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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.: þ974 55021106.
E-mail address: ajimshaw.ms@gmail.com (M.S. Ajimsha).
1360-8592/$ - see front matter ª 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

divided. The authors found significant improvements in both groups on measures of pain and disability... Longitudinal studies found previous LBP to be a predictor of subsequent complaints (Biering-Sørensen. The technique used in this study is the direct MFR technique. 1996) was also evident. indicating a strong association between musculoskeletal disorders and work related factors (Bernard. The proportion of responders. 2004). 1987). Greenman.S.. and that remediation of these disturbances leads to reduced pain in many of the patients (Rosomoff et al. (1988) found that 67% of the total number of episodes reported by nurses within a three year follow up were recurrences. but there are few formal reports of its efficacy. (2000) strongly supporting the notion that exercise therapy is more effective than usual care by a practitioner and/or conventional physical therapy. However. 2003.6%. 1998) and work pressure (Engels et al. manual therapy is often combined with exercises that are tailored to treat specific musculoskeletal dysfunctions (Bookhout. 2003. Indirect MFR involves application of gentle stretch. the etiology and the nature of CLBP have not yet been fully understood. long duration stretch to the myofascial complex.. Aure et al. 1996. 1991). The rationale for these techniques can be traced to various studies that investigated plastic. or supported by fascia (Schleip. Myofascial release (MFR) is a form of manual medicine which involves the application of a low load. All rights reserved. and the hands tend to follow the direction of fascial restriction. ª 2013 Elsevier Ltd. SINGLE BLINDED TRIAL 274 M. Introduction Work related chronic low back pain (CLBP). 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. disabling low back pain. practitioners use knuckles or elbow or other tools to slowly sink into the fascia. Smedley et al. 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.. They suggested the presence of a link between subsequent episodes... 1998). Thorbjo ¨rnsson et al. 2003.2% in 2006 e an overall increase in the prevalence of low back pain of 162% with an annual increase of 11. viscoelastic. treating fascia in the lower back in accordance with the fascial meridians proposed by Myers (2009). MFR generally involves slow.9% in 1992 to 10. (2003) examined the impact of manual and exercise therapy in persons with chronic. Freburger et al. This may result in stress on any structures that are enveloped. Many studies have been performed in various occupational settings. Given these trends. 1998). or stretch the fascia. group compared to the baseline. chronic LBP is defined as LBP lasting more than three months. The primary objective of the present study was to evaluate the efficacy of MFR in the management of CLBP in nursing professionals. 2000. which was 0% for functional disability in the MFR and control group. with the manual therapy group displaying significantly greater gains. 1997). Myofascial practitioners believe that by restoring the length and health of restricted connective tissue. apply tension. Although the utility of specific exercises for treating CLBP has received little empirical attention. MFR is being used to treat patients with back pain. 1990). a review of the literature by van Tulder et al. Heap. varying between 73% and 90% (Maul et al. 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.. Pischinger.the pressure applied is a few grams of force. The 1-year incidence of chronic low back pain has ranged between 4% and 14% (Lake et al. 1996). which could be partly due to an increased sensitivity of a previously injured spine. Thorbjo ¨rnsson et al. Methods This study was carried out in the clinical wing of Myofascial Therapy and Research Foundation. was 73% in the MFR group and 0% in the control group.. 1993. 1983. It has been reported that the majority of chronic pain patients without spinal pathology have evidence of musculoskeletal dysfunctions. Few longitudinal studies have been carried out focusing on the course of low back pain (LBP). India. and improve function (Barnes. but not as clear as that has been shown for the physical factors. Inclusion .. 1988). CONTROLLED. and piezoelectric properties of connective tissue (Schleip. and the pressure applied is a few kilograms of force to contact the restricted fascia. Ajimsha et al.FASCIA SCIENCE AND CLINICAL APPLICATIONS: RANDOMIZED. hold the stretch. Conversely other authors reported no association between previous and subsequent LBP (Astrand and Isacsson. an interest has emerged in the role of manual medicine in the treatment of low back pain. Knibbe and Friele. Direct technique MFR is thought to work directly on restricted fascia. Kerala. intended to restore optimal length. Clinically. 2003). Despite these high prevalences. 2003. pressure can be relieved on pain sensitive structures such as nerves and blood vessels.. 1989). 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). Kopec et al. poses a major health and socioeconomic problem in modern society. The contribution of psychosocial factors (Bongers et al. In the clinical context. Abenhaim et al. decrease pain. sustained pressure (120e300 s) applied to restricted fascial layers either directly (direct technique MFR) or indirectly (indirect technique MFR). 1995). and allow the fascia to ‘unwind’ itself.. defined as participants who had at least a 50% reduction in pain between weeks 1 and 8. This was also found among nurses (Lagerstro ¨m et al. Among nurses the lifetime prevalence was found to be slightly higher. (2009) showed an increasing prevalence of chronic impairing low back pain over a 14-year interval from 3. as promoted by Stanborough (2004).

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). Of these. 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. 3) metabolic bone disease. 1975). Use of oral/systemic steroids. All subjects watched a 15-min videotape that provided educational information on musculoskeletal pain and oriented subjects to the SBE programs for CLBP. and internal consistency is 0. Persons are asked to rate their degree of difficulty ranging from 0 “not difficult at all” to 5 “unable to do”. Between July 2010 and June 2012. with a minimum of a 1 day gap between the 2 sessions. 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. 1995). 5) fracture. Kerala. 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. Test-retest reliability is reported to be 0. FASCIA SCIENCE AND CLINICAL APPLICATIONS: RANDOMIZED. a consistent depth was maintained.. 2004. such as getting out of bed. and ranges from 0 to 100. The Total PRI was used in the present study as the measure of self-reported pain intensity. India. 9) pregnancy. SINGLE BLINDED TRIAL Effectiveness of Myofascial release for low back pain . Myers. In the muscle. 1975). An angle of contact of 15 was maintained in bony areas and about 45 in muscular areas. 1995). 93 nursing professionals were referred to the Myofascial Therapy and Research Foundation with a diagnosis of CLBP. 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. Outcome measures Pain McGill Pain Questionnaire (MPQ) (Melzack. 2) primary joint disease such as active rheumatoid arthritis. the tissue over the PSIS (posterior superior iliac spine) and the intermediate sacral crest was contacted. The treatment was then taken out into the more muscular fibers of the gluteus muscle. The MPQ measures subjective pain experience in a quantitative form. and who were judged to have musculoskeletal pain based on evaluation by the musculoskeletal physician and physical therapist. a) MFR of the lower thoracolumbar fasciae and Gluteus Maximus Client’s Position: Prone Therapist’s position: Standing beside the client at the waistline. Gradually pressure was directed toward the greater trochanter with an intention to contact the fibrous soft tissue over the bones (Fig. Previous research found that repeat administration of the MPQ revealed a 70. Technique: By using the finger pads of the hands. the duration of each treatment session was 60 min (40 min for MFR or SMFR and 20 min for SBE). 275 Procedure Subjects in each group received either Myofascial release (MFR). 6) hyper mobility of the lumbar/sacral spine. CONTROLLED. Disability Quebec Back Pain Disability Scale (QBPDS) (Kopec et al. walking several miles. 1). The protocol was as follows. 8) evidence of radiculopathy. with a primary complaint of CLBP.criteria for this study was nursing professionals aged 20e40 years with a diagnosis of CLBP (defined as pain of 3 or more months duration). 7) cardiovascular or other medical disorder preventing the person from engaging in strenuous exercise. (Duration: 3 min  2 sides Z 6 min) The clients were encouraged to perform mild active nutation and counternutation of the sacrum. Interventions The 2 interventions were provided 3 times weekly for 8 weeks (weeks 1e8). A total score for the scale is derived by summing the responses to each item. Patients were excluded if they displayed: 1) osteoporosis of the spine. The Research Ethics Committee of the Myofascial Therapy and Research Foundation and Medical Research wing of Mahatma Gandhi University. 2009). or 10) severe psychiatric disturbance.95 (Kopec et al. reviewed the study and raised no objections from an ethical point of view. 4) malignant bone disease. b) MFR of the myofascia of the posterior hip & Piriformis Figure 1 MFR of the gluteal and lower thoracolumbar fasciae and Gluteus Maximus. and scores range from 0 to 78. working on the contralateral side. or a sham Myofascial release (SMFR) along with a specific back exercise (SBE) program. 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). MFR procedure We used the following treatment protocol for all the patients in the MFR group (Stanborough. or primary complaint of radiating pain.3% rate of consistency in the PRI score (Melzack.. and making a bed. and consists of twenty groups of single word pain descriptors with the words in each group increasing in rank order intensity.93.

The feet were bolstered so as to allow dorsiflexion. When the first layer of resistance was engaged. the soft tissues over the posterior angle of the lower ribs were engaged with an intention to release the thoracolumbar fascia. 5). Iliocostalis thoracis and lumborum. (Duration: 3 min  2 sides Z 6 min). . the laminar groove was contacted at the level of T12 unilaterally (Fig. A sustained pressure was applied to that area which was repeated to the other side (Fig. A contact was established in the gluteal area about 3 cm from the sacrum. a constant pressure was maintained until that layer softened and the fibers of Piriformis were contacted (approximately 90 s). When the latissimus dorsi and thoracolumbar fascia were contacted. a gradual pressure was applied in an anterior direction. Technique1: With a blunt elbow. 4) (Duration: 2 min  2 sides Z 4 min). Therapist’s position: Standing to the side of the table and facing toward the feet at the level of the client’s waistline. Serratus posterior inferior. The lower leg was lifted off the table to 90 of knee flexion while maintaining the pressure in the Piriformis. The pressure was slowly redirected in an inferior direction. the client was asked to slowly abduct the ipsilateral arm followed by the ipsilateral leg. (Duration: 3 min  2 sides Z 6 min). SINGLE BLINDED TRIAL 276 M. in the direction of the greater trochanter. d) Deeper back muscles e lower Client’s Position: Seated with hips higher than the knees. Ajimsha et al.FASCIA SCIENCE AND CLINICAL APPLICATIONS: RANDOMIZED. Transversus abdominis aponeurosis and Quadratus lumborum. 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). feet slightly forward of the knees and well connected to Figure 4 MFR of the multifidus and associated fascia. CONTROLLED. working on the contralateral side. (Duration: 4 min  2 sides Z 8 min) (Fig. Technique: Piriformis muscle was located by an imaginary line drawn between the midpoint of the lateral aspect of the sacrum and the greater trochanter. 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. c) Prone back work e lower Client’s Position: Prone with the lumbar area stabilized at neutral with a pillow. Technique 3: With a soft fist. Technique 2: The transverse process of L5 was located by first palpating the L4. The pressure was gradually redirected from the ribs to the waistline to engage the thoracolumbar fascia. Possibilities of muscle guarding were monitored and the depth of contact adjusted accordingly (Fig. 3). The leg was supported and guided into internal rotation with an active assistance from the client with direction.S. Client’s position: prone Therapist’s position: Standing beside the client at the waistline. With an elbow. L5 vertebra. Figure 3 Prone release of the lumbar portion of the posterior layer of thoracolumbar fascia. 2). A line of tension was taken along the muscle.

2002). 1997). after treatment (week 8). Pressure was redirected medially toward the table and the first layers of resistance were engaged (Fig. the direction was reversed (local extension without pelvic tilt) while maintaining the pressure through the ground via the feet (4 min). the soft tissues in the waistline at the midline of the coronal plane were contacted. SINGLE BLINDED TRIAL Effectiveness of Myofascial release for low back pain . 1997). MFR to the lateral portions of the thoracolumbar the ground. three times a week for 8 weeks. and strengthening exercises for 20 min per session both for MFR and control groups. Therapist’s position: Standing behind the client at hip level. 3) kneeling quadratus lumborum stretch (Bookhout. Figure 5 fascia. CONTROLLED. Strengthening exercises included: 1) lower abdominal progression (Sahrman. After the completion of the study. Hips in 45 of flexion. The clients were asked to abduct and externally rotate the ipsilateral arm followed by knee and hip extension with ankle dorsiflexion. Once the fascia released (approximately 90 s) the pressure line was redirected in a posterior direction until the PSIS was contacted. Technique1: The knuckles were bilaterally used for the gradual application of the pressure into the tissues on top of the lamina groove (Fig. and 4) gluteus medius strengthening with hip diagonals (Bookhout. Specific exercises were taken from Sahrman (2002) and Bookhout (1997) and combined with self-corrections. The client supports their back via their feet and legs. Stretches included: 1) supine hip flexor stretching (Sahrman. and 4) pelvic clock (Bookhout. patients in the control arm were provided MFR therapy. (3 min  2 sides Z 6 min). 2) prone hip extension (Bookhout. 3) hip abduction/external rotation side lying (Bookhout. as advised by the ethics committee. 2) unilateral prone press-up. 1997). The clients were asked to apply counter pressure against the knuckles through their feet. head supported by a pillow. 2) supine hamstring stretch (Bookhout.277 Technique1: With a soft fist. 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. 3) pubis self-correction. 1997). Self-corrections included: 1) anterior innominate self-correction. 1997). 1997). and 4) tensor fascia latae stretch (Bookhout. knees in 35 of flexion. stretches. 7). e) The trunk e sides Client’s Position: Side lying. Figure 6 Deeper back muscles e lower. 2002). 6). introducing lumbar flexion at the point of contact. Patients were asked to rate their pain severity and disability by completing the MPQ and QBPDS before the treatment (baseline). FASCIA SCIENCE AND CLINICAL APPLICATIONS: RANDOMIZED. Therapist’s position: Standing behind the client and working bilaterally into the thoracolumbar fascia. 1997). Figure 7 MFR to the superficial portion of the waistline. The pressure was firm and anterior. Once it is isolated. The clients were encouraged to isolate the specific segments on which the pressure was applied. 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. and after 12 weeks (follow-up).

We have examined the effect of group and time on the PRTEE value by conducting.7 32. 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. 2 within-subject (time and group) effects and their interaction effect are significant in the models with the multivariate test.8 17.001 (for all the ANOVAs). so we need to correct the F ratios for these effects. MFR Control MFR Control     8. Because all P values from the 4 statistics (Pillai trace. 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.4% for pain and 7.6 8:28 34. Ajimsha et al.5     6.8  7.3 11. The first 2  2 repeated-measures ANOVA represented the beginning and week 8. in accordance with the primary objective of the study.8  8.3  2. but were required to record them in their patient diaries. 74 participants (MFR group.5 9.1  6. defined as participants who had at least a 50% reduction in pain between weeks 1 and 8.2  9. A 2  2 (group  time) repeated-measures ANOVA and a 2  3 (group  time) repeated-measures ANOVA were also conducted.6% reduction of pain and 22.4 27. whereas the second 2  2 repeated-measures ANOVA represented the beginning and week 12.001).001). we compared the MPQ and QBPDS scores of the MFR and control groups at different time intervals.7% reduction in functional disability as shown in the MPQ and QBPDS scores in week 8. The betweengroups (group).7 26.3 28. which persisted as a 43. .9 28. 9. 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. and this was reported to have subsided within a week without any medications.05 was accepted as statistically significant.1 18. Ten patients from the MFR group and 1 from control group reported an increase of pain in the first week after initiation of treatment. n Z 38.0 9. Significant pairs of MFR and control groups vary at weeks 8 and 12 due to the interaction effect between group type and time. then. and the time  group interaction. Hotelling trace. The primary outcome measure was the difference in MPQ and QBPDS scores between baseline (pretest score). n Z 36) completed the study protocol. and the time  group interaction.0 31.6 Week 8 10. a 2-way ANOVA. 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. Wilk ƛ.3 27.1 10. There were significant main effects of time.2 23.1 35.5 8. The test’s betweensubject effects showed a significant interaction between the effects of group and time on value (F2. Within the study period. which were analyzed at weeks 8 and 12 after randomization. as shown in Table 1. group.8% reduction in their MPQ and QBPDS scores in week 8.0 26. and mixed-groups (group  time) interactions were examined. group.7 7. A P < 0. The mean differences between groups vary by time.001).S. for the 2  3 repeated-measures ANOVA. within-groups (time). but there were no differences between the groups at baseline (P > 0.0 Note. Data are mean  SD or as otherwise noted.0 37. 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. CONTROLLED. The patients in the MFR group reported a 53. was 73% in the MFR group and 0% in the control group. P < 0. formed by the combination of the group and time because the size of the sample is more than 30 for each group. no serious adverse events occurred in either of the groups as recorded in the patient diary. The significant values of Mauchly sphericity tests for both of the 2  2 repeated ANOVAs indicate that for the main effects of time. Results Of the 80 individuals recruited into this study. and follow-up at week 12 after randomization.189 Z 522.8     Week 12 7.3  14. All study participants were advised to take medications only when there were any exacerbations. SINGLE BLINDED TRIAL 278 M.6 11.4 13.7% for functional disability during follow-up (week 12) in their MPQ and QBPDS scores respectively.1% and Table 1 Table 2 MPQ and QBPDS readings of MFR and control groups at different intervals. first.0  2.7% reduction of functional disability in the follow-up at week 12 in the MFR group compared to the baseline. were normally distributed approximately for the groups. We observed that the interactions between time and group were significant based on univariate and multivariate methods for all 3 repeated-measures ANOVAs. the assumption of sphericity is met.3% reduction in their pain and 29. week 8 (posttest score). The dependent variables. On the other hand. whereas patients in the control group reported a 26.3 Baseline QBPDS Statistics Participants in both groups were comparable at baseline.FASCIA SCIENCE AND CLINICAL APPLICATIONS: RANDOMIZED. it was 0% for functional disability in the MFR and control group. The proportion of responders. control group. the MPQ and QBPDS values.9 9.9 7.8 13.1 12.418. 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. This indicates the possible existence of their interaction effect (Table 2). In the control group the effect persisted as 20. Measure Group Time MPQ 23. Summary of baseline characteristics.4 Note: Data are expressed as mean  SD.8  16. Roy largest root) are P > 0.

023b 0.250b 0. b The mean difference is significant at the 0. CONTROLLED.971 3. This may be explained because. 2004.05 level... However.133 0.548 0..532 0. the follow-up at week 12 has shown that the treatment effects were less evident compared with week 8 after the treatment. However. it does not reach the levels of uninjured.000 0.. Mayer et al.000 4. repetitive strain injury. and has lead to the development of treatments emphasizing multidisciplinary care (Gatchel et al. idiopathic scoliosis (LeBauer et al. 1997). this is a hypothesis that merits investigation. As with any massotherapy techniques. which can cause segmental pain modulation (Melzack and Wall. 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) and functional restoration (Hazard 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. 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.472 0. 2012). 1979). MFR has been reported to reduce pain and improve quality of life in lateral epicondylitis (Ajimsha et al. which in turn improved their functional status. the analgesics effect of MFR can also be attributable to the stimulation of afferent pathways and the excitation of afferent A delta fibers. SINGLE BLINDED TRIAL Effectiveness of Myofascial release for low back pain . The findings of the present study do not support the notion that MFR and SBE alone are effective in treating CLBP. 1989).624 0. which could be partly due to an increased sensitivity of a previously injured spine. (2003) that manual therapy and specific adjuvant exercise have a significant impact on disability.688 0. 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. injuries resulting from physical trauma. According to Schleip (2003). It has been reported that the majority of chronic pain patients without spinal pathology have evidence of musculoskeletal dysfunctions. even when controlling for clinical pain intensity (Geisser et al. 2011). Abenhaim et al.000 0. 1965) as well as modulation through the activation of descending pain inhibiting systems (Le-Bars et al. 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. and if used alone. and that remediation of these disturbances leads to reduced pain in many of the patients (Rosomoff et al. fascia and connective tissues tend to move with minimal restrictions. it possible that subjects receiving MFR and SBE may have improved their exercise conditioning and low back flexibility. MFR with SBE appears to be efficacious in the treatment of CLBP in nursing professionals. Raynaud phenomenon (Walton. 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. 2009).. The biopsychosocial model of chronic pain has gained widespread acceptance as the appropriate model for understanding chronic pain. under normative conditions...000 Note: Based on estimated marginal means. and reorientation of fibroblasts. factors such as pain-related fear have been found to be associated with decreased lumbar flexion and muscle firing abnormalities among persons with CLBP. 1987).. Although the tensile strength of the healing tissues improves over time. Mayer et al. and inflammation are thought to decrease fascial tissue length and elasticity. In summary.. may be beneficial for a subgroup of persons with CLBP. 1995). Maul et al. 1989. tension headaches (Ajimsha. As deconditioning has been proposed to play a role in chronic pain disability (Hazard et al. The present study supports the notion by Aure et al. 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). 2008). FASCIA SCIENCE AND CLINICAL APPLICATIONS: RANDOMIZED...000 0. 1987). resulting in fascial restriction. cell morphology changes. a Adjustment for multiple comparisons: least significant difference (equivalent to no adjustment). at the 12-week follow-up. MFR and SBE may be beneficial components of multidisciplinary treatment. and in systemic sclerosis (Martin. 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.. Watson et al.413b 2.810 0.435 0. 2008).Table 3 279 Pair wise comparisons of group and time. In addition. (2010) has shown that treatment with MFR after repetitive strain injury resulted in normalization in apoptotic rate. However. 1989.813b 3. It is also possible that pain relief due to MFR is secondary to returning the fascial tissue to its normative length by collagen reorganization. healthy tissue. A study by Meltzer et al. (1988) suggested the presence of a link between subsequent episodes.

162e171. Painrelated fear. Meltzer.... Mayer. Besson. R..J. R..M. 1993.J.M. J. Engels.. Redmond. SINGLE BLINDED TRIAL 280 Study limitations One limitation of this trial was that practitioners could not be blinded. The rising prevalence of chronic low back pain. Occup. van der Gulden. Paoli. J. Environ. Phys. 1987.F. G. Vasseljen. 1987. Abenhaim. second ed. We also did not examine other important treatment outcomes such as pain beliefs. H. J.. 1979.. Hazard. Med. The McGill Pain Questionnaire: major properties and scoring methods... J.. Lack of effect on non convergent neurons. R. et al. Ergonomics 39.. Br. Cao. Med. Rossignol. Hagberg. Spine 29. Work Environ. J. Laubli. R. 971e979.A. Lagerstro ¨m. psychological. Upper Extremity. H. R.. Klipstein. Bookhout. 70e78. 1996. J.C.M. R. T.E. J. tenth ed. Stoll. Geisser. R. J.P. Work-related lowback problems in nursing. mood. et al. Diffuse noxious inhibitory controls (DNIC)..P. Greenman. M. M. S. 1988.. Ind..J. 251e258.K. 1990. S. MI.. 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