Effect of remote myofascial manual therapy along the superficial back line on lumbo-pelvic-hip and neck flexibility and pain intensity: A systematic review and meta-analysis

Abstract

Background

Remote myofascial manual therapy (RMFMT) is increasingly applied to improve flexibility and pain in musculoskeletal practice, yet evidence regarding its clinical efficacy remains inconclusive.

Objective

This meta-analysis evaluated the effectiveness of RMFMT applied along the superficial back line on flexibility and pain intensity.

Methods

This meta-analysis included randomized controlled trials (RCTs) on RMFMT retrieved from four databases (from inception to January 2026). A random-effects model was used to calculate pooled Hedges’ g. Subgroup analyses were conducted according to assessment regions (or pain origins), intervention protocols, and control group types. In addition, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to assess the certainty of evidence and inform the strength of clinical recommendations.

Results

Nine RCTs (mean age: 20–40 years old; participants with pain-related symptoms and asymptomatic) demonstrated that RMFMT significantly improved flexibility (Hedges’ g = 0.525, p < 0.001, I²= 49.014%), with favorable trends observed in both the cervical and lumbo-pelvic-hip regions, particularly when RMFMT was applied alone and compared to inactive control condition. Additionally, four RCTs suggested a borderline significant reduction in pain intensity (Hedges’ g = −0.906, p = 0.070, I² = 87.420%) with similarly positive trends across both anatomical regions.

Conclusion

RMFMT applied along the superficial back line improved flexibility and showed a trend toward pain reduction compared with controls. Evidence certainty was moderate for flexibility and low for pain, supporting a conditional recommendation for RMFMT as an adjunctive intervention. Further high-quality RCTs are needed to strengthen the evidence.

Keywords

fascia manual therapy musculoskeletal system meta-analysis

Introduction

The fascial system is a continuous connective tissue structure that envelops muscles, bones, and internal organs, providing mechanical support and facilitating the transmission of forces across the musculoskeletal framework.¹ It is essential for transmitting mechanical forces, integrating afferent input from mechanoreceptors within the tissue, and supporting both postural control and efficient motor function.² Research also has shown that fascia contains abundant nociceptors and free nerve endings, making it a potential source of pain when inflamed or restricted.³ Because of these factors, fascia is not merely a passive structure, but also actively contributes to movement efficiency and pain modulation. Recently, theoretical developments have further emphasized the concept of myofascia highlighting the inseparable anatomical and functional integration between muscles (myo-) and fascia (-fascia), as well as its continuity, referring to the structural and functional interconnectedness across distant regions of the body.⁴ These emerging perspectives support the hypothesis that interventions applied to remote fascial sites may lead to measurable changes in musculoskeletal outcomes (e.g., pain intensity) at anatomically distant locations.

Myers defined myofascial meridians as anatomically and functionally continuous pathways formed by interconnected muscles and fascial tissues.⁵ The superficial back line, extending from the plantar surface to the cranial fascia, is one of the myofascial meridians that has been more consistently supported by empirical findings.⁶ This myofascial meridian has been believed to play a key role in maintaining upright posture and facilitating coordinated movement through its role in global tension regulation.⁵ A related hypothesis suggests that myofascial meridians may explain remote treatment effect, where mechanical input at one region may produce changes in range of motion at a distant site, either cephalically or caudally. For instance, the book Anatomy Trains describes how myofascial release applied to the plantar fascia can lead to improved toe-touch flexibility through tension redistribution along the superficial back line.⁵ From a physical therapy perspective, clarifying the effectiveness of remote treatment is clinically relevant, as remote interventions may offer time-efficient, less painful, or more tolerable alternatives for patients who cannot receive direct treatment to the symptomatic region.

Despite growing interest in remote myofascial manual therapy (RMFMT) (e.g., myofascial release or stretching) for addressing flexibility and pain along the superficial back line in the cervical and lumbo-pelvic-hip (LPH) regions,^7,8 findings from randomized controlled trials (RCTs) remain inconclusive and heterogeneous. For example, Wilke et al.⁸ reported no significant difference in cervical range of motion improvement between RMFMT and the control group, whereas Behnampour et al.⁷ demonstrated a significant improvement favoring RMFMT. Although previous systematic reviews have assessed the impact of RMFMT on flexibility, they have not yet incorporated potentially influential factors (e.g., assessment region or treatment parameters) and have generally excluded pain intensity as an outcome measure.^9,10 Accordingly, this systematic review and meta-analysis aimed to evaluate the effects of RMFMT applied along the superficial back line on flexibility and pain reduction in the LPH and neck regions. In addition, subgroup analyses were conducted to explore potential moderators that may influence treatment outcomes. We hypothesized that RMFMT applied along the superficial back line would result in greater improvements in flexibility and greater reductions in pain intensity in the LPH and neck regions compared with comparator group.

Methods

We conducted a comprehensive literature search in accordance with the guidelines outlined in the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).¹¹ The PRISMA checklist is provided in Table S1. Our research protocol was registered on Inplasy.com under registration number (INPLASY202570103). The full registration record is available at https://inplasy.com/inplasy-2025-7-0103/

Two reviewers, namely L.-H.L. and LT.-ML., conducted screenings across multiple databases, including PubMed, Medline-Ovid, and Scopus. The search employed the following keywords: (“superficial back line” OR “myofascial chain” OR “myofascial meridian” OR “myofascial continuity”) AND (“myofascial release” OR “stretch” OR “foam rolling”) AND (“remote effect”). We systematically applied variations of these terms to ensure a comprehensive search, covering literature from database inception to January 7, 2026. Detailed search strategies and the number of records retrieved for each database are presented in Table S2.

Inclusion criteria

This meta-analysis was structured according to the PICO framework as follows: the Population (P) comprised human participants; the Intervention (I) involved RMFMT; the Comparison (C) consisted of control conditions without RMFMT; and the Outcomes (O) included changes in flexibility and pain intensity in the LPH and cervical regions. Because lumbar flexion range of motion cannot be assessed independently of hip or pelvic movement, flexibility-related outcomes were operationally defined within the LPH region. Accordingly, interventions targeting the hamstrings were classified as local myofascial manual therapy (LMFMT) when flexibility outcomes were assessed. In contrast, for lumbar pain–related outcomes, hamstring interventions were classified as RMFMT, as the intervention site was anatomically distinct from the lumbar pain assessment region (Table S3).

The inclusion criteria were as follows: (1) RCTs investigated the effects of RMFMT (defined as the application of myofascial release or stretching techniques to anatomical regions distant from the site of outcome assessment) and administered along the superficial back line, with outcomes including flexibility and/or pain intensity; (2) enrolling adults with or without pain, including asymptomatic individuals and those with pain originating from the LPH or neck region; (3) the intervention groups were treated with RMFMT alone or plus other treatments; and (4) at least one comparator group using treatments other than RMFMT.

Exclusion criteria

The exclusion criteria were: (1) non-RCTs; (2) treatment group use of LMFMT alone, defined as applying myofascial release or stretching to the same anatomical region assessed as the outcome (e.g., neck interventions with neck outcome measurement); (3) study designs such as case reports, case series, quasi-experimental trials, single-arm studies, cross-over trials, or longitudinal follow-ups without control groups; (4) absence of flexibility or pain intensity assessments; (5) duplicate participant data from previously published trials; (6) studies in which both the intervention and control groups received RMFMT; and (7) intervention and control groups received analgesic medication as part of the standard treatment protocol.

Two reviewers independently screened all records for eligibility. Inter-rater agreement was assessed using percentage agreement. Disagreements were resolved through discussion, with consultation of a third reviewer when necessary.

Primary outcome measurements

In this meta-analysis, flexibility served as the primary outcome measurement. For the LPH region, commonly adopted tests included the Finger-Floor Distance Test (or Toe Touch Test), the Modified Schober Test, and the Sit-and-Reach Test. For the neck region, cervical flexion range of motion was operationally defined as an indirect indicator of the flexibility of the posterior cervical myofascial structures.

The Finger-Floor Distance Test assesses the distance between the fingertips and the floor during a forward bend with knees extended, reflecting the extensibility of the posterior chain, including the hamstrings and lumbar fascia. This test has demonstrated good test-retest reliability (intraclass correlation coefficient [ICC] 0.99).¹¹ The Modified Schober Test specifically evaluates lumbar spine flexion by measuring the change in distance between marked spinal points during forward bending. The interclass (ICC = 0.91) and intraclass (ICC = 0.95) reliability were found to be excellent.¹² The sit-and-reach test measures forward flexion in a seated position with extended knees, primarily assessing the flexibility of the hamstrings and lower back. It is a standardized test with excellent reliability (ICC 0.84-0.97).¹³ In the neck region, cervical flexion range of motion was measured using a goniometer or inclinometer to quantify the maximum angle of forward head flexion. Previous studies have demonstrated good intra-rater reliability for cervical range of motion measurement (ICC = 0.88).¹⁴

Secondary outcome

The secondary outcome was the change in pain intensity before and after the intervention, assessed using the Visual Analog Scale (VAS). This instrument consists of a 10 cm horizontal line anchored by descriptors such as “no pain” and “worst imaginable pain.

Data extraction

Data extraction was conducted independently by two reviewers. One reviewer first extracted all relevant data, and a second reviewer independently re-extracted the data. The two datasets were then compared, and any discrepancies were resolved through discussion. If consensus could not be reached, a third author adjudicated the disagreement. When outcomes were reported at multiple follow-up points, data from the final assessment at the end of the intervention were used. In multi-arm studies, the Cochrane Handbook recommends three approaches to avoid double counting, including splitting the sample size, combining intervention groups, or excluding one comparison.¹⁵ In the present review, we adopted the sample-splitting approach. When a single intervention group was compared with multiple control groups, the intervention sample size was divided proportionally across comparisons, with rounding applied when exact equal division was not possible, to preserve statistical independence. Likewise, when a single control group was shared by more than one experimental condition, the control sample size was divided proportionally across comparisons, with rounding when necessary, to avoid analytic duplication.¹⁵ For studies reporting non-parametric statistics (e.g., medians, interquartile ranges, or confidence intervals), data were converted to means and standard deviations using established methods recommended by the Cochrane Handbook for Systematic Reviews of Interventions.¹⁶ In studies where therapist-administered myofascial release was followed by continued self-myofascial release, outcome measures obtained immediately after completion of the therapist-administered intervention were preferentially extracted. This approach was adopted to isolate the effects of therapist-delivered interventions and to avoid potential confounding from variability in self-administered protocols. Detailed data extraction and SD conversion information are presented in Table S4.

Assessment and quality classification

The methodological quality of the included studies was evaluated using the Cochrane Risk of Bias 2.0 (RoB 2) tool. This instrument assesses potential bias across several domains, including the randomization process, deviations from intended interventions, missing outcome data, outcome measurement, selective reporting, and overall risk of bias.¹⁷ Risk of bias assessments were independently conducted by two reviewers using the RoB 2 tool. Any discrepancies were resolved through discussion, and if consensus could not be reached, a third reviewer was consulted for final adjudication.

Assessment of certainty of evidence and recommendations

The certainty of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. The certainty in evidence assessment involved categorizing evidence outcomes into four levels: high, moderate, low, or very low. This categorization was based on an analysis of several factors, including the potential for bias, inconsistencies, indirect references, imprecision, and the presence of publication bias.¹⁸

In addition, the GRADE approach classifies the strength of clinical recommendations into two categories: strong and weak/conditional. The framework emphasizes that the strength of a recommendation should be informed by the certainty of the evidence while also considering the balance between desirable and undesirable effects. Clinical recommendations are therefore based on the best available evidence and reflect the degree of confidence in the estimated effects. Generally, higher certainty of evidence supports stronger recommendations, whereas lower certainty of evidence may result in weak or conditional recommendations. The evaluation process was conducted independently by two reviewers. Any discrepancies in their assessments were resolved through discussion, and when necessary, consensus was reached in consultation with the corresponding author.¹⁸

Statistical analysis

A random-effects model was employed a priori to account for expected clinical and methodological heterogeneity across studies, including variations in treatment protocols, participant characteristics, and outcome measurements, allowing for differences in true effect sizes beyond sampling error. Effect size synthesis was conducted using Comprehensive Meta-Analysis software (version 4; Biostat, Englewood, NJ, USA). Statistical significance was determined by a two-tailed p-value less than 0.05. Pooled estimates were reported as Hedges’ g with 95% confidence intervals (CIs). On the other hand, 95% prediction intervals were calculated to complement CIs by characterizing the expected range of effects in future settings.¹⁹ The magnitude of the effects was interpreted based on standard benchmarks, where values of 0.2, 0.5, and 0.8 were considered small, moderate, and large, respectively.²⁰ Between-study heterogeneity was assessed using Cochran's Q test and the I² statistic, with I² values of 25%, 50%, and 75% interpreted as low, moderate, and high heterogeneity, respectively.²¹ To examine the robustness of the findings, sensitivity analyses were performed by the leave-one-out method to assess its influence on the overall effect size. Subgroup analyses were performed hierarchically. Primary stratification was based on the anatomical regions of flexibility assessment (LPH or neck region) or pain origins (lumbar region or neck region). Secondary stratification within each region was conducted according to intervention protocols (RMFMT alone or combined with LMFMT) and types of control groups (inactive or active control) to explore potential effect modifiers. Regarding the classification of anatomical regions, flexibility outcomes assessed using the Finger-Floor Distance Test (or Toe Touch Test), the Modified Schober Test, and the Sit-and-Reach Test were categorized under the LPH region, as these measures might reflect myofascial flexibility across the lumbar spine, pelvis, and hip. In contrast, for pain intensity outcomes, region classification was based on the specific clinical diagnosis reported in each study. Thus, when studies explicitly identified low back pain as the primary condition, the pain outcome was categorized not LPH region but lumbar region. Furthermore, if a study focused on cervicogenic headache, it was classified under pain originating from the cervical region, as this condition is defined as a secondary headache caused by dysfunction of cervical spine structures.

In addition, meta-regression analyses were conducted to examine whether the total number of treatment sessions, mean age, and participant status (pain-related diagnosis vs. non–pain-related diagnosis) served as potential effect modifiers. Pain-related diagnosis referred to participants with clearly defined pain conditions reported in the included studies, such as non-specific low back pain, non-specific neck pain, or headache.

Potential publication bias was assessed following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. This process included visual evaluation of funnel plot symmetry and the use of Egger's regression test, which examines the relationship between effect size and study precision (i.e., standard error). A statistically significant relationship might suggest the presence of small-study effects or potential publication bias.²²

Results

Study identification and selection

The PRISMA flowchart for the literature search is shown in Figure 1. Of the 41 non-duplicated citations identified from the literature search, 20 articles were further analyzed to confirm eligibility. Nine articles were excluded after full-text reading: 2 for not being RCTs, 2 for no LPH or neck pain intensity/ flexibility assessment, 3 for the treatment and control group using RMFMT, 1 for crossover design, and 1 for included medicine care. The precise reasons for exclusion are shown in Table S5. The percentage agreement between the two reviewers during the study screening process was 95%.

Figure 1.

Flow diagram outlining the study selection process according to PRISMA guidelines for the present meta-analysis.

We finally included 11 RCTs (510 participants; treatment duration 1 session - 6 weeks). Three of the included studies were multi-arm RCTs; 1 compared multiple RMFMT groups to one inactive control group,²³ 1 included one RMFMT group compared to an LMFMT group and an inactive control group,⁸ and 1 compared an RMFMT combined with an LMFMT group and an RMFMT-only group to LMFMT group.²⁴ Eight of the included studies were two-arm RCTs; 5 compared to an inactive control group,^7,25–28 and 3 compared to LMFMT.^29–31 Detailed information of the included studies is presented in Tables 1, 2, and S6.

Table 1.

Characteristics of the included studies.

First author (year)	Country	Participants (Female/Male)	Age (years old)	Participant description
Aparicio 2009	Spain	Experiment group: 34 (11/23) Control group: 34 (12/24)	Experiment group: 22.47 ± 3.58 Control group: 22.32 ± 4.12	Presence of MTrP in the hamstring muscles (non-pain-related diagnosis)
Behnampour 2024	Iran	Experiment group: 16 (8/8) Control group: 16 (8/8)	Experiment group: 35.93 ± 2.37 Control group: 36.25 ± 2.93	Nonspecific chronic neck pain,
Deepa 2020	India	Experiment group: 30 (30/0) Control group: 30 (30/0)	20–40 years	Nonspecific low back pain
Do 2018	Korea	Experiment group: 15 (5/10) Control group: 16 (7/9)	Experiment group: 30.53 ± 3.6 Control group: 23.93 ± 4.9	Asymptomatic individuals
Fauris 2021	Spain	Experiment group1: 16 (10/6) Experiment group 2: 15 (7/8) Control group: 15 (7/8)	Experiment group 1: 25.0 ± 7.5 Experiment group 2: 23.5 ± 6.4 Control group: 26.1 ± 6.4	Asymptomatic individuals
Grieve 2015	United Kingdom	Total (8 males and 16 females) Experiment group: 12 Control group: 12	28 ± 11.13	Asymptomatic individuals
Joshi 2018	India	Experiment group 1: 19 (14/5) Experiment group 2: 20 (14/6) Control group: 19 (14/5)	Experiment group 1: 21.7 ± 1.7 Experiment group 2: 22.2 ± 1.8 Control group: 23.1 ± 2.4	Asymptomatic individuals
Martínez-Lema 2021	Chile	Experiment group: 34 (34/0) Control group: 34 (34/0)	Experiment group: 21.47 ± 1.60 Control group: 20.91 ± 1.58	Hamstring shortening (non-pain-related diagnosis)
Tamartash 2023	Iran.	Experiment group: 16 Control group: 16 Total 16 female and 16 male	Experiment group: 40 ± 5.44 Control group: 40 ± 4.67	Nonspecific low back pain
Tavakkoli 2024	Iran	Experiment group:14 (12/2) Control group: 14 (12/2)	Experiment group: 34.86 ± 12.38 Control group: 37.07 ± 7.14	Cervicogenic headache
Wilke 2017	Germany	Experiment group: 21 (9/12) Control group 1: 21 (14/7) Control group 2: 21 (8/13)	Experiment group: 38 ± 13 Control group 1: 38 ± 13 Control group 2: 31 ± 13	Asymptomatic individuals

MTrP, Myofascial Trigger Point.

Table 2.

Summary of the intervention details of the included trials.

First author(year)	Experiment group (per-protocol N)	Control group (per-protocol N)	Experiment treatment protocol	Outcome measure
Aparicio 2009	RMFMT (34)	Placebo technique (34)	Suboccipital muscle inhibition technique. The technique was performed for 2 min. 1 session only	LPH region: finger-floor distance test
Behnampour 2024	RMFMT (16)	No intervention (16)	Self-myofascial release and stretch at gastrocnemius muscle and plantar fascia 6 weeks, 3 sessions / week	Neck flexion VAS (neck)
Deepa 2020	RMFMT + LMFMT (30)	LMFMT (lumbar region) (30)	Myofascial release (lumbar fascia, plantar fascia, suboccipital regions) and stretching (hamstring gastrocnemius) (10 sessions) +self-myofascial release and stretch home exercise (5 days/week, 2 week)	LPH region: modified schober test VAS (lumbar)
Do 2018	RMFMT (15)	Sham treatment (16)	Self-myofascial release (plantar fascia) 5 min / session, only 1session	LPH region: toe touch test
Fauris 2021^#	RMFMT (16) RMFMT (15)	No intervention (15)	Self-myofascial release at plantar fascia, and epicranial 10 min / session, only 1 session,	LPH region: sit-and-reach test
Grieve 2015	RMFMT (12)	No intervention (12)	Self-myofascial release at plantar fascia 2 min per foot, only 1 session	LPH region: sit-and-reach test
Joshi 2018	RMFMT + LMFMT (19) RMFMT (20)	LMFMT (hamstring stretch) (19)	Myofascial release at plantar fascia and suboccipital region (7 sessions) +self-myofascial release and stretch home exercise (once daily for 2 weeks)	LPH region: sit-and-reach test
Martínez-Lema 2021	RMFMT (34)	Sham treatment (34)	Myofascial release at posterior thigh For 90 s each thigh, only 1sessions	Neck flexion
Tamartash 2023	RMFMT (16)	LMFMT (16)	Myofascial release at hamstring and calf muscle Repeated 5 times. Only 1 session	VAS (lumbar)
Tavakkoli 2024	RMFMT (14)	LMFMT (14)	Thoraco-lumbar myofascial release Total 4 treatment sessions	VAS (cervicogenic headache)
Wilke 2017	RMFMT (21)	Sham treatment (21) LMFMT (21)	Self-stretch hamstring and calf muscle only 1 session	Neck flexion

RMFMT, remote myofascial manual therapy; LMFT, local myofascial manual therapy, VAS, visual analog scale

Although six intervention groups were initially identified, only three were included in the comparative analyses to prevent excessive subdivision of control group sample sizes.

Methodological quality of the included studies

With regard to the methodological quality of the included studies, no study was judged to be at low risk of bias. Overall, 63.6% of the included trials (n = 7) were rated as having some concerns, while 36.4% (n = 4) were judged to be at high risk of bias (Figure S1). The primary reasons contributing to judgments of concerns were the lack of reported allocation concealment, absence of blinding of participants, outcome assessors, or therapists, and unclear reporting regarding whether intention-to-treat or per-protocol analyses were performed. Detailed domain-level risks of bias assessments are summarized in Table 3.

Table 3.

Detailed quality assessment of included studies using cochrane risk of bias 2 tool.

Study	Randomization	Deviations from intended intervention	Missing outcome data	Outcome measurement	Selective reporting	Overall risk of bias
Aparicio 2009	S^a	H^bc	S^d	L	L	H
Behnampour 2024	S^a	S^b	L	L	L	S
Deepa 2020	S^a	H^bc	S^d	L	L	H
Do 2018	S^a	H^bc	S^d	L	L	H
Fauris 2021	S^a	S^b	L	L	L	S
Grieve 2015	S^a	S^b	L	L	L	S
Joshi 2018	S^a	S^b	L	L	L	S
Martínez-Lema 2021	S^a	L	L	L	L	S
Tamartash 2023	S^a	S^c	S^d	L	L	S
Tavakkoli 2024	S^a	H^bc	S^d	L	L	H
Wilke 2017	S^a	S^c	L	L	L	S

Allocation concealment was not reported.

No blinding of participants, outcome assessors, or therapists was described.

It was not specified whether an intention-to-treat or per-protocol analysis was performed.

The study did not report whether all randomized participants completed the intervention, nor whether any loss to follow-up occurred.

Remote effect on flexibility improvement

Overall, the flexibility was significantly improved in the RMFMT in 9 RCTs (Hedges’ g = 0.525, 95% CI = 0.251 to 0.800, p < 0.001, I²= 49.014%) (Figure 2). A sensitivity analysis was conducted using the one-study removal method and showed a consistently significant effect on flexibility (Figure S2). Subgroup analyses were conducted based on the regions of flexibility assessment, RMFMT protocols, and types of control groups. Significant effect sizes were observed for both the LPH and neck regions. Specifically, for the LPH region, the effect size was Hedges’ g = 0.438 (95% CI: 0.144 to 0.731, p = 0.003; I² = 31.511%), and for the neck region, Hedges’ g = 0.730 (95% CI: 0.118 to 1.341, p = 0.019; I² = 69.792%) (Figure 3(a)). When RMFMT protocols was included as a moderator, significant effects were observed for RMFMT alone in both the LPH and neck region flexibility assessments (Hedges’ g = 0.350, 95% CI = 0.069 to 0.632, p = 0.015, I² = 00.000%; Hedges’ g = 0.730, 95% CI = 0.118 to 1.341, p = 0.019, I² = 69.792%). When combined with LMFMT, the effect on LPH region flexibility showed a borderline effect (Hedges’ g = 0.610, 95% CI = −0.526 to 1.746, p = 0.293, I² = 83.644%) (Figure 3(b)). Notably, none of the included studies examined the effects of combined interventions on neck region flexibility. When types of control were included as a moderator, RMFMT showed significant improvements in flexibility assessments for both the LPH and neck regions compared to inactive control group (Hedges’ g = 0.403, 95% CI = 0.100 to 0.706, p = 0.009, I² = 00.000%; Hedges’ g = 0.972, 95% CI = 0.519 to 1.424, p < 0.001, I² = 30.533%). However, significant differences were observed in neither the LPH nor the neck region flexibility assessments when compared with the active control group (Hedges’ g = 0.428, 95% CI = −0.398 to 1.253, p = 0.310, I² = 77.439%; Hedges’ g = −0.146, 95% CI = −0.858 to 0.566, p = 0.688, I² = 00.000%) (Figure 3(c)). Details of the divided sample size and the original sample size are provided in Table S7.

Figure 2.

Forest plot of the overall effects of remote myofascial manual therapy (RMFMT) on flexibility.

Figure 3.

The forest plot of subgroup analysis for flexibility based on assessment regions, remote myofascial manual therapy (RMFMT) protocols and types of control.

Meta-regression analyses indicated that the total number of treatment sessions (regression coefficient = 0.054, 95% CI: 0.006 to 0.101, p = 0.026) and population status (regression coefficient = 0.889, 95% CI: 0.398 to 1.379, p = 0.0004) were significant effect modifiers. In contrast, mean age was not a significant moderator (regression coefficient = 0.016, 95% CI: −0.032 to 0.064, p = 0.519) (Figure S3ABC).

Remote effect on pain reduction

A total of four RCTs suggested a trend toward statistical significance reduction in pain intensity following RMFMT, with a pooled effect size of Hedges’ g = −0.906 (95% CI = −1.888 to 0.075, p = 0.070, I² = 87.420%) (Figure 4). The robustness of this effect was confirmed through sensitivity analysis via the leave-one-out method (Figure S4).

Figure 4.

Forest plot of the overall effects of remote myofascial manual therapy (RMFMT) on pain reduction.

Subgroup analysis based on pain origins revealed marginal significance for both pain originating from the lumbar and neck region (Hedges’ g = −0.390, 95% CI = −0.796 to 0.016, p = 0.060, I² = 00.000%; Hedges’ g = −1.567, 95% CI = −4.213 to 1.078, p = 0.246, I² = 94.657%) (Figure 5(a)). Further stratification by RMFMT protocol showed that RMFMT alone also revealed marginal significance for both pain originating from the lumbar and neck regions (Hedges’ g = −0.220, 95% CI = −0.898 to 0.457, p = 0.524, I² = 00.000%; Hedges’ g = −1.567, 95% CI = −4.213 to 1.078, p = 0.246, I² = 94.657%) and only one study assessed combined interventions for pain originating from lumbar (Figure 5(b)). Regarding the types of control, significant reduction in pain originating from the neck region was observed when compared with inactive control (Hedges’ g = −2.939, 95% CI = −3.926 to −1.952, p < 0.001, I² = 0.000%), but no significant difference was identified in pain originating from the lumbar or neck region when compared with active control group (Hedges’ g = −0.390, 95% CI = −0.796 to 0.016, p = 0.060, I² = 0.000%; Hedges’ g = −0.239, 95% CI = −0.961 to 0.483, p = 0.516, I² = 0.000%) (Figure 5(c)). None of the included studies explicitly stated that the source of pain originated from the lumbar spine in the comparison between RMFRT and inactive control. The meta-regression findings indicated a statistically significant relationship between total number of treatment sessions and RMFMT effect size (regression coefficient = −0.152, 95% CI: −0.265 to −0.039, p = 0.009) (Figure S5). Meta-regression analysis of mean age was unable to be conducted due to an insufficient number of studies reporting mean age (n = 3), which precluded stable model estimation. Moreover, population status was not examined as a potential moderator because all included studies exclusively enrolled participants with clearly defined pain-related diagnoses in pain intensity outcome.

Figure 5.

The forest plot of subgroup analysis for pain intensity based on pain origins, remote myofascial manual therapy (RMFMT) protocols and types of control

Assessment of evidence certainty and recommendations

The certainty of evidence for over all pain intensity and disability was considered “moderate” and “low” (Tables S8 and S9). Based on moderate-certainty evidence for improvements in flexibility and low-certainty evidence for pain reduction, a conditional recommendation is made in favor of the intervention.

Publication bias

The funnel plot for flexibility and pain reduction demonstrated a symmetrical distribution of effect sizes, as confirmed by Egger's regression test (p = 0.348; p = 0.294) (Figure S6AB).

Discussion

Overall, RMFMT demonstrated significant beneficial effects on flexibility improvement and showed a positive trend on pain reduction. For flexibility improvement, significant beneficial effects were observed in both the LPH and neck regions, particularly when compared with inactive control. However, adding LMFMT did not provide additional benefits for the LPH region, and no studies explored this factor for the neck region. Regarding pain reduction, positive trends were also observed in both lumbar and neck regions. RMFMT appeared to be more effective when compared with inactive control in the neck region than when compared with active control. However, none of the included studies examined the effect of RMFMT compared to inactive control for pain originating from the lumbar region, nor did they investigate the combined effect of RMFMT and LMFMT on the lumbar or neck region. Furthermore, the meta-regression suggested that higher total treatment dosage might contribute to greater benefits of RMFMT in flexibility enhancement and pain relief. The presence or absence of pain-related diagnosis among participants was significantly associated with improvements in flexibility.

To the best of our knowledge, this is the first meta-analysis of RCTs to investigate the effects of RMFMT on flexibility and pain intensity, with consideration of key factors including the regions of flexibility assessment (or pain origins), intervention types, control group types, and total treatment sessions. Burk et al.⁹ conducted a meta-analysis that included eight studies examining the effects of RMFMT on flexibility improvement. While their work provided valuable insights, the analysis primarily focused on differences between different control group types and did not explore specific region, RMFT protocol, or treatment sessions in detail, as well as did not assess pain reduction. Similarly, Dhiman et al.¹⁰ also conducted a meta-analysis investigating the effects of RMFMT on flexibility improvement. Although their study provided a useful foundation for understanding the comparative effectiveness of these interventions against different control conditions, it likewise did not examine outcomes beyond flexibility, such as pain relief or variations across treatment protocols and regions. Therefore, the present study contributes novel evidence and helps address important gaps in the current understanding of the clinical effects of RMFMT.

Overall, our findings suggest that RMFMT is associated with favorable effects on both flexibility and pain intensity. One possible explanation for these observations involves mechanical interactions along the superficial back line, whereby force transmission through the myofascial network may influence tissue behavior at anatomically distant sites. However, such mechanistic interpretations should be considered hypothetical and interpreted with caution. Evidence supporting fascial force transmission is primarily derived from experimental and laboratory-based studies. Wilke et al.³² demonstrated that passive ankle dorsiflexion to the maximal range resulted in measurable displacement of posterior thigh tissue (semimembranosus), as assessed using high-resolution ultrasound, despite the absence of direct intervention at the thigh. Similarly, Mohr et al. reported comparable findings, lending experimental support to the concept of myofascial continuity.³³ In addition to passive force transmission, active muscular tensioning has also been proposed as a potential mechanism underlying remote effects. do Carmo Carvalhais³⁴ reported that contraction of the latissimus dorsi could transmit tension via the thoracolumbar fascia to the contralateral gluteus maximus, resulting in alterations in hip joint biomechanics, including changes in resting joint position and passive stiffness. Another possible explanation is that myofascial treatment may induce a generalized anti-nociceptive effect,³⁵ primarily mediated through central pain modulatory mechanisms, including reduced central sensitization and activation of descending inhibitory pathways.³⁶ Nevertheless, direct causal evidence linking these mechanisms to clinical improvements in flexibility or pain remains limited. Therefore, the proposed mechanistic explanations should be viewed as speculative and requiring further investigation in well-designed clinical studies.

The subgroup analyses indicated that the beneficial effects of RMFMT were evident only in comparisons with inactive controls, while no significant advantage was observed over active control, such as LMFMT, for flexibility or pain outcomes. The possible explanations are that applying myofascial release directly to the target region can directly restore interfascial glide,³⁴ enhance local circulation,³⁷ and desensitize nociceptors³⁸ in that region. Compared to the indirect effects of remote interventions, directly treating an assessment region is expected to yield more pronounced therapeutic benefits. On the other hand, the combination of RMFMT and LMFMT would theoretically be expected to produce greater improvements in flexibility. However, our findings did not show a significant difference compared to the control group, but effect size was bigger and the confidence interval was notably wide, indicating substantial uncertainty in the effect estimate. Both studies compared with active control groups and under similar treatment durations. In the study by Deepa et al. (2020), the control group received myofascial release and manual stretching targeting only the lumbar region. In contrast, the intervention group received myofascial release targeting the lumbar fascia, plantar fascia, and suboccipital region, in combination with stretching exercises for the hamstrings and gastrocnemius. Previous meta-analyses suggested a trend toward greater effectiveness of muscle stretching compared to myofascial release in improving flexibility, particularly as measured by the sit-and-reach test.³⁹ Because of this, the overall treatment effect size in the intervention group may have been amplified. Conversely, in the study by Josh et al. 2018, the control group performed hamstring stretching, while the intervention group received myofascial release applied to the plantar fascia and suboccipital region in combination with the same hamstring stretching. Given that both groups received identical hamstring stretching, thereby reducing the between-group effect size. Moreover, due to the limited number of included studies, future research is needed to incorporate additional trials in order to more conclusively determine the effectiveness of combined RMFMT and LMFMT interventions.

In addition, this study had other methodological limitations that might affect the interpretation and generalizability of the results. First, considerable heterogeneity was noted in the pooled effect sizes for flexibility and pain outcomes. To address this, subgroup analyses and meta-regression were performed to explore potential sources of between-study variability. Future studies should stratify participants according to pain-related diagnoses and standardize the total number of treatment sessions to better control heterogeneity and improve the interpretability of findings. Second, the wide prediction intervals (e.g., pain intensity overall) indicate considerable uncertainty regarding the range of effects that may be observed in future studies and clinical settings.¹⁹ Future research should prioritize well-designed, adequately powered trials with more homogeneous populations and clearly standardised intervention protocols to better characterize between-study variability and to narrow the uncertainty surrounding treatment effects. Third, although minimal clinically important difference (MCID) values are widely used to interpret the clinical relevance of treatment effects (e.g., approximately 20 mm for the VAS in low back pain⁴⁰), the present meta-analysis synthesized outcomes using standardized effect sizes. Because standardized effect sizes are derived through statistical transformations that incorporate outcome variability and sample size, the original measurement scale is removed. Consequently, these standardized estimates cannot be directly compared with established MCID thresholds, and clinical relevance should be interpreted with caution. Future studies should report raw outcome changes in conjunction with MCID-based responder analyses to improve clinical interpretability. Fourth, both the intervention and follow-up durations were generally brief, limiting the capacity to evaluate the durability of treatment effects. Future studies should incorporate longer intervention periods and extended follow-up to better assess the sustained impact of RMFMT. Fifth, the small number of trials reporting on pain intensity restricted the feasibility of conducting meta-regression analysis to examine the moderating effect of mean age. Further high-quality RCTs are warranted to clarify whether age is an important moderator of pain improvement. Sixth, most of the included studies lacked blinding, which may have introduced performance bias. For example, compensatory equalization may occur when researchers provide additional services to the control group to balance perceived advantages of the intervention. Conversely, compensatory rivalry may arise when control group participants exert greater effort to match outcomes, while resentful demoralization may occur when control participants become discouraged, potentially leading to reduced performance. In addition, many studies did not clearly report whether all participants completed the intervention or whether intention-to-treat or per-protocol analyses were applied. This lack of transparency may compromise statistical conclusion validity by introducing uncertainty regarding the handling of missing data and deviations from intended interventions. Future meta-analyses should aim to include a greater number of high-quality RCTs with rigorous methodological reporting to strengthen both the internal validity and the statistical conclusion validity of pooled estimates.⁴¹ Seventh, several advanced analytical approaches, such as meta-analytic structural equation modeling or multilevel meta-analysis, may offer additional insights into complex data structures and hierarchical dependencies across studies. Future research incorporating larger datasets and utilizing analytical platforms that support these advanced techniques may allow for more comprehensive modeling of complex relationships among interventions, populations, and outcomes. Eighth, the evidence regarding pain intensity remains limited, as this outcome was based on a small number of studies and was characterized by wide confidence intervals. Therefore, the findings should be interpreted with caution and considered preliminary. Future well-designed RCTs with larger sample sizes and adequate statistical power are required to confirm these findings. Ninth, multiple subgroup and meta-regression analyses were conducted in this study, which may increase the risk of Type I error due to multiplicity. Therefore, the subgroup findings should be interpreted with caution and considered exploratory. Future studies with pre-specified hypotheses and adequately powered designs are needed to confirm these findings. Tenth, the included studies did not utilize objective tools with established reliability and validity (e.g., ultrasound imaging) to verify the depth and specificity of tissue engagement during RMFMT. In the absence of such verification, it remains unclear whether treatment effects were exclusively attributable to myofascial structures or also influenced by adjacent tissues (e.g., subcutaneous or neural elements). Future research should integrate imaging or physiological monitoring to enhance internal validity and clarify the mechanisms underlying therapeutic effects. Finally, this meta-analysis is that included studies varied in intervention delivery, with some using therapist-administered myofascial release and others relying solely on self-myofascial release. Future studies should clearly differentiate these approaches and report outcomes separately to improve comparability and interpretability.

In conclusion, this meta-analysis suggests that RMFMT applied along the superficial back line is associated with beneficial effects on flexibility and pain reduction, particularly when compared with inactive control conditions. According to the GRADE framework, the certainty of evidence was moderate for flexibility outcomes and low for pain-related outcomes, indicating greater confidence in the observed improvements in flexibility than in pain relief. Consequently, a conditional recommendation can be made in favor of RMFMT, emphasizing its potential role as an adjunctive intervention rather than a standalone treatment. The additional benefits of combining remote and local treatments remain inconclusive. Future high-quality RCTs with longer follow-up periods and validated tools to monitor both the application parameters and tissue depth of myofascial techniques are warranted to improve the certainty of evidence and inform stronger clinical recommendations.

Supplemental Material

sj-pdf-1-bmr-10.1177_10538127261428186 - Supplemental material for Effect of remote myofascial manual therapy along the superficial back line on lumbo-pelvic-hip and neck flexibility and pain intensity: A systematic review and meta-analysis

Supplemental material, sj-pdf-1-bmr-10.1177_10538127261428186 for Effect of remote myofascial manual therapy along the superficial back line on lumbo-pelvic-hip and neck flexibility and pain intensity: A systematic review and meta-analysis by Long-Huei Lin, Nguyen Thi My Lien, Ilham Fatria and Yi-Chun Huang in Journal of Back and Musculoskeletal Rehabilitation

Footnotes

Acknowledgements

The authors have no acknowledgments to disclose. This study did not receive any funding or external support.

Author contributions

Long-Huei Lin was responsible for the conceptualization, methodology, formal analysis, data curation, original draft preparation, visualization, and supervision. Nguyen Thi My Lien contributed to the literature search, data extraction, validation, and manuscript review and editing. Ilham Fatria was involved in data extraction, risk of bias assessment, and manuscript review and editing. Yi-Chun Huang contributed to the risk of bias assessment and participated in reviewing and editing the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

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