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CRE0010.1177/0269215517732820Clinical RehabilitationLaimi et al.
CLINICAL
Original Article REHABILITATION
Clinical Rehabilitation
a systematic review
Abstract
Objective: To evaluate the evidence on the effectiveness of myofascial release therapy to relieve chronic
musculoskeletal pain and to improve joint mobility, functioning level, and quality of life in pain sufferers.
Data sources and review: Randomized controlled trials were systematically gathered from CENTRAL,
Medline, Embase, CINAHL, Scopus, and PEDro databases. The methodological quality of articles was
assessed according to the Cochrane Collaboration’s domain-based framework. In addition, the effect sizes
of main outcomes were calculated based on reported means and variances at baseline and in follow-up.
Results: Of 513 identified records, 8 were relevant. Two trials focused on lateral epicondylitis
(N = 95), two on fibromyalgia (N = 145), three on low back pain (N = 152), and one on heel pain
(N = 65). The risk of bias was considered low in three and high in five trials. The duration of therapy
was 30–90 minutes 4 to 24 times during 2–20 weeks. The effect sizes did not reach the minimal
clinically important difference for pain and disability in the studies of low back pain or fibromyalgia. In
another three studies with the high risk of bias, the level of minimal clinically important difference was
reached up to two-month follow-up.
Conclusion: Current evidence on myofascial release therapy is not sufficient to warrant this treatment
in chronic musculoskeletal pain.
Keywords
Myofascial release, systematic review, chronic pain, musculoskeletal disorders, manual therapy
myofascial release by patients themselves called reviewer groups rated methodological quality of
“self-myofascial release” was included. This included eight trials. Disagreements were resolved
kind of self-myofascial release uses various types by consensus or by a third reviewer (M.S.). Data
of roller massagers and provides tools for pain were extracted from included trials using a stand-
sufferers, athletes, and fitness trainers.5,7,8 In ath- ardized form based on recommendations by the
letes, self-myofascial release has thought to Cochrane Handbook for Systematic Reviews of
enhance range of joint motion, to speed up recov- Interventions Version 5.1.0. The methodological
ery, and to relieve prolonged muscle soreness5,7,8 quality was assessed according to the Cochrane
and has been suggested to be used as an alterna- Collaboration’s domain-based evaluation frame-
tive to massage. work (Supplementary Table 3). Main domains
Other manual therapies, different types of mas- were assessed in the following sequence: (1) selec-
sage, mobilization, or myofascial trigger point tion bias (randomized sequence generation and
therapy were not included in this review. Even if allocation concealment), (2) performance bias
the term “myofascial trigger point therapy” is (blinding of participants and personnel), (3) detec-
resembling “myofascial release,” trigger point tion bias (blinding of outcome assessment), (4)
therapy relies on a different theory and aims to the attrition bias (incomplete outcome data, e.g., due to
restoration of muscle function by treating muscular dropouts), (5) reporting bias (selective reporting),
“trigger points,” hyperirritable “knots” within taut and (6) other sources of bias. The scores for each
bands of skeletal muscles.4,11 bias domain and the final score of risk of system-
atic bias were graded as low, high, or unclear risk.12
The registration number of this review (Prospero
Search strategy database) is CRD42016035308.
The Cochrane Controlled Trials Register
(CENTRAL), Medline, Embase, CINAHL, PEDro,
and Scopus databases were searched for RCTs Minimal clinically important difference
(abstracts available in English) in February 2016 As clinically irrelevant statistically significant dif-
unrestricted by date, and the search was updated in ferences between intervention and control groups
August 2017. The search clauses are presented in are mainly dependent on the number of persons
Supplementary Table 2.12 We used the Cochrane examined, “minimal clinically important differ-
Highly Sensitive Search Strategy for identifying ence” is widely used to describe better the clinical
randomized trials. In order to avoid missing relevant relevance of findings. “Minimal clinically impor-
studies, use of limits was restricted and further selec- tant difference” is trying to define the smallest
tion was conducted manually. The references of the meaningful score change by separating “slightly
identified articles were also checked for relevancy. better result” from “almost equal” as the cut-off
point for minimal clinical importance for improve-
Study selection and methodological ment, independent of the sample size. This single-
point value is then generalized to other samples
quality assessment and is used on group level. Usually, this value is in
After saving all identified records in a citation the range of 6%–10% of the total score correspond-
manager (Endnote X7.2; Thomson Reuters, New ing to an effect size of 0.30–0.50 with different
York, NY, USA), clear duplicates, conference pro- estimates for different outcome instruments and
ceedings, theses, reviews, and expert opinions health conditions.13 Minimal clinically important
were deleted. Two independent reviewer groups difference has reported to be from 15% to 25% for
(E.B. and N.K. vs. A.M. and K.L.) screened all the numerical rating scale of neck pain, from 18% to
remaining 124 records based on titles and abstracts 28% for visual analogue scale of chronic low back
and, after that, based on the full texts of the selected patients, and even 38% to 51% for the functioning
potentially relevant studies. The same independent measurement in low back pain.14–20
4 Clinical Rehabilitation 00(0)
scope of this review was narrowed down to the mobility of soft tissues remained unnoticed.
effects of myofascial release on pain relief, improved However, both clinical impression and the mobility
joint mobility, functioning, quality of life, and satis- of tissues, even if a target of myofascial release, are
faction after treatment. Thus, other relevant out- difficult to estimate objectively. If the main target of
comes, such as anxiety, clinical impression, or myofascial release is on restoring optimal length of
6
Ajimsha et al.23 Nursing 38 (76) 36 (78) 36/34 Immediately Myofascial Sham myofascial Myofascial release as an adjunct to
and India professionals with (= 8 weeks) and release + back release + back back exercise is more effective than
low back pain 4 weeks after the exercises 3× 60 min/ exercises 3× exercise alone for chronic low back
end of treatment week, 8 weeks 60 min/week, pain in nursing professionals.
8 weeks
Ajimsha et al.22 Computer 33 (61) 32 (57) 31/29 Immediately Myofascial release 3× Sham ultrasound Myofascial release is more
and India professionals with (= 4 weeks) and 30 min/week, 4 weeks 3× 30 min/week, effective than sham ultrasound for
lateral epicondylitis 8 weeks after the 4 weeks lateral epicondylitis in computer
end of treatment professionals.
Ajimsha et al.21 Plantar heel pain 33 (76) 32 (69) 42/41 Immediately Myofascial release 3× Sham ultrasound Myofascial release is more effective
and India (= 4 weeks) and 30 min/week, 4 weeks 3× 30 min/week, than sham ultrasound in plantar heel
8 weeks after the 4 weeks pain.
end of treatment
Arguisuelas Non-specific low 27 (59) 27 (63) 47/46 Immediately Myofascial release 2× Sham myofascial Myofascial release produced a
et al.24 and Spain back pain (= 2 weeks), and 40 min/week, 2 weeks release 2× 40 min/ significant improvement in pain and
10 weeks after the week, 2 weeks disability.
end of treatment Minimal clinically important
differences were included in the 95%
CI. We cannot know whether this
improvement is clinically relevant.
Branchini et al.25 Non-specific low 11 (64) 13 (69) 48/44 Immediately Fascial manipulation Manual therapy Fascial manipulation led to decreased
and Italy back pain (= 4 weeks) and one 1× 45 min/ 2× 45 min/week, symptomatic, improved functional,
and three months week + manual 4 weeks and perceived well-being outcomes
after the end of therapy 1× 45 min/ that were greater amplitude
treatment week, 4 weeks compared to manual therapy alone.
Castro-Sánchez Fibromyalgia 30 (94) 29 (96) 49/46 Immediately Myofascial release of Sham Massage–myofascial release–therapy
et al.26 and Spain (20 weeks), 1 month tender points 90 min/ magnetotherapy reduces the sensitivity to pain at
and 6 months week, 20 weeks 30 min/week, tender points in fibromyalgia. Release
after the end of 20 weeks of fascial restrictions reduces anxiety
treatment and improves sleep quality, physical
function, and physical role. Massage–
myofascial release can be considered
as an alternative and complementary
therapy that can achieve transient
improvements.
Clinical Rehabilitation 00(0)
Laimi et al.
Table 1. (Continued)
Study and Target population N (women %) Age (years), Follow-up Case treatment Control treatment Authors’ conclusion
country cases/controls
Cases Controls
Castro-Sánchez Fibromyalgia 45 41 55/54 Immediately Myofascial release Sham short- Fibromyalgia patients can benefit
et al.27 and Spain Gender distribution not (20 weeks), 2× 60 min/week, wave + sham from myofascial release. Decrease
mentioned 6 months and 20 weeks ultrasound 2× in muscular tension secondary to
12 months after the 30 min/week, the release of myofascial restrictions
end of treatment 20 weeks improves physical function, fatigue,
number of days feeling good,
tiredness on walking, and stiffness.
Myofascial release significantly
improves several clinical dimensions,
with an important and consistent
improvement in pain, sensory, and
affective dimensions.
Khuman et al.28 Lateral 15 (40) 15 (47) 37/38 Immediately Myofascial Conventional Myofascial release improves pain,
and India epicondylitis (4 weeks) after the release + conventional physiotherapy 3×/ functional performance, and hand grip
end of treatment physiotherapy 3× week, 4 weeks for 4 weeks in lateral epicondylitis
30 min/week, 4 weeks probably by normalizing the fascial
tissue length and excitation of
afferent Aδ-fibers, which can cause
segmental pain modulation. Myofascial
release was more effective than
conventional physiotherapy alone for
pain, functional performance, and grip
strength.
Table 2. Effect sizes (raw mean difference in change between groups) of main outcomes of the included studies.
Study Outcome (scale) Reported results, mean (standard Mean Standard 95% Confidence
deviation) difference error interval
Cases Controls
(Continued)
Laimi et al. 9
Table 2. (Continued)
Study Outcome (scale) Reported results, mean (standard Mean Standard 95% Confidence
deviation) difference error interval
Cases Controls
MPQ, McGill Pain Questionnaire (0–78 points); QBPDS, Quebec Back Pain Disability Scale (0–100 points); PRTEE, patient-rated tennis elbow
evaluation (pain and functional disability; 0–100 points); FFI, Foot Function Index (0%–100%); SF-MPQ, Short Form McGill Pain Questionnaire (0–45
points); RMQ, Roland-Morris Questionnaire (0–24 points); FABQ, Fear Avoidance Beliefs Questionnaire (0–96 points); VAS, visual analogue scale for
pain intensity (0–10 cm), figures estimated from a graph; SF-36, 36-item Quality-of-Life Questionnaire (0–100 points); BPI, Brief Pain Inventory (two
subscales from 0 to 40 and 0 to 70 points, the used subscale not mentioned); FIQ, Fibromyalgia Impact Questionnaire (0–100 points); NRS, Numeri-
cal Rating Scale of pain intensity (0–10 points); nr, not reported.
aMcGill Pain Score Sensory and Affective (0–45 points).
bConsidered typo in the original article—value 5.2 replaced by 52.0 for the calculations.
fascia, this restoration is only a pathway in decreas- control treatment in a highly therapist-dependent
ing pain and enabling better functioning.2,4–6 manual treatment is important, as also touching can
Only three of the included RCTs23–25 had a credi- change the effectiveness of the treatment.9 As the
ble control group possibly capable in differentiating participants of the included studies were seeking for
the effect of myofascial release from the effect of a manual treatment option for their chronic pain,
manual touching. Blinding and choosing a credible non-manual sham control procedures—as in four
10 Clinical Rehabilitation 00(0)
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