Effectiveness of the Graston Technique for low back pain and thoracic spinal pain: a systematic review and meta-analysis

ABSTRACT

Objectives

Low back pain (LBP) and thoracic spinal pain are significant global health burdens, and the Graston Technique (GT), a form of instrument-assisted soft tissue mobilization (IASTM), has gained popularity as a treatment option. This systematic review and meta-analysis aim to evaluate the effectiveness of GT for reducing pain and preventing disability in individuals with LBP and thoracic spinal pain.

Methods

We conducted a comprehensive literature search across PubMed, EMBASE, Web of Science, Scopus, and the Cochrane Library, identifying four eligible studies from inception to August 2024. Both randomized and non-randomized controlled trials were included. The primary outcomes were changes in Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores. Quantitative data were analyzed using meta-analysis, and qualitative synthesis was conducted for secondary outcomes. Statistical analyses were conducted using Review Manager (RevMan) version 5.4.

Results

The pooled analysis showed a significant reduction in VAS scores when comparing GT to placebo controls (Mean difference = -1.45, 95%CI [−2.24, −0.66]), suggesting that GT may effectively reduce pain. However, no significant difference was observed when compared to active interventions. The meta-analysis revealed no significant improvement in ODI scores with GT compared to placebo. Qualitative synthesis indicated potential benefits in range of motion, flexibility, proprioception, and quality of life.

Conclusion

The GT may reduce spinal pain, particularly compared to placebo. However, these preliminary results require confirmation from further studies as its impact on functional outcomes and superiority over other treatments remain uncertain. Further high-quality research is necessary to confirm these findings and establish GT’s role in clinical practice.

Introduction

Low back pain (LBP) and thoracic spinal pain represent significant global health burdens, affecting millions of individuals worldwide and contributing substantially to disability and healthcare costs [1,2]. These conditions can significantly impact an individual’s quality of life, work productivity, and overall well-being [2]. As healthcare professionals and researchers continually seek effective treatment modalities for spinal pain, there has been growing interest in instrument-assisted soft tissue mobilization (IASTM) techniques, with the GT emerging as a prominent approach [3].

The GT, developed in the 1990s, is a patented form of IASTM that utilizes specially designed stainless steel instruments to treat soft tissue adhesions and restrictions [4]. This technique is based on the principle that controlled manipulation of affected soft tissues can break adhesions, promoting the remodeling of dysfunctional tissues and facilitating the healing process [4]. GT is commonly used by chiropractors, physical therapists, occupational therapists, and other healthcare professionals to treat various musculoskeletal conditions, including chronic low back pain and thoracic spinal pain [5,6].

Despite its widespread use in clinical practice for LBP and thoracic spinal pain, the evidence base for the effectiveness of the GT remains a subject of debate within the scientific community. Some studies have suggested that GT may be effective in improving pain, range of motion, and functional outcomes in LBP and thoracic spinal pain [5,7,8]. However, other study found limited or inconclusive evidence to support its superiority over other treatment modalities or placebo interventions for these specific conditions [9].

The mechanisms underlying the potential therapeutic effects of the GT in treating spinal pain are not fully elucidated, but several theories have been proposed. These include increased blood flow to treated areas of the spine, breakdown of adhesions and scar tissue in spinal soft tissues, and modulation of pain perception [5,9].

The objective of this systematic review and meta-analysis is to evaluate the effectiveness of the GT in reducing pain and preventing disability in individuals with LBP and thoracic spinal pain. By synthesizing data from both randomized and non-randomized controlled trials, the study aims to assess changes in Visual Analogue Scale (VAS) scores for pain and Oswestry Disability Index (ODI) scores for disability, comparing GT to both placebo and active interventions. Additionally, the study explores secondary outcomes, such as range of motion, flexibility, proprioception, and quality of life, through qualitative analysis, providing a comprehensive understanding of the technique’s overall efficacy.

Methods

Study setup and registration

We adhered to the Cochrane Handbook for Systematic Reviews and Interventions [10] and Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards [11] throughout this study. This study is registered in PROSPERO, the International Prospective Register of Systematic Reviews, under the registration number CRD42024588085.

Search strategy

We conducted a comprehensive literature search across five electronic databases: PubMed, EMBASE, Web of Science, Scopus, and the Cochrane Library from inception to August 2024. The search was performed to identify relevant studies evaluating the effectiveness of the GT for various low back pain or thoracic spinal pain. The detailed search strategy is shown in Supplementary Table S1.

Inclusion and exclusion criteria

The inclusion criteria for this systematic review and meta-analysis were designed to ensure the inclusion of high-quality and relevant studies. Studies were eligible if they evaluated the GT as an intervention for LBP or thoracic spinal pain and included a control group, whether placebo or active interventions. Both randomized controlled trials (RCTs) and non-randomized controlled trials (non-RCTs) were considered to widen the scope of the evidence base. Studies needed to report primary outcomes using standardized measures, such as the VAS for pain and the ODI for disability, as these are widely recognized in the evaluation of musculoskeletal conditions. Additionally, only studies that were published in English were included. The search encompassed all available publications from the database’s inception to August 2024.

The exclusion criteria were applied to maintain the quality and relevance of the included studies. Studies were excluded if they lacked a control group, did not focus on LBP or thoracic spinal pain, or used interventions other than GT. Case reports, opinion pieces, and non-peer-reviewed articles were excluded to ensure the inclusion of only robust research. Studies without clear or measurable outcomes for VAS or ODI were also excluded, as these metrics were central to the meta-analysis. Furthermore, studies that did not report adequate data for statistical analysis, such as missing confidence intervals or unclear results, were excluded. Non-English language studies and those involving subjects with co-morbid conditions that could confound the results, such as severe neurological disorders or systemic diseases, were also excluded to maintain the specificity of the research question.

Study selection

The titles and abstracts of the identified records were reviewed by two authors (K.A. and M.M.). Next, we looked for appropriate studies’ full-text publications to include. Consultations with a third author (M.K.) settled in case of any disputes.

Data extraction

Data were extracted from the included studies using a standardized form, which encompassed several key areas. The study characteristics collected included the country of origin and study design. Participant demographics, such as age, gender, and the specific condition being treated, were also recorded. Details of the intervention, including the GT protocol and any control interventions used, were documented. Outcome measures such as VAS scores, ODI scores, range of motion, flexibility, proprioception, and quality of life were extracted. Additionally, the follow-up duration and sample size of each study were noted.

Quality assessment

To the extent that RCTs are concerned: We utilized the Cochrane Risk of Bias tool 2.0 to assess five areas: randomization procedure, intervention variations, missing outcome data, outcome measurement, and results reporting [12].

In the case of non-randomized trials: The ROBINS-I technique was utilized to evaluate seven domains: confounding, participant selection, intervention classification, deviations from intended interventions, missing data, outcome measurement, and reported result selection [13]. Two independent reviewers performed the quality assessment, with any discrepancies resolved through discussion or consultation with a third reviewer.

Data synthesis and analysis

We conducted both quantitative (meta-analysis) and qualitative synthesis of the included studies: For the meta-analysis, the primary outcomes were changes in VAS and ODI scores. Mean differences (MD) with 95% confidence intervals (CI) were calculated for continuous outcomes. Data were pooled using fixed-effects models to account for variability between studies. Heterogeneity was assessed with the I² statistic and p-value, where a p-value greater than 0.1 indicated substantial heterogeneity. Subgroup analyses were conducted to compare the GT with both placebo controls and active intervention controls separately. Forest plots were generated to visually represent the results. The meta-analysis was performed using Review Manager (RevMan) version 5.4 (Cochrane Collaboration, Oxford, UK).

A narrative synthesis was conducted for outcomes that could not be included in the meta-analysis. These outcomes included range of motion, flexibility, proprioception, quality of life, and adverse events. The narrative approach allowed for a detailed exploration of these results, providing a comprehensive understanding of the effects of the GT on these specific measures.

Results

Three hundred fifty-five entries were located after a thorough search across five databases: 35 from PubMed, 105 from EMBASE, 49 from Web of Science, 68 from Scopus, and 98 from the Cochrane Library. Titles and abstracts were screened in 224 documents after 131 duplicates were removed. Seven reports remained for full-text screening after 217 records were removed. After careful consideration, four of these investigations were incorporated into the meta-analysis and systematic review [5,7,8,14] (Figure 1).

Figure 1.

PRISMA flow diagram illustrating the study selection process.

Baseline and summary of the included studies

Crothers et al. [5] conducted a three-arm randomized, placebo-controlled trial in Australia, focusing on patients with acute or sub-acute nonspecific thoracic spine pain. The study compared GT with high-velocity low-amplitude chiropractic manual adjustments and a placebo [5]. Lee et al. [14] carried out a non-randomized controlled trial in South Korea, evaluating GT against general exercises for patients with chronic low back pain [14]. Moon et al. [8] performed a randomized controlled trial in South Korea, comparing GT to static stretching on hamstring muscle pain [8]. Lastly, Yana et al. [7] conducted a randomized controlled trial in Turkey, examining GT against an exercise program for chronic nonspecific low back pain [7]. Baseline characteristics varied among studies, with ages ranging from 33 to 48.5 years and VAS scores between 4.33 and 6.94. The studies employed different follow-up durations, ranging from 4 weeks to 12 months, and varied in sample size, from 24 to 143 participants per arm. Further details are shown in Table 1.

Table 1.

Summary and baseline of included studies. SMT, spinal manipulative therapy, Vas, Visual analog scale, ODI, Oswestry disability Index, ROM, range of motion, IASTM, instrument-assisted soft tissue mobilization, GT, Graston Technique, SS, static stretching.

Study ID	Study design	Country	Patients type	Graston technique	Control	Follow-Up	Primary outcomes	Conclusion	Study arms	Sample	Age, years*	Sex	VAS score	Weight, kg*	Height, cm*	ODI*
Crothers et al. [5]	Three-arm randomized, placebo-controlled trial	Australia	Patients with acute or sub-acute nonspecific thoracic spine pain	Performed by final-year chiropractic students certified in module one of the Graston Technique, involving manual soft tissue mobilization with specialized instruments, under the direct supervision of a registered chiropractor.	SMT group: High velocity low amplitude chiropractic manual adjustments to the thoracic spine Placebo: Session of de-tuned ultrasound	12 months	Change in Pain intensity and pain-related disability	There was no difference in pain or disability outcomes at any time point between SMT, Graston Technique and sham therapy for thoracic spine pain. However, all groups showed improvement over time.	SMT	36	44.4 ± 13.0	20 (55.6%)	5.5 ± 2.0	-	-	27.2 ± 10.2
									Graston	63	44.8 ± 14.3	32 (50.2%)	5.7 ± 2.1			29.6 ± 11.1
									Control	44	48.5 ± 13.0	54.6 (54.5%)	5.5 ± 2.0			28.1 ± 9.9
Lee et al. [14]	Non-randomized controlled	South Korea	Patients with chronic low back pain	Graston Technique using DR. YOUSTM for 4 weeks, targeting posterior fascia, sacrum, hip lateral rotators, and hamstring muscles with general exercises.	General exercises including stretching and stationary bicycling	4 weeks	Changes in pain level and range of motion	Graston technique significantly reduced pain and improved ROM compared to the control group.	Graston	15	40.6 ± 14.6	13 (76.5%)	5.06 ± 1.27	63.9 ± 15.6	169.3 ± 10.2	-
									Control	15	33.0 ± 9.9		4.89 ± 1.46	61.8 ± 12.9	165.6 ± 7.9
Moon et al. [8]	Randomized controlled trial	South Korea	Patients with nonspecific low back pain	Graston Technique (GT) using the Graston instrument (GT-1) on the hamstring muscle for 60 seconds.	Static stretching (SS) of the hamstring muscle for a total of 60 seconds, performed in a supine position.	Not explicitly specified	Changes in sit and reach test scores and pain Scale scores.	The Graston Technique was a straightforward and effective intervention for patients with nonspecific low back pain, enhancing hamstring extensibility and reducing pain intensity.	Graston	12	34.17 ± 4.91	8 (66.7%)	4.33 ± 1.30	61.92 ± 9.87	169.25 ± 9.18	-
									SS	12	35.25 ± 5.86	8 (66.7%)	4.83 ± 1.34	61.83 ± 11.37	168.50 ± 8.68
Yana et al. [7]	Randomized controlled trial	Turkey	Patients with chronic nonspecific low back pain	Instrument-Assisted Soft Tissue Mobilization (IASTM) using the Graston technique	Exercise program (stretching, strengthening, and postural correction)	4 weeks	Change in Pain intensity, pressure pain threshold, flexibility, proprioception, disability, and quality of life.	Adding the Graston Technique to exercise for patients with chronic nonspecific low back pain more effectively reduces pain and disability, enhances proprioceptive sense, and improves mobility and quality of life.	Graston	15	37.13 ± 8.87	10 (66.7%)	6.94 ± 1.84	74.26 ± 12.90	166.1 ± 10.1	45.2 ± 21.5
									Control	15	39.8 ± 9.30	9 (60%)	5.52 ± 1.83	80.0 ± 16.72	169.8 ± 10.79	28.3 ± 13.6

*Mean ± Standard Deviation.

Quality assessment

The quality assessment of the included non-randomized trial showed moderate quality in confounding and selection of reported results. The other five domains were judged as having a low risk of bias [14] (Figure 2(a)).

Figure 2.

Risk of bias assessment of included studies. (A) risk of bias graph for the non-randomized controlled trial (non-RCT) evaluated across seven domains: D1–D7, with judgments of low risk (green) and moderate risk (yellow). (B) risk of bias graph for randomized controlled trials (RCTs) assessed across five domains and an overall risk judgment. Green circles indicate low risk of bias, and yellow circles indicate some concerns. (C) summary of the risk of bias across all included RCTs, showing the proportion of studies judged as low risk or having some concerns for each domain and overall risk of bias.

Regarding the three included RCTs, Moon et al. [8] and Yana et al. [7] showed an overall low risk of bias due to low bias across the five domains [7,8]. Crothers et al. [5] were judged as having some concerns due to deviations from intended intervention in the intervention group as participants and providers were not blinded to the actual treatment allocation. Also, the selection of the reported results was not clearly stated [5] (Figure 2(b,c)).

Meta-analysis

Change in visual analogue scale (VAS)

Compared to placebo control, the pooled analysis of 3 RCTs [5,7,14], including 167 patients, showed a significant reduction in the VAS score in the GT group (MD = −1.45, 95%CI [−2.24, −0.66], p = 0.0003), and the data were homogenous (p = 0.12, I² = 53%) (Figure 3).

Figure 3.

Forest plot comparing the effects of Graston technique versus control or active control interventions on pain reduction.

On the other hand, there was an insignificant difference between the GT and active intervention control in the change in VAS score (MD = −0.40, 95%CI [−0.84, 0.05], p = 0.08), and the data showed homogeneity (p = 0.51, I² = 0%) [5,8] (Figure 3).

Change in Oswestry disability Index (ODI)

There was an insignificant difference between the GT and placebo control in the change in ODI score from two studies [5,7] (MD = −2.17, 95%CI [−7.15, 2.81], p = 0.39), and the data were homogenous (p = 0.23, I² = 29%) (Figure 4).

Figure 4.

Forest plot comparing the effects of Graston technique versus control interventions on Oswestry disability Index.

Publication bias

For the VAS outcome, the distribution of studies is asymmetrical, with more studies clustering on the left side of the vertical line and varying standard errors, suggesting a possible bias toward publishing certain results. The ODI outcome shows limited data points, with only one visible study, making it difficult to properly assess publication bias, though the single point’s position relative to the funnel boundaries raises concerns about the representativeness of the published evidence (Supplementary Figure S1).

Qualitative synthesis

The qualitative analysis of the four included studies reveals several promising outcomes for the Graston technique. Range of motion (ROM) improvements were a notable finding, with Lee et al. (2016) reporting significant increases in lumbar flexion and extension, lateral bending in both directions and hip flexion for patients receiving the GT [14]. These ROM improvements were generally more pronounced in the Graston group compared to the control group.

Flexibility also showed improvement across multiple studies. Moon et al. [8] observed a significant increase in Sit and Reach Test (SRT) scores after applying the GT [8], while Yana et al. [7] reported a significant, but small, increase in flexibility for their intervention group [7].

Proprioception, an important aspect of body awareness and movement control, was another area of improvement noted in the research. Yana et al. [7] found significant enhancements in proprioception for their intervention group, with decreased angular errors at both 15 and 30 degrees of trunk flexion [7].

Quality of life measures also showed promising results in the study by Yana et al. [7]. The intervention group demonstrated improvements in nearly all quality of life subgroups as measured by the SF-36, with only the ‘social function’ subgroup showing no significant change [7]. In contrast, the control group only improved in the ‘physical role’ and ‘body pain’ subgroups.

While pressure pain threshold increased significantly in both the GT and exercise groups in the study by Yana et al. [7], there was no significant difference between the groups, suggesting that this outcome may not be uniquely influenced by the GT [7]. Finally, both Crothers et al. [5] and Yana et al. [7] reported no significant adverse events related to the interventions [5,7].

Discussion

Our systematic review and meta-analysis of the GT for low back pain (LBP) and thoracic spinal pain revealed mixed results. The pooled analysis demonstrated a significant reduction in VAS scores when comparing GT to placebo control, suggesting that GT may be effective in reducing pain intensity. This effect could be attributed to the mechanical stimulation provided by GT, which may disrupt pain signals or promote tissue healing [15]. However, when compared to active interventions, GT showed no significant difference in VAS scores, indicating that it may not offer superior pain relief over other treatment modalities.

Interestingly, our analysis found no significant difference in ODI scores between GT and placebo control. This discrepancy between pain reduction and functional improvement could suggest that while GT may alleviate pain, it might not directly address the underlying functional limitations associated with LBP and thoracic spinal pain. Alternatively, the ODI may not be sensitive enough to detect the specific functional improvements induced by GT, or the duration of the studies may have been insufficient to capture meaningful changes in disability scores.

The qualitative synthesis revealed promising outcomes in range of motion, flexibility, proprioception, and quality of life measures. These improvements could be explained by GT’s proposed mechanisms of action, including increased blood flow, breakdown of adhesions, and stimulation of mechanoreceptors. However, the heterogeneity in outcome measures and study designs limits our ability to draw definitive conclusions about these secondary outcomes.

Our meta-analysis results both align with and diverge from the findings of the individual studies included in this review. Crothers et al. [5] reported no significant difference in pain or disability outcomes between GT and placebo for thoracic spinal pain, which contrasts with our pooled VAS results but aligns with our ODI findings [5]. This discrepancy might be due to the specific focus on thoracic pain in their study, whereas our analysis encompassed both LBP and thoracic pain.

Lee et al. [14] observed significant improvements in VAS scores for the GT group compared to general exercises, which is aligned with our findings. Moon et al. [8] and Yana et al. [7] both reported significant improvements in pain scores for GT groups, which is consistent with our VAS findings when compared to placebo [7,8]. However, Yana et al. also found significant improvements in ODI scores, which our meta-analysis did not confirm. This discrepancy might be due to differences in study populations, GT protocols, or the pooling of data across studies with varying methodologies. These comparisons highlight the complexity of evaluating GT’s effectiveness and underscore the need for more standardized approaches in future research.

The results of our study suggest that the GT may be effective in reducing pain intensity for individuals with LBP and thoracic spinal pain, particularly when compared to placebo treatments. This finding has potential implications for clinical practice, as GT could be considered as a pain management option for these conditions. However, the lack of significant difference in pain reduction when compared to active interventions implies that GT may not offer superior analgesic effects over other established treatments.

The absence of significant improvement in ODI scores is noteworthy and suggests that pain reduction alone may not translate directly to functional improvements. This finding underscores the importance of a multifaceted approach to treating spinal pain, where interventions targeting both pain and function are integrated into comprehensive treatment plans [16].

It is important to note that only one study in our analysis appeared to fully implement the complete GT protocol [5], which traditionally combines instrument-assisted soft tissue mobilization with a directed exercise program. This limitation in protocol standardization across studies may have influenced our findings and highlighted a critical gap in the current literature. Future research should specifically examine the effectiveness of the complete Graston protocol versus isolated instrument use.

The qualitative improvements observed in the range of motion, flexibility, and proprioception, although not quantitatively analyzed, suggest potential benefits of GT beyond pain reduction [17]. These outcomes are particularly relevant for patients seeking to improve their overall physical function and quality of life. However, the variability in these findings across studies indicates a need for more focused research on these specific outcomes.

From a research perspective, our findings highlight the need for more rigorous, large-scale randomized controlled trials that directly compare GT to both placebo and active interventions. Future studies should aim to standardize GT protocols, incorporate longer follow-up periods, and utilize a consistent set of outcome measures to facilitate more robust meta-analyses.

A key strength of our study is its comprehensive approach, incorporating both quantitative meta-analysis and qualitative synthesis. This dual approach allowed us to examine the primary outcomes of pain and disability while also exploring secondary outcomes that could not be pooled statistically. Notably, this is the first meta-analysis to evaluate the effects of the Graston Technique, providing a pioneering insight into its efficacy. Additionally, our rigorous methodology, including a thorough quality assessment of included studies, enhances the reliability of our findings and contributes to the evidence base surrounding this intervention.

However, our study has several limitations. The small number of included studies and their heterogeneity in terms of study design, patient populations, and outcome measures limit the generalizability of our results. The inclusion of both randomized and non-randomized trials, while increasing the pool of available data, may have introduced bias into our analysis. Furthermore, the varying durations of follow-up across studies make it challenging to assess the long-term effectiveness of GT.

Conclusions

Our systematic review and meta-analysis suggest that the GT may be effective in reducing pain intensity for individuals with low back pain, including both thoracic and lumbar regions, particularly when compared to placebo treatments. However, these findings are preliminary and should be interpreted with caution until further high-quality studies are available. Its effectiveness in improving functional outcomes and its superiority overactive interventions remain uncertain. Based on these findings, we recommend that clinicians consider GT as a potential tool for pain management in LBP and thoracic spinal pain, while recognizing its limitations in addressing functional disabilities. We strongly advocate for further high-quality research, particularly large-scale randomized controlled trials with standardized protocols and comprehensive outcome measures. These studies should focus on comparing GT to both placebo and established active interventions, with longer follow-up periods to assess long-term efficacy. Additionally, future research should aim to elucidate the specific mechanisms by which GT may influence pain, function, and overall well-being in patients with spinal pain conditions.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Availability of data and materials

Data is available from the corresponding author upon reasonable request.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10669817.2025.2523280