MANUSCRIPT TYPE CLINICAL OUTCOMES RESEARCH 24 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 3 – Issue 3 – November 2020 Myofascial Compression Interventions: Comparison of Roller Massage, Instrument Assisted Soft-Tissue Mobilization, and Floss Band on Passive Knee Motion Among Inexperienced Individuals Scott W. Cheatham, PhD, DPT, PT, OCS, AT, CSCS*; Rodrigo E. Martinez, DAT, LAT, ATC†; Alicia Montalvo, PhD, LAT, ATC, CSCS†; Michelle Odai, PhD, LAT, ATC†; Stephanie Echeverry, MS, ATC†; Brianna Robinson, MS†; Elizabeth Bailum, BS†; Kevin Viecco, MS†; Kasey Keller, BS, ATC†; Sofia Nunez-Riveria, MS, ATC†; Adriana Pena, MS, ATC† *California Staet University Dominguez Hills, Carson, CA; †Florida International University, Miami, FL ABSTRACT Myofascial compression interventions have become popular in rehabilitation and fitness. To date, no studies have directly compared foam rolling, instrument assisted soft-tissue mobilization, and floss band among unexperienced individuals. The primary purpose of this investigation was to compare the immediate post intervention effects of foam rolling, instrument assisted soft-tissue mobilization, and floss band on passive knee joint range of motion (ROM) among inexperienced individuals using a standard treatment time. The secondary purpose was to determine the interchangeability of the interventions and to provide preliminary research for long-term comparison studies. This pretest-posttest randomized controlled trial was conducted in a university laboratory. Thirty participants (M=15, W=15) were randomly assigned to three groups: (1) foam rolling, (2) instrument assisted soft-tissue mobilization, and (3) floss band. The intervention time for each group was 2-minutes. The outcome was passive knee joint ROM. Between group analysis revealed a statistically significant post-intervention difference between the three interventions for passive knee flexion ROM (p <.001). Within group comparison for ROM revealed a 2 degree (p<.001) post-intervention increase for foam rolling, a 3.5-degree (p<.001) increase for the instrument assisted soft-tissue mobilization, and a 4-degree (p<.001) increase for the floss band. The three interventions produced similar immediate post intervention effects on passive knee joint ROM among inexperienced individuals. Clinically, these interventions may be interchangeable by producing similar effects on knee ROM. Clinicians may want to consider these finding prior to administering these interventions with their patients. Key Phrases Massage, muscle soreness, pain, release Correspondence Dr. Scott Cheatham, California State University Dominguez Hills, 1000 E. Victoria Street, Carson, CA 90747 E-mail: Scheatham@csudh.edu Full Citation Cheatham SW, Martinez RE, Montalvo A, Odai M, Echeverry S, Robinson B, Bailum E, Viecco K, Keller K, Nunez-Riveria S, Pena, A. Myofascial compression interventions: comparison of roller massage, instrument assisted soft-tissue mobilization, and floss band on passive knee motion among inexperienced individuals. Clin Pract Athl Train. 2020;3(3):24-36. https://doi.org/10.31622/2020/0003.3.5. Submitted: February 13, 2020 Accepted: August 3, 2020 INTRODUCTION Myofascial compression is a popular intervention used by allied health professionals.1 There are several types of myofascial compression interventions such as foam rolling (FR), instrument assisted soft-tissue massage (IASTM), and floss band (FB). These interventions can be found in various clinical and fitness settings. The research on these types of interventions has increased over the past decade. The research on FR has documented positive outcomes with reduced post exercise decrements in muscle performance,2-6 increased post treatment pressure pain thresholds (PPT),4,7-9 and decreased post exercise muscle soreness in healthy individuals.2,3,10-12 Several recent studies have also documented positive post intervention effects of FR for different sports,11,13-15 occupations,16 and chronic pain conditions.17 The IASTM research suggests that the intervention is an effective treatment for tendoinopathies,18,19 arthrofibrosis,20,21 cerebral palsy,22,23 musculoskeletal pathologies,18,24-26 post mailto:Scheatham@csudh.edu https://doi.org/10.31622/2020/0003.3.5 Myofascial Compression Interventions: Comparison of Roller Massage, Instrument Assisted Soft-Tissue Mobilization, and Floss Band on Passive Knee Motion Among Inexperienced Individuals 25 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 3 – Issue 3 – November 2020 mastectomy,27 post total joint arthroplasty,28,29 and athletic performance measures.18,24-26 The FB research is still emerging and the available studies have documented post intervention improvements in jump and sprint performance,30,31 reduced effects of edema in post-surgical patients,32 and improved pain and function in individuals suffering from Achilles tendinopathy.33 One of the most common outcome measures professionals use for all three interventions is joint range of motion (ROM).34 Researchers have found that FR may improve joint ROM at the shoulder,35,36 lumbopelvis,37,38 hip joint,39-45 knee joint, 9,45-47 and ankle.48,49 IASTM has also been shown to improve joint ROM at the shoulder,27,28,50,51,52 hip and knee joint,51,53,54,55 ankle,56 and spine.57 The FB research has documented improved post intervention ankle joint ROM in healthy individuals.30,31 To date, no studies have directly compared the effects of all three interventions on joint ROM among individuals with no prior experience. Only one study has compared the effects of FR and IASTM on passive hip and knee joint ROM in collegiate soccer players.51 The study author did not document if the athletes had prior experience with myofascial compression interventions. The primary purpose of this investigation was to directly compare the immediate post intervention effects of foam rolling, instrument assisted soft-tissue mobilization, and floss band on passive knee joint ROM among inexperienced individuals using a standard treatment time. The secondary purpose was to determine the interchangeability of the interventions and to provide preliminary research for long-term comparison studies. The researchers hypothesize that all three interventions will produce similar post treatment effects on passive knee joint ROM after a standard treatment time. METHODS Participants Thirty healthy, active adults (M=15, W=15) were recruited via convenience sampling and enrolled in the study. Participants were randomly assigned into one of three groups: foam roller (FR) (N=10), instrument assisted soft-tissue mobilization (IASTM) (N=10), and flossing bands (FB) (N=10) (Figure 1). A random number generator was used to allocate participants to each group. Participants reported no prior experience using any of the myofascial interventions in this study. Participant exclusion criteria included the following: musculoskeletal, systemic, neurosensory, or metabolic conditions that would affect joint ROM of the lower extremity or the inability to avoid medications that may affect testing.18,58,59 Participant demographic information is described in Table 2. This pre-test, post-test clinical study was approved by the Institutional Review Board at Florida International University. Outcome Measure and Instrument The outcome measure used for this investigation was passive knee joint ROM. The Clinometer Smartphone Application™ (Plaincode, Stephanskirchen Deutschland) was used to measure each participant. The Clinometer app has been shown to be valid and reliable for measuring lower extremity ROM.60-64 For testing, the participant was placed in the prone lying position on a table. The investigator grasped the left ankle and passively moved the left knee. The knee was flexed to the point where the joint could no longer be passively moved without providing overpressure or to the point of initial discomfort. This position was held and a measurement was taken. The investigator monitored for any compensatory movement throughout the lumbopelvis and lower extremities. The investigator took the average of 3 measurements for each participant. Left passive knee joint ROM measurements have been used in prior myofascial compression studies.65-67 Myofascial Compression Interventions: Comparison of Roller Massage, Instrument Assisted Soft-Tissue Mobilization, and Floss Band on Passive Knee Motion Among Inexperienced Individuals 26 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 3 – Issue 3 – November 2020 Interventions The FR group used a commercial foam roll and related instructional video were used in this investigation (TriggerPoint, a division of Implus, LLC, 2001 TW Alexander Drive Durham, NC 27709, USA). The video demonstrated the use of the foam roll on the left quadriceps muscle group. The GRID® surface foam roll used in this investigation was commercially manufactured with a hard-hollow core (14 cm diameter) with a moderately firm outer ethylene-vinyl acetate (EVA) foam (Figure 2). Participants were issued the foam roll and followed the video with no feedback from the observing investigator. The Figure 1: Data Collection Diagram Excluded (n= 0) Analysed (n= 10) Excluded from analysis (n= 0) Lost to follow-up (n= 0) Discontinued intervention (n= 0) Allocated to Foam Roll Group (n= 10) • Received allocated intervention (n= 10) Lost to follow-up (n= 0) Discontinued intervention (n= 0) Allocated to Flossing Band Group (n= 10) • Received allocated intervention (n= 10) Analysed (n= 10) Excluded from analysis (n= 0) Allocation Analysis Follow-Up Assigned (n= 30) Enrollment Allocated to IASTM Group (n= 10) • Received allocated intervention (n= 10) Lost to follow-up (n= 0) Discontinued intervention (n= 0) Analysed (n= 10) Excluded from analysis (n= 0) Assessed for eligibility (n= 30) Myofascial Compression Interventions: Comparison of Roller Massage, Instrument Assisted Soft-Tissue Mobilization, and Floss Band on Passive Knee Motion Among Inexperienced Individuals 27 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 3 – Issue 3 – November 2020 instructor in the video provided a brief introduction and then discussed the foam rolling technique. The instructor divided the left quadriceps into zone one: top of patella to middle of the quadriceps and zone two: middle quadriceps to anterior inferior iliac spine. The model in the video was instructed to get in the plank position, position the roller above the left patella and roll back and forth in zone one 4x at a cadence of 1inch per second. The model was then instructed to stop at the top of zone one followed by 4 active knee bends to 90 degrees. This sequence was repeated for zone two. The intervention portion lasted a total of 2 minutes. This video has been used in prior foam roll research.68 For the IASTM group, the investigator administered an instrument intervention using the Smart Tools® crossbar tool (423 grams) (Smart Tools, 20636 Castlemaine Circle, OH 4419, USA) (Figure 2) to the left quadriceps muscle. The investigator was a trained researcher certified in several IASTM paradigms. Participants lied supine on a table with hip and knee straight. A water- based gel was used to decrease friction between the skin and instrument. The investigator delivered a superior and inferior longitudinal stroke with the crossbar perpendicular to the soft tissues while maintaining a 45° instrument edge angle. The investigator first began by placing the edge of the instrument just above the patella. The investigator then delivered a superior stroke up towards the anterior inferior iliac spine (AIIS). Just before reaching the AIIS, the investigator reversed the cross bar and delivered an inferior stroke back to the starting position while maintaining the edge angle. The investigator used a 2 second cadence to complete the sequence using only the weight of the tool. The total intervention lasted 2 minutes. For the FB group, a 5.08 cm (2-inch) Rockfloss® floss band (RockTape®, a division of Implus, LLC, 2001 TW Alexander Drive Durham, NC 27709, USA) was used along with a related instructional video. The video demonstrated the use of the floss band to the left quadriceps muscle. Participants were issued the floss band and followed the video with no feedback from the observing investigator. The video narrator provided a brief introduction and then demonstrated the technique using a model. The model wrapped the floss band around the left quadriceps muscle (distal to proximal) using a 50% overlapping pattern with an elongation stretch of 50% band length (Figure 2).69 The wrap covered the quadriceps muscles above the patella to below AIIS. The model then demonstrated an active movement sequence consisting of standing hip flexion (30 seconds), seated knee extension and flexion (30 seconds), and bodyweight squats (1minute). The intervention portion lasted a total of 2 minutes. Participants followed the video and wrapped their own leg. Figure 2: Different myofascial compression devices: Grid foam roller, IASTM tool, and floss band Myofascial Compression Interventions: Comparison of Roller Massage, Instrument Assisted Soft-Tissue Mobilization, and Floss Band on Passive Knee Motion Among Inexperienced Individuals 28 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 3 – Issue 3 – November 2020 Pilot Study Pilot training was conducted over two-sessions to practice the testing procedures and establish intrarater and interrater reliability among three investigators for passive knee joint ROM. Fifteen participants were independently recruited and enrolled for this portion of the investigation. The Intraclass Correlation Coefficient was used to calculate intrarater (ICC model 3, k) and interrater reliability (ICC model 2, k).63,70 The results revealed good intrarater (ICC= 0.99; 95% CI 0.88-1.0) and interrater (ICC= 0.94; 95% CI 0.67-0.99) reliability among all investigators. These coefficients are in accordance with the minimum threshold of ≥ .90 for ICC values postulated to be acceptable for clinical decision making.71 Procedures Prior to testing, eligible participants reviewed and completed study related materials including the written IRB consent form and demographic questionnaire. All participants underwent one session of testing that included pre intervention measures, followed by the intervention, and then immediate post intervention measures. All participants were tested between the hours of 10 A.M. and 2 P.M. and were instructed to not participate in any strenuous activity 5 hours prior to testing. Participants were also instructed to refrain from taking any medications (e.g. opioids, muscle relaxants) that would interfere with testing. All participants were blinded to the testing results and other individuals in the study. For each group, one investigator was assigned to take three pre intervention and three immediate post intervention measures and was blinded from the intervention. A second investigator was present to explain the intervention procedures (FR and FB) to each participant and answer any questions. For the IASTM group, the second investigator administered the intervention. These testing methods have been used in prior myofascial research.72 Statistical Analysis The statistical analysis was performed by the program SPSS version 25.0 (IBM SPSS, Armonk, NY, USA). The descriptive statistics for participants were calculated for age, height, body mass, and body mass index (BMI). The ANOVA statistic was used for continuous descriptive data and the Kruskal Wallis statistic for ordinal descriptive data. The ANCOVA statistic was used to measure between group differences. The independent variable was the group, dependent variable was post test scores, and pretest scores was the covariate.73 Post hoc within group differences were measured with the paired t-test. The average of three joint ROM measurements was used for all pre-test and post-test calculations. The effect size was also measured (d = M1 - M2 / σpooled). The effect size values were interpreted as: >0.70 was considered strong, 0.41 to 0.70 was moderate, and < 0.40 was weak.74 All statistical assumptions were met for the ANOVA, ANCOVA and paired t-test statistics. Statistical significance was considered p< .05 using a two-tailed test. RESULTS Thirty participants were enrolled and completed the study (mean age= 25.43 ± 2.46 years; height= 170.00 ± 9.17 cm; body mass= 73.82 ± 9.65 kg; body mass index (BMI)= 26.65 ± 3.83 kg/m2) (Table 1). Descriptive analysis revealed no statistically significant difference between groups for age (p=0.10), height (p=0.70), body mass (p=0.55), or BMI (p=0.14). All enrolled participants completed the study with no adverse events or attrition. The between group analysis for passive knee joint ROM revealed a statistically significant post intervention difference between the three groups [F (1,39) =612.32, p=<0.001, partial η2=0.944]. The post hoc within group analysis Myofascial Compression Interventions: Comparison of Roller Massage, Instrument Assisted Soft-Tissue Mobilization, and Floss Band on Passive Knee Motion Among Inexperienced Individuals 29 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 3 – Issue 3 – November 2020 revealed an approximate post intervention knee flexion increase of 2 degrees (p <.001, ES=.26) for FR, 3.5 degrees (p=.004, ES= .26) for IASTM, and 4 degree (p<.001, ES=.47) for FB (Table 2). DISCUSSION The primary purpose of this investigation was to directly compare the immediate post intervention effects of FR, IASTM, and FB on passive knee joint ROM among inexperienced individuals. To date, no studies have compared these interventions among this population. The results suggest that these interventions produced a statistical significant post intervention effect. However, there was less than a 2◦ post treatment difference between interventions which may not be clinically meaningful in some settings. It is important to note that the passive joint ROM in this study was taken with a digital device which may be more accurate than standard goniometry.60 These findings are similar to prior research documenting increased post intervention knee ROM values that ranged from 2-7◦ for the these interventions.45-47,51,55 The secondary purpose was to determine the interchangeability of the three interventions using a standard treatment time of 2-minutes which has been a common intervention time used in prior myofascial research.68,69 There was a ROM difference of 1-2◦ between all three interventions which suggests they may produce similar post treatment responses when using the same treatment time and body region (quadriceps muscle). These findings support their interchangeability. For example, a professional may administers a skilled 2-minute IASTM technique to the quadriceps then prescribe a 2- minute self FR or FB intervention as a home exercise to maintain the effects of the IASTM Table 1. Participant demographics (N=30) Characteristics Age (years) Height (cm) Mass (kg) BMI (kg/m2) Foam Roll Group (N=10) 26.13 ± 2.56 (range 23-30) 169.50 ± 8.72 (range 155-183) 72.73 ± 9.35 (range 59-89) 24.67 ± 2.84 (range 21-28) IASTM Group (N=10) 24.80 ± 2.04 (range 23-28) 168.15 ± 9.49 (range 150-180) 77.59 ± 9.49 (range 57-99) 27.34 ± 4.45 (range 21-36) Floss Band Group (N=10) 24.40 ± 2.13 (range 22-31) 172.39 ± 10.37 (range 158-188) 72.26 ± 10.57 (range 57-108) 27.90 ± 4.83 (range 21-38) Data reported as mean± SD; range (min-max); m=meters; BMI= body mass index; kg/m2= kilograms-meter squared Table 2. Pre and post-intervention results (N=30) Pretest Posttest Change P-Value Effect Size Foam Roll Group Knee Flexion ROM (degrees) 115.60 ± 8.66 117.93 ± 9.06 2.33 ± 0.40 <.001 .26 IASTM Group Knee Flexion ROM (degrees) 121.97 ± 13.81 125.48 ± 13.00 3.51 ± 0.81 .004 .26 Floss Band Group Knee Flexion ROM (degrees) 110.73 ± 8.48 114.73 ± 8.43 4.00 ± 0.03 <.001 .47 Data reported as mean ± SD, kPa= kilopascals; statistical significance considered p<.05; Effect size: d = M1 - M2 / σpooled Myofascial Compression Interventions: Comparison of Roller Massage, Instrument Assisted Soft-Tissue Mobilization, and Floss Band on Passive Knee Motion Among Inexperienced Individuals 30 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 3 – Issue 3 – November 2020 treatment. The results of this study are consistent with findings from the Markovic study which compared the efficacy of a 2-minute FR and IASTM intervention on soccer players.51 The authors documented improved post intervention passive knee and hip joint ROM from both interventions (p < 0.05). Thus, these myofascial compression interventions produced similar post treatment effects. There are two main scientific theories being postulated by researchers regarding the post treatment effects of these myofascial compression interventions. These interventions may provide a greater deformation of the local myofascial tissues which creates a mechanical and neurophysiological effect. For the mechanical effect, the pressure of the device or wrap may change the viscoelastic properties of the myofascia by mechanisms such as thixotropy (reduced viscosity), reducing myofascial restriction, fluid changes, and cellular responses.48,75 Clinically, these changes may be observed as a greater lengthening or “stretch tolerance” of the muscle and surrounding tissues as measured by changes in joint ROM. For the neurophysiological effect, the mechanical pressure from the device or wrap may have produced a local and global neurophysiological effect that influences tissue relaxation in the target and surrounding tissues through central nervous system afferent input from the Golgi tendon reflex and mechanoreceptors (e.g. Golgi tendon organ).7,48,75-78 Perhaps, the active joint movements in the FR and FB interventions enhance the effects of the devices as well as the assisted IASTM intervention. Prior research suggests that active myofascial interventions may enhance the neurophysiological effect producing greater benefits.68,79 Future studies are needed to validate these theories. Limitations There are four limitations with this study. First, this study tested healthy non-experienced participants with no pathology. This limits the generalizability to this population. Second, the three different myofascial compression interventions studied were from specific manufacturers. Other similar interventions from different manufacturers may have produced different results. Third, the immediate post intervention effects were investigated. The long-term effects of the intervention cannot be determined. Fourth, the interventions in this study used a specific technique (e.g. left quadriceps) for a predetermined 2 minute intervention time which has been used in prior myofascial research.68,69 Other treatment techniques and intervention times may have produced different results. CONCLUSION This was the first study to directly measure the immediate post treatment effects of three different myofascial compression interventions on passive knee joint ROM among individuals with no prior experience using a standard treatment time. The results suggest that all three interventions may produce similar immediate post treatment effects which supports their interchangeability. Future studies are needed to further validate these results over a long post intervention time period. The goal of this study was to be exploratory and establish the methodology for long-term investigations. Clinicians may want to consider these results when choosing and administering myofascial compression interventions with their patients. Acknowledgements: We would like to thank Implus, LLC for providing permission to use the TriggerPoint instructional video and associated foam roller and RockTape® floss band. We would also like to thank Jasmin Grimes, Kay Scales, Aline Valiengo, and Matthew Hershgordon for helping with this research project. Myofascial Compression Interventions: Comparison of Roller Massage, Instrument Assisted Soft-Tissue Mobilization, and Floss Band on Passive Knee Motion Among Inexperienced Individuals 31 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 3 – Issue 3 – November 2020 REFERENCES 1. Cheatham SW. Roller Massage: A descriptive survey of allied health professionals. J Sport Rehabil. 2019; 28(6):640-649. https://doi.org/10.1123/jsr.2017- 0366. 2. Cheatham SW, Kolber MJ, Cain M, Lee M. The effects of self-myofascial release using a foam roll or roller massager on joint range of motion, muscle recovery, and performance: a systematic review. Int J Sports Phys Ther. 2015; 10(6):827-838. 3. Schroeder AN, Best TM. Is self myofascial release an effective preexercise and recovery strategy? A literature review. Curr Sports Med Rep. 2015; 14(3):200- 208. https://doi.org/10.1249/jsr.00000000 00000148. 4. Macdonald GZ, Button DC, Drinkwater EJ, Behm DG. Foam rolling as a recovery tool after an intense bout of physical activity. Med Sci Sports Exerc. 2014; 46(1):131- 142. https://doi.org/10.1249/MSS.0b013e3 182a123db. 5. MacDonald GZ, Penney MD, Mullaley ME, et al. An acute bout of self- myofascial release increases range of motion without a subsequent decrease in muscle activation or force. J Strength Cond Res. 2013; 27(3):812-821. https://doi.org/10.1519/JSC.0b013e3 1825c2bc1. 6. Cavanaugh MT, Aboodarda SJ, Hodgson DD, Behm DG. Foam rolling of quadriceps decreases biceps femoris activation. J Strength Cond Res. 2017; 31(8):2238- 2245. https://doi.org/10.1519/jsc.00000000 00001625. 7. Aboodarda SJ, Spence AJ, Button DC. Pain pressure threshold of a muscle tender spot increases following local and non-local rolling massage. BMC Musculoskelet Disord. 2015; 16:265. https://doi.org/10.1186/s12891-015- 0729-5 8. Cheatham SW, Baker R. Differences in pressure pain threshold among men and women after foam rolling. J Bodyw Mov Ther. 2017; 21(4):978-982. https://doi.org/10.1016/j.jbmt.2017.0 6.006 9. Cheatham SW, Stull KR, Kolber MJ. Comparison of a vibrating foam roller and a non-vibrating foam roller intervention on knee range of motion and pressure pain threshold: a randomized controlled trial. J Sport Rehabil. 2017; 1- 23. https://doi.org/10.1123/jsr.2017- 0164. 10. Beardsley C, Skarabot J. Effects of self- myofascial release: a systematic review. J Bodyw Mov Ther. 2015; 19(4):747-758. https://doi.org/10.1016/j.jbmt.2015.0 8.007 11. Rey E, Padron-Cabo A, Costa PB, Barcala-Furelos R. The effects of foam rolling as a recovery tool in professional soccer players. J Strength Cond Res. 2017; 33(8): 2194-2201. https://doi.org/10.1519/jsc.00000000 00002277. 12. Romero-Moraleda B, La Touche R, Lerma- Lara S, et al. Neurodynamic mobilization and foam rolling improved delayed- onset muscle soreness in a healthy adult population: a randomized controlled clinical trial. PeerJ. 2017; 5:e3908. https://doi.org/10.7717/peerj.3908. 13. D'Amico A, Paolone V. The effect of foam rolling on recovery between two eight hundred metre runs. J Hum Kinet. 2017; 57:97-105. https://doi.org/10.1515/hukin-2017- 0051. 14. D'Amico AP, Gillis J. The influence of foam rolling on recovery from exercise-induced muscle damage. J Strength Cond Res. 2017. https://doi.org/10.1519/jsc.00000000 00002240. 15. Grgic J, Mikulic P. Tapering practices of croatian open-class powerlifting champions. J Strength Cond Res. 2017; 31(9):2371-2378. https://doi.org/10.1519/jsc.00000000 00001699. 16. Kalen A, Perez-Ferreiros A, Barcala- Furelos R, et al. How can lifeguards recover better? A cross-over study https://doi.org/10.1123/jsr.2017-0366 https://doi.org/10.1123/jsr.2017-0366 https://doi.org/10.1249/jsr.0000000000000148 https://doi.org/10.1249/jsr.0000000000000148 https://doi.org/10.1249/MSS.0b013e3182a123db https://doi.org/10.1249/MSS.0b013e3182a123db https://doi.org/10.1519/JSC.0b013e31825c2bc1 https://doi.org/10.1519/JSC.0b013e31825c2bc1 https://doi.org/10.1186/s12891-015-0729-5 https://doi.org/10.1186/s12891-015-0729-5 https://doi.org/10.1016/j.jbmt.2017.06.006 https://doi.org/10.1016/j.jbmt.2017.06.006 https://doi.org/10.1123/jsr.2017-0164 https://doi.org/10.1123/jsr.2017-0164 https://doi.org/10.1016/j.jbmt.2015.08.007 https://doi.org/10.1016/j.jbmt.2015.08.007 https://doi.org/10.1519/jsc.0000000000002277 https://doi.org/10.1519/jsc.0000000000002277 https://doi.org/10.7717/peerj.3908 https://doi.org/10.1515/hukin-2017-0051 https://doi.org/10.1515/hukin-2017-0051 https://doi.org/10.1519/jsc.0000000000002240 https://doi.org/10.1519/jsc.0000000000002240 https://doi.org/10.1519/jsc.0000000000001699 https://doi.org/10.1519/jsc.0000000000001699 Myofascial Compression Interventions: Comparison of Roller Massage, Instrument Assisted Soft-Tissue Mobilization, and Floss Band on Passive Knee Motion Among Inexperienced Individuals 32 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 3 – Issue 3 – November 2020 comparing resting, running, and foam rolling. Am J Emerg Med. 2017. https://doi.org/10.1016/j.ajem.2017.0 6.028. 17. Ceca D, Elvira L, Guzman JF, Pablos A. Benefits of a self-myofascial release program on health-related quality of life in people with fibromyalgia: a randomized controlled trial. J Sports Med Phys Fitness. 2017; 57(7-8):993-1002. https://doi.org/10.23736/S0022- 4707.17.07025-6. 18. Cheatham SW, Baker R, Kreiswirth E. Instrument assisted soft-tissue mobilization: a commentary on clinical practice guidelines for rehabilitation professionals. Int J Sports Phys Ther. 2019; 14(4):670-682. 19. Cheatham SW, Lee M, Cain M, Baker R. The efficacy of instrument assisted soft tissue mobilization: a systematic review. J Can Chiropr Assoc. 2016; 60(3):200- 211. 20. Black DW. Treatment of knee arthrofibrosis and quadriceps insufficiency after patellar tendon repair: a case report including use of the graston technique. Int J Ther Massage Bodywork. 2010; 3(2):14-21. https://doi.org/10.3822/ijtmb.v3i2.79 21. Henry P, Panwitz B, Wilson JK. Treatment of a bilateral total knee replacement using augmented soft tissue mobilization. Phys Ther Case Reports. 1999; 2(1):27-30 24p. 22. Scheer NA, Alstat LR, Van Zant RS. Astym therapy improves bilateral hamstring flexibility and achilles tendinopathy in a child with cerebral palsy: a retrospective case report. Clin Med Insights Case Rep. 2016; 9:95-98. https://doi.org/10.4137/CCRep.S4062 3. 23. Miller MM, Ray JM, Van Zant RS. The effects of astym therapy(r) on a child with spastic diplegic cerebral palsy. Clin Med Insights Case Rep. 2017; https://doi.org/10.1177/1179547617 746992. 24. Nazari G, Bobos P, MacDermid JC, Birmingham T. The effectiveness of instrument-assisted soft tissue mobilization in athletes, participants without extremity or spinal conditions, and individuals with upper extremity, lower extremity, and spinal conditions: a systematic review. Arch Phys Med Rehabil. 2019; 100(9):1726-1751. https://doi.org/10.1016/j.apmr.2019.0 1.017. 25. Ikeda N, Otsuka S, Kawanishi Y, Kawakami Y. Effects of instrument- assisted soft tissue mobilization on musculoskeletal properties. Med Sci Sports Exerc. 2019; 51(10):2166-2172. https://doi.org/10.1249/MSS.0000000 000002035. 26. Seffrin CB, Cattano NM, Reed MA, Gardiner-Shires AM. Instrument-assisted soft tissue mobilization: a systematic review and effect-size analysis. J Athl Train. 2019; 54(7):808-821. https://doi.org/10.4085/1062-6050- 481-17. 27. Davies CC, Brockopp D, Moe K. Astym therapy improves function and range of motion following mastectomy. Breast Cancer (Dove Med Press). 2016; 8:39-45. https://doi.org/10.2147/BCTT.S10259 8. 28. Chughtai M, Mont MA, Cherian C, et al. A Novel, Nonoperative treatment demonstrates success for stiff total knee arthroplasty after failure of conventional therapy. J Knee Surg. 2016; 29(3):188- 193. https://doi.org/10.1055/s-0035- 1569482. 29. Bhave A, Corcoran J, Cherian JJ, Mont MA. Astym® therapy for the management of recalcitrant knee joint stiffness after total knee arthroplasty. J Long Term Eff Med Implants. 2016; 26(2):151-159. https://doi.org/10.1615/JLongTermEff MedImplants.2016012530. 30. Driller M, Mackay K, Mills B, Tavares F. Tissue flossing on ankle range of motion, jump and sprint performance: A follow-up study. Phys Ther Sport. 2017; 28:29-33. https://doi.org/10.1016/j.ptsp.2017.0 8.081. 31. Driller MW, Overmayer RG. The effects of tissue flossing on ankle range of motion and jump performance. Phys Ther Sport. https://doi.org/10.1016/j.ajem.2017.06.028 https://doi.org/10.1016/j.ajem.2017.06.028 https://doi.org/10.23736/S0022-4707.17.07025-6 https://doi.org/10.23736/S0022-4707.17.07025-6 https://doi.org/10.3822/ijtmb.v3i2.79 https://doi.org/10.4137/CCRep.S40623 https://doi.org/10.4137/CCRep.S40623 https://doi.org/10.1177%2F1179547617746992 https://doi.org/10.1177%2F1179547617746992 https://doi.org/10.1016/j.apmr.2019.01.017 https://doi.org/10.1016/j.apmr.2019.01.017 https://doi.org/10.1249/MSS.0000000000002035 https://doi.org/10.1249/MSS.0000000000002035 https://doi.org/10.4085/1062-6050-481-17 https://doi.org/10.4085/1062-6050-481-17 https://doi.org/10.2147/BCTT.S102598 https://doi.org/10.2147/BCTT.S102598 https://doi.org/10.1055/s-0035-1569482 https://doi.org/10.1055/s-0035-1569482 https://doi.org/10.1615/JLongTermEffMedImplants.2016012530 https://doi.org/10.1615/JLongTermEffMedImplants.2016012530 https://doi.org/10.1016/j.ptsp.2017.08.081 https://doi.org/10.1016/j.ptsp.2017.08.081 Myofascial Compression Interventions: Comparison of Roller Massage, Instrument Assisted Soft-Tissue Mobilization, and Floss Band on Passive Knee Motion Among Inexperienced Individuals 33 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 3 – Issue 3 – November 2020 2017; 25:20-24. https://doi.org/10.1016/j.ptsp.2016.1 2.004. 32. Kage V, Patil Y. Effectiveness of vodoo floss band versus crepe bandage in subjects with post-operative lower limb pedal edema: a radomized clinical trial. Int J Current Adv Res. 2018; 7(6):13498- 13501. http://dx.doi.org/10.24327/ijcar.2018. 13501.2415. 33. Borda J, Selhorst M. The use of compression tack and flossing along with lacrosse ball massage to treat chronic Achilles tendinopathy in an adolescent athlete: a case report. J Man Manip Ther. 2017; 25(1):57-61. https://doi.org/10.1080/10669817.20 16.1159403. 34. Cheatham SW. Roller massage: a descriptive survey of allied health professionals. J Sport Rehabil. 2018:1-10. https://doi.org/10.1123/jsr.2017- 0366. 35. Le Gal J, Begon M, Gillet B, Rogowski I. Effects of self-myofascial release on shoulder function and perception in adolescent tennis players. J Sport Rehabil. 2017:1-19. https://doi.org/10.1123/jsr.2016- 0240. 36. Fairall RR, Cabell L, Boergers RJ, Battaglia F. Acute effects of self- myofascial release and stretching in overhead athletes with GIRD. J Bodyw Mov Ther. 2017; 21(3):648-652. https://doi.org/10.1016/j.jbmt.2017.0 4.001. 37. Grieve R, Goodwin F, Alfaki M, Bourton AJ, Jeffries C, Scott H. The immediate effect of bilateral self myofascial release on the plantar surface of the feet on hamstring and lumbar spine flexibility: A pilot randomised controlled trial. J Bodyw Mov Ther. 2015; 19(3):544-552. https://doi.org/10.1016/j.jbmt.2014.1 2.004. 38. Sullivan KM, Silvey DB, Button DC, Behm DG. Roller-massager application to the hamstrings increases sit-and-reach range of motion within five to ten seconds without performance impairments. Int J Sports Phys Ther. 2013; 8(3):228-236. 39. DeBruyne DM, Dewhurst MM, Fischer KM, Wojtanowski MS, Durall C. Self- mobilization using a foam roller versus a roller massager: which is more effective for increasing hamstrings flexibility? J Sport Rehabil. 2017; 26(1):94-100. https://doi.org/10.1123/jsr.2015- 0035. 40. Behara B, Jacobson BH. Acute effects of deep tissue foam rolling and dynamic stretching on muscular strength, power, and flexibility in division I linemen. J Strength Cond Res. 2017; 31(4):888-892. https://doi.org/10.1519/jsc.00000000 00001051. 41. Monteiro ER, Cavanaugh MT, Frost DM, Novaes JD. Is self-massage an effective joint range-of-motion strategy? A pilot study. J Bodyw Mov Ther. 2017; 21(1):223-226. https://doi.org/10.1016/j.jbmt.2016.1 0.003. 42. Bushell JE, Dawson SM, Webster MM. Clinical relevance of foam rolling on hip extension angle in a functional lunge position. J Strength Cond Res. 2015; 29(9):2397-2403. https://doi.org/10.1519/JSC.0000000 000000888. 43. Mohr AR, Long BC, Goad CL. Effect of foam rolling and static stretching on passive hip-flexion range of motion. J Sport Rehabil. 2014; 23(4):296-299. https://doi.org/10.1123/JSR.2013- 0025. 44. Vigotsky AD, Lehman GJ, Contreras B, Beardsley C, Chung B, Feser EH. Acute effects of anterior thigh foam rolling on hip angle, knee angle, and rectus femoris length in the modified thomas test. PeerJ. 2015; 3:e1281. https://doi.org/10.7717/peerj.1281. 45. Murray AM, Jones TW, Horobeanu C, Turner AP, Sproule J. Sixty seconds of foam rolling does not affect functional flexibility or change muscle temperature in adolescent athletes. Int J Sports Phys Ther. 2016; 11(5):765-776. 46. Su H, Chang NJ, Wu WL, Guo LY, Chu IH. Acute effects of foam rolling, static https://doi.org/10.1016/j.ptsp.2016.12.004 https://doi.org/10.1016/j.ptsp.2016.12.004 http://dx.doi.org/10.24327/ijcar.2018.13501.2415 http://dx.doi.org/10.24327/ijcar.2018.13501.2415 https://doi.org/10.1080/10669817.2016.1159403 https://doi.org/10.1080/10669817.2016.1159403 https://doi.org/10.1123/jsr.2017-0366 https://doi.org/10.1123/jsr.2017-0366 https://doi.org/10.1123/jsr.2016-0240 https://doi.org/10.1123/jsr.2016-0240 https://doi.org/10.1016/j.jbmt.2017.04.001 https://doi.org/10.1016/j.jbmt.2017.04.001 https://doi.org/10.1016/j.jbmt.2014.12.004 https://doi.org/10.1016/j.jbmt.2014.12.004 https://doi.org/10.1123/jsr.2015-0035 https://doi.org/10.1123/jsr.2015-0035 https://doi.org/10.1519/jsc.0000000000001051 https://doi.org/10.1519/jsc.0000000000001051 https://doi.org/10.1016/j.jbmt.2016.10.003 https://doi.org/10.1016/j.jbmt.2016.10.003 https://doi.org/10.1519/JSC.0000000000000888 https://doi.org/10.1519/JSC.0000000000000888 https://doi.org/10.1123/JSR.2013-0025 https://doi.org/10.1123/JSR.2013-0025 https://doi.org/10.7717/peerj.1281 Myofascial Compression Interventions: Comparison of Roller Massage, Instrument Assisted Soft-Tissue Mobilization, and Floss Band on Passive Knee Motion Among Inexperienced Individuals 34 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 3 – Issue 3 – November 2020 stretching, and dynamic stretching during warm-ups on muscular flexibility and strength in young adults. J Sport Rehabil. 2016:1-24. https://doi.org/10.1123/jsr.2016- 0102. 47. Couture G, Karlik D, Glass SC, Hatzel BM. The effect of foam rolling duration on hamstring range of motion. Open Orthop J. 2015; 9:450-455. https://doi.org/10.2174/1874325001 509010450. 48. Kelly S, Beardsley C. Specific and cross- over effects of foam rolling on ankle dorsiflexion range of motion. Int J Sports Phys Ther. 2016; 11(4):544-551. 49. Skarabot J, Beardsley C, Stirn I. Comparing the effects of self-myofascial release with static stretching on ankle range-of-motion in adolescent athletes. Int J Sports Phys Ther. 2015;10(2):203- 212. 50. Laudner K, Compton BD, McLoda TA, Walters CM. Acute effects of instrument assisted soft tissue mobilization for improving posterior shoulder range of motion in collegiate baseball players. Int J Sports Phys Ther. 2014; 9(1):1-7. 51. Markovic G. Acute effects of instrument assisted soft tissue mobilization vs. foam rolling on knee and hip range of motion in soccer players. J Bodyw Mov Ther. 2015; 19(4):690-696. https://doi.org/10.1016/j.jbmt.2015.0 4.010. 52. Coviello JP, Kakar RS, Reynolds TJ. Short- term effects of instrument-assisted soft tissue mobilization on pain free range of motion in a weightlifter with subacromial pain syndrome. Int J Sports Phys Ther. 2017; 12(1):144-154. 53. Baker RT, Hansberger BL, Warren L, Nasypany A. A novel approach for the reversal of chronic apparent hamstring tightness: a case report. Int J Sports Phys Ther. 2015; 10(5):723-733. 54. Gunn LJ, Stewart JC, Morgan B, et al. Instrument-assisted soft tissue mobilization and proprioceptive neuromuscular facilitation techniques improve hamstring flexibility better than static stretching alone: a randomized clinical trial. J Man Manip Ther. 2019; 27(1):15-23. https://doi.org/10.1080/10669817.20 18.1475693. 55. Kim DH, Lee JJ, Sung Hyun You J. Effects of instrument-assisted soft tissue mobilization technique on strength, knee joint passive stiffness, and pain threshold in hamstring shortness. J Back Musculoskelet Rehabil. 2018; 31(6):1169- 1176. https://doi.org/10.3233/BMR- 170854. 56. Rhyu HS, Han HG, Rhi SY. The effects of instrument-assisted soft tissue mobilization on active range of motion, functional fitness, flexibility, and isokinetic strength in high school basketball players. Technol Health Care. 2018; 26(5):833-842. https://doi.org/10.3233/THC-181384. 57. Lee JH, Lee DK, Oh JS. The effect of Graston technique on the pain and range of motion in patients with chronic low back pain. J Phys Ther Sci. 2016; 28(6):1852- 1855. https://doi.org/10.1589/jpts.28.1852. 58. Cheatham SW, Stull KR. Roller massage: a commentary on clinical standards and survey of physical therapy professionals- part 1. Int J Sports Phys Ther. 2018; 13(4):763-772. 59. Cheatham SW, Baker R. Technical Report: Quantification of the rockfloss® floss band stretch force at different elongation lengths. J Sport Rehabil. 2019:1-13. https://doi.org/10.1123/jsr.2019- 0034. 60. Mehta SP, Barker K, Bowman B, Galloway H, Oliashirazi N, Oliashirazi A. Reliability, concurrent validity, and minimal detectable change for iphone goniometer app in assessing knee range of motion. J Knee Surg. 2017; 30(6):577- 584. https://doi.org/10.1055/s-0036- 1593877. 61. Cox RW, Martinez RE, Baker RT, Warren L. Validity of a smartphone application for measuring ankle plantar flexion. J Sport Rehabil. 2018; 27(3). https://doi.org/10.1123/jsr.2017- 0143. 62. Milanese S, Gordon S, Buettner P, et al. Reliability and concurrent validity of knee angle measurement: smart phone app https://doi.org/10.1123/jsr.2016-0102 https://doi.org/10.1123/jsr.2016-0102 https://doi.org/10.2174/1874325001509010450 https://doi.org/10.2174/1874325001509010450 https://doi.org/10.1016/j.jbmt.2015.04.010 https://doi.org/10.1016/j.jbmt.2015.04.010 https://doi.org/10.1080/10669817.2018.1475693 https://doi.org/10.1080/10669817.2018.1475693 https://doi.org/10.3233/BMR-170854 https://doi.org/10.3233/BMR-170854 https://doi.org/10.3233/THC-181384 https://doi.org/10.1589/jpts.28.1852 https://doi.org/10.1123/jsr.2019-0034 https://doi.org/10.1123/jsr.2019-0034 https://doi.org/10.1055/s-0036-1593877 https://doi.org/10.1055/s-0036-1593877 https://doi.org/10.1123/jsr.2017-0143 https://doi.org/10.1123/jsr.2017-0143 Myofascial Compression Interventions: Comparison of Roller Massage, Instrument Assisted Soft-Tissue Mobilization, and Floss Band on Passive Knee Motion Among Inexperienced Individuals 35 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 3 – Issue 3 – November 2020 versus universal goniometer used by experienced and novice clinicians. Man Ther. 2014; 19(6):569-574. https://doi.org/10.1016/j.math.2014.0 5.009. 63. Pereira LC, Rwakabayiza S, Lecureux E, Jolles BM. Reliability of the knee smartphone-application goniometer in the acute orthopedic setting. J Knee Surg. 2017; 30(3):223-230. https://doi.org/10.1055/s-0036- 1584184. 64. Charlton PC, Mentiplay BF, Pua YH, Clark RA. Reliability and concurrent validity of a Smartphone, bubble inclinometer and motion analysis system for measurement of hip joint range of motion. J Sci Med Sport. 2015; 18(3):262-267. https://doi.org/10.1016/j.jsams.2014.0 4.008. 65. Lee SY, Sung KH, Chung CY, et al. Reliability and validity of the Duncan-Ely test for assessing rectus femoris spasticity in patients with cerebral palsy. Dev Med Child Neurol. 2015; 57(10):963-968. https://doi.org/10.1111/dmcn.12761. 66. Marks MC, Alexander J, Sutherland DH, Chambers HG. Clinical utility of the Duncan-Ely test for rectus femoris dysfunction during the swing phase of gait. Dev Med Child Neurol. 2003; 45(11):763-768. https://doi.org/10.1017/s0012162203 001415. 67. Peeler J, Anderson JE. Reliability of the Ely's test for assessing rectus femoris muscle flexibility and joint range of motion. J Orthop Res. 2008; 26(6):793- 799. https://doi.org/10.1002/jor.20556. 68. Cheatham SW, Stull KR. Comparison of a foam rolling session with active joint motion and without joint motion: A randomized controlled trial. J Bodyw Mov Ther. 2018; 22(3):707-712. https://doi.org/10.1016/j.jbmt.2018.0 1.011. 69. Kiefer BN, Lemarr KE, Enriquez CC, Tivener KA, Daniel T. A Pilot Study: Perceptual effects of the voodoo floss band on glenohumeral flexibility. Int J Athletic Ther Train. 2017; 22(4):29-33. https://doi.org/10.1123/ijatt.2016- 0093. 70. Koo TK, Li MY. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J Chiropr Med. 2016; 15(2):155-163. https://doi.org/10.1016/j.jcm.2016.02. 012. 71. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. F. A. Davis Company; 2015. 72. Cheatham SW, Kolber MJ, Cain M. Comparison of video-guided, live instructed, and self-guided foam roll interventions on knee joint range of motion and pressure pain threshold: a randomized controlled trial. Int J Sports Phys Ther. 2017; 12(2):242-249. 73. Dugard P, Todman J. Analysis of pre‐test‐ post‐test control group designs in educational research. Educational Psychology. 1995; 15(2):181-198. DOI: https://doi.org/10.1080/0144341950 150207. 74. Cohen J. A power primer. Psychol Bull. 1992; 112(1):155-159. https://doi.org/10.1037//0033- 2909.112.1.155. 75. Jay K, Sundstrup E, Sondergaard SD, et al. Specific and cross over effects of massage for muscle soreness: randomized controlled trial. Int J Sports Phys Ther. 2014; 9(1):82-91. 76. Cavanaugh MT, Doweling A, Young JD, et al. An acute session of roller massage prolongs voluntary torque development and diminishes evoked pain. Eur J Appl Physiol. 2017; 117(1):109-117. https://doi.org/10.1007/s00421-016- 3503-y. 77. Monteiro ER, Skarabot J, Vigotsky AD, Brown AF, Gomes TM, Novaes JD. Acute effects of different self-massage volumes on the fms overhead deep squat performance. Int J Sports Phys Ther. 2017; 12(1):94-104. 78. Nagi SS, Rubin TK, Chelvanayagam DK, Macefield VG, Mahns DA. Allodynia mediated by C-tactile afferents in human hairy skin. J Physiol. 2011; 589(Pt 16):4065-4075. https://doi.org/10.1016/j.math.2014.05.009 https://doi.org/10.1016/j.math.2014.05.009 https://doi.org/10.1055/s-0036-1584184 https://doi.org/10.1055/s-0036-1584184 https://doi.org/10.1016/j.jsams.2014.04.008 https://doi.org/10.1016/j.jsams.2014.04.008 https://doi.org/10.1111/dmcn.12761 https://doi.org/10.1017/s0012162203001415 https://doi.org/10.1017/s0012162203001415 https://doi.org/10.1002/jor.20556 https://doi.org/10.1016/j.jbmt.2018.01.011 https://doi.org/10.1016/j.jbmt.2018.01.011 https://doi.org/10.1123/ijatt.2016-0093 https://doi.org/10.1123/ijatt.2016-0093 https://doi.org/10.1016/j.jcm.2016.02.012 https://doi.org/10.1016/j.jcm.2016.02.012 https://doi.org/10.1080/0144341950150207 https://doi.org/10.1080/0144341950150207 https://doi.org/10.1037/0033-2909.112.1.155 https://doi.org/10.1037/0033-2909.112.1.155 https://doi.org/10.1007/s00421-016-3503-y https://doi.org/10.1007/s00421-016-3503-y Myofascial Compression Interventions: Comparison of Roller Massage, Instrument Assisted Soft-Tissue Mobilization, and Floss Band on Passive Knee Motion Among Inexperienced Individuals 36 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 3 – Issue 3 – November 2020 https://doi.org/10.1113/jphysiol.2011. 211326. 79. Cheatham SW, Stull KR, Batts WN, Ambler-Wright T. Roller Massage: Comparing the Immediate Post-Treatment Effects Between an Instructional Video and a Self-Preferred Program Using Two Different Density-Type Roller Balls. J Hum Kinet. 2020; 71:119-129. https://doi.org/10.2478/hukin-2019- 0077. https://doi.org/10.1113/jphysiol.2011.211326 https://doi.org/10.1113/jphysiol.2011.211326 https://doi.org/10.2478/hukin-2019-0077 https://doi.org/10.2478/hukin-2019-0077 Allocation Analysis Follow-Up Enrollment