Physiotherapy 123 (2024) 56–68

Systematic review
Effectiveness of myofascial release for adults with
chronic neck pain: a meta-analysis ]]
]]]]]]
]]

Lea Overmann a, , Robert Schleip b, Dennis Anheyer a,

⁎

Johannes Michalak a
a
Department of Psychology, University of Witten-Herdecke, Germany
b
Department of Sport and Health Sciences, Technical University Munich, Germany

Abstract
Background Every second human will experience a phase of neck pain in their lifetime and a high rate of chronicity exists. Because of the
complexity and multiple influencing factors, chronic pain conditions are associated with a long treatment and diagnostic process. This leads
to a prolonged healing process and high costs.
Objective To evaluate the effect of myofascial release on the variables of pain and range of motion in patients with chronic neck pain.
Method Selection criteria were set to create a search algorithm for a systematic search in the databases: PubMed, Google Scholar, EBM
Reviews, Medline, CINAHL, PEDro, and Science Direct. The risk of bias and the methodological quality was analyzed with the PEDro scale.
Result Ten randomized controlled trials, with 549 participants met the eligibility criteria. The methodological quality was ranked from good
to excellent. The myofascial release showed a significant difference in pain (p = 0.03), rotation to the right (p = 0.05), and lateral flexion to the
right (p = 0.04), compared to other treatment methods. No significant effect was found for improvements in pressure pain threshold.
Conclusion Modest effects are observed in pain reduction, suggesting potential benefits of myofascial release in managing chronic neck
pain. Further research with standardized protocols and direct comparisons to established therapies is crucial for a comprehensive under­
standing of myofascial release efficacy.
Contribution of the paper
• Effective pain reduction: Myofascial release might significantly impact the reduction of neck pain.
• Uncertain Impact on PPT and ROM: Outcomes for Pressure-Pain Threshold (PPT) and Range of Motion (ROM) remain inconclusive,
requiring further research.
• Treatment Diversity Complexity: Diverse treatment comparators pose challenges in isolating MFR effects, emphasizing the need for
standardized protocols and caution when interpreting the results.
What does the meta-analysis add to the current literature.
• Scientific Gap and Need for Further Research: The meta-analysis highlights a significant scientific gap in definitive evidence sup­
porting myofascial release treatments for chronic neck pain. The identified shortage of studies underscores the need for further research to
establish MFR’s efficacy, emphasizing standardized protocols, long-term effects, and direct comparisons with established therapies.
• Consideration of Treatment Modality Variations: The analysis contributes to understanding the complexity introduced by variations in
treatment modalities. The meta-analysis emphasizes the importance of homogeneous study designs to enhance outcome comparability. This insight
is valuable for researchers and clinicians aiming to interpret and apply findings from diverse studies in the field of MFR and chronic neck pain.
© 2023 The Author(s). Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Myofascial release; Chronic pain; Range of motion; Pressure-pain-threshold; Fascia

⁎
Corresponding author.
E-mail address: overmann.lea@gmx.de (L. Overmann).

https://doi.org/10.1016/j.physio.2023.12.002
0031-9406/© 2023 The Author(s). Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 L.Overmann et al. / Physiotherapy 123 (2024) 56–68 57

Introduction "Does MFR have a significant impact on reducing pain and

improving cervical spine range of motion in patients with
The prevalence of chronic pain in Western societies is chronic neck pain?".
estimated at 8% [1]. Neck pain is a common experience,
with a high incidence of chronic cases [2]. Chronic primary Method
pain, as classified by the International Classification of
Disease (ICD), persists or recurs for longer than 3 months The present meta-analysis elaborated on the foundation
and affects one or more anatomical regions of the body [3]. of the Preferred Reporting Items for Systematic Reviews
Middle-aged females with sedentary lifestyles are particu­ and Meta-Analyses (PRISMA) [18].
larly affected [4]. The head and neck regions are known for
their susceptibility to pain syndromes [5]. A survey con­ Selection criteria
ducted in Western societies involving 4839 participants
revealed that 46% experienced constant pain lasting over 2 The PICO Worksheet was used to create the research
years, and 19% had lost their jobs due to chronic pain question and determine keywords for databases, used to
conditions [6]. The German Federal Statistical Office carry out an advanced search. The study’s content was
highlights the association of chronic pain with prolonged centered on the combination of “Myofascial Release” and
treatment and diagnostic processes, resulting in delayed “Chronic neck pain” with a focus on “Randomized
healing and increased costs [7]. In recent decades, the Controlled Trials.” Synonyms for these terms included:
treatment approach for chronic neck pain has shifted to­ “Soft tissue massage”, “Soft tissue manipulation”, “MFR”,
wards interdisciplinary pain management that includes “MFT”, and “Fascia”. Further keywords were:
physiotherapy as a first-line treatment [2]. "Indirect myofascial release", "Hands-on myofascial
An anatomical structure that is hypothesized, to be strongly release", "Randomized Controlled Trials as Topic",
related to the intensity of pain is the fascial continuum [9]. "Clinical Trial", "Randomized trials", "Pain", "Pain per­
Even though it has great versatility, scientific research is still ception", "Pain management", "Nociception". The ther­
sparse [10]. Trauma, inflammations or infections, and struc­ apeutic intervention utilized in this study is referred to as
tural imbalance of the body lead to a tightening of the fascial passive MFR or "hands-on" MFR. Manual techniques are
strain. If this condition becomes long-term, the loss of phy­ employed by a therapist without the aid of tools or instru­
siological adaptability leads to a lack of flexibility, pain, and ments, such as a foam roller. Throughout passive MFR, the
limitation in movement [11]. At the structural level, the fascia therapist utilizes their hands to apply gentle and sustained
solidifies, the collagen becomes dense and fibrous, and the pressure to targeted areas of the body, with a specific focus
elastin loses its resiliency, impacting physiological and bio­ on the fascial system. This tactile approach enables the
mechanical processes and activating nociceptors [9]. Myo­ therapist to discern subtle changes within the fascial layers,
fascial release (MFR) influences these fascial alterations and is allowing for a responsive application to facilitate the release
therefore recommended in the treatment of chronic pain [12]. of tension. Randomized controlled trials (RCT) in peer-re­
The purpose is to alleviate pain, restore the optimal length of a viewed journals published in English or German language
muscle, improve function, and relieve tissue tenderness of the before May 2022 were included. Studies were analyzed in
myofascial system [13]. MFR involves applying a low-load the case of a control group, that received a placebo treat­
and long-duration stretch to the barriers in the myofascial ment or different physiotherapeutic interventions. The
tissue, with one therapist providing treatment to a single outcome measures must be the intensity of the pain (VAS or
person at a time [14]. PPT) and/or ROM of the cervical spine. The statistical
Webb and Rajendran 2016 conducted a meta-analysis, to analysis had to present the mean (M), standard deviation
evaluate the effectiveness of MFR in joint ROM and pain, (SD), p-value, and effect size. The methodological quality
across various body regions. was examined with the PEDro scale [19]. The trials had to
The MFR group showed significant differences in all accomplish a score of six (Risk-of-Bias Rating). Studies
outcome domains [15]. that did not report pain and/or ROM were excluded, in
Comparable results were found in a meta-analysis re­ addition to a variety of pathologies, for example, cranio­
garding the effectiveness of MFR in chronic low back pain mandibular dysfunction (CMD), migraine, and tension-type
[16]. The thoracolumbar fascia has received the most atten­ headaches.
tion in studies on low back pain, while research on the deep
fascia of the neck is limited [17]. Current evidence indicates Literature research
a strong correlation between the facial system and the gen­
eration and sustaining of pain, therefore investigating the The literature search was conducted from March 2022 to
effectiveness of MFR specifically for the neck is crucial. The June 2022, utilizing MeSH terms on the PubMed database
objectives of this meta-analysis are to review the existing to facilitate a comprehensive exploration employing stan­
literature on chronic neck pain and evaluate the effectiveness dardized medical vocabulary. The search algorithm applied
of MFR. The research question guiding this analysis is: was as follows: ("Myofascial Release"[MeSH Terms] OR
 58 L.Overmann et al. / Physiotherapy 123 (2024) 56–68

"Myofascial Release" OR "indirect myofascial release" OR the form of generalizability and applicability were ex­
"hands-on myofascial release") AND ("Randomized amined in addition to the quality of the statistical in­
Controlled Trials as Topic"[Mesh] OR "Randomized formation provided. It consists of the following 10 items:
Controlled Trial" OR "Clinical Trials as Topic"[Mesh] OR Random allocation, concealed allocation, baseline com­
"Clinical Trial" OR "randomized trials" OR "clinical trials") parability, blind subjects, blind therapists, blind assessors,
AND ("Pain"[MeSH Terms] OR "Pain" OR "pain percep­ adequate follow-up, intention-to-treat analysis, between-
tion" OR "pain management" OR nociception) AND group comparison, point estimates, and variability. The
Humans [Mesh] AND English[lang]. Subsequently, a sec­ “eligibility criteria” was included as a requirement but not
ondary search was executed on Google Scholar. However, considered in the total score. The items were rated with
due to limitations in supporting complex search algorithms “Yes” if they were clearly described. Otherwise, they were
akin to those in PubMed, a simplified approach was interpreted as insufficient and rated with “No”. A maximal
adopted. Various databases, including EBM Reviews, score of 10 could be reached; higher scores indicated a
MEDLINE, Cochrane Library, PEDro, and Science Direct, lower risk of bias and higher methodological quality.
were incorporated. The screening process initially involved Scores between six and eight were “good” and the scores
title and abstract assessment, followed by the application of above were “excellent”. If a study met less than five criteria,
inclusion criteria. Lastly, articles underwent critical eva­ it was judged as “poor”. In the validation study by Cashin
luation for scientific methodology and risk of bias, as de­ and McAuley, the inter-rater reliability of the PEDro scale
tailed in Table 1. The search was conducted by a single was estimated to be fair to excellent (ICC range 0.53 to
researcher without the use of automated tools. 0.91). Despite the potential variability in the reliability
coefficients, the PEDro scale is a widely used and accepted
Data extraction tool for evaluating the methodological quality of clinical
trials in physiotherapy [19].
Specified variables were extracted from the studies: Year
of publication, sample size, type of intervention, follow-up Statistical analysis
period, primary outcomes, and secondary outcomes (see
Table 2). The following scales and measures were used to On condition that at least two studies were available on a
determine and evaluate the outcomes: specific outcome, pooled analyses were conducted, using R
software version 4.2.2 and the meta-package [23]. M and
1) Visual Analog Scale: The variable pain was evaluated SD were calculated from median, range, interquartile range,
with a VAS scale in which a numerical scale was added.
minimum, maximum, and first or third quartile if necessary.
It is a straight line with the endpoints; no pain (1) and At first, the M, sample size, and SD were outlined from the
pain as bad as it could be (10). The patient must classify pre-and post-measurements of the MFR and control group.
the perception of the severity of the pain. The VAS is a
Based on these values, the confidence interval from 95%
valuable instrument to assess subjective pain intensity was calculated, if not described in the outcomes of the
and changes due to therapy [20]. study. Furthermore, Cohen´s (d) was analyzed to evaluate
2) Pressure-Pain-Threshold: The PPT is measured with
the effect size and detect differences in the mean of the
the application of a pressure algometer. The sensitivity of outcomes of the interventions [24]. Heterogeneity (I2) was
the deep muscular tissue of the trapezius and sternoclei­ used to identify the diversity of the outcomes of the studies
domastoid muscle is examined. A steadily increasing
[25]. Additionally, the p-value was used to analyze if a
pressure is given to the muscle tissue until the patient statistical significance between the groups exists [26]. To
mentions a painful sensation. Higher PPT values are in­ provide a more adequate accounting for uncertainty when
dicative of better outcomes. It is a reliable tool for the
pooling treatment effects from a smaller number of het­
assessment of the effect of a treatment, aimed at reducing erogeneous studies, the Hartung-Knapp correction was used
pain caused by muscle tenderness [21]. in this meta-analysis [27].
3) Range of motion: The range of motion (ROM) of the cer­
vical spine refers to the maximum extent of joint movement,
which includes active and passive mobility [22]. ROM as­ Results
sessment involves active movements in four directions, in­
cluding flexion, extension, rotation, and lateral flexion, with Conducting an advanced literature search on the PubMed
measurements typically reported in degrees. Higher degrees Database, we initially identified 66 articles. After thor­
of ROM are associated with better clinical outcomes. oughly reviewing titles and abstracts, four articles that met
the eligibility criteria were selected. The exclusion of 62
Risk-of-bias rating articles was based on technique-related factors or articles
addressing specific pathologies or general unspecific pain.
The PEDro scale was used for the analysis of the Google Scholar yielded 1700 results. After removing du­
methodological quality. The internal and external validity in plicates and screening titles and abstracts against eligibility
 L.Overmann et al. / Physiotherapy 123 (2024) 56–68 59

Total (0 criteria, six additional RCTs remained for inclusion in the

to 10)
7/10
7/10

7/10
7/10

9/10

9/10

8/10

8/10

8/10

8/10
meta-analysis. No compatible articles were identified from
other sources. A detailed summary can be seen in the
PRISMA-Flowchart (see Fig. 1):
and variability
Point estimate

Study characteristics
Y
Y

Y
Y

Y
The articles were published between May 2014 and
Between- group

August 2021. All in all, 549 patients with chronic neck pain
participated in the studies. The sample sizes varied between
comparison

34 and 96 participants. Participants’ ages ranged from 18 to

69 with a mean value of 40 years. The gender distribution
Y
Y

Y
Y

Y
showed a higher number of females (65.63%). Three stu­
dies only assured equal distribution of gender but did not
treat analysis
Intention to

present the exact number [28, 29, 30]. The average duration
of the treatment sessions was 23 minutes and varied be­
tween 10 to 45 minutes. The intervention and control group
Y
Y

Y
Y

received between one to twelve treatment sessions. Some of

the following interventions were applied in the control
follow-up

group: stability training, strength training, high-velocity

Adequate

low-amplitude techniques (HVLA), laser therapy,

stretching, massage, electrotherapy, and manual therapy.
N
N

N
N

One study included a cross-over of the groups. The first

group did not receive any intervention, while MFR was
assessors

applied in the second group. After two weeks the groups

Blind

made a cross-over [28]. The studies included pre- and post-

Y
Y

N
N

measurements in which the primary and secondary out­

comes were taken directly before and after the intervention.
therapist
Blind

Three articles provided a follow-up period from six days to

N
N

N
N

one month [30,31,32]. Nine articles provided pain as the

primary outcome, and six included the ROM of the cervical
subjects

spine. Three articles dealt with PPT as the primary outcome

Blind

[28,33,34], while three articles included PPT as the sec­

N
N

Y
Y

ondary outcome for the assessment of pain [30,38,37]. The

clinical studies were conducted in private practices for
Comparability

physiotherapy or hospitals and healthcare centers and were

executed by specialized physicians or physiotherapists.
Baseline

Y
Y

Y
Y

Methodological quality

The total score for the rating of the risk of bias assess­
Concealed
allocation

ment and methodological quality of the ten RCTs ranged

between seven to nine points, with a mean of 7.8 (see
Y
Y

Y
Y

Table 1). Two studies received nine points and were clas­
sified as excellent [28,32]. The other studies were assigned
allocation

as “good”, as they gained a score between seven and eight

Random

points. The item with the lowest rating was the “Blinding of
the therapist”. One article met the criterion [32]. The out­
Y
Y

Y
Y

comes of the studies were taken directly before and im­

Celenay & Kay (2016)
El-Gendy & Lasheen

mediately after the intervention. An adequate follow-up

Bakar et al. (2014)

Rodríguez-Fuentes

Rodríguez-Huguet

Rodríguez-Huguet
Namvar & Olyaei

Retamal & Seijo

period was sufficiently fulfilled in three articles [32,35,36].

Gurudut (2018)
Jacobi (2021)
PEDro Scale.

The random and concealed allocation were met in all arti­

et al. (2019)

et al. (2016)

et al. (2021)

et al. (2016)

et al. (2018)

et al. (2020)
Gauns &

cles. Less than 10% of the participants were lost during the
Brück &
Table 1

follow-up period. The statistical results of the between-

Study

group comparison reported more than one key outcome.

 60
Table 2
Summary of included studies.
Study Participants Intervention Primary Outcome (Mean/ Secondary Outcome Follow-up Outcome Measures
Change from baseline) (Mean/Change from
baseline)
Bakar 45 Ex = Myofascial Release PPT right M. Electromyography Pre- and post- Pain = PPT, Pain = PPT,
et al. (2014) Age = 25-45 1 Treatment Sessions of 20 Sternocleidomastoid (SCM): biofeedback (EMG-BF) Measurement, Function= Muscle relaxation Function= Muscle relaxation
Min. Ex: − 0.6, Con: − 1,01 EMG-BF SCM right: No follow-up response Follow-up = Pre- response Follow-up = Pre-
Con = Massage PPT left M. SCM Ex: 2.91, Con: - 2.04 and Post-Measurement and Post-Measurement
1 Treatment Sessions of Ex: − 1.12, Con: − 1.37 EMG-BF SCM left:
20 Min. Ex: 2.14, Con: − 0.91
Brück & 60 Ex = Myofascial Release VAS: Neck Pain and Disability Pre- and post- Pain = VAS, Function Pain = VAS, Function
Jacobi (2021) Age = 30-65 2 Treatment Session of Ex: − 2.1, Con1: − 2.8, Scale (NPDS) Measurement, = ROM, Neck Pain and = ROM, Neck Pain and
15-20 Min. Con2: 0.0 NPDS: Ex: − 11.3, No follow-up Disability Scale Disability Scale
Con1 = HVLA ROM of the cervical spine: Con1: - 11.3, Con2: 1.1 Follow-up = Pre- and Post- Follow-up = Pre- and Post-
2 Treatment Session of Flexion: Ex: 9.5, Con1: 6.7, Measurement Measurement
15-20 Min. Con2: 0.1
Con2 = No treatment Extension: Ex: 11.1,
Con1: 9.9, Con2: 0.5
Lateral flexion left: Ex: 9.2,
Con1: 7.2 Con2: − 0.2
Lateral flexion right: Ex: 9.9,
Con1: 4.8, Con2: 0.8
Rotation left: Ex:10.3,
Con1: 8.8, Con2: 0.1
Rotation right: Ex: 8.9,
Con1: 8.5, Con2: − 0.5
Celenay, & 60 Ex = Myofascial Release, VAS Level of anxiety (SSTAI) Pre- and post- Pain = VAS, PPT, Level of Pain = VAS, PPT, Level of
Kaya (2016) Age = 18-65 Stability Training Rest: Ex: − 2.52, Con: − 2.64 State Anxiety: Measurement, Anxiety = SSTAI, Quality of Anxiety = SSTAI, Quality of
12 Treatment Sessions, Activity: Ex: − 2.43, Con: Ex: − 6.26, Con: − 2.27 No follow-up Life = SF-36 Life = SF-36
3 per week of 40-45Min. 3.00 Trait Anxiety: Follow-up = Pre- and Post- Follow-up = Pre- and Post-
Con = Stability Training Night: Ex: − 3.45, Con: - Ex: − 3.53, Con: − 1.44 Measurement Measurement
L.Overmann et al. / Physiotherapy 123 (2024) 56–68

12 Treatment Sessions, 1.42 Quality of life (SF-36)

3 per week of 40-45Min. PPT Physical component
M. Trapezius right: summary (PCS): Ex: 3.89,
Ex: 2.34, Con: 0.38 Con: 2.99
M. Trapezius left: Mental component
Ex: 2.75, Con: 0.46 summary (MCS):
Ex: 5.61, Con: 1.91
El-Gendy & 60 Ex = Myofascial Release, VAS: Neck Disability Pre- and post- Pain = VAS, Function Pain = VAS, Function
Lasheen Age = 18-40 Stretching, Strength Ex: − 3.25, Con1: − 3.15, index (NDI) Measurement, = ROM, Neck Disability = ROM, Neck Disability
et al. (2019) training Con2: − 1.55 Ex: − 9.23, Con1: − 9.3, No follow-up Index Index
12 Treatment Sessions, ROM of the cervical spine: Con2: − 2.9 (NDI) (NDI)
3 per week Flexion: Ex: 12.75, Follow-up = Pre- and Post- Follow-up = Pre- and Post-
Con1 = Electrotherapy Con1: 12.95, Con2: 2.65 Measurement Measurement
(Low level laser, Extension: Ex: 13.1,
ultrasound), Stretching, Con1: 11.85, Con2: 2.55
Strength Lateral flexion right: Ex:
Table 2 (Continued)
Study Participants Intervention Primary Outcome (Mean/ Secondary Outcome Follow-up Outcome Measures
Change from baseline) (Mean/Change from
baseline)
training 10.6, Con1: 11.65, Con2: 4.8
12 Treatment Sessions, Lateral flexion left: Ex:
3 per week 10.05,
Con2 = Stretching, Strength Con1: 9.00, Con2: 4.65
training Rotation right Ex: 14.0,
12 Treatment Sessions, Con1: 16.0, Con2: 5.25
3 per week Rotation left: Ex: 10.5,
Con1: 11.5, Con2: 3.0
Gauns & 40 Ex = Myofascial Release ROM of the cervical spine: Disability of arm Pre- and post- Function = ROM, DASH- Function = ROM, DASH-
Gurudut Age = 20-50 15 Min, Lateral flexion: Ex: 15.11, shoulder and hand Measurement, Score Score
(2018) 34 Conventional Con: 4.32 questionnaire 6 days Follow-up = Pre- and Post- Follow-up = Pre- and Post-
Namvar & Age = 18-55 Treatment: Rotation: Ex: 17.67, (DASH- Score): Pre- and post- Measurement + 6 days Measurement + 6 days
Olyaei Hot moist pack 20 Min. Con: 4.37 Ex: 25.06, Con: 4.37 Measurement, Pain = VAS, PPT, Function Pain = VAS, PPT, Function
et al. (2016) TENS 15Min. VAS: Ex: − 3.41, Con: 0.11 Extension Power: No follow-up = Extension Power, NDI = Extension Power, NDI
Stretching, strengthening PPT Ex: - 2.57, Follow-up = Pre- and Post- Follow-up = Pre- and Post-
15Min. M. Trapezius right: Con: - 0.23 Measurement Measurement
1 Treatment Session Ex: - 5.56, Con: 0,23 NDI:
Con = Conventional Ex: − 24, Con: − 2,6
treatment
1 Treatment Session of 50
Min.
Ex = Myofascial Release
4 Treatment Sessions
of 20 Min.
Con = No Treatment
Retamal & 96 Ex = Myofascial Release ROM of the cervical spine PPT Pre- and post- Pain= VAS, PPT, Function Pain= VAS, PPT, Function
Seijo Age = 18-40 2 Treatment Sessions of 10 Flexion: Ex: 2.52, Suboccipital right: Measurement, = ROM, NDI = ROM, NDI
et al. (2021) Min. Con1: 1.00, Con2: 2.12 Ex: 0.18, Con1: 0.20, 2 weeks Follow-up = Pre- and Post- Follow-up = Pre- and Post-
L.Overmann et al. / Physiotherapy 123 (2024) 56–68

Con1 = Instrumental Extension: Ex: 1.87, Con2: 0.17 Measurement + 2 weeks Measurement + 2 weeks
Myofascial Release Con1: 1.00, Con2: 2.21 Suboccipital left:
2 Treatment Sessions of 10 Rotation right: Ex: 2.9, Ex: 0.22, Con1: 0.23,
Min. Con1: 2.97, Con2: 2.11 Con2: 0.16
Con2 = Instrumental Rotation left: Ex: 1.84, M. Trapezius right:
Myofascial Release, Con1: 2.83, Con2: 2.68 Ex: 0.08, Con1: 0.15, G3:
Upper Cervical Lateral flexion right: Ex: 0.00
Manipulation 1.13, M. Trapezius left:
2 Treatment Sessions of Con1: 0.9, Con2: 1.17 Ex: 0.08, Con1: 0.09,
10 Min. Lateral flexion left: Ex: 1.26, Con2: 0.00
Con1: − 0.47, Con2: 1.95 NDI:
VAS (active) Ex: − 2.52, Con1: − 2.33,
Flexion: Ex: − 0.27, Con2: − 3.47
Con1: 0.15, Con2: − 0.68
Extension: Ex: - 0.75,
Con1: 0.19, Con2: − 1.09
61
 62
Table 2 (Continued)
Study Participants Intervention Primary Outcome (Mean/ Secondary Outcome Follow-up Outcome Measures
Change from baseline) (Mean/Change from
baseline)
Rotation right: Ex: − 0.58,
Con1: − 0.03, Con2: − 0.63
Rotation left: Ex: − 0,52,
Con1: − 0.22, Con2: − 0.83
Lateral flexion right: Ex:
− 0.78, Con1: − 0.54, Con2:
− 1.14
Lateral flexion left: Ex: -
0.06,
Con1: - 0.45, Con2: − 1.19
Rodríguez- 59 Ex = Myofascial Release VAS: SF-36 Pre- and post- Pain = VAS, Function Pain = VAS, Function
Fuentes Age = 18-69 10 Treatment Sessions of 15 Ex: − 1.5, Con: - 3.62 PSC: Ex: 1.99, Measurement, = ROM, NDI, = ROM, NDI,
et al. (2016) Min ROM of cervical spine Con: 6.41 5 weeks Craniovertebral Angle, Craniovertebral Angle,
Con = Manual Therapy Flexion: Ex:3.3, MSC: Ex: 1.43 Quality of Life = SF-36, Quality of Life = SF-36,
10 Treatment Sessions of Con: 8.14 Con: 11.52 Follow-up = Pre- and Post- Follow-up = Pre- and Post-
15 Min Extension: Ex: 4.24, Costovertebral (C-V) Measurement + 5 weeks Measurement + 5 weeks
Con: 7.41 Angle: Ex: 2.83, Con: 5.0
Lateral Flexion right: Ex: NDI: Ex: − 4.65, Con:
2.97, − 11.53
Con: 6.24
Lateral Flexion left: Ex:
4.07,
Con: 7.17
Rotation right: Ex: 4.14,
Con: 9.17
Rotation left: Ex: 6.17,
Con: 11.48
Rodríguez- 41 Ex = Myofascial Release VAS: Ex: - 4.75, PPT Pre- and post- Pain = VAS, PPT Pain = VAS, PPT
L.Overmann et al. / Physiotherapy 123 (2024) 56–68

Huguet Age = 20-60 5 Treatment Sessions of Con: - 3.76 Suboccipital right: Measurement, Follow-up = Pre- and Post- Follow-up = Pre- and Post-
et al. (2018) 45Min. Ex: 0.76, Con: 0.36 4 weeks Measurement + 4 weeks Measurement + 4 weeks
Con = Multimodal Suboccipital left:
Physiotherapy: Ex: 0.63, Con: 0.35
Ultrasound 10 Min. M. Trapezius right: Ex:
TENS 20 Min. 0.73, Con: 0.35
Massage 20Min. M. Trapezius left: Ex:
5 Treatment Sessions 0.68, Con: 0.43
 L.Overmann et al. / Physiotherapy 123 (2024) 56–68 63

Effects on the outcome domains

Follow-up = Pre- and Post-

Measurement + 4 weeks
Pain
Outcome Measures

Pain = VAS, PPT

Function = ROM In our examination of pain outcomes extracted from
seven RCTs involving 368 participants, a significant dif­
ference emerged (d= −1.15, 95% CI = [−2.11 to 0.2],
p = 0.03) with a calculated mean difference (MD) of −1.15
on the pain rating scale (see Fig. 2). A sensitivity analysis
was conducted, excluding the Namvar et al. study, which
Follow-up = Pre- and Post-

uniquely compared myofascial release with no treatment.

Measurement + 4 weeks

Despite the exclusion of this study, the results retained

statistical significance (p = 0.04) and exhibited a substantial
Pain = VAS, PPT
Function = ROM

effect size (d= 0.86, 95% CI= [−1.64 to −0.09]), under­

scoring the robustness of our findings.

Pressure pain threshold

The PPT was measured at the trapezius and the sub­
occipital areas on the left and the right side. The results of
Pre- and post-
Measurement,

five RCTs with 285 participants were analyzed. A medium

Follow-up

overall effect was shown at the left trapezius, 230 partici­

4 weeks

pants were included (d = 0.59, 95%CI = [ −0.24 to 1.41],

p = 0.12). The PPT of the right trapezius was evaluated with
the data of 254 participants and represented in four RCTs.
There was a medium overall effect size with a non-sig­
nificant difference (d = 0.50, 95%CI = [ 0.48 to 1.47],
Secondary Outcome
(Mean/Change from

Ex: 0.72, Con: 0.41

Ex: 0.63, Con: 0.49

Ex: 0.72, Con: 0.41

Ex: 0.62, G2: 0.41
Suboccipital right:
Suboccipital left:

p = 0.20). Three studies manifest a significant difference on

Thoracic right:
Thoracic left:

both sides. Four RCTs were included for the evaluation of

the PPT of the suboccipital area (N = 205). There was no
baseline)

overall effect and significant difference regarding the right

PPT

Ex= Experimental Group; Con= Control Group, Con1 = Control Group 1; Con2 = Control Group 2

(d = 0.17, 95%CI = [−0.84 to 1.19], p = 0.62) and left

(d = 0.11, 95%CI = [−0.66 to 0.88], p = 0.68) suboccipital
Primary Outcome (Mean/

area (see Fig. 3).

Rotation right: Ex: 8.63,
ROM of cervical spine
Change from baseline)

Ex: 10.85, Con: 10.33

Extension: Ex: 11.70,

Lateral flexion right:

Ex: 6.48, Con: 7.00

Ex: 9.15, Con: 5.33

Flexion: Ex: 11.26,

Lateral flexion left:

Range of motion
VAS: Ex: − 4.82,

Five RCTs provided results including rotation and lateral

Rotation left:
Con: − 3.78

Con: 12.11

Con: 12.85

flexion to the right. The outcomes of 318 participants were

Con: 5.26

included in the evaluation. Lateral flexion to the right

showed a significant difference between the groups and a
medium effect size (d = 0.68, 95%CI = [0.04 to 1.32],
p = 0.04) as well as the rotation to the right (d = 0.52,
Ex = Myofascial Release
5 Treatment Sessions of

95%CI = [ −0.01 to 1.05], p = 0.05). Four RCTs provided

10 Treatment Sessions

results of the degree of flexion, extension, rotation, and

Ultrasound 10 Min.
Con = Multimodal

Massage 20Min.

lateral flexion to the left. 270 participants were included in

TENS 20 Min.
Physiotherapy:

the assessment. Four studies were included for the evalua­

Intervention

tion of the ROM in flexion of which two studies showed

45Min.

significant differences. One favoring the MFR and one fa­

voring the control group. All in all, there was no significant
difference and a medium overall effect (d = 0.70, 95%CI = [
Age = 20-60
Participants

−0.36 to 1.77], p = 0.15). The in-between group comparison

of extension based on four studies showed a medium
54

overall effect and was rated as non-significant (d = 0.54,

Table 2 (Continued)

95%CI = [ −0.54 to 1.62], p = 0.24). Similarities were found

in four studies, that provided the outcomes of rotation to the
et al. (2020)
Rodríguez-

left (d = 0.26, 95%CI = [ −0.54 to 1.05], p = 0.42) and

Huguet

lateral flexion to the left (d = 0.48, 95%CI = [ −0.21 to

Study

1.16], p = 0.12). There was no identification of significant

64 L.Overmann et al. / Physiotherapy 123 (2024) 56–68

Fig. 1. PRISMA- Flowchart of literature search.

Fig. 2. Results of a meta-analysis of VAS.

differences and a small overall effect size between the significant reduction in pain, reflected in VAS scores.
control and MFR group (see Fig. 4). However, findings for PPT and ROM were inconclusive. In
contrast to Guo et al.’s study (2023), which reported no
significant differences in ROM, our meta-analysis identified
Discussion slight significance, in lateral flexion and rotation to the
right, though with slight variances (0.04 and 0.05, respec­
This meta-analysis provides a comprehensive assess­ tively) [39]. These marginal changes, especially the 0.03
ment of MFR efficacy in managing chronic neck pain, minimal difference in VAS, may not be perceptible to pa­
drawing evidence from ten RCTs. The results highlight a tients, underscoring the importance for clinicians to
 L.Overmann et al. / Physiotherapy 123 (2024) 56–68 65

Fig. 3. Results of a meta-analysis of pressure pain threshold.

consider the minimal clinically important difference within inconsistency between studies prompts a critical analysis of
the specific population under study. The observed sig­ observed effects and their clinical significance. Treatment
nificance in pain outcomes compared to the non-significant modality variations in control groups contribute to observed
findings in PPT and ROM prompts careful consideration. heterogeneity, necessitating more homogeneous study de­
Limited trials focusing on PPT may contribute to the ab­ signs for enhanced outcome comparability. Additionally,
sence of significant differences, raising questions about the the absence of blinding, except for Gauns & Gurudut
clinical relevance of MFR for enhancing neck mobility, (2018), introduces complexity, warranting careful con­
particularly given the heterogeneity in interventions. The sideration of potential biases, as seen in other systematic
incorporation of diverse interventions, such as a multimodal reviews [14].
approach combining MFR with stability training, as Chronic pain is a pervasive healthcare problem in in­
demonstrated by previous studies, introduces clinical dustrialized countries and is associated with high societal
relevance but complicates the interpretation of results. and individual costs [8,38]. Prolonged diagnostic pro­
The combined approach makes it challenging to isolate cesses remain a common burden, while conventional
the specific effects of MFR alone [29,34]. Despite good- treatment modalities such as surgeries and medications,
to-excellent methodological quality (see Table 1), including opioids and analgesics, continue to be utilized
66 L.Overmann et al. / Physiotherapy 123 (2024) 56–68

Fig. 4. Results of a meta-analysis of different range of motion outcomes.

 L.Overmann et al. / Physiotherapy 123 (2024) 56–68 67

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