Guillermo Chussir | Sun May 27, 2012
“I am still trying to figure out what he meant.” hahaha
Nice article. Never liked the idea of foam rolling anyways, especially as a warm up.
Does Foam Rolling Work?
May 27 2012
Foam rolling is a form of self massage which involves rolling your body parts on a cylindrical piece of foam.
Claims: It is claimed that foam rolling will help improve range of motion, decrease soreness, and relieve pain. As expected, lot of athletes use it though there is not any evidence to back it up. Some do it before the workout and some do it post workout.
Recently a study was published which looked at foam rolling and its benefits. Let’s take a closer look:
What was the foam rolling study design?
- Subjects: Eleven healthy male who had moderate resistance training experience (moderate to very active).
- Design: It was a within subject design. That is, one leg served as the control and the other leg as the experimental group.
- Protocol: The protocol involved rolling their quads for 2 minutes with a 30 sec break. So the subjects rolled out their quads 3-4 times during each minute
- Outcome measures: The outcome measured were flexibility or ROM of the quads and force changes.
- Results: The study showed a 10 degree increase in ROM after foam rolling compared to the control leg. Yahoo! Also, there was no increase or decrease in the force measurements after foam rolling.
My Comments
Just reading the conclusion of the study will make you believe that foam rolling helps and you should start foam rolling. But that is clearly not how an evidence-based approach works. Before you read this, I would take a look at Greg Lehman’s critique of the study in his blog (Body Mechanic). He wrote a lot of great comments which I have listed below too. I have added a few more below.
Randomization: This was a within-subject design. That is, one leg acted as the experimental group and the other leg was the control. But they just simply used the right leg for the foam rolling and left leg as control. The leg that received the treatment should be randomized. And this is not a minor criticism. Randomization is overlooked by many people, but is one of the most critical components of an RCT. Hence the name ‘Randomized’ controlled trial.
Control Group: There are two problems with the control group:
- Not blinded: Ideally, the control group should have received a similar treatment or sham treatment which feels or looks like foam rolling, but doesn’t have any of the benefits of foam rolling. It is just like giving a sugar pill to the control group in a drug trial. The reason we do this is people would see an increase in performance just by believing that they are doing something that is beneficial. This not sometimes practical, especially when the subject has their same leg as control. That been said, the validity of such studies are always low.
- Passive control: The control group did nothing here. It is now known that drug-industry funded trials show large treatment benefits compared to non-profit funded studies. And one major explanation for this is using a poor control group. The industry funded trials purposely pick a placebo or a sugar pill as the control when they could have used an effective drug or use a low dose of the control drug just to make their drug look great. It is like comparing P90X program to a control group who just sat on their butt and then saying P90X works great in increasing muscle!
Flexibility Measurement: The knee ROM was measured with a goniometer.
- Reliability: Reliability simply means consistency. It is critical that the test we use to measure our results give us the same readings when the test is repeated. Validity means whether the test is measuring what it is supposed to measure, in this case the knee ROM
- Normally, the Ely’s test is used for measuring the knee ROM. But the authors had to use a modified version since the subjects were more flexible than normal. In a recent study, the Ely’s test was shown to be lacking reliability. In fact, the study used experienced clinicians and still the flexibility measurements ranged as much as 20 degrees (the difference in this study was 10 degrees). And this was for an accepted standard test. Now imagine the reliability & validity of a modified test which the authors came up with without any pilot study data?
- Unblinded outcome assessors: In any study, it is quite easy for the study staff to consciously (or unconsciously) read or manipulate the numbers a bit high or low when they know the treatment group. So it is very important to use people to measure outcomes who are unaware (or blinded) of who belongs to which group.Here they were not blinded.
- In a recent meta -analysis, it was shown that that studies that used unblinded outcome assesors showed larger strength gains compared to studies which used blinded outcome assessors. Now it is not very hard to imagine how crucial blinding becomes when the measurements are highly subjective as in this study. Here the assessors ‘pulled’ the leg till the subjects had to say otherwise.
- Surrogate measures: I have wrote about this in the past. The study uses surrogate outcomes like static flexibility and ROM which means nothing to an athlete. I would be more interested if they tested the vertical jump or the squat or other outcomes which are meaningful to an athlete or a weight trainer. Increase in static flexibility has not shown to improve performance nor prevent injuries.
Acute Design: The study design is acute. We don’t know if these flexibility or strength measurement will stay the same if the study was carried out for 6-8 weeks.
What about the application of foam rolling?
- Looking at the above factors, the applicability of the study is pretty minimal. I wouldn’t start anyone on foam rolling based on this study. One positive aspect is the study showed no force decrements with foam rolling. This is a major concern with foam rolling when it is theorized to work by activating an inhibitory response in the muscle. These inhibitor responses are not what we want before training for a race or lifting.
- For people who have the time and who love foam rolling, you can keep doing it. Instead of bashing research, just say “we don’t have any studies to show it doesn’t work and my clients are getting results. This is my anecdotal evidence and I maybe wrong”.
- But for people who don’t have the time, nor care about how they feel, a dynamic warm up (which is more active, gets the blood moving, and more functional) is the better option. Foam rolling ,on the other hand, cannot serve as a warm up and it is completely non-functional.
What about coaches and athletes getting results with foam rolling?
Results: I have repeated this again and again: The term ‘results’ is just too vague to make any meaningful conclusions. Results may be (and this is a big maybe) true, but the question is can it be attributed to that one variable out of hundreds of variables. It is funny when coaches claim foam rolling is good because they are getting results and hundreds of athletes are using it. Now here we go about results:
- Blood letting: Blood letting (letting blood by cutting your vein) was the major medical treatment for almost 2500 years. It was considered as a major treatment when it was killing more people than it cured. And you know why? It was because the doctors were getting ‘results’! If we couldn’t see people dying in thousands, tell me how we are going to see a 10 degree difference or performance improvements in the range of milliseconds?
- Smoking: Smoking is now universally considered to be hazardous for your health. But this realization only came after much careful research in the 1940’s and 50’s. People were dying or the ‘results’ were for us to see, but we had no clue until the research showed it. And why is this? This is because of the random variability. Some heavy smokers died young, while some lived to their 80’s and 90’s. The same variability exists with any intervention whether it is weight training, smoking, or foam rolling. The only way to minimize the variability and get the true picture is through systematic observation and not by more anecdotal ‘results’.
And as a side not, here is what Mike Boyle - a leading strength coach - has to say in his blog about why he uses foam rolling in reply to Greg’s post (and why others should use it). I am still trying to figure out what he meant.
So, back to why we foam roll. In the simplest sense, rolling is step one on the preparatory process. Our goal pre-exercise is to prepare the tissue for the stresses about to be applied. Proper tissue preparation allows an athlete to perform a workout without injury. I think or hope that we can accept the position that tissue changes in response to stress.If the tissue is stressed optimally, the resulting adaptation is positive. If the tissue is overstressed by inappropriate volume (too many reps) , speed of lengthening (too fast) , or inappropriate overload (to much weight) the tissue response can shift from positive to negative. Although tissue soreness is deemed normal, we must acknowledge that there is an ideal amount of that normal response, and the response should be limited to the muscle tissue and not be present in the connective tissue. In other words, sore quads would be OK, but sore knees not be OK.
NOTE: The article is about the analysis of the foam rolling study which looked at foam rolling as a warm up. I haven’t talked about the use of foam rolling for pain or relieving soreness.
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I use foam rolling everyday. I use it to get rid of soreness or to warm up.I think it works because i get results. I also use it to “crack” my back. if i dont use i, i am stiffer and the soreness from workouts lingers. I do think it gets blood flowing to the area that is rolled.
Anoop | Mon May 28, 2012
Thanks Guillermo! Some of Boyle’s comments in reply to Greg’s article were just laughable. Static stretching was oneday considered as a warm up for athletes you know. It wasn’t that coaches saw athletes slowing down or losing strength and stopped static stretching. It was because research showed static stretching to have negative effects on strength.
We have a complete lack of experts who can read research or interpret research in our field.
Thanks Gordon. As I said, if you feel it helps or you love it, keep doing it. You cannot say it was the foam rolling or the placebo effect. When you advise other people to do it based on your personal experience, that’s when it becomes a problem,especially when they pay you.
And mind you, have you ever noticed why all the girls in the gym do a million crunches and leg adductor machine? Because they think it works and they get ‘results’.
Jared Crain | Fri June 01, 2012
I do think it is silly to use foam rolling as a warm-up. I foam roll a bit on my legs, IT band, etc, and it is very much like deep tissue massage. Roll slowly to the points of tightness and pain, then wait there for a moment and the muscle releases. In the past, foam rolling played an important role in healing my hip bursitis (I tried many modalities for extended periods of time and it wasn’t until I began foam rolling everyday that the bursitis let up).
So, in conclusion, my anecdotal evidence is that it works well as a technique for self-massage, but I can’t imagine why you would want to warm-up for exercise with a massage.
Anoop | Sat June 02, 2012
Hi Jared,
Thanks for the comment.
My post is specifically about the study as a warm up and not really as treatment for pain.
And I don’t mind people doing as a warm up as long is there is some evidence to show some performance improvements besides the “I feel better” and “I got better”. There are lot of things in the world that makes me feel better.
Pain is really funny. There are lot of treatments out there that will help with pain. And foam rolling ‘may’ help in that regards.
Anoop | Sun June 03, 2012
Thought I will post it here: This is just a recent study. http://well.blogs.nytimes.com/2012/04/27/for-back-pain-steroid-shots-no-more-effective-than-placebo/
The title is : For Back Pain, Steroid Shots No More Effective Than Placebo.
Just shows the power of placebo. If everybody keeps saying foam rolling works for pain, it will work!
Hey anoop, great critique of this study. When i first read this study i told a PhD friend of mine (sports phys.) about it and he said quite unimpressed “so what?”. I love foam rolling for as mike boyle says “improving tissue quality” (whatever that means), but always considered it a pain in the butt as a warmup.
An aside question, what resources (articles etc) do you recommend one can read for improving ability to properly asses and critique research studies, I read quite a lot of studies but realise I need to improve in this area.
thank you, keep up the great work.
Anoop | Mon June 11, 2012
Hi Oliver,
Thanks!
I think you would love this article: http://www.exercisebiology.com/index.php/site/articles/why_we_need_an_evidence-based_approach_in_the_fitness_field/
I have been doing the same thing for the last 10 years. To be honest, there is not much out there. I read a lot of papers. If you can wait for 1 month, I will be coming up with a screen cast about the how and why. I am working on it.
And thank you for being evidence based. The how part is easy once you understand why it is important. So you have much less work.
No, thank YOU anoop for the clear and commonsense evidence based articles…
Your evidence based approach article was the first of yours I read, i think it was Bret Contreras who mentioned it in an article of his.
Can’t wait for the screen cast!
Hey Anoop, so if foam rolling is not proven..what is your opinion on massage?
Anoop | Wed June 13, 2012
Hi Oliver,
Thanks. In medicine, people are more worried about the how. In our field, we are still fighting about the why we need evidence based approach. That is just unfortunate. i had a lot more examples. I would add those in the screencast.
Hi Gordon,
As I wrote,I am talking about it as a pre-exercise warm up. It may work for pain or for relieving soreness. So it may work for one thing and may not work for other. And as I wrote, if you have the time, and if you like it, go ahead and use it.
I am yet to see any evidence that it shows any performance improvement or improve recovery. There was a recent study on massage which showed it increase certain molecular markers. It was ripped apart my David Gorski of Science based medicine.
And you have to understand Gordon, anecdotal evidence are most often wrong than right. but those are the ones which makes the greatest impact on us. So it is hard to ignore them.
maria | Wed October 03, 2012
hi
I like your article…
Thanks for sharing it.
I read this article because of a recent experience. Yeah yeah, anecdotal.
We have a massage chair here in the house. The other week I was very sore from training. I used it four time one day, and then I think twice a day or two later. The thing is surprisingly powerful. My back muscles were sore from using it. I had two weeks break from training but continued to feel drained. SO I decided to get a proper massage. I didn’t know until the lady started; but every muscle in my body felt as if it was a reservoir of stiffness and pain.
Looking back, I think the chair massage device was the same thing as foam rolling. After having the sensation of feeling my muscles under this ladies hands I personally do not believe that foal rolling does a single thing.
I still feel foam rolling is beneficial. I use it pre and post workout and I use a extremely dense/hard roller to begin and then use one of the new knobby ones. Yes a masseuse would be great if I could afford one. I feel less sore and stiff and the knobby one is great on my IT band and hamstrings. This is one study and I don’t really know if it was done properly. I will tell you that when my calves are tight and sore these tools loosen them up and I feel it e dry time. It is also all part of my routine before going to work and if I don’t do it then I am sore and tight
Great article on how to decide on whether research is valid or not. I have a doctorate in Physical Therapy and would love valid research that would make this possible. However, foam rolling is exactly what you say, a placebo that people use to get “less stiff”. It’s a great marketing campaign made by many therapists to push on their patients.
The one thing I always talk to my patients about is the avoidance of stretching unless needed. Even as a warm up and cool down! The research is completely changing in the last 5 years and shows stretching actually makes instabilities seen in the hip and low back. A simple 5-10 minute walk for a warm up and cool down is enough to “relax” those muscles and prevent injuries.
Anoop | Thu May 09, 2013
Thanks Aaron for the comment.
Foam rolling may work, but atleast from this study, you can never justify foam rolling. A large reason why things work for relieving pain and ‘feeling better’ is the placebo effect. But it is all happening in our unconscious brain that we cannot see it nor believe it.
Good stuff, Anoop. I USED to do foam rolling as part of a warm up because it was in the NASM manual. Not any more. I sometimes have my clients use foam rolling after training if they feel like they need it to alleviate mental/physical tension—almost like deep tissue work.
I understand that there is something about the tissue compression that make the body feel “looser” or lighter. What do you think? Something to do with the sense of touch—like massage therapy—that makes the body feel good?
MetroEast Beast | Thu June 06, 2013
I just started foam rolling from a recommendation from my pt. Only have been doing it a short time, but do feel that it is helping with soreness. I run a lot and even though I don’t feel any shin pain I can tell there is some soreness when using the roller. Very easy only do it a few minutes in t he evening before my stretching routine. Very good article Anoop!
Hello,
As a new reader, I am finding Anoop’s articles to be of great value.
Agreeing or not, is seldom on my high priority list. I mean, even if I’d be inclined to disbelieve, my mind has been opened to other possibilities.
Reading time: grab it when the luxury presents itself.
Opening of the mind: Priceless!
Yo… thank you!
Rather than explaining results touted as effective by anecdotal experience but not explained by a given study as merely placebo as the “go to” explanation, it may be better to say “there is, at this time no/week evidence to support the claims…”. Supplements and even training protocols seem to need the old A,B,C,D ratings like drugs (A=proven helpful….to D= contraindicated for any use)
As far as foam rolling…as a Warm up I must admit I was taken aback the first time I saw it used/recomeded as such. This is because of what I know of the “pre-game stretch” performance degradation with static stretching vs dynamic movement and neuro-muscular activation techniques. (Always exceptions such as pre-stretching hip flexors/psoas to increase sprint time (faster leg turn over due to reduced counter resistance to hip flexion [don’t ask me to site…read that long time ago LOL!] For foam roller use before exersize….…not so much, unless to relieve spasm (longer dynamic W/U still likely better).
For treatment of such things as IT Band syndrome, and to relieve spasm/tightness-Absolutely effective. Pre-TX=palpable spasm, post = soft Non-tender/less painful. Any good studies w/blinded subjects/observers w/ sham TX’s and large enough N….? not now or likely any day soon unfortuantly.
Still not a lot of good studies to support(conflicting results dependent on study design) trigger point massage/injection etc. However, If like me, with chronic intermittent spasms in tares M. and upper back …that will wake me from dead sleep….then use of “thera-cane” to massage spasm till it palpably releases ..then can return to sleep…..there is “some” positive physical response…be it release of local mediators/endorphins, or local over stimulation etc…..the foam roller seems to work similarly (used on non-spastic muscle=not uncomfortable…on inflamed IT band =excruciating pain with use… but by next day significant improvement- for example)
I WISH there was some good evidence to recommend use…. I can only say…”seems to help” (and does for everyone I’ve ever given a tennis ball to roll out their back or foam roller for quads (cyclist)/IT Bands(runner/triathletes) etc. I just can’t say why or that its ”proven”….yet (and placebo, though “effective” and ‘may’ play a role isn’t 100% either.)
Kyle Norman | Wed April 02, 2014
I recall a Dan John article where he briefly discussed foam rolling. He didn’t really think it was all that vital for tissues. If someone liked the way it felt then great. What he liked was that he was getting someone on the ground moving around in a (probably for most adults) novel way. Sort of crawling around and moving/holding your body while foam rolling requires very different work from sitting or standing. There’s no research behind this either but I thought it was an interesting take on where the real benefit to foam rolling might be.
Thanks for the article!
By your logic nobody should do anything unless it’s 100% proven to work. Thats redicuolous. Creatine was out for 10 years before science proved it worked. Testerone was out for 30 years. Sometimes you just have to go by what people are telling you.
Anoop | Sat November 15, 2014
hi Jason,
Good question. You can do whatever you want. It’s your life, your time, your performance.
But when someone is paying you for your service, when you are speaking to a bunch of people as an expert, you need more than “it worked for a few people I knew” as evidence. Blodletting worked for a few people too.
Also I guess you didn’t read the conclusion. I am just pasting it here. Here it is, “For people who have the time and who love foam rolling, you can keep doing it. Instead of bashing research, just say “we don’t have any studies to show it doesn’t work and my clients are getting results. This is my anecdotal evidence and I maybe wrong”.”
triago | Thu February 19, 2015
I cringed when i read the foam rolling study design. No blind? Left leg used as control? That study is literally worthless. Especially when it comes to ROM. I can try to bend over and touch my toes. About four inches shy before it really starts hurting my hams. Then i try a second time, and i’m only two inches shy with less pain. Its nearly impossible to gauge ROM from a study as shabby as that one. But hey, people will buy the foam rollers. And they’re not cheap. It’s just foam, people!
