published 01/14/10, updated 1/29/10

The Graston Technique®

Magic steel massage tools that supposedly scrape the pain away, and “resonate” in the therapist’s hands

by Paul Ingraham, Vancouver, Canada

The eponymous Graston Technique® (GrastonTechnique.com) is a modality empire — a commercialized, trademarked therapy technique — with roughly 6000 practitioners world-wide, almost all of them chiropractors. Graston is an expensive and painful massage technique that employs mean-looking “curvilinear”1 steel tools to apply scraping pressure and achieve “maximum tissue penetration.” Although not always painful, it often is. It is a classic example of a hurts-so-bad-it-must-be-good therapy.

Graston Technique claims to cure and stimulate healing by doing damage first — breaking eggs to make an omelette. In particular, its goal is to “break down scar tissue and fascial restrictions,” and even targets issues that are chronically inflammed — which is not without risks. Graston therapists will firmly scrape an inflammed tendon, for instance.2

Licensing, licensing, licensing

Curiously, in a strange case of licensing backfire, David Graston himself is no longer in control of the Graston Technique® brand; instead, he markets a new system called Sound Assisted Soft Tissue Mobilization (SASTM®), distinguished primarily by the use of tools made from ceramic instead of steel. There’s also a third fairly-well known example, ASTYM® (the acronym stands for “a stimulation”). They are all quite similar. Graston publishes a chart [current as of 11/11/10] showing the differences between the systems, but most are system-marketing benefits — the language of franchising and product promotion, not the language of health care. The only clinical difference mentioned is that he alleges that ceramic tools are “allow for easy handling and minimal amount of pressure needed,” and he describes the steel tools of “competitor 1” as “hard to hold and cold” compared to the ceramic tools of SASTM.

The science of Graston Technique?

The theoretical basis for Graston is speculative and debatable. It is not proven or significantly supported by any research that I am aware of. No good quality study3 of the therapeutic effectiveness of Graston Technique exists, nor is it ever likely to — it is too small a player in the world of manual therapy to attract any serious research attention. It has not done so in over twenty years so far. The state of the evidence is similarly impoverished for SASTM and ASTYM.

Only three studies are cited on the Graston Technique website, which isn’t many to start with. However, two of them are the same paper and another appears to be fictional!4 The only correct citation is barely relevant to Graston Technique: a tiny study of tendonitis for rats.5 Meanwhile, a few other scientific papers are not listed — probably because they make Graston look bad.

Didn’t the Davidson study provide some half-decent support for Graston Technique? I do not deny that the results of the study were positive: massage did indeed seem to have a positive effect on those rats! And that’s interesting. But suggestive data is a long way from proof.6

The Graston Technique’s idea of “supporting research” seems quite watered down to me. The situation is similar on the websites for the ASYTM® system,7 and Graston’s new SASTM® system.8

In theory

Is Graston technique based on a sound idea?

The basic rationale for Graston Technique may not be unreasonable — perhaps inflamed tissue really does “like” to be disturbed a little. There are other precedents for this kind of response in the body. There are several physiological contexts in which moderate stresses on our bodies really provoke a positive change: weight lifting jumps to mind as one of the most obvious examples. We are adaptation machines.

On the other hand, it’s also a well-known biological principle that too much stress is injurious.

And we also now know, thanks to the last 20 years of chronic pain science, that chronic pain is often a failure of nervous stem itself. Many people with serious chronic pain problems — the very same patients who might try something like Graston Technique — are actually pathologically oversensitive. What happens if you “stress” a nervous system in that condition? Simple: the problem gets worse, not better.

And, finally, brand new research has shown quite conclusively (and graphically, on video) that inflammation is actively destructive to tissues: like a gang of insane firefighters, immune cells deliberately over-react and destroy healthy cells just in case there might be an infection.9 This response is completely appropriate in open wounds, but dramatic overkill for all minor internal injuries — like tendonitis. Indeed, it may be a major reason for the stubbornness of conditions like tendonitis. Graston Technique unquestionably has the potential to provoke exactly this reaction.

I’m not saying that there is no benefit. I’m saying it’s not clear — that there are good mysteries here, good questions, good reasons why it might work, not work, or even be dangerous to some patients. The scientific knowledge simply does not exist to say how it will turn out in the end.

And yet it is being sold …

Overconfidence and safety

No potentially dangerous treatment should ever be sold to patients on the basis of such scant data: we’re talking about scraping inflammed tendons here. There is no reason to think that will necessarily go well, and I just spelled out at least two theoretical reasons it could go badly. What if, upon studying more rats, you found that some had a nasty reaction? What if all rats tolerate tendon scraping well … but one in a hundred humans is seriously injured?10

The safety of an aggressive treatment is something you simply have to test, thoroughly, before you can know that the rewards outweigh the risks. Yet Graston proponents cite that single rat study as the main justification not only for treating tendonitis, but essentially any other musculoskeletal condition. Different kinds of tendonitis won’t necessarily respond the same way to the same treatment, let alone completely different musculoskeletal conditions.

Patients should be extremely wary of such clinical overconfidence. Do you want to pay to be a guinea pig?

Are the Graston tools like magic dowsing rods?

They are priced like it. They currently go for about $2500–3500 … for tools about as hard to manufacture as cutlery.

But perhaps they are worth it. The Graston Technique website makes some interesting claims about those tools. Strangest of all, right on their “about” page — always one of the most-visited pages on a website — they climb right out on a marketing limb and describe their massage tools as having spooky powers:

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. … Just as a stethoscope amplifies what the human ear can hear, so do the instruments increase significantly what the human hands can feel.

Graston makes a similar for his SASTM® tools:

The ergonomic design of these instruments provides the clinician with the ability to locate restrictions through sound waves.

These statements are not explained in any more detail. They are lobbed at the reader as-is.

Since it is non-controversial that other stainless steel objects do not vibrate in response to lesions, clearly the claim here is that the Graston tools have some other special property heretofore unknown to physics — magic tools, in other words. Presumably that’s why they cost so much?

One reader protested that the claim isn’t as odd as it sounds. I dispute that, however — I think the intent is clearly to imply some kind of special property.11 I do not believe in dowsing, and I do not believe that these tools are anything like dowsing rods. Even if I did believe in such things, I still wouldn’t go to a surgeon who claimed to use a magic scalpel.12

Summary

There may well be a kernel of truth in Graston Technique, and I would be interested in serious science looking for that kernel. I hope that Graston Technique will eventually be validated by new research — I would be delighted to endorse a new, proven method of treating stubborn pain problems. Three simple randomized controlled trials with at least 50 human subjects with clearly positive results would be sufficient to increase my confidence in Graston Technique® substantially.

However, I think it is unlikely that the results of such testing will be positive. Meanwhile, a vague and unsubstantiated theory is simply not adequate justification for such a severe approach to tissue — especially tissue that’s hurting to begin with.

Notes

Just a marketing term — it doesn’t mean anything. BACK TO TEXT
I’ve encountered several instances of this in the wild. By all accounts, it is an outrageously painful treatment, and it severely aggravated symptoms in all of the cases described to me over the years. I will undoubtedly get email in response to this article reporting additional examples, as well as counter-examples — but the point is that severe negative reactions are absolutely possible, and it’s no surprise that Graston therapists rarely hear about them. BACK TO TEXT
A randomized, blinded, placebo-controlled human trial with at least 50 subjects as a bare minimum as a rough minimum quality. BACK TO TEXT
This was nicely dissected on ScienceBasedMedicine.org in an analysis by Dr. Harriet Hall, the SkepDoc:

(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 Medicine, 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.

BACK TO TEXT
Davidson et al. Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Medicine & Science in Sports & Exercise. 1997. PubMed #9139169. Comments: This small study of rats attempted to demonstrate the possible relevance of Graston Technique to tendon healing. It is cited as the sole example of scientific research supporting the clinical use of Graston Technique. Although it does provide some interesting and positive findings, it is a small study of rats — serious limitations. Rat tendons were injured with a collegenase injection, allowed to heal for three weeks, and then some were treated with Graston Technique. Their gait improved more than untreated rats. The authors claim that the results “suggest” that “may promote healing via increased fibroblast recruitment.” Such cautious phrasing is appropriate: although promising, the effect of treatment on five rats is hardly conclusive. BACK TO TEXT
In science, a single positive study is the sound of one hand clapping. The results must be confirmed by other researchers before they can be taken seriously. And long-term effects were not considered at all. And rats are not humans. And there were so few rats involved that the results could easily have been a fluke — a single unusual rat could have thrown the stats off dramatically, which is why such studies need to be repeated with larger numbers. And the possibility of side effects isn’t in the picture at all.
Consider the example of platelet-rich plasma injection. A faddish treatment, several early studies produced promising results. But small, flawed, early studies conducted by proponents of and investors in a technique have a funny way of coming out all nice. When a larger, better study of platelet-rich plasma injection was published by the Journal of the American Medical Association was published, guess what happened? That’s right: PRP bombed the test. And that’s why we don’t really take early results seriously in science. BACK TO TEXT
ASTYM publishes an impressive-looking research page with dozens of references. However, all of the references are just basic science articles about the physiology of healing, tangentially relevant to ASTYM at best. This is somewhat like responding to the question “Does it work?” by saying, “I am smart. I can cite science papers about physiology.” That’s terrific, what a gift you have, but … does it work?
They prominently cite the very same Davidson et al article I’ve just dissected with regards to Graston Technique. They list only a single study that directly involved ASTYM in any way — and it either doesn’t exist, or isn’t correctly cited, and it’s a study of only 20 subjects in any case (smaller than small).
So much for the impressive-seeming presentation. BACK TO TEXT
Graston’s SASTM website does not present any scientific information whatsoever, but “To request a research packet, please fill out the contact us form.” Why not just publish it? Perhaps because there’s really nothing to publish? BACK TO TEXT
McDonald et al. Intravascular danger signals guide neutrophils to sites of sterile inflammation. Science. 2010. PubMed #20947763. Comments: Researchers at the University of Calgary Faculty of Medicine are using an innovative new imaging technique to study how white blood cells (called neutrophils) respond to inflammation, and have revealed new targets to inhibit the response. Basically this research explains why neutrophils unnecessarily “swarm” sterile injury sites, causing damage and pain with no direct benefit — a biological glitch with profound implications. BACK TO TEXT
A 1% rate adverse effect rate is high — but you could do five human studies, using treatment groups of 20 each, encounter only a single example, and you still wouldn’t have a clue about the real statistical risk. Graston Technique poses a real potential danger, yet its safety hasn’t been studied at all. This is precisely the kind of thing that makes peoples heads explode about drugs — foisting serious side effects on the public, no matter how rare, is the stuff of scandal! BACK TO TEXT
Making a fair point, he argued that it’s “like the way low-profile tires and a stiff suspension transmits road feel to the driver, or the way a steel razor blade feels scratchy when you're stripping paint off of glass.” While that is indeed how scraping with a rigid tool can feel, such a slight enhancement of perception does not appear to be what the Graston website is advertising. The language they use makes it sound much, much better. The stethoscope analogy is egregious hyperbole at the very best — no scraping tool enhances perception as “like a stethoscope”! That’s like saying that eyeglasses enhance vision “like a telescope”!

Furthermore, and significantly, the use of the word “resonate” is even more misleading: in the context of alternative medicine, “resonate” more or less always implies something mystical. BACK TO TEXT
“It tells me where to cut. Now trust me and hold still.” BACK TO TEXT