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Myofascial Release: An Evolving And Simple Definition

December 3, 2018/1 Comment/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Myofascial Release/by Walt Fritz

Urged on my peers on both sides of the argument, here is an initial version of what I hope becomes a more permanent way to describe the work I use and teach. Comments, suggestions, and criticisms are always welcome (post below). Edits will be made to this post as comments come forward, both here as well as from social media.

Myofascial release (MFR) is one style of manual therapy that uses slow, still, prolonged stretching through clothing or directly on the skin to facilitate change in the patient. Whether having its primary effects on fascia, as historically believed, or on skin, muscle, other tissues, or the nervous system in general, it is realistically a more complex direct and indirect interrelationship of overlapping systems. The goal of MFR is most often to reduce the feeling of tightness and to lessen pain, allowing for more freedom of movement and improvement in functional abilities. While other forms of MFR vary, The Walt Fritz, PT form of MFR relies on direct patient feedback to drive evaluation and treatment, assuring that interventions are patient-specific. (edit 5/13/18)

Myofascial release (MFR) is a style of manual therapy most typically associated with its historical roots, which relied on perceptions that one could label pain and various movement disorders a result of tightness/restriction within the fascia/connective tissue. Most therapists using MFR were taught that they were able to selectively and singularly impact these fascial restrictions to the exclusion of other tissues, with the goal of reducing pain and restoring more normal movement patterns, with any mention of the nervous system added as afterthoughts. While MFR has been a popular and effective form of manual therapy for decades, the claims made by its proponents have yet to be proven, though these issues exist for nearly all forms and brands of manual therapy and massage.

Most brands of MFR, manual therapy, and massage claim that pain/movement problems are due to one specific tissue and make claims to be able to specifically impact that particular problem, all while having remarkably similar styles of engagement as the next type of therapy.

While it may be possible to be able to target one tissue under the skin for intervention, more plausible explanations come from neuroscience-based explanations, as well as the potential impact of contextual factors. These models look at more central mechanisms to explain the local effects of manual therapy, including MFR. Using such principles as neurodynamic technique, where nerve tension is reduced, allowing more freedom of movement and less pain, as well as skin/superficially embedded receptors that can signal the effects of MFR at the local level, with changes in pain/movement problems being an outcome of brain output via the central nervous system. These ideas work from the knowledge that the nervous system is in ultimate control, though in partnership with, the remainder of the soft and bony structures in the body. Though neuroscience-based models also lack full proof, they may be “less wrong” than many of the various other models.

Briefly, MFR has a typical style of engagement that uses slow, still, prolonged stretching to facilitate change in the patient. Whether having its primary effects on skin, fascia, muscle, nerves, or other tissues, its goal is to reduce the feeling of tightness and to lessen pain, allowing for more freedom of movement. I call my work MFR in reference to a very recognizable style of hands-on engagement typically associated with myofascial release, rather than due to thoughts that it is fascia that I am selectively engaging.

With such uncertainty, where does that leave the therapist and consumer? Therapists still treat in the manner they were taught, with hands-on interventions typically very helpful. The best choice may be to keep explanations simple. While it may be the fascia, muscle, joints, knots, trigger points, or a host of other tissues and pathologies are responsible for our problems, we can only work through the skin. Everything else is a stretch (pun intended!).

Pathologizing: Our Words Matter

April 9, 2018/1 Comment/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Myofascial Release/by Walt Fritz

As a physical therapist trained in the 1980’s, biomechanical explanations for pain and movement disorders were the norm.

As I drifted into a myofascial release manual therapy in the early 1990’s, the biomechanical model was reinforced and made more narrow through the beliefs that pain and movement dysfunction stem from issues of fascial tightness/restriction. All had evidence to support their views, as well as well-presented logical assumptions.

Myofascial suffered from testimonial-type of evidence, which seemed very compelling to a casual scientific observer (me), who was unwilling to question the sources of presented information.

Biomechanical still are well represented throughout the manual therapies, as evident by the daily squabbles regarding the importance, or lack of, with such issues as posture, weakness, and asymmetry when it comes to both pain as well as movement disorders.

This post is not intended to address these issues, but to briefly discuss the language we use when conversing with our patients/clients.

The Power Of Our Words

Patients pay us to help them.

This help is most often accompanied by the thorough evaluation, after which we proclaim our findings on both what is wrong with them and what should be done to rectify the situation.

We may call this our assessment or diagnosis, depending on the scope of practice allowances and limitations of your profession. Patients expect it and we feel it necessary to give them what they want and deserve, but is it always in their best interest, especially when there is a lack of consensus on the validity of our assessment’s claims?

Biomechanical factors and judgement, such as poor posture being the cause of pain, are popular and logical assumptions which many of our patients believe and you may believe it to be true as well, but is it always true?

While at the computer, I leave my Facebook notifications turned on, which is probably one reason I am so easily distracted. As I was writing this post a notification came in that I will sanitize and post here:

“I’m new to this group, but curious as to many issues a (named surgical procedure) could help with. My biggest issues are forward head posture – my (type of) therapist once told me it was the worst she had ever seen – neck/shoulder/upper back tension that my chiropractor gave up on treating because he didn’t understand why he couldn’t fix it, jaw clenching, anxiety, etc). Anyway, does anyone have a recommendation for a practitioner in (certain city)?”

The writer of this post was speaking from genuine self-concern and must have found some solace in her therapist’s statement about the severity of her forward head, but what does she now do with that?

If she is the worst case her health professional has ever seen, it would seem to me that makes it less likely that she can be helped. There is information easily available that casts doubt on the degree of forward head posture and neck pain, but that therapist has planted a seed in the patient’s brain that she is one of the worst out there, at least from her therapist’s perspective.

Do we really need to say things like this?

Below are some studies that were recently posted to a thread on one of the many groups there, all speaking to the effect of the power of our words. If you’ve never given this much thought, please read through some of the abstracts and papers.

Our words have power, and often the message conveyed negatively impacts outcomes.

Easy to Harm, Hard to Heal: Patient Views About the Back.

CONCLUSION: Negative assumptions about the back made by those with LBP may affect information processing during an episode of pain. This may result in an attentional bias toward information indicating that the spine is vulnerable, an injury is serious, or the outcome will be poor. Approaching consultations with this understanding may assist clinicians to have a positive influence on beliefs.

The enduring impact of what clinicians say to people with low back pain. (Full-text link)

CONCLUSIONS: Health care professionals have a considerable and enduring influence upon the attitudes and beliefs of people with low back pain. It is important that this opportunity is used to positively influence attitudes and beliefs.

Importance of psychological factors for the recovery from a first episode of acute non-specific neck pain – a longitudinal study. (Full-text link)

CONCLUSIONS: Psychological factors emerged from this study as relevant in the early phase of acute neck pain. Particularly persistent anxiety and depression at baseline might be risk factors for a transition to chronic pain that should be addressed in the early management of neck pain patients.

‘Talking a different language’: a qualitative study of chronic low back pain patients’ interpretation of the language used by student osteopaths.

CONCLUSIONS: The language used by student osteopaths’ influences patient beliefs about LBP in a variety of ways. The current study furthers understanding of how language contributes to these beliefs, identifying ways through which communication can contribute to improved healthcare through enhancing patient engagement.

Words That Harm, Words That Heal. (Full-text link)

Both positive and negative beliefs are important in patients with spine pain: findings from the oioc registry.

CONCLUSIONS: Our study demonstrates that both negative and positive beliefs are associated with perceptions of disability, however, in this study only positive beliefs were associated with treatment outcome.

Do you have any studies to share regarding this topic? I’d love to have a look!

Treatment Tips: An Easy Way To Achieve Posterior Pelvic Tilt

December 18, 2017/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Walt Fritz

As I teach, there are certain concepts/techniques which are self-explanatory, while others have nuances which make them harder to convey, both in the classroom as well as once the therapist is back in their clinic. In the past, I’ve sent out Treatment Tips, but the printed word and still photos only go so far. Recently I had another photo shoot to provide updated content for the new Upper Body and Lower Body Foundations in Myofascial Release Seminars as well as the renamed Myofascial Release for Neck, Voice, and Swallowing Disorders Seminar and we shot a dozen or so short sequence videos. Here is the first one and excuse the first-time-editor-mistakes.

Though not a mandatory aspect of lower back/abdominal/pelvis manual therapy/myofascial release, increasing posterior pelvic rotation and applying light lumbosacral traction often changes the dynamics while treating.

My preference, and what I teach, is manual sacral traction applied in supine with the opposite hand on the lower abdominal region.

I beg and plead with therapists to try this method, but I know that placing a hand under their sacral area by placing the arm between the legs is too much of a boundary issue. I get it. So over the past few years, I devised a “cheater’s” method of accomplishing sacral traction/posterior pelvic tilting without the need to place a hand under the sacrum. Watch the video to see what I mean:

Pretty easy, right? If you add a piece of Dycem under the sacrum beforehand, you have an even better-felt sense for the patient. You can find more treatment tips over at Foundations in Myofascial Release Seminars.

Myofasical Release And Massage Therapists

December 8, 2015/22 Comments/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Richard Lebert

Anyone who has spent long hours engaged in a heated discussion over Facebook knows the frustration that comes along with it. These discussions have forced me to question many of my long held beliefs about the fascial system and myofascial release. There is evidence that myofascial release is an effective technique for a number of injuries.

However, when it comes to anything fascia related the professional community is divided with fundamentalist views on both sides.

To some myofascial release is a panacea and others regard fascia as ‘dead tissue’ with no clinical significance.

With some of the research and reading I’ve done, I have wanted to dispel myths and simplify research.

Fascial Anatomy For Massage Therapists

Andreas Vesalius (1514-1564) is often considered to be the first anatomist and is best remembered for publishing the famous anatomy text, De humani corporis fabrica in 1543.

If you look at these early illustrations they present the fascia and muscles as one continuous soft tissue structure.

Fast forward to the 20th century (texts we study) most opt to omit fascial structures in order to depict muscles in a cleaner fashion. Recently there has be a resurgence of this ‘forgotten tissue’ and anatomy textbooks have made an effort to include fascial structures in their depictions and descriptions.

An example of this is The Functional Atlas of the Human Fascial System by Carla Stecco, an Orthopedic surgeon and a professor of human anatomy at the University of Padua in Italy, the same University that once employed Andreas Vesalius in the early 1500’s.

Another example is Anatomy Trains by Thomas Myers, in this book Myers presents conceptual ‘myofascial meridians’, a recent systematic review confirmed a number of these continuous soft tissue structures.

What is Fascia?

To better understand the possible actions of myofascial release, there is a need to clarify the definition of fascia and how it interacts with various other structures: muscles, nerves, vessels.

Simply speaking all fascial tissue is connective tissue, but all connective tissue is not fascial tissue.

The primary job of connective tissue is to support, connect or separate different types of tissues and organs in the body. For the purpose of brevity, connective tissue proper can be divided into dense connective tissue and loose connective tissue. Simply put fascia is a combination of dense and loose layers of connective tissue. As, for the definition of fascia, there are many different ways that fascia is defined, see What is ‘fascia’ A review of different nomenclatures. In this article the definitions of fascia that I use is “Fascia is fibrous collagenous tissue which are part of a body wide tensional force transmission system”

What Are Massage Therapists Doing With Myofascial Release?

The thing is, myofascial release is not well defined, it is a broad term covering a wide variety of techniques.

This includes osteopathic techniques, rolfing, structural integration, massage therapy, cupping and IASTM. My interpretation of myofascial release may differ from others, but in this post I am referring to myofascial release as a manual technique that tensions soft tissue structures and is accompanied by active or passive movement, to promote relative tissue motion.

I have divided the response to myofascial release into three categories, in reality the response likely represents a response of multiple overlapping systems:

Contextual Responses to Myofascial Release
- This is likely to play a role in any therapeutic intervention, the way we present ourselves and present our techniques has influence on the treatment. The magnitude of a response may be influenced by mood, expectation, and conditioning.
Neurological Responses to Myofascial Release
- Fascia is highly innervated by mechanoreceptors, this was document by Robert Schleip in 2003. His article Fascial plasticity – a new neurobiological explanation Part 1– Part 2, this is an interesting and very readable two-part article laying out a possible neurological explanation for the beneficial effects of myofascial release.
Mechanical Responses to Myofascial Release
- The literature of Robert Schleip, Carla Stecco, Antonio Stecco and Thomas Findley support the idea that along with the neurological response and contextual response massage therapy has a mechanical effect on the fascial system. A summary of the proposed mechanisms includes but is not limited to

Any type of massage therapy is actively engaging the nervous system by stimulating mechanoreceptors at the level of the skin, as well as at deeper level fascial layers. Deep slow myofascial release techniques stimulate sensory ending known as the ruffini endings. Stimulating these slow adapting sensory receptors has the ability to alter the motor output and the experience of pain.

“Fascia and the autonomic nervous system appear to be intimately connected. A change in attitude in myofascial practitioners from a mechanical perspective toward an inclusion of the self-regulatory dynamics of the nervous system is suggested.”

-Fascial plasticity – a new neurobiological explanation: Robert Schleip

Are Massage Therapists Breaking Adhesions?

With such a lengthy post on myofascial release I would be remiss if I did not address the notion of breaking down adhesion. “An adhesion is an attachment of tissue at unusual non-anatomic sites which can be, vascular or avascular, innervated or not innervated.”

There is little to no research that I am aware of that would indicate that massage therapy can manually break down mature adhesions. There is however literature to support the idea that massage therapy may be able to break down immature postoperative adhesions.

Research by Geoffrey Bove and Susan Chapelle has demonstrated that manual therapy has the ability to break down immature adhesions. A recent case study demonstrated the effect of manual therapy on immature postoperative adhesions. Susan Chapelle has posted a well put together summary of the latest evidence of massage therapy and the effect on scars and adhesions Susan Chapelle- Understanding and Approach to Treatment of Scars and Adhesions.

What is the Clinical Relevance Of The Fascial System In Massage Therapy?

The “fascial system” serves to provide a conceptual model by which to explain the function of the global fascial net during movement, including the interconnections of fascial tissues with joint capsules, nerves and intramuscular connective tissues.

One of the proposed dysfunctions is an alteration of loose connective tissue that may adversely affect the sliding motion of fascial layers, this may be due to age, trauma or inflammation. This alteration of loose connective tissue is described as a densification In The Functional Atlas of the Human Fascial System.

Is a fascial densification the same thing as fibrosis?

Stecco makes a distinction between a pathological fibrosis and densification:

Densification refers to an alteration of the loose connective tissue (adipose cells, glycosaminoglycans and hyaluronic acid) Densification can involve an alteration in the quantity or quality of the components of loose connective tissue and an alteration in fascial viscosity.

“Densification may affect the sliding and gliding of tissue. The different layers of the body contain viscous loose connective tissues that allow a gliding, sliding function, protecting sensitive neural structures, as well as facilitating pain-free, efficient movement and force transmission. Gliding function may be lost because of trauma, inflammation or aging, resulting in fibrosis, thickening, densification.” -Pavan et al 2014

Fibrosis is defined as an alteration of dense connective tissue, specifically a rearrangement of the composition and structure of the dense connective tissue.

Nerve Entrapment

Many cases of peripheral nerve entrapment occurs following a traumatic injury, this is often the case with the sciatic nerve in proximal hamstring syndrome. It could be argued that this thickening and entrapment of peripheral nerves is a development process, could manual therapy play a role in slowing or reversing this progression?

Conclusion
Over the last couple of months I have spent a lot of time reading and reviewing fascial research, this has changed the way I that I communicate with therapists and patients. Myofascial release is an effective treatment technique, the catch is that it may not work in the way some were taught. Over time the supportive theories behind techniques evolve or change completely, myofascial release is an example of this. Is the name myofascial release better used as an analogous term to describe a palpable change in tissue that is likely due to many overlapping responses? Namely:

Contextual Responses
Neurological Responses
Mechanical Responses

These combined responses results in an increased pliability of soft tissue structures that often translates clinically into improved proprioception, increased range of motion and decreased experience of pain.

I am no longer frustrated when I get in heated discussions on Facebook, if someone can present a convincing argument I am willing to change some of my long standing views. Something I am still frustrated with is that there is a lack of resources available for massage therapists, hopefully this will change over time.