Fascial Manipulation Effect on Shoulder Range of Motion and Strength in Handball Players
Condition: Connective Tissue Defect; Fascia; Anomaly
Study type: Interventional

Summary: 
      The investigators conducted a prospective randomized controlled trial on the female and male
      handball players from the Izola Handball Club (Slovenia) who volunteered to participate in
      the study. Data were collected in the first part of the competition season 2022/2023. The
      participants were randomly divided into investigated and control groups so that each group
      had approximately the same number of participants regarding sex and age. The Fascial
      manipulation (FM) was performed in the investigated group, whereas, in the control group, the
      participants did not receive the FM. Demographics (sex, age, height, weight, throwing
      shoulder, playing position, years of playing) were collected. The study protocol complied
      with the Declaration of Helsinki and was approved by the National Medical Ethics Committee of
      the Republic of Slovenia (0120-78/2022/9).

      The aim of this research was to determine whether and how FM affects IR, HADD ROM and the
      strength of ER in handball players. The hypotheses include: (1) an increase in IR, HADD ROM,
      and strength of ER immediately after FM compared to the control group, (2) maintenance of
      increased ROM and ER strength one month after FM compared to baseline and the control group,
      (3) a decrease in the subjective feeling of tightness immediately and one month after and (4)
      the size of the FM effect increases with years of playing and vice versa.
    

Detailed description: 
      All participants aged 18 or older signed informed consent to participate in the study. For
      participants under 18 years of age, informed consent was signed by their parents or legal
      guardians. Exclusion criteria were prior upper extremity injury or upper extremity surgery
      preventing the player from playing in the last three months, any previous shoulder surgery,
      and goalkeeper position. A cluster random sampling strategy was used. The participants were
      randomly divided into investigated and control groups so that each group had approximately
      the same number of units regarding sex and age. In the investigated group, the Fascial
      manipulation (FM) was performed, whereas, in the control group, the participants did not
      receive the FM.

      One session of Fascial Manipulation® by Stecco was chosen as the therapeutic procedure. The
      principal investigator who performed the FM in the investigated group is a qualified
      therapist with extensive knowledge in manual therapy and a certificate in FM Levels I and II.
      Based on the collected information (a complete medical history, including the chronology of
      any traumatic events, fractures, significant musculoskeletal dysfunctions, scars and surgical
      procedures, specific range of motion, and palpation examinations) and according to the Stecco
      model for the interpretation of the dysfunction of the fascial system, the therapist selected
      an individual combination of condensed points of treatment (centers of coordination - CC
      and/or centers of fusion - CF). All CC and/or CF points that were treated in an individual
      subject were recorded.

      All participants completed three test sessions (pre-test, immediate post-test, and one-month
      post-test). The immediate post-test measurements were recorded directly after the application
      of the FM in the investigated group and after a one-minute waiting period in the control
      group. Testing was repeated 27-34 days (one month) after FM was performed. All three
      measurements for both groups were performed in the same way. All the measurements were
      performed by the two independent examiners - experienced physical therapists, whereby FM was
      performed only by the principal investigator-experienced physical therapist who did not
      participate in the measurements. Before the measurements, participants completed a specific
      standard warm-up for their team consisting of gentle jogging, static and dynamic full-body
      stretching. The warm-up was not standardized for this study.

      Range of motion (ROM) measurements for internal rotation (IR) and horizontal adduction (HADD)
      were recorded using a classic goniometer. For the HADD assessment, participants were
      positioned supine on a standard examination table with both shoulders aligned. The examiner
      stood on top of the table, facing the participant's head, and stabilized the lateral edge of
      the scapula. The participant's upper limb was positioned at 90 degrees of GH abduction with
      90 degrees of elbow flexion. The examiner held the subject's arm distal to the elbow and
      passively moved it into HADD. At the first point of resistance, a second examiner used a
      digital inclinometer to record the amount of motion in degrees (°) by aligning it with the
      humerus.

      Passive IR measurements were taken with the participant lying supine on an examination table,
      with the shoulder at 90 degrees of abduction in the frontal plane and the elbow at 90 degrees
      of flexion. The examiner applied a posterior stabilizing force to the acromial process of the
      scapula and internally rotated the upper limb until the first point of resistance. A second
      investigator then recorded the amount of movement in degrees by aligning the digital
      inclinometer with the axis of the forearm.

      The Easy Force© digital dynamometer was used to determine the strength of the external
      rotation (ER). Maximal isometric strength was measured in Newtons per kilogram (N/kg).
      Subjects lay prone, with the shoulder abducted to 90° in the frontal plane and in neutral
      rotation. The first examiner placed the dynamometer strap around the wrist, 2cm proximal to
      the ulnar styloid process. The tape on the other side of the dynamometer was fixed in a stand
      next to the table, in extension with the wrist. The second examiner fixed the humerus on the
      distal side just above the elbow to limit the motion of the humerus. According to
      standardized testing instructions, the procedure was as follows: one familiarization trial,
      then three maximal isometric tests. Participants were asked to gradually build up their
      strength to maximal effort over a two-second period and finally to hold their maximal effort
      for three seconds. The best measurement from three trials, expressed in N/kg, was used for
      analysis.

      One session of Fascial Manipulation® by Stecco was chosen as the therapeutic procedure for
      the investigated group. The principal investigator who performed the FM is a qualified
      therapist with extensive knowledge in manual therapy and holds certificates in FM Levels I
      and II. The therapist utilized the Stecco model to interpret the dysfunction of the fascial
      system based on comprehensive information collected, including the participant's complete
      medical history, traumatic events, fractures, musculoskeletal dysfunctions, scars, surgical
      procedures, specific range of motion, and palpation examinations. Using this information, the
      therapist selected an individualized combination of condensed treatment points, known as
      centers of coordination (CC) and/or centers of fusion (CF). All CC and/or CF points treated
      in each individual subject were recorded for documentation purposes.
    

Intervention name(s): Fascial Manipulation by Stecco method
Intervention type(s): Procedure
Intervention description(s): Fascial Manipulation (FM) is a method carefully developed by members of the Stecco family after many years of research. FM involves deep kneading of the muscle fascia at specific points called centers of coordination (CC) and centers of fusion (CF) along myofascial sequences, diagonals, and spirals. It has been proposed that the friction caused by manipulation creates localized heat and that, due to the thermosensitive characteristics of fascia, this heat facilitates the transition of hyaluronic acid within the extracellular matrix from a condensed state to a more fluid state, thus restoring the gliding properties of fascia.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: One investigated group with intervention and one control group without intervention
Masking: Single (Care Provider)
Primary purpose: Prevention