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A SYSTEMATIC REVIEW AND META-ANALYSIS OF THE EFFECTS OF FOAM

ROLLING ON RANGE OF MOTION, RECOVERY AND MARKERS OF ATHLETIC
PERFORMANCE

Brendon Skinner, Richard Moss, Lucy Hammond

PII: S1360-8592(20)30021-8
DOI: https://doi.org/10.1016/j.jbmt.2020.01.007
Reference: YJBMT 1917

To appear in: Journal of Bodywork & Movement Therapies

Received Date: 29 March 2019

Revised Date: 5 June 2019
Accepted Date: 28 January 2020

Please cite this article as: Skinner, B., Moss, R., Hammond, L., A SYSTEMATIC REVIEW AND META-
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A SYSTEMATIC REVIEW AND META-ANALYSIS OF THE EFFECTS OF FOAM ROLLING ON RANGE OF
MOTION, RECOVERY AND MARKERS OF ATHLETIC PERFORMANCE

1. Brendon Skinner, Sport Exercise and Life Science, University of Northampton

2. Richard Moss, School of Health Sciences, University of Nottingham
3. Dr Lucy Hammond, Principle Teaching Fellow, University of Warwick

Corresponding author: Brendon Skinner, University Drive, Northampton, NN1 5PH, t: 01604 89 2389,
e: Brendon.skinner@northampton.ac.uk
 1

1 A SYSTEMATIC REVIEW AND META-ANALYSIS OF THE EFFECTS OF FOAM ROLLING ON RANGE

2 OF MOTION, RECOVERY AND MARKERS OF ATHLETIC PERFORMANCE

 2

3 ABSTRACT

4 Objective: To conduct a systematic review with meta-analysis assessing the effects of foam

5 rolling on range of motion, laboratory- and field-based athletic measures, and on recovery.

6 Data sources: MEDLINE, PubMed, EMBASE, SPORTDiscus and Science Direct were searched

7 (2005-June 2018).

8 Study selection: Experimental and observational studies were included if they examined the

9 effects of foam rolling on measures of athletic performance in field or laboratory settings.

10 Data extraction: Two investigators independently assessed methodologic quality using the

11 Physiotherapy Evidence Database (PEDro) Scale. Study characteristics including participant

12 age, sex and physical activity status, foam rolling protocol and pre- and post-intervention mean

13 outcome measures were extracted.

14 Data synthesis: A total of 32 studies (mean PEDro = 5.56) were included in the qualitative

15 analysis, which was themed by range of motion, laboratory-based measures, field-based

16 measures and recovery. Thirteen range of motion studies providing 18 datasets were included

17 in the meta-analysis. A large effect (d=0.76, 95% CI 0.55-0.98) was observed, with foam rolling

18 increasing range of motion in all studies in the analysis.

19 Conclusions: Foam rolling increases range of motion, appears to be useful for recovery from

20 exercise induced muscle damage, and there appear to be no detrimental effect of foam rolling

21 on other athletic performance measures. However, except range of motion, it cannot be

22 concluded that foam rolling is directly beneficial to athletic performance. Foam rolling does

23 not appear to cause harm and seems to elicit equivalent effects in males and females
 3

24 INTRODUCTION

25 Fascia is described as a key component of connective tissue (Threlkeld 1992), where myofascia

26 wraps and encases muscles, forming connective chains running from the cranium to the toes

27 (Meyers 2013). It has been proposed that when negatively altered through modified muscle

28 function, i.e. from overstress, injury, imbalance or fatigue (MacDonald et al 2013a), fascia can

29 stiffen as a result of the development of fascial crosslinks and can consequently generate

30 uneconomical movement patterns (Bushell et al 2015; Kaltenborn 2006). The change in fascia

31 quality is suggested to negatively influence sporting performance (MacDonald et al 2013b).

32

33 Myofascial release is a therapeutic intervention for releasing soft tissue from areas of

34 abnormally tight fascia (Miller & Rockey 2006; Prentice 2003). Myofascial release treatment

35 involves targeted, directional low loading mechanical forces aimed at restoring optimal tissue

36 length and improving function (Ajimsha et al 2015). High or sustained pressure applied via

37 myofascial release is suggested to cause golgi tendon organs to detect sensations of altered

38 tension in the musculature, eliciting relaxation of muscle fibres (Miller & Rockey 2006). A

39 popular approach to self-myofascial release (SMFR) has emerged in the form of foam rolling, a

40 technique whereby individuals use their own body mass to exert compressive rolling forces

41 along targeted musculature, following the orientation of the specific muscle being mobilized

42 (Pearcey et al 2015).

43

44 The use of foam rollers in athletic and recreationally active populations has seen notable

45 increases in recent years due to myofascial release being associated with performance

46 enhancements (Barnes 1997; MacDonald et al 2013b; Renan-Ordine et al 2011). Advocates of

47 foam rolling contend that it can assist in correcting muscular imbalances, improve

48 neuromuscular efficiency, improve range of motion and improve markers of strength and
 4

49 power (Curran et al 2008; Peacock et al 2014; Peacock et al 2015; Škarabot et al 2015; Swan &

50 Graner, 2002). While conflicting evidence has been reported into the efficacy of foam rolling in

51 these areas (Healy et al 2015; Peacock et al 2014; Roylance et al 2013), importantly, it is

52 suggested that the benefits reported have occurred without negative effects on physical

53 performance (Halperin et al 2014; Sullivan et al 2013).

54

55 Since 2013, there has been a proliferation of literature published that evaluates the effects of

56 foam rolling on a variety of markers of athletic performance and has included evaluation pre-

57 and post-exercise (Cavanaugh et al 2017; D’Amico & Paolone, 2017; Janot et al 2013;

58 MacDonald et al 2013a; Pearcey et al 2015). As an indication of the contemporary interest in

59 this area, three reviews have been published since 2015 (Beardsley & Škarabot, 2015;

60 Cheatham et al 2015; Wiewelhove et al 2019), however these reviews have not focused solely

61 on the application of foam rollers, have included other modalities (for example roller massage,

62 stick, blades, tennis ball) or have included broad outcome measures beyond markers of

63 athletic performance, for example on arterial function. To the best of our knowledge, no

64 quantitative synthesis via meta-analysis specifically focusing on the effects of foam rolling has

65 been conducted to date and therefore the pooled effects are unknown. Given the wide uptake

66 of foam rolling among recreational and professional athletes, meta-analysis of this topic would

67 strengthen the ability to specifically draw conclusions on the effectiveness of foam rolling as an

68 intervention which will be beneficial to both users and healthcare practitioners. Therefore, the

69 purpose of this study was to;

70 1) critically appraise the current evidence specific to foam rolling on markers of athletic

71 performance and recovery via qualitative synthesis

72 2) establish the effect of this treatment intervention via meta-analysis

73 3) establish if harmful effects of the application of foam rolling have been published
 5

74 METHODS

75 A protocol for this study was registered with PROSPERO (Hammond et al 2015).

76

77 Search strategy

78 MEDLINE, PubMed, EMBASE, SPORTDiscus, and Science Direct databases were searched for

79 English language, peer reviewed sources. The search strategy for MEDLINE is presented in

80 Table 1. In addition, Current Controlled Trials and the WHO International Clinical Trials Registry

81 Platform for ongoing and recently completed trials were searched, as well as the table of

82 contents of the following journals: British Journal of Sports Medicine, Medicine and Science in

83 Sports and Exercise, Journal of Athletic Training, The Journal of Strength and Conditioning

84 Research and Strength & Conditioning Journal. All searches were conducted from 2005 to 14th

85 June 2018. Following the search, reference lists were reviewed, and subsequently electronic

86 forward citation searches were conducted in Google Scholar for all relevant articles located.

87 Experts and colleagues working in the subject area were also asked to notify the authors on

88 the existence of new or ongoing studies, which were also considered for inclusion.

89

90 Insert Table 1 here

91

92 Inclusion and exclusion criteria

93 Randomized controlled trials, clinical trials, cross-over studies and quasi-experimental studies

94 evaluating the use of self-myofascial release via a foam roller in laboratory or field settings for

95 athletic performance in male or female adolescents (>15 years) and adults were included in

96 this review. Studies were included in which at least one group in the trial comprised

97 participants treated with foam rolling before or after exercise. Foam rolling was defined as

98 self-myofascial release involving a repetitive rolling action over a muscle group using any type
 6

99 of foam roll e.g. dense or rigid. Studies including single or multiple bouts of foam rolling within

100 a single session or over more than one day were included. The authors aimed to include trials

101 that compared the use of foam rolling versus a passive or control intervention (rest, no

102 treatment or placebo treatment) or active interventions including, but not limited to, warm up,

103 cool-down, stretching, massage baseline measures or exercise. It also aimed to include trials

104 that compared different durations or dosages of foam rolling.

105

106 Studies involving injured participants and sedentary individuals and studies focusing on other

107 myofascial modalities (static trigger point massage with an implement, therapist applied roller

108 massage or myofascial release, and therapist or self-applied instrument assisted myofascial

109 techniques) were excluded. Trials that did not report any of the primary outcomes were also

110 not included in the review.

111

112 Primary outcomes

113
1) Flexibility, range of motion
114
2) Muscle contractile properties (e.g. maximal voluntary isometric contraction (MVIC),
115
muscle power, muscle strength/activation, peak torque)
116
3) Maximal oxygen uptake

117 4) Markers of fatigue (e.g. lactate)

118 5) Speed, acceleration, agility, reaction time

119 6) Exercise-induced muscle damage, delayed onset muscle soreness (DOMS)

120

121 Secondary outcomes

122 1) Adverse effects of foam rolling

123 2) Differences of effects between males and females

 7

124

125 Study selection

126 Two review authors (BS, RM) independently selected trials for inclusion. After the removal of

127 duplicates, the titles and abstracts of publications obtained by the search strategy were

128 screened, and any study that was obviously outside the scope of the review was removed. The

129 full text of any papers that potentially met the review inclusion criteria were obtained. The

130 same two review authors then independently selected trials for inclusion in the review

131 according to the inclusion and exclusion criteria, using a standardized form to record their

132 choices. In the event of disagreement between the review authors, this was resolved by

133 consensus or by third party adjudication (LH).

134

135 Quality assessment

136 To assess for risk of bias in the included studies, two review authors (BS, RM) independently

137 assessed risk of bias of studies meeting the inclusion criteria using the PEDro scale

138 (http://www.pedro.org.au/english/downloads/pedro-scale/). To minimize bias in the

139 interpretation of this scale, prior to assessing the included studies, the review authors assessed

140 three unrelated studies that were not included in the current review; disparities in judgements

141 were reviewed and discussed before any of the included studies were evaluated. Each of the

142 included studies was graded for risk of bias by being assigned a score from 0-10 (criterion 1

143 was excluded from the score according to PEDro guidelines), and were considered to be

144 moderate to high quality if achieving a score of ≥ 6

145 (http://www.pedro.org.au/english/downloads/pedro-statistics/). Any disagreements between

146 review authors regarding the risk of bias assessment were resolved by consensus or by

147 adjudication of the third author (LH).

148
 8

149 Data extraction

150 A customized form was created for data extraction (to obtain study details on methodology,

151 eligibility criteria, interventions including detailed characteristics of the exercise protocols and

152 the foam rolling protocol employed, comparisons, outcome measures and participant

153 characteristics including age, sex and sporting level). Subsequently, one review author (LH)

154 independently extracted relevant data for the remaining included papers. Data were extracted

155 for immediately post-foam rolling, as well as further follow up times where reported. For

156 studies involving DOMS, the typical follow-up times of up to 1, 24, 48, 72, 96 and more than 96

157 hours post intervention were used. Primary authors were contacted to obtain or clarify any

158 omitted data.

159

160 Statistical Analysis

161 All of the data extracted were examined by the review authors in order to determine their

162 suitability for meta-analysis. For range of motion, 18 data sets from 13 studies that were

163 deemed comparable were identified and these data were included in the meta-analysis. For

164 each of these, Cohens d and Confidence Intervals (95% CI) were calculated to establish the

165 effect size from pre- to immediately post-foam rolling. For all studies with the exception of one

166 (Couture et al 2015), an increase in score indicated a positive effect of the treatment. For

167 Couture et al (2015), in which an increase in score corresponded to a negative effect of

168 treatment, the effect size was multiplied by –1 to ensure all scales pointed in the same

169 direction (Leard et al 2007). Assessment of heterogeneity between comparable trials was

170 evaluated with I² statistics. Values of I² were interpreted as follows: 0% to 40% might not be

171 important; 30% to 60% may represent moderate heterogeneity; 50% to 90% may represent

172 substantial heterogeneity; and 75% to 100% may represent considerable heterogeneity (Leard

173 et al 2007). Results of the comparable trials were pooled using a random-effects model. The
 9

174 choice of the model was guided by the moderate heterogeneity identified (Neyeloff et al

175 2012). For all other thematic areas there were insufficient trials, or studies were too

176 heterogenous (in both application of foam rolling and outcomes measure recorded) in order to

177 perform meta-analysis.

178 RESULTS

179 Included Studies

180 Two hundred and thirty-four potential articles were identified from the search (Figure 1). Of

181 these, 197 were excluded based on the title or abstract. Thirty-two articles met the inclusion

182 criteria. All included studies were published over a five-year period (2013-2018), indicating the

183 contemporary interest in this area. The mean PEDro score of these papers was 5.56 (Table 2).

184 The papers were organised into the following themes for analysis: range of motion (Behara &

185 Jacobson 2015; Bushell et al 2015; Cheatham et al 2017; Couture et al 2015; Garcia-Gutiérrez

186 et al 2017; Griefahn et al 2017; Junker & Stöggl; Kelly & Beardsley 2016; MacDonald et al

187 2013b; Macgregor et al 2018; Markovic, 2015; Mohr et al 2014; Monterio et al 2018; Morales-

188 Artacho et al 2016; Morton et al 2015; Peacock et al 2015; Roylance et al 2013; Škarabot et al

189 (2015); Su et al 2016; Vygotsky et al 2015), laboratory based measures (Behara & Jacobson

190 2015; Cavanaugh et al 2017; D’Amico and Paolone 2017; Garcia-Gutiérrez et al 2017; Healy et

191 al 2015; Jones et al 2015; Janot et al 2013; MacDonald et al 2013b; Macgregor et al 2018;

192 Monterio et al 2017; Morales-Artacho et al 2016; Morton et al 2015; Su et al 2016), field based

193 measures (Behara and Jacobson, 2015; Healy et al 2015; Jones et al 2015; Peacock et al 2014;

194 Peacock et al 2015) (Table 3) and recovery (Fleckenstein et al 2017; Kalén et al 2017;

195 MacDonald et al 2013a; Pearcey et al 2015; Romero-Moraleda et al 2017) (Table 4). The

196 thematic grouping of field based measures was defined as practically applied tests that have

197 higher external validity compared to laboratory tests that tend to demonstrate higher

198 reliability. As such, some outcomes e.g. force, power, velocity appear in both groupings but are
 10

199 measured differently. Of the 20 studies identified that focussed on foam rolling and range of

200 motion, eight were subsequently excluded from the meta-analysis due to an inability to

201 calculate an effect size for the study as raw data were unavailable (MacDonald et al 2013b;

202 Peacock et al 2014; Peacock et al 2015; Roylance et al 2013; Kay & Blazevich, 2012; Macgregor

203 et al 2018; McHugh & Cosgrave 2010; Morales-Artacho et al 2016), due to methodological

204 heterogeneity (Vygotsky et al 2015) and one where the intervention was applied for recovery

205 purposes (MacDonald et al 2013a).

206

207 Insert Figure 1 here

208

209 Insert Table 2 here

210

211 Insert Table 3 here

212

213 Insert Table 4 here

214

215 Range of motion studies

216 The largest number of studies located (n=20, pooled mean age 22.72 ±3.32 years) investigated

217 effects of foam rolling on range of motion. The mean PEDRO score was 5.60. Thirteen studies

218 investigated range of motion measured in degrees (Behara & Jacobson 2015; Bushell et al.

219 2015; Cheatham & Baker 2017; Couture et al 2015; MacDonald et al 2013b; Macgregor et al

220 2018; Mohr et al 2014; Monterio et al 2018; Morales-Artacho et al 2016; Morton et al 2015; Su

221 et al 2016; Vygotsky et al 2015) and nine studies investigated muscle length measured in

222 centimetres (Garcia-Gutiérrez et al 2017; Junker & Stöggl, 2015; Kelly & Beardsley, 2016;

223 Peacock et al 2014; Peacock et al 2015; Roylance et al 2013; Su et al 2016; Vygotsky et al

 11

224 2015), with all studies involving foam rolling to the lower limb or trunk. Only two of these

225 studies included investigations of effects of range of motion taking place over more than one

226 day (3 days [Macgregor et al 2018] and 3 weeks [Bushell et al 2015]).

227

228 Seven of the identified studies included a comparator modality (Garcia-Gutiérrez et al 2017;

229 Markovic 2015; Mohr et al 2015; Monteiro et al 2018; Roylance et al 2013; Škarabot et al 2015;

230 Su et al 2016) and seven included a control group (Bushell et al 2015; Griefahn et al 2017;

231 Junker and Stöggl 2015; Kelly and Beardsley 2016; MacGregor et al 2018; MacDonald et al

232 2013b; Morales-Artacho et al 2017).

233

234 The majority of studies identified a positive increase in RoM following the application of foam

235 rolling compared to baseline measurements or control (Garcia-Gutiérrez et al 2017; Griefahn

236 et al 2017; Junker and Stöggl 2015; Kelly and Beardsley 2016; MacDonald et al 2013b;

237 Markovic 2015; Mohr et al 2015; Monteiro et al 2018; Morton et al 2015; Peacock et al 2015;

238 Roylance et al 2013; Su et al 2016). Eight of fourteen studies with a comparator modality, such

239 as instrument assisted soft tissue therapy or roller massage, demonstrated no significant

240 difference in RoM between groups with the application of only foam rolling (Behara and

241 Jacobson 2015; Bushell et al 2015; Cheatham et al. 2017; Couture et al 2015; Morales-Artacho

242 et al 2017; Roylance et al 2013; Škarabot et al 2015; Vygotsky et al 2015).

243 Only one study (Markovic 2015) found a greater improvement in RoM with the application of

244 instrument assisted soft tissue therapy compared to foam rolling.

245

246 The meta-analysis included eighteen effect sizes from thirteen studies reflecting a total of 330

247 participants (see Figure 2). All effect sizes were positive, indicating an improvement in range of
 12

248 motion following foam rolling, and the weighted mean effect size was d=0.76, 95% CI (0.55-

249 0.98), large effect.

250

251 Insert Figure 2 here

252

253 Laboratory based measures

254 Thirteen studies investigating a wide range of laboratory-based outcomes, including torque,

255 velocity, power, impulse, force, tendon stiffness, maximal voluntary contraction,

256 electromechanical delay, half relaxation time, EMG and tetanus, were identified. Twelve of

257 these studies involved recreational athletes and one study was performed with elite collegiate

258 athletes (Behara & Jacobson 2015) (pooled mean age 22.70 ±3.30 years). Seven studies

259 involved male participants, one involved female participants and the remaining five

260 investigated males and females together. The mean PEDRO score was 5.85. The majority of

261 papers focused on acute responses, with two studies investigating foam rolling over more than

262 one day (3 days [Macgregor et al 2018] and 4 days [Monterio et al 2017]). Twelve studies

263 provided control or comparator groups (e.g. dynamic stretch, passive stretch, planking) for

264 comparison. Within these studies incidences of no significant differences between groups

265 were reported in seven studies (Behara & Jacobson 2015; D’Amico & Paolone 2017; Garcia-

266 Gutiérrez et al. 2017; Healy et al 2015; Janot et al 2013; Jones et al 2015; ; Morton et al 2015)

267 with two studies (MacGregor et al 2018; Su et al 2016) reporting significantly improved

268 outcomes following the use of foam rolling between groups. One study included a comparator

269 group but made no analytical comparison within the study findings reported (Cavanaugh et al

270 2017), and one study included no comparator or control (Monteiro et al 2017). No studies

271 were identified that investigated the effect on maximal oxygen uptake.

272
 13

273

274 Field based measures

275 In the five studies included for analysis of field-based measures, outcomes investigated

276 included power, speed, velocity, strength, force and agility. All five investigations were

277 conducted with physically or recreationally active individuals to lower limb muscles, (pooled

278 mean age of 22.02 ± 1.93 years) with only one investigation including female subjects (Healy et

279 al 2015). The mean PEDro score of these studies was 4.20 which is the lowest methodological

280 quality identified for this review. No field-based studies were identified that investigated the

281 effect of foam rolling on field-based measures over more than one day. Four of the studies

282 provided control or comparator groups (e.g. dynamic stretch, planking, dynamic warm up) for

283 comparison. Three of the studies (Behara and Jacobson 2015; Healey et al 2015; Jones et al

284 2015) reported no differences between groups, with one study (Peacock 2014) reporting

285 significant improvements in performance following foam rolling compared to a dynamic warm

286 up.

287

288 Measures of recovery

289 Five studies were located that investigated the effect of foam rolling on recovery from exercise

290 (See Table 4). All were conducted in young participants (pooled mean age 23.36 ±2.91 years),

291 and the mean PEDro score of these papers was 5.6. Two studies used the same muscle damage

292 protocols to induce DOMS, and measured performance parameters at pre-test, post 0 hours,

293 post 24 hours, post 48 hours, post 72 hours (MacDonald et al 2013a; Pearcey et al 2015),

294 whereas Romero-Moraleda et al (2017) took measurements at baseline, immediately post-

295 and 48 hours post-damaging exercise, with the foam rolling delivered at 48 hours post-

296 exercise. Two further studies examined the effect of foam rolling on recovery, but not from

297 eccentric, damaging exercise; Fleckenstein et al (2017) considered the effects on

 14

298 neuromuscular fatigue 5 minutes after a fatiguing protocol, and Kalén et al (2017) looked at

299 lactate clearance following a simulated water rescue in lifeguards. All studies included a

300 comparator (e.g. running, neurodynamic mobilisation) (Kalen et al 2018; Romero-Moraleda et

301 al. 2017) or control group (Fleckenstein et al 2017; MacDonald et al 2013a; Pearcey et al 2015)

302 with findings indicating that foam rolling attenuated the effects of muscle damage in

303 comparison to control groups.

304

305 Adverse Effects of Foam Rolling

306 No studies included within this review identified any adverse or harmful effects from the

307 application of foam rolling.

308

309 DISCUSSION

310 This systematic review and meta-analysis present a novel set of findings on the effects of foam

311 rolling on a range of important athletic measures. This work represents a new synthesis of

312 contemporary evidence for this popular tool.

313

314 Effect of foam rolling on range of motion

315 This review shows that foam rolling has a large, positive effect upon range of motion

316 immediately following application (d=0.76, 95% CI (0.55-0.98)), and that the positive effects of

317 foam rolling on range of motion are elicited irrespective of the measurement method, the

318 foam rolling dosage application or the sex of the participants. Foam rolling has been shown to

319 consistently bring about an increase in both joint range of motion and muscular length. For an

320 athletic population, the importance of a change in range of motion is dependent upon multiple

321 factors such as the joint involved, individual baseline measurement and/or the specific

322 demands of a given sporting activity. The minimum clinically important difference for hip
 15

323 flexion for example, has not yet been established however the values found in this analysis are

324 in agreement with published evidence within this field (Hammer et al 2017). The increase in

325 range of motion observed may be attributed to a number of factors including tissue

326 extensibility, temperature, perfusion, fatiguing factors, realignment of tissue fibres (Madding

327 et al 1987; McHugh & Cosgrave 2010; Gajdosik 2001; Wepple & Magnusson 2010). However,

328 while the acute effects are evident, the chronic effects are not, and it cannot be concluded

329 that foam rolling has a positive effect on range of motion or flexibility over time. It should also

330 be noted that a wide range of methods were used to assess range of motion, and while these

331 are well established (e.g. goniometry, inclinometry, isokinetic dynamometry, sit and reach test

332 amongst other) and have generally shown good to excellent levels of reliability (Charlton et al

333 2015; Drouin et al 2004; Kolber & Hanney 2012; Konor et al 2012), measurement error could

334 contribute to these positive findings.

335

336 Effect of foam rolling on laboratory-based measures

337 Findings are equivocal with regards the effects of foam rolling on laboratory-based measures.

338 Seven investigations found no significant improvements (Behara & Jacobson 2015; D’Amico &

339 Paolone 2017; Garciz-Gutiérrez et al 2017; Healy et al 2015; Jones et al 2015; Morales-Artacho

340 et al 2016; MacDonald et al 2013b), and seven studies showing significant positive effects

341 (peak power output and percentage power drop [Janot et al 2013], passive peak torque [Su et

342 al 2016], rate of torque development, maximal voluntary contraction and tendon stiffness

343 [Morton et al 2015], protecting the decline in MVIC [Macgregor et al. 2018], reduced EMG

344 [Cavanaugh et al 2017], improved FMS score [Monterio et al. 2017], reduced muscle stiffness

345 and increased knee extension peak torque [Morales-Artacho et al 2016]). However,

346 inconsistencies are apparent in the application of the foam rolling between studies, with

347 protocols ranging from a single 30 second bout per muscle through to ten sets of 60 seconds,
 16

348 making direct comparison of studies challenging. Nevertheless, findings suggest that multiple

349 sets of application may be required to elicit an effect, as no beneficial response from a single

350 set application was consistently reported (Behara & Jacobson 2015; D’Amico & Paolone, 2017;

351 Healy et al 2015; Jones et al 2015). This suggests that a dose-response relationship may be

352 present. There were also no differences in responses found between male and female

353 participants. To explain the increases in performance measures, it has been proposed that

354 myofascial release may result in increases in alpha-motor neuron activity and output, while

355 subjects who undertook foam rolling are also able to maintain muscle activity due to less

356 neural inhibition as a result of healthier connective tissue permitting better communication

357 from afferent receptors in the connective tissue (Janot et al 2013; MacDonald et al 2013a).

358

359 Effect of foam rolling on field-based measures

360 Collectively the evidence suggests that there is no detrimental effect of up to 120 seconds of

361 pre-exercise foam rolling on subsequent field-based measures. Four studies (Behara &

362 Jacobson 2015; Healy et al 2015; Jones et al 2015; Peacock et al 2015) indicated that lower

363 limb foam rolling had no effect on power, speed and agility, and Peacock et al (2014) reported

364 positive responses in these aspects of athletic measures following foam rolling. These findings

365 show similarities with the literature on static stretching, for example, Kay & Blazevich (2012)

366 proposed that short durations of stretching (<60 s) can be performed pre-exercise without

367 compromising maximal muscle measures. Further to this, the results from foam rolling studies

368 reflect positively against reports that suggest static stretching to single muscles over 100-

369 seconds (2 sets x 50 s) may be detrimental to power-based activities e.g. counter movement

370 jump (Cornwell et al 2001). However, no investigation included in this analysis has conducted

371 foam rolling dosage greater than 120-seconds. The low to moderate quality rating of these

372 studies indicate that the findings of these studies should be interpreted with caution. It has
 17

373 been proposed that the variability in effectiveness of foam rolling on field-based performance

374 measures may lie in the complexity of the test itself (Pearcey et al 2015); minimal changes

375 were reported for multidirectional tests (e.g. T-test), which are associated with greater

376 degrees of motor control, co-ordination and multiple muscle interactions, in comparison to the

377 more notable changes on unidirectional tests e.g. sprint test. As noted in relation to

378 laboratory-based measures, there is inconsistency on the dosage of foam rolling applied

379 making direct comparisons between studies difficult.

380

381 Effect of foam rolling on recovery

382 All studies identified appeared to show positive effects on foam rolling in the context of post-

383 exercise recovery; for exercise-induced muscle damage/DOMS, studies support the use of a

384 daily bout of foam rolling to lower limb muscles up to 72 hours following damaging exercise,

385 compared to no intervention at all. Foam rolling attenuated the effects of muscle damage on

386 muscle soreness/pain threshold, range of motion and performance-based measures of power

387 and speed. However, there were no beneficial effects found for swelling, and evoked

388 contractile properties. In their paper, MacDonald et al (2013a) considered the possible

389 mechanisms for the observed beneficial effects of foam rolling and suggest that foam rolling

390 appears to have a beneficial effect on the connective tissues, most probably at the

391 myotendinous junction, rather than being beneficial to muscle recovery; this is suggested on

392 the basis that there was reduced muscle soreness while also having greater decrements to

393 evoked contractile properties. They propose that the decrease in pain may have resulted in

394 less neural inhibition. Collectively, this appears to make foam rolling helpful for dynamic

395 movements. Foam rolling was also found to be beneficial compared to passive recovery for

396 lactate clearance (Kalén et al 2017) and demonstrated a non-significant trend for attenuating

397 the effects of neuromuscular fatigue, measured by perceived exhaustion, muscle force and
 18

398 reactive strength index (Romero-Moraleda et al 2017). In the wider literature, studies of

399 DOMS, common methods to attenuate the symptoms include nutritional and pharmacological

400 strategies, electrical, manual and cryotherapies, and exercise (Howatson & Van Someren

401 2008). No study has compared foam rolling to these commonly used approaches to reduce the

402 impact of DOMS, therefore it is not possible to identify whether foam rolling is any more

403 effective than alternative, commonly adopted modalities. More recently published studies

404 considering foam rolling and post-exercise recovery (Kalén et al 2017; Roylance et al 2013)

405 have included comparators other than control (running and neurological mobilization

406 respectively), which performed as effectively as foam rolling in attenuating the effects of the

407 exercise protocols.

408

409 Limitations of the literature identified and generalizability of the results

410 The methodological quality of the studies performed in this area remain varied but has

411 improved over time, with 18 of the 32 studies included in this review being considered as

412 moderate to high quality, scoring 6 or greater on PEDro quality assessment (Behara &

413 Jacobson 2015; Cavanaugh et al 2017; Cheatham et al 2017; D’Amico & Paolone 2017;

414 Fleckenstein et al 2017; Garcia-Gutiérrez et al 2017; Griefahn et al 2017; Janot et al 2013;

415 Kalén et al 2018; Kelly & Beardsley 2016; MacDonald et al 2013b; Macgregor et al 2018;

416 Monteiro et al 2017; Monteiro et al 2018; Morales-Artacho, 2017; Romero-Moraleda et al

417 2017; Roylance et al 2013; Su et al 2016). Encouragingly, the more recently published

418 literature appears to be of higher methodological quality, however, the findings reported in

419 this review should be interpreted in light of the risk of bias associated with the studies

420 included. More studies are needed with stronger methodological rigour in this area of inquiry.

421
 19

422 More specific methodological concerns with the studies in this review include that some

423 studies involved a large physical contact area and duration of foam rolling and large battery of

424 performance measures, which has the potential to create inter-participant differences in both

425 the fatiguing effects of a long bout of foam rolling, and differences in elapsed time from

426 intervention to test. It is unclear whether randomization of order of both application of foam

427 rolling, and measurement of outcome tests was undertaken in order to reduce the chance of

428 order effects influencing the findings. Furthermore, foam rolling is, by its very nature, a self-

429 limiting activity and it is not possible to normalize or standardize the degree of pressure

430 exerted by the foam roller on the muscles when self-administered, as opposed to being

431 administered mechanically (Bradbury-Squires et al 2015; Swan & Graner 2002). Collectively,

432 these factors have the potential to impact on participant performance measures and

433 therefore, study outcomes.

434

435 The studies identified through this systematic review have focussed on lower limb muscles and

436 study populations comprise mainly of college-aged participants. It is unknown whether the

437 same effects of foam rolling found within this review are present in older or paediatric

438 populations, or following foam rolling to the upper limb muscles. The question of whether

439 foam rolling has benefits to endurance-based athletes also remains unanswered. The majority

440 of studies have identified the acute effects of foam rolling, but whether a dose-response

441 relationship exists is unclear. The studies that have explored the effects of foam rolling have

442 looked primarily at the presence of effects but have not considered in detail why these effects

443 have been brought about.

444

445 Limitations of this review

 20

446 This is the one of the first studies to attempt a meta-analysis of data from foam rolling

447 literature, however conducting the meta-analysis was challenging. It was only possible to

448 calculate effect sizes from pre- to post-intervention, which does not account for control or

449 comparator, which would be usual for meta-analysis. Additionally, some papers qualified to be

450 included in the meta-analysis, but the data could not be accessed, and therefore they were

451 excluded from the quantitative synthesis.

452

453 This review, while narrower than previous reviews conducted on foam rolling, is still broad in

454 its scope and attempts to compare a wide range of parameters that have been investigated in

455 a range of ways. This variation within the published literature was also present within the

456 different domains of this analysis, as evidenced within the range of motion meta-analysis

457 which demonstrated moderate heterogeneity. Many studies judged as having low

458 methodological quality were included, which has the potential to introduce bias into the

459 conclusions reported here.

460

461 CONCLUSION

462 There is a clear beneficial acute effect of foam rolling on range of motion, however longer-

463 term effects remain unknown. There appears to be no detrimental effects of foam rolling on

464 other athletic performance measures, but it cannot be concluded that foam rolling is directly

465 beneficial to athletic performance markers including MVIC, muscle power, muscle

466 strength/activation, peak torque, maximal oxygen uptake, speed, acceleration, agility or

467 reaction time. Foam rolling appears useful for recovery from activity, but it is not possible to

468 state whether it is any more or less effective than other commonly used modalities. Foam

469 rolling does not appear to be harmful to an athlete through its application and while there are

470 fewer studies that have included female participants, foam rolling seems to elicit equivalent
 21

471 effects in males and females. It is noteworthy that there has been a proliferation of research in

472 this area since 2013, and this review reflects the infancy of the major research in this field. In

473 order to develop the evidence base in this field, future research should be directed towards

474 the following areas;

475 1) developing a better understanding of whether there is an optimal dosage or dose-

476 response relationship

477 2) investigation to determine the effects of long-term use of foam rolling to determine if

478 any chronic effects exist

479 3) comparing the effects of foam rolling on DOMS with other commonly accepted

480 approaches to recovery to damaging exercise, in order to better inform that body of

481 evidence

482 4) conducting work into a more diverse population beyond young, active males, and

483 considering its application for endurance-based athletes

484 5) developing a better understanding of the mechanisms by which foam rolling has its

485 effect

486

487 CLINICAL RELEVANCE

488 • In practical terms, these studies have demonstrated that it is neither harmful nor

489 detrimental to performance for male or female athletes to perform foam rolling

490 before or after activity.

491 • For athletes seeking an acute increase in muscle flexibility or joint range of motion,

492 foam rolling is a useful tool to include as part of a warm up or pre-exercise activity.

493 • Coupled with the positive effects on muscle and tendon stiffness, this may be of

494 particular use or importance for athletes involved in ballistic sports for which the

495 stretch-shortening cycle is important (Morales-Artacho et al 2016).

 22

496 • Foam rolling is beneficial for reducing some of the common symptoms associated with

497 exercise induced muscle damage.

498 • Given its effectiveness, ease of application and relative comfort (compared to cold

499 water immersion for example) and relatively low cost, it may be preferential to

500 athletes over other recovery modalities that are available.

501
 23

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 33

745 TABLES

746 Table 1 - MEDLINE (Ovid format) search strategy

747 Table 2 - PEDro ratings for included studies

748 Table 3 - Performance measures summary

749 Table 4 - Post-exercise recovery summary

 34

750 CAPTIONS TO ILLUSTRATIONS

751 Figure 1 - PRISMA search strategy flow chart

752 Figure 2 - Forest plot to show the meta-analysis of foam rolling on range of motion
Table 1 - MEDLINE (Ovid format) search strategy

1. Foam roll$.mp.
2. Self-myofascial release.mp.
3. Self-massage.mp.
4. 1 or 2 or 3
5. exp Athletic performance/
6. exp Range of motion, articular/
7. Range of movement
8. Flexibility
9. exp Muscle strength/
10. exp Muscle tonus/
11. MVIC
12. Muscle adj6 power
13. Muscle adj6 activation
14. Peak torque
15. Speed
16. Acceleration
17. VO2 max
18. Maximal oxygen uptake
19. Agility
20. Reaction time
21. exp Muscle fatigue/
22. Muscle adj6 soreness
23. Muscle adj6 damage
24. exp Lactic acid/
25. exp Muscle, skeletal/
26. 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22
or 23 or 24 or 25
27. 4 and 26
Table 1 - PEDro ratings for included studies

Study Methodological Quality Criteria Quality

1 2 3 4 5 6 7 8 9 10 11 Score
Behara and Jacobsen (2015) 1 1 1 1 0 0 0 1 1 1 1 7
Bushell et al. (2015) 1 0 0 1 0 0 0 1 1 1 1 5
Cavanaugh et al. (2017) 1 1 0 1 0 0 0 1 1 1 1 7
Cheatham et al. (2017) 1 1 0 1 1 0 1 1 1 1 1 9
Couture et al. (2015) 1 0 0 1 0 0 0 0 1 1 1 4
D'Amico and Paolone (2017) 1 1 0 1 1 0 0 1 1 1 1 8
Fleckenstein et al. (2017) 1 1 0 1 0 0 0 1 1 1 1 7
Garcia-Gutiérrez et al. (2017) 1 1 0 1 0 0 0 1 1 1 1 7
Griefahn et al. (2017) 1 1 1 1 0 1 1 1 1 1 1 10
Healey et al. (2015) 1 1 0 1 0 0 0 0 1 1 1 5
Janot et al. (2013) 1 1 0 1 0 0 1 1 1 1 1 7
Jones (2015) 1 0 0 1 0 0 0 0 1 1 1 5
Junker and Stöggl (2015) 1 1 0 1 0 0 0 0 1 1 1 5
Kalén et al. (2018) 1 1 0 1 0 0 0 1 1 1 1 7
Kelly and Beardsley (2016) 1 1 0 1 0 0 0 1 1 1 1 6
MacDonald et al. (2013a) 0 1 0 1 0 0 0 0 0 1 1 4
MacDonald et al. (2013b) 1 1 0 1 0 0 0 1 1 1 1 6
Macgregor et al. (2018) 1 1 0 1 0 0 0 1 1 1 1 7
Markovic (2015) 1 1 0 1 0 0 0 0 0 1 1 4
Mohr et al. (2014) 0 1 0 1 0 0 0 0 0 1 1 4
Monteiro et al. (2017) 1 1 0 1 0 0 0 1 1 1 1 7
Monteiro et al. (2018) 1 1 0 1 0 1 1 1 1 1 1 9
Morales-Artacho (2017) 1 1 0 1 0 0 0 1 1 1 1 6
Morton et al. (2015) 0 1 0 1 0 0 0 0 0 1 1 4
Peacock et al. (2014) 1 0 0 1 0 0 0 0 0 1 1 3
Peacock et al. (2015) 0 0 0 0 0 0 0 0 0 1 1 2
Pearcey et al. (2015) 0 1 0 1 0 0 0 0 0 0 1 3
Romero-Moraleda et al. (2017) 1 1 0 1 1 1 1 1 1 1 1 10
Roylance et al. (2013) 1 1 0 1 0 0 0 1 1 1 1 6
Škarabot et al. (2015) 1 1 1 1 0 0 0 0 0 1 1 5
Su et al. (2016) 1 1 0 1 0 0 0 1 1 1 1 7
Vygotsky et al. (2015) 1 0 0 1 0 0 0 1 1 1 1 5
Table 1 - Performance measures summary

Author & Sample FR Protocol Control / Muscle Group Performance Outcome / Significant Narrative
Date Comparator Measure Grouping
Group
Behara and N=14 1min per Comparator Hamstrings Tendo Speed 1. No significant differences Field,
Jacobson NCAA Division 1 muscle group group, Quadriceps Analyser of between groups Laboratory
(2015) Offensive (bilaterally) Dynamic Gluteals Counter-Movement 2. Peak CMJ Power = No and ROM
Linesmen totalling 8mins. Stretch Gastrocnemius Jump (x3) for Significant Diff
20.04(±1.41) (same Power (W) and 3. Average CMJ Power = No
years old, 6 muscles) Velocity (m•s-1); 4. Peak CMJ Velocity = No
years + Baseline Bubble
5. Average CMJ velocity =
participation in Control Inclinometer for
No
organised sport group, no Hip Flexion pRoM
intervention (°); 6. Peak Torque (Knee Ext) =
Biodex System 4 No
Pro® dynamometer 7. Average Torque (Knee
for Peak and Ext) = No
Average Isometric 8. Peak Torque (Knee Flex) =
Torque in Knee No
Flexion and 9. Average Torque (Knee
Extension (N•m) Flex) = No
10. pRoM = Significant
Increase (p=0.0001)
Bushell et N= 31, physically 3x1min (30sec Control Quadriceps Hip Extension Angle 1. No Significant diff ROM
al. (2015) active (min rest) between group, no (°) via Dartfish between control and
1.5hrs p/wk), lunges of intervention software intervention groups
21.35 (± 2.44) sessions 1&2 immediately or across all
years old, n=19 and for 5 6 lunges
males, n= 12 separate 2. Yes – within group
females unsupervised
(intervention) –
sessions
Significant increase in hip
occurring on
 different days extension within session 2
in the week (p=≤0.05; r = -0.11)
between 3. No significant diff within
sessions 1 and group) in hip extension
2. from baseline to session 3
Cavanaugh N=18, 4 x 45 sec (15 Control Quadriceps EMG (mV) 1. Significant decrease in Laboratory
et al. (2017) recreationally sec rest) group, no and Hamstring Perceived Pain Bicep Femoris activation
active, males n= intervention (VAS) (P=0.015)
10, 25±4.6, 2. No significant sex-based
females n=8, interactions
21.75 ± 3.2 3. Significant interaction
between perceived pain
and muscle group rolled
(P<0.001)
4. No comparator
conclusions made
Cheatham N= 45, n=28 1 x 2mins Comparator Quadriceps Pressure Pain 1. Significant increase in ROM
et al. (2017) males, n=17 group, (left only) Threshold (kPa) PPT in all conditions
females, 26 ± instruction ROM (°) 2. Significant increase in
6.5 of foam ROM
rolling 3. No significant dif
between ROM and PPT.
No control
group
Couture et N=33, 4x30sec “long Comparator Hamstrings Passive knee 1. No significant diffs across ROM
al. (2015) recreationally sets” (30sec group, extension test (°) all conditions or between
active, 20 (± 1.5) rest) and different via inclinometer genders
years old, n=19 2x30sec “short application 2. No comparator
males, n=14 sets” (30sec time of conclusions made
females rest) foam rolling
D’Amico N= 16 trained 1x30 sec per Control Glut, Hip Run time (mins) 1. No significant effect of FR Laboratory
and males, 20.5 ± muscle group group, flexors, Quads, Stride length and
Paolone 3.3 30min ITBS, hip extension on any variables
(2017) passive rest Adductors, VCO2 2. No significant differences
Gastrocnemius Blood Lactate between groups for run
(mmol) time
Garcia- N= 38, n=19 3x20sec Control Tricep Surae ROM (cm) 1. Significant increase in ROM and
Gutiérrez et males, 21.8±2.7, group, no MVIC (kg) ROM in FR and FR + Laboratory
al. (2017) n=females, foam roll or vibration groups
19.5±7.2, vibration 2. No significant difference
recreationally in MVIC between groups
active
Griefahn et N=38, n= 13 3 x 30sec per Control Glut Max, ROM (MMST) (cm) 1. No significant different in ROM
al. (2017) males, n=25 muscle group, no Erector Spinae, Fascial Mobility lumbar flexion
females intervention Latissimus (mm) 2. Significant increase in
23.34±2.58, Dorsi fascial mobility (P<0.001)
active for 3hrs 3. No significant difference
per week in mechanosensitivity
4. FRG (1.7915 mm) to the
CG (0.0139 mm), this
show also a highly
significant result (p <
0.001).
Healey et al. N=26, healthy 1x30sec on Comparator Quadriceps; Vertec Vertical 1. No significant diffs in Field,
(2015) college, (21.56 ± each muscle group, Hamstrings; Jump for Height Power, Height, Force, Laboratory
2.04 years, n=13 Planking ITB; (cm) and Power (W) Agility.
men, n=13 exercise Gastrocnemius; (3xrapid jumps); 2. No significant diffs
women), Latissimus Isometric Squat between groups
recreationally Dorsi; Force (N) (10sec)
active Rhomboids via force plate;
Pro Agility -5-10-5
test (sec);
Janot et al. n=23; 3x30sec Control Gluteals, Peak Power Output Whole sample analysis Laboratory
(2013) 20.3±1.4 group, no Quadriceps, (PPO) (W), Percent showed -
 Healthy adults intervention Hip Flexors, Power Drop (PPD) 1. No significant diffs in
(n=9 male, n=14 Hamstrings, (%), Max Power PPD, PPO, MPO or APO
female) Comparator Gastrocnemius, (MPO) (W), Av. or between groups
group, Static Adductors, ITB Power (APO) via Gender split analysis showed -
Stretching Wingate Test (W) 1. Significant increase in
(SS) Male PPO (p=<0.05) in FR
& SS groups
2. Female PPD significant
decreased (p=<0.05)
3. Male PPD significant
increased (p=<0.05)
4. Absolute PPO was not
significantly (p > .05)
affected following MFR
compared to the control
trial in women
5. Relative PPO, absolute
and relative MPO, and
absolute and relative
APO were not
significantly (p >.05)
altered by either
treatment modality
compared to the control
trial in both men and
women
Jones et al. N=20 1 x 30sec per Control Gastrocnemius; Vertical Jump 1. No significant diffs in all Field and
(2015) recreationally muscle group, Quadriceps; Height (cm), tests Laboratory
trained males, (bilaterally); 40 rolling Hamstrings; Impulse (N*s-1), 2. No significant diffs
24.05 (± 2.02) rolls per min skateboard Gluteals Ground Reaction, between conditions
years old Force (N*Kg-1),
 Take off Velocity
(m*s-1) via force
plate
Junker and N=40, healthy 3x30-40sec (10 Control Hamstrings Sit and reach test 1. Significant increase ROM
Stöggl males, 31.3 reps per leg) group, no (cm) between Foam Roll and
(2015) (±9.2) years old applied intervention Control group (p=0.033)
bilaterally 2. Significant increase
within Foam Roll group
(p=0.001)
Kelly and N= 26, control 3 x 30 sec (10 Control Tricep Surae ROM (cm) 1. No significant between ROM
Beardsley group n=13 5 sec rest) group, no group effects
(2016) males 8 females Dominant side intervention 2. Significant within group
24.4±1.7, FR only on effects of FR of both
group n=13 8 contralateral rolled and contralateral
males, 5 limb limbs (p=0.00)
females, 24.8 ±
2, recreationally
active
MacGregor N=16, 2 minutes of Control Quadriceps Tensiomyography 1. Foam rolling protected ROM,
et al. (2018) recreationally foam rolling on group, rest (mechanical decline of MVC Laboratory
active males 25 3 consecutive properties) (mm/s), compared to rest
years (± 4.4) yrs days modified active 2. Statistically reduced EMG
kneeling lunge (°) post-foam rolling
compared to rest
3. Greater radial
displacement of muscle
belly in foam rolling
condition compared to
rest
4. No change in ROM across
time or between
 condition

MacDonald N=11 healthy 2 x 1min (30sec Control Quadriceps RFD (N*s-1), Force 1. No Significant diff in Laboratory
et al. university males rest), 3-4 reps group, no (N), MVC (N) via Force, RFD or Muscle and ROM
(2013b) 22.3 (±3.8) years per minute foam rolling Wheatstone Bridge Activation between
old stain gauge (BioPac groups
Systems); Twitch 2. Significant increase in
Force via DS7AH ROM post foam rolling at
Digitimer), Tetanus,
post 2 and 10 minutes
Muscle
(p=0.001)
Inactivation, ½
relaxation time 3. Significant -ve correlation
between quad force and
knee ROM (p= 0.01) pre-
test, no longer present
post-test at 2 & 10min in
Foam Roll group,
4. Significant -ve correlation
remained (p=0.05) for
control group) at 2 &
10min
Markovic N=20, regional n=10 2x1min Comparator Quadriceps; Supine Passive 1. Significant increase in ROM
(2015) level male per muscle group, Hamstrings Knee Flexion (°); immediate knee and hip
soccer players, instrument Passive Straight Leg range of motion
19(±2) yrs assisted soft Raise (°) via digital 2. Effects were higher for
tissue inclinometer the FAT group (pre-to
therapy before, immediate post-test gains in knee
and 24hrs
and hip ROM: 13.1° and
15.2°; or 10% and 19%)
vs. FR group (pre-to post-
test gains in knee and hip
ROM: 6.6° and 7.0°, or
 5% and 9%)
Mohr et al. N=40, 22(±3.8) n=10, 3x1 min Control Hamstring Passive Hip Flexion 1. Significant increase in ROM
(2015) yrs, healthy but (30sec rest), group, no (°) via bubble passive hip-flexion ROM
with less than 1sec inferior – intervention inclinometer (p= 0.001)
90(°) hamstring 1 sec superior 2. Combined FR /Static
flexibility cadence Stretch had a greater
change in passive hip-
flexion ROM compared
with the Static Stretching
(p = .04), FR (p=.006), and
control (p = .001)
3. There were no significant
differences between any
of the other treatments
(P > .09)
Monteiro et N=20 1 x 30 seconds, No control ITB, latissimus Functional 1. FMS overhead deep Laboratory
al. (2017) recreationally 1 x 60 seconds, group or dorsi Movement Screen squat improved
active, 1 x 90 seconds, comparator Overheat deep significantly after 90 and
resistance 1 x 120 seconds modality squat 120 seconds of ITB foam
trained females, (total 300 rolling in FR only group
26.2 (± 6.4) yrs seconds) on 2. No other statistically
each side over
significant differences
4 consecutive
were observed
days
Monteiro et N=18 1 x 120 seconds Comparator Quadriceps Passive hip flexion 1. Hip flexion statistically ROM
al. (2018) recreationally set group, roller and extension (°) increased immediately
active, massage after foam rolling and
resistance maintained the increase
trained males, at 10, 20 and 30 minutes
26.5 (± 4.2) yrs post-foam rolling
2. Hip extension statistically
 increased immediately
after foam rolling and
maintained the increase
at 10 and 20 minutes
post-foam rolling
3. FR was statistically
superior in improving hip
extension ROM as
compared to RM
immediately post
intervention relative to
the baseline values
4. Greater statistical
increases in hip flexion
ROM were also achieved
in the FR condition as
opposed to RM
immediately post
intervention and at 10-
and 30-minutes post
intervention

Morales- N=14 physically 1-minute Control Hamstrings Passive knee 1. No significant difference ROM,
Artacho et active males, bilateral set group, rest extension on in range of motion after Laboratory
al. (2017) 26.6 (± 4.5) yrs followed by 10 isokinetic foam rolling
x 1 minute sets Comparator dynamometer at 2. Cycling (5min) and Mixed
on alternating group, 2°/seconds, passive (5 & 30min) increased
leg, with 30 Cycling torque (N•m), ROM
seconds rest Mixed
muscle stiffness 3. No significant changes in
between sets (Cycling +
(Pa) torque observed in foam
(total time 15 FR)
minutes) rolling condition
 4. Reduction in stiffness at 5
minutes post FR, Cycling
and Mixed maintained up
to 30 minutes
5. Significant reduction in
torque at 5min in Cycling
and Mixed compared to
no changed in control
and FR groups

Morton et N=19, male, 22 4 reps x 1min Comparator Hamstrings Passive Knee 1. Significant increase in ROM,
al. (2015) (±3) yrs, (15-30 sec rest group, Static Extension (°) via passive ROM over time (p Laboratory
recreationally between reps) stretch Biodex = 0.001)
active dynamometer, Rate 2. Cohen’s d effect size
of Torque value for the pooled
Development means (d = 0.64) suggests
(N•m), Peak Passive
a moderate to high
Torque (N•m),
practical significance for
Muscle Stiffness
(Pa), MVIC (Nm) ROM with no diff
between conditions
3. Significant increase in
peak passive torque (p =
0.03), no diff between
groups
4. Reduction in muscle
stiffness post FR (p=0.02),
no diff between groups
5. MVIC and RTD (d=0.13)
low practical significance
Peacock et N=11 physically 1 x 5 rolls per Comparator Erector spinae; V Jump - vertec 1. Significant increase in V. Field
al. (2014) active males 30sec group, Multifidus; (cm) Jump (p = 0.012)
 22.18 dynamic Gluts; Standing Long Jump compared to DWU
(± 2.18) yrs warm up Hamstrings; (cm) 2. Significant increase in
(DWU) Calf; Quads; Agility - (18.3 pro Standing Long Jump
Hip flexors; agility test) (sec) (p=0.007) compared to
Pectoralis 1RM bench press DWU
major & minor (kg) 3. Significant increase in
37m sprint (sec) Agility (p=0.001)
compared to DWU
4. Significant difference in
37m Sprint time (p =
0.002) compared to DWU
5. Significant increase in
1RM (p=0.024) compared
to DWU
Peacock et N=16 athletically Med-Lat 1 x 5 No control M-L group = V. Jump vertec (cm) 1. Significant increase in Field and
al. (2015) trained rolls per 30sec group Erector Spinae; Broad Jump (cm) ROM in Anteroposterior ROM
males,21.9 Gluts; Agility 5-10-5 test group (p=0.003)
(±2.0) yrs Ant-post 5 rolls Hamstring; Pec (sec) 2. No significant differences
per 30sec Major; Gastroc; Bench Press NFL in all other tests
Quads rep out test
A-P group = Sit and Reach (cm)
Lats; Ext
Obliques;
Piriformis,
Gluts;
Peroneals,
Adductors, ITB
Roylance et N=27 healthy 10min total Comparator erector spinae, Sit and Reach (cm) 1. No change in acute ROM ROM
al. (2013) university group, static upper back, following FR in isolation
students, n=14 stretch and gluteals 2. Significant increase in
male, n= 13 postural piriformis, ROM with FR in
female, alignment hamstrings, combination with
22.7 (± 2.4) yrs exercise. gastrocnemius
 with sit and and soleus postural alignment
reach score exercise or static
<34.3cm stretching
3. No comparator
conclusions made
Škarabot et N= 11, 3 sets x 30 Comparator Gastrocnemius Weight bearing 1. No increase ROM by FR ROM
al. (2015) adolescent, seconds (15- group, static / Soleus lunge (cm) alone
trained sec rest stretching 2. Significant increase in
swimmers (n=6 between sets) ROM when FR+SS
males, n=5 combined (p < 0.05)
females), 15.3 (± 3. Post hoc testing revealed
1.0) yrs
increases in passive ankle
dorsiflexion ROM
between baseline and
post-intervention by
6.2% for SS (p < 0.05) and
9.1% for FR+SS (p < 0.05)
but not for FR.
Su et al. N= 30, n=15 3x30sec (per Comparator Quadriceps Knee Flexion (°) 1. Significant increase in ROM and
(2016) male 21.47 leg) group, Static and Hamstrings Peak Torque (Nm) modified Thomas test in Laboratory
±1.77, n-15 Stretch (SS) Sit and reach (cm) all conditions (p<0.017)
females 21.40 ± and Modified Thomas with significant greater
1.18 Dynamic test increase with FR
Stretch (DS) 2. Significant increase in
knee extension peak
torque (P=0.003)
compared to SS
4. Significant increase in sit
and reach (P <0.001) &
compared to SS & DS
 5. Significant increase in
Knee Flexion (P<0.017)
Vygotsky et N=23, healthy 2 sets x 60sec No control Quadriceps Modified Thomas 1. No significant increase in ROM
al. (2015) students (n=7 (30sec rest group or Test (°) ROM
male, n=16 between sets) comparator 2. No comparator
female) 22 (± modality. conclusions made
3.3) yrs
Table 1 - Post-exercise Recovery Summary

Author & Date Sample EIMD Protocol FR dosage / Control/ Muscle Group Markers of Findings
Protocol comparator DOMS/EIMD
Group
Fleckenstein et N=45, 23 Functional agility 5 minutes rolling, No treatment Quadriceps, 1. Maximum No significant
al. (2017) males, 24.8 short term each muscle control group hamstrings, voluntary differences between
±2.3, 22 fatigue protocol, treated bilaterally adductors, ITB, force groups over time
females 25 involving 3 for 30 seconds gastrocnemius 2. Reactive
±2 maximum each strength
counter index
movement jumps, Preventative 3. Pain (VAS)
20 seconds step (prior to
up on a 40cm box fatiguing) or
at 220 beats per regenerative
minute, 3 x body (after fatiguing)
weight squats,
the pro-agility Baseline,
shuttle; repeated immediately after
until participants fatiguing exercise,
can no longer 5 minutes post
maintain 90% fatigue
maximum jump
height. The
minimum number
of rounds to be
performed was 3.
Kalén et al. N = 12, Running 10m to 1min per leg per No treatment Quadriceps, ITB, 1. Blood Lactate 1. Post recovery
(2018) 24±4.9, water, swim muscle. Total control group Hamstring, 2. RPE lactate levels
 Surf 100m with fins, rolling 20 mins Adductors and were significantly
Lifeguards gaining control of Comparator Gluteals lower for foam
casualty, toeing group, (25 rolling and
casualty to shore, minutes running groups
extracting sitting) or compared to
casualty Running (4 passive recovery
2. No significant
minutes
differences for
walking, 16
lactate or RPE
minutes
between groups
running, 5
minutes
walking)
MacDonald et n=20 10 x 10 five exercises on No treatment Anterior, lateral, 1. Thigh girth 1. TF – Foam
al. (2013a) Physically repetitions of both the right and control group posterior, and 2. muscle Rolling reduced
active, back squat at 60% left legs for two medial aspect of soreness TF with
resistance of 1 repetition 60-s bouts each the thigh, along 3. muscle moderate to
trained (3 x maximum, with 2 with the gluteal activation large size effect
per week minutes rest muscles 4. MVC force 2. RFD – Foam
Rolling reduced
or more) between each set 5. vertical jump
RFD with large
Foam roll: 6. twitch force
effect size at
age 7. electromecha
72hr but no
25.1±3.6 nical delay
substantial
yr; control: 8. rate of force between group
age 24.0 development differences
±2.8 yr 9. half 3. Potentiated
Male relaxation Twitch Force
time (PTF) – between
10. Quadriceps group
passive ROM differences at 48
11. Hamstrings and 72hr with
passive ROM foam rolling
12. Hamstrings reducing PTF
dynamic ROM with large and
moderate size
At pre-test, post 0 effects
hours, post 24 4. MVC – no
hours, post 48 between group
hours, post 72 differences
hours 5. Voluntary
Activation (VA) –
between group
differences at
post 24,48 and
72 hrs with foam
rolling increasing
VA (moderate to
large size effect)
6. ½ relaxation
time – no
between group
differences
7. Passive Quad
ROM showed
increase in ROM
with moderated
effect size
between groups
at 48 and 72 hrs
8. Passive
Hamstring ROM
 – Foam rolling
showed increase
in ROM with
moderate effect
size at 72hrs
9. Dynamic
Hamstring ROM
showed increase
in ROM with
moderated
effect size at
24hrs
10. moderate size
effect in
reducing DOMS
at 24hrs.
11. large size effect
in reducing
DOMS at 48hrs
and 72hrs.

Pearcey et al. n=8 10 x 10 45 second bout No treatment Quadriceps, 1. pressure-pain 1. Moderate effect
(2015) Recreation repetitions of followed by 15 control group adductors, threshold of on Sprint time at
ally back squat at 60% seconds rest, to a hamstrings, the 24hrs and 72hrs
resistance of 1 repetition total of 20 iliotibial (IT) quadriceps 2. Small effect on
trained maximum, with 2 minutes including band, and 1. sprint speed broad jump at
males minutes rest rest times. gluteal muscles (30-m sprint 24hrs but large
effect at 72hrs
age = 22.1 between each set Performed time)
3. Agility unlikely to
± 2.5 years, directly after test 2. power
be affected by
 height = measures, 24 (broad-jump foam rolling by
177.0 ± 7.5 hours post, and distance) an amount
cm, mass = 48 hours post. 3. change-of- greater than the
88.4 ± 11.4 direction smallest
kg speed (T-test) worthwhile
4. dynamic change post
exercise
strength-
4. moderate effect
endurance
on dynamic
(maximal
strength-
back 15-squat
endurance at
repetitions at
48hrs post-
70% of 1RM).
exercise. Unlikely
At pre-test, post 0 to have any
hours, post 24 meaningful
hours, post 48 effect at 24hrs or
hours, post 72
72hrs.
hours
5. moderate effect
on the decline in
pressure pain
threshold at
24hrs and a large
effect at 48hrs.
Unlikely to have
any meaningful
effect at 72hrs.

Romero- N=32, 21 100 drop jumps 1 session of 5 x 1 Comparator Quadriceps 1. Change in 1. Significant
Moraleda et al. males, 11 (5 x 20 with 2 mins sets with 30 group, Neuro- numeric pain reduction in pain
(2017) females, mins rest) from a seconds rest to muscular rating scale post foam
age 22.2 ± 0.5m high box the quadriceps; treatment 2. Surface EMG rolling, with no
2.2 years outcome (femoral 3. Strength significant
measurements neurodynamic (MVIC) differences
immediately mobilisation) between groups
taken at baseline, 2. Strength: After
after muscle treatment, only
the FR group had
damage and post
a statistically
foam rolling (over
significant
a 48-hour period)
improvement
(p<0.01) in
strength
compared to
pre-treatment.
3. MVIC: vastus
medialis and
vastus lateralis
improved
significantly in
both groups
(p<0.01); while
the rectus
femoris only
significantly
improved in the
FR group
(p<0.01)
compared to
pre-treatment.
4. Maximal peak
activation: no
significant
differences
between the
groups
Identification

Records identified through Additional records identified

database searching through other sources
(n = 212) (n = 34)

Records after duplicates removed

(n = 234)
Screening

Records screened Records excluded

(n = 234) (n = 197)

Full-text articles assessed Full-text articles excluded

for eligibility (n = 5)
Eligibility

(n = 37)

Studies included in
qualitative synthesis
(n = 32)
Included

Studies included in
quantitative synthesis
(meta-analysis)
(n = 13)
To whom it may concern:

I can confirm there are no conflict of interests aligned with this investigation. Should any
issue arise, please contact me on Brendon.Skinner@northampton.ac.uk

Many thanks

Brendon Skinner
Senior Lecturer Sport Rehabilitation and Conditioning

University of Northampton

University Drive

Northampton

NN1 5PH

t: 01604 89 2389

e: Brendon.skinner@northampton.ac.uk