- Research
- Open access
- Published:
- Erkan Erol ORCID: orcid.org/0000-0002-0087-18211 &
- Beyza Nur Bulut ORCID: orcid.org/0009-0001-5391-14871,2
BMC Musculoskeletal Disorders volume25, Articlenumber:1046 (2024) Cite this article
-
229 Accesses
-
Metrics details
Abstract
Background
Soft tissue techniques are frequently used to treat musculoskeletal disorders. Releasing the muscles through intervention from remote areas is especially important in cases where the muscles are sensitive, inaccessible or cannot be positioned appropriately. This study aimed to examine the effect of instrument-assisted soft tissue mobilization (IASTM) on hamstring flexibility via the fascial chain.
Methods
35 healthy individuals were included in the study. Straight leg raise (SLR) and popliteal angle (PA) measurements were performed to measure hamstring flexibility. IASTM was applied to the triceps surae muscle and plantar fascia on the non-dominant sides of the participants. The non-dominant legs of the individuals constituted the intervention group, while no intervention was applied to their dominant legs, designated as the control group.
Results
Each group significantly differed in the SLR and PA before and after intervention (p < 0.001, p < 0.001). There was no difference in SLR and PA between groups at the beginning and end (p > 0.05). There was no difference between the groups regarding the SLR and PA measurement changes from baseline to post-intervention (p = 0.583, p = 0.892).
Conclusions
According to the current study results, a single session of IASTM applied to remote areas does not increase hamstring flexibility.
Trial registration
ClinicalTrials.gov NCT05750550, Date: 19/02/2023.
Peer Review reports
Background
In recent years, the importance of holistic treatment and the view that distant body parts can affect each other has been increasing. In this context, the interest in deep fascia, which surrounds the body like a network system, is increasing and myofascial techniques and methods are being developed. The myofascial system is crucial for understanding musculoskeletal disorders [1]. For example, tension in the suboccipital muscles may be related to tension in the hamstrings, and this relationship may be based on the myofascial connection between these structures [2]. In this context, the primary issue in musculoskeletal disorders may sometimes be located in a farther away structure. The number of studies on myofascial approaches’ effectiveness in treating musculoskeletal problems is increasing [3,4,5].
Myofascial connections may have “remote effects.” Remote effects can be defined as a distant impact on the range of motion, either caudally or cephalically, resulting from a mechanical intervention in one part of the myofascial chain [1]. For example, plantar fascia treatment may lead to increased hamstring flexibility and hip range of motion. Thomas Myers accurately described myofascial meridians, offering a great field of treatment for myofascial techniques [6]. The Superficial Back Line (SBL), defined by Myers, is an essential myofascial chain [6]. Extending from the sole of the feet to the top of the head, the SBL keeps the body upright. In their study, Fousekis et al. applied instrument-assisted soft tissue mobilization (IASTM) to the parts distant from the hamstrings over the SBL and investigated the change in hamstring flexibility [3]. They reported that participants’ hamstring flexibility increased by providing relaxation through the fascial chain [3]. Wilke et al. reported that stretching applied to the lower extremity increased cervical ROM over SBL as a result of their study [7]. These studies showed that interventions in remote regions over SBL can effectively improve the range of motion.
Instrument-assisted soft tissue mobilization is a manual therapeutic technique that detects and treats scar tissue and adhesions that cause pain and loss of function [4]. A stainless steel instrument is used in this technique [5]. IASTM stretches and relaxes muscle tissues and contributes to healing by regulating blood flow [8]. Lee et al. examined the effects of IASTM and roller massage on hamstring flexibility and reported that both techniques were effective [9]. Rhyu et al. reported that IASTM effectively increased calf flexibility [10]. Study results indicate that IASTM can be effective in improving joint range of motion.
Intervention studies conducted through myofascial chains contribute to a better understanding of myofascia. There are studies on SBL and IASTM in the literature. However, to our knowledge, there has yet to be a study evaluating the hamstring flexibility of a single session IASTM applied to a distant region over the SBL. The present study aimed to examine the acute effect of IASTM on hamstring flexibility via the fascial chain. Our hypotheses are as follows:
H0: A single session of IASTM applied to a distant region via the SBL does not increase hamstring flexibility.
H1: A single session of IASTM applied to a distant region via the SBL increases hamstring flexibility.
Methods
Participants
The study’s procedures were carried out in full compliance with the ethical guidelines of the Helsinki Declaration. Permission was obtained from Tokat Gaziosmanpaşa University Ethics Committee, and the study was conducted at Tokat Gaziosmanpaşa University between March 2023 and June 2023. The clinical trial registration number of the study is NCT05750550 (Date: 19/02/2023). Participants who exhibited a straight leg raise (SLR) measurement of less than 80° and a popliteal angle measurement (PA) exceeding 15° were enrolled in the study. Those with injuries or pain that could affect lower extremity movements were excluded from the study. SLR and PA measurements were performed with a digital inclinometer (Baseline Digital Inclinometer) to measure hamstring flexibility. Sample size determination was conducted using the G*Power software through a power analysis. Considering a Type I error rate (α) of 0.05, a study power (β) of 0.80, and a strong effect size (d = 0.7) derived from a reference study, the required sample size was calculated to be 35 participants (with two legs assessed per participant, resulting in a total of 70 legs) [9]. Thirty-five individuals who met the criteria were included in the study.
Procedures
Assessments
SLR and PA measurements were performed to measure hamstring flexibility. Measurements were taken before and after the intervention since the intervention lasted 15min, and approximately 15min elapsed between the initial and final measurements.
Straight leg raise
With the participant’s supine position, the digital inclinometer was placed on the tibial tuberosity. The researcher passively lifted the participant’s leg, extending the knee. The leg was elevated until tension was sensed, and the angular measurement on the inclinometer was noted. Subsequently, the leg was returned to its initial position, which was repeated for both legs. The straight leg raise has been shown in a reference study to be excellent and reliable, with 0.93–0.97 ICC as an assessment method [11].
Popliteal angle
While the participant was supine, the hip and knee were positioned at 90 degrees. The digital inclinometer was placed on tibial tuberosity, and participants were instructed to extend their knees while keeping their hips stable. The angular measurement on the inclinometer was recorded once the maximum extension was reached. Subsequently, the leg was returned to its initial position, which was repeated for both legs. The popliteal angle has been shown in a reference study to be excellent and reliable, with 0.96–0.98 ICC as an assessment method [12].
The assessments were conducted by the second author, B. N. B.
Intervention
IASTM was applied to the triceps surae muscle and plantar fascia on the non-dominant sides of the participants for 15min. The triceps surae and plantar fascia are on the same fascial chain as the hamstrings, specifically the superficial back line [6]. The continuity of the fascial chain links the plantar fascia, triceps surae and hamstring muscles, and in the SLR and PA tests, the chain is tensed.
The non-dominant legs of the individuals constituted the intervention group, while no intervention was applied to their dominant legs, designated as the control group. In the literature, some studies assign one extremity of participants as the intervention group and the other as the control group, as well as studies that apply different interventions to both extremities [9, 13, 14].
Statistical analyses
Analyses were performed using the IBM SPSS 22.0 Statistics program. According to the skewness and kurtosis test, variables ranging from − 2 to + 2 exhibited a normal distribution [15]. Paired t-test was used to compare SLR and PA measurements at two-time points (baseline and final assessments) in each group. Independent samples t-test was used to compare the baseline and final assessments between groups. Repeated measures ANOVA was used to compare the groups’ SLR and PA measurement changes. The significance level was set at 0.05. The results were statistically interpreted at a 95% confidence level. The effect size was assessed using ηp², where values less than 0.06 indicate a small effect size, values between 0.06 and 0.14 represent a moderate effect size, and values greater than 0.14 indicate a large effect size [16].
Results
Characteristics of the study sample are summarised in Table1.
Each group had a significant difference in the SLR and PA before and after intervention (p < 0.001, p < 0.001). There was no difference in SLR and PA between groups at the beginning and end (p > 0.05). Group-time interaction analysis revealed no significant difference between the groups in terms of changes in SLR and PA measurements (p = 0.583, p = 0.892) (Table2).
Discussion
This study aimed to examine the acute effect of IASTM on hamstring flexibility via the fascial chain. However, the increase in hamstring flexibility achieved with a single session of IASTM applied through the fascial chain was not greater than that of the control group. This result supports our null hypothesis (H0). Based on this outcome, a single session of IASTM may not have been sufficient.
Soft tissue techniques are frequently used in the treatment of musculoskeletal disorders. Releasing the muscles through intervention from remote areas is especially important in cases where the muscles are sensitive, inaccessible or cannot be positioned appropriately. Fousekis et al. applied IASTM to the parts distant from the hamstrings over the SBL and reported that participants’ hamstring flexibility increased by providing relaxation through the fascial chain [3]. They emphasised that increased flexibility may have been observed due to myofascial techniques loosening the body generally and locally, reducing myofascial tone, and increasing stretch tolerance. Patel et al. examined the effectiveness of self-myofascial release in their study with 30 healthy individuals. It has been reported that hamstring flexibility increased in a single session due to self-myofascial release (with a tennis ball) applied to the participants’ bilateral soles [17]. They hypothesised that the sweeping pressure generated by the tennis ball rolling under the sole causes the fascia to stretch and ROM to increase. In the present study, hamstring flexibility increased after the intervention. However, this increase was not greater than the flexibility increase in the control leg. Therefore, based on this result, we cannot conclude that hamstring flexibility can be increased with a single session of IASTM. It is possible that the intervention dosage was insufficient. There is no consensus in the literature regarding the dosage of IASTM. If a long-term intervention program, as applied by Fousekis et al., had been implemented, or if both legs had been treated, as in the study by Patel et al., different results might have been obtained [3, 17].
Aparicio and colleagues examined the effect of suboccipital relaxation on hamstring flexibility in individuals with short hamstring syndrome. Their hypotheses were the connections of the suboccipital and hamstring muscles with postural control, dura mate and myofascial chains. As a result of the study, they reported an increase in hamstring flexibility [2]. This study shows that an intervention in the neck area can increase leg flexibility. In previous years, Taylor and his colleagues conducted a study involving isometric contract-relax of the suboccipital muscles [18]. However, they concluded that the contraction-relaxation technique applied to the suboccipital muscles did not increase the flexibility of the hamstrings. As seen, there are different results in the literature regarding “remote effects” from interventions applied to the same area. These inconsistent results may arise from using different interventions and outcome measurement methods. Additionally, the dosage and frequency of the intervention may also influence the results. Further studies are needed in this field. A systematic review sought to answer whether myofascial interventions may remotely affect range of motion. Based on the eight studies examined by the authors, it was found that remote myofascial techniques are associated with an increased range of motion at distant body segments [1]. However, this result is limited due to small effect sizes, wide confidence intervals, and a high risk of bias across the studies [1].
The current study found no difference in hamstring flexibility between the intervention and control leg. However, a significant increase was noted between the last and first measurements in both legs. Our first thought is that IASTM applied to a leg’s triceps surae and plantar fascia may have provided release along the SBL line. Therefore, releasing and increased SLR may also be observed in the other leg. This may explain why no significant difference was observed between the groups. The second opinion is that a single session of IASTM applied to a remote area may not have a strong enough effect to increase hamstring flexibility. Additionally, since the final measurement was conducted immediately after the intervention and the interval between measurements was as short as 15min, myofascial release may not have been fully achieved.
It may be a limitation that the other extremities of the participants were assigned as the control group in the study. When relaxation is achieved through SBL, flexibility may increase bilaterally. Another limitation is that the effect of IASTM is observed acutely. We recommend that the impact of short- and long-term application of IASTM be investigated in future studies.
Conclusions
According to the current study results, a single session of IASTM applied to remote areas does not increase hamstring flexibility. Further studies on different soft tissue techniques, dosage and frequency are needed.
Data availability
The data of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy or ethical restrictions.
Abbreviations
- IASTM:
-
Instrument assisted soft tissue mobilization
- PA:
-
Popliteal angle
- SBL:
-
Superficial back line
- SLR:
-
Straight leg raise
References
Burk C, Perry J, Lis S, et al. Can Myofascial Interventions Have a Remote Effect on ROM? A Systematic Review and Meta-Analysis. J Sport Rehabil. 2020;29:650–6. https://doi.org/10.1123/jsr.2019-0074.
Aparicio ÉQ, Quirante LB, Blanco CR, et al. Immediate Effects of the Suboccipital Muscle Inhibition Technique in Subjects With Short Hamstring Syndrome. J Manipulative Physiol Ther. 2009;32:262–9. https://doi.org/10.1016/j.jmpt.2009.03.006.
FouseKis K, Eid K, TaFa E, et al. Can the application of the Ergon® IASTM treatment on remote parts of the superficial back myofascial line be equally effective with the local application for the improvement of the hamstrings’ flexibility? A randomized control study. J Phys Ther Sci. 2019;31:508–11. https://doi.org/10.1589/jpts.31.508.
Garrett TR, Neibert PJ. Graston Technique® as a treatment for patients with chronic plantar heel pain. Clin Pract Athl Train. 2019;2:35–47. https://doi.org/10.31622/2019/0003.4.
Stanek J, Sullivan T, Davis S. Comparison of Compressive Myofascial Release and the Graston Technique for Improving Ankle-Dorsiflexion Range of Motion. J Athl Train. 2018;53:160–7. https://doi.org/10.4085/1062-6050-386-16.
Myers TW. Anatomy Trains: Myofascial Meridians for Manual Therapists and Movement Professionals. 4th ed. Elsevier Health Sciences; 2020.
Wilke J, Niederer D, Vogt L, et al. Remote effects of lower limb stretching: preliminary evidence for myofascial connectivity? J Sports Sci. 2016;34:2145–8. https://doi.org/10.1080/02640414.2016.1179776.
McKivigan JM, Touro GT. An analysis of graston technique® for Soft-Tissue therapy. Rehabil Sci. 2020;5:31–7. https://doi.org/10.11648/j.rs.20200504.11.
Lee J, Young A, Erb NJ, et al. Acute and Residual Effects of IASTM and Roller Massage Stick on Hamstring Range of Motion. J Allied Health. 2020;49:e51–5.
Rhyu H-S, Han H-G, Rhi S-Y. The effects of instrument-assisted soft tissue mobilization on active range of motion, functional fitness, flexibility, and isokinetic strength in high school basketball. Technol Heal Care. 2018;26:833–42. https://doi.org/10.3233/THC-181384.
Neto T, Jacobsohn L, Carita AI, et al. Reliability of the Active-Knee-Extension and Straight-Leg-Raise Tests in Subjects With Flexibility Deficits. J Sport Rehabil. 2015;24. https://doi.org/10.1123/jsr.2014-0220.
Kim M-H, Kim Y, Jung D-H, et al. Reliability of Measured Popliteal Angle by Traditional and Stabilized Active-Knee-Extension Test. Phys Ther Korea. 2009;16:1–7.
Harrison K, Carver M, Dietrich W, et al. The Use of Instrument Assisted Soft Tissue Mobilization Verse Massage and Proprioceptive Neuromuscular Facilitation Stretching Techniques on Improving Hamstring Flexibility. Int J Orthop Res. 2020;3:35–45. https://doi.org/10.33140/IJOR.03.01.08.
Doeringer JR, Ramirez R, Colas M. Instrument-Assisted Soft Tissue Mobilization Increased Hamstring Mobility. J Sport Rehabil. 2023;32:165–9. https://doi.org/10.1123/jsr.2022-0015.
Mallery P, George D. SPSS for windows step by step. Allyn & Bacon, Inc.; 2000.
Richardson J. Eta squared and partial eta squared as measures of effect size in educational research. Educ Res Rev. 2011;6:135–47. https://doi.org/10.1016/j.edurev.2010.12.001.
Patel DG, Vyas NJ, Sheth MS. Immediate effect of application of bilateral self myo-fascial release on the plantar surface of the foot on hamstring and lumbar spine flexibility: A quasi experimental study. Int J Ther Appl. 2016;32:94–9. https://doi.org/10.20530/IJTA_32_94-99.
Taylor D, Fryer G, McLaughlin P. The effect of cervical spine isometric contract-relax technique on hamstring extensibility. Australas Chiropr Osteopat. 2003;11:21–6.
Acknowledgements
This study was supported by the Turkish Scientific and Technical Research Council within the scope of project 2209-A.
Funding
This study was funded by the Turkish Scientific and Technical Research Council within the scope of project 2209-A.
Author information
Authors and Affiliations
Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Tokat Gaziosmanpaşa University, Taşlıçiftlik Campus, Tokat, 60250, Türkiye
Erkan Erol&Beyza Nur Bulut
Independent Researcher, İstanbul, Türkiye
Beyza Nur Bulut
Authors
- Erkan Erol
View author publications
You can also search for this author in PubMedGoogle Scholar
- Beyza Nur Bulut
View author publications
You can also search for this author in PubMedGoogle Scholar
Contributions
Concept development: EE, Design: EE, Data collection: BNB, Analysis: EE, Writing: EE, BNB, Critical review: EE, BNB.
Corresponding author
Correspondence to Erkan Erol.
Ethics declarations
Ethics approval and consent to participate
The study’s procedures were carried out in full compliance with the ethical guidelines of the Helsinki Declaration. Informed consent was obtained from the participants. Approval was granted by the Ethics Committee of Tokat Gaziosmanpaşa University (Number: 83116987-636 Date: 20/10/2022).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
About this article
Cite this article
Erol, E., Bulut, B.N. Acute effect of instrument-assisted soft tissue mobilization on hamstring flexibility via fascial chain. BMC Musculoskelet Disord 25, 1046 (2024). https://doi.org/10.1186/s12891-024-08182-7
Received:
Accepted:
Published:
DOI: https://doi.org/10.1186/s12891-024-08182-7
Keywords
- Fascial chain
- Superficial back line
- Instrument-assisted soft tissue mobilization
- Hamstring flexibility