Journal of Bodywork & Movement Therapies (2011) 15, 63e67 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt ORIGINAL RESEARCH Comparison of an indirect tri-planar myofascial release (MFR) technique and a hot pack for increasing range of motion Jay Kain, PT, PhD, ATC, IMTC a, Laura Martorello, PT, DPE b, *, Edward Swanson, PT, PhD, MBA, MEd b, Sandra. Sego, PhD b a Jay Kain Physical Therapy, Great Barrington, MA 01230, USA b American International College, 1000 State Street, Springfield, MA 01109, USA Received 25 June 2009; received in revised form 7 December 2009; accepted 8 December 2009 KEYWORDS Myofascial release technique; MFR; Hot pack; Gleno-humeral joint Summary Purpose: The purpose of the randomized clinical study was to scientifically assess which intervention increases passive range of motion most effectively: the indirect tri-planar myofascial release (MFR) technique or the application of hot packs for gleno-humeral joint flexion, extension, and abduction. Methods: A total of 31 participants from a sample of convenience were randomly assigned to examine whether or not MFR was as effective in increasing range of motion as hot packs. The sample consisted of students at American International College. Students were randomly assigned to two groups: hot pack application (N Z 13) or MFR technique (N Z 18). The independent variable was the intervention, either the tri-planar MFR technique or the hot pack application. Group one received the indirect tri-planar MFR technique once for 3 min. Group two received one hot pack application for 20 min. The dependent variables, passive glenohumeral shoulder range of motion in shoulder flexion, shoulder extension, and shoulder abduction, were taken pre- and post-intervention for both groups. Data was analyzed through the use of a two-way factorial design with mixed-factors ANOVA. Results: Prior to conducting the study, inter-rater reliability was established using three testers for goniometric measures. A 2 (type of intervention: hot packs or MFR) by 2 (pre-test or post-test) mixed-factors ANOVA was calculated. Significant increases in range of motion were found for flexion, extension and abduction when comparing pre-test scores to post-test scores. The results of the ANOVA showed that for passive range of motion no differences were found for flexion, extension and abduction between the effectiveness of hot packs and MFR. For each of the dependent variables measured, MFR was shown to be as effective as hot packs in increasing range of motion, supporting the hypothesis. * Corresponding author. Tel.: þ1 413 205 3024; fax: þ1 413 654 1430. E-mail address: laura.martorello@aic.edu (L. Martorello). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.12.002
64 J. Kain et al. Discussion and conclusion: Since there was no significant difference between the types of intervention, both the hot pack application and the MFR technique were found to be equally effective in increasing passive range of motion of the joint in flexion, extension, and abduction of the gleno-humeral joint. The indirect tri-planar intervention could be considered more effective as an intervention in terms of time spent with a patient and the number of patients seen in a 20-min period. No equipment is required to carry out the MFR intervention, whereby using a hot pack requires the hot pack, towels, and a hydraculator unit with the use of the indirect tri-planar intervention, a therapist could treat four to five patients in the time it would take for one standard hot pack treatment of 20 min, less the hands-on intervention of the therapist. ª 2009 Elsevier Ltd. All rights reserved. Introduction Few studies have examined the effectiveness of myofascial release (MFR) techniques on the direct parameters of patient outcomes (Hanten, 1994; Barnes, 1997; Bucher, 1993, 1994; Weiselfish-Giammatteo and Kain, 2005). Additionally, experimental research does not exist that compares the effectiveness of MFR outcomes versus any modality intervention. Within the field of rehabilitation, especially physical therapy, a common outcome reference for evidence-based research lies in a pre- and post-assessment of range of motion (ROM). For the purposes of the most accurate reflection of change, passive ROM assessment appears to be the most objective to measure. Further, when ROM assessments utilize physiologic and accessory joint motion, outcomes are more reliable and objective (Weiselfish-Giammatteo and Kain, 2005; Kaltenborn, 1976; Prentice, 1990). The post-treatment effects of MFR intervention have been postulated to parallel those of massage and soft tissue mobilization techniques. These effects include circulatory changes, blood flow changes, capillary dilatation, cutaneous temperature changes, and changes in metabolism (Cantu and Grodin, 1992). These changes are reflected in increased ROM, improved biomechanics of the joint, increased extensibility of tissues, improved flexibility, muscle relaxation, reduction of spasm, decreased tone, reduction of edema and analgesia (Cantu and Grodin, 1992) Heat in its various forms has been a popular longstanding modality used to facilitate healing. Transmission of heat, either by conduction, convection, radiation, and/or conversion, comprises the most common methods of heat usage. Whether the modality is a whirlpool, hot pack, diathermy, moist air sauna, infrared, paraffin, whirlpool or ultrasound the outcome potential is nearly the same (Taylor, 1990). For the purpose of this study, hot packs were chosen as our comparative modality for a number of reasons: (1) the simplicity of access to the modality (2) the ease of application (3) the accepted usage within the field of rehabilitation (4) minimal contraindications (5) standardization of application. Predicted outcomes for the use of heat parallel those of MFR. However, Taylor (1990) points out that many of the assumed outcomes of heating are not backed up by scientific evidence. One such example Taylor (1990) offered was that the reduction of stiffness of arthritic joints is more the result of decreased viscosity of synovial fluid rather than the heating effect on connective tissues. Taylor (1990) further noted that there was no objective evidence that superficial heating had a suppressive effect on the mechanisms responsible for maintaining muscle spasms. The outcome predictors for the application of superficial heat were the result of. secondary physiological and/or psychological factors from the heat application (Taylor, pp. 835e848). The purpose of this study was to compare end results, passive ROM, after MFR techniques and hot pack application. The MFR technique is specifically described as an indirect three-planar soft tissue MFR technique as outlined by Weiselfish-Giammatteo and Kain (2005). The technique was applied for 3 min while the hot pack was applied for a standard 20 min. As MFR and the superficial heat application of hot packs have similar outcome predictors, it was felt that passive ROM assessment would yield similar results with both treatments. Should ROM assessments demonstrate comparable outcomes, MFR would exhibit a significant improvement in treatment efficacy (3 min versus 20 min). This study would be one of the first to show objective, measurable changes from the use of an MFR technique. Methods Participants This study was reviewed by the Human Participants Review Board at American International College and was approved for data collection. Each participant signed an informed consent prior to testing. All testing was administered at American International College in Springfield, Massachusetts. All participants (N Z 31) were selected from a sample of convenience from the junior and senior physical therapy classes and were randomly assigned into two treatment groups The independent variable used was the type of intervention, either the tri-planar MFR technique or the hot pack application. Group one (N Z 18) received the indirect tri-planar MFR technique once for 3 min. Group two (N Z 13) received one hot pack application for 20 min. The dependent variables, passive gleno-humeral shoulder range of motion in shoulder flexion, shoulder extension, and
Indirect tri-planar MFR or a hot pack for increasing range of motion 65 shoulder abduction were taken pre- and post-intervention for groups one and two. Both groups received treatment to their dominant upper extremity. All participants were goniometrically tested in supine position for range of motion at the gleno-humeral joint. Prior to conducting the study, inter-rater reliability (r Z 0.96) was established using three different testers for goniometric measures. Inclusion criteria included participants who were painfree in their dominant upper extremity with no history of acute or sub-acute injury. Participants dominant arm was utilized for testing procedures. This was determined by establishing which hand the participant used when writing. No attempt was made to further delimit the study based on gender, time of day, chronic injuries (beyond 6 months), race, or age. Experimental procedures Participants were tested on the same day using two different examination rooms. Participants were positioned on standard plinths in the supine position to standardize testing. The head and neck were placed in the neutral position (i.e. zero degrees of side bending/rotation and flexion of the head and neck while supine). The dominant arm was placed at the side at zero degrees abduction, flexion, and rotation as a starting point for the measurement of passive range of motion (PROM) during pre- and post-testing. This position was maintained during application of the hot packs as well as the MFR techniques. Participants were allowed to talk during either intervention, yet allowing no movement of the head or neck in any plane. The practitioner s hands were placed lightly on the body during application of the tri-planar MFR technique. The practitioner s hands remained in light contact with the participant s shoulder throughout the treatment intervention. Every effort was made not to change or alter hand pressure during the treatment. Instrumentation and measurements Inter-rater reliability was established prior to testing to demonstrate accuracy in range of motion measurements between examiners. Shoulder PROM was goniometrically measured by independent examiners who were unaware of the interventions used for each participant. One examiner measured PROM using a standard goniometer, while another examiner passively moved the participant dominant extremity through a designated ROM. ROM assessments utilized Kaltenborn s convex/concave constructs in determining the end ROM (Kaltenborn, 1976). End ROM was established when the examiner was able to palpate the humeral head move in an anterior/superior pattern. All motion was measured in the three cardinal planes of movement (i.e. sagittal, coronal, and transverse planes). Flexion and extension were measured in the sagittal plane; abduction was measured in the coronal plane. In situations where the accessory movement was not palpable, movement at the tendon insertion or muscle belly was used to determine the end point of motion. Standard goniometric measurements were taken using landmark assessment as outlined by Kendall and McCreary (2005) and Worthingham and Daniels (1972). All motion was limited to pure, planar alignment, and alteration from the criteria excluded the participants from testing. Passive range of motion was performed on all participants pre- and post-treatment by the same individuals. Participants who were randomly assigned to the hot pack (superficial heat) application received a standard hydrocollator pack. It contained silicate gel in a cotton canvas bag. The hot pack was placed in a heating unit filled with water maintained at a steady 79.4 C (175 F). The packs were layered equally and enclosed in terrycloth covers. A standard six layers of towels were used with all participants. More layering was added only during treatment time if requested by the participant due to excessive heat build up. All hot packs were applied for 20 min with the patient in the supine position with hot packs positioned over the anterior shoulder of the extremity examined. Participants assigned to the MFR group received treatment in the supine position. The same physical therapist performed all treatment interventions. The specific MFR technique was the clavi-pectoral indirect soft tissue threeplanar fulcrum release. The technique required the practitioner to sit on the side of the participant s dominant extremity, slightly superior to the gleno-humeral joint to be treated. The practitioner s hands were then spread maximally on the anterior and posterior aspects of the participant s gleno-humeral joint. The palms of the practitioner were facing the participant. A light touch that allowed for full contact with no added pressure was utilized. The fingers were spread so as to engage as much tissue around and over the joint as possible. Once contact was established, the practitioner gently moved both hands in opposite directions in one plane at a time. The typical sequence for planar assessment was the sagittal, coronal, and then transverse planes. Once the practitioner moved the hands in opposite directions, they were then returned to the starting point and moved in the same plane in opposite directions. The practitioner then determined which two-handed combination moved with greater ease. The hands would be moved into that easier direction and held steady until the later two planes were assessed and stacked on the first plane. Once the direction of the sagittal plane movement was determined, the practitioner held both hands in that position of ease. This constituted the first part of the threeplanar fulcrum. The next step was to move both hands in opposite directions in the coronal plane while maintaining the hands in the direction of ease in the sagittal plane. Again, the practitioner determined the direction of combined movements which were easiest. Once determined, the practitioner stacked the coronal plane ease of movement on the sagittal plane hand position. This completed the second part of the three-planar fulcrum. The practitioner then held both hands in two different directions of tissue ease. The process was then repeated a third time in the transverse plane with the last plane of the indirect fulcrum motion stacked on the first two planes of movement. The practitioner moved his hands in three planes, establishing a fascial fulcrum over the gleno-humeral joint and clavi-pectoral region. All participants were treated in the supine position for a period of 3 min. The timing started
66 J. Kain et al. once the three-planar fulcrum was established by the practitioner. Post-test passive range of motion was then repeated for that joint for each participant. Results A total of 31 participants were tested in this study. Participants were randomly assigned to one of two groups and were measured with a goniometer for passive range of motion of the gleno-humeral joint pre-intervention and post-intervention. Prior to conducting the study, inter-rater reliability was established using three testers for goniometric measures (r Z 0.96). Groups consisted of participants receiving one of the two interventions, hot pack or myofascial release. Thirteen participants received the hot pack intervention while 18 received the myofascial release intervention. A 2 (type of intervention: hot packs or MFR) by 2 (pre-test or post-test) mixed-factors ANOVA was calculated. Significant increases in range of motion were found for flexion, F(1,29) Z 12.42, p Z 0.001 when comparing pre-test scores to post-test scores. Significant increases in range of motion were found for extension, F(1,29) Z 20.34, p Z 0.001 when comparing pre-test scores to post-test scores. Significant increases in range of motion were found for abduction, F(1,29) Z 14.51, p Z 0.001 when comparing pre-test scores to post-test scores. The purpose of the study was to examine whether or not MFR was as effective in increasing range of motion as hot packs. The results of the ANOVA showed that for passive range of motion no differences were found for flexion between the effectiveness of hot packs (M Z 56.85, SD Z 6.35) and MFR (M Z 58.33, SD Z 7.58), F(1,29) Z 1.822, p Z 0.187. This suggests that for flexion, the MFR treatment is as effective as hot packs. For the extension of the gleno-humeral joint, the ANOVA showed no significant differences in the use of hot packs (M Z 39.27, SD Z 6.00) and MFR (M Z 41.22, SD Z 4.47), F(1,29) Z 0.241, p Z 0.628. Finally, for abduction the hot packs (M Z 60.08, SD Z 5.02) did not differ in effectiveness from the MFR (M Z 60.86, SD Z 4.35), F(1,29) Z 0.44, p Z 0.512. For each of the dependent variables measured, MFR was shown to be as effective as hot packs in increasing range of motion, supporting the hypothesis. Discussion Since there was no significant difference between the types of intervention, both the hot pack application and the myofascial release technique were found to be equally effective in increasing passive range of motion of the joint in flexion, extension, and abduction of the gleno-humeral joint. The group receiving the hot pack intervention had an increase in joint passive range of motion from pre to post application as did the myofascial group. The MFR intervention was as effective as the standard intervention of hot packs. In determining which intervention to administer, the clinician needs to consider some basic elements; how much time does the clinician have to provide treatment?, is equipment an issue?, and does the clinician have the necessary skills to effectively administer the intervention? Providing myofascial techniques requires decreased time to administer the intervention, no equipment to purchase in order to administer the intervention, no preparation time; however, this technique does require additional training on the part of the physical therapist in order to provide a safe, effective intervention. On the other hand, the clinician is aware that hot pack use requires more time to administer the intervention but is easy to administer, requires the purchase of a hot pack, the hot pack cover, and towels, requires preparation time but does not require additional training. Hot pack use requires up to 20 min to administer the intervention, while the myofascial release technique requires 3 min to administer. In the time needed to apply and administer a hot pack on one patient, approximately 5e6 patients could have been treated using the myofascial release technique with similar outcomes in range of motion. The hot pack intervention requires the purchase expenses as listed above, while the myofascial technique requires the hands of the skilled clinician to administer. The speed of the myofascial release technique and the lack of equipment would suggest that it is a more time efficient type of intervention, provided the therapist is trained in this technique. Both interventions have been found to be equally effective in increasing passive range of motion. This study did not take measurements for either intervention long-term, resulting in a limitation of the study to truly assess the effectiveness of joint range of motion over a long period of time. However, it is the responsibility of the physical therapist to establish strategies for maintaining range of motion gained during the therapy visit. Based upon the premise that each clinician has the right to be an autonomous practitioner, both of the identified modalities should be considered in physical therapy intervention strategies. Editor s note: The description of the MFR method, described in this paper as tri-planar indirect MFR, might be confusing for some readers. In osteopathic circles, in particular, this approach would more commonly be described as a Functional Positional Release approach. (Johnstone 2003). References Barnes, M.F., 1997. Efficacy study of the effect of a myofascial release treatment technique on obtaining pelvic symmetry. Journal of Bodywork and Movement Therapies 1 (5), 289e296. Bucher, B.M., 1993. Myofascial manipulative release of carpal tunnel syndrome: documentation with magnetic resonance imaging. Journal of the American Osteopathic Association 93 (12), 1273e1278. Bucher, B.M., 1994. Myofascial release of carpal tunnel syndrome. Journal of the American Osteopathic Association 93 (1), 92e94. 100e101. Cantu, R., Grodin, A., 1992. Myofascial Manipulation: Theory and Clinical Application. Aspen Publishers, Gaithersburg, MD. Hanten, W.P., 1994. The effects of myofascial release leg pull and sagittal plane isometric contract relax techniques on passive straight leg raise angle. Journal of Orthopedic and Sports Physical Therapy 20 (3), 138e144. Johnston, W.L., 2003. Functional technique: an indirect method. In: Ward, R.C. (Ed.), Foundations for osteopathic medicine, 2/e. Lippincott, Williams & Wilkins, Philadelphia, pp. 969e 984.
Indirect tri-planar MFR or a hot pack for increasing range of motion 67 Kaltenborn, F., 1976. Manual Therapy for the Extremity Joints. Olaf Norlis Bokhandel, Oslo, Norway. Kendall, F., McCreary, E., 2005. Muscles, Testing and Function. Williams and Wilkins, Baltimore, MD. Prentice, W., 1990. Rehabilitation Techniques in Sports Medicine. Times Mirror/Mosby College Publishers, Saint Louis, MO. Taylor, L.P., 1990. In: Taylor s Manual of Physical Evaluation and Treatment, vol. II. Slack Inc., Thorofare, NJ. Weiselfish-Giammatteo, S., Kain, J., 2005. Integrative Manual Therapy for the Connective Tissue System: Myofascial Release. North Atlantic Books, Berkeley, CA. Worthingham, C., Daniels, L., 1972. Muscle Testing: Techniques of Manual Examination, third ed. WB Saunders, Philadelphia, PA.