Myofascial release (MFR) is a rapidly spreading form of massage therapy encompassing a variety of techniques, performed by applying a low, sustained pressure to manipulate fascial tissue (McKenney, Elder, Elder & Hutchins, 2013). Application of MFR intends to relieve pain and restore impaired function by stretching restricted fascia and releasing hypersensitive myofascial trigger points (MTrPs) in taut muscle bands (Borg-Stein & Simons, 2002).
Despite its widening acceptance and use as a treatment strategy, MFR remains surrounded by medical scepticism due to a relative lack of clinical-based evidence (Ajimsha, Al-Mudahka, & Al-Madzhar, 2015). A literature review undertaken by Remvig, Ellis, and Patijn (2013) drew to the conclusion that the efficacy of MFR as a treatment failed to be proven following the analysis of 23 studies. Furthermore, Kidd (2009) argues that MFR is not evidence-based medicine as its subjective nature indicates reliance on therapist skill and ability to sense changes in the tissue.
The purpose of the following report is to explore and analyse studies either supporting or disproving the efficacy of MFR as a therapeutic treatment, specifically regarding pain conditions such as Fibromyalgia Syndrome (FMS), Carpal Tunnel Syndrome (CTS), Chronic Lower Back Pain (CLBP) and Plantar Fasciitis (PF), along with increasing muscle range of motion (ROM). In doing so, it will be concluded as to whether or not MFR should be incorporated in clinical practice.
It is imperative that ethical guidelines are adhered to as a Physiotherapist when performing therapeutic techniques such as MFR (Muhammad, 2014). According to Muhammad (2014), health professionals must address ethical issues as outlined by the principles of autonomy, beneficence, non-maleficence and justice. Thus, it must be ensured that treatment provides benefit, avoids any harm, demonstrates fairness and equality and allows patients to ultimately make their own decisions. (Delany, Fryer & van Kessel, 2015). Informed consent is another vital element of ethical Physiotherapy practice as patients must be made aware of the nature of their treatment, including risks and benefits (Delany & Frawley, 2012). An extensive review undertaken by McKenney et al. (2013) into MFR treatment of orthopaedic conditions revealed that of six eligible case studies, informed consent was confirmed to be given in only one. Although this doesn’t necessarily indicate that the remaining five lacked informed consent altogether, it certainly raises concerns regarding the neglection of ethical practice in treatment both within and beyond the scope of MFR.
Fibromyalgia syndrome (FMS) is a pain condition characterised by chronic musculoskeletal pain leading to fatigue, anxiety, depression symptoms and reduced quality of life and sleep (Castro-Sanchez et al., 2018). Despite it’s exact cause remaining unknown, a recent study by Sanchez et al. (2018) found that the number of widespread active MTrPs in FMS patients correlates directly to their experienced pain intensity. A 2011 study by Castro-Sanchez et al. randomly assigned 47 FMS patients to 20 weeks of twice-weekly MFR treatment to compare their post-experimental pain levels with those of a control group of identical size. It was discovered that the experimental group displayed a significant reduction in the number of MTrPs and an overall improvement in FMS symptoms and subsequently quality of life (Castro-Sanchez et al., 2011). A more recent study conducted by Sanchez et al. (2018) compared the effectiveness of dry needle therapy and MFR in treating FMS over a four-week period, concluding that dry needling provided greater pain relief and reduction of FMS symptoms than MFR. However, this study presented limitations as it was conducted over a short period and each technique was applied independently; whereas in practice, multi-modal treatment approaches are commonly employed (Castro-Sanchez et al., 2018). Considering this, the effectiveness of MFR as a treatment of FMS remains supported but future studies should explore the effectiveness of combining techniques such as dry needling and MFR.
Another example of the positive outcomes achieved through application of MFR is in the treatment of Carpal Tunnel Syndrome (CTS), described as pain and paraesthesia in the first, second and third fingers (Pratelli et al., 2015). Pratelli et al. (2015) carried out a study comparing the effectiveness of MFR and low intensity laser therapy (LLLT) in 70 symptomatic hands, applying each treatment to 35 hands once a week for three weeks. Function and VAS score evaluations were made 10 days and three months after the last treatment, with results supporting the conclusion that MFR exceeds LLLT in CTS treatment effectiveness, indicating that it provides greater relief of median nerve compression by reducing fascia viscosity (Pratelli et al., 2015). Experimental fairness was guaranteed as the treatments were all applied by the same therapist with five years of experience in performing MFR, minimising the previously mentioned effects associated with the subjective nature of the technique. Similar future investigations should be conducted over a longer period as the lack of long-term follow-up evaluation dates serve as a limitation of this study, however, the short-term benefits of MFR as a CTS treatment remain valid.
An increase in ROM is an expected result of MFR due to its ability to stretch restricted fascia (Borg-Stein & Simons, 2002). Kuruma et al. (2013) reported on the effectiveness of MFR compared to static stretching in terms of increasing active range of motion (AROM) and passive range of motion (PROM) of the quadriceps and hamstrings muscles. A group of 40 participants was divided into four evenly sized testing groups: MFR for quadriceps, MFR for hamstrings, static stretching for quadriceps and a control group. AROM and PROM were measured both prior to and following eight minutes of intervention and the results revealed that the increase in AROM and PROM achieved by MFR was marginally greater than static stretching (Kuruma et al., 2013). Although this finding supports the ability of MFR to improve ROM, its effectiveness over static stretching failed to be convincingly proven due to the limitations of the study. The extensiveness of the study was minimal as only one intervention phase was completed, as opposed to consistently repeating MFR and static stretching over a longer period of weeks or months to further examine the effectiveness of each technique on long-term ROM.
Ajimsha, Binsu & Chithra (2014) further iterated the therapeutic capabilities of MFR via their experimental study, exploring the treatment of CLBP in nursing professionals. The selection of nurses as subjects for this treatment is considered appropriate as their lifetime prevalence of CLBP is ten percent greater than that of the general population (Ajimsha et al., 2014). 74 nurses diagnosed with CLBP participated in the study and were randomly separated into two groups. One group received MFR treatment thrice weekly for eight weeks in conjunction with performing specific back exercises (SBE) including self-corrections, stretches and strengthening exercises for 20 minutes each session. Although the remaining control group was subject only to performing the SBE for the intervention duration, Ajimsha et al. (2014) noted that they were provided MFR therapy following the completion of the study, serving as a demonstration of ethical practice through adherence to the principles of beneficence and justice. Eight weeks following intervention, patients in the MFR group recorded a 53.3% pain reduction and 29.7% increase in functional ability, significantly exceeding the improvements experienced by the control group and therefore validating the effectiveness of MFR in conjunction with SBE as a CLBP intervention. Although the enduring nature of the observed improvements remains unknown due to the lack of long-term assessment conducted, the benefits of MFR in CLBP patients are clear and long-term intervention stands as an avenue for future studies.
An additional study that delves into the promising area of MFR intervention in pain conditions conducted an analysis of symptom improvement in patients diagnosed with Plantar fasciitis (PF) (Ajimsha, Binsu & Chithra, 2018). Ajimsha et al. (2018) separated 65 patients into an MFR group receiving 12 treatment sessions, delivered over four weeks, of MFR applied to the gastrocnemii, soleus and plantar fascia, along with a control group. Follow-up measurements at 12 weeks after the last treatment revealed that the MFR and control groups reported decreases of 72.4% and 7.4%, respectively, in pain and functional disability (Ajimsha et al., 2018). The results align with the hypothesis that MFR would relieve the fascial restriction and MTrPs contributing towards PF, despite the trial being limited by the difficulty associated with determining whether the MFR applied to the gastrocnemii, soleus or plantar fascia promoted the most improvement.
When considering the evidence presented by a range of peer reviewed studies, it is reasonable to accept the validation of MFR as an effective therapeutic technique. The efficacy of MFR across a wide scope including multiple pain conditions and ROM was highlighted, especially in cases where MFR was applied in conjunction with alternate intervention strategies such as dry needling, static stretching and SBE. Limitations of each investigation, such as the lack of long-term assessment, were identified and raised concerns regarding the reliability of the clinical evidence. However, the analysis of each limitation established directions of future studies as opposed to discrediting the evidence. According to currently available literature, it can thereby be concluded that MFR should be applied as a therapeutic intervention and component of multi-modal treatment strategies in clinical practice.
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- Samuel Lehmann (Author), 2019, Myofascial Release as a Therapeutic Intervention in Clinical Practice, Munich, GRIN Verlag, https://www.grin.com/document/903775