A Narrative Review

Home , Myofascial release, Neuromuscular therapy

Journal of Bodywork & Movement Therapies xxx (2016) 1e6

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Journal of Bodywork & Movement Therapies

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Effect of self-myofascial release on myofascial pain, muscle ﬂexibility, and strength: A narrative review

* Leonid Kalichman , Chen Ben David

Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences at Ben-Gurion University of the Negev, Beer- Sheva, Israel article info abstract

Article history: Background: Numerous techniques have been employed to treat myofascial pain syndrome. Self- Received 20 August 2016 myofascial release (SMFR) is a relatively new technique of soft tissue mobilization. The simplicity and Received in revised form portability of the SMFR tools allow it to be easily implemented in any type of fitness or rehabilitation 27 October 2016 program. It is an active method and can be used by anyone at home or at the workplace. Accepted 6 November 2016 Objective: To review the current methods of SMFR, their mechanisms, and efficacy in treating myofascial pain, improving muscle flexibility and strength. Keywords: Methods: PubMed, Google Scholar, and PEDro databases were searched without search limitations from Myofascial pain Trigger points inception until July 2016 for terms relating to SMFR. fi Myofascial release Results and conclusions: During the past decade, therapists and tness professionals have implemented Self-myofascial release SMFR mainly via foam rolling as a recovery or maintenance tool. Researchers observed a significant Stretching increase in the joint range of motion after using the SMFR technique and no decrease in muscle force or Foam rolling changes in performance after treatment with SMFR. SMFR has been widely used by health-care professionals in treating myofascial pain. However, we found no clinical trials which evaluated the influence of SMFR on myofascial pain. There is an acute need for these trials to evaluate the efficacy and effectiveness of SMFR in the treatment of the myofascial syndrome. © 2016 Elsevier Ltd. All rights reserved.

1. Introduction Borg-Stein and Simons, 2002). The prevalence of myofascial pain syndrome varies from 21% of patients seen in a general orthopedic Myofascial pain syndrome is a common chronic condition clinic and 30% of patients seen in general medical clinic com- characterized by pain originating from myofascial trigger points plaining of regional pain to as high as 85e93% of patients pre- (MTrPs) and fascial restrictions. MTrPs are small, highly sensitive senting to specialty pain management centers (Borg-Stein and areas located in a palpable taut band of skeletal muscle fibers (Borg- Simons, 2002). Stein and Simons, 2002; Simons et al., 1999; Vulfsons et al., 2012). Numerous techniques are presently being employed to treat MTrPs in a particular muscle causes a specific pain pattern and myofascial pain categorized as invasive (injection therapy, MTrP dysfunction that is easily detected by weakness and reduced range dry needling, etc.) and noninvasive (massage, stretching, myofas- of motion (ROM) (Vulfsons et al., 2012). A growing number of in- cial release (MFR), deep tissue massage, neuromuscular therapy, dividuals experience musculoskeletal pain which affects their daily therapeutic ultrasound, laser, etc.) (Aguilera et al., 2009). activities and function (Vernon and Schneider, 2009; Vulfsons et al., One of the commonly used manual techniques is MFR to help 2012). reduce restrictive barriers or fibrous adhesions observed between Myofascial pain is considered one of the most frequent causes of layers of the fascial tissue (MacDonald et al., 2013). MFR is a hands- muscular pain presenting in primary care (Aguilera et al., 2009; on soft tissue procedure applying a gentle stretch to the restricted fascia. Deep tissue massage is a type of massage therapy focusing on realigning deeper layers of muscles and connective tissue (Riggs, 2007). Some of the same strokes are used in classic massage ther- * Corresponding author. Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University apy, however, the movement is slower, the pressure is deeper and of the Negev, P.O.B. 653, Beer Sheva, 84105, Israel. the manipulation is concentrated on areas of muscular tension (i.e. E-mail addresses: [email protected], [email protected] (L. Kalichman). http://dx.doi.org/10.1016/j.jbmt.2016.11.006 1360-8592/© 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Kalichman, L., Ben David, C., Effect of self-myofascial release on myofascial pain, muscle flexibility, and strength: A narrative review, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.11.006 2 L. Kalichman, C. Ben David / Journal of Bodywork & Movement Therapies xxx (2016) 1e6 the palpable tight band in the muscles, densified fascia, etc). Other body awareness, posture and flexibility, challenge neuromuscular methods such as neuromuscular therapy (Granger, 2011) and control and alleviate muscular tension and pain (Feldenkrais, myotherapy (Prudden, 2011) use static pressure, also called 2009). ischemic compression (Cagnie et al., 2013) on MTrPs. Foam rolling is performed with a foam cylinder that can vary in Most of the methods mentioned above are passive; the patient size, shape, and density. Different lengths are available rendering is contingent on the therapist. Self- myofascial release (SMFR) a foam rollers more travel-friendly and easier to maneuver on technique of soft tissue mobilizations that become popular in the different parts of the body. Foam rollers have become popular in last decade (Boyle, 2006), is performed under the same principles, clinics and athletic training rooms for their easy use and versatility. but instead of a therapist providing soft-tissue manual therapy, an They also aim to improve mobility and ROM, reduce scar tissue and individual treats him/herself. SMFR is increasingly becoming a adhesions, decrease muscle tone and overactive muscles, improve common practice in treating soft-tissue restrictions. The simplicity the quality of movement, and replace hands-on sessions or deep and availability of SMFR allow it to be easily implemented in many tissue massage. types of training or rehabilitation program. Foam rollers are best used in treating large muscle groups. Each The SMFR technique involves small undulations back and forth muscle group has a designated position and protocol with different over a special tool such as a dense foam roller or massage balls, starting and end points. Generally, most rolling protocols include starting at the proximal portion of the muscle and working 30e60 s of rolling on the specified muscle with the action repeated downwards to the distal portion of the muscle or vice versa. on the opposite limb. Some protocols also call for the roller to be Sometimes the undulations are concentrated over the painful area stopped and held on any tender or painful areas in an attempt to of the muscle or a patient can be positioned over the SMFR tool for release a muscle spasm or MTrPs. Individuals with poor tissue 6e30 s in order to provide sustained compression on the MTrP. The quality and are new to foam rolling, generally need to spend more small undulations place direct and sweeping pressure on the soft- time on the roller in order to achieve best results. Foam rolling tissue which is believed to cause a warming of the fascia, breaking sessions can be performed once or twice a day and may be used up fibrous adhesions between the fascial layers and thus restoring before a workout as a warm-up tool or after as a recovery option soft-tissue extensibility (MacDonald et al., 2013). On the other (Weerapong et al., 2005). hand, the effect as suggested by others is similar to one of deep The medicine ball (special balls or tennis, golf, lacrosse balls) tissue massage or ischemic compression (Fernandez-de-las-Pe nas~ may be more versatile than the foam roller since the balls can et al., 2006; Fryer and Hodgson, 2005; Hanten et al., 2000; Hong concentrate on a focal spot as well as work in a three-dimensional et al., 1993). mode. A tennis ball is suitable for treating muscle or fascia on a Aim: To examine the current methods of SMFR, their mecha- smaller surface area (Robertson, 2008). nisms, and efficacy in treating myofascial pain, improving muscle The roller massager (or “the stick”) is a portable ergogenic de- flexibility and strength. vice constructed of dense foam wrapped around a solid plastic cylinder. This device used in a similar fashion as the foam roller is 2. Methods increasingly being used by athletes to massage muscles and other soft tissues (Halperin et al., 2014). However, instead of relying on PubMed, Google Scholar and PEDro databases were searched body weight, the patient uses his upper body. Manufacturers claim without search limitations from inception until July 2016. The da- that in as little as 30 s of massage, muscles can improve in flexi- tabases were searched for the keywords related to self-myofascial bility, strength, and power (Halperin et al., 2014). The roller release: myofascial pain, trigger points, tight muscles, muscle massager is also narrower in diameter which aids in reaching some pain, myofascial release, self-myofascial release, stretching, foam tendons (Robertson, 2008). rolling, pain ball, lacrosse ball, golf ball, tennis ball, “the stick”, Thera Cane (Thera Cane Co, PO Box 9220, Denver, CO 80262) is a Thera Cane, Knobler, and the combination of these terms. plastic J-shaped cane with six knobs placed at various points on the Criteria for inclusion in the review were use of any type of cane. The cane was designed to allow minimal exertion by the user research deals with existing methods of SMFR and their applica- and create sustained pressure in hard-to-reach areas. tions. Trails of any design and methodological quality were Despite the popularity and numerous benefits of SMFR, limited included. No language restrictions were imposed. The reference research has been conducted on its efficacy and effectiveness in lists of all articles retrieved in full were also searched. treating musculoskeletal disorders. Most of these studies have The search results were pooled duplicates deleted. The titles and focused on SMFR using the foam roller. The studies on other SMFR abstracts of all articles were reviewed. Full texts of potentially tools such as the roller massager and Thera Cane are rare and no relevant papers were read and their reference lists were searched studies were found on the use of medicine balls. for additional relevant articles. After excluding all irrelevant papers total of 42 publications were included in the review. 3.2. Biological mechanism of SMFR

3. Findings Research reports on SMFR mechanisms are limited. However, the theoretical framework of bodywork methods can be used to 3.1. SMFR tools/methods understand the mechanisms of the SMFR. Exerting mechanical pressure is theorized to decrease adhesions between tissue layers, Different tools can be used for SMFR, i.e. a foam roller, roller improve muscular compliance and decrease muscle stiffness of the massager, “the Stic”Thera Cane, massage balls, and even sports muscle fibers (Sherer, 2013). Applying prolonged or amplified equipment such as tennis, lacrosse or golf balls. pressure with a foam roller to the muscle belly will cause the Foam rollers were first used by practitioners of the Feldenkrais muscle to relax. A massage appears to help athletes reduce method, a mind-body modality combining theories of motor ischemia by increasing blood circulation to the skin and muscles, development, biomechanics, psychology and martial arts. This reduce parasympathetic activity and release relaxation hormones method encourages the student to experiment and ideally become and endorphins. The possible neurological effects occurring with more aware of their movements without much assistance from the reflex stimulation, decrease the neuromuscular excitability of the instructor. Foam rollers are used to restore alignment, improve muscle and minimize MTrPs activity and pain, muscle spasms and

Please cite this article in press as: Kalichman, L., Ben David, C., Effect of self-myofascial release on myofascial pain, muscle flexibility, and strength: A narrative review, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.11.006 L. Kalichman, C. Ben David / Journal of Bodywork & Movement Therapies xxx (2016) 1e6 3 excessive tension (Sherer, 2013). includes decreasing the tonus of a related striated muscle fibers The pressure applied by SMFR tools is comparable to the pres- which subsequently contributes to the release felt through the sure induced by manual ischemic compression. The rolling is application of SMFR (Abes, 2013; Schleip, 2003a). SMFR results in similar to longitudinal stroking (striping) of deep tissue massage breaking the pain-spasm cycle by releasing muscle spasms and (Rolfing). Performing ischemic compression entails applying decreasing adhesions, thus restoring normal homeostasis to con- increasing pressure on the MTrPs usually with the thumb, to a nective tissue (Mohr et al., 2014). degree severe enough to result in temporary ischemia or a lack of The muscle spindle is located in the belly of the muscle and blood flow to the compressed area until the pain reaches its senses muscle length change. When the muscle spindle detects an maximal tolerable level (Abes, 2013; Cagnie et al., 2013). The pur- aggressive stretch to the muscle, the neural pathways send efferent pose of this method is to increase local blood flow upon release, signals to that muscle, ensuring a contraction which resists the which is thought to facilitate the removal of waste products, supply excessive stretch. Forceful static stretching that does not alleviate oxygen, and promote healing of the tissue (Abes, 2013). muscle spindle activation after 8 s can damage muscle spindle re- A possible explanation for the increased ROM after ischemic ceptors and increase the risk of muscle strains or tears (Fama and compression is that manual pressure on the contraction knot of the Bueti, 2011). MTrPs causes lengthening of the sarcomeres. Decreased abnormal The Golgi tendon organ, located in the tendon, reacts to tension of the taut band and general pain reduction may also changes in tension placed upon the muscle. If the Golgi tendon contribute to increased ROM. Cagnie et al. (2013) examined the organ senses excessive muscle contraction that can potentially short-term effects of ischemic compression treatment in a small harm the related soft tissue structures, it becomes excited and sample of office workers with mildly severe chronic pain. They results in the relaxation or failure of a contraction. Stimulation of found that a four-week treatment of MTrPs for ischemic compres- the Golgi tendon organ inhibits the muscle spindle and causes sion resulted in significant improvements in general neck and muscle relaxation (Fama and Bueti, 2011). This phenomenon is shoulder complaints, pressure pain sensitivity, mobility and muscle called autogenic inhibition. Autogenic inhibition can also occur by strength (Cagnie et al., 2013). A possible explanation for the sig- applying pressure during the foam roll thus stimulating the Golgi nificant improvement of muscle strength may be that the short- tendon organ. When stimulation passes a certain threshold, it ened sarcomeres were lengthened by ischemic compression and inhibits muscle spindle activity and decreases muscular tension. If may have contributed to the contraction of the involved muscle. autogenic inhibition occurs during foam rolling, muscle stiffness The theory is that reactive hyperemia after applying ischemic decreases and muscle compliance increases, thus negatively compression may lead to an improved oxygen supply and a affecting performance and increasing the risk of injury during decreased production of nociceptive and inflammatory substances, physical activity (Fama and Bueti, 2011). This could explain the thus resulting in less damage to the muscle fibers and conse- potential decrease in performance and strength which was seen in quently, better strength production (Cagnie et al., 2013). Fama and Bueti's (Fama and Bueti, 2011) study. They concluded Curran et al. (2008) compared the effects of two types of foam that foam rolling warm up exhibited negative effects by rollers: a bio-foam and a multi-rigid layered roll. The amount of decreasing jump performance. pressure exerted on the soft tissue was significantly different. The mean pressure exerted on the soft tissue of the lateral thigh by a 3.3. Effects of SMFR multi-rigid layered roll (51.8 ± 10.7 kPa) was significantly greater than that of the conventional bio-foam roll (33.4 ± 6.4 kPa). The 3.3.1. SMFR in treating myofascial pain mean contact area of a multi-rigid layered roll (47.0 ± 16.1 cm2) In spite the wide use of foam rolling, medicine balls and roller was significantly less than that of the bio-foam roll massagers in treating myofascial pain, we found no clinical trials (68.4 ± 25.3 cm2). In conclusion, using the more dense foam roller which specifically evaluated the influence of these methods of lead to a more focal and greater pressure on the treated tissue SMFR on myofascial pain. (Curran et al., 2008). According to Schleip, the physiology behind the SMFR technique 3.3.2. Effect of Thera Cane SMFR on myofascial pain can be attributed to the autonomic nervous system and the central Hanten et al. (2000) evaluated the effectiveness of a home nervous system (Schleip, 2003a, 2003b). program of ischemic pressure using Thera Cane followed by sustained stretching for the treatment of MTrPs. The subjects were 3.2.1. Autonomic nervous system instructed to place the muscle with the primary MTrP in a Pressure applied through the SMFR is believed to activate the lengthened position using various combinations of head and autonomic nervous system by stimulating interstitial type III and IV shoulder girdle movements, depending on the location of the MTrP. receptors which respond to a light touch; the Ruffini endings in the While holding this position, the subject was instructed to place the fascia respond to deep sustained pressure. SMFR proponents argue Thera Cane over the patient's primary MTrP, then to gradually in- that stimulating these receptors lowers the overall sympathetic crease the pressure to the MTrP and hold the pressure until a tone, increases gamma motor neuron activity and promotes the release (feels like a “letting go” or a “melting” of the muscle with relaxation of intra-fascial smooth muscle cells (Wiktorsson-Moller the primary MTrP, accompanied by a decrease in pain) was felt. The et al., 1983). In addition, it is believed that the autonomic nervous subject was instructed to repeat the procedure, at least twice a day system promotes vasodilation and local fluid dynamics which alter for five consecutive days until no further release was obtained. The the viscosity of fascia by changing the ground substance to a more results of this study showed that a combination of these techniques gel-like state. All of these combined effects are hypothesized to is effective in reducing MTrPs sensitivity and pain intensity in in- yield a palpable release of the trigger point and improve muscle dividuals with neck and upper back pain. However, it is impossible function (Abes, 2013; Barnes, 1997; Schleip, 2003a). to determine if the effect was produced by the Thera Cane ischemic compression, by the sustained stretch or by the combination of 3.2.2. Central nervous system both techniques. Stimulation of the mechanoreceptors simultaneously activates There is an acute need for these trials to evaluate the efficacy the autonomic nervous system and the central nervous system. The and effectiveness of SMFR in the treatment of the myofascial central nervous system's response to such localized pressure syndrome.

3.3.3. Influence of the foam roller SMFR on ROM/flexibility foam rolling; the greatest advantage of the SMFR is that the subject One of the most common methods used to improve flexibility is not dependent on the presence of the therapist. and joint ROM is static stretching; however, a major limitation of Two systematic reviews were recently published on the effect of this method is that it could lead to decreased power and force SMFR (Beardsley and Skarabot, 2015; Cheatham et al., 2015). The production if performed prior to an athletic activity (Simic et al., common conclusion of these reviews is that SMFR appears to have a 2013). Stretching places strain on the origin and insertion of the range of potentially valuable effects for both athletes and the muscle and may cause damage to the sarcomeres, thus diminishing general population, including enhancing ROM. However, due to the muscle force output. In addition, the elongation of tendinous tis- heterogeneity of methods among studies, there currently is no sues can have an effect on force output through a reduction in consensus on the optimal SMFR program. either the passive or active stiffness of the musculotendinous unit (Sullivan et al., 2013). 3.3.4. The influence of foam roller SMFR on performance and An alternative, which has been growing in popularity, is SMFR strength with either a foam roller or a roller massager. Halperin et al. (2014) Healey et al. (2014) conducted a randomized, crossover study found that both roller massage and static stretching (performed for examining whether the use of foam rollers before athletic tests three sets of 30 s each) increased ROM of plantar flexor muscles could enhance performance. Twenty-six healthy athletes per- immediately and 10 min after the interventions. However, the roller formed a series of planking or foam rolling exercises and then massage increased and static stretching decreased maximal force performed a series of athletic performance tests (vertical jump output during the post-test measurements. In a recent study height and power, isometric force and agility). No significant dif- (Skarabot et al., 2015) of 11 resistance-trained, adolescent athlete ferences were found between foam rolling and planking for all four use of foam rolling alone did not lead to improvement in passive of the athletic tests, however, the study found that post-exercise ankle dorsiflexion ROM, however using the foam rolling in addition fatigue after foam rolling was significantly less in subjects who to static stretching was significantly superior to using static had performed planking (p 0.05). The reduced feeling of fatigue stretching alone (9.1% vs. 6.2%, p < 0.05). may allow participants to extend acute workout time and volume, A study conducted by MacDonald et al. (2013) found that two which can lead to chronic performance enhancements (Healey sets of 1 min of SMFR using a foam roller on the quadriceps mus- et al., 2014). cles, improved knee joint ROM for up to 10 without a concomitant Abes (2013) investigated the immediate effects of a standard deficit in muscle performance. Mohr et al. (2014) examined the foam rolling protocol on the explosive strength of the plantar combination of foam rolling and static stretching and their influ- flexors and alpha motor neuron excitability in the soleus. Explosive ence on passive hip flexion ROM. Forty subjects with less than a 90 strength was measured through vertical jump height and the passive hip flexion ROM participated in the study. During each of Reactive Strength Index. Alpha motor neuron excitability was the six sessions, the subject's passive hip flexion ROM was measured by H-reflex amplitude as an H-wave to M-wave ratio measured before and immediately after static stretching, foam obtained from the soleus muscle. The intervention which followed rolling and static stretching, foam rolling or nothing (controls). standard professional guidelines consisted of 2.5 min of foam Subjects using the foam roll and static stretch experienced a greater rolling for the intervention group and rest for the control group, change in passive hip flexion ROM compared with the static stretch, followed by a 5-min warm-up on a cycle ergometer. With respect to foam-rolling and control groups (Mohr et al., 2014). The study explosive strength, this study found that the foam rolling protocol concluded that using the foam roller for three sets of 2-min repe- did not induce any significant changes in jump height or explosive titions increased hip flexion ROM. strength of the plantar flexors. In addition, the foam rolling protocol Sherer et al (Sherer, 2013) studied the effects of foam roller use produced no significant effect on the excitability of the motor on hamstring flexibility (measured by the sit-and-reach method) in neuron pool. These findings are similar to Sullivan et al.'s (Sullivan a group of weight training athletes. Participants in the intervention et al., 2013) who found that an acute bout of foam rolling had no group performed the foam rolling twice a week for a period of four effect on maximal voluntary contraction, electromechanical decay weeks. The control group did not receive any intervention. The and evoked twitch force on the quadriceps. results showed that hamstring flexibility in the control group did Fama and Bueti (2011) evaluated the acute effect of a foam not change; in the foam rolling group flexibility significantly roller warm-up routine and a dynamic warm-up routine on increased (Sherer, 2013). Similarly, Sullivan et al. (2013) found a strength, power, and reactive power. The outcome measures were 4.7% increase in hamstring ROM following two sets of five and 10 s three different jump testing: squat jump, countermovement jump with a roller massager. and depth jump. Subjects were randomly assigned into the dy- On the other hand, there were studies that found that SMFR was namic warm up group or the foam roller group: the foam roller ineffective in increasing hamstring flexibility (Couture et al., 2015; was bilaterally applied to the lower extremities on each muscle Miller and Rockey, 2006; Morton et al., 2016). For example, Miller group for 1 min. The dynamic treatment consisted of 10 repeti- and Rockey (2006) investigated whether foam rollers would in- tions performed on each leg, with a walk-back recovery. Nine crease the flexibility of the hamstring muscles when measured by college-aged recreational males with a minimum of one-year an active knee extension test. Foam rolling was performed three experience in plyometric training completed the study. The re- days a week for eight weeks on individuals considered to have tight sults showed that a dynamic warm-up produced a significant in- hamstrings prior to the study. No significant differences were found crease in countermovement jump height compared to the foam between the foam rolling and the control groups. roller warm-up. When comparing the two warm-up techniques, In a study by Sharp (2012), the benefits of using a hands-on the foam roller routine did not elicit any significant changes in approach of MFR called the 'Emmet technique' was compared to performance in the squat jump or depth jump. Also, the foam the use of SMFR using the foam roller. The results showed that ROM roller warm-up did not improve performance, on the contrary, it significantly increased in both groups, but the Emmet hands-on was actually detrimental to the countermovement jump (Fama approach was more effective in increasing ROM. A vertical jump and Bueti, 2011). was also evaluated showing no significant differences between the To conclude the aforementioned, there is no evidence that foam foam rolling group and the Emmet group (Sharp, 2012). Even the rolling SFMR is effective in improvement of muscle strength or effectiveness of a hands-on approach was shown to be superior to performance and cannot be recommended pre as a warm-up

3.3.7. Stress reduction The authors declare that they have no conflict of interest. Recent Korean pilot study (Kim et al., 2014) aimed to examined the effect of the SFMR induced with a foam roller on the reduction Acknowledgments of stress by measuring the serum concentration of cortisol. Young female subjects were asked to walk for 30 min on a treadmill and The authors thank Mrs. Phyllis Curchack Kornspan for her then the control group rested for 30 min by lying down, whereas editorial services. the experimental group performed a 30 min of SMFR. Statistically significant levels of serum cortisol reduced in both groups, but References there was no significant difference between the groups. Therefore

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