Perceived Pain Responses to Foam Rolling Associate with Basal Heart Rate Variability
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R E S E A R C H
Perceived Pain Responses to
Foam Rolling Associate with
Basal Heart Rate Variability
Marvette Wilkerson, MS, Christopher Anderson, BS, Gregory J. Grosicki, PhD,
Andrew A. Flatt, PhD*
Biodynamics and Human Performance Center, Department of Health Sciences and Kinesiology, Georgia
Southern University (Armstrong Campus), Savannah, Georgia, USA
Background: Foam rolling (FR) is a INTRODUCTION
self-myofascial release technique with
unclear effects on autonomic functioning, The physiological stress response is
indexed by heart rate variability (HRV). partly regulated by the sympathetic (i.e.,
FR can be perceived as painful or relax- fight or flight) and parasympathetic (i.e.,
ing, which may explain interindividual rest and digest) branches of the auto-
HRV responses. nomic nervous system, which helps to
Purpose: To determine if acute FR alters maintain homeostasis through the coor-
resting HRV. A secondary aim was to de- dination of diverse physiological systems.(1)
termine if perceived pain during FR would Heart rate variability (HRV), defined as
predict HRV responses. the variation in time between successive
Setting: Academic institution. heartbeats, is a simple, non-invasive, and
Methods: In a randomized, crossover cost-effective tool to evaluate autonomic
design, healthy adults (50% female) per- functioning as a means to gain insight
formed total body FR or control on sepa- into stress recovery and physical activity
rate days. Perceived pain ratings were readiness.(2) Depressed HRV reflects au-
obtained following FR of each muscle tonomic imbalance shifted in the sympa-
group and summed to generate an overall thetic direction. Short-term reductions in
perceived pain rating. Seated measures HRV have been associated with stress and
of the mean RR interval and the natural fatigue,(3) whereas chronically suppressed
logarithm of the root-mean square of suc- values are associated with various patho-
cessive RR interval differences (LnRMSSD, logical conditions(4) and greater all-cause
a parasympathetic HRV index) were ob- mortality risk.(5) Contrastingly, higher HRV
tained at 5-10 min pre-, 5-10 min post-, and is associated with superior health and
25-30 min post-FR. longevity.(6) As such, regular (e.g., daily)
Results: No effects were observed for tracking of HRV is becoming increasingly
RR interval (p = .105–.561) or LnRMSSD (p popular in healthy,(7) athletic,(8) and clini-
= .110–.129). All effect sizes ranged f rom cal populations alike.(9) Moreover, there
trivial–small (0.00–0.26). Changes in RR is great interest in lifestyle behaviors and
interval (r = 0.220–0.228, p = .433–.488) and interventional strategies to mitigate physi-
LnRMSSD (r = 0.013–0.256, p = .376–.964) cal stress via activation of the parasym-
were not associated with pain scale sum. pathetic nervous system, reflected by an
Baseline LnRMSSD was associated with increase in HRV.(10)
pain scale sum (r = -0.663; p = .001). Massage is an intervention convention-
Conclusion: FR did not systematically ally used to decrease muscle tension (11)
alter HRV, nor did perceived pain ratings that has shown promise as a means to
predict HRV responses. Those with lower modulate autonomic stress via stimulation
pre-FR HRV reported higher perceived of cardiac-parasympathetic activity under
pain during FR. Basal cardiac autonomic resting(12,13) or postexercise conditions.(14)
activity may, therefore, influence pain sen- However, massage may be inaccessible for
sitivity to FR in healthy adults. many due to prohibitive costs or exorbitant
time requirements. Whether more readily
KEYWORDS: self-myofascial release; car- available bodywork alternatives may simi-
diac autonomic; rolling massage larly reduce physiological stress, reflected
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International Journal of Therapeutic Massage and Bodywork—Volume 14, Number 2, June 2021WILKERSON: FOAM ROLLING AND HEART RATE VARIABILITY
by increased parasympathetic activity and was determined that a minimum total of
thus HRV, remains to be determined. 10 subjects was required (G*Power software
Self-myofascial release techniques are version 3.1.9.4; Franz Faul, Heinrich-Heine-
commonly used by athletes and wellness Universität, Düsseldorf, Germany). Thus,
enthusiasts as a means to enhance recov- 15 healthy and recreationally active young
ery through a reduction in pain and inflam- adults were recruited for this study via
mation.(15) Foam rolling is among the most convenience sampling. One subject was
popular forms of self-myofascial release, excluded due to an irregular heart rhythm.
and involves a series of body weight exer- Thus, 14 volunteers were included in the
cises intended to apply compressive forces final analysis (50% female; age = 25.86 ±
to a specific muscle or group of muscles 2.13 yrs.; height = 172.04 ± 12.82 cm, weight
using a high-density foam cylinder. Previ- = 84.16 ± 16.90 kg). All participants reported
ous research has provided evidence for the having performed foam rolling exercise
efficacy of foam rolling as a means to in- within the past 30 days and were free from
crease joint range of motion(16) and reduce cardiovascular, metabolic, and orthopedic
delayed onset muscle soreness.(17) How- disorders. Subjects reported not taking
ever, research on the cardiac autonomic any heart rate-altering medications (e.g.,
influence of foam rolling is limited and β-blockers or β2-2 agonists). The study was
has produced mixed results. Though evi- approved by the University’s Institutional
dence for an increase in parasympathetic Review Board. All study procedures, risks,
activity following foam rolling has been and benefits were explained to the partici-
observed,(18) other studies have shown no pants and written informed consent was
significant effects.(19) One possible explana- obtained prior to participation.
tion for these inconsistent findings may
be that interindividual cardiac autonomic Study Design
responses to muscular trigger point com-
pressions may be influenced by pain sen- Using a randomized cross-over design,
sation,(20) where foam rolling may reduce participants reported to the laboratory for
HRV among pain-sensitive individuals via two visits, each of which was separated by
nociceptor-mediated sympathetic acti- a minimum of 48 hrs but no more than
vation.(21) However, associations between seven days, and were scheduled at the
cardiac autonomic activity and perceived same time of day to control for diurnal
pain ratings in response to foam rolling variation in HRV.(23) Participants performed
have yet to be investigated. a bout of foam rolling or simulated control
Given the similarities between passive in random order. Perceived pain ratings
massage and self-myofascial release using were obtained throughout the foam rolling
a foam roller, an improved understand- intervention and summed intraindividu-
ing of whether foam rolling may serve as ally. Electrocardiographic (ECG) recordings
a cost- and time-effective alternative to were performed for 10 min immediately
reduce stress via autonomic modulation before and for 30 min after each condition.
is warranted. The purpose of the present
study was to determine if an acute foam Procedures
rolling session affects resting cardiac
parasympathetic activity, measured using Intervention
HRV. A secondary aim was to evaluate the The intervention consisted of an acute
hypothesis that subjective ratings of pain foam rolling session lasting ~7 min that was
during the foam rolling session would pre- performed using a moderate density foam
dict HRV responses. roller (AXIS Standard 91.4 cm × 15.2 cm,
OPTP, Minneapolis, MN). The single-session
foam rolling intervention targeted major
METHODS muscle groups throughout the body in
the following sequence, performed for one
Participants series: 1) lower posterior leg, 2) knee flexors,
3) knee extensors, 4) elbow extensors, 5)
The smallest worthwhile change thresh- latissimus dorsi, and 6) upper back. Sub-
old commonly used in HRV-guided exercise jects started the foam rolling session on
training interventions is ± 0.5 of the baseline the right side of the body and proceeded
standard deviation.(22) To detect an effect to roll the specified muscle group for 30
size of 0.5 with 80% power and α of 0.05, it sec before switching to their left side. For
15
International Journal of Therapeutic Massage and Bodywork—Volume 14, Number 2, June 2021WILKERSON: FOAM ROLLING AND HEART RATE VARIABILITY each muscle, participants were instructed of delayed-onset muscle soreness on per- to roll back and forth at a self-selected ceived pain ratings. pace in a direction parallel to the muscle architecture. Constant tension was applied Statistical Analysis throughout and the process was repeated for each group of muscles. For the con- Normality of the standardized residuals trol condition, participants were asked to for RR interval and RMSSD were assessed simulate the foam rolling exercises without with Shapiro-Wilks Tests. Natural logarithm the use of the foam roller. The simulation (Ln) transformations were applied to the involved performing movements and nonnormally distributed RMSSD values (p isometric holds in positions that mimic
WILKERSON: FOAM ROLLING AND HEART RATE VARIABILITY
Table 1. Mean and Standard Deviation for:
Table 1(a). Condition
Control Foam Roll p, ES
RR Interval (ms) 857.7 ± 141.9 858.1 ± 109.5 .56, 0.00
LnRMSSD 3.83 ± 0.54 3.95 ± 0.53 .11, 0.22
Table 1(b). Time
T1 T2 T3 T1 vs. T2 T1 vs. T3 T2 vs. T3
p, ES p, ES p, ES
RR Interval (ms) 861.2 ± 137.8 842.9 ± 122.6 860.8 ± 119.9 .12, -0.14 .95, 0.00 .21, 0.14
LnRMSSD 3.93 ± 0.55 3.87 ± 0.54 3.86 ± 0.53 .24, -0.11 .10, -0.13 .88, -0.02
Table 1(c). Condition × Time
T1 T2 T3 T1 vs. T2 T1 vs. T3 T2 vs. T3
p, ES p, ES p, ES
RR Interval (ms)
Foam Roll 873.2 ± 117.3 842.9 ± 112.2 858.1 ± 104.9 .14, -0.26 .80, -0.13 .79, 0.14
Control 849.3 ± 159.3 842.9 ± 136.4 863.8 ± 138.6 .99, -0.04 .96, 0.09 .76, 0.15
Foam Roll vs. Control p, ES .66, -0.17 1.00, 0.00 1.00, 0.05
LnRMSSD
Foam Roll 4.03 ± 0.52 3.88 ± 0.56 3.94 ± 0.55 .11, -0.27 .65, -0.16 .85, 0.10
Control 3.84 ± 0.59 3.87 ± 0.52 3.77 ± 0.52 .99, 0.05 .83, -0.12 .49, -0.19
Foam Roll vs. Control p, ES .29, -0.33 .99, -0.02 .40, -0.31
LnRMSSD = natural logarithm of the root mean square of successive R-R interval differences; T1 = time point 1
(baseline); T2 = time point 2 (5–10 min post-foam rolling or control); T3 = time point 3 (25–30 min post-foam
rolling or control); ES = effect size.
DISCUSSION Contrary to our hypothesis, a total
body foam rolling session did not affect
In this randomized, crossover study, we indices of cardiac autonomic activity. Ini-
observed no effect of an acute foam rolling tial research in this area demonstrated
session on resting RR interval or vagally- reductions in heart rate, blood pressure,
mediated HRV in young and recreation- and stress hormones (e.g., cortisol), con-
ally active men and women. Meanwhile, a comitant with an increase in HRV following
significant, inverse relationship between passive massage techniques.(29) Building
pain scale sum and baseline LnRMSSD upon these findings, a recent investigation
was observed, portending to a link be- provided evidence for greater parasympa-
tween activity of the Vagus nerve and the thetic modulation, indexed by increased
perception of pain. Collectively, these find- normalized high frequency spectral power
ings highlight that self-myofascial release (p < .01) and reduced systolic and diastolic
using a foam roller is an ineffective means blood pressure, for up to 30 min following
of modulating autonomic stress via cardiac total body foam rolling in 15 healthy young
parasympathetic stimulation, but that adults.(18) Another study reported improve-
resting vagal activity appears to influence ments in cardiovascular health mark-
pain perception. ers (i.e., improved endothelial function
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International Journal of Therapeutic Massage and Bodywork—Volume 14, Number 2, June 2021WILKERSON: FOAM ROLLING AND HEART RATE VARIABILITY
Figure 1. Individual RR interval and natural logarithm Figure 2. Association between pain scale sum and
of the root mean square of successive differences baseline RR interval and natural logarithm of the root
(LnRMSSD) responses to foam rolling (FR) vs. control. mean square of successive RR interval differences
(LnRMSSD).
assessed by plasma nitric oxide concentra-
tions, reduced arterial stiffness indexed by in combination with the recreationally ac-
pulse-wave velocity) following a foam roll- tive nature of our participants, complete
ing intervention relative to control (n = 10 recovery of HRV would be anticipated by
healthy young adults, p < .05).(30) Although our 30 min time point (i.e., T3).(32) Neverthe-
lacking a control condition, similar findings less, passive relaxation during therapeu-
have recently been reported that showed tic massage may explain observations of
reductions in central blood pressure indi- acute reductions in HR and improvements
ces and arterial stiffness, predominantly in HRV.(12,33) Other notable differences that
at the 30 min time point following foam may amplify parasympathetic modulation
rolling (p < .05).(31) However, in agreement from massage include the use of aromatic
with the current findings, no changes in oils,(34) and potential massage-induced in-
resting heart rate (i.e., RR interval) were creases in oxytocin and reductions in adre-
observed (p > .05).(31) Also in support of the nocorticotropic hormone and cortisol,(35,36)
current findings, foam rolling was recently that do not occur with foam rolling.(37) In
demonstrated to have no appreciable in- addition, manual techniques by trained
fluence on indices of autonomic function therapists may be more effective at target-
(i.e., RMSSD and pulse wave velocity) fol- ing trigger points, which has been shown
lowing a demanding high-intensity sprint to increase vagal HRV parameters.(20) Fur-
session.(19) Collectively, foam rolling seems ther identification of the mechanism(s)
to favorably augment hemodynamic pa- underlying the therapeutic differences
rameters under resting conditions,(18,30,31) between passive massage and self-myo-
but its impact on centrally-mediated car- fascial release using a foam roller may help
diac control remains equivocal. to guide future interventions seeking to
Compared to therapeutic massage, the increase the efficacy of foam rolling as a
more active nature of foam rolling exercise strategy to mitigate autonomic stress.
inherently necessitates a transient with- To aid in the discovery of mechanisms
drawal of parasympathetic modulation responsible for HRV responses to foam roll-
that may be anticipated to acutely de- ing, we were the first to query participant
press HRV. An increased oxygen demand discomfort via pain scale summation. The
as a result of both dynamic and isometric null association between this metric and
skeletal muscle activation to support one’s relative changes in HRV at either postint-
body mass whilst foam rolling, stimulates ervention time point implies that the lack
an increase in respiration and heart rate. of observed cardiac parasympathetic ben-
However, given the low intensity and short efit was not a product of excess nociceptor
duration of our foam rolling intervention, stimulation. Contrasting with our finding,
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International Journal of Therapeutic Massage and Bodywork—Volume 14, Number 2, June 2021WILKERSON: FOAM ROLLING AND HEART RATE VARIABILITY
changes in perceived pain via visual analog participants performed the foam rolling
scale in response to manual trigger point exercise at a self-selected pace, which
relief of the neck was associated (n = 21, r2 may enhance external validity. However,
= 0.272, p < .05) with high frequency spec- interindividual differences in foam rolling
tral power (a vagal-related HRV index).(20) It speed are acknowledged as a limitation
was hypothesized that overuse of muscles of the present investigation. Furthermore,
builds an excess of acetylcholine at the whether similar HRV responses would be
motor endplate, causing a sustained con- observed among individuals without foam
tractile state in muscle fibers (i.e., knots), rolling experience is unclear. Though foam
which leads to local ischemia- or hypoxia- rolling sessions were consistently moni-
induced pain.(20) Alleviation of pain through tored by the lead investigator, compressive
trigger point relief is thought to be a result forces on the foam roller could be some-
of reduced sympathetic activity, which may what self-regulated by participants. Thus,
increase peripheral blood flow, promote subtle modifications to body positioning
removal of noxious byproducts, and blunt could have alleviated foam roller-induced
excess discharge of acetylcholine.(20) An al- discomfort, effecting perceived pain rat-
ternative rationale for our lack of an associa- ings. Further investigation is therefore
tion may be explained by pain being more warranted to support the current f ind-
commonly associated with indices of sym- ings, particularly in regard to HRV and
pathetic baroreflex activity more so than pain sensitivity. Finally, the study was un-
vagal-related HRV.(21) Additionally, effects derpowered for detecting smaller effects
of pain on cardiovascular and autonomic than those which were targeted, which is
parameters may only be transient(21) and, another limitation.
thus, uncaptured after 5 min of seated rest The major f inding of the present in-
post-foam rolling in the current protocol. vestigation was that a total body foam
Intriguingly, baseline LnRMSSD was rolling session failed to influence vagally-
significantly associated with the magni- mediated HRV or resting mean RR inter-
tude of pain sensation among the current val in healthy, recreationally active young
sample. The association between chronic adults. The lack of association between
pain and reduced vagal-related HRV is self-reported pain and changes in HRV or
well established.(38) However, few studies RR interval following foam rolling exercise
have investigated the association between suggests that pain-related factors were
basal HRV and pain responses.(21) It’s been not likely responsible for interindividual
shown that a derivative of high-frequency difference in cardiac autonomic responses.
spectral power predicted perceived pain However, our novel f inding of an asso-
intensity (0–10 scale) among conscious ciation between basal HRV and perceived
burn patients undergoing scheduled pain in response to foam rolling suggests
wound treatment.(39) Contrastingly, greater that parasympathetic activity may influ-
low-frequency spectral power (reflective of ence pain sensitivity.
baroreflex activation) was associated with
lower ratings of unpleasantness, but not
pain intensity, during thermal hand pain ACKNOWLEDGMENTS
(4°C cold plate exposure),(40) and high-fre-
quency power showed no predictive ability We thank the participants for volunteer-
for any of the pain-related outcomes.(40) ing their time to partake in the study. The
Though HRV was not assessed, a previous study was conducted without funding.
investigation reported that vagal nerve
stimulation via an implantable device
suppressed pain scale ratings among 10 CONFLICT OF INTEREST NOTIFICATION
epileptic patients undergoing experimen-
tally induced pain.(41) Interpreted together, The authors declare there are no con-
these findings allude to a potential roll for flicts of interest.
targeting the parasympathetic nervous
system for pain management.
Strengths of this study include our ran- COPYRIGHT
domized, crossover design, as well as the
inclusion of both male and female partici- Published under the CreativeCommons
pants with a recent history of foam rolling. Attribution-NonCommercial-NoDerivs
Unlike previous research in the field, our 3.0 License.
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International Journal of Therapeutic Massage and Bodywork—Volume 14, Number 2, June 2021WILKERSON: FOAM ROLLING AND HEART RATE VARIABILITY
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