Article

Clinical Rehabilitation
25(9) 800–813
Effects of myofascial release ! The Author(s) 2011
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DOI: 10.1177/0269215511399476
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function, and postural stability in
patients with fibromyalgia: a
randomized controlled trial

Adelaida Marı́a Castro-Sánchez1, Guillermo A Matarán-Peñarrocha2,

Manuel Arroyo-Morales3, Manuel Saavedra-Hernández1,
Cayetano Fernández-Sola1 and Carmen Moreno-Lorenzo3

Abstract
Objective: To determine the effect of myofascial release techniques on pain symptoms, postural stability
and physical function in fibromyalgia syndrome.
Design: A randomized, placebo-controlled trial was undertaken.
Subjects: Eighty-six patients with fibromyalgia syndrome were randomly assigned to an experimental
group and a placebo group.
Interventions: Patients received treatments for 20 weeks. The experimental group underwent 10
myofascial release modalities and the placebo group received sham short-wave and ultrasound
electrotherapy.
Main measures: Outcome variables were number of tender points, pain, postural stability, physical
function, clinical severity and global clinical assessment of improvement. Outcome measures were
assessed before and immediately after, at six months and one year after the last session of the corre-
sponding intervention.
Results: After 20 weeks of myofascial therapy, the experimental group showed a significant improvement
(P < 0.05) in painful tender points, McGill Pain Score (20.6  6.3, P < 0.032), physical function
(56.10  17.3, P < 0.029), and clinical severity (5.08  1.03, P < 0.039). At six months post intervention,
the experimental group had a significantly lower mean number of painful points, pain score (8.25  1.13,
P < 0.048), physical function (58.60  16.30, P < 0.049) and clinical severity (5.28  0.97, P < 0.043).
At one year post intervention, the only significant improvements were in painful points at second left
rib and left gluteal muscle, affective dimension, number of days feeling good and clinical severity.

1
Department of Nursing and Physical Therapy, University of
Almerı́a (UAL), Spain Corresponding author:
2
Malaga-North Sanitary District (Andalusian Health Public Adelaida Marı́a Castro-Sánchez, Carretera de Sacramento S/N,
Service), Málaga, Spain Departamento de Enfermerı́a y Fisioterapia, Universidad de
3
Department of Physical Therapy, University of Granada (UGR), Almerı́a, Almerı́a, Spain
Spain Email: adelaid@ual.es

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Castro-Sánchez et al.
Conclusion: The results suggest that myofascial release techniques can be a complementary therapy for
pain symptoms, physical function and clinical severity but do not improve postural stability in patients with
fibromyalgia syndrome.
Keywords
Pain assessment, fibromyalgia, physical therapy, postural instability, chronic fatigue syndrome
Received: 17 July 2010; accepted: 14 January 2011
Introduction
Fibromyalgia is a syndrome of widespread
chronic pain associated with persistent fatigue,
generalized morning rigidity, non-reparative
sleep, cephalea, irritable bladder, dysmenor-
rhoea, extreme sensitivity to cold, restless legs,
undefined pattern of numbness, tingling and
intolerance to exercise.1,2 The condition may
affect peripheral and/or central mechanisms of
postural control, and is associated with balance
problems and an increased frequency of falls.3
According to Chaitow,4 the dysfunction
model in fibromyalgia syndrome has three aetio-
logical factors (biochemical, biomechanical and
psychosocial) that interact with innate and
acquired characteristics to determine the vulner-
ability and susceptibility of an individual. The
following interactions among these factors
have been proposed: (1) a negative emotional
state may produce specific biochemical changes,
weakened immunological function and alter-
ation of muscle tone; (2) hyperventilation modi-
fies blood oxygenation at neuronal level,
generating a state of anxiety/apprehension and
having a direct impact on structural components
of the thoracic and cervical region; and (3)
chemical changes in blood flow may produce
mood and structural changes.4
Although fibromyalgia is not a musculoskel-
etal disease, most of the symptoms manifest at
this level. Bialosky et al.5 introduced the term
‘facilitation phenomenon’ to explain some
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801
events in musculoskeletal pain, especially myo-
fascial pain, stating that neuronal structures
may become hyperreactive at spinal or para-
spinal tissue level (‘segmental facilitation’).
Points of hyperreactivity are designated ‘trigger
points’ when detected in ligament, tendon or
periosteal tissue and ‘myofascial trigger points’
when in muscle or fascia.
Central sensitization is well documented in
fibromyalgia but its cause remains unclear. It
occurs when persistent nociceptive input leads
to increased excitability in the dorsal horn neu-
rons of the spinal cord.6 In this hyperexcited
state, spinal cord neurons produce an enhanced
responsiveness to noxious stimulations and
even to formerly innocuous stimulations.
There is some evidence of dysfunction of the
intramuscular connective tissue or fascia in
fibromyalgia.6
Vleeming et al.7 highlighted that the posterior
oblique system of functional stability involves
thoracolumbar fascia and paravertebral, latissi-
mus dorsi, trapezius and gluteus maximus mus-
cles, being closely related to the psoas muscle.
Alterations in this system are related to psoas
weakness, with a direct influence on sacroiliac
articulation. Hence, adipose thickening of the
thoracolumbar fascia may be related to alter-
ation of the fascial functional system, generating
one of the most frequent localizations of pri-
mary fascial entrapment in fibromyalgia
patients. Based on this theory, Schleip8
802
developed a map of ‘hypersensitivity points’ in
the most frequent areas of fascial plane entrap-
ment. These hypersensitivity points coincide
with the points described by the American
College of Rheumatology.8
Liptan6 proposed inflammation of the fascia
as the source of peripheral nociceptive input that
leads to central sensitization in fibromyalgia,
attributing the fascial dysfunction to inadequate
growth hormone production and hypothalamic
pituitary adrenal axis dysfunction in fibromyal-
gia. The main cell of the richly innervated fascia,
the fibroblast, secretes proinflammatory cyto-
kines in response to strain, and immunohisto-
chemical studies of biopsies have revealed
elevated levels of collagen and inflammatory
mediators in the connective tissue surrounding
muscle cells in fibromyalgia patients.6 According
to Liptan, if it is confirmed that inflammation
and dysfunction of the fascia can lead to central
sensitization in fibromyalgia, treatment options
could be expanded to include manual therapies
directed at the fascia, such as myofascial release.
While various studies have demonstrated the
efficacy of different complementary thera-
pies,8–16 effective and readily available methods
of manual therapy could be valuable in the treat-
ment of fibromyalgia.
In a study on fibromyalgia and balance dis-
orders and falls, Jones et al.17 found that fibro-
myalgia symptoms of fatigue, stiffness, pain,
sleep, anxiety and feeling depressed were associ-
ated with difficulties in knowing how far one can
lean from a seated position, accurately attaining
vertical realignment, maintaining balance while
standing with eyes closed, and reaching laterally
or forward while keeping heels on the ground.
Their findings suggest that the totality of fibro-
myalgia symptoms rather than pain alone may
be responsible for the poor balance demon-
strated in the study.18 A previous study by our
group on the efficacy of myofascial therapy
in fibromyalgia patients found that one weekly
session produced a significant improvement
in anxiety, sleep and quality of life.19 The
aim in the present study was to explore
whether a more intensive therapeutic protocol
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Clinical Rehabilitation 25(9)
(two sessions/week) could achieve an improve-
ment in physical function and postural stability
in these patients.
The objective of this study was to evaluate the
usefulness of myofascial therapy to improve
pain, physical function, and postural stability
in fibromyalgia patients, based on the fascial
connection between the rectus capitis posticus
minor muscle and the dura mater at the level
of the atlanto-occipital joint.20 Numerous
researchers have postulated that a lesion or
stressful event in this area may trigger the
chronic pain of fibromyalgia syndrome.10,20–22
Methods
This single-blind clinical trial was nested in an
experimental study. Intragroup and intergroup
differences (experimental group and placebo
group) were evaluated at baseline (pre-test),
immediately after the 20-week intervention,
and again at six months and one year. The
experimental period was from 15 November
2007 to 15 March 2009. Before enrollment, all
subjects signed informed consent to participate
in the study, which was approved by the ethics
committee of the University of Almeria.
Participants were told they could leave the
study at any time. Written informed consent
was obtained from all patients before their par-
ticipation in the study, which complied with the
ethical criteria established in the Helsinki
Declaration (2008 modification) on research
projects and with current Spanish legislation
on clinical trials (Royal Decree 223/2004
February 6) and biomedical research (Law 14/
2007 of July 3). The confidentiality of study
material was in accordance Spanish legislation
on personal data protection (Law 15/1999 of
December 13).
The target population consisted of patients
diagnosed with fibromyalgia syndrome by phy-
sicians at the Torrecardenas Hospital Complex,
and the accessible population comprised those
with computerized clinical records held by the
Fibromyalgia Association of Almeria (Spain)
and receiving pharmacology therapy: 32 patients
Castro-Sánchez et al.
treated with anxiolytics, 41 with antidepressants,
86 with anti-inflammatories, 43 with corticoids,
26 with antibiotics, 64 with sleep inducers, and
79 with muscle relaxants.
Inclusion criteria were: age 40–65 years,
agreement to attend evening therapy sessions,
limitation of usual activities due to pain on at
least 1 day in the previous 30 days, and/or mod-
erate or worse average pain level (4 on 10-
point scale).23 Exclusion criteria were: receipt
of non-pharmaceutical therapies; presence of
infection, fever, hypotension, treatment-limiting
respiratory disorders; and alterations in cutane-
ous integrity.24 The theoretical sample, recruited
by consecutive sampling, was formed by
155 patients. Out of 155 patients in the accessi-
ble population, 61 were excluded, and the
remaining 94 patients were randomly assigned
by means of a balanced stratified assignment
to an experimental (n ¼ 47) or placebo (n ¼ 47)
group. The groups were balanced for type of
medication received, sex and age by using a strat-
ification system that generates a sequence of let-
ters (from a table of correlatively ordered
permutations) for each category and combina-
tion of categories. The sequences assigned to
patients were placed in envelopes containing the
allocation to each study group.
Researchers telephoned selected patients and
invited them to the laboratory for initial inter-
view; for females of childbearing age, the
appointment was on the day after the expected
end of the menstrual period. At this interview,
demographic characteristics were recorded and
baseline outcome data were gathered. All deter-
minations were obtained at least 3 hours after
the last food intake and 4 hours after the last
medication dose.25 After the initial interview,
patients were randomly assigned to the experi-
mental or placebo group. Both groups under-
went their corresponding intervention for 20
weeks. Assessments were repeated immediately
after the final treatment session and at six
months and one year. Outcomes were deter-
mined by another researcher, who was blinded
to the study group of patients. However, the
physiotherapist (specialist in myofascial
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803
therapy) who administered both intervention
protocols and the patients themselves were not
blinded to their status.
Intervention protocol
Patients in the experimental group underwent
a myofascial therapy protocol, administered
in the following order:20,26–29 deep fascia
release in temporal region, suboccipital release,
compression–decompression of temporoman-
dibular joint, global release of cervicodorsal
fascia, release of pectoral region, diaphragm
release (transverse slide), transverse diaphrag-
matic plane, lumbosacral decompression, release
of psoas fascia and release of fascia of the
lumbar square (Appendix 1).
Twice-weekly for 20 weeks, the experimental
group received a 1-hour session of 10 myofascial
release modalities. The placebo group received
sham short-wave and ultrasound treatment for
30 minutes twice-weekly for 20 weeks. Both elec-
trotherapy procedures were applied with discon-
nected equipment on cervical, dorsal and lumbar
regions for 10 minutes on each region. Patients
were unaware that the equipment was discon-
nected and that this was a sham treatment.
Outcome measures
Data on demographic characteristics were col-
lected at baseline. Primary outcome variables
were number of tender points, pain and postural
stability. Secondary outcome variables were
physical function, clinical severity and global
clinical assessment of improvement.
Assessment of tender points
Eighteen tender points were evaluated using a
pressure algometer (at 4 kg of pressure) that
measures pressure (applied with a rubber tip)
in 0.5 kg intervals from 0 to 5 kg (Wagner FPI
10-USA). Tender points were bilateral at: lower
back of head at insertion of occipital muscles;
anterior sides of intertransverse spaces, from
cervical vertebra C5 to C7; medium area of
804
upper trapezius muscle; origin of supraspinal
muscle above scapulae close to their internal
margin; insertion of second ribs above sternum;
bony prominence of humerus at the origin of
forearm extensor muscle; upper external quad-
rants of buttock in anterior fold of gluteal
muscle; crest of greater trochanter of femur at
insertion of piriform muscles; subcutaneous
tissue of internal side of knee above joint
line.30,31
Pain
The McGill Pain Questionnaire (MPQ) was
used to assess pain levels. It is based on a
multidimensional perception of pain: sensory–
discriminative, motivational–affective, and
cognitive–evaluative.32 It includes: (1) 62 des-
criptors distributed among 15 classes and the
three dimensions, with scores ranging from
0 to 33 for the sensory dimension, 0 to 12 for
the affective dimension, and 0 to 45 for the eval-
uative (sensory + affective) dimension; (2) a
visual analogue scale (VAS) to assess pain inten-
sity and relief experienced by the patient (0 ¼ no
pain, 10 ¼ unbearable pain); and (3) a represen-
tation of the human figure on which patients
indicate the exact localization of pain.32
Postural stability
Postural stability was determined by studying
the balance of patients with a stabilometer plat-
form (Biodex Medical System, USA), used for
the diagnosis and proprioceptive treatment of
patients with balance disorders.33 Patients were
asked to find the most stable foot placement on
the platform, since this position was main-
tained throughout all three trials. This was
the reference point from which the centre of
pressure was measured. Patients were instructed
to maintain the platform as stable as possible.
The stabilometer setting was at level 8 during
all tests. Patients were instructed to cross their
arms at chest level to minimize their use to
attain balance. Each lower extremity was
tested three times, as in previous studies using
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Clinical Rehabilitation 25(9)
the Biodex Stabilometer for assessment pos-
tural stability.33 The mean of three trials was
determined. A higher score indicates lesser pos-
tural stability.
Physical function
The Spanish version of the 10-item
Fibromyalgia Impact Questionnaire was used
to measure the impact of fibromyalgia symp-
toms on the physical and mental health of
patients.34 It explores physical, psychological,
social and well-being dimensions and includes
six visual analogue scales to evaluate fatigue,
pain, rigidity, morning tiredness, anxiety and
depression components. It assesses well-being,
physical function, loss of working days and
capacity for work. The Spanish version was val-
idated in a sample of 102 females from the city
of Madrid, obtaining high degrees of test–retest
stability for almost all scales, except for scales of
sleep disturbance, rigidity and anxiety, which
showed moderate stability degrees, similar to
the findings of the English version of the ques-
tionnaire. The authors recorded a high degree
of internal consistency, although the relation-
ship of the questionnaire with the currently
most objective test (number of painful tender
points) was discrete. Nonetheless, the authors
demonstrated that the Fibromyalgia Impact
Questionnaire is a good instrument to detect
sensitivity to therapeutic change.34
Clinical severity
The Clinical Global Impression Severity Scale
was used to assess the physical state of the
patient. Patients rated themselves on a Likert
scale (1 ¼ disease-free to 7 ¼ extremely ill).35
Global Clinical Assessment of Improvement
The Clinical Global Impression Improvement
Scale was used to assess the overall clinical
improvement as perceived by patients, who
responded on a Likert scale (1 ¼ much better
to 7 ¼ extremely ill).36
Castro-Sánchez et al.
All quantitative data were entered in a SPSS
17.0 database. The reliability and validity of the
model was studied by analysing residual inde-
pendence, normality and variance homogeneity.
Residual independence was analysed by plotting
the values obtained against residues, resulting in
randomly distributed points showing no specific
trend and therefore verifying the residual inde-
pendence assumption. Residual normality was
studied by using a Q-Q graph, finding the
dots to be located close to the line and there-
fore confirming the residual normality assump-
tion. Variance homogeneity was tested with
the Levene test, obtaining a 95% confidence
level and P-value > 0.05, confirming variance
equality.
Frequency distributions were generated to
examine missing data, out of range scores and
the logical distribution of response options, and
all measures were scored. We calculated an
imputed score for standardized scales miss-
ing  10% of responses. Independent t-tests
were used to compare baseline demographic
characteristics between participants and drop-
outs and between experimental and placebo
groups. Within-group changes in painful
points, physical function, pain, postural stabil-
ity, clinical severity and severity improvement
were analysed by using a 2 (groups: experimen-
tal and placebo)  4 (time points: baseline,
immediately post intervention, at six months
and one year) repeated-measures analysis of var-
iance (ANOVA). A 95% confidence interval
(CI) (a ¼ 0.05) was considered in all tests.
Results
Figure 1 depicts the flow of participants through
the trial. Out of 155 patients screened for eligi-
bility, 94 were enrolled and randomly assigned
to intervention (n ¼ 47) and placebo (n ¼ 47)
groups. The study was fully completed by 45
in the experimental group and 41 in the placebo
group (see Figure 1 for drop-out details).
Data on patient characteristics are given in
Table 1. No significant differences were found
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805
between experimental and placebo groups in
mean baseline mean scores for any outcome
measure except ‘degree of stiffness’. No signifi-
cant differences in demographic variables were
found between the groups.
Improvements between baseline and follow-
up assessments were found in some but not
all outcome measures. Results reported below
are based on the whole sample unless other-
wise indicated. At baseline, the patients had
a large number of painful points, with a mean
of 32.4 (SD 4.6) in the experimental group
and 32.3 (SD 8.9) in the control group.
After 20 weeks of myofascial therapy, the exper-
imental group showed a significant fall in
the number of painful points on the left side
lower cervicals (F ¼ 6.42, P < 0.028), left trape-
zius muscle (F ¼ 3.24, P < 0.042), second
right rib (F ¼ 3.16, P < 0.048), second left
rib (F ¼ 4.12, P < 0.046), right gluteal muscle
(F ¼ 7.23, P < 0.017), left gluteal muscle
(F ¼ 5.51, P < 0.031) and right greater trochan-
ter (F ¼ 5.62, P < 0.031). The placebo group
showed no changes in tender points. At six
months post intervention, the experimental
group had a significantly lower mean number
of painful points at left lower cervical
level (F ¼ 3.19, P < 0.045), second left rib
(F ¼ 3.52, P < 0.042), right gluteal muscle
(F ¼ 5.71, P < 0.030), and left gluteal
muscle (F ¼ 3.15, P < 0.048). At one year, the
only significant reduction in painful points
was at second left rib (F ¼ 3.18, P < 0.042) and
left gluteal muscle (F ¼ 3.15, P < 0.048). Tables 2
and 3 show the differences in painful tender
points between study groups.
At baseline, both groups had elevated VAS-
assessed pain scores, with a mean of 91.30 (SD
8.7) for the experimental group and 89.04 (SD
9.3) for the placebo group. After 20 weeks of
therapy, the experimental group recorded signif-
icant improvements in all dimensions of the
McGill Pain Score: sensory (F ¼ 3.21,
P < 0.041), affective (F ¼ 5.29, P < 0.031), sen-
sory + affective (F ¼ 5.44, P < 0.032) and VAS
(F ¼ 6.19, P < 0.026). At one year post interven-
tion, a significant improvement persisted in the
806 Clinical Rehabilitation 25(9)

Total number of patients

that potentially could Exclusion (n=61)
have been recruited Did not meet inclusion criteria
(n=155) (n=54)
Refused to participate
(n=7)
Total number of
patients registered
Experimental (n=94) Placebo
Group Group

Received allocated intervention (n=47) Received allocated intervention (n=47)

Completed intervention & study Completed intervention & study
assessments (n=45) assessments (n=41)

Lost to follow-up (n=2) Lost to follow-up (n=6)

Personal family problems (n=1) Change of address to another city (n=1)
Personal health problems (n=1) Personal family problems (n=1)
Personal health problems (n=2)
Did not respond to contact (n=1)
Began a new pharmacological treatment
during the study (n=1)
Outcome data (n=45)

Outcome data (n=41)

Figure 1. Flow of participants through the randomized trial. None of the 94 participants reported adverse effects.

affective dimension alone (F ¼ 3.22, P < 0.042).
The placebo group showed no significant
changes in these variables during the study.
Table 4 shows significant differences between
study groups.
No significant difference in postural stabil-
ity was found between groups at any time,
and there were no significant changes in
either group among the different time points
(Table 4).
At baseline, patients had an elevated global
Fibromyalgia Impact Questionnaire score, with
a mean of 64.95 (SD 18.2) for the experimental
group and 63.94 (SD 16.4) for the placebo
group. After 20 weeks of therapy, the experi-
mental group showed a significant improvement
in total Fibromyalgia Impact Questionnaire
score (F ¼ 6.54, P < 0.029), number of days feel-
ing good (F ¼ 6.81, P < 0.022), pain (F ¼ 6.95,
P < 0.021), fatigue (F ¼ 5.02, P < 0.038), tired-
ness on waking (F ¼ 5.24, P < 0.032) and stiff-
ness (F ¼ 4.96, P < 0.038). At six months post
intervention, improvements persisted in total
score (F ¼ 2.71, P < 0.049), number of days feel-
ing good (F ¼ 5.32, P < 0.032), pain (F ¼ 5.07,
P < 0.037), fatigue (F ¼ 3.36, P < 0.045), tired-
ness on waking (F ¼ 3.51, P < 0.041) and stiff-
ness (F ¼ 3.29, P < 0.043). At one year, only
number of days feeling good (F ¼ 3.02,
P < 0.044) showed a significant improvement.
No significant improvements in any dimension
were shown by the placebo group at any time

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Castro-Sánchez et al. 807

Table 1. Patient characteristics

Experimental group Placebo group Total

(n ¼ 45) (n ¼ 41) (n ¼ 86)

Mean age 55.3 53.5 54.4

Age range 47–65 45–64 45–65
Frequency % Frequency % Frequency %
Marital status
Married 36 80 33 80.5 69 80.2
Separated/divorced 6 13.3 2 4.9 8 9.3
Widowed 1 2.2 2 4.9 3 3.5
Single 2 4.4 3 7.3 5 5.8
Other 0 0 1 2.4 1 1.2
Educational level
High school graduate 1 2.2 2 4.9 3 3.5
Some college 14 31.1 18 43.9 32 37.2
College graduate 12 26.7 6 14.6 18 20.9
Graduate school 18 40 15 36.6 33 38.4
Income levela
Less than 9 999E 23 51.1 21 51.2 44 51.2
10 000–14 999E 18 40 14 34.1 32 37.2
15 000–19 999E 1 2.2 2 4.9 3 3.5
20 000–24 999E 0 0 2 4.9 2 2.3
25 000E or more 0 0 1 2.4 1 1.2
a
Three patients in the experimental group and one in the placebo group did not respond to the question on income level.

point. Table 4 shows the significant differences
between the groups.
Mean (SD) baseline clinical severity scores
did not significantly differ (P < 0.109) between
the experimental (6.25 (SD 0.73)) and placebo
(5.92 (SD 0.84)) groups. The experiment group
showed significant differences at the three post-
therapy assessments: immediate (F ¼ 5.02,
P < 0.039), six months (F ¼ 3.29, P < 0.043),
and one year (F ¼ 3.36, P < 0.045). The placebo
group showed no significant differences at any
time. Table 4 shows the differences between
study groups.
Clinical improvement was not recorded at
baseline. The groups differed in this parameter
immediately, six months and one year after the
intervention (Table 4). Neither group showed
significant differences between the score
immediately after the intervention and those
recorded at six months and one year.
Discussion
After a 20-week weekly programme of myofas-
cial therapy, fibromyalgia patients showed
a significant reduction in pain according to
pressure algometry results and McGill
Pain Questionnaire, Clinical Global Impression
Severity Scale and Fibromyalgia Impact
Questionnaire scores. However, there was no
significant decrease in postural stability as a
result of this treatment.
We found that sociodemographic variables
(e.g. age, previous duration of disorder, aca-
demic level, profession) had no influence on
the intensity of the impact of fibromyalgia as

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808 Clinical Rehabilitation 25(9)

Table 2. Significant differences between groups in numbers of patients with painful tender points (9 tender points I)

Baseline PTP 20 weeks PTP 6 months PTP 1 year PTP

Tender points EG PG P Pre-T EG PG P 1st PT EG PG P 2nd PT EG PG P 3 rd PT

RO 31 35 0.274 25 33 0.046* 27 35 0.039* 29 34 0.199

LO 29 34 0.199 24 35 0.032* 26 36 0.029* 28 36 0.041*
LCR 35 28 0.055 29 29 1.000 30 29 0.833 32 31 0.893
LCL 32 37 0.201 22 36 0.009* 24 35 0.020* 28 34 0.051
RTM 30 36 0.153 26 35 0.034* 29 34 0.199 29 36 0.048*
LTM 35 31 0.274 27 33 0.159 29 37 0.040* 30 37 0.049*
RSM 29 35 0.060 24 33 0.031* 25 32 0.053 28 33 0.209
LSM 32 33 0.893 28 33 0.209 30 34 0.329 33 35 0.778
2nd RR 34 28 0.065 26 29 0.431 31 30 0.897 33 29 0.356
*P-value < 0.05 (95% confidence interval).
Values are presented as means (SD).
PTP, painful tender points; EG, experimental group; PG, placebo group; Pre-T, pre-therapy; 1st PT, post therapy (immediately after 20
weeks of treatment); 2nd PT, post therapy (six months after treatment); 3 rd PT, post therapy (one year after treatment); RO, right
occiput; LO, left occiput; LCR, lower cervicals (righ-side); LCL, lower cerivicals (left-side); RTM, right trapezius muscle; LTM, left
trapezius muscle; RSM, right supraspinatus muscle; LSM, left supraspinatus muscle; 2nd RR, second right rib.

Table 3. Significant differences between groups in numbers of patients with painful tender points (9 tender points II)

Baseline PTP 20 weeks PTP 6 months PTP 1 year PTP

Tender points EG PG P Pre-T EG PG P 1st PT EG PG P 2nd PT EG PG P 3rd PT

2nd LR 35 30 0.211 25 31 0.156 27 33 0.159 27 32 0.204

RLE 29 34 0.199 23 34 0.031* 26 35 0.034* 29 35 0.060
LLE 27 31 0.328 22 32 0.028* 25 33 0.046* 26 32 0.063
RG 35 30 0.211 23 31 0.047* 25 33 0.046* 29 32 0.454
LG 34 32 0.739 24 33 0.031* 26 33 0.056 26 34 0.048*
RGT 29 31 0.781 20 30 0.030* 24 31 0.055 25 32 0.045*
LGT 27 29 0.743 22 29 0.054 24 31 0.055 26 30 0.269
RK 32 34 0.739 29 35 0.060 31 35 0.274 32 34 0.739
LK 31 35 0.274 28 34 0.065 29 35 0.060 30 36 0.156
*P-value < 0.05 (95 % confidence interval).
Values are presented as numbers of patients with painful tender points.
PTP, painful tender points; EG, experimental group; PG, placebo group; Pre-T, pre-therapy; 1st PT, post therapy (immediately after 20
weeks of treatment); 2nd PT, post therapy (six months after treatment); 3 rd PT, post therapy (one year after treatment); 2nd LR
second left rib; RLE, right lateral epicondyle; LLE, left lateral epicondyle; RG, right gluteal muscle; LG, left gluteal muscle; RGT, right
greater trochanter, LGT, left greater trochanter; RK, right knee; LK, left knee.

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 Table 4. Differences between groups in Fibromyalgia Impact Questionnaire score, McGill Pain Score, Clinical Global Impression Severity Scale, Clinical
Global Impression Improvement Scale and postural stability

Baseline M (SD) 20 weeks M (SD) 6 months M (SD) 1 year M (SD)

Castro-Sánchez et al.

Outcome measure EG PG P Pre-T EG PG P 1st PT EG PG P 2nd PT EG PG P 3 rd PT

FIQ score
Total (0–100) 64.95 63.94 0.618 56.10 65.85 0.038* 58.60 64.08 0.048* 62.80 65.01 0.329
(18.2) (16.4) (17.3) (18.5) (16.3) (18.1) (20.1) (19.8)
NDFG (0–10) 1.84 2.04 0.133 3.24 1.96 0.028* 2.88 2.01 0.036* 2.55 1.99 0.047*
(1.56) (2.10) (1.46) (1.67) (1.56) (1.44) (1.76) (1.62)
Pain (0–10) 9.2 8.9 0.176 7.3 8.2 0.036* 8.5 8.0 0.042* 8.8 8.7 0.519
(0.6) (1.1) (1.4) (1.1) (0.7) (1.3) (0.5) (0.7)
Fatigue (0–10) 8.1 8.6 0.097 7.2 8.7 0.026* 7.4 8.5 0.037* 7.8 8.8 0.038*
(1.5) (1.3) (2.2) (1.9) (1.9) (1.7) (2.3) (1.6)
Tiredness on 8.5 7.9 0.076 7.1 7.9 0.044* 7.5 7.6 0.724 7.8 7.7 0.791
waking (0–10) (2.3) (2.6) (2.1) (2.3) (1.9) (1.8) (2.2) (1.9)
Stiffness (0–10) 7.8 6.9 0.042* 6.6 7.5 0.042* 6.9 7.8 0.043* 7.3 7.8 0.089
(1.9) (2.7) (2.8) (1.9) (2.5) (2.4) (2.5) (2.1)
McGill Pain Score
Sensory (0–33) 19.3 19.9 0.321 16.5 20.3 0.021* 17.3 20.7 0.042* 18.2 21.2 0.038*
(9.2) (10.6) (8.6) (6.5) (7.8) (7.1) (8.3) (7.9)
Affective (0–12) 5.6 4.9 0.077 4.2 5.3 0.029* 4.5 5.2 0.042* 4.8 5.1 0.232

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(3.4) (4.2) (3.4) (4.1) (2.9) (3.8) (3.6) (2.9)
Sensory + 24.9 25.3 0.092 20.6 25.9 0.019* 21.9 26.2 0.022* 23.2 26.7 0.036*
affective (0–45) (12.6) (10.7) (6.3) (5.3) (7.2) (6.8) (7.6) (6.9)
VAS (0–10) 9.13 8.90 0.219 7.98 8.87 0.038* 8.25 8.94 0.043* 8.74 8.92 0.306
(0.8) (1.3) (1.03) (1.01) (1.13) (1.34) (1.08) (0.96)
CGIs (1–7) 6.25 5.92 0.109 5.08 6.02 0.044* 5.28 5.98 0.048* 5.49 6.17 0.147
(0.73) (0.84) (1.03) (0.96) (0.97) (0.84) (0.74) (0.91)
(continued)
809
810 Clinical Rehabilitation 25(9)

EG, experimental group; PG, placebo group; Pre-T, pre-therapy; 1st PT, immediately post therapy; 2nd PT, 6 months post therapy; 3 rd PT, 1 yr post-therapy; NDFG, number of
P 3 rd PT
measured by the Fibromyalgia Impact

0.049*
0.526
Questionnaire, in agreement with results of the
original questionnaire validation study.34
Lindberg37 considers that variables related to
(0.89)

(1.37)
instrumental quality of life should be analysed
1 year M (SD)

6.49

5.50
PG

separately from those related to well-being, but

the Spanish version of this questionnaire does
(1.24)

(1.24)
not make this distinction. Other authors used
5.83

5.39
EG

the Fibromyalgia Impact Questionnaire to

assess the outcomes of manual lymph drainage
P 2nd PT

therapy and connective tissue massage and

0.046*

0.684

found significant improvements in a lower

number of items than in our study, although
they studied a sample of women for only three
days feeling good; CGIs, Clinical Global Impression Severity Scale; CGIi, Clinical Global Impression Improvement Scale.
6 months M (SD)

weeks, and the persistence of these effects was

(0.97)

(1.06)
6.30

5.52

not recorded.38
PG

Significant improvements in physical function

and pain, similar to the present results, were
(0.88)

(1.97)

reported after a programme of connective

5.62

5.42
EG

tissue manipulation in patients with fibromyal-

gia.39 Our group previously reported an
P 1st PT

0.043*

improvement in 8 out of 18 painful tender

0.055

points by the once-weekly application of myo-

fascial therapy.19 In the present study, with two-
weekly sessions, a significant improvement was
20 weeks M (SD)

(1.03)

(0.94)

obtained in 10 painful tender points and in the

6.13

5.49
PG

sensitive, affective and sensitive + affective

dimensions of the McGill Pain Score.
In countries such as Sweden, Holland,
(0.97)

(1.89)
5.28

5.10

Denmark, Norway and the United States, the

EG

‘Mesendieck System’ is one of the first therapies

P Pre-T

applied to patients with musculoskeletal prob-

–0.793

lems due to muscle balance alterations; it

Values are presented as means (standard deviation).

encourages patients to understand the causes

of their muscular pain in order to internalize
(0.46)
–5.47
Baseline M (SD)

the life habits that must be modified to improve

*P-value < 0.05 (95% confidence interval).
PG

their body functions. A study 40 of 90 fibromy-

algia patients reported that they still showed sig-
nificant improvements in physical function and
(0.79)
–5.38
EG

pain at 18 months after application of the

Mesendieck System.
Table 4. Continued

postural stability
Outcome measure

Fatigue, stiffness, pain, sleep, anxiety and

feeling depressed were associated with difficulty
in maintaining balance.17 In a previous study,19
CGIi (1–7)

myofascial therapy significantly improved pain,

sleep duration, anxiety and physical role in
fibromyalgia patients. In the present study, a

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Castro-Sánchez et al.
more intensive protocol of myofascial therapy
failed to achieve a significant improvement in
postural stability. However, a significant
improvement was found in fatigue, tiredness
on walking, stiffness, and number of days feeling
good immediately after the therapy. A more
prolonged course may be required to signifi-
cantly improve the postural stability of these
patients by obtaining greater and longer lasting
benefits in terms of pain, physical function, anx-
iety, fatigue, stiffness and quality of sleep.
Authors who adopted multiple approaches in
fibromyalgia patients (pharmacological therapy,
physical exercise and cognitive education tech-
niques) obtained significant improvements in
almost all Fibromyalgia Impact Questionnaire
items.40,41 There were no changes in the phar-
macological therapy of the patients during the
present study. Other authors42 who used a mul-
timodal approach (physical, educational and
pharmacological measures) in fibromyalgia
patients obtained significant differences in 9 of
the 13 items in the Fibromyalgia Impact
Questionnaire, although they stressed that the
presence of depression is a key factor influencing
Fibromyalgia Impact Questionnaire results.
Another study that applied myofascial therapy
in combination with aerobic exercise proposed
myofascial pain treatment within a programme
of multidimensional rehabilitation for patients
with generalized chronic pain.43
The lack of a postural stability test with a
higher level of difficulty is a study limitation.
However, the decision was taken not to exceed
level 8 due to the loss of stability shown by
patients in a preliminary pilot study. Another
limitation is that the therapist who administered
both intervention protocols and the patients
themselves could not be blinded. A further
study weakness is the absence of a ‘hands-on’
component in the sham treatment with discon-
nected electrotherapy equipment. Further
research is warranted to compare outcomes
obtained with our protocol with those of other
manual therapies.
This study has demonstrated that fibromyal-
gia patients can benefit from myofascial
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811
techniques. In these patients, the decrease in
muscular tension secondary to the release of
myofascial restrictions improves physical func-
tion, fatigue, number of days feeling good, tired-
ness on walking and stiffness. Myofascial
therapy significantly improves several clinical
dimensions of the fibromyalgia syndrome, with
an important and consistent improvement in
pain, sensory, and affective dimensions.
Clinical messages
. Myofascial therapy can contribute to
improving physical function, fatigue,
number of days feeling good, tiredness
on walking, and stiffness in fibromyalgia
patients.
. Myofascial therapy improves pain and
other clinical, sensory and affective dimen-
sions of fibromyalgia syndrome. However,
a programme of 40 treatment sessions
produces no significant improvement in
the postural stability of these patients.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.
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