Journal of Bodywork & Movement Therapies 28 (2021) 225e230

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Fascia Science and Clinical Applications

Acute effects of myofascial release with portable electric massager at

different frequencies: A randomized pilot study
Ewertton de Souza Bezerra a, b, c, Morgana Lunardi d, Raphael Luiz Sakugawa d,
Fernando Diefenthaeler d, *
a
Human Performance Laboratory, Universidade Federal do Amazonas, Faculdade de Educaça ~o Física e Fisioterapia, Manaus, AM, Brazil
b
Programa de Po ~o Stricto Sensu em Ci^
s Graduaça encias da Saúde, Faculdade de Medicina, Universidade Federal do Amazonas, Faculdade de Educaça ~o Física
e Fisioterapia, Manaus, AM, Brazil
c
Programa de Po ~o Stricto Sensu em Ci^
s Graduaça encias do Movimento Humano, Faculdade de Educaça ~o Física e Fisioterapia, Universidade Federal do
Amazonas, Faculdade de Educaça ~o Física e Fisioterapia, Manaus, AM, Brazil
d
Biomechanics Laboratory, Federal University of Santa Catarina, Floriano polis, SC, Brazil

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

Article history: Introduction: The present study aimed to analyze the acute effects of a myofascial release session (MFR)
Received 5 February 2021 with a portable electric massager (PEM) at different frequencies (25 Hz and 52 Hz) on the superficial and
Received in revised form deep fascial motion.
1 May 2021
Methods: The limbs of fourteen participants (12 men and 2 women, age ¼ 34 ± 10 years;
Accepted 16 July 2021
height ¼ 1.74 ± 0.09 m; weight ¼ 72.77 ± 13.1 kg; right thigh fat thickness ¼ 4.18 ± 3.49 mm; left thigh
fat thickness ¼ 4.13 ± 3.35 mm) were randomized to one of the two PEM frequencies (25 Hz vs. 52 Hz).
Keywords:
All evaluations were carried out at the same time of day and by the same evaluator (blind). The protocol
Fascial motion
Muscular architecture
consisted of 9 min of MFR on the vastus lateralis, alternating between three sites of 5 cm. Before and after
Muscular fascia the MFR session, the fascial motion was measured in the vastus lateralis (superficial and deep layer)
Vastus lateral using B-mode ultrasound at two knee positions (0 and 45 ).
Results: The superficial and deep layers presented significant increases in fascia length after myofascial
release with the knee extended 0 (p < 0.001) and flexed 45 (p < 0.001). In addition, the fascial motion
was not influenced by the frequency applied during the experimental protocol and was independent of
layer and knee position. However, the deep layer showed an increase at knee flexed at 45 compared to
the superficial layer. On the other hand, there was no difference between layers when the knee was
extended (0 ). The findings of this study indicate that PEM appears to be effective in changing the fascial
motion of the vastus lateralis.
© 2021 Elsevier Ltd. All rights reserved.

1. Introduction Fascial tissues are seen as an interconnected dimensional network

In skeletal muscle, interactions between contractile elements
and the connective tissue at various levels result in emergent
properties that determine mechanical performance (Langevin and
Huijing, 2009). Among the connective tissues that interact in the
skeletal muscle system, the muscular fascia can be understood as a
tissue of fibrous collagens that forms part of a system that transmits
dimensional force throughout the body (Abu-Hijleh et al., 2012).
* Corresponding author. Laborato rio de Biomec^ anica (BIOMEC), Centro de
Desportos, Universidade Federal de Santa Catarina, Campus Joa ~o David Ferreira
Lima, Trindade, 88040-900, Florianopolis, Santa Catarina, Brazil.
E-mail address: fernando.diefenthaeler@ufsc.br (F. Diefenthaeler).
that adapts their fiber arrangement and density according to local
dimensional demands (Abu-Hijleh et al., 2012). Therefore, it is
suggested that connective tissue may change after overuse syn-
dromes or traumatic injuries (i.e., become denser), although it is
not clear whether this is due to a change in the composition of
collagen fibers or fibroblasts (Stecco et al., 2013).
In recent years, a treatment known as myofascial release (MFR)
has been widely used. This treatment involves specifically guided,
low-load, long-lasting mechanical forces to manipulate the myo-
fascial complex. The treatment is designed to restore optimal
length, decrease pain, and improve muscle function. Its application
is based on the hypothesis that, due to fascial continuity, fascial
restrictions in one specific region of the body cause undue stress in

https://doi.org/10.1016/j.jbmt.2021.07.037
1360-8592/© 2021 Elsevier Ltd. All rights reserved.
E. de Souza Bezerra, M. Lunardi, R.L. Sakugawa et al.
other regions of the body. Therefore, the manipulation of the fascia
at a certain body point can cause alterations in other points that,
although not connected by the muscles, are connected by the fascia
(Kalichman and Ben David, 2017).
Myofascial release usually involves slow and sustained pressure
(120e300 s) applied to the restricted fascial layers, using an indi-
rect or direct technique. The indirect technique involves gentle
guided stretching along the path of least resistance until free
movement is achieved (Stroiney et al., 2020). During this technique,
the pressure applied is a few grams of force, and the hands tend to
follow the direction of the fascia restrictions, to maintain the fascia
stretched and loose (Ajimsha et al., 2015). On the other hand, the
direct technique is based on the pressure applied directly on the
restricted fascia: in this way, professionals use joints (e.g. elbows)
or other tools to slowly sink into the fascia, applying pressure of a
few kilograms of force on the restricted fascia, in order to apply
tension or stretch the fascia (Abu-Hijleh et al., 2012).
There are different techniques for applying MRF, passive
(applied by a body therapist), and active (self MRF application). The
latter has grown in popularity in recent years, mainly due to the
emergence of different tools that facilitate application, such as foam
roller or massage balls (Ajimsha et al., 2015). In addition, equip-
ment that uses different application frequencies has appeared on
the commercial market, which can provide both relaxation and
muscle pre-activation, according to the effects advertised by the
manufacturers of the different brands available. This tool is known
as a portable electric massager (PEM), and its main purpose is to act
on the muscular fascia, which consists predominantly of elastic
collagen fibers. Collagen fibers adapt to the mechanical load in a
specific manner, dependent on the magnitude, duration, and fre-
quency of the tension. The PEM allows manipulation of the fre-
quency of the applied load by increasing the number of repetitions
per unit of time, which is more complex than when using manual
techniques or self-release.
In line with the reasons mentioned above, there is growing in-
terest in understanding the mechanism behind the myofascial
release. As far as we know, there are three types of imaging tech-
niques for fascia analysis: computed tomography, magnetic reso-
nance imaging, and ultrasound imaging. Among these three
techniques, B-mode ultrasound offers better image quality to
analyze the fascia (Fede et al., 2018). Furthermore, Ichikawa et al.
(2015), demonstrated that 4 min of myofascial release in the
vastus lateralis may cause a large variation in motion in the su-
perficial layer, but no changes in the deeper layer, leading to
speculation that the procedure time should be extended. Thus, the
current pilot study aimed to analyze the acute effects on superficial
and deep fascial motion after an MFR with a PEM at different fre-
quencies (25 Hz and 52 Hz). We hypothesized that the higher fre-
quency (52 Hz) would cause a change in the fascial motion due to
the greater range of frequency coverage, which would not occur for
the lowest frequency (25 Hz).
2. Methods
2.1. Experimental approach to the problem
This study consisted of a randomized, controlled, blind experi-
mental design, in which the participants underwent an MFR ses-
sion with each lower limb treated with one of the two frequencies
recommended by the PEM manufacturer. The independent variable
was the applied frequency (25 Hz vs. 52 Hz), and the dependent
variables were the superficial and deep fascial motion of the vastus
lateralis muscle. All evaluations were performed at the same time
of day and by the same evaluator who did not have access to the
randomization of the groups. All subjects provided written
226
Journal of Bodywork & Movement Therapies 28 (2021) 225e230
informed consent. Ethical approval was obtained from the local
Human Research Ethics Committee (Protocol number:
32063720.9.0000.0121) and the study was retrospectively regis-
tered at the Brazilian Registry of Clinical Trials (ReBEC) (protocol
number RBR-10qc32q5).
Initially, participants were assessed for anthropometric mea-
surements (body mass and height), then ultrasound measurements
were taken from the vastus lateralis muscle at 0 (knee extended)
and 45 (knee flexed) positions in both limbs. After the initial
measurements, we realized the randomization (http://www.
randomization.com/) of the limb and treatment to be applied
(25 Hz and 52 Hz). After the application of intervention in both
limbs, a new evaluation was carried out in the same order as before
the intervention, Fig. 1.
2.2. Subjects
Fourteen participants volunteered for this study (12 men and 2
women), (age ¼ 34 ± 10 years; height ¼ 1.74 ± 0.09 m;
weight ¼ 72.7 ± 13.1 kg; right thigh thickness fat ¼ 4.18 ± 3.49 mm;
left thigh thickness fat ¼ 4.13 ± 3.35 mm). Participants had not
experienced any muscle injury in the previous 3 months and were
instructed not to perform physical activity for 48 h before data
collection and to maintain their usual diet.
2.3. Procedures
2.3.1. Ultrasound measure
The superficial and deep fascial motion of the vastus lateralis
was measured using B-mode ultrasound before and after the MFR
session with the PEM. The measurements were recorded from the
central point of a straight line, connecting the greater trochanter
and the lateral epicondyle of the femur with the ventral iliotibial
band. An ultrasound imaging system (model LOGIC S7 Expert,
General Electric, USA) was used to extract the image of the vastus
lateralis muscle. A 50 mm wide linear probe (6e15 MHz linear
array) was placed perpendicular to the skin and the angle was
adjusted to provide the clearest high luminance image of the
muscle beam without pressure distortion.
The measurement was performed on the superficial fascia, be-
tween the subcutaneous tissue and the vastus lateralis muscle, and
on the deep fascia, between the vastus lateralis and vastus inter-
mediary muscles (Fig. 2). A tape was used to stabilize the position
and guide the probe on the skin of each participant, which appears
as a vertical black shaded band (‘the shadow’) to the left of the
ultrasound image (Fig. 2). The intersections of the shadow and the
fascia were defined as standard points A (superficial fascia) and C
(deep fascia). Next, the contact point closest to the fascial beam for
A/C was defined as point B/D.
The obtained images were analyzed using an image analysis
system (ImageJ, US NIH, Bethesda, MD, USA), considering the
following measures: the distance between A and B (pre) and A and
B' (post) in the superficial layer, and between C and D (pre) and C
and D' (post) in the deep layer (Fig. 2). The differences between
these distances (post distance - pre distance) in the superficial and
deep layers were considered the fascial motion. All points were
marked and saved in a still image. The knee joint was then moved
passively from 0 to 45 , and the same procedure was performed
(Kay and Blazevich, 2009; Kubo et al., 2001). The evaluator and the
analyzer were blinded to the MFR treatment condition.
2.3.2. Myofascial release session
The myofascial release session was performed using a PEM
(AMCove, Mascarry technology, USA). The PEM is a massage tool
that allows regulation of the number of applications per second
E. de Souza Bezerra, M. Lunardi, R.L. Sakugawa et al.
Fig. 1. Experimental procedure.
Fig. 2. Analysis of fascial motion in a real ultrasound image.
Note: A and B - superficial fascia distance before the intervention; A and B0 - superficial fascia distance after the intervention; C and D - deep fascia distance before the intervention;
C and D0 - deep fascia distance after the intervention.
(frequency) of the head of the device, enabling greater depth of
coverage in the muscle tissue. The MFR session was performed in
the supine position, on the vastus lateralis muscle, using two fre-
quencies (25 Hz and 52 Hz). The order of the MFR was carried out in
a randomized way, with a frequency of 25 Hz applied to one leg and
52 Hz to the other. After randomization, the session was started
with the application of the MFR with the PEM at three sites (one
proximal and two distal), adopting 50% of the distance between the
trochanter and lateral epicondyle of the femur as the reference.
MFR application lasted 9 min alternately (1 min at each site) in the
proximal-distal direction (Fig. 1).
The same investigator was who set the equipment to the correct
frequency, applied the PEM to all individuals, and controlled the
time of application of the MFR using a stopwatch. The investigator
had previous experience with the equipment. During the applica-
tion the evaluator and the analyzer did not remain in the same
room; as well as, the researcher who applied the PEM was blinded
to the evaluation and data analysis.
2.3.3. Statistical analysis
All values are reported as mean, standard deviation, and 95%
confidence interval. The normality and homoscedasticity of the
results in all measures were tested using the Shapiro-Wilk and
Mauchly criteria, respectively. The main effects of treatment within
and between groups were assessed using a mixed model (time [pre
vs. post] x 2 groups [25 Hz vs. 52 Hz]). When a significant level of F
was identified, a Bonferroni post hoc test was performed to find
differences in means between pairs. The pre-intervention measures
between groups were verified with a student-t test for independent
samples. An alpha level of p  0.05 was used to determine statis-
tical significance. All statistical procedures were completed using
JASP 0.11.1 for Windows (University of Amsterdam, Amsterdam,
Netherlands). The effect size was classified according to Cohen
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Journal of Bodywork & Movement Therapies 28 (2021) 225e230
(1988): with 0.1, 0.20e0.40, 0.50e0.70, and 0.80 considered
trivial, small, moderate, and large, respectively.
3. Results
A time effect was observed for all layers at both frequencies
during the experimental protocols, independent of the knee posi-
tion. The superficial fascia length of the vastus lateralis showed a
significant increase after MFR with the knee extended (p < 0.001)
and flexed at 45 (p < 0.001). Similar results were observed for the
deep fascia with the knee extended (p < 0.001) and flexed at 45
(p < 0.001) (Fig. 3). However, superficial and deep fascia lengths did
not show an interaction (time x treatment) for knee position
[extended (p ¼ 0.80 and p ¼ 0.40, respectively) or flexed at 45
(p ¼ 0.24 and p ¼ 0.30, respectively)]. In addition, there was no
significant effect between treatment (25 Hz vs. 52 Hz) and knee
position (0 and 45 ), p > 0.05.
Table 1 presents the Cohen's d effect between pre- and post-for
both treatments (25 Hz and 52 Hz). Thigh fat thickness was similar
between groups (p ¼ 0.89).
The fascial motion was not influenced by frequency (25 Hz or
52 Hz) applied during the experimental protocol, independent of
layer (superficial and deep), and knee position (0 and 45 ), Fig. 4A.
However, the deep layer showed an increase when the knee was
flexed at 45 compared to the superficial layer. However, no dif-
ference was observed between layers when the knee was extended
(0 ), Fig. 4B.
4. Discussion
This study aimed to analyze the acute effects of an MFR session
with a PEM at different frequencies (25 Hz and 52 Hz) on the su-
perficial and deep fascial motion. The main results showed an
E. de Souza Bezerra, M. Lunardi, R.L. Sakugawa et al. Journal of Bodywork & Movement Therapies 28 (2021) 225e230

Fig. 3. Measurement of the superficial and deep fascial motion pre- and post-intervention using 25 Hz (white bar) and 52 Hz (gray bar). Individual results are represented for each
frequency. P-value indicates the difference in the timeline (pre vs. post). Mean and confidence interval of 95%.

Table 1 increase in both superficial and deep layers, independent of fre-

Effect size (Cohen's d) between pre and post-intervention for all treatments. quency and knee position. Our first hypothesis that the higher
Layer Frequency (Hz) frequency (52 Hz) would cause a change in the fascial motion due
to the greater range of frequency coverage, which would not occur
Knee Position Superficial 4 25 52
0 0.7 (moderate) 0.7 (moderate)
for the lowest frequency (25 Hz), was rejected. Therefore, our re-
45 0.9 (large) 0.6 (moderate) sults confirm the benefits of using a PEM (independent of fre-
Deep quency) as a new strategy to be applied during MFR.
0 0.6 (moderate) 0.8 (large) To date, studies on MFR have presented more outcomes based
45 0.8 (large) 1.1 (large)
on performance effects such as vertical jump (Smith et al., 2018;

Fig. 4. Fascial motion (measure post e measure pre) of both superficial and deep layers during two different knee positions: A) comparison between frequencies, 25 Hz (white bar)
and 52 Hz (gray bar); B) comparison between layers independent of frequency. P-value indicates the difference between conditions and Cohen's (d) magnitude of the effect. Mean
and standard deviation.

228
E. de Souza Bezerra, M. Lunardi, R.L. Sakugawa et al.
Stroiney et al., 2020), balance (Park and Hwang, 2016), and static
stretching of hamstrings (Joshi et al., 2018; Smith et al., 2018), while
few studies have focused on changes in the mechanism of the fascia
structure (Ichikawa et al., 2015; Yoshimura et al., 2019). Our study is
the first to investigate the effects of PEM on fascia length. Although
these results are preliminary, they allow us to understand the time
effect of the PEM on the muscle fascia, independently of the fascia
layer (superficial and deep) and frequency of the device (25 Hz or
52 Hz). It is worth mentioning that moderate and large effect sizes
were observed during these conditions, independently of the
length of the fascia (knee extended and flexed at 45 ). Similar
outcomes were found by Ichikawa et al. (2015) after a manual
technique with a cross-handed hold for 4 min. Although our
technique was applied twice as long (9 min), it does not depend on
the experience of the therapist, which is necessary for the tech-
nique applied in the abovementioned study. Furthermore, alter-
ations in superficial and deep aponeurosis occurred after self-
myofascial release (GRID Foam Roller) for 3 min (distal rolling
plus proximal) (Yoshimura et al., 2019).
Conversely, some differences can be observed between our MFR
experimental protocol and previous studies. While Ichikawa et al.
(2015) used 4 min of manual technique, without skin or fre-
quency pressure control, we used a PEM for 9 min (alternating
1 min on each 5 cm to give a total of 15 cm application area) with
two different frequencies (25 Hz and 52 Hz, meaning 1500 and
3120 vibrations per minute, respectively). Our lowest frequency
(25 Hz) was higher than the frequency used by Yoshimura et al.
(2019) who applied a self-myofascial release with 25 cycles per
minute for 3 min (total of 75 cycles). According to the authors, the
low pressure and frequency were the reasons for the lack of
changes (post vs. pre) in fascial length during self-myofascial
release (Yoshimura et al., 2019).
On the other hand, we observed positive changes in both su-
perficial and deep fascia layers. In our particular case, the frequency
was a positive point. According to Ichikawa et al. (2015), progres-
sive pressure and stretching are advantages provided by MFR
release due to the densification of collagen and elastic fibers in both
application conditions (manual or mechanic).
A brief explanation for MFR with devices similar to the one used
in our study (PEM) or the manual technique applied on the fascia
could be related to the shear force mechanism applied to the deep
fascia, which might explain the alterations observed (Holey and
Dixon, 2014). This mechanism possibly reorganizes collagen fibers
(Turrina et al., 2013), which are regularly placed under physiolog-
ical strain, causing matrix remodeling activity in the fibroblasts
(main components of collagen fibers) (Schleip and Müller, 2013).
This appears to influence not only the motion of the deep fascia but
also the gliding of the above layers during myofascial release
(Ichikawa et al., 2015).
Regarding fascial motion of the vastus lateralis, our finding is
similar to that of Ichikawa et al. (2015). While those authors
observed alteration in both superficial and deep layers, we only
found changes in the deep layer compared to the superficial layer
when the knee was flexed (45 ). It appears that changes in the deep
fascia might be observed more at greater muscle lengths (knee
flexed at 45 ) than at shorter muscle lengths (knee extended).
Although the PEM did not demonstrate a similar release to the
manual technique, it is worth mentioning that the manual tech-
nique requires an experienced therapist (Ichikawa et al., 2015),
while PEM does not. Nonetheless, both conditions appear to
stimulate Ruffini organs, which tend to lower sympathetic activity,
leading to a more parasympathetic state, modifying muscle tone
and tissue viscosity, and reducing intra-fascial smooth muscle cells
(Schleip, 2003). Notwithstanding, further evaluations of cellular
mechanisms to clarify the load and frequency effects of increasing
229
Journal of Bodywork & Movement Therapies 28 (2021) 225e230
fascia length are necessary.
This study has several limitations that influence the interpre-
tation of the results. First, the myofascial release is usually applied
along the whole muscle length. Although we opted for a small
application area, changes in fascial motion were observed. Second,
as this is a pilot study, the sample size was small. However, our
results provide the opportunity to calculate sample sizes in future
studies (see details about partial eta squared in supplementary
material). Although we employed an independent and experienced
ultrasound evaluator (blind) to control bias, the intraclass correla-
tion coefficient was performed only for intra-day reliability; the
experiment in this study was conducted on the same day, but we
suggest future studies consider inter-day reliability across 2 days.
The findings of this study indicate that the PEM is effective for
changing superficial and deep fascia motion of the vastus lateralis
muscle. On the other hand, although the PEM is well-known on the
market, its application in sports and health settings remains un-
clear. Our findings were promising; the intervention presented an
immediate effect on the fascial motion of the vastus lateralis in
recreationally active people, and thus, PEM might be easily used as
a myofascial release technique. Future research on the immediate
and long-term effects is needed to better define PEM application in
sports performance (i.e., repeated sprints, jumps, etc.) and health
conditions (i.e., acute pain, micro-injuries).
5. Clinical relevance
 The PEM effectively changes superficial and deep fascia, sug-
gesting an important method to realize the MFR.
 The PEM can be used to the immediate effect in MFR in rec-
reationally active people; however, we do not know the long-
term effects.
CRediT authorship contribution statement
Ewertton de Souza Bezerra: Conceptualization, Data curation,
Formal analysis, Investigation, Methodology, Project administra-
tion, Supervision, Visualization, Writing e original draft, Roles,
Writing e original draft, Writing e review & editing. Morgana
Lunardi: Conceptualization, Data curation, Formal analysis, Inves-
tigation, Methodology, Visualization, Writing e original draft,
Roles, Writing e original draft, Writing e review & editing. Raphael
Luiz Sakugawa: Data curation, Formal analysis, Investigation,
Methodology, Visualization, Writing e original draft, Roles, Writing
e original draft, Writing e review & editing. Fernando Die-
fenthaeler: Conceptualization, Methodology, Project administra-
tion, Supervision, Visualization, Roles, Writing e original draft,
Writing e review & editing, Writing e original draft.
Declaration of competing interest
The authors Ewertton de Souza Bezerra, Morgana Lunardi,
Raphael L. Sakugawa and Fernando Diefenthaeler of the research
article entitled “Acute effects of myofascial release with portable
electric massager at different frequencies: a randomized pilot
study” declare no conflicts of interest.
Acknowledgement
The authors thank Coordenaça ~o de Aperfeiçoamento de Pessoal
de Nível SuperiordBrasil (CAPES)dFinance Code 001 for ML and
RLS and National Council of Scientific Research (CNPq) Brazil for the
provision of scholarship for FD.
E. de Souza Bezerra, M. Lunardi, R.L. Sakugawa et al. Journal of Bodywork & Movement Therapies 28 (2021) 225e230

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