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Do Self-Myofascial Release Devices Release Myofascia? Rolling Mechanisms: A Narrative Review By Todd Hargrove

Key P oi nts 1. Rolling can reduce pain and improve ROM without decreases in strength. 2. After rolling, local tissues show decreased stiffness. 3. Thixotrophy (reduction in viscosity of thick liquids through heating or agitation) is a potential explanation for the local effects of rolling. 4. Rolling causes decreased pain and increased ROM at untreated areas, suggesting the primary importance of non-local mechanisms, probably involving modulation of the nervous system.

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BACKGROUND & OBJECTIVE

‘Rolling’ can reduce pain and improve flexibility, without decreasing strength

Research shows that “rolling” with foam, massage balls or other instruments can reduce pain and improve flexibility, without decreasing strength (1, 2). The purpose of this narrative review was to examine the mechanisms for these effects, and whether they involve any process that can be called “myofascial release.”

MYOFASCIAL TONE AND SOFT TISSUE RESTRICTIONS Excess stiffness of fascia or restrictions in fascial mobility have been reported to occur in response to insufficient or excess loading, injury, inflammation, or disease. The proposed mechanisms for these restrictions include contraction of myofibroblast cells, adhesions, changes in fascial hydration, and changes in muscle volume.

meter; increase tissue elasticity by a small amount as measured by shear wave elastography; and increase blood flow in the general area. These effects manifest 10-30 minutes after treatment. The authors consider the local mechanisms by which these changes could occur.

Trigger points have also been advanced as a reason for soft tissue stiffness, but the authors note questions about the validity and reliability of this diagnosis. Further, there is little research showing how rolling could treat a trigger point, so any related claims should be viewed with caution.

It is not plausible that rolling could remove myofascial adhesions, as this would require more pressure than could be applied with a roller (3, 4). However, local effects on fascial stiffness might occur through changes in blood flow, water content, or viscoelasticity of tissues. For example, rolling may cause thick liquids to become less viscous through the process of thixotrophy, which may occur when they are sheared, agitated or heated.

DOES MYOFASCIAL TISSUE RELEASE FOLLOWING SELF‑MASSAGE?

The relevance of these local changes to the effects of rolling are called into question by numerous studies finding that rolling has effects distant from the treated area. Three studies have found decreased pain in the contralateral leg. Other studies have noted increased ROM in untreated joints. For example, rolling of the plantar fascia has been found to improve hamstring flexibility and contralateral ankle dorsiflexion, and rolling of the hamstrings has been found to increase ROM in the shoulder.

Studies have found that rolling can: decrease tissue stiffness of the anterior thigh by approximately 20% as measured by semi-electronic tissue compliance

“The term ‘self-myofascial release’ is a misnomer and misleading as applied to rolling.”

One proposed mechanism for these global effects is modulation of the nervous system, which

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exerts control over pain and ROM, and is highly sensitive to stimuli detected by sensory organs that could be activated by rolling. The resulting sensory inputs could trigger DNIC (diffuse noxious inhibitory control), which suppresses nociception, or activation of the parasympathetic system, which alters various hormones that affect pain perception. Any reductions in pain would help explain increased flexibility, because “stretch tolerance” is an important determinant of ROM, and probably the primary mechanism whereby stretching improves ROM (5).

CLINICAL IMPLICATIONS In light of the mechanisms proposed by the authors, it would appear that the benefits of rolling are likely to be temporary and not progressive. If foam rolling could remove adhesions or trigger points, the benefit would be more permanent, but there is no good evidence that this can occur. Instead, the benefit is likely due to either reduced pain sensitivity or reduced tissue viscosity, and these effects would be expected to subside after a few hours. Further, these mechanisms can be invoked by a wide variety of other active and passive interventions, such as manual therapy, stretching or exercise.

CONCLUSION Based on the foregoing, the authors conclude that the term ‘self-myofascial release’ is a misnomer and misleading as applied to rolling. Although rolling may cause local thixotrophic effects, it is not clear that they account for its benefits, especially when more global effects have been shown. Further research is needed to clarify the relative importance of global versus local mechanisms.

Therefore, rolling is a tool for gaining temporary improvements in pain and range of motion, but there are other means to do so. Like many other interventions whose primary effect is temporary symptom modification, they can be used as part of a program of graded exposure and progressive exercise.

+ Study reference Behm D, Wilke J (2019) Do Self-Myofascial Release Devices Release Myofascia? Rolling Mechanisms: A Narrative Review. Sport Med, 1-9, doi:10.1007/s40279-019-01149-y.

Todd Hargrove

SUPPORTING REFERENCES 1.

Aboodarda SJ, Spence AJ, Button DC. Pain pressure threshold of a muscle tender spot increases following local and non-local rolling massage. BMC Musculoskelet Disord. 2015;16:265.

2.

Mohr AR, Long BC, Goad CL. Effect of foam rolling and static stretching on passive hip-flexion range of motion. J Sport Reha- bil. 2014;23(4):296–9.

3.

Schleip R. Fascial plasticity—a new neurobiological explanation: Part I. J Bodyw Mov Ther. 2003;7(1):11–9.

4.

Schleip R. Fascial plasticity—a new neurobiological explanation: Part 2. J Bodyw Mov Ther. 2003;7(2):104–16.

5.

Behm DG, Blazevich AJ, Kay AD, McHugh M. Acute effects of muscle stretching on physical performance, range of motion, and injury incidence in

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Clinical Commentary: Rehabilitation Following Subscapularis Tendon RepaiR By Robin Kerr

Key P oi nts 1. Subscapularis tendon repairs, although less common that other rotator cuff repairs, need specific input to ensure restoration of internal rotation and anterior shoulder stability 2. Therapists must consider the graded application of loading to healing tissues 3. This program promotes a 5-phase process with objective criterion needing to be met prior to advancement to the next phase

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BACKGROUND & OBJECTIVE The purpose of this clinical commentary was to provide an evidence-based protocol for postoperative rehabilitation following subscapularis (SSC) tendon repair. SSC tears have been reported in up to 37% of patients undergoing arthroscopic rotator cuff surgery (1), however detailed clinical rehabilitation literature is sparse. Despite SSC tendon tears being less common than other rotator cuff tears, the importance of subscapularis for internal rotation and anterior shoulder stabilization mandates safe and effective postoperative rehabilitation. This paper reinforces the

need for staged progression through rehabilitation in tandem with tissue healing phases (2). 5 PHASE SSC REPAIR REHABILITATION GUIDELINES The rehabilitation program was divided into 5 phases taking into consideration the biology of healing, any underlying pathology and integrity of the repair. Progression through each phase of rehabilitation was based on proposed criteria derived via merging time-based and performancebased principles (3,4).

Clinical Tests for SSC Integrity

SOME INTERESTING SUBSCAPULARIS FACTS ▲ ▲ ▲ ▲ ▲ ▲ ▲

SSC is the largest and most powerful rotator cuff muscle at 53% of the cuff moment. Upper 60% of the insertion is a tendinous and the lower 40$ consists of muscle. Majority of SSC tears are degenerative Traumatic tears often result from violent external rotation eg. MVA “Antero-superior tears” = SSC tears often associated with tears and dislocation of Long Head Biceps and anterior portion of the Supraspinatus Tendon Surgical repair often advocated for full thickness tendon lesions Sub-coracoid impigement can contribute to the pathogenesis of SSC tears. The senior author performs a sub-coracois decompression simultaneously with SSC repair

Altintas 2019

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PHASE 1: MAXIMAL PROTECTION Goals:

CRITERA FOR PROGRESSION TO PHASE 2

Decrease pain and inflammation

Restore passive mobility within ER limits (30°)

Pain-free restricted ADL using the sling

Exercises/Treatment: Abduction sling day and night

Waist level activity as tolerated e.g. keyboard

Regular cryotherapy

ROM: active hand, wrist and elbow.

PASSIVE shoulder ROM

LIMITED external rotation < 30°

Scapular mobility – avoid for two weeks with full thickness repairs. Then gentle introduction of scapula motions with SLING ON.

Isometrics: None weeks 0-3 for full tears. Afterwards sub-maximal and pain free isometrics in neutral e.g. rhythmic stabilization

• Manual Therapy: PROM, soft tissue work such as lymphatic drainage, NO mobilisation to glenohumeral joint •

Maximally protect the reconstruction via optimization of the environment for tissue healing e.g. avoid smoking, ensure stable blood glucose levels

Kinetic Chain Exercises: breathing, “Core” exercises in crook lying, focus on lower extremity movement e.g. stationary recumbent bike

“This paper reinforces the need for staged progression through rehabilitation in tandem with tissue healing phases.”

Pain less than 3/10 at rest Functional Tasks: 3 out of 5 1. Light meal preparation 2. Feed self-hand to mouth 3. Waist height ADLs 4. Less than 2 sleep disturbances per night 5. DASH score < 60 Passive ROM: Forward elevation 120̕, Abudction 90̕, ER 30̕ Able to perform active “scapular clock”

PHASE 2: MUSCULAR ENDURANCE Goals: • Careful progression to full active ROM (AROM) • Improvement of endurance ability and control of the shoulder complex • Normal use of arm during ADLs – apart from overhead lifts, jerking or repetitive actions • Discontinue sling Exercises – PROM > AAROM • Active assisted ROM (AAROM) 1 week before active ROM (AROM) • Light stretching until full passive ROM (PROM) • Low load, long stretches & joint mobilisations at 5-6 weeks post-op • Isotonic – no or low load + high repetition exercises • Gravity load is enough • MVIC of 15% or less e.g. table slides, pulley assisted elevation • Bar/stick or foam roller for ER AAROM in supine Exercises – AAROM > AROM • Fair isometric contraction + AAROM => AROM commences • Supine, side-lye or prone -> progress to standing • ROM exercises+ scapular control • Stepwise neuromuscular training e.g. rhythmic stabilization at various angles, diagonal PNF, open chain scapular exercises e.g. supine serratus punch

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• •

Unloaded CKC (closed kinetic chain) e.g. standing foam roller wall slides NO loaded CKC at this point

CRITERA FOR PROGRESSION TO PHASE 3 ▲

Pain < 3/10 with ROM Functional Tasks: 3 out of 5 1. Repetitively reach overhead 2. Wash or dry hair 3. Tuck in back of shirt 4. Sleep Undisturbed 5. DASH score < 40 Active ROM: Forward elevation 120̕, Abduction 120̕, ER 45̕ Repeated AROM Fatigue Protocol: 20 reps of each for Scaption 90̕, Abduction 90̕, Side-lying ER 0̕ Normal Scapular Dryskinesis Testing These criteria MUST BE MET PRIOR TO STARTING PHASE 3.

21-50% MVIC e.g. upright bar elevation, forward punch, IR at 0° abduction Later stages: > 50% MVIC initiated e.g. IR at 45° abduction, ER at 0-90° abduction, dynamic hug, diagonals: IR at 90° Abduction, low & high row, resisted active elevation/flexion

FINDING THE BALANCE BETWEEN EXTERNAL & INTERNAL ROTATION The literature suggests external : internal rotator muscle strength ratio should be 0.66-.075 : 1. Although there is conflicting evidence, it appears that there is enhanced activation of SSC with less activation of pectoralis major, latissimus dorsi and teres major when performing IR at 90° abduction (5).

▲ ▲

CLOSED CHAIN BODY WEIGHT EXERCISE Initially should be static then progressed to increased weight bearing through the upper extremities. Progression from wall -> tabletop -> quadruped grades loading, e.g. push up with a plus, quadruped reaches +/- stability /perturbation from a balance board etc.

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Controlled concentric and eccentric contractions

Exercises: • Strengthen entire shoulder girdle • Phase 2 exercises can now be loaded e.g. bands, weights, cables

CRITERA FOR PROGRESSION TO PHASE 4 ▲

PHASE 3: MUSCULAR STRENGTH Goals: • Improve strength - increase resistance, reduce repetitions. Not prior to 6 weeks post-op • Advance muscular endurance • Advance dynamic stability exercises • Periodization format to load the repair and stimulate remodeling • Advanced strengthening starts at 10 weeks postop • Light impact such as jogging can start at the end of this phase • If the patient does not require advanced or power movement they can be discharged with a HEP and returned to usual unrestricted activity after this phase.

Functional Tasks: 3 out of 5 1. Carry heavy object > 20 lbs at waist 2. Lift a weight/object overhead > 5 lbs 3. Push self-up during transfers 4. Perform household chores 5. DASH score < 20 Active ROM > 90% of contralateral side MMT 4/5, HHD >80% contralateral side, ERO/ IRO > 70%

* HHD (hand-held dynamometry) tests should be performed at ER0, IR0, ER90, IR90, abduction and scaption at 90°.

PHASE 4: POWER Goals: • Incorporate speed and explosive strength • Sport/occupation-specific movement patterns • Repetition, speed and load varied to facilitate feed forward processing


Exercises: • Ensure trunk stabilization -> shoulder linkages for force distribution • Plyometric exercises: double upper e.g. med ball throws to ground, side, overhead • Progress to single arm e.g. IR wall dribbles, IR throws against trampoline, supine 90-90 IR medicine ball toss • Can be performed at 90° abduction to improve IR/ER strength & throwing ability • Closed chain progressed e.g. suspension/TRX

CRITERA FOR PROGRESSION TO PHASE 5 ▲ ▲

MMT 5/5, HDD > 90% CONTRALATERAL SIDE ER90/IR90 > 70% PASS ON ALL FUNCTIONAL TESTS: 1. Med Ball Plyometric wall bounce: 2lbs x 60sec @ 165bpm 2. Single Arm Seated Shot-Put Test > 90% contralateral side 3. CKCUEST >21 touches in 15 seconds 4. UEY-Balance: total normalized excursion score >90% contralateral side

PHASE 5: RETURN TO SPORT PROGRAM Goals: • Full sports participation without compensation or risk of re-injury Guidelines: • Clinical and sport specific testing – mobility & strength-based criteria •

Simulated sport activity

Return to training

Playing lower level competition and less minutes until confident

If throwing sport - emphasis on late cocking and acceleration phase of throwing

Following successful completion of: •

Throwing Athletes: Throwing Progression

Golfers: Golf Progression Return to unrestricted activity/full sports participation

+ Study reference Altintas B, Bradley H, Logan C, Delvecchio B, Anderson N, Millett P (2019) Clinical Commentary: Rehabilitation Following Subscapularis Tendon Repair. The International Journal of Sports Physical Therapy, 14(2), doi: 10.26603/ijspt20190318

Robin Kerr

SUPPORTING REFERENCES 1.

Garavaglia G, Taverna E, Ufenast H. (2011).The frequency of subscapularis tears in arthroscopic rotator cuff repairs: A retrospective study comparing magnetic resonance imaging and arthroscopic findings. Int J Shoulder Surg.;5(4):90.

2.

Katthagen JC, Vap AR, Tahal DS, Horan MP, Millett PJ.(2017).Arthroscopic repair of isolated partial and full thickness upper third subscapularis tendon tears: Minimum 2-year outcomes after single-anchor repair and biceps tenodesis. Arthroscopy;33(7):1286-1293.

3.

Thigpen CA, Shaffer MA, Gaunt BW, Leggin BG, Williams GR, Wilcox RB. (2016).The American Society of Shoulder and Elbow Therapists’ consensus statement on rehabilitation following arthroscopic rotator cuff repair. J. Shoulder Elb Surg. 225(4):521-535.

4.

van der Meijden OA, Westgard P, Chandler Z, Gaskill TR, Kokmeyer D, Millett PJ. (2012). Rehabilitation after arthroscopic rotator cuff repair: current concepts review and evidence-based guidelines. Int J Sports Phys Ther. ;7(2):197-218.

5.

Decker MJ, Tokish JM, Ellis HB, Torry MR, Hawkins RJ.(2003) Subscapularis muscle activity during selected rehabilitation exercises. Am J Sports Med.;31(1):126-134.

6.

Kokmeyer D, Dube E, Millett, PJ.(2016) Prognosis driven rehabilitation after rotator cuff repair surgery. Open Orthop. J.;10(Suppl 1: M10):339-348.

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