Journal of Bodywork & Movement Therapies (2016) 20, 98e103

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journal homepage: www.elsevier.com/jbmt

PILOT STUDY

A pilot study of balance performance benefit

of myofascial release, with a tennis ball, in
chronic stroke patients
Du-Jin Park, PT, Ph.D. a, Young-In Hwang, PT, Ph.D. b,*
a
Department of Physical Therapy, College of Health Medicine, Kaya University, 208 Samgye-ro,
Gimhae, Kyongnam 609-757, Republic of Korea
b
Dong-A University Medical Center, 26, Daesingongwon-ro, Seo-gu, Busan 602-715, Republic of Korea

Received 23 March 2015; received in revised form 9 May 2015; accepted 18 June 2015

KEYWORDS
Hemiplegia;
Balance training;
Soft tissue;
Myofascial release

Abstract Background: We hypothesised that the balance of spastic chronic stroke patients is
related to myofascial problems. We performed myofascial release (MFR) with a tennis ball on
the affected limb, as suggested by Myers.
Purpose: This study investigated the benefits of 8 weeks of MFR using a tennis ball on the balance of spastic patients.
Methods: Eight stroke patients were enrolled voluntarily after providing informed consent. All
subjects received 8-week interventions with MFR using a tennis ball three times per week. The
patients were evaluated using the Berg Balance Scale (BBS) and Timed Up & Go (TUG) test
before and after 4 and 8 weeks of the intervention.
Results: There were significant differences in the BBS scores (p Z 0.001). The TUG time
decreased significantly at 4 and 8 weeks (p Z 0.034).
Conclusion: Myofascial release appears to improve the balance of spastic chronic stroke patients; however, further studies should evaluate the effective of MFR on walking in stroke patients and determine the mechanism of the effect of MFR.
2015 Elsevier Ltd. All rights reserved.

Introduction

* Corresponding author. Tel.: 82 51 240 5650; fax: 82 51 240

5656.
E-mail addresses: [email protected] (D.-J. Park), eva1223@
naver.com (Y.-I. Hwang).
http://dx.doi.org/10.1016/j.jbmt.2015.06.009
1360-8592/ 2015 Elsevier Ltd. All rights reserved.

Fascia is connective tissue found throughout the body, in all

muscles, bones, vessels, and organs. It provides support,
stability, and cushioning (Schleip et al., 2012; Langevin and
Huijing, 2009). Fascia is integral to the continuity of the
body and is essential in human posture and movement

A pilot study of balance performance benefit, of myofascial release, in stroke patients

(Schleip, 2003). In addition, the fascia distributes forces so
that they are absorbed over a larger area, rather than
having the force focused at one point (Findley and
DeFilippis, 2005).
Tightness of the fascia is related to physiological and
biomechanical guarding mechanism to protect from
trauma. However, the fascia can lose pliability, restricting
movement and placing tension on body parts (Barnes,
1997). Trauma to the fascia can lead to the production of
reorganised fascia that is thicker, shorter, and oriented
differently from the fascia before injury (Myers, 2001;
Schleip, 2003; Stecco, 2004; Hammer, 2007; Chaitow,
2008; Masi and Hannon, 2008).
Repeated inflammation can alter the alignment of connective tissues depending on the direction of forces, and
compromise human kinetics (Goodman et al., 2003; Findley
and DeFilippis, 2005). In addition, poor posture, injury, and
stress can cause malalignment of the body, resulting in
thicker fascia as compensation (Findley and DeFilippis,
2005).
Rolf (1977) reported that the characteristics of fascia
were similar to those of collagen fibres, which are formed
in the ground substance, a shapeless, semifluid, and the
collagen fibres slowly alter the arrangement of the chemical substances within them. The recent definition of fascia
suggested by the Third International Fascia Research
Congress is as follows. .fibrous collagenous tissues which
are part of a body wide tensional force transmission system. The latest definition of fascia also includes the
following ones: dense planar multidirectional connective
tissue, loose planar connective tissue, other loose (e.g.
fatty layers within subcutaneous tissue) connective tissue,
joint capsules, organ capsules, muscular septi, retinaculi,
tendons, ligaments, epimysium, perimysium, endomysium,
epineurium, dura mater, periosteum, mediastinum, mesentery, annulus fibrosus in spinal discs (Schleip et al.,
2012). These fascial tissues appear to be an interconnected tensional network which is adapted to fibre
arrangement and density and determined by local tensional
demands (Pilat, 2012; Schleip et al., 2012).
The water in a cell is differs from that in a glass. There is
unexpected large exclusion zone (EZ) inside the water in a
cell which is called EZ which is physically different from
bulk water, the characteristics of which are more restrictive and viscous than bulk water: (Pollack, 2010; Pollack
et al., 2011). Extracellular Matrix (ECM) is believed to
contain a form of EZ, which contributes to the structural
and biomechanical support of the cells (Gurvan et al.,
2010).
Reddy et al. (1979) suggested that pressure could create
flow in the extracellular matrix and interstitial fluids.
Several authors insisted that the therapeutic mechanism of
the pressure could be related to viscous flow and a piezoelectric phenomenon which would allow the elongation of
the viscoelastic fascia when the gentle pressure with light
weight is applied (Pilat, 2003; Castro-Sa
nchez et al.,
2011a,b).
Sherman et al. (2006) defined MFR therapy as a clinical
massage technique that concentrates the manipulations on
muscles or fasciae. MFR is based on the principle that
trauma, inflammation, infection, and structural imbalance
cause fascial strain (Barnes, 2004). Fascial strain from

99

continuous traction or tension leads to fascial entrapment

of neural structures, which might induce dysfunction and
symptoms (Bruno and Emiliano, 2014; Myers, 2001). MFR has
been used to treat patients with myofascial pain syndrome
involving the lower back, shoulder, and other body areas.
Few studies have examined MFR in chronic stroke patients. Continuous traction or tension in the fascia can
occur in stroke patients with spasticity, hypertonicity, or
muscle stiffness. Several authors insisted that spastic hypertonia causes mechanical stiffness of the muscles (Dietz,
1992; Brown, 1994; Ada et al., 1998). This stiffness might
cause permanent structural changes due to the mechanical
effects on muscles and connective tissues (Katz and Rymer,
1989; Carey and Burghardt, 1993). In addition, some authors hypothesised that fascia such as the perimysium
might move actively, but the thickness of the perimysium
might be increased by muscle immobilisation, especially in
tonic muscles, resulting in increased passive muscle stiffness (Schleip et al., 2006). Furthermore, myofascial force
transmission demonstrates that around 40% of tensional
forces are transmitted via adjacent fascial structures
opposed to via the muscular tendon (Huijing et al., 2007).
Most of the studies of MFR have examined myofascial
pain syndrome, and none has examined MFR in stroke patients. Whisler et al. (2012) report on MFR in six children
with cerebral palsy. Therefore, this study investigated the
effects of myofascial release in the lower extremity performed with a tennis ball on the balance of chronic stroke
patients.

Subjects and methods

Ten individuals with hemiplegia were recruited from S
rehabilitation centre in Busan, Korea. The subjects complained of stiffness in the affected lower limb while
walking. We initially recruited seven males and three females, but two of the males dropped out, leaving six with
right hemiplegia and two with left hemiplegia. The demographic characteristics of the patients are summarised in
Table 1.
Inclusion criteria were (a) a diagnosis of hemiplegia due
to haemorrhagic or ischaemic stroke, (b) more than 6
months post stroke, (c) the ability to follow simple instructions, (d) a modified Ashworth score for the affected
lower extremity greater than 1, (e) the ability to walk
independently or with assistive devices, and (f) no orthopaedic problems involving the lower extremities that would
affect gait. The exclusion criteria were (a) a stroke
involving more than one hemisphere, (b) a flaccid lower
extremity, and (c) premorbid problems that would impede
patterns.
Informed consent was acquired from the subjects before
conducting the study according to the requirements of the
Declaration of Helsinki. Ethics approval for the study was
granted by Kaya University in South Korea.

Intervention
A tennis ball was used to obtain myofascial release (MFR) in
the sole (plantar fasciae), triceps surae, hamstring, and
sacrotuberous ligament, all parts of the superficial back

100
Table 1

D.-J. Park, Y.-I. Hwang

The characteristics of the hemiplegic subjects.

Subjects

Sex

Age (yr)

Since onset (months)

Etiology

Affected side

Height (cm)

Weight (kg)

Assistive device

1
2
3
4
5
6
7
8

M
M
M
M
M
F
F
F

61
50
80
68
51
56
77
64

48
61
67
63
27
55
60
54

ICH
CVA
INF
INF
ICH
ICH
ICH
ICH

R
R
L
R
R
L
R
R

169.3
163.2
156.6
160.5
163.2
156.5
150.0
147.4

65.1
52.8
68.8
42.0
72.6
62.9
46.8
51.2

Single-cane
NA
Single-cane
Single-cane
Single-cane
Single-cane
Quad-cane
Quad-cane

ICH: intracranial haemorrhage, INF: cerebral infarction.

line (SBL; Myers, 2014, pp. 75e96) as a modified exercise in

chronic stroke patients. This was performed on the
affected side in all participants three times a week for 8
weeks (total 24 times).
The eight physical therapists who performed the MFR
with a tennis ball were trained in the procedure thoroughly.
To perform MFR, the therapist:
a) held the affected ankle of the individual and rolled a
tennis ball under the sole from the toes back to the front
edge of the heel for 10 min (Fig. 1); and
b) rolled the tennis ball back and forth transversely under
the calf and thigh of each participant for 20 min (Fig. 2)
The pressure placed on the rolling tennis ball was the
amount that the patients could tolerate. If this was too
painful, pressure was reduced to tolerable levels.

Measurements
The eight participants were evaluated using the Berg Balance Scale (BBS) and Timed Up & Go (TUG) test before
and after 4 and 8 weeks of intervention. The therapist who
performed the assessments had 10 years of experience and
worked with an assistant who helped the participants
perform the tests safely. There was a 5-min rest between
the tests.
Berg Balance Scale
The BBS is a functional balance measurement that consists
of 14 items (Berg et al., 1995). Each item is rated on a 5point ordinal scale ranging from 0 to 4, with 0 indicating
the inability to complete the task entirely and 4 indicating
the ability to complete the task criterion (Berg et al.,

Figure 1

1995). Scores can range from 0 to 56. The higher the

score, the better the postural control. The internal consistency of the BBS in each stroke patient averaged 0.9726
(range 0.92e0.98) (Berg et al., 1995). The inter-rater reliability was 0.95 (95% confidence interval [CI], 0.93e0.97)
and the testeretest reliability was 0.98 (Berg et al., 1995).
Timed Up & Go test
The TUG is the time in seconds that it takes for the subject
to stand up from a chair, walks straight for 3 m, turn
around, return to the chair, and sit down. The subject was
seated comfortably and did not lean on the back support
when standing up. The time was measured from when the
patients buttocks first left the chair to when they touched
it again. When turning, the subjects used their unaffected
side. A TUG time < 10 s means functional independence,
while a time > 30 s means functional dependence. The
inter-rater reliability of the TUG is high in chronic stroke
patients (Ng and Hui-Chan, 2005; Flansbjer et al., 2005).

Statistical analysis
The differences in the mean values for the functional balance at 0, 4, and 8 weeks were compared using the Friedman test. The data were processed using SPSS ver. 17.0 for
Windows (SPSS, Chicago, IL). The level of statistical significance was set at 0.05.

Results
The BBS scores differed significantly (p Z 0.001) after 4 and
8 weeks. After 4 weeks, the scores for each BBS item
increased, except for items 11 and 14. At 8 weeks, the

MFR with a tennis ball on sole and calf (affected side).

A pilot study of balance performance benefit, of myofascial release, in stroke patients

Figure 2

101

MFR with a tennis ball on post. thigh and sacroiliac ligament (affected side).

scores for each item were increased compared with week 4,

except items 11 and 12. The TUG time decreased significantly after 4 and 8 weeks (p Z 0.034) (Table 2, Fig. 3).

Discussion
This study found significant improvements in the balance of
spastic stroke patients treated with MFR for 8 weeks based
on the BBS and TUG test. After the 8-week intervention,
there was a significant decrease in the TUG time. A negative significant relationship has already been found between TUG and BBS (Manaf et al., 2014).
Many therapists perform a tool assisted therapy as an
MFR approach. A tennis ball was used as a tool to perform
the study as a simple approach. For the performance of the
MFR by using tennis balls to be made adaptable in the
study, pressure was applied only within the subjects pain
tolerance levels. Myers (2014, 3rd edition, pp. 78e79) also
suggested that rolling a tennis ball on the plantar fasciae as
a self exercise.
Recent studies have demonstrated that spastic stroke
patients have normal reflex stiffness of the ankle extensors,
but the muscles themselves are stiff intramuscularly, which
altered the intra- and extra-muscular supporting structures
(Sinkjaer et al., 1993; Sinkjaer and Magnussen, 1994). In
addition, Fride
and Lieber (2003) suggested that spastic
muscle cells are shorter and stiffer than normal cells.
We postulate that a myofascial release around the posterior sacrotuberous ligament and in the lower extremity on
the affected side might increase pelvic and sacral flexibility, which would significantly improve the BBS and TUG
scores related to balance and walking velocity. Furthermore, the stiffness of the lower extremity and pelvis connected to the SBL would be released, improving the
flexibility and stability of the affected side. Myers (2014,
3rd edition, pp. 78e79) also suggests that the SBL exists
bilaterally, not unilaterally. However, Stecco (2004) insisted that the plantar fascia is completely connected to the

Table 2 The results after interventions of myofascial

release with a tennis ball in chronic stroke patients (N Z 8).
0-week test 4-week test 8-week test F a
29.75 
15.00
TUG
61.52 
(sec) 41.43

BBS

34.75 
15.73
51.30 
34.28

37.50 
16.96
53.30 
35.48

2 0.001**
2 0.034*

Figure 3 Each average score of BBS items in chronic stroke

patients (0-, 4-, 8-week).

lower and upper limb fascia, through the pelvic floor and to
the contralateral low back fascia in the 3-dementional
plane sequences. In addition, Myers (2001) and Stecco
(2004) asserted that myofascial connections (myofascial
trains or sequences) could be directly effective in the
organisation of movement and muscular force transmission.
Therefore, we postulate that the released stiffness on the
affected side would influence the SBL and improve balance
and walking velocity.
On the BBS scale, item 7 and 13 differed largely at 8
weeks (Fig. 3). Item 7 is standing unsupported with the feet
together and item 13 is standing unsupported with one foot
in front. Both items demonstrated improved balance on
reducing the base of support on the feet. The therapists used
the MFR to release the plantar fasciae and intrinsic muscles
of the affected foot via the sensory inputs of pressure and
compression through the rolling motion of the tennis ball.
Another study examined self-MFR using a tennis ball and
found significant differences in muscle length between the
control and intervention groups (Grieve et al., 2014).
This study was limited by the small sample size. Nevertheless, it used a non-parametric test to minimise errors
and obtained clinically significant results. Another limitation was that several therapists participated in the intervention. The therapists were trained in MFR using a tennis
ball and well-acquainted with matters that require attention. Despite the number of therapists, significant differences were obtained, implying that the training was
effective.

102
Even self-MFR is effective in stiff individuals (Grieve
et al., 2014). Another limitation is that there was no control group, so a future study of MFR with a tennis ball should
include a comparison between control and intervention
groups. We should also examine the relationship between
spasticity and MFR with a tennis ball in stroke patients.

Conclusion
This pilot study investigated the effects of MFR with a
tennis ball for 8 weeks on the balance of patients with
chronic spasticity. The results suggest that it improved
balance. However, further studies must examine the
effectiveness of MFR in stroke patients, such as walking
patterns. We also need to elucidate the mechanisms of MFR
in stroke patients.

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Further reading
Barnes, J., 1990. Myofascial Release: the Search for Excellence,
tenth ed. Rehabilitation Services Inc, Paoli, PA.
Oschman, J.L., 1997. Connective Tissue Energetics. Introduction to
a presentation for the Stichting Opleiding Manuele Therapie.
Amersfoort, The Netherlands.