascia quality resulting in less stiffness, increased ROM, and improved function. IASTM also affects other tissue types, such as collagen. Molecular cross-links within collaganeous tissues also create adhesions and disrupt the normal tissue quality, resulting in additional stiffness and movement impairments.(10)

A specialized application of IASTM is the Graston Technique (GT). GT is an instrument-assisted soft tissue assessment and mobilization method delivering load deformation via the use of six different stainless steel instruments. Mechanical deformation influences the extracellular matrix (ECM) modulating the synthesis of proteoglycans and collagen by fibroblasts, thus increasing collagen formation.(10)

The following items are listed as the mode of action for GT:(10)

  • Increases skin temperature
  • Facilitates reflex changes in the chronic muscle holding pattern
  • Alters spinal reflux activity (facilitated segment)
  • Increases the rate and amount of blood flow to and from the area
  • Increases cellular activity in the region, including fibroblasts and mast cells
  • Increases histamine response secondary to mast cell activity




Research by Meltzer et al.(12) demonstrated, on a cellular level, the beneficial effects of fibroblasts on myofascial release as a result of using IASTM. Further research by Borgini et al.(13) demonstrated the influence of direct compressive force on dense fascial restrictions, using an Italian type of IASTM which was developed at the University of Padua. The principles applied in the study have a direct carryover to how GT works.

Overall, the expected outcome of IASTM is the stimulation of tissue repair, leading to decreased pain and stiffness, increased range of motion and function, and decreased total treatment time.



Graston Technique for Achilles Tendon Injuries Video, 2011 (11)


Indications, Contraindications, & Precautions of IASTM:

Indications for Use: (1)

  • Cervical sprain/strain
  • Lumbar sprain/strain
  • Carpal Tunnel Syndrome
    IASTM.jpg
    Reprinted from Tensegrity Chiropractic Website (14)
  • Plantar Fasciitis
  • Lateral Epicondylitis/algia
  • Medial Epicondylitis/algia
  • Rotator Cuff Tendinitis
  • Patellofemoral Disorders
  • Achilles Tendinitis
  • Trigger Finger
  • Shin Splints
  • Post-Surgical Scar Tissue
  • de Quervain's Syndrome
  • Fibromyalgia
  • IT Band Syndrome
  • Low Back Pain
  • Joint Sprain
  • Muscle Strain

Contraindications for Use: (1,15)

  • Neoplastic Disorders/Cancer
  • Kidney Infections
  • Anticoagulant Medication
  • Rheumatoid Arthritis
  • Uncontrolled Hypertension
  • Osteomyelitis
  • Osteoporosis
  • Generalized Infection
    scar.jpg
    Reprinted from Scar Repairex Website (16)
  • Fractures
  • Open Wound
  • Unhealed Suture Site/Sutures
  • Thrombophlebitis
  • Patient Intolerance/Non-compliance
  • Hypersensitivity
  • Hematoma
  • Myositis Ossificans

Precautions for Use: (1)

  • Varicose Veins
  • Burn Scars
  • Acute Inflammatory Conditions (i.e. synovitis)
  • Pregnancy
  • *Extra care should be taken for clean up in individuals with blood-borne diseases (HIV/AIDS)*



How to Use & Apply IASTM:

GT foot.jpg
Reprinted from Columbia Integrated Health Centre - Graston Technique Website (17)
GT elicits the use of six specially designed steel instruments for specific parts of the body. These tools are used to detect soft tissue lesions. They accomplish this by acting like "tuning forks," allowing for an increased biofeedback in the ability of the clinician to sense vibrations.(7) A distinct vibration is incurred whenever the instrument comes into contact with soft tissue lesions, thus guiding the clinician to the specific area in need of treatment.(4) Furthermore, the use of the tools also allows clinicians to spare the direct repetition of using their hands during treatment. This is a great advantage as many manual therapists report thumb pain and injuries, which can lead to a loss of income and clientele.(6,8)


GT may be applied over the problematic tendon, muscle, ligament, fascia, or scar, and can treat non-surgical or surgical conditions associated with these tissues. Treatment dosage and frequency is determined by the healing stage of the tissue, patient tolerance, and tissue reactions. GT can also be administered statically, dynamically, or during functional movement.(8)

The specifically-shaped instruments further allow the clinician to provide precise force application during treatment by allowing the instrument to mold over body contours.(8) The varied edges of each instrument also allow for the clinician
to control the type of massage stroke and depth (dosage) of treatment, and to alter this depth so that it is comfortable to patients.(8,18) The instruments also allow for the applied force to occur in the targeted area between the subcutaneous tissues and deeper connective tissues, rather than between the cutaneous tissue and the clinician's hands.(18)
emollient.jpg
Reprinted from Graston Technique Website, 2010 (19)


IASTM procedure involves using the instruments to apply force (massage) in a transverse direction to the underlying soft tissue lesion, therefore inducing the physiological inflammatory response. First, an emollient is applied to the patient's skin in order to reduce friction. The clinician may choose to wear rubber gloves to increase their grip on the tools if they desire.(8) Next, IASTM is applied until a fair amount of redness develops in the area of the soft tissue lesion (<5min), signifying the start of the inflammatory response. Patients may experience slight pain with treatment, which is a normal reaction. Ice can be applied to the area afterwards to decrease pain.

*IASTM should not be used as a sole method of treatment.*
"Range of motion and strengthening exercises should be used in conjunction with IASTM to promote (proper) soft tissue adaptation and remodeling of soft tissue." (4) Therefore, patients should work on these exercises in the clinic and/or receive a home exercise program to promote these activities.



Current Evidence on the Use of IASTM (Graston Technique):



An article from the Journal of Bodywork and Movement Therapies published in 2008 by W. Hammer, DC (1) discussed three case studies using GT. The cases included a 45 year old female with a four week history of supraspinatus tendinosis; a 46 year old athletic male with a four month history of Achilles tendinosis; and a 50 year old female with a three month history of plantar fasciosis. Subjective history and functional testing was used to confirm the presence of the pathologies initially. A three patients were treated according to GT protocol and given a home exercise program consisting of stretching and strengthening activities. Results showed that the use of GT in addition to a home exercise program eliminated pain and normalized function in these three patients.



Graston Technique Demonstration for Tennis Elbow Video, 2010 (20)

A more recent article published by D. Black, PT, DPT, SCS, ATC in 2010 in The International Journal Therapeutic Massage and Bodywork (4) discussed a case report on the use of physical therapy in conjunction with GT for treating knee arthrofibrosis and quadriceps insufficiency following a patellar tendon repair in a 37 year old male. The patient was seen for 5 visits over a 4 week period. Each treatment session included a warm-up, GT, patellar or tibiofemoral joint mobilization, flexion ROM activities, strengthening exercises, modalities to control edema, and home exercise program assignment. The article concluded that the addition of the GT to traditional physical therapy "may have made a difference in clinical and functional improvement measures and allowed for decreased visit frequency." Furthermore, by using GT to break up the post-surgical soft tissue adhesions, osteokinematic and arthrokinematic motion was more likely to improve.



Related Links:



References:
  1. Hammer WI. The effect of mechanical load on degenerated soft tissue. Journal of Bodywork and Movement Therapies. 2008;12(3):246–56. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19083680. Accessed October 5, 2012.
  2. Gan J. Gua Sha - Scaping [image]. Borderless News and Views Website. http://borderlessnewsandviews.com/2012/07/gua-sha-traditional-healing-technique/. Updated July 14, 2012. Accessed October 16, 2012.
  3. GT Instruments [image]. Graston Technique Wikipedia Website. http://en.wikipedia.org/wiki/Graston_Technique. Updated April 14, 2012. Accessed October 16, 2012.
  4. Black DW. Treatment of knee arthrofibrosis and quadriceps insufficiency after patellar tendon repair: a case report including use of the Graston Technique. International Journal of Therapeutic Massage & Bodywork. 2010;3(2):14–21. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3091431&tool=pmcentrez&rendertype=abstract.
  5. Burnside J. Instrument assisted soft tissue mobilization: Effect on strength and range of motion. 2004;(August):1–9.
  6. Kline C. Instrument-assisted soft-tissue mobilization (IASTM) Part I: Chiropractic help or hindrance? Journal of the American Chiropractic Association. 2010:2–6.
  7. Burke J, Buchberger DJ, Carey-Loghmani MT, et al. A pilot study comparing two manual therapy interventions for carpal tunnel syndrome. Journal of Manipulative and Physiological Therapeutics. 2007;30(1):50–61. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17224356.
  8. DeLuccio J. Instrument assisted soft tissue mobilization utilizing Graston Technique: A Physical Therapist’s Perspective. Orthopaedic Physical Therapy Practice. 2006;18(3):32–34.
  9. Hammer W. Instrument-assisted soft-tissue mobilization: A scientific and clinical perspective. Dynamic Chiropractic. 2004;22(11):3–6.
  10. Hammer W. Functional soft-tissue examination & treatment by manual methods. 3rd ed. Sudbury, MA: Jones & Bartlett 2007;33-161
  11. Graston Technique for Achilles Tendon Injuries [video online]. May 4, 2011. http://www.youtube.com/watch?feature=player_embedded&v=lR9OXRVSIkI. Accessed October 5, 2012.
  12. Meltzer KR, Cao TV, Schad JF, et al. In vitro modeling of repetitive motion injury and myofascial release. Journal of Bodywork and Movement Therapies. 2010;14(2):162–171. Available at: http://linkinghub.elsevier.com/retrieve/pii/S1360859210000033?showall=true.
  13. Borgini E, Stecco A, Day JA, Stecco C. How much time is required to modify a fascial fibrosis? Journal of Bodywork and Movement Therapies. 2010;14(4):318–325. Available at: http://linkinghub.elsevier.com/retrieve/pii/S1360859210000537?showall=true.
  14. Graston-Technique [image]. Tensegrity Chiropractic Website. http://tensegritychiro.com/?page_id=232. Accessed October 16, 2012.
  15. Crothers A, Walker B, French SD. Spinal manipulative therapy versus Graston Technique in the treatment of non-specific thoracic spine pain: design of a randomised controlled trial. Chiropractic & Osteopathy. 2008;16:12. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2584064&tool=pmcentrez&rendertype=abstract. Accessed October 15, 2012.
  16. Burn Scar [image]. Scar Repairex Website. http://www.scarrepairex.com/types-of-scar.php. Accessed October 16, 2012.
  17. GT Applied to Foot [image]. Columbia Integrated Health Centre - Graston Technique Website.http://www.columbiaintegratedhealth.com/graston-technique. Accessed October 16, 2012.
  18. Bayliss AJ, Klene FJ, Gundeck EL, Loghmani MT. Treatment of a patient with post-natal chronic calf pain utilizing instrument-assisted soft tissue mobilization: a case study. The Journal of Manual & Manipulative therapy. 2011;19(3):127–34. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3143010&tool=pmcentrez&rendertype=abstract. Accessed October 15, 2012.
  19. Graston Emollient [image]. Graston Technique - GT Products Website.https://www.grastontechnique.com/CartUSA2.html. Accessed October 5, 2012.
  20. Graston Technique Demonstration for Tennis Elbow [video online]. May 28, 2010.
    http://www.youtube.com/watch?v=8IAODPPWT8g&feature=player_embedded. Accessed October 16, 2012.