Instrument-Assisted Soft Tissue Mobilization

DR. M. SUSAN GUYER, DPE, ATC, CSCS EATA STUDENT PROGRAM SUNDAY JANUARY 11 TH, 2 0 1 5 Background

 Graston Technique® is an instrument-assisted soft tissue mobilization that effectively break down scar tissue and fascial restrictions.  The technique detects and effectively treats areas exhibiting soft tissue fibrosis or chronic inflammation.  Graston Technique® is an interdisciplinary treatment: GT = GIASTM + Exercise

Diagnostic Indications

 GT is indicated for virtually any patient who would benefit from soft tissue mobilization.  After evaluation, soft tissue mobilization is used to release and lengthen tight, shortened, restricted tissue with the goal of restoring musculoskeletal balance and normalizing function. Addressing Shortened Muscles For the Clinician

 Provides improved diagnostic treatment.  Detects major and minor fibrotic changes.  Reduces manual stress; provides hand and joint conservation.

For the Patient

 Decreases overall time of treatment.  Fosters faster rehabilitation/recovery.  Resolves chronic conditions thought to be permanent.

Good results with the following:

 Medial epicondylitis/osis  De Quervain’s Syndrome  Back pain  Post-surgical scars  Plantar fasciitis/fasciosis  Myofascial pain  Patella Tendinitis/osis  IT Band Syndrome  Achilles Tendinitis/osis  Also:  Wrist Tendinitits/osis  Pre/post competition  Petrissage/Milking edema

Contraindications

Red Flags – Absolute Yellow Flags – Relative

 Medications (anti-coagulants,  Open wound steroids, hormone replacement  Unhealed fractures therapy and NSAID)  Cancer  Thrombophlebitis  Varicose veins  Burn scars  Uncontrolled  Acute inflammatory conditions hypertension  Kidney dysfunction  Lymphedma  Hypersensitivity  Infection  Hematoma  Rheumatoid arthritis  Pregnancy  Osteomyelitis  Osteoporosis  Myositis ossificans  Hemophilia family history  Polyneuropathies

Graston Technique Instrument

 The instruments are contoured to facilitate treatment around different body parts.  Concave instrument:  Equalizes or disperses pressure over a larger surface area  Useful for increasing comfort, especially with a pain-sensitive patient  Convex instrument:  Maximize pressure in a small surface area  Allows clinician to pinpoint pressure accurately Instrument Contact Instruments

 Treatment edge  Single-beveled edge  Double-beveled edge  Basic handholds  Guidelines  30-60 degrees  Treatment edge faces in the direction the instrument is moving Treatment strokes

 Direction of the stroke  Perpendicular, parallel or diagonal to tissue fibers  Amplitude of the stroke  Large/small, broad/narrow  Rate of the stroke  Rapid/slow  Pressure of the stroke  Superficial  Contact point  On the instrument with the body tissue  Angle of the instrument  45 degrees Strokes

 Sweep  Fan  Brush  Strum  J-Stokes  Swivel  Scoop  Framing GT 1

 Purpose  To evaluate and treat generalized restrictions. Scan and prepare the tissue for deeper treatment.  Application  Good for large muscle groups. Middle and Upper Trapezius

Sweep Fan GT 2

 Purpose  Deeper work, knobs may be used for deeper penetration in a specific, localized area.  Application  Fits around convex soft tissue and bony landmarks Patella

Framing Brushing GT3

 Purpose  Used for localizing restrictions and treatment to a small area.  Application  Commonly used during most treatment sessions, allows more specific application of pressure. Patella GT4

 Purpose  Versatile instrument, used to scan and locate restrictions during an assessment.  Application  Generalized assessment of the region to detect soft tissue abnormalities.

Plantar Fascia GT5

 Purpose  Used as a general scanning instrument as well as a treatment instrument.  Application  More aggressive treatment of muscle restrictions, useful in releasing restrictions between ribs.

Gastrocnemius GT6

 Purpose  Originally designed for treating carpal tunnel, used to release fascial restrictions in the hands and wrist area.  Application  Between metacarpals, metatarsals and phalanges, thenar and hypothenar eminences. Sweep and Swivel Treatment Duration

 Active Warm up  3-5 minutes  GISTM session:  Usually around 8-10 minutes for treatment of an involved region  GISTM per lesion:  Approximately 30-60 seconds. This pertains to a specific lesion within a specific tissue structure  GISTM per joint:  Approximately 3-5 minutes.  Duration:  The goal is 4-8 sessions

Basic components of the Gaston Techniques

Cardiovascular warm-up • Increase blood flow and tissue heating • Increase tissue plasticity

GISTM • Break up soft tissue restrictions

Specifically • Lengthen shortened structures Targeted • Low-load, long duration stretches to Stretches facilitate plastic changes Basic components of the Gaston Techniques

High • Davis’ Law of Soft Tissue – Fatigue shortened structures and change fascial compartment Repetition, low dimension weight exercise • Early goal is not strength

Low repetition, • SAID Principle, LTG – Strengthen weak or high weight lengthened structures exercise

• Minimize post-treatment inflammation , soreness Cryotherapy and bruising as indicated by mode of treatment Warm-up Treatment Stretch Rehabilitation Cryo-therapy Research

 Research conducted, found that the controlled micro trauma induced through Graston Technique® protocol, increased the amount of fibroblasts to the treated area.  Inflammation to the scar tissue helps initiate the healing cascade.  The structure of the tissue is rearranged, and damaged tissue is replaced by new tissue.  Graston Technique®, generally achieving better outcomes when compared to traditional therapies, and resolving injuries that have failed to respond to other therapies.

Average Complete Excellent Good Fair Unchanged Injury Success Rate # of Treatments 100% 90%+ 80%+ 70%+ less than 70%

Achilles Tendinitis 8 4 73 15 0 8 92

Ankle Sprain 8 6 52 24 6 12 82

Plantar Fasciitis 7 2 44 24 11 19 70

Patella Femoral Syndrome 11 5 42 24 24 5 71

Cervical Pain 11 4 49 29 13 5 82

Low Back Pain 11 8 44 35 6 7 87

Fibromyalgia 10 6 31 44 6 13 81

Hip Pain 9 8 30 50 4 8 88

Hamstring Strain 8 12 58 12 12 6 82

ITB Tendinitis 7 0 64 18 9 9 82

Lat Epicondylitis 10 15 44 31 4 6 90

Med Epicondylitis 8 13 27 20 7 33 60

Rotator Cuff Tendinitis 9 14 40 38 3 5 92

Adhesive Capsulitis 15 0 18 55 18 9 73

Carpal Tunnel Syndrome 8 5 60 21 9 5 86

Wrist Tendinitis 7 13 46 33 4 4 92

Scar Pain 9 0 46 8 38 8 54

* = Median # of treatments

Success Rate: Percentage of Resolution equates to attaining the patient/clinician goals of

1) increase in function Summary

 Excellent technique for chronic pathologies.  Good outcomes when protocol is used.  Can keep a patient more active during the recovery phase.