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FASCIA SCIENCE AND CLINICAL APPLICATIONS: RANDOMIZED, CONTROLLED,

SINGLE BLINDED TRIAL

Effectiveness of Myofascial release in the

management of chronic low back pain in
nursing professionals
M.S. Ajimsha, MPT, ADMFT, PhD a,*, Binsu Daniel, MPT, ADMFT b,
S. Chithra, MSc b
a
b

Department of Physiotherapy, Hamad Medical Corporation, Doha, Qatar

Myofascial Therapy and Research Foundation, India

Received 2 February 2013; received in revised form 24 April 2013; accepted 5 May 2013

KEYWORDS
Myofascial release;
Specific back
exercises;
Chronic low back pain

Summary Objective: To investigate whether Myofascial release (MFR) when used as an

adjunct to specific back exercises (SBE) reduces pain and disability in chronic low back pain
(CLBP) in comparison with a control group receiving a sham Myofascial release (SMFR) and
specific back exercises (SBE) among nursing professionals.
Design: Randomized, controlled, single blinded trial.
Setting: Nonprofit research foundation clinic in Kerala, India.
Participants: Nursing professionals (N Z 80) with chronic low back pain (CLBP).
Interventions: MFR group or control group. The techniques were administered by physiotherapists certified in MFR and consisted of 24 sessions per client over 8 weeks.
Main outcome measure: The McGill Pain Questionnaire (MPQ) was used to assess subjective
pain experience and Quebec Back Pain Disability Scale (QBPDS) was used to assess the
disability associated with CLBP. The primary outcome measure was the difference in MPQ
and QBPDS scores between week 1 (pretest score), week 8 (posttest score), and follow-up
at week 12 after randomization.
Results: The simple main effects analysis showed that the MFR group performed better than
the control group in weeks 8 and 12 (P < 0.005). The patients in the MFR group reported a
53.3% reduction in their pain and 29.7% reduction in functional disability as shown in the
MPQ and QBPDS scores in week 8, whereas patients in the control group reported a 26.1%
and 9.8% reduction in their MPQ and QBPDS scores in week 8, which persisted as a 43.6% reduction of pain and 22.7% reduction of functional disability in the follow-up at week 12 in the MFR

* Corresponding author. Tel.: 974 55021106.

E-mail address: ajimshaw.ms@gmail.com (M.S. Ajimsha).
1360-8592/$ - see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jbmt.2013.05.007

FASCIA SCIENCE AND CLINICAL APPLICATIONS: RANDOMIZED, CONTROLLED, SINGLE BLINDED TRIAL

Journal of Bodywork & Movement Therapies (2014) 18, 273e281

FASCIA SCIENCE AND CLINICAL APPLICATIONS: RANDOMIZED, CONTROLLED, SINGLE BLINDED TRIAL

274

M.S. Ajimsha et al.

group compared to the baseline. The proportion of responders, defined as participants who
had at least a 50% reduction in pain between weeks 1 and 8, was 73% in the MFR group and
0% in the control group, which was 0% for functional disability in the MFR and control group.
Conclusions: This study provides evidence that MFR when used as an adjunct to SBE is more
effective than a control intervention for CLBP in nursing professionals.
2013 Elsevier Ltd. All rights reserved.

Introduction
Work related chronic low back pain (CLBP), poses a major
health and socioeconomic problem in modern society. It has
been shown that 60e80% of the general population suffers
from low back pain at some time during their lives (Maul
et al., 2003). The 1-year incidence of chronic low back
pain has ranged between 4% and 14% (Lake et al., 2000;
Kopec et al., 2004). Freburger et al. (2009) showed an
increasing prevalence of chronic impairing low back pain
over a 14-year interval from 3.9% in 1992 to 10.2% in 2006 e
an overall increase in the prevalence of low back pain of
162% with an annual increase of 11.6%. Among nurses the
lifetime prevalence was found to be slightly higher, varying
between 73% and 90% (Maul et al., 2003; Knibbe and Friele,
1996; Smedley et al., 1995). Despite these high prevalences, the etiology and the nature of CLBP have not yet
been fully understood. Many studies have been performed
in various occupational settings, indicating a strong association between musculoskeletal disorders and work
related factors (Bernard, 1997). This was also found among
nurses (Lagerstro
m et al., 1998). The contribution of psychosocial factors (Bongers et al., 1993; Thorbjo
rnsson
et al., 1998) and work pressure (Engels et al., 1996) was
also evident, but not as clear as that has been shown for the
physical factors. It has been reported that the majority of
chronic pain patients without spinal pathology have evidence of musculoskeletal dysfunctions, and that remediation of these disturbances leads to reduced pain in many of
the patients (Rosomoff et al., 1989).
Few longitudinal studies have been carried out focusing
on the course of low back pain (LBP). In the clinical
context, chronic LBP is defined as LBP lasting more than
three months. Longitudinal studies found previous LBP to
be a predictor of subsequent complaints (Biering-Srensen,
1983; Thorbjo
rnsson et al., 1998). This is confirmed by results of a five year follow up study indicating that previous
back injury was a significant predictor of subsequent low
back injury among nurses (Maul et al., 2003; Heap, 1987).
Conversely other authors reported no association between
previous and subsequent LBP (Astrand and Isacsson, 1988).
However, Abenhaim et al. (1988) found that 67% of the total
number of episodes reported by nurses within a three year
follow up were recurrences. They suggested the presence
of a link between subsequent episodes, which could be
partly due to an increased sensitivity of a previously injured
spine.
Given these trends, an interest has emerged in the role
of manual medicine in the treatment of low back pain.
Myofascial release (MFR) is a form of manual medicine
which involves the application of a low load, long duration

stretch to the myofascial complex, intended to restore

optimal length, decrease pain, and improve function
(Barnes, 1990). It has been hypothesized that fascial restrictions in one part of the body cause undue tension in
other parts of the body due to fascial continuity. This may
result in stress on any structures that are enveloped,
divided, or supported by fascia (Schleip, 2003). Myofascial
practitioners believe that by restoring the length and
health of restricted connective tissue, pressure can be
relieved on pain sensitive structures such as nerves and
blood vessels. MFR generally involves slow, sustained
pressure (120e300 s) applied to restricted fascial layers
either directly (direct technique MFR) or indirectly (indirect
technique MFR). Direct technique MFR is thought to work
directly on restricted fascia; practitioners use knuckles or
elbow or other tools to slowly sink into the fascia, and the
pressure applied is a few kilograms of force to contact the
restricted fascia, apply tension, or stretch the fascia. Indirect MFR involves application of gentle stretch- the
pressure 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 rationale for these techniques can be traced to various studies
that investigated plastic, viscoelastic, and piezoelectric
properties of connective tissue (Schleip, 2003; Greenman,
2003; Pischinger, 1991).
MFR is being used to treat patients with back pain, but
there are few formal reports of its efficacy. The technique
used in this study is the direct MFR technique, as promoted
by Stanborough (2004). The primary objective of the present study was to evaluate the efficacy of MFR in the
management of CLBP in nursing professionals, treating
fascia in the lower back in accordance with the fascial
meridians proposed by Myers (2009). Clinically, manual
therapy is often combined with exercises that are tailored
to treat specific musculoskeletal dysfunctions (Bookhout,
1996). Although the utility of specific exercises for treating CLBP has received little empirical attention, a review of
the literature by van Tulder et al. (2000) strongly supporting the notion that exercise therapy is more effective than
usual care by a practitioner and/or conventional physical
therapy. Aure et al. (2003) examined the impact of manual
and exercise therapy in persons with chronic, disabling low
back pain. The authors found significant improvements in
both groups on measures of pain and disability, with the
manual therapy group displaying significantly greater gains.

Methods
This study was carried out in the clinical wing of Myofascial
Therapy and Research Foundation, Kerala, India. Inclusion

criteria for this study was nursing professionals aged 20e40

years with a diagnosis of CLBP (defined as pain of 3 or more
months duration), with a primary complaint of CLBP; and
who were judged to have musculoskeletal pain based on
evaluation by the musculoskeletal physician and physical
therapist. Patients were excluded if they displayed: 1)
osteoporosis of the spine; 2) primary joint disease such as
active rheumatoid arthritis; 3) metabolic bone disease; 4)
malignant bone disease; 5) fracture; 6) hyper mobility of
the lumbar/sacral spine; 7) cardiovascular or other medical
disorder preventing the person from engaging in strenuous
exercise; 8) evidence of radiculopathy, or primary
complaint of radiating pain; 9) pregnancy; or 10) severe
psychiatric disturbance. Use of oral/systemic steroids, use
of analgesics on more than 10 days a month and any other
treatment for CLBP during the previous 6 months were also
excluded from the study.
The Research Ethics Committee of the Myofascial Therapy and Research Foundation and Medical Research wing of
Mahatma Gandhi University, Kerala, India, reviewed the
study and raised no objections from an ethical point of
view. Between July 2010 and June 2012, 93 nursing professionals were referred to the Myofascial Therapy and
Research Foundation with a diagnosis of CLBP. Of these, 80
individuals who met the inclusion criteria and provided
written informed consent were randomized to the MFR or to
the control arm of the study. Participants were asked to
maintain a pain and medication diary in which any medication or change in pain pattern during the treatment
period was to be recorded with date and time. Two evaluators blinded to the group to which the participants
belonged analyzed scores from the McGill Pain Questionnaire (MPQ) and Quebec Back Pain Disability Scale (QBPDS).

Outcome measures
Pain
McGill Pain Questionnaire (MPQ) (Melzack, 1975). The MPQ
measures subjective pain experience in a quantitative
form, and consists of twenty groups of single word pain
descriptors with the words in each group increasing in rank
order intensity. The sum of the rank values for each
descriptor based on its position in the word set results in a
score termed the Pain Rating Index (PRI). The Total PRI was
used in the present study as the measure of self-reported
pain intensity, and scores range from 0 to 78. Previous
research found that repeat administration of the MPQ
revealed a 70.3% rate of consistency in the PRI score
(Melzack, 1975).
Disability
Quebec Back Pain Disability Scale (QBPDS) (Kopec et al.,
1995). The QBPDS is a 20-item scale where patients are
asked to rate the amount of difficulty they have performing
various activities of daily living, such as getting out of bed,
walking several miles, and making a bed. Persons are asked
to rate their degree of difficulty ranging from 0 not difficult at all to 5 unable to do. A total score for the scale is
derived by summing the responses to each item, and ranges
from 0 to 100. Test-retest reliability is reported to be 0.93,
and internal consistency is 0.95 (Kopec et al., 1995).

275

Procedure
Subjects in each group received either Myofascial release
(MFR), or a sham Myofascial release (SMFR) along with a
specific back exercise (SBE) program. All subjects watched
a 15-min videotape that provided educational information
on musculoskeletal pain and oriented subjects to the SBE
programs for CLBP.

Interventions
The 2 interventions were provided 3 times weekly for 8
weeks (weeks 1e8), with a minimum of a 1 day gap between the 2 sessions; the duration of each treatment
session was 60 min (40 min for MFR or SMFR and 20 min for
SBE).
MFR procedure
We used the following treatment protocol for all the patients in the MFR group (Stanborough, 2004; Myers, 2009).
The protocol was as follows.
a) MFR of the lower thoracolumbar fasciae and Gluteus
Maximus
Clients Position: Prone
Therapists position: Standing beside the client at the
waistline, working on the contralateral side.
Technique: By using the finger pads of the hands, the
tissue over the PSIS (posterior superior iliac spine) and the
intermediate sacral crest was contacted. Gradually pressure was directed toward the greater trochanter with an
intention to contact the fibrous soft tissue over the bones
(Fig. 1). The treatment was then taken out into the more
muscular fibers of the gluteus muscle. An angle of contact
of 15 was maintained in bony areas and about 45 in
muscular areas. In the muscle, a consistent depth was
maintained. (Duration: 3 min  2 sides Z 6 min) The clients
were encouraged to perform mild active nutation and
counternutation of the sacrum.
b) MFR of the myofascia of the posterior hip & Piriformis

Figure 1 MFR of the gluteal and lower thoracolumbar fasciae

and Gluteus Maximus.

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M.S. Ajimsha et al.

Clients position: prone

Therapists position: Standing beside the client at the
waistline, working on the contralateral side.
Technique: Piriformis muscle was located by an imaginary line drawn between the midpoint of the lateral aspect
of the sacrum and the greater trochanter. A contact was
established in the gluteal area about 3 cm from the sacrum.
With an elbow, a gradual pressure was applied in an anterior direction. When the first layer of resistance was
engaged, a constant pressure was maintained until that
layer softened and the fibers of Piriformis were contacted
(approximately 90 s). A line of tension was taken along the
muscle, in the direction of the greater trochanter. Possibilities of muscle guarding were monitored and the depth of
contact adjusted accordingly (Fig. 2). The lower leg was
lifted off the table to 90 of knee flexion while maintaining
the pressure in the Piriformis. The leg was supported and
guided into internal rotation with an active assistance from
the client with direction. (Duration: 3 min  2
sides Z 6 min).
c) Prone back work e lower
Clients Position: Prone with the lumbar area stabilized
at neutral with a pillow. The feet were bolstered so as to
allow dorsiflexion.
Therapists position: Standing to the side of the table
and facing toward the feet at the level of the clients
waistline.
Technique1: With a blunt elbow, the laminar groove was
contacted at the level of T12 unilaterally (Fig. 3). The
pressure was slowly redirected in an inferior direction. The
contact was intended to focus at the surface (posterior
layer of thoracolumbar fascia and Latissimus dorsi) as well
as the mid-layer muscles (Longissimus and Spinalis thoracis). (Duration: 3 min  2 sides Z 6 min).
Technique 2: The transverse process of L5 was located
by first palpating the L4. With a supported thumb the area
immediately inferior to the L5 process was palpated which
is a small zone of soft tissue between the iliac crest and the

Figure 2

MFR of the Piriformis using an elbow.

Figure 3 Prone release of the lumbar portion of the posterior

layer of thoracolumbar fascia.

L5 vertebra. A sustained pressure was applied to that area

which was repeated to the other side (Fig. 4) (Duration:
2 min  2 sides Z 4 min).
Technique 3: With a soft fist, the soft tissues over the
posterior angle of the lower ribs were engaged with an
intention to release the thoracolumbar fascia, Serratus
posterior inferior, Iliocostalis thoracis and lumborum. The
pressure was gradually redirected from the ribs to the
waistline to engage the thoracolumbar fascia, Transversus
abdominis aponeurosis and Quadratus lumborum. When the
latissimus dorsi and thoracolumbar fascia were contacted,
the client was asked to slowly abduct the ipsilateral arm
followed by the ipsilateral leg. (Duration: 4 min  2
sides Z 8 min) (Fig. 5).
d) Deeper back muscles e lower
Clients Position: Seated with hips higher than the knees,
feet slightly forward of the knees and well connected to

Figure 4

MFR of the multifidus and associated fascia.

277
Technique1: With a soft fist, the soft tissues in the
waistline at the midline of the coronal plane were contacted. Pressure was redirected medially toward the table
and the first layers of resistance were engaged (Fig. 7).
Once the fascia released (approximately 90 s) the pressure
line was redirected in a posterior direction until the PSIS
was contacted. The clients were asked to abduct and
externally rotate the ipsilateral arm followed by knee and
hip extension with ankle dorsiflexion. (3 min  2
sides Z 6 min).

Figure 5
fascia.

MFR to the lateral portions of the thoracolumbar

the ground. The client supports their back via their feet
and legs.
Therapists position: Standing behind the client and
working bilaterally into the thoracolumbar fascia.
Technique1: The knuckles were bilaterally used for the
gradual application of the pressure into the tissues on top
of the lamina groove (Fig. 6). The pressure was firm and
anterior. The clients were asked to apply counter pressure
against the knuckles through their feet, introducing lumbar
flexion at the point of contact. The clients were encouraged to isolate the specific segments on which the pressure
was applied. Once it is isolated, the direction was reversed
(local extension without pelvic tilt) while maintaining the
pressure through the ground via the feet (4 min).
e) The trunk e sides
Clients Position: Side lying, head supported by a pillow.
Hips in 45 of flexion, knees in 35 of flexion.
Therapists position: Standing behind the client at hip
level.

Figure 6

Deeper back muscles e lower.

Control intervention
Patients in the control group received sham Myofascial
release (SMFR) over the same areas as the application of
MFR (in the other group) for 40 min per treatment session,
three times a week for 8 weeks. SMFR were applied by
gently placing the hand over the areas treated in the MFR
group just enough to maintain contact for the desired time.
After the completion of the study, patients in the control
arm were provided MFR therapy, as advised by the ethics
committee. Patients were asked to rate their pain severity
and disability by completing the MPQ and QBPDS before the
treatment (baseline), after treatment (week 8), and after
12 weeks (follow-up).
Specific exercises were taken from Sahrman (2002) and
Bookhout (1997) and combined with self-corrections,
stretches, and strengthening exercises for 20 min per session both for MFR and control groups. Self-corrections
included: 1) anterior innominate self-correction; 2) unilateral prone press-up; 3) pubis self-correction; and 4) pelvic
clock (Bookhout, 1997). Stretches included: 1) supine hip
flexor stretching (Sahrman, 2002); 2) supine hamstring
stretch (Bookhout, 1997); 3) kneeling quadratus lumborum
stretch (Bookhout, 1997); and 4) tensor fascia latae stretch
(Bookhout, 1997). Strengthening exercises included: 1)
lower abdominal progression (Sahrman, 2002); 2) prone hip
extension (Bookhout, 1997); 3) hip abduction/external
rotation side lying (Bookhout, 1997); and 4) gluteus medius
strengthening with hip diagonals (Bookhout, 1997).

Figure 7

MFR to the superficial portion of the waistline.

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M.S. Ajimsha et al.

All study participants were advised to take medications

only when there were any exacerbations, but were required
to record them in their patient diaries, which were
analyzed at weeks 8 and 12 after randomization. Practitioners who provided MFR therapy in this study had been
trained in the techniques for at least 100 h and had a
median experience of 12 months with the technique.

Measure Group

Time

MPQ

23.2
23.0
37.1
35.3

Baseline

QBPDS

Statistics
Participants in both groups were comparable at baseline, as
shown in Table 1. The primary outcome measure was the
difference in MPQ and QBPDS scores between baseline
(pretest score), week 8 (posttest score), and follow-up at
week 12 after randomization. Statistical analysis of the
data was done by using a 2  3 (group  time) analysis of
variance (ANOVA) and 2  2 (group  time) and 2  3
(group  time) repeated-measures ANOVA. The betweengroups (group), within-groups (time), and mixed-groups
(group  time) interactions were examined; then, in
accordance with the primary objective of the study, we
compared the MPQ and QBPDS scores of the MFR and control groups at different time intervals. A P < 0.05 was
accepted as statistically significant.

Results
Of the 80 individuals recruited into this study, 74 participants (MFR group, n Z 38; control group, n Z 36)
completed the study protocol. Two participants from the
MFR group and 4 from the control group dropped out of the
study without providing any specific reason and their data
were excluded from the results presented below. Within
the study period, no serious adverse events occurred in
either of the groups as recorded in the patient diary. Ten
patients from the MFR group and 1 from control group reported an increase of pain in the first week after initiation
of treatment, and this was reported to have subsided within
a week without any medications.
The mean differences between groups vary by time. This
indicates the possible existence of their interaction effect
(Table 2). The patients in the MFR group reported a 53.3%
reduction in their pain and 29.7% reduction in functional
disability as shown in the MPQ and QBPDS scores in week 8,
whereas patients in the control group reported a 26.1% and

Table 1

Table 2 MPQ and QBPDS readings of MFR and control

groups at different intervals.

Summary of baseline characteristics.

Characteristics

MFR group
(n Z 38)

Control group
(n Z 36)

Men: woman
Age (y)
Body mass index
(Kg/m2)
Duration of
Job (y)
Duration of
condition (mo)

9:29
35.8  8.4
27.3  2.6

8:28
34.2  9.3
27.0  2.0

9.8  7.5

8.1  6.9

28.3  14.7

26.8  16.0

Note. Data are mean  SD or as otherwise noted.

MFR
Control
MFR
Control






8.7
7.6
11.8
13.6

Week 8
10.8
17.0
26.0
31.8






Week 12
7.9
9.3
11.1
12.4

13.1
18.3
28.7
32.5






6.9
7.5
9.1
10.4

Note: Data are expressed as mean  SD.

9.8% reduction in their MPQ and QBPDS scores in week 8,

which persisted as a 43.6% reduction of pain and 22.7%
reduction of functional disability in the follow-up at week
12 in the MFR group compared to the baseline. In the
control group the effect persisted as 20.4% for pain and
7.7% for functional disability during follow-up (week 12) in
their MPQ and QBPDS scores respectively. The proportion of
responders, defined as participants who had at least a 50%
reduction in pain between weeks 1 and 8, was 73% in the
MFR group and 0% in the control group; it was 0% for
functional disability in the MFR and control group. We have
examined the effect of group and time on the PRTEE value
by conducting, first, a 2-way ANOVA. The dependent variables, the MPQ and QBPDS values, were normally distributed approximately for the groups, formed by the
combination of the group and time because the size of the
sample is more than 30 for each group. The tests betweensubject effects showed a significant interaction between
the effects of group and time on value (F2,189 Z 522.418,
P < 0.001). The simple main effects analysis (Table 3)
showed that the MFR group significantly performed better
than the control group in weeks 8 and 12 (P < 0.001), but
there were no differences between the groups at baseline
(P > 0.001).
A 2  2 (group  time) repeated-measures ANOVA and a
2  3 (group  time) repeated-measures ANOVA were also
conducted. The first 2  2 repeated-measures ANOVA represented the beginning and week 8, whereas the second
2  2 repeated-measures ANOVA represented the beginning
and week 12. The significant values of Mauchly sphericity
tests for both of the 2  2 repeated ANOVAs indicate that
for the main effects of time, group, and the time  group
interaction, the assumption of sphericity is met. On the
other hand, for the 2  3 repeated-measures ANOVA, the
significance values of the Mauchly criterion tests indicate
that the main effects of time and the group  time interaction have violated the sphericity assumption, so we need
to correct the F ratios for these effects. There were significant main effects of time, group, and the time  group
interaction. Because all P values from the 4 statistics (Pillai
trace, Wilk , Hotelling trace, Roy largest root) are
P > 0.001 (for all the ANOVAs), 2 within-subject (time and
group) effects and their interaction effect are significant in
the models with the multivariate test. We observed that
the interactions between time and group were significant
based on univariate and multivariate methods for all 3
repeated-measures ANOVAs. Significant pairs of MFR and
control groups vary at weeks 8 and 12 due to the interaction
effect between group type and time.

Table 3

279

Pair wise comparisons of group and time.

MPQ

QBPDS

Time

Group I

Group II

Mean difference
(Group I value  Group II value)

SE

Pa

Baseline
Week 8
Week 12
Baseline
Week 8
Week 12

Control
Control
Control
Control
Control
Control

MFR
MFR
MFR
MFR
MFR
MFR

1.000
4.813b
3.250b
0.971
3.413b
2.023b

0.548
0.810
0.624
0.435
0.688
0.532

0.133
0.000
0.000
0.472
0.000
0.000

Note: Based on estimated marginal means.

a
Adjustment for multiple comparisons: least significant difference (equivalent to no adjustment).
b
The mean difference is significant at the 0.05 level.

Discussion
The principal finding in this concept study is that the MFR
intervention tested was significantly more effective than
SMFR for decreasing the pain and functional disability of
CLBP when given as an adjunct to specific back exercises
(SBE).
The biopsychosocial model of chronic pain has gained
widespread acceptance as the appropriate model for understanding chronic pain, and has lead to the development
of treatments emphasizing multidisciplinary care (Gatchel
et al., 1995) and functional restoration (Hazard et al.,
1989; Mayer et al., 1987). It has been reported that the
majority of chronic pain patients without spinal pathology
have evidence of musculoskeletal dysfunctions, and that
remediation of these disturbances leads to reduced pain in
many of the patients (Rosomoff et al., 1989). In addition,
factors such as pain-related fear have been found to be
associated with decreased lumbar flexion and muscle firing
abnormalities among persons with CLBP, even when controlling for clinical pain intensity (Geisser et al., 2004;
Watson et al., 1997). Maul et al. (2003) in their eight year
longitudinal follow up study concluded that CLBP among
nursing professionals is having a recurrent rather than an
aggravating course. Abenhaim et al. (1988) suggested the
presence of a link between subsequent episodes, which
could be partly due to an increased sensitivity of a previously injured spine. Repetitive strain and reduced flexibility can enhance musculoskeletal dysfunctions by
inducing repetitive microtraumas in the low back region
with subsequent lack of repair in the soft tissues and
replacement with immature reparative tissue. Although
the tensile strength of the healing tissues improves over
time, it does not reach the levels of uninjured, healthy
tissue.
MFR has been reported to reduce pain and improve
quality of life in lateral epicondylitis (Ajimsha et al., 2012),
tension headaches (Ajimsha, 2011), idiopathic scoliosis
(LeBauer et al., 2008), Raynaud phenomenon (Walton,
2008), and in systemic sclerosis (Martin, 2009). A study by
Meltzer et al. (2010) has shown that treatment with MFR
after repetitive strain injury resulted in normalization in
apoptotic rate, cell morphology changes, and reorientation
of fibroblasts. It is possible that treatment with MFR in CLBP
patients may result in a halt in the repetitive injury process
of the soft tissues at the lower back by facilitating the

healing process and the soft tissue architecture to return

toward normality. According to Schleip (2003), under
normative conditions, fascia and connective tissues tend to
move with minimal restrictions. However, injuries resulting
from physical trauma, repetitive strain injury, and inflammation are thought to decrease fascial tissue length and
elasticity, resulting in fascial restriction. It is also possible
that pain relief due to MFR is secondary to returning the
fascial tissue to its normative length by collagen reorganization; this is a hypothesis that merits investigation. As
with any massotherapy techniques, the analgesics effect of
MFR can also be attributable to the stimulation of afferent
pathways and the excitation of afferent A delta fibers,
which can cause segmental pain modulation (Melzack and
Wall, 1965) as well as modulation through the activation
of descending pain inhibiting systems (Le-Bars et al., 1979).
However, the follow-up at week 12 has shown that the
treatment effects were less evident compared with week 8
after the treatment. This may be explained because, at the
12-week follow-up, the treatment effect obtained may be
disguised by the continuation of the job in the same environment or by the natural course of the chronic low back
pain.
The results of the study indicate that subjects receiving
Myofascial release (MFR) in adjunct with Specific Back Exercises (SBE) displayed significant improvements in pain and
functional disability when comparing to the pre-treatment
level. The present study supports the notion by Aure et al.
(2003) that manual therapy and specific adjuvant exercise
have a significant impact on disability. As deconditioning
has been proposed to play a role in chronic pain disability
(Hazard et al., 1989; Mayer et al., 1987), it possible that
subjects receiving MFR and SBE may have improved their
exercise conditioning and low back flexibility, which in turn
improved their functional status.
The findings of the present study do not support the
notion that MFR and SBE alone are effective in treating
CLBP. Multidisciplinary interventions addressing psychosocial factors that contribute to the experience of pain
appear to have the greatest efficacy in treating chronic
pain (Gatchel et al., 1995). However, MFR and SBE may be
beneficial components of multidisciplinary treatment, and
if used alone, may be beneficial for a subgroup of
persons with CLBP. In summary, MFR with SBE appears to
be efficacious in the treatment of CLBP in nursing
professionals.

FASCIA SCIENCE AND CLINICAL APPLICATIONS: RANDOMIZED, CONTROLLED, SINGLE BLINDED TRIAL

Effectiveness of Myofascial release for low back pain

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280

Study limitations
One limitation of this trial was that practitioners could not
be blinded. Second, long-term outcomes were not
assessed, and it is not known whether the differences
observed at post-treatment can be maintained over a long
time. We also did not examine other important treatment
outcomes such as pain beliefs, mood, and quality of life.

Conclusions
This study provides evidence that MFR when used as an
adjunct to SBE is more effective than a control intervention
for CLBP in nursing professionals. A significant proportion of
nursing professionals with CLBP might benefit from the use
of MFR. The mechanisms underlying these responses merit
further investigation.

Acknowledgments
This research was supported by a grant from the Mahatma
Gandhi University, Kottayam, India.
We thank all the practitioners and professionals of
MFTRF, India and the physicians who participated in the
consensus process and analysis to establish the trial interventions. We are expressing our special gratitude to Mr.
R. Nanda Gopan, Assistant Professor, PSG College of Physiotherapy, Tamilnadu, India for his manuscript language
analysis.

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Effectiveness of Myofascial release for low back pain