Efficacy of Myofascial Release

University of Puget Sound
Sound Ideas
School of Occupational Master's Capstone Occupational Therapy, School of

Projects
5-2018
Efficacy of Myofascial Release

Michelle Chait OTS
Erin Eaton OTS

Tiffany Farley OTS

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Part of the Occupational Therapy Commons
Recommended Citation
Chait, Michelle OTS; Eaton, Erin OTS; and Farley, Tiffany OTS, "Efficacy of Myofascial Release" (2018).
School of Occupational Master's Capstone Projects. 40.
https://soundideas.pugetsound.edu/ot_capstone/40
This Article is brought to you for free and open access by the Occupational Therapy, School of at Sound Ideas. It
has been accepted for inclusion in School of Occupational Master's Capstone Projects by an authorized
administrator of Sound Ideas. For more information, please contact [email protected].
Running head: EFFICACY OF MYOFASCIAL RELEASE
Efficacy of Myofascial Release
May 2018
This evidence project, submitted by
Michelle Chait, OTS

Erin Eaton, OTS
Tiffany Farley, OTS
has been approved and accepted

in partial fulfillment of the requirements for the degree of
Master of Science in Occupational Therapy from the University of Puget Sound.
___________________________________
Project Chairperson: Sheryl Zylstra, DOT, MS, OTR/L
_________________________________ ________________________________
OT635/636 Instructors: George Tomlin, PhD, OTR/L, FAOTA; Renee Watling, PhD, OTR/L, FAOTA
________________________________________
Acting Director, Occupational Therapy Program: Anne B. James, PhD, OTR/L, FAOTA
_________________________________________
Dean of Graduate Studies: Sunil Kukreja, PhD
Keywords: Myofascial Release, Upper Extremity, Orthopedic Conditions

EFFICACY OF MYOFASCIAL RELEASE 2
Abstract
In collaboration with Tomi Johnson and Domonique Herrin, hand therapists working in a
MultiCare rehabilitation clinic, we sought to answer the question: In adults with upper extremity and
cervical spine orthopedic and peripheral nerve conditions, does myofascial release (MFR) lead to
functional outcomes (such as decreased pain or disability, or increased range of motion etc.), compared to
therapeutic exercises, other manual therapeutic techniques, and/or modalities? Twenty-three research
articles, systematic reviews and meta-analyses were included in our evaluation of the research. Based on
our findings, moderate evidence exists to support the use of MFR in the upper extremity and its
effectiveness in decreasing pain and disability, and increasing passive range of motion (PROM), strength,
posture, quality of life (QoL), and overall function. We recommend that further research be conducted on
the effectiveness of myofascial release within the scope of occupational therapy to determine the effects
of myofascial release related to the upper extremity.
An informational binder that contained our critically appraised topic (CAT) table with summaries
and copies of each article in the CAT was created as a future resource for our collaborating practitioners.
Additionally, an inservice presentation was created to share the research findings with physical therapists
and physicians who work alongside our collaborators. A pre/post inservice survey was created to monitor
the effectiveness of these resources. Attendees reported a 62% increase in knowledge regarding current
research investigating the efficacy of myofascial release following the presentation. It is recommended
that future critical appraisals on this topic include studies examining the lower extremity due to the
perceived generalizability of the fascial system from one region of the body to another, or studies
involving self-myofascial release (e.g. patient-administered, foam rolling, etc.) that have become
increasingly popular methods of implementation within the literature.

Executive Summary
We met with our collaborators, Tomi Johnson and Domonique Herrin, in September 2017 to
discuss their research needs. They initially requested information regarding research investigating the
efficacy of myofascial release in the treatment of upper extremity orthopedic and peripheral nerve
conditions. Based on this request, our original research question was developed: In adults with upper
extremity orthopedic conditions, does myofascial release lead to decreased pain and edema and increased
functional performance, compared to therapeutic exercises including no manual techniques? After
completing our literature search, this question evolved into our final research question based on the
available evidence: In adults with upper extremity and cervical spine orthopedic and peripheral nerve
conditions, does myofascial release lead to functional outcomes (such as decreased pain or disability, or
increased range of motion etc.), compared to therapeutic exercises, other manual therapy techniques,
and/or modalities?
After analyzing twenty-three articles, the following themes were identified: MFR without
treatment comparison, MFR treatment alone compared to other treatment, MFR combined therapies
compared to other combined therapies, and MFR examined in systematic reviews. In five articles
(Ajimsha et al., 2012; Castro-Martin et al., 2017; Doraisamy et al., 2010; Namvar et al., 2016; Nisture &
Welling, 2014) examining MFR without treatment comparison, statistically significant functional
improvements were found in all five studies. In six studies (Gandhi et al, 2016; Kain et al., 2011; Piecelli
et al., 2011; Rodriguez-Huguet et al., 2017; Sata et al., 2012; Singh & Chauhan, 2014) comparing MFR
alone to another type of therapy, statistically significant outcomes following MFR treatment were found
in all studies. Additionally, the MFR groups had statistically significant better outcomes in five of the six
studies compared to other treatments (Piecelli et al., 2011; Rodriguez-Huguet et al., 2017; Sata et al.,
2012; Singh & Chauhan, 2014). When MFR combined therapy was compared to other combined
therapies in six studies (Chaudhary et al., 2003; Hou et al., 2002; Khuman et al., 2013; Kumar & Jetly,
2016; Rodriguez-Fuentes et al., 2016; Trivedi et al., 2014), statistically significant improvements in
functional outcomes were found in all six articles using MFR techniques, but there is limited evidence
supporting that MFR combined with other treatment is more effective than exercises alone and
inconclusive when compared to other manual therapy and modality combinations. In addition, five
systematic reviews and one meta-analysis showed that the majority of articles found MFR to have
positive and superior results compared to other techniques and treatments. Only one article reported
adverse effects of mild, transient soreness after initial MFR treatment.
Based on the number of articles and level of rigor, there is currently moderate evidence to suggest that
MFR may lead to positive outcomes in the treatment of orthopedic and peripheral nerve conditions.
Further high quality Level I research is needed to determine the efficacy of MFR when used to treat upper
extremity orthopedic and peripheral nerve conditions. After completing our research, we created an
informational binder that contained our critically appraised topic (CAT) table with summaries. Copies of
each article in the CAT were created as a future resource for our collaborating practitioners. In addition,
we provided an inservice presentation to share our findings with physical therapists and physicians who
work alongside our collaborators at the MultiCare rehabilitation clinic. A pre/post inservice survey was
created to monitor the effectiveness of these resources. Attendees reported a 62% average increase in
knowledge regarding current research investigating the efficacy of myofascial release following the
presentation. In addition, when asked how much more likely therapists were to use myofascial release in
their practice, the mean response on the post-inservice survey was a 7.8 (more likely) on a scale of 1-10.
CRITICALLY APPRAISED TOPIC PAPER
Focused Question:
In adults with upper extremity and cervical spine orthopedic and peripheral nerve conditions, does
myofascial release lead to functional outcomes (such as decreased pain or disability, or increased range of
motion etc.), compared to therapeutic exercises, other manual therapy techniques, and/or modalities?
Collaborating Occupational Therapy Practitioner:

Tomi Johnson, OTR/L, CHT and Domonique Herrin, OTR/L, LMT
Prepared By:
Michelle Chait, Erin Eaton, Tiffany Farley
Chair:
Sheryl Zylstra, DOT, OTR/L
Course Mentor:
George Tomlin, PhD, OTR/L, FAOTA
Date Review Completed:

11/14/17
Clinical Scenario:
Our collaborating practitioners, Tomi Johnson and Domonique Herrin, are hand therapists working in a
MultiCare rehabilitation clinic. Domonique Herrin is a recent graduate with less than one year of
experience, and Tomi Johnson is a Certified Hand Therapist (CHT) with more than five years of
experience; both previously worked as massage therapists. Their manager oversees three other clinics,
and he reports to the clinic director. The MultiCare rehabilitation clinic system is currently being merged
with another system, thus their upper management organization is experiencing changes. The primary
patient population at the clinic is adults with orthopedic and nerve injuries of the upper extremity. Clients
are typically seen for 45 minutes twice a week for eight weeks. Payer sources include Medicare,
Medicaid, and private insurance. Due to the nature of the MultiCare system, the results of this research
project will not impact the current policies in place throughout the organization, but will impact the
collaborator’s ability to justify their services to referring physicians.
The collaborating practitioners requested evidence supporting the use of myofascial release in the
treatment of upper extremity orthopedic and peripheral nerve conditions. Research evidence would allow
them to use better scientific, pragmatic, narrative, and conditional reasoning to guide their interventions.
If strong evidence is found regarding its efficacy, it will also provide validation not only to the physicians
who are referring patients to them, but also for justifying services billed in therapy.
Review Process
Procedures for the selection and appraisal of articles
Inclusion Criteria:
· Articles published on or after 1980 at first, changed to 2000 - see “Quality Control/Review Process”
(p. 3)
· Articles published in or translated into English
· Adult participants (18 years and older) with orthopedic or peripheral nerve conditions of the upper
extremity
· Interventions involving therapist-administered myofascial release
· Intervention occurring in any practice setting
Exclusion Criteria:
· Participants under the age of 18
· Participants with central neurological disorders
· Interventions involving self-myofascial release or instrument-assisted myofascial release
· Articles not published in peer reviewed journals
Search Strategy
Categories Key Search Terms
Patient/Client Older adult, young adult, grown-up, developed, mature, elderly, fully grown,
Population musculoskeletal conditions, musculoskeletal injuries, orthopedic impairments,
orthopedic trauma, orthopedic pain, musculoskeletal disorders, peripheral nerve
injury, lateral epicondylitis, carpal tunnel syndrome
Intervention Myofascial release (MFR), myofascial soft tissue mobilization
(Assessment)
Comparison Therapeutic exercises, sham therapy, no therapy, conventional treatment,
modalities
Outcomes Decreased pain, decreased disability, increased ROM, increased function,
increased quality of life
Databases and Sites Searched

PubMed/Medline, PEDro, CINAHL, SPORTDiscus, Cochrane Library, OTSeeker, Google Scholar, OT
Search
American Journal of Occupational Therapy, British Journal of Occupational Therapy, Canadian Journal
of Occupational Therapy, Australian Journal of Occupational Therapy, Journal of Hand Therapy,
Physical Therapy Journal
Quality Control/Review Process:

Three reviewers independently searched the above databases and sites. Date of publication was used as a
filter for efficiency purposes and to prevent duplications. Assigned date ranges include: 1980-1999, 2000-
2008, and 2009-2016. Articles published in 2017 were searched for collectively as a group due to a delay
of indexing in certain databases. Each reviewer searched for articles using the aforementioned keywords
and identified articles as relevant based on whether the keywords were identified in the abstract;
orthopedic must be accompanied by myofascial release or an identified synonym to be considered
relevant. Each reviewer then created a reference list of selected articles and these lists were reviewed as a
group. Full text articles were collected after the group determined that an article met the inclusion criteria.
After identified articles were reviewed, search criteria were further refined to exclude the following:
articles published in 1980-1999, articles that examined the lower extremity, and interventions involving
self-myofascial release or instrument assisted myofascial release. The earlier years were excluded in order
to include only the most relevant research regarding MFR application and outcomes. MFR application to
the lower extremity was also excluded in order to maintain the focus towards an outpatient hand therapy
clinic that primarily treats conditions of the upper extremity. Additionally, all described self-MFR and
instrument-assisted MFR were excluded to emphasize the use of skilled manual therapy that is directly
administered by the therapist. Researchers also performed citation and reference tracking to uncover
further articles that met criteria.
Results of Search
Table 1. Search Strategy of databases.
Search Terms Date Database Initial Articles Total
Hits Excluded Selected for
Review
Date Range: 2017-2018
“myofascial release” AND Nerve 10/31/17 PubMed 12 11 (1 repeat) 1
“myofascial release” 11/1/17 PubMed 38 37 (2 1

repeats)
“myofascial release” 01/20/18 PubMed 42 42 (2 0

repeats
“myofascial release” 01/20/18 CINAHL 43 43 (2 0

repeats)
“myofascial release” 01/20/18 PEDro 8 8 (2 repeats) 0
“myofascial release” 01/20/18 SPORT 38 38 (2 0

Discus repeats)
“myofascial release” 01/20/18 OTSeeker 0 0 0
“myofascial release” 01/20/18 OT Search 0 0 0
“musculoskeletal manipulations” 9/21/17 & PubMed 51 44 (4 7

[mesh] “myofascial release” 10/5/17 repeats)
myofascial release AND 10/5/17 PEDro 2 1 (1 repeat) 1

orthopaedic
myofascial release AND 10/5/17 PEDro 5 1 4

musculoskeletal disorders

orthopaedic injuries

orthopaedic impairments

orthopaedic pain

orthopaedic trauma
myofascial soft tissue 10/5/17 PEDro 0 0 0

mobilization AND orthopaedic
Found on ScienceDirect when 10/5/17 NA 99 86 (1 repeat) 13

looking at Ramos-Gonzalez
article
myofascial release AND 10/5/17 PubMed 13 10 (5 3

orthopaedic repeats)
myofascial release AND 10/6/17 PubMed 2 2 (2 repeats) 0

orthopedic trauma
myofascial release AND upper 10/6/17 PubMed 3 3 (1 repeat) 0

extremity
myofascial release AND 10/6/17 CINAHL 7 5 (2 repeats) 2

orthopedic
myofascial release AND 10/6/17 CINAHL 0 0 0

orthopaedic AND injury
myofascial release AND 10/6/17 CINAHL 2 2 (1 repeat) 0

musculoskeletal disorders
myofascial soft tissue 10/6/17 CINAHL 0 0 0

mobilization AND orthopedic
injury

orthopedic trauma

orthopedic pain
myofascial release AND 10/10/17 SPORT 3 3 (1 repeat) 0

musculoskeletal conditions Discus
myofascial release AND 10/10/17 SPORT 0 0 0

orthopedic injuries Discus

orthopedic impairments Discus

orthopedic trauma Discus

orthopedic pain Discus
myofascial release 10/10/17 Cochrane 1 1 0

myofascial soft tissue 10/10/17 Cochrane 2 2 0

mobilization
myofascial release AND 10/10/17 Cochrane 1 1 (1 repeat) 0

orthopaedic
myofascial release AND 10/10/17 Cochrane 0 0 0

orthopaedic impairments
myofascial release AND 10/10/17 OT Seeker 0 0 0

orthopedic
“myofascial release” 10/10/17 OT Seeker 1 1 (1 repeat) 0
myofascial soft tissue 10/10/17 OT Seeker 0 0 0

mobilization
myofascial release 10/10/17 OT Search 1 1 0
myofascial release AND 10/10/17 OT Search 0 0 0

orthopedic
allintitle: “myofascial release” 10/10/17 Google 0 0 0

AND orthopedic Scholar
allintitle: “myofascial release” 10/10/17 Google 276 251 (13 25

Scholar repeats)
myofascial release AND 10/12/17 PTJ 8 8 0

orthopedic
myofascial release 10/12/17 AJOT 3 3 0
myofascial release 10/12/17 BJOT 0 0 0
myofascial release 10/12/17 CJOT 0 0 0
myofascial release 10/5/17 PubMed 66 64 2
myofascial release in academic 10/5/17 CINAHL 86 78 (1 repeat) 8

journals
myofascial release in academic 10/5/17 SPORT 25 25 (5 0

journals Discus repeats)
myofascial release 10/5/17 Cochrane 1 1 0
myofascial release 10/5/17 OT Seeker 0 0 0
myofascial release 10/5/17 AJOT 2 2 0

myofascial release 10/5/17 J of Hand 7 7 0

Therapy
myofascial release in research 10/9/17 PTJ 3 3 0

articles
allintitle: “myofascial release 10/9/17 Google 74 73 (4 1

Scholar repeats)
myofascial release 10/10/17 BJOT 1 1 0
“myofascial release” AND 10/5/17 PubMed 4 1 3

orthopedic AND adult
“myofascial soft tissue 10/5/17 PubMed 0 0 0

mobilization” AND orthopedic
OR musculoskeletal

musculoskeletal AND adult
“myofascial release” AND 10/5/17 PubMed 8 5 (3 repeats) 3

intervention

therapy
“myofascial release” AND adult 10/5/17 PubMed 0 0 0

AND therapy
“myofascial release” AND 10/5/17 CINAHL 0 0 0

orthopedic OR orthopaedic AND
adult
“myofascial release” 10/5/17 CINAHL 18 13 (1 repeat) 5
“myofascial release” AND 10/5/17 CINAHL 1 1 0

orthopedic
“Myofascial soft tissue 10/5/17 CINAHL 0 0 0

mobilization”
“myofascial release” AND 10/5/17 SPORT 0 0 0

orthopedic OR orthopaedic AND Discus
adult
“myofascial release” 10/5/17 SPORT 4 3 (1 repeat) 1

Discus
“myofascial release” 10/5/17 OT Search 11 11 0
“myofascial release” 10/5/17 OT Seeker 0 0 0
“myofascial release” AND 10/10/17 Cochrane 3 3 (1 repeat) 0

orthopedic
“myofascial release” 10/10/17 Cochrane 5 3 (2 repeats) 2
“myofascial release” AND 10/10/17 Google 53 52 1

orthopedic injury AND adults scholar
“myofascial release” 10/10/17 AJOT 1 1 0
“myofascial release” 10/10/17 BJOT 0 0 0
“myofascial release” 10/10/17 CJOT 0 0 0
“myofascial release” 10/10/17 JHT 6 6 0
“myofascial release” 10/10/17 PTJ 1 1 0
Total number of initial articles used in review from database searches = 83 (Revised total = 21 after
changes made to exclude articles prior to 2000, lower extremity, and self-myofascial release)
Table 2. Articles from citation tracking.

Article Date Database Initial Articles Total Selected for
Hits Excluded Review
Kain et al. (2011) 10/21/17 Google 25 25 0

Scholar
Khuman et al. (2013) 10/21/17 Google 5 5 0

Scholar
Laimi et al. (2017) 10/21/17 Google 0 0 0

Scholar
Nisture & Welling 10/21/17 Google 5 4 1

(2014) Scholar
Sata (2012) 10/21/17 Google 4 4 0

Scholar
Rodriguez-Fuentes et al. 10/21/17 Google 2 2 0

(2016) Scholar
Singh et al. (2014) 10/21/17 Google 3 3 0

Scholar
Trivedi et al. (2014) 10/21/17 Google 8 8 0

Scholar
Chaudhary et al. (2013) 10/21/17 Google 4 4 0

Scholar
Doraisamy et al. (2010) 10/21/17 Google 4 4 0

Scholar
Ghandhi et al. (2016) 10/21/17 Google 0 0 0

Scholar
Castro-Martin et al. 10/21/17 Google 2 2 0

(2017) Scholar
Hou et al. (2002) 10/21/17 Google 347 347 0

Scholar
Ajimsha et al. (2014) 10/21/17 Google 32 32 0

Scholar
McKenny et al. (2013) 10/21/17 Google 31 31 0

Scholar
Parravicini & Bergna 10/21/17 Google 0 0 0

(2017) Scholar
Piper et al. (2016) 10/21/17 Google 12 12 0

Scholar
Webb & Rajendran 10/21/17 Google 4 4 0

(2016) Scholar
Total number of articles used in review from citation tracking = 1
Table 3. Articles from reference tracking.

Article Date Articles Articles Total Selected for
Referenced Excluded Review
Laimi et al. (2017) 11/09/17 28 28 0
Namvar et al. (2016) 11/09/17 37 37 0
Rodriquez-Huguet et al. 11/09/17 34 34 0

(2017)
Nisture & Welling (2014) 11/09/17 23 23 0
Khuman et al. (2013) 11/11/17 27 27 0
Kain et al. (2011) 11/11/17 12 12 0

Sata (2012) 11/11/17 25 25 0
Doraisamy et al. (2010) 11/11/17 17 17 0
Gandhi et al. (2016) 11/11/17 32 32 0
Ajimsha et al. (2012) 11/11/17 28 28 0
Castro-Martin et al. (2017) 11/11/17 55 55 0
Singh & Chauhan (2014) 11/11/17 13 13 0
Trivedi et al. (2014) 11/11/17 27 27 0
Kumar & Jetly (2016) 11/12/17 41 41 0
Hou et al. (2002) 11/12/17 49 49 0
Chaudhary et al. (2013) 11/11/17 22 22 0
Rodriguez- Fuentes et al. 11/11/17 49 48 1

(2016).
Ajimsha et al. (2014) 11/12/17 37 37 0
McKenney et al. (2013) 11/12/17 15 15 0
Parravicini & Bergna 11/12/17 61 61 0

(2017)
Piper et al. (2016) 11/12/17 59 59 0
Webb & Rajendran (2016) 11/12/17 104 104 0
Picelli et al. (2011) 11/12/17 39 39 0
Total number of articles used in review from reference tracking = 1
Total number of articles used in review from database searches = 21

Total number of articles used in review from citation tracking = 1
Total number of articles used in review from reference tracking = 1
Total number of articles used in review from UPS Master’s Thesis = 0
Total number of articles used in CAT = 23
Summary of Study Designs of Articles Selected for the CAT Table
Pyramid Side Study Design/Methodology of Selected Number of

Articles Articles
Selected
Experimental _5.5_Meta-Analyses of Experimental Trials 20.5 (duplicate
_14_Individual Randomized Controlled Trials with a D1)
_1_Controlled Clinical Trials
_0_Single Subject Studies
Outcome _0_Meta-Analyses of Related Outcome Studies 2

_0_Individual Quasi-Experimental Studies
_0_Case-Control Studies
_2_One Group Pre-Post Studies
Qualitative _0_Meta-Syntheses of Related Qualitative Studies 0

_0_Small Group Qualitative Studies
_0_brief vs prolonged engagement with
participants
_0_triangulation of data (multiple sources)
_0_interpretation (peer & member-checking)
_0_a posteriori (exploratory) vs a priori
(confirmatory) interpretive scheme
_0_Qualitative Study on a Single Person
Descriptive _0.5_Systematic Reviews of Related Descriptive 0.5 (duplicate

Studies with an E1)
_0_Association, Correlational Studies
_0_Multiple Case Studies (Series), Normative
Studies
_0_Individual Case Studies
Comments: TOTAL = 23
One systematic review included both experimental and descriptive studies, and
was therefore, represented twice in this table indicated by the “0.5” marks above.
AOTA Levels
I- 20
II- 1
III- 2
IV- 0
V- 0
Table Summarizing QUANTITATIVE Articles

Author, Year, Study Objectives Study Design, Participants: Interventions & Summary of Study Limitations
Journal Level of Sample Size, Outcome Results
Abbreviation, Evidence, Description, Measures
Country PEDro score Inclusion and
Exclusion
Criteria
MFR Without Treatment Comparison
Ajimsha et al. To investigate if Single blind RCT N = 68 I: MFR treatment MFR group had No practitioner
MFR reduces pain Intervention n = 33 30 min 3x/wk for 4 greater sig blinding. Limited
2012 and functional AOTA = I (1 dropout) wks. Ctrl group reductions in participant
Pyramid = E2 Ctrl n = 32 (2 received sham PRTEE scores (p information.
disability of lateral
Arch Phys Med PEDro = 7/10 dropouts) ultrasound therapy < 0.001). At 4 wks,
Rehabil epicondylitis in for same duration. MFR = 78.7%
computer Mean age = 29.9 reduction from
India professionals. 56% F O: Pain Severity baseline, ctrl =
and Functional 6.8% reduction
IC: Computer Disability: PRTEE from baseline. At
professionals 20- 12 wks, MFR =
40 y.o., dx: Lateral 63.1% reduction
epicondylitis on from baseline, ctrl
mouse operating = 2.2% incr from
arm, pain lasting at baseline.
least 3 mo, use
computer for 50%
or more of the
work day
EC: Trauma to
affected elbow in
preceding 6 wks,
hx of elbow
instability, elbow
surgery, or upper
limb/cervical spine
pathology, use of
oral systemic
steroids/analgesics,
other lateral
epicondylitis tx in
previous 6 mo
Castro-Martin et To investigate Single-blind RCT N = 21 I: 2 sessions (tx Tx resulted in sig Small,
al. effects of Mean age = 50 and placebo) decr on VAS homogenous
myofascial AOTA = I 21 F separated by 4 wk affected arm (p < sample. No follow-
2017 Pyramid = E2 interval, randomly 0.031), but not up beyond post
induction w/
PEDro: 7/10 IC: Dx stage I- assigned to order cervical (p < intervention.
Arch Phys Med placebo IIIA breast cancer, of interventions. 0.332). Sig incr in
Rehabil electrotherapy for ages 25-65, Tx: 30 min AROM: shld
cervical/shld on completed myofascial ER/ABD/IR (p <
Spain breast cancer adjuvant therapy induction of upper 0.001), cervical
survivors. limb rotation (p <
EC: Cancer Placebo: 30 min 0.022) and cervical
recurrence, shortwave therapy lateral flex (p <
sustained 0.038). Not sig for
trauma/had surgery O: Pain: VAS, total mood
in cervical/thoracic Shld-Cervical disturbance (p <
/upper limb areas AROM: .929).
not related to Goniometer,
cancer in last 6 Psychological
mo, not given Distress: Profile of
medical clearance Mood States
Doraisamy et al. To investigate One group pre- N = 31 I: Single session, Sig reduction in No blinding.
effect of MFR in post study 24 F MFR head and number of Disproportionate
2010 relieving 18-58 y.o. neck muscles headache days (p < number of females.
AOTA = III 0.001) and pain (p No long-term
symptoms of
Global Jrnl of Pyramid = O4 I: Headache for at O: Pain: VAS, < 0.001) at 1 wk follow-up.
Health Sci chronic tension PEDro = 5/6 least 3 days/wk for Number of follow-up.
type headache. past four wks headache days/wk
India
E: Cervical spine
surgeries,
intracranial causes
to headache
Namvar et al. To investigate Double blind RCT N = 34 I: MFR tx 20 The MFR group Study did not
effectiveness of Intervention n = 17 mins, 2x/wk for 2 had stat sig disclose sex of
2016 MFR on pain, AOTA = I Ctrl n = 17 weeks. increase in pain participants. No
Pyramid = E2 Mean age = 36.9 Ctrl received no tx. threshold (p < long-term follow-
disability, max
Int J Med Res PEDro = 8/10 y.o. 0.001) and up.
Health Sci isometric O: Pain: VAS, extension power (p
contraction IC: 18-55 y.o., Disability: NDI, < 0.001) and sig
Iran strength and neck pain w/ or Max Isometric decr in pain (p <
pressure pain w/out shld or Contraction of 0.001) and
threshold in unilateral upper Neck Extensors: disability index (p
patients with non- limb symptoms for Pressure < 0.001). MFR
at least 3 mo biofeedback group performed
specific chronic
device, Pressure stat sig better on
neck pain EC: Whiplash Pain Threshold: all outcome
w/in 6 wks, hx of Pressure measures (p <
cervical spine Algometer 0.001) than the ctrl
cancer, fx, or group, except
surgery, bilateral extension power (p
upper limb pain, = 0.313)
cervical spinal
stenosis, positive
neurologic
findings, long-term
corticosteroid use,
MFR tx in month
before study
Nisture & Welling To investigate One group pre- N = 15 I: MFR on upper MFR led to sig No ctrl group.
effectiveness of post Mean age 33.5 y.o. limb and neck for improvement in Intervention
2014 gross MFR of 60% Female 10-15 min/session, pain (p = 0.001), includes both MFR
AOTA = III each position held and disability and TENS.
upper limb and
Int J Dent Med Res Pyramid = O4 IC: Dx for 90 sec. (DASH p < 0.001, Short tx period.
neck in subjects PEDro = 4/7 w/mechanical neck Following MFR, NPQ (p < 0.001) Small sample size.
India w/mechanical neck pain along TENS for 15
pain and referred w/referred pain to min/session. Tx
pain on pain, and unilateral upper given 1x/day for 5
functional abilities limb, onset of pain days.

< 1 mo, 20-50 y.o.,
willing to O: Pain: VAS,
participate in Upper Limb
study. Functioning:
DASH, NPQ
EC: Signs of
neurological
involvement,
cervical disc
prolapse, cervical
spondylosis, spinal
stenosis, previous
spinal injury, hx
cervical trauma,
congenital
torticollis, frequent
migraine,
carcinoma,
pregnancy
MFR Only vs. Other Treatment
Gandhi et al. To investigate Pilot RCT N = 38 I: 6 wks Pain: Decr for both Homogenous
effectiveness of Intervention n = 19 Ctrl: MFR only groups, tx group sample. MFR not
2016 MFR w/shld AOTA = I Ctrl n = 19 Tx: MFR + taping had larger decr described. Number
taping on Pyramid = E2 18-22 y.o. of treatments over
Bangladesh Jrnl of PEDro = 6/10 O: Pain: SPADI: Decr for
Med Sci subacromial numerical pain both groups, tx 6 wks not clear.
IC: Male,
impingement basketball player, rating scale, group had larger Unclear if results
Bangladesh syndrome in 18-22 y.o., Functional Ability: decr were stat sig.
collegiate subacromial SPADI
basketball players impingement
syndrome dx
EC: Hx previous
shld injury, tape
allergy, skin
infections
Kain et al. To compare Single Blind RCT N = 31 I: MFR technique MFR led to sig No demographic
passive shld ROM Intervention n = 18 used: Clavi- incr in PROM for information. No
2011 after MFR AOTA = I Ctrl n = 13 pectoral indirect shld flex (p = exclusion criteria.
Pyramid = E2 soft tissue three- 0.001), ext (p = No blinding of
technique and hot
J Bodywork Mov PEDro = 6/10 IC: Pain free in planar fulcrum 0.001), and abd (p therapists or
Ther pack application. dominant UE w/no release to = 0.001). subjects. No long-
hx of acute or dominant shld. Tx No sig diff found term follow-up.
US subacute injury once in supine btw groups in Interventions only
position for 3 min. PROM for shld given once.
Ctrl group flex (p = 0.187) ,
received hot pack ext (p = 0.628), or
applied to abd (p = 0.512).
dominant anterior
shld for 20 min.
O: Shld PROM:
Goniometer
Picelli et al. To investigate Single Blind Pilot N = 18 I: Group A: 3, 30 Stat sig Small sample size
whether MFR is RCT Mean age 40.5 y.o. min sessions, differences in limits
2011 more effective 39% Male every 5 days, for decr pain and generalizability.
AOTA = I 2wks. Received incr cervical Lack of long-term
than conventional
Eur J Phys Rehabil Pyramid = E2 Group A (MFR) MFR to head, active flex at follow up. Did not
Med therapy to improve PEDro = 8/10 n=9 neck, scapula, and post-tx eval consider direction
cervical ROM in Group B thorax. when MFR of head impact
Italy patients with (conventional) Group B: 10, 30 compared to from MVA.
subacute whiplash, n=9 min sessions, mobilization
and to assess if every 5 days, for 2 exercises (p =
MFR decr neck IC: age 18-60, dx wks. 20 min of 0.03). W/in
whiplash due to neck mob groups, stat sig
pain and disability.
MVA, exercises + 10 min incr in AROM
symptomatic w/in of neck stretching. on all six
72 hrs of accident, Patients evaluated AROM
wore soft collar. before, parameters
immediately after, among MFR
EC: fx or and two wks post- group at post-tx
dislocation of tx. and follow-up

cervical spine, (flex: p < 0.001,
amnesia or O: Cervical ext: p = 0.008,
unconsciousness, AROM: R lat flex: p =
secondary accident Goniometer, Pain: 0.001, L lat
w/ injuries to head, VAS, Disability: flex: p = 0.001,
neck, or thorax, hx NDI, Pressure R rot: p =
of chronic head, Pain Threshold: 0.004, L rot: p
neck, thorax pain pressure algometer = 0.002), but
w/in last 6 mo, sig only two stat
psych disease, sig for
drug or alcohol mobilization
abuse. group at post-tx
(R rot: p =
0.003, L rot: p
= 0.008) and
only R rot stat
sig at follow-
up.
Rodriguez- Huguet To investigate Single blind RCT N = 41 I: MFR tx At end of tx No medium or
et al. effectiveness of Intervention n = 20 consisted of 4 diff change in pain for long-term follow-
MFR on pain in AOTA = I Ctrl n = 21 (1 maneuvers MFR group was up.
2017 Pyramid = E2 dropout at 1 mo performed greater than ctrl (p
patients with neck
PEDro = 8/10 follow-up) 1x/session. Tx = 0.021) w/large
Am J Phys Med pain Mean age 38.02 occurred 5x over 2 btw group effect
Rehab y.o. wks, lasting size (R2 = 0.33). At
48.78% male <45min. one month follow-
Spain Mean mo w/neck Ctrl received up change in pain
pain 3.34 ultrasound, TENS, for MFR group
and massage was greater than
IC: 20-60 y.o., 5x/wk for 2 wks. ctrl (p < 0.001)
both sexes, dx w/large btw group
mechanical neck O: Pain: VAS, effect size (R2 =
pain > 1 mo Pressure Pain 0.29)
Threshold:
EC: Neck pain Pressure
from trauma, Algometer

whiplash, or fx,
neoplasia, severe
osteoporosis,
infectious, or
inflammatory
process,
pacemaker,
pregnancy, neck
surgery, MFR in
previous month
Sata To compare RCT N = 52 I: MFR given MFR group No blinding. No
efficacy of muscle Intervention n = 27 slowly for 20 sec performed sig long-term follow-
2012 energy technique AOTA = I Ctrl n = 25 repeated 3-4x. better than ctrl in up. Short tx period.
Pyramid = E2 Mean age 30.12 Applied once daily pain intensity (p = Extensive
and MFR on
Indian J of Physio PEDro = 6/10 y.o. for 6 days. 0.0037), disability exclusion.
& Occ Therapy trigger point in (p = 0.0175), and
upper trapezius. IC: Pain in neck, Ctrl: Muscle pain threshold (p =
India 20-50 yo, either energy technique 0.0003)
sex, dx w/upper of post facilitation
trapezius spasm stretching. Applied
3wks-3mo, pain once daily for 6
felt maximally days.
over upper
trapezius region, O: Pain Intensity:
active trigger point VAS, Neck
in trapezius, Disability:
willing to NDI, Pain
participate in study Threshold: PPT
EC: Degenerative
neurological
traumatic, or
cancer conditions,
uncooperative pts
Singh & Chauhan To compare RCT N = 28 I:Group A: MFR Both MFR and No follow-up post
efficacy of MFR Group A (MFR) n Group B: PRT PRT decr pain and intervention.
2014 and PRT in TTH. AOTA = I = 14 Each technique disability for TTH. Lack of statistics
Pyramid = E2 Group B (PRT) n done for 2 However, MFR on reported.
J Med Sci & PEDro = 6/10 = 14 sessions/wk w/ 3 suboccipital
Clinical Res repetitions for 4 muscle more
IC: 25-45 y.o., wks total. effective for decr
India presence of trigger pain and disability
points in O: Pain: VAS, in TTH than PRT.
suboccipital area. Disability: HDI
EC: Hx of meds
from 1+ yr for
TTH, hx of trauma
to cervical region,
vertebrobasilar
insufficiency, hx
of cervicogenic
head/migraine,
malignancy in
cervical area.
MFR Combined Therapy vs. Other Treatment
Chaudhary et al. To compare effects Single-blind RCT N = 45 I: 5 sessions MFR group No follow-up post
of conventional Group A (n=15) Group A: MFR showed sig intervention.
2013 physiotherapy, AOTA = I Group B (n=15) (deep transverse improvement in Limited age group.
Pyramid = E2 Group C (n=15) friction for 10 min
ART, and MFR on VAS (p < 0.001),
Int J Health Sci Pedro: 8/10 Mean age = 28.7 followed by
Res pain, grip strength, 25 F myofascial 3x for pressure pain
functional 90sec) + exercises threshold (p <
India performance for IC: Ages 20-40, Group B: cold 0.001), and
CLE. pain in last mo, pack (20 min) + AROM (p < 0.001)
limited neck exercises compared to cold
movements due to Group C: exercises pack and exercises
pain, palpable only
group.
tender spot in
upper trapezius O: Pain: VAS,
Pain Pressure
EC: Pain from Threshold:
cervical pathology, Algometer, Lateral
healing fx over Cervical ROM:
neck or upper Goniometer
back, clotting
disorders, wound
over neck, shld
pathology,
degenerative
cervical spine
Hou et al. To investigate RCT N = 119 I: Stage 1 - Sig decr pain Multiple
immediate effect Stage 1 n = 48 ischemic threshold and pain, interventions and
2002 of physical AOTA = I B1 n = 21 compression to sig incr for pain combinations
Pyramid = E2 B2 n = 13 determine pain tolerance for all 6 make it difficult to
therapeutic
Arch Phys Med PEDro = 5/10 B3 n = 9 threshold and txs (p < 0.05). understand which
Rehabil modalities on B4 n = 10 tolerance pressures therapy is most
cervical B5 n = 9 of MTrPs in upper When combined effective.
US myofascial pain B6 n = 9 trapezius muscles w/AROM, heat
and trigger-point 107 F Stage 2 - 6 therapy, and
sensitivity 30-60 y.o. therapeutic interferential
combinations current, MFR sig
IC: Cervical B1 (ctrl): hot pack incr pain tolerance
myofascial pain, + AROM and pain threshold
palpable MTrPs in B2: B1 + ischemic and sig reduced
single/both sides compression pain when
of upper trapezius B3: B2 + TENS compared to heat +
B4: B1 + stretch AROM alone (p <
EC: No neck/shld w/spray 0.05) and ischemic
surgery in past yr, B5: B4 + TENS compression (p <
no B6: B1 + 0.05), but not
radiculopathy/mye interferential when ischemic
lopathy, no hx of current + MFR compression is
disk combined
disease/degenerati O: Pain: VAS, w/TENS.
ve jt disease/fx Pain Threshold:
/dislocation of PThM, Pain

cervical vertebrae, Tolerance: PToM
no cognitive
deficits,
willingness to
participate
Khuman et al. To investigate RCT N = 30 I: MFR tx 30 min MFR group sig No blinding.
effectiveness of Intervention n = 15 3x/wk for 4wks positive decr in No long-term
2013 MFR to reduce AOTA = I Ctrl n = 15 and received pain (p = 0.001), follow-up. Short
Pyramid = E2 Mean age 37.45 conventional duration time.
pain, and incr incr functional
Int J Health Sci PEDro = 7/10 y.o. physiotherapy
Res functional 56.65% male program of pulse disability (p =
performance and Duration 8.5 mo ultrasound, 0.001), and incr
India grip strength in stretching, and grip strength (p =
individuals IC: 30-45 y.o., strengthening. 0.001). MFR
w/CLE. both genders, CLE 3x/wk for 4wks group performed
> 3 mo, unilateral Ctrl received sig better than ctrl
involvement, conventional
in pain (p < 0.001),
NPRS score 4-8 physiotherapy
disability (p <
EC: Hx of trauma, O: Pain: NPR, 0.001), and grip
surgery, acute Functional strength (p =
infections, Disability: 0.001).
systemic disorders, PRTEE,
cervical spine/UE Grip Strength:
dysfunction, Hand
neurological or, dynamometer
CV disease,
osteoporosis,
steroid infiltration,
ossification and
calcification of
soft tissue,
malignancies,
athletes, received
physiotherapy w/in
3 mo,
unwillingness to
attend all tx
sessions and
assessments.
Kumar & Jetly To compare Comparative Study N = 30 I: Both groups: 12 Both groups No blinding. No
effectiveness of Group A sessions over 4 showed sig (p < control group. No
2016 MFR and cyriax AOTA = II (ultrasound + wks 0.05) improvement long-term follow-
Pyramid = E3 MFR) n = 15 Group A: 5 min of in VAS and up.
manual therapy to
Indian J of Physio PEDro = 5/10 Group B ultrasound PRTEE scores
& Occ Therapy decr pain and incr (Ultrasound + followed by 10 after 12 tx
function for lat Cyriax manual min of MFR sessions. No sig
India epicondylitis therapy) n = 15 Group B: 5 min differences btw
ultrasound group
IC: Ages 20-50, followed by 10 improvements
chronic >2mo, min of cyriax indicating both tx
tenderness on manual therapy decr pain and
palpation, pos (using deep disability.
Cozen’s and Mill’s transverse friction
tests massage)
EC: no previous or O: Pain: VAS,

current other Functional
trauma to elbow, Disability: PRTEE
symptomatic
arthritis at elbow
jt, cervical
radiculopathy,
absence of tennis
elbow signs,
corticosteroid
inject w/in 3 mo
Rodriguez- To investigate if Single blind RCT N = 59 I: Group 1: MT + Pain and Small sample as
Fuentes et al. MFR in Two therapeutic tx analgesic tx Disability: stat sig defined by
mechanical AOTA = I groups: Group 2: MFR + decr in neck pain researchers. No
2016 Pyramid = E2 Group 1 (MT) n = analgesic tx follow-up. Sample
occupational neck and functional
pain has clinical PEDro = 8/10 29 disability for both only drawn from
Am J Phys Med advantages over a Group 2 (MFR) n 10, 50-min tx groups (p < 0.001). those w/
Rehab different MT = 30 sessions for 4 wks. MFR showed no occupational neck
Mean age = 38.2 pain.
protocol. diff compared w/
Spain 56% F O: Pain: VAS,
Cervical MT post-tx.
IC: 18-65 y.o., Disability: NDI,
have mechanical QoL: Short-Form QoL: Group 2
neck pain, score Health Survey, showed stat sig
10% or higher on Craniovertebral incr on the global
Neck Disability Angle and Physical and
Index or 2 points Cervical AROM:
Mental Component
or more on VAS at Goniometer
initial eval. Summaries of the
Short-Form Health
EC: Neck pain due Survey (p = 0.000
to neoplasia, and p = 0.000,
metastasis, respectively).
osteoporosis, Group 1 showed
infectious or
sig improvements
inflam processes,
fx, congenital in only two
anomalies, dimensions of the
herniated disc, global components
whiplash, cervical (incr physical
stenosis, function, p <
radiculopathy,
0.001; and decr
previous neck
surgery, neck pain bodily pain, p =
w/ dizziness, 0.040).
pregnancy,
received Craniovertebral
physiotherapy tx in Angle and Active
previous 3 mo Cervical AROM:
stat sig incr in
angle and AROM
for both groups.

Stat sig diff btwn
groups observed
after 5 tx sessions
(incr
craniovertebral
angle, p = 0.014;
flex, p = 0.021;
ext, p = 0.003; R
side bending, p =
0.001; R rotation,
p = 0.031). Greater
stat sig
improvement w/
MFR.
Trivedi et al. To compare effects RCT N = 36 I: 12 sessions After 4 wks of tx, No long-term
of conventional Three therapeutic 3x/wk for 4 wks both ART and follow-up. No
2014 physiotherapy, AOTA = I tx groups: Group A: MFR groups blinding.
Pyramid = E2 Group A (ctrl/ ultrasound + improved more
ART, and MFR on
Int J Physiother & PEDro = 6/10 conventional exercise program than ctrl group
Res pain, grip strength, physiotherapy) n Group B: across all outcome
functional = 12 ultrasound + measures (p =
India performance for Group B (ART) n exercise + ART 0.019, p = 0.001, p
CLE. = 12 Group C: = 0.583,
Group C (MFR) ultrasound + respectively).
n= 12 exercise + MFR MFR improved
Mean age = 38.3 stat sig more than
y.o. O: Pain: NPRS, ART, thus MFR is
Strength: more effective at
IC: Ages 30-45, Dynamometer, reducing pain,
symptomatic Functional Ability: disability, and
chronic lateral PRTEE given at improving grip
epicondylitis, pain baseline and post- strength.
intensity btw 3-6 tx.
on 10 point rating
scale
EC: hx of trauma,
surgery, acute
infections,
malignancy,
cervical spine or
other UE
dysfunction,
neurological
diseases, CV
disease,
osteoporosis,
recent steroid
infiltration,
athletes, received
physiotherapy w/in
3 mo
Key to Abbreviations (Alphabetical)

Abbreviation Full Phrase
ABD Abduction
AROM Active range of motion
ART Active release technique
Btw Between
CLE Chronic lateral epicondylitis
Ctrl Control
DASH Disabilities of the Arm, Shoulder, and Hand
Decr Decrease
Diff Difference
EC Exclusion criteria
Eval Evaluation
ER External rotation
Ext Extension
Flex Flexion
Fx Fracture
HDI Headache Disability Index
Hx History
I Intervention
IC Inclusion criteria
Incr Increase
IR Internal rotation
ITB Iliotibial Band
IThC Indexes of Changes in Pain Threshold
Jt Joint
LE Lower extremities
MFR Myofascial release
Min Minute/s
Mo Month
MRT Myofascial release therapy
MT Manual therapy
MTrP Myofascial Trigger Point
MVA Motor vehicle accident
NDI Neck Disability Index
NPQ Northwick Park Neck Pain Questionnaire
NPRS Numerical Pain Rated Scale
NSAIDs Non-Steroidal Anti-Inflammatory Drug
O Outcomes
PPT Pressure Pain Threshold - Pressure Algometer
PRT Positional release therapy
PRTEE Patient Rated Tennis Elbow Evaluation
PThM Pain Threshold Meter
PToM Pressure Tolerance Meter
Pts Patients
QoL Quality of life

RA Rheumatoid Arthritis
RCT Randomized controlled trial
Shld Shoulder
Sig Significant
SPADI Shoulder Pain and Disability Index
Stat Statistically
TCA Tricyclic Antidepressant
TENS Transcutaneous Electric Nerve Stimulation
TTH Tension type headache
Tx Treatment
VAS Visual Analogue Scale
Wk/s Week/s
W/ With
y.o. Years old
Yr Year
Table Summarizing Meta-Analyses/Meta-Syntheses/Systematic Review Articles

Author, Year, Study Objectives Study Design, Number of Interventions & Summary of Study Limitations
Journal Levels of Papers Included, Outcome Results
Abbreviation, Evidence of Inclusion and Measures
Country Studies Exclusion
Criteria
Ajimsha et al. To analyze RCTs Systematic Review N = 133 reviewed I: MFR alone, 9/19 found MFR Multiple outcome
to determine N = 19 selected MFR + PNF, MFR better than no tx or measures difficult
2014 effectiveness of AOTA = I Databases + contrast bath + sham tx for to compare.
Range = I searched include ultrasound, MFR + musculoskeletal
MFR
J Bodywork Mov MEDLINE, self-exercise and painful
Ther Pyramid = E2 CINAHL, conditions. 7/19
Academic Search O: Hip and shld found MFR + CT
Qatar PEDro = N/A Premier, PROM, pain, foot more effective
Cochrane Library, function, pelvic than ctrl groups
PEDro position, blood receiving no tx,
pressure, heart sham tx, or CT.

SC: Keywords rate, RMDQ, 1/19 found MFR
“myofascial PRTEE, number of inferior to PNF.
release” and days w/o
myofascial release headache, MPQ,
therapy”. No date QBPDS, muscle
limitations. stiffness, reaction
time, grip strength,
IC: RCTs in peer- functional
reviewed journal, performance, PPT
10+ participants,
sufficient
information to
analyze, used
MFR as tx, in
English, human
and adult
participants
EC: Non-RCTs,
trigger point
therapy, did not
use MFR as
defined, PNF and
MFR w/o
explanations
Laimi et al. To analyze of Meta-Analysis N = 124 papers I: MFR alone; All studies Small sample of
evidence on reviewed MFR, back concluded MFR articles. Studies
2017 effectiveness of AOTA = I N = 8 selected exercises; Fascial effective in pain came from 3
Range = I manipulation, reduction and countries and 5
MFR to relieve
Clin Rehabil Databases manual therapy; improving research groups.
musculoskeletal Pyramid = E2 searched include MFR of tender functioning. Incomplete meta-
Finland pain, improve jt Medline, Embase, points; MFR, High risk of bias analytic process
mobility, PEDro = N/A CINHAL, PEDro, conventional for 5/8 articles. with no statistics
functioning level, Scopus, and physiotherapy. Studies on lateral completed on
and QoL CENTRAL epicondylitis assembled studies.
O: Pain intensity changes in scales

SC: RCTs, No or frequency, jt evaluating pain
date limitations ROM, level of and function
functioning, QoL. reached minimal
IC: Adults w/ clinical importance
chronic in 2 mo follow up.
musculoskeletal Evidence found to
pain, tx MFR, be scarce and
comparison to any inconsistent.
other tx, placebo,
sham, or no tx, High quality RCTs
outcome of need to be
between group diff conducted on
in pain intensity/ larger samples
frequency, ROM, w/longer follow-
functioning level, ups.
QoL.
EC: Pain
associated w/
malignancy or
specific
neurological
disease, tx of non-
specific massage,
other manual
therapies,
myofascial trigger
point tx.
McKenney et al. To analyze the Systematic Review N = 88 studies I: MFR alone; 8/10 studies Overall quality of
literature to reviewed moist heat pack, revealed MFR had studies was poor to
2013 determine N = 10 selected as MFR, positive effects, moderate. 6/10
AOTA = I eligible mobilization; studies were case
effectiveness of but not all were
J Athletic Training Range = I - IV w/inclusion/ trigger-point studies, the others
MFR for exclusion criteria release, MFR, stat sig. 2/10 were experimental
US orthopedic Pyramid = E2, D4 applied. contract-relax studies showed no w/small sample
conditions. Databases PNF; MFR, jt effect. sizes. Ethical

PEDro = N/A searched w/no date manipulation; approval identified
limitations ultrasound, in only 5 studies,
included contrast bath, only 1/6 case
MEDLINE, exercises, MFR; studies confirmed
CINAHL, massage, MFR, participants gave
Academic Search strengthening informed consent.
Premier, Cochrane
Library, and O: Jt position,
Physiotherapy decreased pain/
Evidence “popping”/
Database tenderness/ trigger
(PEDro). points, activity
tolerance, QoL,
SC: A/PROM
Studies published
in scientific peer-
reviewed journals,
used indirect and
passive MFR as tx
for orthopedic
conditions,
published in
English, and
studied adults 18
y.o. and older were
included.
Parravicini & To analyze Systematic Review N = 95 articles I: Direct In-vitro studies No statistical
Bergna biological effects reviewed manipulation: suggest analysis
from direct or AOTA = I N = 24 selected as Static stretching, prophylactic MFR implemented for
2017 Range = N/A eligible MFR, and “other (that stimulates review, may
indirect
Study types not w/inclusion/exclus direct fibroblast activity) weaken
J Bodywork Mov manipulation of documented. ion criteria manipulative may regulate interpretation of
Ther fascial system for applied. techniques” inflammation and results. Only
functional Pyramid = N/A including EMG improve wound analyzed in-vitro
Italy outcomes. Databases variability induced healing; clinically, studies, should be
PEDro = N/A searched include by massage, MR, may prevent injury expanded to
Medline, Scopus, high-frequency for pts w/risk observe effects of
Cochrane, Pedro, ultrasound, factors for MSD MFR and other
Ostmed Dr., and relationship btw injury. MFR manual techniques
authors’ full article constant sliding, reversed negative on human body in
publications on perpendicular effects of conjunction
Fascial Research vibration, repetitive motion w/biological
Congress Website. tangential strain for wound processes.
oscillation. closure. Lower
SC: Exploring Indirect magnitude and
biological effects Manipulation: longer duration (at
of any form of Strain least 5 min) of
MFR tx, written in counterstrain MFR improved
English, written (positional release wound healing
w/in past 10 yrs. therapy) (collagen
synthesis,
Authors searched O: Decreased secretion).
independently in tension, Sustained
“phase 1” to ID inflammation, stretching changed
abstracts that met maintaining fibroblast shape
inclusion criteria. viscoelasticity of resulting in large-
In “phase 2” connective tissue, scale relaxation of
inclusion criteria scarring & fibrosis connective tissue;
were applied to post-injury, muscle clinically,
full text. regeneration, prevention of
relieving MSD stiffening tissues
pain and improves ROM
dysfunction and reduces pain.
Piper et al. To analyze Systematic Review N = 9869 articles I: MFR vs. sham MFR and Only reviewed
effectiveness of screened ultrasound therapy, movement re- quantitative
2016 soft-tissue therapy AOTA = I N = 6 selected as deep diacutaneous education (MET) outcome measures
Range = I eligible fibrolysis (DF; are beneficial for w/ no
compared to
Manual Therapy w/inclusion/exclus clinical massage) lateral considerations for
placebo/shame tx Pyramid = E1 ion criteria tx vs. sham epicondylitis. qualitative
Canada or no tx for applied. superficial DF, Relaxation perspectives for
improving funct PEDro = N/A MET vs. massage (to relax effectiveness of
recovery and Databases corticosteroid mm, move fluids, MFR.

clinical outcomes searched include injection (CSI), reduce pain)
in pts w/MSD and MEDLINE, splint and MFR vs. combined w/ other
EMBASE, splint only, trigger modalities (splint,
UE/LE injuries.
CINAHL, point soft tissue nerve gliding,
PsychINFO, therapy + self- exercises, etc.)
SPORTDiscus, stretching vs. self- showed short-term
Cochrane Central stretching only. benefits for carpal
Register of tunnel syndrome.
Controlled Trials. O: Self-rated DF not effective
recovery, for subacromial
SC: Studies from functional impingement
1990-2015, recovery (e.g.
published in return to activities,
English, RCTs, work, school),
cohort studies, clinical outcomes
case-control (e.g. disability,
studies, and pain intensity,
inception cohort of health-related
min of 30 QoL),
participants per tx administrated
group for RCTs, or outcomes (e.g.
100 subjects per time on disability
exposed group for benefits), or
cohort or case- adverse events.
control studies.
Only quantitative
outcomes. Phase
one, independent
reviewers screened
titles and abstracts
as relevant,
possibly relevant,
or irrelevant.
Phase two,
reviewers viewed
full texts to
determine
eligibility.
Webb & To analyze Systematic Review N = 1046 articles I: Muscle energy All articles Restricted primary
Rajendran existing evidence and Meta-Analysis screened; 56 full technique, strain concluded that outcome to jt
for effect of texts ordered and counter-strain, MFT incr jt ROM ROM. No outcome
2016 AOTA = I screened ischaemic and reduced pain. measure of pt
manually applied
Range = I N = 9 selected as compression, & perspective. Small
J Bodywork Mov MFT on jt ROM eligible various MFTs number of articles
Ther and pain on “non- Pyramid = E2 w/inclusion/exclus (MFR, w/small samples.
pathological ion applied. neuromuscular Incomplete meta-
UK symptomatic PEDro = N/A technique, & analytic process
subjects.” Databases positional release with no statistics
searched: PEDro, therapy) completed on
Cochrane Library, assembled studies.
NLM PubMed, O: Jt ROM: tape
EMBASE, measure, cervical
EBSCOhost, ROM device,
MEDLINE, Psych goniometer,
and Beh Sci calipers; pain:
Collection, VAS, pain
PsychINFO, component of
SPORTDiscus, Oswestry
CINAHL Plus. Disability Scale.
SC: RCTs, adult

human subjects,
peer-reviewed
published from
2003 to present,
objective measure
of jt ROM, had
differentiated
MFTs from other
tx. Article
excluded were
non-RCTs, non-
English, in-vitro
studies, non-local
jt ROM outcomes,
non-manual MFR
techniques
(Graston, dry
needling, etc.).
Key to Abbreviations (Alphabetical)

Abbreviation Full Phrase
CT Conventional Therapy
Ctrl Control
EC Exclusion criteria
Hx History
I Intervention
IC Inclusion criteria
Jt Joint
MET Muscle Energy Technique
MFR Myofascial release
MFT Myofascial Technique
Mo Month
MR Muscle Repositioning
MPQ McGill Pain Questionnaire
MSD Musculoskeletal Disorder
O Outcomes
PNF Proprioceptive Neuromuscular Facilitation
PPT Pressure Pain Threshold
PROM Passive range of motion
PRTEE Patient Rated Tennis Elbow Evaluation
QBPDS Quebec Back Pain Disability Scale
QoL Quality of life
RCT(s) Randomized control trial(s)

RMDQ Roland Morris Disability Questionnaire
ROM Range of Motion
SC Search criteria
Sig Significant
Tx Treatment
Summary of Key Findings
Introduction. Twenty-three articles addressing the effectiveness of myofascial release (MFR)
were included in this examination of a critically appraised topic. MFR was defined for the purposes of
this review as being one form of manual therapy technique that specifically manipulates the fascia
surrounding muscles through application of a graded, prolonged stretch. MFR may be applied locally
or in a more general method depending on the specific needs of the client. Of the included articles, six
were Level I systematic reviews or meta-analyses, 14 were Level I randomized controlled trials, one
was a Level II two groups, nonrandomized study, and two were Level III one-group, nonrandomized
studies. Articles were analyzed for similarities in type of comparison treatment, region of the body,
participants, and outcomes. The following themes were identified: MFR without treatment
comparison, MFR treatment alone compared to other treatment, MFR combined therapies compared to
other combined therapies, and MFR in systematic reviews. The rigor of each article was evaluated
using three scales: the PEDro scale (1999), the American Occupational Therapy Association Levels of
Evidence (Sackett et al.,1996), and the Tomlin and Borgetto Research Pyramid (2011).
MFR without treatment comparison. Five articles examined the effectiveness of MFR
without comparison to another form of equivalent treatment (Ajimsha et al., 2012; Castro-Martin et al.,
2017; Doraisamy et al., 2010; Namvar et al., 2016; Nisture & Welling, 2014). Three Level I studies
(Ajimsha et al., 2012; Castro-Martin et al., 2017; Namvar et al., 2016) evaluated the effects of MFR by
comparing MFR to sham therapy. Ajimsha et al. (2012) and Namvar et al. (2016) found statistically
significant reductions in pain and disability when compared to sham therapy. Castro-Martin et al.
(2017) found decreased pain in one of two treated areas and a significant increase in active range of
motion (AROM) in shoulder and cervical joints. One Level III study found significant improvement in
pain and upper limb function (Nisture & Welling, 2014). However, MFR was combined with
Transcutaneous Electrical Nerve Stimulation (TENS), which makes it difficult to attribute outcomes
directly to MFR. Another Level III study found significantly reduced pain associated with chronic
tension headache (Doraisamy et al., 2010). This study only included one treatment session, though,
and headache quantity and pain level was gathered retrospectively through an interview, which could
result in inaccurate baseline data. Overall, statistically significant functional improvements were found
in the five studies that examined the effectiveness of MFR without comparing MFR to another
treatment, providing strong, but limited evidence for MFR.
MFR treatment alone compared to other treatment. Six Level I studies compared MFR
therapy alone to another treatment method (Gandhi et al, 2016; Kain et al., 2011; Piecelli et al., 2011;
Rodriguez-Huguet et al., 2017; Sata et al., 2012; Singh & Chauhan, 2014). All studies found
statistically significant outcomes following MFR treatment and, in addition, significantly better
outcomes were found among the MFR groups in five of the six studies compared to other treatments
(Piecelli et al., 2011; Rodriguez-Huguet et al., 2017; Sata et al., 2012; Singh & Chauhan, 2014). When
compared to positional release therapy (Singh & Chauhan, 2014) and post facilitation stretching (Sata
et al., 2012), MFR resulted in greater reductions of pain and disability of muscles of the cervical spine.
When compared to ultrasound, TENS, and massage, MFR resulted in greater significant reductions in
neck pain (Rodriguez-Huguet et al., 2017). Picelli et al. (2011) found statistically significant
differences in pain and cervical active flexion at post-treatment evaluation when MFR was compared
to mobilization exercises, with greater significant reductions observed in the MFR treatment group;
pain remained statistically significant between groups at follow-up, but active flexion did not.
However, within groups, statistically significant increases in AROM were found on all six AROM
parameters among the MFR group at post-treatment and follow-up, but only three were statistically
significant for the mobilization group at post-treatment followed by one at follow-up. Gandhi et al.
(2016) compared MFR alone to MFR with kinesiotaping and found decreased pain and disability
levels for both groups, with better results when combined with kinesiotaping; however, it was unclear
whether these results were statistically significant. Finally, one study (Kain et al., 2011) did not find
any significant differences between MFR and heat modalities on pain, disability, or ROM; yet, the
differences were observed in a much shorter duration among the MFR group compared to the group
that received heat modalities. These results further provide evidence, although limited by the level of
rigor as determined by the PEDro scale, that MFR is an effective treatment for increasing functional
outcomes and may be more effective than other treatments on certain functional outcomes.
MFR combined therapy compared to other combined therapies. Five Level I articles and
one Level II article examined MFR combined with another treatment method in comparison to a
different treatment method or methods (Chaudhary et al., 2003; Hou et al., 2002; Khuman et al., 2013;
Kumar & Jetly, 2016; Rodriguez-Fuentes et al., 2016; Trivedi et al., 2014). Statistically significant
improvements in pain, disability, strength, quality of life (QoL), and AROM were found using MFR
techniques in all six articles. In two of six studies, MFR groups combined with exercises or
conventional physiotherapy were accompanied by significantly more improvement than other
treatment groups on all outcome measures, when compared to cold pack plus exercise or conventional
physiotherapy alone (Chaudhary et al., 2003; Khuman et al., 2013). When compared to Active Release
Technique combined with ultrasound and exercise (Trivedi et al., 2014), greater significant
improvements in pain, functional disability, and grip strength were found among the MFR combined
with ultrasound and exercise treatment group for lateral epicondylitis.
Mixed results regarding intergroup differences were found in two of six studies. Hou et al.
(2002) found greater improvements in pain among the MFR combined group when compared to heat
pack, AROM, and ischemic compression, but not when ischemic compression was combined with
TENS. Rodriguez-Fuentes et al. (2016) showed no statistically significant group differences for pain
and disability when MFR and analgesic treatment were compared to manual therapy and analgesic
treatment, but did find greater statistically significant improvements with MFR analgesic therapy for
QoL and AROM. In one of the six studies, no statistically significant differences on pain and disability
outcomes were found between groups that combined ultrasound with either MFR or deep transverse
friction massage (Kumar & Jetly, 2016). These results suggest that while MFR combined therapy
resulted in statistically significant positive outcomes, in six of six articles there is limited evidence
supporting that MFR combined with other treatment is more effective than exercises alone and
inconclusive when compared to other manual therapy and modality combinations.

MFR in systematic reviews. Five Level I systematic reviews and one Level I meta-analysis
were examined for the effectiveness of MFR used alone as a treatment, as well as MFR used with
other conventional therapies or modalities (e.g., stretching, ultrasound, exercises, nerve glides, etc.).
The total number of articles reviewed within all six studies was 76 with 12 of those being identified
more than once through the systematic reviews. One systematic review (Parravicini & Bergna, 2017)
specifically reviewed in-vitro studies for insight into the physiological changes and effects of MFR use
in therapy. The Parravicini and Bergna (2017) article will be considered separately from this synthesis
based on the different approach and outcomes of their 24, non-repeated, identified articles.
The 52 reviewed articles (excluding articles from Parravicini & Bergna, 2017) included
similar outcomes such as increasing passive range of motion (PROM), function, strength, posture, and
QoL; and decreasing pain and disability. All 17 studies reviewed in Laimi et al. (2014) and Webb and
Rajendran (2016) reported increased function and PROM, and decreased pain following MFR. No
adverse effects were reported in these 17 articles. Additionally, 29 of the 35 articles from Ajimsha et
al. (2014), McKenney et al. (2013), and Piper et al. (2016) showed increased PROM, function,
strength, posture, QoL, and decreased pain and disability. However, one article reviewed in Ajimsha et
al. (2014) found MFR to be inferior to Proprioceptive Neuromuscular Facilitation (PNF). While 8 of
10 articles reviewed in McKenney et al. (2013) showed positive results, the remaining two indicated
no effect after MFR treatment. Similarly, while five of six articles reviewed in Piper et al. (2016)
showed positive results, one reported adverse effects of transient, mild soreness after the initial MFR
treatment which can be expected after putting soft tissue through a rigorous manual therapy session for
the first time.
Parravicini and Bergna (2017) reviewed 24 in-vitro studies and concluded that prophylactic
MFR stimulates fibroblast activity to regulate inflammation, reverses the negative effects of repetitive
motion strain, improves collagen synthesis and secretion for wound healing, and promotes large-scale
relaxation of connective tissue due to changes in fibroblast shape. Clinical assumptions were made for
application by the observed physiological changes. These assumptions include that MFR may prevent
injury for patients with risk factors for musculoskeletal disorders, limit stiffening of tissues, improve
PROM, and reduce pain. Overall, the five systematic reviews and one meta-analysis captured positive
and beneficial outcomes from the application of MFR.
Implications for Consumers
Based on the number of articles and level of rigor, there is currently moderate evidence to
suggest that MFR may lead to positive outcomes in the treatment of orthopedic and peripheral nerve
conditions. Only two articles within a systematic review showed no effect following MFR treatment
(McKenney et al., 2013), while only one article across all studies showed mild, transient soreness after
the initial MFR treatment (Piper et al., 2016). All other individual studies and systematic reviews
found no major negative or harmful results. Nine of 11 studies that compared MFR to other forms of
treatment found significantly better outcomes among the groups that received MFR. Although
moderate and promising evidence has been reported, there is currently limited research available
examining the long term implications of the use of MFR. Ultimately, consumers seeking manual
therapy as a method for improving functional outcomes should be informed that MFR treatment does
not likely cause any short-term adverse effects and has, up to this point, been shown to result in
positive outcomes.
Implications for Practitioners
While limited high quality evidence exists to support the use of MFR when treating upper
extremity and cervical orthopedic or peripheral nerve conditions, studies classified as having
moderate rigor on the PEDro scale found positive results in regards to pain, disability, range of
motion, and quality of life. MFR was found to have better outcomes when compared directly to
another form of treatment, but results were inconclusive when different treatments were combined.
Often in practice, therapists will use many forms of treatment with a client. One reason to incorporate
MFR into treatment would be that it is time efficient, typically only requiring a few minutes per area,
and would therefore not only prepare the client more quickly for the remaining treatment, but allow for
more billable units during the therapy session. For example, one study (Kain et al., 2011) that found
statistically significant positive outcomes didn’t find significant differences in PROM between MFR
and the application of heat, but MFR was administered for three minutes and the heat pack was applied
for 20 minutes.
Implications for Researchers
Further high quality Level I research is needed to determine the efficacy of MFR when used to
treat upper extremity orthopedic and peripheral nerve conditions, such as carpal tunnel syndrome and
lateral epicondylitis. This research would fill a gap regarding the limited number of studies currently
available that address the upper extremity, and that would be beneficial specifically for hand
therapists. Additionally, higher quality randomized controlled trials need to be conducted with the
inclusion of larger sample sizes and longer follow-up periods.
Bottom Line for Occupational Therapy Practice/ Recommendations for Better Practice
While moderate evidence exists to support the use of MFR in the upper extremity, the
available evidence does suggest that MFR is an effective treatment method for decreasing pain and
disability, and increasing PROM, strength, posture, QoL, and overall function. More research is
needed within the scope of occupational therapy to determine the effects of MFR, specifically research
related to the upper extremity. Currently, most research on MFR has been conducted by physical
therapists. It is encouraged that occupational therapists contribute to the research to validate the
effectiveness of MFR for the upper extremity.

References
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management of lateral epicondylitis in computer professionals. Archives of Physical Medicine
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Ajimsha, M., Al-Mudahka, N. R., & Al-Madzhar, J. (2014). Effectiveness of myofascial release:
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Castro-Martín, E., Ortiz-Comino, L., Gallart-Aragón, T., Esteban-Moreno, B., Arroyo-Morales, M., &
Galiano-Castillo, N. (2017). Myofascial induction effects on neck-shoulder pain in breast
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Chaudhary, E., Shah, N., Vyas, N., Khuman, R., Chavda, D., & Nambi, G. (2013). Comparative study
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Gandhi, V. M., Arun, B., & Kumar, R. P. (2016). Effectiveness of myofascial release therapy with
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Kain, J., Martorello, L., Swanson, E., & Sergo, S. (2011). Comparison of indirect tri-planar myofascial
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Khuman, P. R., Trivedi, P., Devi, S., Sathyavani, D., Nambi, G., & Shah, K. (2013). Myofascial
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Kumar, R., & Jetly, S. (2016). Comparison between myofascial release technique and cyriax manual
therapy in pain and disability in subjects with lateral epicondylitis. Indian Journal of
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McKenney, K., Elder, A. S., Elder, C., & Hutchins, A. (2013). Myofascial release as a treatment for
orthopaedic conditions: A systematic review. Journal of Athletic Training, 48, 522-527.
doi:10.4085/1062-6050-48.3.17
Namvar, H., olyaei, G., Moghadam, B. A., & Hosseinifar, M. (2016). Effect of myofascial release
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pressure pain threshold in patients with chronic nonspecific neck pain: Double blinded
randomized clinical trial. International Journal of Medical Research & Health Sciences, 5,
500-506.
Nisture, P., & Welling, A. (2014). Effect of gross myofascial release of upper limb and neck on pain
and function in subjects with mechanical neck pain with upper limb radiculopathy – A clinical
trial. International Journal of Dental and Medical Research, 1, 8-16.
Parravicini, G., & Bergna, A. (2017). Biological effects of direct and indirect manipulation of the
fascial system: Narrative review. Journal of Bodywork & Movement Therapies, 21, 435-445.
doi:10.1016/j.jbmt.2017.01.005
Picelli, A., Ledro, G., Turrina, A., Stecco, C., Santilli, V., & Smania, N. (2011). Effects of myofascial
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Piper, S., Shearer, H. M., Cote, P., Wong, J. J., Yu, H., Varatharajan, S., … Taylor-Vaisey, A. L.
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Involvement Plan
Introduction
The primary need of our research collaborators, Tomi Johnson and Domonique Herrin, was to
inform referring surgeons about the efficacy of myofascial release (MFR), how MFR may help their
clients, and thus provide the potential of increasing referral rates. Tomi and Domonique also expressed
that they would like to share this information with physical therapists practicing in the same clinic who
are skeptical of the benefits of manual therapies.
After some discussion, we decided that knowledge translation would occur through two methods.
First, our research team created an informational binder that contained our critically appraised topic
(CAT) table with summaries and copies of each article in the CAT for ease of access to the research.
Additionally, the binder included a table of contents and was organized using the themes from the original
CAT paper (MFR without Treatment Comparison, MFR Treatment Alone Compared to Other Treatment,
MFR Combined Therapy Compared to Other Combined Therapies, and MFR in Systematic Reviews).
Each included article had a cover sheet identifying the population, treatment comparisons, and key
findings.
Second, we disseminated information through an inservice for surgeons and physical therapists
where we shared the results of our research. This inservice was an informal twenty minute presentation
occurring during the therapists’ lunch break. Our collaborating practitioners requested that we create a
handout with an overview of our findings for this meeting. To best gauge how the information being
presented was received by attendees, we created both a pre- and post-inservice survey. These surveys
inquired about the respondents’ current level of knowledge of MFR, opinion of MFR, and likelihood to
use MFR.
Context
Organizational. The largest hurdle for knowledge translation was reaching the surgeons in a way
that was meaningful and applicable to them regarding the research behind MFR. Additionally, whose
MultiCare-owned clinic was acquired by Olympic Sports and Spine Rehabilitation, so they will be
undergoing a transition period within the next few months. This could change the organizational structure
and access to other MultiCare departments, along with new and differing rules and regulations for holding
meetings during working hours.
Departmental. Our research collaborators share clinic space with physical therapists. The
physical therapists in their department generally provide intervention through exercise and do not use
myofascial release, as they believe exercise is more efficacious than myofascial release.
Individual. Both occupational therapists are trained in and utilizing myofascial release in their
current practice, so implementation is already occurring. Our research has validated the continued use of
myofascial release in their practice.
Tasks/Products and Target Dates
Task/Product Deadline Date Steps w/Dates to Achieve Final Outcome
Create informational binder 04/06/18 Update CAT summaries - 02/20/18

Finalize binder sections & layout - 03/01/18
Purchase binder materials - 03/10/18
Print CAT summaries - 03/15/18
Print articles - 03/15/18
Organize binder - 03/20/18
Provide inservice 04/13/18 Schedule inservice date - 02/28/18

Create inservice handout - 03/20/18
Create pre/post inservice handout - 03/20/18
Divide talking points - 03/20/18
Outcomes of Activities and Evaluation
The long-term outcome of our involvement plan is to increase the number of referrals to
occupational therapy, though for the purpose of this project, we will be monitoring the knowledge and
opinions regarding MFR among inservice attendees. This will be accomplished by providing attendees a
brief survey prior to and following the inservice. These surveys will provide us with information
regarding the amount of change in the attendees’ knowledge and opinions of MFR and their likelihood of
referring for it or incorporating it into practice.

Description of Activities and Products Completed
Informational Binder
An informational binder was requested by our collaborating practitioners as a resource to
physicians and the other therapists in the Multicare clinic. Through discussion with our collaborating
practitioners, we identified the binder contents to contain the following: cover page, table of contents,
executive summary, summaries of every article, copies of each article, and our final CAT table.
The first step to compiling the informational binder was completing final edits to the CAT
summaries. These edits included suggestions by our faculty chair and course mentor. After edits were
incorporated into the CAT summaries, we created a summary of each of the 23 articles included in our
CAT table. These summaries highlighted the research participants, inclusion criteria, outcomes measured,
and results. Summaries were reviewed by all group members for accuracy before being incorporated into
the binder. Once summaries were approved, a clean copy of article was printed. Each article and summary
were filed within the binder in alphabetical order by author within the sections corresponding to the
identified theme.
When the research binder was presented to our collaborating practitioners at the time of the
inservice, they requested the addition of electronic copies of all articles included in the research project.
Articles were electronically compressed in a folder, which was then sent to Tomi Johnson via email.
Inservice
An inservice presentation was requested by our collaborating practitioners to share our findings
on the efficacy of myofascial release with other therapists working in their clinic and potentially with
referring physicians. While this inservice was requested by the collaborating practitioners, they were
uncertain if it would be feasible due to changes in clinic management occurring during the timeline for
the knowledge translation portion of the project. While waiting for a date to be scheduled for the
presentation, research findings were divided between student researchers and talking points were created,
as well as an informational handout, pre-survey and post-survey.

The inservice was scheduled to be held onsite in the collaborating practitioners’ clinic on March
30th at 1:20pm. Physical therapists, our collaborating practitioners, and physicians were originally invited
to attend. However, due to conflicting schedules, only the clinic’s physical therapists and our
collaborating practitioners attended the inservice. Prior to beginning the inservice, a pre-survey was
administered and collected. Additionally, a brief handout was provided highlighting the main points of
our presentation. We provided a 15-minute presentation that included information regarding our research
methods, results, implications and limitations. Before administering a post-survey, we allowed time for
questions and answers.
Tasks/Products Completion Dates

Task/Produ Original Actual Date Steps w/Dates to Actual Completion Date and
ct Deadline Completed Achieve Final Comments
Date Outcome
Create 04/06/18 03/29/18 Update CAT Update CAT summaries -

informationa summaries - 02/20/18. Feedback from our
l binder 02/20/18 course mentor and faculty chair
was incorporated into the CAT
summaries.
Finalize binder Finalize binder sections &

sections & layout - layout - 03/19/18. The writing
03/01/18 of summaries for articles were
divided between group
members and completed by the
above date.
Purchase binder Purchase binder materials -

materials - 03/10/18 03/22/18. Binder materials
were donated from one group
member.
Print CAT Print CAT summaries -

summaries - 03/26/18. All CAT summaries
03/15/18 were printed by one group
member.
Print articles - Print articles - 03/26/18.

03/15/18 Articles were divided between
three group members for
printing.
Organize binder - Organize binder - 03/28/18. All

03/20/18 components of the binder were

combined just before the
Provide 04/13/18 03/29/18 Schedule inservice Schedule inservice date -

inservice date - 02/28/18 03/13/18. Due to changes
occurring in clinicians’ clinic,
we were not able to schedule an
inservice date until this time.
Create inservice Create inservice handout -

handout - 03/20/18 03/26/18. The inservice
handout was started prior to this
date, but not finalized until just
prior to the inservice.
Create pre/post Create pre/post inservice

inservice handout - handout - 03/26/18. Drafts of
03/20/18 the inservice pre/post survey
were begun but not finalized
until just prior to the inservice
date.
Divide talking points Divide talking points -

- 03/20/18 03/20/18. Talking points were
divided by area of expertise and
familiarity within the research.
Outcomes and Effectiveness
A simple pre- and post-survey was administered during the inservice and responses were
designed to be answered on a scale of 1-10. The pre-survey consisted of four questions including:
1) What is your current level of knowledge regarding current research investigating the efficacy
of using myofascial release to treat musculoskeletal disorders?
2) Based on your current level of knowledge, how likely would you be to recommend myofascial
release to a patient with a musculoskeletal disorder to decrease pain?
release to a patient with a musculoskeletal disorder to increase range of motion?
4) How much do you agree with the following statement: Therapeutic exercise is more effective
than intervention using myofascial release for treating conditions related to a musculoskeletal disorder.
The post-survey included the same four questions as the pre-survey, but included the following
final question: After learning about research regarding myofascial release are you more or less likely to
use myofascial release in practice?
While we believe that the informational binder will be an effective resource for increasing
knowledge and comprehension of the available evidence on the efficacy of myofascial release, it is
difficult to evaluate the long-term effectiveness of the resource binder. The binder will be available to our
collaborating practitioners and the other therapists in the clinic, but utilization is up to their discretion.
This resource was delivered to our collaborating practitioners during the inservice presentation. At this
time, clinicians expressed appreciation for the resource and interest in referring to articles regarding
evidence regarding myofascial release and exercise therapies. We believe that the inclusion of electronic
articles will increase the utilization and effectiveness of the binder as a resource as this will increase
access and transferability of articles between therapist and other interested parties.
Due to the limited number of inservice attendees, it is difficult to confidently ascertain the
effectiveness of our presentation, but the use of a simple pre- and post-survey allowed us to assess the
immediate effectiveness of our inservice presentation amongst a small audience. Analysis of responses to
pre- and post-inservice survey questions indicate a positive change in views following the presentation.
Following the presentation, survey results indicated there was a 62% average increase in knowledge
regarding current research investigating the efficacy of myofascial release. There was an average 20%
increase in attendees’ likelihood of using myofascial release to treat pain and an average 15% increase in
likelihood to use myofascial release to increase range of motion. One attendee responded, “I want to take
a class more now” when asked if they were more or less likely to use myofascial release in practice after
participating in the inservice presentation. Similarly, when asked the same question, the mean response on
the post-survey was a 7.8 (more likely) on a scale of 1-10. When asked, “How much do you agree that
therapeutic exercise is more effective than intervention using myofascial release for treating conditions
related to a musculoskeletal disorder?” attendees responded similarly in both the pre- and post-survey.
When verbally asked a follow-up to this question, attendees responded that it was difficult for them to
answer because treatment decisions are guided by multiple factors.
After reflecting on the methods utilized to examine the effectiveness of our binder and inservice
presentation, we believe that questions could have been written more clearly to increase our ability to
make definitive conclusions regarding the knowledge translation process. To increase our understanding
of attendees’ viewpoints prior to and following the inservice presentation, we could have included
questions regarding their level of practice experience and level of experience using myofascial release,
while also including short answer questions to receive qualitative information regarding attendees’
viewpoints on the subject matter. To better evaluate the effectiveness of our resource binder, a follow-up
email could have been sent to our collaborating practitioners to appraise whether this resource met their
needs.
Evaluation of Overall Process and Project
In September 2017, we were pleased to meet our two collaborating practitioners in their
Covington outpatient clinic. During our first meeting, we were intrigued to learn of their interest for
myofascial release, and whether the research supported the positive results that they were observing in
their clinic. MFR being a new treatment topic to all three student researchers, we quickly learned of the
nuance in skill required to administer it, and some of the controversies and opinions around whether it
truly provided the benefits that practitioners claimed. From their ideas, we were able to develop a
question about the efficacy of myofascial release and its credibility when compared to other forms of
therapy. The process naturally unfolded and allowed us to move forward to the next stage of our project.
After the research question was generated, our database searches began. This, combined with the
construction of the CAT table, was a lengthy and tedious process that required strict organization,
attention to detail, and ongoing communication within the group. Fortunately, we developed a systematic
way to organize our searches, maintain records of articles, and develop a consistent writing style that
helped us manage the process efficiently over two semesters. The consensus of all three researchers was
that our similar working styles and desire for high-quality work provided a foundation for success with no
major setbacks.
While no major setbacks occurred during the initial search process or construction of the CAT
table, our initial project did evolve through the input of our faculty chair, Sheryl Zylstra DOT, MS,
OTR/L, and our course mentor, George Tomlin, PhD, OTR/L, FAOTA. With their guidance we refined
our inclusion and exclusion criteria, removing articles published prior to the year 2000, articles discussing
self-myofascial release or instrument assisted myofascial release, and articles pertaining to the lower
extremity. These refinements increased the manageability of the project, reducing the number of initial
relative articles from 83 to 21.
The process of working with our collaborating practitioners through presenting our preliminary
findings to identifying the most appropriate and useful method of knowledge translation was a
streamlined and rewarding process. At each stage the ideas and information presented to our collaborating
practitioners was well received. As graduates of the University of Puget Sound occupational therapy
program, our collaborating practitioners appeared aware of the program demands and thus created a
feasible, initial question and knowledge translation piece that would fulfill their needs without creating
extraneous demands.
Reflecting on the year long research process, we believe there has been a valuable impact on our
professional development. Conducting research has instilled in us an understanding of the benefits and
importance of evidence-based practice. Furthermore, through the research process we have learned how
to search for, evaluate, and synthesize research findings, while also learning time management,
communication, and intraprofessional collaboration skills. These skills will contribute to our success as
future occupational therapy practitioners.

Recommendations for the Future
Due to the limited number of articles specifically involving the upper extremity, further projects
on this same topic may be difficult to implement. However, additional research could be conducted to
investigate the use of MFR on the lower extremity as well. We hypothesized that because the fascial
system is consistent throughout the body, results found for MFR performed on the lower extremity should
be generalizable to other parts of the body as well (e.g., the upper extremity and cervical spine).
Additionally, we excluded articles that examined self-myofascial techniques and instrument-
assisted myofascial release in order to specifically investigate therapist-administered techniques. The
number of articles that incorporated these techniques indicates a fair increase in popularity and use of
these types of MFR. An additional outlet to explore could be comparing the use of instrument-assisted
MFR to therapist-administered manual MFR.

Appendix A
Pre/Post Inservice Survey
Please answer the following questions on a scale of 1-10:
1) What is your current level of knowledge regarding current research investigating the efficacy of
using myofascial release to treat musculoskeletal disorders?
(1 - no knowledge, 10 - expert knowledge)
1 2 3 4 5 6 7 8 9 10
release to a patient with a musculoskeletal disorder to decrease pain?
(1 - never recommend, 10 - always recommend)
1 2 3 4 5 6 7 8 9 10
release to a patient with a musculoskeletal disorder to increase range of motion? (1 - never
recommend, 10 - always recommend)
1 2 3 4 5 6 7 8 9 10
4) How much do you agree with the following statement: Therapeutic exercise is more effective
than intervention using myofascial release for treating conditions related to a musculoskeletal
disorder. (1 - completely disagree, 10 - completely agree)
1 2 3 4 5 6 7 8 9 10
Post question
1. After learning about research regarding myofascial release are you more or less likely to use
myofascial release in practice? (1 - not at all likely, 10 - extremely likely)
1 2 3 4 5 6 7 8 9 10
Appendix B
Inservice Handout
Permissions for Scholarly Use
To properly administer the Research Repository and preserve the contents for future use, the University
of Puget Sound requires certain permissions from the author(s) or copyright owner. By accepting this
license, I still retain copyright to my work. I do not give up the right to submit the work to publishers or
other repositories. By accepting this license, I grant to the University of Puget Sound the non-exclusive
right to reproduce, translate (as defined below), and/or distribute my submission (including the abstract)
worldwide, in any format or medium for non-commercial, academic purposes only. The University of
Puget Sound will clearly identify my name(s) as the author(s) or owner(s) of the submission, including
a statement of my copyright, and will not make any alteration, other than as allowed by this license, to
my submission. I agree that the University of Puget Sound may, without changing the content, translate
the submission to any medium or format and keep more than one copy for the purposes of security,
back up and preservation. I also agree that authorized readers of my work have the right to use it for
non-commercial, academic purposes as defined by the "fair use" doctrine of U.S. copyright law, so long
as all attributions and copyright statements are retained. If the submission contains material for which I
do not hold copyright and that exceeds fair use, I represent that I have obtained the unrestricted
permission of the copyright owner to grant the University of Puget Sound the rights required by this
license, and that such third-party owned material is clearly identified and acknowledged within the text
or content of the submission. I further understand that, if I submit my project for publication and the
publisher requires the transfer of copyright privileges, the University of Puget Sound will relinquish
copyright, and remove the project from its website if required by the publisher.
Name: ____Michelle Chait__________________________ Date: ______________________
____________________________________________________________________________
Signature of MSOT Student
Name: ____Erin Eaton_____________________________ Date: ______________________
____________________________________________________________________________
Name: ___Tiffany Farley___________________________ Date: ______________________
____________________________________________________________________________

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University of Puget Sound

School of Occupational Master's Capstone Occupational Therapy, School of

Efficacy of Myofascial Release

Erin Eaton OTS

Tiffany Farley OTS

Follow this and additional works at: https://soundideas.pugetsound.edu/ot_capstone

Part of the Occupational Therapy Commons

Efficacy of Myofascial Release

This evidence project, submitted by

Michelle Chait, OTS

has been approved and accepted

Keywords: Myofascial Release, Upper Extremity, Orthopedic Conditions

of myofascial release related to the upper extremity.

increasingly popular methods of implementation within the literature.

functional performance, compared to therapeutic exercises including no manual techniques? After

adverse effects of mild, transient soreness after initial MFR treatment.

CRITICALLY APPRAISED TOPIC PAPER

Collaborating Occupational Therapy Practitioner:

Date Review Completed:

Databases and Sites Searched

Quality Control/Review Process:

Date Range: 2017-2018

“myofascial release” AND Nerve 10/31/17 PubMed 12 11 (1 repeat) 1

“myofascial release” 11/1/17 PubMed 38 37 (2 1

“myofascial release” 01/20/18 PubMed 42 42 (2 0

“myofascial release” 01/20/18 CINAHL 43 43 (2 0

“myofascial release” 01/20/18 PEDro 8 8 (2 repeats) 0

“myofascial release” 01/20/18 SPORT 38 38 (2 0

“myofascial release” 01/20/18 OTSeeker 0 0 0

“myofascial release” 01/20/18 OT Search 0 0 0

Date Range: 2009-2016

“musculoskeletal manipulations” 9/21/17 & PubMed 51 44 (4 7

myofascial release AND 10/5/17 PEDro 2 1 (1 repeat) 1

myofascial release AND 10/5/17 PEDro 5 1 4

myofascial release AND 10/5/17 PEDro 0 0 0

myofascial release AND 10/5/17 PEDro 0 0 0

myofascial release AND 10/5/17 PEDro 0 0 0

myofascial release AND 10/5/17 PEDro 0 0 0

myofascial soft tissue 10/5/17 PEDro 0 0 0

Found on ScienceDirect when 10/5/17 NA 99 86 (1 repeat) 13

myofascial release AND 10/5/17 PubMed 13 10 (5 3

myofascial release AND 10/6/17 PubMed 2 2 (2 repeats) 0

myofascial release AND upper 10/6/17 PubMed 3 3 (1 repeat) 0

myofascial release AND 10/6/17 CINAHL 7 5 (2 repeats) 2

myofascial release AND 10/6/17 CINAHL 0 0 0

myofascial release AND 10/6/17 CINAHL 2 2 (1 repeat) 0

myofascial soft tissue 10/6/17 CINAHL 0 0 0

myofascial release AND 10/10/17 CINAHL 0 0 0

myofascial release AND 10/10/17 CINAHL 1 1 0

myofascial release AND 10/10/17 SPORT 3 3 (1 repeat) 0

myofascial release AND 10/10/17 SPORT 0 0 0

myofascial release AND 10/10/17 SPORT 0 0 0

myofascial release AND 10/10/17 SPORT 2 2 0

myofascial release AND 10/10/17 SPORT 0 0 0

myofascial release 10/10/17 Cochrane 1 1 0

myofascial soft tissue 10/10/17 Cochrane 2 2 0

myofascial release AND 10/10/17 Cochrane 1 1 (1 repeat) 0

myofascial release AND 10/10/17 Cochrane 0 0 0

myofascial release AND 10/10/17 OT Seeker 0 0 0

“myofascial release” 10/10/17 OT Seeker 1 1 (1 repeat) 0