During the course of attending massage school at A New Beginning School of Massage, students are given a number of assignments that requiring research and writing. Some of these assignments result in very insightful and well thought out information and decision-making outcomes. I am happy to share some of their assignments for you to enjoy.
I. Why research?
Research design common in the field of massage therapy includes randomized, controlled studies; case studies; and untested theoretical frameworks. While less common, survey research is certainly a viable option for determining client experience or perceived results. In theory, all these types of research are valid, but we must remember a study is only as valid as its methodology. Theoretical framework must be solid; it is not sufficient to collect random data from a sample, of, say, pregnant women in the hopes of finding something interesting. If I hypothesize that regular prenatal massage reduces risk of preterm delivery for women in high-risk pregnancies, my sample should include women in high-risk pregnancies. The control group would receive no massage, and the experimental group would receive massage.
First, I need to define "high risk" and determine how I will operationalize my variables. To ensure that women in my sample are more or less equivalent, I will limit my sample to patients in a high risk hospital ward. The experiemental group will receive an hour-long relaxation massage three times a week, to include the same massage techniques. The control group will sit with a massage therapist with the same frequency, but will not receive massage.
This design raises some questions. High-risk pregnancies are not identical and any number of confounding variables might affect my results, affecting the study's internal validity. The experiment is not double blind, meaning the massage therapist knows which subjects are control and what are the experimental group. This many not even be single blind, as subjects are likely to deduce they are the control group when they receive no massage whatsoever (and ethics in research requires human subjects are aware of the nature of the experiment). A small sample size will compromise the study's external validity. How will I measure "reduced risk" of preterm delivery? Length of hospital stay before delivery? Total number of week's gestation before delivery? Finally, once my study makes its way through the peer review process and is published, what will it mean if researchers fail to replicate my findings?
Astute massage therapists will have these questions in mind when analyzing the latest research. They will also be mindful of the source: is the study published in a peer-reviewed scholarly journal? And another layer to the onion; is this journal ranked and what is its impact factor? A case study or an experiment where n=1 may raise some interesting questions, but we should proceed with caution in terms of drawing any conclusions. Questions in science are seldom cut and dry. Meta-analyses or literature reviews can help clarify the latest consensus in a particular field of inquiry. Admittedly, staying current on the research can seem daunting. But how else can we know if our therapies produce any results? Evidence-based practices separate the professionals from the quacks. Massage is not a science, but that doesn't mean it can't be studied. Any inquiry that furthers our understanding of the natural world (of which massage is very much a part) is fundamentally beneficial, even to massage therapists who are not clinically minded--and their clients. Knowledge is power.
II. The question
With that in mind, I have undertaken a review of an unrelated research question: Can fascia be stretched to release adhesions?
Fascia is the web of connective tissues throughout the body. It is, according to Jean-Claude Guimberteau, a network "of total tissue continuity" (2016), linking the entirety of our physical being with itself. The theory behind myofascial release is that fascia can become adhered to surrounding structures as a result of trauma, injury or misuse (Osborn, 2016). Only in recent decades, however, have scientists come to consider this tissue's importance and an emerging body of research aims to understand it.
A number of studies concern self-myofascial release (SMR) as foam rollers are widely used among athletes to aid in recovery, improve performance and increase range of motion (ROM). SMR is not shown to improve performance (Healy et al, 2011; Schroeder and Best, 2015), although as Healy et al. also find that SMR reduces fatigue, they theorize SMR could indirectly improve performance as athletes are able to train longer and/or with more intensity. Foam rollers have been shown in multiple studies to improve ROM (MacDOnald et al, 2013; Schroeder and Best; Grieve et al, 2015) and, Schroeder and Best, in their exhaustive literature review, find that SMR improves soreness.
Studies consider myofascial release at the hands of trained therapists, as well. Anne Walton (2008), in a single case study, found MR lessened the severity and length of symptoms in a woman with Raynaud's disease. In a randomized, controlled study of plantar fasciitis (Suman et al, 2007), a control group received traditional treatments (including plantar fascia stretching exercises). The test group received the traditional treatments in addition to the MR. MR decreased pain and increased foot function.
Tozzi et al (2011) looked at cervical and lumbar pain using dynamic ultrasound. Two blinded experts rated cervical sliding for the cervical group, reno-diaphragmatic distance and neck bladder mobility for the lumbar group. Surveys were administered to participants on the day of treatment and the third day following treatment. Myofascial treatments were found to release areas of "impaired sliding fascial mobility" and decreased pain.
But are these findings unique to myofascial techniques? Could a therapist achieve the same results with, say, Swedish massage? In a study of 12 fibromyalgia patients, both Swedish massage and MR improved symptoms, although MR showed "consistent focal improvement" in the body while Swedish massage did not (Lipton et al, 2013). More study is needed, as the mechanism of MR is not understood (Schroeder and Best).
In summary, MR and SMR have been shown to lessen symptoms and aid recovery. Findings support the claim that fascia can stretch to release adhesions, but questions remain. I found no paper directly showing that results are attributed to releasing fascial adhesions (although Tozzi et al were closest)--it is possible that we're not testing what we think we're testing. I am curious what technology can identify an adhesion, and how that might further research. I would also like to see more long-term studies and larger sample sizes.
Certainly our understanding of this integrated web within the human body lends a more holistic perspective on movement, illness and trauma. Myofascial release isn't the only game in town, either. More research is necessary across fascial techniques and also with other modalities--I would like to see a follow-up to Liptan et al's provocative pilot study. And finally, for this massage student, greater understanding of statistical methods is also a must. I will be interested to deepen my hands-on undeerstanding as my education progresses; ultimately I would like to apply this knwoeldge in my proactice.
Guimberteau, Jean-Claude. "The living fascia." Massage & Bodywork, 2016
Grieve et al. "The immediate effect of bilateral self-myofascial release on the plantar surface of the feet on hamstring and lumbar spine flexibility; a pilot randomized controlled trial." Journal of Bodywork and Movement Therapies, 2015.
Healy et al. "The effects of foam rolling on myofascial release and performance." Journal of Strength and Conditioning Research, 2011
Liptan et al. "A pilot study of myofascial release therapy compared to Swedish massage in fibromyalgia." Journal of Bodywork and Movement Therapies, 2013.
Macdonald, Penney et al. "An acute bout of self-myofascial release increases range of motion without a subsequent decrease in muscle activation or force." Journal of Strength and Conditoning Research, 2013.
Osborn, Karrie. "Addressing fascia with myofascial release." Massage & Bodywork, 2016
Schroeder and Best. "Is self-myofascial release an effective pre-exercise and recovery strategy? A literature review." Current Sports Medicine Reports, 2015.
Suman et al. "Effectiveness of myofascial release in treatment of plantar fasciitis-a RCT." Indian Journal of Physiotherapy and Occupational Therapy, 2007.
Tozzi, Bongiorno, et al. "Fascial release effects on patients with non-specific cervical or lumbar pain." Journal of Bodywork and Movement Therapies, 2011.
Walton, Anne. "Efficacy of myofascial release techniques in the treatment of primary reynaud's phenomenon." Journal of Bodywork and Movement Therapies, July 2008.