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Journal of Bodywork & Movement Therapies (2011) 15, 431e435

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CLINICAL METHODS

Effectiveness of direct vs indirect technique


myofascial release in the management of tension-
type headache
M.S. Ajimsha, MPT (Neuro), ADMFT, PhD (Physiotherapy) a,b,*

a
Myofascial Therapy and Research Foundation, India
b
School of Physiotherapy, AIMST University, 08100 Bedong, Kedah, Malaysia

Received 27 July 2010; received in revised form 18 January 2011; accepted 18 January 2011

KEYWORDS Summary Background: Tension-type headache (TTH) is essentially defined as bilateral head-
Myofascial release; ache of a pressing or tightening quality without a known medical cause. Myofascial release (MFR)
Myofascial trigger is currently being applied for patients with TTH but its efficacy has not been evaluated formally.
points; Objective: To investigate whether direct technique myofascial release (DT-MFR) reduces the
Tension headache frequency of headache more effectively than the indirect technique myofascial release (IDT-
MFR) in comparison to a Control Group receiving slow soft stroking.
Design: Randomized, controlled, single blinded trial.
Setting: The clinical wing of Myofascial Therapy and Research Foundation, Kerala, India.
Participants: 63 patients with episodic or chronic tension-type headache.
Interventions: DT-MFR, IDT-MFR or Control. The techniques were administered by certified myo-
fascial release practitioners and consisted of 24 sessions per patient over 12 weeks.
Main outcome measure: Difference in numbers of days with headache between Weeks 1e4 (i.e.
4 weeks prior to start of Intervention) and Weeks 17e20, following 12 weeks of Intervention
between Weeks 5e16 as recorded by participants in headache diaries.
Results: The number of days with headache per 4 weeks decreased by 7.1 (2.6) [mean (SD)] days
in the DT-MFR group compared with 6.7 (1.8) days in the IDT-MFR group and 1.6 (0.5) days in the
control group, (P < 0.001). Patients in the DT-MFR Group, IDT-MFR Group and Control Group re-
ported a 59.2%, 54% and 13.3% reduction in their headache frequency in Weeks 17e20 compared
to that in Weeks 1e4.
Conclusions: This study provides evidence that Direct Technique or Indirect Technique Myofas-
cial Release is more effective than the Control Intervention for tension headache.
2011 Elsevier Ltd. All rights reserved.

* Tel.: 60124362154.
E-mail address: ajimshaw.ms@gmail.com.

1360-8592/$ - see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2011.01.021
432 M.S. Ajimsha

Introduction a diagnosis of episodic or chronic TTH lasting at least 12


months, and who had completed a 4-week baseline head-
Tension-type headache (TTH) is essentially defined as ache diary were eligible for inclusion in the study. Those
bilateral headache of a pressing or tightening quality with a history of additional migraine headache, secondary
without a known medical cause. Tension-type headache is headaches, age >50 years, use of analgesics on more than
classified as episodic if it occurs on less than 15 days 10 days a month, prophylactic headache treatment with
a month and as chronic if it occurs more often (IHS, 1997). drugs in the 4 weeks prior to randomization, and any other
A survey from the United States found a one-year preva- treatment for TTH during the previous 12 months were
lence of 38% for episodic tension-type headache and 2% for excluded. The study protocol was approved by the Ethics
chronic tension-type headache (Schwartz et al., 1998). Committee of MFTRF. Between July 2008 and February
Present pain models for tension-type headache suggest that 2009, 76 patients were referred to MFTRF, India, with
nociceptive inputs from peripheral tender muscles can lead a diagnosis of TTH. Of this, 63 individuals who met the
to central sensitization in chronic tension-type headache Inclusion Criteria and provided written informed consent
(De-Las-Pen as et al., 2007). Myofascial Trigger Points are were randomized to DT-MFR, IDT-MFR, or Control using
highly prevalent in patients with tension-type headache a 2:2:1 list (as done in studies by Tully et al, 2007; Sherman
(Couppe et al., 2007). et al, 2010). Participants were not blinded to the inter-
Myofascial Release (MFR) is the application of a low load, vention they were randomized to. Two evaluators blinded
long duration stretch into the myofascial complex, intended to the group to which the participants belonged analyzed
to restore the optimal length of this complex, decrease pain headache diaries.
and improve function (Barnes, 1990). It has been hypothe-
sized that fascial restrictions in one part of the body cause Interventions
undue tension in other parts of the body, due to fascial
continuity; in turn, this may create stress on any structures All 3 interventions were provided twice weekly for 12 weeks
that are enveloped, divided, or supported by fascia (Schleip (Weeks 5e16); the duration of each treatment session was 1 h.
et al, 2003). Myofascial practitioners believe that by
restoring the length and health of restricted connective DT-MFR technique
tissue, pressure can be relieved on pain sensitive structures
such as nerves and blood vessels. Myofascial release gener- The technique used was same for all the patients in DT-MFR
ally involves slow, sustained pressure (120e300 s) applied to (Stanborough, 2004). All techniques were performed bilat-
restricted fascial layers either directly (DT-MFR) or indirectly erally, 3 min on each side.
(IDT-MFR). The rationale for these techniques can be traced The Protocol was as follows:
to various studies that looked at the plastic, viscoelastic and
piezoelectric properties of connective tissue (Schleip, 2003;
I. Upper Trapezius release
Greenman, 2003; Pischinger, 1991).
II. Lateral/anterior cervical techniques.
Myofascial Release is being used to treat patients with
a) Using soft fist to treat the fascia at the mastoid
TTH (Baldry, 2005; Stanborough, 2004; Richter and Hebgen,
process.
2009), but there are few formal reports of its efficacy. At
b) Using the first three metacarpophalangeal joints to
the Myofascial Therapy and Research Foundation in Kot-
treat the submastoid and occipital soft tissue.
tayam, Kerala, India, both the Direct Technique Myofascial
III. Deep posterior myofasciae.
Release (DT-MFR, as promoted by Stanborough, 2004) and
a) Release of nuchal ligament.
Indirect Technique Myofascial Release (IDT-MFR, as
b) Melting into the deep small muscles of the posterior
promoted by Manheim, 2001) are used. DT-MFR is thought to
neck.
work directly on restricted fascia; practitioners use knuckles
c) Release of the deep neck flexor muscles.
or elbow or other tools to slowly sink into the fascia, and the
IV. Release of cranial base and suboccipital myofascia.
pressure applied is a few kilograms of force to contact the
V. Decompression of the occipital condyles.
restricted fascia, apply tension, or stretch the fascia. IDT-
VI. Release of the temporalis fascia.
MFR involves application of gentle stretch e the pressure
VII. Release of the epicranial aponeurosis.
applied is a few grams of force, and the hands tend to follow
the direction of fascial restriction, hold the stretch, and
allow the fascia to unwind itself. The primary objective of
IDT-MFR technique
the present study was to evaluate the efficacy of DT-MFR and
IDT-MFR in the management of TTH, treating fascia in the
head, neck and face in accordance with the fascial meridians The technique used was same for all the patients in IDT-MFR
proposed by Myers (2003). It was not the intent of this study (Manheim, 2001). Steps V and VI were performed bilaterally
to compare which among DT-MFR and IDT-MFR is more for 5 min on each side.
effective for the management of tension-type headache. The Protocol was as follows:

I. Gross stretch of the posterior cervical musculature


Methods (10 min).
II. Cranial base release (10 min).
This study was carried out in the clinical wing of MFTRF, III. Hair pull (10 min).
Kottayam, Kerala, India. Individuals aged 18e50 years with IV. Ear pull (10 min).
Effectiveness of direct vs indirect technique myofascial release 433

V. Stretch of face muscles (10 min). DT-MFR and two participants in the IDT-MFR groups did not
VI. Gross stretch of the Sternocleidomastoid (10 min). maintain headache diaries as advised and their data were
excluded from the results presented below.
Within the study period, no serious adverse events
Control intervention
occurred in any of three Groups. Three patients from the
DT-MFR group and one from the IDT-MFR group reported
Patients in the Control Group received slow soft stroking
headaches in the first week following initiation of treat-
with finger pads all over the head in the same areas as the
ment, and this was reported to have subsided within a week
application of Myofascial Release (in the other Groups) for
without any medication.
the same duration (1 h per treatment session), twice
There were no statistically significant differences
a week for 12 weeks. After the completion of the study,
between the groups for any of the baseline characteristics
patients in the Control arm were provided MFR therapy, as
(Table 1).
advised by the Ethics Committee.
From Weeks 1e4 to Weeks 17e20, the number of days with
Patients in all groups filled in headache diaries the
headache per 4 weeks decreased by 7.1 (SD 2.6) days in the
month before randomization (Weeks 1e4), and following
DT-MFR group compared with 6.7 (SD 1.8) days in the IDT-MFR
treatment (Weeks 9e20). All study participants were
group and 1.6 (SD 0.5) days in the Control Group (difference:
advised to take medication for headache exacerbations as
DT-MFR vs IDT-MFR, 0.6 days, 95% confidence interval 2.4 to
required, but were required to record them in their head-
1.2 days, P Z 0.51; DT-MFR vs Control Group, 5.8 days, 7.6
ache diaries. Practitioners who provided MFR therapy in this
to 4.0 days, P < 0.001, IDT-MFR vs Control Group, 5.4 days,
study had been trained in the techniques for at least 100 h
7.2 to 3.7 days, P < 0.001) (Table 2).
and had a median experience of 10 months with the tech-
The proportion of responders, defined as participants who
nique. The DT-MFR, IDT-MFR, and Control Treatments con-
had at least 50% reduction in headache days between Weeks
sisted of 24 sessions, each lasting an hour, given over 12
1e4 and Weeks 17e20, was 81.8% in the DT-MFR Group, 86.4%
weeks in 2 sessions per week with a minimum of 2 days gap
in the IDT-MFR Group, and 0% in the Control Group. Patients
between sessions. The primary outcome measure was the
in the DT-MFR group reported a 59.2% reduction in their
difference in number of days with headache between
headache frequency; IDT-MFR group reported 54% reduction
Weeks 1e4 and Weeks 17e20.
whereas Control Group reported 13.3% reduction in their
pain frequency per 4 weeks in the Weeks 17e20. However,
Statistics differences in headache frequency between the DT-MFR and
the IDT-MFR Groups were statistically insignificant.
The three groups at baseline were compared using one-way
analysis of variance. Then, in accordance with the primary Discussion
objective of the study, we compared the number of days with
headache in the DT-MFR and IDT-MFR groups as compared to
The principal finding of this proof of the concept study is
Control Group using unpaired t-test. A two-tailed P value less
that both of the Myofascial Release interventions tested in
than 0.05 was accepted as statistically significant.
this study were significantly more effective than slow
stroking for decreasing the frequency of tension-type
Results headache. The principal difference between the Direct and
Indirect Techniques of Myofascial Release used in this study
Of the 63 individuals recruited into this study, 56 partici- is that the pressure applied was of the order of kilograms
pants (22 in DT-MFR Group; 22 in IDT-MFR Group and 12 in and for a shorter duration in the Direct Technique, whereas
Control Group) completed the study protocol. Two partic- in the Indirect Technique the amount of pressure is of the
ipants in the DT-MFR and one participant each from the order of a few grams but sustained longer. One limitation of
remaining 2 Groups dropped out of the study without this trial was that practitioners could not be blinded.
providing any specific reason for it. One participant in the Another limitation was the absence of long-term follow up

Table 1 Baseline characteristics of study participants (n Z 56).


Characteristic All Patients DT-MFR IDT-MFR Control Group
(n Z 56) (n Z 22) (n Z 22) (n Z 12)
Males:Females 20:36 7:15 8:14 5:7
Age (Years) 43.8 (5.4) 43.7 (5.6) 44.7 (5.2) 43.0 (5.4)
Body Mass Index (Kg/m2) 24.6 (5.7) 24.7 (5.9) 24.8 (6.2) 24.2 (5.0)
Episodic Tension-Type Headache 47 (83.9) 20 (90.9) 18 (81.8) 9 (75)
Chronic Tension-Type Headache 9 (16.1) 2 (9.1) 4 (18.2) 3 (25)
Duration of Condition (Years), 7.4 (7.7) 7.1 (7.2) 7.3 (8.1) 7.7 (7.7)
as seen from physicians reports
Frequency of Headache in 12.1 (2.7) 12 (2.8) 12.4 (2.8) 12 (2.5)
Weeks 1e4 (Baseline)
Data are the mean (SD) except for Gender and TTH, which are expressed as ratio and number (Percentage) respectively.
434 M.S. Ajimsha

Table 2 Headache diary readings (17e20 weeks) following completion of 3 months Intervention. Data are the means (SD).
Headache Diary Reading DT-MFR IDT-MFR Control Group
Headache Frequency (Weeks 1e4) 12 (2.8) 12.4 (2.8) 12 (2.5)
Frequency of Headache (Weeks 17e20) 4.9 (1.7) 5.7 (1.3) 10.4 (2.7)
Mean (SD) of difference in days with headache 7.1 (2.6) 6.7 (1.8) 1.6 (0.5)
between Weeks 1e4 and Weeks 17e20
Comparison of headache frequency scores DT-MFR vs IDT-MFR DT-MFR vs Control group IDT-MFR vs Control Group
of the DT-MFR, IDT-MFR and the Control 0.6 (2.4 to 1.2) 5.8 (7.6 to 4.0) 5.4 (7.2 to 3.7)
Groups of the Weeks 17e20.
(95% Confidence Interval)
P value by unpaired t-test 0.51 <0.001 <0.001

of study participants. A slight improvement over time manipulations and delivering quality hands on care for
occurred in the Control Group; this could be due to those in need.
a meaning response (Moerman and Jonas, 2002).
Myofascial Release has been reported to reduce pain and
improve quality of life in idiopathic scoliosis (LeBauer et al.,
2008), Raynauds phenomenon (Walton, 2008) and in
Acknowledgment
systemic sclerosis (Martin, 2009). A recent study has shown
that treatment with Myofascial Release following repetitive We thank all the practitioners and professionals of MFTRF,
strain injury resulted in normalization in apoptotic rate, cell India and the physicians who participated in the consensus
morphology changes, and reorientation of fibroblasts process and analysis to establish the trial interventions. We
(Meltzer et al., 2010). Active myofascial trigger points in the are expressing our special gratitude to Dr. E. S. Prakash,
cervical and suboccipital musculature have been identified Associate Professor, School of Medicine, AIMST University,
in 65% of individuals with chronic tension-type headache (De- Malaysia for his expertise editing of the manuscript.
Las-Penas et al., 2006; Couppe et al., 2007). According to
Schleip (2003), under normal conditions, fascia tends to References
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