Journal of Bodywork & Movement Therapies xxx (2018) 1e6

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Randomized Clinical trial

Effect of remote myofascial release on hamstring flexibility in

asymptomatic individuals e A randomized clinical trial
Durga Girish Joshi, Ganesh Balthillaya, Anupama Prabhu*
Department of Physiotherapy, School of Allied Health Sciences (SOAHS), Manipal Academy of Higher Education, Manipal 576104, India

a r t i c l e i n f o a b s t r a c t

Article history: Background: The existence of continuity between fascia and muscles that may be anatomically distant
Received 14 May 2017 from each other is emphasized in the tensegrity principle. Despite evidence from in vitro studies, there is
Received in revised form a dearth of literature concerning the in vivo behavior of these connections.
18 December 2017
Aim: To compare the effect of Static Stretching (SS) of hamstrings with remote Myofascial Release (MFR)
Accepted 9 January 2018
(bilateral plantar fascia and suboccipital region) and a combination of SS and remote MFR on hamstring
flexibility. The secondary aim of this study was to investigate the difference between therapist admin-
Keywords:
istered and self-administered interventions.
Superficial Back Line
Fascia
Design: Three arm assessor-blinded Randomized Clinical Trial (RCT).
Suboccipital Participants: Fifty-eight asymptomatic participants (16 Males; Mean age 22.69 ± 2.65 years).
Plantar fascia Method: Participants with tight hamstrings defined by a passive Knee Extension Angle (KEA) > 20
were
included in the study and were assigned to one of the three groups. Group A (n ¼ 19) was SS, group B
(n ¼ 20) was remote MFR, group C (n ¼ 19) was a combination group who received both SS and remote
MFR. Seven sessions of therapist administered intervention were delivered over a period of 10 days,
which was followed by a 2-week self-administered home program. KEA and Sit and Reach Test (SRT)
were used as outcomes and measurements were performed at baseline, end of the seventh session and
after atwo-week follow-up.
Results: The results demonstrated that hamstring flexibility improved in all three groups after therapist
administered interventions (p < 0.05), whereas, group C demonstrated additional benefits. None of the
groups showed a statistically significant (p > 0.05) change in the KEA with self-intervention.
Conclusion: The findings of this study indicated that all three interventions were effective in improving
hamstring flexibility in young asymptomatic individuals when performed by the therapist.
© 2018 Elsevier Ltd. All rights reserved.

1. Introduction
Flexibility is the ability to move a single joint or a series of joints
efficiently through an unrestricted, pain-free Range of Motion
(ROM) (Grieve et al., 2015). Reduced flexibility can result in
decreased ROM which in turn leads to altered biomechanics and
thus joint dysfunctions (Grieve et al., 2015; Moon et al., 2017).
Hamstrings are considered to have greater tendency to shorten as it
is a multi-joint muscle and is constantly under varying amounts of
tensile forces (Davis et al., 2005; Medeiros et al., 2016). Poor
hamstring flexibility has been associated with lower extremity in-
juries and low backache (Grieve et al., 2015; Esola et al., 1996;
* Corresponding author.
E-mail address: anupama.prabhu@manipal.edu (A. Prabhu).
Mason et al., 2016; Hartig and Henderson, 1999; Witvrouw et al.,
2003; Hyong and Kang, 2013). Restoring hamstring flexibility is
vital in the management of various musculoskeletal disorders
(Michaeli et al., 2017; Medeiros et al., 2016).
Fascia is defined as “fibrous collagenous tissue, which is part of a
body-wide tensional force transmission system” (Schleip et al.,
2012), emerging evidence suggests fascia to be an active tissue
with functional roles related to joint stability, general movement
coordination, proprioception, and nociception (Tozzi, 2012; Stecco
et al., 2007). There is growing evidence for the existence of
morphological continuity between the skeletal muscles with fascia
working as a linking component. This myofascial continuity be-
tween anatomically distant structures is highlighted in various
studies (Wilke et al., 2015; Krause et al., 2016).
Myers (2014) developed the concept of ‘Anatomy Trains’ which
joins individual muscles into functional complexes, each with a

https://doi.org/10.1016/j.jbmt.2018.01.008
1360-8592/© 2018 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Joshi, D.G., et al., Effect of remote myofascial release on hamstring flexibility in asymptomatic individuals e A
randomized clinical trial, Journal of Bodywork & Movement Therapies (2018), https://doi.org/10.1016/j.jbmt.2018.01.008
2 D.G. Joshi et al. / Journal of Bodywork & Movement Therapies xxx (2018) 1e6

distinct meaning in human movement. Among these myofascial
chains, the Superficial Back Line (SBL) was frequently identified by
multiple human cadaveric experimental studies (Fig. 1) (Wilke
et al., 2015). Evidence also points towards force transmission to
distant anatomical structures via myofascial pathways (Krause
et al., 2016). Amongst various approaches which work on the
fascial tissue structures, Myofascial Release (MFR) technique was
considered to have potential in pain reduction, improving flexi-
bility, reducing disability thus enhancing function in the activities
of daily living (Mohr et al., 2014; Skarabot et al., 2015; Cho et al.,
2015; Beardsley and Skarabot, 2015). This technique involves spe-
cifically guided low load, long duration mechanical forces to
manipulate the myofascial complex (Ajimsha et al., 2015). Self-
administered MFR by participants has also shown promising re-
sults in improving flexibility (Grieve et al., 2015; Beardsley and
Skarabot, 2015).
Static stretching of hamstrings is a commonly utilized technique
to enhance hamstring flexibility (Davis et al., 2005; Medeiros et al.,
2016; Mohr et al., 2014; Konrad et al., 2016). However, its impli-
cation is limited in certain cases due to the relative pathology of the
surrounding tissue structures like sciatic nerve mechanosensitivity
or acute hamstring strain. The concept of myofascial chains directed
towards SBL may be utilized as an alternative in such presentations
to enhance the flexibility of hamstrings. In recent times, there has
been increased emphasis on a holistic diagnostic and treatment
approach considering the anatomical connections through the
myofascial chains (Krause et al., 2016; Wilke et al., 2016), yet its
functional relevance in vivo studies lack sufficient evidence.
Hence, the purpose of this study was to compare the effect of SS
of hamstrings with remote MFR (bilateral plantar fascia and sub-
occipital region), and its combination on hamstring flexibility in
asymptomatic individuals. The secondary objective was to inves-
tigate between a therapist administered and self-administered
intervention on hamstring flexibility.
2. Materials and methods
2.1. Study design
The study was a single-blinded three-armed, randomized clin-
ical trial approved by the Institutional Research and Ethics Com-
mittee. All the experimental procedures were in accordance with
the university's guidelines and the amended Declaration of Helsinki
on human experiments. Participants were recruited through pur-
posive sampling.
2.2. Participants
The participants were healthy university students recruited be-
tween February 2016 and February 2017 using advertisements on
campus and clinics. Participants of either gender aged between 20 to
40 years with a passive KEA of 20
were included in the study. The
exclusion criteria were as follows: Hypermobility (Beighton
score  4), involvement in regular flexibility/yoga program, severe
orthopedic, neurological, or endocrine diseases, recent (<6 months)
lower limb, spinal or soft tissue injuries, and any contraindications
to MFR. Participants were explained in detail about the study pro-
cedure and written informed consent was obtained prior to
enrollment.
2.3. Randomization
To ensure equal distribution of participants across the groups,
stratified block randomization was carried out. Ten blocks of six
participants were prepared by a researcher not involved in the
assessment of outcome measures. Every block ensured two par-
ticipants in each group at the completion of a block. In the last
block, two participants could not be recruited as the study was time
bound. Participants were randomly allocated to one of the three

Fig. 1. Myers' Superficial Back Line. Reproduced with permission from the Journal of Bodywork and Movement Therapies. 1997; 1(2):95.

Please cite this article in press as: Joshi, D.G., et al., Effect of remote myofascial release on hamstring flexibility in asymptomatic individuals e A
randomized clinical trial, Journal of Bodywork & Movement Therapies (2018), https://doi.org/10.1016/j.jbmt.2018.01.008
 D.G. Joshi et al. / Journal of Bodywork & Movement Therapies xxx (2018) 1e6
groups namely Group A (SS), Group B (Remote MFR) and the Group
C (SS þ Remote MFR).
2.4. Interventions
Group A received SS to bilateral Hamstrings, Group B received
remote MFR (bilateral plantar fascia and the suboccipital region),
whereas, Group C received both SS and remote MFR. A total of
seven therapist administered sessions were performed in a period
of 10 days. On the last day of therapist administered session
following the measurement of outcomes all participants were
taught self-administration of techniques i.e. self SS, Self-MFR and
self SS with self-MFR to group A, group B, and group C respectively,
this was performed by the participants for a period of two weeks as
home program.
Static stretching: The participant was made to lie in a supine
position with head in neutral and hands by the sides. Straps were
used to stabilize the participant's contralateral limb and pelvis to
the plinth. To perform static stretching, hip and knee was taken into
90-90 position and knee was slowly extended until the therapist
felt maximum resistance. The stretch was maintained for 30 s and
repeated thrice with a rest interval of 15 s between each repetition.
SS was then performed for the contralateral limb in a similar
manner.
All participants in the group A and group C were taught self-SS
of hamstrings on the seventh session of therapist administered
intervention. The participants were asked to sit in a long sitting
position with feet against the wall and were instructed to flex at the
hips as far as possible with the knees maintained in extension. They
were advised to prevent flexing upper back and neck to avoid other
parts of the SBL from getting stretched. Participants were asked to
hold this position for 30 s and repeat it thrice with 15-s rest in
between each repetition once daily for two weeks.
MFR to the plantar fascia: The participant was asked to lie in a
prone position with feet off the edge of the couch. Therapist stood
at the foot end of the couch with knuckles engaging the soft tissues
at the calcaneal attachment of the plantar fascia, applying a deep
pressure working downward in the direction of the ball of the foot
with pressure maintained throughout the end of the technique.
This release sequence was carried out for two minutes and the
same release sequence was repeated for the contralateral foot.
To perform the self-MFR for plantar fascia the method described
in the study performed by Grieve et al. (2015) was utilized. The
participants in the group B and C were provided with a tennis ball
and asked to sit on a chair with the ball under the foot, by leaning
forward the participant was asked to apply pressure over the ball
and roll the ball back and forth over the entire medial arch of the
foot for two minutes, maintenance of the pressure whilst rolling
was emphasized. The same was repeated for the other foot and
performed once daily.
MFR to the sub-occipital region: The participant was made to lie
in a supine position with the therapist standing at the head end of
the couch. The therapist placed the pad of his fingers on the pos-
terior aspect of the head in the upper cervical region. A stretch was
applied with the fingertips from a caudal to cephalad direction
while maintaining a vertical pressure deep into the sub-occipital
region. Whilst maintaining the pressure, fingers slowly glided up
to the base of the occiput covering the entire suboccipital region.
This was performed for two minutes.
For the self-intervention, participants were provided with a tool
resembling the peanut lacrosse ball prepared by fusing two tennis
balls with tape. The participants were instructed to stand against
the wall and place the tool in the suboccipital region. To carry out
the procedure the participants had to tuck the chin in and while
maintaining the pressure move in an upward and downward
Please cite this article in press as: Joshi, D.G., et al., Effect of remote myofascial release on hamstring flexibility in asymptomatic individuals e A
randomized clinical trial, Journal of Bodywork & Movement Therapies (2018), https://doi.org/10.1016/j.jbmt.2018.01.008
3
direction to cover the entire suboccipital region. This was per-
formed by the participants for two minutes and repeated once daily
for two weeks.
2.4.1. Outcome measures
KEA and SRT were included as outcome measures. All outcomes
were measured by an investigator who was blinded to group allo-
cation. They were assessed at three-time points, namely, at base-
line, after the seventh session of therapist administered
intervention and after two weeks of the home program.
2.5. Knee Extension Angle Test (KEA)
Hamstring flexibility was measured using passive KEA and the
procedure as described by Davis et al. (2008), was followed for the
measurements. Gravitational inclinometers were utilized while
performing the passive knee extension from the 90-90 position,
first resistance (R1) encountered by the investigator was consid-
ered as the criteria to stop the movement and readings were taken.
This test has shown excellent test-retest reliability (0.84e0.93)
(Gnat et al., 2010) and is recommended as a gold standard measure
for hamstring muscle length (Davis et al., 2008).
2.6. Sit and Reach Test (SRT)
Classic SRT was performed as reported in the literature
(Liemohn et al., 1994). The participants were instructed to reach
forward in a smooth, controlled manner and avoid jerky move-
ments to reach farther. The average of three readings was consid-
ered in the data.
2.7. Data analysis
The statistical analyses were conducted using SPSS version 16.
Descriptive statistics were used to analyze the demographic data.
The level of statistical significance was set at p  0.05. A repeated
measures ANOVA was used to analyze the between and within
group significance. When significant results were found to identify
specific differences, post hoc analysis with pairwise comparison
was performed.
3. Results
A total of 172 participants were screened as per the inclusion
and exclusion criteria; out of which 58 met the inclusion criteria.
The study flowchart is shown in Fig. 2. Participants were randomly
assigned into three groups i.e. Group A (n ¼ 19), Group B (n ¼ 20)
and Group C (n ¼ 19). Participants' baseline characteristics are
shown in Table 1.
Results for comparison of hamstring flexibility through passive
KEA and SRT between the groups are demonstrated in Table 2. A
change in outcomes from baseline in all the three groups is evident,
although, there was no significant difference in hamstring flexi-
bility between the three groups.
Table 3 shows the comparison between therapist administered
and self-administered techniques on hamstring flexibility. There is
a significant improvement in the SRT measurements in the thera-
pist administered techniques across all three groups, whereas in
the self-administration of techniques only group A and C has shown
significant change. When the KEA measurements are taken into
consideration, it is seen that there is a significant improvement
from baseline to post therapist administered intervention but there
is no improvement of KEA in the participant performed techniques.
4 D.G. Joshi et al. / Journal of Bodywork & Movement Therapies xxx (2018) 1e6

Fig. 2. CONSORT flow diagram of participants through the trial.

Table 1 abnormal loading on the musculoskeletal system (Wilson, 2002).

Demographic characteristics of the participants. Various stretching techniques like PNF stretching, self-stretching,
Characteristics Group A Group B Group C ballistic stretching and static stretching to increase the length of
(n ¼ 19) (n ¼ 20) (n ¼ 19) hamstrings has been described in the literature (Davis et al., 2005;
Age (Years), Mean (SD) 23.1 (2.4) 22.2 (1.8) 21.7 (1.7) Michelle et al., 2008). In recent times, there is evidence for
Gender (M/F) (5,14) (6,14) (5,14) corroborating the idea of myofascial force transmission for a more
Height (Cm), Mean (SD) 162.9 (10.3) 162.0 (10.3) 165.6 (9.9) holistic diagnostic and treatment approach (Wilke et al., 2017).
Weight (Kg), Mean (SD) 62.7 (12.2) 59 (10.7) 65.5 (10.61)
SS is known to be an effective strategy for increasing hamstring
flexibility in healthy adults (Medeiros et al., 2016) the proposed
mechanism which could be responsible for an increase in the
4. Discussion muscle length through SS might be attributed to an increase in the
number of sarcomeres in series, increased viscoelasticity and
In the present study, it was found that therapist administered reduced stiffness of muscles and connective tissue (Halbertsma
technique produced a statistically significant improvement in the et al., 1996; Magnusson et al., 1996) increased stretch tolerance
hamstring flexibility across all three groups. Also, the combination (Ben and Harvey, 2010; Konrad and Tilp, 2014) and by modifying
group had added improvement in flexibility than SS or remote MFR sensation (Weppler and Magnusson, 2010).
alone. Optimal hamstring flexibility is vital for smooth movements MFR has a wide range of effects; it helps in reducing delayed
of the spine and lower limbs, reduced flexibility can impose onset muscle soreness, decreasing pain, modulates autonomic

Please cite this article in press as: Joshi, D.G., et al., Effect of remote myofascial release on hamstring flexibility in asymptomatic individuals e A
randomized clinical trial, Journal of Bodywork & Movement Therapies (2018), https://doi.org/10.1016/j.jbmt.2018.01.008
 D.G. Joshi et al. / Journal of Bodywork & Movement Therapies xxx (2018) 1e6 5

Table 2
Comparison of the outcome measures- SRT and KEA between the groups.

Group A Group B Group C Between group

T1 T2 T3 T1 T2 T3 T1 T2 T3

SRT (cm) 31.7 (7.8) 34.3 (7.7) 36.9 (8.2) 32.6 (6.5) 35.3 (6.6) 35.6 (7.3) 32.4 (8.5) 35.0 (7.5) 39.1 (7.7) p ¼ 0.082
KEA (
) (Right) 41.1 35.0 (11.1) 33.3 (11.3) 41.6 32.6 (9.2) 32.3 (10.2) 45.7 (14.4) 34.5 (10.0) 32.3 (10.2) p ¼ 0.757
(8.7) (9.9)
KEA (
) 41.7 32.9 (8.5) 32.7 37.8 31.3 (9.3) 28.5 47.1 (12.9) 35.3 (9.7) 31.4 (10.3) p ¼ 0.182
(Left) (8.7) (10.1) (8.5) (9.2)

T1 e Baseline, T2 e after 7 sessions of therapist administered technique, T3 e after 2 weeks' self-administration of techniques.
Data expressed as mean (SD).

Table 3 SRT showed a significant change in hamstring flexibility by the

Pairwise comparison of the outcome measures between different time intervals self-administration of techniques in group A and group C but failed
within the groups.
to show any improvement in group B. The results of which con-
Group A Group B Group C tradicts the findings of a review which reported self-MFR to be
PT Self PT Self PT Self effective in increasing flexibility (Beardsley and Skarabot, 2015).
This could be attributed to the lack of experience of the participants
SRT (cm) 2.668 2.237 2.435 0.795 2.763 3.942
(0.004) * (0.018) * (0.007) * (1.00) (0.006) * (0.001) * to perform tool-assisted self-MFR which might have attenuated
KEA (
) 9.000 1.421 9.500 4.30 10.842 1.789 their performance efficiency, as it was reported that experience
(Right) (0.002)* (1.00) (0.002) * (0.072) (0.002) * (0.868) with self-MFR could be a factor to influence flexibility (Skarabot
KEA (
) 8.316 0.316 7.30 3.40 11.368 3.474
et al., 2015). Other plausible reason which might have conceiv-
(Left) (0.007) * (1.00) (0.015) * (0.060) (p < 0.05) * (0.070)
ably affected the results would be the failure to instruct on the level
PT - Therapist administered technique. Self - Self-administered technique. of pressure to be applied while performing the technique, pressure
Data expressed in mean differences *p < 0.05.
application in self MFR is expected to affect the change in flexibility
(Beardsley and Skarabot, 2015). The time duration for outcomes
nervous system activity, and increases flexibility (Kim et al., 2014; measurements following the last session of the home program (2
MacDonald et al., 2013, 2014; Mikesky et al., 2002). Studies inves- weeks) was not fixed, this could be an additional factor for the lack
tigating the effects of MFR on flexibility has applied the technique of flexibility in group B on SRT following self-administration of MFR
locally on the muscle to be stretched (MacDonald et al., 2013: Mohr as studies show an increase in flexibility with self MFR to be short
et al., 2014), there is inadequate evidence related to its remote ef- term of up to 10 min (Jay et al., 2014; Halperin et al., 2014).
fects pertaining to the myofascial chains. The hypothesis often used
to explain the effect of MFR on flexibility is through a neurophys-
4.1. Limitations and future scope
iological mechanism (Simmonds et al., 2012), bioelectric model
(O'Connell, 2003), increased viscoelastic property and thixotropic
Self-administration of intervention was not standardised to
property (Mohr et al., 2014), piezoelectricity (Ajimsha et al., 2015).
compare with therapist administered intervention. Adherence of
The favorable improvement in hamstring flexibility via remote
the participants to two-week self-administration of techniques as
MFR observed in this study can be explained by the fascially
home program was not documented with an exercise log-book.
mediated transfer of forces through the SBL. Evidence points to-
This would have provided further information on the number of
wards the transmission of forces through intramuscular connective
missed sessions and clarity on the effect of self-administration of
tissue pathways and intermuscular connective tissue pathways
techniques on hamstring flexibility. Other recreational activities
(Krause et al., 2016; Huijing and Jaspers, 2005; Yucesoy, 2010;
performed by the participants during the time of this study was not
Turrina et al., 2013). Previous studies performed with the similar
controlled. This observed effect of remote MFR paves the way for
purpose to investigate the functional significance of SBL have
further research in symptomatic individuals to investigate the
yielded identical results (Grieve et al., 2015; Hyong and Kang, 2013;
relationship of tight hamstrings and remote MFR.
Hyong and Kim, 2012; Wilke et al., 2016; Wilke et al., 2017; Sung-
Hak et al., 2015).
Although the differences in outcomes between three groups 5. Conclusion
were not statistically significant, the mean change in the KEA was
greater than the minimum difference (5
) for KEA in all the groups. This study has shown that therapist administered static
Our results extended these findings showing that increase in flex- stretching of hamstrings, remote myofascial release to the plantar
ibility was greater when performed in combination. It could be aspect of the foot and the suboccipital region was equally effective
attributed to the larger area of the SBL being intervened and a in improving the hamstring flexibility, with its combination
greater duration of treatment received by group C, which might deriving significantly increased hamstring flexibility.
have led to an additional improvement in the outcome measures.
The secondary objective of the study was to investigate the Conflict of interest statement
difference between therapist applied and self-administration of
intervention. Results showed that therapist administered tech- This research did not receive any specific grant from funding
nique was significant in improving outcomes than the self- agencies in the public, commercial, or not-for-profit sectors.
administered technique. A plausible factor could be non-
adherence to the home program suggested to the participants. Acknowledgement
Some participants reported missing few sessions of the home
program which was not documented as exercise log book was not The authors would like to thank Mr. Prabu Raja G (Department
maintained, only telephonic reminders were given at the beginning of Exercise and Sports Sciences, Manipal Academy of Higher Edu-
of each week. cation) for sharing his knowledge with us during this research.

Please cite this article in press as: Joshi, D.G., et al., Effect of remote myofascial release on hamstring flexibility in asymptomatic individuals e A
randomized clinical trial, Journal of Bodywork & Movement Therapies (2018), https://doi.org/10.1016/j.jbmt.2018.01.008
6 D.G. Joshi et al. / Journal of Bodywork & Movement Therapies xxx (2018) 1e6

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Please cite this article in press as: Joshi, D.G., et al., Effect of remote myofascial release on hamstring flexibility in asymptomatic individuals e A
randomized clinical trial, Journal of Bodywork & Movement Therapies (2018), https://doi.org/10.1016/j.jbmt.2018.01.008