As a physical therapist who appreciates good science, I have a problem with loose use of the term evidence based medicine as it is often misused to describe a wide array of quackery. Just because you can get a journal to publish an inherently biased study, with poor or no controls, and get it listed on pubmed.com does not make the intervention in question evidence based. Placebo effects do sometimes lessen pain, but I don’t think interventions that work primarily or wholly by placebo are particularly “evidence based.” However I suppose that’s up to opinion, so if we can all agree that placebo treatments are legitimate and evidence based, let me know because I think I can get rich doing psychic surgery like the magician and debunker James Randi:
Graston Technique has already been criticized here. I’ve read nearly all the “research” in question and my conclusions were largely the same as Harriet’s, in that most of those papers weren’t controlled studies, but rather case reports where a single patient, with an ailment known to heal on it’s own, gets better some time after being rubbed with Graston instruments. Almost always in addition to rubbing the person with the Graston instruments the patients were also treated with some combination of rest, stretch and strengthening exercise, generally agreed to aid in the healing of said ailment. Still the Graston instruments got the credit. Don’t take our word for it, Graston is not shy about their “published research” with most of their papers available in full text.
So far I haven’t seen as much criticism of ASTYM. ASTYM is the trademarked acronym which stands for Augmented Soft Tissue Mobilization (and I don’t know where they got the Y) which is a form of IASTYM (instrument assisted soft tissue mobilization). ASTYM is basically the same treatment as Graston Technique but uses plastic instead of stainless steel tools, and is supported mostly by a similar but separate group of case reports. ASTYM originator Thomas L Sevier, MD (and one of the authors of the study I review below) does go on at length in his blog about how ASTYM is “very different” but they look awful similar to me. Apparently there is a need for product differentiation amongst competitors in what has been aptly termed the “Modality Empire”.
While Graston Technique seems more popular among chiropractors, ASTYM for some reason is pushed more by, or perhaps pushed more to, physical therapists (niche marketing I guess). In either case the combination of tools, training, and subscriptions literally costs thousands of dollars, and I can’t imagine how they would promote healing any better than if you rub the handle of a butter knife over and around a person’s injury. In fact in in traditional Chinese medicine they sometimes do just that with a soup spoon with the technique called Gua Sha. The great thing about Gua Sha however is that if you think the techniques have validity, or just want to try it out, you can use a spoon, or you can splurge on a professional Gua Sha set (like I did) for just $10.00 with free shipping. I tried Gua Sha on some employees and a few patients and can’t say I (or they) noticed it did much. However, had I just forked out $969 to register as a clinician, paid $360 per set tools and agreed to a $2000 per year annual commitment for my office, I think cognitive dissonance would be considerable and I’d be loath to admit to my patients (or myself) that augmented soft tissue mobilization wasn’t the greatest.
So what’s the big idea anyway? Well you rub the instruments up and down, sideways, and sometimes diagonally over and around a persons painful region then bill them a unit of manual therapy. ASTYM looks like this:
For the record, the above treatment most certainly isn’t being performed in my clinic, and the patient, who I surmise has low back pain is being kept in sustained lumbar flexion, which I am no fan of either.
Since my blog is mostly about physical therapy science, I thought I would talk about what might be called the foundation study that got both Graston and ASTYM on the map and is cited by just about every other case report to come after it. The treatment was performed on rats and the the findings were pretty interesting particularly when looked at from something other than the authors perspective. The study is this one…
…full text is available here and my comments are as follows:
As you can read in the study, 4 groups of 5 rats were used. Group A was the control, group B had it’s tendon damaged with collagenase and was left to heal on its own, Group C had it’s tendon damaged and was treated with ASTM (apparently ASTYM wasn’t trademarked yet), Group D was a normal tendon massaged with ASTM. The animals were later sacrificed and fibroblasts were counted and averaged with 3 (counted per microscopic field) in the control group, 10 in the damaged group, 15 in the damaged treated with ASTM group, and 4 in the normal tendon treated with ASTM group.
The study authors interpreted the results to mean that the ASTM treatment recruited fibroblasts which would then augment healing process. However an alternative interpretation is that the ASTM just further damaged the tendon as evidenced by the increased fibroblasts, and thus impeded the healing process. If attracting fibroblasts is what healing is all about, why wouldn’t the authors just recommend more injections of the collagenase? Hitting the tendon with a hammer or stabbing it with a knife would also likely attract a fair number of fibroblasts.
So whose interpretation is right? Well, the last paragraph on the 4th page says the knee range of motion in both injured tendons decreased by 25 degrees. The same paragraph says 24.6 degrees of the lost range of motion was restored in the untreated tendon. The ASTM treated tendons only restored 21.1 degrees of of the lost 25 degrees, indicating the ASTM treated rats recovered less of their range of motion. So according to their own paper ASTM impeded the recovery, at least of knee range of motion.
Prior to the researchers sacrificing the rats they had them walk on a treadmill and they said:
“The gait results presented here appear to support the morphological data in that only the animals in Group C significantly improved their running performance after injury. The gait data further indicate that both the injured groups appeared to improve with time. However, the ASTM treatment animals (Group C) appeared to return to their original pattern within the time frame of this study.”
But did the ASTYM treated rats really walk better? Gait results for all groups are only given in table format on page 5 of the paper, which is hardly legible in the PDF, but with student or professional access the HTML version is very readable. I would think gait speed or endurance would be good to test, but the authors either didn’t think so, or didn’t report it. However per the graph stride length of the ASTM treated group was over twice as far away (12.5 cm) from the control group (11.25 cm) as was the untreated rats (10.7 cm). Stride frequency of the ASTM group (1.74 Hz) was also twice as far away from the control group (1.96 Hz) as was the untreated group (2.05 Hz). With both stride length and frequency of the ASTM group being considerably more different from the controls (that were in fact normal) I really don’t see how the authors could look at the data and conclude that the ASTM treated rats gait was more normal. Maybe they were squinting. Rather, the graph gives objective data that the ASTM rats were taking longer slower steps, than both the control and untreated rats. I’m not an expert in rat gait patterns, but to me it looks like they were limping at least twice as bad as the rats that were left to heal on their own.
So was the increased number of fibroblasts in the ASTM treated rats indicative healing of the rats augmented or impeded? I’ll just say the paper clearly shows that at 33 days post-injury, the ASTM treated rats had more fibroblasts, less knee range of motion, and altered stride length/frequency, all of which was further from normal than the rats left to heal unmolested. You be the judge.
I for one don’t want to see physical therapists portrayed like the reflexologist or magnet salesman in
my favorite TV show.
Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.
Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.
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