Active Release Techniques and The Graston Technique: Do we have to choose?

by Dale J. Buchberger

Doctors, chiropractic students, academic colleagues, athletic trainers and physical therapists ask me everyday, “what do you think of Graston?” or “what do you think of Active Release Techniques®?” Which one should I learn first or at all?

First of all it is important to understand my activity and involvement with each technique before you can judge as to my objectivity in writing this article. I believe that my experience with each technique is what allows me to maintain an objective view on each technique. My scientific and academic background also lend to objectivity. Despite my best efforts I am sure that proponents from either camp will find criticisms with my views. But it is the debate that makes life interesting.

I have been involved with practicing Active Release Techniques since 1992. I was amongst the first group assembled in Bensalem, Pennsylvania at a CCSP seminar when Dr. P. Michael Leahy demonstrated (on me) what has become known as Active Release Techniques or ART. Since that time I have been utilizing Active Release Techniques. I have been an instructor for Active Release Techniques since 1998 and have published several articles discussing Active Release Techniques. My involvement with Graston began approximately two years ago. I am now a treating investigator on a research project involving the use of GISTM (Graston) for repetitive strain disorders of the hand and wrist. For the last year or so I have been using both ART and GISTM in my practice and have discussed both techniques with patients, colleagues and students.

The following is my explanation of both techniques, usage in private practice, as well as practicality in the chiropractic profession. I believe this is a rationale unbiased explanation of both techniques. From there you have to make your own choices; ART, Graston or both?

Active Release Techniques
Developed by P. Michael Leahy, DC.

Active Release Techniques Soft tissue management system® is a manual soft tissue technique using the examiners hands to apply the technique. The main concept is to reestablish motion between fascial planes thus reducing fibrous adhesions and reestablishing neural and myofascial glide between tissues. The technique utilizes patient active motion when ever possible. A tension contact is used as opposed to compressive contacts used in other soft tissue techniques. The primary direction is to go with venous drainage during an ART treatment although reverse directions are occasionally used with appropriate modification. I currently use ART on 100% of my patients. My practice is specifically referral from patients, medical practitioners, physical therapists and chiropractors. The technique is applied to acute, chronic, overuse; repetitive strain injuries and NMS post operative cases of all types. The number of postoperative cases is growing constantly. The technique is dynamic, it only requires you to use your hands and contrary to popular belief a lubricant is not necessary when the technique is applied correctly.

One rap on ART is that it is tough on your hands. This is true in two cases: 1) Every patient you treat is built like Arnold Schwarzenegger. And at that this would be if you were working on them from the hip to the knee exclusively 2) You are applying the technique incorrectly. This is the most common cause of sore hands and thumbs with ART use. Harder is not better! Using ART is actually a case of less is more!

The other big rap is that the technique is too expensive to learn and that Dr. Leahy is entrepreneurial. 1) I would agree that Dr. Leahy is entrepreneurial. But the last time I checked this was the United States of America and that was legal. As a health care practitioner, if you open a private practice you are an entrepreneur as well. So if that’s your beef get over it. 2) No other technique gives you an instructional ratio of 5-8 students per instructor; i.e. you get what you pay for. 3) No other technique provides the hours of hands on instruction, instructional manual, videotapes, protocol updates and puts patients in your office. 4) If you are not using what you have learned in an ART seminar on Monday morning then it was too expensive (then you should put the tapes and manual next to the stationary bicycle in your basement). 5) The protection of the technique is for consumer protection not Dr. Leahy’s. If the technique were not right protected it would be watered down like every other technique and would be essentially useless to the consumer. As it is there are folks in health care claiming to do ART and quite frankly they don’t have a clue. You have instructors at chiropractic colleges who have never taken a course but claim to teach ART. In addition to opening their institution up to a copyright infringement lawsuit they are also doing their students a disservice by falsely representing themselves as something they are not. When I refer a patient to an ART practitioner I am confident that they are receiving ART as I perform it and not some bastardized version of something that was passed down from someone who read an article on it and was never trained. As chiropractors we get upset when a non-chiropractor learns to manipulate from some minimal training. ART falls into this category. If anything, Dr. Leahy should be applauded for not only raising the bar educationally but attempting to improve professional integrity in a profession that continues to shoot itself in the foot by washing it’s dirty laundry in public and looking for the “cheap” way out (more on this socioeconomic phenomenon later).

The Graston Technique (GISTM)

Developed by David Graston who suffered a multiple ligament injury of his knee in an accident in 1987. The surgical reconstruction left him with limited range of motion. Having failed traditional physical therapy or orthopedic management he began using cross friction massage as described by Cyriax. The extensive manual work caused fatigue in his hands and he subsequently developed stainless steal tools to assist in the application of myofascial work on scar tissue. The Graston Instrument assisted soft tissue mobilization technique is a soft tissue technique designed to mobilize, reduce and reorganize fibrotic restrictions in the neuromusculoskeletal system. The technique is delivered through the use of six (6) hand held stainless steel instruments. A specially designed lubricant must be applied to the skin prior to utilizing the instrument. The lubricant allows the instrument to glide over the skin without causing irritation. The special lubricant also allows the instrument to glide without causing an accumulation of the lubricant on the instrument as commonly happens with ultrasound gel on an ultrasound head.

The treatment is applied in multiple directions: with venous drainage, against venous drainage and cross fiber in multiple directions to the lesion. As with other soft tissue techniques the treatment application is also part of the diagnostic process. As the Graston tools are applied a “vibratory” sensation is felt through the tool to the examiners fingertips. The patient simultaneously experiences a similar sensation while the tool traverses the area being treated. I currently use The Graston technique on approximately 30% of my patients. I have found the technique to be very useful on 1) very chronic cases, frozen shoulder, de Quervains, etc. 2) Cases where ART, proper rehabilitation and other traditional forms of treatment have been ineffective.

When using the Graston instruments the examiner must be careful to keep the tools clean and use appropriate grips. As the tools become slippery the examiner has a tendency to grip harder. This in itself can cause repetitive strain injuries to the examiner. Again keeping the tools clean will help avoid treatment-induced injury to the examiner.

Although the Graston workshops are not as pricey as the ART workshops the tools do carry a heavy price tag. Graston does provide you with an instructional manual. It is my understanding that they are also working on a provider network similar to ART. Instructional videotapes are not available for the Graston technique.

Unlike ART, Graston does not have an individual that the health care professions can complain to regarding cost of the tools and workshop. Therapy Care Resources (TCR) of Indianapolis, Indiana is the owner/manager of the Graston Technique. If there were an individual versus a company this may change public voice regarding cost of the instruments as is the case with ART.

Application of Both Techniques

While using both techniques I have found that the Graston technique compliments ART very well and vice versa. Something that is not talked about very much is the necessity of the patient to undergo an exercise routine consisting of strengthening and flexibility exercises specific to their condition. Either technique falls short of it’s maximal effectiveness if the patient does not comply with a balanced program of strengthening and flexibility training. I believe that the effectiveness of either technique is limited by: 1) The starting product. Is the patient de-conditioned and lacking sufficient muscular volume to apply the technique to? Are we applying the technique to tissue that has undergone fatty degeneration? How will this affect the duration and outcome of the treatment? 2) How long have they had the problem? 3) Once treated, will they go back and perform the injury inducing task again?

Graston is a good precursor to ART when the patient presents with diffuse fibrous restrictions that for practical time and financial restraints are better treated with Graston initially. The examiner must realize that the goal of Graston is to create an inflammatory response and allow remodeling to take over from this point. This is contrary to ART, which attempts to establish motion without inducing a dramatic inflammatory response. Once the restrictions reduce and become more isolated, introducing ART into the treatment plan at this point has been a very effective scenario.

Practicality in the Chiropractic Profession

Both techniques will positively impact and compliment private chiropractic practice. Manual soft tissue techniques address an aspect of manual therapy practice (chiropractic) that joint manipulation cannot address. Adding soft tissue manipulative techniques to your practice will only improve your outcomes and expand the areas of the body and number of conditions you can treat rationally and effectively.

The management difficulties arise with time and reimbursement or the proverbial “bottom line”. In some U.S. States DC’s can be reimbursed for soft tissue manipulation (STM). In many states however reimbursement for STM’s is not common and getting patients to pay for these services outside of their HMO/Insurance coverage may be like pulling hens teeth until they are at the end of their rope. Now I am sure there are some very good business people in certain geographical areas of the U.S. who are receiving both patient and insurance reimbursement for STM’s. These however are not the masses. For example: New York State workers compensation reimbursement is around $26 (rounded up!) regardless of what service is performed. For a practicing chiropractor to pay the bills and feed a family treating 2-3 patients per hour at $26/visit is absurd. Considering what we pay for the additional training, we should be reimbursed at a fair and reasonable rate for the service that is provided. Not because of the additional training but because the additional training allows us to provide a better service that leads to improved outcomes.

This being said, Active Release Techniques is probably the more practical technique to introduce into chiropractic practice. It can be applied readily without the need of extra equipment. When properly trained the practitioner can treat a given region or condition in a reasonable office visit and compliment Chiropractic Manipulative Therapies (CMT’s) immediately. Along the lines of reimbursement ART has begun the “ART Elite Provider Network” (ART EPN). This is a PPO based on improved care with appropriate reimbursement for the service provided versus watered down care with ridiculously low reimbursement. In other words better treatment equals better outcomes and should receive better reimbursement. This is a great idea and hopefully it will flourish. The ART EPN is new and data is not available at this time.

Graston, while it is a valuable adjunctive therapy to chiropractic practice can be less practical in areas of the U.S. where chiropractic reimbursement is limited to CMT or global fees. To repeat what I have stated earlier in this article, Graston is extremely affective in stubborn cases. These are the cases however where the majority of patient’s will pay almost anything to get better. This reduces the reimbursement issue. Graston does add significant time to the office visit, especially if you follow the Graston protocol to the letter. If you alter the protocol to fit an increased number of patients into the office secondary to lower or no reimbursement then the effectiveness of the technique may suffer.

In My Opinion

Both ART® and Graston® techniques are invaluable adjunctive therapies for the practicing chiropractor. Both techniques provide an avenue with which to address the soft tissue component of the injury and treatment equation. Although chiropractors by their training have good manual skills when it comes to joint manipulation the DC education falls grossly short when it comes to soft tissue applications and skill. Since the chiropractic institutions are too busy arguing over who is going to control the political and financial arena of “soft tissue” treatments or “proprietary techniques” the student’s pay the price of educational censorship. In fact students just want the information to give them a competitive edge in the market. The world is changing and it includes soft tissue management working in conjunction with joint manipulation and rehabilitative exercise programs. Chiropractic institutions need to recognize this or the physical therapy and athletic training professions will leave them behind.

My recommendation is to learn ART first for the following reasons:

1. You get reacquainted with the anatomy we long forgot.
2. You get reacquainted with your hands and tactile sense.
3. It’s dynamic. Wherever you are, you have your tools.
4. It is a system of diagnosis and treatment.
5. Continuing education in biomechanical education and application is available.
6. You actually get patients referred to you.
7. The athletic and occupational world knows what ART can do for them.
8. It makes sense.
9. You spent between 60-120K on your chiropractic education (depending when you graduated), the 5-8K you spend on ART won’t kill you.
10. You can still be the first on your block to know something new and chiropractic students can enroll in ART workshops while in school for a significant discount.

Then learn Graston (for students-you cannot take Graston until you graduate so this is an additional reason to take ART first). Graston gives you that added bullet in your arsenal to get those difficult cases better. When you combine ART, Graston, manipulation and rehabilitation you are the most complete NMS treatment machine.

The bottom line is you should consider learning both techniques. You and your patients will be better for it.

Response from Graston:

• GT was developed and proven in clinical trials at Ball Memorial Hospital and Ball State University in Muncie Indiana

• Purpose of the technique is for the diagnosis and treatment of soft tissue dysfunction

• The instruments are used to break cross-fiber links, splay fibers and increase fascial mobility

• When clinically indicated, GT is used to re-initiate the inflammatory process, stimulating the healing cascade by introducing small amounts of micro-trauma to the tissue resulting in a proliferate invasion of blood, nutrients and fibroblasts to the region resulting in collagen depreciation and maturation

• GT is currently in the core curriculum at Bridgeport, National College, Northwestern College and in the kinesiology graduate curriculum at Indiana University for athletic trainers. It is also on track to be an elective at NYCC, Cleveland Kansas City and Palmer- West. Clinic faculty at CMCC have been trained in GT and the Technique is used with some limitation there.

• There are currently 5 research projects taking place on the Technique as follows:
1. NYCC – Carpal Tunnel Syndrome
2. Texas Back Institute – Lumbar Spine Range of Motion Post Surgical Fusion
3. Louisiana State University – Instrument Assisted Soft Tissue Mobilization: Effect on Strength and Range of Motion
4. St Vincent Hospital Indianapolis Indiana – Comparison of Outcomes of GT Instruments with other Rigid Tools
5. Indiana University School of Health and Rehabilitation Sciences – Effects of Instrument-assisted Cross Fiber Massage on the Biomechanical and Histological Properties of the Collateral Ligament in a Rat Model

As to pricing, this is not posted on our website because it is a PUBLIC site. We do not feel that the general public should be privy to the cost to the clinicians to become a GT provider. We always make available the total cost of the GT Instrument Package via fax or phone. In the event of any complaint, we have two provider relation representatives to answer questions, complaints and/or forward the call to Carla as Director of Operations or to me, as clinical director. We also offer direct contact with our instructors to answer questions of a clinical nature.

Richard E Vincent DC Exec VP
Director of Clinical Services
Graston Technique
508-457-5057

References

1. Davidson, C., Ganion, L, Gehlsen, G., Verhoestra, B., Roepke, J., and T Sevier. Rat Tendon Morphologic and Functional Changes Resulting from Soft Tissue Mobilization. Med. and Sci Sports Exer. 29:313-319, 1997.

2. Schiottz-Christensen, B, Mooney, V, Azad, S, Selstad, D., Gulick, J, Bracker, M. The Role of Active Release Manual Therapy For Upper Extremity Overuse Syndromes – A Preliminary Report. Journal of Occupational Rehabilitation. 9(3): 201-211, 1999.

3. Leahy PM, Mock LE. Altered biomechanics of the shoulder and the subscapularis. Chiropr Sports Med 1991; 5:62-66.

4. Buchberger DJ Scapular dysfunctional impingement syndrome as a cause of grade two rotator cuff tear: a case study. Chiropr Sports Med 1993; 7:38-45.

5. Buchberger DJ. The prevalence of subscapularis dysfunction in a baseball population. Med Sci Sports Exer 1999;31(5):S262

6. Buchberger DJ. Use of active release techniques in the postoperative shoulder: A case report. J Sports Chiro Rehab1999;13:60-65

7. Leahy PM. Improved treatments for carpal tunnel and related syndromes. Chiropr Sports Med 1995;9:6-9?

8. Leahy PM. Active release techniques soft tissue management system, manual. Colorado Springs: Active Release Techniques, LLP, 1996:51-56

9. Carey MT, Hammer WI, Vincent RE. Graston technique instruction manual, second edition. October 2001 Indianapolis, IN.

Article Update:

Now that Sound Assisted Soft Tissue Mobilization (SASTM®) has come into the fold I have received many questions about the difference not only between ART® and Graston Technique® (refer to previous article ART® versus Graston Technique®) but now the difference between Graston Technique® and SASTM®.

ART®, Graston Technique® and SASTM®: The differences between these three techniques

ART®:

ART® is an exceptional technique and treatment and diagnostic system for resolution of myofascial, fascial and neuromyofascial restriction. When applied appropriately ART® is more forgiving to the patient and the treated tissues, has a superior educational program with standardization for reproducible results, a large network and government acceptance. ART® is lacking in standardized independent research to validate its anecdotal data. Clinical limitations are in degenerative tendon disease. Not necessarily reliant on eccentric training in association with treatment but reconditioning and nutritional programs clearly improve results anecdotally.

Graston Technique® and SASTM®: Are better techniques for densely restricted tissue, post-operative scar tissue and tendinosis. Instrument based soft tissue techniques are superior for true degenerative tendon disease such as tendinosis compared to manual techniques using the practitioner’s hands. Patients who have better overall health will improve to a greater degree with instruments. Eccentric exercise is a necessary component to the use of instrument related soft tissue techniques. Using instruments without the addition of eccentric exercises will reduce outcomes effectiveness.

The following are differences between Graston technique® and SASTM®:

Graston Technique® and SASTM® are equally effective instrument based soft tissue techniques. Either group of instruments will yield similar results in experienced providers. Either technique or instruments produce an ecchymosis response.

The differences are in practitioner wear and tear, cost and patient comfort;

The Graston Technique® stainless steel instruments are more comfortable to the patient but over time more stressful to the provider’s hands and more costly upfront. The Graston Technique® company does a very good job with their continuing education and training program.

The SASTM® instruments are slightly less comfortable to the patient but over time are more forgiving to the practitioner’s hands and are more cost effective than the Graston Technique® instruments. The SASTM® Company has a less stringent and less effective training and educational program compared to Graston Technique®.