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Benefits of a self-myofascial release program

on health-related quality of life in people with
fibromyalgia: A...

Article · January 2017

DOI: 10.23736/S0022-4707.17.07025-6

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Benefits of a self-myofascial release programme on health-related quality of life in
people with fibromyalgia: a randomized controlled trial.

Diego Ceca,1* Laura Elvira,1 José F. Guzmán,2 Ana Pablos,1

1
Faculty of Physical Activity and Sport Sciences, Universidad Católica de Valencia
“San Vicente Mártir”, Torrent, Valencia, Spain; 2 Faculty of Physical Education and
Sports, Universitat de València, Valencia, Spain.

*Corresponding author: Diego Ceca, Faculty of Physical Activity and Sport Sciences,
Universidad Católica de Valencia “San Vicente Mártir”, C/ Ramiro de Maeztu 14,
46900 Torrent, Valencia, Spain. E-mail: diego.ceca@ucv.es

1
Abstract

BACKGROUND: Fibromyalgia (FM) is a disease with symptoms that significantly

limit the life of affected patients. Earlier studies have shown that the application of self-
myofascial release provides benefits in variables such as fatigue, range of motion
(ROM) or perceived muscle pain in a healthy population. Despite this, the self-
myofascial release technique has not yet been used in people with FM. This study aimed
to find out the benefits of applying a self-myofascial release programme on health-
related quality of life in people with FM.

METHODS: 66 participants with FM were randomized into two groups, intervention

(n=33) and control (n=33). The intervention group (IG) participated in the self-
myofascial release programme for twenty weeks. The study assessed the impact of a
self-myofascial release programme on cervical spine, shoulder and hip ROM and self-
reported disease impact. Two measurements were performed, one at baseline (pre-
intervention) and one post-intervention. Two-way mixed-effect (between-within)
ANOVA was used for the statistical analysis.

RESULTS: Significant changes (p< 0.05) were achieved between the two
measurements and between groups for final Fibromyalgia Impact Questionnaire (FIQ-S)
score and for five of its seven subscales, including: days per week feeling good, pain
intensity, fatigue, stiffness and depression/sadness, as well as all the ROM variables
evaluated (neck flexion, neck extension, lateral neck flexion and rotation (bilateral),
shoulder flexion and abduction and hip abduction) excluding hip flexion.

CONCLUSION: The application of a self-myofascial release programme can improve

the health-related quality of life of people with FM, provided that regular, structured
practice is carried out.

Key words: Fibromyalgia-Quality of life-Fascia-Pain-FIQ

2
 TEXT

Introduction

Fibromyalgia (FM) is a syndrome that involves widespread pain.1 Patients commonly

suffer from other symptoms such as chronic fatigue, cold fingers and toes, depression,

sleep problems,2 muscle spasms and pain, tingling in the limbs and morning stiffness,

among others.3,4

In order to improve this situation, which often limits patients' functional capacity to

perform daily activities,5 studies have been carried out to explore the benefits of

different physical activity programmes on quality of life and functional performance.6–9

Patients usually describe their musculoskeletal pain as intense or unbearable,10 affecting

areas in the vicinity of the spine such as the cervical area and the proximal region of the

limbs,11–13 arms and trochanters,14 shoulders and hips.15

Dysfunction of intramuscular connective tissue, 16,17 inflammation of the myofascial

tissue and the release of pro-inflammatory cytokines by fibroblasts as a reaction to

muscle tension have been observed in these patients, leading to a state of chronic

peripheral sensitization, which results in the adaptation of neurological structures and

causes the onset of chronic sensitization.18,19

In response to these symptoms, myofascial release techniques have been applied,

achieving positive results in variables such as pain intensity, quality of life, sleep

quality, and neck and upper back pain.20–23 This technique consist of a myofascial

massage applied by a physiotherapist.

Recent studies have begun to use the self-myofascial release technique. In this case, it is

the subject who carries out different exercises to perform their self-massage using

different materials such as a foam roller or balls of varying hardness.

3
When self-myofascial release was applied in a healthy population, it brought about

improvements in physical performance, flexibility, range of motion (ROM) of hip and

knee joints and a reduction in muscle pain, joint stress, 24–27 and the feeling of fatigue

when doing exercise or the effects of Delayed Onset Muscle Soreness.28,29 Moreover,

improvements have been observed in athletes in vertical jump performance, muscle

activation and active and passive ROM.30,31

Despite this, no studies have been conducted to date on the effect of self-myofascial

release in people with FM.

Considering this information, this study aimed to determine the benefits of applying a

self-myofascial release programme on health-related quality of life in people with FM,

in terms of cervical spine, shoulder and hip ROM and self-reported disease’s impact.

Having reviewed the scientific literature, it was hypothesized that the self-myofascial

release programme would be an effective tool for improving health-related quality of

life in a population with FM.

Material and Methods

Study design

A randomized controlled trial with parallel-group study was designed. To obtain data in

order to make an inter- and intra-group comparison of the results, two measurements

were carried out, one before applying the programme (pre-intervention) and the other

after its completion (post-intervention), at three different sports centres in the province

of Valencia (Spain) where the intervention programme was carried out.

Participants

The sample consisted of people diagnosed with FM Syndrome, according to the

diagnostic criteria proposed by the American College of Rheumatology.32,33 The

inclusion criteria were: being over 18 years of age, having a diagnosis of FM and
4
having signed the informed consent. The exclusion criteria were: having a diagnosis of

heart, kidney or liver failure, respiratory problems that could limit the application of the

programme, a cardiovascular event during the last year, not agreeing to follow the

proposed intervention programme, and not being considered outliers (individual values

greater than the mean plus 2 SDs).

The software G*Power 3.1 was used to determine the required sample size. The primary

outcome measure for this study was change in final FIQ score at the 20-week point. An

intervention study34 reported a mean±SD improvement of 9.614±14 points in final FIQ

score after a 6-month aerobic exercise intervention in patients with FM, representing an

18% change from baseline (a 14% change in FIQ score is regarded as clinically

important).35 On this basis, sample-size calculations indicated that 10 participants were

needed to show an improvement in FIQ total score of this magnitude, using a power of

0.9 and level of .05.

The sample was obtained through two associations of people affected by FM in the

province of Valencia (Spain). After an introductory meeting that was held in December

2013, 113 participants were considered potentially eligible. Of these, 33 participants

made up the Intervention Group (IG), in which the self-myofascial release programme

was implemented, and 33 the Control Group (CG) who received no treatment (Figure

1).

Randomization to either group was done in a 1:1 allocation ratio using random block

sizes of 2 and 4, through a prespecified computer-generated randomization list by an

investigator who was blinded to the study’s objective. Likewise, to eliminate possible

bias during the measurements, the patients were assessed by investigators who were

blinded to the treatment allocation and the intervention programme.

5
Informed consent was obtained from all individuals who were included in the study. All

study procedures involving human participants were performed in accordance with the

ethical standards of the institutional (University of Valencia Research in Humans Ethics

Committee; procedure number H1427122754390), Spanish legislation on clinical trials

(Royal Decree 223/2004, of February 6) and the 1964 Declaration of Helsinki and its

later amendments or comparable ethical standards.

Intervention

The subjects included in the IG followed a 20-week self-myofascial release programme,

consisting of two 50-minute sessions per week conducted from January 2014 to June

2014.

The sessions were structured in three parts. First, the participants performed mobility

exercises involving major muscle groups for ten minutes. They then continued with

thirty minutes of self-myofascial release exercises using different materials according to

the intensity of pressure required for each muscle group at each stage in the programme.

The main part of all sessions ended with a self-myofascial release exercise for the

trapezius muscle. Lastly, the session ended with ten minutes of static stretching

exercises. A single set of 10 repetitions (45-60 seconds) was performed for each

exercise.

Of the two scheduled weekly sessions, one of them worked on the muscles of the upper

body, while the exercises in the other session focused on the muscle groups of the lower

body. These exercises were always led by a specialist in physical activity whose

example the IG subjects copied.

Throughout the programme the pressure exerted gradually increased in intensity. This

progression was based on three premises: hardness of the material, body weight resting

on the material and size of the contact surface with the material.
6
In relation to the hardness of the material and the size of the contact surface, five tools

were used during the sessions of the programme, ordered from least to greatest pressure

exerted: large foam balls (Ø 20 cm), small foam balls (Ø 8 cm), spiky rubber balls (Ø

15 cm), foam rollers (Ø 14.5 cm) and tennis balls. All the required material was

administered by the research group.

Therefore, three types of exercises were prepared for different areas of application

based on the body weight resting on the material, ordered from lowest to highest

intensity:

- Hand exercises: in which the participants applied pressure to the material with

their hand in order to massage their muscles.

- Standing exercises: in which the subject exerted pressure on the material,

which in turn was situated between the participant's body and the wall.

- Floor exercises: in which the subject rested all their body weight on the

material, which was situated between the participant's body and the floor.

The progression followed throughout the intervention programme can be seen in

Supplementary Table I. It must be noted that, due to the characteristics of the study

population, the physical burden of the sessions was also taken into consideration, as was

the safety of the positions adopted while performing the exercises.

Outcomes

Health-related quality of life. A validated Spanish version of the Fibromyalgia Impact

Questionnaire (FIQ-S) was used.36 The items of this questionnaire assess different

parameters such as physical and psychological functioning, giving an overall score

between 0 and 100. Also, the FIQ-S contains different Visual Analogue Scales (VAS)

for assessing aspects such as: pain, fatigue, sleep, stiffness, anxiety and

7
depression/sadness, which are scored from 0 to 10. This questionnaire has been used in

numerous studies carried out in Spain in recent years with populations of similar

characteristics.21,37

Range of motion (ROM). To determine the joint range of motion, goniometric

measurements were carried out according to the method described by Silver 38 and the

American Academy of Orthopedic Surgeons,39 amongst others. The range of motion of

the hip and shoulder joints (always of the dominant side) was assessed in flexion and

abduction movements. The mobility of the cervical spine was also assessed in

movements of flexion and extension, lateral flexion (bilateral) and rotation (bilateral).

Two measurements were taken in each of these tests and the mean value was used.

When the difference between the first and second measurement differed by more than

5%, a third measurement was taken.

Statistical analysis

IBM SPSS Statistics v22.0 (SPSS Inc., Chicago IL) software was used for the data

analysis. The participants’ demographics were compared by group using a chi-square

test. A descriptive analysis (mean and standard deviation) of the variables was

performed and subsequently all the variables were analysed in a two-way mixed-effect

(between-within) ANOVA including 2 (group: control, intervention) x 2 (time: pre-

intervention, pre-intervention) with repeated measures on the last factor using 95%

confidence intervals (p< 0.05). The Bonferroni correction and post-hoc pairwise

comparisons were used. Effect sizes (η2) were also calculated, with values of < 0.06

being considered small, < 0.14 moderate and > 0.14 large.40

Results

8
Demographic information.

The study personnel recruited 113 potentially eligible candidates. Of those recruited,

14.15% were ineligible, 21.3% declined to participate, 6.2% declare other reasons and

58.4% of those eligible were enrolled (Figure 1). The subjects were randomly assigned

to the two study groups. Of the 66 people who completed the pre-intervention test (n =

33 intervention; n = 33 waitlist control), 65.2% completed the post-intervention test (n=

23 intervention; n= 20 wait list control). Compliance with adherence to the protocol

compared to the total number of sessions was 85%. A waitlist control design was

chosen because the investigators wanted an ethically-sound model that provided all

participants with access to the lifestyle intervention. Also, a waitlist control group was

considered more appropriate than a passive control group, given that illness impact was

comparable in both groups. Demographics of the participants are shown in Table I.

Health-related quality of life and Range of Motion

Results for the health-related quality of life (see Table II) and ROM (see Table III)

show the effect of interaction between these variables in both groups.

Health-related quality of life changes are shown in Figure 2 and Figure 3. They reveal

statistically significant (p< 0.01) changes over time for the IG in the final FIQ-S score,

as well as the subscales “Days per week feeling good”, “Pain intensity”, “Fatigue”,

“Stiffness”, and “Depression/Sadness”.

Cervical spine ROM results are shown in Figure 4. Statistically significant differences

(p< 0.001) can be observed between the two measurements in the IG for all the

variables. Likewise, Figure 5 shows statistically significant differences (p< 0.01) for the

IG in the two variables (flexion and abduction) analysed for shoulder joint, and only in

abduction movement for the hip.

9
 Discussion

Very few studies have been published on the use of myofascial release in people with

FM, and this work provides the first scientific evidence of the application of myofascial

self-massage using materials such as foam rollers or balls of different size, hardness or

density. Most of the existing studies have focused on a healthy young population, so its

application in special populations is an area that is yet to be explored.

This being the case, it was proposed that an intervention programme should be carried

out by professionals in the field of physical activity and sport, based on performing and

learning self-myofascial release exercises that focus on the progressive application of

pressure to muscular connective tissue to try to reduce the limiting effects of this

disease, such as muscle pain and stiffness, and to increase the range of joint movement,

amongst others. These effects undoubtedly have an impact on quality of life41 and have

been shown to improve with the application of myofascial stimulation,20–23,30 which is

the object of this paper.

Health-related quality of life

After reviewing the scientific literature on the effect of myofascial release techniques

applied by physiotherapists (not based on self-massage exercises) in a population

similar to that of this study, it can be seen that the improvements achieved between pre-

intervention and post-intervention measurements in this study in terms of overall FIQ-S

score are consistent with the results found in similar studies. 21,22,23 In this regard, we

found a reduction of 9.93 points in the total FIQ-S score, which is a similar result to that

obtained in two of these previous works.21,23

10
Likewise, the results for the fatigue subscale may also be in line with studies which

claim that performing exercises with a foam roller reduced the feeling of fatigue.29,42

This can be seen in the difference between the CG and IG in the post-intervention

measurement. A comparison reveals that the result obtained for the difference of means

between the two measurements for the IG (1.74) differs from other similar research in

which myofascial or connective tissue massage was applied in people with FM (0.9 and

2.66).21,22

Permanent widespread pain is another of the most common symptoms that has a major

impact on quality of life in patients with FM. 1,4,43 In this study, widespread pain

intensity in the IG, evaluated using the FIQ-S pain subscale, also decreased significantly

(1.7 points between the two measurements) after the intervention, thus corroborating the

results obtained in studies conducted in a similar population.20-22

These improvements would be directly related to the reconditioning (i.e. tissue

hydration, low levels of fascial strain or reduction of fascial restrictions) of myofascial

tissue,20,21 which may lead a decrease in fibroblast stimulation and therefore a decrease

in proinflammatory cytokine segregation. This situation could reduce the continuous

stimulation of peripheral nerve endings, favouring less hyperresponsiveness of the

central nervous system.18,19

The results therefore suggest that regular application of the self-myofascial release

programme could be an important tool for reducing two aspects of great significance to

patients, namely the disease's impact on daily activities or situations and the sensation

of widespread pain, and for increasing the number of days per week that they felt good.

Range of Motion

Patients with FM tend to have areas that are particularly affected by localized pain.

According to some studies, the areas most commonly affected by this symptom are in

11
the vicinity of the spine, the superior region of the trapezius and the proximal region of

the limbs, such as the shoulders and hips.11,13,15 This can limit the muscular action of

these areas, and patients often complain of a feeling of stiffness or difficulty moving the

joint.

Despite this generalized stiffness described by most of the people who are diagnosed

with FM, there are studies which suggest that a high percentage of those affected

(almost 65%) in this population present benign joint hypermobility. 44,45 In this case, the

results for all the ROM variables assessed were initially within normal parameters and

even showed considerable limitations in certain movements, as established by the

American Academy of Orthopedic Surgeons.

It must also be mentioned that no studies have been carried out to date in people with

FM describing the influence of myofascial release or self-myofascial release exercises

on flexibility and ROM. The results of this study therefore offer a contribution that

should be taken into consideration within the current state of research on myofascial

stimulation techniques in this population. In this case, they can only be compared with

studies in populations of healthy young adults and women of approximately 60 years of

age.

We have thus been able to observe that the overall improvement in the different ROM

variables assessed corroborates the positive effect described in various studies after

applying several sets of self-myofascial release exercises.24,25,30 This can be directly

related to the improvement found in the perception of stiffness obtained for the IG in the

FIQ-S subscale, which showed a decrease of 1.8 points. This result lies between the

values (1.2 and 2.24) found in two studies that applied different massage techniques to

connective tissue in subjects diagnosed with FM.21,22

12
Moreover, in some studies ROM or flexibility has been assessed using different tests

such as the sit and reach test, the finger-floor distance test and the straight leg raise test,

or by assessing active knee extension. As in the case of this study, all these studies

found significant improvements between the data collected before and after performing

the exercises.31,46,47

As with the variables related to daily functionality or health-related quality of life, the

application of a 20-week self-myofascial release programme may lead to a series of

anatomical changes to myofascial tissue, correcting common pathological processes

such as myofascial densification, fibrosis, adhesions and dehydration.48 With the

improvement of myofascial viscoelasticity,49 these changes can enable correct gliding of

the different fascial layers50 and therefore facilitate proper joint function.

As mentioned in the previous section, these results show that doing correctly structured

self-myofascial release exercises could be positive for improving patients' daily

performance by increasing their ROM.

Limitations

Some of the usual biases in these studies tend to be due to the randomization and

blinding process. Despite the high variability in symptoms presented by the population,

the similarities observed between both groups (except for hip flexion) demonstrated the

effectiveness of randomization, which ensures more reliable results in this trial.

However, subjects were not blinded to the intervention type. This is a relative

limitation, although it is not feasible to carry out blinding in trials involving exercises.

Conclusions

13
The results obtained in this study show that the continued application of a supervised

programme based on self-myofascial release exercises that develop an adequate

progression of pressure intensity on the muscles through the use of materials of different

sizes and densities, can improve the health-related quality of life of people with FM

while having beneficial effects in terms of stiffness, fatigue, widespread pain intensity

and ROM.

It should also be remembered that this is the first study to describe the benefits of a self-

myofascial release programme in people with FM. Despite the results achieved in this

study, the research team believes it is necessary to conduct further studies of a similar

nature in the same population in order to corroborate the findings.

14
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Authors’ contributions. – AP and LE prepared the study design and coordination; DC,

carried out the intervention; AP, JFG and DC analyzed data. All authors were involved

in writing the paper and had final approval of the submitted and published version.

Funding. - This work was supported by Decathlon San Antonio (Valencia, Spain),

which donated some of the equipment used in the study, and has been made possible

thanks to funding from the Catholic University of Valencia “San Vicente Mártir”

through the grants for hiring trainee research personnel (2013). This study has had no

financial benefit for the authors, and represents results of original work that have not

been published elsewhere in any form.

Conflict of interest. - The authors declare no conflict of interest.

Acknowledgements. - The authors wish to thank everyone who has collaborated in this

study, including the Valencian Fibromyalgia Patient Association (AVAFI – Asociación

Valenciana de Afectados de Fibromialgia) and the Asociación de Afectados por la

Fibromialgia de Almussafes. They are also grateful to the Town Council of Pobla de

Farnals and the Municipal Women's Information and Guidance Center (CMIO - Centro

Municipal de Información y Orientación a la Mujer) for giving permission to use their

facilities.

22
 TITLES OF TABLES

Table I. - Demographic data of the sample.

Table II. - Descriptive data and changes pre/post intervention of FIQ-S variables.

Table III. - Descriptive data and changes pre/post intervention of ROM variables.

TITLES OF FIGURES

Figure 1. - Flow chart of study participants.

Figure 2. - Simple effects of mixed analysis of variance for final FIQ-S score. Final

FIQ-S score is assessed from 0 to 100. Significance level: ***p< 0.001; **p< 0.01; *p<

0.05.

Figure 3. - Simple effects of mixed analysis of variance for FIQ-S subscales. Day per

week feeling good subscale is scored from 0 to 7; Pain, Fatigue, Stiffness and

Depression/Sadness subscales are scored from 0 to 10. Significance level: ***p< 0.001;

**p< 0.01; *p< 0.05.

Figure 4. - Simple effects of mixed analysis of variance for cervical spine ROM. All

results are expressed in degrees (º). Significance level: ***p< 0.001; **p< 0.01; *p<

0.05.

Figure 5. - Simple effects of mixed analysis of variance for shoulder and hip ROM. All

results are expressed in degrees (º). Significance level: ***p< 0.001; **p< 0.01; *p<

0.05.

23
Table I. Demographic data of the sample.
IG CG Total
Variable
(n=23) (n=20) (N=43)
Gender (female) 20 19 39
Ethnicity White 23 20 43
Occupational status
Employed 3 4 7
Unemployed 12 12 24
Disabled/unable to
8 4 12
work/retirees
Drugs
Antidepressants 16 13 29
Anxiolytics 15 14 29
Antialgic 17 14 31
Anti-inflammatory 3 2 5
Beta 2 adrenergic 1 1 2
Thyroid preparations 3 3 6

Note: data are expressed with the number of participants who

meet each condition. *p < 0.05.
Table II. - Descriptive data and changes pre/post intervention of FIQ-S variables.
Pre- Post- Pre-Intervention – Between-group
Intervention Intervention Post-Intervention interaction
Variable Group Mean(SD) Mean(SD) Mean(95% CI) p η2
IG 38.92(5.78) 28.99(11.0) -9.93(-13.25 to -6.62) <0.001 0.275
FIQ-S final score (0-100)
CG 35.66(6.01) 35.22 (7.41) -0.44(-4.00 to 3.11)
FIQ-S Subscales (0-10)
IG 1.43(1.41) 2.65(1.67) 1.22(0.54 to 1.90) <0.001 0.270
Days/week feeling good
CG 1.75(1.83) 1.05(1.43) -0.7(-1.43 to 0.03)
IG 7.46(2.56) 5.76(3.32) -1.7(-2.77 to -0.62) 0.009 0.155
Pain intensity
CG 7.30(1.82) 7.75(2.04) 0.45(-0.71 to 1.61)
IG 9.02(1.27) 7.28(2.41) -1.74(-2.62 to -0.86) 0.015 0.135
Fatigue
CG 8.33(1.73) 8.20(1.81) -0.13(-1.07 to 0.82)
IG 9.09(1.23) 7.18(2.94) -1.91(-3.01 to -0.80) 0.061 0.085
Sleep
CG 7.75(2.66) 7.37(3.17) -0.38(-1.54 to 0.79)
IG 8.66(1.64) 6.70(3.09) -1.95(-3.15 to -0.76) 0.002 0.220
Stiffness
CG 7.27(3.01) 8.20(2.11) 0.92(-0.33 to 2.18)
IG 7.65(2.86) 5.02(3.24) -2.63(-3.97 to -1.29) 0.056 0.086
Anxiety
CG 7.03(3.33) 6.30(2.85) -0.73(-2.16 to 0.71)
IG 8.28(1.86) 5.02(3.14) -3.26(-4.47 to -2.05) 0.002 0.219
Depression/sadness
CG 5.98(3.58) 5.70(3.00) -0.28(-1.57 to 1.02)
Notes: The descriptive analysis values are shown as the mean(standard deviation). SD= Standard Deviation;
CI= Confidence Interval. All significant effects were considered at p< 0.05. Thresholds for η2: < 0.06 small;
< 0.14, moderate; > 0.14, large.
Table III. - Descriptive data and changes pre/post intervention of ROM variables.
Pre- Post- Pre-Intervention – Between-group
Intervention Intervention Post-Intervention interaction
Variable Group Mean(SD) Mean(SD) Mean(95% CI) p η2
IG 32.76(10.82) 49.11(12.28) 16.35(11.78 to 20.91) <0.001 0.280
Neck Flexion (º)
CG 30.88(9.41) 34.00(11.56) 3.12(-1.77 to 8.02)
IG 30.59(15.34) 48.11(14.32) 17.52(11.91 to 23.14) <0.001 0.330
Neck Extension (º)
CG 33.15(10.27) 32.35(10.80) -0.8(-6.82 to 5.22)
IG 30.54(10.29) 40.11(11.50) 9.57(6.41 to 12.73) <0.001 0.359
Right Lateral Neck Flexion (º)
CG 28.57(7.36) 27.15(7.49) -1.42(-4.81 to 1.96)
IG 25.24(8.55) 36.83(9.08) 11.59(9.13 to 14.04) <0.001 0.535
Left Lateral Neck Flexion (º)
CG 24.85(6.73) 24.20(6.95) -0.65(-3.28 to 1.98)
IG 49.63(12.61) 64.20(11.25) 14.57(11.47 to 17.66) <0.001 0.477
Right Neck Rotation (º)
CG 50.4(11.7) 51.2(10.4) 0.83(-2.50 to 4.15)
IG 53.80(12.24) 64.72(12.94) 10.92(6.39 to 15.44) 0.008 0.162
Left Neck Rotation (º)
CG 49.70(14.09) 51.38(11.74) 1.68(-3.18 to 6.53)
IG 115.76(35.67) 140.54(31.94) 24.78(11.05 to 38.51) 0.011 0.153
Shoulder Flexion (º)
CG 97.92(26.96) 95.28(22.31) -2.64(-18.26 to 12.98
IG 94.57(34.66) 121.30(36.25) 26.05(14.85 to 38.62) <0.001 0.347
Shoulder Abduction (º)
CG 90.53(30.39) 78.55(22.29) 11.92(-24.52 to 0.57)
IG 100.36(9.69) 108.69(16.08) 8.33(1.59 to 15.07) 0.068 0.085
Hip Flexion (º)
CG 86.45(17.47) 85.71(18.57) -0.74(-782 to 6.35)
IG 25.80(9.25) 37.28(8.18) 11.48(7.40 to 15.55) <0.001 0.324
Hip Abduction (º)
CG 21.63(6.60) 22.00(6.86) -1.65(-6.02 to 2.72)
Notes: The descriptive analysis values are shown as the mean(standard deviation). SD= Standard Deviation; CI=
Confidence Interval. All significant effects were considered at p< 0.05. Thresholds for η2: < 0.06 small; < 0.14,
moderate; > 0.14, large.
 Assessed for eligibility (n=113)

Excluded (n=47)
- Not meeting inclusion criteria (n=16)
Enrollment - Declined to participate (n=24)
- Other reasons (n=7)

Randomized (n=66)

Allocation

Allocated to intervention (n=33) Allocated to control group (n=33)

- Received allocated intervention (n=33) - Received allocated intervention (n=33)
- Did not receive allocated intervention (n=0) - Did not receive allocated intervention (n=0)

Follow-Up

- Lost to follow-up (new job, surgical Lost to follow-up (Nonattendance post-test

intervention, timetable problems) (n=10) measurements) (n=13)
-Discontinued intervention (n=0) Discontinued intervention (n=0)

Analysis
Analysed (n=23) Analysed (n=20)
- Excluded from analysis (outliers) - Excluded from analysis (outliers)
- Sleep FIQ-S subscale (n=1) - Shoulder flexion (n=2)
- Stiffness FIQ-S subscale (n=1) - Shoulder abduction (n=1)
- Hip flexion (n=2)

Figure 1. Flow chart of study participants.

Figure 1. Simple effects of mixed analysis of variance
for final FIQ-S score. Final FIQ-S score is assessed
from 0 to 100. Significance level: ***p< 0.001; **p<
0.01; *p< 0.05.
Figure 3. Simple effects of mixed analysis of variance for FIQ-S subscales. Day per week feeling
good subsacle is scored form 0 to 7; Pain, Fatigue, Stiffnes and Depression/Sadness subscales are
scored form 0 to 10. Significance level: ***p< 0.001; **p< 0.01; *p< 0.05.
Figure 4. Simple effects of mixed analysis of variance for cervical spine ROM. All results are
expressed in degrees (º). Significance level: ***p< 0.001; **p< 0.01; *p< 0.05.
 Figure 5. Simple effects of mixed analysis of variance for shouder and hip ROM. All results are
expressed in degrees (º). Significance level: ***p< 0.001; **p< 0.01; *p< 0.05.

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