Can Voodoo Flossing Increase Climbing Performance and Recovery? | Research Review
Hooper’s Beta Ep. 108
INTRO
Voodoo flossing is said to decrease pain, speed up healing, increase mobility, and even improve your performance. Let’s see if there’s any proof of that. By the end of this video, you’ll be able to answer the following questions:
How does flossing work?
Does flossing improve our rehab?
Does flossing improve our performance?
Are there any safety concerns?
Is it worthwhile for climbers?
MECHANISM
Let’s start by looking at the mechanism -- or how it works.
To get the benefits of flossing, you’re supposed to wrap an extremity with an elastic band for a couple minutes while performing exercises or stretches targeting that area.
The overarching mechanism here is obvious: compression.
Compression can cause interesting things to happen in the body.
Compression on veins, capillaries, and arteries restricts blood flow. If you watched the recent Hooper’s Beta video on blood flow restriction training, you know this seems to enhance tissue growth under certain conditions. Also, once the bands are released, some researchers hypothesize that the reperfusion of blood to the tissue benefits healing.
Compression on fascia -- the thin connective tissue that surrounds muscles -- creates a shearing force as the tissue moves. This breaks up adhesions in the fascia, allowing muscles to glide over each other more freely and potentially improving range of motion.
Compression on specific areas of the body also alters the activity of local mechanoreceptors, which relay physical stimuli like pressure to the brain. Some researchers hypothesize that strategically stimulating mechanoreceptors could essentially override some pain signals, resulting in a decreased perception of pain.
Taken individually, in a vacuum, all these factors have varying degrees of evidence as effective therapies. However, there is no evidence to explicitly show how much of a role each of them play with flossing, or if the compression of flossing is enough to even induce them in the first place.
So, upon inspection, the pillars with which voodoo flossing is built are admittedly not of sand, but are certainly not of Roman concrete either.
Regardless, let’s see how effective voodoo flossing is in practice, according to the research, and if you want to support us making these in-depth videos, hit the like button!
THE RESEARCH
As a quick recap, remember that not all research is created equal. Some studies may not meet the general standards for high quality scientific evidence.
With flossing, it’s difficult to have a placebo control because it’s usually going to be obvious to participants when they do or do not have restrictive bands on them. This may make the research more prone to biased results.
With that in mind, let’s start our research review by trying to answer our first question: Does flossing improve our rehab?
Overview: This 2021 paper studied the efficacy of flossing -- when added to routine treatment in patients with lateral epicondylitis -- compared to conventional physical therapy. They had six patients split into two groups with the study lasting about four weeks. They measured the participants’ pain with the visual analog pain scale (VAS) and the Patient-Rated Tennis Elbow Evaluation (PRTEE) form.
Results: The floss group saw a change in pain from 8/10 to a 4/10, whereas the control went from 7/10 to a 5/10. There was also a 14 point difference favoring the floss group in relation to the PRTEE form, though this was considered statistically insignificant.
Researcher’s Conclusion: Sample size is too small to make any bold claims, but the results indicate a positive effect from flossing.
My Take: Of course the sample size is too small, but I like that this study was done over a fairly long duration and is relatable to climbers. Even if we acknowledge that the p-values weren’t strong enough to make any bold claims, we can assume this was a case of “it didn’t hurt, and maybe helps a little.” Sometimes that’s a good thing; when there’s a possibility of benefit without a high cost it allows more people to try it out.
Verdict: No strong evidence for or against flossing for rehabbing epicondylitis, but potentially some benefit.
Let's see if there are any articles with more conclusive results.
Overview: This 2020 paper studied the effects of flossing on five male recreational athletes with patellofemoral pain syndrome (PFPS) for two days. Participants performed three series of jumping exercises per day while researchers measured things like jump height, jump velocity, and perceived pain. The first day involved performing the exercises and measurements before, during, and after flossing. The second day involved the same exercises and measurements but without flossing.
Results: Between the first set and the third set of exercises, day one saw a statistically significant increase in jump height, time in air, jump velocity, jump power, and jump force, plus a statistically significant decrease in perceived pain. Day two saw no statistically significant changes.
Researcher’s Conclusion: This study adds useful information with relation to flossband application and the reduction of pain and increased performance of those with PFPS.
My Take: There are so many problems with this study stemming from a terminal lack of data and questionable study design. First, there were only five participants. Second, the study was only conducted over the course of two sequential days, with the second day meant to be the control.
Without getting into too much of a rant, suffice it to say that this simply does not give us enough data to account for errors, biases, and other variables. Why did the pain start out at a four on the first day and a six on the second day? Why did jump height start at a 36 on the first day and 32 on the second? Did the flossing give them such a mega workout that they were sore the next day, couldn’t perform as well, and had more pain? Were they just tired from the day before? Were they excited the first day? WHO KNOWS!
Verdict: Problematic study design and lack of data throws all results into question. No strong evidence for or against flossing for rehab.
Unfortunately it looks like we’re left with pretty underwhelming evidence about flossing for rehab. This study got me wondering, though: Could flossing improve our performance?
ARTICLE III: The effects of tissue flossing on ankle range of motion and jump performance [3]
Overview: This 2016 study had 29 male and 23 female participants. Researchers measured the effects of flossing on each participant’s ankle, using the contralateral ankle as the control. They measured weight bearing lunges, plantar flexion range of motion, dorsiflexion range of motion, and jump height (performance). Measurements were taken in a single session before flossing and five minutes after flossing.
Results: Compared to the control ankle, the flossing ankle showed a 1.6 cm improvement in the weight bearing lunge test, a three degree increase in plantarflexion (PF) range of motion, a six degree increase in dorsiflexion (DF) range of motion, a .02 meter increase in jump height, and a 0.15 meters per second increase in jump velocity.
Researchers’ Conclusions: All results were associated with a small effect size in favor of the floss band treatment on the ankle joint, pointing to performance improvements and reduced injury risk in sports involving jumping. Whether or not the effects will last beyond five minutes is undetermined.
My Take: Again we’re dealing with disconcertingly little data as the study was conducted in a single day, though the larger sample size helps offset that a bit. Overall it seems clear that the flossing ankles saw greater increases in range of motion (at least for five minutes), however I question their claims of improved performance. The jump height of the flossing ankle increased by about ~1.57 inches (.04 meters) while the control ankle increased by ~.78 inches (.02 meters). Without more testing and a placebo-control, I don’t think you can say with confidence that tiny difference was a result of flossing and not one of the many other variables. But hey, if it is the placebo effect at work, that’s not all bad -- sometimes that’s the best treatment we have! Plus, they say football is a game of inches. Well, does .78 inches count!?
Verdict: Meh.
Hmm, okay, let’s ask a slightly different question: Is flossing better than other techniques?
Overview: This 2021 article with 80 participants broken into four groups set out to compare the immediate and short term effects of three modalities: instrument assisted soft tissue mobilization (IASTM), tissue flossing, and kinesio taping (KT) with regard to shoulder function in amateur athletes. They used the dominant arm as their treatment and the non-dominant arm as the control group. They looked at the athletes’ internal rotation and external rotation range of motion, isokinetic strength, throwing performance, and seated shot-put performance. They performed these tests immediately after the treatment was applied as well as 45 minutes later.
Results: All therapeutic interventions significantly improved the strength and functional performance of the dominant shoulder in comparison with the control (P < .005) immediately after and 45 minutes after the treatment.
Researchers’ Conclusions: IASTM, tissue flossing and KT can significantly increase range of motion, strength, and total work at both slow and fast isokinetic speeds, as well as the functional performance of overhead athletes’ shoulders. Limitations of the study include: amateur athletes (which may have an impact on training adaptations) plus a lack of a placebo-control group. Also, using EMG or other technology to evaluate muscle activation patterns would have been more accurate.
My Take: It’s unfortunate they only took their measurements for one day (what is it with these one-day studies!?), but it’s great that they had so many participants and compared multiple modalities! With no real differences in outcomes between modalities in the immediate and short term, I guess it’s a personal choice whether you think that’s evidence for or against flossing. Without a placebo-control we again have no reason to rule out the placebo effect. (If you’re curious, there actually is a different flossing study that tried to do a placebo-control and they found no significant difference between the flossing and control groups.)
Verdict: It may or may not be the placebo effect, but flossing appears to be equally as effective as IASTM and KT for increasing some aspects of shoulder performance within 45 minutes of treatment.
Okay, let’s finish off our investigation by trying to get a broader perspective. It’s time for a systematic review!
Overview: This 2021 review included 23 articles from 2014 to 2021. They sought to summarize the latest evidence on the effects of flossband application on joint range of motion, pain, muscle tightness, strength, and performance. (We’ll focus on range of motion, strength, and performance to keep things tidy.)
Results:
Range of motion: 14/14 articles found no significant advantage of flossing over controls or other modalities.
Strength: 4/6 articles found improvement in ankle or knee extension strength.
Performance: 7/10 articles found some kind of improvement with flossing, most of which were studying jumping.
Researchers’ Conclusions:
Range of motion: Flossband application is beneficial in improving ankle, shoulder, and knee range of motion.
Strength: Flossband application is beneficial to enhance muscle strength but conflicting results regarding increasing muscle activity.
Performance: Flossband application could potentially lead to higher rate of force development, and improve physical functional performance.
My Take: Wait, what!? The researchers conclude that flossing is effective for improving range of motion, but the results say that 14/14 articles found no difference between the floss group and control… What gives?
Here’s what’s happening: Both the floss groups and the control groups improved. So, yes, technically you could say “flossing is beneficial.” However, an equally true and less confusing statement would be: “While there do not appear to be any negative effects of flossing on range of motion, it does not appear to be more effective than any of the other interventions.”
For strength and performance, it seems the evidence is in favor of flossing, though the researchers don’t acknowledge the possibility of placebo effect and, based on the lackluster design of some of the other studies we looked at, I don’t have a lot of confidence in the data.
Verdict: Appears largely in favor of flossing for range of motion, strength, and performance, but I’ve become skeptical of the quality of these studies and their conclusions.
A RANT ON RESEARCH
Whew, okay, that was a lot. And if you’re anything like me, you might be feeling a little fatigued by the constant “data unclear, not enough data, can’t say for sure” stuff in a lot of these research review videos. So I actually think it's worth an explanation and maybe a bit of a rant.
Modalities like voodoo flossing present an interesting dilemma for this channel and hardcore evidence-lovers like Emile and me (and maybe you, too). There is often limited or unclear research on these subjects, with some evidence pointing to small benefits mired by the possibility of mere placebo effect, biased results, small sample sizes, and more. Though essential for us to recognize, this can lead to a rather tedious mindset for the average person in which the conclusion is always uncertain and the recommendation vague -- a perpetual shrug 🤷.
So what do we do instead? Do we simply throw out any idea that lacks an overwhelming cascade of perfect evidence?
Consider the following:
Human studies are hard for a variety of reasons (funding, complexity, uncontrollable variables, humans are just messy, etc.)
“Exercise science” is hard
Many modalities are new and/or simply haven’t been studied thoroughly
Research that’s specific (or even loosely relevant) to climbing is sparse
Clearly, perfection is not possible, as we would be left with very few options to help people and no room for experimentation.
Alternatively, do we attempt to subvert the inherent “grayness” of this science with “colorful” interpretations and bold conclusions? This approach is heavily incentivized by media platforms and, all too often, scientific platforms as well. Of course, the pitfalls of the “fitness influencer” mindset are too prevalent and obvious to even list.
So, to ignore the inherent imperfections of human research is foolish, but to accept nothing short of perfection is not productive, and to manipulate it into something more sensational is dangerous and dishonest. Essentially, there is no easy solution.
Nuanced, critical thinking and a willingness to accept uncertainty will always be the way.
Moreover, whether or not the merits of a particular study or body of research are enough to overcome its flaws will ultimately come down to a bit of an educated guess. The more data we have to work with, the more educated that guess can become, which is why we do these research review videos!
In the case of voodoo flossing, we once again find ourselves in that unsatisfying gray area, but let’s try to answer our original questions nonetheless.
WHAT WE LEARNED
Is flossing research good? As usual, the quality is mixed -- there are no bangers, but some studies are okay while others are quite poor. The main thing to note is how essential it is to read more than just the abstract or researcher’s conclusion if you want accurate information, as these can often be oddly written and even misleading.
Does flossing improve our rehab? There is some evidence in favor of flossing for rehab -- even if it is just the placebo effect. However, there is not enough data to draw a strong conclusion.
Does flossing improve our performance? There is some evidence to suggest increased range of motion, strength, and performance with flossing -- most notably for climbers in the shoulder. However, the only data we have is for relatively short term effects, with all studies recording measurements somewhere between five and 45 minutes after flossing. Note that, if flossing does improve performance, it may be an indirect result from a decreased perception of pain rather than a direct mechanical or neurological effect.
Are there any safety concerns? If performed correctly, it does not appear so. However there are some contraindications which we’ll list here:
High blood pressure
Active or history of DVT (deep vein thrombosis)
Pregnancy
Varicose veins
Cardiac disease
Skin or dermatologic issues such as latex allergies
Also, note: Floss bands should not be applied to the head, neck, or chest.
Is it worthwhile for climbers? More research is needed, but because the risk appears negligible there’s not much reason to shy away if you’re interested. In general, in my practice, I won’t be rushing out to tell people to buy floss bands. There are many other modalities and protocols that will assist your training and rehab effectively that have more long-term research behind them. I don’t want to completely dismiss it because I’m always open to new ideas and research, but until I see better evidence I probably won’t be using it on myself either. Unless of course I’m trying that “V10 dyno” in Joe’s Valley and I miss the holds by 0.78 inches ;).
But I’m curious: What do you all think of the research? Is flossing worth a try? If you’ve tried it, what did you find?
If you think other people should see this information, please give the video a thumbs up, and until next time…
Train with proven, effective methods to advance your rehab and training, climb knowing you’re super well educated on these topics, send it without the voodoo floss magic aid…. But then repeat it after having applied flossing and see if it feels easier to you ;)
Disclaimer:
As always, exercises are to be performed assuming your own risk and should not be done if you feel you are at risk for injury. See a medical professional if you have concerns before starting new exercises.
Written and Presented by Jason Hooper, PT, DPT, OCS, SCS, CAFS
IG: @hoopersbetaofficial
Filming and Editing by Emile Modesitt
www.emilemodesitt.com
IG: @emile166
Title
Comparative study regarding the benefits of using medical flossing in lateral epicondylitis
Citation
VRABIE, D., ABALAȘEI, B.-A., & IACOB, G.-S. (2021). Comparative study regarding the benefits of using medical flossing in lateral epicondylitis. SPORT AND SOCIETY. https://doi.org/10.36836/2021/2/41
Key Thoughts
Methods
6 subjects
who had localized pain in the area of the lateral epicondyle exacerbated with the Cozen test.
duration of the symptoms, they having less than 3 months
pain intensity during palpation more than 5 on the Visual Analog Scale (VAS).
The main objective of this study was to investigate the effectiveness of medical flossing added to physiotherapy treatment in patients with epicondylitis, compared to conventional physiotherapy treatment.
3 rehabilitation sessions per week
Group A benefited of the application of the medical flossing during the eccentric exercises targetting the arm and forearm muscles
Another tool for measuring the degree of pain and dysfunction was the PRTEE (Patient-Rated Tennis Elbow Evaluation) questionnaire applied at the beginning of treatment and after 4 weeks of treatment
Results
The statistical interpretation showed that the pain level was significantly lower in the group that benefited from the implementation of medical flossing than the control group
Data obtained from the application of the PRTEE questionnaire show close values between groups in terms of total functional score
Conclusions
Because the number of subjects required to draw a relevant conclusion regarding the effectiveness of the use of medical flossing has been limited, future studies in this area are needed to establish a recovery protocol that includes the use of medical flossing in lateral epicondylitis.
The results from the above tables and figures demonstrate the utility of the medical flossing during eccentric and flexibility exercises in a combination with other therapeutic methods.
Title
The Effects of Tissue Flossing on Perceived Knee Pain and Jump Performance: A Pilot Study
Key Thoughts
In the field of sports, it has been proven that the prolonged use of compressive garments has improved performance in different sports
Five young male recreational athletes with PFPS
Two different days (intervention and control) were used to carry out the protocol, using the application of the floss band in the first of them, and eliminating its use in the second.
Significant differences were found in all the analysed variables regarding the performance of the vertical jump in the protocol applying the floss bands (p<0.05). No significant differences were found in any of the variables analysed related to the vertical jump performance in the protocol that did not apply the floss bands
Significant differences in perceived pain were found in the protocol applying the floss bands (p<0.001). No significant difference in perceived pain was found in the protocol that did not apply floss bands
the application of the floss bands was found to significantly improve the performance of the CMJ, as well as significantly reduce the perception of pain in the knee where the floss bands were applied, but not during their application, but after their removal.
Title
The effects of tissue flossing on ankle range of motion and jump performance.
Citation
Driller MW, Overmayer RG. The effects of tissue flossing on ankle range of motion and jump performance. Phys Ther Sport. 2017 May;25:20-24. doi: 10.1016/j.ptsp.2016.12.004. Epub 2016 Dec 12. PMID: 28254581.
Key Thoughts
Introduction
potential mechanisms behind the benefit of using floss bands may be attributed to fascial shearing and/or reperfusion of blood to the muscle
Methods
Fifty-two recreational athletes (29 male/23 female
To be eligible for the study, all participants were required to be participating in regular physical exercise sessions (>3 times per week) and free from lower-limb injuries (hip, knee or ankle) that may have affected their ability to perform the single-leg jumps
floss band (FLOSS) or no floss band (CON) to the ankle-
Results
FLOSS resulted in significant enhancements in all test measures pre to post application of the floss bands (WBLT, PF, DF JUMPH, JUMPv, p < 0.01), while there were no significant differences pre to post CON (p > 0.05). All measures were all associated with small effects sizes in favour of FLOSS when compared to CON
The WBLT resulted in a 1.8 cm increase pre to post for FLOSS, compared to a 0.2 cm increase in CON.
ROM for both PF (+5) and DF (-7) were improved in FLOSS, compared to just +2 and -1 for CON
Similar increases were observed pre to post for JUMPH in both FLOSS and CON (0.04mand 0.02 m, respectively).
JUMPV was further enhanced (pre to post) in FLOSS (0.15 ms1). when compared to CON (0.03 m1)
Title
The Effects of Instrument-Assisted Soft Tissue Mobilization, Tissue Flossing, and Kinesiology Taping on Shoulder Functional Capacities in Amateur Athletes
Citation
Angelopoulos P, Mylonas K, Tsepis E, Billis E, Vaitsis N, Fousekis K. The Effects of Instrument-Assisted Soft Tissue Mobilization, Tissue Flossing, and Kinesiology Taping on Shoulder Functional Capacities in Amateur Athletes. J Sport Rehabil. 2021 Apr 9;30(7):1028-1037. doi: 10.1123/jsr.2020-0200. PMID: 33837162.
Key Thoughts
In the context of the above scientific deficits and conflictin findings, the purpose of the present study was to compare the immediate and short-term effects of innovative soft tissue techninques with specific instruments (the Ergon® IASTM Technique) and bands (the kinetic flossing technique), of their combined application, and of kinesiology taping on shoulder functionality of amateur athletes
Furthermore, the evaluation of athletes’ functional performance both immediately after and 45 minutes after the application of therapeutic techniques can enhance the functional value of our findings as participation in overhead sports requires high-level performance for extended periods.
Our findings indicate that all therapeutic interventions evaluated in this study—which are widely used by athletes—can significantly enhance the functional ability of the treated shoulder compared to the nontreated shoulder.
These results reinforce the hypothesis that specialized soft tissue and neuromuscular techniques, when applied with specific techniques representing the specific kinetic protype of the sport, can significantly enhance shoulder functional performance in overhead” athletes and should be included in the preparation and rehabilitation techniques of athletes.
Our findings show that IASTM, tissue flossing and kinesiology taping can significantly increase ROM, strength, and total work at both slow and fast isokinetic speeds, as well as the functional performance of overhead athletes’ shoulders.
These positive adaptations could theoretically be attributed to better myofascial recruitment and neuromuscular activation during sport-specific movements, which in turn contribute to better muscular function and improved sliding of the fascial layer
The improvement of shoulder joint strength production after both individual and combined applications of the IASTM and flossing is also supported by the existing literature on the fascial function and myofascial transmission of force.
Fascia has contractile properties like that of smooth muscle due to the presence of myofibroblasts, as they contain alpha smooth muscle actin. This can influence musculoskeletal dynamics and resting muscle tone
This is also supported by the fact that the dynamic function of myofascial structures, which due to the significant percentage of muscle fibers attached to the muscle surrounding fascia, plays an essential role in the production of muscle strength and work.
These functional properties of myofascia can explain the effectiveness of soft tissue techniques in improving muscle strength and total work, as the improvement that a soft tissue release mobilization technique can induce to fascial layers sliding can simultaneously enhance strength production.
Furthermore, this study evaluated healthy amateur athletes and not high-level professional athletes with more evident shoulder overloading and shoulder training adaptations
Another critical limitation that could affect the findings of the study is the absence of a placebo group.
This issue needs to be clarified in future research as the application of ball throwing movement during the application of the therapeutic interventions of the present study can be a training stimulus capable of influencing the results
Still, better evaluation tools such as electrogoniometers and electromyograms could be used to perform functional tests to evaluate muscle activation and performance more accurately.
Future research should also evaluate the long-term effects of these therapeutic interven tions on the shoulder girdle’s functional capacity in overhead athletes to substantiate their clinical value
Title
The effect of tissue flossing technique on sports and Injury Prevention and Rehabilitation: A systematic review of recent research
Citation
Jianhong, G., Soon, C. C., Seng, T. J., Zaremohzzabieh, Z., & Samsudin, S. (2021). The effect of tissue flossing technique on sports and Injury Prevention and Rehabilitation: A systematic review of recent research. International Journal of Human Movement and Sports Sciences, 9(6), 1157–1173. https://doi.org/10.13189/saj.2021.090611
Key Thoughts
Introduction
The purpose of this literature review is to summarize updated evidence about the effects of flossband application on joint range of motion (ROM), pain, muscle tightness, strength, and physical functional performance as well as identify research gaps for future study
Unfortunately, there is little evidence Overall for This technique And the Current evidence. Very few studies showed either positive or negative support for use of tissue flossing.
Methods
studies across seven years from January 2014 to May 2021.
23 full-text journal articles were included for further qualitative analysis
Results
Effect on ROM
Nineteen out of 23 studies examined the effectiveness of flossband application on the ROM of various joints.
Fourteen out of 19 individual studies focused on comparing the effects of flossband application on ankle dorsiflexion of range of motion (DFROM) to other interventions.
The findings of these 14 studies show that there was no significant difference during DFROM between the flossband group and the control group, but there was a positive trend
However, there was a significant difference of DFROM between the pre- and post-tests in the flossband group
Only one out of 19 individual studies wrapped flossband on the upper arm, and the results showed that shoulder flexion was significantly improved
Effect on Hamstring length
One finding revealed that there was no significant difference in hamstring tightness among the groups
Another result showed that there was a significant difference in SLR changes after immediate removal of the flossband compared to the control group.
Effect on Muscle Strength
Six out of 23 studies compared the acute effect of flossband application on the calf or thigh of healthy participants to improve ankle or knee strength, as well as muscle activation.
There was no significant difference of isometric maximal voluntary contraction (IMVC) of ankle plantar flexion force and gastrocnemius (GC) activation among the groups
flossband application on the thigh has benefits in improving the IMVC of knee extension strength, or eccentric MVC of knee flexion, and increasing neuromuscular activity, compared to the control group
In Galis‟ study [24], the result showed that there was no significant difference between the strength of ankle flexion and extension among the groups (control group, group with 150 mmHg flossband wrapping pressure and 200 mmHg flossband wrapping pressure),
Effect on Performance
Ten out of 23 studies examined the acute effect of flossband application on the squat, running, and jumping
The study revealed that squat function was significantly improved after flossband application, but there was no significant difference in squat performance among the groups.
this result indicated that the flossband seems to be as effective as dynamic stretching with closed-kinematics chain or static stretching with closed-kinematics chain
There are two out of 10 individual studies that compared the time of the 5-meter, 10-meter, and 15-meter sprint performance in healthy athletes
The results showed that there was an improvement in the 10-meter sprint and 15-meter sprint group compared to the control group, and these benefits will last up to 45 minutes
Seven out of 10 studies compared the changes in jumping performance between the flossband group and the control group.
Five out of 7 studies showed that there was a significant improvement in jump height, jump velocity, jump power, and jump force after applying a flossband. However, there was only an improvement trend between groups
Discussion
In the field of acute effects of flossband application on the ankle, Driller [19] found that flossband wrapped around the ankle significantly improved ankle dorsiflexion ROM in healthy young athletes. However, these two results were only associated with small effect sizes of 0.21 and 0.31,
I have to chime in here. I’m not even including everything in their discussion because it no longer is comparing it to the control. Just showing it is effective…. But not mentioning the results of the control like the prior group. Wow, super misleading!
Conclusions
50% flossing tension or approximately 150 mmHg wrapping pressure could lead to positive effects on the outcomes of ROM, pain, muscle stiffness, muscle strength and physical function performance when compared with low or high tension or pressure.
Future Research
At the same time, those studies only investigated the short-term effects rather than the long-term effects of flossband application
Title
Effects of Tissue Flossing on the Healthy and Impaired Musculoskeletal System: A Scoping Review
Citation
Konrad A, Močnik R, Nakamura M. Effects of Tissue Flossing on the Healthy and Impaired Musculoskeletal System: A Scoping Review. Front Physiol. 2021 May 21;12:666129. doi: 10.3389/fphys.2021.666129. PMID: 34093228; PMCID: PMC8176205.
Key Thoughts
Introduction
suggested that flossing can increase the range of motion and/or performance (e.g., strength or jumping performance), speed up recovery, and decrease pain caused by various disease or injuries
1 to 3min and to overlap the floss band by 50% with regard to the previous wrap
a floss band application can be applied either on a joint and/or on soft tissue
it has been recommended that movements of the flossed joint or muscles are performed to end range of motion, to enhance the efficacy of the application
In general, there is a belief that flossing can stimulate the mechanoreceptors in the underlying fascial layers, leading to reperfusion of the compressed tissue (hence leading to enhanced blood flow), or causes fascial shearing, and consequently the fascia’s sliding potential will be restored
However, as of the time of writing, there was only some little scientific evidence on the responsible mechanisms behind the possible changes on the range of motion and performance parameters
Therefore, the purpose of this scoping review is to provide an overview of the whole scope of flossing and to clarify the effects and the mechanisms of both a single floss band treatment and a repeated floss band treatment over several weeks the range of motion, performance parameters (e.g., strength or jump performance), pain (caused by various diseases or injuries), injury, and disease, and also on recovery (e.g., delayed-onset muscle soreness, DOMS) in any kind of participant (e.g., athletes, patients).
A further goal is to compare a floss band treatment with other treatments (e.g., stretching or foam rolling) and to clarify if different pressure levels for the applied floss band have an impact on various outcomes.
the aims of this review are to identify the available evidence and to identify knowledge gaps.
15 studies investigated the acute effects of a single floss band application on the range of motion of several joints
RANGE OF MOTION (the following are all related just to range of motion)
Results
The results of the individual studies show that 15 out of the 29 range of motion measures showed a significant increase (individual results of the studies as pre–post comparison) following the floss band application (see Table 2) However, out of these 15 measures, in three measures, the same increase in range of motion was also found in the control group (no floss band applied, but a stretch or movement was performed)
Therefore, these findings indicate that a movement or stretch alone, without a floss band, can lead to a similar conditioning effect
Hence, no favorable effect of flossing was confirmed in these three studies compared to the control condition (i.e., stretching or movement without a flos band). This is in line with a meta-analysis about ankle joint flossing on the dorsiflexion range of motion (Kielur and Powden, 2020), where the authors reported significant increases in the before-to-after comparison, but there were no significant changes when the control groups were included in the meta-analysis
Possible Mechanism
Changes in soft tissue (tissue stiffness)
Changes in perception of pain or stretch
Similar to foam rolling, a flossing treatment causes pressure on the treated muscle, skin, and fascia. Hence, according to this theory, this could have an impact on fluid viscosity and would lead to less resistance to movement
Long Term Effects
Since studies of the long-term effects of flossing have been diverse in terms of the population (patients vs. healthy participants) and the treated joints (ankle vs. shoulder) and due to the fact that the sample sizes have been rather small, no general conclusion should be made.
Conclusion
it can be assumed that both joint flossing and soft tissue flossing have a positive impact on the range of motion, but with only a small to moderate magnitude of change.
This might be explained by the fact that the control condition (movement or stretching alone, without a floss band treatment) induced similar changes in the range of motion in some
Possible mechanism for an increase in the range of motion following a single flossing application is likely related to increased stretch rather than changes in the stiffness of the myotendinous tissue
more studies are needed to determine the effects of a long-term flossing treatment of various populations
PERFORMANCE (the following are all related to performance)
Conclusions
According to the involved studies, it can be concluded that a single floss band treatment seems to have no detrimental effects on performance.
In contrast, there is small evidence that joint flossing (knee and ankle) may increase jump height, and thigh flossing might have a positive impact on knee extensor and knee flexor MVC. However, the reported effect sizes are rather small (mean, 0.244; ranging from 0 to 0.77).
The possible mechanisms for such an increase in performance are increased muscle activity and improved neuromuscular function
This goes in line with the results of Kaneda et al. (2020a), who reported a higher RFD (0–50ms) of the plantar flexors and increased muscle activity of the gastrocnemius lateralis muscles following the floss band treatment, indicating neurological adaptations.
However, enhanced muscle activation was not reported in a further study by Kaneda et al. (2020b) about the effects on the hamstring muscles and the study of Konrad et al. (2020a) about the effects on the quadriceps muscle, although both studies reported increases in performance.
PAIN/RECOVERY
Conclusions
The participants reported significantly reduced DOMS on the measured time points (24 and 48 h post-exercise) compared to the control condition (no flossing)
Thus, the authors concluded that a flossing treatment cannot induce a faster recovery rate or reduce DOMS.
A possible difference between these two reports might be found in the floss band application.
In the study of Prill et al. (2019), the subjects had to move their arm in several directions (flexion, extension, internal/external rotation), but in the study of Gorny and Stöggl (2018), the subjects performed no movement during the application.
Since both the visual analog scale and Likert muscle scale are subjective measures, more objective measures like movement biomechanics (e.g., in running as reported in Paquette et al., 2017) might have led to a clearer picture if flossing can indeed speed up recovery.
PRESSURE IN WRAPPING
The average pressure reported by the 10 studies was 167.3 24.6± mmHg, with a range of 120–210 mmHg. This variety of pressure could have had an impact on the results found between and also within the studies.
It can be assumed that the difference in the pressure where the floss band is applied can have an impact on the results both between and within studies.
Both studies reported favorable results with the low-pressure floss band applications in terms of the range of motion and strength parameters
adverse effects in the high-pressure group in both the range of motion and strength outcome and therefore concluded that tighter does not automatically mean better
Caution should be taken with too much pressure applied by the floss bands. Galis and Cooper (2020) reported some adverse effects in the high-pressure group (200 mmHg) compared to the low- pressure group (150 mmHg) in both the range of motion and strength outcome and therefore concluded that tighter does not automatically mean better. Even worse, one study reported harmful effects, e.g., violent pain, changes in the color of the skin, hematoma, or numbness, in participants who received a floss band treatment on the shoulder
COMPARISON TO OTHER TREATMENTS
Compared to dynamic stretching, Kaneda et al. (2020b) reported a more pronounced effect with a flos band treatment in the increase in hip range of motion and one strength parameter (maximal eccentric knee extension torque). With regard to static stretching and the comparison with a floss band treatment, Kaneda et al. (2020a) reported that RFD was more pronounced in the flossing group than the static stretching group (calf muscles). Interestingly, while the mechanism for the increase in the range of motion following static stretching was considered to be reduced muscle stiffness the floss band treatment showed neurological adaptations as suggested by the observed increase in stretch tolerance (i.e., higher passive torque at end range of motion). Kaneda and colleagues concluded in both studies (Kaneda et al., 2020a,b) that flossing should be applied as a warm-up treatment rather than as a stretching exercise.
A further frequently investigated warm-up modality, besides stretching, is foam rolling, in terms of possible benefits in the range of motion (Nakamura et al., 2021), strength (Reiner et al., 2021), or recovery (Nakamura et al., 2020). Cheatham et al. (2020) compared a flossing treatment with a single session of foam rolling and also with instrument-assisted soft tissue mobilization (a kind of massage). All three modalities showed an increase in the range of motion, but there was no difference found between the modalities.
To date, there is not much evidence about the possible benefit of flossing compared to other treatments.
When compared to stretching, flossing showed a superior conditioning (warm-up)
effect in a few parameters (Kaneda et al., 2020a: RFD; Kaneda et al., 2020b: range ofmotion,maximal eccentric knee extension), but in most parameters (Kaneda et al., 2020a: range of motion, MVC; Kaneda et al., 2020b: maximal eccentric knee flexion MVC; RFD), no significant difference was reported.
Moreover, the mechanism which is responsible for the changes in the range of motion or performance following flossing is likely different to that in stretching.
No differences in the effects on the range of motion have been detected between flossing and foam rolling and instrument-assisted soft tissue mobilization.
However, more research is needed to compare the long-term effects of the different techniques (flossing vs. stretching) or even to investigate the combined effects (e.g., flossing and stretching combined).
Conclusions
Although not yet clearly understood, a possible mechanism for such changes in the range of motion is likely due to increased stretch tolerance rather than changes in the mechanical parameters of the muscle (e.g., stiffness)
All in all, there is a need to conduct long-term studies about the effects of flossing treatments on various parameters like the range of motion or performance and their mechanism (e.g., pain tolerance)
Since to date a lot of theories and only poor evidence exists on the topic of flossing, we strongly encourage performing further prospective studies about the acute and long-term impact on the healthy and impaired musculoskeletal system and theunderlying mechanisms.
Title
Acute Effects of Tissue Flossing Coupled with Functional Movements on Knee Range of Motion, Static Balance, in Single-Leg Hop Distance, and Landing Stabilization Performance in Female College Students
Citation
Wu S-Y, Tsai Y-H, Wang Y-T, Chang W-D, Lee C-L, Kuo C-EA, Chang N-J. Acute Effects of Tissue Flossing Coupled with Functional Movements on Knee Range of Motion, Static Balance, in Single-Leg Hop Distance, and Landing Stabilization Performance in Female College Students. International Journal of Environmental Research and Public Health. 2022; 19(3):1427. https://doi.org/10.3390/ijerph19031427
Key Thoughts
Introduction
Developed by physical therapist Kelly Starrett [21], FLOSS is a type of elastic band made of rubber that can be wrapped around joints or muscle groups during exercise or stretching. Most tissue flossing mechanisms involve blood flow restriction (BFR). Reperfusion, fascial shearing, and occlusion of blood to muscle tissue may be the physiological mechanisms underlying the effect of flossing [22]. For example, tissue flossing results in temporary tissue ischemia and blood flow reperfusion after FLOSS removal, which can enhance metabolic response and alter the microenvironment by increasing growth hormone and catecholamine levels. These hormones may affect sports performance
Moreover, tissue flossing may increase the pain threshold through compression (e.g., gate control theory), thus improving ROM and muscle flexibilit
and were still present at least 7 h after the removal of FLOSS
The effect of tissue flossing on flexibility and static and dynamic balance in the lower limbs requires further research.
Methods
Twenty healthy female university students who were active in recreational sports were enrolled
recreationally active (exercising 2–3 times weekly)
randomly assigned
During this interval, participants were prohibited from participating in intense exercise, which was defined by a rating of perceived exertion greater or equal to 14 [41] and included activities such as weight training and moderate- to high-intensity running.
The assessments were performed immediately after and 20 min after each intervention.
Outcomes
The primary outcome was muscle flexibility
An Ely test was used to assess the flexibility of each patient’s rectus femoris
This test has a high intraclass correlation coefficie
A popliteal angle test was used to assess the flexibility of each patient’s hamstrings
The secondary outcomes were time spent sustaining a single-leg stance [47], distance on the single-leg triple-hop test [48], and landing stabilization performance
perform the following functional movement tasks: walking knee hugs, side squats, and forward lunges
Pressure was produced through wrapping of the joint with 50% tension and 50% overlap.
As a control, a 4-inch ELA was wrapped around the dominant knee of each participant with the same wrapping technique as for the floss band, and the physical therapist guided the participant to perform the same three functional movement tasks that they performed when wearing the FLOSS wrapping
The ELA, when applied in accordance with manufacturer instructions, is designed to stretch in accordance with the movement of the body for comfort.
Results
All the participants completed all of the trials in the study without adverse events.
No significant differences in preintervention measurements were identified between the two conditions
Primary outcomes
In our analysis of quadricep flexibility, no significant condition time interaction was observed
In our analysis of hamstring flexibility, a significant condition time interaction was Observed
Secondary outcomes
In our analysis of static balance, no significant condition time interaction was observed, and the main effects of time and condition were nonsignifican
As indicated in Table 3, in our analysis of dynamic balance, the effects of the FLOSSintervention on single-leg triple hop for both feet did not exhibit a significant condition
In our analysis of landing stabilization, no significant condition time interaction was observed
Discussion
The results of our study indicated that after receiving a FLOSS applied to the knee joint, the participants exhibited significantly higher hamstring flexibility for up to 20 min.
The participants exhibited no significant changes in static or dynamic balance
none of the participants reported pain, numbness, cold or hot sensations, skin irritation, or other adverse effects during or after the mechanical compression and transient BFR in this study.
The possible therapeutic effects of floss bands may be attributed to a combination of myofascial rehydration, partial vascular occlusion, and local BFR
The compression of FLOSS and the movements performed while flossing induce fascial shearing, which can deform adhesion points, facilitate myofascial sliding, and facilitate the restoration of normal fascial alignment
the compression of a floss band and the additional functional movements trigger mechanoreceptors, according to the gate control theory of pain, which results in pain relief
Reperfusion to the temporary ischemic area has been reported to induce the release of exercise performance related factors, such as growth hormones and catecholamines, and alter muscle contraction strength and torque
In the static balance and single-leg hop tests, no significant differences were identified among the participants’ values at pretest versus immediately or 20 min after intervention in either group; this indicates that tissue flossing cannot significantly affect the stability and balance of the lower limbs.
The participants’ average LESS scores did not decrease significantly immediately after flossing, which indicates that mechanical compression and transient BFR during flossing does not affect the risk of knee injury.
In practical applications, tissue flossing serves as a new option for athletes who wish to increase their joint ROM quickly and briefly
