Fiona McMahon PT, DPT
If you follow anything in the physical therapy world, you probably have heard about myofascial release, or MFR if your hip to our abbreviations. It has been a darling of the manual therapist’s tool kit for some time. But did you know their many different camps of physical therapy and these different camps prefer different tools? I love coming from a field that can produce multiple solutions to any given problem. I feel it maximizes every unique individuals’ chances of finding meaningful relief through treatment, but it’s definitely fair to say that MFR does have some detractors in the physical therapy field. In this blog, I will be discussing why MFR is a wonderful tool for treatment of pain conditions and functional issues. MFR doesn’t always get the love it deserves and it is my hope, that by the end of this blog you will understand how MFR is thought to work and why it can be so helpful.
What the heck is the myofascial system?
As the name would imply, the myofascial system is the combination of the muscular system (myo) and the fascial system (fascial). Most of us have a pretty good concept of the muscular system but the concept of fascia is slightly more elusive. Fascia is the covering and connection of just about everything in the body. It wraps around organs, nerves, and muscles and allows these parts to retain their shape and function well. The composition of fascia is fascinating, even if you aren’t a total nerd, like me. We may encounter fascia when removing that filmy substance from a chicken breast while preparing it. When you see that film it looks pretty simple, but on a microscopic level that “stuff” is actually teaming with diverse and different cells all doing different things. Within fascia we have adipocytes, (fat cell makers), fibroblasts, which make collagen and elastin…. AND ARE CONTRACTILE! Yes I put this in all caps because it is amazing and it can be easy to overlook when you are thinking about fascia. Fascia also has mast cells (which make histamine) and histocytes (are part of the immune system). It’s honestly a cell party inside that stuff. Keeping with the metaphor of cell party, the house those cells are chilling in is made up of collagen (which provides support), elastin (which provides strength and flexibility), and ground substance (which is the cushioning).
All this stuff together helps fascia to accomplish some pretty cool tasks. Like I said before, fascia covers everything in the body and helps it keep its form. It also allows organs and muscles to slide and glide over each other, which is obviously very important when we are thinking of muscles. But what’s most interesting, in my opinion, is that fascia acts as a sense organ. It is innervated with type III and IV sense receptors and responds to light touch. It can contract and when fascia is stimulated it has an effect on the autonomic nervous system (think flight or fight). You probably could guess that issues within the myofascial system could wreak havoc on the rest of the body.
What goes wrong with the myofascial system and why does it get messed up?
The concept of fascia and its dysfunction contributing to pain is not necessarily a new one. People were thinking about myofascial pain although they had different words for it as early as the late 1600’s with the first description of trigger points in 1816. Trigger points have been called many different things from “nodular tumors” in the 1800’s to “muskelshweile” meaning muscle calluses, which is my personal favorite.
So where do these “muscle calluses” and trigger points come from? The reasons are myriad. Fascia can become restricted with discrete injuries (what I term, “the Oh Poo moment”, where you know you have injured yourself) or they may build quietly over time due to poor posture and other types of repetitive strain or chronic muscle holding.
Fascial restrictions and trigger points can cause a whole host of symptoms. It should seem obvious that restrictions in the fascia of a certain area of the body will restrict the movement in in that area. But fascial restrictions can present in less obvious ways.
Fascial restrictions can affect organs and dysfunction in the organs can affect fascia. This is because of the somatovisceral reflex and viscerosomatic reflex respectively. We see a lot of organ and myofascial interplay at Beyond Basics Physical Therapy. We commonly see increased trigger points in parts of the body that are innervated by similar nerve root fibers off of the spinal cord. Specifically, we may see someone who has endometriosis adhesions on their rectum experience pain and trigger points in their pelvic floor. Additionally trigger points in the pelvic floor can refer to other parts of the body and present as pain in the bladder or rectum, and other places.
Restrictions and trigger points in the fascia are linked to a whole host of symptoms. Treating the body at the level of the fascia is often very helpful at easing or resolving these symptoms. Below is a non exhaustive list of symptoms and conditions related to myofascial trigger points and dysfunction:
- Fibromyalgia pain syndrome
- Myofascial pain syndrome
- Tension headaches
- Pelvic pain
- Complex regional pain syndrome
- Back pain
- Urinary and fecal incontinence
- Sports and orthopedic injuries
How do we treat it?
Here is where it gets “controversial” in the health community. Fascia is strong. Really, really strong. Some would say as strong as steel. There are many in the community that claim myofascial release is impossible because there’s no clinician who is strong enough and applying enough force to break through and make a difference in the knots… I mean, I have a pretty solid deadlift but you won’t be finding me bending metal beams anytime soon. This argument misses the point and fails to recognize how complex fascia is. Think back to our cell party. We are not simply trying to break through fascia; we are providing a sensory stimulus and allowing the fascia to adapt or change in response. When true myofascial release is formed correctly, very little force is being used and it is usually an extremely gentle technique that can be tolerated by many patients who may not have been able to tolerate more aggressive techniques. When performing myofascial release, the clinician engages the barrier, meaning they apply enough force to feel the first inklings of resistance, and they hold their pressure there and slowly take up slack as the barrier melts underneath them. There is nothing forceful about it. In fact, when I first learned this technique from a mentor trained in Barnes myofascial release technique, she would always say, “If you think you are working too hard, you probably are”. There’s nothing steel beam bendy about MFR at all. Myofascial release allows the tissue to respond to the input the clinician is providing, rather than aggressively stretching, mashing, or pulling it. Although the exact mechanism of how MFR works is elusive, many theories recognize the individual players and cell types within the fascia, (remember our cell party), whether that be down regulation of the autonomic nervous system, (reduced fight or flight), activation of the central nervous system, and release of chemicals from the cells within the fascia.
The fact is with physical therapy, there are so many different tools that one can use. Usually clinicians tend to gravitate towards what they are good at and what tends to help the maximum number of their patients. At BBPT we value MFR as a helpful tool in our repertoire.
Ajimsha M.S., Al- Mudahka N. Effectiveness of myofascial release: Systemic review of randomized control trials. J Bodyw Mov Ther. 2015 Jan;19(1):102-12.
Horton R, “Mobilization of the myofascial layer: pelvis and lower extremity”. Raleigh, NC, USA. 9/22/2017- 9/ 24-2017. lecture.
Shah J, Thaker N, Heimur J, et al. Myofascial trigger points then and now: A historical and scientific prospective. PM R. 2015; 7(7): 746-61