A pilot study of myofascial release therapy compared to Swedish massage in Fibromyalgia

A pilot study of myofascial release therapy compared to Swedish massage in Fibromyalgia
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  This article appeared in a journal published by Elsevier. The attachedcopy is furnished to the author for internal non-commercial researchand education use, including for instruction at the authors institutionand sharing with colleagues.Other uses, including reproduction and distribution, or selling orlicensing copies, or posting to personal, institutional or third partywebsites are prohibited.In most cases authors are permitted to post their version of thearticle (e.g. in Word or Tex form) to their personal website orinstitutional repository. Authors requiring further informationregarding Elsevier’s archiving and manuscript policies areencouraged to visit:  Author's personal copy FASCIA SCIENCE AND CLINICAL APPLICATIONS: QUASI-EXPERIMENTALPILOT STUDY A pilot study of myofascial release therapycompared to Swedish massage inFibromyalgia Ginevra Liptan, MD a, *, Scott Mist, PhD, MAcOM b ,Cheryl Wright, PhD, FNP-BC b , Anna Arzt, DNP, FNP-BC b ,Kim Dupree Jones, PhD, FNP-BC a,b a The Frida Center for Fibromyalgia, 6400 SW Canyon Ct., Ste 100, Portland, OR 97221, USA b OHSU School of Nursing, 3455 SW US Veterans Hospital Rd., Portland, OR 97239, USA Received 28 February 2012; received in revised form 18 October 2012; accepted 22 November 2012 KEYWORDS Fascia;Fibromyalgia;Myofascial release;Massage therapy;Central sensitization;Swedish massage Summary  Fibromyalgia (FM) is characterized by widespread muscle pain and soft tissuetenderness. However, a lack of definitive muscle pathology has made FM both a diagnosticand a treatment puzzle. Much of the evidence for pathology in FM lies in the central nervoussystem e in particular abnormal amplification of pain signals in the spinal cord e a manifesta-tion of central sensitization. An emerging body of evidence posits that peripheral pain gener-ated from the muscles and fascia may trigger and maintain central sensitization in FM.SinceFMpatientssofrequentlyseekmanualtherapytorelievemusclesymptoms,thepresentstudy compared two different manual therapy techniques in a parallel study of women with FM.Eightsubjectsreceivedmyofascial release(MFR)whilefour subjectsreceivedSwedishmassage,90 min weekly for four weeks. Overall symptom burden and physical function were assessed bythe Fibromyalgia Impact Questionnaire Revised (FIQ-R).A unique challenge for the manual therapist in treating conditions involving central sensitiza-tion is to determine if localized pain reduction can be achieved with targeted therapy in thecontextofongoingwidespreadpain.Localizedpainimprovementwasmeasuredbyanovelques-tionnaire developed for this study, the modified Nordic Musculoskeletal Questionnaire (NMQ).Between-groupdifferencesinFIQ-Rdidnotreachstatisticalsignificance,butthetotalchangescores on FIQ-R for the MFR group (mean Z 10.14, SD Z 16.2) trended in the hypothesized andpositive direction compared to the Swedish massage group (mean Z 0.33, SD Z 4.93) yieldinga positive Aikin separation test. Although overall modified NMQ scores improved in both groups * Corresponding author. Tel.:  þ 1 503 477 9616; fax:  þ 1 503 477 9808. E-mail address: (G. Liptan).1360-8592/$ - see front matter   ª  2012 Elsevier Ltd. All rights reserved.  Available online at journal homepage: Journal of Bodywork & Movement Therapies (2013)  17 , 365 e 370      F     A     S     C     I     A     S     C     I     E     N     C     E     A     N     D     C     L     I     N     I     C     A     L     A     P     P     L     I     C     A     T     I     O     N     S    :     Q     U     A     S     I   -     E     X     P     E     R     I     M     E     N     T     A     L     P     I     L     O     T     S     T     U     D     Y  Author's personal copy therewerenoconsistentfocalareasofimprovementfortheSwedishmassagegroup.Incontrast,the MFR group reported consistent pain reductions in the neck and upper back regions on theNMQ. These data support the need for larger randomized controlled trials of MFR versus other massage techniques and support the assessment of localized pain reduction in future manualtherapy studies in FM. ª 2012 Elsevier Ltd. All rights reserved. Background/significance Fibromyalgia (FM) is a syndrome of widespread musclepain and fatigue that affects between 2 and 3 percent ofthe U.S. population, with similar numbers worldwide(Lawrence et al., 1998; White et al., 1999; Wolfe et al., 1995). FM is defined as a self-report of at least threeconsecutive months of widespread musculoskeletal pain,with tenderness at a minimum of 11 of 18 specific softtissue tender points on physical examination as estab-lished diagnostic criteria (Wolfe et al., 1990). Although FM is characterized by muscle pain, the preponderance ofevidence to date points to pathology in the centralnervous system. In particular, three decades of researchhas demonstrated augmentation of pain processing in FM(Gracely et al., 2002; Staud et al., 2004; Jensen et al., 2009; Robinson et al., 2011). This exaggerated nervous system response to pain is a phenomenon termed ‘centralsensitization’. Central sensitization occurs when there ispersistent peripheral nociceptive input leading to anincreased excitability of the dorsal horn neurons of thespinal cord. There is persuasive evidence that chronic painrepetitively activates both A-delta and C fibers, whichstimulate the release of neurotransmitters and neuro-modulators such as substance P, nerve growth factor,glutamate and calcitonin gene-related peptide (Urban andGebhart, 1999). These neurochemicals sensitize neurons insuch a manner that they become hyperexcitable andrespond inappropriately to low/normal levels ofstimulation.However, in an illness whose primary complaint ismuscle pain, the muscles cannot be ignored. In fact,muscle may play a key role in triggering the central nervoussystem sensitivity observed in FM (Staud, 2011). An emerging body of evidence points to peripheral paingenerated from muscle and fascia as the trigger of centralsensitization in FM. Myofascial trigger points are spots ofexquisite muscle tenderness and hyperirritability, and FMmuscles have significantly more trigger points than dohealthy muscles (Alonso-Blanco et al., 2011). A recent double blind study found that myofascial trigger pointinjections not only relieved regional muscle symptoms butalso reduced global pain sensitivity in FM subjects .Theauthors conclude that ‘localized muscle/joint pains impactsignificantly on FM, probably through increased centralsensitization by the peripheral input; their systematicidentification and treatment are recommended’ (Affaitatiet al., 2011).Reducing regional FM muscle pain through lidocaineinjections has also been shown to diminish pain directly atthe injection site as well as contralateral hyperalgesia andwind up, both important components of centralsensitization (Staud et al., 2009). These studies indicate that targeting peripheral muscle pain generators canimprove both local pain and reduce central pain sensitivity.Addressing local muscle pain is therefore an importanttherapeutic goal in FM.Many FM patients already try to target muscle painlocally  e  manual therapies are used by 44 e 75% of FMpatients (Barbour, 2000; Wahner-Roedler et al., 2005). The most frequently chosen technique is Swedish massage,which typically consists of moderate pressure stroking ofthe neck, back, legs and arms with the goal to increasecirculation and promote general relaxation. Many massagestyles have been examined in FM, but to date no studieshave directly compared two different techniques. Twosingle-arm studies and six randomized controlled trials haveassessed various massage techniques including Swedishmassage, shiatsu, mechanical deep massage, connectivetissue massage, and manual lymphatic drainage. All ofthese studies found short-term reduction in FM symptoms,but only one single-arm study showed long-term benefits(Kalichman, 2010).Recentlythepain-generatingroleoffasciainmaintainingFM symptomshasbeensuggested,raisingthepossibilitythatmanual therapies that specifically target the fascia mayprovidemoreeffectiveFMpainreduction(Liptan,2010).The fascia surrounding skeletal muscle is a highly innervatedconnective tissue. Its principal cell is the fibroblast, whichregulates inflammation and tissue repair. Fibroblast activa-tion is induced by various stimuli that occur with tissueinjury. In vitro modeling reveals that repetitive mechanicalstraining of fibroblasts induces changes in cellular morphology and secretion of inflammatory mediators (Doddet al., 2006). Biopsy studies have demonstrated excessivelevels of collagen and inflammatory mediators in the fasciaofsubjects withFM(Ru¨steretal.,2005;Spaethetal.,2005). These findings suggest the presence of tissue injury in FMfascia similar to that seen in repetitive strain injuries(Sharma and Maffulli, 2006).Myofascial release therapy (MFR) is a combination ofmanual traction and prolonged assisted stretching maneu-vers designed to break up fascial adhesions. In vitromodeling of simulated MFR on fibroblasts injured byrepetitive strain resulted in normalization of cellmorphology and attenuation of inflammatory responses(Meltzer et al., 2010).Two recent studies by Castro-Sa´nchez and colleaguesfound that MFR was effective in reducing FM pain, and alsoprovided durable pain reduction which persisted at onemonth and to a lesser extent at six months post-intervention (Castro-Sa´nchez et al., 2011a, 2011b). Thepresent pilot study compares Swedish massage directly toMFR  e  a head to head comparison that has not been366 G. Liptan et al.      F     A     S     C     I     A     S     C     I     E     N     C     E     A     N     D     C     L     I     N     I     C     A     L     A     P     P     L     I     C     A     T     I     O     N     S    :     Q     U     A     S     I   -     E     X     P     E     R     I     M     E     N     T     A     L     P     I     L     O     T     S     T     U     D     Y  Author's personal copy performed previously. Since MFR more directly targets theproposed peripheral pain generators residing in the fasciawe hypothesize it will produce more effective pain reliefthan Swedish massage for FM subjects. Methods Design This quasi-experimental pilot study enrolled a conveniencesample of 12 women with FM. Inclusion and exclusion criteria Study subjects were between the ages of 21 and 50, witha confirmed diagnosis of FM established by 1990 ACRcriteria (Wolfe et al., 1990). Participants had to be on a stable regimen of pharmacological and/or non-pharmacological treatment for FM the previous threemonths leading up to study period and agree to maintaintheir present medication unchanged for the duration oftheir participation in the study. Exclusion criteria were painconditions not associated with FM such as diabeticneuropathy, lumbar or cervical disc disease, or severedepression. Subjects were excluded if they were currentlyreceiving any form of manual therapy such as massage,MFR, Rolfing, chiropractic, or physical therapy, or if theystated an intolerance to touch. Also excluded were anysubjects undergoing disability application or involved inlitigation or scheduled elective surgery during the studyperiod. Protocol All subjects were evaluated at pre-intervention, prior toeach therapy session, and at two weeks post-intervention.All subjects received 90 min of massage once weekly for four weeks consecutive weeks, totaling six treatment hoursper subject. Three therapists delivered the intervention.Each was a licensed massage therapist with experiencetreating FM patients with both Swedish massage andadvanced training in MFR. For each Swedish massagesession, the therapist utilized moderate pressure strokingof the neck, back, legs, and arms. MFR therapy consisted ofprolonged assisted stretching of painful areas of soft tissueof the neck, back, arms, and legs. The study was approvedby Oregon Health & Sciences University Internal ReviewBoard, and a signed consent form was obtained from allsubjects. Measures The primary outcome measure was the Fibromyalgia ImpactQuestionnaire Revised (FIQ-R), a 21-item self-reportinstrument assessing FM primary symptoms, physical func-tion deficits, and quality of life. This is an updated versionof an extensively validated measure with higher numbersindicating more severe symptoms and impaired physicalfunction (Bennett et al., 2009a). The FIQ-R was used to determine if further study was indicated, based on Aickinseparation testing (Aickin, 2004).In order to measure localized improvement in pain in thecontext of widespread, chronic pain, we modifiedthe Nordic Musculoskeletal Questionnaire (NMQ). This vali-dated tool assesses musculoskeletal complaints in differentbody regions (Kuorinka et al., 1987). The NMQ was adapted for this study to rate pain in seven different body regions:neck, shoulders, upper back, arms, lower back, upper legs,and lower legs, on a scale of 0 e 3 (see Appendix 1). Higher numbers on the NMQ indicate greater pain.All outcomes were measured by a single examiner, whowas blinded to treatment group. Univariate statistics wereused to characterize the sample, while the Aickin separa-tion test was applied to the FIQ-R to determine whether further studies were indicated. The Aickin separation test isused for early phase trials to determine whether the datawere 1) in the hypothesized direction, 2) counter to thehypothesized direction or 3) equivocal. Results in thehypothesized direction warrant further research withadequate power to test for efficacy (Aickin, 2004). Results On average, the subjects were 34.5 years of age (SD Z 5.5),with FM for 2.6 years (SD Z 0.9). Ninety percent had triedmassage in the past with 70% reporting some immediateimprovement, which waned several hours post massage(See complete demographics on Table 1). There were nobaseline differences between groups. There were noadverse events or early discontinuations. Recruitment wascompleted in ten days. Baseline tenderness was high inboth groups (baseline myalgic score 31.9 (SD  Z  7.7) and36.3 (SD  Z  3.1) in the MFR and Swedish massage groupsrespectively. Myalgic score is measured by severity of painon palpation of each of the 18 ACR tender points, withhigher score indicating more pain on a scale of 0 e 54(Tastekin et al., 2007).The Aickin separation test indicated that the FIQ-R totalchange score in the MFR group (mean Z 10.14, SD Z 16.2)trended in the hypothesized direction compared to theSwedish massage group (mean  Z  0.33, SD  Z  4.93) (SeeFig. 1). Between-group differences in FIQ-R did not reachstatistical significance.Secondary analyses revealed that 5 of 8 subjects in theMFR group reported clinically significant FIQ-R improve-ment post-intervention compared to one subject in theSwedish massage group. A 14% change in the FIQ-R isconsidered clinically significant (Bennett et al., 2009b). Three subjects in the MFR group had reductions of   30percent in the FIQ-R.The modified NMQ revealed consistent pain reductionswere observed in the neck and upper back regions in theMFR group. Although modified MNQ scores improved in bothgroups there were no consistent focal areas of improve-ment for the Swedish massage group. Discussion In recent studies by Castro-Sa´nchez and colleagues, MFRwas effective in reducing FM pain but the MFR dose inComparative study: massage and myofascial release therapy for fibromyalgia 367      F     A     S     C     I     A     S     C     I     E     N     C     E     A     N     D     C     L     I     N     I     C     A     L     A     P     P     L     I     C     A     T     I     O     N     S    :     Q     U     A     S     I   -     E     X     P     E     R     I     M     E     N     T     A     L     P     I     L     O     T     S     T     U     D     Y  Author's personal copy both studies was considerably greater than in thepresent study  e  90 min once weekly for 20 weeks or twice weekly for 24 weeks (Castro-Sa´nchez et al.,2011a, 2011b). However these studies were limited bylack of an active comparison group. Instead thecomparator groups were sham magnetic therapy or shamultrasound.The current study extends the Swedish and MFR studiesin the extant literature by comparing two active manualtherapies head-to-head in a parallel design. This is a criticalnext step on a path toward maximizing treatment efficacyof specific massage therapies and individualizing thera-peutic techniques to specific patient profiles. As thecurrent study was parallel in design, it is less likely thatHawthorne, placebo effect or therapeutic relationshipinfluenced the data. The placebo response is a biologicallyactive process known to reduce pain and often encouragedin clinical practice (Watson et al., 2012). However, it mayconfound the mechanism of action of therapies whenstudies do not compare two active modalities in a parallelfashion.The primary research question asked by this study waswhether a manual therapy that addresses the fascia is morehelpful than one that focuses on muscle relaxation for reducing symptoms of FM. Although the difference did notreach statistical significance, the Aickin separation testindicated further research to compare the two techniquesis indicated. This study also confirms that both MFR andSwedish massage were well-tolerated, acceptable inter-ventions for persons with FM, and that a 90-min session wastolerable, independent of baseline disease severity or tenderness.A secondary research question addressed how tomeasure improvement in localized areas of pain in thesetting of widespread pain and central sensitization. This isa dilemma that will need to be addressed in all futurestudies of conditions characterized by central sensitizationsuch as FM, temporomandibular disorder, chronic head-aches, low back pain and painful bladder syndrome/inter-stitial cystitis (Kindler et al., 2011). We append a novel Table 1  Demographic data from both interventiongroups.Demographics % of subjectsMarital statusMarried/domesticpartnership/long-termlive-in partner 50Divorced/separated 30Never married 20RaceCaucasian 100Hispanic 20Education levelHigh school 20Trade/technical school/community college20Some college 30College 10Post-graduate education 20Income < $9000 20$40,000 e $59,000 40$60,000 e $69,999 10$70,000 e $79,000 20$100,000 e $199,999 10Length of time with FM symptoms1 e 5 years 606 e 10 years 10 > 10 years 30Length of time since diagnosis0 e 6 months 207 e 12 months 1013 months e 4 years 505 þ  years 20Self-reported trigger for FM onsetMotor vehicle accident 40Viral illness 10Other physical trauma(e.g. fall or injury)20None identified 30Comorbid conditions a TMD 40Endometriosis 20Migraine 50Sleep apnea 30Restless leg 20Interstitial cystitis 10IBS 50Diabetic neuropathy 10Arthritis 10Tried massage in the pastYes 90No 10Experience with massageMassage made painworse during and after massage10Pain relief during butbenefits last only a fewhours70Table 1 ( continued  )Demographics % of subjectsPain relief during andpain relieving effect lastedfor several weeks10Working outside the homeYes 50No 50Receiving disability benefitsYes 10No 90Smoking statusFormer smoker 30Current smoker 0%Non-smoker 70 TMD-temporomandibular dysfunction; IBS-irritable bowelsyndrome. a All subjects had more than one comorbid condition. 368 G. Liptan et al.      F     A     S     C     I     A     S     C     I     E     N     C     E     A     N     D     C     L     I     N     I     C     A     L     A     P     P     L     I     C     A     T     I     O     N     S    :     Q     U     A     S     I   -     E     X     P     E     R     I     M     E     N     T     A     L     P     I     L     O     T     S     T     U     D     Y
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