Myofascial Release Therapy's Effect on Immune System in Breast Cancer Survivors Modulated by Positive Attitude

Fernández-Lao C, Cantarero-Villanueva I, Díaz-Rodríguez L, Fernández-de-las-Peñas C, Sánchez-Salado C, Arroyo-Morales M. The influence of patient attitude toward massage on pressure pain sensitivity and immune system after application of myofascial release in breast cancer survivors: a randomized, controlled crossover study. J Manipulative Physiol Ther.2012;35(2):94-100.

Osteopathic manipulation has been shown to significantly decrease pain in several patient populations,¹ enhance the immune system in animals,² and increase salivary immunoglobulin A (IgA) levels in humans.³ Myofascial release (MFR) is a type of osteopathic manipulative treatment or therapy technique used to manage somatic dysfunction in which the osteopathic physician or osteopath engages the patient's myofascial tissues with his or her hands using a sustained force. This force is adjusted on the basis of continual palpatory feedback to achieve release of tension in the myofascial tissues. Robert C. Ward, DO, and others introduced the term “myofascial release” in educational settings in the early 1980s, although the technique was based on methods pioneered by the founder of osteopathic medicine, Andrew Taylor Still, MD, DO.⁴ For the past 30 years, John F. Barnes, PT, and others have popularized MFR among physical therapists and other manual therapists.⁵ In this study, researchers from Spain considered not only the efficacy of MFR as taught by Barnes and performed by a manual therapist, but also the influence of the patient attitude toward massage on pressure pain sensitivity and immune effects in breast cancer survivors.

Inclusion criteria were as follows: a diagnosis of breast cancer (stage I to stage IIIA), age of 25 to 65 years, completion of coadjuvant oncology treatment, and moderate to high fatigue during the preceding week. Patients were excluded if they received chemotherapy or radiotherapy at the time of the study. A sample size of at least 16 participants was determined on the basis of “detecting between-sessions clinical differences of 20% on PPT [pressure pain sensitivity] (with an α level of .05), a desired power of 80%, and an estimated interindividual coefficient of variation of 20%.”

The researchers recruited 20 female breast cancer survivors (mean [standard deviation] age, 49 [8] years) who were at least 1 year out of coadjuvant treatment with a combination of radiation or chemotherapy or radiotherapy after either lumpectomy (70%) or mastectomy (30%). In addition, 16 women (80%) were taking estrogen receptor antagonist or aromatase inhibitor drugs; 2 (10%) were taking monoclonal antibody HER2; and 3 (15%) were taking analgesics (ibuprofen or acetaminophen).

For the treatment group, an experienced therapist administered an MFR protocol that included “longitudinal strokes, J stroke, sustained suboccipital pressure, frontalis bone spread, and ear pull technique.” The 40-minute treatment was confined to the neck and shoulder areas, with the duration adjusted at the therapist's discretion, using the participant's tissue response. The control group received a 40-minute educational session on healthy lifestyles, emphasizing nutrition, relaxation techniques, or physical exercise. Three weeks after receiving an intervention, each participant crossed over to receive the other intervention.

Participants were seen at the same time of the day on 2 occasions separated by 3 weeks. At each session, they received either the MFR protocol or control intervention. Salivary flow rate, cortisol and IgA concentrations, and α-amylase activity from saliva samples were obtained before and immediately after interventions. Pressure pain thresholds over the cervical spine and temporalis muscles were assessed bilaterally. The attitude toward massage scale was collected before the first session.

Analysis of covariance revealed that the only statistically significant change from the MFR protocol was an increase in the salivary flow rate (P=.010). The other parameters were not changed significantly by either intervention. However, when the attitude toward massage scale was included in the analysis, participants with a positive attitude toward massage had statistically significant increases in saliva IgA levels (P=.001), but the other parameters were not significantly affected.

The novel aspect of this study is the inclusion of the patient's attitude toward manual therapy (eg, massage), with a positive attitude correlated to increased immune activity. However, there are several limitations for osteopathic physicians and osteopaths to consider. Confining the protocol to specific body regions (ie, head and neck) pre-cluded a total structural examination of the musculoskeletal system for other areas of somatic dysfunction and selection of treatments appropriate to manage those dysfunctions. Thus, the MFR protocol may not have included the techniques needed to treat patients' unidentified somatic dysfunctions that may have been related to their pain pressure sensitivity and fatigue. Osteopathic physicians and osteopaths often combine manual procedures when managing pain or immune system dysfunctions. For a patient population similar to this study's, osteopathic physicians and osteopaths might have used MFR combined with techniques such as counterstrain, muscle energy, balanced ligamentous and membranous tension, facilitated positional release, and lymphatic drainage techniques.

Thus, the manual therapy protocol used in this study bears the same name as an osteopathic manipulative treatment technique but shares little else. The restricted use of MFR by this study's therapist, patterned after the Barnes approach, could not significantly decrease pain or stress hormone levels, nor increase IgA immune activity. Since it cannot be recognized as the same procedure used by osteopathic physicians or osteopaths, it should not be considered as the definitive study on the issue of whether MFR techniques in general benefit this patient population. It is imperative that we as osteopathic physicians and osteopaths conduct our own investigations into the efficacy of manual procedures because we cannot rely on other health professionals who reinterpret our procedures. Myofascial release as used by various practitioners is not the same procedure in spite of the same name, and determining the true benefit of this or any of our other manual procedures will require further studies.—M.A.S.