Graston Technique in the Treatment of Soft Tissue Dysfunction

The Effects of Graston Technique in the Treatment of Soft Tissue Dysfunction

By: Lynda Bunn Faculty Advisor: Daryl Ridgeway, D.C.

Senior Research Project June 28, 2012

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ABSTRACT Objective: The purpose of this literature review is to understand tissue dysfunction resulting in myofascial trigger points, and the diagnostic criteria most commonly used to distinguish them. Discussion of the benefits of utilizing The Graston Technique as treatment for aberrant tissue and the effectiveness it has on the reduction of myofascial trigger points. Also discussed are results obtained through several trial studies performed at Logan College of Chiropractic’s Research Department and their findings for the use of Graston Technique on different body regions.

Data Collection: Utilized for collection of data are online databases PubMed, Graston Technique website, and Senior Research Projects performed at Logan College of Chiropractic, textbooks and chiropractic journals in order to gain understanding of tissue dysfunction, effects of utilizing the Graston Technique and the development of the Graston Technique.

Conclusion: The benefits of Graston Technique prove to be effective in reducing myofascial trigger points. Discussion of pre and post findings discovered through research provided by Logan Chiropractic College of several different body regions, participants of various age and gender report a decrease in percent disability according to Outcome Assessment Questionnaires and an increase in pain tolerance when an increased amount of pressure was applied after treatment.

Key Terms: Graston Technique, myofascial trigger points, chiropractic, assisted soft tissue mobilization.

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Introduction The human body is composed of many interactive systems: respiratory, nervous, digestive, excretory, endocrine, skeletal, muscular, circulatory and integumentary. Most of which do not operate by themselves. Physiologic reactions are thought to occur when a person experiences pain and include a number of responses such as raised blood pressure, bounding pulse, a surge of hormones, muscle contractility, and so forth, encompassing several systems at once. The relationship between movement and function can be easily disrupted by stresses and/or injury. The dysfunction of tissue complicates the interaction between systems such as the skeletal and muscular. It can be due to repetitive movement or injury causing fascia and muscle to bind together, inhibiting the muscle’s ability to move efficiently. Posture and movement can be analyzed for qualities of pattern response in people with physical pain. Pain is not just an experience of the body it also has psychological, social, cultural and spiritual factors, while it is experienced differently for each individual, and is influenced by many factors. The body has amazing adaption skills in response to long term pain, however, proper function pays the price. Maintaining proper function of the human body is the primary goal of health care today. Chiropractic takes an approach of treating musculoskeletal systems to restore proper function and mobility to aid in the reduction of pain and to enhance the healing process. A very common pain generator seen in chiropractic practices is the myofascial trigger point. Myofascial is comprised of the word “myo” referring to muscle and “fascia”, which refers to the collagenous web that surrounds, supports, and connects all of our muscles. Myofascial trigger points can be one of the most important contributors to chronic problems. Trigger points are discrete, focal, hyperirritable spots found in a hypertonic muscle band. Pain felt from a

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trigger point can be both local and referred. Trigger points can also be manifested due to chronic conditions, repetitive stresses and/or acute trauma. The interaction between the skeletal and muscular systems act as muscles contract and the skeleton provides attachment points for the muscles, by way of a tendon. This takes place at two points, its anchor the origin, and its point of movement the insertion. When the function is disrupted by a myofascial trigger point, the synergistic role of these two systems is also disrupted and malfunction begins. Since all movement is dependent on related supporting structures for its control it has shown beneficial to address aberrant soft tissue as well as skeletal dysfunction. Techniques used successfully to alleviate myofascial trigger points include Graston Technique, Active Release Technique, ischemic compression, and many more. These techniques used before and after spinal adjustments have proven to help maintain the proper alignment, thereby allowing the body to heal and achieve optimal function. This literature review will focus on the effects of the utilization of Graston Technique and the reduction of myofascial trigger points. Beginning with the functionality of the skeletal and muscular systems and the effects of dysfunction, tissue response to injury, the pain response, diagnostic criteria of a myofascial trigger point, the Graston Technique and its integrative role in treating these conditions. Ending with results obtained through senior research projects performed at Logan College of Chiropractic using the Graston Technique to treat soft tissue dysfunction.

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Anatomy and Physiology of the Musculoskeletal System A brief understanding of the musculoskeletal system, how it is developed and what its optimal functioning purpose is. It is first understood that the musculoskeletal system is of two separate entities, the skeleton and the muscles, held together by surrounding tissues, tendons and ligaments. Together they form an undeniable structure to function as support and protection of our internal organs, brain and spinal cord; it also provides storage of nutrients such as calcium in our bones and glycogen in our muscles, and gives structure, a framework if you will, which in turn allows for stability and movement. The skeletal system is made up of 206 bones in the human body, this is an approximation due to anomalies of nature where some people may be born with or without the exact number. Classifications of bones pertain to their shape including long, flat, short, and irregular; regardless of their anatomical form, bones are comprised of both spongy and compact bone. Bone is a dynamic tissue, throughout life it is continuously being formed and resorbed. The constant remodeling and reorganization of bone is the direct result of many factors including mechanical stimuli, endocrine or metabolic changes, and often due to the effects of drug use. As previously mentioned, bones provide nutrient storage and the majority of the body’s calcium storage is in bone tissue. Physiologic demands release calcium into the blood when needed and/or it can be used to produce new bone. Calcium homeostasis is an essential part of the boney skeleton with the use of three other hormones: Vitamin D3, parathyroid hormone and calcitonin 1. As with any system in the body, the balance and involvement of multiple systems needed to coordinate calcium homeostasis involve the bones, kidney and intestines. Whereas most people think of bones as simply a structural unit.

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The human body contains more than 600 muscles, comprised of three different muscle types: skeletal, cardiac, and smooth. Skeletal muscles move bones and other structures; cardiac muscle forms most of the walls of the heart and adjacent parts of the great vessels; and smooth muscle forms part of the walls of most vessels and hollow organs, moves substances through viscera such as the intestine, and controls movement through blood vessels 2. Muscular tissues have four main functions within the body that are achieved through contraction and relaxation of the tissues: body movement, stabilization of the body, storing and moving substance in the body, and producing heat 3. Skeletal muscle attachments are described as having an origin and an insertion. The origin is usually at the proximal end while the insertion is at the distal end. The origin remains fixed during contraction and the insertion is moveable. This unique characteristic distinguishes it from any other body tissue. In the case of skeletal muscle, the individual cells or muscle fibers, ordinarily long and thin, become shorter and fatter under stimulus and take on their tremendous pulling power. Soft tissue refers to the “softer” aspects of the outer body, not including bones and joints, examples include muscles, tendons, and fascia. There are 4 types of classifications of soft tissue including: epithelial tissue which is skin, vessels and lining of organs; connective tissue which makes up tendons, ligaments, cartilage, fat, blood and bone; muscle tissue which is made up of 3 types skeletal, smooth and cardiac; and nervous tissue which makes up the brain, spinal cord and nerves. Soft tissue injuries are very common and range from minor to very serious, depending on the nature of the injury. Muscles, bones, joints, tendons and ligaments together comprise the musculoskeletal system, allowing the freedom of movement. Although skeletal muscles are not considered

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essential for survival in the same way that the muscles of the heart and other organs are, they are extremely important for enabling us to carry out our everyday activities and providing a quality of life. For the concerns of this review the focus will be on skeletal muscle and how the integrity is compromised by way of injury to itself or surrounding elements of the musculoskeletal system.

Tissue Response The body’s initial response to tissue damage is tissue destruction, and an inflammatory response is activated. The response is dependent on whether or not the tissue is able to adapt when damage occurs; otherwise the tissue becomes injured or the tissue dies. For this review our concern is tissue that becomes injured and structural changes take place effecting the proper function of the musculoskeletal system. The inflammatory response is the body’s internal defense mechanism against injury. In the body’s effort to protect itself it neutralizes and destroys toxins at the site of an injury so that infection cannot spread to other tissues. The inflammatory response involves many steps. First vasodilation of the blood vessels making them more permeable to substances normally contained within the vessels are now able to travel out into the injured tissue creating greater blood flow to the injury site. A larger amount of blood flow to the injured site allows the body to remove toxins and dead cells. There is a release of chemicals such as histamines, kinins, and prostaglandins, while white blood cells and clot forming substances enter the damaged area. Heat, redness and swelling occur minutes after an injury due to the increase in blood circulating and increased permeability of capillaries, while pain is a result of damage to nerves, toxin irritation, and/or pressure that occurs due to the swelling. The presence of prostaglandins and

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kinins are also pain generators attributed to the inflammatory response. Phagocytes migrate to the area to clean up any bacteria and ward off infection. White blood cells permeate through the capillaries to reach the injured tissue to clear away any toxic debris while the body’s nutrient storage is released for use in the injured tissue to support the defensive immune system cells and injured cells. While the inflammatory response is the body’s way of dealing with soft tissue injuries, it can also be prolonged and cause extensive damage to the body linking pain and mobility problems that can be difficult to deal with. Some connective tissues have a capacity to continuously renew themselves such as bone; however, muscular tissue has a much lower capacity to renew itself due to a slower division of cells to replace damaged muscle fibers 3. There are three phases of tissue repair for restoring homeostasis: resolution, restoration and regeneration. Resolution is where there has been little tissue damage and therefore has normal restoration; restoration happens when resolution has been delayed; and regeneration is the replacement of tissue by the same tissue. Regeneration of tissue is dependent on the tissue type, the degree of physiologic health and nutritional status of the injured person, and their ability to heal, leading to the body’s level of capability for phagocytosis, endothelial production, production of fibroblasts, and the active repair process of parenchymal cells. When acute inflammation fails to resolve within one month it is then termed subacute inflammation. Inflammation lasting longer than one month and as long as years is then termed chronic inflammation. Chronic inflammation can also be a result of repeated microtrauma and overuse or repetitive trauma, leading to proliferation of connective tissue and tissue degeneration.

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Characteristics of chronic inflammation include the presence of lymphocytes, plasma cells, and macrophages in contrast to the presence of neutrophils during the acute inflammatory stage. Chemicals present include bradykinins that are responsible for vasodilation/perfusion to the tissue and pain, while the presence of prostaglandins are also responsible for vasodilation but can be inhibited by the use of NSAID’s or aspirin. With tissue damage begins the formation of scar tissue. This tissue is less viable than normal tissue, its firm and inelastic, developing from exudates with high protein and debris levels that result in granulation tissue. Scar tissue consists of fibroblasts and collagen forming a dense mass that disrupts the normal tissue function. In addition, scars can cause sensory alterations that mimic medical conditions 4. As stated by Michael Schneider in the Principles of Manual Trigger Point Therapy 5, there are four distinct stages of muscle degeneration, based on the degree of chronicity: Stage I, the mitochondria swell and myofilaments become moth-eaten; Stage II, myofilament destruction; Stage III, sarcomeres become disrupted and/or fragmented; Stage IV, there is complete disruption of contractile elements, necrosis, collagen and scar accumulation. Not only is there a physiological response to tissue damage but there is a strong tendency for many people to make postural adjustments into positions that help alleviate pain surrounding an injury, but this can weaken the structure and create compensatory muscular stress. Most holistic health practitioners feel that taking anti-inflammatory drugs only mask and lessen the chance of proper healing, while natural remedies, such as soft tissue manipulation, do not interfere with the body’s innate ability to heal and repair injured tissue.

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The Presence of Pain Two types of pain patterns include sclerotomal and dermatomal allowing for deep or superficial pain with slow or fast characteristics. Sclerotomal pain is transmitted by C fibers causing a deep aching pain that is poorly localized and usually referred away from the site of damage. Sclerotomal pain may radiate but does not follow the pattern of radiation corresponding to a specific nerve root distribution the way that dermatomal pain patterns do. These pain patterns can be projected to multiple areas of the brain causing depression, anxiety, fear or anger. Pain assessment can be difficult due to its subjective nature, self report is the best reflection of pain and discomfort. Assessment of pain can be acquired using rating scales such as the visual analog scales (0-10, marked no pain to severe pain) or verbal descriptor scales (marked none, slight, moderate, and severe). For the treatment of pain you must break the pain-spasm-hypoxia-pain cycle through treatment. Many agents can be used for this purpose from heat/cold, electrical stimulationinduced analgesia, manual therapies such as the Graston technique, ART, soft tissue mobilization and so on. Treating the psychological aspects of pain can be much more difficult. Again, pain is subjective and the pain threshold will vary from one individual to another. There are a number of theories relative to the components of pain whether physiological and/or psychological.

Myofascial Trigger Points Myofascial trigger points (MTPs) are often misunderstood or even overlooked. The most distinctive characteristics seen clinically of MTPs are pain related to voluntary muscle activity. There has been no consistent pattern to the choice of specific diagnostic criteria or their combinations. Upon physical examination the 4 most commonly applied criteria for MTPs are: (1) tender spot in a taut band of skeletal muscle, (2) patient pain recognition, (3) predicted pain 10

referral pattern, and (4) local twitch response. The patient may also experience a painful limitation of stretch range of motion, and muscle weakness. Myofascial trigger points are routinely diagnosed and treated by clinicians in many musculoskeletal health disciplines. To date there no laboratory or imaging technique has been established as the gold standard criteria. However, there are three measurable devices to help substantiate objectively the presence of a MTP characteristic are electromyographic (EMG), biochemical or diagnostic ultrasound. Furthermore, there is currently no reliable list of physical diagnostic criteria for MTPs. The detection of MTPs is solely dependent on manual palpation and patient feedback. Myofascial trigger points were identified using the above mentioned criteria established by Simons, Travell, and Simons in their book Myofascial Pain and Dysfunction, The Trigger Point Manual 6. MTPs are classified as two types, active and latent, depending on their clinical characteristic. The active trigger point is painful for the patient at rest, when compression is directly applied to the nodule, and it has a referred pain pattern that is similar to the patient’s complaint. A latent trigger point does not produce spontaneous pain. Pain is elicited only when compression is applied directly to the nodule along with other characteristics such as increased muscle tension and muscle shortening which may restrict movement or cause muscle weakness. Both active and latent trigger points can cause a significant motor dysfunction and there is a long list of differential diagnosis that may be confused with MTPs.

The Graston Technique Many manual techniques have been used for soft tissue dysfunction such as cross friction massage, myofascial release, active release technique, and more, which have proven successful for the treatment of aberrant tissue. With these techniques the practitioner administers treatment

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with the use of their hands where in many instances the amount of pressure applied can be straining and/or tiring after repeated sessions and multiple patients. An alternative is the manual application through the use of instrumentation with a highly specialized set of tools called The Graston Technique. David Graston developed the Graston Technique in 1987, utilizing tools and a technique to assist in his own recovery from a skiing injury to his right knee. Research in the early 1990’s was explored at Ball Memorial Hospital and Ball State University in Muncie, Indiana. After several years of gathering data, the Graston Technique was considered the cornerstone for treatment of chronic and acute injuries at the TherapyCare resources out-patient clinic in Indianapolis, IN. The Graston Technique has been determined to be an effective rehabilitation tool for a variety of diagnosis including plantar fasciitis, tarsal tunnel syndrome, shin splints, and ankle sprains 7. The tools are six specially designed stainless steel instruments used to detect soft tissue fibrosis enabling the clinician to effectively break up scar tissue and fascial restrictions. The combination of concave and convex shapes mold the instruments to various contours of the body allowing for minimal stress to the clinician’s hands and maximum tissue penetration. The uniqueness of the instruments is that as the clinician passes over aberrant tissue the tool resonates through the clinician’s hands, analogous to how a stethoscope magnifies the sound of the heart, increasing significantly what the human hands can feel, allowing isolation of adhesions and facial restrictions 8. An important feature of the Graston instruments is the ability to penetrate and feel the texture of tissues at a much deeper level than felt by the human hand 9. The instruments are passed over the affected area in multiple directions to determine which directions create the abnormal barrier sensation 10. This helps the practitioner to treat the lesion in the most efficient and specific manner.

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Benefits to patients suffering from aberrant soft tissue due to injury and/or mechanical stresses include a decrease in overall time of treatment, faster rehabilitation and/or recovery, reduces the need for anti-inflammatory medication, and may resolve chronic conditions thought to be permanent. Benefits to the clinician are a decrease of fatigue and energy conservation, an increase of having a mechanical advantage, decrease treatment time, conservation of the joint, and it enhances patient care and improves the ability to locate aberrant soft tissue. Graston instrumentation works well in releasing soft tissue contractures associated with joint dysfunction as in osteoarthritis, and to avoid joint replacement surgery by releasing the surroundings contractures, causing the forces applied through the joint to normalize.

Senior Research Performed at Logan College of Chiropractic - Results of the Effects of Utilizing the Graston Technique Research has been performed at Logan College of Chiropractic to investigate the effects of utilizing the Graston Technique to reduce the presence and/or pain due to trigger points. For the purpose of this review included are the results of multiple research projects. Particiapnts in all studies were either placed in the treatment group or a sham group, unaware as to which group they are in, the results pertain only to the treatment group. A Pilot Study For Graston Technique For Improving Trigger Points In The Upper Trapezius Muscle was performed April 2004 11. The study had 20 participants with at least one trigger point in one of their upper trapezius muscles. The participants were inspected, algometer readings and VAS were recorded then re-recorded post treatment. The results were as follows: 2 out of 10 trigger points were reduced or eliminated; 8 VAS readings were reduced and 2

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increased; and 2 out of 10 algometer readings improved, 4 worsened, 3 stayed the same, and 1 was eliminated. The Effect of Graston Technique on Trigger Points in the Upper Trapezius Muscles was performed December 2009 12. The study had 25 volunteers who met the inclusion criteria of having trigger points in the upper trapezius muscles. Each participant’s data was collected by algometry and VAS recordings then re-recorded post treatment. This study consisted of 4 separate sessions for the treatment group, the results are as follows: upon the conclusion of the final treatment 12 participants recorded a decrease of the VAS, while 2 remained the same; 13 showed an increase in pressure reading and only 1 had a decrease. Graston Technique and Its Effects on Trigger Points in the Upper Trapezius Muscle performed May 2006 13. This study involved 18 participants all meeting the inclusion criteria of having trigger points in the upper trapezius muscles. Data was collected by algometry and VAS recordings then re-recorded post treatment. The study consisted of 4 treatments. The overall results were as follows: 15 participants had a decrease in pain elicited by pressure. The Effect of Graston Soft Tissue Technique on Trigger Points of the Masseter Muscle: A Pilot Study, performed December 2010 14. This study had 10 participants with trigger points in the masseter muscle and temporomandibular dysfunction. Data was collected with the usage of a TMJ Disability Questionnaire and algometry readings. The study consisted of 6 sessions. The results are as follows: 7 out of the 10 reported a decrease in percentage of disability according to the TMJ Disability Questionnaire, and the algometer reading showed an increase in pain tolerance in 6 out of the 10 subjects. The Effects of Graston Soft Tissue Therapy on Iliotibial Band Tightness, study not dated 15.

This study was performed on 20 participants that satisfied the criteria of being 18 years of age

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with a history of being involved in some level of physical activity. Data was collected by performing Ober’s orthopedic test, history of past and present physical activity, and VAS. The results showed that all participants in the treatment group showed some level of pain relief and the subjective pain number was lower post treatment. Graston Technique on Cervical Spine Soft Tissue Located in Suboccipital Region and its effect on Range of Motion, study not dated 16. The study had 20 participants with the primary goal to separate and break down scar tissue of the cervical musculature demonstrating a significant increase in range of motion. The results are as follows: data gathered demonstrated a significant change in the measured cervical extension. 

Conclusion The critical need is for competent scientific studies to address the cause of the pain, and to begin to identify which therapy or combination of therapeutic approaches is most effective for the specific causes. Specifically we need to know more about the relationship between TrPs and articular dysfunctions as causes. The Graston Technique research performed at Logan College of Chiropractic demonstrates that treatment goals were obtained to reduce trigger points, decrease pain, and increases in algometer readings and decreases in disability questionnaires. Positive results have been obtained for the effectiveness of the Graston Technique to relieve patients of pain and tissue dysfunction, but further research in this area needs to be conducted to lend support.

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References 1. Guyton, A.C. and Hall, J.E. (2011). Textbook of Medical Physiology-12th Edition. Elsevier Inc., Philadelphia, PA. (pg. 955) 2. Moore, Keith L. Essential Clinical Anatomy. 3rd Edition. 2007. (pg.16) 3. Tortora, G.J., Derrickson, B. Principles of Anatomy and Physiology. 11th Edition, 2006. John Wiley & Sons, Inc: Hoboken, NJ. (pg. 140, 302) 4. Manheim, Carol J. The Myofascial Release Manual. 4th Edition, 2008. (pg.261) 5. Schneider, Michael J. Principles of Manual Trigger Point Therapy. Pittsburg, PA. 1994. (pg. 10). 6. Simons, D., Travell J., Simons, L., Cummings, B., Travel & Simons’s Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd Edition, 1999. (pg. 21-22) 7. Carey, T., Hammer W. Graston Technique Instruction Manual. Ed. Richard E. Vincent. Indianapolis, IN: 2nd Edition, 1996. (pg 7, 9, 10, 93-95) 8. Warren I. Hammer. Functional Soft-Tissue Examination and Treatment by Manual Methods. 3rd Edition. (pg. 589) 9. Hammer, Warren. Graston Technique A Necessary Piece of the Puzzle. Dynamic Chiropractic. September 24, 2001. v.19, issue 20. 10. Hammer, Warren. Applying the Graston Technique: An Update. Dynamic Chiropractic. January 1, 2003; v.21, issue1. 11. Welty, Diana et al. A Pilot Study for Graston Technique for Improving Trigger Points in the Upper Trapezius Muscle. April 30, 2004. A Logan College of Chiropractic Research Study.

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12. Corum, Debra, et al. The Effect of Graston Technique on Trigger Points in the Upper Trapezius Muscles. December 2009. A Logan College of Chiropractic Research Study. 13. Brimm, Jamie, et al. Graston Technique and Its Effect on Trigger Points in the Upper Trapezius Muscle. May 2006. A Logan College of Chiropractic Research Study. 14. Cass, Shanna, et al. The Effect of Graston Soft Tissue Technique on Trigger Points of the Masseter Muscle: A Pilot Study. December 2010. A Logan College of Chiropractic Research Study. 15. Brooks, Amber, et al. The Effects of Graston Soft Tissue Therapy on Iliotibial Band Tightness. Date not specified. A Logan College of Chiropractic Research Study. 16. Pharr, Patrick, et al. Graston Technique on Cervical Spine Soft Tissue Located in Suboccipital Region and its Effect on Range of Motion. Date not specified. A Logan College of Chiropractic Research Study.

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