Accepted Manuscript

Effectiveness of myofascial release: systematic review of randomized controlled trials

M.S. Ajimsha, MPT, ADMFT, PhD Noora R. Al-Mudahka, PT, MBA J.A. Al-Madzhar,
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PII: S1360-8592(14)00086-2
DOI: 10.1016/j.jbmt.2014.06.001
Reference: YJBMT 1142

To appear in: Journal of Bodywork & Movement Therapies

Received Date: 5 December 2013

Revised Date: 4 June 2014
Accepted Date: 6 June 2014

Please cite this article as: Ajimsha, M.S., Al-Mudahka, N.R., Al-Madzhar, J., Effectiveness of myofascial
release: systematic review of randomized controlled trials, Journal of Bodywork & Movement Therapies
(2014), doi: 10.1016/j.jbmt.2014.06.001.

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 ACCEPTED MANUSCRIPT

1 EFFECTIVENESS OF MYOFASCIAL RELEASE:

2 SYSTEMATIC REVIEW OF RANDOMIZED

3 CONTROLLED TRIALS

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4 M.S. Ajimsha, MPT, ADMFT, PhD a,*, Noora R. Al-Mudahka, PT, MBA a, Al-
5 Madzhar JA, PT a

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6
a
7 Department of Physiotherapy, Hamad Medical Corporation, Doha, Qatar

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8

9 INTRODUCTION: Myofascial release (MFR) is a form of manual therapy that involves the

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10 application of a low load, long duration stretch to the myofascial complex, intended to restore
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11 optimal length, decrease pain, and improve function. Anecdotal evidence shows great promise for

12 MFR as a treatment for various conditions. However, research to support the anecdotal evidence is
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13 lacking. OBJECTIVE: To critically analyze published randomized controlled trials (RCTs) to

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14 determine the effectiveness of MFR as a treatment option for different conditions. DATA
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15 SOURCES: Electronic databases: MEDLINE, CINAHL, Academic Search Premier, Cochrane

16 library, and Physiotherapy Evidence Database (PEDro), with key words myofascial release
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17 and myofascial release therapy. No date limitations were applied to the searches. STUDY

18 SELECTION: Articles were selected based upon the use of the term myofascial release in the
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19 abstract or key words. The final selection was made by applying the inclusion and exclusion criteria
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20 to the full text. Studies were included if they were English-language, peer-reviewed RCTs on MFR

21 for various conditions and pain. DATA EXTRACTION: Data collected were number of

22 participants, condition being treated, treatment used, control group, outcome measures and results.

23 Studies were analyzed using the PEDro scale and the Center for Evidence-Based Medicine's Levels

24 of Evidence scale. CONCLUSIONS: The literature regarding the effectiveness of MFR was mixed

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25 in both quality and results. Although the quality of the RCT studies varied greatly, the result of the

26 studies was encouraging, particularly with the recently published studies. MFR is emerging as a

27 strategy with a solid evidence base and tremendous potential. The studies in this review may help as

28 a respectable base for the future trials. KEY WORDS: myofascial release, myofascial release

29 therapy

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30

31 * Corresponding author. Tel.: +974 55021106.

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32 E-mail address: ajimshaw.ms@gmail.com (M.S. Ajimsha).

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33

34 INTRODUCTION

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35 Myofascial release (MFR) is a widely employed manual therapy treatment that involves specifically
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36 guided low load, long duration mechanical forces to manipulate the myofascial complex, intended to

37 restore optimal length, decrease pain, and improve function (Barnes., 1990). MFR when used in
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38 conjunction with conventional treatment is said to be effective to provide immediate relief of pain
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39 and tissue tenderness (Hou et al., 2002, McKenney et al., 2013). It has been hypothesized that fascial

40 restrictions in one region of the body cause undue stress in other regions of the body due to fascial
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41 continuity. This may result in stress on any structures that are enveloped, divided, or supported by
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42 fascia (Schleip., 2003). Myofascial practitioners claim that by restoring the length and health of

43 restricted connective tissue, pressure can be relieved on pain sensitive structures such as nerves and
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44 blood vessels.
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45 MFR generally involves slow, sustained pressure (120-300 s) applied to restricted fascial layers

46 either directly (direct MFR technique) or indirectly (indirect MFR technique). Direct MFR technique

47 is thought to work directly over the restricted fascia: practitioners use knuckles or elbow or other

48 tools to slowly sink into the fascia, and the pressure applied is a few kilograms of force to contact the

49 restricted fascia, apply tension, or stretch the fascia. Indirect MFR involves a gentle stretch guided

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50 along the path of least resistance until free movement is achieved (GOT, 2009). The pressure applied is a

51 few grams of force, and the hands tend to follow the direction of fascial restrictions, hold the stretch,

52 and allow the fascia to loosen itself (Ajimsha et al., 2013) The rationale for these techniques can be

53 traced to various studies that investigated plastic, viscoelastic, and piezoelectric properties of

54 connective tissue (Schleip., 2003,2012; Pischinger., 1991; Greenman., 2003).

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55 Recent Fascia Research Congresses (FRC) define fascia as a soft tissue component of the

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56 connective tissue system that permeates the human body (Huijing and Langevin, 2009). One could

57 also describe them as fibrous collagenous tissues that are part of a body-wide tensional force

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58 transmission system (Schleip R et al., 2012). The complete fascial net includes dense planar tissue

59 sheets, ligaments, tendons, superficial fascia and even the innermost intramuscular layer of the

60
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endomysium. The term fascia now includes the dura mater, the periosteum, perineurium, the fibrous
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61 capsular layer of vertebral discs, organ capsules as well as bronchial connective tissue and the
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62 mesentery of the abdomen (Schleip R et al., 2012). Fascial tissues are seen as one interconnected

63 tensional network that adapts its fiber arrangement and density, according to local tensional demands
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64 (Schleip R et al., 2012).

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65 Authors such as Day (2009), Stecco (2013) and Langevin (2011) and colleagues, have suggested

66 that connective tissue could become tighter/denser in overuse syndromes, or after traumatic injuries,
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67 but it is unclear if this is due to an alteration of collagen fiber composition, of fibroblasts, or of

ground substance. The same authors suggest that the alteration of fascial pliability could be a source
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68
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69 of body misalignment, potentially leading to poor muscular biomechanics, altered structural

70 alignment, and decreased strength and motor coordination. MFR practitioners claim to be clinically

71 efficacious in providing immediate pain relief and to improve physiologic functions that have been

72 altered by somatic dysfunctions (Hou et al., 2002, McKenney et al., 2013). MFR directs force to

73 fascial fibroblasts, as well as indirect strains applied to nerves, blood vessels, the lymphatic system,

74 and muscles. Laboratory experiments suggest that fibroblasts, the primary cell type of the fascia,
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75 adapt specifically to mechanical loading in manners dependent upon the strain magnitude, duration

76 and frequency. Meltzer et al (2010), in their in-vitro modeling study demonstrated that treatment

77 with MFR, after repetitive strain injury, resulted in normalization of apoptotic rate, and reduction in

78 production of inflammatory cytokines.

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80 MFR is being used to treat patients with a wide variety of conditions, but there is little research to

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81 support its efficacy. According to Kidd (2009) the application of MFR is inherently not evidence-

82 based medicine since it relies on clinician-patient interaction, it cannot be a neutral treatment;

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83 therefore, the subjectivity of the interaction cannot be removed when we try to determine its

84 outcome. Kidd indicated that much of the effect of MFR relies on the skill of the clinician and his or

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her ability to sense the changes in the tissue. In addition, biological effects of touch can change the
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86 effectiveness of the treatment, depending on the state of either the clinician or the patient. This
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87 variability means that interrater reliability is low, and therefore, according to Kidd, prevents MFR

88 from being considered evidence-based. Yet the same arguments have been applied to other manual
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89 therapies in the past that now are considered part of evidence-based practice. Although MFR is a
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90 popular therapy and anecdotal reports describe positive outcomes from MFR treatments, research is

91 necessary to demonstrate its effectiveness to refute Kidds argument. Therefore, the purpose of this
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92 systematic review was to critically analyze previously published literatures of RCTs to gather the

documented effectiveness of MFR.

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94
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95 METHODS

96 We searched the following electronic databases with no date limitations: MEDLINE, CINAHL,

97 Academic Search Premier, Cochrane library, and Physiotherapy Evidence Database (PEDro) by

98 adhering to the systemic review process followed by McKenney et al (2013) in their study. Two

99 reviewers performed independent searches in September 2013 which was later updated in May 2014.

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100 Key words used for the search were myofascial release and myofascial release therapy. Each

101 reviewer identified articles as relevant based on the use of the term myofascial release in the abstract

102 or key words. The lists were compared, and articles identified by both reviewers were collected in

103 full text. A total of 133 articles were identified as relevant by both reviewers.

104 The 2 experienced reviewers with sound knowledge in the PEDro and CEBMs scales, screened the

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105 full-text articles for inclusion based on a set of inclusion and exclusion criteria. The inclusion criteria

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106 were as follows: (1) RCTs published in a scientific peer-reviewed journal, (2) studies with 10 or

107 more participants, (3) contained sufficient information to complete an analysis, (4) used indirect and

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108 passive MFR as an experimental treatment, (5) published in English, (6) studied human participants,

109 and (7) included adult participants only (18 years and older). Articles were excluded if published as

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case studies, editorials, expert opinions, or instructive articles; used trigger point therapy; or did not
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111 use MFR as defined. Studies on myofascial trigger-point therapy, proprioceptive neuromuscular
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112 facilitation (PNF) and MFR used as a conventional treatment without distinct explanations were also

113 excluded. Subsequently, 19 articles met the criteria for inclusion in our analysis.
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114 Next, the reviewers assessed all studies meeting the inclusion criteria using 2 scales: the PEDro scale
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115 (2012) (Table 1) and the Centre for Evidence-Based Medicines (CEBMs) Levels of Evidence scale

116 (Phillips et al., 2009) (Table 2). The PEDro scale assesses methodological quality and consists of a
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117 checklist of 11 criteria, 10 of which are scored. For each criterion the study met, 1 point was

awarded. The points were tallied and presented as a score out of 10. The scale applies only to
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118
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119 experimental studies. For this review, investigations with PEDro scores of 6 to 10 were considered

120 high quality, of 4 to 5 were considered moderate quality, and of 0 to 3 were considered low quality.

121 The PEDro scale does not evaluate clinical usefulness. The CEBM Levels of Evidence scale assesses

122 quality based on study design, which categorize the studies in a scale ranging from 1 to 5 with

123 further subdivision for each.

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124 Systemic reviews with homogeneity of RCTs are ranked in the highest levels while expert opinions

125 rank the least (Table 2). In both scales, RCTs receives higher rankings, particularly with long-term

126 follow-up and narrow confidence intervals. The reviewers solved any rating discrepancies through

127 verbal discussion. A consensus was reached regarding all studies during the first meeting, which

128 were documented in the review process.

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129

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130 RESULTS

131 Of the 133 studies identified in the original search, 19 were eligible as per the inclusion criteria

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132 (Figure 1). The PEDro scores of the studies ranged from 5 of 10 to 8 of 10. Five studies rated as 1b

133 and 14 studies as 2b in the CEBM ratings. The most common reason for a 2b rank was that the study

134
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had a small sample size and/or no long-term follow-up to treatment. The key characteristics and
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135 methodological details are provided in Table 3.
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136 Data Synthesis

137 The quality of research on MFR as a treatment varies widely. The recent published studies are
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138 appreciable in their adherence to near normal RCT guidelines. Of the 19 studies included in our
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139 analysis, we ranked the 5 RCTs at levels 1b and 14 at level 2b on the CEBM scale, indicating a

140 relatively high quality study design. Scores on the PEDro scale indicated moderate- to high-quality
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141 study designs. The lowest score was 5 of 10 and the highest was 8 of 10.

Hanten and Chandler (1994) conducted a moderate-quality study that was rated at level 2b on
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142
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143 the CEBM scale and 6 of 10 on the PEDro scale. The purpose of the study was to compare the effect

144 of MFR and PNF in increasing the straight leg raise (SLR) in the management of hamstring

145 tightness. The study highlighted the point that, though MFR is effective in increasing the SLR angle

146 against a control group receiving no treatment, the effect is inferior to a PNF treatment. The study

147 itself had positive outcomes (see Table 3), but it lacked random selection of participants and follow-

148 up.
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149 The study by Barnes et al (1997) on pelvic symmetry was ranked as level 2b and earned a

150 PEDro score of 8 of 10. Overall, it was a high quality study; however, a few concerns lowered the

151 CEBM ranking, including the small sample size and the lack of follow-up. Only 10 participants were

152 involved, and the authors acknowledged that 23 participants were needed in the treatment group and

153 15 in the control group to meet the assumptions for parametric data analysis. Overly, the follow-up

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154 measurements were conducted immediately after the treatment. Despite these limitations, the 8 of 10

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155 ranking on the PEDro scale indicated that the study was well designed.

156 Hsieh et al (2002) investigated the relative effectiveness of three manual treatments including

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157 MFR for patients with subacute low back pain (SALBP). The study was rated as a high-quality one,

158 ranked at level 1b on the CEBM scale and earned 7 of 10 points on the PEDro scale. The 1b rating

159
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reflects a study that was well designed, with a sufficient number of participants and adequate long-
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160 term follow-up. The PEDro score indicates that the study design was strong. The back pain improved
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161 in all groups, but there were no differences between the groups. Because the Hsieh et al study was

162 high quality, the results are relevant to use of MFR as an adjunct to a formal treatment for SALBP.
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163 Another level 2b study was performed by Kuhar et al (2007), who used MFR to treat plantar
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164 fasciitis. This study scored 7 of 10 points on the PEDro scale. Patients were evaluated at the

165 beginning of the treatment and then once more on the final day of treatment. However, no
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166 measurements were taken as follow up, which lessened the study quality to level 2 on the CEBM

scale. As a result, we know only the immediate effects of MFR and cannot comment on long-term
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167
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168 effectiveness. Significant reduction in pain and improvement in foot function was reported as the

169 short term effect.

170 Arroyo-Morales et al (2008) in their RCT studied the effects of MFR after high-intensity

171 exercise, which scored level 2b in CEBM scale with a quality of 6/10 in PEDro scale. The study

172 included 62 healthy, active individuals. After baseline measurements, the subjects performed

173 standardized warm-up exercises followed by three 30-second Wingate tests. After completing the
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174 exercise protocol, the subjects were randomly assigned to MFR or a placebo group for a 40-minute

175 recovery period. Holter recording and BP measurements were taken after exercise protocol and after

176 the intervention and found that MFR favors the recovery of heart rate variability and diastolic BP

177 after high-intensity exercise to pre exercise levels. Short duration and lack of follow up along with

178 normal, healthy individual were considered as the limitation of the study with an assumption that

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179 high-level sports people might possibly show a different behavior which makes the study into the 2b

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180 level.

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182 Tozzi, P et al (2011) studied pain perception and the mobility of fascial layers by using a

183 dynamic ultrasound (US) in patients with neck pain (NP) and low back pain (LBP). Sixty patients

184
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with nonspecific neck pain and 60 with nonspecific back pain were divided into experimental and
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185 control groups who were evaluated in the area of complaint, by Dynamic US Topographic Anatomy
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186 Evaluation, before and after MFR were applied in situ, in the corresponding painful region, for not

187 more than 12 minute. The effects were compared with those from the respective sham control group
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188 of 60 cases. The result highlighted that MFR can be effective in releasing area of impaired sliding
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189 fascial mobility, and to improve pain perception over a short term duration in people with non-

190 specific NP or LBP. The study obtained 2b level evidence with a quality of 7/10. The study is
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191 important because it suggested that dynamic US evaluation can be a valid and non-invasive

instrument to assess effective sliding motion of fascial layers in vivo. Main limitations noted were
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192
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193 that pain assessment was for a short period of time following treatment and on a relatively small

194 study population without a follow up.

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196 A study with 30 chronic myogenous temporo mandibular disorder (TMD) patients by

197 Kalamir et al (2010) investigated the effectiveness of intra-oral MFR therapy (IMT) by randomizing

198 into three groups; IMT, IMT plus self-care and a wait list control with pain and ROM as the
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199 primary outcome measures. The measurements were taken at baseline, 6 weeks post-treatment, and 6

200 months post-treatment. They concluded that IMT with or without self-care may be beneficial in

201 chronic TMD over the short-medium term and advocated a larger scale study over a longer term. The

202 study obtained high quality rating on the PEDro scale (8/10) and 2b rating in CEBM.

203

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204 Kain et al in 2011 compared an indirect tri-planar MFR technique and a hot pack for

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205 increasing gleno-humeral joint range of motion on 31 healthy individuals. Both the hot pack

206 application and the MFR technique were found to be as efficacious in increasing passive range of

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207 motion of the gleno-humeral articulation. The tri-planar MFR could be considered more effective as

208 an intervention in terms of time spent with a patient and the number of patients seen in a 20-min

209
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period and lack of equipment needed for MFR compared to hot pack use. The speed of the MFR
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210 technique and the lack of equipment would suggest that it is a more time efficient type of
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211 intervention, provided the therapist is trained in this technique. Improper blinding, concealing and

212 follow-up grade the quality of the study as moderate (5/10 in PEDro) and level 2b in CEBM.
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213 Castro-Snchez et al conducted two (2010, 2011) high quality studies in fibromyalgia. Both
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214 studies were rated as 7/10 in PEDro scale and 1b in CEBM due to their methodological standards.

215 The first one; was to determine whether MFR therapy can improve pain, anxiety, quality of sleep,
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216 depression, and quality of life in patients with fibromyalgia. Seventy four fibromyalgia patients were

randomly assigned to MFR and placebo groups. The intervention period was 20 weeks. Pain,
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217
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218 anxiety, quality of sleep, depression, and quality of life were determined at baseline, after the last

219 treatment session, and at 1month and 6 months. Right away after treatment and at 1 month, anxiety

220 levels, quality of sleep, pain, and quality of life were improved in the experimental group over the

221 placebo group. Even so, at 6 months post intervention, there were only significant differences in the

222 quality of sleep index. They have documented the exclusion of 35 of the 231 eligible participants due

223 to incompatibility with their work schedules as their major limitation and commented that patients
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224 with less severe pain may have been able to improve more rapidly. The second study was with 86

225 fibromyalgia patients to find out the effect of a 20 week MFR on pain, physical function, and

226 postural stability over a placebo group. MFR improved pain, sensory, and affective dimensions

227 without change in postural stability. They concluded that MFR techniques can be a complementary

228 therapy for fibromyalgia syndrome. The authors attributed that lack of a postural stability test with a

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229 higher level of difficulty might have an effect on the result. Lack of blinding of therapists and

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230 patients and the absence of a hands-on component in the sham treatment was another drawback.

231 They recommended further research to compare outcomes with other manual therapies.

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232

233 A study by Ajimsha M S (2011) on 63 tension headache patients compared the direct MFR technique

234
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and indirect MFR technique with a sham control receiving slow soft stroking. The study was of
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235 moderate quality (6/10) on PEDro with 2b level of evidence. The techniques consisted of 24 sessions
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236 per patient over 12 weeks with the difference in number of days with headache at baseline and post

237 test as the outcome measure. Patients in the direct MFR group, the indirect MFR group and the
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238 control group reported a 59.2%, 54% and 13.3% reduction respectively in their headache frequency
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239 in post test compared to the baseline. Lack of follow up, blinding of the therapists and the patient

240 were the major limitations of the study.

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241 Two moderate to high quality studies were found on quality of life of breast cancer survivors

(BCS). The first study was by Fernndez-Lao et al (2012) on the influence of patient attitude towards
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242
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243 massage on pressure pain sensitivity and immune system after application of MFR. Twenty BCS, in

244 a two week study, received MFR or control (special attention) intervention. Salivary flow rate,

245 immunoglobulin A concentrations & the attitude toward massage scale were the outcome measures.

246 MFR led to an immediate increase in salivary flow rate in BCS with cancer-related fatigue. The

247 authors suggested that the effect of MFR on immune function was modulated by a positive patient's

248 attitude toward massage. Lack of therapist blinding and follow ups were the main drawbacks of the
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249 study. The authors acknowledged that alterations of stress response to cancer related fatigue could

250 reduce the ability of MFR in changing salivary cortisol concentrations and -amylase activity and

251 placebo effect associated with hands-on techniques might have influenced the outcome.

252 The second study was conducted by Cantarero-Villanueva et al (2011). Seventy eight BCS

253 participated in effectiveness of core stability exercises and recovery MFR on fatigue with the Profile

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254 of Mood State questionnaire as the main outcome measure. The experimental group received core

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255 stability exercises & MFR while the control group received usual health care advices for a period of

256 8 weeks. Mood state, fatigue, trunk curls endurance, and leg strength were determined at baseline,

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257 after the last treatment session, and at 6 months of follow up. The multimodal program with MFR

258 reduced fatigue, tension, depression, improved vigor & muscle strength. The study was of moderate

259
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to high quality (7/10) with level 2b evidence. The main drawback was that the control group was
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260 allowed to freely increase physical activity during the study. They reasoned that this possible bias
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261 was controlled as the control group did not demonstrate substantial gains in physical activity during

262 the study.

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263 A comparative study was performed on the effectiveness of MFR and PT for venous
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264 insufficiency in postmenopausal women by Ramos-Gonzlez et al (2012), which is of high quality

265 (8/10) with a 2b level of evidence. Sixty five postmenopausal women with stage I or II venous
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266 insufficiency were enrolled into two groups. The control and experimental group patients underwent

physical venous return therapy (kinesiotherapy) for a 10-week period, during which the experimental
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267
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268 group patients also received 20 sessions of MFR. Main outcome measures were blood pressure, cell

269 mass, intracellular water, basal metabolism, venous velocity, skin temperature, pain and quality of

270 life. The combination of MFR and kinesiotherapy improved the venous return, pain and quality of

271 life in postmenopausal women with venous insufficiency. Lack of follow up and non blinding of the

272 researchers were the primary limitations.

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274 Ajimsha et al (2012) in their study investigated whether MFR reduces the pain and functional

275 disability of lateral epicondylitis in comparison with a control group receiving sham ultrasound

276 therapy in computer professionals (N=68) for 12 sessions per client over 4 weeks with the Patient-

277 Rated Tennis Elbow Evaluation (PRTEE) as the main outcome measure. The study was of a

278 moderately high quality on the PEDro scale (7/10) with 1b- level in CBEM. The MFR group

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279 performed better than the control group at weeks 4 and 12. Patients in the MFR and control groups

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280 reported a 78.7% and 6.8% reduction, respectively, in their pain and functional disability in week 4

281 compared with that in week 1, which persisted as 63.1% in the follow-up at week 12 in the MFR

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282 group. Lack of therapist blinding was the major limitation of the study. A slight improvement over

283 time occurred in the control group at week 4 and the authors are attributing this to a meaning

284 response.
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285 A similar type of study was carried on by Khuman et al (2013) on a smaller sample size of chronic
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286 lateral epicondylitis (CLE) subjects. Thirty CLE subjects were divided into MFR & conventional

287 physiotherapy (n=15) and conventional physiotherapy (n=15) groups. Numerical pain rated scale,
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288 PRTEE and hand dynamometer were the outcome measures. They concluded that a 4 weeks MFR
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289 program was effective in improving pain, functional performance and grip strength in CLE subjects

290 compared to the control group. Lack of follow up and improper blinding were the major limitations.
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291 The study scored 2b level of evidence with a quality of 7/10.

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292
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293 Another study by Ajimsha et al (2014) on the effectiveness of MFR in the management of chronic

294 low back pain (CLBP) in nursing professionals falls under a high quality one with a PEDro score of

295 7/10 and CBEM level of 1b. The participants were nursing professionals (N = 80) with CLBP. The

296 aim was to investigate whether MFR when used as an adjunct to specific back exercises (SBE)

297 reduces pain and disability in CLBP in comparison with a control group receiving a sham MFR and

298 SBE among nursing professionals. The McGill Pain Questionnaire (MPQ) was employed to assess
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299 subjective pain experience and Quebec Back Pain Disability Scale (QBPDS) was employed to

300 evaluate the disability associated with CLBP. The primary outcome measure was the difference in

301 MPQ and QBPDS scores between week 1 (pretest score), week 8 (posttest score), and follow-up at

302 week 12 after randomization. The patients in the MFR group reported a 53.3% diminution in their

303 pain and 29.7% decrease in functional disability as evidenced in the MPQ and QBPDS scores in

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304 week 8, whereas patients in the control group reported a 26.1% and 9.8% decrease in their MPQ and

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305 QBPDS scores in week 8, which persisted as a 43.6% reduction of pain and 22.7% reduction of

306 functional impairment in the follow-up at week 12 in the MFR group compared to the baseline. The

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307 authors advocated examining other outcomes such as pain beliefs, mood, and quality of life in future

308 studies.

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310 Kuruma et al conducted a study (2013) on the effects of MFR and stretching technique on range of

311 motion (ROM) and reaction time (RT) with a medium quality procedure (5/10 PEDro) and 2b level
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312 in CBEM. Forty healthy individuals were randomly allocated to four groups: MFR for quadriceps;
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313 MFR for hamstrings; stretch for quadriceps; and controls. Active ROM was significantly increased in
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314 the two MFR groups and the stretch group. Passive ROM was significantly increased by MFR in the

315 quadriceps and stretching groups. Premotor time was significantly reduced by MFR in the quadriceps
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316 and hamstrings groups. Compared to controls, RT was significantly lower after the interventions in

317 the quadriceps and hamstrings groups. Lack of blinding, concealing and follow up were the main
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318 limitations of the study.

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319 A recent study by Ajimsha et al (2014) investigated whether MFR reduces the pain and functional

320 disabilities associated with plantar heel pain (PHP) in comparison with a control group receiving

321 sham ultrasound therapy. Sixty six PHP patients, in a 4 week study, received MFR or control

322 intervention. The study was a well designed and executed one, with sufficient number of participants

323 and adequate follow-up, ranked level 2b on the CEBM scale and scored 8/10 on the PEDro scale.

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324 The primary outcome measure was the difference in foot function index scale at week 1, week 4, and

325 follow-up at week 12 after randomization. Additionally, pressure pain thresholds (PPT) over the

326 affected gastrocnemii and soleus muscles and over the calcaneus were assessed. The simple main

327 effects analysis showed that the MFR group performed better than the control group in weeks 4 and

328 12 (P < 0.001). Patients in the MFR and control groups reported a 72.4% and7.4% reduction,

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329 respectively, in their pain and functional disability in week 4, which persisted as 60.6% in the

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330 follow-up at week 12 in the MFR group compared to the base-line. The mixed ANOVA revealed a

331 significant group-by-time interaction for changes in PPT over the gastrocnemii and soleus muscles,

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332 and over the calcaneus compared to the control group (P < 0.05). The short term follow up was

333 mentioned as the major limitation of the study. The authors recommended future studies to compare

334
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the MFR with established treatments like arch supports, self stretching or even with surgical
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335 procedures.
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336

337
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338 DISCUSSION
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339 Nineteen RCTs covering 1,228 patients were included in this systematic review. The sample size

340 varied from 10 to 200 with an average of 65 (SD44). The methodological qualities of the included
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341 RCTs were moderate to high. Seventeen studies were with higher methodological quality and the
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342 remaining 2 were of moderate quality, which is appreciable for a relatively new approach with
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343 considerable amount of practice variations. The literature regarding the effectiveness of MFR was

344 mixed in both quality and results. The quality of the RCT studies varied greatly, some were more

345 substantial than others. The results of the studies were encouraging, particularly with the recently

346 published studies. In many RCTs the MFR was adjunctive to other treatments and the potential-

347 specific MFR effect cannot be judged.

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348 Nine studies concluded that MFR may be better than no treatment or sham treatment for

349 various musculoskeletal and painful conditions. Seven studies demonstrated that MFR with a

350 conventional therapy is more effective than a control group receiving no treatment (3 studies), sham

351 treatment (1 study) or with a conventional therapy. Hanten and Chandler (1994) have found in their

352 study that, though MFR was effective in reducing hamstring tightness against a control group

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353 receiving no treatment, the effect was inferior to a PNF treatment. Two other studies highlighted

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354 MFR to be equally effective to conventional or alternative treatments (e.g., joint manipulation,

355 back school or hot packs). These data suggest that the MFR can be a useful adjunct to the

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356 conventional therapies for various conditions.

357

358
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It seems reasonable that in the authors qualitative synthesis, the best evidence would be provided by
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359 the higher quality studies, which are less likely to have biased results. Although the levels of
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360 evidence in this review may be considered arbitrary, it seems unlikely that a different rating system

361 would have resulted in different conclusions. It has to be remembered in this situation that, generally
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362 small sample sizes increase the possibility of type II error, where the likelihood of a study producing
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363 a false negative result will be high. (Sim and Wright, 2000). Although attempts were made to find all

364 published RCTs, some relevant trials might have been overlooked. Due to resource and language
EP

365 constraints, only English language publications were included in the review and no effort was made

to identify unpublished trials

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366
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367

368 The included studies were very heterogeneous in terms of population included, type of MFR

369 administered, control groups, outcome measures, timing of follow-up, and presentation of data. Like

370 any other manual therapy interventions MFR also varies considerably in the technique, the pressure,

371 individual treatment times and overall number of treatment sessions. Until evidence is available on

372 the possible mechanism of action of MFR, or until different interventions have been compared
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373 directly, there is no logical basis for choosing the optimal intervention. The experience and training

374 of the myofascial therapists who gave the treatments were mentioned in a few studies. No serious

375 adverse events were reported in the trials included in this review. Seven studies have reported minor

376 adverse events. The great variation in incidence of minor adverse events is probably due to different

377 definitions of adverse reaction, research designs or styles of MFR in the various studies.

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378

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379 Some studies used a protocol of a fixed set of points for all patients while others used a flexible

380 protocol where the points were selected for each individual. Both methods are considered to be valid

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381 and were analyzed together in this systematic review. There is evidence that MFR alone or added to

382 other conventional therapies, relieves pain and improves function not lesser than conventional

383
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therapies studied. According to these results, MFR may be useful as either a unique therapy or as an
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384 adjunct therapy to other established therapies for a variety of conditions like sub acute low back pain,
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385 fibromyalgia, lateral epicondylitis, plantar fasciitis, headache, fatigue in breast cancer, pelvic

386 rotation, hamstring tightness etc. It is also noticeable that the magnitudes of the effects were mostly
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387 restrained.
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388

389 The experimental studies in this review can serve as a starting point for future research by
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390 demonstrating the wide assortment of potential conditions that MFR may effectively treat. Although

a wide variety of conditions are being treated with MFR, it is important to have evidence to support
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391
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392 those actions. Anecdotal evidence is a good starting point, but it is time for scientific evidences on

393 MFR to support its clinical use.

394

395 To attain the highest-quality evidences, good quality RCT designs should be utilized in the future

396 researches. Participants should be randomized, the design should be double blinded, and the clinician

397 performing the MFR should use it regularly in clinical practice. The subjective component of MFR
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398 must be addressed in future study designs. Because of the nature of the technique, the effectiveness

399 of MFR can vary with the comfort level of the patient, so the patient and clinician should both feel at

400 ease around one another. Only one medical condition should be studied at a time, and MFR should

401 be used alone. As well, if possible, MFR should be compared with a control (no-treatment) group

402 and with other established treatments. These guidelines will result in higher-quality studies that can

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403 help us determine the true effectiveness of MFR as a treatment for a wide variety of conditions.

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404 CONCLUSIONS

405 The literature regarding the effectiveness of MFR was mixed in both quality and results. Although

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406 the quality of the RCT studies varied greatly, the result of the studies was encouraging, particularly

407 with the recently published studies. MFR is emerging as a strategy with a solid evidence base and

408
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tremendous potential. The studies in this review may serve as a good foundation for the future trials.
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409

410
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411 REFERENCES
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412
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413 1. Ajimsha, M. S., 2011. Effectiveness of direct vs indirect technique myofascial release in

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415 therapies, 15 (4), 431-435.

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417 release in the management of lateral epicondylitis in computer professionals. Archives of

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418 physical medicine and rehabilitation, 93 (4), 604-609.

419 3. Ajimsha, M. S., Daniel, B., & Chithra, S., 2014. Effectiveness of Myofascial release in

420 the management of chronic low back pain in nursing professionals, Journal of Bodywork

421 and Movement Therapies, 18, 273-281

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422 4. Ajimsha, M. S., Daniel, B., & Chithra, S., 2014. Effectiveness of myofascial release in

423 the management of plantar heel pain: A randomized controlled trial.The Foot;

424 http://dx.doi.org/10.1016/j.foot.2014.03.005

425 5. Arroyo-Morales, Manuel, et al., 2008 "Effects of myofascial release after high-intensity

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427 therapeutics 31(3); 217-223.

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428 6. Barnes, J.F., 1990. Myofascial Release: the Search for Excellence, tenth ed.

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430 7. Barnes, M. F., 1997. Efficacy study of the effect of a myofascial release treatment

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432 Therapies, 1(5), 289-296.

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AN
433 8. Cantarero-Villanueva, Irene, et al., 2012. Effectiveness of Core Stability Exercises and
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434 Recovery Myofascial Release Massage on Fatigue in Breast Cancer Survivors: A

435 Randomized Controlled Clinical Trial, Evidence-Based Complementary and Alternative

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436 Medicine, vol. 2012, Article ID 620619, 9 pages, doi:10.1155/2012/620619

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437 9. Castro-Snchez, Adelaida Mara, et al., 2011. "Effects of myofascial release techniques

438 on pain, physical function, and postural stability in patients with fibromyalgia: a
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439 randomized controlled trial." Clinical Rehabilitation 25 (9): 800-813.

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441 Therapy on Pain, Anxiety, Quality of Sleep, Depression, and Quality of Life in Patients

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444 11. Centre for Evidence-Based Physiotherapy, 2012. Physiotherapy evidence database

445 (PEDro). http://www.pedro.org.au/. Accessed January 11, 2012.

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446 12. Day JA, Stecco C, Stecco A., 2009, Application of fascial manipulation technique in
447 chronic shoulder pain anatomical basis and clinical implications. J Bodyw Mov Ther.
448 13:12835.
449 13. Fernndez-Lao, Carolina, et al., 2012. "The influence of patient attitude toward massage

450 on pressure pain sensitivity and immune system after application of myofascial release in

451 breast cancer survivors: a randomized, controlled crossover study." Journal of

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452 Manipulative and Physiological Therapeutics 35 (2): 94-100.

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453 14. Glossary of Osteopathic Terminology". American Association of Colleges of Osteopathic

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455 15. Greenman, P.E., 2003. Principles of Manual Medicine. Lippincott, Williams & Wilkins,

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456 Philadelphia, pp. 155-158 AN
457 16. Hanten, W. P., & Chandler, S. D., 1994. Effects of myofascial release leg pull and sagittal

458 plane isometric contract-relax techniques on passive straight-leg raise angle. The Journal
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459 of orthopaedic and sports physical therapy, 20(3), 138.

460 17. Hou, C.R., Tsai, L.C., Cheng, K.F., Chung, K.C., Hong, C.Z., 2002. Immediate effects of
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461 various physical therapeutic modalities on cervical myofascial pain and trigger-point
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462 sensitivity. Arch. Phys. Med. Rehabil. 83 (10), 1406-1414.

463 18. Hsieh, Chang-Yu J., et al., 2002. "Effectiveness of four conservative treatments for
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464 subacute low back pain: a randomized clinical trial." Spine 27(11); 1142-1148
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465 19. Huijing, P.O., Langevin, H.M., 2009. Communicating about fascia: history, pitfalls and
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466 recommendations. International Journal of Therapeutic Massage and Bodywork 2 (4), 3-

467 8.
468 20. Kain, Jay, et al., 2011. "Comparison of an indirect tri-planar myofascial release (MFR)

469 technique and a hot pack for increasing range of motion." Journal of bodywork and

470 movement therapies 15(1): 63-67.

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471 21. Kalamir, Allan, et al., 2010. "Intra-oral myofascial therapy for chronic myogenous

472 temporomandibular disorders: a randomized, controlled pilot study." The Journal of

473 manual & manipulative therapy 18 (3): 139.

474 22. Khuman, P. Ratan, et al., 2013. Myofascial Release Technique in Chronic Lateral

475 Epicondylitis: A Randomized Controlled Study. International Journal of Health Sciences

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476 and Research (IJHSR), 3(7), 45-52.

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477 23. Kidd, R. F., 2009. Why myofascial release will never be evidence-based.International

478 Musculoskeletal Medicine, 31(2), 55-56.

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479 24. Kuhar, S., Subhash, K., & Chitra, J., 2007. Effectiveness of myofascial release in

480 treatment of plantar fasciitis: A rct. Indian Journal of Physiotherapy and Occupational

481 Therapy, 1(3), 3-9.

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482 25. Kuruma, Hironobu, et al., 2013. Effects of Myofascial Release and Stretching Technique
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483 on Range of Motion and Reaction Time. Journal of Physical Therapy Science, 25(2),

484 169-171.
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485 26. Langevin HM, Fox JR, Koptiuch C, Badger GJ, Greenan-Naumann AC, Bouffard NA, et
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486 al.,2011, Reduced thoracolumbar fascia shear strain in human chronic low back pain.
487 BMC Musculoskelet Disord.12:203.
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489 27. McKenney, K., Elder, A. S., Elder, C., & Hutchins, A., 2013. Myofascial Release as a
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490 Treatment for Orthopaedic Conditions: A Systematic Review. Journal of Athletic

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491 Training: Jul/Aug 2013, Vol. 48, No. 4, pp. 522-527.

492 28. Meltzer, K.R., Cao, T.V., Schad, J.F., King, H., Stoll, S.T., Standley, P.R., 2010. In vitro

493 modeling of repetitive motion injury and myofascial release. J. Bodyw. Mov. Ther. 14,

494 162-171.

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495 29. Myers, T.W., 2009. Anatomy Trains: Myofascial Meridians for Manual and Movement

496 Therapists, second ed. Churchill Livingstone, Edinburgh.

497 30. Phillips B, Ball C, Sackett D, Badenoch D, Strauss S, Haynes B, et al., 2009. Oxford

498 Centre for Evidence-based Medicine Levels of Evidence (March 2009); available from

499 URL: http://www.cebm.net/?o=1025; Accessed March January 11, 2012.

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500 31. Pischinger, A., 1991. Matrix and Matrix Regulation: Basis for a Holistic Theory in

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501 Medicine. Haug International, Brussels.

502 32. Ramos-Gonzlez, Elena, et al., 2012. "Comparative study on the effectiveness of

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503 myofascial release manual therapy and physical therapy for venous insufficiency in

504 postmenopausal women." Complementary therapies in medicine20 (5): 291-298.

505
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33. Schleip, R., 2003. Fascial plasticitya new neurobiological explanation: Part 1. Journal of
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506 Bodywork and movement therapies, 7(1), 11-19.
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507 34. Schleip, R., Chaitow, L., Findley, T.W., Huijing, P., 2012. Fascia -The Tensional

508 Network of the Human Body. The Science and Clinical Applications in Manual and
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509 Movement Therapy. Elsevier, Edinburgh

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510 35. Schleip R, Jager H & Klingler W., 2012. What is fascia? A review of different

511 Nomenclatures; Journal of Bodywork & Movement Therapies (2012) 16, 496-502
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512 36. Sim, J., & Wright, C., 2000. Research in health care: concepts, designs and methods.

Nelson Thornes.
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513
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514 37. Stecco A, Gesi M, Stecco C, Stern R., 2013, Fascial Components of the Myofascial Pain
515 Syndrome; Curr Pain Headache Rep 17:352
516 38. Tozzi, Paolo, Davide Bongiorno, and Claudio Vitturini., 2011. "Fascial release effects on

517 patients with non-specific cervical or lumbar pain." Journal of Bodywork and Movement

518 Therapies 15 (4): 405-416.

519

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520 Figure 1. Study flow diagram.

521
Search Completed with Key words
522
Myofascial Release, Myofascial Release Therapy, Randomized
523
524 Controlled Trials
525

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526
527 The MEDLINE CINAHL Academic PEDro
528
Cochrane Search Database

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Library Premier
529
530

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531
532
133 Articles

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533
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534
535
536
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537 Inclusion and Exclusion criteria Applied

538
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539
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540
541 19 Articles
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542
543
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544
545
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Reviewed for level of

546
evidence
547
548
549
550
551

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552 Table 1. Physiotherapy Evidence Database (PEDro) Scale Scores

1. Eligibility criteria were specified (no points awarded)

2. Subjects were randomly allocated to groups
3. Allocation was concealed
4. The groups were similar at baseline regarding the most important prognostic indicators
5. There was blinding of all subjects

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6. There was blinding of all therapists who administered the therapy
7. There was blinding of all assessors who measured at least one key outcome

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8. Measures of at least one key outcome were obtained from more than 85% of the subjects
initially allocated to groups

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9. All subjects for whom outcome measures were available received the treatment or control
condition as allocated
10. The result of between-group comparisons are reported for at least one key outcome

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11. The study provides both point measures and measures of variability for at least one key
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outcome
553
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554
555 Table 2. Centre of Evidence-Based Medicine: Levels of Evidence
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Level Definition
1a Systematic reviews of randomized controlled trials
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1b Individual randomized controlled trial

1c All-or-none studies
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2a Systematic reviews of cohort studies

2b Individual cohort studies or low-quality randomized controlled trials
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2c Outcomes research
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3a Systematic reviews of case-control studies

3b Individual case-control studies

4 Case series, poorly designed cohort or case-control studies

5 Animal and bench research, expert opinion

556

557
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558 Table 3: Study results & grading included in the systematic review

Leve
l of
First Samp Main PEDr
Treatment Evid
Author Condition le Treatment Control Outcome Results o
Schedule ence
Year Size Measures Score
(CE
BM)
MFR to leg Post
x 10-15 treatment
Hanten Supine Passive hip
Hamstrings min, Single gains

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WP 75 rest x 5 flexion 6/10 2b
tightness Contract- session PNF: 10.40
1994 min ROM
relax PNF MFR: 6.60
x 4 min Control: 0.90

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MFR
Barnes Unilateral Better pelvic
pelvic Rest x 10 Single Pelvic
MF Pelvic 10 alignment 8/10 2b
region, 10 min session Position
1997 Rotation post MFR
min

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Back school
Back
:1/week x 3,
school Back pain
MFR , joint VAS,
program, improved in

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Hsieh Sub acute manip & Roland
MFR, joint all. No
CY Low Back 200 NA combined Morris 7/10 1b
manip or difference
2002 Pain MFR + joint activity
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combined between
manip: scale
MFR + groups
3/week x 3
joint manip
Ultrasound
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x 5 min, Ultrasoun
contrast d x 5 min, 10 Significant
Kuhar S Plantar
30 bath 20 in, contrast consecutive FFI, VAS reduction in 7/10 2b
2007 fasciitis
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exercises, bath 20 in, days VAS and FFI

MFR x 15 exercises
min
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sham
treatment
favors the
with
recovery of
disconnec
Arroyo- healthy HRV and
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MFR x 40 ted Single

Morales active 62 HRV & BP diastolic BP 6/10 2b
min ultrasound session
2008 individuals after high-
and
intensity
magnetoth
exercise
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erapy x 40
min
MFR
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NP: Sham improved

MFR x 6 fascial
non-specific NP: MFRx
Min dynamic mobility&
Tozzi P cervical(NP 6 min Single
120 LBP: ultrasound pain in 7/10 2b
2010 ) or lumbar LBP: MFR session
Sham (US) people with
pain (LBP) x 12 Min
MFR x 12 non-specific
in NP or LBP.

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MFR x 15
chronic
min, MFR MFR alone
Kalamir myogenous 2
15 min ROM & or with self-
A temporoman 30 Waist list sessions/we 8/10 2b
with self Pain care is
2010 dibular ek x 5
care & beneficial
disorders
exercises
MFR is as
indirect tri- passive effective
J. Kain Healthy planar hot pack x Single shoulder as hot packs
31 5/10 2b
2011 individual MFR x 3 20 min session range of in increasing
min motion range of

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motion
MFR
Disconnec improved
Castro-
ted 1 VAS, pain

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Snchez Fibromyalgi MFR x 90
74 Maganeto session/wee STAI, BDI, & quality of 7/10 1b
, AM a min
therapy x k x 20 PSQI life in
2011
30 min patients with

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fibromyalgia
MFR
improved
sham
number of pain, sensory,
short-

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Castro- tender and affective
wave and 2
Snchez Fibromyalgi MFR x 60 points, dimensions
86 ultrasound sessions/we 7/10 1b
, AM a min MPQ and without
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treatment ek x 20
2011 postural change in
x
stability. postural
30 min
stability
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Direct
MFR x 60 MFR is
Ajimsha Slow soft 2 numbers of
tension min effective than
MS 63 stroking x sessions/we days with 6/10 2b
headache Indirect a control
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2011 60 min ek x 12 headache

MFR x 60 intervention
min
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Salivary
Special flow rate,
Neck and immediate
Fernnd attention 2 sessions immunoglo
Breast shoulder increase in
ez-Lao 20 & separated by bulin A 6/10 2b
cancer MFR x 40 salivary flow
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2012 Education 2 weeks (IgA)

min rate & IgA
x 40 min concentrati
ons,
multimodal
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program with
MFR reduced
Cantarer
Multimoda fatigue,
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o- usual care 3
Breast l exercise tension,
Villanue 78 sessions/we POMS 7/10 2b
cancer and MFR x advises depression, &
va, I ek x 8
90 min improved
2012
vigor &
muscle
strength

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MFR x 50
blood Improvement
min x 2 Venous
venous pressure, in
Ramos- session/we return
insufficienc venous venous return
Gonzle ek Venous kinesiothe
y in 65 10 weeks velocity, blood flow, 8/10 2b
z E return rapy 2
postmenopa skin pain and
2012 kinesiother times
usal women temperatur quality of life
apy 2 times daily
e, pain noted
daily
Lateral
MFR is
Epicondyliti sham
Ajimsha 3 effective
s (LE) in MFR x 30 ultrasound

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MS 68 sessions/we PRTEE for LE in 7/10 Ib-
Computer Min therapy x
2012 ek x 4 Computer
Professional 30 min
Professionals
s
chronic low

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specific
back
back SBE & MFR with
Ajimsha pain(CLBP) 3
exercises Sham MPQ, SBE is
MS in 80 sessions/we 7/10 1b
(SBE) & MFR x 60 QBPDS effective for

SC
2014 nursing ek x 8
MFR x 60 min CLBP
professional
min
s
MFR to

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hamstring
ROM,
x 8 Min.
muscle
Kuruma MFR to Lay improved
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Healthy Single stiffness,
H 40 Quadriceps supine x 8 ROM & ease 5/10 2b
individuals session and
2013 x 8 Min. min of movement
Reaction
stretch for
Time
quadriceps
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8 min,
MFR
significant
forearm x Ultrasoun
decrease in
30 min, d x 5 min pain,
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Chronic pain,
Khuman Ultrasound Stretching 3 functional
Lateral improvement
PR 30 x 5 min and sessions/we performanc 7/10 2b
Epicondyliti in functional
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2013 Stretching strengthen ek x 4 e & grip

s performance
and ing strength
& grip
strengtheni exercise
strength
ng exercise
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significant
decrease in
pain &
plantar sham
Ajimsha 3 functional
MFR x 30 ultrasound
MS heel pain 66 sessions/we FFI & PPT disability, 8/10 2b
C

Min therapy x
2014 (PHP) ek x 4 improvement
30 min
in pressure
AC

pain
threshold
559 Abbreviations: Myofascial Release (MFR), Not Applicable (NA), Range of Motion (ROM), State- Trait Anxiety
560 Inventory (STAI), Beck Depression Inventory (BDI), Pittsburgh Quality of Sleep Index Questionnaire (PSQI), McGill
561 Pain Questionnaire, (MPQ), Profile of Mood State (POMS) questionnaire, Quebec Back Pain Disability Scale (QBPDS), Chronic
562 Low Back Pain (CLBP), Patient-Rated Tennis Elbow Evaluation (PRTEE). Minutes (Min), Manipulation (Manip), Center for
563 Evidence-Based Medicine (CEBM), Proprioceptive Neuromuscular Facilitation (PNF), Visual Analogue Scale (VAS), Foot Function Index
564 (FFI), Heart rate variability (HRV), Blood Pressure (BP), Foot function index (FFI), Pressure pain threshold (PPT).

565
566

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