732820

research-article2017
CRE0010.1177/0269215517732820Clinical RehabilitationLaimi et al.

CLINICAL
Original Article REHABILITATION

Clinical Rehabilitation

Effectiveness of myofascial 1­–11

© The Author(s) 2017
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DOI: 10.1177/0269215517732820
https://doi.org/10.1177/0269215517732820

chronic musculoskeletal pain: journals.sagepub.com/home/cre

a systematic review

Katri Laimi1, Annika Mäkilä1, Esa Bärlund2, Niina

Katajapuu2, Airi Oksanen1, Valpuri Seikkula1,3, Jari
Karppinen3 and Mikhail Saltychev1

Abstract
Objective: To evaluate the evidence on the effectiveness of myofascial release therapy to relieve chronic
musculoskeletal pain and to improve joint mobility, functioning level, and quality of life in pain sufferers.
Data sources and review: Randomized controlled trials were systematically gathered from CENTRAL,
Medline, Embase, CINAHL, Scopus, and PEDro databases. The methodological quality of articles was
assessed according to the Cochrane Collaboration’s domain-based framework. In addition, the effect sizes
of main outcomes were calculated based on reported means and variances at baseline and in follow-up.
Results: Of 513 identified records, 8 were relevant. Two trials focused on lateral epicondylitis
(N = 95), two on fibromyalgia (N = 145), three on low back pain (N = 152), and one on heel pain
(N = 65). The risk of bias was considered low in three and high in five trials. The duration of therapy
was 30–90 minutes 4 to 24 times during 2–20 weeks. The effect sizes did not reach the minimal
clinically important difference for pain and disability in the studies of low back pain or fibromyalgia. In
another three studies with the high risk of bias, the level of minimal clinically important difference was
reached up to two-month follow-up.
Conclusion: Current evidence on myofascial release therapy is not sufficient to warrant this treatment
in chronic musculoskeletal pain.

Keywords
Myofascial release, systematic review, chronic pain, musculoskeletal disorders, manual therapy

Date received: 20 February 2017; accepted: 30 August 2017

1Department of Physical and Rehabilitation Medicine, Turku Corresponding author:

University Hospital and University of Turku, Turku, Finland Katri Laimi, Department of Physical and Rehabilitation
2Turku University of Applied Sciences, Turku, Finland Medicine, Turku University Hospital and University of Turku,
3Department of Expert Services, Turku University Hospital PO Box 28, FI-20701 Turku, Finland.
and University of Turku, Turku, Finland Email: katri.laimi@tyks.fi
2 Clinical Rehabilitation 00(0)
Introduction
Chronic musculoskeletal pain imposes a substantial
burden on healthcare systems and is a common cause
of deteriorated daily functioning and quality of life.1
Among therapies suggested for managing such pain
is myofascial release—a rapidly spreading form of
manual therapy aiming pain relief by restoring
impaired functions of soft tissues. The theory behind
therapeutic effects of myofascial release is based on
the special role of connective tissue sheets—
“fascia”—as a main factor determining musculoskel-
etal system functioning.2 According to that theory,
fascial system, as spreading from head to toe, may
behave like an organ with different functions and
capabilities making a major contribution to the
dynamic properties of the body.2,3 Tightened or stiff-
ened fascial tissue or its reduced sliding ability (due to
either repeated micro-trauma or acute injury) is
thought to be a source of tension to the rest of the
body leading to pain and to the loss of functional
capacity.2–5 It is believed that by stretching restricted
fascia, myofascial release therapy is able to normalize
the length and the sliding properties of myofascial tis-
sues releasing also pressure from the pain-sensitive
structures and restoring the mobility of the joints.2,3,6
The descriptive characteristics and main results
of previous narrative reviews on the effectiveness of
myofascial release therapy are presented in detail in
Supplementary Table 1. Even if these reviews
mostly reported encouraging evidence on the effec-
tiveness of myofascial release, none of the reviews
were sufficiently robust in terms of methodology
and selection of studies to warrant a change in clini-
cal practice. Five reviews included healthy partici-
pants, one included mainly case studies, and the last
one reported results of two studies from only one
study group. No review has yet summarized the evi-
dence on the effectiveness of myofascial release in
chronic musculoskeletal pain patients based on ran-
domized controlled studies alone.4–10
In previous reviews, there are no effect sizes to
support the reported encouraging conclusions on
myofascial release. Based on the reviews of low-
quality studies, the evidence of myofascial release
can at most be considered vague. When choosing
appropriate treatment options in chronic pain, it
would be important to know whether the effect of
chosen treatment reaches only statistical signifi-
cance or also the minimal clinical importance. It is
not known either whether the therapeutical effect of
myofascial release is long enough to justify the use
of this treatment in a chronic pain situation.
The objective of this study was to evaluate the
evidence on the effectiveness of myofascial release
therapy to relieve pain and to improve joint mobil-
ity, functioning level, and quality of life among
patients with chronic musculoskeletal pain.
Literature search methods
Search criteria
Criteria for considering studies for this review were
based on PICO framework (Population, Intervention,
Comparison, and Outcome) as follows:
Population: adults with chronic (at least three
months) musculoskeletal pain excluding pain
associated with malignancy or specific neuro-
logical diseases like Parkinson disease, multiple
sclerosis, and stroke.
Intervention: Myofascial release therapy exclud-
ing myofascial trigger point treatment, non-
specific massage, or other types of manual
therapy.
Comparison: Any other treatment, placebo,
sham, or no treatment
Outcome: Between-group differences in changes
in pain intensity or frequency, joint range of
motion, level of functioning, and quality of life.
Differences between groups in satisfaction in
treatment.
Myofascial release therapy
There are two main myofascial release tech-
niques in use: direct and indirect release. Both of
these techniques were included in this review.
The direct release uses, for example, therapist’s
knuckles, elbows, or tools, and applies sustained
few-kilogram pressure (90–120 seconds) directly
on restricted tissue barriers. In turn, the indirect
release technique stretches myofascial complex
by lower load and longer duration.2,4,6 Also, direct
Laimi et al. 3
myofascial release by patients themselves called
“self-myofascial release” was included. This
kind of self-myofascial release uses various types
of roller massagers and provides tools for pain
sufferers, athletes, and fitness trainers.5,7,8 In ath-
letes, self-myofascial release has thought to
enhance range of joint motion, to speed up recov-
ery, and to relieve prolonged muscle soreness5,7,8
and has been suggested to be used as an alterna-
tive to massage.
Other manual therapies, different types of mas-
sage, mobilization, or myofascial trigger point
therapy were not included in this review. Even if
the term “myofascial trigger point therapy” is
resembling “myofascial release,” trigger point
therapy relies on a different theory and aims to the
restoration of muscle function by treating muscular
“trigger points,” hyperirritable “knots” within taut
bands of skeletal muscles.4,11
Search strategy
The Cochrane Controlled Trials Register
(CENTRAL), Medline, Embase, CINAHL, PEDro,
and Scopus databases were searched for RCTs
(abstracts available in English) in February 2016
unrestricted by date, and the search was updated in
August 2017. The search clauses are presented in
Supplementary Table 2.12 We used the Cochrane
Highly Sensitive Search Strategy for identifying
randomized trials. In order to avoid missing relevant
studies, use of limits was restricted and further selec-
tion was conducted manually. The references of the
identified articles were also checked for relevancy.
Study selection and methodological
quality assessment
After saving all identified records in a citation
manager (Endnote X7.2; Thomson Reuters, New
York, NY, USA), clear duplicates, conference pro-
ceedings, theses, reviews, and expert opinions
were deleted. Two independent reviewer groups
(E.B. and N.K. vs. A.M. and K.L.) screened all the
remaining 124 records based on titles and abstracts
and, after that, based on the full texts of the selected
potentially relevant studies. The same independent
reviewer groups rated methodological quality of
included eight trials. Disagreements were resolved
by consensus or by a third reviewer (M.S.). Data
were extracted from included trials using a stand-
ardized form based on recommendations by the
Cochrane Handbook for Systematic Reviews of
Interventions Version 5.1.0. The methodological
quality was assessed according to the Cochrane
Collaboration’s domain-based evaluation frame-
work (Supplementary Table 3). Main domains
were assessed in the following sequence: (1) selec-
tion bias (randomized sequence generation and
allocation concealment), (2) performance bias
(blinding of participants and personnel), (3) detec-
tion bias (blinding of outcome assessment), (4)
attrition bias (incomplete outcome data, e.g., due to
dropouts), (5) reporting bias (selective reporting),
and (6) other sources of bias. The scores for each
bias domain and the final score of risk of system-
atic bias were graded as low, high, or unclear risk.12
The registration number of this review (Prospero
database) is CRD42016035308.
Minimal clinically important difference
As clinically irrelevant statistically significant dif-
ferences between intervention and control groups
are mainly dependent on the number of persons
examined, “minimal clinically important differ-
ence” is widely used to describe better the clinical
relevance of findings. “Minimal clinically impor-
tant difference” is trying to define the smallest
meaningful score change by separating “slightly
better result” from “almost equal” as the cut-off
point for minimal clinical importance for improve-
ment, independent of the sample size. This single-
point value is then generalized to other samples
and is used on group level. Usually, this value is in
the range of 6%–10% of the total score correspond-
ing to an effect size of 0.30–0.50 with different
estimates for different outcome instruments and
health conditions.13 Minimal clinically important
difference has reported to be from 15% to 25% for
numerical rating scale of neck pain, from 18% to
28% for visual analogue scale of chronic low back
patients, and even 38% to 51% for the functioning
measurement in low back pain.14–20
4 Clinical Rehabilitation 00(0)
Quantitative analysis
A meta-analysis was inapplicable due to the dis-
similarities of the included RCTs. The effect sizes
of the main outcomes of the included studies were
calculated based on the reported mean values and
standard deviations at baseline and in follow-up.
The results were reported as raw mean differences
along with their standard errors and 95% confi-
dence intervals. All calculations for the quantita-
tive analysis were performed using Comprehensive
Meta Analysis (CMA, Version 3.3; Biostat,
Englewood Cliffs, NJ, USA) available from www.
meta-analysis.com.
Results
The search process is reported in Figure 1. Of 513
records, finally 8 were considered relevant for quali-
tative analysis21–28 (Figure 1 and Supplementary
Table 3).
These eight relevant RCTs were involving in
total 457 participants (Table 1). The duration of
follow-up ranged from immediate assessment
after the end of treatment28 up to one year.27 The
risk of bias was considered high in five of eight
trials21–23,25,28 (Supplementary Table 3). Three
RCTs were conducted in the outpatient clinic of
Myofascial Therapy and Research Foundation,21–23
two samples involved the members of Fibromyalgia
Association,26,27 one sample was gathered in a
physiotherapy outpatient department,28 and two in
tertiary outpatient clinics.24,25 The control proce-
dures included sham myofascial release,23,24 sham
ultrasound,21,22,27 or sham magnetotherapy.26 Two
studies focused on adding myofascial release to
manual or physiotherapy25,28 (Table 1).
Table 2 shows the main results of the included
studies along with the effect sizes. The authors of
each of the eight studies concluded that myofascial
release is effective in reducing pain and improving
functioning. In a one- to three-month follow-up of
low back pain sufferers,23–25 reported changes did
not reach the minimal clinical importance except
for pain in one study with different baseline val-
ues.25 In the studies on lateral epicondylitis and
heel pain, the change in scales evaluating pain and
function reached minimal clinical importance in a
two-month follow-up,21,22 while the effect sizes of
the two studies on fibromyalgia were either small
or insignificant up to 12 months.26,27
Discussion
In this first quantitative systematic review of RCTs
on the effectiveness of myofascial release therapy
in chronic musculoskeletal pain, the evidence was
found to be scarce and inconsistent. The heteroge-
neity of study populations did not enable counting
pooled effect sizes. When effect sizes of individual
studies were counted, only three low-quality studies
reached clinically important short-term (up to two
months) improvement either in pain or functioning
when compared with sham treatment, while other
five studies did not show clinically significant dif-
ferences between intervention and control groups.
One of the main weaknesses of our review was
the fact that despite of systematic wide search, only
eight relevant studies were available for the analysis.
In addition, these studies came from only three
countries and five research groups. Five of the
included studies were considered having high risk of
bias. Even if independent reviewers easily filtered
myofascial release studies from other manual ther-
apy studies, and checking the reference lists of pre-
vious reviews did not reveal caps in our study, it is
always possible that some relevant studies were
missed. To avoid this bias, all of reviewers were
experienced physiotherapists or specialists of physi-
cal and rehabilitation medicine. We also broadened
our search from the original one in 2016 to the
updated search in 2017, but widening search clauses
added only one relevant article of “fascial manipula-
tion.”25 Too narrow search clauses in systematic
reviews would diminish the value of results espe-
cially in the field of manual therapies with possibly
many different terms for one type of therapy, while
resembling names for different kinds of therapy. For
example, “myofascial release” and “fascial manipu-
lation” are in the focus of our study, while “myofas-
cial therapy” for muscular trigger points is not
targeted to fascial tissues. As we only focused on
chronic pain patients, the results cannot be straightly
extrapolated to acute musculoskeletal pain. The
Laimi et al. 5

Figure 1.  Flowchart of the search process.

scope of this review was narrowed down to the
effects of myofascial release on pain relief, improved
joint mobility, functioning, quality of life, and satis-
faction after treatment. Thus, other relevant out-
comes, such as anxiety, clinical impression, or
mobility of soft tissues remained unnoticed.
However, both clinical impression and the mobility
of tissues, even if a target of myofascial release, are
difficult to estimate objectively. If the main target of
myofascial release is on restoring optimal length of
 6

Table 1.  Descriptive characteristics of the included studies.

Study and Target population N (women %) Age (years), Follow-up Case treatment Control treatment Authors’ conclusion
country cases/controls
Cases Controls

Ajimsha et al.23 Nursing 38 (76) 36 (78) 36/34 Immediately Myofascial Sham myofascial Myofascial release as an adjunct to
and India professionals with (= 8 weeks) and release + back release + back back exercise is more effective than
low back pain 4 weeks after the exercises 3× 60 min/ exercises 3× exercise alone for chronic low back
end of treatment week, 8 weeks 60 min/week, pain in nursing professionals.
8 weeks
Ajimsha et al.22 Computer 33 (61) 32 (57) 31/29 Immediately Myofascial release 3× Sham ultrasound Myofascial release is more
and India professionals with (= 4 weeks) and 30 min/week, 4 weeks 3× 30 min/week, effective than sham ultrasound for
lateral epicondylitis 8 weeks after the 4 weeks lateral epicondylitis in computer
end of treatment professionals.
Ajimsha et al.21 Plantar heel pain 33 (76) 32 (69) 42/41 Immediately Myofascial release 3× Sham ultrasound Myofascial release is more effective
and India (= 4 weeks) and 30 min/week, 4 weeks 3× 30 min/week, than sham ultrasound in plantar heel
8 weeks after the 4 weeks pain.
end of treatment
Arguisuelas Non-specific low 27 (59) 27 (63) 47/46 Immediately Myofascial release 2× Sham myofascial Myofascial release produced a
et al.24 and Spain back pain (= 2 weeks), and 40 min/week, 2 weeks release 2× 40 min/ significant improvement in pain and
10 weeks after the week, 2 weeks disability.
end of treatment Minimal clinically important
differences were included in the 95%
CI. We cannot know whether this
improvement is clinically relevant.
Branchini et al.25 Non-specific low 11 (64) 13 (69) 48/44 Immediately Fascial manipulation Manual therapy Fascial manipulation led to decreased
and Italy back pain (= 4 weeks) and one 1× 45 min/ 2× 45 min/week, symptomatic, improved functional,
and three months week + manual 4 weeks and perceived well-being outcomes
after the end of therapy 1× 45 min/ that were greater amplitude
treatment week, 4 weeks compared to manual therapy alone.
Castro-Sánchez Fibromyalgia 30 (94) 29 (96) 49/46 Immediately Myofascial release of Sham Massage–myofascial release–therapy
et al.26 and Spain (20 weeks), 1 month tender points 90 min/ magnetotherapy reduces the sensitivity to pain at
and 6 months week, 20 weeks 30 min/week, tender points in fibromyalgia. Release
after the end of 20 weeks of fascial restrictions reduces anxiety
treatment and improves sleep quality, physical
function, and physical role. Massage–
myofascial release can be considered
as an alternative and complementary
therapy that can achieve transient
improvements.
Clinical Rehabilitation 00(0)
 Laimi et al.

Table 1. (Continued)
Study and Target population N (women %) Age (years), Follow-up Case treatment Control treatment Authors’ conclusion
country cases/controls
Cases Controls

Castro-Sánchez Fibromyalgia 45 41 55/54 Immediately Myofascial release Sham short- Fibromyalgia patients can benefit
et al.27 and Spain Gender distribution not (20 weeks), 2× 60 min/week, wave + sham from myofascial release. Decrease
mentioned 6 months and 20 weeks ultrasound 2× in muscular tension secondary to
12 months after the 30 min/week, the release of myofascial restrictions
end of treatment 20 weeks improves physical function, fatigue,
number of days feeling good,
tiredness on walking, and stiffness.
Myofascial release significantly
improves several clinical dimensions,
with an important and consistent
improvement in pain, sensory, and
affective dimensions.
Khuman et al.28 Lateral 15 (40) 15 (47) 37/38 Immediately Myofascial Conventional Myofascial release improves pain,
and India epicondylitis (4 weeks) after the release + conventional physiotherapy 3×/ functional performance, and hand grip
end of treatment physiotherapy 3× week, 4 weeks for 4 weeks in lateral epicondylitis
30 min/week, 4 weeks probably by normalizing the fascial
tissue length and excitation of
afferent Aδ-fibers, which can cause
segmental pain modulation. Myofascial
release was more effective than
conventional physiotherapy alone for
pain, functional performance, and grip
strength.

CI, confidence interval.

7
8 Clinical Rehabilitation 00(0)

Table 2.  Effect sizes (raw mean difference in change between groups) of main outcomes of the included studies.
Study Outcome (scale) Reported results, mean (standard Mean Standard 95% Confidence
deviation) difference error interval

Cases Controls

Ajimsha et al.23 MPQ (0–78)

Baseline 23.2 (8.7) 23.0 (7.6)  
After treatment 10.8 (7.9) 17.0 (9.3) –6.4 1.76 –9.86 –2.94
4 weeks 13.1 (6.9) 18.3 (7.5) –5.4 1.62 –8.58 –2.22
QBPDS (0–100)
Baseline 37.1 (11.8) 35.3 (13.6)  
After treatment 26.9 (11.1) 31.8 (12.4) –6.7 2.55 –11.70 –1.70
4 weeks 28.7 (9.1) 32.5 (10.4) –5.6 2.42 –10.33 –0.87
Ajimsha et al.22 PRTEE (0–100)
Baseline 65.2 (5.9) 64.5 (4.9)  
After treatment 13.8 (2.2) 60.1 (5.7) –47.0 1.20 –49.36 –44.64
8 weeks 23.9 (4.1) 65.9 (4.5) –42.7 1.12 –44.89 –40.51
Ajimsha et al.21 FFI (0–100)
Baseline 63.0 (4.44) 61.4 (5.22)  
After treatment 17.4 (4.02) 56.9 (6.91) –41.1 1.17 –43.40 –38.80
8 weeks 24.8 (3.98) 60.2 (8.11) –37.0 1.30 –39.54 –34.46
Arguisuelas SF-MPQ (0–45)
et al.24 Baseline 22.3 (8.3) 23 (9.3)  
After treatment 13.08 (n/r)a 18 (n/r) –4.1 nr –10.2 –2.1
12 weeks 15.28 (n/r) 23.7 (n/r) –7.8 nr –14.5 –1.1
Pain (0–100)
Baseline 60.5 (23.9) 63.3 (24.0)  
After treatment 27.1 (n/r) 33.8 (n/r) –6.6 nr –20.9 –7.6
12 weeks 43.0 (n/r) 52.0 (n/r) –9.0 nr –25.8 –7.9
RMQ (0–24)
Baseline 59.7 (20.1) 63.6 (18.3)  
After treatment 7.5 (n/r) 10.1 (n/r) –2.6 nr –6.2 –1.0
12 weeks 8.1 (n/r) 11.8 (n/r) –3.7 nr –7.6 –0.2
FABQ (0–96)
Baseline 59.7 (20.1) 63.6 (18.3)  
After treatment 48.6 (n/r) 62.59 (n/r) –14.3 nr –27.8 –0.8
12 weeks 16.3 (n/r) 18.9 (n/r) –13.5 nr –27.6 –0.5
Branchini VAS (0–10)
et al.25 Baseline 5.5 (2.4) 2.6 (1.9)  
After treatment 0.4 (0.5) 1.1 (1.1) –3.6 0.7 –5.1 –2.1
1 month 0.6 (0.9) 2.2 (1.1) –4.5 0.7 –5.9 –3.1
3 months 1.1 (1.2) 2.0 (1.3) –3.8 0.7 –5.2 –2.4
SF-36 (0–100)
Baseline 58.0 (13.6) 57.7 (16.8)  
After treatment 85.9 (6.5) 67.5 (16.3) 18.1 5.4 7.5 28.7
1 month 83.7 (8.8) 69.6 (18.4) 13.8 5.7 2.7 24.9
3 months 82.4 (8.9) 70.3 (18.2) 11.8 5.6 0.8 22.8
BPI
Baseline 8.8 (3.9) 7.2 (2.5)  
After treatment 1.7 (1.3) 4.8 (3.2) –4.7 1.2 –7.1 –2.3
1 month 1.3 (1.8) 4.4 (3.2) –4.7 1.2 –7.0 –2.4
3 months 1.8 (1.9) 4.1 (3.6) –3.9 1.2 –6.3 –1.5
RMQ (0–24)
Baseline 6.9 (3.5) 7.0 (4.0)  
After treatment 1.8 (2.3) 3.9 (3.0) –2.0 1.3 –4.5 0.5
1 month 1.7 (2.1) 3.9 (3.1) –2.1 1.3 –4.6 0.4
3 months 1.5 (2.0) 4.1 (4.0) –2.5 1.3 –5.1 0.1

(Continued)
Laimi et al. 9

Table 2. (Continued)
Study Outcome (scale) Reported results, mean (standard Mean Standard 95% Confidence
deviation) difference error interval

Cases Controls

Castro- VAS (0–10)

Sánchez et al.26 Baseline 9.1 (1.1) 9.5 (1.3)  
After treatment 7.9 (1.8) 9.0 (1.3) –0.7 0.34 –1.37 –0.03
1 month 8.4 (1.1) 9.3 (1.1) –0.5 0.27 –1.03 0.03
6 months 8.8 (1.3) 9.7 (1.5) –0.5 0.31 –1.10 0.10
SF-36 (0–100)
Physical function  
Baseline 5.2b (5.4) 50.2 (8.5)  
6 months 48.2 (7.4) 51.2 (6.3) 4.8 1.68 1.50 8.10
Physical role
Baseline 26.0 (7.3 26.4 (6.3 1.6 1.67 –1.68 4.88
6 months 25.5 (8.4) 27.5 (6.3)  
Body pain
Baseline 76.6 (6.3) 78.9 (11.4)  
6 months 75.6 (8.2) 77.8 (9.7) 0.1 2.14 –4.10 4.30
General health
Baseline 67.8 (5.2) 68.8 (7.2)  
6 months 67.5 (7.2) 68.1 (6.4) 0.4 1.56 –2.65 3.45
Castro- FIQ (0–100)
Sánchez et al.27 Baseline 65.0 (18.2), 63.9 (16.4)  
6 months 58.6 (16.3) 64.1 (18.1) –6.6 3.35 –13.16 –0.04
12 months 62.8 (20.1) 65.0 (19.8) –3.3 3.64 –10.44 3.84
McGill Pain Scorea (0–45)
Baseline 25.0 (12.6) 25.3 (10.7)  
6 months 21.9 (7.2) 26.2 (6.8) –4.0 2.03 –7.98 –0.02
12 months 23.2 (7.6) 26.7 (6.9) –3.2 2.03 –7.17 0.77
VAS (0–10)
Baseline 9.1 (0.8) 8.9 (1.3)  
6 months 8.3 (1.1) 8.9 (1.3) –0.8 0.22 –1.24 –0.36
12 months 8.7 (1.1) 8.9 (1.0) –0.4 0.21 –0.81 0.01
Khuman et al.28 NRS (0–10)
Baseline 6.2 (1.65) 5.9 (1.38)  
After treatment 1.3 (0.48) 3.3 (1.23) –2.3 2.24 –6.69 2.09
PRTEE (0–100)
Baseline 57.8 (3.58) 59.7 (3.03)  
After treatment 10.1 (4.42) 31.3 (7.47) –19.3 1.85 –22.92 –15.68

MPQ, McGill Pain Questionnaire (0–78 points); QBPDS, Quebec Back Pain Disability Scale (0–100 points); PRTEE, patient-rated tennis elbow
evaluation (pain and functional disability; 0–100 points); FFI, Foot Function Index (0%–100%); SF-MPQ, Short Form McGill Pain Questionnaire (0–45
points); RMQ, Roland-Morris Questionnaire (0–24 points); FABQ, Fear Avoidance Beliefs Questionnaire (0–96 points); VAS, visual analogue scale for
pain intensity (0–10 cm), figures estimated from a graph; SF-36, 36-item Quality-of-Life Questionnaire (0–100 points); BPI, Brief Pain Inventory (two
subscales from 0 to 40 and 0 to 70 points, the used subscale not mentioned); FIQ, Fibromyalgia Impact Questionnaire (0–100 points); NRS, Numeri-
cal Rating Scale of pain intensity (0–10 points); nr, not reported.
aMcGill Pain Score Sensory and Affective (0–45 points).
bConsidered typo in the original article—value 5.2 replaced by 52.0 for the calculations.

fascia, this restoration is only a pathway in decreas-
ing pain and enabling better functioning.2,4–6
Only three of the included RCTs23–25 had a credi-
ble control group possibly capable in differentiating
the effect of myofascial release from the effect of
manual touching. Blinding and choosing a credible
control treatment in a highly therapist-dependent
manual treatment is important, as also touching can
change the effectiveness of the treatment.9 As the
participants of the included studies were seeking for
a manual treatment option for their chronic pain,
non-manual sham control procedures—as in four
10 Clinical Rehabilitation 00(0)
included studies21,22,26,27—did probably not fulfill
their expectations. Six of eight studies were focusing
on intensive myofascial release treatment (12 to 24
times in 4–20 weeks), and the follow-up times were
mostly too short for the proper cost-effectiveness
evaluation.21–25,28 Despite these weaknesses, this
review was the first attempt to gather the evidence on
effectiveness of myofascial release in chronic mus-
culoskeletal pain systematically and to evaluate that
evidence both qualitatively and quantitatively.
All previous narrative reviews on myofascial
release in other health conditions have concluded
with a suggestion that is favorable to release
(Supplementary Table 1). Our quantitative review
was unable to confirm these earlier positive conclu-
sions. One reason may lay in the differences between
target populations and in limiting study designs to
RCTs only. Due to these differences in the inclusion
criteria, the earlier reviews are barely comparable
with our study. As regards the population of interest,
the review closest to our review was probably one by
McKenney et al.9 which evaluated myofascial
release in orthopedic patients. However, as that
review included mainly case studies, the methodo-
logical evaluation was not possible. The most impor-
tant difference between our study and previous
reviews may be hidden in including effect size calcu-
lations in this review. It is self-evident that small
positive effects seen in the majority of trials will
inevitably lead to favorable conclusions of reviews if
minimal clinical importance of the results is
ignored.13,14,16,19,20 Measuring effect size of interven-
tion is vital in evaluating both statistical and clinical
significance of the results. For example, in a previous
review by Yuan et al., myofascial release was
reported to have large positive effects on fibromyal-
gia based on two studies by Castro-Sánchez et al.
However, in these two studies, even if statistically
significant improvement in pain level was reported,
the results did not even reach the clinical importance
as they fell under the level of 15%–28% (or 1.5 to 2
points on a numerical rating scale) that has been sug-
gested to represent a limit for minimal clinically
important difference.15,18–20 Respectively, minimal
clinically important difference in measurement of
functioning in low back pain has previously been
proposed to be even 38%–51%, which is higher than
statistically significant improvement in functioning
reported by Ajimsha et al.16 (as measured by the
Quebec Back Pain Disability Scale).
In chronic musculoskeletal pain patients, the
theoretical background of myofascial release pro-
vides one model when trying to explain functional
changes of the body without measurable structural
diseases. As the application of myofascial release
relies on clinician–patient interaction, the subjectiv-
ity of the interaction cannot be removed when we
try to determine its outcome.9 Clinical treatment
decisions rely on the scientific background, on cost-
effectiveness, and on harmfulness of treatment
options. In future, high-quality RCTs conducted on
larger samples with longer follow-ups may alter the
conclusion of this review.
Clinical Messages
•• Current evidence of myofascial release
therapy in chronic pain relies on only a
few studies.
•• In quantitative analysis, previous posi-
tive conclusions could not be confirmed.
•• It is not known whether this kind of therapy
is more effective in treating chronic muscu-
loskeletal pain than sham procedures.
Acknowledgements
We want to thank University Hospital physiotherapists
Kirsi Peltonen and Sirpa Heinonen for their help during
the evaluation of the included trials.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
1. Park PW, Dryer RD, Hegeman-Dingle R, et al. Cost bur-
den of chronic pain patients in a large integrated delivery
system in the United States. Pain Pract. Epub ahead of
print 7 October 2015. DOI: 10.1111/papr.12357.
Laimi et al. 11
2. Barnes MF. The basic science of myofascial release: mor-
phologic change in connective tissue. J Bodyw Mov Ther
1997; 1(4): 231–238.
3. Klingler W, Velders M, Hoppe K, et al. Clinical relevance
of fascial tissue and dysfunctions. Curr Pain Headache
Rep 2014; 18(8): 439.
4. Mauntel TC, Clark MA and Padua DA. Effectiveness
of myofascial release therapies on physical performance
measurements: a systematic review. Athl Train Sports
Health Care 2014; 6(4): 189–196.
5. Schroeder AN and Best TM. Is self myofascial release an
effective preexercise and recovery strategy? A literature
review. Curr Sports Med Rep 2015; 14(3): 200–208.
6. Ajimsha MS, Al-Mudahka NR and Al-Madzhar JA.
Effectiveness of myofascial release: systematic review
of randomized controlled trials. J Bodyw Mov Ther 2015;
19(1): 102–112.
7. Beardsley C and Skarabot J. Effects of self-myofascial
release: a systematic review. J Bodyw Mov Ther 2015;
19(4): 747–758.
8. Cheatham SW, Kolber MJ, Cain M, et al. The effects of
self-myofascial release using a foam roll or roller mas-
sager on joint range of motion, muscle recovery, and
performance: a systematic review. Int J Sports Phys Ther
2015; 10(6): 827–838.
9. McKenney K, Elder AS, Elder C, et al. Myofascial release
as a treatment for orthopaedic conditions: a systematic
review. J Athl Train 2013; 48(4): 522–527.
10. Yuan SLK, Matsutani LA and Marques AP. Effectiveness
of different styles of massage therapy in fibromyalgia:
a systematic review and meta-analysis. Man Ther 2015;
20(2): 257–264.
11. Lluch E, Nijs J, De Kooning M, et al. Prevalence, incidence,
localization, and pathophysiology of myofascial trigger
points in patients with spinal pain: a systematic literature
review. J Manipulative Physiol Ther 2015; 38(8): 587–600.
12. Higgins J and Green S. Cochrane handbook for systematic
reviews of interventions. The Cochrane Collaboration,
http://handbook.cochrane.org/ (2011, accessed 4 August
2016).
13. Angst F. MCID: the minimal clinically important differ-
ence assigns significance to outcome effects. J Rheumatol
2016; 43(2): 258–259.
14. Hagg O, Fritzell P, Nordwall A, et al. The clinical
importance of changes in outcome scores after treat-
ment for chronic low back pain. Eur Spine J 2003;
12(1): 12–20.
15. Kovacs FM, Abraira V, Royuela A, et al. Minimum detect-
able and minimal clinically important changes for pain in
patients with nonspecific neck pain. BMC Musculoskelet
Disord 2008; 9: 43.
16. Lauridsen HH, Hartvigsen J, Manniche C, et al. Respon-
siveness and minimal clinically important difference
for pain and disability instruments in low back pain
patients. BMC Musculoskelet Disord 2006; 7(1): 82.
17. Park KB, Shin JS, Lee J, et al. Minimum clinically impor-
tant difference and substantial clinical benefit in pain,
functional, and quality of life scales in failed back surgery
syndrome patients. Spine 2017; 42(8): E474–E481.
18. Pool JJM, Ostelo RWJG, Hoving JL, et al. Minimal clini-
cally important change of the neck disability index and the
numerical rating scale for patients with neck pain. Spine
2007; 32(26): 3047–3051.
19. Salaffi F, Stancati A, Silvestri CA, et al. Minimal clini-
cally important changes in chronic musculoskeletal pain
intensity measured on a numerical rating scale. Eur J Pain
2004; 8(4): 283–291.
20. Van der Roer N, Ostelo RW, Bekkering GE, et al.
Minimal clinically important change for pain intensity,
functional status, and general health status in patients
with nonspecific low back pain. Spine 2006; 31(5):
578–582.
21. Ajimsha MS, Binsu D and Chithra S. Effectiveness of myo-
fascial release in the management of plantar heel pain: a
randomized controlled trial. Foot 2014; 24(2): 66–71.
22. Ajimsha MS, Chithra S and Thulasyammal RP.
Effectiveness of myofascial release in the management of
lateral epicondylitis in computer professionals. Arch Phys
Med Rehabil 2012; 93(4): 604–609.
23. Ajimsha MS, Daniel B and Chithra S. Effectiveness of
myofascial release in the management of chronic low back
pain in nursing professionals. J Bodyw Mov Ther 2014;
18(2): 273–281.
24. Arguisuelas MD, Lison JF, Sanchez-Zuriaga D, et al. Effects
of myofascial release in nonspecific chronic low back pain:
a randomized clinical trial. Spine 2017; 42(9): 627–634.
25. Branchini M, Lopopolo F, Andreoli E, et al. Fascial
manipulation® for chronic aspecific low back pain: a
single blinded randomized controlled trial. F1000Res
2015; 4: 1208.
26. Castro-Sánchez AM, Mataran-Pearrocha GA, Granero-
Molina J, et al. Benefits of massage-myofascial release
therapy on pain, anxiety, quality of sleep, depression, and
quality of life in patients with fibromyalgia. Evidence-
based complementary and alternative medicine, http://
onlinelibrary.wiley.com/o/cochrane/clcentral/arti-
cles/668/CN-00856668/frame.html
27. Castro-Sánchez AM, Mataran-Penarrocha GA, Arroyo-
Morales M, et al. Effects of myofascial release tech-
niques on pain, physical function, and postural stability in
patients with fibromyalgia: a randomized controlled trial.
Clin Rehabil 2011; 25(9): 800–813.
28. Khuman PR, Trivedi P, Devi S, et al. Myofascial
release technique in chronic lateral epicondylitis: a ran-
domized controlled study. Int J Health Sci Res 2013;
3(7): 45–52.