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COMPARISON OF FOAM ROLLING AND ISCHEMIC COMPRESSION IN THE
TREATMENT OF HAMSTRING TIGHTNESS
By
Nathan P. Sheneberger, B.A.
Bethel University
A Thesis Submitted in Partial Fulfillment of
the Requirements of the Degree of Master of Science in Athletic Training
to the office of Graduate and Extended Studies of
East Stroudsburg University of Pennsylvania
May 10, 2019
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ABSTRACT
A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master
of Science in Athletic Training to the office of Graduate Extended Studies of East
Stroudsburg University of Pennsylvania
Student’s Name: Nathan Sheneberger
Title: A Comparison of Foam Rolling and Ischemic Compression in Treating Hamstring
Tightness
Date of Graduation: May 10, 2019
Thesis Chair: Kelly Harrison, Ph.D.
Thesis Member: Gerard Rozea, Ph.D.
Thesis Member: Keith Vanic, Ph.D.
Abstract
Both foam rolling (FR), and ischemic compression (IC) have been shown to be
effective in treating muscle tightness, but the literature lacks studies comparing them.
This study was a crossover design consisting of 11 healthy NCAA Division II and III
collegiate basketball players. Subjects underwent, in a randomized order, 3 treatments: 1)
2x90s trials of FR, 2) 3x30-60s of IC and 3) No treatment; with a 1-week period between
each treatment. Variables measure pre and post treatment were: active hamstring range of
motion (ROM), pain-pressure threshold (PPT), vertical jump height (VJ), and peak power
output (PPO). A global rate of change survey (GROC) was given to measure the subject’s
perceived effect of the treatment. This study found, following each of the three
treatments, a significant increase in ROM, VJ, and PPO. The improvement recorded in
ROM, VJ and PPO does not appear to be the result of FR or IC.
KEY WORDS: foam rolling, ischemic compression, hamstring, myofascial release
TABLE OF CONTENTS
ABSTRACT
TABLE OF CONTENTS..................................................................................................i
LIST OF TABLES .......................................................................................................... v
LIST OF FIGURES .......................................................................................................vii
ABBREVIATION LIST .............................................................................................. viii
CHAPTER 1.................................................................................................................... 1
Background to the Problem .................................................................................. 1
Statement of the Problem ..................................................................................... 1
Purpose of the Study ............................................................................................ 2
Significance of the Study ..................................................................................... 2
Research Design .................................................................................................. 2
Research Question ............................................................................................... 3
Null Hypotheses ................................................................................................... 3
Directional Hypothesis ......................................................................................... 3
Limitations ........................................................................................................... 3
Delimitations ....................................................................................................... 4
Assumptions ........................................................................................................ 5
Definition of Terms.............................................................................................. 6
Expected Findings ................................................................................................ 7
CHAPTER 2.................................................................................................................... 9
Introduction ......................................................................................................... 9
i
Presentation of Symptomatology ........................................................................ 11
Myofascia ............................................................................................... 13
Thixotropy.............................................................................................. 15
Treatment Interventions ..................................................................................... 16
Mechanism of Intervention................................................................................. 17
Foam Rolling.......................................................................................... 17
Ischemic Compression ............................................................................ 19
Intervention Options .......................................................................................... 21
Assessing Treatment Effectiveness..................................................................... 21
Flexibility-Active Knee Extension .......................................................... 21
Pressure Sensitivity-Pain-Pressure Threshold ......................................... 22
Jump Performance-Vertical Jump and Peak Power Output...................... 23
Vertical Jump.............................................................................. 23
Peak Power Output ..................................................................... 23
Perceived Effectiveness-Global Rate of Change Survey.......................... 24
Conclusions ....................................................................................................... 25
CHAPTER 3.................................................................................................................. 26
Purpose of the Study .......................................................................................... 26
Research Design ................................................................................................ 26
Target Population and Participant Selection ....................................................... 27
Participants ........................................................................................................ 27
Procedures ......................................................................................................... 28
ii
Measurements ........................................................................................ 29
Active Knee Extension ................................................................ 29
Pain-Pressure Threshold.............................................................. 30
Vertical Jump.............................................................................. 32
Peak Power Output ..................................................................... 33
Global Rate of Change ................................................................ 33
Instruments ............................................................................................. 34
Intervention ............................................................................................ 35
Foam Rolling .............................................................................. 35
Ischemic Compression ................................................................ 36
Control........................................................................................ 38
Data Analysis ..................................................................................................... 38
CHAPTER 4.................................................................................................................. 39
Results ............................................................................................................... 39
Participant Demographics ....................................................................... 39
Comparison Among Time and Myofascial Release Techniques on Active
Knee Extension ........................................................................... 40
Comparison Among Time and Myofascial Release Techniques on PainPressure Threshold ...................................................................... 44
Comparison Among Time and Myofascial Release Techniques on Peak
Vertical Jump Height .................................................................. 48
Comparison Among Time and Myofascial Release Techniques on Peak
Power Output During Vertical Jump ........................................... 52
Comparison Among Myofascial Release Techniques on Global Rate of
Change Ranks Scores .................................................................. 56
iii
CHAPTER 5.................................................................................................................. 60
Introduction ....................................................................................................... 60
Discussions for Range of Motion on Performance .............................................. 60
Discussions for Pain-Pressure Threshold ............................................................ 64
Discussions for Vertical Jump Height ................................................................ 66
Discussions for Peak Power Output During Vertical Jump ................................. 68
Discussions for Global Rate of Change .............................................................. 69
Summary ........................................................................................................... 71
Findings ............................................................................................................. 72
Conclusions ....................................................................................................... 73
Recommendations for Future Research .............................................................. 73
APPENDICES............................................................................................................... 75
REFERENCES .............................................................................................................. 87
iv
LIST OF TABLES
Table 4.1: Demographics ............................................................................................... 40
Table 4.2: Summary of mean active knee extension produced before and after
varying myofascial release techniques ......................................... 41
Table 4.3: One-way ANOVA with repeated measures of time for active knee
extension..................................................................................... 42
Table 4.4: Mean differences within subjects measures of time on active knee
extension..................................................................................... 42
Table 4.5: One-way ANOVA with repeated measures of treatment technique for
active knee extension .................................................................. 43
Table 4.6: One-way ANOVA with repeated measures of interaction between time
and treatment technique for active knee extension ....................... 44
Table 4.7: Summary of mean pain-pressure threshold readings produced before
and after varying myofascial release techniques .......................... 45
Table 4.8: One-way ANOVA with repeated measures of time for pain-pressure
threshold ..................................................................................... 46
Table 4.9: One-way ANOVA with repeated measures of treatment technique for
pain-pressure threshold ............................................................... 47
Table 4.10: One-way ANOVA with repeated measures of interaction between
time and treatment technique for pain-pressure threshold ............ 48
Table 4.11: Summary of mean peak vertical jump heights produced before and
after varying myofascial release techniques ................................. 49
Table 4.12: One-way ANOVA with repeated measures on time for peak vertical
jump height ................................................................................. 50
Table 4.13: Mean differences within subject measures of time on peak vertical
jump height ................................................................................. 51
Table 4.14: One-way ANOVA with repeated measure on treatment technique for
peak vertical jump height ............................................................ 51
v
Table 4.15: One-way ANOVA with repeated measure on the interaction between
time and treatment technique for peak vertical jump height ......... 52
Table 4.16: Summary of peak power outputs produced before and after varying
myofascial release techniques ..................................................... 53
Table 4.17: One-way ANOVA with repeated measures on time for peak power
output ......................................................................................... 54
Table 4.18: Mean differences within subjects measures of time on peak power
outputs ........................................................................................ 55
Table 4.19: One-way ANOVA with repeated measures on treatment technique for
peak power output....................................................................... 55
Table 4.20: One-way ANOVA with repeated measures on the interaction between
time and treatment technique for peak power output.................... 56
Table 4.21: Summary of mean global rate of change rank scores for differing
variables ..................................................................................... 57
Table 4.22: Summary of mean global rate of change rank scores for perceived
muscle pain, tightness and fatigue after different myofascial
release techniques ....................................................................... 59
Table 4.23: Summary of mean global rate of change scores for perceived muscle
pain, tightness and fatigue after different myofascial after different
myofascial release techniques ..................................................... 59
vi
LIST OF FIGURES
Figure 3.1: Active Knee Extension ................................................................................ 30
Figure 3.2: Pain-Pressure Threshold .............................................................................. 32
Figure 3.3: Vertical Jump .............................................................................................. 33
Figure 3.4: Foam Rolling ............................................................................................... 36
Figure 3.5: Ischemic Compression ................................................................................. 38
Figure 4.1: Mean active knee extension before and after varying myofascial
release techniques ....................................................................... 41
Figure 4.2: Mean pain-pressure threshold readings produced before and after
varying myofascial release techniques ......................................... 46
Figure 4.3: Mean peak vertical jump height produced before and after varying
myofascial release techniques ..................................................... 50
Figure 4.4: Mean peak vertical jump height produced before and after varying
myofascial release techniques ..................................................... 54
Figure 4.5: Mean global rate of change rank scores for differing variables ..................... 58
vii
ABBREVIATION LIST
ACh .... ........................................................................................................ Acetylcholine
AChE . ................................................................................................. Aceytelcholinease
AChR . ........................................................................................ Acetylcholine Receptors
ADL ... ...................................................................................... Activities of Daily Living
AKE ... .......................................................................................... Active Knee Extension
ANOVA ........................................................................................... Analysis of Variance
AROM ........................................................................................ Active Range of Motion
ATP.... ........................................................................................... Adenine Triphosphate
CGRP . ........................................................................... Calcitonin Gene-Related Peptide
cm ...... ........................................................................................................... Centimeters
CON ... .................................................................................................................. Control
DOMS .......................................................................... Delayed On-Set Muscle Soreness
EPP .... ....................................................................................... Expanded Polypropylene
FR ...... ........................................................................................................ Foam Rolling
GROC .......................................................................................... Global Rate of Change
IC ....... .......................................................................................... Ischemic Compression
in ........ .................................................................................................................... Inches
kg ....... ............................................................................................................. Kilograms
kgf ...... ............................................................................................... Kilograms of Force
kPa/s... ........................................................................................ Kilo Pascals per Second
lbf....... .................................................................................................... Pounds of Force
viii
MET ... ..................................................................................... Muscle Energy Technique
MRT... ............................................................................. Myofascial Release Techniques
MTrP(s).................................................................................. Myofascial Trigger Point(s)
N ........ ................................................................................................................ Newtons
NBA ... ............................................................................ National Basketball Association
NCAA ............................................................... National Collegiate Athletic Association
NRS ... ......................................................................................... Numerical Rating Scale
ozf ...... .................................................................................................... Ounces of Force
PFPS .. .............................................................................. Patellofemoral Pain Syndrome
PPO .... ................................................................................................ Peak Power Output
PPT .... ........................................................................................ Pain-Pressure Threshold
PRO ... ........................................................................................ Patient-Rated Outcomes
ROM .. .................................................................................. Hamstring Range of Motion
sd........ ................................................................................................ Standard Deviation
SLR .... ................................................................................................... Single-Leg Raise
VJ ....... .................................................................................... Peak Vertical Jump Height
W ....... .....................................................................................................................Watts
ix
CHAPTER 1
INTRODUCTION
BACKGROUND TO THE PROBLEM
The hamstring muscles are a commonly strained because these muscles cross
multiple joints and are involved in controlling movements at both the hip and the knee
joints.1 An epidemiological study done by the NCAA showed that 1% of
recorded injuries in games for male and female basketball players were hamstring
strains,2,3 but in practice hamstring injury rate increased to 4-5%.2,3 It has been reported
that limited flexibility may predispose a person to musculoskeletal injuries.4-6 There are
many techniques that have been developed to help and treat muscular tightness. These
techniques can be broken down into two categories: self-release and clinician-release.
Both techniques have significant amounts of literature backing their effectiveness,4,7-17
but there is minimum research directly comparing the efficacy self-release techniques and
clinician-release techniques.
STATEMENT OF THE PROBLEM
Numerous studies have investigated the use of self-release techniques4,9,10,12-14 and
clinician-release techniques.11,15,16,17 In providing high quality care to patients, healthcare
1
professionals are bound by both time and money. With the breadth of literature
supporting both techniques, clinicians need to know if there is a more efficacious choice.
Is self –release techniques or clinician-release techniques better at treating muscle
tightness?
PURPOSE OF THE STUDY
The purpose of this study was to compare the acute effects of two
myofascial release techniques on muscle flexibility, soreness, and performance. The
technique used for the self-release was Foam Rolling (FR). The technique used for the
clinician-release was Ischemic Compression (IC).A third non-treatment trial was also
used as a control condition (CON).
SIGNIFICANCE OF THE STUDY
This study supported the use of myofascial release and provided guidance in
determining the efficacy of the techniques in their ability to treat muscle tightness.
RESEARCH DESIGN
This study employed a 2 x 3 repeated measures cross-over design. The study
design allowed for the participants to be their own control. The variables measured were
active hamstring range of motion (ROM), pain-pressure threshold (PPT), vertical jump
(VJ) peak power output (PPO) and global rate of change (GROC).
Data was collected before and immediately after each treatment for ROM, PPT,
VJ and PPO. GROC data was collected immediately after the treatment. A repeated
measures design was used to assess for changes in the dependent variable under each
intervention condition. There was at least a 7-day washout period between each treatment
2
which allowed ample time for any lingering effects from the previous treatment to have
subsided. The same clinician performed all the variable measurement to minimize any
difference in measuring.
The data collected was analyzed using a 2x3 ANOVA for ROM, PPT, PPO, and
VJ. The data collected from GROC was analyzed using a Kruskal Wallis and Chi squared
test.
RESEARCH QUESTION
Is there a difference in treatment effect between pre and post testing for FR, IC,
and no treatment (CON) on hamstring ROM, PPT, VJ, PPO and GROC?
NULL HYPOTHESES
For the purposes of statistical analyses, it was hypothesized that:
1. There is no significant difference among FR, IC, and CON in increasing ROM.
2. There is no significant difference among FR, IC, and CON in increasing PPT.
3. There is no significant difference among FR, IC and CON in increasing VJ.
4. There is no significant difference among FR, IC and CON in increasing PPO.
5. There is no significant difference among FR, IC and CON in increasing GROC.
DIRECTIONAL HYPOTHESIS
1. Both FR and IC will be clinically significant in increasing ROM, PPT, PPO, VJ
and GROC when compared to get CON.4,7-17
LIMITATIONS
The following factors could not be controlled and may have affected the accuracy
and generalizability of the data collected in this study.
3
1. This study utilized a small homogeneous sample of convenience and therefore
limiting the external validity of the study.
2. The study relied on self-reporting of potential confounding factors such as
abstaining from the use of over-the-counter or prescription pain relieving
medications.
3. The subjects in this study were concurrently engaged in in-season basketball
activities. This potentially put them at greater risk for injury or the introduction of
confounding factors associated with competitive play.
4. Participants were not screened prior to acceptance into the study for MTrPs. Thus
the presence of MTrPs was not guaranteed and the results could be skewed
because of the absence of MTrPs.
5. Data collected for this study was completed at two different facilities with two
different clinicians delivering the interventions. Although specific treatment
protocols were provided and practiced by both clinicians there is the potential that
the interventions delivered at both sites were not equal.
6. The pelvis and spine were not stabilized during AKE thus limiting the accuracy
and reliability of the measurements.
7. Body weight values used for calculating PPO were obtained from the subjects’
pre-participation sports screening collected prior to the study thus reducing the
accuracy of this calculation.
DELIMITATIONS
This study was delimited to the following participants and conditions:
4
1. NCAA Division II and III Men’s and Women’s Basketball student-athletes at 2
colleges in northeastern Pennsylvania
2. Subjects had to be free of lower extremity injuries during and for 6 months prior
to the start of the study.
3. Subjects reporting a history of psychiatric, cardiovascular, endocrine,
neurological or metabolic disorders were excluded.
4. Subjects in the study were instructed to refrain from consuming, alcohol, nicotine,
analgesics or pain relievers 48 hours prior to testing as these substances can alter
pain perception and physical performance.
ASSUMPTIONS
Several assumptions guided this study:
1. Subjects would tell the truth about their health history.
2. Subjects refrained from consuming alcohol, analgesics, pain relievers or other
illicit drugs.
3. Subjects communicated truthfully about levels of pain, stretch or
improvements.
4. Subjects were consistent in their answers no matter the treatment received.
5. Subjects put forth maximal effort in treatments and in measurements.
6. Subjects did not have any additional treatment affecting hamstring flexibility,
tightness or function beyond what is typically done as part of their inseason training program.
5
DEFINITION OF TERMS
Myofascial Release: Manual therapy technique that helps to reduce restrictive barriers or
fibrous adhesions seen between layers of fascial tissue.12
Ischemic Compression: Application of sustained pressure on a myofascial trigger point
with the intent of decreasing muscle tenderness and tension.18
Trigger Point: “A focus of hyperirritability in a tissue that, when compressed, is locally
tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness, and
sometimes to referred autonomic phenomena and distortion of proprioception.”18
Algometer: An instrument that measures the application of pressure and evoking of pain
to the skin and underlying tissues in N.19
Foam Rolling: The use of body weight on a foam roller to create pressure on the
opposing body tissue.20
Vertical Jump: the vertical distance between the highest vane tapped during the standing
vertical reach and the vane tapped at the highest point of the jump.10
Peak Power Output: the maximum amount of force produced by a participant during a
vertical jump10
Global Rate of Change: A 3-question survey used to quantify a patient’s improvement or
deterioration over time, to determine the effect of an intervention. GROC scales ask that a
person assess his or her current health status, recall that status prior to treatment, and then
select from a list of rating one that most accurately reflects the change in symptom.
GROC scale used for this study was a standard 15-point scale.21
6
Pain Pressure Threshold: The lowest amount of pressure needed to elicit pain using
an algometer measuring in the units of N.19
Active Knee Extension: the upward movement of the lower leg from 90 degrees of knee
flexion to full knee extension at 180 degrees. This is measured by a goniometer, starting
from a position of 90 degrees of knee flexion and 90 degrees of hip flexion while lying
supine until slight discomfort is felt with the hip position unchanged and the foot
relaxed.4
Active Range of Motion: The extent of movement (usually expressed in degrees) of an
anatomical segment at a joint. The movement should be caused only by voluntary effort
to move the body part being tested.18
Injury: not being able to participate in training or competition for at least 7 days.4
Active varsity player: participant holds a spot on the team's current varsity roster.
EXPECTED FINDINGS
•
It is expected that there will be a significant difference in ROM with FR when
compared to CON.4,9,12-14
•
It is expected that there will be a significant difference in PPT with FR when
compared to CON.16
•
It is expected that there will be a significant difference in VJ with FR when
compared to CON.13
•
It is expected that there will be a significant difference in PPO with FR when
compared to CON.16
7
•
It is expected that there will be a significant difference in GROC with FR when
compared to CON.13
•
It is expected that there will be a significant difference in ROM with IC when
compared to CON.7,15,17
•
It is expected that there will be a significant difference in PPT with IC when
compared to CON.7,11,17
•
It is expected that there will be a significant difference in GROC with IC when
compared to CON.17
8
CHAPTER 2
REVIEW OF LITERATURE
INTRODUCTION
This study specifically focused on muscle tightness of the hamstrings in
basketball players. Other studies have examined hamstring tightness10,14 in soccer
players4-6 but few studies have looked at the impact of hamstring
tightness on basketball players, even though the prevalence of hamstring injuries has
been documented by both the NCAA2,3 and the NBA.22,23 In the NCAA,
hamstring injuries for men and women were 1% of all injuries in games and 4-5% of all
the injuries recorded in practice.2,3 In the NBA, hamstring injuries accounted for 3.3% of
all recorded injuries.23 Because of the data found in the NCAA and NBA, hamstring
injuries are shown to be a problem. Muscle tightness, sprinting, and the eccentric
contraction of the hamstrings during deacceleration while running can make it more
vulnerable to muscle straings.23
Hamstring flexibility has been shown to be a factor in the onset of hamstring
injuries in athletics.4-6 Hamstring flexibility is defined, for this study, as the ability of the
hamstring to lengthen allowing for the knee, hip and back to move through their range of
9
motion. Hamstring flexibility can be influenced by joint capsule and soft tissue
restrictions.24,25
Thomas Myers in his Anatomy Trains24,25 book identify several myofascial or
connective tissue lines throughout the body. The hamstrings are a part of the straight back
fascial line (SBL). The SBL is a line of fascia shown by Meyers et al24,25 to run from the
plantar fascia to the cranium. The SBL runs through the Achilles tendon, gastrocnemius,
hamstrings, sacrotuberous ligament (STL) and erector spinae which connects to the
cranium. The hamstrings and STL connect at the ischial tuberosity. Since the hamstrings
are a part of the SBL, if the hamstrings are tight it affects the mechanics of other joints
and muscles.24-26
A study by Cruz-Monetecinos et al26 showed the amount of pelvic motion allowed
affected the amount of force transferred between the gastrocnemius and the hamstrings. If
the hamstrings do not allow for adequate pelvic motion it affects force distribution and
the biomechanics of the body26 this can lead to an increased chance of overuse injuries,
muscle strains and ligament sprains.6
Hamstring tightness can influence the biomechanics of the body as well as
performance. In collegiate basketball, players need to have the ability to sprint,
explosively cut and jump without hindrance from muscle tightness. If hamstring tightness
does not allow for the ability to perform the movements properly a decrease in
performance is likely to occur.27 Wilson et al27 provided evidence that a decrease in the
active tightness of a muscle will increase the force production during a vertical jump.
10
Another factor that can influence performance but is also influenced by hamstring
tightness is pain. The pain may manifest itself in the hamstrings or in other areas of the
body such as the low back or knees.6,28-31 A study done by Esola et al28 showed that
participants with low back pain had decreased hip motion but increased lumbar motion. It
has been postulated that a decrease in hip motion caused by hamstring tightness increases
the stress put on the lumbar spine leading to an increase in pain and potential injury.28,29
Another study looking at the effects of hamstring tightness on patella femoral pain
syndrome (PFPS) showed a strong correlation between the presence of PFPS and
hamstring tightness.30 Giving evidence that hamstring tightness may predispose an
individual to developing PFPS.30 A different study conducted by Henderson et al6
focused on the prevalence of hamstring injuries in English Premier League Soccer
players and their correlation to multiple factors. A correlation between hamstring injury
and tightness was found.6 The study showed that for every degree loss of active hip
flexion increased the odds of hamstring injury by 1.296. Another factor that has been
shown to affect hamstring tightness and pain are MTrPs.
PRESENTATION OF SYMPTOMATOLOGY
MTrPs are thought to be caused by either a chronic overuse injury or by
nociceptive input.33-35 Some factors which can influence the formation of MTrPs are type
of stresses and the external environment the muscle is in. MTrPs have been commonly
found in individuals who do have to sustain postures for long periods of time and/or
repeatedly perform maximal or submaximal concentric and/or eccentric exercises.33,34,36
11
It is theorized the sustaining or repeating a movement or exercise affects the interstitial
environment and function of the cell.
Several factors, in the local cellular environment, are thought to contribute to the
development of MTrPs. Theory being, is that muscle exertion at too high of level or
sustained for too long can result in local hypoxemia causing a cascade of reactions. The
reactions are theorized to look similar to this: a muscle’s demand for oxygen exceeds its
immediate availability37, triggering anaerobic glycolysis which produces an inadequate
amount of ATP and lactic acid (LA) as a byproduct33,38. The decreased supply of ATP
causes the muscle to spasm34,39, increasing the metabolic crisis and production of LA33,38.
The body can remove LA from the local environment33, but if the rate of
production is greater than rate of removal it accumulates in the tissue resulting in a
lowering of pH.33,40,41 A lower interstitial pH can increase muscle tenderness by
decreasing the nociceptor threshold33. The nociceptor threshold is decreased in two ways:
an increased production of calcitonin gene-related peptide (CGRP) and an increased
regulation of aceytelcholinease (AChE)33. CGRP is a compound that elevates two things:
the release of acetylcholine (ACh) and the production of acetylcholine receptors
(AChR)33. Meaning there is a greater ability for ACh to bind and produce a nociceptive
message resulting in a perceived area of tenderness42.
AChE is an enzyme that helps to moderate nociceptor substances, specifically
ACh33. With an increased regulation of AChE there is an increased efficiency for ACh to
produce a nociceptive message, resulting in a perceived area of tenderness33. The result
12
within the muscle is two-fold: an area of palpable tightness and increased muscle
tenderness.
MYOFASCIA
Fascia surrounds every part of our body. There are multiple layers of fascia that
surround a muscle. Fascia consists of connective tissue cells and fibers surrounded by a
gelatinous ground substance.43 This ground substance which surrounds the fascial cells
and fibers is made of water, hyaluronic acid and other glycosaminoglycans which allows
these elements to easily slide and slide across one another enabling free and unrestricted
movement.43,44 However, trauma, inflammation and/or disease can alter fascial tissue and
the molecular composition of the ground substance reducing its viscosity and restricting
movement. Scar tissue or extra connective tissue is laid down following the injury
forming adhesions between the skin and muscle. It is theorized, the adhesions restrict
normal function and movement of the fascial layers, skin and muscle.45 The adhesion
could possibly cause local dehydration, ischemia, pain, loss of ROM, decreased
performance or MTrP.45 Soft tissue mobilization techniques such as FR and IC have been
theorized to produce a variety of effects to the muscle and fascial tissues. These effects
can be generally divided into the mechanical and neurophysiological models.
The mechanical models theorize that the material properties of fascia are affected
by the pressure exerted through FR and IC which in turn alters the viscoelastic properties
of the fascia.12 Many theories have been proposed as to the mechanisms which cause this
change in property: thixotropy, piezoelectricity, plastic deformation. 40,43,46-48
13
Mechanically compressing the tissue either via a FR or IC is likely to engage the
thixotropic property of fascia resulting in greater ease of movement. 49 This is achieved
because fascia is colloidal in nature and when energy through compression is applied to
the tissue the fascia becomes more viscous thus allowing for a greater ease of
movement.43,50
Both FR and IC can potentially cause a piezoelectric effect within the tissues
because the mechanical force applied during treatment. A mechanical change in muscle
whether by changing length or deformation is theorized to modify the pizioelectric effect
of the body.43,51 Whether this change in charge is enough to significantly alter tissue
physiology and yield some benefit is still unknown.43,51
Another mechanical mechanism that is theorized to occur is plastic deformation
of the fascia. Plastic deformation is a low-grade sustained deformation force to collagen
rich tissues which in turn yields changes to the stress-strain cycle.43 The stress-strain
cycle is a model to explain how increasing the stress (load) on the muscle increases the
strain (deformation) of the muscle. As the stress is sustained the muscle loses its original
shape and in response will tighten up to protect the muscle. For the muscle to return to its
original shape outside forces need to be applied; (i.e. FR or IC) these will cause the
muscle to relax and soften.48
Along with the mechanical effects, compression of a MTrP has shown to have
neurophysiological effects as well. Some of the effects that have been studied are the
alteration of nociceptor thresholds via pain gating, possible alteration of the interstitial
chemistry and reprogramming of the nervous system. Studies by Aguilera et al7 and Shah
14
et al17 showed, following treatments of compression on MTrPs, the nociceptor or painpressure threshold was increased. With a greater threshold for pain muscles may move
more freely without the inhibition of pain.
Following compression on a MTrP a study by Morsaka et al52 found the
interstitial environment had changed. Increased amounts of lactate and glucose were
documented in the area following the treatment. The increased availability of glucose is
likely from an increase in blood flow to the area, providing an increase in substrate
availability to muscle.40,46,52 With the increase in nutrients to the area muscles can
function properly resulting in less tension in the area. The decrease in muscle tension,
subsequently decreases the tension on the nerves allowing for an uninhibited flow of
neural signals.
Compression at a MTrP has also been shown to increase parasympathetic nervous
activity.53 An increase in parasympathetic nervous activity is theorized to block the
release of ACh.54 A more regulated release of ACh, is theorized to increase the
nociceptor threshold of the muscle, allowing for proper muscle function.40,46,55
THIXOTROPY
Thixotropy of fascia is defined as a change in energy in the fascia which causes a
change of properties for a solid state to a more fluid state.12,43 This is achieved through
the friction caused by the posterior thigh moving on top of the roam roller. It is theorized,
due to the deformation of the fascia that MTrPs will be relived.12
15
TREATMENT INTERVENTIONS
Direct soft tissue mobilization techniques such as, petrissage (kneading),
compression, and gliding, have been used by clinicians to treat symptoms of muscle
tightness since ancient times.26 The type of direct soft tissue mobilization presented in
this review will focus on myofascial release techniques (MRT). MRT is a soft tissue
mobilization technique that uses moderate to deep pressure delivered manually by a
clinician or self-administered using a device such as a foam roller. MRT attempt to
reduce restrictive barriers and adhesions within fascial tissue.43 Some of the
physiological properties MRT utilizes are friction, ischemia and thixotropy. The
application of these properties causes mechanical and physiological changes to the
muscle which help resolve MTrPs. The different MRT can be broken down into two
categories, self-release and clinician-release.
Studies by MacDonald et al12 and Mohr et al14 showed self-MRT’s effectiveness
in decreasing muscle tenderness. These findings were supported by Bradbury et al.9
Using a machine operated roller stick, Bradbury et al9 was also able to decrease muscle
stiffness while increasing neuromuscular recruitment. Gulick et al56 using self-IC by a
Backnobber II tool and was able to decrease muscle stiffness and tenderness of the neck
musculature. Studies by McDonald et al12 and Pearcey et al16 provided evidence MRT
was able to decrease muscle tightness and tenderness while improving performance
during a vertical jump. Two of the most commonly used MRT to decrease muscle
tightness and tenderness while improving muscle performance are FR, a self-release
technique, and IC, a clinician-release technique.
16
MECHANISM OF INTERVENTION
FOAM ROLLING
FR is defined as small movements on a dense foam roller that starts at the
proximal end of the hamstring and works distal or vise-versa.57 While these motions are
being performed, direct pressure is applied on the soft-tissue. The pressure creates
friction and a thixotropic effect of the soft tissue.43,49,50 The thixotropic effect causes a
change in the viscosity of the fascia.57,58 This physiological change of the fascia
increases the extensibility of the fascia through the breaking MTrPs and improving
muscle tightness, tenderness and performance.7,12,15-17
MacDonald 2013 et al12 examined the use of FR as a recovery tool for the lower
extremity. During randomized control trial 20 different male subjects completed an
intense lower body exercise protocol to elicit delayed-onset muscle soreness during 5
separate sessions which were separated by a minimum of 24 hours. After each session the
subjects either received either no foam rolling or a 20-minute foam rolling intervention.
The participants in the FR group foam rolled: immediately, 24 hours post-exercise, 48
hours post exercise, and 72 hours post exercise. The result of this study found that FR
reduced muscle soreness at all the time measurements, improved ROM, and vertical jump
height when compared to the control condition.
Pearcey et al16 examined the effects of FR on muscle recovery in the quadriceps.
During this cross-over design study 8 subjects completed an intense exercise protocol to
elicit delayed-onset muscle soreness during 2 separate sessions scheduled approximately
4 weeks apart. After each session they either received no foam rolling or a 20-minute
17
foam rolling intervention, which was performed immediately, 24, 48 hours post-exercise.
The result of this study found that FR improved muscle soreness and lessened the
detrimental effect of DOMS on sprint times, power, and dynamic strength-endurance
compared to the control condition.
MacDonald et al13 examined the effects of FR on muscle performance of the
quadriceps. During a within-subject design, 11 healthy male subjects underwent 4
different trials with 24-48 hours in between each trial. The trials included: 1) Control
measuring ROM, 2) Control measuring knee extensor force, 3) FR measuring ROM, and
4) FR measuring knee extensor force. Results from the study showed a positive
correlation between FR and knee extension and a negative correlation between force
production and ROM prior to FR which was resolved following FR.
Krause et al20 created a study design which will look the effect of FR on passive
tissue tightness on the quadriceps. The study will employ a crossover design with 16
participants which will undergo 3 different treatments: 1) FR to the quadriceps, 2) passive
static stretch to the quadricep, 3) No intervention. No conclusions were included with the
article since the study was still in the recruiting phase.
The literature had many different protocols for the application of FR. This study
chose to utilize the protocol laid out by Krause et al20 with modifications of extending the
treatment time from 60 seconds to 90 seconds by MacDonald et al13 to keep treatment
times between interventions similar.
18
ISCHEMIC COMPRESSION
IC is defined by Travell et al18 as the “application of progressively stronger
pressure on a trigger point for eliminating the trigger point’s tenderness and
hyperirritability”. IC breaks the cycle of the MTrPs by theoretically changing the
biochemical concentration of inflammatory mediators, neuropeptides, cytokines, and
catecholamines of the environment.39,52 The release of the pressure is thought to causes a
reactive hyperemia of the area.34,44 The change of chemistry and resulting hyperemia
brings in the oxygen and nutrients needed to create ATP and stop the flow of ACh. 34,44
With the MTrPs resolved muscle tightness and/or tenderness would decrease and in
theory performance would improve.7,8,15,17,61
A study by Aguileria et al7 examined the effect of IC and ultrasound for the
treatment of MTrPs in the trapezius muscle. During the randomized control trial 66
healthy individuals were randomly assigned to one of three treatments: IC, ultrasound,
and sham ultrasound. Results from the study showed a decrease in basal electrical activity
and MTrP sensitivity in both of the therapeutic modality groups and an increase in
cervical AROM for the IC treatment group.
A study by Shah et al17 examined the effect of IC and muscle energy technique
(MET) on MTrPs in the upper trapezius muscle. 30 participants, with non-specific neck
pain, were randomly divided into two groups, IC and MET, and received treatment every
day for a week. Results from the study showed a significant improvement in all three of
the outcome measures (PPT, VAS, cervical AROM), for both groups. When comparing
between groups the IC treatment group had a significant improvement in PPT compared
19
to the MET treatment group. The MET treatment group had a significant improvement in
cervical AROM when compared to the IC treatment group.
A study by Nambi et al15 examined the effect of IC and MET on MTrPs in the
upper trapezius muscle. During a quasi-experiment 30 participants with palpable MTrPs
in their upper trapezius were randomly divided into two treatment groups, IC and MET,
and received treatment three times a week for four weeks. Results from the study showed
a statistically significant improvement in both groups for cervical range of motion.
A study by Berggreen et al8 examined the effects of MTrP massage on MTrPs in
the muscles of the head, neck and shoulders. During the randomized control trial 29
females with chronic tension-type headaches were randomly assigned to two groups, the
MTrP massage group or control group. The MTrP massage group received treatment one
time a week for ten weeks. Results from the study showed a significant improvement in
morning pain and the number of trigger points in the MTrP massage treatment group
compared to the control group. None of the previous studies on IC concentrated on lower
extremity performance so it is unknown how IC will affect the VJ performance.
This study compared FR and IC. These two techniques were chosen due to their
low cost, large availability of previous literature, no specialized training needed to
perform the treatments and high rate of use within sports medicine facilities. The methods
which will be used to evaluate each techniques effectiveness is ROM, PPT, PPO, VJ and
GROC. Based on the literature, it can be assumed that FR and IC will have a positive
effect on areas of assessment. The researcher in the reviewing the literature did not find a
20
study comparing these two techniques so it is unknown whether one of the techniques
will be more effective than the other at reducing hamstring tightness.
INTERVENTION OPTIONS
The outside interventions applied to the MTrPs are IC and FR. These two
interventions will be assessed by effects on the hamstrings change of ROM, PPT, PPO
and GROC and the patient’s results in performing a VJ.
ASSESSING TREATMENT EFFECTIVENESS
The collection of patient-reported, clinician-reported outcomes, and functional
performance outcomes are typically used to assess treatment effects and judge efficacy. A
wide range clinical outcome measures have been used in the literature to assess the
effectiveness of various myofascial release techniques. For this research investigation
flexibility, pressure sensitivity, jump performance, power production and subjects’
perception of change were the outcome variables used to compare the effects of the FR
and IC interventions.
FLEXIBILITY-ACTIVE KNEE EXTENSION
Hamstring flexibility was assessed using AKE. AKE has been found to be a valid
and reliable method of assessing hamstring with intra-tester ICCs values ranging from
.79-.94.59,60 The AKE test was selected over the straight leg raise (SLR) because it is
considered easier to control because it only involves motion at one joint rather than two
and is an active measure rather than passive giving a better functional assessment.58 FR
has been found in multiple studies to increase the ROM of the muscle it which it is being
applied.4,9,12-14 No previous studies were found assessing IC effect on hamstring
21
tightness. Most studies used to test IC’s ability to affect ROM have been in the upper
trapezius and neck.15,17,61 These studies have produced promising results in being able to
increase ROM.7,15,17,61 Since this study is using the hamstrings as the body part of focus it
is unknown whether FR or IC will have a greater effect on increasing the ROM of the
hamstrings.
PRESSURE SENSITIVITY- PAIN-PRESSURE THRESHOLD
Point tenderness or pressure sensitivity during digital palpation is a common
complaint in muscle pathologies especially MTrPs. An algometer is an instrument that
can be used to measure the amount of force applied to a localized area. PPT is defined as
the lowest amount of pressure needed to elicit pain.19 Previous research has used the PPT
as measure for evaluating and quantifying myofascial pain and assessing changes in
muscle tenderness over time.19,62 As MTrPs resolve, PPT has been shown to increase.16
Studies have supported the use of algometers as a reliable way to test PPT and have
reported ICC values between .70-.97.19,62-66 FR had minimal studies using PPT as a
measure but in the small pool of literature there was support for FR abilities to increase
PPT.16 PPT was a common measure in the literature to test the effect of IC. Multiple
sources have shown statistical significance of IC’s ability to positively affect PPT.7,11,17
From the literature, IC was found to have a greater breadth of support in its ability to
increase PPT, but it all was focused on the upper trapezius.7,11,17 It is unknown which
intervention is better increasing PPT in the hamstrings.
22
JUMP PERFORMANCE- VERTICAL JUMP AND PEAK POWER OUTPUT
Performance measurements were utilized to test the effects of the myofascial
treatments on power output and simulate the demands common within basketball. VJ and
PPO were chosen because they utilize the hamstrings and are similar to motions
performed in basketball.
VERTICAL JUMP
VJ is a commonly used measure of athletic performance to provide a global
assessment of lower extremity muscular power and coordination. VJ is defined as the
vertical distance between the highest point reached when standing with arm fully raised
and highest point of the jump.10 There are several testing methods identified in the
literature: drop jump, run-and-jump and, what was used in this study, countermovement
jump.
Rodriguez-Rosell et al67 investigated the reliability and validity of 4 different
vertical jump test in 186 male soccer and basketball players. They found that all vertical
jump tests studied were reliable measures with ICC values ranging from .969-.998. In this
study they also found a strong correlation between vertical jump tests and sprint and
strength performance.
PEAK POWER OUTPUT
PPO was defined as the maximum amount of force produced by the individual
when performing a vertical jump. PPO is calculated by using a participant’s peak VJ,
height and weight. This information was inserted into the Johnson and Bahamonde68
formula for power output. Balmar et al69 investigated the reliability and validity if peak
23
power predicts performance power. They found that PPO affords a valid and reliable
measure for performance with ICC values of 0.99. Previous studies on FR have mixed
results on the effectiveness in FR positively effecting PPO.16 It is unknown how IC will
affect PPO due to a lack of literature using PPO as a variable in IC studies.
GLOBAL RATE OF CHANGE SCALES
The GROC is a patient reported outcomes measure designed to gather information
on the subjects’ perception of any changes that occur over time in response to an
intervention. GROC scales are commonly used both in research and in actual clinical
practice to determine treatment efficacy and provide patients with a formal mechanism to
provide qualitative feedback to the clinician regarding symptom improvement or
deterioration. Kamper et al21 did an appraisal of the common GROC scale used in patient
care. They found that although there is significant variability in design and scoring, most
GROC scales can provide clinically relevant and reliable information. Key factors that
affect the reliability and face validity of these measure is the question wording, the size of
the rating scale (7 vs. 15 pts), and how much time elapsed between the administration of
the treatment or the scale. Questions needed to be specific to the injury that is of interest,
specific to the construct of interest and anchored by a specific time point to use as a
reference in which to compare their current condition.21 When questions are worded
correctly, the GROC has been shown to be a reliable measure of patient-reported
change.21 Literature supports those who perform FR experience a therapeutic effect
which positively affects their GROC score. The literature supports those who undergo IC
experience a therapeutic effect which positively effects their reported GROC score.13,17
24
Since there is no literature directly comparing FR and IC it is unknown whether there will
be a statistical difference between them. In the review of literature there was a study
which looked at the psychological and emotional effect of touch.70 The study found
through the touch of a hand massage individuals cortisol levels decreased.70 Individual’s
levels of relaxation and safety were increased based on responses on two different PRO
scales.70 As positive as the findings are from this study they need to be taken with caution
since there was no control and the study applied a different type of massage for different
purposes. Both FR and IC have support for their ability to increase GROC but since there
is no research that has compared the two techniques it is unknown whether FR or IC will
have a statistically significant increase when compared to the other.
CONCLUSIONS
From the review of literature, it was shown that both IC and FR have a positive
effect on decreasing muscle tightness, tenderness and/or improving performance while
resolving MTrPs. 4,7,9,11-17,61 The treatment of MTrPs has been shown to increase the
ROM4,7,9,12-15,17,61, PPT7,11,16,17, VJ,13 PPO16 and GROC13,17 of the muscle and soft tissue
when compared to the control. This study is important because it compares FR and IC to
a control as well as to each other. This design will help give support to each of the
techniques. The design also allows for a comparison to help guide clinicians whether FR
or IC is more effective in treating hamstring tightness. This is important because not only
does this help with effectiveness but also helps guide clinicians to how to best allocate
time and resources when they are treating patients.
25
CHAPTER 3
METHODS
PURPOSE OF THE STUDY
The purpose of this study was to compare two MRT and their ability to decrease
muscle stiffness and tenderness and improve performance. The techniques can be broken
down into two groups: self-release techniques and clinician-release techniques. Although
several studies have evaluated the effectiveness of both types of release techniques,
studies directly comparing two treatment approaches are limited. This study looks to
compare a self-release technique, FR, to a clinician-release technique, IC and the
effectiveness of each in treating hamstring tightness, flexibility, perceived pain and
function, and power output.
RESEARCH DESIGN
The study employed many measures to strengthening the integrity of the study.
The measures taken to improve the integrity of the study included: adopting a
randomized crossover design, blinding the assessor to the treatment given, a random
order for the administration of the treatments, and a one-week washout period between
each treatment. Each participant received each treatment once in a randomized order. The
26
treatments were: FR, IC and CON. Receiving each treatment once reduced any training
effects which are accumulated through multiple treatment of one technique.
TARGET POPULATION AND PARTICIPANT SELECTION
The target population for this study was active varsity collegiate basketball
players. The reason for choosing collegiate basketball players was because it is a sport in
which men and women participate and is popular sport for both genders in the United
States. Basketball athletes were also chosen because they provided a good sample of
jump trained individuals whose sporting event requires both dynamic and explosive
strength. The collegiate basketball teams provided a convenience sample who were
trained and relatively consistent in their jumping. Lastly, collegiate basketball players
were chosen because they have not been well represented in previous MRT studies. 4-6
PARTICIPANTS
Participants for this study were recruited from two university men’s and women’s
collegiate basketball programs in northeastern PA. The inclusion criteria were that they
were healthy, active team members between the ages of 18-30 years. Participants with
current or recent history of lower extremity injury were excluded from the study. This
was done to avoid potential aggravation of the injury and reduce possible influence of
these conditions on the repeated performance measures. An injury was defined as not
being able to participate in training or competition for at least 7 days. People with a
history of psychiatric, cardiovascular, endocrine, neurological or metabolic disorders that
could increase the risk of adverse responses to deep tissue mobilization, or injury during
physical assessment were also excluded. Participants in the study were instructed to
27
refrain from consuming, alcohol, nicotine, analgesics or pain relievers 48 hours prior to
testing as these substances can alter pain perception and physical performance.
PROCEDURES
Prior to the first treatment, participants were with an informed consent form. The
principle investigator (PI) provided an overview of the study and was available to answer
participant’s question. Once consent was obtained, subjects completed a health-history
questionnaire which was reviewed, and eligibility determined. The measurements were
taken using the subject’s dominant leg. Dominant leg was defined as the leg that the
subject would use to kick a soccer ball. The pre-test measurements were taken by the
blinded principle investigator in a set order, in a separate area from the treatments. The
order was VJ, ROM, PPT, PPO was later calculated using recorded data. After
completing the pre-test measurements participants went to the intervention area and were
randomly assigned, by two experienced clinicians (CV, CS), to one of three treatments by
randomly shuffling, face down a deck of 3 playing cards. Each of the three cards were
correlated with one of the three treatments:FR, IC or CON. For this study there were 6
possible trial sequences. After each subsequent treatment the card chosen was not
replaced in the deck. This ensured that each participant received all three treatments. CS
and CV delivered/supervised all treatment trials. Following the completion of the
designated treatment, the participants returned to the measurement area for post-test
measurements. The order for post-test measurements was: GROC, VJ, ROM, PPT, PPO.
A period of at least 7 days served as a wash-out phase between the three
experimental testing sessions which were done over a consecutive 3-week period8
28
MEASUREMENTS
ACTIVE KNEE EXTENSION
The AKE followed the protocol used by Norris et al71, except instead of using the
right leg, we used the subject’s dominant leg. (Figure 3.1) The protocol consisted of
the principal investigator marking the center of the knee joint axis over the lateral joint
line of the dominant leg. Two lines were then drawn from this point: one, joining the axis
point to the center of the greater trochanter of the femur, and a second, joining the axis
point to the apex of the lateral malleolus. The lines were removed with alcohol after the
post testing and redrawn at the commencement of each testing session.
The subjects’ reference zero was when they were supine on a bench and they had
their hip and knee flexed to 90°. The subject monitored the position of their femur with
their dominant hand and were instructed not to allow the femur to move away from the
hand at any point during the test. The participant then was instructed to slowly extend
their dominant leg as far as possible, keeping their foot relaxed and not allowing their
thigh to move away from their hand. Participants then held this position for 5 seconds
prior to the measurement being taken. Each participant performed a single repetition of
the movement to familiarize themselves with the action. Once the participant was
comfortable with the movement, it was repeated and measured three times. The angle of
knee extension was measured using a JAMAR 12.5" (32cm) EZ Read goniometer
(Performance Health, Trenton, NJ) and the angle fell between 0 and 90 degrees.
Therefore, a participant with 50 degrees of AKE initially would have moved their leg 50
29
degrees towards a straight leg. An improvement, post-treatment, would be any movement
greater than 50 degrees.
The center of the goniometer was positioned over the axis point previously
marked on the lateral joint line, and the goniometer arms were positioned along the lines
marked on the femur and fibula. The goniometer measurements were taken, recorded,
and averaged. The calculated average score was then used for analysis.
FIGURE 3.1
ACTIVE KNEE EXTENSION
90°
90°
90°
PAIN-PRESSURE THRESHOLD
PPT was used to assess muscle tenderness and was defined as the minimal
amount of pressure that causes pain.19 The subjects’ PPT was measured using a Wagner
FPX 50 (Wagner Instruments, Greenwich, CT) handheld digital algometer with a 1cm2 flat rubber tip. This device has a firm pistol grip handle and displays a 5-digit force
reading in selectable units: lbf, kgf, N and ozf. The unit of measure for force in this study
was newtons (N). To perform the measurement consistently the PI, prior to commencing
the study, practiced applying 9.8 N/s consistently for 5 seconds. The PI counted 1-one
thousand, 2-one thousand…5-one thousand then checked the algometer reading to see if
30
the reading was close to 49 N. This was repeated until a measurement of 49 N was
consistently preformed.
The algometer was consistently placed midway between the ischial tuberosity and
fibular head because there was no guarantee of a MTrP being present in the hamstrings.
(Figure 3.2) The midway point was found by having the subject positioned prone on the
table with the knees extended. A tape measure was used to measure the distance between
the ischial tuberosity and head of the fibula and the halfway point in between those two
landmarks was used for the placement site of the tip of the algometer. This location was
selected because of observations made by Travel and Simons18. Travel and Simons
theorized this is to be common region for trigger points in the hamstring due to the
musculotendinous junction of the biceps femoris.18
Participants were instructed to say “yes” at the instant they felt pain rather than
pressure. Force was gradually applied at a constant rate of approximately 9.8 N/s until the
participant indicated pain was present. The PPT measure was taken 3 times with a 30second interval between measurements. The applied force readings were recorded in N
and the 3 trials averaged for analyses.
31
FIGURE 3.2
PAIN-PRESSURE THRESHOLD
VERTICAL JUMP
The subject’s VJ was measured following the protocol used by Healey et
al.10 The protocol used a Vertec (Perform Better, West Warwick, RI) to measure the
height jumped. The vane stack was raised to a height which the, participants could not
jump higher or lower than the set of vanes. “Without a preparatory or stutter step, the
participants was instructed to perform a countermovement jump by quickly flexing the
knees and hips, moving the trunk forward and downward and swinging the arms
backward. During the jump, the dominant arm reached upward, whereas
the nondominant arm moved downward relative to the body. At the highest point in the
jump, the subjects tapped the highest possible vane with the fingers of the dominant hand.
(Figure 3.3) The score was vertical distance between the height of the highest vane
tapped during the standing vertical reach and the vane tapped at the highest point of the
32
jump. The best of 3 trials with 3-minute rest period was recorded to the nearest 0.5
inch.”10
FIGURE 3.3
VERTICAL JUMP
PEAK POWER OUTPUT
The subject’s PPO was calculated using the formula developed by Johnson and
Bahamonde68. To calculate PPO the participant’s height in cm, weight in kg and VJ in cm
was needed. The results the formula produced were recorded and stored in an Excel
document to the nearest .01W.
GLOBAL RATE OF CHANGE SCALE
A 15-point GROC scale that ranged from -7 to +7. The scale descriptors used
were similar to the ones used by Jaeschke et al72. Zero on the scale represented no
33
change, positive numbers indicated improvement and negative numbers indicated
deterioration. Subject were asked to rate any perceived changes in the treated muscle’s
tightness, performance and pain. immediately post treatment. Question formatting and
administration recommendations described by Kamper et al.21 were also used in
designing this instrument. Several researchers have used a change in a 15-point GROC
score of greater than 3 to indicate a clinically meaningful change.73-75
INSTRUMENTS
Algometer: In this study, a Wagner FPX 50 (Wagner Instruments, Greenwich,
CT) handheld digital algometer with a 1-cm2 flat rubber tip was used to assess pressure
pain threshold. This device has a firm pistol grip handle and displays a 5-digit force
reading in selectable units: lbf, kgf, N and ozf.
Goniometer: In this study, a JAMAR 12.5" (32cm) EZ Read goniometer with a
scale which reads 0 to 180 degrees and 0 to 360 degrees in 1-degree increments was used
to record range of motion.
Vertec: In this study, a Vertec (Perform Better, West Warwick, RI) a stand
mounted measurement device that telescopes upward and has colored vanes that are
spaced 1/2" inch apart that rotate was used to measure vertical jump.
GROC questionnaire: In this study, a three question 15-point GROC scale was
used to measure the subjective post treatment change for a participant. This survey has
been previously used by Jaeschke et al72. and assesses subjectively a person’s degree of
muscle pain, tightness and fatigue prior and after a treatment.
34
INTERVENTION
Subjects were randomly assigned and underwent one of three treatments: FR, IC
and CON. Two different athletic medicine facilities with two different treating clinicians
were used to conduct the study. The environments for both athletic medicine facilities
were busy with people going in and out with variable noise volumes. Each of the
treatments took approximately 5 minutes in length and had different levels of supervision
depending on the treatment. Following each treatment, post treatment measurements
commenced as soon as the participant exited the treatment area and entered the
measurement area. The distance needed to travel for both facilities was similar, being no
more than 100 feet.
FOAM ROLLING
Subjects were randomly assigned and underwent one of three treatments, FR, IC
and CON. Subjects assigned to FR were instructed on how to properly perform the
intervention but were not supervised. Participants followed the protocol designed by
Krause et al.20, but the treatment time was increased from 60s to 90s based on findings by
MacDonald et al12 and was performed on the hamstring instead of the quadriceps. The FR
intervention was performed in the supine position with support given by the arms. (Figure
3.4) The participants were instructed to place their body weight on a closed-cell EPP
foam roller with a length of 36” and a diameter of 6” (TheraBand, Akron, OH).
Using a participant’s own body weight pressure was applied to the tissue of the
posterior thigh, subjects performed a rolling motion from the proximal aspect of the
posterior thigh (ischial tuberosity) to the posterior knee (popliteal fold). Once the foam
35
roller reaches the posterior knee, participants were instructed to return to the starting
position and continue the sequence for the remainder of the 90s. The rolling frequency
was standardized using a metronome set at 60 beats per minute (bpm). Participants were
instructed to roll at a velocity of two metronome beats (thus 2s) for each rolling direction,
resulting in 22.5 complete rolling cycles in 90s. Intensity of pressure was controlled
subjectively by using a Numerical Rating Scale (NRS), participants were instructed not to
exceed a rating of 7/10 (0 representing no discomfort and 10 representing maximal
discomfort) during the intervention. After a 30s break in a relaxed supine position,
participants performed a second bout. Subjects were observed to make sure they were
properly performing the FR treatment.
FIGURE 3.4
FOAM ROLLING
ISCHEMIC COMPRESSION
Ischemic Compression is manual therapy technique whose purpose is to reduce
muscle and MTrP tenderness and hyperirritability and can be defined as the “application
of progressively stronger pressure on a TrP”.18 The identification of TrPs followed the
guidelines laid out in the Trigger Point Manual.18,76 Participants laid prone on the
36
treatment table with their dominant leg hanging off the edge of the treatment table
modestly exposed, putting the hamstrings on stretch. (Figure 3.5) Massage cream was
applied to the entire length of the hamstrings. The clinician then started at the ischial
tuberosity and applied petrissage to the full length of the hamstring muscles. The
clinician worked their way down each hamstring muscle until a corded muscle or pea-like
structure was palpated. Cross-friction or circulating massage was then applied to the
muscle fibers. If the cross-friction or circulating movement produced symptoms of pain
(referred pain, twitch response, or localized pain) the area was identified as a TrP and IC
was applied.
Ischemic compression followed a treatment protocol based on a description laid
out by Travel et al18,76 and tested by Berggreen et al8 with modifications by Nambi et al.15
The treating clinician pressed their thumb directly into the MTrP to produce pain that was
controlled subjectively with a target NRS rating of 7/10 (0 representing no discomfort
and 10 representing maximal discomfort) during the intervention. The applied pressure
was sustained until pain was resolved or 90 seconds elapsed. The procedure was repeated
up to three times depending on if MTrPs were present. Following, three applications or
each of the three hamstrings being scanned, four strokes of effleurage massage were
applied to the hamstring muscle. Then the hamstring was placed on passive stretch for 30
seconds to range the muscle. The total treatment time was approximately 5 minutes in
length.
37
FIGURE 3.5
ISCHEMIC COMPRESSION
CONTROL
The methodology of the control treatment followed the protocol as laid out in a
study by Mohr et al.14 Participants, during the control treatment, were instructed to lie
down supine on the treatment table for 5 minutes.
DATA ANALYSIS
Statistical analysis was completed using IBM SPSS Statistics version 24.0
software (Armonk, NY). Descriptive statistics were calculated for all data collected. This
study used a repeated measures 2x3 analysis of variance (ANOVA) determine withinsubjects factors for Time (Pre, Post-intervention) and between-subjects for Trials (FR, IC,
CON), and Kruskal Wallis in combination with a Chi Square test was used for the GROC
to assess the difference between the trial conditions (FR, IC CON).
38
CHAPTER 4
RESULTS
This study was designed to determine the acute effects of two myofascial release
techniques, FR and IC, on AKE, PPT, VJ, PPO and GROC. This chapter is a presentation
of the data in the following sections: a) participation demographics, b) comparison
among time and trial condition on hamstring ROM during AKE, c) comparison among
time and trial condition on hamstring PPT, d) comparison among time and trial condition
on maximum height reached during a VJ, e) comparison among time and trial condition
on PPO during VJ, and f) comparison of among trial conditions on GROC scale scores.
PARTICIPATION DEMOGRAPHICS
A summary of the demographics of the study participants is presented in Table
4.1. A total of 13 subjects volunteered but only 11 completed the study. One was deemed
ineligible to participate due to an acute knee injury and one participant dropped out for
unspecified reasons. Of the 11 subjects who completed the study, 4 were males (mean
age=19.5±1 year; height=174±9.9cm; weight=100±6.7kg) and 7 were females (mean
age=19.6±.69years; height=168.8±7.9cm; weight=66.1±3.3kg). Participants in study
were active basketball players from two schools competing in the NCAA Division II
39
(N=6) and a Division III (N=5) levels. No males participated in the study from the
NCAA Division II level due to scheduling conflicts and postseason participation.
TABLE 4.1
DEMOGRAPHICS
Gender
Age(years)
Height(cm)
Mass(kg)
Division II
Division III
Overall
-19.7±.8
173.9±10.4
78.5±17.7
6
5
Male
4
19.5±1
184.4±0.5
100.0±6.7
0
4
Female
7
19.8±0.7
167.9±8.0
66.2±3.6
6
1
COMPARISON AMONG TIME AND MYOFASCIAL RELEASE
TECHNIQUES ON ACTIVE KNEE EXTENSION
A summary of the different pretreatment and posttreatment myofascial release
techniques means, and standard deviations of AKE is presented in Table 4.2 and Figure
4.1. To test whether pretreatment means (FR:62.00, IC:55.71, CON:65.45) were
significantly different than posttreatment means (FR:63.89, IC:62.65, CON:64.68), a oneway ANOVA with repeated measures was performed. Table 4.3 illustrates the sum of
squares, degrees of freedom and the F-ratio over time (pretreatment, posttreatment) for
active knee extension. There was a significant difference in mean AKE over time
(F=6.17, p=.032). The p=.032 suggests that the intervention or the time elapsed is
connected to the change in the mean values. A one-way ANOVA with repeated measures
showed an effect for condition on knee-joint ROM (P<.05).Post hoc analyses however
showed that the changes seen in AKE from pretesting to post-testing for the FR and IC
condition were not statically different from those seen in during the control condition.
40
TABLE 4.2
SUMMARY OF MEAN ACTIVE KNEE EXTENSION PRODUCED BEFORE AND
AFTER VARYING MYOFASCIAL RELEASE TECHNIQUES
(N=11)
Myofascial Release
Technique
Controla
Foam Rollinga
Ischemic
Compressiona
Pretreatment Mean
65.4545
62.0000
55.7121
Pretreatment sd
13.7196
13.2642
16.0430
Posttreatment Mean
64.6818
63.8939
62.6515
Posttreatment sd
12.7912
12.0850
14.5782
a
Measurements in degrees
FIGURE 4.1
MEAN ACTIVE KNEE EXTENSION BEFORE AND AFTER VARYING
MYOFASCIAL RELEASE TECHNIQUES
41
TABLE 4.3
ONE-WAY ANOVA WITH REPEATED MEASURES OF TIME FOR ACTIVE KNEE
EXTENSION
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time
1
119.118
119.118
6.16`7
0.032
Error
10
193.169
19.317
Total
11
312.435
TABLE 4.4
MEAN DIFFERENCES WITHIN SUBJECTS MEASURES OF TIME ON ACTIVE
KNEE EXTENSION
(N=11)
Time
Pretreatment
Posttreatment
Means
(61.056a)
(63.742a)
Pretreatment (61.056a)
-------
-2.687a,b
Posttreatment (63.742a)
2.687a,b
-------
a
Measurement differences are in degrees
Significant at the 0.05 level
b
To test whether mean between-group differences between three trials (FR, IC,
CON) were significant, a one-way ANOVA with repeated measures was performed and
found there were no statistical differences (p=.434) in mean AKE among the three trials
(FR, IC, CON). Table 4.5 illustrates the sum of squares, degrees of freedom and F-ratio
among trial conditions (FR, IC, CON).
42
TABLE 4.5
ONE-WAY ANOVA WITH REPEATED MEASURES OF TREATMENT
TECHNIQUE FOR ACTIVE KNEE EXTENSION
(N=11)
Df
Sum of Squares
MS
F
Sig.
Treatment
2
391.051
195.526
.869
0.434
Error
20
4498.328
224.916
Total
22
4889.379
To test whether interaction between time and myofascial release technique were
significant, a one-way ANOVA with repeated measures was performed. Table 4.6
illustrates the sum of squares, degrees of freedom and the F-ratio for the interaction
between time (pretreatment, posttreatment) and myofascial release technique (FR, IC,
CON). A significant F-ratio (df=2, Error df=20, F=5.88) was determined for the
interaction between time and treatment technique (p=.01). But since no significant
differences between the two treatment interventions and the control then whatever
change, either positive or negative, that occurred between pre and post testing is not
likely the result from the intervention.
43
TABLE 4.6
ONE-WAY ANOVA WITH REPEATED MEASURES OF INTERACTION BETWEEN
TIME AND TREATMENT TECHNIQUE FOR ACTIVE KNEE EXTENSION
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time*Technique
2
168.748
84.374
5.883
0.010
Error
20
286.854
14.343
Total
22
455.602
COMPARISON AMONG TIME AND MYOFASCIAL RELEASE TECHNIQUES ON
PAIN-PRESSURE THRESHOLD
A summary of the different pretreatment and posttreatment myofascial release
techniques means, and standard deviations of PPT is presented in Table 4.7 and Figure
4.2. To test whether pretreatment means (FR:44.52, IC:42.63, CON:43.28) were
significantly different than posttreatment means (FR:47.75, IC:52.81, CON:40.16), a oneway ANOVA with repeated measures was performed. Table 4.8 illustrates the sum of
squares, degrees of freedom and the F-ratio over time (pretreatment, posttreatment) for
pain-pressure threshold readings. The F-ratio over the time of measurement main effect
was not significant (df=1, Error df=10, F=3.34, p=.097) which indicates that the time of
measurement did not affect PPT of the hamstrings. Though there was no statistically
significant results there were trends to show that FR and IC can increase PPT where the
CON decreased the PPT.
44
TABLE 4.7
SUMMARY OF MEAN PAIN-PRESSURE THRESHOLD READINGS PRODUCED
BEFORE AND AFTER VARYING MYOFASCIAL RELEASE TECHNIQUES
(N=11)
Myofascial Release
Technique
Controla
Foam Rollinga
Ischemic
Compressiona
Pretreatment Mean
43.2788
44.5212
42.6303
Pretreatment sd
11.1361
10.6746
9.6690
Posttreatment Mean
40.1576
47.7455
52.8091
Posttreatment sd
7.9805
12.7084
15.1788
a
Measurements in N
45
FIGURE 4.2
MEAN PAIN-PRESSURE THRESHOLD READINGS PRODUCED BEFORE AND
AFTER VARYING MYOFASCIAL RELEASE TECHNIQUES
(N=11)
TABLE 4.8
ONE-WAY ANOVA WITH REPEATED MEASURES OF TIME FOR PAINPRESSURE THRESHOLD
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time
1
193.812
193.812
3.342
0.097
Error
10
579.863
57.986
Total
11
773.675
46
To test whether mean differences between myofascial release techniques were
significant, a one-way ANOVA with repeated measures was performed. Table 4.9
illustrates the sum of squares, degrees of freedom and the F-ratio among myofascial
release techniques (FR, IC, CON) for PPT readings. The F-ratio for the between
myofascial release techniques main effect was not significant (df=2, Error df=20, F=1.73,
p=.203) which indicate that the type of myofascial release technique did not affect PPT.
TABLE 4.9
ONE-WAY ANOVA WITH REPEATED MEASURES OF TREATMENT
TECHNIQUE FOR PAIN-PRESSURE THRESHOLD
(N=11)
Df
Sum of Squares
MS
F
Sig.
Technique
2
425.541
212.770
1.731
0.203
Error
20
2457.914
122.896
Total
22
2883.455
To test whether interactions between time and myofascial release technique were
significant, a one-way ANOVA with repeated measures was performed. Table 4.10
illustrates the sum of squares, degrees of freedom and the F-ratio among time
(pretreatment, posttreatment) and myofascial release technique (FR, IC, CON) for PPT
readings. A significant F-ratio (df=2, Error df=20, F=10.34) was determined for the
interaction between time and treatment technique (p=.001) but the interaction is not
meaningful since the main effects for time and treatment technique were not significant.
47
TABLE 4.10
ONE-WAY ANOVA WITH REPEATED MEASURES OF INTERACTION BETWEEN
TIME AND TREATMENT TECHNIQUE FOR PAIN-PRESSURE THRESHOLD
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time*Treatment
2
486.788
243.394
10.336
0.001
Error
20
470.971
23.549
Total
22
957.759
COMPARISON AMONG TIME AND MYOFASCIAL RELEASE
TECHNIQUE ON PEAK VERTICAL JUMP HEIGHT
A summary of the different pretreatment and posttreatment myofascial release
techniques means, and standard deviations of VJ is presented in Table 4.11 and Figure
4.3. To test whether pretreatment means (FR:16.85, IC:18.15, CON:17.62) were
significantly different from posttreatment means (FR:18.45, IC:18.67, CON:17.86), a
one-way ANOVA with repeated measures was performed. Table 4.12 illustrates the sum
of squares, degrees of freedom and the F-ratio over time (pretreatment, posttreatment) for
VJ height. A significant F-ratio (df=1, Error df=10, F=6.85) was determined for the
among pretreatment and posttreatment measurements main effect (p=0.026). A pairwise
comparison was then performed to determine the differences. Table 4.13 summarizes the
mean VJ height differences between pretreatment measurements and posttreatment
measurements. The pairwise comparison revealed a significant difference between
pretreatment and posttreatment measurements.
48
TABLE 4.11
SUMMARY OF MEAN PEAK VERTICAL JUMP HEIGHTS PRODUCED BEFORE
AND AFTER VARYING MYOFASCIAL RELEASE TECHNIQUES
(N=11)
Myofascial Release
Technique
Controla
Foam Rollinga
Ischemic
Compressiona
Pretreatment Mean
17.6212
16.8485
18.1515
Pretreatment sd
3.4206
3.3254
3.0336
Posttreatment Mean
17.8636
18.4548
18.6667
Posttreatment sd
3.6193
3.4455
3.0669
a
Measurements in inches.
49
FIGURE 4.3
MEAN PEAK VERTICAL JUMP HEIGHTS PRODUCED BEFORE AND AFTER
VARYING MYOFASCIAL RELEASE TECHNIQUES
(N=11)
TABLE 4.12
ONE-WAY ANOVA WITH REPEATED MEASURES ON TIME FOR PEAK
VERTICAL JUMP HEIGHT
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time
1
10.245
10.245
6.848
0.026
Error
10
14.960
1.496
Total
11
25.205
50
TABLE 4.13
MEAN DIFFERENCES WITHIN SUBJECT MEASURES OF TIME ON PEAK
VERTICAL JUMP HEIGHT
(N=11)
Time
Pretreatment
Posttreatment
Means
(17.540a)
(18.328a)
Pretreatment (17.540a)
-------
-.788a,b
Posttreatment (18.328a)
.788a,b
-------
a
Measurement differences are in in
Significant at the 0.05 level
b
To test whether mean differences between myofascial release techniques were
significant, a one-way ANOVA with repeated measures was performed. Table 4.14
illustrates the sum of squares, degrees of freedom and the F-ratio among myofascial
release techniques (FR, IC, CON) for VJ height. The F-ratio for the between myofascial
release techniques main effect was not significant (df=2, Error df=20, F=0.246, p=0.784)
which indicate that the type of myofascial release technique did not affect VJ height.
TABLE 4.14
ONE-WAY ANOVA WITH REPEATED MEASURES ON TREATMENT
TECHNIQUE FOR PEAK VERTICAL JUMP HEIGHT
(N=11)
Df
Sum of Squares
MS
F
Sig.
Technique
2
7.527
3.763
0.246
0.784
Error
20
305.607
15.280
Total
22
313.134
51
To test whether interactions between time and myofascial release technique were
significant, a one-way ANOVA with repeated measures was performed. Table 4.15
illustrates the sum of squares, degrees of freedom and the F-ratio among time
(pretreatment, posttreatment) and myofascial release technique (FR, IC, CON) for VJ
height. The F-ratio for the interaction among time and treatment technique main effect
was not significant (df=2, Error df=20, F=2.41, p=0.116) which indicates that the
interaction between time and treatment technique did not affect VJ height.
TABLE 4.15
ONE-WAY ANOVA WITH REPEATED MEASURE ON THE INTERACTION
BETWEEN TIME AND TREATMENT TECHNIQUE FOR PEAK VERTICAL JUMP
HEIGHT
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time*Treatment
2
5.730
2.865
2.408
0.116
Error
20
23.793
1.190
Total
22
29.523
COMPARISON AMONG TIME AND MYOFASCIAL RELEASE
TECHNIQUES ON PEAK POWER OUTPUT DURING VERTICAL JUMP
A summary of the different pretreatment and posttreatment myofascial release
techniques means, and standard deviations of PPO is presented in Table 4.16 and Figure
4.4. To test whether pretreatment means (FR:3963.13, IC:4386.94, CON:4084.83) were
significantly different from posttreatment means(FR:4277.53, IC:4490.55,
CON:4141.99), a one-way ANOVA with repeated measures was performed. Table 4.17
52
illustrates the sum of squares, degrees of freedom and the F-ratio over time (pretreatment,
posttreatment) for PPO. A significant F-ratio (df=1, Error df=10, F=7.067) was
determined for the between pretreatment and posttreatment measurements main effect
(p=.024). A pairwise comparison was then performed to determine the differences. Table
4.18 summarizes the mean PPO differences between pretreatment and posttreatment
measurements. The pairwise comparison revealed a significant difference between
pretreatment measurements and posttreatment measurements.
TABLE 4.16
SUMMARY OF PEAK POWER OUTPUTS PRODUCED BEFORE AND AFTER
VARYING MYOFASCIAL RELEASE TECHNIQUES
(N=11)
Myofascial Release
Technique
Controla
Foam Rollinga
Ischemic
Compressiona
Pretreatment Mean
4084.8273
3963.1309
4386.9382
Pretreatment sd
1263.7752
1400.7099
1364.7201
Posttreatment Mean
4141.9909
4277.5309
4490.5473
Posttreatment sd
1287.7612
1301.2328
1344.3749
a
Measurements in W
53
FIGURE 4.4
MEAN PEAK POWER OUTPUT PRODUCED BEFORE AND AFTER VARYING
MYOFASCIAL RELEASE TECHNIQUES
(N=11)
TABLE 4.17
ONE-WAY ANOVA WITH REPEATED MEASURES ON TIME FOR PEAK POWER
OUTPUT
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time
1
413946.721
713946.72
7.067
0.024
Error
10
587819.283
58571.928
Total
11
1001766.004
54
TABLE 4.18
MEAN DIFFERENCES WITHIN SUBJECTS MEASURES OF TIME ON PEAK
POWER OUTPUTS
(N=11)
Time
Pretreatment
Posttreatment
Means
(4144.965a)
(4303.356a)
Pretreatment (4144.965a)
-------
-158.391a,b
Posttreatment (4303.356a)
158.391a,b
-------
a
Measurement differences are in W
Significant at the 0.05 level
b
To test whether mean differences between myofascial release techniques were
significant, a one-way ANOVA with repeated measures was performed. Table 4.19
illustrates the sum of squares, degrees of freedom and the F-ratio among myofascial
release techniques (FR, IC, CON) for PPO. The F-ratio for the between myofascial
release techniques main effect was not significant (df=2, Error df=20, F=1.18, p=.329)
which indicate that the type of myofascial release technique did not affect PPO.
TABLE 4.19
ONE-WAY ANOVA WITH REPEATED MEASURES ON TREATMENT
TECHNIQUE FOR PEAK POWER OUTPUT
(N=11)
Df
Sum of Squares
MS
F
Sig.
Treatment
2
1520023.798
760011.90
1.177
0.329
Error
20
12914117.35
645705.87
Total
22
14434141.148
55
To test whether interactions between time and myofascial release technique were
significant, a one-way ANOVA with repeated measures was performed. Table 4.20
illustrates the sum of squares, degrees of freedom and the F-ratio among time
(pretreatment, posttreatment) and myofascial release technique (FR, IC, CON) for PPO.
The F-ratio for the interaction among time and treatment technique main effect was not
significant (df=2, Error df=20, F=2.15, p=.142) which indicates that the interaction
between time and treatment technique did not affect PPO.
TABLE 4.20
ONE-WAY ANOVA WITH REPEATED MEASURES ON THE INTERACTION
BETWEEN TIME AND TREATMENT TECHNIQUE FOR PEAK POWER OUTPUT
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time*Treatment 2
206727.646
103363.82
2.153
0.142
Error
20
960309.591
48015.48
Total
22
1167037.237
COMPARISON AMONG MYOFASCIAL RELEASE TECHNIQUES ON GLOBAL
RATE OF CHANGE RANK SCORES
A summary of the differing variable means and standard deviations of GROC
rank scores is presented in Table 4.21 and Figure 4.5 (FR:3.17, IC:2.17, CON:2.46). A
Kruskal Wallis and Chi Squared Tests were conducted on the different myofascial release
techniques to compare their effects on each of the variables tested by the GROC and the
results are presented in Table 4.22 and 4.23. The results are presented in mean rank
scores not in the GROC scale scores. The scores were presented in this way to allow for
56
the GROC scores to be statistically analyzed. Differences can be seen, in Table 4.22,
between treatments for each variable (Pain: FR:14.29, IC:25.32, CON:15.00; Tightness:
FR:16.42, IC:25.86, CON:12.38; Fatigue: FR:17.79, IC:24.23, CON:12.50) but due to the
type of test and data, significance was unable to be determined between treatments. The
Chi-Square test, Table 4.23, revealed statistically significant perceived increases for each
of the variables (Pain, Tightness, Fatigue). The Chi-Squared test did not parse out
between the variables to determine if there was significant between group differences.
TABLE 4.21
SUMMARY OF MEAN GLOBAL RATE OF CHANGE RANK SCORES FOR
DIFFERING VARIABLES
(N=11)
Variables Tested
Muscle Pain
Muscle Tightness
Muscle Fatigue
Mean
2.4571
3.1714
2.1714
Sd
2.2274
2.4792
2.4553
57
FIGURE 4.5
MEAN GLOBAL RATE OF CHANGE RANK SCORES FOR DIFFERING
VARIABLES
(N=11)
58
TABLE 4.22
SUMMARY OF MEAN GLOBAL RATE OF CHANGE RANK SCORES FOR
PERCEIVED MUSCLE PAIN, TIGHTNESS AND FATIGUE AFTER DIFFERENT
MYOFASCIAL RELEASE TECHNIQUES
(N=11)
Myofascial Release
Technique
Control
Foam Rolling
Ischemic
Compression
Mean Rank Score for
Perceived Muscle
Pain
15.00
14.29
25.32
Mean Rank Score for
Perceived Muscle
Tightness
12.38
16.42
25.86
Mean Rank Score for
Perceived Muscle
Fatigue
12.50
17.79
24.23
TABLE 4.23
SUMMARY OF MEAN GLOBAL RATE OF CHANGE RANK SCORES FOR
PERCEIVED MUSCLE PAIN, TIGHTNESS AND FATIGUE AFTER DIFFERENT
MYOFASCIAL RELEASE TECHNIQUES
(N=11)
Muscle Pain
Muscle Tightness
Muscle Fatigue
Chi-Square
8.514
10.820
7.994
Df
2
2
2
Asymp. Sig.
.014
.004
.018
59
CHAPTER 5
DISSCUSSION AND CONCULSION
INTRODUCTION
The purpose of this study was to compare the effectiveness of foam rolling and
ischemic compression and their effectiveness in treating hamstring tightness. The
effectiveness of the treatments was measured using ROM and PPT of the hamstrings, VJ
and PPO during VJ and GROC. This chapter is presented in the following sections: a)
discussion for ROM performance, b) discussion for PPT, c) discussion for VJ height, d)
discussion for PPO during VJ, e) discussion of GROC, f)summary, g) findings, h)
conclusions and i) recommendations for further study.
DISCUSSION FOR RANGE OF MOTION PERFORMANCE
The results of this study found that a single treatment of FR or IC did not yield a
significant improvement in HS flexibility (AKE) compared to the control condition. AKE
improved from pre and post-testing but no condition (FR, IC, or CON) was significantly
better than another. This finding that the FR condition did not significantly improve
ROM compared to the control condition is consistent with the finding of several previous
studies14,61,77-79. Mohr et al.14 conducted a study comparing the effects of 4 different
60
treatment conditions on passive hip-flexion ROM: foam rolling (FR), static stretching
(SS), foam rolling and static stretching (FR+SS) and control (CON). In the Mohr et al14
study all conditions studied significantly changed passive hip-flexion, but only the
combined FR+SS yielded significantly greater changes in passive hip-flexion ROM
compared to the other conditions. In another pretest-posttest study77 assessing the effect
of a single 60 sec FR session on hip flexor and quadriceps muscle flexibility found that
FR no significant effect on individual muscle flexibility measures. In this study FR
condition did show a small gain in overall flexibility compared to the control, but the
authors concluded that was insignificant in terms of improving overall function.77
Couture et al78, conducted a small repeated measures study evaluating the effects of a
single bout of self-administered FR using 2 protocols (Long= 4x 30 sec and Short=2x
30sec) on passive knee extension ROM. The subjects were measured on 3 consecutive
days where the baseline measure was used as the control and the 2 protocols were
delivered in a counterbalanced order. Neither of the FR protocol resulted significant
changes in passive knee extension ROM compared to baseline.
The present study’s finding suggest that a single session of FR may not be
sufficient to product significant improvements in ROM. However, this conclusion is not
consistent with several previous studies that found that a single bout of FR resulted in
improvements in knee ROM.7,9,12,13 Bradbury-Squires et al 9 conducted a small repeated
measures pretest-posttest study comparing both a 20 and 60-second application of FR to
the quadriceps muscle to a control condition. In this study both FR protocols elicited a
greater improvement in knee flexion than the control condition. Two key differences
61
between the current study and the Bradbury-Squires et al9 study were the muscles treated
(HS vs. Quads) and the method of delivery for the FR. The HS are a deeper muscle
groups and their location in relation to the femur can make it harder to effectively
compress them with the foam roller compared to the more superficial quadriceps. Also, in
the Bradbury-Squires study9 the amount of compression pressure used was controlled by
the roller device used. In the present study, the amount of pressure used was determined
by the individual subject based on perceived discomfort. Because of the location and
depth of the HS muscles and the lack of external pressure control it is plausible that some
subjects in this study may have used insufficient pressure to adequately mobilize the HS
muscles. Aguilera et al7 conducted a randomized control trail which compared IC to US
and its ability to increase ROM, decrease MTrP sensitivity, and decrease electrical
output. The current study differs from Aguilera et al7 by the muscle that was tested and
the presence of MTrPs. The current study tested the hamstrings where Aguilera et al
tested the upper trapezius. The upper trapezius is a more superficial muscle allowing for
greater ease of compression of the muscle possibly resulting in a greater and more
noticeable change in ROM. The current study did not require the participants to have
MTrPs but the participants in the Aguilera et al7 study needed to have latent MrTPs. The
presence of MTrPs whether active or latent could explain why the current study did not
see a significant difference between treatments. Having MTrPs present in theory explains
why IC would have a positive effect on it. The muscle is spasm and IC will help then
lengthen the muscle returns it to its originally tension and increasing ROM.
62
MacDonald et al13 conducted a small randomized controlled trial which looked at
the effectiveness of FR versus a control in treating DOMS in the lower extremity. In this
study13, FR was able to decrease the effects of DOMS while improving passive quadricep
and hamstring ROM and dynamic hamstring ROM. There were a few key differences
between the current study and MacDonald et al.13 One was the muscles treated, (HS vs
HS, Quads, Glutes, ADDs and IT band) another the amount of times FR was applied (1
vs 3), and lastly the condition of the athletes. (not sore vs sore) Receiving multiple
treatments may have a compounding effect to improve muscle extensibility and
performance which are only seen over the course of time as compared to looking at the
acute effects of one FR treatment. Treating multiple muscles may increase the effects of
FR since the agonist and the antagonist muscles are both being treated decreasing the
restriction to movement throughout the joint. In this study13, treating just one muscle
group may limit the effects that could be produced since muscles are affected by their
opposing muscle. Lastly, the improvement in ROM with FR might only occur when there
is existing muscle soreness. The subjects in the MacDonald study13 may have only seen
improvements in ROM since they were sore where the subjects in the current study were
not sore.
MacDonald et al12 conducted a randomized control trial comparing the ability of
FR to a control in increasing quadricep range of motion. Different from the current study,
MacDonald et al12 found that FR increased ROM compared to a control. Some of the
differences between MacDonald et al and the current study that could explain the
differing results is the presence of delayed onset muscle soreness (Sore vs. Not Sore) and
63
the muscle FR (Quadriceps vs Hamstrings). MacDonald et al12 did testing on the
quadriceps which is a more superficial muscle compared to the hamstrings which is a
deeper muscle and covered with more adipose tissue. The resulting factor is that current
study allowing for the muscle treated to receive a higher dose of treatment. The other
difference between the studies is the presence of DOMS. MacDonald et al12 had the study
participants, prior to FR go through a standardized workout routine to induce delayedonset muscle soreness in the quadriceps. Following the exercise routine, it is possible the
participants quadriceps were at a shortened state and due to decrease in muscle length the
treatment of FR would have greater effects on the muscle as compared to someone who
was not sore, like the participants from the current study.
DISCUSSIONS FOR PAIN-PRESSURE THRESHOLD
The results of this study found that a single treatment of FR or IC did not yield a
significant improvement in HS pain-pressure threshold (PPT) compared to the control
condition but for both FR and IC a trend of increased PPT was seen posttreatment
compared to the CON. For IC on average a 10N increase in PPT was seen. Similar results
were found in a study by Ravichandran et al.61 Ravichandran et al61 conducted a small
single-blind randomized control trial comparing IC with CON (ultrasound). In
congruence with the current study trends toward improvement were noted but no
statistically significant results were found.
Contrary to this finding, several studies have found FR and IC to be effective in raising
PPT8,16,54,56,80 . Pearcey et al16 used a repeated-measures within subjects crossover study
to assess the effect of FR on subjects suffering from induced DOMS. The key differences
64
in this study were the number of times FR was applied (0 hours post vs 0, 24, 48 hours
post), the muscles FR was applied to (HS vs the entire LE) and then soreness of the
subjects (not sore vs sore). Treating a muscle multiple times versus once may result in
compounding effects from the treatment that would not be seen in the current study since
FR was only applied once. The results from Pearcey et al16 maybe different because of
the muscles treated (HS, Quads, ADD, IT band and Glutes vs HS). Treating a larger area
of muscle provides potentially greater chance of eliciting the purported mechanical and
pain modulation effects. Another difference between the current study and Pearcey et al16
is how the PPT was measured. In the study by Pearcey et al16 participants were weight
bearing and PPT was assessed on the quads compared to the current study which assessed
the PPT while the participants were non-weight bearing and was assessed on the
hamstrings. Being weight bearing naturally causes the quads to be contracted. Having the
quads contracted increase the tension of the muscle being treated. The quads do not have
as much adipose tissue, as compared to the hamstrings, between the muscle and the
surface of the skin allowing for a greater ease to compress the desired muscle tissue.
Testing the participant’s quads while weight bearing is a significant difference between
the studies which may explain the difference between them. Lastly, another reason the
current study’s results may have been different from Pearcey et al16 were the subjects in
the study conducted by Pearcey et al16 were already sore prior to FR. The effect of FR
may be more pronounced in individuals with DOMS compared to healthy non-painful
subjects. Since the current study’s subjects were not sore the results seen in the study by
Pearcey et al16 may only have been due to the subjects being sore prior to FR.
65
Similarly, studies by Gulick et al56 and Jagad et al80 conducted single-blind randomized
controlled trials comparing IC to a control. Both Gulick et al56 and Jagad et al80 found
following IC, there was a statistically significant inter and intra group increase in PPT.
The key differences between the current study and the studies conducted by Gulick et al56
and Jagad et al80 is what was used as sites of treatment (standardized point vs MTrPs), the
amount of treatments (1 vs 3/7) and the body part used for treatment (Hamstrings vs
Upper Trapezius). A key difference is Gulick et al56 and Jagad et al80 used MTrPs as the
sites for treatment compared to the current study which used a single standardized point
on every participant regardless if that point was sore or not. Using sites that have a
decreased pain-pressure threshold as the points which measurements are taken from
could show a greater effect from the treatment since the sites were more sensitive to pain
prior to the treatment than the sites measured from in the current study. Another
difference between the current study and Gulick et al56 and Jagad et al80 is the amount of
treatments. Gulick et al56 and Jagad et al80 performed IC multiple times compared to a
single treatment in the current study. Though the current study did not look at the longterm effects of repetitive treatments, having multiple treatments may produce a
compounding effect that would not have been seen in this study. Overall differences in
the muscles treated, inclusion criteria, and protocol could explain why the results of the
current study did not match that of previously conducted studies.
DISCUSSION FOR PEAK VERTICAL JUMP HEIGHT
The results of this study found that a single treatment of FR or IC did not yield a
significant improvement in vertical jump (VJ) compared to the control condition. VJ
66
improved from pre and post-testing but no condition (FR, IC, or CON) was significantly
better than another. Similar results were found in a different study.10 Healy et al10
conducted a randomized crossover design comparing the effects of a single session of FR
to a control of planking. No statistically significant results were found in between
treatments, which is consistent with a previous study by Healey et al.11 but both
treatments did induce an increase in PPO. Overall these results suggest that the
application of a myofascial release technique, FR or IC, can positively effect VJ.
The present study’s findings indicate that a single session of FR does not
significantly increase VJ compared to the control treatment. A previous study conducted
by MacDonald et al13 conducted a randomized control trial comparing FR to a control
that found contradicting results to the current study.13 In the MacDonald et al 13 the
subjects had identified muscle soreness, the treatment consisted FR multiple muscles, and
the exposure time was 3x longer than the current study. These differences may account
for the differences in findings. Receiving multiple treatments may have a compounding
effect on muscle performance (VJ) which is only seen over the course of time as
compared to looking at the acute effects of one FR treatment. Treating multiple muscles
may also increase the effects of FR since the agonist and the antagonist muscles are both
being treated which may increase proper or more affective in muscle contraction . Lastly,
the improvement in VJ with FR might only occur when there is existing muscle soreness.
The subjects in the MacDonald study13 may have only seen improvements in VJ since
they were sore where the subjects in the current study were not sore and therefore
explains why there is a difference in results between the studies.
67
DISCUSSION FOR PEAK POWER OUTPUT DURING VERTICAL JUMP
The results of this study found that a single treatment of FR or IC did not yield a
significant improvement in peak power output (PPO) compared to the control condition.
PPO improved from pre and post-testing but no condition (FR, IC, or CON) was
significantly better than another. Similar results were found in a different study.10 Healy
et al10 conducted a randomized crossover design comparing the effects of a single session
of FR to a series of planking exercise on vertical jump height and power, isometric force,
and agility test performance. No statistically significant results were found in between
treatments, which is consistent with the current study, but both treatments, in each of the
studies did induce an increase in PPO. Overall these results suggest that the application of
a myofascial release technique, FR or IC, can positively effect PPO.
The present study’s findings indicate that a single session of FR does not
significantly increase PPO compared to the control treatment. A previous study found
contradicting results to the current study.13 MacDonald et al13 conducted a randomized
control trial comparing FR to a CON. The key differences between the current study and
MacDonald et al13 are: one was the muscles treated, (HS vs HS, Quads, Glutes, ADDs
and IT band) two the amount of times FR was applied (1 vs 3), and lastly the condition of
the athletes. (not sore vs sore) Receiving multiple treatments may have a compounding
effect on muscle performance (PPO) which is only seen over the course of time as
compared to looking at the acute effects of one FR treatment. Treating multiple muscles
may also increase the effects of FR since the agonist and the antagonist muscles are both
being treated which may increase proper or more affective in muscle contraction . Lastly,
68
the improvement in PPO with FR might only occur when there is existing muscle
soreness. The subjects in the MacDonald study13 may have only seen improvements in
PPO since they were sore where the subjects in the current study were not sore and
therefore explains why there is a difference in results between the studies.
DISCUSSION FOR GLOBAL RATE OF CHANGE
The results of this study indicate the application of myofascial release techniques
causes a statistically significant perceived improvement in muscular pain, tightness, and
fatigue. The current results agree with previous research which has shown both FR and
IC to be effective methods of for treating muscular pain.8,10,11,13,17,54 The method utilized
by the current study to collect the perceived effect of the treatment differs by using a 15item GROC scale instead of a 10-cm VAS scale. This method was chosen due to the
ability to have a discrete answer instead of a continuous answer. Both ways have been
shown to effective tools to measure the participant’s perceived benefit from a
treatment.8,10,11,13,17,54
Even though significance was found by the study the degree of significance did
not equal or exceed the threshold of minimum meaningful difference of ≥5 ranks set by
Stratford et al81 for a 15-item scale. This agrees with Nambi et al15 which did not find
significant difference in perceived muscular pain following IC. Another randomized
crossover study also did not find any significant difference in pain between 20-sec and
60-sec of FR and a CON.9
The current study’s findings indicate that a single treatment of FR or IC does not
significantly change perceived muscle pain, tightness or performance. Previous research
69
has shown differing results.7,8,82 A randomized control trial comparing IC, US and a
control was conducted by Aguilera et al7. The key difference between the current study
and Aguilera et al7 is the muscle treated (HS vs Up Trap). The HS is a deeper muscle
compared to the upper trapezius meaning that the same applied pressure may not elicit
the same results because the HS is a deeper muscle.
A double-blind randomized trial comparing the effects of FR and neuromuscular
stabilization on DOMS.82 The three key differences between the current study and the
study by Moraleda et al82 is the muscle treated (HS vs Quads), condition of the
participants (not sore vs sore) and the presence of a control (CON vs no CON). The HS
are a deeper muscle groups and their location in relation to the femur can make it harder
to effectively compress them with the foam roller compared to the more superficial
quadriceps. The subjects in the study by Moraleda et al82 may have only seen
improvements in perceived pain since they were sore where the subjects in the current
study were not sore. Lastly, in the current study used a CON to see if the effects produced
by the treatments were from the treatments or from other sources. The study by Moraleda
et al82 did not utilize a CON so the improvements seen may have been due to other
factors apart from or in addition to the treatment.
Berggreen et al8 conducted a randomized control study comparing the effects of
IC to a CON. The two key differences between the current study and the study conducted
by Berggreen et al8 are the muscles treated (HS vs Up Trap, Neck and Facial
musculature), the condition of the participants (not sore vs sore) and the number of
treatments (1 vs 10). The HS is a deeper muscle compared to the upper trapezius
70
meaning that the same applied pressure may not elicit the same results because the HS is
a deeper muscle. The subjects in the study by Berggreen et al8 may have only seen
improvements in perceived pain since they were dealing with chronic pain where the
subjects in the current study did not deal with chronic pain. Lastly, receiving multiple
treatments may have a compounding effect on perceived pain which is only seen over the
course of time as compared to looking at the acute effects of one IC treatment.
SUMMARY
As mentioned earlier it has been reported that both FR, and IC have been shown
to effectively treat muscle tightness. However previous research lacked studies
comparing the effectiveness of FR to IC. Therefore, the goal of this study was to compare
the effectiveness of FR to IC to increase ROM and PPT of the hamstrings, VJ height,
PPO and the perceived GROC. Statistical significance was found in all three treatment
groups (FR, IC and CON) when comparing pretreatment measurements to posttreatment
measurements for AROM, VJ and PPO. There was no between-group significance
AROM, PPO or VJ. Statistically significant increases in perceived GROC were found
following the application of FR and IC but the increases were not large enough (≤5) for a
clinically meaningful increase. The application of FR, and IC did not produce any
significant increases in hamstring PPT. The results did find a perceived difference
between FR and IC, but no measurable differences were found. These results give
support that the application of myofascial release techniques can increase ROM, VJ
height and PPO.
71
FINDINGS
As a result of the current study and analysis of data the following this were found:
1. There was a significant increase in ROM between pretreatment and
posttreatment measurements
2. There were no significant differences between FR, IC, and CON in
increasing ROM of the hamstrings.
3. There was no significant increases in PPT between pretreatment and
posttreatment measurements for FR, IC or the CON
4. There were no significant differences between FR, IC, and CON in
increasing PPT.
5. There was a significant increase in VJ height between pretreatment and
posttreatment measurements
6. There were no significant differences between FR, IC, and CON in
increasing VJ height.
7. There was a significant difference between pretreatment and posttreatment
measurements in increasing the PPO of the hamstrings.
8. There were no significant differences between FR, IC, and CON in
increasing the PPO of the hamstrings.
9. There was not a meaningful improvement for perceived muscle pain,
tightness and fatigue following a treatment of FR, IC or CON.
72
CONCLUSIONS
Within the scope and limitations of this investigation, it seems reasonable to
conclude that:
1. An application of FR or IC on the hamstrings may have a beneficial effect
on hamstring ROM.
2. An application of FR or IC on the hamstrings may have a beneficial effect
on VJ height.
3. An application of FR or IC on the hamstrings has a beneficial effect on
PPO.
4. An application of FR or IC on the hamstrings had no effect on hamstring
PPT.
5. An application of FR or IC on the hamstrings overall had no meaningful
increase on perceived muscle pain, tightness or fatigue.
RECOMMENDATIONS FOR FUTURE RESEARCH
The following recommendations for further study seem warranted based on the
data obtained and questions that arose throughout the course of this study.
1. A study should be performed that uses more sport specific tools to
measure performance outcomes after varying myofascial release
techniques.
2. A study should be performed that compares the outcomes of varying
myofascial release techniques to different levels of competition.
73
3. A study should be performed comparing the outcomes of varying
myofascial release techniques to level of previous exposure to myofascial
release techniques.
4. A study should be performed comparing the long-term effects of varying
myofascial release techniques.
5. A long-term study should be performed comparing the outcomes of
varying myofascial release techniques.
74
APPENDIX A
INSTITUTIONAL REVIEW BOARD APPROVAL FORMS
75
APPENDIX B
INFORMED CONSENT FORM
77
INFORMED CONSENT
For a Research Study entitled
A Comparison of Foam Rolling and Ischemic Compression in Improving Hamstring
Tightness
You are invited to participate in a research study to evaluate the effects of two manual
therapy techniques on hamstring muscle tightness and pain. The study is being conducted
by Nathan Sheneberger, at East Stroudsburg University in Athletics Department. You
were selected as a possible participant because you are between the ages of 18-30 and are
a collegiate basketball player.
What will be involved if you participate? If you decide to participate in this research study,
you will be asked to engage 3 brief sessions over a 3-week period. During the initial
session, you will receive one of three 5-minute manual therapy treatments delivered to
the posterior thigh area. Muscle flexibility, function, pain and survey data will be collected
before and immediately following the treatment. Participants will then be
scheduled for 2 other sessions approximately
a
week
apart.
During
each session the muscle
flexibility, function, pain and survey data
will
be recollected. Your total time commitment will be approximately 60-75 minutes over a 3week period.
Are there any risks or discomforts? The risks associated with participating in this study
are possible muscle discomfort and skin redness during the application of the
treatment intervention. The interventions utilized in this study are designed to stretch and
elongate skin, muscle, and fascial tissues and can be uncomfortable. Some participants
may experience mild muscle soreness and possible visible bruising of the skin in the
hamstring area. To minimize these risks, we will be using well trained clinicians and
a 10-point discomfort scale during the intervention. The clinician delivering
manual therapy will be monitoring for any discomfort throughout the treatment session to
avoid any discomfort rating beyond a 7 on the discomfort scale.
All participants have the option to discontinue the treatment at any time. Any subjects
reporting symptoms inconsistent with mild muscle soreness or localize skin irritation will
be immediately referred to the University Health Center or personal physician for follow
up. Participants are responsible for any costs associated with medical treatment.
Are there any benefits to yourself or others? Participants will receive an assessment of their
hamstring flexibility. This information may be helpful in identifying a potential risk factor
in hamstring muscle injuries. Participants will also receive two 5-minute manual therapy
treatment of an intervention reported in previous studies to improve hamstring flexibility,
78
function and pain. We/I cannot promise you that you will receive any or all of the benefits
described.
Will you or you receive compensation for participating? There is no compensation for
participating in this study.
Are there any costs? There are no direct costs to participants associated with participation
in this study.
If you change your mind about participating, you can withdraw at any time during the
study. Your participation is completely voluntary. If you choose to withdraw, your data
can be withdrawn as long as it is identifiable. Your decision about whether or not to
participate or to stop participating will not jeopardize your future relations with East
Stroudsburg University, the Athletic Training Department or any of the East Stroudsburg
University personnel associated with this study.
Your privacy will be protected. Any information obtained in connection with this study
will remain confidential. The information obtained during this study may be used in
follow-up research, published in a professional journal, or presented at professional
meetings but your name and identify will not be reveal.
If you have questions about this study, please ask them now or
contact Nathan Sheneberger by phone at (320)-405-9824 or e-mail at
nsheneberg@live.esu.edu. A copy of this document will be given to you to keep.
If you have questions about your rights as a research participant, you may contact the East
Stroudsburg University Institutional Review Board by phone (570)-422-3336 or e-mail at
sdavis@esu.edu.
THIS PROJECT HAS BEEN APPROVED BY THE EAST STROUDSBURG
UNIVERSITY OF PENNSYLVANIA INSTITUTIONAL REVIEW BOARD FOR THE
PROTECTION OF HUMAN SUBJECTS.
HAVING READ THE INFORMATION PROVIDED, YOU MUST DECIDE
WHETHERE OR NOT YOU WISH TO PARTICIPATE IN THIS RESARCH STUDY.
YOUR SIGNATURE INDICATES YOUR WILLINGNESS TO PARTICIPATE.
__________________________________ __________________________________
Participant Signature
Date
Investigator obtaining consent Date
____________________________
Printed Name
_______________________________
Printed Name
79
APPENDIX C
HEALTH SCREENING FORM
80
Health Screening Form
This study involves the use of myofascial therapy techniques that may include deep pressure
and soft tissue stretching. To minimize potential risks of adverse effects from this type of deep
tissue work, we are collecting the following information. This information will be kept
confidential and used for your protection only. Please be truthful in providing you responses. If
you have any questions or concerns regarding the items below or any other health issues you
may have, please don’t hesitate to ask the investigator while completing this form.
Directions: Please circle either YES or NO for each item below. If you answer YES, please provide
a brief explanation in the space provided.
1.
Have you had a
hamstring injury in the
past 6 months?
YES
NO
Are you currently
undergoing treatment for
a lower extremity injury?
YES
NO
YES
NO
YES
NO
Explain:
2.
Explain:
3.
Do you have any open
wounds, increased skin
sensitivity, or other skin
conditions in the area of
the posterior (back) of
the thigh and legs?
Explain:
4.
Do you have a history or
have been diagnosed
with any systemic
conditions or diseases
81
such as: diabetes,
fibromyalgia, phlebitis or
thrombophlebitis,
arteriosclerosis, clotting
or bleeding disorders,
chronic inflammatory
disorder, or autoimmune
disorders?
Explain:
5.
Do you currently have or
have you had any
neurological
conditions/symptoms
such as: spinal disc
herniation, neuropathy,
numbness, tingling, or
shooting pain into
extremities, or any
history of lower back
pain that included
symptoms that radiated
into your arms or legs?
YES
NO
YES
NO
YES
NO
Explain:
6.
Are you currently taking
any medications that
alter pain perception or
have any effect on
healing or the normal
inflammatory response
(e.g. anti-coagulants,
NSAIDs, steroids, muscle
relaxants, or analgesics
(pain relievers))?
Explain:
7.
Do you have any other
health conditions or
concerns that you feel
may expose you to
potential risks from deep
82
Explain:
tissue mobilization or
stretching techniques?
Interviewer notations:
______________________________________________________________________________
______________________________________________________________________________
______________ Participation Status: Cleared Not Cleared
Participant’s Name (Print): _______________________________Date: __________
Participant’s Signature:_______________________________ Date: __________
PI’s Signature: _______________________________Date: __________
83
APPENDIX D
GLOBAL RATE OF CHANGE SCALE SURVEY
84
Global Rating of Change Scale
Please rate any changes in pain or discomfort in the back of the thigh, knee or calf of the limb
treated since you began this treatment until now (check only one):
7)
A very great deal worse (-
About the same (0)
A great deal worse (-6)
Quite a bit worse (-5)
Moderately worse (-4)
Somewhat worse (-3)
A little bit worse (-2)
A tiny bit worse (-1)
A very great deal better
(7)
A great deal better(6)
Quite a bit better (5)
Moderately better (4)
Somewhat better (3)
A little bit better (2)
A tiny bit better (1)
Please rate any changes in muscle tightness or restriction in the back of the thigh, knee or calf
of the limb treated since you began this treatment until now (check only one):
7)
A very great deal worse (-
About the same (0)
A great deal worse (-6)
Quite a bit worse (-5)
Moderately worse (-4)
Somewhat worse (-3)
A little bit worse (-2)
A tiny bit worse (-1)
A very great deal better
(7)
A great deal better(6)
Quite a bit better (5)
Moderately better (4)
Somewhat better (3)
A little bit better (2)
A tiny bit better (1)
Please rate any changes in muscle performance or fatigue in the back of the thigh, knee or calf
of the limb treated since you began this treatment until now (check only one):
7)
A very great deal worse (-
About the same (0)
A great deal worse (-6)
Quite a bit worse (-5)
85
A very great deal better
(7)
A great deal better(6)
Quite a bit better (5)
Moderately worse (-4)
Somewhat worse (-3)
A little bit worse (-2)
A tiny bit worse (-1)
Moderately better (4)
Somewhat better (3)
A little bit better (2)
A tiny bit better (1)
Investigator/Clinician Notations:
Subject: ____________________
Time: _____
Date: _____
Clinician Initials: _____
86
REFERENCES
1. Davis DS, Ashby PE, McCale KL, McQuain JA, Wine JM. The effectiveness of 3
stretching techniques on hamstring flexibility using consistent stretching
parameters. J Strength Cond Res. 2005; 19(1):27-32.
2. Dick R, Hertel J, Agel J, Grossman J, Marshall SW. Descriptive epidemiology of
collegiate men’s basketball injuries: national collegiate athletic association injury
surveillance system, 1988-1989 through 2003-2004. J Athl Train. 2007; 42(2):194201.
3. Agel J, Olson DE, Dick R, Arendt EA, Marshall SW, Sikka RS. Descriptive
epidemiology of collegiate women’s basketball injuries: national collegiate athletic
association injury surveillance system, 1988-1989 through 2003-2004. J Athl
Train. 2007; 42(2):202-210.
4. Sheffield K, Cooper N. The immediate effects of self-myofascial release on female
footballers. sportEX dynamics. 2013; 38(10):12-17.
5. Witvrouw E, Danneels L, Asselman P, D’Have T, Cambier D. Muscle flexibility
as a risk factor for developing muscle injuries in male professional soccer players.
Am J Sports Med. 2003; 31(1):41-46.
6. Henderson G, Barnes CA, Portas MD. Factors associated with increased
propensity for hamstring injury in English premier league soccer players. J Sci
Med Sport. 2010; 13(4):397-402.
7. Aguilera FJM, Martin DP, Masanet RA, Botella AC, Soler LB, Morell FB.
Immediate effect of ultrasound and ischemic compression techniques for the
treatment of trapezius latent myofascial trigger points in healthy subjects: a
randomized control study. J Mani Phys Thera. 2009; 32(7):515-520.
8. Berggreen S, Wilk E, Lund H. Treatment of myofascial trigger points in female
patients with chronic tension-type headache: a randomized controlled trial. Ad
Physio. 2012; 14:10-17.
9. Bradbury-Squires DJ, Noftall JC, Sullivan KM, Behm DG, Power KE, Button DC.
Roller-massager application to the quadriceps and knee-joint range of motion and
neuromuscular efficiency during a lunge. J Athl Train. 2015; 50(2):133-140.
10. Healey KC, Hatfield DL, Blanpied P, Dorfman LR, Riebe D. The effects of
myofascial release with foam rolling on performance. J Strength Cond Res.
2014;28(1)61-68.
11. Kostopoulos D, Nelson AJ, Ingber RS, Larkin RW. Reduction of spontaneous
electrical activity and pain perception of trigger points in the upper trapezius
muscle through trigger point compression and passive stretching. J Musculo Pain.
2008; 16(4):266-278.
12. MacDonald G, Penney M, Mullaley M, Cuconato A, Drake C, Behm DG, Button
DC. An acute bout of self-myofascial release increase range of motion without a
87
subsequent decrease in muscle activation or force. J Strength Cond Res.
2013;27(3):812-21.
13. MacDonald G, Button DC, Drinkwater EJ, Behm DG. Foam rolling as a recovery
tool after an intense bout of physical activity. Med Sci Sports Exerc.
2014;46(1):132-42.
14. Mohr AR, Long BC, Goad CL. Effect of foam rolling and static stretching on
passive hip-flexion range of motion. J Sports Rehabil. 2014; 23:296-299.
15. Nambi GS, Sharma R, Inbasekaran D, Vaghesiya A, Bhatt U. Difference in effect
between ischemic compression and muscle energy technique on upper trapezius
myofascial trigger points: comparative study. Intl J Health Allied Sci. 2013;
2(1):17-22.
16. Pearcey G, Bradbury-Squires DJ, Kawamoto JE, Drinkwater EJ, Behm DG, Button
DC. Foam rolling for delayed-onset muscle soreness and recovery of dynamic
performance measures. J Athl Train. 2015; 50(1):5-13.
17. Shah N, Shah N. Comparison of two treatment techniques: muscle energy
technique and ischemic compression of upper trapezius trigger point in subjects
with non-specific neck pain. Intl J Thera and Rehabil Res. 2015; 4(5):260-264.
18. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point
Manual: Lower Extremities. Vol 2. Philadelphia, PA: Lippincott Williams &
Wilkins; 1993.
19. van Wilgen P, van der Noord R, Zwerver J. Feasibility and reliability of pain
pressure threshold measurements in patellar tendinopathy. J Sci Med Sport.
2011;14:477-481.
20. Krause F, Wilke J, Neiderer D, Vogt L, Banzer W. Acute effects of foam rolling
on passive tissue stiffness and fascial sliding: study protocol for a randomized
controlled trial. Trials. 2017; 18 (114).
21. Kamper SJ, Maher CG, Mackay G. Global rating of change scales: a review of
strengths and weaknesses and considerations for design. J Man Mani Thera.
2009;17(3):163-170.
22. Drakos MC, Domb B, Starkey C, Callahan L, Allen AA. Injury in the national
basketball association: a 17-year overview. Sports Health. 2010;2(4):284-290.
23. Opar DA, Williams MD, Shield AJ. Hamstring strain injuries: factors that lead to
injury and re-injury. Sports Med. 2012; 42(3):209-226.
24. Meyers TW. The anatomy trains. J Bodyw Mov Ther 1997; 1:91-101.
25. Meyers TW. The anatomy trains: part 2. J Bodyw Mov Ther. 1997; 1:135-145.
26. Cruz-Montecinos C, Gonzalez Blanche A, Lopez Sanchez D, Cerda M, SanzanaCuche R, Cuesta-Vargas A. In vivo relationship between pelvis motion and deep
fascia displacement of the medial gastrocnemius: anatomical and functional
implications. J Anat. 2015; 227(5):665-672.
88
27. Wilson GJ, Newton RU, Murphy AJ, Humphrines BJ. The optimal training load
for the development of dynamic athletic performance. Med Sci Sports Exerc. 1993;
25(11):1279-1286.
28. Esola MA, McClure PW, Fitzgerald GK, Siegler S. Analysis of lumbar spine and
hip motion during forward bending in subjects with and without a history of low
back pain. Spine. 1996; 21:71-78.
29. Van Dillen LR, Gombatto SP, Collins DR, Engsberg JR, Sahrmann SA. Symmetry
of timing of hip and lumbopelvic rotation motion in 2 different subgroups of
people with low back pain. Arch Phys Med Rehabil. 2007; 351-360.
30. Kwon O, Yun M, Lee W. Correlation between intrinsic patellofemoral pain
syndrome in young adults and lower extremity biomechanics. J Phys Ther Sci.
2014; 26(7): 961-964.
31. McHugh MP, Connolly DA, Eston RG, Kremenic IJ, Nicholas SJ, Gleim GW. The
role of passive muscle stiffness in symptoms of exercise-induced muscle damage.
Am J Sports Med. 1999; 27(5): 594-599.
32. Reis FJJ, Macedo AR. Influence of hamstring tightness in pelvic, lumbar and trunk
range of motion in low back pain and asymptomatic volunteers during forward
bending. Asian Spine J. 2015; 9(4): 535-540.
33. Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr Pain
Headache Rep. 2012; 16:439-444.
34. Gerwin RD, Dommerholt J, Shah JP. An expansion of Simons’ integrated
hypothesis of trigger point formation. Curr Pain Headache Rep. 2004. 8:468-475.
35. Xiaoqiang Z, Shusheng T, Qiangmin H. Understanding of myofascial trigger
points. Chin Med J. 2014; 127(24):1-7.
36. Herzog W, Leonard TR, Joumaa, V, Mehta A. Mysteries of muscle contraction. J
Applied Biomech. 2008; 24:1-13.
37. Brückle W, Sückfull M, Fleckstein W, Weiss C, Müller W. Tissue pO2
measurement in taut back musculature (m. erector spinae). Z Rheumatol. 1990;
49(4):208-216.
38. Kraemer WJ, Fleck SJ, Deschenes MR. Exercise Physiology: Integrating Theory
and Application.1st ed. Baltimore, MD and Philadelphia, PA: Lippincott Williams
& Wilkins; 2012.
39. Sluka KA, Kalra A, Moore SA. Unilateral intramuscular injections of acidic saline
produce a bilateral, long-lasting hyperalgesia. Muscle Nerve. 2001; 24:37-46.
40. Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura Ly, Phillips TM, Gerber LH.
Biochemicals associated with pain and inflammation are elevated in sites near to
and remote from active myofascial trigger points. Arch Phys Med Rehabil 2008;
89:16–23.
41. Issberner U, Reeh PW, Steen KH. Pain due to tissue acidosis: a mechanism for
inflammatory and ischemic myalgia? Neurosci Lett. 1996; 208:191-194.
89
42. Hocking MJL. Trigger points and central modulation-a new hypothesis. J
Musculoskeletal Pain. 2010; 18:186-203.
43. Barnes MF. The basic science of myofascial release: morphologic change in
connective tissue. J Bodyw Mov Ther. 1997. 1:231-238.
44. Stecco C, Stern R, Porzionato A, Macchi V, Masiero S, Stecco A, de Caro R.
Hyaluronan within fascia in the etiology of myofascial pain. Surg Radiol Anat.
2011; 33:891-896.
45. Barnes J. Myofascial release. In: Hummer WI, ed Functional Soft Tissue
Examination and Treatment by Manual Methods: New Perspectives. Gaithersburg,
MD: Aspen; 2005:533-548.
46. Shah JP, Phillips TM, Danoff JV, Gerber LH. An in vivo microanalytical
technique for measuring the local biochemical milieu of human skeletal muscle. J
Applied Phys 2005; 99:1977–1984.
47. Cheung K, Hume P Maxwell L. Delayed onset muscle soreness: treatment
strategies and performance factors. Sports Med. 2003; 33(2):145-164.
48. Zachazewski JE. Physical Therapy. Philadelphia, PA: JB Lippincott Co; 1989.
49. Sefton J. Myofascial release for athletic trainers, part 1: theory and session
guidelines. Athl Thera Today. 2004; 9:48-49.
50. Juhan D. Job’s Body. Barrytown, NY. Station Hill Press. 1987.
51. Athensteadt H. Pyroelectric and piezioelectric properties of vertebrates. Ann New
York Acad Sci. 1974; 238:68-110.
52. Moraska AF, Hickner RC, Kohrt WM, Brewer A. Changes in blood flow and
cellular metabolism at a myofascial trigger point with trigger point release
(ischemic compression): a proof-of-principle pilot study. Arch Phys Med Rehabil.
2013; 94(1):196-200.
53. Takamoto, K., Sakai, S., Hori, E., Urakawa, S., Umeno, K., Ono, T., Nishijo, H.
Compression on trigger points in the leg muscle increases parasympathetic nervous
activity based on heart rate variability. J Physiol Sci. 2009; 59:191–197.
54. Takamoto K, Bito I, Urakawa S, Sakai S, Kigawa M. Effects of compression at
myofascial trigger points in patients with acute low back pain: a randomized
controlled trail. Eur J Pain. 2015; 19(8):1186-1196.
55. Simons, D.G. Review of enigmatic MTrPs as a common cause of enigmatic
musculoskeletal pain and dysfunction. J Electromyogr Kinesiol. 2004; 14:95–107.
56. Gulick DT, Palmbaro K, Lattanzi JB. Effect of ischemic pressure using a
Backnobber II device on discomfort associated with myofascial trigger points. J
Bodyw Move Thera. 2011; 15:319-325.
57. Okamoto T, Masuhara M, Ikuta K. Acute effects of self-myofascial release using a
foam roller on arterial function. J Strength Cond Res. 2013; 28(1):69-73.
58. Stecco C, Porzionato A, Lancerotto L Secco A, Macchi V, Day JA, de Caro R.
Histological study of the deep fasciae of the limbs. J Bodyw Mov Ther. 2008;
12:225-230.
90
59. Gabbe BJ, Bennell KL, Wajswelner H, Finch CF. Reliability of common lower
extremity musculoskeletal screening tests. Phys Ther Sport. 2004;5(2):90–97.
60. Connor S, McCaffrey N, Whyte E, Moran K. Reliability of a modified active knee
extension test for assessment of hamstring flexibility. Int. J Athl Train Threa.
2015; 20(4):32-36.
61. Ravichandran P, Ponni HK, Aseer P. Effectiveness of ischemic compression
trapezius myofascial trigger points in neck pain. Int J Physiother. 2016; 3(2):186192.
62. Kinser AM, Sands WA, Stone M. Reliability and validity of a pressure algometer.
Journal of Strength and Conditioning Research. 2009; 23(1): 312-314.
63. Chesteron, LS, Sim J, Wright CC, Foster NE. Interrater reliability of algometry in
measuring pressure pain thresholds in healthy humans, using multiple raters. Clin
J. Pain. 2007; 23(9):760-766.
64. Persson AL, Brogårdh C, Sjölund BH: Tender or not tender: test-retest
repeatability of pressure pain thresholds in the trapezius and deltoid muscles of
healthy women. J Rehabil Med. 2004; 36:17–27.
65. Nussbaum EL, Downes L. Reliability of clinical pressure-pain algometric
measurements obtained on consecutive days. Physical Therapy. 1998;78:160-169.
66. Fabio, A. Pressure algometry in healthy subjects: Inter-examiner variability. Scand
J. Rehab. 1998; 30(1):3-8.
67. Rodrıguez-Rosell, D, Mora-Custodio, R, Franco-Marquez, F, Ya ´n ˜ez-Garcı ´a,
JM, Gonzalez-Badillo, JJ. Traditional vs. sportspecific vertical jump tests:
reliability, validity, and relationship with the legs strength and sprint performance
in adult and teen soccer and basketball players. J Strength Cond Res 2017;31 (1):
196–206.
68. Johnson DL, Bahamonde R. Power output estimate in university athletes. J
Strength Cond Res. 1996; 10(3):161-166.
69. Balmer J. Peak power predicts performance power during an outdoor 16.1 km
cycling time trial. Med Sci Sports Exerc. 2000; 32(8):1485-1490.
70. Maratos FA, Duarte J, Barnes C, McEwan K, Sheffield D, Gilbert P. The
physiological and emotional effects of touch: Assessing a hand-massage
intervention with high self-crtics. Psych Res. 2017;250:221-227.
71. Norris CM, Matthews M. Inter-tester reliability of a self-monitored active knee
extension test. J Body Move Thera. 2005; 9:256-259.
72. Jaeschke R, Singer J, Guyatt GH. Measurement of health status: ascertaining the
minimal clinically important difference. Control Clin Trials. 1989:407-415.
73. Fritz JM, Irrgang JJ. A comparison of a modified Oswestry Low Back
Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther. 2001;
81(2):776-788.
91
74. Vela LI, Denegar CR. The Disablement in the Physically active Scale, part II: the
psychometric properties of an outcomes scale for musculoskeletal injuries. J Athl
Train. 2010; 45(6): 630-641.
75. Wang WC, Wu SL. The random-effect generalized rating scale model. J Ed
Measure. 2011;48(4):441-456.
76. Simons D, Travell J, Simons L. Myofascial Pain and Dysfunction: The Trigger
Point Manual: Upper Extremities. Vol 1. Baltimore, MD: Williams & Wilkins;
1999.
77. Murray A, Jones T, Horoleanu C, Turnea A, and Sprole J. Sixty seconds of foam
rolling does not affect functional flexibility or change muscle temperature in
adolescent athletes. Int J Sport Phys Thera. 2016; 11(5):765-776.
78. Couture G, Karlik D, Glass S, Hatzel B. The effect of foam rolling duration on
hamstring range of motion. Open Ortho J. 2015; 9(1):450-455.
79. Kim SA, Oh KY, Choi WH, Kim IK. Ischemic compression after trigger point
injection affect the treatment of myofascial trigger points. Ann Rehabil Med. 2013;
37(4):541-546.
80. Jagad BH, Jagad KB. Effects of ischemic compression on the trigger points in the
upper trapezius muscle. Ind J Physiothera Occup Thera. 2013; 7(1):99-104.
81. Stratford PW, Binkley JM, Solomon P, Gill C, Finch E. Assessing change over
time in patients with low back pain. Phys Thera. 1994; 74:528-533.
82. Romero-Moraleda B, La Touche R, Luma-Lara S, Fener-Peña R, Paredes V,
Belin-Peinado A, Muñoz-García D. Neurodynamic mobilization and foam rolling
improved delayed-onset muscle soreness in a healthy adult population: a
randomized controlled clinical trial. Peer J. 2017; 5(3908):1-18.
92
TREATMENT OF HAMSTRING TIGHTNESS
By
Nathan P. Sheneberger, B.A.
Bethel University
A Thesis Submitted in Partial Fulfillment of
the Requirements of the Degree of Master of Science in Athletic Training
to the office of Graduate and Extended Studies of
East Stroudsburg University of Pennsylvania
May 10, 2019
SIGNATURE/APPROVAL PAGE
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ABSTRACT
A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master
of Science in Athletic Training to the office of Graduate Extended Studies of East
Stroudsburg University of Pennsylvania
Student’s Name: Nathan Sheneberger
Title: A Comparison of Foam Rolling and Ischemic Compression in Treating Hamstring
Tightness
Date of Graduation: May 10, 2019
Thesis Chair: Kelly Harrison, Ph.D.
Thesis Member: Gerard Rozea, Ph.D.
Thesis Member: Keith Vanic, Ph.D.
Abstract
Both foam rolling (FR), and ischemic compression (IC) have been shown to be
effective in treating muscle tightness, but the literature lacks studies comparing them.
This study was a crossover design consisting of 11 healthy NCAA Division II and III
collegiate basketball players. Subjects underwent, in a randomized order, 3 treatments: 1)
2x90s trials of FR, 2) 3x30-60s of IC and 3) No treatment; with a 1-week period between
each treatment. Variables measure pre and post treatment were: active hamstring range of
motion (ROM), pain-pressure threshold (PPT), vertical jump height (VJ), and peak power
output (PPO). A global rate of change survey (GROC) was given to measure the subject’s
perceived effect of the treatment. This study found, following each of the three
treatments, a significant increase in ROM, VJ, and PPO. The improvement recorded in
ROM, VJ and PPO does not appear to be the result of FR or IC.
KEY WORDS: foam rolling, ischemic compression, hamstring, myofascial release
TABLE OF CONTENTS
ABSTRACT
TABLE OF CONTENTS..................................................................................................i
LIST OF TABLES .......................................................................................................... v
LIST OF FIGURES .......................................................................................................vii
ABBREVIATION LIST .............................................................................................. viii
CHAPTER 1.................................................................................................................... 1
Background to the Problem .................................................................................. 1
Statement of the Problem ..................................................................................... 1
Purpose of the Study ............................................................................................ 2
Significance of the Study ..................................................................................... 2
Research Design .................................................................................................. 2
Research Question ............................................................................................... 3
Null Hypotheses ................................................................................................... 3
Directional Hypothesis ......................................................................................... 3
Limitations ........................................................................................................... 3
Delimitations ....................................................................................................... 4
Assumptions ........................................................................................................ 5
Definition of Terms.............................................................................................. 6
Expected Findings ................................................................................................ 7
CHAPTER 2.................................................................................................................... 9
Introduction ......................................................................................................... 9
i
Presentation of Symptomatology ........................................................................ 11
Myofascia ............................................................................................... 13
Thixotropy.............................................................................................. 15
Treatment Interventions ..................................................................................... 16
Mechanism of Intervention................................................................................. 17
Foam Rolling.......................................................................................... 17
Ischemic Compression ............................................................................ 19
Intervention Options .......................................................................................... 21
Assessing Treatment Effectiveness..................................................................... 21
Flexibility-Active Knee Extension .......................................................... 21
Pressure Sensitivity-Pain-Pressure Threshold ......................................... 22
Jump Performance-Vertical Jump and Peak Power Output...................... 23
Vertical Jump.............................................................................. 23
Peak Power Output ..................................................................... 23
Perceived Effectiveness-Global Rate of Change Survey.......................... 24
Conclusions ....................................................................................................... 25
CHAPTER 3.................................................................................................................. 26
Purpose of the Study .......................................................................................... 26
Research Design ................................................................................................ 26
Target Population and Participant Selection ....................................................... 27
Participants ........................................................................................................ 27
Procedures ......................................................................................................... 28
ii
Measurements ........................................................................................ 29
Active Knee Extension ................................................................ 29
Pain-Pressure Threshold.............................................................. 30
Vertical Jump.............................................................................. 32
Peak Power Output ..................................................................... 33
Global Rate of Change ................................................................ 33
Instruments ............................................................................................. 34
Intervention ............................................................................................ 35
Foam Rolling .............................................................................. 35
Ischemic Compression ................................................................ 36
Control........................................................................................ 38
Data Analysis ..................................................................................................... 38
CHAPTER 4.................................................................................................................. 39
Results ............................................................................................................... 39
Participant Demographics ....................................................................... 39
Comparison Among Time and Myofascial Release Techniques on Active
Knee Extension ........................................................................... 40
Comparison Among Time and Myofascial Release Techniques on PainPressure Threshold ...................................................................... 44
Comparison Among Time and Myofascial Release Techniques on Peak
Vertical Jump Height .................................................................. 48
Comparison Among Time and Myofascial Release Techniques on Peak
Power Output During Vertical Jump ........................................... 52
Comparison Among Myofascial Release Techniques on Global Rate of
Change Ranks Scores .................................................................. 56
iii
CHAPTER 5.................................................................................................................. 60
Introduction ....................................................................................................... 60
Discussions for Range of Motion on Performance .............................................. 60
Discussions for Pain-Pressure Threshold ............................................................ 64
Discussions for Vertical Jump Height ................................................................ 66
Discussions for Peak Power Output During Vertical Jump ................................. 68
Discussions for Global Rate of Change .............................................................. 69
Summary ........................................................................................................... 71
Findings ............................................................................................................. 72
Conclusions ....................................................................................................... 73
Recommendations for Future Research .............................................................. 73
APPENDICES............................................................................................................... 75
REFERENCES .............................................................................................................. 87
iv
LIST OF TABLES
Table 4.1: Demographics ............................................................................................... 40
Table 4.2: Summary of mean active knee extension produced before and after
varying myofascial release techniques ......................................... 41
Table 4.3: One-way ANOVA with repeated measures of time for active knee
extension..................................................................................... 42
Table 4.4: Mean differences within subjects measures of time on active knee
extension..................................................................................... 42
Table 4.5: One-way ANOVA with repeated measures of treatment technique for
active knee extension .................................................................. 43
Table 4.6: One-way ANOVA with repeated measures of interaction between time
and treatment technique for active knee extension ....................... 44
Table 4.7: Summary of mean pain-pressure threshold readings produced before
and after varying myofascial release techniques .......................... 45
Table 4.8: One-way ANOVA with repeated measures of time for pain-pressure
threshold ..................................................................................... 46
Table 4.9: One-way ANOVA with repeated measures of treatment technique for
pain-pressure threshold ............................................................... 47
Table 4.10: One-way ANOVA with repeated measures of interaction between
time and treatment technique for pain-pressure threshold ............ 48
Table 4.11: Summary of mean peak vertical jump heights produced before and
after varying myofascial release techniques ................................. 49
Table 4.12: One-way ANOVA with repeated measures on time for peak vertical
jump height ................................................................................. 50
Table 4.13: Mean differences within subject measures of time on peak vertical
jump height ................................................................................. 51
Table 4.14: One-way ANOVA with repeated measure on treatment technique for
peak vertical jump height ............................................................ 51
v
Table 4.15: One-way ANOVA with repeated measure on the interaction between
time and treatment technique for peak vertical jump height ......... 52
Table 4.16: Summary of peak power outputs produced before and after varying
myofascial release techniques ..................................................... 53
Table 4.17: One-way ANOVA with repeated measures on time for peak power
output ......................................................................................... 54
Table 4.18: Mean differences within subjects measures of time on peak power
outputs ........................................................................................ 55
Table 4.19: One-way ANOVA with repeated measures on treatment technique for
peak power output....................................................................... 55
Table 4.20: One-way ANOVA with repeated measures on the interaction between
time and treatment technique for peak power output.................... 56
Table 4.21: Summary of mean global rate of change rank scores for differing
variables ..................................................................................... 57
Table 4.22: Summary of mean global rate of change rank scores for perceived
muscle pain, tightness and fatigue after different myofascial
release techniques ....................................................................... 59
Table 4.23: Summary of mean global rate of change scores for perceived muscle
pain, tightness and fatigue after different myofascial after different
myofascial release techniques ..................................................... 59
vi
LIST OF FIGURES
Figure 3.1: Active Knee Extension ................................................................................ 30
Figure 3.2: Pain-Pressure Threshold .............................................................................. 32
Figure 3.3: Vertical Jump .............................................................................................. 33
Figure 3.4: Foam Rolling ............................................................................................... 36
Figure 3.5: Ischemic Compression ................................................................................. 38
Figure 4.1: Mean active knee extension before and after varying myofascial
release techniques ....................................................................... 41
Figure 4.2: Mean pain-pressure threshold readings produced before and after
varying myofascial release techniques ......................................... 46
Figure 4.3: Mean peak vertical jump height produced before and after varying
myofascial release techniques ..................................................... 50
Figure 4.4: Mean peak vertical jump height produced before and after varying
myofascial release techniques ..................................................... 54
Figure 4.5: Mean global rate of change rank scores for differing variables ..................... 58
vii
ABBREVIATION LIST
ACh .... ........................................................................................................ Acetylcholine
AChE . ................................................................................................. Aceytelcholinease
AChR . ........................................................................................ Acetylcholine Receptors
ADL ... ...................................................................................... Activities of Daily Living
AKE ... .......................................................................................... Active Knee Extension
ANOVA ........................................................................................... Analysis of Variance
AROM ........................................................................................ Active Range of Motion
ATP.... ........................................................................................... Adenine Triphosphate
CGRP . ........................................................................... Calcitonin Gene-Related Peptide
cm ...... ........................................................................................................... Centimeters
CON ... .................................................................................................................. Control
DOMS .......................................................................... Delayed On-Set Muscle Soreness
EPP .... ....................................................................................... Expanded Polypropylene
FR ...... ........................................................................................................ Foam Rolling
GROC .......................................................................................... Global Rate of Change
IC ....... .......................................................................................... Ischemic Compression
in ........ .................................................................................................................... Inches
kg ....... ............................................................................................................. Kilograms
kgf ...... ............................................................................................... Kilograms of Force
kPa/s... ........................................................................................ Kilo Pascals per Second
lbf....... .................................................................................................... Pounds of Force
viii
MET ... ..................................................................................... Muscle Energy Technique
MRT... ............................................................................. Myofascial Release Techniques
MTrP(s).................................................................................. Myofascial Trigger Point(s)
N ........ ................................................................................................................ Newtons
NBA ... ............................................................................ National Basketball Association
NCAA ............................................................... National Collegiate Athletic Association
NRS ... ......................................................................................... Numerical Rating Scale
ozf ...... .................................................................................................... Ounces of Force
PFPS .. .............................................................................. Patellofemoral Pain Syndrome
PPO .... ................................................................................................ Peak Power Output
PPT .... ........................................................................................ Pain-Pressure Threshold
PRO ... ........................................................................................ Patient-Rated Outcomes
ROM .. .................................................................................. Hamstring Range of Motion
sd........ ................................................................................................ Standard Deviation
SLR .... ................................................................................................... Single-Leg Raise
VJ ....... .................................................................................... Peak Vertical Jump Height
W ....... .....................................................................................................................Watts
ix
CHAPTER 1
INTRODUCTION
BACKGROUND TO THE PROBLEM
The hamstring muscles are a commonly strained because these muscles cross
multiple joints and are involved in controlling movements at both the hip and the knee
joints.1 An epidemiological study done by the NCAA showed that 1% of
recorded injuries in games for male and female basketball players were hamstring
strains,2,3 but in practice hamstring injury rate increased to 4-5%.2,3 It has been reported
that limited flexibility may predispose a person to musculoskeletal injuries.4-6 There are
many techniques that have been developed to help and treat muscular tightness. These
techniques can be broken down into two categories: self-release and clinician-release.
Both techniques have significant amounts of literature backing their effectiveness,4,7-17
but there is minimum research directly comparing the efficacy self-release techniques and
clinician-release techniques.
STATEMENT OF THE PROBLEM
Numerous studies have investigated the use of self-release techniques4,9,10,12-14 and
clinician-release techniques.11,15,16,17 In providing high quality care to patients, healthcare
1
professionals are bound by both time and money. With the breadth of literature
supporting both techniques, clinicians need to know if there is a more efficacious choice.
Is self –release techniques or clinician-release techniques better at treating muscle
tightness?
PURPOSE OF THE STUDY
The purpose of this study was to compare the acute effects of two
myofascial release techniques on muscle flexibility, soreness, and performance. The
technique used for the self-release was Foam Rolling (FR). The technique used for the
clinician-release was Ischemic Compression (IC).A third non-treatment trial was also
used as a control condition (CON).
SIGNIFICANCE OF THE STUDY
This study supported the use of myofascial release and provided guidance in
determining the efficacy of the techniques in their ability to treat muscle tightness.
RESEARCH DESIGN
This study employed a 2 x 3 repeated measures cross-over design. The study
design allowed for the participants to be their own control. The variables measured were
active hamstring range of motion (ROM), pain-pressure threshold (PPT), vertical jump
(VJ) peak power output (PPO) and global rate of change (GROC).
Data was collected before and immediately after each treatment for ROM, PPT,
VJ and PPO. GROC data was collected immediately after the treatment. A repeated
measures design was used to assess for changes in the dependent variable under each
intervention condition. There was at least a 7-day washout period between each treatment
2
which allowed ample time for any lingering effects from the previous treatment to have
subsided. The same clinician performed all the variable measurement to minimize any
difference in measuring.
The data collected was analyzed using a 2x3 ANOVA for ROM, PPT, PPO, and
VJ. The data collected from GROC was analyzed using a Kruskal Wallis and Chi squared
test.
RESEARCH QUESTION
Is there a difference in treatment effect between pre and post testing for FR, IC,
and no treatment (CON) on hamstring ROM, PPT, VJ, PPO and GROC?
NULL HYPOTHESES
For the purposes of statistical analyses, it was hypothesized that:
1. There is no significant difference among FR, IC, and CON in increasing ROM.
2. There is no significant difference among FR, IC, and CON in increasing PPT.
3. There is no significant difference among FR, IC and CON in increasing VJ.
4. There is no significant difference among FR, IC and CON in increasing PPO.
5. There is no significant difference among FR, IC and CON in increasing GROC.
DIRECTIONAL HYPOTHESIS
1. Both FR and IC will be clinically significant in increasing ROM, PPT, PPO, VJ
and GROC when compared to get CON.4,7-17
LIMITATIONS
The following factors could not be controlled and may have affected the accuracy
and generalizability of the data collected in this study.
3
1. This study utilized a small homogeneous sample of convenience and therefore
limiting the external validity of the study.
2. The study relied on self-reporting of potential confounding factors such as
abstaining from the use of over-the-counter or prescription pain relieving
medications.
3. The subjects in this study were concurrently engaged in in-season basketball
activities. This potentially put them at greater risk for injury or the introduction of
confounding factors associated with competitive play.
4. Participants were not screened prior to acceptance into the study for MTrPs. Thus
the presence of MTrPs was not guaranteed and the results could be skewed
because of the absence of MTrPs.
5. Data collected for this study was completed at two different facilities with two
different clinicians delivering the interventions. Although specific treatment
protocols were provided and practiced by both clinicians there is the potential that
the interventions delivered at both sites were not equal.
6. The pelvis and spine were not stabilized during AKE thus limiting the accuracy
and reliability of the measurements.
7. Body weight values used for calculating PPO were obtained from the subjects’
pre-participation sports screening collected prior to the study thus reducing the
accuracy of this calculation.
DELIMITATIONS
This study was delimited to the following participants and conditions:
4
1. NCAA Division II and III Men’s and Women’s Basketball student-athletes at 2
colleges in northeastern Pennsylvania
2. Subjects had to be free of lower extremity injuries during and for 6 months prior
to the start of the study.
3. Subjects reporting a history of psychiatric, cardiovascular, endocrine,
neurological or metabolic disorders were excluded.
4. Subjects in the study were instructed to refrain from consuming, alcohol, nicotine,
analgesics or pain relievers 48 hours prior to testing as these substances can alter
pain perception and physical performance.
ASSUMPTIONS
Several assumptions guided this study:
1. Subjects would tell the truth about their health history.
2. Subjects refrained from consuming alcohol, analgesics, pain relievers or other
illicit drugs.
3. Subjects communicated truthfully about levels of pain, stretch or
improvements.
4. Subjects were consistent in their answers no matter the treatment received.
5. Subjects put forth maximal effort in treatments and in measurements.
6. Subjects did not have any additional treatment affecting hamstring flexibility,
tightness or function beyond what is typically done as part of their inseason training program.
5
DEFINITION OF TERMS
Myofascial Release: Manual therapy technique that helps to reduce restrictive barriers or
fibrous adhesions seen between layers of fascial tissue.12
Ischemic Compression: Application of sustained pressure on a myofascial trigger point
with the intent of decreasing muscle tenderness and tension.18
Trigger Point: “A focus of hyperirritability in a tissue that, when compressed, is locally
tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness, and
sometimes to referred autonomic phenomena and distortion of proprioception.”18
Algometer: An instrument that measures the application of pressure and evoking of pain
to the skin and underlying tissues in N.19
Foam Rolling: The use of body weight on a foam roller to create pressure on the
opposing body tissue.20
Vertical Jump: the vertical distance between the highest vane tapped during the standing
vertical reach and the vane tapped at the highest point of the jump.10
Peak Power Output: the maximum amount of force produced by a participant during a
vertical jump10
Global Rate of Change: A 3-question survey used to quantify a patient’s improvement or
deterioration over time, to determine the effect of an intervention. GROC scales ask that a
person assess his or her current health status, recall that status prior to treatment, and then
select from a list of rating one that most accurately reflects the change in symptom.
GROC scale used for this study was a standard 15-point scale.21
6
Pain Pressure Threshold: The lowest amount of pressure needed to elicit pain using
an algometer measuring in the units of N.19
Active Knee Extension: the upward movement of the lower leg from 90 degrees of knee
flexion to full knee extension at 180 degrees. This is measured by a goniometer, starting
from a position of 90 degrees of knee flexion and 90 degrees of hip flexion while lying
supine until slight discomfort is felt with the hip position unchanged and the foot
relaxed.4
Active Range of Motion: The extent of movement (usually expressed in degrees) of an
anatomical segment at a joint. The movement should be caused only by voluntary effort
to move the body part being tested.18
Injury: not being able to participate in training or competition for at least 7 days.4
Active varsity player: participant holds a spot on the team's current varsity roster.
EXPECTED FINDINGS
•
It is expected that there will be a significant difference in ROM with FR when
compared to CON.4,9,12-14
•
It is expected that there will be a significant difference in PPT with FR when
compared to CON.16
•
It is expected that there will be a significant difference in VJ with FR when
compared to CON.13
•
It is expected that there will be a significant difference in PPO with FR when
compared to CON.16
7
•
It is expected that there will be a significant difference in GROC with FR when
compared to CON.13
•
It is expected that there will be a significant difference in ROM with IC when
compared to CON.7,15,17
•
It is expected that there will be a significant difference in PPT with IC when
compared to CON.7,11,17
•
It is expected that there will be a significant difference in GROC with IC when
compared to CON.17
8
CHAPTER 2
REVIEW OF LITERATURE
INTRODUCTION
This study specifically focused on muscle tightness of the hamstrings in
basketball players. Other studies have examined hamstring tightness10,14 in soccer
players4-6 but few studies have looked at the impact of hamstring
tightness on basketball players, even though the prevalence of hamstring injuries has
been documented by both the NCAA2,3 and the NBA.22,23 In the NCAA,
hamstring injuries for men and women were 1% of all injuries in games and 4-5% of all
the injuries recorded in practice.2,3 In the NBA, hamstring injuries accounted for 3.3% of
all recorded injuries.23 Because of the data found in the NCAA and NBA, hamstring
injuries are shown to be a problem. Muscle tightness, sprinting, and the eccentric
contraction of the hamstrings during deacceleration while running can make it more
vulnerable to muscle straings.23
Hamstring flexibility has been shown to be a factor in the onset of hamstring
injuries in athletics.4-6 Hamstring flexibility is defined, for this study, as the ability of the
hamstring to lengthen allowing for the knee, hip and back to move through their range of
9
motion. Hamstring flexibility can be influenced by joint capsule and soft tissue
restrictions.24,25
Thomas Myers in his Anatomy Trains24,25 book identify several myofascial or
connective tissue lines throughout the body. The hamstrings are a part of the straight back
fascial line (SBL). The SBL is a line of fascia shown by Meyers et al24,25 to run from the
plantar fascia to the cranium. The SBL runs through the Achilles tendon, gastrocnemius,
hamstrings, sacrotuberous ligament (STL) and erector spinae which connects to the
cranium. The hamstrings and STL connect at the ischial tuberosity. Since the hamstrings
are a part of the SBL, if the hamstrings are tight it affects the mechanics of other joints
and muscles.24-26
A study by Cruz-Monetecinos et al26 showed the amount of pelvic motion allowed
affected the amount of force transferred between the gastrocnemius and the hamstrings. If
the hamstrings do not allow for adequate pelvic motion it affects force distribution and
the biomechanics of the body26 this can lead to an increased chance of overuse injuries,
muscle strains and ligament sprains.6
Hamstring tightness can influence the biomechanics of the body as well as
performance. In collegiate basketball, players need to have the ability to sprint,
explosively cut and jump without hindrance from muscle tightness. If hamstring tightness
does not allow for the ability to perform the movements properly a decrease in
performance is likely to occur.27 Wilson et al27 provided evidence that a decrease in the
active tightness of a muscle will increase the force production during a vertical jump.
10
Another factor that can influence performance but is also influenced by hamstring
tightness is pain. The pain may manifest itself in the hamstrings or in other areas of the
body such as the low back or knees.6,28-31 A study done by Esola et al28 showed that
participants with low back pain had decreased hip motion but increased lumbar motion. It
has been postulated that a decrease in hip motion caused by hamstring tightness increases
the stress put on the lumbar spine leading to an increase in pain and potential injury.28,29
Another study looking at the effects of hamstring tightness on patella femoral pain
syndrome (PFPS) showed a strong correlation between the presence of PFPS and
hamstring tightness.30 Giving evidence that hamstring tightness may predispose an
individual to developing PFPS.30 A different study conducted by Henderson et al6
focused on the prevalence of hamstring injuries in English Premier League Soccer
players and their correlation to multiple factors. A correlation between hamstring injury
and tightness was found.6 The study showed that for every degree loss of active hip
flexion increased the odds of hamstring injury by 1.296. Another factor that has been
shown to affect hamstring tightness and pain are MTrPs.
PRESENTATION OF SYMPTOMATOLOGY
MTrPs are thought to be caused by either a chronic overuse injury or by
nociceptive input.33-35 Some factors which can influence the formation of MTrPs are type
of stresses and the external environment the muscle is in. MTrPs have been commonly
found in individuals who do have to sustain postures for long periods of time and/or
repeatedly perform maximal or submaximal concentric and/or eccentric exercises.33,34,36
11
It is theorized the sustaining or repeating a movement or exercise affects the interstitial
environment and function of the cell.
Several factors, in the local cellular environment, are thought to contribute to the
development of MTrPs. Theory being, is that muscle exertion at too high of level or
sustained for too long can result in local hypoxemia causing a cascade of reactions. The
reactions are theorized to look similar to this: a muscle’s demand for oxygen exceeds its
immediate availability37, triggering anaerobic glycolysis which produces an inadequate
amount of ATP and lactic acid (LA) as a byproduct33,38. The decreased supply of ATP
causes the muscle to spasm34,39, increasing the metabolic crisis and production of LA33,38.
The body can remove LA from the local environment33, but if the rate of
production is greater than rate of removal it accumulates in the tissue resulting in a
lowering of pH.33,40,41 A lower interstitial pH can increase muscle tenderness by
decreasing the nociceptor threshold33. The nociceptor threshold is decreased in two ways:
an increased production of calcitonin gene-related peptide (CGRP) and an increased
regulation of aceytelcholinease (AChE)33. CGRP is a compound that elevates two things:
the release of acetylcholine (ACh) and the production of acetylcholine receptors
(AChR)33. Meaning there is a greater ability for ACh to bind and produce a nociceptive
message resulting in a perceived area of tenderness42.
AChE is an enzyme that helps to moderate nociceptor substances, specifically
ACh33. With an increased regulation of AChE there is an increased efficiency for ACh to
produce a nociceptive message, resulting in a perceived area of tenderness33. The result
12
within the muscle is two-fold: an area of palpable tightness and increased muscle
tenderness.
MYOFASCIA
Fascia surrounds every part of our body. There are multiple layers of fascia that
surround a muscle. Fascia consists of connective tissue cells and fibers surrounded by a
gelatinous ground substance.43 This ground substance which surrounds the fascial cells
and fibers is made of water, hyaluronic acid and other glycosaminoglycans which allows
these elements to easily slide and slide across one another enabling free and unrestricted
movement.43,44 However, trauma, inflammation and/or disease can alter fascial tissue and
the molecular composition of the ground substance reducing its viscosity and restricting
movement. Scar tissue or extra connective tissue is laid down following the injury
forming adhesions between the skin and muscle. It is theorized, the adhesions restrict
normal function and movement of the fascial layers, skin and muscle.45 The adhesion
could possibly cause local dehydration, ischemia, pain, loss of ROM, decreased
performance or MTrP.45 Soft tissue mobilization techniques such as FR and IC have been
theorized to produce a variety of effects to the muscle and fascial tissues. These effects
can be generally divided into the mechanical and neurophysiological models.
The mechanical models theorize that the material properties of fascia are affected
by the pressure exerted through FR and IC which in turn alters the viscoelastic properties
of the fascia.12 Many theories have been proposed as to the mechanisms which cause this
change in property: thixotropy, piezoelectricity, plastic deformation. 40,43,46-48
13
Mechanically compressing the tissue either via a FR or IC is likely to engage the
thixotropic property of fascia resulting in greater ease of movement. 49 This is achieved
because fascia is colloidal in nature and when energy through compression is applied to
the tissue the fascia becomes more viscous thus allowing for a greater ease of
movement.43,50
Both FR and IC can potentially cause a piezoelectric effect within the tissues
because the mechanical force applied during treatment. A mechanical change in muscle
whether by changing length or deformation is theorized to modify the pizioelectric effect
of the body.43,51 Whether this change in charge is enough to significantly alter tissue
physiology and yield some benefit is still unknown.43,51
Another mechanical mechanism that is theorized to occur is plastic deformation
of the fascia. Plastic deformation is a low-grade sustained deformation force to collagen
rich tissues which in turn yields changes to the stress-strain cycle.43 The stress-strain
cycle is a model to explain how increasing the stress (load) on the muscle increases the
strain (deformation) of the muscle. As the stress is sustained the muscle loses its original
shape and in response will tighten up to protect the muscle. For the muscle to return to its
original shape outside forces need to be applied; (i.e. FR or IC) these will cause the
muscle to relax and soften.48
Along with the mechanical effects, compression of a MTrP has shown to have
neurophysiological effects as well. Some of the effects that have been studied are the
alteration of nociceptor thresholds via pain gating, possible alteration of the interstitial
chemistry and reprogramming of the nervous system. Studies by Aguilera et al7 and Shah
14
et al17 showed, following treatments of compression on MTrPs, the nociceptor or painpressure threshold was increased. With a greater threshold for pain muscles may move
more freely without the inhibition of pain.
Following compression on a MTrP a study by Morsaka et al52 found the
interstitial environment had changed. Increased amounts of lactate and glucose were
documented in the area following the treatment. The increased availability of glucose is
likely from an increase in blood flow to the area, providing an increase in substrate
availability to muscle.40,46,52 With the increase in nutrients to the area muscles can
function properly resulting in less tension in the area. The decrease in muscle tension,
subsequently decreases the tension on the nerves allowing for an uninhibited flow of
neural signals.
Compression at a MTrP has also been shown to increase parasympathetic nervous
activity.53 An increase in parasympathetic nervous activity is theorized to block the
release of ACh.54 A more regulated release of ACh, is theorized to increase the
nociceptor threshold of the muscle, allowing for proper muscle function.40,46,55
THIXOTROPY
Thixotropy of fascia is defined as a change in energy in the fascia which causes a
change of properties for a solid state to a more fluid state.12,43 This is achieved through
the friction caused by the posterior thigh moving on top of the roam roller. It is theorized,
due to the deformation of the fascia that MTrPs will be relived.12
15
TREATMENT INTERVENTIONS
Direct soft tissue mobilization techniques such as, petrissage (kneading),
compression, and gliding, have been used by clinicians to treat symptoms of muscle
tightness since ancient times.26 The type of direct soft tissue mobilization presented in
this review will focus on myofascial release techniques (MRT). MRT is a soft tissue
mobilization technique that uses moderate to deep pressure delivered manually by a
clinician or self-administered using a device such as a foam roller. MRT attempt to
reduce restrictive barriers and adhesions within fascial tissue.43 Some of the
physiological properties MRT utilizes are friction, ischemia and thixotropy. The
application of these properties causes mechanical and physiological changes to the
muscle which help resolve MTrPs. The different MRT can be broken down into two
categories, self-release and clinician-release.
Studies by MacDonald et al12 and Mohr et al14 showed self-MRT’s effectiveness
in decreasing muscle tenderness. These findings were supported by Bradbury et al.9
Using a machine operated roller stick, Bradbury et al9 was also able to decrease muscle
stiffness while increasing neuromuscular recruitment. Gulick et al56 using self-IC by a
Backnobber II tool and was able to decrease muscle stiffness and tenderness of the neck
musculature. Studies by McDonald et al12 and Pearcey et al16 provided evidence MRT
was able to decrease muscle tightness and tenderness while improving performance
during a vertical jump. Two of the most commonly used MRT to decrease muscle
tightness and tenderness while improving muscle performance are FR, a self-release
technique, and IC, a clinician-release technique.
16
MECHANISM OF INTERVENTION
FOAM ROLLING
FR is defined as small movements on a dense foam roller that starts at the
proximal end of the hamstring and works distal or vise-versa.57 While these motions are
being performed, direct pressure is applied on the soft-tissue. The pressure creates
friction and a thixotropic effect of the soft tissue.43,49,50 The thixotropic effect causes a
change in the viscosity of the fascia.57,58 This physiological change of the fascia
increases the extensibility of the fascia through the breaking MTrPs and improving
muscle tightness, tenderness and performance.7,12,15-17
MacDonald 2013 et al12 examined the use of FR as a recovery tool for the lower
extremity. During randomized control trial 20 different male subjects completed an
intense lower body exercise protocol to elicit delayed-onset muscle soreness during 5
separate sessions which were separated by a minimum of 24 hours. After each session the
subjects either received either no foam rolling or a 20-minute foam rolling intervention.
The participants in the FR group foam rolled: immediately, 24 hours post-exercise, 48
hours post exercise, and 72 hours post exercise. The result of this study found that FR
reduced muscle soreness at all the time measurements, improved ROM, and vertical jump
height when compared to the control condition.
Pearcey et al16 examined the effects of FR on muscle recovery in the quadriceps.
During this cross-over design study 8 subjects completed an intense exercise protocol to
elicit delayed-onset muscle soreness during 2 separate sessions scheduled approximately
4 weeks apart. After each session they either received no foam rolling or a 20-minute
17
foam rolling intervention, which was performed immediately, 24, 48 hours post-exercise.
The result of this study found that FR improved muscle soreness and lessened the
detrimental effect of DOMS on sprint times, power, and dynamic strength-endurance
compared to the control condition.
MacDonald et al13 examined the effects of FR on muscle performance of the
quadriceps. During a within-subject design, 11 healthy male subjects underwent 4
different trials with 24-48 hours in between each trial. The trials included: 1) Control
measuring ROM, 2) Control measuring knee extensor force, 3) FR measuring ROM, and
4) FR measuring knee extensor force. Results from the study showed a positive
correlation between FR and knee extension and a negative correlation between force
production and ROM prior to FR which was resolved following FR.
Krause et al20 created a study design which will look the effect of FR on passive
tissue tightness on the quadriceps. The study will employ a crossover design with 16
participants which will undergo 3 different treatments: 1) FR to the quadriceps, 2) passive
static stretch to the quadricep, 3) No intervention. No conclusions were included with the
article since the study was still in the recruiting phase.
The literature had many different protocols for the application of FR. This study
chose to utilize the protocol laid out by Krause et al20 with modifications of extending the
treatment time from 60 seconds to 90 seconds by MacDonald et al13 to keep treatment
times between interventions similar.
18
ISCHEMIC COMPRESSION
IC is defined by Travell et al18 as the “application of progressively stronger
pressure on a trigger point for eliminating the trigger point’s tenderness and
hyperirritability”. IC breaks the cycle of the MTrPs by theoretically changing the
biochemical concentration of inflammatory mediators, neuropeptides, cytokines, and
catecholamines of the environment.39,52 The release of the pressure is thought to causes a
reactive hyperemia of the area.34,44 The change of chemistry and resulting hyperemia
brings in the oxygen and nutrients needed to create ATP and stop the flow of ACh. 34,44
With the MTrPs resolved muscle tightness and/or tenderness would decrease and in
theory performance would improve.7,8,15,17,61
A study by Aguileria et al7 examined the effect of IC and ultrasound for the
treatment of MTrPs in the trapezius muscle. During the randomized control trial 66
healthy individuals were randomly assigned to one of three treatments: IC, ultrasound,
and sham ultrasound. Results from the study showed a decrease in basal electrical activity
and MTrP sensitivity in both of the therapeutic modality groups and an increase in
cervical AROM for the IC treatment group.
A study by Shah et al17 examined the effect of IC and muscle energy technique
(MET) on MTrPs in the upper trapezius muscle. 30 participants, with non-specific neck
pain, were randomly divided into two groups, IC and MET, and received treatment every
day for a week. Results from the study showed a significant improvement in all three of
the outcome measures (PPT, VAS, cervical AROM), for both groups. When comparing
between groups the IC treatment group had a significant improvement in PPT compared
19
to the MET treatment group. The MET treatment group had a significant improvement in
cervical AROM when compared to the IC treatment group.
A study by Nambi et al15 examined the effect of IC and MET on MTrPs in the
upper trapezius muscle. During a quasi-experiment 30 participants with palpable MTrPs
in their upper trapezius were randomly divided into two treatment groups, IC and MET,
and received treatment three times a week for four weeks. Results from the study showed
a statistically significant improvement in both groups for cervical range of motion.
A study by Berggreen et al8 examined the effects of MTrP massage on MTrPs in
the muscles of the head, neck and shoulders. During the randomized control trial 29
females with chronic tension-type headaches were randomly assigned to two groups, the
MTrP massage group or control group. The MTrP massage group received treatment one
time a week for ten weeks. Results from the study showed a significant improvement in
morning pain and the number of trigger points in the MTrP massage treatment group
compared to the control group. None of the previous studies on IC concentrated on lower
extremity performance so it is unknown how IC will affect the VJ performance.
This study compared FR and IC. These two techniques were chosen due to their
low cost, large availability of previous literature, no specialized training needed to
perform the treatments and high rate of use within sports medicine facilities. The methods
which will be used to evaluate each techniques effectiveness is ROM, PPT, PPO, VJ and
GROC. Based on the literature, it can be assumed that FR and IC will have a positive
effect on areas of assessment. The researcher in the reviewing the literature did not find a
20
study comparing these two techniques so it is unknown whether one of the techniques
will be more effective than the other at reducing hamstring tightness.
INTERVENTION OPTIONS
The outside interventions applied to the MTrPs are IC and FR. These two
interventions will be assessed by effects on the hamstrings change of ROM, PPT, PPO
and GROC and the patient’s results in performing a VJ.
ASSESSING TREATMENT EFFECTIVENESS
The collection of patient-reported, clinician-reported outcomes, and functional
performance outcomes are typically used to assess treatment effects and judge efficacy. A
wide range clinical outcome measures have been used in the literature to assess the
effectiveness of various myofascial release techniques. For this research investigation
flexibility, pressure sensitivity, jump performance, power production and subjects’
perception of change were the outcome variables used to compare the effects of the FR
and IC interventions.
FLEXIBILITY-ACTIVE KNEE EXTENSION
Hamstring flexibility was assessed using AKE. AKE has been found to be a valid
and reliable method of assessing hamstring with intra-tester ICCs values ranging from
.79-.94.59,60 The AKE test was selected over the straight leg raise (SLR) because it is
considered easier to control because it only involves motion at one joint rather than two
and is an active measure rather than passive giving a better functional assessment.58 FR
has been found in multiple studies to increase the ROM of the muscle it which it is being
applied.4,9,12-14 No previous studies were found assessing IC effect on hamstring
21
tightness. Most studies used to test IC’s ability to affect ROM have been in the upper
trapezius and neck.15,17,61 These studies have produced promising results in being able to
increase ROM.7,15,17,61 Since this study is using the hamstrings as the body part of focus it
is unknown whether FR or IC will have a greater effect on increasing the ROM of the
hamstrings.
PRESSURE SENSITIVITY- PAIN-PRESSURE THRESHOLD
Point tenderness or pressure sensitivity during digital palpation is a common
complaint in muscle pathologies especially MTrPs. An algometer is an instrument that
can be used to measure the amount of force applied to a localized area. PPT is defined as
the lowest amount of pressure needed to elicit pain.19 Previous research has used the PPT
as measure for evaluating and quantifying myofascial pain and assessing changes in
muscle tenderness over time.19,62 As MTrPs resolve, PPT has been shown to increase.16
Studies have supported the use of algometers as a reliable way to test PPT and have
reported ICC values between .70-.97.19,62-66 FR had minimal studies using PPT as a
measure but in the small pool of literature there was support for FR abilities to increase
PPT.16 PPT was a common measure in the literature to test the effect of IC. Multiple
sources have shown statistical significance of IC’s ability to positively affect PPT.7,11,17
From the literature, IC was found to have a greater breadth of support in its ability to
increase PPT, but it all was focused on the upper trapezius.7,11,17 It is unknown which
intervention is better increasing PPT in the hamstrings.
22
JUMP PERFORMANCE- VERTICAL JUMP AND PEAK POWER OUTPUT
Performance measurements were utilized to test the effects of the myofascial
treatments on power output and simulate the demands common within basketball. VJ and
PPO were chosen because they utilize the hamstrings and are similar to motions
performed in basketball.
VERTICAL JUMP
VJ is a commonly used measure of athletic performance to provide a global
assessment of lower extremity muscular power and coordination. VJ is defined as the
vertical distance between the highest point reached when standing with arm fully raised
and highest point of the jump.10 There are several testing methods identified in the
literature: drop jump, run-and-jump and, what was used in this study, countermovement
jump.
Rodriguez-Rosell et al67 investigated the reliability and validity of 4 different
vertical jump test in 186 male soccer and basketball players. They found that all vertical
jump tests studied were reliable measures with ICC values ranging from .969-.998. In this
study they also found a strong correlation between vertical jump tests and sprint and
strength performance.
PEAK POWER OUTPUT
PPO was defined as the maximum amount of force produced by the individual
when performing a vertical jump. PPO is calculated by using a participant’s peak VJ,
height and weight. This information was inserted into the Johnson and Bahamonde68
formula for power output. Balmar et al69 investigated the reliability and validity if peak
23
power predicts performance power. They found that PPO affords a valid and reliable
measure for performance with ICC values of 0.99. Previous studies on FR have mixed
results on the effectiveness in FR positively effecting PPO.16 It is unknown how IC will
affect PPO due to a lack of literature using PPO as a variable in IC studies.
GLOBAL RATE OF CHANGE SCALES
The GROC is a patient reported outcomes measure designed to gather information
on the subjects’ perception of any changes that occur over time in response to an
intervention. GROC scales are commonly used both in research and in actual clinical
practice to determine treatment efficacy and provide patients with a formal mechanism to
provide qualitative feedback to the clinician regarding symptom improvement or
deterioration. Kamper et al21 did an appraisal of the common GROC scale used in patient
care. They found that although there is significant variability in design and scoring, most
GROC scales can provide clinically relevant and reliable information. Key factors that
affect the reliability and face validity of these measure is the question wording, the size of
the rating scale (7 vs. 15 pts), and how much time elapsed between the administration of
the treatment or the scale. Questions needed to be specific to the injury that is of interest,
specific to the construct of interest and anchored by a specific time point to use as a
reference in which to compare their current condition.21 When questions are worded
correctly, the GROC has been shown to be a reliable measure of patient-reported
change.21 Literature supports those who perform FR experience a therapeutic effect
which positively affects their GROC score. The literature supports those who undergo IC
experience a therapeutic effect which positively effects their reported GROC score.13,17
24
Since there is no literature directly comparing FR and IC it is unknown whether there will
be a statistical difference between them. In the review of literature there was a study
which looked at the psychological and emotional effect of touch.70 The study found
through the touch of a hand massage individuals cortisol levels decreased.70 Individual’s
levels of relaxation and safety were increased based on responses on two different PRO
scales.70 As positive as the findings are from this study they need to be taken with caution
since there was no control and the study applied a different type of massage for different
purposes. Both FR and IC have support for their ability to increase GROC but since there
is no research that has compared the two techniques it is unknown whether FR or IC will
have a statistically significant increase when compared to the other.
CONCLUSIONS
From the review of literature, it was shown that both IC and FR have a positive
effect on decreasing muscle tightness, tenderness and/or improving performance while
resolving MTrPs. 4,7,9,11-17,61 The treatment of MTrPs has been shown to increase the
ROM4,7,9,12-15,17,61, PPT7,11,16,17, VJ,13 PPO16 and GROC13,17 of the muscle and soft tissue
when compared to the control. This study is important because it compares FR and IC to
a control as well as to each other. This design will help give support to each of the
techniques. The design also allows for a comparison to help guide clinicians whether FR
or IC is more effective in treating hamstring tightness. This is important because not only
does this help with effectiveness but also helps guide clinicians to how to best allocate
time and resources when they are treating patients.
25
CHAPTER 3
METHODS
PURPOSE OF THE STUDY
The purpose of this study was to compare two MRT and their ability to decrease
muscle stiffness and tenderness and improve performance. The techniques can be broken
down into two groups: self-release techniques and clinician-release techniques. Although
several studies have evaluated the effectiveness of both types of release techniques,
studies directly comparing two treatment approaches are limited. This study looks to
compare a self-release technique, FR, to a clinician-release technique, IC and the
effectiveness of each in treating hamstring tightness, flexibility, perceived pain and
function, and power output.
RESEARCH DESIGN
The study employed many measures to strengthening the integrity of the study.
The measures taken to improve the integrity of the study included: adopting a
randomized crossover design, blinding the assessor to the treatment given, a random
order for the administration of the treatments, and a one-week washout period between
each treatment. Each participant received each treatment once in a randomized order. The
26
treatments were: FR, IC and CON. Receiving each treatment once reduced any training
effects which are accumulated through multiple treatment of one technique.
TARGET POPULATION AND PARTICIPANT SELECTION
The target population for this study was active varsity collegiate basketball
players. The reason for choosing collegiate basketball players was because it is a sport in
which men and women participate and is popular sport for both genders in the United
States. Basketball athletes were also chosen because they provided a good sample of
jump trained individuals whose sporting event requires both dynamic and explosive
strength. The collegiate basketball teams provided a convenience sample who were
trained and relatively consistent in their jumping. Lastly, collegiate basketball players
were chosen because they have not been well represented in previous MRT studies. 4-6
PARTICIPANTS
Participants for this study were recruited from two university men’s and women’s
collegiate basketball programs in northeastern PA. The inclusion criteria were that they
were healthy, active team members between the ages of 18-30 years. Participants with
current or recent history of lower extremity injury were excluded from the study. This
was done to avoid potential aggravation of the injury and reduce possible influence of
these conditions on the repeated performance measures. An injury was defined as not
being able to participate in training or competition for at least 7 days. People with a
history of psychiatric, cardiovascular, endocrine, neurological or metabolic disorders that
could increase the risk of adverse responses to deep tissue mobilization, or injury during
physical assessment were also excluded. Participants in the study were instructed to
27
refrain from consuming, alcohol, nicotine, analgesics or pain relievers 48 hours prior to
testing as these substances can alter pain perception and physical performance.
PROCEDURES
Prior to the first treatment, participants were with an informed consent form. The
principle investigator (PI) provided an overview of the study and was available to answer
participant’s question. Once consent was obtained, subjects completed a health-history
questionnaire which was reviewed, and eligibility determined. The measurements were
taken using the subject’s dominant leg. Dominant leg was defined as the leg that the
subject would use to kick a soccer ball. The pre-test measurements were taken by the
blinded principle investigator in a set order, in a separate area from the treatments. The
order was VJ, ROM, PPT, PPO was later calculated using recorded data. After
completing the pre-test measurements participants went to the intervention area and were
randomly assigned, by two experienced clinicians (CV, CS), to one of three treatments by
randomly shuffling, face down a deck of 3 playing cards. Each of the three cards were
correlated with one of the three treatments:FR, IC or CON. For this study there were 6
possible trial sequences. After each subsequent treatment the card chosen was not
replaced in the deck. This ensured that each participant received all three treatments. CS
and CV delivered/supervised all treatment trials. Following the completion of the
designated treatment, the participants returned to the measurement area for post-test
measurements. The order for post-test measurements was: GROC, VJ, ROM, PPT, PPO.
A period of at least 7 days served as a wash-out phase between the three
experimental testing sessions which were done over a consecutive 3-week period8
28
MEASUREMENTS
ACTIVE KNEE EXTENSION
The AKE followed the protocol used by Norris et al71, except instead of using the
right leg, we used the subject’s dominant leg. (Figure 3.1) The protocol consisted of
the principal investigator marking the center of the knee joint axis over the lateral joint
line of the dominant leg. Two lines were then drawn from this point: one, joining the axis
point to the center of the greater trochanter of the femur, and a second, joining the axis
point to the apex of the lateral malleolus. The lines were removed with alcohol after the
post testing and redrawn at the commencement of each testing session.
The subjects’ reference zero was when they were supine on a bench and they had
their hip and knee flexed to 90°. The subject monitored the position of their femur with
their dominant hand and were instructed not to allow the femur to move away from the
hand at any point during the test. The participant then was instructed to slowly extend
their dominant leg as far as possible, keeping their foot relaxed and not allowing their
thigh to move away from their hand. Participants then held this position for 5 seconds
prior to the measurement being taken. Each participant performed a single repetition of
the movement to familiarize themselves with the action. Once the participant was
comfortable with the movement, it was repeated and measured three times. The angle of
knee extension was measured using a JAMAR 12.5" (32cm) EZ Read goniometer
(Performance Health, Trenton, NJ) and the angle fell between 0 and 90 degrees.
Therefore, a participant with 50 degrees of AKE initially would have moved their leg 50
29
degrees towards a straight leg. An improvement, post-treatment, would be any movement
greater than 50 degrees.
The center of the goniometer was positioned over the axis point previously
marked on the lateral joint line, and the goniometer arms were positioned along the lines
marked on the femur and fibula. The goniometer measurements were taken, recorded,
and averaged. The calculated average score was then used for analysis.
FIGURE 3.1
ACTIVE KNEE EXTENSION
90°
90°
90°
PAIN-PRESSURE THRESHOLD
PPT was used to assess muscle tenderness and was defined as the minimal
amount of pressure that causes pain.19 The subjects’ PPT was measured using a Wagner
FPX 50 (Wagner Instruments, Greenwich, CT) handheld digital algometer with a 1cm2 flat rubber tip. This device has a firm pistol grip handle and displays a 5-digit force
reading in selectable units: lbf, kgf, N and ozf. The unit of measure for force in this study
was newtons (N). To perform the measurement consistently the PI, prior to commencing
the study, practiced applying 9.8 N/s consistently for 5 seconds. The PI counted 1-one
thousand, 2-one thousand…5-one thousand then checked the algometer reading to see if
30
the reading was close to 49 N. This was repeated until a measurement of 49 N was
consistently preformed.
The algometer was consistently placed midway between the ischial tuberosity and
fibular head because there was no guarantee of a MTrP being present in the hamstrings.
(Figure 3.2) The midway point was found by having the subject positioned prone on the
table with the knees extended. A tape measure was used to measure the distance between
the ischial tuberosity and head of the fibula and the halfway point in between those two
landmarks was used for the placement site of the tip of the algometer. This location was
selected because of observations made by Travel and Simons18. Travel and Simons
theorized this is to be common region for trigger points in the hamstring due to the
musculotendinous junction of the biceps femoris.18
Participants were instructed to say “yes” at the instant they felt pain rather than
pressure. Force was gradually applied at a constant rate of approximately 9.8 N/s until the
participant indicated pain was present. The PPT measure was taken 3 times with a 30second interval between measurements. The applied force readings were recorded in N
and the 3 trials averaged for analyses.
31
FIGURE 3.2
PAIN-PRESSURE THRESHOLD
VERTICAL JUMP
The subject’s VJ was measured following the protocol used by Healey et
al.10 The protocol used a Vertec (Perform Better, West Warwick, RI) to measure the
height jumped. The vane stack was raised to a height which the, participants could not
jump higher or lower than the set of vanes. “Without a preparatory or stutter step, the
participants was instructed to perform a countermovement jump by quickly flexing the
knees and hips, moving the trunk forward and downward and swinging the arms
backward. During the jump, the dominant arm reached upward, whereas
the nondominant arm moved downward relative to the body. At the highest point in the
jump, the subjects tapped the highest possible vane with the fingers of the dominant hand.
(Figure 3.3) The score was vertical distance between the height of the highest vane
tapped during the standing vertical reach and the vane tapped at the highest point of the
32
jump. The best of 3 trials with 3-minute rest period was recorded to the nearest 0.5
inch.”10
FIGURE 3.3
VERTICAL JUMP
PEAK POWER OUTPUT
The subject’s PPO was calculated using the formula developed by Johnson and
Bahamonde68. To calculate PPO the participant’s height in cm, weight in kg and VJ in cm
was needed. The results the formula produced were recorded and stored in an Excel
document to the nearest .01W.
GLOBAL RATE OF CHANGE SCALE
A 15-point GROC scale that ranged from -7 to +7. The scale descriptors used
were similar to the ones used by Jaeschke et al72. Zero on the scale represented no
33
change, positive numbers indicated improvement and negative numbers indicated
deterioration. Subject were asked to rate any perceived changes in the treated muscle’s
tightness, performance and pain. immediately post treatment. Question formatting and
administration recommendations described by Kamper et al.21 were also used in
designing this instrument. Several researchers have used a change in a 15-point GROC
score of greater than 3 to indicate a clinically meaningful change.73-75
INSTRUMENTS
Algometer: In this study, a Wagner FPX 50 (Wagner Instruments, Greenwich,
CT) handheld digital algometer with a 1-cm2 flat rubber tip was used to assess pressure
pain threshold. This device has a firm pistol grip handle and displays a 5-digit force
reading in selectable units: lbf, kgf, N and ozf.
Goniometer: In this study, a JAMAR 12.5" (32cm) EZ Read goniometer with a
scale which reads 0 to 180 degrees and 0 to 360 degrees in 1-degree increments was used
to record range of motion.
Vertec: In this study, a Vertec (Perform Better, West Warwick, RI) a stand
mounted measurement device that telescopes upward and has colored vanes that are
spaced 1/2" inch apart that rotate was used to measure vertical jump.
GROC questionnaire: In this study, a three question 15-point GROC scale was
used to measure the subjective post treatment change for a participant. This survey has
been previously used by Jaeschke et al72. and assesses subjectively a person’s degree of
muscle pain, tightness and fatigue prior and after a treatment.
34
INTERVENTION
Subjects were randomly assigned and underwent one of three treatments: FR, IC
and CON. Two different athletic medicine facilities with two different treating clinicians
were used to conduct the study. The environments for both athletic medicine facilities
were busy with people going in and out with variable noise volumes. Each of the
treatments took approximately 5 minutes in length and had different levels of supervision
depending on the treatment. Following each treatment, post treatment measurements
commenced as soon as the participant exited the treatment area and entered the
measurement area. The distance needed to travel for both facilities was similar, being no
more than 100 feet.
FOAM ROLLING
Subjects were randomly assigned and underwent one of three treatments, FR, IC
and CON. Subjects assigned to FR were instructed on how to properly perform the
intervention but were not supervised. Participants followed the protocol designed by
Krause et al.20, but the treatment time was increased from 60s to 90s based on findings by
MacDonald et al12 and was performed on the hamstring instead of the quadriceps. The FR
intervention was performed in the supine position with support given by the arms. (Figure
3.4) The participants were instructed to place their body weight on a closed-cell EPP
foam roller with a length of 36” and a diameter of 6” (TheraBand, Akron, OH).
Using a participant’s own body weight pressure was applied to the tissue of the
posterior thigh, subjects performed a rolling motion from the proximal aspect of the
posterior thigh (ischial tuberosity) to the posterior knee (popliteal fold). Once the foam
35
roller reaches the posterior knee, participants were instructed to return to the starting
position and continue the sequence for the remainder of the 90s. The rolling frequency
was standardized using a metronome set at 60 beats per minute (bpm). Participants were
instructed to roll at a velocity of two metronome beats (thus 2s) for each rolling direction,
resulting in 22.5 complete rolling cycles in 90s. Intensity of pressure was controlled
subjectively by using a Numerical Rating Scale (NRS), participants were instructed not to
exceed a rating of 7/10 (0 representing no discomfort and 10 representing maximal
discomfort) during the intervention. After a 30s break in a relaxed supine position,
participants performed a second bout. Subjects were observed to make sure they were
properly performing the FR treatment.
FIGURE 3.4
FOAM ROLLING
ISCHEMIC COMPRESSION
Ischemic Compression is manual therapy technique whose purpose is to reduce
muscle and MTrP tenderness and hyperirritability and can be defined as the “application
of progressively stronger pressure on a TrP”.18 The identification of TrPs followed the
guidelines laid out in the Trigger Point Manual.18,76 Participants laid prone on the
36
treatment table with their dominant leg hanging off the edge of the treatment table
modestly exposed, putting the hamstrings on stretch. (Figure 3.5) Massage cream was
applied to the entire length of the hamstrings. The clinician then started at the ischial
tuberosity and applied petrissage to the full length of the hamstring muscles. The
clinician worked their way down each hamstring muscle until a corded muscle or pea-like
structure was palpated. Cross-friction or circulating massage was then applied to the
muscle fibers. If the cross-friction or circulating movement produced symptoms of pain
(referred pain, twitch response, or localized pain) the area was identified as a TrP and IC
was applied.
Ischemic compression followed a treatment protocol based on a description laid
out by Travel et al18,76 and tested by Berggreen et al8 with modifications by Nambi et al.15
The treating clinician pressed their thumb directly into the MTrP to produce pain that was
controlled subjectively with a target NRS rating of 7/10 (0 representing no discomfort
and 10 representing maximal discomfort) during the intervention. The applied pressure
was sustained until pain was resolved or 90 seconds elapsed. The procedure was repeated
up to three times depending on if MTrPs were present. Following, three applications or
each of the three hamstrings being scanned, four strokes of effleurage massage were
applied to the hamstring muscle. Then the hamstring was placed on passive stretch for 30
seconds to range the muscle. The total treatment time was approximately 5 minutes in
length.
37
FIGURE 3.5
ISCHEMIC COMPRESSION
CONTROL
The methodology of the control treatment followed the protocol as laid out in a
study by Mohr et al.14 Participants, during the control treatment, were instructed to lie
down supine on the treatment table for 5 minutes.
DATA ANALYSIS
Statistical analysis was completed using IBM SPSS Statistics version 24.0
software (Armonk, NY). Descriptive statistics were calculated for all data collected. This
study used a repeated measures 2x3 analysis of variance (ANOVA) determine withinsubjects factors for Time (Pre, Post-intervention) and between-subjects for Trials (FR, IC,
CON), and Kruskal Wallis in combination with a Chi Square test was used for the GROC
to assess the difference between the trial conditions (FR, IC CON).
38
CHAPTER 4
RESULTS
This study was designed to determine the acute effects of two myofascial release
techniques, FR and IC, on AKE, PPT, VJ, PPO and GROC. This chapter is a presentation
of the data in the following sections: a) participation demographics, b) comparison
among time and trial condition on hamstring ROM during AKE, c) comparison among
time and trial condition on hamstring PPT, d) comparison among time and trial condition
on maximum height reached during a VJ, e) comparison among time and trial condition
on PPO during VJ, and f) comparison of among trial conditions on GROC scale scores.
PARTICIPATION DEMOGRAPHICS
A summary of the demographics of the study participants is presented in Table
4.1. A total of 13 subjects volunteered but only 11 completed the study. One was deemed
ineligible to participate due to an acute knee injury and one participant dropped out for
unspecified reasons. Of the 11 subjects who completed the study, 4 were males (mean
age=19.5±1 year; height=174±9.9cm; weight=100±6.7kg) and 7 were females (mean
age=19.6±.69years; height=168.8±7.9cm; weight=66.1±3.3kg). Participants in study
were active basketball players from two schools competing in the NCAA Division II
39
(N=6) and a Division III (N=5) levels. No males participated in the study from the
NCAA Division II level due to scheduling conflicts and postseason participation.
TABLE 4.1
DEMOGRAPHICS
Gender
Age(years)
Height(cm)
Mass(kg)
Division II
Division III
Overall
-19.7±.8
173.9±10.4
78.5±17.7
6
5
Male
4
19.5±1
184.4±0.5
100.0±6.7
0
4
Female
7
19.8±0.7
167.9±8.0
66.2±3.6
6
1
COMPARISON AMONG TIME AND MYOFASCIAL RELEASE
TECHNIQUES ON ACTIVE KNEE EXTENSION
A summary of the different pretreatment and posttreatment myofascial release
techniques means, and standard deviations of AKE is presented in Table 4.2 and Figure
4.1. To test whether pretreatment means (FR:62.00, IC:55.71, CON:65.45) were
significantly different than posttreatment means (FR:63.89, IC:62.65, CON:64.68), a oneway ANOVA with repeated measures was performed. Table 4.3 illustrates the sum of
squares, degrees of freedom and the F-ratio over time (pretreatment, posttreatment) for
active knee extension. There was a significant difference in mean AKE over time
(F=6.17, p=.032). The p=.032 suggests that the intervention or the time elapsed is
connected to the change in the mean values. A one-way ANOVA with repeated measures
showed an effect for condition on knee-joint ROM (P<.05).Post hoc analyses however
showed that the changes seen in AKE from pretesting to post-testing for the FR and IC
condition were not statically different from those seen in during the control condition.
40
TABLE 4.2
SUMMARY OF MEAN ACTIVE KNEE EXTENSION PRODUCED BEFORE AND
AFTER VARYING MYOFASCIAL RELEASE TECHNIQUES
(N=11)
Myofascial Release
Technique
Controla
Foam Rollinga
Ischemic
Compressiona
Pretreatment Mean
65.4545
62.0000
55.7121
Pretreatment sd
13.7196
13.2642
16.0430
Posttreatment Mean
64.6818
63.8939
62.6515
Posttreatment sd
12.7912
12.0850
14.5782
a
Measurements in degrees
FIGURE 4.1
MEAN ACTIVE KNEE EXTENSION BEFORE AND AFTER VARYING
MYOFASCIAL RELEASE TECHNIQUES
41
TABLE 4.3
ONE-WAY ANOVA WITH REPEATED MEASURES OF TIME FOR ACTIVE KNEE
EXTENSION
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time
1
119.118
119.118
6.16`7
0.032
Error
10
193.169
19.317
Total
11
312.435
TABLE 4.4
MEAN DIFFERENCES WITHIN SUBJECTS MEASURES OF TIME ON ACTIVE
KNEE EXTENSION
(N=11)
Time
Pretreatment
Posttreatment
Means
(61.056a)
(63.742a)
Pretreatment (61.056a)
-------
-2.687a,b
Posttreatment (63.742a)
2.687a,b
-------
a
Measurement differences are in degrees
Significant at the 0.05 level
b
To test whether mean between-group differences between three trials (FR, IC,
CON) were significant, a one-way ANOVA with repeated measures was performed and
found there were no statistical differences (p=.434) in mean AKE among the three trials
(FR, IC, CON). Table 4.5 illustrates the sum of squares, degrees of freedom and F-ratio
among trial conditions (FR, IC, CON).
42
TABLE 4.5
ONE-WAY ANOVA WITH REPEATED MEASURES OF TREATMENT
TECHNIQUE FOR ACTIVE KNEE EXTENSION
(N=11)
Df
Sum of Squares
MS
F
Sig.
Treatment
2
391.051
195.526
.869
0.434
Error
20
4498.328
224.916
Total
22
4889.379
To test whether interaction between time and myofascial release technique were
significant, a one-way ANOVA with repeated measures was performed. Table 4.6
illustrates the sum of squares, degrees of freedom and the F-ratio for the interaction
between time (pretreatment, posttreatment) and myofascial release technique (FR, IC,
CON). A significant F-ratio (df=2, Error df=20, F=5.88) was determined for the
interaction between time and treatment technique (p=.01). But since no significant
differences between the two treatment interventions and the control then whatever
change, either positive or negative, that occurred between pre and post testing is not
likely the result from the intervention.
43
TABLE 4.6
ONE-WAY ANOVA WITH REPEATED MEASURES OF INTERACTION BETWEEN
TIME AND TREATMENT TECHNIQUE FOR ACTIVE KNEE EXTENSION
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time*Technique
2
168.748
84.374
5.883
0.010
Error
20
286.854
14.343
Total
22
455.602
COMPARISON AMONG TIME AND MYOFASCIAL RELEASE TECHNIQUES ON
PAIN-PRESSURE THRESHOLD
A summary of the different pretreatment and posttreatment myofascial release
techniques means, and standard deviations of PPT is presented in Table 4.7 and Figure
4.2. To test whether pretreatment means (FR:44.52, IC:42.63, CON:43.28) were
significantly different than posttreatment means (FR:47.75, IC:52.81, CON:40.16), a oneway ANOVA with repeated measures was performed. Table 4.8 illustrates the sum of
squares, degrees of freedom and the F-ratio over time (pretreatment, posttreatment) for
pain-pressure threshold readings. The F-ratio over the time of measurement main effect
was not significant (df=1, Error df=10, F=3.34, p=.097) which indicates that the time of
measurement did not affect PPT of the hamstrings. Though there was no statistically
significant results there were trends to show that FR and IC can increase PPT where the
CON decreased the PPT.
44
TABLE 4.7
SUMMARY OF MEAN PAIN-PRESSURE THRESHOLD READINGS PRODUCED
BEFORE AND AFTER VARYING MYOFASCIAL RELEASE TECHNIQUES
(N=11)
Myofascial Release
Technique
Controla
Foam Rollinga
Ischemic
Compressiona
Pretreatment Mean
43.2788
44.5212
42.6303
Pretreatment sd
11.1361
10.6746
9.6690
Posttreatment Mean
40.1576
47.7455
52.8091
Posttreatment sd
7.9805
12.7084
15.1788
a
Measurements in N
45
FIGURE 4.2
MEAN PAIN-PRESSURE THRESHOLD READINGS PRODUCED BEFORE AND
AFTER VARYING MYOFASCIAL RELEASE TECHNIQUES
(N=11)
TABLE 4.8
ONE-WAY ANOVA WITH REPEATED MEASURES OF TIME FOR PAINPRESSURE THRESHOLD
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time
1
193.812
193.812
3.342
0.097
Error
10
579.863
57.986
Total
11
773.675
46
To test whether mean differences between myofascial release techniques were
significant, a one-way ANOVA with repeated measures was performed. Table 4.9
illustrates the sum of squares, degrees of freedom and the F-ratio among myofascial
release techniques (FR, IC, CON) for PPT readings. The F-ratio for the between
myofascial release techniques main effect was not significant (df=2, Error df=20, F=1.73,
p=.203) which indicate that the type of myofascial release technique did not affect PPT.
TABLE 4.9
ONE-WAY ANOVA WITH REPEATED MEASURES OF TREATMENT
TECHNIQUE FOR PAIN-PRESSURE THRESHOLD
(N=11)
Df
Sum of Squares
MS
F
Sig.
Technique
2
425.541
212.770
1.731
0.203
Error
20
2457.914
122.896
Total
22
2883.455
To test whether interactions between time and myofascial release technique were
significant, a one-way ANOVA with repeated measures was performed. Table 4.10
illustrates the sum of squares, degrees of freedom and the F-ratio among time
(pretreatment, posttreatment) and myofascial release technique (FR, IC, CON) for PPT
readings. A significant F-ratio (df=2, Error df=20, F=10.34) was determined for the
interaction between time and treatment technique (p=.001) but the interaction is not
meaningful since the main effects for time and treatment technique were not significant.
47
TABLE 4.10
ONE-WAY ANOVA WITH REPEATED MEASURES OF INTERACTION BETWEEN
TIME AND TREATMENT TECHNIQUE FOR PAIN-PRESSURE THRESHOLD
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time*Treatment
2
486.788
243.394
10.336
0.001
Error
20
470.971
23.549
Total
22
957.759
COMPARISON AMONG TIME AND MYOFASCIAL RELEASE
TECHNIQUE ON PEAK VERTICAL JUMP HEIGHT
A summary of the different pretreatment and posttreatment myofascial release
techniques means, and standard deviations of VJ is presented in Table 4.11 and Figure
4.3. To test whether pretreatment means (FR:16.85, IC:18.15, CON:17.62) were
significantly different from posttreatment means (FR:18.45, IC:18.67, CON:17.86), a
one-way ANOVA with repeated measures was performed. Table 4.12 illustrates the sum
of squares, degrees of freedom and the F-ratio over time (pretreatment, posttreatment) for
VJ height. A significant F-ratio (df=1, Error df=10, F=6.85) was determined for the
among pretreatment and posttreatment measurements main effect (p=0.026). A pairwise
comparison was then performed to determine the differences. Table 4.13 summarizes the
mean VJ height differences between pretreatment measurements and posttreatment
measurements. The pairwise comparison revealed a significant difference between
pretreatment and posttreatment measurements.
48
TABLE 4.11
SUMMARY OF MEAN PEAK VERTICAL JUMP HEIGHTS PRODUCED BEFORE
AND AFTER VARYING MYOFASCIAL RELEASE TECHNIQUES
(N=11)
Myofascial Release
Technique
Controla
Foam Rollinga
Ischemic
Compressiona
Pretreatment Mean
17.6212
16.8485
18.1515
Pretreatment sd
3.4206
3.3254
3.0336
Posttreatment Mean
17.8636
18.4548
18.6667
Posttreatment sd
3.6193
3.4455
3.0669
a
Measurements in inches.
49
FIGURE 4.3
MEAN PEAK VERTICAL JUMP HEIGHTS PRODUCED BEFORE AND AFTER
VARYING MYOFASCIAL RELEASE TECHNIQUES
(N=11)
TABLE 4.12
ONE-WAY ANOVA WITH REPEATED MEASURES ON TIME FOR PEAK
VERTICAL JUMP HEIGHT
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time
1
10.245
10.245
6.848
0.026
Error
10
14.960
1.496
Total
11
25.205
50
TABLE 4.13
MEAN DIFFERENCES WITHIN SUBJECT MEASURES OF TIME ON PEAK
VERTICAL JUMP HEIGHT
(N=11)
Time
Pretreatment
Posttreatment
Means
(17.540a)
(18.328a)
Pretreatment (17.540a)
-------
-.788a,b
Posttreatment (18.328a)
.788a,b
-------
a
Measurement differences are in in
Significant at the 0.05 level
b
To test whether mean differences between myofascial release techniques were
significant, a one-way ANOVA with repeated measures was performed. Table 4.14
illustrates the sum of squares, degrees of freedom and the F-ratio among myofascial
release techniques (FR, IC, CON) for VJ height. The F-ratio for the between myofascial
release techniques main effect was not significant (df=2, Error df=20, F=0.246, p=0.784)
which indicate that the type of myofascial release technique did not affect VJ height.
TABLE 4.14
ONE-WAY ANOVA WITH REPEATED MEASURES ON TREATMENT
TECHNIQUE FOR PEAK VERTICAL JUMP HEIGHT
(N=11)
Df
Sum of Squares
MS
F
Sig.
Technique
2
7.527
3.763
0.246
0.784
Error
20
305.607
15.280
Total
22
313.134
51
To test whether interactions between time and myofascial release technique were
significant, a one-way ANOVA with repeated measures was performed. Table 4.15
illustrates the sum of squares, degrees of freedom and the F-ratio among time
(pretreatment, posttreatment) and myofascial release technique (FR, IC, CON) for VJ
height. The F-ratio for the interaction among time and treatment technique main effect
was not significant (df=2, Error df=20, F=2.41, p=0.116) which indicates that the
interaction between time and treatment technique did not affect VJ height.
TABLE 4.15
ONE-WAY ANOVA WITH REPEATED MEASURE ON THE INTERACTION
BETWEEN TIME AND TREATMENT TECHNIQUE FOR PEAK VERTICAL JUMP
HEIGHT
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time*Treatment
2
5.730
2.865
2.408
0.116
Error
20
23.793
1.190
Total
22
29.523
COMPARISON AMONG TIME AND MYOFASCIAL RELEASE
TECHNIQUES ON PEAK POWER OUTPUT DURING VERTICAL JUMP
A summary of the different pretreatment and posttreatment myofascial release
techniques means, and standard deviations of PPO is presented in Table 4.16 and Figure
4.4. To test whether pretreatment means (FR:3963.13, IC:4386.94, CON:4084.83) were
significantly different from posttreatment means(FR:4277.53, IC:4490.55,
CON:4141.99), a one-way ANOVA with repeated measures was performed. Table 4.17
52
illustrates the sum of squares, degrees of freedom and the F-ratio over time (pretreatment,
posttreatment) for PPO. A significant F-ratio (df=1, Error df=10, F=7.067) was
determined for the between pretreatment and posttreatment measurements main effect
(p=.024). A pairwise comparison was then performed to determine the differences. Table
4.18 summarizes the mean PPO differences between pretreatment and posttreatment
measurements. The pairwise comparison revealed a significant difference between
pretreatment measurements and posttreatment measurements.
TABLE 4.16
SUMMARY OF PEAK POWER OUTPUTS PRODUCED BEFORE AND AFTER
VARYING MYOFASCIAL RELEASE TECHNIQUES
(N=11)
Myofascial Release
Technique
Controla
Foam Rollinga
Ischemic
Compressiona
Pretreatment Mean
4084.8273
3963.1309
4386.9382
Pretreatment sd
1263.7752
1400.7099
1364.7201
Posttreatment Mean
4141.9909
4277.5309
4490.5473
Posttreatment sd
1287.7612
1301.2328
1344.3749
a
Measurements in W
53
FIGURE 4.4
MEAN PEAK POWER OUTPUT PRODUCED BEFORE AND AFTER VARYING
MYOFASCIAL RELEASE TECHNIQUES
(N=11)
TABLE 4.17
ONE-WAY ANOVA WITH REPEATED MEASURES ON TIME FOR PEAK POWER
OUTPUT
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time
1
413946.721
713946.72
7.067
0.024
Error
10
587819.283
58571.928
Total
11
1001766.004
54
TABLE 4.18
MEAN DIFFERENCES WITHIN SUBJECTS MEASURES OF TIME ON PEAK
POWER OUTPUTS
(N=11)
Time
Pretreatment
Posttreatment
Means
(4144.965a)
(4303.356a)
Pretreatment (4144.965a)
-------
-158.391a,b
Posttreatment (4303.356a)
158.391a,b
-------
a
Measurement differences are in W
Significant at the 0.05 level
b
To test whether mean differences between myofascial release techniques were
significant, a one-way ANOVA with repeated measures was performed. Table 4.19
illustrates the sum of squares, degrees of freedom and the F-ratio among myofascial
release techniques (FR, IC, CON) for PPO. The F-ratio for the between myofascial
release techniques main effect was not significant (df=2, Error df=20, F=1.18, p=.329)
which indicate that the type of myofascial release technique did not affect PPO.
TABLE 4.19
ONE-WAY ANOVA WITH REPEATED MEASURES ON TREATMENT
TECHNIQUE FOR PEAK POWER OUTPUT
(N=11)
Df
Sum of Squares
MS
F
Sig.
Treatment
2
1520023.798
760011.90
1.177
0.329
Error
20
12914117.35
645705.87
Total
22
14434141.148
55
To test whether interactions between time and myofascial release technique were
significant, a one-way ANOVA with repeated measures was performed. Table 4.20
illustrates the sum of squares, degrees of freedom and the F-ratio among time
(pretreatment, posttreatment) and myofascial release technique (FR, IC, CON) for PPO.
The F-ratio for the interaction among time and treatment technique main effect was not
significant (df=2, Error df=20, F=2.15, p=.142) which indicates that the interaction
between time and treatment technique did not affect PPO.
TABLE 4.20
ONE-WAY ANOVA WITH REPEATED MEASURES ON THE INTERACTION
BETWEEN TIME AND TREATMENT TECHNIQUE FOR PEAK POWER OUTPUT
(N=11)
Df
Sum of Squares
MS
F
Sig.
Time*Treatment 2
206727.646
103363.82
2.153
0.142
Error
20
960309.591
48015.48
Total
22
1167037.237
COMPARISON AMONG MYOFASCIAL RELEASE TECHNIQUES ON GLOBAL
RATE OF CHANGE RANK SCORES
A summary of the differing variable means and standard deviations of GROC
rank scores is presented in Table 4.21 and Figure 4.5 (FR:3.17, IC:2.17, CON:2.46). A
Kruskal Wallis and Chi Squared Tests were conducted on the different myofascial release
techniques to compare their effects on each of the variables tested by the GROC and the
results are presented in Table 4.22 and 4.23. The results are presented in mean rank
scores not in the GROC scale scores. The scores were presented in this way to allow for
56
the GROC scores to be statistically analyzed. Differences can be seen, in Table 4.22,
between treatments for each variable (Pain: FR:14.29, IC:25.32, CON:15.00; Tightness:
FR:16.42, IC:25.86, CON:12.38; Fatigue: FR:17.79, IC:24.23, CON:12.50) but due to the
type of test and data, significance was unable to be determined between treatments. The
Chi-Square test, Table 4.23, revealed statistically significant perceived increases for each
of the variables (Pain, Tightness, Fatigue). The Chi-Squared test did not parse out
between the variables to determine if there was significant between group differences.
TABLE 4.21
SUMMARY OF MEAN GLOBAL RATE OF CHANGE RANK SCORES FOR
DIFFERING VARIABLES
(N=11)
Variables Tested
Muscle Pain
Muscle Tightness
Muscle Fatigue
Mean
2.4571
3.1714
2.1714
Sd
2.2274
2.4792
2.4553
57
FIGURE 4.5
MEAN GLOBAL RATE OF CHANGE RANK SCORES FOR DIFFERING
VARIABLES
(N=11)
58
TABLE 4.22
SUMMARY OF MEAN GLOBAL RATE OF CHANGE RANK SCORES FOR
PERCEIVED MUSCLE PAIN, TIGHTNESS AND FATIGUE AFTER DIFFERENT
MYOFASCIAL RELEASE TECHNIQUES
(N=11)
Myofascial Release
Technique
Control
Foam Rolling
Ischemic
Compression
Mean Rank Score for
Perceived Muscle
Pain
15.00
14.29
25.32
Mean Rank Score for
Perceived Muscle
Tightness
12.38
16.42
25.86
Mean Rank Score for
Perceived Muscle
Fatigue
12.50
17.79
24.23
TABLE 4.23
SUMMARY OF MEAN GLOBAL RATE OF CHANGE RANK SCORES FOR
PERCEIVED MUSCLE PAIN, TIGHTNESS AND FATIGUE AFTER DIFFERENT
MYOFASCIAL RELEASE TECHNIQUES
(N=11)
Muscle Pain
Muscle Tightness
Muscle Fatigue
Chi-Square
8.514
10.820
7.994
Df
2
2
2
Asymp. Sig.
.014
.004
.018
59
CHAPTER 5
DISSCUSSION AND CONCULSION
INTRODUCTION
The purpose of this study was to compare the effectiveness of foam rolling and
ischemic compression and their effectiveness in treating hamstring tightness. The
effectiveness of the treatments was measured using ROM and PPT of the hamstrings, VJ
and PPO during VJ and GROC. This chapter is presented in the following sections: a)
discussion for ROM performance, b) discussion for PPT, c) discussion for VJ height, d)
discussion for PPO during VJ, e) discussion of GROC, f)summary, g) findings, h)
conclusions and i) recommendations for further study.
DISCUSSION FOR RANGE OF MOTION PERFORMANCE
The results of this study found that a single treatment of FR or IC did not yield a
significant improvement in HS flexibility (AKE) compared to the control condition. AKE
improved from pre and post-testing but no condition (FR, IC, or CON) was significantly
better than another. This finding that the FR condition did not significantly improve
ROM compared to the control condition is consistent with the finding of several previous
studies14,61,77-79. Mohr et al.14 conducted a study comparing the effects of 4 different
60
treatment conditions on passive hip-flexion ROM: foam rolling (FR), static stretching
(SS), foam rolling and static stretching (FR+SS) and control (CON). In the Mohr et al14
study all conditions studied significantly changed passive hip-flexion, but only the
combined FR+SS yielded significantly greater changes in passive hip-flexion ROM
compared to the other conditions. In another pretest-posttest study77 assessing the effect
of a single 60 sec FR session on hip flexor and quadriceps muscle flexibility found that
FR no significant effect on individual muscle flexibility measures. In this study FR
condition did show a small gain in overall flexibility compared to the control, but the
authors concluded that was insignificant in terms of improving overall function.77
Couture et al78, conducted a small repeated measures study evaluating the effects of a
single bout of self-administered FR using 2 protocols (Long= 4x 30 sec and Short=2x
30sec) on passive knee extension ROM. The subjects were measured on 3 consecutive
days where the baseline measure was used as the control and the 2 protocols were
delivered in a counterbalanced order. Neither of the FR protocol resulted significant
changes in passive knee extension ROM compared to baseline.
The present study’s finding suggest that a single session of FR may not be
sufficient to product significant improvements in ROM. However, this conclusion is not
consistent with several previous studies that found that a single bout of FR resulted in
improvements in knee ROM.7,9,12,13 Bradbury-Squires et al 9 conducted a small repeated
measures pretest-posttest study comparing both a 20 and 60-second application of FR to
the quadriceps muscle to a control condition. In this study both FR protocols elicited a
greater improvement in knee flexion than the control condition. Two key differences
61
between the current study and the Bradbury-Squires et al9 study were the muscles treated
(HS vs. Quads) and the method of delivery for the FR. The HS are a deeper muscle
groups and their location in relation to the femur can make it harder to effectively
compress them with the foam roller compared to the more superficial quadriceps. Also, in
the Bradbury-Squires study9 the amount of compression pressure used was controlled by
the roller device used. In the present study, the amount of pressure used was determined
by the individual subject based on perceived discomfort. Because of the location and
depth of the HS muscles and the lack of external pressure control it is plausible that some
subjects in this study may have used insufficient pressure to adequately mobilize the HS
muscles. Aguilera et al7 conducted a randomized control trail which compared IC to US
and its ability to increase ROM, decrease MTrP sensitivity, and decrease electrical
output. The current study differs from Aguilera et al7 by the muscle that was tested and
the presence of MTrPs. The current study tested the hamstrings where Aguilera et al
tested the upper trapezius. The upper trapezius is a more superficial muscle allowing for
greater ease of compression of the muscle possibly resulting in a greater and more
noticeable change in ROM. The current study did not require the participants to have
MTrPs but the participants in the Aguilera et al7 study needed to have latent MrTPs. The
presence of MTrPs whether active or latent could explain why the current study did not
see a significant difference between treatments. Having MTrPs present in theory explains
why IC would have a positive effect on it. The muscle is spasm and IC will help then
lengthen the muscle returns it to its originally tension and increasing ROM.
62
MacDonald et al13 conducted a small randomized controlled trial which looked at
the effectiveness of FR versus a control in treating DOMS in the lower extremity. In this
study13, FR was able to decrease the effects of DOMS while improving passive quadricep
and hamstring ROM and dynamic hamstring ROM. There were a few key differences
between the current study and MacDonald et al.13 One was the muscles treated, (HS vs
HS, Quads, Glutes, ADDs and IT band) another the amount of times FR was applied (1
vs 3), and lastly the condition of the athletes. (not sore vs sore) Receiving multiple
treatments may have a compounding effect to improve muscle extensibility and
performance which are only seen over the course of time as compared to looking at the
acute effects of one FR treatment. Treating multiple muscles may increase the effects of
FR since the agonist and the antagonist muscles are both being treated decreasing the
restriction to movement throughout the joint. In this study13, treating just one muscle
group may limit the effects that could be produced since muscles are affected by their
opposing muscle. Lastly, the improvement in ROM with FR might only occur when there
is existing muscle soreness. The subjects in the MacDonald study13 may have only seen
improvements in ROM since they were sore where the subjects in the current study were
not sore.
MacDonald et al12 conducted a randomized control trial comparing the ability of
FR to a control in increasing quadricep range of motion. Different from the current study,
MacDonald et al12 found that FR increased ROM compared to a control. Some of the
differences between MacDonald et al and the current study that could explain the
differing results is the presence of delayed onset muscle soreness (Sore vs. Not Sore) and
63
the muscle FR (Quadriceps vs Hamstrings). MacDonald et al12 did testing on the
quadriceps which is a more superficial muscle compared to the hamstrings which is a
deeper muscle and covered with more adipose tissue. The resulting factor is that current
study allowing for the muscle treated to receive a higher dose of treatment. The other
difference between the studies is the presence of DOMS. MacDonald et al12 had the study
participants, prior to FR go through a standardized workout routine to induce delayedonset muscle soreness in the quadriceps. Following the exercise routine, it is possible the
participants quadriceps were at a shortened state and due to decrease in muscle length the
treatment of FR would have greater effects on the muscle as compared to someone who
was not sore, like the participants from the current study.
DISCUSSIONS FOR PAIN-PRESSURE THRESHOLD
The results of this study found that a single treatment of FR or IC did not yield a
significant improvement in HS pain-pressure threshold (PPT) compared to the control
condition but for both FR and IC a trend of increased PPT was seen posttreatment
compared to the CON. For IC on average a 10N increase in PPT was seen. Similar results
were found in a study by Ravichandran et al.61 Ravichandran et al61 conducted a small
single-blind randomized control trial comparing IC with CON (ultrasound). In
congruence with the current study trends toward improvement were noted but no
statistically significant results were found.
Contrary to this finding, several studies have found FR and IC to be effective in raising
PPT8,16,54,56,80 . Pearcey et al16 used a repeated-measures within subjects crossover study
to assess the effect of FR on subjects suffering from induced DOMS. The key differences
64
in this study were the number of times FR was applied (0 hours post vs 0, 24, 48 hours
post), the muscles FR was applied to (HS vs the entire LE) and then soreness of the
subjects (not sore vs sore). Treating a muscle multiple times versus once may result in
compounding effects from the treatment that would not be seen in the current study since
FR was only applied once. The results from Pearcey et al16 maybe different because of
the muscles treated (HS, Quads, ADD, IT band and Glutes vs HS). Treating a larger area
of muscle provides potentially greater chance of eliciting the purported mechanical and
pain modulation effects. Another difference between the current study and Pearcey et al16
is how the PPT was measured. In the study by Pearcey et al16 participants were weight
bearing and PPT was assessed on the quads compared to the current study which assessed
the PPT while the participants were non-weight bearing and was assessed on the
hamstrings. Being weight bearing naturally causes the quads to be contracted. Having the
quads contracted increase the tension of the muscle being treated. The quads do not have
as much adipose tissue, as compared to the hamstrings, between the muscle and the
surface of the skin allowing for a greater ease to compress the desired muscle tissue.
Testing the participant’s quads while weight bearing is a significant difference between
the studies which may explain the difference between them. Lastly, another reason the
current study’s results may have been different from Pearcey et al16 were the subjects in
the study conducted by Pearcey et al16 were already sore prior to FR. The effect of FR
may be more pronounced in individuals with DOMS compared to healthy non-painful
subjects. Since the current study’s subjects were not sore the results seen in the study by
Pearcey et al16 may only have been due to the subjects being sore prior to FR.
65
Similarly, studies by Gulick et al56 and Jagad et al80 conducted single-blind randomized
controlled trials comparing IC to a control. Both Gulick et al56 and Jagad et al80 found
following IC, there was a statistically significant inter and intra group increase in PPT.
The key differences between the current study and the studies conducted by Gulick et al56
and Jagad et al80 is what was used as sites of treatment (standardized point vs MTrPs), the
amount of treatments (1 vs 3/7) and the body part used for treatment (Hamstrings vs
Upper Trapezius). A key difference is Gulick et al56 and Jagad et al80 used MTrPs as the
sites for treatment compared to the current study which used a single standardized point
on every participant regardless if that point was sore or not. Using sites that have a
decreased pain-pressure threshold as the points which measurements are taken from
could show a greater effect from the treatment since the sites were more sensitive to pain
prior to the treatment than the sites measured from in the current study. Another
difference between the current study and Gulick et al56 and Jagad et al80 is the amount of
treatments. Gulick et al56 and Jagad et al80 performed IC multiple times compared to a
single treatment in the current study. Though the current study did not look at the longterm effects of repetitive treatments, having multiple treatments may produce a
compounding effect that would not have been seen in this study. Overall differences in
the muscles treated, inclusion criteria, and protocol could explain why the results of the
current study did not match that of previously conducted studies.
DISCUSSION FOR PEAK VERTICAL JUMP HEIGHT
The results of this study found that a single treatment of FR or IC did not yield a
significant improvement in vertical jump (VJ) compared to the control condition. VJ
66
improved from pre and post-testing but no condition (FR, IC, or CON) was significantly
better than another. Similar results were found in a different study.10 Healy et al10
conducted a randomized crossover design comparing the effects of a single session of FR
to a control of planking. No statistically significant results were found in between
treatments, which is consistent with a previous study by Healey et al.11 but both
treatments did induce an increase in PPO. Overall these results suggest that the
application of a myofascial release technique, FR or IC, can positively effect VJ.
The present study’s findings indicate that a single session of FR does not
significantly increase VJ compared to the control treatment. A previous study conducted
by MacDonald et al13 conducted a randomized control trial comparing FR to a control
that found contradicting results to the current study.13 In the MacDonald et al 13 the
subjects had identified muscle soreness, the treatment consisted FR multiple muscles, and
the exposure time was 3x longer than the current study. These differences may account
for the differences in findings. Receiving multiple treatments may have a compounding
effect on muscle performance (VJ) which is only seen over the course of time as
compared to looking at the acute effects of one FR treatment. Treating multiple muscles
may also increase the effects of FR since the agonist and the antagonist muscles are both
being treated which may increase proper or more affective in muscle contraction . Lastly,
the improvement in VJ with FR might only occur when there is existing muscle soreness.
The subjects in the MacDonald study13 may have only seen improvements in VJ since
they were sore where the subjects in the current study were not sore and therefore
explains why there is a difference in results between the studies.
67
DISCUSSION FOR PEAK POWER OUTPUT DURING VERTICAL JUMP
The results of this study found that a single treatment of FR or IC did not yield a
significant improvement in peak power output (PPO) compared to the control condition.
PPO improved from pre and post-testing but no condition (FR, IC, or CON) was
significantly better than another. Similar results were found in a different study.10 Healy
et al10 conducted a randomized crossover design comparing the effects of a single session
of FR to a series of planking exercise on vertical jump height and power, isometric force,
and agility test performance. No statistically significant results were found in between
treatments, which is consistent with the current study, but both treatments, in each of the
studies did induce an increase in PPO. Overall these results suggest that the application of
a myofascial release technique, FR or IC, can positively effect PPO.
The present study’s findings indicate that a single session of FR does not
significantly increase PPO compared to the control treatment. A previous study found
contradicting results to the current study.13 MacDonald et al13 conducted a randomized
control trial comparing FR to a CON. The key differences between the current study and
MacDonald et al13 are: one was the muscles treated, (HS vs HS, Quads, Glutes, ADDs
and IT band) two the amount of times FR was applied (1 vs 3), and lastly the condition of
the athletes. (not sore vs sore) Receiving multiple treatments may have a compounding
effect on muscle performance (PPO) which is only seen over the course of time as
compared to looking at the acute effects of one FR treatment. Treating multiple muscles
may also increase the effects of FR since the agonist and the antagonist muscles are both
being treated which may increase proper or more affective in muscle contraction . Lastly,
68
the improvement in PPO with FR might only occur when there is existing muscle
soreness. The subjects in the MacDonald study13 may have only seen improvements in
PPO since they were sore where the subjects in the current study were not sore and
therefore explains why there is a difference in results between the studies.
DISCUSSION FOR GLOBAL RATE OF CHANGE
The results of this study indicate the application of myofascial release techniques
causes a statistically significant perceived improvement in muscular pain, tightness, and
fatigue. The current results agree with previous research which has shown both FR and
IC to be effective methods of for treating muscular pain.8,10,11,13,17,54 The method utilized
by the current study to collect the perceived effect of the treatment differs by using a 15item GROC scale instead of a 10-cm VAS scale. This method was chosen due to the
ability to have a discrete answer instead of a continuous answer. Both ways have been
shown to effective tools to measure the participant’s perceived benefit from a
treatment.8,10,11,13,17,54
Even though significance was found by the study the degree of significance did
not equal or exceed the threshold of minimum meaningful difference of ≥5 ranks set by
Stratford et al81 for a 15-item scale. This agrees with Nambi et al15 which did not find
significant difference in perceived muscular pain following IC. Another randomized
crossover study also did not find any significant difference in pain between 20-sec and
60-sec of FR and a CON.9
The current study’s findings indicate that a single treatment of FR or IC does not
significantly change perceived muscle pain, tightness or performance. Previous research
69
has shown differing results.7,8,82 A randomized control trial comparing IC, US and a
control was conducted by Aguilera et al7. The key difference between the current study
and Aguilera et al7 is the muscle treated (HS vs Up Trap). The HS is a deeper muscle
compared to the upper trapezius meaning that the same applied pressure may not elicit
the same results because the HS is a deeper muscle.
A double-blind randomized trial comparing the effects of FR and neuromuscular
stabilization on DOMS.82 The three key differences between the current study and the
study by Moraleda et al82 is the muscle treated (HS vs Quads), condition of the
participants (not sore vs sore) and the presence of a control (CON vs no CON). The HS
are a deeper muscle groups and their location in relation to the femur can make it harder
to effectively compress them with the foam roller compared to the more superficial
quadriceps. The subjects in the study by Moraleda et al82 may have only seen
improvements in perceived pain since they were sore where the subjects in the current
study were not sore. Lastly, in the current study used a CON to see if the effects produced
by the treatments were from the treatments or from other sources. The study by Moraleda
et al82 did not utilize a CON so the improvements seen may have been due to other
factors apart from or in addition to the treatment.
Berggreen et al8 conducted a randomized control study comparing the effects of
IC to a CON. The two key differences between the current study and the study conducted
by Berggreen et al8 are the muscles treated (HS vs Up Trap, Neck and Facial
musculature), the condition of the participants (not sore vs sore) and the number of
treatments (1 vs 10). The HS is a deeper muscle compared to the upper trapezius
70
meaning that the same applied pressure may not elicit the same results because the HS is
a deeper muscle. The subjects in the study by Berggreen et al8 may have only seen
improvements in perceived pain since they were dealing with chronic pain where the
subjects in the current study did not deal with chronic pain. Lastly, receiving multiple
treatments may have a compounding effect on perceived pain which is only seen over the
course of time as compared to looking at the acute effects of one IC treatment.
SUMMARY
As mentioned earlier it has been reported that both FR, and IC have been shown
to effectively treat muscle tightness. However previous research lacked studies
comparing the effectiveness of FR to IC. Therefore, the goal of this study was to compare
the effectiveness of FR to IC to increase ROM and PPT of the hamstrings, VJ height,
PPO and the perceived GROC. Statistical significance was found in all three treatment
groups (FR, IC and CON) when comparing pretreatment measurements to posttreatment
measurements for AROM, VJ and PPO. There was no between-group significance
AROM, PPO or VJ. Statistically significant increases in perceived GROC were found
following the application of FR and IC but the increases were not large enough (≤5) for a
clinically meaningful increase. The application of FR, and IC did not produce any
significant increases in hamstring PPT. The results did find a perceived difference
between FR and IC, but no measurable differences were found. These results give
support that the application of myofascial release techniques can increase ROM, VJ
height and PPO.
71
FINDINGS
As a result of the current study and analysis of data the following this were found:
1. There was a significant increase in ROM between pretreatment and
posttreatment measurements
2. There were no significant differences between FR, IC, and CON in
increasing ROM of the hamstrings.
3. There was no significant increases in PPT between pretreatment and
posttreatment measurements for FR, IC or the CON
4. There were no significant differences between FR, IC, and CON in
increasing PPT.
5. There was a significant increase in VJ height between pretreatment and
posttreatment measurements
6. There were no significant differences between FR, IC, and CON in
increasing VJ height.
7. There was a significant difference between pretreatment and posttreatment
measurements in increasing the PPO of the hamstrings.
8. There were no significant differences between FR, IC, and CON in
increasing the PPO of the hamstrings.
9. There was not a meaningful improvement for perceived muscle pain,
tightness and fatigue following a treatment of FR, IC or CON.
72
CONCLUSIONS
Within the scope and limitations of this investigation, it seems reasonable to
conclude that:
1. An application of FR or IC on the hamstrings may have a beneficial effect
on hamstring ROM.
2. An application of FR or IC on the hamstrings may have a beneficial effect
on VJ height.
3. An application of FR or IC on the hamstrings has a beneficial effect on
PPO.
4. An application of FR or IC on the hamstrings had no effect on hamstring
PPT.
5. An application of FR or IC on the hamstrings overall had no meaningful
increase on perceived muscle pain, tightness or fatigue.
RECOMMENDATIONS FOR FUTURE RESEARCH
The following recommendations for further study seem warranted based on the
data obtained and questions that arose throughout the course of this study.
1. A study should be performed that uses more sport specific tools to
measure performance outcomes after varying myofascial release
techniques.
2. A study should be performed that compares the outcomes of varying
myofascial release techniques to different levels of competition.
73
3. A study should be performed comparing the outcomes of varying
myofascial release techniques to level of previous exposure to myofascial
release techniques.
4. A study should be performed comparing the long-term effects of varying
myofascial release techniques.
5. A long-term study should be performed comparing the outcomes of
varying myofascial release techniques.
74
APPENDIX A
INSTITUTIONAL REVIEW BOARD APPROVAL FORMS
75
APPENDIX B
INFORMED CONSENT FORM
77
INFORMED CONSENT
For a Research Study entitled
A Comparison of Foam Rolling and Ischemic Compression in Improving Hamstring
Tightness
You are invited to participate in a research study to evaluate the effects of two manual
therapy techniques on hamstring muscle tightness and pain. The study is being conducted
by Nathan Sheneberger, at East Stroudsburg University in Athletics Department. You
were selected as a possible participant because you are between the ages of 18-30 and are
a collegiate basketball player.
What will be involved if you participate? If you decide to participate in this research study,
you will be asked to engage 3 brief sessions over a 3-week period. During the initial
session, you will receive one of three 5-minute manual therapy treatments delivered to
the posterior thigh area. Muscle flexibility, function, pain and survey data will be collected
before and immediately following the treatment. Participants will then be
scheduled for 2 other sessions approximately
a
week
apart.
During
each session the muscle
flexibility, function, pain and survey data
will
be recollected. Your total time commitment will be approximately 60-75 minutes over a 3week period.
Are there any risks or discomforts? The risks associated with participating in this study
are possible muscle discomfort and skin redness during the application of the
treatment intervention. The interventions utilized in this study are designed to stretch and
elongate skin, muscle, and fascial tissues and can be uncomfortable. Some participants
may experience mild muscle soreness and possible visible bruising of the skin in the
hamstring area. To minimize these risks, we will be using well trained clinicians and
a 10-point discomfort scale during the intervention. The clinician delivering
manual therapy will be monitoring for any discomfort throughout the treatment session to
avoid any discomfort rating beyond a 7 on the discomfort scale.
All participants have the option to discontinue the treatment at any time. Any subjects
reporting symptoms inconsistent with mild muscle soreness or localize skin irritation will
be immediately referred to the University Health Center or personal physician for follow
up. Participants are responsible for any costs associated with medical treatment.
Are there any benefits to yourself or others? Participants will receive an assessment of their
hamstring flexibility. This information may be helpful in identifying a potential risk factor
in hamstring muscle injuries. Participants will also receive two 5-minute manual therapy
treatment of an intervention reported in previous studies to improve hamstring flexibility,
78
function and pain. We/I cannot promise you that you will receive any or all of the benefits
described.
Will you or you receive compensation for participating? There is no compensation for
participating in this study.
Are there any costs? There are no direct costs to participants associated with participation
in this study.
If you change your mind about participating, you can withdraw at any time during the
study. Your participation is completely voluntary. If you choose to withdraw, your data
can be withdrawn as long as it is identifiable. Your decision about whether or not to
participate or to stop participating will not jeopardize your future relations with East
Stroudsburg University, the Athletic Training Department or any of the East Stroudsburg
University personnel associated with this study.
Your privacy will be protected. Any information obtained in connection with this study
will remain confidential. The information obtained during this study may be used in
follow-up research, published in a professional journal, or presented at professional
meetings but your name and identify will not be reveal.
If you have questions about this study, please ask them now or
contact Nathan Sheneberger by phone at (320)-405-9824 or e-mail at
nsheneberg@live.esu.edu. A copy of this document will be given to you to keep.
If you have questions about your rights as a research participant, you may contact the East
Stroudsburg University Institutional Review Board by phone (570)-422-3336 or e-mail at
sdavis@esu.edu.
THIS PROJECT HAS BEEN APPROVED BY THE EAST STROUDSBURG
UNIVERSITY OF PENNSYLVANIA INSTITUTIONAL REVIEW BOARD FOR THE
PROTECTION OF HUMAN SUBJECTS.
HAVING READ THE INFORMATION PROVIDED, YOU MUST DECIDE
WHETHERE OR NOT YOU WISH TO PARTICIPATE IN THIS RESARCH STUDY.
YOUR SIGNATURE INDICATES YOUR WILLINGNESS TO PARTICIPATE.
__________________________________ __________________________________
Participant Signature
Date
Investigator obtaining consent Date
____________________________
Printed Name
_______________________________
Printed Name
79
APPENDIX C
HEALTH SCREENING FORM
80
Health Screening Form
This study involves the use of myofascial therapy techniques that may include deep pressure
and soft tissue stretching. To minimize potential risks of adverse effects from this type of deep
tissue work, we are collecting the following information. This information will be kept
confidential and used for your protection only. Please be truthful in providing you responses. If
you have any questions or concerns regarding the items below or any other health issues you
may have, please don’t hesitate to ask the investigator while completing this form.
Directions: Please circle either YES or NO for each item below. If you answer YES, please provide
a brief explanation in the space provided.
1.
Have you had a
hamstring injury in the
past 6 months?
YES
NO
Are you currently
undergoing treatment for
a lower extremity injury?
YES
NO
YES
NO
YES
NO
Explain:
2.
Explain:
3.
Do you have any open
wounds, increased skin
sensitivity, or other skin
conditions in the area of
the posterior (back) of
the thigh and legs?
Explain:
4.
Do you have a history or
have been diagnosed
with any systemic
conditions or diseases
81
such as: diabetes,
fibromyalgia, phlebitis or
thrombophlebitis,
arteriosclerosis, clotting
or bleeding disorders,
chronic inflammatory
disorder, or autoimmune
disorders?
Explain:
5.
Do you currently have or
have you had any
neurological
conditions/symptoms
such as: spinal disc
herniation, neuropathy,
numbness, tingling, or
shooting pain into
extremities, or any
history of lower back
pain that included
symptoms that radiated
into your arms or legs?
YES
NO
YES
NO
YES
NO
Explain:
6.
Are you currently taking
any medications that
alter pain perception or
have any effect on
healing or the normal
inflammatory response
(e.g. anti-coagulants,
NSAIDs, steroids, muscle
relaxants, or analgesics
(pain relievers))?
Explain:
7.
Do you have any other
health conditions or
concerns that you feel
may expose you to
potential risks from deep
82
Explain:
tissue mobilization or
stretching techniques?
Interviewer notations:
______________________________________________________________________________
______________________________________________________________________________
______________ Participation Status: Cleared Not Cleared
Participant’s Name (Print): _______________________________Date: __________
Participant’s Signature:_______________________________ Date: __________
PI’s Signature: _______________________________Date: __________
83
APPENDIX D
GLOBAL RATE OF CHANGE SCALE SURVEY
84
Global Rating of Change Scale
Please rate any changes in pain or discomfort in the back of the thigh, knee or calf of the limb
treated since you began this treatment until now (check only one):
7)
A very great deal worse (-
About the same (0)
A great deal worse (-6)
Quite a bit worse (-5)
Moderately worse (-4)
Somewhat worse (-3)
A little bit worse (-2)
A tiny bit worse (-1)
A very great deal better
(7)
A great deal better(6)
Quite a bit better (5)
Moderately better (4)
Somewhat better (3)
A little bit better (2)
A tiny bit better (1)
Please rate any changes in muscle tightness or restriction in the back of the thigh, knee or calf
of the limb treated since you began this treatment until now (check only one):
7)
A very great deal worse (-
About the same (0)
A great deal worse (-6)
Quite a bit worse (-5)
Moderately worse (-4)
Somewhat worse (-3)
A little bit worse (-2)
A tiny bit worse (-1)
A very great deal better
(7)
A great deal better(6)
Quite a bit better (5)
Moderately better (4)
Somewhat better (3)
A little bit better (2)
A tiny bit better (1)
Please rate any changes in muscle performance or fatigue in the back of the thigh, knee or calf
of the limb treated since you began this treatment until now (check only one):
7)
A very great deal worse (-
About the same (0)
A great deal worse (-6)
Quite a bit worse (-5)
85
A very great deal better
(7)
A great deal better(6)
Quite a bit better (5)
Moderately worse (-4)
Somewhat worse (-3)
A little bit worse (-2)
A tiny bit worse (-1)
Moderately better (4)
Somewhat better (3)
A little bit better (2)
A tiny bit better (1)
Investigator/Clinician Notations:
Subject: ____________________
Time: _____
Date: _____
Clinician Initials: _____
86
REFERENCES
1. Davis DS, Ashby PE, McCale KL, McQuain JA, Wine JM. The effectiveness of 3
stretching techniques on hamstring flexibility using consistent stretching
parameters. J Strength Cond Res. 2005; 19(1):27-32.
2. Dick R, Hertel J, Agel J, Grossman J, Marshall SW. Descriptive epidemiology of
collegiate men’s basketball injuries: national collegiate athletic association injury
surveillance system, 1988-1989 through 2003-2004. J Athl Train. 2007; 42(2):194201.
3. Agel J, Olson DE, Dick R, Arendt EA, Marshall SW, Sikka RS. Descriptive
epidemiology of collegiate women’s basketball injuries: national collegiate athletic
association injury surveillance system, 1988-1989 through 2003-2004. J Athl
Train. 2007; 42(2):202-210.
4. Sheffield K, Cooper N. The immediate effects of self-myofascial release on female
footballers. sportEX dynamics. 2013; 38(10):12-17.
5. Witvrouw E, Danneels L, Asselman P, D’Have T, Cambier D. Muscle flexibility
as a risk factor for developing muscle injuries in male professional soccer players.
Am J Sports Med. 2003; 31(1):41-46.
6. Henderson G, Barnes CA, Portas MD. Factors associated with increased
propensity for hamstring injury in English premier league soccer players. J Sci
Med Sport. 2010; 13(4):397-402.
7. Aguilera FJM, Martin DP, Masanet RA, Botella AC, Soler LB, Morell FB.
Immediate effect of ultrasound and ischemic compression techniques for the
treatment of trapezius latent myofascial trigger points in healthy subjects: a
randomized control study. J Mani Phys Thera. 2009; 32(7):515-520.
8. Berggreen S, Wilk E, Lund H. Treatment of myofascial trigger points in female
patients with chronic tension-type headache: a randomized controlled trial. Ad
Physio. 2012; 14:10-17.
9. Bradbury-Squires DJ, Noftall JC, Sullivan KM, Behm DG, Power KE, Button DC.
Roller-massager application to the quadriceps and knee-joint range of motion and
neuromuscular efficiency during a lunge. J Athl Train. 2015; 50(2):133-140.
10. Healey KC, Hatfield DL, Blanpied P, Dorfman LR, Riebe D. The effects of
myofascial release with foam rolling on performance. J Strength Cond Res.
2014;28(1)61-68.
11. Kostopoulos D, Nelson AJ, Ingber RS, Larkin RW. Reduction of spontaneous
electrical activity and pain perception of trigger points in the upper trapezius
muscle through trigger point compression and passive stretching. J Musculo Pain.
2008; 16(4):266-278.
12. MacDonald G, Penney M, Mullaley M, Cuconato A, Drake C, Behm DG, Button
DC. An acute bout of self-myofascial release increase range of motion without a
87
subsequent decrease in muscle activation or force. J Strength Cond Res.
2013;27(3):812-21.
13. MacDonald G, Button DC, Drinkwater EJ, Behm DG. Foam rolling as a recovery
tool after an intense bout of physical activity. Med Sci Sports Exerc.
2014;46(1):132-42.
14. Mohr AR, Long BC, Goad CL. Effect of foam rolling and static stretching on
passive hip-flexion range of motion. J Sports Rehabil. 2014; 23:296-299.
15. Nambi GS, Sharma R, Inbasekaran D, Vaghesiya A, Bhatt U. Difference in effect
between ischemic compression and muscle energy technique on upper trapezius
myofascial trigger points: comparative study. Intl J Health Allied Sci. 2013;
2(1):17-22.
16. Pearcey G, Bradbury-Squires DJ, Kawamoto JE, Drinkwater EJ, Behm DG, Button
DC. Foam rolling for delayed-onset muscle soreness and recovery of dynamic
performance measures. J Athl Train. 2015; 50(1):5-13.
17. Shah N, Shah N. Comparison of two treatment techniques: muscle energy
technique and ischemic compression of upper trapezius trigger point in subjects
with non-specific neck pain. Intl J Thera and Rehabil Res. 2015; 4(5):260-264.
18. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point
Manual: Lower Extremities. Vol 2. Philadelphia, PA: Lippincott Williams &
Wilkins; 1993.
19. van Wilgen P, van der Noord R, Zwerver J. Feasibility and reliability of pain
pressure threshold measurements in patellar tendinopathy. J Sci Med Sport.
2011;14:477-481.
20. Krause F, Wilke J, Neiderer D, Vogt L, Banzer W. Acute effects of foam rolling
on passive tissue stiffness and fascial sliding: study protocol for a randomized
controlled trial. Trials. 2017; 18 (114).
21. Kamper SJ, Maher CG, Mackay G. Global rating of change scales: a review of
strengths and weaknesses and considerations for design. J Man Mani Thera.
2009;17(3):163-170.
22. Drakos MC, Domb B, Starkey C, Callahan L, Allen AA. Injury in the national
basketball association: a 17-year overview. Sports Health. 2010;2(4):284-290.
23. Opar DA, Williams MD, Shield AJ. Hamstring strain injuries: factors that lead to
injury and re-injury. Sports Med. 2012; 42(3):209-226.
24. Meyers TW. The anatomy trains. J Bodyw Mov Ther 1997; 1:91-101.
25. Meyers TW. The anatomy trains: part 2. J Bodyw Mov Ther. 1997; 1:135-145.
26. Cruz-Montecinos C, Gonzalez Blanche A, Lopez Sanchez D, Cerda M, SanzanaCuche R, Cuesta-Vargas A. In vivo relationship between pelvis motion and deep
fascia displacement of the medial gastrocnemius: anatomical and functional
implications. J Anat. 2015; 227(5):665-672.
88
27. Wilson GJ, Newton RU, Murphy AJ, Humphrines BJ. The optimal training load
for the development of dynamic athletic performance. Med Sci Sports Exerc. 1993;
25(11):1279-1286.
28. Esola MA, McClure PW, Fitzgerald GK, Siegler S. Analysis of lumbar spine and
hip motion during forward bending in subjects with and without a history of low
back pain. Spine. 1996; 21:71-78.
29. Van Dillen LR, Gombatto SP, Collins DR, Engsberg JR, Sahrmann SA. Symmetry
of timing of hip and lumbopelvic rotation motion in 2 different subgroups of
people with low back pain. Arch Phys Med Rehabil. 2007; 351-360.
30. Kwon O, Yun M, Lee W. Correlation between intrinsic patellofemoral pain
syndrome in young adults and lower extremity biomechanics. J Phys Ther Sci.
2014; 26(7): 961-964.
31. McHugh MP, Connolly DA, Eston RG, Kremenic IJ, Nicholas SJ, Gleim GW. The
role of passive muscle stiffness in symptoms of exercise-induced muscle damage.
Am J Sports Med. 1999; 27(5): 594-599.
32. Reis FJJ, Macedo AR. Influence of hamstring tightness in pelvic, lumbar and trunk
range of motion in low back pain and asymptomatic volunteers during forward
bending. Asian Spine J. 2015; 9(4): 535-540.
33. Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr Pain
Headache Rep. 2012; 16:439-444.
34. Gerwin RD, Dommerholt J, Shah JP. An expansion of Simons’ integrated
hypothesis of trigger point formation. Curr Pain Headache Rep. 2004. 8:468-475.
35. Xiaoqiang Z, Shusheng T, Qiangmin H. Understanding of myofascial trigger
points. Chin Med J. 2014; 127(24):1-7.
36. Herzog W, Leonard TR, Joumaa, V, Mehta A. Mysteries of muscle contraction. J
Applied Biomech. 2008; 24:1-13.
37. Brückle W, Sückfull M, Fleckstein W, Weiss C, Müller W. Tissue pO2
measurement in taut back musculature (m. erector spinae). Z Rheumatol. 1990;
49(4):208-216.
38. Kraemer WJ, Fleck SJ, Deschenes MR. Exercise Physiology: Integrating Theory
and Application.1st ed. Baltimore, MD and Philadelphia, PA: Lippincott Williams
& Wilkins; 2012.
39. Sluka KA, Kalra A, Moore SA. Unilateral intramuscular injections of acidic saline
produce a bilateral, long-lasting hyperalgesia. Muscle Nerve. 2001; 24:37-46.
40. Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura Ly, Phillips TM, Gerber LH.
Biochemicals associated with pain and inflammation are elevated in sites near to
and remote from active myofascial trigger points. Arch Phys Med Rehabil 2008;
89:16–23.
41. Issberner U, Reeh PW, Steen KH. Pain due to tissue acidosis: a mechanism for
inflammatory and ischemic myalgia? Neurosci Lett. 1996; 208:191-194.
89
42. Hocking MJL. Trigger points and central modulation-a new hypothesis. J
Musculoskeletal Pain. 2010; 18:186-203.
43. Barnes MF. The basic science of myofascial release: morphologic change in
connective tissue. J Bodyw Mov Ther. 1997. 1:231-238.
44. Stecco C, Stern R, Porzionato A, Macchi V, Masiero S, Stecco A, de Caro R.
Hyaluronan within fascia in the etiology of myofascial pain. Surg Radiol Anat.
2011; 33:891-896.
45. Barnes J. Myofascial release. In: Hummer WI, ed Functional Soft Tissue
Examination and Treatment by Manual Methods: New Perspectives. Gaithersburg,
MD: Aspen; 2005:533-548.
46. Shah JP, Phillips TM, Danoff JV, Gerber LH. An in vivo microanalytical
technique for measuring the local biochemical milieu of human skeletal muscle. J
Applied Phys 2005; 99:1977–1984.
47. Cheung K, Hume P Maxwell L. Delayed onset muscle soreness: treatment
strategies and performance factors. Sports Med. 2003; 33(2):145-164.
48. Zachazewski JE. Physical Therapy. Philadelphia, PA: JB Lippincott Co; 1989.
49. Sefton J. Myofascial release for athletic trainers, part 1: theory and session
guidelines. Athl Thera Today. 2004; 9:48-49.
50. Juhan D. Job’s Body. Barrytown, NY. Station Hill Press. 1987.
51. Athensteadt H. Pyroelectric and piezioelectric properties of vertebrates. Ann New
York Acad Sci. 1974; 238:68-110.
52. Moraska AF, Hickner RC, Kohrt WM, Brewer A. Changes in blood flow and
cellular metabolism at a myofascial trigger point with trigger point release
(ischemic compression): a proof-of-principle pilot study. Arch Phys Med Rehabil.
2013; 94(1):196-200.
53. Takamoto, K., Sakai, S., Hori, E., Urakawa, S., Umeno, K., Ono, T., Nishijo, H.
Compression on trigger points in the leg muscle increases parasympathetic nervous
activity based on heart rate variability. J Physiol Sci. 2009; 59:191–197.
54. Takamoto K, Bito I, Urakawa S, Sakai S, Kigawa M. Effects of compression at
myofascial trigger points in patients with acute low back pain: a randomized
controlled trail. Eur J Pain. 2015; 19(8):1186-1196.
55. Simons, D.G. Review of enigmatic MTrPs as a common cause of enigmatic
musculoskeletal pain and dysfunction. J Electromyogr Kinesiol. 2004; 14:95–107.
56. Gulick DT, Palmbaro K, Lattanzi JB. Effect of ischemic pressure using a
Backnobber II device on discomfort associated with myofascial trigger points. J
Bodyw Move Thera. 2011; 15:319-325.
57. Okamoto T, Masuhara M, Ikuta K. Acute effects of self-myofascial release using a
foam roller on arterial function. J Strength Cond Res. 2013; 28(1):69-73.
58. Stecco C, Porzionato A, Lancerotto L Secco A, Macchi V, Day JA, de Caro R.
Histological study of the deep fasciae of the limbs. J Bodyw Mov Ther. 2008;
12:225-230.
90
59. Gabbe BJ, Bennell KL, Wajswelner H, Finch CF. Reliability of common lower
extremity musculoskeletal screening tests. Phys Ther Sport. 2004;5(2):90–97.
60. Connor S, McCaffrey N, Whyte E, Moran K. Reliability of a modified active knee
extension test for assessment of hamstring flexibility. Int. J Athl Train Threa.
2015; 20(4):32-36.
61. Ravichandran P, Ponni HK, Aseer P. Effectiveness of ischemic compression
trapezius myofascial trigger points in neck pain. Int J Physiother. 2016; 3(2):186192.
62. Kinser AM, Sands WA, Stone M. Reliability and validity of a pressure algometer.
Journal of Strength and Conditioning Research. 2009; 23(1): 312-314.
63. Chesteron, LS, Sim J, Wright CC, Foster NE. Interrater reliability of algometry in
measuring pressure pain thresholds in healthy humans, using multiple raters. Clin
J. Pain. 2007; 23(9):760-766.
64. Persson AL, Brogårdh C, Sjölund BH: Tender or not tender: test-retest
repeatability of pressure pain thresholds in the trapezius and deltoid muscles of
healthy women. J Rehabil Med. 2004; 36:17–27.
65. Nussbaum EL, Downes L. Reliability of clinical pressure-pain algometric
measurements obtained on consecutive days. Physical Therapy. 1998;78:160-169.
66. Fabio, A. Pressure algometry in healthy subjects: Inter-examiner variability. Scand
J. Rehab. 1998; 30(1):3-8.
67. Rodrıguez-Rosell, D, Mora-Custodio, R, Franco-Marquez, F, Ya ´n ˜ez-Garcı ´a,
JM, Gonzalez-Badillo, JJ. Traditional vs. sportspecific vertical jump tests:
reliability, validity, and relationship with the legs strength and sprint performance
in adult and teen soccer and basketball players. J Strength Cond Res 2017;31 (1):
196–206.
68. Johnson DL, Bahamonde R. Power output estimate in university athletes. J
Strength Cond Res. 1996; 10(3):161-166.
69. Balmer J. Peak power predicts performance power during an outdoor 16.1 km
cycling time trial. Med Sci Sports Exerc. 2000; 32(8):1485-1490.
70. Maratos FA, Duarte J, Barnes C, McEwan K, Sheffield D, Gilbert P. The
physiological and emotional effects of touch: Assessing a hand-massage
intervention with high self-crtics. Psych Res. 2017;250:221-227.
71. Norris CM, Matthews M. Inter-tester reliability of a self-monitored active knee
extension test. J Body Move Thera. 2005; 9:256-259.
72. Jaeschke R, Singer J, Guyatt GH. Measurement of health status: ascertaining the
minimal clinically important difference. Control Clin Trials. 1989:407-415.
73. Fritz JM, Irrgang JJ. A comparison of a modified Oswestry Low Back
Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther. 2001;
81(2):776-788.
91
74. Vela LI, Denegar CR. The Disablement in the Physically active Scale, part II: the
psychometric properties of an outcomes scale for musculoskeletal injuries. J Athl
Train. 2010; 45(6): 630-641.
75. Wang WC, Wu SL. The random-effect generalized rating scale model. J Ed
Measure. 2011;48(4):441-456.
76. Simons D, Travell J, Simons L. Myofascial Pain and Dysfunction: The Trigger
Point Manual: Upper Extremities. Vol 1. Baltimore, MD: Williams & Wilkins;
1999.
77. Murray A, Jones T, Horoleanu C, Turnea A, and Sprole J. Sixty seconds of foam
rolling does not affect functional flexibility or change muscle temperature in
adolescent athletes. Int J Sport Phys Thera. 2016; 11(5):765-776.
78. Couture G, Karlik D, Glass S, Hatzel B. The effect of foam rolling duration on
hamstring range of motion. Open Ortho J. 2015; 9(1):450-455.
79. Kim SA, Oh KY, Choi WH, Kim IK. Ischemic compression after trigger point
injection affect the treatment of myofascial trigger points. Ann Rehabil Med. 2013;
37(4):541-546.
80. Jagad BH, Jagad KB. Effects of ischemic compression on the trigger points in the
upper trapezius muscle. Ind J Physiothera Occup Thera. 2013; 7(1):99-104.
81. Stratford PW, Binkley JM, Solomon P, Gill C, Finch E. Assessing change over
time in patients with low back pain. Phys Thera. 1994; 74:528-533.
82. Romero-Moraleda B, La Touche R, Luma-Lara S, Fener-Peña R, Paredes V,
Belin-Peinado A, Muñoz-García D. Neurodynamic mobilization and foam rolling
improved delayed-onset muscle soreness in a healthy adult population: a
randomized controlled clinical trial. Peer J. 2017; 5(3908):1-18.
92