- Email: [email protected]
Comparison of a foam rolling session with active joint motion and without joint motion: A randomized controlled trial
Journal of Bodywork & Movement Therapies 22 (2018) 707e712
Contents lists available at ScienceDirect
Journal of Bodywork & Movement Therapies journal homepage: www.elsevier.com/jbmt
FASCIA SCIENCE AND CLINICAL APPLICATIONS: RANDOMIZED CONTROLLED TRIAL
Comparison of a foam rolling session with active joint motion and without joint motion: A randomized controlled trial Scott W. Cheatham a, *, Kyle R. Stull b a b
California State University Dominguez Hills, 1000 E. Victoria Street, Carson, CA, 90747, USA National Academy of Sports Medicine, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 March 2017 Received in revised form 14 January 2018 Accepted 20 January 2018
Background: Foam rolling has become a popular form of self-myofascial release or roller massage among health and fitness professionals. Due to this popularity, foam roller devices can be found in many clinical and fitness settings. Despite the popularity, there are still several unknowns regarding foam rolling such the optimal technique. Specifically, there is a lack of research analyzing different foam roll techniques such as combining active joint motion with foam rolling. Purpose: The purpose of this study was to compare the effects of a foam rolling session to the left quadriceps with active joint motion and without joint motion on passive knee flexion range of motion (ROM) and pressure pain thresholds (PPT). Methods: Thirty healthy adults were randomly allocated to one of two intervention groups: active joint motion and no joint motion. Each foam roll intervention to the left quadriceps lasted a total of 2 min. Dependent variables included passive knee flexion ROM and pressure pain threshold measures (PPT). Statistical analysis included subject demographic calculations and appropriate parametric and nonparametric tests to measure changes within and between intervention groups. Results: For left knee ROM, the active joint motion group demonstrated the greatest immediate increase in passive ROM (8 , p < .001) than the non-motion group (5 , p < .001). For PPT, the active joint motion group demonstrated the greatest immediate increase (180 kPa, p < .001) followed by the non-motion group (133 kPa, p < .001). Between group comparisons revealed a significance between groups for passive knee ROM (p < .001) and PPT (p < .001). Conclusion: A short session of foam rolling with active joint motion appears to have a greater effect on passive joint ROM and PPT than rolling without motion. These observed changes may be influenced by the agonistic muscle activity during active motion. This activity may modulate activity of the antagonist muscle through reciprocal inhibition and other neural pathways. Future research is needed to confirm these findings. © 2018 Elsevier Ltd. All rights reserved.
Keywords: Massage Muscle soreness Myofascial Recovery Roller Release Self
1. Introduction Foam rolling has become a popular form of self-myofascial release (SMR) or roller massage among health and fitness professionals (Thompson, 2015, 2016). Due to this popularity, foam roll devices can be found in a wide array of clinical and fitness settings. The research suggests that SMR using a foam roller produces shortterm benefits for increasing flexibility and joint range of motion (ROM)(Beardsley and Skarabot, 2015; Cheatham et al., 2017a, 2015,
* Corresponding author. E-mail address: [email protected] (S.W. Cheatham). https://doi.org/10.1016/j.jbmt.2018.01.011 1360-8592/© 2018 Elsevier Ltd. All rights reserved.
2017c), reducing decrements in muscle performance (Cheatham et al., 2015), pressure pain thresholds (PPT) (Aboodarda et al., 2015; Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017c) and reducing effects of delayed onset muscle soreness (DOMS) (Beardsley and Skarabot, 2015; Cheatham et al., 2015; Schroeder and Best, 2015). Despite the popularity and reported short-term benefits (2 min), there are still several unknowns regarding foam rolling such as the optimal type of roller, time, cadence, and technique (Cheatham et al., 2015). As far as technique, only one study has assessed the effects of specific foam rolling techniques. Peacock and colleagues (Peacock et al., 2015) examined the effects of foam rolling the lower body in the sagittal and coronal or frontal plane on
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flexibility and performance with NFL combine drills. The researchers found that sagittal plane rolling was effective (p 0.05) at improving flexibility (Peacock et al., 2015). Most SMR publications using foam rollers have used similar sagittal plane rolling techniques on the lower body (Beardsley and Skarabot, 2015; Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a, 2015, 2017b). One rolling technique that has not been studies is the effects of active joint motion during a foam rolling session. A recent literature search (August 2017) of electronic databased including: PubMed, PEDro, Science Direct, and the EBSCO host collection revealed no studies analyzing the effects of active joint movement during foam rolling. During foam rolling, active movement via agonist muscle contraction may enhance the effects on the antagonist tissues through modulating muscle activity via reciprocal inhibition and other neurological pathways (Hamm and Alexander, 2010). The purpose of this study was to compare the effects of a foam rolling session to the left quadriceps with active joint motion and without joint motion on passive knee flexion ROM and PPT.
Table 1 Consort flow diagram.
2. Methods This pretest, posttest randomized controlled trial was part of a larger study analyzing various aspects of SMR interventions using a foam roller. This study arm analyzed the effects of active joint motion during a foam rolling session. This study has be approved by the university Institutional Review Board at California State University Dominguez Hills (IRB# 16e180). 2.1. Subjects Thirty healthy adults (M ¼ 19, F ¼ 11) (age ¼ 25 ± 3.4 years, height ¼ 171.46 ± 9.3 cm; body mass ¼ 77.10 ± 20.6; body mass index (BMI) ¼ 26.78 ± 6.11) were recruited via convenience sampling (e.g. flyers) and randomly allocated into two groups of 15 subjects: (1) active joint motion (2) no joint motion (see Table 1). A computerized random number generator was used to assign subjects to a group. The non-joint motion group was considered the control. Recruited subjects reported participated in recreational
S.W. Cheatham, K.R. Stull / Journal of Bodywork & Movement Therapies 22 (2018) 707e712
709
Table 2 Subject demographics (N ¼ 30). Characteristics
Age (years)
Height (cm)
Mass (kg)
BMI (kg/m2)
Active Joint Motion (N ¼ 15)
24.33 ± 1.72 (range 23e25) 26.40 ± 5.11 (range 21e39)
172.93 ± 10.13 (range 166e179) 170.00 ± 8.10 (range 155e183)
80.97 ± 22.08 (range 51e129) 73.23 ± 19.21 (range 50e113)
26.86 ± 5.29 (range 23e30) 26.71 ± 7.01 (range 19e46)
No Joint Motion (N ¼ 15)
Data reported as mean ± SD; range (min-max); m ¼ meters; BMI ¼ body mass index; kg/m2 ¼ kilograms-meter squared.
fitness activities (e.g. walking), and prior experience using a foam roller within the last two years but were not currently using any devices. Exclusion criteria included the presence of any musculoskeletal, systemic, or metabolic disease that would affect lower extremity joint range of motion or tolerance to PPT testing and the inability to avoid medications that may affect testing. Descriptive demographic information is provided in Table 2. 2.2. Instruments Two instruments were used in this investigation to measure ROM and PPT. For passive ROM, the baseline digital inclinometer (Fabrication Enterprises, White Plains, NY, USA) was used to measure passive knee flexion ROM. This device has been shown to be valid and reliable for measuring lower extremity ROM and has been used in prior foam roller research (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a). Second, The JTECH (Midvale, UT) Tracker Freedom® wireless algometer was used with the accompanying Tracker 5® Windows® based software to measure pressure pain threshold. This instrument has also been validated and used in prior foam roll research (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a).
measures for each group. For passive knee flexion ROM, subjects lied prone on a carpeted floor. The examiner grasped the left ankle and passively moved the left knee to the end of the available flexion ROM to the point where the knee could no long be passively moved without providing overpressure (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a; Lee et al., 2015; Marks et al., 2003; Peeler and Anderson, 2008). The ROM measurement was then taken by placing the inclinometer on the middle aspect of the tibia just below the ankle joint. The examiner monitored for any compensatory movement through the lower extremity and pelvis. This testing technique was chosen since it replicated the same hip position and knee movements that occurred during the foam roll interventions (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a). For PPT, the left quadriceps group was tested with the subject in the relaxed standing position (2 measurements). The 1.0-cm2 probe of the algometer was placed into the midline of the left quadriceps (rectus femoris) midway between the iliac crest and superior border of the patella. The graded force was applied at a constant rate of 50e60 kPa per second (kPa/sec) until the subject verbally reported the presence of pain. These outcome measures have been used in prior foam roll research (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a; Pearcey et al., 2015).
2.3. Foam roller The GRID half size foam roller (TriggerPoint, a division of Implus, LLC, 5321 Industrial Oaks Blvd., Austin, Texas 78735, USA) was used for this investigation. The GRID foam roll is a rigid solid plastic cylinder with a medium density, multilevel foam outer covering. This roller has been used in prior foam roll research (Fig. 1) (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a; Skarabot et al., 2015). 2.4. Outcome measures Two outcome measures were used for the pretest and posttest
2.5. Pilot study Prior to data collection, a two-session pilot training was conducted to establish intrarater reliability. The primary investigator took all the measurements. The primary investigator is a United States licensed physical therapist with over 13 years of experience and board certified in orthopaedics. Ten independent subjects were recruited and tested for this portion of the study. The intrarater reliability was calculated using the Intraclass Correlation Coefficient (ICC model 3, 3). There was good intrarater reliability for passive knee flexion ROM (ICC ¼ 0.95; 95% CI 0.83e0.99) and pressure algometry (ICC ¼ 0.94; 95% CI 0.61e0.90) (Portney and Watkins, 2009). 2.6. Procedures
Fig. 1. GRID foam roller.
All eligible participants were given an IRB approved consent form to read and sign before testing. Participants then completed a questionnaire to provide demographic information. All participants were tested by one investigator and were blinded from the results and other participants enrolled in the study. Testing was conducted between the hours of 10 a.m. and 2 p.m. and subjects were instructed to refrain from any strenuous activity 3 h prior to testing and from taking any medication that would interfere with testing. All subjects underwent one session of testing that included: pretest measures, followed by the intervention, then immediate posttest measures. The primary investigator was not blinded to the measurement results. Prior to testing, the primary investigator first explained the process to each subject and answered any questions. For the active joint motion intervention, subjects followed a commercial internet based instruction video (TriggerPoint, a
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own preferred cadence for 2 min. Subjects were instructed to keep the left knee straight during the intervention. The investigator monitored the intervention time and did not provide any feedback unless to correct any aberrant knee motion. 2.7. Statistical analysis Statistical analysis was performed using SPSS version 24.0 (IBM SPSS, Chicago, IL, USA). Subject descriptive data was calculated and reported as the mean and standard deviation (SD) for age, height, body mass, and body mass index (BMI) (see Table 2). Group differences were calculated using the ANOVA statistic for continuous level data and the Kruskal Wallis statistic for ordinal level data. Between group difference were calculated using the ANCOVA statistic (Dugard and Todman, 1995). For the ANCOVA, the independent variable was the group, dependent variable was post-test scores, and pretest scores was the covariate. Within group comparisons were calculated using the paired t-test. Effect size (ES) was calculated (d ¼ M1 - M2/spooled) for each group. Effect size of >0.70 was considered strong, 0.41 to 0.70 was moderate, and <0.40 was weak (Cohen, 1992). All statistical assumptions were met for the ANOVA, ANCOVA and paired t-test statistics. Statistical significance was considered p < .05 using a conservative two-tailed test. 3. Results
Fig. 2. Active joint ROM intervention.
division of Implus, LLC, 5321 Industrial Oaks Blvd., Austin, Texas 78735, USA) that demonstrated the use of the GRID foam roll on the left quadriceps muscle group. Subjects had their own foam roll and followed the video with no feedback from the observing primary investigator. The instructor in the video provided a brief introduction and then discussed the foam rolling technique. The instructor divided the left quadriceps into zone one: top of patella to middle of the quadriceps and zone two: middle quadriceps to anterior superior iliac spine. The model in the video was instructed to get in the plank position, position the roller above the left patella and roll back and forth in zone one 4 at a cadence of 1inch per second. The model was then instructed to stop at the top of zone one followed by 4 active knee bends to 90 . This sequence was repeated for zone two. The intervention portion lasted a total of 2 min (see Fig. 2). This video has been used in prior foam roll research (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a). For the non-joint motion intervention or control, the primary investigator demonstrated the plank position and placement of the GRID roller under the left quadriceps group. Subjects rolled from the top of the patella to the anterior superior iliac spine using their
Thirty subjects completed the study (see Table 1). There was no statistically significant difference between groups for age (p ¼ .16), height (p ¼ .40), body mass (p ¼ .31), and BMI (p ¼ .52). There were no adverse events or subject attrition during data collection. Subject demographic data is presented in Table 2. 3.1. Between group analysis Between group comparisons were calculated. For passive knee flexion ROM, the analysis revealed a statistically higher value for active joint motion than the non-motion group [F (2,27) ¼ 224.74, p¼ <.001]. For PPT, the active joint motion group had a significantly higher value than the non-motion group [F (2,27) ¼ 206.14, p¼<.001]. 3.2. Within group comparison Within group comparison results are presented in Table 3. For passive knee flexion ROM, the analysis revealed a posttest increase of approximately 8 (p < .001, ES: 0.76) for the active joint motion group and approximately 5 (p¼<.001, ES: 0.37) for the non-motion group. For PPT, a posttest increase of approximate 180 kPa (p < .001, ES: 0.83) for the active joint motion group and 133 kPa (p < .001, ES: 0.53) for the non-motion group was calculated.
Table 3 Pretest, posttest descriptive results (N ¼ 30).
Active joint motion Knee ROM (degrees) Pressure Pain Threshold (kPa) No joint motion Knee ROM (degrees) Pressure Pain Threshold (kPa)
Pretest
Posttest
Change
P-Value
Effect Size
126.46 ± 10.12 1094.67 ± 220.22
134.47 ± 10.93 1274.02 ± 213.30
8.01 ± 0.81 179.35 ± 40.87
<.001 <.001
.76 .83
135.29 ± 7.07 1138.67 ± 245.00
140.20 ± 6.04 1271.33 ± 256.73
4.91 ± 1.03 132.66 ± 11.73
<.001 <.001
.37 .53
*IR: internal rotation; Data reported as mean ± SD, kPa ¼ kilopascals; statistical significance considered p < .05; Effect size: d ¼ M1 - M2/spooled.
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4. Discussion This investigation analyzed the difference between a foam rolling session on the left quadriceps with active joint motion and without joint motion. To the authors knowledge, no other studies have analyzed active joint motion during foam rolling. The results suggest that a short session of foam rolling with active joint motion may have a greater immediate effect on post-treatment flexibility and PPT (p .05) than no joint motion. Perhaps, the agonistic action of the hamstrings to bend the knee during the foam rolling session enhanced the treatment by modulating the activity of the antagonistic quadriceps through reciprocal inhibition and activation of other neural pathways (Herda et al., 2013). Similar hypotheses and findings have been reported with dynamic and Proprioceptive Neuromuscular Facilitation (PNF) stretching which may utilize similar neurologic pathways (Aguilar et al., 2012; Behm et al., 2016; Kallerud and Gleeson, 2013; Mizuno, 2017). Clinicians may want to explore the use of active joint motion of the agonist during foam rolling to enhance the effects of the intervention to the antagonist tissues. Researchers have only compared foam rolling and dynamic motion in prior research but never have combined the two techniques. Su and colleagues (Su et al., 2016) and Bahera and colleagues (Behara and Jacobson, 2017) both compared the effects of foam rolling to dynamic stretching on flexibility and muscle strength in the lower extremity. The researchers found that short bouts of both foam rolling and dynamic stretching had positive effects on flexibility without effecting muscle strength (Behara and Jacobson, 2017; Su et al., 2016). Thus, combining active joint motion to a short foam rolling session (2 min) may enhance the effects of the intervention. Further investigations are needed to confirm this theory and its clinical significance since the statistical significance was only revealed in these results. 4.1. Limitations There are specific limitations to the investigation that need to be discussed. First, this investigation tested healthy subjects which limits the generalizability of the results to this population. Second, the immediate effects of each foam roll intervention were studied with the left leg only. Third, the testing examiner was not blinded to the results of the study due to limited resources which could have led to testing biases. However, the testing protocol has been used in prior studies (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a, 2017c). Fourth, the instructional video used in the active joint motion intervention only demonstrated one foam rolling technique on the left quadriceps group. Other rolling techniques may have produced different results as well as testing other muscle groups. 4.2. Future research Future research should attempt to determine the longer-term effects of combining active joint motion with foam rolling. Measuring the effects over several time points may reveal more information than a single session. Peacock and colleagues (Peacock et al., 2015) were the only other researchers to analyze different foam rolling techniques. Despite the current research, there are many unanswered questions about foam rolling which presents a challenge for clinicians since they are unable to provide an evidence based recommendation to their clients (Beardsley and Skarabot, 2015; Cheatham et al., 2015). Researchers should strive to conduct quality research and to answer some of the many frequent questions. Perhaps, developing a consensus on the optimal shortterm foam roll program would provide enough evidence to
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produce higher quality long-term studies. This investigation attempted to address one of the frequent questions regarding foam rolling technique. 5. Conclusion This investigation compared a short session of foam rolling with active joint motion and no motion. The result suggest that active joint motion during foam rolling may have greater immediate effects on flexibility and PPT than foam rolling with no joint motion. Future research is needed to fully validate these findings. Foam rolling is a popular intervention that needs further study to develop a consensus among researchers and clinicians. Conflicts of interest The authors have no conflict of interest with this manuscript. Acknowledgements We would like to thank Trigger Point Technologies for providing permission for the use of the instructional video and associated foam roller. References Aboodarda, S.J., Spence, A.J., Button, D.C., 2015. Pain pressure threshold of a muscle tender spot increases following local and non-local rolling massage. BMC Muscoskel. Disord. 16, 265. Aguilar, A.J., DiStefano, L.J., Brown, C.N., Herman, D.C., Guskiewicz, K.M., Padua, D.A., 2012. A dynamic warm-up model increases quadriceps strength and hamstring flexibility. J. Strength Cond. Res. 26, 1130e1141. Beardsley, C., Skarabot, J., 2015. Effects of self-myofascial release: a systematic review. J. Bodyw. Mov. Ther. 19, 747e758. Behara, B., Jacobson, B.H., 2017. Acute effects of deep tissue foam rolling and dynamic stretching on muscular strength, power, and flexibility in division I linemen. J. Strength Cond. Res. 31, 888e892. Behm, D.G., Blazevich, A.J., Kay, A.D., McHugh, M., 2016. Acute effects of muscle stretching on physical performance, range of motion, and injury incidence in healthy active individuals: a systematic review. Appl. Physiol. Nutr. Metabol. 41, 1e11. Cheatham, S.W., Baker, R., 2017. Differences in pressure pain threshold among men and women after foam rolling. J. Bodyw. Mov. Ther. [Epub ahead of print]. Cheatham, S.W., Kolber, M.J., 2017. Does self-myofascial release with a foam roll change pressure pain threshold of the ipsilateral lower extremity antagonist and contralateral muscle groups? An Exploratory Study. J Sport Rehabil 1e18. Cheatham, S.W., Kolber, M.J., Cain, M., 2017a. Comparison of video-guided, live instructed, and self-guided foam roll interventions on knee joint range of motion and pressure pain threshold: a randomized controlled trial. Int J Sports Phys Ther 12, 242e249. Cheatham, S.W., Kolber, M.J., Cain, M., Lee, M., 2015. The effects of self-myofascial release using a foam roll or roller massager on joint range of motion, muscle recovery, and performance: a systematic review. Int J Sports Phys Ther 10, 827e838. Cheatham, S.W., Kolber, M.J., Mokha, G.M., Hanney, W.J., 2017b. Concurrent validation of a pressure pain threshold scale for individuals with myofascial pain syndrome and fibromyalgia. J. Man. Manip. Ther. 1e11. Cheatham, S.W., Stull, K.R., Kolber, M.J., 2017c. Comparison of a vibrating foam roller and a non-vibrating foam roller intervention on knee range of motion and pressure pain threshold: a randomized controlled trial. J. Sport Rehabil. 1e23. Cohen, J., 1992. A power primer. Psychol. Bull. 112, 155e159. Dugard, P., Todman, J., 1995. Analysis of pre-test-post-test control group designs in educational research. Educ. Psychol. 15, 181e198. Hamm, K., Alexander, C.M., 2010. Challenging presumptions: is reciprocal inhibition truly reciprocal? A study of reciprocal inhibition between knee extensors and flexors in humans. Man. Ther. 15, 388e393. Herda, T.J., Herda, N.D., Costa, P.B., Walter-Herda, A.A., Valdez, A.M., Cramer, J.T., 2013. The effects of dynamic stretching on the passive properties of the muscletendon unit. J. Sports Sci. 31, 479e487. Kallerud, H., Gleeson, N., 2013. Effects of stretching on performances involving stretch-shortening cycles. Sports Med. 43, 733e750. Lee, S.Y., Sung, K.H., Chung, C.Y., Lee, K.M., Kwon, S.S., Kim, T.G., Lee, S.H., Lee, I.H., Park, M.S., 2015. Reliability and validity of the Duncan-Ely test for assessing rectus femoris spasticity in patients with cerebral palsy. Dev. Med. Child Neurol. 57, 963e968. Marks, M.C., Alexander, J., Sutherland, D.H., Chambers, H.G., 2003. Clinical utility of the Duncan-Ely test for rectus femoris dysfunction during the swing phase of
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gait. Dev. Med. Child Neurol. 45, 763e768. Mizuno, T., 2017. Changes in joint range of motion and muscle-tendon unit stiffness after varying amounts of dynamic stretching. J. Sports Sci. 35, 2157e2163. Peacock, C.A., Krein, D.D., Antonio, J., Sanders, G.J., Silver, T.A., Colas, M., 2015. Comparing acute bouts of sagittal plane progression foam rolling vs. Frontal plane progression foam rolling. J. Strength Cond. Res. 29, 2310e2315. Pearcey, G.E., Bradbury-Squires, D.J., Kawamoto, J.E., Drinkwater, E.J., Behm, D.G., Button, D.C., 2015. Foam rolling for delayed-onset muscle soreness and recovery of dynamic performance measures. J. Athl. Train. 50, 5e13. Peeler, J., Anderson, J.E., 2008. Reliability of the Ely's test for assessing rectus femoris muscle flexibility and joint range of motion. J. Orthop. Res. 26, 793e799. Portney, L.G., Watkins, M.P., 2009. Foundations of Clinical Research: Applications to
Practice. Pearson/Prentice Hall). Schroeder, A.N., Best, T.M., 2015. Is self myofascial release an effective preexercise and recovery strategy? A literature review. Curr. Sports Med. Rep. 14, 200e208. Skarabot, J., Beardsley, C., Stirn, I., 2015. Comparing the effects of self-myofascial release with static stretching on ankle range-of-motion in adolescent athletes. Int J Sports Phys Ther 10, 203e212. Su, H., Chang, N.J., Wu, W.L., Guo, L.Y., Chu, I.H., 2016. Acute effects of foam rolling, static stretching, and dynamic stretching during warm-ups on muscular flexibility and strength in young adults. J. Sport Rehabil. 1e24. Thompson, W.R., 2015. Worldwide survey of fitness trends for 2016: 10th anniversary edition. ACSM's Health & Fit. J. 19, 9e18. Thompson, W.R., 2016. Worldwide survey of fitness trends for 2017. ACSM's Health & Fit. J. 20, 8e17.
Contents lists available at ScienceDirect
Journal of Bodywork & Movement Therapies journal homepage: www.elsevier.com/jbmt
FASCIA SCIENCE AND CLINICAL APPLICATIONS: RANDOMIZED CONTROLLED TRIAL
Comparison of a foam rolling session with active joint motion and without joint motion: A randomized controlled trial Scott W. Cheatham a, *, Kyle R. Stull b a b
California State University Dominguez Hills, 1000 E. Victoria Street, Carson, CA, 90747, USA National Academy of Sports Medicine, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 March 2017 Received in revised form 14 January 2018 Accepted 20 January 2018
Background: Foam rolling has become a popular form of self-myofascial release or roller massage among health and fitness professionals. Due to this popularity, foam roller devices can be found in many clinical and fitness settings. Despite the popularity, there are still several unknowns regarding foam rolling such the optimal technique. Specifically, there is a lack of research analyzing different foam roll techniques such as combining active joint motion with foam rolling. Purpose: The purpose of this study was to compare the effects of a foam rolling session to the left quadriceps with active joint motion and without joint motion on passive knee flexion range of motion (ROM) and pressure pain thresholds (PPT). Methods: Thirty healthy adults were randomly allocated to one of two intervention groups: active joint motion and no joint motion. Each foam roll intervention to the left quadriceps lasted a total of 2 min. Dependent variables included passive knee flexion ROM and pressure pain threshold measures (PPT). Statistical analysis included subject demographic calculations and appropriate parametric and nonparametric tests to measure changes within and between intervention groups. Results: For left knee ROM, the active joint motion group demonstrated the greatest immediate increase in passive ROM (8 , p < .001) than the non-motion group (5 , p < .001). For PPT, the active joint motion group demonstrated the greatest immediate increase (180 kPa, p < .001) followed by the non-motion group (133 kPa, p < .001). Between group comparisons revealed a significance between groups for passive knee ROM (p < .001) and PPT (p < .001). Conclusion: A short session of foam rolling with active joint motion appears to have a greater effect on passive joint ROM and PPT than rolling without motion. These observed changes may be influenced by the agonistic muscle activity during active motion. This activity may modulate activity of the antagonist muscle through reciprocal inhibition and other neural pathways. Future research is needed to confirm these findings. © 2018 Elsevier Ltd. All rights reserved.
Keywords: Massage Muscle soreness Myofascial Recovery Roller Release Self
1. Introduction Foam rolling has become a popular form of self-myofascial release (SMR) or roller massage among health and fitness professionals (Thompson, 2015, 2016). Due to this popularity, foam roll devices can be found in a wide array of clinical and fitness settings. The research suggests that SMR using a foam roller produces shortterm benefits for increasing flexibility and joint range of motion (ROM)(Beardsley and Skarabot, 2015; Cheatham et al., 2017a, 2015,
* Corresponding author. E-mail address: [email protected] (S.W. Cheatham). https://doi.org/10.1016/j.jbmt.2018.01.011 1360-8592/© 2018 Elsevier Ltd. All rights reserved.
2017c), reducing decrements in muscle performance (Cheatham et al., 2015), pressure pain thresholds (PPT) (Aboodarda et al., 2015; Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017c) and reducing effects of delayed onset muscle soreness (DOMS) (Beardsley and Skarabot, 2015; Cheatham et al., 2015; Schroeder and Best, 2015). Despite the popularity and reported short-term benefits (2 min), there are still several unknowns regarding foam rolling such as the optimal type of roller, time, cadence, and technique (Cheatham et al., 2015). As far as technique, only one study has assessed the effects of specific foam rolling techniques. Peacock and colleagues (Peacock et al., 2015) examined the effects of foam rolling the lower body in the sagittal and coronal or frontal plane on
708
S.W. Cheatham, K.R. Stull / Journal of Bodywork & Movement Therapies 22 (2018) 707e712
flexibility and performance with NFL combine drills. The researchers found that sagittal plane rolling was effective (p 0.05) at improving flexibility (Peacock et al., 2015). Most SMR publications using foam rollers have used similar sagittal plane rolling techniques on the lower body (Beardsley and Skarabot, 2015; Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a, 2015, 2017b). One rolling technique that has not been studies is the effects of active joint motion during a foam rolling session. A recent literature search (August 2017) of electronic databased including: PubMed, PEDro, Science Direct, and the EBSCO host collection revealed no studies analyzing the effects of active joint movement during foam rolling. During foam rolling, active movement via agonist muscle contraction may enhance the effects on the antagonist tissues through modulating muscle activity via reciprocal inhibition and other neurological pathways (Hamm and Alexander, 2010). The purpose of this study was to compare the effects of a foam rolling session to the left quadriceps with active joint motion and without joint motion on passive knee flexion ROM and PPT.
Table 1 Consort flow diagram.
2. Methods This pretest, posttest randomized controlled trial was part of a larger study analyzing various aspects of SMR interventions using a foam roller. This study arm analyzed the effects of active joint motion during a foam rolling session. This study has be approved by the university Institutional Review Board at California State University Dominguez Hills (IRB# 16e180). 2.1. Subjects Thirty healthy adults (M ¼ 19, F ¼ 11) (age ¼ 25 ± 3.4 years, height ¼ 171.46 ± 9.3 cm; body mass ¼ 77.10 ± 20.6; body mass index (BMI) ¼ 26.78 ± 6.11) were recruited via convenience sampling (e.g. flyers) and randomly allocated into two groups of 15 subjects: (1) active joint motion (2) no joint motion (see Table 1). A computerized random number generator was used to assign subjects to a group. The non-joint motion group was considered the control. Recruited subjects reported participated in recreational
S.W. Cheatham, K.R. Stull / Journal of Bodywork & Movement Therapies 22 (2018) 707e712
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Table 2 Subject demographics (N ¼ 30). Characteristics
Age (years)
Height (cm)
Mass (kg)
BMI (kg/m2)
Active Joint Motion (N ¼ 15)
24.33 ± 1.72 (range 23e25) 26.40 ± 5.11 (range 21e39)
172.93 ± 10.13 (range 166e179) 170.00 ± 8.10 (range 155e183)
80.97 ± 22.08 (range 51e129) 73.23 ± 19.21 (range 50e113)
26.86 ± 5.29 (range 23e30) 26.71 ± 7.01 (range 19e46)
No Joint Motion (N ¼ 15)
Data reported as mean ± SD; range (min-max); m ¼ meters; BMI ¼ body mass index; kg/m2 ¼ kilograms-meter squared.
fitness activities (e.g. walking), and prior experience using a foam roller within the last two years but were not currently using any devices. Exclusion criteria included the presence of any musculoskeletal, systemic, or metabolic disease that would affect lower extremity joint range of motion or tolerance to PPT testing and the inability to avoid medications that may affect testing. Descriptive demographic information is provided in Table 2. 2.2. Instruments Two instruments were used in this investigation to measure ROM and PPT. For passive ROM, the baseline digital inclinometer (Fabrication Enterprises, White Plains, NY, USA) was used to measure passive knee flexion ROM. This device has been shown to be valid and reliable for measuring lower extremity ROM and has been used in prior foam roller research (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a). Second, The JTECH (Midvale, UT) Tracker Freedom® wireless algometer was used with the accompanying Tracker 5® Windows® based software to measure pressure pain threshold. This instrument has also been validated and used in prior foam roll research (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a).
measures for each group. For passive knee flexion ROM, subjects lied prone on a carpeted floor. The examiner grasped the left ankle and passively moved the left knee to the end of the available flexion ROM to the point where the knee could no long be passively moved without providing overpressure (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a; Lee et al., 2015; Marks et al., 2003; Peeler and Anderson, 2008). The ROM measurement was then taken by placing the inclinometer on the middle aspect of the tibia just below the ankle joint. The examiner monitored for any compensatory movement through the lower extremity and pelvis. This testing technique was chosen since it replicated the same hip position and knee movements that occurred during the foam roll interventions (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a). For PPT, the left quadriceps group was tested with the subject in the relaxed standing position (2 measurements). The 1.0-cm2 probe of the algometer was placed into the midline of the left quadriceps (rectus femoris) midway between the iliac crest and superior border of the patella. The graded force was applied at a constant rate of 50e60 kPa per second (kPa/sec) until the subject verbally reported the presence of pain. These outcome measures have been used in prior foam roll research (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a; Pearcey et al., 2015).
2.3. Foam roller The GRID half size foam roller (TriggerPoint, a division of Implus, LLC, 5321 Industrial Oaks Blvd., Austin, Texas 78735, USA) was used for this investigation. The GRID foam roll is a rigid solid plastic cylinder with a medium density, multilevel foam outer covering. This roller has been used in prior foam roll research (Fig. 1) (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a; Skarabot et al., 2015). 2.4. Outcome measures Two outcome measures were used for the pretest and posttest
2.5. Pilot study Prior to data collection, a two-session pilot training was conducted to establish intrarater reliability. The primary investigator took all the measurements. The primary investigator is a United States licensed physical therapist with over 13 years of experience and board certified in orthopaedics. Ten independent subjects were recruited and tested for this portion of the study. The intrarater reliability was calculated using the Intraclass Correlation Coefficient (ICC model 3, 3). There was good intrarater reliability for passive knee flexion ROM (ICC ¼ 0.95; 95% CI 0.83e0.99) and pressure algometry (ICC ¼ 0.94; 95% CI 0.61e0.90) (Portney and Watkins, 2009). 2.6. Procedures
Fig. 1. GRID foam roller.
All eligible participants were given an IRB approved consent form to read and sign before testing. Participants then completed a questionnaire to provide demographic information. All participants were tested by one investigator and were blinded from the results and other participants enrolled in the study. Testing was conducted between the hours of 10 a.m. and 2 p.m. and subjects were instructed to refrain from any strenuous activity 3 h prior to testing and from taking any medication that would interfere with testing. All subjects underwent one session of testing that included: pretest measures, followed by the intervention, then immediate posttest measures. The primary investigator was not blinded to the measurement results. Prior to testing, the primary investigator first explained the process to each subject and answered any questions. For the active joint motion intervention, subjects followed a commercial internet based instruction video (TriggerPoint, a
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own preferred cadence for 2 min. Subjects were instructed to keep the left knee straight during the intervention. The investigator monitored the intervention time and did not provide any feedback unless to correct any aberrant knee motion. 2.7. Statistical analysis Statistical analysis was performed using SPSS version 24.0 (IBM SPSS, Chicago, IL, USA). Subject descriptive data was calculated and reported as the mean and standard deviation (SD) for age, height, body mass, and body mass index (BMI) (see Table 2). Group differences were calculated using the ANOVA statistic for continuous level data and the Kruskal Wallis statistic for ordinal level data. Between group difference were calculated using the ANCOVA statistic (Dugard and Todman, 1995). For the ANCOVA, the independent variable was the group, dependent variable was post-test scores, and pretest scores was the covariate. Within group comparisons were calculated using the paired t-test. Effect size (ES) was calculated (d ¼ M1 - M2/spooled) for each group. Effect size of >0.70 was considered strong, 0.41 to 0.70 was moderate, and <0.40 was weak (Cohen, 1992). All statistical assumptions were met for the ANOVA, ANCOVA and paired t-test statistics. Statistical significance was considered p < .05 using a conservative two-tailed test. 3. Results
Fig. 2. Active joint ROM intervention.
division of Implus, LLC, 5321 Industrial Oaks Blvd., Austin, Texas 78735, USA) that demonstrated the use of the GRID foam roll on the left quadriceps muscle group. Subjects had their own foam roll and followed the video with no feedback from the observing primary investigator. The instructor in the video provided a brief introduction and then discussed the foam rolling technique. The instructor divided the left quadriceps into zone one: top of patella to middle of the quadriceps and zone two: middle quadriceps to anterior superior iliac spine. The model in the video was instructed to get in the plank position, position the roller above the left patella and roll back and forth in zone one 4 at a cadence of 1inch per second. The model was then instructed to stop at the top of zone one followed by 4 active knee bends to 90 . This sequence was repeated for zone two. The intervention portion lasted a total of 2 min (see Fig. 2). This video has been used in prior foam roll research (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a). For the non-joint motion intervention or control, the primary investigator demonstrated the plank position and placement of the GRID roller under the left quadriceps group. Subjects rolled from the top of the patella to the anterior superior iliac spine using their
Thirty subjects completed the study (see Table 1). There was no statistically significant difference between groups for age (p ¼ .16), height (p ¼ .40), body mass (p ¼ .31), and BMI (p ¼ .52). There were no adverse events or subject attrition during data collection. Subject demographic data is presented in Table 2. 3.1. Between group analysis Between group comparisons were calculated. For passive knee flexion ROM, the analysis revealed a statistically higher value for active joint motion than the non-motion group [F (2,27) ¼ 224.74, p¼ <.001]. For PPT, the active joint motion group had a significantly higher value than the non-motion group [F (2,27) ¼ 206.14, p¼<.001]. 3.2. Within group comparison Within group comparison results are presented in Table 3. For passive knee flexion ROM, the analysis revealed a posttest increase of approximately 8 (p < .001, ES: 0.76) for the active joint motion group and approximately 5 (p¼<.001, ES: 0.37) for the non-motion group. For PPT, a posttest increase of approximate 180 kPa (p < .001, ES: 0.83) for the active joint motion group and 133 kPa (p < .001, ES: 0.53) for the non-motion group was calculated.
Table 3 Pretest, posttest descriptive results (N ¼ 30).
Active joint motion Knee ROM (degrees) Pressure Pain Threshold (kPa) No joint motion Knee ROM (degrees) Pressure Pain Threshold (kPa)
Pretest
Posttest
Change
P-Value
Effect Size
126.46 ± 10.12 1094.67 ± 220.22
134.47 ± 10.93 1274.02 ± 213.30
8.01 ± 0.81 179.35 ± 40.87
<.001 <.001
.76 .83
135.29 ± 7.07 1138.67 ± 245.00
140.20 ± 6.04 1271.33 ± 256.73
4.91 ± 1.03 132.66 ± 11.73
<.001 <.001
.37 .53
*IR: internal rotation; Data reported as mean ± SD, kPa ¼ kilopascals; statistical significance considered p < .05; Effect size: d ¼ M1 - M2/spooled.
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4. Discussion This investigation analyzed the difference between a foam rolling session on the left quadriceps with active joint motion and without joint motion. To the authors knowledge, no other studies have analyzed active joint motion during foam rolling. The results suggest that a short session of foam rolling with active joint motion may have a greater immediate effect on post-treatment flexibility and PPT (p .05) than no joint motion. Perhaps, the agonistic action of the hamstrings to bend the knee during the foam rolling session enhanced the treatment by modulating the activity of the antagonistic quadriceps through reciprocal inhibition and activation of other neural pathways (Herda et al., 2013). Similar hypotheses and findings have been reported with dynamic and Proprioceptive Neuromuscular Facilitation (PNF) stretching which may utilize similar neurologic pathways (Aguilar et al., 2012; Behm et al., 2016; Kallerud and Gleeson, 2013; Mizuno, 2017). Clinicians may want to explore the use of active joint motion of the agonist during foam rolling to enhance the effects of the intervention to the antagonist tissues. Researchers have only compared foam rolling and dynamic motion in prior research but never have combined the two techniques. Su and colleagues (Su et al., 2016) and Bahera and colleagues (Behara and Jacobson, 2017) both compared the effects of foam rolling to dynamic stretching on flexibility and muscle strength in the lower extremity. The researchers found that short bouts of both foam rolling and dynamic stretching had positive effects on flexibility without effecting muscle strength (Behara and Jacobson, 2017; Su et al., 2016). Thus, combining active joint motion to a short foam rolling session (2 min) may enhance the effects of the intervention. Further investigations are needed to confirm this theory and its clinical significance since the statistical significance was only revealed in these results. 4.1. Limitations There are specific limitations to the investigation that need to be discussed. First, this investigation tested healthy subjects which limits the generalizability of the results to this population. Second, the immediate effects of each foam roll intervention were studied with the left leg only. Third, the testing examiner was not blinded to the results of the study due to limited resources which could have led to testing biases. However, the testing protocol has been used in prior studies (Cheatham and Baker, 2017; Cheatham and Kolber, 2017; Cheatham et al., 2017a, 2017c). Fourth, the instructional video used in the active joint motion intervention only demonstrated one foam rolling technique on the left quadriceps group. Other rolling techniques may have produced different results as well as testing other muscle groups. 4.2. Future research Future research should attempt to determine the longer-term effects of combining active joint motion with foam rolling. Measuring the effects over several time points may reveal more information than a single session. Peacock and colleagues (Peacock et al., 2015) were the only other researchers to analyze different foam rolling techniques. Despite the current research, there are many unanswered questions about foam rolling which presents a challenge for clinicians since they are unable to provide an evidence based recommendation to their clients (Beardsley and Skarabot, 2015; Cheatham et al., 2015). Researchers should strive to conduct quality research and to answer some of the many frequent questions. Perhaps, developing a consensus on the optimal shortterm foam roll program would provide enough evidence to
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produce higher quality long-term studies. This investigation attempted to address one of the frequent questions regarding foam rolling technique. 5. Conclusion This investigation compared a short session of foam rolling with active joint motion and no motion. The result suggest that active joint motion during foam rolling may have greater immediate effects on flexibility and PPT than foam rolling with no joint motion. Future research is needed to fully validate these findings. Foam rolling is a popular intervention that needs further study to develop a consensus among researchers and clinicians. Conflicts of interest The authors have no conflict of interest with this manuscript. Acknowledgements We would like to thank Trigger Point Technologies for providing permission for the use of the instructional video and associated foam roller. References Aboodarda, S.J., Spence, A.J., Button, D.C., 2015. Pain pressure threshold of a muscle tender spot increases following local and non-local rolling massage. BMC Muscoskel. Disord. 16, 265. Aguilar, A.J., DiStefano, L.J., Brown, C.N., Herman, D.C., Guskiewicz, K.M., Padua, D.A., 2012. A dynamic warm-up model increases quadriceps strength and hamstring flexibility. J. Strength Cond. Res. 26, 1130e1141. Beardsley, C., Skarabot, J., 2015. Effects of self-myofascial release: a systematic review. J. Bodyw. Mov. Ther. 19, 747e758. Behara, B., Jacobson, B.H., 2017. Acute effects of deep tissue foam rolling and dynamic stretching on muscular strength, power, and flexibility in division I linemen. J. Strength Cond. Res. 31, 888e892. Behm, D.G., Blazevich, A.J., Kay, A.D., McHugh, M., 2016. Acute effects of muscle stretching on physical performance, range of motion, and injury incidence in healthy active individuals: a systematic review. Appl. Physiol. Nutr. Metabol. 41, 1e11. Cheatham, S.W., Baker, R., 2017. Differences in pressure pain threshold among men and women after foam rolling. J. Bodyw. Mov. Ther. [Epub ahead of print]. Cheatham, S.W., Kolber, M.J., 2017. Does self-myofascial release with a foam roll change pressure pain threshold of the ipsilateral lower extremity antagonist and contralateral muscle groups? An Exploratory Study. J Sport Rehabil 1e18. Cheatham, S.W., Kolber, M.J., Cain, M., 2017a. Comparison of video-guided, live instructed, and self-guided foam roll interventions on knee joint range of motion and pressure pain threshold: a randomized controlled trial. Int J Sports Phys Ther 12, 242e249. Cheatham, S.W., Kolber, M.J., Cain, M., Lee, M., 2015. The effects of self-myofascial release using a foam roll or roller massager on joint range of motion, muscle recovery, and performance: a systematic review. Int J Sports Phys Ther 10, 827e838. Cheatham, S.W., Kolber, M.J., Mokha, G.M., Hanney, W.J., 2017b. Concurrent validation of a pressure pain threshold scale for individuals with myofascial pain syndrome and fibromyalgia. J. Man. Manip. Ther. 1e11. Cheatham, S.W., Stull, K.R., Kolber, M.J., 2017c. Comparison of a vibrating foam roller and a non-vibrating foam roller intervention on knee range of motion and pressure pain threshold: a randomized controlled trial. J. Sport Rehabil. 1e23. Cohen, J., 1992. A power primer. Psychol. Bull. 112, 155e159. Dugard, P., Todman, J., 1995. Analysis of pre-test-post-test control group designs in educational research. Educ. Psychol. 15, 181e198. Hamm, K., Alexander, C.M., 2010. Challenging presumptions: is reciprocal inhibition truly reciprocal? A study of reciprocal inhibition between knee extensors and flexors in humans. Man. Ther. 15, 388e393. Herda, T.J., Herda, N.D., Costa, P.B., Walter-Herda, A.A., Valdez, A.M., Cramer, J.T., 2013. The effects of dynamic stretching on the passive properties of the muscletendon unit. J. Sports Sci. 31, 479e487. Kallerud, H., Gleeson, N., 2013. Effects of stretching on performances involving stretch-shortening cycles. Sports Med. 43, 733e750. Lee, S.Y., Sung, K.H., Chung, C.Y., Lee, K.M., Kwon, S.S., Kim, T.G., Lee, S.H., Lee, I.H., Park, M.S., 2015. Reliability and validity of the Duncan-Ely test for assessing rectus femoris spasticity in patients with cerebral palsy. Dev. Med. Child Neurol. 57, 963e968. Marks, M.C., Alexander, J., Sutherland, D.H., Chambers, H.G., 2003. Clinical utility of the Duncan-Ely test for rectus femoris dysfunction during the swing phase of
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