The Effects of Foam Rolling after Task-Oriented Circuit Training on Gait, Balance, and Range of Motion in Parkinson’s Disease: A Randomised Controlled Trial

Abstract

Introduction

Task-oriented circuit training (TOCT) is known to improve balance and gait in people with Parkinson’s disease. This study aimed to examine whether post-TOCT myofascial release with foam roller (FR) could extend this effect by improving gait parameters, balance performance, and joint range of motion (ROM) in Parkinson’s disease (PD).

Methods

The study was conducted in the neurological rehabilitation unit and involved 36 participants with PD who were randomised into an intervention group (IG, n = 18) and a sham group (SG, n = 18). Both groups received TOCT for 3 days and 8 weeks. After exercise, myofascial release was applied to the neck, trunk, and lumbar region using three sets of 60-s FR in both groups. Participants’ spatiotemporal gait parameters, balance, cervical, trunk, and ankle dorsiflexion ROM, motor symptoms, stability limits, functional mobility, quality of life, and goal attainment level were assessed before and after the procedure.

Results

Compared with the SG, gait speed, balance, stability limits, dynamic sitting balance, and trunk control improved in the IG; neck, trunk, and ankle ROM increased; and motor symptom severity decreased (p < 0.05). There was no statistically significant difference in quality of life and goal attainment scores between groups (p > 0.05).

Conclusion

FR is an effective method of supporting TOCT to improve gait speed, balance, and ROM in PD. Our findings support the inclusion of myofascial release in PD rehabilitation programmes. Clinical Trial Number: NCT05900934 (ClinicalTrials.gov).

Introduction

People with Parkinson’s disease (PwPD) often experience difficulties with mobility, balance, and joint mobility [1]. Changes in posture and range of motion (ROM) can significantly impact activities that involve movement magnitude, such as stride length [2, 3]. Early signs of gait disturbance in untreated Parkinson’s disease (PD) include reduced trunk rotation, reduced and asymmetric arm swing, and increased double support time [4]. In the early stages of PD, before the onset of lordosis, ROM is limited, and movements are restricted [5]. In addition, a reduction in axial rotation movement can affect gait characteristics, including speed and stride length [6].

Foam roller (FR) has been reported to aid the healing process, improve ROM, muscle performance, and proprioceptive sensation in various body regions [7]. They can also reduce exercise-induced muscle soreness and improve performance and balance [8–10]. The activation of fascial mechanoreceptors may influence muscle tone due to the physiological relationship between muscle and fascia [11]. Studies indicate that FR can reduce fascial scarring from repetitive exercise, increase flexibility, and enhance balance [8, 12]. Furthermore, combining FR with exercise improves functional range, alleviates pain, and enhances performance in individuals with multiple sclerosis (MS) as well as reduces motor symptoms and improves balance in those with PD, more effectively than either intervention alone [13–15].

Task-oriented circuit training (TOCT) is an alternative form of exercise that can improve balance and gait function in PD, stroke, and MS [16–18]. TOCT is a rehabilitation protocol that translates work tasks, including key motor tasks, into activities based on the tasks that people need to perform in their daily lives [17, 18]. Research has shown that TOCT is also beneficial in improving postural stability, reducing the risk of falls, and enhancing dynamic balance and functional performance in PwPD [17, 19].

Although numerous studies have investigated the effects of exercise in PwPD, the impact of combining exercise with FR on gait and other variables remains unexplored. A recent pilot study demonstrated that FR combined with TOCT may reduce disease-related motor symptoms and enhance dynamic balance [15]. These preliminary findings underscore the need for further investigation into the specific effects of FR. Given that limitations in trunk ROM in PwPD may be influenced not only by neural but also by non-neural (e.g., fascial) structures, exploring the role of myofascial release is of particular interest. Therefore, the present study aimed to examine the effects of post-exercise myofascial release on gait, balance, and joint ROM in individuals with PD.

Methods

Study Design

This parallel-group, assessor-blinded, randomised clinical trial compared two groups of participants with PD. The study was conducted at the Faculty of Physical Therapy and Rehabilitation, Hacettepe University (January 2023 to January 2025). The trial is registered as NCT05900934.

Study Population

The study included participants diagnosed with PD who applied to Hacettepe University Faculty of Physiotherapy and Rehabilitation and who met the following inclusion criteria: Hoehn and Yahr stages 1–3, aged between 40 and 80 years, with a score of at least 23 on the standardised Mini-Mental State Examination [20], stable in terms of motor fluctuations and medication, and no additional neurological problems. Participants were excluded from the trial if they had cardiopulmonary problems, visual or hearing impairment, were unable to walk independently, had a musculoskeletal condition that prevented exercise, had undergone deep-brain stimulation for PD, had participated in a physiotherapy programme in the previous 6 months, had previous experience of using FR, or had knowledge of the principles of using FR. Participants were excluded from the trial if they missed three consecutive sessions or a total of five sessions during the 24-session intervention.

The sample size calculation was based on the assessed stride length in PD according to Zanardi et al. [2]. The minimum sample size was calculated to be 32 participants (16 in each group) by using G-Power (ver. 3.1) software (confidence level: 95%, power: 80%, and effect size: 1.032). Considering the 10% dropout rate, it was planned that a total of 36 people to be included in the study, with 18 in each group [2, 21]. The CONSORT flowchart is shown in Figure 1, and the CONSORT checklist is located in the online supplementary material 1 (for all online suppl. material, see https://doi.org/10.1159/000550230).

Fig. 1.

Recruitment and randomisation of patients in the study.

Randomisation and Masking

To maintain balanced allocation across groups, the principal investigator (S.A.Y.) implemented a block randomisation method, grouping participants in sets of 18. Group allocation was performed using an online tool available at https://www.randomization.com. The assignments were placed in opaque, sealed envelopes labelled with sequential numbers, which were then distributed to participants by the researcher [15].

Treatment sessions for both groups were conducted at different times, when the participants were in ‘on’ state. The sham group (SG) and intervention group (IG) were blinded to the type of myofascial release they received to prevent participants from learning about each other’s interventions. The practitioner therapist (K.K.) was the only individual who was not blinded and was not involved in the assessments and statistics. The statistician and evaluator were also blinded to the participants’ results during the two assessments.

Study Intervention

The TOCT exercise programme comprises 14 workstations, each with its own programme content. The programme content was applied consistently with the research in the literature (online suppl. material 2) [16, 18]. Both groups had FR applied to the same areas at the same times and intervals on different session days. However, the intensity of application and the position of application were different, in accordance with the literature [10, 22]. The erector spinae and latissimus dorsi muscles of the lumbar, thoracic, and cervical spine regions were rolled for three sets of 60-s applications with 30 s of rest between sets, for a total of 14 min after all individual exercise sessions. The pressure intensity was determined using a perceived discomfort level 7/10 target numeric rating scale (0 representing no discomfort and 10 representing maximal discomfort), based on feedbacks from individuals during each session for the IG [23]. However, the FR was adjusted to minimise mechanical pressure (0/10 target numeric rating scale) on body structures in the SG [22]. It has been reported that even light rolling can activate skin receptors and increase pain sensitivity. Therefore, the participants performed foam rolling in accordance with the previously reported very light, painless foam rolling ‘sham’ application [23]. The detailed application procedure was described in our previous study [15].

Outcome Measures

Primary outcome measures were gait parameters, balance, and ROM measurements were made with GAITRite electronic walkway (CIR System Inc., Clifton, NJ 07012, USA), Berg Balance Scale (BBS), and universal goniometer. GAITRite is the gold standard for the assessment of time-distance characteristics of gait [24]. Time-distance characteristics of individuals’ gait, such as velocity (cm/s), cadence (steps/s), stride duration (s), gait cycle time (s), stride length (cm), and mean normalised velocity, are evaluated. The Turkish version of BBS was used to evaluate functional balance [25]. Active ROM was measured three times for cervical region, thoracic region, and ankle dorsiflexion movements. All joints are positioned according to the anatomical position before the measurement, which is considered the baseline position and was performed according to the method described by the American Academy of Orthopaedic Surgeons and Norkin and White [26, 27]. Only ankle dorsiflexion ROM was assessed using the lunge test method described in the literature. The participant’s dominant foot is placed with the toes perpendicular to the wall and the heel off the ground, and in this position, the participant is asked to lunge forward and touch the knee to the wall. The degree at the last point that the individual could reach during the forward lunge was recorded [27]. A universal goniometer was used for all ROM measurements.

Secondary Measurements

Secondary measures were motor symptoms of the disease, postural measures, functional mobility, quality of life, and treatment goal attainment. The Turkish version of the MDS-UPDRS-III (Unified Parkinson’s Disease Rating Scale-Motor Score) was utilised to evaluate the severity of motor symptoms. When the total score increases, the motor symptoms of the disease also increase [28]. The Bertec Balance Check Screener™ force platform system (BP5050, Bertec Co., Columbus, OH, USA) is a device that can assess the patient’s limits of stability in two different ways (anteroposterior and lateral) [29]. The timed-up-and-go test is a clinical test that assesses gait and balance in PD and is used to evaluate functional mobility [30]. Parkinson’s Disease Questionnaire (PDQ-8) is a self-report evaluation of health-related quality of life over the past month, with eight items. The total score is calculated as a percentage, and higher scores are suggestive of poorer health-related quality of life [31]. The Goal Attainment Scale (GAS) assesses the extent to which individuals have achieved their treatment goals throughout the treatment. Each goal is rated on a 5-point scale of −2, −1, 0, +1, +2. While 0 = expected outcome after intervention, −2 = much less than expected outcome, −1 = less than expected outcome, +1 = greater than expected outcome, +2 = much greater than expected outcome, and the total score is calculated, the level of achievement of the treatment goal is evaluated [32]. Each participant’s assessment was performed during the ‘on’ period, which was defined as the time when the patient had recovered 60 min after receiving the last dose of l-dopa, at the same assessment site and at the same time of day, as coordinated by the evaluator.

Statistics

All data were tested for normality using the Shapiro-Wilk test, followed by visual inspection of the Q-Q plot and the box plots. Categorical data were summarised as numbers and percentages, and numerical data were summarised as means, standard deviations, medians, and quartiles. For categorical data, group comparisons were made using chi-squared tests, exact p values were calculated, and Cramer’s V effect sizes were calculated. For numerical variables, independent group (sample) comparisons were made using the independent sample t test, and before-after comparisons were made using the paired sample t test. When t tests were used, Cohen’s d effect sizes were calculated and reported. Analyses were performed using JAMOVI (version 2.3.28), and 5% was accepted as the statistical significance level.

Results

Two participants in the IG were unable to continue due to transport and personal reasons, while one participant in the SG had to withdraw due to a change in working hours. Ultimately, 17 participants in the SG and 16 participants in the IG completed the study. When demographic characteristics were compared, no statistically significant difference was found between the groups (Table 1, p > 0.05). BMI was statistically significantly higher in the SG (29.3 ± 4.65) than in the IG (26.45 ± 3.03) (p = 0.036). In addition, there was no difference between the outcome measures of the groups at pre-test except for trunk flexion, left trunk lateral flexion, and left trunk rotation ROM (p > 0.05).

Table 1.

Baseline characteristics of participants

Parameters	Sham group	Intervention group	Between-group comparisons
	$\overline{X}$ ±SD	$\overline{X}$ ±SD	t value	p value	Cohen’s d
Age, years	66.11±8.11	61.83±9.74	1,432	0.161	0.477
Height, m	1.68±0.12	1.7±0.09	−0.645	0.523	−0.215
Weight, kg	82.13±11.94	77.07±13.13	1,210	0.235	0.403
BMI, kg/m2	29.3±4.65	26.45±3.03	2,181	0.036*	0.727
Disease duration, years	9.06±8.29	7±3.34	0.975	0.336	0.325
sMMSE score	27.28±2.54	27.89±2.19	−0.773	0.445	−0.258
HY scale (1–5)	2.56±0.51	2.28±0.46	1,712	0.096	0.571
Levadopa equivalent daily doses, mg	478.89±150.68	422.78±190.07	0.981	0.333	0.327

​		n	%	n	%	Chi-square	p value	Cramer’s V
Sex	Female	5	27.8	4	22.2	0.148	1.000	0.064
	Male	13	72.2	14	77.8
Disease onset	Right	11	61.1	7	38.9	1,778	0.318	0.222
	Left	7	38.9	11	61.1

Continuous data presented as mean ± standard deviation, and categorical data as frequency (%) (Statistical significance is marked with * for p < 0.05).

HY scale, Hoehn and Yahr scale; sMMSE, standardised Mini-Mental State Examination; $\overline{\mathit{X}}$, mean; SD, standard deviation.

Values of spatiotemporal gait analysis are reported in Table 2. After treatment, the mean of the SG was statistically significantly lower than the mean of the IG in terms of velocity, and normalised velocity (Cohen’s d = −0.718, p = 0.048 and Cohen’s d = −0.702, p = 0.049, respectively). When evaluating the patient groups within groups, differences were found in speed, cadence, stride time, cycle time, stride length, and mean normalised speed in the SG and in speed, stride length, and mean normalised speed in the IG (p < 0.05).

Table 2.

Comparison of gait parameters

Gait parameters	SG (n = 17)					IG (n = 16)					Between-group comparison: pre			Between-group comparison: post
	pre	post	within-group comparison: pre-post			pre	post	within-group comparison: pre-post
	$\overline{X}$ ±SD	$\overline{X}$ ±SD	t a	p value	Cohen’s d	$\overline{X}$ ±SD	$\overline{X}$ ±SD	t a	p value	Cohen’s d	t b	p value	Cohen’s d	t b	p value	Cohen’s d
Velocity, cm/s	100.34±27.12	114.56±23.41	−2,830	0.012*	−0.687	115.07±26.94	130.72±21.51	−3,246	0.005*	−0.811	−1,635	0.111	−0.545	−2,061	0.048*	−0.718
Cadence, cycles/min	107.34±14.33	114.95±8.91	−2,967	0.009*	−0.720	112.07±12.19	116.9±7.06	−1,463	0.164	−0.366	−1,067	0.293	−0.356	−0.694	0.493	−0.242
Stride duration, s	0.57±0.08	0.526±0.04	3.20	0.006*	0.777	0.541±0.07	0.517±0.03	1,219	0.242	0.305	1,131	0.266	0.377	0.659	0.515	0.230
Cycle time, s	1.13±0.16	1.04±0.08	3,299	0.005*	0.8	1.08±0.13	1.32±1.17	−0.841	0.414	−0.21	1,110	0.275	0.370	−0.975	0.337	−0.340
Stride length, cm	111.68±23.72	119.58±21.5	−2,276	0.037*	−0.552	122.15±21.25	133.75±18.94	−3,859	0.002*	−0.965	−1,396	0.172	−0.465	−2,004	0.054	−0.698
Mean normalised velocity, m/s	1.19±0.33	1.35±0.26	−2,354	0.032*	−0.571	1.36±0.32	1.52±0.24	−3,165	0.006*	−0.768	−1,555	0.129	−0.518	−2,047	0.049*	−0.702

$\overline{X},$ mean; SD, standard deviation.

Statistical significance is marked with * and bold for p < 0.05.

^aPaired sample t test.

^bIndependent sample t test.

BBS and ROM measurements are presented in Table 3. As a result of the pre-post evaluations of the groups, BBS and trunk flexion in the SG and BBS, cervical extension, cervical rotation, trunk rotation, and ankle dorsiflexion ROM in the IG increased (Table 3, p > 0.05). After the treatment, for the BBS, cervical extension, left cervical lateral flexion, left cervical rotation, trunk lateral flexion, trunk rotation, and ankle dorsiflexion measurements, the IG was found to be statistically significantly higher than the SG (p < 0.05).

Table 3.

Comparison of the BBS and ROM measurements

Parameters	SG (n = 17)					IG (n = 16)					Between-group comparison: pre			Between-group comparison: post
	pre	post	within-group comparison: pre-post			pre	post	within-group comparison: pre-post
	$\overline{X}$ ±SD	$\overline{X}$ ±SD	t a	p value	Cohen’s d	$\overline{X}$ ±SD	$\overline{X}$ ±SD	t a	p value	Cohen’s d	t b	p value	Cohen’s d	t b	p value	Cohen’s d
BBS score (0–56)	51.17±3.57	54±2.06	−5,074	<0.001*	−1,231	52.5±4.91	55.25±1.13	−2,398	0.03*	−0.6	−0.932	0.358	−0.311	−2,142	0.04*	−0.746
Cervical flexion ROM, °	41.26±8.38	41.35±8.06	0.189	0.852	0.046	41.85±6.51	43.56±5.18	−0.196	0.847	−0.049	−0.235	0.816	−0.078	−0.929	0.36	−0.324
Cervical extension ROM, °	44.72±8.44	45.9±8.84	−0.42	0.680	−0.102	49.92±9.11	54.44±9.09	−2,596	0.02*	−0.649	−1,779	0.084	−0.593	−2,734	0.01*	−0.952
Cervical right lat. flexion ROM, °	22.85±6.16	23.41±8.07	−0.166	0.870	−0.04	24.81±9.95	26.81±6.14	−0.531	0.603	−0.133	−0.713	0.481	−0.238	−1,356	0.185	−0.472
Cervical left lat. flexion ROM, °	23.83±5.14	23.61±7.35	0.468	0.646	0.114	25.79±8.98	29.02±6.37	−1,187	0.254	−0.297	−0.804	0.427	−0.268	−2,256	0.031*	−0.786
Cervical right rotation ROM, °	60.79±8.44	63.82±8.73	−1,496	0.154	−0.363	63.09±10.23	68.02±9.14	−2,569	0.021*	−0.642	−0.736	0.467	−0.245	−1.35	0.187	−0.47
Cervical left rotation ROM, °	62.44±9.14	63.49±9.59	0.017	0.987	0.004	66.25±9.21	72.27±10.53	−2.14	0.049*	−0.535	−1,249	0.22	−0.416	−2,506	0.018*	−0.873
Trunk flexion, °	88.55±14.23	92.96±11.53	−2,129	0.049*	−0.516	104.51±14.39	102.37±18.47	0.957	0.354	0.239	−3,346	0.002*	−1,115	−1,768	0.087	−0.616
Trunk right lat. flexion ROM, °	25.35±6.31	26.53±6.86	−0.731	0.475	−0.177	28.66±5.9	30.81±4.9	−1.14	0.272	−0.285	−1,625	0.113	−0.542	−2,052	0.049*	−0.715
Trunk left lat. flexion ROM, °	23.36±5.73	23.9±3.96	−0.487	0.633	−0.118	28.31±6.56	31.71±4.94	−2,775	0.014*	−0.694	−2,411	0.021*	−0.804	−5,022	<0.001*	−1,749
Trunk right rotation ROM, °	93.64±12.75	93.65±11.93	0.367	0.718	0.089	100.05±16.76	109.89±18.68	−2,896	0.011*	−0.724	−1,291	0.206	−0.43	−2,997	0.005*	−1,044
Trunk left rotation ROM, °	90.22±13.31	93.23±13.69	−0.419	0.681	−0.102	105.22±18.33	113.33±16.55	−2,576	0.021*	−0.644	−2,809	0.008*	−0.936	−3,811	<0.001*	−1,327
Ankle dorsiflexion ROM, °	44.44±5.97	46.29±4.72	−2,049	0.057	−0.497	47.22±6.08	51.44±4.4	−4,893	<0.001*	−1,223	−1,384	0.175	−0.462	−3,232	0.003*	−1,126

BBS, Berg Balance Scale; ROM, range of motion; lat., lateral; $\overline{X},$ mean; SD, standard deviation.

Statistical significance is marked with * and bold for p < 0.05.

^aPaired sample t test.

^bIndependent sample t test.

The mean MDS-UPDRS-III score in the IG was statistically significantly lower than the mean score in the SG (Cohen’s d = 0.851, p = 0.021). When comparing the lateral stability limits, it was observed that the SG mean (19.11 ± 3.91) was statistically significantly lower than the IG mean (Cohen’s d = −0.751, p = 0.039). In addition, the difference between groups after treatment was not statistically significant for both PDQ-8 and GAS (p = 0.326 and p = 0.971, respectively) (Table 4). The results are also presented graphically as online supplementary material, along with confidence interval values (online suppl. material 3).

Table 4.

Comparison of motor symptoms, posturographic measures, trunk impairment, quality of life, and GAS measures

Parameters	SG (n = 17)					IG (n = 16)					Between-group comparison: pre			Between-group comparison: post
	pre	post	within-group comparison: pre-post			pre	post	within-group comparison: pre-post
	$\overline{X}$ ±SD	$\overline{X}$ ±SD	t a	p value	Cohen’s d	$\overline{X}$ ±SD	$\overline{X}$ ±SD	t a	p value	Cohen’s d	t b	p value	Cohen’s d	t b	p value	Cohen’s d
MDS-UPDRS-III (0–108)	41.61±11.76	28.35±10.5	5,014	<0.001*	1,216	37±12.76	20.63±7.28	5,687	<0.001*	1,422	1,127	0.268	0.376	2,442	0.021*	0.851
LoS L-R, cm	19.49±5.13	19.11±3.91	0.437	0.668	0.106	19.03±5.33	22.12±4.11	−3,438	0.004*	−0.86	0.261	0.796	0.087	−2,156	0.039*	−0.751
LoS F-B, cm	12.61±4.35	13.67±3.32	−1,322	0.205	−0.321	13.09±3.15	15.64±3.67	−3,242	0.005*	−0.811	−0.375	0.710	−0.125	−1,623	0.115	−0.565
TUG test, s	11.3±4.17	9.75±2.49	2,272	0.037*	0.551	9.47±2.87	7.68±1.74	3,595	0.003*	0.899	1,528	0.136	0.509	2,750	0.01*	0.958
PDQ-8, %	23.61±11.05	13.79±9.25	3,887	0.001*	0.943	23.35±15.07	10.55±9.4	4.78	<0.001*	1,195	0.060	0.953	0.02	0.998	0.326	0.348
GAS, %	36.78±0.1	59.54±7.75	−12,124	<0.001*	−2,941	36.43±1.1	59.63±7.42	−11.4	<0.001*	−2,943	1,305	0.202	0.462	−0.036	0.971	−0.013

MDS-UPDRS, Movement Disorders Society Unified Parkinson’s Disease Rating Scale; LoS, limits of stability; A-P, anteroposterior; L, lateral; F-B, forward-backward; L-R, left-right; TUG, timed-up and go; PDQ-8, Parkinson’s Disease Questionnaire-8; GAS, Goal Attainment Scale; $\overline{X},$ mean; SD, standard deviation.

Statistical significance is marked with * and bold for p < 0.05.

^aPaired sample t test.

^bIndependent sample t test.

Discussion

Our study investigated the effects of myofascial release after TOCT in PwPD and found that it was superior to TOCT and sham treatment in improving gait speed and balance; increasing ROM, lateral stability limits; and reducing motor symptom severity. In addition, the results showed that over an 8-week training programme with myofascial release did not outperform a sham treatment in terms of improving quality of life and goal attainment.

The impact of myofascial release on gait has not been thoroughly assessed in PD. However, a study found that applying myofascial release to the hamstring muscle for five consecutive days by a manual therapist increased the maximum gait speed in young adults [33]. In an 8-week case study investigating the effects of deep myofascial release, deep friction massage, and proprioceptive neuromuscular facilitation techniques, as well as a home programme consisting of self-stretching, it was demonstrated that people with chronic myofascial pain syndrome have impaired gait performance due to restricted ankle and knee joint mobility. Additionally, quantitative gait analysis demonstrated the effectiveness of myofascial treatments [34]. In a study by Lee et al., the acute effects of the FR were investigated in young adults. The study showed that clinical measurements indicated an increase in dorsiflexion ROM and gait speed [35]. In our study assessing the effects of myofascial release after exercise on PwPD, we found that the IG showed significantly greater improvements in ankle ROM, walking speed, and stride length compared to the SG after 8 weeks of treatment in PwPD. Myofascial release, which has been shown to affect the neural components, interacting muscles, and local blood flow around the applied area by providing a decrease in tissue adhesion and improvement in thixotropic responses, positively affects body structure and functions, especially joint movement, and indirectly showed that it is an effective method in reducing gait problems, which is an important activity [22]. In PD, where the nervous system is affected, releasing the muscles using FR has been shown to increase the stride length, as demonstrated in our study. This, in turn, makes it easier to walk faster (shown by increased velocity and normalised velocity), which is one of the most important things for PwPD. However, studies using FR on the lower body (the muscles around the knee and hip joints) may show better results in improving gait in PwPD.

Myofascial release and manual therapy have been shown to increase ROM through similar physiological mechanisms in various study groups, including healthy individuals, athletes, and those with neurological diseases [13, 35–37]. Manual therapy applied locally around the foot with TOCT has been shown to improve balance, gait speed, mobility, dual-task mobility, falls, health-related quality of life, and active and passive talocrural ROM results when applied with exercise in stroke patients [36]. In a study conducted by Hosswini and Sedaghati, involving 24 participants with MS, they reported positive effects of myofascial release with FR combined with exercise for 8 weeks on ROM [13]. Additionally, older adults with non-specific low back pain also experienced an increase in spinal mobility after core stabilisation exercises combined with a roller massager, which is another myofascial release method with similar mechanisms of action [37]. In another study, myofascial release was applied using a lacrosse ball on individuals with low back pain. The results showed that myofascial release was more effective in improving trunk lateral flexion and trunk rotation ROM compared to lumbar stabilisation exercises [38]. Our study found that the IG had higher ankle dorsiflexion ROM, cervical extension, cervical lateral flexion, cervical rotation, trunk lateral flexion, and trunk rotation ROM compared to the SG. After TOCT, the study suggests that myofascial release devices have a positive effect on ROM in PwPD. This increase in ROM occurs by triggering a series of neuromuscular and neurovascular reflexes [22, 39] similar to those in different groups. Myofascial release is a local method that can effectively target ROM increase [7, 36]. Furthermore, our baseline measurements revealed that the IG group had a greater ROM in their trunk joints. Being overweight may have had a negative impact on the ROM of the trunk joints in our participants, particularly during baseline measurements [40].

The post-FR balance parameters have been the subject of evaluation using various tests in different studies [7, 8, 13, 41]. Espí-López et al. [7] investigated the effects of FR on dynamic balance in athletes after exercise with the star excursion balance test and found that dynamic balance improved. A recent study also showed that applying FR to the calf muscles of university-level athletes improved their balance when moving around, as tested in a laboratory [41]. In this study, we evaluated static and dynamic balance and found that TOCT combined with FR improved balance. Additionally, objectively assessed stability limits increased lateral direction, indicating that FR is an effective method for improving dynamic balance after exercise, as seen in other research groups. The findings of Kara et al. [42] suggest that exercise programmes with functional content have the potential to enhance dynamic balance in PwPD, thereby increasing stability limits. The present study also demonstrates that myofascial release applied in conjunction with exercise contributes more to the improvement of dynamic balance by increasing stability limits in laboratory conditions. It has been documented that the execution of Pilates exercises has been shown to enhance functional balance in MS patients [13]. Similarly, in individuals with stroke, clinical balance and gait outcomes exhibited enhancement following 8 weeks of myofascial release employing a tennis ball on the plantar surface of the foot and calf region, analogous to FR. This enhancement was ascribed to elevated flexibility and diminished spasticity, consequent to myofascial release [8]. The findings of the present study demonstrate that performance-based and clinical balance and gait measurements showed improvements in both groups, with more pronounced improvements observed in stability limits, functional balance, and clinical gait performance in the IG. In light of the research demonstrating impaired balance in PwPD in comparison to healthy individuals [1, 6], we believe that the improvement achieved with myofascial release is due to its targeted application on the trunk and neck regions, thereby increasing ROM and potentially reducing axial rigidity.

There is a lack of information regarding the impact of myofascial release on patient participation levels. According to the literature, myofascial release can improve performance during activities, increase ROM, and does not cause pain during or after application [7, 9, 43]. It is important to note that these evaluations are objective and supported by evidence. Our study found that, compared with the SG, myofascial release did not result in any additional improvement in goal attainment or quality of life for our patients when applied after TOCT. This is the first study to evaluate the effects of myofascial release on participation levels. The diversity of treatment goals set by the individuals at the beginning of the study may have contributed to this outcome. However, the effectiveness of the treatment depends on factors such as the duration, intensity, and type of exercise programme, rather than just a local application.

Although various manual therapy modalities have been reported to reduce disease severity in PD [44, 45], the effect of myofascial release modalities on motor symptoms has not been evaluated. Terrell et al. [44] conducted a study to evaluate the acute effects of osteopathic manual therapy. The study found that applying osteopathic manual therapy to the whole body for 25–30 min was effective in reducing disease severity. However, disease-related sub-scores were not examined in this study [44]. In a recent study, Seçkinoğulları et al. [45] found that disease-related activities of daily living, motor symptoms, and disease severity decreased after a 10-min lumbosacral mobilisation. The researchers suggested that lumbosacral mobilisation may have increased the mobility of the region and contributed to the regulation of axial muscle tone [45]. Previous studies have reported that muscle tone may decrease due to the activation of fascia mechanoreceptors. Additionally, the pressure applied during myofascial release may stimulate the Golgi tendon organs, leading to a decrease in motor unit firing rate and muscle tension [11]. Our study found that myofascial release after TOCT reduced motor symptoms and disease severity to a greater extent than sham application. Compared to previous studies, our research demonstrates that FR reduces muscle tone through fascial mechanoreceptors, making it a potential method for improving disease-related motor symptoms. While the mechanism is not yet fully understood, it is believed to be effective via neuromuscular and neurovascular pathways. It is important to note that our findings are objective and based solely on the data collected.

There were no statistically significant baseline differences between the groups, but the SG was marginally older, had a longer disease duration, and had higher baseline MDS-UPDRS-III scores and levodopa levels. While these clinical differences were not statistically significant, they may have influenced the outcomes observed post intervention. It has been documented that multidisciplinary intensive rehabilitation treatment during hospitalisation provides greater benefits to patients in more advanced stages of recovery in PD (i.e., those with worse baseline scores) [46]. Healthy older adults with low physical fitness showed a higher rate of improvement in lower extremity endurance compared to older adults with high physical fitness [47]. In addition, participants in the IG who already have better baseline results showed smaller observable improvements after the intervention because of the ceiling effect.

In conclusion, our study demonstrated that myofascial release combined with TOCT has positive effects on known local outcomes, such as increased ROM, as well as reducing motor symptoms associated with PD. It was also found to improve gait and balance, increase stability limits, improve trunk control, and enhance performance related to gait and balance. Alongside these results, our study suggests that exercise interventions involving holistic and purpose-specific activities may enhance the benefits that patients gain from the exercise programme. From a clinical perspective, when applied alongside exercise programmes for PwPD, myofascial release, which uses principles similar to those of soft tissue mobilisation, offers an easy-to-use method that patients can perform themselves instead of relying on a therapist. Given its simplicity and usability, it could be a useful method in the clinic without any help by health professionals. Follow-up assessments (e.g., 3–6 months post intervention) should be implemented to develop comprehensive treatment interventions for PD and other neurological disorders, and to extend these effects. Such trials could focus on the effects of myofascial release techniques in combination with exercise or foam rolling alone.

Limitations

There are several limitations to this study. First, the most appropriate criteria regarding the duration of application, rest periods, and application frequency of FR are still under discussion. Although we believe that we have applied the most suitable method of application and duration for patients, we acknowledge that the duration of application may affect physiological responses. Additionally, the potential for placebo effects and therapist influence when applying FR should not be overlooked, as these can lead to bias. To prevent this, we have followed the procedures outlined in previous literature. Therefore, future research should focus on determining the optimal FR method and duration. Second, our study has an important limitation in that we did not evaluate the tolerance and satisfaction levels of PwPD towards myofascial release. Although we selected the method that appeared most appropriate in the literature for PwPD, we did not subjectively evaluate their experiences during implementation. It was not evaluated because we considered quality of life and level of goal attainment to be more important outcomes in our study population. In addition, we believe that the presence of a physiotherapist during all sessions and constant communication helped to mitigate this limitation. Finally, although the study was planned as a randomised and blinded study, and the groups were assigned using the closed envelope method, the individuals in the myofascial release group had higher spatiotemporal characteristics of gait, ROM, and mobility measurements in the baseline measurements, despite being statistically similar.

Conclusion

Exercise protocols are effective in reducing gait, balance, and disease-related symptoms. In addition, the FR, which is an inexpensive assistive device that can enhance the effects of exercise and is easy for PwPD to use, provided results that can enhance the effects of exercise. In PwPD, FR applied in combination with exercise increased walking speed, ROM, and dynamic balance and decreased motor symptoms associated with PD. FR can be used after TOCT by patients alone and by physiotherapists in the clinic to improve certain parameters in PwPD, especially when these parameters are the target.

Acknowledgments

The authors are grateful to all the participants.

Statement of Ethics

The study protocol was authorized by the Ethics Review Board of Hacettepe University (protocol code: KA-22060) and it adhered to the Declaration of Helsinki. Written informed consent was obtained from all participants.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This study was not supported by any sponsor or funder.

Author Contributions

K.K. was involved in treatment follow-up. M.D. and M.K. contributed to data analysis. M.D., S.A.Y., C.Ö., M.K., and Y.D. contributed to the study design and plan. M.D., Y.D., and M.K. contributed to the interpretation of the data and drafting of the manuscript. All authors approved and endorsed the final manuscript.

Funding Statement

This study was not supported by any sponsor or funder.

Data Availability Statement

The data supporting the findings of this study are not publicly available due to ethical procedures, but can be obtained from the corresponding author upon request.