A critical evaluation of percussion muscle gun therapy as a rehabilitation
tool focusing on lower limb mobility. A literature review
Jack Martin, Department of Health and Wellbeing. University of winchester
Sparkford Rd, Winchester SO22 4NR
Abstract
Aims: In recent years there has been a significant rise in the popularity of muscle gun devices.
However, the current research regarding muscle gun devices is unclear. Therefore, this literature
review will explore the current literature regarding the effect of muscle gun devices on range of
motion, muscle activation, force output and the possibility of reducing perceived muscle soreness.
Methods: Four databases were used along with two academic search engines to search for
studies that satisfied the inclusion criteria. To fulfil the inclusion criteria studies had to be of a prepost design focusing on the use of percussion massage devices. Results: Thirty-nine included
studies were used in this literature review. It was found that handheld percussive massage
devices are the most effective method of increasing lower limb range of motion compared to foam
rolling and other self-myofascial protocols. The use of handheld percussive massage devices
directly after exercise reduces delayed onset muscle soreness. However, there was no reported
significant increase in muscle activation or force output following the usage of a handheld
percussive massage device. Conclusion: The use of muscle gun devices is recommended as
part of a structured warm-up pre-exercise due to an increase in range of motion, reduction in
perceived muscle soreness whilst having no negative impact on muscle activation and force
output. Muscle guns may also be implemented as part of a rehabilitation programme post injury
due to their ability to increase range of motion and reduce perceived pain and muscle soreness.
Introduction
The soft tissue component of connective tissue is called fascia. The fascia tissue is described as
the fascia surrounding each muscle and organ in the body (Beardsley and Škarabot, 2015). The
fascia includes a superficial, deep, and sebaceous tissue (Rhyu et al., 2018). When fascia tissue
becomes tight, it can result in a loss of pliability, preventing the fascia from reaching its full length
(Findley et al., 2012). The increased tightness in fascia results in a reduced joint range of motion,
muscle strength and soft tissue extensibility (MacDonald et al., 2013). Previous literature has
shown that myofascial release aids in reducing tightness in affected areas of fascia. Myofascial
therapy is defined as “the facilitation of mechanical, neural and psychophysiological adaptive
potential as interfaced by the myofascial system” (Manheim, 2008). The majority of myofascial
release techniques focus on the concept of tight loose. The concept focuses on providing an
increased stimulation level to an agonist muscle so that it becomes tight, and the tighter it
becomes, the looser its agonist muscle becomes by reciprocal inhibition (Duncan, 2014).
Myofascial release refers to techniques which aim to manipulate soft tissue. There are three
primary types of myofascial releases: direct myofascial release, indirect myofascial release and
self-myofascial release. Direct myofascial release, aims to work directly on areas of the restricted
fascia. Practitioners use fists, knuckles, elbows and other tools to slowly sink into the restricted
fascia applying a few kilograms of force in an attempt to stretch the fascia (Simmonds et al.,
2012). Indirect myofascial release aims to stretch the area of restricted fascia gently. Ajimsha
(2011) found that gentle traction applied to the tight fascia will result in a transfer of heat and an
increased blood flow in the targeted area. The intention of indirect myofascial release is to allow
the body's inherent ability for self-correction, eliminating pain and restoring the body's optimum
performance (Duncan, 2014). Self-myofascial release is defined as when an individual uses a soft
object to provide myofascial release under their own body weight (Beardsley and Škarabot, 2015).
An individual will usually use a soft foam roller or ball such as tennis ball to rest one's body weight
on and then use gravity to induce pressure by rolling along the length of the specific muscle
groups with the chosen object (Okamoto et al., 2014). In recent years there has been a variety of
new devices and tools that have been developed to aid self-myofascial release, including but not
limited to vibrating foam rollers (Benito et al., 2019) and percussion therapy tools (D. J. Cochrane,
2011). Vibrating foam rollers and hand-held percussion devices have provided similar benefits to
traditional self-myofascial release techniques (Lee et al., 2018).
Theragun™ and Hyperice are the two primary companies who currently share a large monopoly
of the muscle gun market, although other companies have created similar or nearly identical
designs. Vibrating foam rollers and hand-held percussion devices are focused on reducing the
impact of delayed-onset muscle soreness. However, they can be used for many other use cases
including but not limited to, being used during a dynamic warm-up (Healey et al., 2014), increasing
muscle activation before maximal polymeric activities such as vertical jumping and the
countermovement jump (Byrne et al., 2020).
Due to there being limited research on the topic of muscle gun devices, and owing to the increase
in their popularity, this literature review will aim to explore all relevant articles that have
investigated the effects of muscle gun devices regarding their ability to improve critical
physiological or biomechanical variables. Specifically, this literature review will explore the effects
of muscle gun devices regarding range of motion, muscle activation, force output and their ability
to reduce the perception of muscle soreness. This literature review will also aim to analyse the
results from previously published studies and compare the effects of muscle gun devices to other
devices that are used for myofascial release to determine if muscle gun devices are the best
device for aiding myofascial release.
Methods
A systematic literature search on articles published up to 9 December 2020 was carried
out in PubMed (Medline), Scopus, SPORTDiscus and Web of Science. Additionally, two academic
search engines Google Scholar and ResearchGate, were used. A search strategy was developed
based on the following keywords vibration massage, percussion massage, muscle gun, range of
motion, massage therapy and lower limb. Studies were included in the review if they measured
percussion muscle guns' effect on lower limb range of motion, power output. Additionally, studies
that explored the ability of muscle gun devices to reduce delayed onset muscle soreness were of
interest. All studies had to use human participants and were published in English.
The previously outlined search strategy resulted in a total of 39 included articles. Titles
and abstracts were reviewed to determine whether studies fulfilled the selection criteria. Studies
were eligible for inclusion if they met the following criteria: (1) articles must be written in English
and must have been published before December 2020; (2) percussion massage via a handheld
device must be included as a primary intervention during the study; (3) studies needed to be of a
pre-post design with a focus on the use of percussion massage on lower limb range of motion or
another biomechanical paramotor; (4) a full-text version of the article had to be publicly available
with public access to all data used within the study.
Articles were only included in the full-text review if it was deemed that their title and
abstract met the inclusion criteria' fundamental demands. All eligible papers were then screened
via analysing the full text. Several articles were removed at this stage due to the entire manuscript
not being in the public domain, despite efforts attempting to contact the authors.
Figure 1: Prisma flow diagram
Figure one shows how the study inclusion criteria was implemented. Figure one also
demonstrates the flow of information through this literature review. The prisma flow diagram was
made using the Prisma 2020 statement and the corresponding guidelines developed by Page et
al. (2020)
The development of different devices to aid in self-myofascial release
Previous research has shown myofascial release to be an effective method of soft tissue
mobilisation. Contemporary research regarding myofascial release and self-administered
myofascial release focused on different manual soft tissue mobilisation techniques (Beardsley
and Škarabot, 2015). However, in recent years there has been an increase in the development of
tools to increase myofascial release. The foam roller was the original tool developed to enhance
myofascial release (Clark and National Academy of Sports Medicine, 2001). Since the first
introduction of foam rollers, several other devices aim to increase the self-myofascial release
experience. Foam rollers combined with a vibration element have gained increased popularity in
recent years. Ahmed and Akter (2019) reported that the use of a vibrating foam roller has a
positive impact on hamstring range of motion. Several other studies have explored the use of
vibration foam rolling on quadriceps (Lim et al., 2019), knees (Cheatham and Stull, 2018) and
other body parts (Cheatham and Stull, 2018; García-Gutiérrez et al., 2018; Wilke et al., 2020).
These studies reported an acute increase in range of motion following the use of a vibrating foam
roller. On the other hand, Thompson et al. (2014) discovered that using a vibrating foam roller is
a safe method to increase bone density.
Following the developments of vibrating foam rollers, the creation of percussion muscle guns aims
to provide a greater level of usability and precision when conducting self-myofascial release.
Handheld percussive massage treatment has gained popularity in the therapeutic and athletic
communities in the last few years. At the time of writing, there are two primary manufacturers of
these devices, Theragun™ and Hyperice. However, many companies have created very similar
products which aim to provide percussion massages to the users in a similar way that would be
achieved by a massage therapist. Previous literature has reported that vibration therapy leads to
mechanical oscillatory motions, thus enhancing reflex activity by stimulating the muscle spindle
to initiate a tonic vibratory reflex. Lee et al. (2018) demonstrated that vibration therapy
corresponds with an increase in intramuscular temperature. Further to this finding, Lee et al.
(2018) also reported an increase in muscle temperature from vibration therapy increases countermovement jump height. Therefore, handheld percussion massage devices may be used during a
warm-up before physical activity to promote increased muscle temperature (Cochrane et al.,
2008) and muscle activation (Cochrane et al., 2010).
Themes of the literature
Devices that aim to aid in self-myofascial release have a demonstrated ability to
increase motion range (Yoshimura et al., 2019). The relationship between selfmyofascial release and range of motion is well established in the literature, with many
studies previously exploring the effects of different methods of self-myofascial release
on lower limb range of motion (de Souza et al., 2019; MacDonald et al., 2013; Škarabot
et al., 2015). However, with recent developments in technology focusing on improving
self-myofascial protocols (Luo et al., 2017), it is unclear if handheld percussion
massage devices are the best method of improving lower limb range of motion.
Nineteen of the included studies used a handheld percussive device as the intervention
method and measured its effect on lower limb range of motion. Of the previously
mentioned studies, thirteen used a muscle gun that delivered percussions at 53 Hz. Six
studies used a handheld percussive device operating at 80+ Hz. All of the experiments
used a soft attachment head for the device and investigated its effect on the hip-flexor
range of motion. The mean intervention time equalled 5 ± 2 minutes. The use of the
muscle gun varied between the included studies, several studies instructed participants
to use the device on themselves whilst other students used a researcher or a lab
technician to administer the device on the participant.
Lower limb range of motion following the use of a muscle gun
One significant theme explored within the included literature was the effect of self-myofascial
release devices on range of motion. Previous studies have shown a positive relationship between
foam rolling and range of motion (Couture et al., 2015; Mohr et al., 2014; Wilke et al., 2020).
Furthermore, recent research has reported that the use of vibrating foam rollers is the most
effective method of increasing range of motion compared to non-vibrating foam rollers and static
stretching (Benito et al., 2019; Romero-Moraleda et al., 2019). Researchers have suggested that
foam rolling before training and as a recovery tool is an optimal way to increase ROM, without the
potential performance decrements associated with static stretching (MacDonald et al., 2013; Su
et al., 2017). Benito et al. (2019) and Romero-Moraleda et al. (2019) reported that vibrating foam
rolling achieved an average increase of 18.5% hip joint range of motion, whereas the nonvibrating foam rolling increased hip joint range of motion by 15%. Several studies have
demonstrated the increased joint range of motion following vibration foam rolling. However, there
are several limitations associated with this method. One limitation of both vibrating and nonvibrating foam rollers is that they can only be used on some specific joints due to their large
design. However, due to the much smaller design of the soft attachment head used with handheld
percussive massage devices, they can target specific muscle areas and be used on smaller joints
compared to foam rollers. Konrad et al. (2020) found that a single percussive massage performed
using the Hypervolt device increased dorsiflexion range of motion by +5.4° compared to the
control group of static stretching. The findings expressed by Konrad et al. (2020) were attributed
to a reduction in muscle stiffness and general muscle tightness. The Hypervolt device may be
more effective due to its ability to produce a greater frequency of percussions per minute,
compared to the lower vibration frequency of vibrating foam rollers (Han et al., 2017).
Correspondingly, the greater frequency achieved by the Hypervolt divide makes it more effective
at reducing muscle stiffness compared to vibrating foam rollers.
Patel and Patel (2020) conducted a case study on the effect of the Theragun™ device on back
flexibility. The case study was of a pre-post design and used a sit and reach test to measure lower
thoracic spine range of motion and flexibility whilst using the physical discomfort scale developed
by Zourdos et al. (2016) to measure perceived pain. The physical discomfort scale developed by
Zourdos et al. (2016) uses a 1-10 scale with a value of 1 equating to minimal perceived discomfort
and a value of 20 equating to a maximal level of perceived discomfort. Patel and Patel (2020)
reported that after one week of a single 5-minute daily hamstring and lower back massage using
the Theragun™ device, the participant experienced a change in sit and reach test from -3 to +2
and the rating of perceived pain decreased from 8 to 2. These findings suggest that the daily use
of a Theragun™ device on the hamstrings and lower back increase hip flexor and thoracic range
of motion. Correspondingly, the reported results from Patel and Patel (2020) also illustrate that
daily use of a Theragun™ device reduces physical discomfort when completing strenuous
physical activity. Therefore, Patel and Patel (2020) concluded that the Theragun™ device
effectively increases lower back flexibility and reduces associated pain in the lower back region.
Guzman et al. (2014) presented a research poster on the impact of a single percussive therapy
application on lower body active range of motion. The research was a randomised crossover
design with a sample size of 24 participants. The intervention group participants were required to
undergo a single 5-minute percussive therapy treatment on the hamstring of their dominant limb.
Active and passive hip flexion and knee flexion range of motion were tested 10 minutes post
percussive therapy treatment. The results from Guzman et al. (2014) demonstrated that a single
5-minute percussive therapy treatment significantly improved hip flexion range of motion by 4.5 ±
6.8° with no reported change in the control group.
Similarly, Knee flexion range of motion significantly increased, following a single 5-minute
percussive therapy treatment (2.0 ± 0.9°) with no detected change in the control group. Park,
(2020) conducted a very similar study exploring the effect of localised percussion massage on
tricep Flexibility. The intervention's time duration was 5 minutes; this was a common theme
amongst the included studies, with nearly all of them using a 5 minute intervention period.
However, the findings of Park (2020) reported that a single localised percussion massage did not
lead to any significant difference in tricep range of motion. Whilst there was no reported change
in range of motion following the percussive massage intervention in Park (2020), the other studies
investigating the effect of handheld percussive massage devices reported significant increases in
range of motion following their use. Therefore, handheld percussive massage devices can acutely
increase lower limb range of motion. However, their ability to improve upper limb range of motion
is not yet proven.
Effect of Muscle gun devices on muscle activation and force output
There were several studies that focused on muscular activation and force output in the lower
limbs. Alvarado Hernandez, (2020) conducted research investigating Percussion therapy's effects
on lower limb range of motion and athletic performance. Alvarado Hernandez, (2020) used a
Theragun™ during a warm-up with the aim of improving force output and muscular activation
during a vertical jump, countermovement jump and a drop jump. Specifically, the Theragun™ was
applied bilaterally on the quadriceps, hamstrings, gluteus maximus and medius, calves, peroneals
and planter muscle groups. Each muscle group receives percussive treatment for a total of 30
seconds with the highest speed (40 percussions per second) selected on the device. There was
no control group implemented in the study. However, the study was of a pre-post design with the
participants acting as their own control when first tested without the Theragun™ warm up. The
results reported that there was no significant increase in countermovement jump height. Only 11
out of 20 participants reported an increase in jump height (0.02m average) following a Theragun™
aided warm up. Also, percussion treatment in the form of the Theragun™ showed no significant
differences in peak knee flexion angles during the countermovement jump and drop jump.
Therefore, the research conducted by Alvarado Hernandez, (2020) reports that the use of a
percussive handheld device as part of a warm-up before maximal jumping does not increase jump
performance or markers of muscular activation. Previous research by Healey et al. (2014) found
that 30 seconds of foam rolling of lower limbs did not affect vertical jump performance. This finding
is similar to that of Jones et al. (2015) who reported no significant difference between foam rolling
and not foam rolling in jump height, impulse, relative ground reaction force, or take-off velocity.
Additionally, Ahmed and Akter (2019) used a vibrating foam roller during a warm-up, similar to
Alvarado Hernandez, (2020), and found no difference in jump performance between the
intervention group and control group. Finally, Konrad et al. (2020) explored the effects of the
Hypervolt percussive massage device (similar in design to the Theragun™) on Plantar Flexor
Muscles range of motion and performance. The study found no difference in maximal voluntary
contraction performance after using the Hypervolt device compared to the control group. The
changes between pre and post-treatment for the massage group and control group were +0.53
newton-meters of torque (Nm) (+0.003%; p = 0.99) and +1.69 Nm (+1.0%; p = 0.65), respectively.
There are currently no published studies investigating the effect of handheld percussive massage
devices on muscle activation. Kujala et al. (2019) reported no significant change in vertical jump
performance following 5 minutes of percussive massage treatment of the lower limb region. The
findings of the highlighted studies Kujala et al. (2019), Alvarado Hernandez, (2020), and Konrad
et al.. (2020) are similar to the findings of Davis et al. (2020), who investigated the effects of
conventional massage on athletic performance and found that traditional massage had no
significant effect on muscle activation. However, Cheatham et al. (2019) and Germann et al.
(2018) reported an increase in strength due to localised vibration foam rolling. One reason for this
difference in findings may be that vibration therapy can stimulate more muscle receptors, leading
to increased muscle fibre recruitment (Fallon and Macefield, 2007; Germann et al., 2018).
Therefore, it is evident that handheld percussive massage deceives such as the Theragun™ and
Hypervolt do not increase muscular activation when used as part of a warm-up before physical
activity. The current literature suggests that the best method of increasing muscular activation
through self-myofascial release during a structured warm-up would be to use a vibrating foam
roller (Ahmed and Akter, 2019; Hsu et al., 2020; Lim and Park, 2019).
Delayed onset muscle soreness following the use of Muscle guns devices
The last significant theme discovered in the included literature was the effect of
handheld percussive massage devices on delayed onset muscle soreness. Previous
studies have reported that conventional massage can improve delayed onset muscle
soreness (Han et al., 2014; Moraska, 2005; Willems et al., 2009). Several studies have
also reported that a single use of vibrating or non-vibrating foam rollers can reduce
delayed onset muscle soreness (Benito et al., 2019; Cheatham et al., 2019; Lim et al.,
2019; Romero-Moraleda et al., 2017). One of the primary findings was that a single bout
of self-myofascial release with a vibrating or non-vibrating foam roller was an effective
method of decreasing an individual's pain threshold and other markers of delayed onset
muscle soreness. A review by Weerapong et al. (2005) reported that delayed onset
muscle soreness could be improved by using a foam roller or traditional massage to
promote increased muscle blood flow, a reduction in muscle compliance and a
reduction in the perception of pain. Imtiyaz et al. (2014) compared the effects of wholebody vibration therapy to traditional massage regarding the prevention of delayed onset
muscle soreness. The study results reported a significant reduction in the development
of delayed onset muscle soreness following whole-body vibration therapy imminently
after exercise. Cafarelli et al. (1990) and Cochrane (2017) conducted a similar study
investigating the effect of whole-body vibration therapy on recovery from muscular
fatigue. Cafarelli et al. (1990) reported that when whole-body vibration therapy was
employed directly after exercise, the perception of muscle tightness, stiffness and
soreness was significantly reduced.
Additionally, Cochrane, (2017) explored the effect of wearable vibration devices on
reducing symptoms on delayed onset muscle soreness in biceps and triceps. Thirteen
males were included in the study and received 15 minutes of vibration therapy, at a
frequency of 120 Hz, imminently and 24, 48, and 72 hours post eccentric exercise. The
participants acted as their own control group, with only one arm receiving the vibration
therapy.
The results of Cochrane (2017) reported that localised vibration therapy through a wearable
vibration device resulted in an acute reduction in the level of biceps brachii pain 24 and 72
hours post-intervention. The intervention arm experienced an increase in passive and active
range of motion for an acute duration. Subsequently, the research carried out by Cochrane
(2017) demonstrates that localised vibration therapy has similar effects on percussion theory
regarding elevating the effects of delayed onset muscle soreness (Konrad et al., 2020; Seckel
and Remel, 2017). Therefore, it can be theorised, that a percussion massage device would be
an effective method of treating whole-body symptoms of delayed onset muscle soreness.
Conclusion
In conclusion, it is evident that handheld percussive massage devices, such as the Hypervolt,
Theragun™ or other muscle guns, are an effective method of increasing range of motion and
reducing the effects of delayed onset muscle soreness. However, handheld percussive massage
devices are unable to increase muscle activation and force output. Therefore, it is recommended
that individuals use handheld percussive massage devices as part of a structured warm-up before
exercise as muscle guns can acutely increase range of motion and reduce markers of fatigue
without negatively impacting force output or muscle activation. Equally, it can be stated that
handheld percussive massage devices would be useful in a rehabilitation setting due to their
ability to reduce perceived pain and release tight or restricted fascia whilst simultaneously
increasing range of motion.
Recommendations for future research
Future research should explore the effects of handheld percussive massage devices on long term
lower limb range of motion. This literature review found that a single use of a muscle gun device
can acutely increase range of motion. However, it is still unclear if repeated use of a muscle gun
device can increase joint range of motion over a longer period of time. Subsequently, future
research should investigate how long the acute changes in range of motion last for after a single
application of a muscle gun device. Future research should also focus on the long term effects of
repeated muscle gun use over a period of consecutive days.
Practical applications
Muscle gun devices should be used as part of a structured warm-up before exercise to acutely
increase range of motion and reduce the perception of prior pain and fatigue. Muscle gun devices
can also be used during exercise, for example, betweens sets during resistance or strength
training, because muscle gun devices do not reduce muscle activation or force output. For clinical
populations, muscle gun devices provide an easy to use method of myofascial release that can
be self-administered or can be administered by another individual.
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