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Some advise re: MFR
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Some advise re: MFR - January 28, 2007 9:59:00 AM
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jlharris
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From: Nebraska
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Here's the situation: Was/am treating a pt for neck pain after an MVA. Referring uses a STAMP for his RX's that says: "Myofascial release 2-3x week x 6 weeks". I'm fairly new to the clinic I'm at but it was explained to me that he always sends pt's out with the script and to just treat the pt. Fine. I tx with ROM, Cx stab ex's, STM, and an occasional modality.
Pt goes back to the MD after 3 weeks (with many inconsistencies in his objective exam, but we will ignore that now) and the MD wants him to go to PT down the street because I wasn't doing MFR. Forget whether or not he was improving, or in his case, possibly malingering I technically didn't do MFR so he needs 6 more weeks of PT getting MFR.
Now, his case manager (oh yeah, he's work comp) calls and asks me to call the MD to tell him why STM is just as good as MFR and should return to me for his neck. So there's my delimma. I know the "theory" behind MFR is bogus*, but can't find any articles on comparing outcomes of MFR vs. standard soft tissue mobilization/massage. Any of you great people have any good sources I can bring to the conversation with the MD? Anything would be greatly appreciated.
*edit - Make that "not proven" and without much anatomical and physiologic basis.
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Jason L. Harris, PT, DPT
My PT Blog
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Re: Some advise re: MFR - January 28, 2007 1:03:00 PM
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PTupdate.com
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MFR is nothing more than a glamorized and glitzed STM....you should have just said you are doing it and prevented all the issues. "Cleansing strokes", "J-strokes", arm/leg pulls were all around before John Barnes was born....there is no claim that any technique was purely invented by that school.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
PS: I recently read this, and I am sure all will get a good laugh:
http://quackfiles.blogspot.com/2005/12/please-release-me-let-me-go-mfr.html
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Some advise re: MFR - January 28, 2007 1:04:00 PM
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proud
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Jason,
It is always tough trying to say one technique is "the way to go". Evidence based practice would indicate that your approach is the way to go really. Studies in MSK management are difficult but we have to provide "best practice" as best we can.
http://www.cochrane.org/reviews/en/ab004249.html
I think it would be irresponsible for the MD to work against the available evidence( I do not think a systematic review specifically on MFR has been done. I could be wrong). At least your approach could be somewhat backed up...keeping your name off the quackfiles.
In many ways the MD could really open him/herself up to potential lawsuits for choosing non EBM over the above. I do know of some court cases involving just that scenario and the MD lost. Anyone care to provide the reference???
That is how I would approach that one. For what it is worth.
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Re: Some advise re: MFR - January 28, 2007 2:45:00 PM
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jlharris
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From: Nebraska
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Thanks for the feedback. The next step is to be sure I come across coherent and to the point.
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Jason L. Harris, PT, DPT
My PT Blog
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Re: Some advise re: MFR - January 28, 2007 4:26:00 PM
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Andrew M. Ball PT PhD
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I agree with Proud. The first question is, "How is MFR alone functional?" Beyond that, there are only a handful of peer-reviewed studies that examine the value of MFR in the literature. Last time I checked, one was for craniomandibular pain, one was for post-mastectomy pain, one was with respect to carpal-tunnel pain, and one focused on how to teach it in a PT program.
The only study relevant to most of our daily practice is Hanten WP, et al. Effects of myofascial release leg pull and sagittal plane isometric contract-relax techniques on passive straight-leg raise angle. JOSPT. 1994 Sep;20(3):138-44. In that study, contract-relax techniques were compared to MFR for the purpose of increasing passive hip ROM. BOTH MFR and C/R produced results, but C/R produced significantly better effects than did MFR.
I read that, therefore, to mean that when a case manager or MD asks why a PT didn't do MFR despite specific order . . . that the response should be, "There was no difficulty in treating with contract-relax in the improvement of range of motion at the joint in question. The literature show CR to be more efficient and effective in realizing the functional goal outline, and the use of MFR for any other purpose would be 'off label.' We've tried several other 'on-label' techniques and have found them to be most effective. The suggestion for MFR, therefore, was unnecessary --- but we will certainly consider MFR failing more evidence-based treatment options."
Dr. Andrew M. Ball, PT, DPT, PhD
Doctor of Physical Therapy
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Dr. Andrew M. Ball, PT, DPT, Ph.D.
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Re: Some advise re: MFR - January 28, 2007 5:50:00 PM
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Karie
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Jason,
Just an added note, you might want to find out this MD's background with MFR and why he considers it so important. Before you can discuss your treatment protocol effectively with him, you might need to know where he's coming from and that will make it easier for you to counter with your treatment plan of care. Just a suggestion.
Karie
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Re: Some advise re: MFR - January 28, 2007 7:56:00 PM
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ianwvu
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From: Glendale, AZ
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Jason,
I agree with Duff. Of course this is for future reference, and may not help you out with the M.D. now. But you could have done a suboccipital release and called in MFR. Hell, you could do a posterior talus glide and call it MFR. The patients don't know the difference. You know how many times I have gone through an intense treatemnt of Sub Cranial OA and AA mobs, Traction, Cervico-Thoracic Mobs/manips, Rib Mobilizations, etc, and the patient still comes out saying "that massage you do really helps". Just pull on their neck and tell them its MFR= problem solved.
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Re: Some advise re: MFR - January 29, 2007 2:29:00 AM
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PTupdate.com
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"You know how many times I have gone through an intense treatemnt of Sub Cranial OA and AA mobs, Traction, Cervico-Thoracic Mobs/manips, Rib Mobilizations, etc, and the patient still comes out saying "that massage you do really helps".
.....That happens so very often. Part of me gets frustrated, but I'm not that egotistical overall...I brush it off, and understand deep inside I made them better and happy. However, at times when conversation is not flowing, I'll explain what I am doing to them, why, and the jargon for it. Those patients will rarely thank you for the "massage"
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Some advise re: MFR - January 29, 2007 2:35:00 AM
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jlharris
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From: Nebraska
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Great suggestion Andrew. Thank you for being so specific.
Karie, that is a good point. I was contemplating the fact that I shouldn't just jump in on why MFR is this wonderful thing (compared to other common PT soft tissue treatments) w/o knowing why he likes to order it. I mean, the guy has had a stamp made for his PT orders.
I plan to speak with the MD today. I'll let you all know how it went. Thanks again.
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Jason L. Harris, PT, DPT
My PT Blog
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Re: Some advise re: MFR - January 30, 2007 2:34:00 AM
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Shill
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The other thing is that there are many views on what MFR really is, from the wacky gentle pressure fascial memory garbage to the ultra deep tissue stripping STM. This physician may not actually know what "real" MFR is. A call could clear this up, without being too confrontational.
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Steve Hill PT
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Re: Some advise re: MFR - January 30, 2007 2:27:00 PM
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jlharris
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From: Nebraska
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Thanks for all the help everyone. Ends up the physician is unavailable when I call and has, so far, not returned my messages to please call me when he is available. Oh well.
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Jason L. Harris, PT, DPT
My PT Blog
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Re: Some advise re: MFR - January 30, 2007 2:41:00 PM
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Marc Bronson
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Jason,
It's my understanding that MFR, like ART, has standardized protocols and that the providers are certified thereby ensuring some kind of quality control. That might be one of the reasons why the MD is recommending that specifically.
I get the same thing from my patients, thanking me for the "massage" when I do my soft tissue work. I would like to think that the ART and MRT protocols allow for more specificity (theoretically at least). In the end, all soft tissue treatments are most likely simply neuromodulating pain via stimulation of peripheral nerve branches and activating mechanoreceptors (shhhh don't tell Leahy I said that! ;)
Cheers,
M.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: Some advise re: MFR - January 30, 2007 2:49:00 PM
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drbuddy
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That is one of the things I really like about IASTM. No one mistakes that for massage. I do use ART-like procdures too with the same effect. I think patient education is the key and maybe make a distinction between plain ol' massage and manual therapy.
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Re: Some advise re: MFR - January 30, 2007 3:01:00 PM
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Marc Bronson
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Buddy T
I agree, although I prefer to use my hands as often as possible as it gives me better feedback as to what the response is beneath them. That being said, I've had phenomenal success treating tendonapathies with IASTM (the original Graston instruments).
The more approaches you have, the better, I find the best success by integrating the soft tissue treatments with some electro-acu followed by some corrective exercises that focuses on proper motor control and awareness.
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BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: Some advise re: MFR - January 30, 2007 5:28:00 PM
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jlharris
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From: Nebraska
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My contention is (standard protocol or not) show me the literature that shows MFR acheives better outcomes than the standard STM I learned and trained with in PT school. No idea what ART or IASTM is, so hard for me to compare that to my situation.
The fact that John Barnes seems to think the myofascial system carries our consciousness at speeds greater than the speed of light holding in it memories of old injuries, emotions, etc., really make me question how one would choose to pay to learn it. Especially since the only literature he provides (publicly) are testimonials and articles written by him.
No, I have a feeling the neurosurgeon really doesn't know what MFR is, or proposes to be. I've met the man before. I'm sure he'd like to have a discussion with John Barnes on whether he thinks the nervous system really doesn't carry the important messages of our body and consciousness. If only he'd pick up the phone to call me back.......
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Jason L. Harris, PT, DPT
My PT Blog
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Re: Some advise re: MFR - January 31, 2007 4:30:00 PM
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Marc Bronson
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From: Toronto
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Jason,
[URL=http://www.activerelease.com]www.activerelease.com[/URL]
[URL=http://www.grastontechnque.com]www.grastontechnique.com[/URL]
Active Release Techniques are basically protocols to break up fibrotic tissue due to RSI and cumulative trauma disorders as well as to "release" peripheral nerve entrapments. It's a great review of applied anatomy and although there is no real research out there yet, those who practice the protocols cannot deny it's relative effectiveness clinically.
Graston is an instrument based soft tissue mobilization, whose goal is to break down disordered fibrotic healing and reintroduce the inflammatory process and follow it up with exercise to get a more organized healing of collagen and so on. Works amazingly well in the nooks and crannies of feet, hands, tendons, ligaments and so on.
I've heard about Barnes' attachments to emotions to fascia which seems ridiculous. The Soma forum has thoroughly deconstructed that topic and I completely agree with their conclusions that clearly the theory behind it doesn't stand scientific scrutiny. But again, that doesn't mean the application of MFR clinically does not help out patients.
Cheers,
M.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: Some advise re: MFR - January 31, 2007 8:44:00 PM
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ianwvu
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From: Glendale, AZ
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Jason,
Seriously, don't wait by the phone to hear from the doctor. You may have not been around enough M.D.'s and physician offices to realize how crazy things are there and how little the majority of them really care about the specifics of PT. He probably took some course that mentioned MFR, and that's why he has it on a stamp of it for his standard PT treatment. If he thought it was some specific specialized treatment, he would not put it on a stamp. Instead he would dole these patients out to only the "certified" MFR PTs.
Making calls to him to discuss the benefits of STM and the lack of evidence for the use of MFR will ultimately just lose you another referral source.
I would chalk this patient up as a loss. Continue to market the doc (most likely he wont remember this situation anyways), and next time, just say you are doing MFR. I mean, isn't everything we do hands on releasing the myofascia in one way or another?
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Re: Some advise re: MFR - February 1, 2007 2:42:00 AM
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jlharris
Posts: 477
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From: Nebraska
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@Marc
Thanks for taking the time to reference that for me. I guess I have heard of Active Release before. Do DC's use a machine called ART also? I may be confused there. Also, I truly believe pt's who need soft tissue work will get better with MFR. My contention (just like the one I have with CST) is the "theory" behind it is amazingly unreal.
@ianwvu
LOL, my wifes a surgeon (senior resident) so I do have some understanding of their schedule. I don't think it's an excuse to not call me (or have his nurse or PA or whatever) to discuss concerns about HIS pt that I am/was treating.
I do agree with you that this is a lost cause. I get the impression from his front office that it's more that he wants this specific PT to see the pt and not so much a MFR issue. My wife is trying to talk me into sending him an "information" package on MFR and STM. She's worked with the guy and says he's into EBM, so thinks it might help. I think, like you said, it'd loose us a referal source.
Thanks again everyone.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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Re: Some advise re: MFR - February 4, 2007 6:18:00 AM
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Marc Bronson
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Jason,
Have no idea what an ART machine is, but if it does exist, and it is being used by DC's I can pretty much be almost 100% confident to tell you what their "beliefs" are and what schools they most likely came from....
Just a little word regarding a discussion on another thread, re: the PT/DC thing in Arkansas, I agree that the proposed legislation is unfair to the PT's in that State, but your comments regarding the lack of "university" training by the DC's seems to infer that ALL education for DC's is seemingly inferior to the university level. My alma mata, which is a private school and is considered a private university by our provincial governement, had better test scores on our national board exams that the the other chiro school in Canada which is within a public university. I'm not going to spin it and say CMCC DC Degree program is "better" than the public university one, but I will say that it's a fallacy to believe that all DC education (even in the US) is inferior university programmes.
For the record, I'm not trying to be inflammatory, but rather pointing out that traditional memes towards all DC's is beginning to be, IMHO, outdated since there are increasingly people like Buddy T, Karim and myself who are (seemingly!)strong NMSK clinicians.
Cheers,
M.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: Some advise re: MFR - February 4, 2007 6:54:00 AM
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proud
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Marc,
Can you comment a little more on the graston technique and it's instruments.
In reading the web page, the technique appears to have been around for 13+ years.
I wonder how those research trials they speak of have been progressing? Any ideas?
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