Tennis Elbow: Evidence Anyone?

An excellent summary of the current evidence for the management of lateral epicondylitis can be found at medpage Today.  One of the original articles is also attached.

John

Download bissetbrjsportsmed2005srmalatepipt.pdf

Comments

[David Penn]

John,

Although there does not seem to be convincing evidence in the review provide regarding the efficacy of physical therapy interventions, we have been using a strategy called graston technique (www.grastontechnique.com) which is based on the old Cyriax model of tranverse friction massage. The difference is that stanless steel tools are utilized to cause the soft tissue controlled injury vs. the fingers. The competitor group astym.com has done a good job of collecting outcome data on various diagnosis which can be used as a marketing tool to MD's. There are some studies that support the changes at the cellular level.

Sevier TL, Gehlsen GM, Wilson JK, Stover SA, and Helfst RH: Traditional physical therapy vs. Graston Technique Augmented Soft Tissue Mobilization in treatment of lateral epicondylitis. Journal of the American College of Sports Medicine 27 (5), 1995.
Forty patients diagnosed with lateral epicondylitis were randomly assigned to one of two groups; traditional PT protocol; phonophoresis and manual cross-friction; the Graston Technique protocol. Both groups received identical cryotherapy, exercise and stretching programs. Pain level, mechanical finger power and grip strength were measured. There was a statistical difference between groups, in favor of the Graston Technique protocol for the above measures.

Just thought I would pass on what I think to be a solid technique for soft tissue injuries that can be supported. It can also give a relatively immediate tangible result in some cases, particularly tennis elbow as measured by increases in Jamar grip scores - pre and post treatment.
Indeed, more study needs to be performed to further clarify how much a contribution this technique has assiociated with it. I hope to participate in such a study if the barrier to submission are not insurmoutable.
David

[John Childs]

David:

Fortuitous timing with your comment. We are actually in the early stages of discussion with Dr. Sevier to conduct a trial of ASTYM in patients with plantar fasciitis. You may have just invited yourself to participate:)

John

[Jason Silvernail]

David-
It is my understanding from the others involved with the technique that there is a bit of money involved in "learning" the technique and purchasing the tools for Graston Technique.

From the site:
"Education and training are an integral part of the success of the Graston Technique.® Only those clinicians who have successfully completed the Graston Technique Basic Training seminar are qualified to use the instruments on patients."

The website lists neither the prices of "GT Accreditation" nor the tools.
It reminds me of seeing "Market Price" on a menu at a restaurant, kind of a "if you have to ask, you can't afford it" type of thing.

Knowing the usual deal with our CEU system and profits often coming before professional advancement, is the feeling that the possible outcomes here are worth the investment?
Do you feel comfortable sharing on the blog what the costs are?
Thanks.
J

[britt smith]

John,
The last week's blogs have been very interesting. The link between CEUs, continue ed. in general, generation of new innovations and assimilation of what is 'hard' evidence with emerging evidence and that 'hard' evidence continues to evolve (and devolution). I was asked yesterday by the a local insurance to review a case of an out of town patient seeing an 'out of network' PT using muscle activiation technique. I will be on an appeals panel in a few weeks. I've been looking up the MAT website [created by an exercise phys./strength coach with a MS in PE] when the Graston Technique came across the press (thanks). I look at the website David gave us...very interesting. Graston appears to have some early research/outcomes studies that look promising, but the MAT website is SELL, SELL, SELL with testimonials and sweeping statements of effectiveness (www.muscleactivation.com). The most stricking aspect of the MAT website is that commercial interests/marketing are way out in front of the evidence. Very 'info-mercial' in the selling of courses, DVDs etc.
Our culture of entreprenieurship is very difficult for the undiscerning eye, and even someone with some experience sorting for evidence.
I don't see much EBP having on the web these days.
Britt

[John Childs]

Britt:

Good comments all the way around. Just to add some interesting twist in the discussion, have a look at www.astym.com versus www.grastontechnique.com. It won't take long to figure out there have to be some intellectual property issues in play. I believe Dr. Sevier is formally affiliated with ASTYM, but the approaches are similar enough that I suspect the two companies don't get together for morning tea. The mix of money and research is absolutely essential to innovation and progress, but the delicate balance that exists between what are competing priorities can easily be lost.

John

[Chad Garvey]

We have been using the ASTYM system for a short time for tennis elbow as well as other various tendinopathies and although we haven't been able to do any of our own outcome studies, we have noted fairly promising in-clinic results. The Graston and ASTYM techniques, according to a clinician from Performance Dynamics (who licenses the ASTYM system), originated from the same idea and group of people headed by Dr. Sevier. Just FYI, for anyone who is interested.

[David Penn]

All of the comments here are right on the money in terms of relationships,competing interests and application similarity. John's comment about having " morning tea" is very true.

Having been trained in both strategies, I have been able to look at it from the 40,000 foot view. Dr. Sevier has done much of the preliminary work using the tools developed by Mr. Graston and as I understand it, the original studies were performed with the stainless steel tools. I have worked with about 250 clients using both techniques. I found that the acrylic tools cause a greater degree of bruising which can be taken as an unanticipated adverse affect if not educated adequately.

From a cost perspective, Jason, this is what we had to look at from a cost/benifit ratio. ASTYM only leases the tools ( $500/year per set and charges a $6/visit fee. The tools that ASTYM was distributing at the time we used the system was limited to 4 with the largest tool being about as wide as your hand. The have good ergonomic design to them. Eduation is seperate at 950/therapist and required. No PT/OT can use the equipement in your clinic unless you are trained. Graston techinique wraps education with the tools at a cost of about $2,900 but that is all that you pay and includes two seperate CEU courses ( beginning and advanced techniqes).

My results have been favorable with tendinosis conitions as well as with adhesions (superficial) or scarred areas either from surgery or repeated trauma. I can only speak anectodally, but I have enough confidence in the system that I purchased 6 sets. You do the math. It is typically billed as manual therapy 1 or 2 units depending on the number of areas, sensitivity of the patient and goals.

My investment in these companies is $0 and think that both have scientific merit that needs to be validated in well contructed studies performed by people in this group. I would jump at the opportunity participate in this type of study.

Sorry for being so long winded. Hope I answered your questions. See yout his weekend, John, in San Antonio.

[David Penn]

Not sure if I was clear that my initial training and experience was with ASTYM in 1998 and made a transition to Graston in 2004.

Sorry for the confusion.

DP

[Jon Newman]

So what is the theory behind why pressing on a tendon makes tendinosis go away? Or is the symptoms that change and not the condition? Are the objects special or would the edge of my hand or a book be ok? I'm being quite serious and figure I should ask them before studies are actually done so hopefully they are controlled for. It would be much more economical for the health care industry and patients could self treat if rocking any thin hard object across their arm will do. Of course I don't have full appreciation of the technique which is why I'm asking.

jon

[Jason Silvernail]

I'm with Jon on this one. I know the principles behind soft tissue mobilization, I'm a smart guy and can find or have made tools to do a similar job. What's the purpose of paying all this money and all the advertising? Other than saying you are a "Graston Accreditied" or "Astym Accredited" clinic?

I don't want to come across as harsh about it, but thinking about my wallet and cost/benefit ratio, I can't help but wonder about those issues.
I know as John C pointed out that research and money go hand-in-hand, and I can accept that. But do we ever think the money from those companies will go toward a head-to-head trial of their copyrighted gadgets vs homemade ones applied with the same principles?
If we can reasonably assume the answer is "no" how do we justify the expense and the patronage of such companies?

J

[John Childs]

Jason:

I hope I didn't convey the idea I'm sold on this technique. The jury is still out by a long shot when it comes to making a buy versus no buy decision for a clinical practice in my opinion. I am just acknowledging that at least this group has some preliminary data in an animal model and beginning the climb up the evidence hierarchy to determine the answers to the relevant questions:

1) Is this technique better than an alternative form of care (stretching, manual therapy, etc.)?

2) If so, is it cost-effective? This technique has to really be effective to justify the expense, not an easy hurdle to clear from a cost-effectiveness perspective.

3) Even if cost-effective, do you need the tools in the first place to accomplish the inteded objective? Can you do this with your hands? A homeade instrument? If any, what are the intellectual property implications associated with homeade intruments?

As a researcher, I tend to be a skeptic until proven otherwise. This tendency would preclude me from purchasing the devices until more definitive evidence can be shown. On the other hand, I can't envision any harm, so...if I'm in private practice and might be able to use this technique to more effectively market my practice, the cost-effectiveness threshold might look a little different.

Time will tell. I'm encouraged though that at least this group is interested in pursuing relevant research in patients. This is a far cry from many of the other device-oriented approaches advocated in practice.

John

[Jason Silvernail]

Thanks, John and David. I think John's last post was a good summary on this topic overall. You're right, perhaps the greater focus on evidence early on is reason enough to patronize these companies. We do need to promote a feeling in the profession that any new system or device has to have some quality accompanied research behind it, or it might just get laughed off the web. Or at least disregared by serious practitioners.
Thanks for the dialogue.
Jason.

[MIchael DuPriest]

My clinical experience with Graston has been positive. I prefered the Graston tools over ASTYM due to cost. I also have essentially stopped using iontophoresis at the tune of about $700 per month in electrode costs, not to mention unpredictable reimubursement. Manual therapy is a much better billing choice. As far as making your own tools: " So doctor, Mrs Complainer states that you injured her with some tools you were using for massage. I also understand that you made these tools. Have these been tested for patient use? Are these tools patented? Where did you get your training to use these tools doctor?" You know I thought the same thing and then I thought about the above.

Mike d

[Jason Silvernail]

Good point, Mike.
However, could we not say the same thing about any tool in the clinic? The wands we use for ROM exercises, the bands or weights we use for conditioning, the balance devices for proprio?
Some of these things have been tested for safety (like burst resistant exercise balls) but most have no evidence of testing for safety.

Many soft tissue mob devices (I remember a hand held trigger point device called the 'Knobble') have been around for many, many years. Is there any reason to think that experience with them, litigation-wise, would be different than with these Graston/Astym tools?
J

[Mike C]

Follow-up to Graston vs Astym. There is a Chinese medicine technique called Guasha that has probably been around for a thousand years. There are tools available that look very much like the tool sets for Graston/Astym. The Guasha concept/model is of course different and the technique is different but similar enough to probably impart the same physiological effect. See what you think.

[Michael Hartman]

I know I am a little late to the party but hopefully this will get bumped. To Make a long story short I developed my own tool and have ben selling it online . I would gladly donate a tool for a research project to compare a simple tool (mine) to the sets sold by Graston and ASTYM. You may contact me at gr8doc AT gmail.com

[Caroline]

Michael Hartman, I tried to reach you at gr8doc AT gmail.com but comcast sever stated invalid address. Do you have another way of getting in touch? I would be interested in finding the site where your tool that you developed is on line.

[seattle chiropractor]

The benefit of the Graston is the amount of improvement that can be achieved in a short amount of time compared to the manual soft-tissue mobilization techniques I had been relying on previously. I can see more patients during the course of a day with Graston as compared to manual techniques because of the time-efficiencies gained from use of the instruments, which has increased my collections tremendously. To me, the cost of the training and the tools was a bargain!