Maintenance Notice

Due to necessary scheduled maintenance, the JMIR Publications website will be unavailable from Wednesday, July 01, 2020 at 8:00 PM to 10:00 PM EST. We apologize in advance for any inconvenience this may cause you.

Who will be affected?

Advertisement

Citing this Article

Right click to copy or hit: ctrl+c (cmd+c on mac)

Published on 31.07.20 in Vol 9, No 7 (2020): July

Preprints (earlier versions) of this paper are available at http://preprints.jmir.org/preprint/15612, first published Jul 29, 2019.

This paper is in the following e-collection/theme issue:

    Protocol

    Self-Myofascial Release Intervention and Mobile App in Patients With Hemophilic Ankle Arthropathy: Protocol for a Randomized Controlled Trial

    1Tú. Bienestar 360º, Physiotherapy and Medical Center, San Javier-Murcia, Spain

    2Department of Physiotherapy, European University of Madrid, Madrid, Spain

    3Fishemo CEE, Spanish Federation of Hemophilia (FEDHEMO), Madrid, Spain

    4Real Fundación Victoria Eugenia, Madrid, Spain

    5Department of Physiotherapy, Catholic University San Antonio-UCAM, Murcia, Spain

    6Optimus Osteopathy and Physiotherapy Clinic, Murcia, Spain

    7Department of Basic Phycology and Methodology, University of Murcia, Murcia, Spain

    InHeFis Research Group

    *these authors contributed equally

    Corresponding Author:

    Rubén Cuesta-Barriuso, PT, MSc, PhD

    Department of Physiotherapy

    European University of Madrid

    Tajo Street

    Villaviciosa de Odón

    Madrid, 28670

    Spain

    Phone: 34 912115369

    Email: ruben.cuestab@gmail.com


    ABSTRACT

    Background: Hemophilic ankle arthropathy is manifested by degenerative functional alterations and chronic pain. Myofascial release techniques are used to treat soft tissue adhesions, relieve pain, and reduce tissue sensitivity.

    Objective: This study aims to evaluate the safety and efficacy of a protocol using self-myofascial release with a foam roller to be applied in patients with hemophilic ankle arthropathy.

    Methods: Patients with ankle arthropathy (N=70) will be recruited, enrolled, and assigned to one of two groups—experimental or control—in a 1:1 allocation ratio. Patients will be recruited from 5 centers in different regions of Spain. Patient data will be collected at baseline, posttreatment, and follow-up. The primary outcome will be frequency of ankle joint bleeding (self-reported). The secondary outcomes will be ankle range of motion (measured with a digital goniometer); joint pain (measured with a visual analog scale and an algometer); joint status (measured using the Hemophilia Joint Health Score); muscle strength (measured with a dynamometer); functionality of lower limbs (measured using the 6-minute walking test); activity (self-reported); and muscle flexibility (measured using the fingertip-to-floor test). The treatment program includes 11 exercises that must be administered bilaterally. A mobile app will be developed where each patient will be able to observe the exercises to be carried out. Each session will last 15 minutes with 5 physiotherapy sessions per week for a period of 3 months. It is expected that patients with hemophilia who receive the foam roller intervention will show improvement in mobility, pain, and status of the ankle joint; muscle strength; and function in the lower extremities.

    Results: The study has been approved by the institutional review board of the University of Murcia. Patient recruitment will begin in September 2020, and the intervention period will last until June 2021. Data collection will take place between September 2020 and October 2021.

    Conclusions: This protocol describes a randomized clinical trial to examine the safety and efficacy of a self-myofascial release intervention using a foam roller in patients with hemophilic ankle arthropathy.

    Trial Registration: ClinicalTrials.gov NCT03914287; http://clinicaltrials.gov/ct2/show/NCT03914287.

    International Registered Report Identifier (IRRID): PRR1-10.2196/15612

    JMIR Res Protoc 2020;9(7):e15612

    doi:10.2196/15612

    KEYWORDS

    Crowdfunding campaign to support this specific research

    We help JMIR researchers to raise funds to pursue their research and development aimed at tackling important health and technology challenges. If you would like to show your support for this author, please donate using the button below. The funds raised will directly benefit the corresponding author of this article (minus 8% admin fees). Your donations will help this author to continue publishing open access papers in JMIR journals. Donations of over $100 may also be acknowledged in future publications.

    keyboard with crowdfunding key instead of enter key

    Suggested contribution levels: $20/$50/$100



    Introduction

    Hemophilia is a congenital coagulopathy characterized by a deficiency of a clotting factor (factor VIII in hemophilia A and factor IX in hemophilia B). Most clinical manifestations are musculoskeletal such as bruising and hemarthrosis. The recurrence of joint bleeding causes degenerative, progressive, and chronic joint deterioration (hemophiliac arthropathy); chronic pain; and a deteriorated perception of the patient's quality of life. Symptoms of hemophilic arthropathy include limited range of motion, decreased periarticular muscle strength, decreased proprioception, and chronic pain [1,2].

    The ankle joint, a crucial component of locomotion, is one of the most affected joints (as are the knee and elbow joints) [3], imposing important functional and proprioceptive limitations. These limitations are the result of developing intra-articular alterations such as joint space narrowing, the development of osteophytes, bone deformities, or axial alterations [4]. Prophylactic treatment has been shown to be highly effective in the prevention of hemophilic arthropathy [5]; however, many patients, nevertheless, develop these sequelae as a result of late initiation of treatment, poor adherence to prophylaxis, or the development of inhibitors (antibodies to factor VIII or factor IX concentrates).

    The treatment of hemophilic ankle arthropathy includes pharmacologic and orthopedic interventions with the aim of improving symptoms in the patient. The administration of anti-inflammatory and analgesic drugs [6], conducting synoviorthesis to remove the synovial membrane, and ultimately, arthrodesis of the ankle joint are the most common treatments [7].

    Physiotherapy can play an extremely important role in the treatment of hemophilic ankle arthropathy. Manual therapy techniques [8], therapeutic exercise [9], or electrotherapy [10] have provided positive results in the control of chronic pain in patients with hemophilic ankle arthropathy.

    The degenerative process, itself, is one of the intrinsic mechanisms affecting the fascial system, since it favors loss of elasticity and flexibility, and triggers a process of pathological cross-linking of collagen fibers. Fascial therapy aims to remove fascial tissue restriction through mechanical stimuli applied for 3 to 5 minutes in order to promote the piezoelectric effect in the crystalline matrix of the fascia [11]. The mechanical stimulus to the fascia (in the form of either pressure or tangential compression) triggers a secondary conjunctive cellular response and promotes cellular communication through piezoelectric and mechanotransduction mechanisms [12]. Although pilot and cohort studies [13,14] have proven that this technique is safe in patients with hemophilic arthropathy of the ankle, clinical studies need to be conducted with a large sample size in order to confirm that this technique is indeed suitable.

    Fascia is the soft tissue component of the connective tissue matrix that extends through the human body forming a continuous three-dimensional composite of structural support throughout the body [15]. Myofascial release is a physiotherapy technique in which sustained pressure is applied in order to reduce restrictions of the fascia. Mechanical stimulation favors the readjustment of collagen fibers and improves the quality of movement, fluid circulation, and lymphatic drainage [16]. These changes can help break apart adhesions caused by processes such as scarring and fibrosis in the body. Myofascial induction is a manual physiotherapy technique that applies the principles of biomechanical loading of soft tissue and modification of neural reflexes through stimulation of the mechanoreceptors in the fascia to release fascial restrictions and restore healthy tissue [17].

    Self-myofascial release with a foam roller is used to treat fascial adhesions and to restore the normal extensibility of soft tissues [18]. Self-myofascial release has similar effects to those provided by manual fascial release techniques. These benefits include easing muscle tension and stiffness, reducing pain, reducing inflammation, alleviating muscle spasms, and increasing joint mobility. Myofascial release techniques have been used to treat adhesions of the soft tissue, to relieve pain and tissue sensitivity, and to reduce edema and inflammation, while improving muscle recovery [19]. In self-myofascial release, patients use their own body weight and materials such as a foam roller to exert pressure on the affected soft tissues [20,21]. Scientific evidence has shown that these types of tools help improve the range of motion as well as pre and postexercise muscle performance [21,22]. The efficacy of these types of exercises to improve joint mobility has been tested in relation to improving mobility in knee flexion [20] and relative to improving ankle joint mobility [23].

    The use of foam rollers for myofascial release is based on findings of postintervention changes to joint range of motion and pressure pain thresholds which may be due to a mechanical and neurophysiological responses [24,25]. The direct pressure of the roller may produce local mechanical and global neurophysiological effects that relax the tissues and attenuate pain in the targeted and surrounding area [26]. Local pressure from the roller may affect the viscoelastic properties of the myofascia which may be responsible for such changes within the tissue. Other mechanisms that may be involved include thixotropy (reduced viscosity when stress is applied), reduced myofascial restriction (from the breaking apart of physical adhesions), fluid-related changes (forced fluid displacement within the tissue), and cellular responses (elicited through mechanotransduction from the applied stress within the tissues) [24]. Researchers have also found that foam-rolling reduces arterial stiffness, increases arterial tissue perfusion, and improves vascular endothelial functions related to tissue relaxation [27].

    The objective of this paper is to describe our approach to the design and implementation of a protocol for self-myofascial release using a foam roller for patients with hemophilic ankle arthropathy with the aim of reducing the frequency of joint bleeding; improving range of motion; reducing joint pain; and restoring functionality, structural integrity, muscle flexibility, and muscle strength.


    Methods

    Study Design

    This study is designed as a randomized controlled multicenter clinical trial (ClinicalTrials.gov; NCT03914287) to establish the safety and efficacy of a physiotherapy intervention consisting of self-myofascial release using a foam roller. Once eligibility is determined, participants will be randomized to either the intervention (experimental) group or the control group.

    Clinical Record and Selection Criteria

    This study has been approved by the research ethics committee of the University of Murcia (2428/2019). Patients will be included if they have been diagnosed with hemophilia A or B, are 18 years of age or older, have been diagnosed with bilateral hemophilic arthropathy of the ankle (more than 3 points of joint damage on the Hemophilia Joint Health Score), and are on prophylactic or on-demand treatment with factor VIII or factor IX concentrates.

    Patients will be excluded from the study if they are not able to ambulate; have been found to have inhibitors (antibodies to factor VIII or factor IX), have neurological or cognitive alterations that prevent them from understanding the questionnaires and physical tests, or choose not to give informed consent (have not signed the statement of informed consent).

    Sample Size

    The target sample size for inclusion in the study is 70 patients. The sample size is justified with respect to the prevalence of patients with congenital coagulopathies; there are 2039 patients with either hemophilia A and B or von Willebrand disease in Spain, of which 612 meet the selection criteria for the study (Spanish Federation of Hemophilia). Based on these data, the sample size at national level would be 236 individuals, with a confidence level of 95% and an expected dropout ratio of 15%. Thus, a sample size of a total of 70 patients from the 5 centers will be used.

    Randomization

    Participants will be randomly assignment using opaque envelopes to one of two groups—experimental and control. Random assignment of patients will be carried out after cluster recruitment (based on hemophilia type and patient age) to ensure homogeneity of the study groups. This assignment will be carried out by a person who is not involved in the study objectives and who is unaware of the identity of the participants.

    Outcome Measures

    Baseline assessments will be carried out at Hemophilia Association centers. Measurements will be performed by a physiotherapist who is unaware of patient group assignments.

    After the treatment period and 3 months after completion, the patients included in both groups (experimental and control) will be re-evaluated by the same rater under the same conditions as their initial evaluation.

    Dependent variables (range of motion, joint pain, functionality, joint state, muscle strength, muscle flexibility, and record of activity) will be measured at each study assessment (baseline, posttreatment, and follow-up). A 10-point visual analog scale will be used to evaluate patient perception of joint pain, ranging from 0 (no pain) to 10 (maximum perceived pain). An algometer (FPN100; Wagner Instruments) will be used for the assessment of pressure-induced pain (the amount of pressure at which the person perceives pain), both at the joint and at other body sites [28]. Pressure will be applied gradually at the site, increasing at rate of 50 kPa/s until the patient reports that the sensation is painful [29]. In patients with ankle arthropathy, bilateral measurements will be taken anterior to the lateral malleolus (ankle) [30] and at two other sites—the spinous process of the L5 vertebra and on the extensor carpi radialis longus muscle of the forearm (5 cm distal to the lateral epicondyle of the humerus) [28]. Using a portable instrument [31] for assessing physical activity, patient physical activity level (average number of steps per day, average distance per day, average amount of active time, and energy consumption) will be recorded. The Hemophilia Joint Health Score [32] will be used to evaluate the joint condition of knees, ankles, and elbows. It includes 8 items (inflammation and its duration, pain, atrophy and muscle strength, crepitus, and reduced flexion and extension) ranging from 0 to 20 points per joint (the higher the score, the greater the joint deterioration).

    The 6-minute walking test [33] measures the distance walked over a period of 6 minutes as an assessment of submaximal capacity to perform exercise. This instrument was developed for use in patients with respiratory disease and heart failure, but has been used in children and adults with a variety of chronic conditions, including hemophilia [34-36]. The test is performed on a 30 to 50-meter track, and the use of walking aids or orthopedic devices is permitted. Ankle range of motion will be measured by a digital goniometer using a protocol designed by Thornton et al [37]; the assessment can be performed with the patient standing. The axis of the goniometer will be placed alongside the lateral malleolus of the ankle. The fixed arm will be placed parallel to the fibula while the mobile arm is aligned to be parallel with the fifth metatarsal bone. This measuring instrument allows more accurate measurements than those obtained with a plastic goniometer. The patient will be asked to perform 3 repetitions of each movement. The mean of the 3 measurements will be used [28]. The maximum isometric strength of the plantar flexor muscles of the ankle will be evaluated on both limbs with a manual dynamometer. The patient will be placed in a supine position with 90º ankle dorsiflexion. The dynamometer will be located proximal to the metatarsophalangeal joints on the plantar side) and will be held by the evaluator [38]. The patient will be asked to perform 3 maximal effort isometric contractions (each for 5 seconds with a 30-second break in between) against the dynamometer and the mean of the 3 measurements will be used [28]. The fingertip-to-floor test [39] assesses the degree of flexibility of the posterior muscles of the lower limbs. The distance between the fingertips and the floor is calculated at maximum hip flexion with knees extended.

    Intervention

    Patients will continue their factor VIII or factor IX concentrate treatment as prescribed by their referring hematologists. Throughout the study, the prescribed pharmacologic treatment, dosage, and periods of substitute treatment of the participants will not be altered. Participants in the control group will receive no physical therapy using self-myofascial release and will continue with their usual routine of physical activity and exercise. Outcomes will be assessed under the same conditions as those of the experimental group.

    At the beginning of the study, the main investigator will explain the characteristics of the intervention to be carried out to the experimental group. Each session will last approximately 15 minutes, with 5 physiotherapy sessions over a period of 3 months. Each patient will perform the interventions at home. Participants will have free access to the mobile app. Access to the platform will be approved after the patient signs the informed consent form. Once the study is complete, the contents of the app (Table 1) will be available on the website of the Hemophilia Physiotherapy research group (InHeFis).

    The protocol for self-myofascial release of the lower limbs using a foam roller and solid ball massage, adapted to patients with hemophilic ankle arthropathy, will include self-myofascial release of the plantar, back of the leg, and hamstring regions, as well as adductor, abductor, and pelvitrochanteric muscles. Table 1 shows the physiotherapy protocol. Periodic follow-up will be performed, through phone calls and by SMS text messages, to answer questions from patients regarding the use of the app.

    A mobile app (designed by the research group) will be used to demonstrate all the exercises in the self-myofascial release protocol. Each time the patient exercises, he or she will be able to watch a video explaining the characteristics of each exercise (time, repetitions, position, and action). This free app will also collect adherence data recorded as days of exercise by the participant.

    Patient will need to have a suitable floor mat. A massage ball will be used for pressure point massage (solid ball massage), typically 40 mm to 50 mm in diameter, made of a hard polyurethane, but slightly padded. Two smooth low-deformability foam rollers (90 cm in length and 15 cm in diameter) will also be used.

    Table 1. Physiotherapy protocol using self-myofascial release for patients with hemophilic ankle arthropathy.
    View this table

    Data Analysis

    The distribution of the sample, the changes after the intervention and follow-up period in each group, and the intra and interindividual effect will be analyzed. We will use the intent-to-treat method to include all individuals who were randomized in the final data analysis.

    The statistical analysis will be carried out using SPSS statistical software (version 19.0; IBM Corp). The Kolmogorov-Smirnov test will be used to test for normality, and the Levene test will be used to test for homoscedasticity. If the conditions of normality and homoscedasticity are violated, nonparametric tests will be used.

    Descriptive statistics (mean and standard deviation) will be calculated for all dependent variables. A one-way repeated measures analysis of variance will be used to compare the groups (experimental and control) at 3 assessment times (baseline, posttreatment, and follow-up). If the interaction is found to be significant, pairwise comparisons will be performed. The significance level will be set at α=.05. To control the error rate, Bonferroni correction will be applied. The results of the F test will depend on the significance of Mauchly sphericity. If significant, the Greenhouse-Geisser correction will be used. To assess clinical relevance, we will calculate the standard error of measurement and minimum detectable change for each dependent variable.


    Results

    The study has been approved by the ethics committee of the University of Murcia (ID: 2428/2019). Patient recruitment will begin in September 2020, and an intervention period will continue until June 2021. Data collection will take place between September 2020 and October 2021.


    Discussion

    This project is the most ambitious physiotherapy study, in terms of methodology, recorded to date in Spain. The inclusion of 70 patients with hemophilia from 5 different regions for participation in a physiotherapy program will confer on this project a high statistical power, which is unusual in a rare pathology such as hemophilia. Patients with hemophilic ankle arthropathy will undergo treatment with self-myofascial release using a foam roller. The research team is made up of multidisciplinary hemophilia specialists, renowned physiotherapists with extensive clinical experience, and researchers in the field of hemophilia, as well as experts in methodology and statistics. Coordination between different regions of Spain, with the participation of universities, hospitals and associations of patients, is an uncommon effort in the field of hemophilia-related physiotherapy research.

    Another potential strength is that this protocol can help to establish a rapid, safe, and effective intervention for patients with hemophilia. In addition to clinical improvements, it could facilitate greater adherence to physiotherapy treatments and improve the quality of life of individuals with hemophilia.

    Self-myofascial release requires no economic investment in the case of manual therapy. Validating its safety and efficacy could promote the development of a quick, inexpensive, and simple physiotherapy intervention that can easily be used widely.

    Acknowledgments

    We would like to thank our association network of patients with hemophilia and the Spanish Federation of Hemophilia, without whom this work will not be possible. We would also like to thank the staff who assisted in the implementation of this project. This work will be supported by Baxalta US Inc, now part of Shire (RC-B as principal investigator; HE-FOAM .PO#1000408459). The content is solely the responsibility of the authors.

    Conflicts of Interest

    None declared.

    Multimedia Appendix 1

    CONSORT-EHEALTH checklist (V. 1. 6. 1).

    PDF File (Adobe PDF File), 271 KB

    References

    1. Gringeri A, Ewenstein B, Reininger A. The burden of bleeding in haemophilia: is one bleed too many? Haemophilia 2014 Jul;20(4):459-463. [CrossRef] [Medline]
    2. Valentino LA. Blood-induced joint disease: the pathophysiology of hemophilic arthropathy. J Thromb Haemost 2010 Sep;8(9):1895-1902 [FREE Full text] [CrossRef] [Medline]
    3. Gouw SC, Timmer MA, Srivastava A, de Kleijn P, Hilliard P, Peters M, et al. Measurement of joint health in persons with haemophilia: a systematic review of the measurement properties of haemophilia-specific instruments. Haemophilia 2019 Jan;25(1):e1-e10. [CrossRef] [Medline]
    4. Rodriguez-Merchan EC. Prevention of the musculoskeletal complications of hemophilia. Adv Prev Med 2012;2012:201271 [FREE Full text] [CrossRef] [Medline]
    5. Manco-Johnson MJ, Abshire TC, Shapiro AD, Riske B, Hacker MR, Kilcoyne R, et al. Prophylaxis versus episodic treatment to prevent joint disease in boys with severe hemophilia. N Engl J Med 2007 Aug 09;357(6):535-544. [CrossRef] [Medline]
    6. Holstein K, Klamroth R, Richards M, Carvalho M, Pérez-Garrido R, Gringeri A, European Haemophilia Therapy Standardization Board. Pain management in patients with haemophilia: a European survey. Haemophilia 2012 Sep;18(5):743-752. [CrossRef] [Medline]
    7. Rodriguez-Merchan EC. Management of hemophilic arthropathy of the ankle. Cardiovasc Hematol Disord Drug Targets 2017;17(2):111-118. [CrossRef] [Medline]
    8. Cuesta-Barriuso R, Gómez-Conesa A, López-Pina J. Effectiveness of two modalities of physiotherapy in the treatment of haemophilic arthropathy of the ankle: a randomized pilot study. Haemophilia 2014 Jan;20(1):e71-e78. [CrossRef] [Medline]
    9. Mazloum V, Rahnama N, Khayambashi K. Effects of therapeutic exercise and hydrotherapy on pain severity and knee range of motion in patients with hemophilia: a randomized controlled trial. Int J Prev Med 2014 Jan;5(1):83-88 [FREE Full text] [Medline]
    10. Gomis M, González L, Querol F, Gallach JE, Toca-Herrera J. Effects of electrical stimulation on muscle trophism in patients with hemophilic arthropathy. Arch Phys Med Rehabil 2009 Nov;90(11):1924-1930. [CrossRef] [Medline]
    11. O’Connell JA. Bioelectric responsiveness of fascia: a model for understanding the effects of manipulation. Techniques in Orthopaedics 2003;18(1):67-73. [CrossRef]
    12. Tutusaus R, Potau JM. Sistema Fascial. Anatomía, valoración y tratamiento. Barcelona: Editorial Médica Panamericana SA; 2015.
    13. Donoso-Úbeda E, Meroño-Gallut J, López-Pina JA, Cuesta-Barriuso R. Safety and effectiveness of fascial therapy in adult patients with hemophilic arthropathy. A pilot study. Physiother Theory Pract 2018 Oct;34(10):757-764. [CrossRef] [Medline]
    14. Donoso-Úbeda E, Meroño-Gallut J, López-Pina JA, Cuesta-Barriuso R. Safety of fascial therapy in adult patients with hemophilic arthropathy of ankle. A cohort study. Musculoskelet Sci Pract 2018 Jun;35:90-94. [CrossRef] [Medline]
    15. Findlay T, Schleip R. Introduction. In: Findlay T, Schleip R, editors. Fascia Research: Basic Science and Implications for Conventional and Complementary Health Care. Munich: Elsevier; 2007:2-9.
    16. Bordoni B, Lintonbon D, Morabito B. Meaning of the solid and liquid fascia to reconsider the model of biotensegrity. Cureus 2018 Jul 05;10(7):e2922 [FREE Full text] [CrossRef] [Medline]
    17. Castro-Sánchez AM, Matarán-Peñarrocha GA, Arroyo-Morales M, Saavedra-Hernández M, Fernández-Sola C, Moreno-Lorenzo C. Effects of myofascial release techniques on pain, physical function, and postural stability in patients with fibromyalgia: a randomized controlled trial. Clin Rehabil 2011 Sep;25(9):800-813. [CrossRef] [Medline]
    18. Crane JD, Ogborn DI, Cupido C, Melov S, Hubbard A, Bourgeois JM, et al. Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. Sci Transl Med 2012 Feb 01;4(119):119ra13 [FREE Full text] [CrossRef] [Medline]
    19. Paolini J. Review of myofascial release as an effective massage therapy technique. Athl Ther Today 2009;14(5):30-34. [CrossRef]
    20. MacDonald GZ, Penney MDH, Mullaley ME, Cuconato AL, Drake CDJ, Behm DG, 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 Mar;27(3):812-821. [CrossRef] [Medline]
    21. Sullivan KM, Silvey DBJ, 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 Jun;8(3):228-236 [FREE Full text] [Medline]
    22. 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 Nov;10(6):827-838 [FREE Full text] [Medline]
    23. Škarabot J, Beardsley C, Štirn 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 Apr;10(2):203-212 [FREE Full text] [Medline]
    24. Kelly S, Beardsley C. Specific and cross-over effects of foam rolling on ankle dorsiflexion range of motion. Int J Sports Phys Ther 2016 Aug;11(4):544-551 [FREE Full text] [Medline]
    25. Cheatham SW, Kolber MJ. Does roller massage with a foam roll change pressure pain threshold of the ipsilateral lower extremity antagonist and contralateral muscle groups? an exploratory study. J Sport Rehabil 2018 Mar 01;27(2):165-169. [CrossRef] [Medline]
    26. Grabow L, Young JD, Alcock LR, Quigley PJ, Byrne JM, Granacher U, et al. Higher quadriceps roller massage forces do not amplify range-of-motion increases nor impair strength and jump performance. J Strength Cond Res 2018 Nov;32(11):3059-3069. [CrossRef] [Medline]
    27. Okamoto T, Masuhara M, Ikuta K. Acute effects of self-myofascial release using a foam roller on arterial function. J Strength Cond Res 2014 Jan;28(1):69-73. [CrossRef] [Medline]
    28. Skou ST, Simonsen O, Rasmussen S. Examination of muscle strength and pressure pain thresholds in knee osteoarthritis: test-retest reliability and agreement. J Geriatr Phys Ther 2015;38(3):141-147. [CrossRef] [Medline]
    29. Leffler A, Kosek E, Lerndal T, Nordmark B, Hansson P. Somatosensory perception and function of diffuse noxious inhibitory controls (DNIC) in patients suffering from rheumatoid arthritis. Eur J Pain 2002;6(2):161-176. [CrossRef] [Medline]
    30. Dhondt W, Willaeys T, Verbruggen LA, Oostendorp RA, Duquet W. Pain threshold in patients with rheumatoid arthritis and effect of manual oscillations. Scand J Rheumatol 1999;28(2):88-93. [CrossRef] [Medline]
    31. Pérez-Alenda S, Carrasco JJ, Megías-Vericat JE, Poveda JL, Bonanad S, Querol F. Quantification of physical activity in adult patients with haemophilic arthropathy in prophylaxis treatment using a fitness tracker. Haemophilia 2018 Jan;24(1):e28-e32. [CrossRef] [Medline]
    32. Fischer K, de Kleijn P. Using the Haemophilia Joint Health Score for assessment of teenagers and young adults: exploring reliability and validity. Haemophilia 2013 Nov;19(6):944-950. [CrossRef] [Medline]
    33. Balke B. A simple field test for the assessment of physical fitness. rep 63-6. Rep Civ Aeromed Res Inst US 1963 Apr:1-8. [Medline]
    34. Douma-van Riet DCM, Engelbert RHH, van Genderen FR, Ter Horst-De Ronde MTM, de Goede-Bolder A, Hartman A. Physical fitness in children with haemophilia and the effect of overweight. Haemophilia 2009 Mar;15(2):519-527. [CrossRef] [Medline]
    35. Groen W, van der Net J, Lacatusu AM, Serban M, Helders PJM, Fischer K. Functional limitations in Romanian children with haemophilia: further testing of psychometric properties of the Paediatric Haemophilia Activities List. Haemophilia 2013 May;19(3):e116-e125. [CrossRef] [Medline]
    36. Salim M, Brodin E, Spaals-Abrahamsson Y, Berntorp E, Zetterberg E. The effect of Nordic Walking on joint status, quality of life, physical ability, exercise capacity and pain in adult persons with haemophilia. Blood Coagul Fibrinolysis 2016 Jun;27(4):467-472. [CrossRef] [Medline]
    37. Thornton J, Sabah S, Segaren N, Cullen N, Singh D, Goldberg A. Validated method for measuring functional range of motion in patients with ankle arthritis. Foot Ankle Int 2016 Aug;37(8):868-873. [CrossRef] [Medline]
    38. van der Ploeg RJ, Fidler V, Oosterhuis HJ. Hand-held myometry: reference values. J Neurol Neurosurg Psychiatry 1991 Mar;54(3):244-247 [FREE Full text] [CrossRef] [Medline]
    39. Perret C, Poiraudeau S, Fermanian J, Colau MM, Benhamou MA, Revel M. Validity, reliability, and responsiveness of the fingertip-to-floor test. Arch Phys Med Rehabil 2001 Nov;82(11):1566-1570. [CrossRef] [Medline]

    Edited by C Hoving; submitted 29.07.19; peer-reviewed by M Alshehri, E Sadeghi-Demneh; comments to author 06.09.19; revised version received 04.11.19; accepted 28.04.20; published 31.07.20

    ©Antonio Javier Meroño-Gallut, Rubén Cuesta-Barriuso, Raúl Pérez-Llanes, Elena Donoso-Úbeda, José-Antonio López-Pina. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 31.07.2020.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org, as well as this copyright and license information must be included.