Anne Aurand / The Bulletin

Bend runner Sanna Phinney lay on her side on a massage table. Chiropractor Bari Liebowitz smoothed an emollient along her iliotibial (IT) band, the outside of her leg between her hip and knee. Then, grasping both ends of a handlebar-shaped stainless steel rod, she pressed the tool into Phinney’s flesh and briskly kneaded her IT band — a tender spot for many runners.

Liebowitz switched to a knife-shaped tool and worked on Phinney’s glutes. Phinney rolled over and Liebowitz rubbed the handlebar tool into her patient’s quadriceps.

This is the Graston technique, an instrument-assisted soft tissue therapy that breaks up scar tissue and adhesions around muscles, tendons and ligaments. Stiff, bumpy scars and adhesions, Liebowitz said, don’t expand and contract the way healthy tissue does, limiting movement and creating pain.

About 70 percent of her Graston patients are athletes: swimmers with lower back or shoulder problems; cyclists with back, gluteus or neck problems; runners with knee, hip and shin pain.

Phinney’s skin turns pink as Liebowitz rubs the metal on it. Phinney said the rubbing doesn’t hurt, but other practitioners said the treatments can be uncomfortable. Liebowitz said she’s bringing blood flow and heat into the area, explaining the color. Sometimes little broken blood vessels look pink. Some people get bruises.

Breaking up tissue can create inflammation and jump-start the healing process in which the tissue can rebuild better than it was before, she and others who use Graston said. It speeds up healing.

Liebowitz and other Graston technique practitioners said the tools allow them to feel where adhesions and nodular tissues have formed, in comparison to smooth normal tissues. Normal healthy tissue would feel smooth under the tool. Tissues that are restricted in their movement feel more gritty and textured.

Graston techniques are incorporated into different methods of care, used in conjunction with chiropractic care, physical therapy and naturopathic medicine by a small handful of professionals in Central Oregon.

With Liewbowitz, chiropractic and Graston care costs $55 for a half-hour visit or $295 for six treatments, for those paying cash. However, most insurance companies will cover Graston, she said, if they cover chiropractic care. It’s billed as “soft tissue release.” Referrals from doctors are not necessary, she said.

At the Center for Integrated Medicine in Redmond, naturopaths and chiropractors Payson Flattery and Sather Ekblad use Graston therapy on patients ranging from rodeo riders to office workers, said Ekblad. It’s used for carpal tunnel syndrome, fibromyalgia, and a number of strains and pains, tailored to each patient.

“We’re focused on the average, off-the-street individual,” Ekblad said. He combines it with chiropractic manipulations and low-level, or cold laser therapy, which uses light energy to improve microcirculation and alter cellular functions.

Graston, Ekblad said, initiates some controlled inflammation by breaking up tissue restrictions, such as scars and adhesions created from chronic inflammation. Then, he said, laser treatments help cellular-level healing.

“Whatever you do in addition to Graston is more beneficial than if you had not done Graston,” he said.

In some form, the theory has been around for a long time. Graston is just one patented medical spin on soft tissue stimulation, he said.

David Graston was a machinist who patented a set of tools under his name. Variations of the concept exist under other names, including SASTM (sound assisted soft tissue mobilization) which David Graston now runs.

Therapeutic Associates physical therapy offices provide Graston techniques as well as a related form of tissue therapy, called ASTYM, which stands for “a stimulation” of the body’s healing response, according to the ASTYM website ASTYM treatments aim to “induce biological changes at a cellular level to promote the resorption of scar tissue, and to stimulate tissue turnover and regeneration of soft tissues,” the website said.

The treatments don’t appear vastly different to an untrained eye. The differences look as basic as steel tools versus plastic tools. ASTYM tools are different shapes, have sharper edges, and come in fewer models, said Chris Cooper, a physical therapist for Therapeutic Associates at the Athletic Club of Bend. But there are other subtle differences in the therapies, too, he said. Graston treatment mechanically breaks down unhealthy tissues, which, in the process, can damage some healthy, functional tissue, Cooper said. ASTYM more specifically targets dysfunctional tissue and stimulates the most fibrous tissue to heal normally.

Treatments do not just treat the spot of pain; in the case of an elbow injury, he would treat the whole arm. Fascia, a web of connective tissue around muscles that connects to bones and joints, connects everything in the body. “There’s restriction that’s present away from the injury that affects the injury,” Cooper said.

He uses ASTYM most commonly on a variety of chronic tendon problems, repetitive motion injuries. Tennis elbow. Plantar fasciitis. Achilles, rotator cuff or patellar tendonitis. Hip bursitis.

As a physical therapist, Cooper said, it’s his job to figure out what load — the intensity and duration of exercise — the body needs after an ASTYM treatment. “If it’s a golfer with elbow pain, they can’t go play golf if it hurts but they can take half swings in the living room to have the tissue going through that motion, to have that load,” he said. There’s also a protocol for stretching and hydration that goes along with his treatments, he said.

Theresa Rubadue-Doi, a chiropractor with the Northwest Crossing Chiropractic&Health Center in Bend, uses Graston especially when someone doesn’t respond to conventional chiropractic care, she said.

“I have used various techniques over the years, and Graston has added another avenue to help people. It is really amazing how fast this technique works to help chronic and even acute conditions,” she said.

Many case reports and some small studies have supported the use of these techniques.

The International Journal of Therapeutic Massage and Bodywork in 2010 said Graston and physical therapy had improved the range of motion and muscular activity surrounding the knee of a patient with arthrofibrosis, which is what happens after surgery creates excessive scar tissue in the knee.

The Journal of the Canadian Chiropractic Association in 2009 reported on a case in which tibialis posterior strain (foot pain, common in runners) was relieved in a triathlete after Graston, acupuncture, electrical stimulation, and other rehabilitative therapies.

The Journal of Manipulative Physical Therapy in 2005 published a study that concluded that Graston reduced lower back pain after six treatments. The journal published another article in 2007 that showed an improvement in carpal tunnel syndrome symptoms after an average of eight treatments.