Journal of Sport Rehabilitation, 2021 , 30, 129- 135 Human Kinetics ~

https://doi.org/10.1123/]sr.2019-0160
© 2021 Human Kinetics, inc. ORIGINAL RESEARCH REPORT

Acute Effects of Tissue Flossing on Ankle Range of

Motion and Tensiomyography Parameters
Matjaz Vogrin, Fiona Novak, Teja Licen, Nina Greiner, Samo Miki, and Milos Kalc

Context: Recently , a few papers have suggested that tissue flossing (TF) acutely improves range of motion (ROM) and
neuromuscular performance . However, the effects of TF on muscle contractile properties are yet to be defined. Objective : To
investigate the acute effects o f TF on ankle ROM and associated muscle gastrocnemius medialis displacement and contraction
time assessed with tensiomyography . Design : Crossover design in a single session . Setting: University laboratory . Participants :
Thirty recreationally trained volunteers ( age 23 . 00 [4 . 511 y). Intervention: Active ankle plantar flexion and dorsiflexion were
performed for the duration of 2 minutes (3 sets, 2-min rest between sets), while a randomly selected ankle was wrapped using TF
elastic band ( BAND ) and the other ankle served as a control condition (CON ). Main Outcome Measures Participants performed
an active ankle plantar fiexion and dorsifiexion ROM test and muscle gastrocnemius medialis tensiomyography displacement and
contraction time measurement pre, 5 , 15 , 30, and 45 minutes afterthe floss band application . Results . There were no statistically
significant differences between BAND and CON conditions (active ankle plantar fiexion ROM: P =.09: active ankle dorsiflexion
ROM : P = . 85): however, all ROM measurements were associated with medium or large effect sizes in favor of BAND compared
with CON . No significant changes were observed in the tensiomyography parameters . Conclusions. The results of this study
suggest that TF applied to the ankle is a valid method to increase ROM and at the same time maintaining muscular stiffness.

Keywords: body region(s). goniometry, young adult, muscle contraction, muscle function

In recent years, tissue flossing (TF) has become an increas-
ingly popular technique among physical therapists and condition-
ing trainers. lt consists of tightly wrapping part of a limb or a joint
with 1 - to 2-mm-thick elastic band partially restricting blood flow
to the tissues distal to the application site. It is a common practice to
perform active range of motion (ROM) or strength tasks during the
occlusion period (1-3 min). The procedure was first described by
Starrett and Cordoza, 1 where the authors used elastic bands to
increase ROM, claiming that the potential mechanism responsible
for the increased ROM can be attributed to fascial sharing and/or
reperfusion of blood to the occluded area.
Despite the popularity of the procedure, there is a limited
number of peer-reviewed papers in the field of athletic settings
using TF. Driller and Overmayet found that floss band applied to
the ankle increases ROM and improves single-leg jump perfor-
mance in recreational athletes. Driller et aP also found benefits for
the use of floss bands applied to the ankle joint to improve
flexibility, sprint, and jumping performance in recreational athletes
for up to 45 minutes following the last band application. TF has also
been successfully implemented in treating delayed onset muscle
soreness, reporting a decrement in pain.1.5; however, the effects were
not significantly above other techniques used to decrease delayed
onset muscle soreness pain. On the other hand, Mills et a16 lacked to
find similar improvements in professional rugby players.
Compared with static stretching, which is known to increase
ROM, although concomitantly decrease neuromuscular perfor-
mance,7 TF has the potential to increase ROM and in addition
maintain or even improve the ability to produce force. Authors
Vogrin, Novak. Licen, Greiner, Miki. and Kalc are with the Faculty of' Medicine,
Institute of Sports Medicine, University of Maribor, Maribor, Slovenia. Vogrin is
also with the Department of Orthopaedics, University Medical Center Maribor,
Maribor. Slovenia. Kalc (milos.kalc@ism-mb.si) is corresponding author.
found similitudes between TF and blood flow restriction training
(BFR), which is a similar technique where the muscle is com-
pressed using compression cuffs and the blood Bow is partially
occluded. The physiological mechanism involved in BFR is sug-
gested to be a metabolic "overload," normally associated with
higher muscle activation observed during high-intensity resistance
exercise.8 Therefore, it offers a way to enhance muscular response
without the need for high mechanical loads.9 However, the expla-
nation of why TF leads to an increased ROM is stilllacking. Starrett
and Cordozal as well as Driller and Overmayet claimed that the
main reason for an increased ROM after TF application can be
attributed to fascial sharing. To our best knowledge, at the time of
writing, there were no studies investigating the effect of BFR
training on ROM, making it difficult to address which mechanisms
are responsible for an increased ROM after blood flow occlusion.
Besides TF, a similar technique known as self-myofascial
release is widely used to increase flexibility. 10 Self-myofascial
release is usually created by applying pressure on muscle and fascia
using foam rollers (FRs).11 The main mechanisms causing such
effect are currently still a part of an ongoing scientific debate;
potential mechanisms behind FR can be divided into mechanical,
focused on alterations of fascial tissue, 12.13 and neurophysiologi-
cal.14 In addition, evidence of roller massage-induced decrease of
neural modulation of spinal excitability to the soleus H-reflex has
recently been proven.15
Despite the H-reflex being commonly used as an indirect
measure of alpha motoneuron excitability. a novel noninvasive
method, known as tensiomyography (TMG). resulted to be a valid
and reliable tool for measuring mechanical and contractile proper-
ties of the skeletal muscle.16 TMG assessment consists in detecting
of
the mechanical response (lateral thickening in millimeters)
skeletal muscle belly to a single electrically evoked twitch stimu-
lation.17 TMG twitch contraction time (Tc) provides information
about muscle composition and muscle fiber distribution; as
129
 130 Vogrin et al

demonstrated, Tc parameter can be used as a noninvasive estima-

tion of myosin heavy chain composition in human skeletal mus-
cles.18 On the other hand, the amplitude of TMG twitch (Dm
parameter) has been associated to muscle stiffness.19 (A larger
Dm is interpreted as a drop in muscle stiffness.)
To date, there are only a few studies that investigated the effect
of foam rolling on TMG parameters, providing contradictory
evidence; in fact, one study20 registered an increase of Dm, which
can be associated with a lower muscle stiffness, after 3 days of
consecutive foam rolling, which, however, were not reflected in
ROM improvement; on the other hand, 2 other studies21.22 reported
a significant increase in ROM maintaining muscle stiffness (Dm
unaltered) in the treated muscles.
At the time of conducting this study, there were no other
published papers investigating the effects of TF or BFR on TMG
parameters (Tc and Dm); therefore, the aim of this study was to
investigate the effect of TF on ankle joint ROM, TMG muscle
contraction time, and TMG muscle displacement in different time
points after the application of floss band in young healthy subjects.
As presented in the previously mentioned studies, we expected an
increase in ankle ROM, maintaining TMG parameters such as Tc
and Dm. It was expected that the effect of flossing will last at least
30 minutes after its last application.
Methods
Design
Prior to the main testing, participants performed a warm-up routine
consisting of 6-minute stepping on a 30-cm-high box. A full step
cycle lasted 2 seconds (right step-up, left step-up, right step-down,
and left step-down), exchanging leg every minute, timed by a
metronome. Following warm-up, participants were instructed to
sit on a regular medical exam table, ankles placed at the edge of
the table to ease the floss band (Medical Flossing Band 1.3 mm)
application. The floss band was applied on one randomly chosen
ankle (12 right and 18 left), to provide the randomization of the
experiment. While the ftossed ankle served as the experimental
condition (BAND), the other ankle served as a control (CON). The
Noss band was applied by a standardized ankle-bandaging technique,
across the transverse arch, aligned with the distal head of the
metatarsal of the foot. The foot was circulated by the wrap twice,
followed by 3 wraps and finished by a standard figure 8 wrapping
technique (to lateral malleolus, around the Achilles, to medial
malleolus, toward the distal head of the fifth metatarsal, around
the bottom of the foot and back to the beginning). Each wrap was
followed by a 50% overlap to the previous one, and the band
was secured with the remained band underneath the final wrap
(Figure 1). Once the band was applied, participants performed slow
continuous active plantar flexion (2 s) and dorsiflexion (2 s) of the
ankle in the maximum ROM for 2 minutes without stopping, moving
both feet simultaneously. This protocol was repeated in 3 sets, with
120-second rest between sets. The rest was divided into 2 parts:
75 seconds of complete rest and 45 seconds of floss band application.
In the complete rest period, subjects were not allowed to stand and
walk. However, they were instructed to perform 3 full circles with
their ankles to ease the pain caused by tight wrapping. After the last
Boss band application, the participants were instructed to walk
around the laboratory for 2 minutes in order to promote a normal
blood flow before measurements took place. Active ROM and TMG
measurements on both legs were performed in random order at 5
time points during the session: the first measurement took part
r
Ill
# ''
Figure 1 - Pictures of (A) ankle ftossing with a standardized ankle-
bandaging technique in the shape of number 8e (B) Tensiomyography
probe and electrode positions on muscle gastrocnemius medialis.
immediately after the warm-up routine representing the baseline
(pre); the same assessment protocol followed 5,15, 30, and 45 min-
utes (posts, posti 5, Post30' and post,~5) after the last flossing inter-
vention (see Figure 2 for details). Between measurements,
participants were sitting on the medical examination table, knees
extended and ankles placed on the edge of the table, instructed to sit
still as much as possible without moving their ankles.
Participants
A total of 30 recreationally trained athletes (18 women and 12 men)
participated in this study. The average age of the volunteers was
23,00 (4,51) B All participants were regularly involved in physical
exercise sessions (approximately 3 times/wk) and were free from past
ankle injuries. All the measurements were performed in a single
testing session. The volunteers were acquainted with the experimen-
tal procedure, and their voluntary cooperation was confirmed by a
written consent on the day of the testing. All procedures were in
accordance with the latest version of the Declaration of Helsinki and
were approved by the Research Ethics Committee of the University
Medical Center Maribor, Slovenia.
Procedures
The ROM was assessed on both ankles using an analog goniometer
(17 crm EZ Read Jamar Goniometer; Patterson Medical, Warren-
ville, IL). The measurement was performed while participants were
in a supine position, and the center of the goniometer was placed just
below the lateral malleolus of the ankle, with one arm lined up
through the lateral aspect of the fibula and the other arm lined up with
the fifth metatarsophalangealjoint. Maximal dorsifiexion andplantat'
tlexion have been assessed separately starting from a neutral ankle
position. The measurement was repeated 3 times at each time point
(pre and post5-45) and the largest ROM, expressed in degrees, within
each time point was selected. Acceptable intratester reliability for

JSR Vol. 30, No. 1, 2021


50
3-8
Pre
f
4 N
Time: ~
Warm-up
6 min
1
: 1 2 min
t
1 2 mil 1
2 min
s_
1 2 min 1
2 min
Measurement: 12(5TM9
Figure 2 - Schematic illustration of the experimental protocol. TMG indicates tensiomyography; ROM, range of motion; ADP, active dorsifiexion
and plantar flexion.
assessing ankle ROM using a manual goniometer has been reported
previously (intraclass correlation coefficient = -.85).23
The TMG measurement procedure was performed on muscle
gastrocnemius medialis (GM) on both legs and was carried out by
an experienced investigator. Subjects were lying prone on the
medical examination table, with a foam cushion placed above
the ankle supporting - 5° ofankle plantar flexion. The TMG sensor,
a probe-like digital displacement transducer (TMG-BMC Ltd,
Ljubljana, Slovenia) supported by a stand arm fixed on a tripod,
was placed perpendicular to the muscle GM belly in such way that
it was in contact with the muscle and pressing against
it by a minimal pressure (-1.5 x10-2 N/mm2-manufacturer's
data). The identification of the correct measuring point was selected
by visually and manually pulsating the muscle belly to determine
the thickest part of the muscle, and later, if needed, it was adjusted
to obtain the highest mechanical response when externally stimu_
lated. Then, 2 self-adhesive 5- x 5-cm electrodes (anode and
cathode) were attached to the skin equally distant from the mea-
suring point in line with muscle GM fibers. The electrodes were
unplugged and remained on the skin for the whole duration of the
experimental protocol to avoid possible changes in muscle
response due to alterations in surface electrodes placement.24
Once the measuring position was selected , it was carefully labeled
with a surgical skin marker to ensure the sensor was placed on the
exact same position on subsequent assessments.
A single 1 -ms wide stimulation pulse was delivered using a
constant current electrical stimulator (TMG-BMC Ltd) in order to
elicit a muscle response. To determine muscle GM highest meehan-
ical response, the following procedure was performed at the baseline:
an initial stimulation amplitude of 30 mA was used and progres-
sively increased by 10 mA increments until the mechanic response
did not increase further. To avoid the phenomenon of postactivation
potentiation or fatigue, a rest period of approximately 10 seconds
was given between each stimulus. Two highest mechanical re-
sponses and related stimulation amplitudes were recorded and saved
as proposed by Simunit.25 Highest mechanical responses were
typically elicited at stimulation amplitudes between 60 and 90 mA.
The saved stimulation amplitude was used to elicit mechanical
responses at time points after the flossing interventions (posts-45)
The highest mechanical response was then used to calculate
TMG parameters. From every mechanical response, the maximal
displacement amplitude (Dm--expressed in millimeters), delay time
(Td-expressed in milliseconds), contraction time (Tc-expressed
in milliseconds), sustained time (Ts-expressed in milliseconds),
and half-relaxation time (Tr-expressed in milliseconds) were
JSR Vol. 30, No. 1, 2021
Effects of Tissue Flossing on Ankle ROM and TMG 131
C
·W
+ Posts Post 15 Post30 post'.
_R
1 2 mi' 1
fTTT
5 min
1
| 10 min | 15 min | 15 min
/
|
lili
52'*LEG 52'E.IM-9 521-19 52'Z.IM-9
calculated. According to the TMG parameters reliability study on
muscle gastrocnemius medialis performed by Ditroilo et al,16 only
Dm and Te showed acceptable reliability (intraclass correlation
coefficient: .62:92 for Tc and .86-.95 for Dm); for this reason,
only these parameters were considered in further analysis.
Statistical Analyses
Statistical analyses were performed using the programming lan-
guage R (version 3.5.1).26 Data were inspected for normality of
distribution using Shapiro-Wilk test. A 2-way repeated-measures
analysis of variance using the Afex package27 was performed to
determine the effect of different treatments (BAND or CON) over
time (pre, Posts postus, Post.Yo, and post#) on all measured vari-
ables. The assumption of sphericity was assessed using the Mauchly
test. When the assumption of sphericity was violated, the degrees of
freedom were corrected using Greenhouse-Geisser correction
(GGe). Post hoc tests were performed as pairwise comparisons
using Tukey adjustment in the Emmeans package,28 to determine
the differences between single treatments in different time points.
Standardized changes in the mean of each measure were used
to assess magnitudes of effects and were calculated using Cohen d
and interpreted using thresholds of 0.2, 0.5 , and 0 .8 for small,
moderate, and large, respectively .29 An effect size of +0.2 was
considered the smallest worthwhile effect with an effect size of
<0.2 considered to be trivial. The effect was deemed unclear if its
95 % confidence interval overlapped the thresholds for small posi-
tive and small negative effects.30 Statistical significance was set at
P < .05 for all analyses.
Results
Descriptive analysis ROM and TMG data are given in Table 1, All
observed variables were normally distributed. Cohen d effect sizes
for comparisons of all post measures (postS, Post,5, Post,0, and
pos45) to pretest values are given in Table 2.
ROM Analysis
The analysis o f active ankle plantar flexion ROM data revealed that
the assumption of sphericity had been violated for the main effect
of time (Mauchly test, W= 0.452, P= .01); therefore, the degrees of
freedom have been corrected using GGe. After GGe correction, the
main effect of time resulted to be statistically significant
(F3,88,13= 3.00. P<.001, Ro = .011), while there were nosignificant
 132 Vogrin et al

Table 1 Mean (SD) of ROM and TMG

Int Assessment Baseline Posts Posti 5 Post*) Post,~5
ROM data
BAND ROMIDF· deg 103.60 (6.11) 101.13 (5.15)** 100.47 (5.16)** 99.27 (5.13)** 99.90 (5.48) .*
CON ROALm, dog 101.93 (6.75) 101,47 (6.65)* 100 00 (6.49)** 100.50 (6.59)** 100.40 (6.44)**
BAND ROMPF, deg 164.40 (8.13) 167.47 (6.95)** 167.63 (6.70)** 167.57 (7.28)** 167.67 (7.26) **
CON ROMPF, deg 164.83 (8.03) 165.57 (8.06) 165.23 (8.18) 165.87 (8.37) 165.93 (7.71)
TMG data
BAND Dm, mm 2.41 (1.15) 2.35 (1.12) 2.28 (1.09) 2.39 (1.16) 2.29 (1.04)
CON Dm, mm 2.41 (0.89) 2.42 (1.08) 2.38 (1.09) 2.48 (1.10) 2.39 (1.09)
BAND Tc, ms 20.59 (3.37) 21.68 (4.17) 21.38 (3.56) 21.68 (3.78) 21.24 (3,31)
CON Tc, ms 20.01 (3.25) 21.39 (4.23)* 20.92 (3.67) 20.94 (3.17) 20.79 (3.40)
Abbreviations: BAND, tissue flossing intervention type; CON, control condition intervention type: Dm, TMG gastrocnemius muscle displacement; Int, type of
intervention; ROM. range of motion; ROMDF, active ankle dorsifiexion ROM: ROMPV, active ankle plantar fiexion ROM: Tc, TMG gastrocnemius muscle contraction
time. TMG. tensiomyography. Asterisks indicate statistically significant differences compared to baseline ("P < ,05: **P < .01; *"c"P < ,001).

Table 2 Effect Sizes for ROM and TMG

Posts Post,5 Posbo Post45
Assessment Effect size (95% Cl) Effect size (95% Cl) Effect size (95% Cl) Effect size (95% Cl)
ROMDF, deg -0.70 (-0.31 to -1.09): medium -0.63 (-0.18 to -1.08); medium -0.81 (-0,35 to-1.28), large -0,67(-0.23 to-1.10).medium
ROMPF, deg 0. 70 (0 . 31 to 1 . 09); medium 0.81 (0.22 to 1 .40); large 0.64 (0.07 to 1 . 22 ); medium 0 .63 (0. 07 to 1 . 19); medium
Dm, mm -0. 14 (-0. 59 to 0.30); trivial -0. 19 (-0. 63 to 0. 24); trivial -0. 19 (-0 . 60 to 0. 22); trivial -0. 18 (-0. 59 to 0. 22); trivial
Tc, ms -0 . 10 (-0. 39 to 0 . 18 ); trivial -0.06 GO.45 to 0.33 ); trivial -0.08 (-0. 33 to 0.50); trivial -0. 07 (-0.48 to 0. 32); trivial
Abbreviations: BAND, tissue flossing intervention type: CI, confidence interval; CON, control condition intervention type; Dm, TMG gastrocnemius muscle displacement;
ROM. range of motion; ROMDF, active ankle dorsifiexion ROM: ROMPF, active ankle plantar flexion ROM: Tc. TMG gastrocnemius muscle contraction time; TMG,
tel'~siomyography.

differences in the main effect ofthe type ofintervention (Fl,29 - 3.00.
P =.09, 216 -.009) There was a significant interaction effect
between the type of intervention and time (6,„6 = 3.776, P = .006,
46 = .004). Post hoc tests revealed that for BAND condition, there
were significant ROM improvements between baseline and post5
(A= 3.07°, t= 4.97, P<.001); post,5 (a= 3.23°, t= 4.75, P<.001);
post30 (A = 3.17°, t= 5.49, P<.001); and pos45 (a= 3.27°, t= 5.71,
P = .006), but there were no significant differences in CON condition.
There were medium to large benefits associated to BAND when
compared with CON in all post time points (Table 2).
The analysis of active ankle dorsiflexion ROM data revealed
that the assumption of sphericity had been violated for the main
effect of time (Mauchly test, W= 0.243,P<.001); therefore, the
degrees of freedom have been corrected using GGe. After GGe
correction, the main effect of time resulted to be statistically
significant (F2,50.72,38 - 16.182, P < .001, 11~ = .029), while there
were no significant differences in the main effect of type of
intervention (Fl,29 = 0.034, P = .85, 1125 =.0001). There was a
significant interaction effect between the type of intervention
and time (F4,116 = 6.752, P <.001, ~ =.006). Post hoc test re-
vealed that for BAND condition, there were significant ROM
improvements between baseline and post5 (A = -2,47°, t= 4.858,
P=.001); post15 (A=-3.13°, t=5.793, P<.001); post3O (A =
-4.33°, t=8.105, P<.001); and post45 (A=-3.70°, t=6.704,
P < .001), as well as for CON condition, there were significant
ROM improvements found between baseline and posts (A = -0.46,
t = 3.624, P = .015); post,5 (A = -1.13°, t = 5.271, P <.001); post.~o
(a=-1.43°. t= 7.125, P<.001); and post45 (6= -1.53°, t= 6.466,
JSR Vol. 30, No. 1, 2021
P <.001). There were medium to large benefits associated to
BAND when compared with CON in all post time points (Table 2).
TMG Analysis
The analysis of Tc data revealed that the assumption of sphericity had
been violated for the main effect of time (Mauchly test, W= 0.34,
P<.001); therefore, the degrees of freedom have been corrected
using GGe. After GGe correction, the main effect of time resulted to
be Statistically Significant (F2,56,74.24=4.304, P=.01, '16 =.014),
There was no significant main effect of type of intervention (F4,116 =
1.878, P= .18, 46 =.005) and no significant interaction effect
bftween the type of intervention and time (F4,116= 0.41. P=.80,
'16 = .0004). Post hoc tests revealed that for CON condition, there
were significant differences between baseline and post5 (A= 1.38 ms,
t = -3.743, P = .009), but there were no significant differences in
BAND condition . However, there were only trivial effects registered
between FLOSS and CON (Table 2). The analysis of Dm data
revealed no significant main effect of time (F,1,116 = 1.189, P= .32,
2 = .001) and type of intervention (Fi,29=0·308, P=.58,
49
46 =.001) and no significant interaction effect between the type
of intervention and time (F#,1 16 -0.41, P = .80, 46 = .0003)
Discussion
The aim of this study was to investigate the effect of TF on ankle
joint ROM, TMG muscle contraction time, and muscle displace-
ment in different time points after the application of Boss band in

young healthy participants. The results ofthis study suggest that TF
has a considerable potential to increase ankle ROM in healthy
young subjects up to 45 minutes following the application. As it
was presented in the "Results" section (Table 2), ROM increased
after the application of floss band in ankle plantar flexion as well
as in dorsillexion and remained increased up to 45 minutes after
the application. Although there were no significant differences
between BAND and CON conditions in plantar flexion and dorsi-
fiexion , there were medium to large benefits associated to BAND
compared with CON in all ROM post time points. TMG parameters
Dm and Tc resulted unaffected by the intervention in BAND
condition, meanwhile CON condition produced a prolongation
of Tc compared with baseline. however, the effects resulted to be
trivial.
The results of this study are partially in line with the results ofa
paper with a similar protocol,2 where much larger increments in
active ROM were reported. While CON conditions in both studies
affected ankle ROM in analogous ways producing increments of
approximately 1 ° to 2°, in BAND condition, Driller and Over-
mayeb reported average increments of 5° in plantar flexion and
7° in dorsiflexion immediately after TF, compared with 3' in
plantar flexion and 4° in dorsifiexion reported in this study. In
addition, the reported results from this study are the maximum
increment in ROM collected over 45 minutes after the last elastic not acutely affect muscle stiffness or has an extremely localized
band application. Taking into consideration that ROM increments
immediately after the last elastic band application, the differences
between the studies are even bigger. However, both studies pre-
sented positive effects of TF intervention on ankle active ROM
compared with the control intervention.
The reasons for discrepancies between studies are difficult to
explain because the implied protocols were similar; however,
Driller and Overmayer2 assessed ankle flexibility using the
weight-bearing lunge test prior active ROM assessment, which
could have additionally affected ROM measurements. Although
this study registered lower ROM increments, the registered incre-
ments represented larger effects compared with the study of Driller
and Overmayer.2 The differences can be attributed to the selection
of the participant sample, which resulted to be more homogenous in
this study. In fact, ROM SD ranged from 5.13 to 8.37 in this study
compared with 12 to 16 in Driller and Overmayer2 study.
This study demonstrates that the effect of TF on ROM can be
seen at least 45 minutes after the last elastic band application. These
results are comparable with a recent follow-up study,3 where
countermovement jumps and 15-m sprint resulted to be increased
up to 45 minutes after the application of TF. The mechanisms
responsible for ROM improvement are yet to be defined. In
addition to most studies, muscle flossing instructors speculate
that physiological mechanisms triggered via TF are similar to
those stimulated via BFR. It was suggested that reperfusion of
blood to the occluded area, enhanced growth hormone and cate-
cholamine responses might improve exercise performance.31.32 To
our best knowledge, there are no studies investigating the effect of
BFR on ROM, in addition, the joint wrapping technique used in
this study differs substantially from the classical occlusion tech-
niques mainly used in BFR, where muscles are compressed.
Starrett and Cordoza' claimed that ROM improvement after TF
is to be attributed to fascial shearing. TF effects on ROM can be
compared with those elicited via self-myofascial release or foam
rolling. Potential mechanisms behind FR can be divided into
2 categories: first, mechanical, focused around alterations of fascial
tissue, mainly by altering the content of water12 and reducing
inflammation in the fascia13 and second, neurophysiological,
JSR Vol. 30, No. 1, 2021
Effects of Tissue Flossing on Ankle ROM and TMG 133
focusing on afferent signaling from mechanoreceptors, where
pressure applied to mechanoreceptors might stimulate the nervous
system and thereby lead to reduced muscular tension.14 There is
some evidence that FR massage decreases neural modulation of
spinal excitability to the soleus H-reflex. 15
The study presented in this paper is the first attempt to evaluate
the effects of TF on TMG parameters. It has been demonstrated that
TMG is a reliable technique to assess muscle tension and muscle
contraction velocity . 16 It has been recently established that the
increase of Dm is well associated with a reduction in passive
muscle tension after a fatiguing protocol, which demonstrates that
Dm can be used to detect changes in muscle stiffness.33 The
outcomes of this study show no significant changes in displacement
(Dm ) and marginal changes in temporal parameters (Te ) of the
muscle GM. Tc values were significantly longer compared with the
baseline in CON condition, but not after the Boss band application.
However, only trivial effects sizes have been found between CON
and BAND for both TMG parameters.
The lack of significant changes discovered in Tc in the BAND
group may indicate that flossing does not change muscle contractile
properties; meanwhile, sole active ROM movement alone can
elongate muscle contraction time. The absence of significant
differences in Din in both groups could implicate that TF does
a lack of studies
effect solely on the wrapped body part. Due to
involving flossing and TMG, it is difficult to provide strong
evidence for the presumed mechanisms mentioned previously;
however. in foam rolling studies, it has been demonstrated that
Dm was not acutely affected after a foam rolling session although
ROM increased significantly.16,2' It suggests that similar to foam
rolling, TF technique improves ROM and at the same time does not
affect muscle contraction mechanics and muscle stiffness. Those
arguments are additionally supported by the outcomes of a recent
study,2 where TF increased ROM and at the same time improved
countermovement jump and 15-m sprint performance.
The condition created by TF is similar to the environment
of localized tissue hypoxia, where muscle needs to adapt to a lack of
oxygen.34 Although flossing application is usually shorter (sets of
1-3 min) than systemic acute hypoxia stimulation (up to 40 min),
there is some evidence that systemic hypoxia achieved using
hypoxic chambers can stimulate similar physiological responses
to resistance training as BFR techniques.34 If we look through
the hypoxia point of view, it has already been established that the
excitation of sarcolemma remains unchanged.35.36 However, in a
study where the efficacy of TMG assessing muscle contractile
function at acute moderate altitude, an increment of Tc and decre-
ment of Dm were demonstrated in the condition of hypoxia.37
This study might have some limitations. First, as seen in BFR
studies, the pressure applied using the compression cuff seems to
play an important role. Nevertheless, Driller and Overmayeri in a
recent TF study reported the applied pressure exerted by the elastic
band. However, in practical applications of daily TF, pressure
cannot be controlled during execution; therefore, we decided not
to include pressure control in this study. Second, since TMG
response can only be elicited on surface skeletal muscles, we
collected the response of the muscle GM although we applied
the elastic band on the ankle joint. The results would potentially
differ, if the flossing band would be applied directly on the calf
muscles. In a recent study, TF has been effectively used to treat
perceived symptoms of delayed onset muscle soreness5 wrapping
the involved muscle. The authors suggested that in accordance to
the mechanisms of compression therapy, flossing could reduce the
134 Vogrin et al
inflammatory response by reducing the influx of inflammatory
mediators. We can hypothesize that applying the elastic band on
the muscle due to a lower liquid content, it will probably result in
lower muscle tension and consequently an increased Dm. Future
research should be focused on different applications of the elastic
band. A particular importance should be paid to a placebo group
where the elastic band is only loosely wrapped around the joint, to
exclude the possible effects of cutaneous sensory stimulation.
Conclusions
The results of this study suggest that TF could be a valid method to
increase ROM and at the same maintaining muscle stiffness. No
significant differences between Dm in both conditions, and a lack
of significant differences in Tc in the BAND condition indicates
that muscle stiffness and muscle contractile mechanisms remain
unchanged. Follow-up assessments suggest that TF has a positive
effect on increasing active ankle ROM for at least 45 minutes after
the last elastic band application .
Acknowledgments
The authors acknowledge and thank all participants in this study and
members of the institute, who helped execute the research. The authors
have no conflicts of interest to disclose.
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