Self-myofascial Release as a Treatment Approach to Improve Joint Range of Motion

Fascia is a sheet of connective tissue surrounding and binding together structures including nerves, blood vessels and muscle fibres throughout the entire body. In the normal, healthy state, fascia can stretch and move without restriction and by doing so, helps maintain good posture, range of motion (ROM), flexibility and strength (Schleip and Klingler 2012). Several factors can damage fascia and affect its compliance, including inflammation, inactivity, repetitive motions or disease (Sullivan et al 2013). When fascia is damaged, it becomes tight and loses its elasticity. It binds around the affected area, resulting in the formation of fibrous adhesions between tissue layers. Fibrous adhesions are known to be painful and can restrict joint ROM and decrease strength, endurance and soft tissue elasticity. (MacDonald et al 2013). Therefore, targeting these adhesions may aid in joint mobilisation. Myofascial release (MFR) therapy is a collective term given to a range of manual therapy techniques which use applied pressure to manipulate fascia in a way that enables restricted connective tissues fibres to rearrange and become more flexible.

This technique can relieve pain, increase joint ROM and increase flexibility (Shah and Bhalara 2012). Self-myofascial release (SMR) works under the same principles as myofascial release but allows the individual themselves to apply pressure to the affected soft tissue area, instead of the clinician (Beardsley and Šcarabot 2015). Pressure can be applied using different devices, including the most commonly used dense foam roller and roller massager (Sullivan et al 2013). A foam roller (FR) is a dense foam cylinder that a person rolls their bodyweight over to increase ROM for a specific body region. The exact mechanism of action behind this is unknown. It is thought that the undulating pressure applied during rolling causes the fibrous adhesions in the restricted tissue to break apart, thus stretching fascia and restoring soft tissue extensibility. The more portable roller massager is similar to the foam roller in its mechanism of action, however, the roller-massager relies on an individual’s upper body strength to apply the pressure over muscle, rather than their body weight (Sullivan et al 2013). SMR via foam rolling (FR) or roller massage (RM) is becoming a popular treatment approach to increase myofascial flexibility and in turn, joint ROM (Cheatham et al 2015).

Several studies have investigated the effect of either FR or RM on joint ROM across a broad population of people. The main areas tested for ROM were the knee, ankle, hip and lower extremity. Studies found both beneficial and ineffective effects of SMR therapy. MacDonald et al (2013) examined the effects of FR on knee flexion ROM in 11 male subjects. Subjects served as their own controls and were tested prior to FR, two- and ten-minutes post-FR and after no FR across four sessions with one to two days rest between each session. 10° increase in knee flexion ROM was found two minutes post-test and an 8° increase in knee flexion ROM was found at ten minute post-test when compared to the control group results, suggesting that FR can increase knee ROM. Bradbury-Squires et al (2015) compared the effects of 5 sets of 20 and 60 seconds of RM and no RM on knee joint ROM in ten recreationally active men. 10% and 16% increases in knee ROM were found following 20 and 60 second of RM respectively. In relation to ankle ROM, studies have compared the effects of FR and RM to static stretching. The outcomes implied that FR was only effective in conjunction with static stretching, but RM was found to be an effective measure by itself. Škarabot et al (2015) investigated the effects of three sessions of 30 seconds of FR in 11 resistance-trained adolescents. Ankle ROM was measured pre-test, immediately post-test and ten, fifteen- and twenty-minutes post-test. While a 9. 1% increase in ankle ROM was found in the treatment group experiencing performing static stretching and FR, no increases in ankle ROM were found for the group performing FR only.

On the other hand, Halperin et al (2014) studied the effects of the RM in 14 recreationally trained subjects and found that RM alone increased ankle dorsiflexion ROM immediately and 10 minutes post-test by 4%. Bushell et al (2015) studied the effects of FR on hip extension ROM in 31 subjects of varying training backgrounds. The treatment group underwent three one-minute FR sessions with 30 seconds rest between each session. A significant increase in hip extension ROM was found during the second session in the treatment group. Mohr et al (2014) measured the effects of FR combined with static stretching on hip flexion ROM in 40 male subjects with less than 90° passive hip ROM. The results demonstrated that FR alone produced low increases in ROM, but ROM was increased when FR was combined with static stretching. These results further support Škarabot’s suggestion that joint ROM is best improved using a combination of FR and static stretching. Monteiro et al (2014) studied the effects of 120-second-long sessions of both FR and RM in 18 resistance-trained men. Both FR and RM interventions produced a significant increase in hip ROM when compared with the control. Contrary to both Bushell, Škarabot and Monteiro’s findings, Mikesky et al (2002) found no acute improvements following two minutes of RM on hip ROM in 30 subjects. Need to expand on thisInterpretation of the literature indicates that self-myofascial release via foam rolling or roller massage may improve joint ROM over a short-term period.

However, due to the heterogeneity of the studies it is difficult to come to any firm conclusions. Based on PEDro scores, the average quality of the studies carried out on SMR effects on joint ROM is moderate. No studies were able to satisfy the blinding criteria of subjects or therapists and very few studies reported satisfying the concealment of allocation or blinding of assessors criteria. There are several other limitations that should be taken into consideration when interpreting the findings of these studies. For instance, sample sizes were small across all studies and while subjects varied in levels of activity they all were within a similar age range. Moreover, half of the studies carried out their research on male-only populations. This must be taken into account when reviewing their results as SMR effects may be different in females. Many of the investigations assessing the effects of SMR on joint ROM used different types of roller massager and foam roller, varying from custom-made or commercial devices to controlled-pressure devices. Couture et al (2015) carried out a study on factors influencing RM effects on joint ROM and concluded that higher density tools may have a stronger effect than softer density ones. Therefore, the type of SMR tool used in each study must be taken into consideration, as differences in the type of tool used may alter the effects observed.

Furthermore, differences in the instructions for the use of these tools may be held accountable for changes in ROM observed. Instructions on the amount of pressure to be applied and the exact place where it was to be applied to, varied widely between study protocols. Force applied was a controlled factor in some studies, and not in the majority of others. Sullivan et al (2013) and Bradbury-Squires et al (2015) used controlled limited force using a special device while Macdonald et al (2013) instructed to use “as much bodyweight as possible”, and Halperin et al (2014) provided a force measurement on the basis of a pain scale. Using special devices to control force ensured consistent pressure and cadence, thus eliminating any variations that may arise if a subject were applying their own pressure. Intervention times for all studies ranged from two to five sessions for 30 seconds to one minute.

The time spent rolling may have had an impact on the rolling effects. Most studies found beneficial effects from one to two minutes of treatment. Cadence also differed across studies, with some studies not reporting any cadence guidelines. Pace of rolling should be clarified as effects may vary due to different cadences used. Further study into establishing a protocol for FR or RM which specifies optimal rolling and cadence time and the force to be applied is required in order to reduce variation in assessment methodology across studies. In conclusion, self-myofascial release therapy with a foam roller or roller massager, proves promising as a treatment approach for improvement of joint ROM. However, SMR research is still very much in its infancy and further research is required over both short and long-term periods with larger sample sizes, to confirm its physiological mechanisms and to establish a definite SMR protocol and specific method assessment methodology.