Journal of Bodywork & Movement Therapies (2011) 15, 431e435

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CLINICAL METHODS

Effectiveness of direct vs indirect technique

myofascial release in the management of tension-
type headache
M.S. Ajimsha, MPT (Neuro), ADMFT, PhD (Physiotherapy) a,b,*

a
Myofascial Therapy and Research Foundation, India
b
School of Physiotherapy, AIMST University, 08100 Bedong, Kedah, Malaysia

Received 27 July 2010; received in revised form 18 January 2011; accepted 18 January 2011

KEYWORDS Summary Background: Tension-type headache (TTH) is essentially defined as bilateral head-
Myofascial release; ache of a pressing or tightening quality without a known medical cause. Myofascial release (MFR)
Myofascial trigger is currently being applied for patients with TTH but its efficacy has not been evaluated formally.
points; Objective: To investigate whether direct technique myofascial release (DT-MFR) reduces the
Tension headache frequency of headache more effectively than the indirect technique myofascial release (IDT-
MFR) in comparison to a Control Group receiving slow soft stroking.
Design: Randomized, controlled, single blinded trial.
Setting: The clinical wing of Myofascial Therapy and Research Foundation, Kerala, India.
Participants: 63 patients with episodic or chronic tension-type headache.
Interventions: DT-MFR, IDT-MFR or Control. The techniques were administered by certified myo-
fascial release practitioners and consisted of 24 sessions per patient over 12 weeks.
Main outcome measure: Difference in numbers of days with headache between Weeks 1e4 (i.e.
4 weeks prior to start of Intervention) and Weeks 17e20, following 12 weeks of Intervention
between Weeks 5e16 as recorded by participants in headache diaries.
Results: The number of days with headache per 4 weeks decreased by 7.1 (2.6) [mean (SD)] days
in the DT-MFR group compared with 6.7 (1.8) days in the IDT-MFR group and 1.6 (0.5) days in the
control group, (P < 0.001). Patients in the DT-MFR Group, IDT-MFR Group and Control Group re-
ported a 59.2%, 54% and 13.3% reduction in their headache frequency in Weeks 17e20 compared
to that in Weeks 1e4.
Conclusions: This study provides evidence that Direct Technique or Indirect Technique Myofas-
cial Release is more effective than the Control Intervention for tension headache.
2011 Elsevier Ltd. All rights reserved.

* Tel.: 60124362154.
E-mail address: ajimshaw.ms@gmail.com.

1360-8592/$ - see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2011.01.021
432
Introduction
Tension-type headache (TTH) is essentially defined as
bilateral headache of a pressing or tightening quality
without a known medical cause. Tension-type headache is
classified as episodic if it occurs on less than 15 days
a month and as chronic if it occurs more often (IHS, 1997).
A survey from the United States found a one-year preva-
lence of 38% for episodic tension-type headache and 2% for
chronic tension-type headache (Schwartz et al., 1998).
Present pain models for tension-type headache suggest that
nociceptive inputs from peripheral tender muscles can lead
to central sensitization in chronic tension-type headache
(De-Las-Pen as et al., 2007). Myofascial Trigger Points are
highly prevalent in patients with tension-type headache
(Couppe et al., 2007).
Myofascial Release (MFR) is the application of a low load,
long duration stretch into the myofascial complex, intended
to restore the optimal length of this complex, decrease pain
and improve function (Barnes, 1990). It has been hypothe-
sized that fascial restrictions in one part of the body cause
undue tension in other parts of the body, due to fascial
continuity; in turn, this may create stress on any structures
that are enveloped, divided, or supported by fascia (Schleip
et al, 2003). Myofascial practitioners believe that by
restoring the length and health of restricted connective
tissue, pressure can be relieved on pain sensitive structures
such as nerves and blood vessels. Myofascial release gener-
ally involves slow, sustained pressure (120e300 s) applied to
restricted fascial layers either directly (DT-MFR) or indirectly
(IDT-MFR). The rationale for these techniques can be traced
to various studies that looked at the plastic, viscoelastic and
piezoelectric properties of connective tissue (Schleip, 2003;
Greenman, 2003; Pischinger, 1991).
Myofascial Release is being used to treat patients with
TTH (Baldry, 2005; Stanborough, 2004; Richter and Hebgen,
2009), but there are few formal reports of its efficacy. At
the Myofascial Therapy and Research Foundation in Kot-
tayam, Kerala, India, both the Direct Technique Myofascial
Release (DT-MFR, as promoted by Stanborough, 2004) and
Indirect Technique Myofascial Release (IDT-MFR, as
promoted by Manheim, 2001) are used. DT-MFR is thought to
work directly on restricted fascia; practitioners use knuckles
or elbow or other tools to slowly sink into the fascia, and the
pressure applied is a few kilograms of force to contact the
restricted fascia, apply tension, or stretch the fascia. IDT-
MFR involves application of gentle stretch e the pressure
applied is a few grams of force, and the hands tend to follow
the direction of fascial restriction, hold the stretch, and
allow the fascia to unwind itself. The primary objective of
the present study was to evaluate the efficacy of DT-MFR and
IDT-MFR in the management of TTH, treating fascia in the
head, neck and face in accordance with the fascial meridians
proposed by Myers (2003). It was not the intent of this study
to compare which among DT-MFR and IDT-MFR is more
effective for the management of tension-type headache.
Methods
This study was carried out in the clinical wing of MFTRF,
Kottayam, Kerala, India. Individuals aged 18e50 years with
M.S. Ajimsha
a diagnosis of episodic or chronic TTH lasting at least 12
months, and who had completed a 4-week baseline head-
ache diary were eligible for inclusion in the study. Those
with a history of additional migraine headache, secondary
headaches, age >50 years, use of analgesics on more than
10 days a month, prophylactic headache treatment with
drugs in the 4 weeks prior to randomization, and any other
treatment for TTH during the previous 12 months were
excluded. The study protocol was approved by the Ethics
Committee of MFTRF. Between July 2008 and February
2009, 76 patients were referred to MFTRF, India, with
a diagnosis of TTH. Of this, 63 individuals who met the
Inclusion Criteria and provided written informed consent
were randomized to DT-MFR, IDT-MFR, or Control using
a 2:2:1 list (as done in studies by Tully et al, 2007; Sherman
et al, 2010). Participants were not blinded to the inter-
vention they were randomized to. Two evaluators blinded
to the group to which the participants belonged analyzed
headache diaries.
Interventions
All 3 interventions were provided twice weekly for 12 weeks
(Weeks 5e16); the duration of each treatment session was 1 h.
DT-MFR technique
The technique used was same for all the patients in DT-MFR
(Stanborough, 2004). All techniques were performed bilat-
erally, 3 min on each side.
The Protocol was as follows:
I. Upper Trapezius release
II. Lateral/anterior cervical techniques.
a) Using soft fist to treat the fascia at the mastoid
process.
b) Using the first three metacarpophalangeal joints to
treat the submastoid and occipital soft tissue.
III. Deep posterior myofasciae.
a) Release of nuchal ligament.
b) Melting into the deep small muscles of the posterior
neck.
c) Release of the deep neck flexor muscles.
IV. Release of cranial base and suboccipital myofascia.
V. Decompression of the occipital condyles.
VI. Release of the temporalis fascia.
VII. Release of the epicranial aponeurosis.
IDT-MFR technique
The technique used was same for all the patients in IDT-MFR
(Manheim, 2001). Steps V and VI were performed bilaterally
for 5 min on each side.
The Protocol was as follows:
I. Gross stretch of the posterior cervical musculature
(10 min).
II. Cranial base release (10 min).
III. Hair pull (10 min).
IV. Ear pull (10 min).
Effectiveness of direct vs indirect technique myofascial release 433

V. Stretch of face muscles (10 min).
VI. Gross stretch of the Sternocleidomastoid (10 min).
Control intervention
Patients in the Control Group received slow soft stroking
with finger pads all over the head in the same areas as the
application of Myofascial Release (in the other Groups) for
the same duration (1 h per treatment session), twice
a week for 12 weeks. After the completion of the study,
patients in the Control arm were provided MFR therapy, as
advised by the Ethics Committee.
Patients in all groups filled in headache diaries the
month before randomization (Weeks 1e4), and following
treatment (Weeks 9e20). All study participants were
advised to take medication for headache exacerbations as
required, but were required to record them in their head-
ache diaries. Practitioners who provided MFR therapy in this
study had been trained in the techniques for at least 100 h
and had a median experience of 10 months with the tech-
nique. The DT-MFR, IDT-MFR, and Control Treatments con-
sisted of 24 sessions, each lasting an hour, given over 12
weeks in 2 sessions per week with a minimum of 2 days gap
between sessions. The primary outcome measure was the
difference in number of days with headache between
Weeks 1e4 and Weeks 17e20.
Statistics
The three groups at baseline were compared using one-way
analysis of variance. Then, in accordance with the primary
objective of the study, we compared the number of days with
headache in the DT-MFR and IDT-MFR groups as compared to
Control Group using unpaired t-test. A two-tailed P value less
than 0.05 was accepted as statistically significant.
Results
Of the 63 individuals recruited into this study, 56 partici-
pants (22 in DT-MFR Group; 22 in IDT-MFR Group and 12 in
Control Group) completed the study protocol. Two partic-
ipants in the DT-MFR and one participant each from the
remaining 2 Groups dropped out of the study without
providing any specific reason for it. One participant in the
DT-MFR and two participants in the IDT-MFR groups did not
maintain headache diaries as advised and their data were
excluded from the results presented below.
Within the study period, no serious adverse events
occurred in any of three Groups. Three patients from the
DT-MFR group and one from the IDT-MFR group reported
headaches in the first week following initiation of treat-
ment, and this was reported to have subsided within a week
without any medication.
There were no statistically significant differences
between the groups for any of the baseline characteristics
(Table 1).
From Weeks 1e4 to Weeks 17e20, the number of days with
headache per 4 weeks decreased by 7.1 (SD 2.6) days in the
DT-MFR group compared with 6.7 (SD 1.8) days in the IDT-MFR
group and 1.6 (SD 0.5) days in the Control Group (difference:
DT-MFR vs IDT-MFR, 0.6 days, 95% confidence interval 2.4 to
1.2 days, P Z 0.51; DT-MFR vs Control Group, 5.8 days, 7.6
to 4.0 days, P < 0.001, IDT-MFR vs Control Group, 5.4 days,
7.2 to 3.7 days, P < 0.001) (Table 2).
The proportion of responders, defined as participants who
had at least 50% reduction in headache days between Weeks
1e4 and Weeks 17e20, was 81.8% in the DT-MFR Group, 86.4%
in the IDT-MFR Group, and 0% in the Control Group. Patients
in the DT-MFR group reported a 59.2% reduction in their
headache frequency; IDT-MFR group reported 54% reduction
whereas Control Group reported 13.3% reduction in their
pain frequency per 4 weeks in the Weeks 17e20. However,
differences in headache frequency between the DT-MFR and
the IDT-MFR Groups were statistically insignificant.
Discussion
The principal finding of this proof of the concept study is
that both of the Myofascial Release interventions tested in
this study were significantly more effective than slow
stroking for decreasing the frequency of tension-type
headache. The principal difference between the Direct and
Indirect Techniques of Myofascial Release used in this study
is that the pressure applied was of the order of kilograms
and for a shorter duration in the Direct Technique, whereas
in the Indirect Technique the amount of pressure is of the
order of a few grams but sustained longer. One limitation of
this trial was that practitioners could not be blinded.
Another limitation was the absence of long-term follow up

Table 1 Baseline characteristics of study participants (n Z 56).

Characteristic All Patients DT-MFR IDT-MFR Control Group
(n Z 56) (n Z 22) (n Z 22) (n Z 12)
Males:Females 20:36 7:15 8:14 5:7
Age (Years) 43.8 (5.4) 43.7 (5.6) 44.7 (5.2) 43.0 (5.4)
Body Mass Index (Kg/m2) 24.6 (5.7) 24.7 (5.9) 24.8 (6.2) 24.2 (5.0)
Episodic Tension-Type Headache 47 (83.9) 20 (90.9) 18 (81.8) 9 (75)
Chronic Tension-Type Headache 9 (16.1) 2 (9.1) 4 (18.2) 3 (25)
Duration of Condition (Years), 7.4 (7.7) 7.1 (7.2) 7.3 (8.1) 7.7 (7.7)
as seen from physicians reports
Frequency of Headache in 12.1 (2.7) 12 (2.8) 12.4 (2.8) 12 (2.5)
Weeks 1e4 (Baseline)
Data are the mean (SD) except for Gender and TTH, which are expressed as ratio and number (Percentage) respectively.
434
Table 2 Headache diary readings (17e20 weeks) following completion of 3 months Intervention. Data are the means (SD).
Headache Diary Reading DT-MFR
Headache Frequency (Weeks 1e4) 12 (2.8)
Frequency of Headache (Weeks 17e20) 4.9 (1.7)
Mean (SD) of difference in days with headache 7.1 (2.6)
between Weeks 1e4 and Weeks 17e20
Comparison of headache frequency scores DT-MFR vs IDT-MFR
of the DT-MFR, IDT-MFR and the Control 0.6 (2.4 to 1.2)
Groups of the Weeks 17e20.
(95% Confidence Interval)
P value by unpaired t-test 0.51
of study participants. A slight improvement over time
occurred in the Control Group; this could be due to
a meaning response (Moerman and Jonas, 2002).
Myofascial Release has been reported to reduce pain and
improve quality of life in idiopathic scoliosis (LeBauer et al.,
2008), Raynauds phenomenon (Walton, 2008) and in
systemic sclerosis (Martin, 2009). A recent study has shown
that treatment with Myofascial Release following repetitive
strain injury resulted in normalization in apoptotic rate, cell
morphology changes, and reorientation of fibroblasts
(Meltzer et al., 2010). Active myofascial trigger points in the
cervical and suboccipital musculature have been identified
in 65% of individuals with chronic tension-type headache (De-
Las-Penas et al., 2006; Couppe et al., 2007). According to
Schleip (2003), under normal conditions, fascia tends to
move with minimal restrictions. However, injuries resulting
from physical trauma, repetitive strain injury, and inflam-
mation are thought to decrease fascia tissue length and
elasticity resulting in fascial restriction. It is possible that
pain relief due to myofascial release is secondary to return-
ing the fascial tissue to its normal length. Shah et al. (2008)
have experimentally assessed the biochemical milieu of
active trigger points and have characterized them as con-
sisting of a higher than normal concentration of inflammatory
mediators. It is also possible that myofascial release leads to
blood flow changes that allow the inflammatory mediators to
be removed away from trigger points; this is a hypothesis that
merits investigation.
Conclusions
Both the Direct and Indirect Techniques of Myofascial
Release investigated in this trial were more effective than
a Control Intervention consisting of slow soft stroking with
finger pads for the treatment of tension-type headache.
A significant proportion of patients with TTH might benefit
from the use of Myofascial Release. The mechanisms
underlying these responses merit investigation.
Funding sources and conflicts of interest
This study was funded by the Myofascial Therapy and
Research Foundation, India. No authors declare any conflict
of interest, financial or otherwise.
MFTRF India is a registered Non Governmental Organi-
zation, formed with the aim of conducting education,
research and awareness programs in the field of soft tissue
M.S. Ajimsha
IDT-MFR Control Group
12.4 (2.8) 12 (2.5)
5.7 (1.3) 10.4 (2.7)
6.7 (1.8) 1.6 (0.5)
DT-MFR vs Control group IDT-MFR vs Control Group
5.8 (7.6 to 4.0) 5.4 (7.2 to 3.7)
<0.001 <0.001
manipulations and delivering quality hands on care for
those in need.
Acknowledgment
We thank all the practitioners and professionals of MFTRF,
India and the physicians who participated in the consensus
process and analysis to establish the trial interventions. We
are expressing our special gratitude to Dr. E. S. Prakash,
Associate Professor, School of Medicine, AIMST University,
Malaysia for his expertise editing of the manuscript.
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