Fitting myofascial release into an evidence‑based culture
Friday, April 14, 2017
Historically, manual therapy has played an integral part of physical/occupational/massage therapy and more recently speech-language pathology. With the multiple modality brands and styles of branded and nonbranded manual therapy — each seeming to claim such a wide range of tissue-specific targets and effects — it is difficult for the therapist and consumers to make sense of the claims made by each modality.
Myofascial release (MFR) has a long, though somewhat tarnished, history. Wikipedia describes the various forms of myofascial release and some of the beliefs that accompany each, but leaves it up to the reader to determine how to define myofascial release. The article also points out criticisms of the work and claims.
The explanations describe a narrative that views fascial (connective tissue) restriction or shortening as being the result of injury, etc., and being responsible for pain and various movement disorders. Each then goes into modality/brand-specific explanations as to how fascial tightness is targeted through various hands-on work and how it is restored to its normal length.
Each also seems to present science to support each work, which makes it even more confusing for the therapist and consumers, as an overview of the science each presents shows that all use nearly the same evidence, even though the methodologies may be vastly different.
With MFR being viewed as a range of work from gentle, sustained fascial holds to much deeper, quicker strokes and varying with or without the use of lubricant, it does seem a bit confusing that such similar proof is used to support each work. When one factors in versions of myofascial release that claim emotional trauma that resulted from an injury are stored within fascial restrictions, the muddiness of the brand is apparent.
Part of the myofascial release narrative states that restrictions cannot be imaged by any current technology (X-ray, MRI, etc.) nor can be detected on other forms of diagnostic testing, with claims that only the skilled hands of an MFR therapist can detect such restrictions. No wonder MFR lacks credibility!
While it is possible to rather accurately palpate known body landmarks, palpation of a pathology that has yet to be proven to exist further calls MFR's validity into question. Fascia researchers are discovering some pretty interesting facts about fascia, such as those shown by information presented at recent Fascia Congresses. But most reveal more about the anatomy and physiology of fascia with scant evidence of our ability to selectively target through the skin for the purposes of diagnosing and treating fascial restriction.
The skin represents a rather thick and formidable boundary for affecting isolated structure beneath it, but claims continue to be made to the contrary. Evidence is said to be results — happy patients.
Unfortunately, patient satisfaction is different from evidence. While patient satisfaction/preference forms the one of three components required in the evidence-based model, accurate and up-to-date evidence as well as clinician experience are at least equally important.
Most in the field hold a preference stating that credible research is the most important aspect of the triad, over clinician experience and patient preference/satisfaction. With such views, MFR often gets moved down on the list of credible interventions.
After practicing and teaching MFR for the past 25 years, I do understand much of the medical community's mistrust of myofascial release, as it suffers from some real problems. Briefly, there is a decided lack of credible proof that we are able to selectively identify (so-called) fascial restrictions and just as selectively target them for intervention, all to the exclusion of other tissues and structure.
MFR students are given evidence in the form of case studies and randomized controlled trials (RCTs), and many RCTs do exist showing myofascial release a successful intervention for a wide range of problems facing therapists.
But as to showing just how fascia/fascial tightness can be conclusively shown to be the pathology and that it is to be selectively targeted in a therapeutic manner, little is mentioned beyond the inherited and rather antiquated explanation/narrative given over the past many decades. Reading through the dozens of RCTs, the reader notices a pattern of regurgitating the same story of how fascia gets traumatized/shortened and that with the application of proper pressures we can restore it to a more normal length.
Physiological properties and actions are mentioned, but little is provided to show that these processes were validated other than in metaphoric ways. Few delve into deconstructing this narrative, but accept it at face value and move on into the actual study. It may be possible for fascia to suffer such ills, and we may be able to be selectively target it from outside the skin, but as of yet little has been published to prove this.
A second and more troubling aspect of myofascial release, at least some versions of it, are the questionable stories of how restricted fascia stores memories of the trauma that created the fascia restriction in the first place and how only MFR can release these emotional holding patterns. Anecdotes and testimonials are the only proof offered but provide the clinician with nothing tangible.
In papers that shed doubt on MFR's evidence, in 2008, Lars Remvig shows little evidence for the diagnostic criteria/methods or efficacy of MFR, based on the papers examined, while a newer study in 2013 by Kristin McKenney, et al, found some promising but mixed results gleaned from RCTs and case study examples.
But whether one examines these two review papers or dozens of other published papers on MFR, one is struck by the near-total lack of examination and updating of the explanatory narrative that accompanies descriptions of myofascial release.
If one examines the multiple RCTs and other papers, lower levels of acceptance/credibility become apparent. However, there is still something inherent in what therapists do with their hands when they perform what is called myofascial release that proves to be helpful for such issues as carpal tunnel syndrome, post-radiation head/neck cancer fibrosis and TMJ disorders, to name a few.
Skeptics point to the generic nature of the manner of touch engaged in myofascial release, and how it differs so little from so many other named modalities and styles, and I tend to agree with these thoughts. Touch is often quite helpful, and it can be explained by in a wide variety of ways, including indirect effect (placebo), neurological/autonomic influences, as well as possible tissue-specific narratives of explanation.
As one reads and compares the many different manual therapy inherited and current narratives, one is struck by the diversity of perceived tissue-specific effects with relatively narrow variations in how touch, pressure and stretch is applied. While purveyors of each individual modality/brand would strongly disagree, I think credibility would rise if such similarities were acknowledged.
Work is being done by some in the manual therapy communities to create simpler narratives, ones that are more acceptable/palatable to the general medical community. But when money is being made by each modality and the unique narrative brings in students, little movement is probable in coming together for such simpler/plausible narratives.
Examining each modality, the student is presented with evidence, but the more observant, science-minded person can see the holes in the narratives. Not to exclude the possibility that fascial tightness/restriction is not at all involved with pain and movement disorders, but there are more credible explanations for such dysfunction.
As a practitioner and teacher of myofascial release through continuing education seminars, I am often barraged with complaints from both sides to discontinue using the term myofascial release to describe my work and seminars. Traditional MFR communities see my views as disrespectful of those who have brought it to the masses. They think if I do not feel that fascia is what we are primarily affecting, then I should stop calling my work MFR. Point taken.
Robert F. Kidd goes a step further by stating that MFR will never be evidence-based, as, for one reason, it is an art form. Therapists and their inherent skills cannot be removed from the equation to objectively measure outcomes. If this were true, then no form of manual therapy would be validated via research and evidence, as all involve therapists who tend to perform better over time.
Those in the science community often will criticize me for retaining the term myofascial release to describe my work, as they feel that there is nothing about the physiologic/neurologic process of manual therapy that releases anything, especially fascia, unless it is used as a simple metaphor for change. As to the thought that fascia/fascial restrictions store emotions and that only through MFR can a person let go of those held emotions and heal, those in the science community take greater umbrage with these beliefs, as do I.
So why do I continue to use the term to describe my work? To me, myofascial release has become less about the older narratives used to describe aspects of the work than it has the physical action I've done with my hands over the past 25 years. Even though I have let go of believing I am primarily and selectively targeting fascia to the exclusion of all else, I still consider what I do with my hands MFR.
MFR as I use it may resemble other branded modalities, but to me what I do is MFR. There is value in retaining the brand name as it does have a name recognition value by both the therapy community as well as the general public. It is important for all to move away from modality-specific interventions and focus on the concepts that effect treatment.
So how can myofascial release fit into our current culture of evidence-based practice? If taken as an actual belief, myofascial release does have some pretty deep and fatal flaws. But if one allows for the concept and words myofascial release to be used in a more metaphoric way — think Kleenex as it is generally used to describe a facial tissue — then I see no reason to completely ban its use in an evidence-based culture.
Am I fudging things to rationalize my choice to use and teach MFR? Possibly, but similar pathways are used by nearly all in the manual therapy field, even those who claim full evidence to support their work. Critics will continue to disagree, from both sides, but such is the nature of science.
When we perform actions in certain ways and in certain sequences, positive actions result. When I touch people in ways I think of as MFR, patients improve, as shown on the many RCTs and case studies.
Is it perfect? Does it represent the highest level of evidence available to our professions? No, it is not. But we work from what works best for us and allow the evidence to form.
MFR may never fit completely into interventions/professions that demand full evidence-based proof before using a modality or approach, but I do think it is possible to move myofascial release toward a better, more science-informed narrative. Results and outcomes matter, but so does the credibility of the narratives used to explain a work.
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