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Accepted Manuscript

Do exercises with the Foam Roller have a short-term impact on the Thoracolumbar
fascia? - A randomized controlled trial

Annika Griefahn, BSc PT, Jan Oehlmann, BSc PT, Christoff Zalpour, Prof Dr. Med.
Harry von Piekartz, PhD in Movement and Rehabilitationscience, MSc, PT MT (OMT)

PII: S1360-8592(16)30091-2
DOI: 10.1016/j.jbmt.2016.05.011
Reference: YJBMT 1364

To appear in: Journal of Bodywork & Movement Therapies

Please cite this article as: Griefahn, A., Oehlmann, J., Zalpour, C., von Piekartz, H., Do exercises with
the Foam Roller have a short-term impact on the Thoracolumbar fascia? - A randomized controlled trial,
Journal of Bodywork & Movement Therapies (2016), doi: 10.1016/j.jbmt.2016.05.011.

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Do exercises with the Foam Roller have a short-term impact on the

Thoracolumbar fascia? - A randomized controlled trial

Annika Griefahn BSc PT, Jan Oehlmann BSc PT, Christoff Zalpour, Dr. Med . Harry von

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Piekartz , PhD, MSc , PT MT (OMT)

corresponding author:

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Prof Dr. Harry von Piekartz

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PhD in Movement and Rehabilitationscience | PT,MT(OMT)
University of Applied Science Osnabrueck, 49076 Osnabrck, Germany
Department of movement ad Rehabilitationscience

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E-Mail H.von-Piekartz@hs-osnabrueck.de
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Tel +49541969-3526| Caprivistrasse 30a |
49076 Osnabrck Germany
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SUMMARY

Due to new research results in the past few years, interest in the fascia of the human body

has increased. Dysfunctions of the fascia are indicated by various symptoms, amongst

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others, musculoskeletal pain. As a result stronger focus has been put on researching

therapeutic approaches in this area. The main aim of this study was to investigate the

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effect of Foam Roll exercises on the mobility of the thoracolumbar fascia (TLF). Study has

been conducted in a randomized and controlled trial which sampled 38 healthy athletic

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active men and women.

The subjects were randomly assigned to a Foam Roll Group (FMG), a Placebo Group

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(PG) and a Control Group (CG). Depending on the assigned group the volunteers were
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either instructed to do exercises with the Foam Roll, received a pseudo treatment with the

Foam Roll or received no treatment.


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A total of three measurements were carried out. The most important field of research was
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the mobility of the TLF, which was determined using a sonographic assessment. In

addition the lumbar flexion and the mechanosensivity of relevant muscles were
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determined.
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After the intervention, the FMG showed an average increase of 1.7915 mm for the mobility

of the TLF (p <0.001 / d = 0.756). In contrast, only an average improvement of 0.1681 mm


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(p = 0.397) was shown in the PG, while the CG showed a slight improvement of
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0.0139 mm (p = 0.861). However, no significant changes were observed with regard to the

lumbar flexion and mechanosensivity of the treated muscles.

Thus, evidence is given that the use of Foam Roll exercises significantly improves the

mobility of the thoracolumbar fascia in a healthy young population.


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INTRODUCTION

Physiotherapy attempts to influence tissue structures by using movement to enhance the

function and increase the personal health of individual people. Recent research around

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fascia tissue has allowed for a new treatment perspectives. Fascias represent the soft

portion of the connective tissue, which pervades the entire human body and forms a

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continuous three-dimensional network for the stability of body structures (Findley et al.

2012). This network is a unit from head to toe and as a result, fascias are present at all

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levels of the body (Barnes 1997). Recent studies indicate that the purpose of fascia goes

far beyond the function of support. Additionally, fascias act as a force transmitter between

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muscle and bone and thus are essential for all movements (Paoletti 2011). Interestingly,
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fascia can act as an energy-saver due to their ability to preload like a catapult, reducing

force through energy bias. This catapult mechanism is often compared to the jump of a
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kangaroo (Schleip and Mller 2013).


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In addition, Schleip et al. (2008) has found that myofibroblasts are embedded within the

fascia, which have a similar contractility as smooth muscle cells allowing fascia to also
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have a direct impact on the musculoskeletal system. This confirms the hypothesis that
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dysfunctions in the fascial system can lead to discomfort and pain. Moreover, fascias

represent an important human sensory organ as the numerous mechanoreceptors play a


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crucial role in proprioception (Stecco 2006, 2008).


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One of the biggest fascia in the human body is the thoracolumbar fascia (TLF). It serves,

in particular, the transmission of power between pelvis and trunk as well as between the

upper and lower extremities (Benjamin 2009).

It seems evident that ischemia and hypoxia of tissue caused by trauma, overstretching,

overloads or lack of exercise can cause changes to the basic substance of the fascia and

that elasticity is reduced (Barnes 1997). This can in turn cause pain and discomfort.
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Langevin et al. (2011) have shown with the help of ultrasound images that people with

back pain have a significantly lower mobility of the TLF. This provides a direct connection

between the mobility of the fascia and back problems. In order to eliminate dysfunctions

like these, physiotherapists use various treatment approaches.

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Literature lists various methods that affect fascia. One of the best known is the so-called

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Myofascial Release (MFR) technique. Here, the therapist brings either manual pressure or

pull to the tissue until the voltage limit is reached. Or the pressure or pull is then

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maintained until a reduction in tissue tension, the so-called release, is felt (Barnes 1997).

Treating the fascia via the direct technique involves application of pressure to the tissue,

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while treatment of the fascia via the indirect technique uses traction against the fascia
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(Ajimsha 2011). Another possibility is Foam Rolling, which may be used independently by

the therapist. By using this method, superficial structures such as muscle and fascia may
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be treated individually (Thmmes 2014). The idea behind using a Foam Roller, which

typically consists of a solid plastic, allows for the muscle and fascia to be rolled out using
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ones own body weight in different starting positions. By rolling out the tissue, glued fascial
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structures are broken up and the hydration of the connective tissue increases allowing an

increase in lubricity of the fascial layers (Thmmes 2014). In addition, the Golgi receptors
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are stimulated in the fascia imparting an inhibitory reflex, which reduces the muscle tone
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(Roylance et al. 2013). Some studies already indicate a positive effect of Foam Rolling on

muscle tension (MacDonald et al. 2014, Healey et al. 2014) and an increase in joint
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mobility in different areas of the body as it affects muscle elasticity (MacDonald et al. 2014

Roylance et al. 2013).In contrast, the effect of Foam Rolling has not been examined for

the mobility of the fascia and consequently, the TLF.

Studies provide evidence that preexisting and protracted LBP is correlated with reduced

lumbar mobility caused by limited TLF flexibility which severely restricts peoples mobility

(Langevin et al. 2011). This warrants the following question: Do exercises with a foam
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roller have a short term impact on the mobility of the thoracolumbar fascia?. According to

the authors, there is little research to support the issue on the systematic improvement of

mobility by independent methods, such as the Foam Rolling.

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METHODS

Because the mobility of the TLF has not yet been explored by way of Foam Rolling, the

study was explored first healthy subjects. The aim was to determine whether there is a

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significant difference in the mobility of the TLF among three treatment groups, namely

(intervention, placebo, and control).

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The protocol was created according the Ethical Principles for Medical Research Involving

Human Subjects as formulated in the Declaration of Helsinki and accepted by the ethics

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commission of the University of Applied Science Osnabrck in Germany.

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Subjects

For the study subjects between the ages of 18 and 30 years were recruited. Subjects had

to do sports at least 1-2 times a week for at least 3 hours to be eligible for the study. To

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comply with the preventive aspect of the study and avoid research biases, the following

additional restrictions applied, as confirmed by the subject: 1) no acute pain or discomfort

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in the spine at start of the study, 2) no disabilities on other parts of the musculoskeletal

system for at least 12 months prior to study start and 3) no prior exposure to Foam

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Rolling. In total 38 subjects (23.34 years / SD = 2.58 years) were recruited from various

schools and sports clubs around Osnabrck and the University Applied Science of

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Osnabrck. The sample showed a split of 25 women and 13 men with a total average BMI
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of 23.18 kg / m (SD = 2.14 kg / m). Between the three groups were no significant

differences in view of age and BMI.


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Figure 1: Flow chart of the study

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Measuring instruments

In the following text standardization of the lumbar flexion and used measures like Modified

Schober test (MMST), Algometry of the dorsal lumbar muscles and sonography of the TFL

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will be discussed.

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Standardization of lumbar motion (flexion)

A MyLab One, of Esaote Biomedica Germany GmbH, ultrasound machine was used for

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the ultrasound video of the TLF. This device was used in conjunction with a linear sonde

SL3323 13-6. The video of the fascia was taken while the subject assumed a

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thoracolumbar flexion of 30 degrees, which was measured by two digital goniometers.
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The goniometers were centrally adhered and plumb aligned with an adhesive Velcro at

the level of the spinal segments S2 and C7 on the spine (Laudner et al. 2013). To
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exercise the thoracolumbar flexion, the subjects had to sit on the treatment table with their
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feet having contact to the ground (Watanabe et al. 2004). The subjects were then

instructed to place their hands lightly on the thighs and keep the elbows close to the body.
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A dash was made where the finger pads touched the thighs. Subsequently, the subjects

performed a slow flexion of the upper body without moving their arms. While the elbows
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and fingers remained still, the forward motion of the fingers pushing against the thighs
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resulted from the movement of the upper body. At the point where the subtracted values
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of the two goniometers showed a flexion of 30 degrees, the movement was stopped and a

second line was marked on the thighs. The subjects wore fleece gloves during execution

in order to minimize friction between the thighs and the hands. In order to ensure that

finger movement only results from upper body flexion, the elbows of the subjects were

fixed to the torso with a belt. In addition, a metronome was used to ensure standardized

speed of movement. In the next step of the study investigators fortified an ultrasound

probe located two centimeters lateral and to the right of the spine, at the height of the
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intervertebral space of L2 and L3. At this point the TLF is best to detect since it runs

parallel to the skin tissue (Langevin et al. 2011). A template made of foam rubber was

made and fitted to ensure that the probe remained in place when the movement was

recorded. The examiner also ensured that pressure was constant and the probe was

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always perpendicular to the tissue. For recording the moving of the trunk flexion of exactly

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30 degrees, the subjects repeated this movement three times. The marks on the thighs

then served as a guide for repeated measurements.

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Figure 2: Trunk flexion during ultrasound assessment. During starting position from behind (a), during the start

of trunk flexion from the side and during the maneuver (c)

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a) b) c)
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Modified Schober test (MMST)

The MMST was originally designed to ensure that the mobility of the entire lumbar spine is

measured. Correspondingly the MMST was used to measure the lumbar flexion before

and after the Foam Rolling. Miller et al. (1992) examined the reliability and validity of the

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Schober test and found that the upper marker of the test only moved on average to

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the level of the spinal segments L2 and L3 and consequently did not measure the entire

lumber flexion. For this reason, the upper marker point of the MMST is 15 cm cranial to

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the centerline of the two posterior superior iliac spine (PSIS) marked (Tousignant et al.

2005). The lower fixed point just marks this centerline of the PSIS. It is believed that

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during a trunk flexion the area between the two fixed points increases (Horre 2004). In the
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position of a maximum trunk flexion the distance between the two marks increases and is

measured. To finally calculate the mobility of the lumbar spine the measured distance
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requires 15cm correction which was the starting point to only have the result of the

increase. (WiIliams et al. 1993). The study by Tousignant et al. (2005) demonstrated an
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acceptable intertesterreliability (ICC = 0.91) a good intratesterreliability (ICC = 0.95) and a


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moderate validity (r = 0.67).

For the test, the subjects were first asked to stand in an upright position, with the legs
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shoulder-width apart. Their arms were left loosely hanging next to the torso throughout the
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entire test. After the examiner had marked the two fix points with a line, the subjects were

instructed to bend the upper body forward as far as possible with the knees locked. In this
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position, the distance between the marked points was measured again with a tape

measure and then offset against the 15 cm of the output value.


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Mechanosensivity of the dorsal spine muscles

Finally, the mechanosensivity, in this study the paintolerance, for the treated muscles was

measured by using the Baseline Dolorimeter 12-1442 algometry, manufactured by

Enterprises Fabrication (New York, USA). The flat circular, probe of the algometer has a

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surface of 1.52 cm that is pushed against the skin allowing for the measurement of up to

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10kg of pressure. Walton et al. (2011) determined reliability scores for the test with a

different algometer. The reliability scores demonstrated a good inter-tester reliability and

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good test-retest reliability with an ICC ranging from 0.79 to 0.9 and 0.76 to 0.79,

respectively (Walton et al. 2011)

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To assess Foam Roll treatment on muscles, various myofascial trigger points (mTrPs)
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were selected. Due to the anatomical relationship between the TLF and mTrPs, the mm.

multifidii, the mm. longissimus thoracis and the mm. latissimus dorsi were selected. To
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test the mechanosensivity of the mm. multifidii a point directly to the right and left of the

spinosus process of L5 was defined (Gautschi 2013). Investigation of the Mm. longissimus
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thoracis identified a point 3 cm lateral to the spinosus process of L1 (Lluch et al. 2015).
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During the investigation of the four above mentioned study points the subjects lied prone

on the treatment table. The arms of the subjects were relaxed and stretched naturally
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alongside the body. To safely palpate the trigger point of the mm. latissimus dorsi muscle
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the subjects were asked to lie down on the side, first on the left and thereafter on the right.

This fifth point was defined at 3 cm lateral to the lateral margin of the scapula, at the level
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of the inferior angle (Gautschi 2013:1). Prior to testing the pressure points with the

algometer, the examiner informed the participants to signal verbally once the change in

pressure was high enough to exhibit pain. Thereafter the examiner started the test by

holding the algometer perpendicular to the respective spots and slowly increased the

pressure. When the subject felt that pain had reached an uncomfortable level

(paintolerance), the algometer was removed immediately and the corresponding value
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was recorded. Since pre-tests indicated a variance of values, the test during the study

was carried out three times for each point and thereafter the mean value was calculated. It

is also important to note that measurements were always carried out in the same order

during a testing passage.

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Sonographic motion analysis

Analysis of ultrasound videos regarding the mobility of the TLF were made using the

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Cross Correlation Program Motion Analysis (CCS) 2014 v1 of Dilley (Dilley et al. 2001).

According to the author, this program has been mainly used for nervous system

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movements and not for fascia. A similar program was already being used in the work of
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Langevin et al. (2011), which was created to calculate how displaceable the various layers

of the TLF are. In the Langevin study an intratesterreliability ICC = 0.98 has been
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determined. In the study by Ellis et al. (2008) a test-retest reliability of ICC = 0.75 was

found for calculating the mobility of the tibial nerve.


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The videos recorded during the lumbar flexion were first loaded into the program and
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converted into frames. To analyze the mobility of the TLF regions of interest (ROI) were

set on the TLF by clicking with the cursor on the structure of the TLF shown on the
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screen. According to Dilley, the ROI had to be carefully placed only on the TLF to prevent
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measurement errors (Dilley et al. 2001). Because of the anatomy of the TLF and the

different moving directions when doing a trunk flexion, six ROIs were selected. On each
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layer of the TLF three ROIs were set in accordance with Langevin et al. (2011).

Consequently the measurement should not be affected by conflicting pixel shifts (Dilley et

al. 2001). During the trunk flexion the Motion Analysis program determines the values of

preliminary fascia mobility by calculating every pixel shift that arises within the ROI

through a cross-correlation between the different frames (Dilley et al. 2001). Then the

movements between the individual frames were added to the result. The so called value
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"Cumulative hypotenuse", measured in millimeters, represents the entire mobility of

fascia.

The mobility of the TLF is also influenced by the surrounding tissue. Therefore three

additional ROIs were set on the background to calculate the background mobility. In a

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final step the background mobility was subtracted from the preliminary fascia mobility

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resulting in the final fascia mobility value.

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Figure 3: Fascia movement analysis of a volunteer using CCS during the study

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Method

The investigators were blinded during the study, since intervention and investigation were

always carried out in separate rooms. To eliminate bias, chief investigators decided to

conduct a double-blind study, which meant leaving the experimental investigators

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uninformed about which group they were testing. All examination and interventions were

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carried out in the laboratory of movement at the University of Applied Science in

Osnabrck.

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At the beginning of the study, the subjects were randomly assigned to one of three groups

by a number selected from a coated bag (1 = FMG 2 = PG, 3 = CG). Name, age, gender,

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physical activity level, and the height and weight of the subjects were recorded on the
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study sheet by investigator (A).

The measurements are executed before the intervention (baseline) and exact 10 minutes
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after the treatment. The Control Group got no intervention and has to wait for the same

time as the duration of the intervention. As discussed before the volunteers were
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randomized divided in 3 groups.


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Foam Roll Group:


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Examinator A gave instructions performing the standard exercises in direction and


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duration. The volunteers used their body weight to roll out the mm. gluteaus maximus, the

mm. erector spinae of the lumbar and thoracic spine, and the mm. latissimus dorsi
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(Benjamin 2009).

Each exercise was performed for three intervals of 30 seconds each. The basis for this

division was found in the clinical experience of Lukas (2012), which states that the

individual muscle groups should be rolled out for 30 seconds and repeated two times, to

get a full time of 1 minute and 30 seconds.


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The exercises should be carried out in such way that a smooth rolling motion is created

over this dorsal muscle chain with a rhythm of 2-3 seconds respecting pain.

Placebo Group:

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Like the FRG, the PG was given a treatment plan; however, this was set up so that little or

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no mechanical effect was to be expected on the body structures. Contrary to the FRG, the

placebo subjects were to only roll out each body area with little pressure put on the Foam

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Roll without a pain sensation. The same areas (mm. gluteaus maximus, the mm. erector

spinae of the lumbar and thoracic spine, mm. latissimus dorsi) were rolled out, also for a

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total time of 1 minute and 30 seconds like the FRG. The examination ad treatment
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strategy was exactly the same as from the FRG.
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Control Group:

The subjects in the control group received no treatment, but more than one measurement
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was still taken, the second measurement has been conducted twenty minutes after the
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first measurement. By doing more measurements, comparative figures could be collected

to enhance the overall informative value of the study.


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STATISTICAL ANALYSIS

Statistical data analysis was performed using the 22nd version of the software program

IBM SPSS Statistics. To be sure that there will be no differences between the groups the

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output values were compared and measured. The output values for the mobility of the

fascias showed p-values between 0.261 and 0.82. And the p-values of the lumbar flexion

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(from 0.528 until 0.799) and for the mechanosensivity (from 0.233 until 0.988) showed no

significance. For the pre-post value comparison within each group the t-test for paired

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samples was performed. For the comparison of the changes between the three groups the

t-test was performed for the independent samples. For calculation of abnormally

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distributed data, either the Mann-Whitney-U-test or the Wilcoxon-test was used. To
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support the practical relevance of the results, the effective size (d) was also determined by

Cohen. The significance level for all tests was set at p 0.05.
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Results

The results indicated that significant improvement of the mobility of the fascia only
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occurred in the region of the measurement with the CCS. The statistical analysis of other
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outcomes showed no significant results.


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Mobility of fascia
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Compared to the initial measurement, the mobility of the TLF in the FRG improved on

average 1.7915 mm (p < 0.001) after the second measurement was taken (see Table 1).

Furthermore, a significant p-value of p < 0.001 was recorded when comparing the

changes between the FRG and the PG. The comparison between the FRG and the CG

was also found to be highly significant at a value of p < 0.001.

In this case, because there are statistically significant results, the effective size (d) was

also calculated. The changes of the mobility of fascia in the FRG could be assigned to an
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effect size of d = 0.756. This corresponds to an average clinical relevance of changes

(see Table 1).

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Table 1: Pre-Post comparison of the mobility of fascia

Sonographic Pre-Post comparison in mm

Pre Post Difference effective


Group Difference p-value

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average average in % size

Foam Roll 4.1955 5.987


1.7915 56.47 p<0.001** d=0.756

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Group (SD=2.3573) (SD=2.3874)

4.3606 4.5287

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Placebo Group 0.1681 2.65 p=0.397 X
(SD=0.9952) (SD=1.3501)

5.1581 5.172

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Control Group 0.0139 2.18 p=0.861 X
(SD=2.244) (SD=2.1572)
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Tabular results of execution to mobility of fascia (mm), calculated with the CCS to Dilley. The values represent the

before and after comparison of individual groups and are given to the differences, p-values and the effective size d.
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(Source: authors)
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In comparison the averages after the intervention from FRG (1.7915 mm) to the PG

(0.1681 mm) showed a significant value p = 0.001. In this case the effect size (d) was also

calculated (d = 1.54). The next averages were calculated from the FRG (1.7915 mm) to

the CG (0.0139 mm), this show also a highly significant result (p < 0.001). Because of the

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significant value also the effect size was measured. The effect size was calculated by a

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value of d = 1.692). In this case the changes in the mobility of fascia compared with the

PG (0.1681 mm) and the CG (0.0139 mm) showed no significance value.

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Table 2: Changes in the mobility of fascia between FRG, PG and CG

Sonographic Differences in mm compared between FRG, PG and CG

Foam Roll Group Placebo Group

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p-value Effect size
Average Average

1.7915 (SD=1.3152) 0.1681 (SD=0.6601) p=0.001 d=1.54

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Foam Roll Group Control Group
p-value Effect size

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Average Average

1.7915 (SD=1.3152) 0.0139 (SD=0.6909) p<0.001 d=1.692

Placebo Group
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p-value Effect size
Average Average
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0.1681 (SD=0.6601) 0.0139 (SD=0.6909) p=0.575 X

Tabular results of changes in the mobility of fascia (mm), between the FRG, PG and CG. The values
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represent comparing the averages from each group with the others. For individual groups and are given to the
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p-values and the effective size d. (Source: authors)


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Lumbar flexion

The statistical analysis of the values of the lumbar flexion, which were determined by

using the MMSTs, showed no significant changes. Neither in the pre-post comparison

within the three groups (see Table 3) nor by the comparison of the changes between

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each group, were significant changes detected. The values of the FRG showed an

average improvement of lumbar flexion of 0.0077 cm (p = 0.935).

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The results of the PG showed an improvement of 0.0333cm (p = 0.753) and that of the

CG a reduction of 0.0077cm (p = 0.933).

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Table 3: Pre-Post comparison of the values of MMSTs within the groups

MMST Pre-Post comparison in cm

Group Pre average Post average Difference p-value

6.892
Foam Roll Group 6.885 (SD=1.4673) 0.0077 p=0.935
(SD=1.3194)

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7.108
Placebo Group 7.075 (SD=1.0358) 0.0333 p=0.753
(SD=1.0808)

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6.723
Control Group 6.731 (SD=1.5702) -0.0077 p=0.933
(SD=1.5282)

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Tabulated results of the execution of MMSTs (cm). The values represent the pre and post comparison of

individual groups and are given to the differences and p-values. (Source: authors)

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Mechanosensivity of the dorsal spine muscles

The data analysis of mechanosensivity also showed no significant results. In table 4

the values of the FRG in the pre-post comparison are listed. It can be seen that there

are no significant changes in the pre-post comparison (p = 0.254 to p = 0.991).

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By comparing the differences between the FRG and the PG significances that are

located in a range of p = 0.051 to p = 0.884 were apparent. Accordingly, there are no

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significant differences in the comparison between these two groups. Only the value

indicating the difference between the groups in terms of the right latissimus dorsi

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muscle, located with p = 0.051 is close to the set level of significance.

Furthermore, no statistical significance was observed between the FRG and the CG as

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indicated by the p-values ranging from p = 0.126 to p = 0.777.
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Table 4: Pre-Post comparison of mechanosensivity for the Foam Roll Group

Foam Roll Group


muscle
Pre Post Difference p-value

M. multifidius right 6.6821 (SD=1.8326) 6.5538 (SD=2.7032) -0.1283 p=0.807

M. multifidius left 6.7256 (SD=2.003) 6.6333 (SD=2.7035) -0.0923 p=0.825

M. longissimus right 7.1897 (SD=2.6069) 6.8536 (SD=2.6233) -0.3361 p=0.382

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M. longissimus left 6.8946 (SD=2.3848) 6.9051 (SD=2.5605) 0.0105 p=0.861

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M. latissimus dorsi right 4.8664 (SD=2.5082) 4.4667 (SD=2.1966) -0.3997 p=0.254

M. latissimus dorsi left 4.0231 (SD=1.5421) 4.0205 (SD=1.6155) -0.0026 p=0.991

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The pre-post comparison within the Foam Roll Group, measured by the algometry (kg / cm2). Are shown

the mean values, with the associated standard deviation, the difference, and the p-value. (Source: authors)

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DISCUSSION

The results show that the mobility of the TLF has significantly improved shortly after the

Foam Roll exercises (p <0.001). Apparently the Foam Rolling influenced may not only

the elasticity of the muscles, as studies of Roylance et al. (2013) or MacDonald et al.

(2014) demonstrated, but also the mobility of the fascia, in this case, the TLF.

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The values of the mobility of the TLF showed a significant difference in view of the

baseline and after the practice session with the Foam Roll for example it was found an

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average improvement of the mobility of 1.7915 mm (56.4654%) (p > 0.001) in the FRG.

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The additionally calculated effect size (d = 0.756) is just below the limit of 0.8 the

level at which a medium-sized effect is observed (Rasch et al 2010). This supports the

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argument that Foam Rolling is of clinical relevance for mobility improvement. It is
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important to have a look on the pre averages of the FRG (4.1955 mm) in comparison to

the pre averages of the CG (5.1581). This values show that pre averages of the FRG
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were the lowest and this could be a point why there is the greatest increase after using

a Foam Roller.
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These results are closely related to the study of Langevin et al. (2011). The study found
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that the movement capacity of the TLF is significantly better in healthy volunteers, as in

patients with chronic low back pain. Consequently it is advocated that an association
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between the mobility of the fascia and their pathological changes in view of the disease

lower back pain exists. This could also lead to the conclusion that a movable fascia,
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represents a "healthy" fascia. Therefore, improved mobility of the fascia, as noted in


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the researched case, could prevent complaints in this area. If the mobility can be

enhanced using the Foam Roller, this may be prevent musculoskeletal problems.

An important discussion point is to investigate whether an improved average mobility of

the fascia by 1 mm may be of clinical significance because such movement seems very

low compared to the trunk flexion of 30 degrees. In addition, the results raise the

question why the fascia mobility in the FRG has significantly improved after the
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exercises, while the lumbar flexion and mechanosensivity treated muscles showed no

significant changes.

The above results in connection with the study of Sherer (2013) and MacDonald et al.

(2014), showed that the effect of Foam Rolling should be studied over a period of

several days or weeks. Since the effect of Foam Rolling was only examined

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immediately after the intervention, as described above, it is possible that regular

application of the Foam Roll, over a longer period, could lead to even more significant

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changes in fascia mobility.

Furthermore, subjects only had a rest period of ten minutes after the exercises. The

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study of Schleip et al. (2012) showed an increased level of water content in the fascia

30 minutes after fascia stretching. Therefore, the rest period may have been too short,

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so that the second measurement does not reflect the overall effect of the exercises.
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It also seems possible that a mobility improvement of the fascia of 1mm falls too small

to affect the active lumbar flexion and the mechanosensivity muscle significantly. It
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appears that long-term treatments with the Foam Roller may increase the significance
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values of the other data points.


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Next steps should investigate whether Foam Roll exercises reduce LBP. Evidence that
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TLF characteristics (e.g. strength) strongly vary between healthy people and LBP

patients, is already given by the study of Langevin et al (2011).


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CONCLUSION

The results of this study have shown that Foam Rolling exercises can increase the

mobility of the TLF in a healthy young population. By using ultrasound images and

CCS, it has been demonstrated that the mobility significantly increases after the

exercises however there was no difference in lumbar flexion mobility and

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mechanosensivity of the dorsal back region.

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This study is restricted on the Foam Roll exercises on TFL mobility for a short time in

healthy volunteers .More research in other body region like lower extremity (e.g. tractus

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iliotibialis) or lateral side of the lower arm with different durations and time Intervals in

healthy volunteers and persons with dysfunction and pain may lead to more knowledge

in this domain.
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ACKKNOWLEDGE

The authors acknowledge Esaote ultrasound system and Dr. Andrew Dilley for making

the Cross Correlation Software available. Also thanks Kerstin Klau sharing her

knowledge about scanning peripheral nerves.

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REFERENCES

Ajimsha MS (2011): Effectiveness of direct vs indirect technique myofascial release in

the management of tension-type headache IN: Journal of Bodywork and Movement

Therapies, 15(4): 431-435

PT
RI
Barnes MF (1997): The basic science of myofascial release: morphologic changes in

connective tissue. IN: Journal of Bodywork and Movement Therapies, 1(4): 231-238

SC
Benjamin M (2009): The fascia of the limbs and back - a review IN: Journal of

U
Anatomy, 214(1): 1-18
AN
Dilley A, Greening J, Lynn B, Leary R, Morris V (2001): The use of the cross-
M

correlation analysis between high-frequency ultrasound images to measure longitudinal

median nerve movement IN: Ultrasound in Biology and Medicine, 27(9): 1211-1218
D
TE

Ellis R, Hing W, Dilley A, McNair P (2008): Reliability of measuring sciatic and tibial

nerve movement with diagnostic ultrasound during a neural mobilisation technique IN:
EP

Ultrasound in Medicine and Biology, 34(8): 1209-1216


C

Findley T, Chaudhry H, Stecco A, Roman M (2012): Fascia research - A narrative


AC

review. IN: Journal of Bodywork and Movement Therapies, 16(1): 67-75

Gautschi R (2013): Manuelle Triggerpunkt-Therapie. Myofasziale Schmerzen und

Funktionsstrungen erkennen, verstehen und behandeln, Georg Thieme Verlag,

Stuttgart: 152, 170, 258, 288


ACCEPTED MANUSCRIPT
Healey KC, Hatfield DL, Blanpied P, Dorfman LR, Riebe D (2014): The effects of

myofascial release with foam rolling on performance IN: The Journal of Strength and

Conditioning Research, 28(1): 61-68

Horre T (2004): Finger-Boden-Abstand und Schober-Test - Gengen diese Test

PT
wissenschaftlichen Kriterien ? IN: Manuelle Therapie, 8(2): 55-65

RI
Langevin HM, Fox JR, Koptiuch C, Badger GJ, Greenan-Naumann AC, Bouffard

NA, Konofagou EE, Lee WN, Triano JJ, Henry SM (2011): Reduced thoracolumbar

SC
fascia shear strain in human chronic low back pain IN: BMC Muskuloskeletal Disorders,

12(1): 203

U
AN
Laudner K, Lynall R, Williams JG, Wong R, Onuki T, Meister K (2013):

Thoracolumbar range of motion in baseball pitchers and position players IN:


M

International Journal of Sports Physical Therapy, 8(6): 777-783


D
TE

Lukas C (2012): Faszienbehandlung mit der Blackroll, Herstellung und Verlag: BoD -

Books on Demand, Berlin: 23ff., 25, 27, 28, 28f., 31, 36ff.
EP

Lluch E, Nijs J, De Kooning M, Van Dyck V, Vanderstraeten R, Struyf F, Roussel


C

NA (2015): Prevalence, Incidence, Localization, and Pathophysiology of Myofascial


AC

Trigger Points in Patients With Spinal Pain: A Systematic Literature Review IN: Journal

of Manipulative and Physiological Therapeutics, 38(8): 587-600

MacDonald GZ, Button DC, Drinkwater EJ, Behm DG (2014): Foam rolling as a

recovery tool after an intense bout of physical activity IN: Medicine and Science in

Sports and Exercise, 46(1): 131-142


ACCEPTED MANUSCRIPT
Miller SA, Mayer T, Cox R, Gatchel RJ (1992): Reliability problems associated with

the modified schber technique for true lumbar flexion measurement IN: Spine, 17(3):

345-348

Paoletti S (2011): Faszien, Anatomie, Strukturen, Techniken, Spezielle Osteopathie,

PT
Urban und Fischer Verlag, Elsevier GmbH, Mnchen: 87ff., 103, 114, 117, 118f., 122

RI
Rasch B, Friese M, Hofmann W, Naumann E (2010): Quantitative Methoden 1.

Einfhrung in die Statistik fr Psychologen und Sozialwissenschaftler, 3. erweiterte

SC
Auflage, Springer-Verlag, Berlin Heidelberg: 68

U
Roylance DS, George JD, Hammer AM, Rencher N, Fellingham GW, Hager RL,
AN
Myrer WJ (2013): Evaluating acute changes in joint range-of-motion using self-

myofascial release, postural alignment exercises, and static stretches IN: International
M

Journal of Exercise Science 6(4): 310-319


D
TE

Schleip R, Duerselen L, Vleeming A, Naylor IL, Lehmann-Horn F, Zorn A, Jaeger

H, Klingler W (2012): Strain hardening of fascia: Static stretching of dense fibrouse


EP

connective tissue can induce a temporary stiffness increase accompanied by enhanced

matrix hydration IN: Journal of Bodywork and Movement Therapies, 16(1): 94-100
C
AC

Schleip R, Klingler W, Lehmann-Horn F (2008): Faszien besitzen eine der glatten

Muskulatur vergleichbare Kontraktionsfhigkeit und knnen so die muskuloskelettale

Mechanik beeinflussen IN: Osteopathische Medizin, 9(4): 19-21

Schleip R, Mller DG (2013): Training principles for fascial connective tissues:

Scientific foundation and suggested practical applications IN: Journal of Bodywork and

Movement Therapies, 17(1): 103-115


ACCEPTED MANUSCRIPT
Sherer E (2013): Effects of utilizing a myofascial foam roll on hamstring flexibility,

Master Thesis, Paper 1140, Eastern Illinios University, IN:

http://thekeep.eiu.edu/theses/1140 (zuletzt abgerufen: 04.01.2015)

Stecco C, Porzionato A, Lancerotto L, Stecco A, Macchi V, Day JA, De Caro R

PT
(2008): Histological study of the deep fasciae of the limbs IN: Journal of Bodywork and

Movement Therapies, 12(3): 225-230

RI
Stecco C, Porzionato A, Macchi V, Tiengo C, Parenti A, Aldegheri R, Delmas V,

SC
De Caro R (2006): A histological study of the deep fascia of the upper limb IN: Italian

Journal of Anatomy and Embryology, 111(2): 105-110

U
AN
Thmmes (2014): Faszientraining, Physiologische Grundlagen, Trainingsprinzipien,

Anwendungen im Team- und Ausdauersport sowie Einsatz in Prvention und


M

Rehabilitation, Copress Verlag in der Stiebner Verlag GmbH, Mnchen: 12, 13, 15,
D

29ff., 30, 31, 33, 40f., 56, 170


TE

Tousignant M, Poulin L, Marchand S, Viau A, Place C (2005): The modified -


EP

modified schober test for range of motion assessment of lumbar flexion in patients with

low back pain: A study of criterion validity, intra- and inter-rater reliability and minimum
C

metrically detectable change IN: Disability and Rehabilitation, 27(10): 553-559


AC

Walton DM, Macdermid JC, Nielson W, Teasell RW, Chiasson M, Brown L (2011):

Reliability, standard error, and minimum detectable change of clinical pressure pain

threshold testing in people with and without acute neck pain IN: Journal of Orthopaedic

and Sports Physical Therapy, 41(9): 644-650


ACCEPTED MANUSCRIPT
Watanabe K, Miyamoto K, Masuda T, Shimizu K (2004): Use of ultrasonography to

evaluate thickness of the erector spinae muscle in maximum flexion and extension of

the lumbar spine IN: Spine 29(13): 1472-1477

Williams R, Binkley J, Bloch R, Goldsmith CH, Minuk T (1993): Reliability of the

PT
modified-modified schber and double inclinometer methods for measuring lumbar

flexion and extension IN: Physical Therapy, 73(1): 33-44

RI
U SC
AN
M
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C EP
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