Junk Mail

So over the past several years, I have gotten alot of junk mail for continuing education courses.  A frequent advertisement that comes to my house is one promoting “Principles of the John F. Barnes’ Myofascial Release Approach”.   I have contacted this company by both phone and email to request to be taken off of the list.  But I still get their advertisements (too bad this type of paper doesn’t work in the bathroom…).  Anyways, from the advertisement it appears that 75,000 therapists use the approach and a statement that it is “the wave of the future”.   So I went to the literature to investigate these claims…
A search  @ www.scholar.google.com for “John F Barnes Myofascial Release Approach” yielded 261 results.  The first citation is a 2004 article called The “Missing Link” in Your Treatment by John F. Barnes.
In this article, he states: “Therapists tired of working in “assembly line” atmospheres, focusing on quick symptomatic treatment, and who are overloaded with burdensome paperwork are joining facilities and private practices that focus on myofascial release.”   He goes on to state “the health professions had ignored the importance of an entire physiological system, the fascial system that profoundly influences all other structures of the body.”  He discusses some anatomy and more importance of fascia and concludes by telling us how “Physical therapists of the near future will function quite differently from those of the past…The therapist skilled in Myofascial Release is concerned with releasing and reorganizing the body’s fascial restrictions mechanically and reorganizing the neuromuscular system.”  No citations were included in any of the statements.  (This reference appears to be an ad for Saskatoon Massage Therapy which states it must be cited as “John F. Barnes book the Search for Excellence”)
As I sifted through the other citations, there were alot of non-peer reviewed entries similiar to this.  I did find a RCT entitled “Effectivess of Myofascial Release in Treatment of Plantar Fasciitis: A RCT”.  This study was a randomized controlled trial that involved 30 subjects who received either therapeutic ultrasound, contrast bath, strengthening and stretching compared to a group that additionally received myofascial release.  The MFR group did better  (was it the unwinding of fascia or simply the no-specific effects of manual therapy?).
My questions to the readers of this blog are:
1. Do you believe fascia to be important in diminishing pain?
2. If yes to #1, can you provide sound scientific rationale to support your answer as well as describe how the effects are not due to the cutaneous receptors within the skin, placebo or another comparable explanation…

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  • I do not deny fascia it exists, but the plausibility of “it” playing a more important (or THE most important as MFR claims) role in a painful problem “acute” or “chronic” seems quite unlikely. Further, the construct that we, with nothing but our hands and small forces, can permanently re-organize or meaningfully affect the fascia structurally is, quite frankly, ludicrous. Lastly, the theory and model behind the effect of the intervention is not in line with current investigations into the mechanisms of manual therapy. So, if patients are improving with “MFR” the reason why is not as stated….

    kridgeway July 19, 2012 11:55 pm Reply
  • I think you should word the question differently. How about:
    “Can a physical therapist, using their hands or simple instruments, change the length or the elastic properties of fascia? If so, can you provide evidence supporting this belief?”
    Because the first principle of Myofascial Release is that physical therapists impart a PHYSICAL change to the fascia, which decreases pain.
    It seems that logical sequence is what needs to be supported by evidence by people who make money teaching myofascial release.
    Otherwise, we have to assume a non-mechanical effect, such as placebo.
    Tim Richardson, PT

    Tim Richardson, PT (@timrichpt) July 20, 2012 6:13 pm Reply
  • Thanks for the replies guys!!!! I really like the rewording Tim and will likely re-poll in a subsequent post. I find it quite interesting that individuals can legally teach unproven pseudoscience in continuing education courses. If the scientific rationale was plausable, MAYBE this would be ok. But with our current scientific understanding of pain, the role of fascia is very minimal. This post comes to mind when discussing stuff like this: http://scienceblogs.com/insolence/2012/07/20/a-chiropractor-strikes-back-at-the-institute-for-science-in-medicine-again/

    Joseph Brence, DPT July 21, 2012 8:49 am Reply
  • You guys should really view the DVD “Strolling Under the Skin” by Dr JC Guimberteau (www. terrarosa.com.au.) You might feel differently about a manual technique such as this one if you observed fascia in action. I have been a manual therapist for 12 years and treated every external joint restriction imaginable using Maitland, Butler, McKenzie, Paris etc. before taking a Barnes course. If you allow 20-25 minutes to work with your patients using your hands, every treatment, you can make soft tissue changes but it does not happen in one session. Placebo? That’s some powerful placebo when all my post surgical and neurologic patients see marked improvement. That “placebo” worked so well I was able to open my own practice. You should absolutely take the course, which fully explains the fascial network and would give you the answers you seek!

    Marie Francis July 22, 2012 4:34 pm Reply
    • Hey Marie,
      Thanks a ton for checking out the blog!!! My beliefs are based upon a current understanding of the neurophysiological mechanisms of pain (ie. the neuromatrix). I am simply curious how one who provides manual therapy “knows” they are doing anything past the layers of skin? I guess I have not developed the “feel” for connective tissue yet (despite being half-way through fellowship training and completing the entire course series of Maitland Australian Physiotherapy Seminars). Being a Maitland-trained and Butler-following therapist, I do not treat a “joint restrictions” (not either of their “terms” nor something they would follow) and literature states that our palpation skills of stuff under the skin is very unreliable.
      Your questioning of placebo is fascinating. Patient expectations have a very large influence over our outcomes and if a patient thinks something will work, it will work (read more: https://forwardthinkingpt.com/2011/05/03/how-individual-expectation-can-influence-outcomes-in-the-treatment-of-musculoskeletal-pain/). You state the “placebo” worked so well you were able to open up your own practice but there are reiki masters, acupuncturists, and other questionable professional practices which thrive, despite the effects being rather non-specific. As PTs, much of what we do, including our personal patient interactions, elicit a placebo response and we can not ignore or dispute this (loads of literature supporting this—it’s not a bad thing).
      If you disagree and can provide a plausible scientific argument supported by quality scientific literature, I would be more than happy to post it on this site. Just let me know!!!

      Joseph Brence, DPT July 22, 2012 9:53 pm
    • Hi Joseph,
      Thank you for you blog. Its a good resource to have available. Could you clarify what you are saying when you write in this post “Being a Maitland-trained and Butler-following therapist, I do not treat a “joint restrictions” (not either of their “terms” nor something they would follow)”. I haven’t taken any maitland or maybe it would be clearer to me. Thanks

      Luke July 25, 2012 12:20 am
    • Hi Joseph,
      I simply replied to encourage you to actually take a course before you call it’s brochure “junk mail”. That would be the best way to give an unbiased opinion. I was skeptical about MFR until I took a 10 day seminar. Yes, there is a feel, and you are also palpating through connective tissue when perform a joint mobilization. I used it to find the endfeel using Maitland techniques in MT1 and MT2, both of which I took years ago. The term used when I took it was “physiologic barrier”. If it restricts movement, I call it a restriction. Please forgive my improper verbage. If you are familiar with the Butler technique, you know you can actually palpate some nerve roots, and ultrasound studies presented in some of the introductory courses actually show the nerve root moving as a result of specific flossing and gliding techniques.
      My office is not “questionable professional practice”.
      Medicare recognizes myofascial release and reimburses for it under the manual therapy code.
      I base all my opinions on actual outcomes only, especially after taking a 10 day seminar.
      I’m not questioning your education or your ability to perceive endfeel.
      I’m also not saying the placebo effect does not exist, I’m saying the Barnes technique is real and is not based on a placebo effect.
      I will add you should be very careful when you mention patient relationships as a major factor in treatment success because, then, you question the skills of the PT working on that patient and the effectiveness of physical therapy in general.
      Things like progressing 8 weeks ahead of protocol, full return to work related essential functions, full joint mobility after surgery and decreased pain are what I deem a good response to treatment. These patients come through my door after they have been treated for several weeks at other offices without success.
      It’s not a placebo when the patients that come to me are quite frustrated and don’t think anything is going to work for them. It’s rare to meet a patient that didn’t like their PT, even though they didn’t meet their surgeon’s goals or decreased their pain.
      You’re response surprised me, I thought you might have said, “maybe I will look further into that” or something similar.
      P.S. Here are some studies for you. There are much more listed on my website. Thanks, I think.
      Adams MA, Dolan P. Time dependent changes in the lumber spine’s resistance to bending. Clin Biomech. 1996;11(4):194-200.
      Alenghat FJ, Ingber DE. Mechanotransduction: All signals point to cytoskeleton, matrix, and integrins. Sci. STKE. 2002;119:PE6.
      Barnes JF. Myofascial release in treatment of thoracic outlet syndrome. J Bodyw Mov Ther. 1996;1(1):53-57.
      Bogduk N. Patho-anatomic basis for soft tissue injuries to the spine: A re-evaluation of the anatomy of the spinal muscles and fascia. ABS Newsletter. Summer 1991: 26.
      Chen Q, Bensamoun S, Basford J. Identification and quantification of myofascial taut bands with magnetic resonance elastography. Arch Phys Med Rehabil. 2007;88(12):1658-1661.
      Chaudhry H, Schleip R, Ji Z, et al. Three-Dimensional mathematical model for deformation of human fasciae in manual therapy. J Am Osteopath Assoc. 2008;108(8):379-390.
      Dodd JG, Good MM, Nguyen TL, et al. In vitro biophysical strain model for understanding mechanisms of osteopathic manipulative treatment. J Am Osteopath Assoc. 2006;106(3):157-166.

      Marie Francis August 6, 2012 7:38 am
  • Joseph,
    Funny you brought this up, I just got the same package sent to our clinic. I have not taken any courses through Barnes but I have some of the same feeling as you on this topic. I feel you and the other comments summed it up nicely in terms of current understanding of science behind OMPT. Another aspect of this approach that I feels wor brining up is the ‘attention effect’. If a clinician spends a large amount of time with a patient 1:1 and even hands-on, I can imagine their is an effect just due to time spent and also maybe patients say they are better to make therapsist feel better as they have spent that much time with them. Either they ge the relief from mechanoreceptor activation for a long period of time (such as massage…which always feels good…we have all been through that!). This seems to be up that alley, but again I don’t practice this approach persoanlly so I may be wrong.

    Harrison Vaughan July 24, 2012 9:32 am Reply
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  • If you like to, you should check out the work of Stecco (fascialmanipulation.com) and the explanation of the hypothesied mechanism of action!

    Francesco August 12, 2012 7:24 am Reply

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