“My work is called Myofascial Release due to the style of engagement that most resembles traditional gentle, sustained myofascial release treatment. While a popular belief, I no longer believe that I am able to singularly and selectively target fascia (connective tissue) beneath the skin to the exclusion of all other tissues, as many in the myofascial release field believe. Having a broader, more scientifically plausible explanation allows the consideration of many more factors to influence our interventions.” Walt Fritz, PT

That has been my “disclaimer” for a while now, though it is frequently modified and updated.

Since 1992 I have been integrating myofascial release (MFR) into my treatment and have found it exceedingly effective in dealing with issues of pain and a very wide range of movement disorders. Success tends to reinforce the thought that we know what we are doing, as well as the stories about what we are impacting that were taught as a part of the training in MFR, which may be one of the biggest mistakes a therapist can make.

Even though this last sentence may seem absurd, my ability to help you does not mean that I knew what was wrong with you or what, if any, tissues were impacted/changed to cause your distress. The more that I’ve learned, the more I realize how little I know.

Myofascial release is not unlike most forms of manual therapy and massage, in that each modality claims that dysfunction is caused by problems within its target tissue, whether fascia, muscle, joints, viscera, or dozens of other anatomical structures or pathologies (real or metaphoric), and that practitioners of that modality are able to singularly and selectively target those problems to relieve or eliminate the issue.

Positive outcomes are used as proof of claims, though little credible evidence has been published to validate the claims, both in terms of dysfunction residing only in that tissue or that that tissue alone was impacted with the therapy.

The average consumer is seldom exposed to these truths, as once they get involved with a health professional or therapist who is either recommending or specializing in a particular modality or belief, the compelling narrative often takes over. The therapist, experienced as they are, often does provide significant relief from whatever the patient was seeking care for, providing further apparent validation to the stories told. Many patients never make it to a point where they start asking questions about the science and evidence behind the stories, as they were simply seeking relief. They then tell their friends or doctor about this therapist and how that therapist found the problem within the (fill in the blank with whatever tissue or pathology the therapist believed).

MFR is no different from others in that therapists claim to be able to identify problems based on patterns that resulted from so-called fascia restrictions within the body and to be able to selectively reduce or eliminate the restrictions.

Evidence tends to be outcome-based rather than based on actual scientific research.

While outcomes do matter, it does little to validate the beliefs of the therapist. MFR has dozens of published papers to show that is an effective modality in treatment, but nearly all of the papers use the near-century-old narrative to validate its effect. Open up a paper that speaks to MFR as being an effective modality and read the introduction. It may make sense to you, as that is how most of us are taught. But does the so-called science hold up to the scrutiny of outside critique?

Skilled manual therapy can provide tremendous relief of pain and improve the ability to move, sleep, breathe, swallow, play, dance, and much more. But why does every modality carry such different names and explanations?

If one had the ability to observe dozens of sessions with dozens of health practitioners using as many different forms of manual therapy/massage but used earplugs to block out the sound during these sessions, you might be struck by the similarity in the overall type of engagement throughout all of these practitioners. The earplugs would prevent you from hearing the stories told by the therapist, allowing you to be a simple visual observer of how a session progresses; seeing how the therapist’s method of interaction unfolds. While some sessions are done on dry skin or over clothing and others use a lubricant, such as massage lotion, and some methods move across the skin in a more traditional massage/like fashion while others stay stationary, there is a remarkable quality of similarity throughout all of these interactions.

Still, others may use what appear to be light pressures while others probe or push deeper into the body. If you were not wearing the earplugs you’d be witness to stories of how light pressure accomplishes outcomes and effects that deeper pressures cannot, and vice versa, or that certain kinds of evaluation/treatment pressures are able to selectively impact certain tissues/pathologies. You would also hear stories of how postural or asymmetry is a major cause of problems, while other therapists/modalities never mention these topics. But without sound, the visuals may be a bit confusing as most manual therapy is not that different from the next.

So what gives? If all of those therapists are using similar actions, can the widely varied science-sounding stories be true? Might there be simpler explanations that apply to all forms of manual therapy/massage?

Occam’s razor is a principle used in the scientific method that states, “(W)hen presented with competing hypothetical answers to a problem, one should select the one that makes the fewest assumptions.” (1)

In essence, the simplest explanation is typically the best one.

All of the wildly different explanations of MFR, deep tissue work, craniosacral therapy, Swedish Massage, Rolfing, and the dozens of other named modalities may be true, but are there simpler explanations that apply to all of them, instead of each one having its own science, known only to skilled practitioners of that form of therapy?

Explaining pain/problems based on muscular anatomy and pathology, such as spasms, strains, tears, remains a popular one, both with the public as well as those within the medical and health professions, but is it the whole story; the entire reason why pain exists? Patients frequently come to me blaming their pain on their posture, their weakness, their job/computer/cell phone use, or other issues, but are these true? Each tissue belief system and pathology-blaming has its followers, but each tends to practice within a rabbit hole; a hole that does not allow one to see what others are doing, thinking, or putting into practice.

Instead of each modality being unique, able to singularly and selectively able to influence one tissue, pathology, or disorder, might they all be quite similar, with only the difference being the explanation? Might they possibly be different roads to the same destination?

So if I do not believe all of the stories told by therapists and educators, what do I believe?

Looking at manual therapy and massage from a plausibility perspective, one might best start with the skin. Being the only tissue that we can be certain we are impacting, does the skin possess sufficient action potential to contribute sufficiently to the gains seen as a result of therapy? Without going into great detail in this shorter paper, many feel that it may. The published work of Michael Shacklock (2) and Nee/Butler (3) speak to the probability of pain and related dysfunction being a result of tunnel syndromes within the nerves of the body, with outcomes improved by specific nerve tunnel glides/stretches. While these originated as precise and patterned movements, the latest research puts forth the possibility of simpler therapeutic engagements of the nerves, which may be an aspect of even general manual therapy/massage. Another aspect of the skin is the richness of receptors whose sole purpose is to provide feedback to the brain for processing. Diane Jacobs, PT (4) speaks at-length of these receptors and how simple and gentle engagement of the skin may be sufficient to cause the brain to change the outcome to the periphery.

Can the brain alone change pain in the body? With ultimate control over all bodily processes, I think it would be safe to say, “yes”. Skin contact and probable impact is an unavoidable consequence of ALL manual therapy.

There is far greater to be said about indirect and contextual factors involved when receiving myofascial release, manual therapy, or massage from a dedicated therapist. There is a great deal of evidence that points to these factors as potentially playing more of a role than many therapists wish to believe. We (therapists) like to think that it is our skill and experience that improve our outcomes and it may, at last to some extent, but not for all of the reasons we think. Brian Fulton, RMT, in his book, “The Placebo Effect in Manual Therapy” (5) speaks at length to these factors and how the science story the therapist tells has an impact on potential outcomes, with the better told the story, the greater the potential for increased indirect (placebo) effects. This makes sense, as if we sound like we know what we are talking about and about to do, trust is increased. With trust often come greater outcomes. One problem with this research is that there are no provisions for the accuracy of the story. As long as it sounds plausible and is told in believable ways, potential outcomes improve.

These aspects of neuroscience and brain/pain science do not eliminate the possibility that tissue-specific results, such as releasing fascial restriction, from occurring. But the deeper we dive into the body the more speculation that must take place in order to rationalize the actions of our manual therapy.

Fascia may be releasing, trigger points may be disappearing, muscles may be lengthening/reducing tone, and all of those other promises that your therapist made to you may be happening…but there is a decided lack of irrefutable evidence that these are indeed happening. I’m not suggesting that you have an argument with every therapist or patient who makes claims such as these, as it is sometimes not an argument worth undertaking. There are many instances when I seek help from another health professional who provides me relief from or helps with an issue but has issues with their explanation. It would be egocentric to believe I have all of the answers and, as such, I remain open to the new and emerging science that points to potential changes in our target tissues as we treat. But the stories told do not always match the outcomes achieved. Neurological explanations for why manual therapy, myofascial release, and massage feel so helpful may not be completely correct and universally accepted, but these explanations might well be less wrong that many of the other stories. Every day, I am trying to be less wrong.

References

 

1. Occam’s razor: https://en.wikipedia.org/wiki/Occam%27s_razor
2. Michael Shacklock: Cinical Neurodynamics (2005).
3. Nee, R.J., Butler, D: Management of peripheral neuropathic pain: Integrating neurobiology, neurodynamics, and clinical evidence. Physical Therapy in Sport 7 (2006) 36–49.doi:10.1016/j.ptsp.2005.10.002
4. Diane Jacobs, PT: http://humanantigravitysuit.blogspot.com/
5. The Placebo Effect in Manual Therapy, by Brian Fulton, 2015 (Link)

 

 

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!).