published 8/13/09, updated 3/22/10

A Review of Myofascial Release (MFR) Therapy

Concepts and controversies in one of the most popular of all styles of manual therapy

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

There is considerable public and professional confusion about the terms “myofascial” and “fascial” in combination with the words “therapy” and “release.” It’s important for therapy consumers to understand that “myofascial release” can mean pretty much anything a therapist wants it to mean, as long as it has something to do with muscle (myo), fascia (connective tissue) and any kind of therapy that allegedly “releases” these things.

Patients often ask me, “What do you think of myofascial release?” But “myofascial release” is such a vague and abused term that it could refer to virtually anything I’m doing to my patient at the moment they happen to ask.

Myofascial release according to Barnes

The words “myofascial release” particularly refer to a proprietary treatment modality, as promoted by John F. Barnes, the physical therapist who publishes www.MyofascialRelease.com. MFR is a classic example of what I call a “modality empire.”1

Barnes successfully sells several workshops, books and tapes, and a great deal of therapy at his four American clinics. He boasts in a recent article in Massage Magazine: “I have trained more than 50,000 therapists and physicians who are achieving these kinds of important results on millions of clients per month.”2

Myofascial release according to Myers and others

Although John Barnes is the face and champion of MFR, many other therapists promote MFR-ish modalities as well. There is considerable overlap between MFR and other therapies, especially ROLFING® and various forms of “structural integration.” Many therapists first encounter MFR’s core ideas in the popular writings and workshops of Tom Myers of Anatomy Trains® (www.AnatomyTrains.com) — another successful modality empire that overlaps MFR so much that the two are nearly indistinguishable. I wonder to what degree they are competitors, or synergistic?

The same therapy style is often shortened to just “fascial release” (or fascial therapy or fascial stretching). When I was in school in 1999, I did an internship with a particularly popular therapist with a bad case of “healer syndrome” — the belief that you are God’s gift to patients — who taught and practiced an incredibly painful style of fascial release, which is still the most extreme example I have ever seen. To this day, the term “fascial release” seems to be particularly common in my area. As far as I can tell, the treatment philosophy is precisely the same as MFR.

Many massage therapists seem to be thrilled with MFR and similar ideas, regarding them as the bleeding edge of bodywork.

More terminology: Myo, fascial, and release

“Myo” is the Latin prefix for muscle, and “fascia” refers to the sheets of connective tissue that wrap everything in our anatomy. Gristle in a steak is cow fascia.

Fascia is an integral component of the muscular system (as it is of all systems). It certainly is neat stuff.3 4 Barnes and Myers call it a physiological system itself, but that’s a bit of an exaggeration. It may have some system-like qualities, but it’s definitely not a physiological system — it’s a component of all systems.

So, referring to “myofascial” anything is basically the same as referring to “the muscular system” and the connective tissues that permeate it.

And what about this “release” stuff? Well, “release” sounds good. Who wouldn’t want to be released? It implies that something is stuck and must be unstuck.

MFR versus massage therapy

What’s the difference? MFR certified therapists are unlikely to describe their technique as “therapeutic massage” — certainly not after having paid thousands of dollars to John Barnes for workshops to become certified in MFR.5 MFR is allegedly an advanced treatment system, much superior to the garden variety tools of the average massage therapist. While “ordinary” massage therapy has been around for decades, MFR founder John Barnes says that MFR is an “innovative and effective whole-body approach” that “has exploded on the therapeutic scene with an impact and degree of acceptance unprecedented in the history of healthcare.”

MFR is a collection of “a multitude of Myofascial Release techniques and movement therapy,” a great deal of which overlap with other popular manual therapies.6 If there is anything unique about MFR, it is a few techniques devoted to stretching fascia. This is the central idea of MFR, and this is the idea that I’m reviewing.

The term “myofascial therapy” often involves a certain amount of marketing and even regulatory avoidance

In many places, it is illegal to call yourself a “massage therapist” without training and government certification. The words “massage therapy” are “protected.” But “myofascial release” is not protected, and yet also virtually interchangeable with “massage therapy.” So, poorly trained therapists often call themselves “myofascial therapists” to get around the law and make themselves sound more like therapists than they are.

Naturally, this is an irritation not only to doctors and other mainstream health care professionals, but to well-trained massage therapists as well. Certification is supposed to reduce public confusion about the nature of massage therapy. Unfortunately, chaos rules: literally tens of thousands of unlicensed, barely-trained practitioners are out there calling themselves “myofascial therapists” — and many of them may even be fine people (many of them might even be you, dear readers — many of my customers are professionals in that category trying to learn more about trigger point therapy). But, make no mistake about it, the public is understandably confused.

MFR and myofascial trigger points

And there’s yet another point of confusion with the term “myofascial.”

“Myofascial trigger points” is the formal, technical term wisely prescribed for general use by Travell and Simons.7 It is the “correct” term for the phenomenon of muscle knots. It is specific and should not be confused with “myofascial release,” though the concepts do have some overlap — a therapist describing myofascial release might well be referring to therapy for myofascial trigger points.

MFR proponents claim that MFR techniques are essential for effective treatment of myofascial trigger points. I discuss this claim more in my trigger points tutorial. I disagree — after a decade of delving deeply into the subject of trigger points, I am unaware of evidence that any single form of therapy is clearly more effective at getting rid of trigger points.

MFR’s claims are vague

The rationale for MFR is not clear and consistent amongst its promoters. I do not understand from their descriptions exactly what must be done to help patients and why. Rather than explaining a specific mechanism, MFR practitioners tend to focus on general excitement about the physiological complexity of fascia, and dramatic claims of therapeutic effect. Barnse’s 2009 article in Massage Magazine (previously cited) is an excellent example. He writes:

The fascial system functions as a fiber-optic network that bathes each cell with information, energy, light, sound, nutrition, oxygen, biochemicals and hormones and flushes out toxins at an enormous speed.

Barnes never specifies or clarifies what he means by any of this (anywhere), or how he thinks he knows it. He is generally impressed at how allegedly marvellous and complex fascia is, but does not say how manipulation of such a system leads to a therapeutic effect — only that it does.

The consistent, profound results of myofascial release are so impressive, even when all else has failed, critics have said it is impossible because it breaks the laws of science. I have trained more than 50,000 therapists and physicians who are achieving these kinds of important results on millions of clients per month. Therefore, a more realistic perspective may be that science is flawed.

Exciting and colourful language are fine — in marketing. In health care, humility is a greater virtue.

Fascia is everywhere

Fascia’s clinical importance is often attributed to the fact that it is everywhere, and that it has functions unknown — or barely known — to science. This has been broadly true of lot of tissues throughout medical history. For instance, blood is everywhere, and we still do not understand its physiology all that well.8

MFR emphasizes the interconnectedness of anatomy via fascia, always implying that pulling on any one part of fascia affects the whole body, like — and this is the inevitable analogy — pulling on the corner of a sweater affects all the threads. (This sweater analogy appears virtually everywhere online that MFR is discussed.)

The central idea is that this stuff can get tight and restrictive, and then needs to be released, and that therapists can achieve this by various methods of yanking on it. The yanking may be extremely intense, too — fascial therapy can be one of the most painful of all hands-on techniques.

Another key idea is the fascia’s mysterious properties can be exploited for therapeutic effect: that there’s something about fascia that, when it is stretched, enables it to heal or stimulate healing.

All of these ideas can and should be questioned.

Is it possible to “loosen” fascia?

If MFR can’t “loosen” fascia, it’s game over: MFR without fascial stretching would be like chiropractic without joint popping. This central claim of MFR must hold up, or the rest of the vague ideas and excitement packaged with it are a largely moot point.

Unfortunately for MFR, fascia is extremely tough stuff, like sheets of flexible iron. It has lots of natural elasticity, and there are strict limits on that elasticity. Pull it hard enough and it will tear, but that’s extremely difficult and painful — it’s an injury! Pull it less hard and it simply sproings back to the way it was.

Slow, steady microtearing (“wicking”) might achieve what’s known as “remodelling” — ripping it ever so slightly and then allowing it to heal — but this would require extraordinary intensity and persistence, and the effects would be difficult to predict. For instance, the tissue might well “heal” with no significant change in extensibility, or even less.

Manipulation of fascia undoubtedly temporarily softens it via thixotropic effect — but that’s just a minor and very temporary change in texture, not a lasting change in extensibility that could have any meaningful therapeutic effect.

Perhaps “loosening” could be achieved by tearing adhesions between layers of fascia? This is vaguely plausible. Fascia does stick together, Velcro-like, and when this process advances far enough it can cause significant limitations. Strong pressure can tear them loose. The fascia itself isn’t being stretched, but there is something you could call a “release” there. But adhesions aren’t an important clinical phenomenon in very many people! Like bed sores, they tend to matter to people with pretty significant injuries, spasticity and paralysis. The average person with back pain isn’t likely to have adhesions of any importance.

I think there is very little (maybe even nothing) that a therapist can do to change or “loosen” fascia. At best, it’s just not clear how it can be achieved in any practical or lasting way.

Fascia is tough stuff, like sheets of flexible iron.

Like so many other manual therapies, MFR cannot actually demonstrate that it can do the central thing that it claims it can do. Craniosacral therapists can’t demonstrate that they can move skull bones;9 chiropractors can’t find “subluxations” to correct;10 massage therapists can’t agree on the diagnosis of trigger points.11

Spookier possibilities? Magic fascia?

It is not out of the realm of possibility that manipulation of fascia has complex or subtle physiological effects, due to the potentially surprising nature of fascia. Maybe MFR does some good in this way, without physically “loosening” anything. We’ll just overlook for a moment the fact that virtually all MFR therapists talk as if “loosening” is actually happening, and imagine a world where MFR works because fascia is “special.”

The scientific mystery thing cuts both ways. Either fascia is a bit mysterious … or it is not. Either fascia has functions barely known to physiologists … or it does not. If it is not mysterious, and is pretty much what it appears to be — gristle — then there is no basis for MFR.

But if it is mysterious, then why do MFR therapists claim to have fine-tuned control over that behaviour? And not just control, but the ability to produce reliable therapeutic effects with it?

The problem with trying to exploit subtle and poorly understood physiological complexity is that it’s pretty hard to be sure that you know what you are doing — it’s mysterious, after all. If there’s anything we can all absolutely agree on it, it’s that biology is mind-bogglingly complex. So why do MFR therapists believe that they not only “get it” better than biologists, but that they “get it” so well that they can use the knowledge to get specific, helpful physiological effects?

It’s a bit daring to claim that you can do something really well that no one else can do at all, based on your masterful understanding of something no else understands.

The acupuncture connection

A particularly popular idea in MFR is the notion that the meridians of Chinese medicine correspond directly to fascial anatomy. If you polled MFR therapists, I think you would find that nearly all of them believe that MFR is doing the same thing that acupuncture is doing. MFR therapists believe that MFR works for the same reasons. Most MFR therapists probably believe that acupuncture works.

Unfortunately for MFR, acupuncture has been consistently failing fair scientific tests for years now,12 so the association between MFR’s “fascial meridians” and TCM’s “qi meridians” is of dubious value. If the acupuncturists can’t manipulate these meridians effectively enough to achieve clear, reliable therapeutic effects, why would pulling on fascia be able to do it?

Is there any evidence that MFR works despite the controversies ?

Any honest person would forgive MFR its theoretical uncertainties as long as it actually worked. If it works, great! We’ll figure out why eventually. This is the spirit of evidence-based medicine.

However, I am not aware of any tests of the effectiveness of MFR therapists working on patients with significant pain problems of any kind. Scientific testing has not yet shown that MFR works. The sole study done to date in which MFR was compared directly to another therapy — an “isometric contract-relax technique” — found it to be inferior.13

That’s right: MFR was less effective than clenching and relaxing muscles. This is a classic example of a test of therapy failing to impress — which it should be able to do quite easily if it’s even half as great as advertised. If it works, where’s the easily obtained proof? If it works even half as well as claimed, it should be easy to produce a few studies demonstrating its potency. I look forward to reading the results of that research.

What’s New In this Article?

March 22, 2010 — Corrected some typographic errors and updated a couple references.

February 2, 2010 — Edited for length and readability. The article is much less wordy now.

Notes

“Modality empire” is my own term for a proprietary method of manual therapy — a sub-discipline — championed and promoted by a single entrepreneur. Most have healer syndrome, make big promises, and profit from unusually expensive therapy and workshops. Professionals are sold on the opportunity to purchase credibility in the form of increasing “levels” of certification, but the quality of these certifications is completely unregulated and often dubious. A modality empire is as much a business model as a method of helping people. There is a great deal of overlap between modality empires and quackery. Classic examples of modality empires include Ida Rolf’s ROLFING®, John Barne’s myofascial release, and John Upledger’s craniosacral therapy. Sometimes a modality empire is particularly unoriginal, re-packaging old ideas for a new generation of workshop consumers, like Paul St. John’s take on trigger point therapy (St. John Neuromuscular Therapy™). Return to text.
Myofascial Release Perspective: Therapeutic Insight—Fascia, a Liquid-Crystalline Matrix Return to text.
From Wikipedia: Fascia “is the soft tissue component of the connective tissue system that permeates the human body. It interpenetrates and surrounds muscles, bones, organs, nerves, blood vessels and other structures. Fascia is an uninterrupted, three-dimensional web of tissue that extends from head to toe, from front to back, from interior to exterior.” Return to text.
Fascia probably has some fascinating physiological properties. MFR proponents never tire of pointing this out — that fascia isn’t “dead,” that it’s a complex tissue — as if medical science is blind and stupid to this simple fact. It’s true, fascia was once viewed as an inert, Saran-Wrap-like substance with nothing interesting going on. But that was a long time ago! Fascia has long been widely recognized by physiologists and doctors for some of its intriguing properties. Exactly what those properties are and how to exploit them therapeutically is an entirely different matter, however. Return to text.
Prices for several different workshops advertised on www.MyofascialRelease.com cost between USD $750 and $1800, as of August 12, 2009. Unless otherwise specified, all quotations attributed to Barnes are from Barnes’ website as of August 12, 2009. Return to text.
Barnes writes, “We promote independence through education in proper body mechanics and movement, through the enhancement of strength, flexibility, and postural and movement awareness.” That’s an awful lot of stuff that MFR doesn’t have exclusive rights to! Return to text.
Travell and Simons both wrote often, and at length, about the importance of a consistent nomenclature for trigger points. One of the most serious problems with the history of trigger point science is that they have been “discovered” by so many different researchers and doctors, and given different names, creating a real mess of overlapping and imprecise jargon and terminology. Return to text.
Just like many chiropractors still believe that nerves control every aspect of physiology (they really don’t), osteopaths started their profession with the nearly identical idea that blood was the great regulator of everything, and that the key to all health care was to ensure good blood flow. Medical science advanced and it became clear that blood flow, while important, is hardly the only thing required for health! Return to text.
Downey et al. Journal of Orthopaedic & Sports Physical Therapy. 2006. This study tried to show the effects on the skulls and cerebrospinal fluid circulation of rabbits. The researchers found that “low loads of force, similar to those used clinically when performing a craniosacral frontal lift technique, resulted in no significant changes in coronal suture movement or intracranial pressure in rabbits.” In short, if you can’t move rabbit skull bones or change their intracranial pressure, it’s safe to assume that you probably can’t do it to humans either — and without that mechanism in good working order, craniosacral therapy has no basis at all. The researchers concluded: “These results suggest that a different biological basis for craniosacral therapy should be explored.” But, of course, a “different biological basis” for craniosacral therapy has never even been suggested, let alone tested. Return to text.
French et al. Journal of Manipulative & Physiological Therapeutics. 2000. I do enjoy reliability studies, and this is one of my favourites. Three chiropractors were given twenty patients with chronic low back pain to assess, using a complete range of common chiropractic diagnostic techniques, the works. Incredibly, assessing only a handful of lumbar joints, the chiropractors agreed which joints needed adjustment only about a quarter of the time (just barely better than guessing). That’s an oversimplification, but true in spirit: they couldn’t agree much, and researchers concluded that all of these chiropractic diagnostic procedures “should not be seen … to provide reliable information concerning where to direct a manipulative procedure.” Return to text.
Lucas et al. Clinical Journal of Pain. 2009. Return to text.
For more detail, see another article on SaveYourself.ca, Does Acupuncture Work for Pain? Evidence now clearly shows that acupuncture can’t help people with common chronic pain problems, especially low back pain and neck pain. Return to text.
Remvig et al. “Myofascial Release: An evidence-based treatment approach?” International Musculoskeletal Medicine. 2009. Full Abstract:
OBJECTIVES: To assess the current state of scientific knowledge about myofascial release, a noninvasive manual treatment technique, and to identify the reliability of diagnostic tests for myofascial dysfunction and efficacy of the treatment.

METHODS: A literature search was undertaken, as well as exploring more widely for information concerning the subject, allowing an assessment of the rationale for the treatment and of the studies carried out.

RESULTS: Twenty-three items were identified in the literature search. No studies were found with which to determine reliability of the diagnostic method, but four randomised controlled studies of the treatment were identified. Two of the efficacy studies comprised several different modalities of treatment, so that no conclusions could be drawn. In one further study, the numbers were too small to allow safe conclusions; in the other, the myofascial release treatment was inferior to an isometric contract-relax technique. Overall, no good evidence of efficacy has been shown.

CONCLUSIONS: We are unable to reach any conclusion on the diagnostic criteria and methods or on any efficacy of myofascial release. We recommend strongly that reliability studies be performed on diagnostic tests for myofascial dysfunction (tightness/looseness), so that efficacy studies can be performed on a more solid diagnostic foundation.
Return to text.