Instrument-Assisted Soft-Tissue Mobilization

1. international journal of Athletic Therapy & training may 2011  5
The Graston Technique® represents a
specific approach to soft tissue manipula-
tion that uses six different stainless steel
instruments (Figure 1) to release scar tissue,
adhesions, and fascial restrictions.1 The tools
used for the Graston Technique® were initially
developed by a competitive water skier who
had a tool and dye background.2 When he
injured his knee and did not respond com-
pletely to therapy, he began to experiment
with various shapes of tools to mimic the
manual techniques of
his therapist in order
to provide an enhanced
manipulation of his soft
tissue. From his curios-
ity, and trial and error
by the therapy staff,
the Graston Technique®
of Instrument-Assisted
Soft Tissue Manipula-
tion (ISTM) was devel-
oped. The purpose of
this report is to pro-
vide an overview of the
Graston Technique®,
which will include a review of documented
therapeutic outcomes.
The Graston Technique
Most clinicians agree that there is no single
technique, tool, or modality that will com-
pletely resolve an impairment of musculosk-
eletal function.The goal of therapy is to provide
an optimal environment for healing, by either
modifying physiologic responses to injury
© 2011 Human Kinetics - ATT 16(3), pp. 5–8
Monique Mokha, PhD, ATC, Report Editor
Instrument-Assisted Soft Tissue Mobilization
THERAPEUTIC MODALITIES
Robert Stow, PhD, ATC, CSCS • University of Wisconsin-Eau Claire
(e.g., inflammation, muscle spasms, pain)
or enhancing components of normal mus-
culoskeletal function (e.g., increase range of
motion, increased muscular strength).3 The
principles of the Graston Technique® fits well
with this philosophy; it is one tool that can
be used in the rehabilitation plan to achieve
the desired outcome. In developing this
plan, a systematic approach should be used,
including six sequential steps that should be
followed during the therapy session:1
• Examination
• Warm-Up
• ISTM
• Stretching exercises
• Strengthening exercises
• Cryotherapy
Upon completion of the pretreatment
examination, the targeted tissue area should
be warmed, preferably through cardiovas-
cular exercise. Warm-up of tissues that are
adjacent to the targeted treatment site is
beneficial. Options include use of a stationary
The Graston Technique® can assist the
clinician with manual therapy assessment
and treatment of soft tissue pathology.
The Graston Technique® is just one part of
the overall rehabilitation program.
Patients must be well informed of the
potential effects when using this therapeu-
tic approach.
Key PointsKey Points
Figure1 Stainless steel instruments.

2. 6  may 2011 international journal of Athletic Therapy & training
cycle, upper body ergometer, or elliptical trainer. Light
jogging for 5-10 minutes is also beneficial or the admin-
istration of ultrasound, diathermy, or a heat pack. For
example, when treating plantar fasciitis, the Achilles
tendon and the posterior lower leg musculature could
be warmed through 5-10 minutes on a stationary cycle.
After the warm-up, the ISTM treatment is administered.
Subsequently, targeting stretching and therapeutic
exercise should be performed. Both of these reha-
bilitation procedures are necessary to promote tissue
lengthening and collagen fiber realignment, which help
to prevent the released tissue from becoming restricted
again. The treatment session should be concluded with
cryotherapy, which may be substituted with heat or
some other modality, depending on the specific nature
of the patient’s condition.
When deciding if ISTM might provide an effective
treatment option, the etiology of the injury and the
type of pathology must be considered. Table 1 outlines
indications for use of ISTM, which is primarily focused
on soft tissues; however, not all soft tissue pathologies
can be effectively treated through ISTM. Currently, the
benefits derived from ISTM include release of fascial
restrictions, breakdown of collagen cross-linkages,
increased blood flow, and possibly an increase in
regenerative cellular activity.1,4-6 Even with the greatest
care, however, there are potentially adverse treatment
responses to ISTM that may occur. The patient may
experience discomfort during administration of the
treatment, and petechiae (i.e., bruising) may become
apparent during or after the treatment (Figure 2).
Bruising results from localized trauma, which may be
associated with separation of adhesions from healthy
tissue.4 Personal clinical experience has shown that the
cervical region, lateral thigh, anterior pelvic regions,
and posterior calf appear to be most sensitive during
administration of ISTM. Although discomfort and bruis-
ing may be experienced, patients who have realized
a decrease in symptoms have returned repeatedly
for additional ISTM sessions. The patient must be
informed about the potential effects and benefits of
the treatment, and other therapeutic modalities should
be administered for pain management. See Table 2 for
precautions and contraindications.
Instruments
The Graston Technique® instruments have either a
convex or a concave shape. The concave shape allows
for the pressure applied by the clinician to be dispersed
over a large area, thereby promoting comfort during
treatment. The convex shape concentrates pressure
over a smaller surface area, which may cause greater
patient discomfort, but allows the clinician to focus on
a defined specific area of tissue. The instruments have
either a single-beveled edge or double-beveled edge.
The GT-2 and GT-6 instruments have a double-beveled
Figure2 Adverse treatment responses to ISTM.
Table 1. Instrument-Assisted
Soft tissue mobilization:
possible indications 1,4
Indications
Medial & Lateral
Epicondylosis
Carpal Tunnel Syndrome
Neck & Back Pain Plantar Fasciitis
Rotator Cuff Tendinosis Tibialis Posterior
Tendinosis
DeQuervain’s Syndrome Post-Surgical & Traumatic
Scars
Myofascial Pain &
Restrictions
Chronic & Acute Sprains/
Strains
Non-Acute Bursitis RSD (Reflex Sympathetic
Dystrophy)
IT-Band Syndrome Wrist Tendinosis
Reduced ROM
due to Scar Tissue
Achilles Tendinosis

3. international journal of Athletic Therapy & training may 2011  7
edge, which limits the depth of tissue penetration.
Because this design is tolerated well by the patient, it
can be used in sensitive areas, and it is appropriate for
treatment of areas that do not allow a for full-stroke
movements. The single-beveled edge is used to obtain
greater tissue penetration and separation of subcuta-
neous tissues.
Therapeutic Outcome
Research evidence that documents the effectiveness
of ISTM is limited; however, several experimental
and case studies have produced positive findings.
McLaughlin7 investigated the effectiveness of ISTM
for reduction of edema associated with ankle sprains.
Participants were intercollegiate, intramural, and high
school athletes. They were randomly assigned to either
a traditional edema control protocol or a traditional
edema control protocol that was combined with ISTM.
There was no significant difference in edema control
between the two groups (i.e., both therapeutic protocols
were equally effective in reducing edema). Achieve-
ment of full weight-bearing status for the group that
received ISTM averaged one day sooner than that for
the comparison group, however.
Loghmani and Warden5 assessed short-term and
long-term effects of ISTM on healing of the medial
collateral ligament (MCL) in an animal model. Fifty-
one rats had bilateral MCL injuries surgically induced
to both hind legs. Thirty-one of the animals received
instrument-assisted cross-fiber massage treatment
three times per week for three weeks to one extremity
(i.e., the other was untreated), and 20 animals received
the same treatment for 10 weeks to one extremity. At
four and 12 weeks postinjury, MCLs were harvested
for testing. The nontreated MCLs were noted to have
more adhesions and granular tissue, which made the
harvesting process more challenging.5 In comparison
to nontreated MCLs at four weeks postinjury, the
treated MCLs had 43.1% greater tensile strength,
39.7% greater stiffness, and were able to absorb 57.1%
more energy before failure. At 12 weeks postinjury, the
treated MCLs were 15.4% stiffer than the nontreated
ligaments, but there was no significant difference in
tensile strength or energy absorption to failure. The
treated ligaments demonstrated greater cellularity
and better collagen fiber alignment when compared
to the nontreated ligaments at weeks 4 and 12. The
nontreated ligaments demonstrated greater scarring
and more poorly organized collagen, especially at four
weeks postinjury.
Use of ISTM was reported in a case study that
involved a 59-year-old man with a one-year history of
intense low back pain (i.e., subactue lumbar compart-
ment syndrome) that caused him to miss two to three
days of work every two to three months.8 His initial
treatment protocol consisted of bed rest and analgesics.
His pain was managed well enough to allow him to
work as a shoe salesman until he experienced pain that
would not subside, and that prevented performance of
his activities of daily living for a period of two weeks.
ISTM treatments were administered to the hamstrings,
sacrum, right hip lateral rotators, and low back region.
The patient received six treatment sessions (twice per
week for three weeks), and each included performance
of two sets of three stretches to the affected area after
administration of ISTM. The patient was instructed
to perform the stretches at home between treatment
sessions. After the six sessions, the patient was asymp-
tomatic and able to complete all tasks necessary for
daily living and work.
Summary
Training expenses and the cost of the instruments are
the primary limitations to widespread utilization of
ISTM. Also, the time required to attain skill mastery
in the use of the instruments limits the number of
clinicians who can use it effectively, which limits the
Table 2. Instrument-Assisted
Soft Tissue Mobilization:
Precautions and
Contraindications1,4
Precautions Contraindications
Anti-coagulant medica-
tions
Open wound (unhealed
suture site)
Cancer Unhealed fractures
Varicose veins Thrombophlebitis
Burn scars Uncontrolled hypertension
Acute inflammatory
conditions
Patient intolerance/
hypersensitivity
Kidney dysfunction Hematoma
Inflammatory condition
secondary to infection
Osteomyelitis
Rheumatoid arthritis Myositis ossificans
Pregnancy Hemophilia

4. 8  may 2011 international journal of Athletic Therapy & training
accumulation of evidence to support its use. ISTM is
not a magical cure for all ills; it must be used in con-
junction with other therapeutic procedures for its full
benefits to be realized.
Athletic trainers and therapists who are interested
in learning ISTM can access information at www.
grastontechnique.com, or by calling 888.926.2727.
Graston Technique® training is offered at various loca-
tions throughout the United States, Canada, and Eng-
land. Completion of two training modules is required
for certification (i.e., Module 1, Basic Training and
Module 2, Upper/Lower Extremities and Spine). 
References
1. Carey-Longmani, MT, Hammer. WI. Graston Techniqueâ In: Hammer,
WI, ed. Functional Soft-Tissue Examination and Treatment by Manual
Methods. Boston, MA: Jones and Bartlett; 2007: 589-625.
2. Graston Technique. History of the Graston Technique Page. http://
grastontechnique.com/AboutUs/CompanyHistory.html. Accessed
March 29, 2010.
3. Starkey, C. Therapeutic Modalities. 3rd ed. Philadelphia, PA: F.A. Davis;
2004.
4. Hammer WI. The effect of mechanical load on degenerated soft tissue.
J Bodywork Move Ther. 2008;12:(3):246-256.
5. Loghmani MT, Warden SJ. Instrument-assisted cross-fiber massage
accelerates knee ligament healing. J Orthop Sports Phys Ther. 2009;
39:(7):506-514.
6. Carey MT. Graston Technique Instruction Manual, 2nd ed. Indianapolis,
IN: TherapyCare Resources INC; 2001.
7. McLaughlin, E. An Evaluation of the Effectiveness of the Modified Graston
Technique on Reducing Edema Following an Acute Ankle Sprain [master’s
thesis]. Bloomington, IN: Indiana University; 2006.
8. Hammer, W., Pfefer, M. Treatment of a case of subacute lumbar
compartment syndrome using the graston technique. J Manipulative
Physiol Ther. 2005, 28(3):199-204.
Robert Stow is an assistant professor and director of the athletic
training education program in the Department of Kinesiology at the
University of Wisconsin - Eau Claire and is certified in the use of the
Graston Technique.
©2010 • Paperback • 336 pp
Print: ISBN 978-0-7360-7228-1
E-book: ISBN 978-0-7360-8548-9
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