International Journal of

Environmental Research
and Public Health

Article
Effect of Acute Self-Myofascial Release on Pain and Exercise
Performance for Cycling Club Members with Iliotibial Band
Friction Syndrome
Jong Jin Park 1,2,† , Hae Sung Lee 2,3,† and Jong-Hee Kim 2,3, *

1 GYMNOW Fitness, Seoul 04417, Republic of Korea

2 Department of Physical Education, College of Performing Arts and Sport, Hanyang University,
Seoul 04763, Republic of Korea
3 BK21 FOUR Human-Tech Convergence Program, Hanyang University, Seoul 04763, Republic of Korea
* Correspondence: carachel07@[Link]; Tel.: +82-2-2220-1325
† These authors contributed equally to this work.

Abstract: Cycling is a popular sport, and the cycling population and prevalence of related injuries and
diseases increase simultaneously. Iliotibial band friction syndrome is a common chronic overuse injury
caused by repetitive knee use in cycling. Self-myofascial release using foam rollers is an effective
intervention for this syndrome; however, studies reporting positive results on self-myofascial release
in cycling are limited. Therefore, this study investigated the effect of self-myofascial release on pain
and iliotibial band flexibility, heart rate, and exercise performance (cadence, power, and record) in
adult male cyclists with iliotibial band friction syndrome. We evaluated the pain and exercise ability
of the control (n = 11) and self-myofascial release (n = 11) groups before and after cycling twice.
Significant differences were observed in the pain scale, the iliotibial band flexibility, and cycling pain
and power. The posterior cadence of the self-myofascial release group was 3.2% higher than that of
the control group. The control group’s record time increased by 74.64 s in the second cycling session
Citation: Park, J.J.; Lee, H.S.; Kim,
compared to the first cycling session, while that of the self-myofascial release group decreased by
J.-H. Effect of Acute Self-Myofascial
Release on Pain and Exercise
30.91 s in the second cycling session compared to the first cycling session. Self-myofascial release
Performance for Cycling Club is effective in relieving pain and may improve cycling performance by increasing the iliotibial
Members with Iliotibial Band Friction band flexibility.
Syndrome. Int. J. Environ. Res. Public
Health 2022, 19, 15993. https:// Keywords: cycling; self-myofascial release; iliotibial band friction syndrome; pain; cycling performance
[Link]/10.3390/ijerph192315993

Academic Editor: Dong-il Kim

Received: 11 October 2022 1. Introduction

Accepted: 25 November 2022
A bicycle is an eco-friendly, convenient means of transportation, and cycling, as a sport,
Published: 30 November 2022
significantly benefits the physical and mental health of participants. In addition, despite
Publisher’s Note: MDPI stays neutral the relatively simple design of bicycles, achieving a high speed is possible, increasing the
with regard to jurisdictional claims in motivation to participate in the exercise and, thus, increasing physical activity. Recently, given
published maps and institutional affil- the increased awareness of the global eco-friendliness of cycling [1], decrease in participation
iations. in indoor sports (such as weight training and swimming), and increased participation in
outdoor sports (such as walking and cycling), due to variants of the SARS-CoV-2 pandemic [2],
interest in cycling is expected to continue. Following this trend, the number of cycling
participants is currently reported to reach 2 billion worldwide, and is expected to rise to
Copyright: © 2022 by the authors.
5 billion by 2050 [3]. All cycling-cause injury rate who engage in competitive cycling exercise,
Licensee MDPI, Basel, Switzerland.
including cycling club members, was about 30.1% [4].
This article is an open access article
The motion in the impedance zone when increasing power during pedaling of a bicycle
distributed under the terms and
is a pedal-pushing motion, with the knee joint extended at 90–110◦ , and the opposite knee
conditions of the Creative Commons
Attribution (CC BY) license (https://
joint flexed at 30–35◦ , with repeated rotation [5]. During this movement, the quadriceps
[Link]/licenses/by/
femoris, gastrocnemius, soleus, and gluteus maximus are involved in extension. Regarding
4.0/). flexion, the rectus femoris, hamstring, iliopsoas, and tibialis anterior generate power [6].

Int. J. Environ. Res. Public Health 2022, 19, 15993. [Link] [Link]
Int. J. Environ. Res. Public Health 2022, 19, 15993 2 of 13

In general, a skilled person with a cadence of 85 rotations per min (RPM) repeats approxi-
mately 5000 pedals in 1 h, which can lead to severe injuries due to a fine range of motion
(ROM) restrictions, anatomical structure, and posture imbalance [7]. In order to prevent
these injuries and perform exercises smoothly, mobility and flexibility of connective tissues,
such as the muscles, ligaments, tendons, and fascia surrounding the joints, must be secured.
Moreover, if mobility and flexibility are limited, inflammatory vasoactive neuropeptides
are released with severe pain [7]. If this pain is overlooked and the individual does not rest
and undergo rehabilitation, it can lead to serious chronic conditions, such as tendinosis
and iliotibial band friction syndrome (ITBFS) [8]. ITBFS frequently occurs in people who
participate in sports involving repetitive knee use, such as cycling, running, skiing, soccer,
basketball, and tennis [9,10]. ITBFS, accompanied by a sharp stabbing pain in the outer
knee area, is reported in 12% of runners [11] and 15–24% of cyclists [12]. When pedaling a
bicycle with a limited joint ROM, the rapidly repeated flexion and extension of the knee
puts excessive fatigue and pressure on the iliotibial band (ITB) on the upper lateral femoral
epicondyle. Consequently, it causes microscopic damage to the knee tendons, bones, and
fascia, resulting in inflammatory pain [13,14]. ITBFS pain is so severe that even elite cyclists
with top-level skills give up training and events or experience poor performance [13].
Non-invasive rehabilitation tools, such as stretching, massage, and fascial relaxation,
are recommended to effectively relax local tissue adhesions through repeated friction [15].
Particularly, due to ITB division into the proximal, median, and distal parts and physical
elongation, it is not feasible to expect effective ITB elongation only with clinical stretch-
ing. It has been suggested that self-myofascial release (SMR), using a foam roller, can be
more effective [16]. SMR using a foam roller can be used immediately on the painful area
regardless of time and place. Furthermore, SMR improves fascial damaged tissue adhesion,
blood circulation, autonomic nervous system control, ROM, and flexibility and reduces
pain [17,18]. Enthusiasts and club members who actively participate in exercise tend to be
highly motivated to exercise and have strong will to return to exercise or sport, so they over-
look the pain and are less likely to actively participate in long-term rehabilitation programs.
Studies have been recently conducted to confirm the immediate effect of SMR; however,
there are conflicting opinions on the impact so far [19–22]. It has also been suggested that
ITBFS has complex and unpredictable mechanisms, typically following a fluctuating course,
with relapse or improvement at any point in the treatment progression [23]. Furthermore,
emerging studies are establishing optimal SMR programs and verifying that they can
induce immediate benefits. However, since ITBFS is clinically diagnosed, patient recruit-
ment, research design and application, and ethical issues are major barriers to research.
Until recently, related studies analyzed exercise performance (such as ROM, flexibility, and
jump power) at a basic level, and exercise performance in actual sports was unclear [24].
Therefore, it is necessary to establish an optimal acute SMR ITBFS program and verify the
effectiveness of exercise for effective recovery and rapid return to the field among club
members with high motivation to participate in cycling.
This study aimed to investigate the effect of one-time SMR using a foam roller, an
effective method of mediating ITBFS, via special tests, visual analog scale (VAS), and
exercise performance on adult male cycling club members diagnosed with ITBFS. Hence, we
hypothesized that the SMR group would show positive pain relief and exercise performance
compared to the control group. The participants were divided into the control and SMR
groups, and the differences between VAS, heart rate (HR), exercise performance (cadence,
power, record), and special test results (Renne’s test, Noble’s compression test, Ober’s test)
while cycling, and after acute SMR, were compared and analyzed.

2. Materials and Methods

2.1. Study Subject
This study was conducted on informed cycling club members who consented after
knowing the purpose and method of this study, in Seoul, Korea. The inclusion criteria were:
(1) Adult men aged 20–45 y, (2) Individuals with over one year of cycling experience who
 2. Materials and Methods
2.1. Study Subject
This
study was conducted on informed cycling club members who consented after
Int. J. Environ. Res. Public Health 2022, 19, 15993 3 of 13
knowing the purpose and method of this study, in Seoul, Korea. The inclusion criteria
were: (1) Adult men aged 20–45 y, (2) Individuals with over one year of cycling experience
who had been active for the past year, (3) Those who had experienced knee pain while
had been active for the past year, (3) Those who had experienced knee pain while pedaling
pedaling a bicycle, (4) Individuals positive in the ITBFS diagnostic test. The exclusion
a bicycle, (4) Individuals positive in the ITBFS diagnostic test. The exclusion criteria were:
criteria were: (1) Individuals in poor condition due to drinking and lack of sleep, (2) Those
(1) Individuals in poor condition due to drinking and lack of sleep, (2) Those whose joint
whose joint surgery history might affect the study results, and (3) Individuals who did
surgery history might affect the study results, and (3) Individuals who did not consent to
not consent to the study. Finally, 22 candidates were enrolled in the study, excluding two
the study. Finally, 22 candidates were enrolled in the study, excluding two with negative
with negative ITBFS test results. They were grouped using the convenience sampling
ITBFS test results. They were grouped using the convenience sampling method (Table 1).
method (Table 1).
Table 1. Characteristics of study subjects.
Table 1. Characteristics of study subjects.
Group Sex Age (Year) Height (cm) Weight (kg) Career (Year)
Group Sex Age (year) Height (cm) Weight (kg) Career (year)
32.8 ± 4.8 174.3 ± 4.3 75.1 ± 6.0
Control group (n = 11)
Control group (n = 11) Male
Male 32.8 ± 4.8 174.3 ± 4.3 75.1 ± 6.0 4.14.1± ±
2.02.0
34.8 ± 4.3 175.8 ± 4.2 77.2 ± 7.7
SRM group (n = 11)
SRM group (n = 11) Male
Male 34.8 ± 4.3 175.8 ± 4.2 77.2 ± 7.7 3.53.5± ±
1.81.8
All data are represented as mean ± SEM.
All data are represented as mean ± SEM.

2.2.
2.2. Study
Study Design
Design
ITB
ITB flexibility and
flexibility pain scale
and pain scale were
were measured
measuredthrough
throughaapre‐special
pre-specialITFBS
ITFBSpositive
positivetest
test
in
in the control and SMR groups. After the first 10 km cycling course, the control group had a
the control and SMR groups. After the first 10 km cycling course, the control group had
static restrest
a static forfor
120120
minmin
[25].[25].
TheThe
SMR group
SMR conducted
group the intervention
conducted the interventionusing a foam
using roller
a foam
for 20 min after a static rest of 100 min, and then both groups underwent
roller for 20 min after a static rest of 100 min, and then both groups underwent a post‐ a post-cycling
special
cycling test
specialafter the
test second
after cycling
the second on the
cycling onsame course.
the same TheThe
course. exercise
exercisewas
wasevaluated
evaluated by
collecting the HR, cadence, power, and record results during the first
by collecting the HR, cadence, power, and record results during the first and second and second cycling
sessions (Figure 1).
cycling sessions (Figure 1).

Figure 1. Schematic
Figure 1. Schematic design of experimental
design of experimental procedures.
procedures.

2.2.1. Special Test

2.2.1. Special Test
Using the results of previous studies, Renne’s test and Noble’s compression test
Using the results of previous studies, Renne’s test and Noble’s compression test for
for VAS assessment, and Ober’s test for ITB flexibility assessment, were performed as
VAS assessment, and Ober’s test for ITB flexibility assessment, were performed as
diagnostic methods for ITBFS (Table 2) [26,27]. In addition, a digital angle meter (AG-02LB,
diagnostic methods for ITBFS (Table 2) [26,27]. In addition, a digital angle meter (AG‐
Gain Express Holdings Ltd., Kwawan, Hong Kong) was used to obtain accurate results.
02LB, Gain Express Holdings Ltd., Kwawan, Hong Kong) was used to obtain accurate
An experienced licensed physical therapist with over five years of clinical experience
results. An experienced licensed physical therapist with over five years of clinical
conducted the special tests. The tests were performed pre-first and post-second cycling.
 Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW

Int. J. Environ. Res. Public Health 2022, 19, 15993 4 of 13

experience conducted the special tests. The tests were performed pre-fir
cycling.

Table 2. Special test method forTable

evaluation of iliotibial
2. Special bandfor
test method friction syndrome.
evaluation of iliotibial band friction syndrome

Special Test
Special Test Method Method

[Renne’s test]
1.[Renne’s test]<break/>1.
The subject sat down until The
kneesubject sat down
was at flexion untilup.
30◦ stand knee was a
[Link].<break/>2. Pain
Pain in the lateral in the lateral
epicondyle epicondyle was checked.<br
was checked.
* pain<break/>3.
Positive on pain Subjective visual analog scale evaluation was con
3. Subjective visual analog scale evaluation was conducted

[Noble’s compression test]

1.[Noble’s compression
The subject’s test]<break/>1.
knee was passively 90◦ . subject’s knee was p
flexed toThe
2.90°.<break/>2.
The examiner applied pressureapplied
The examiner on lateralpressure
epicondyleonand
lateral epicond
the upper gradually.
gradually.<break/>3. The knee was self-extended and checke
3. The knee was self-extended and checked for lateral pain
before30◦30°.<break/>*
before . Positive on pain<break/>4. Subjective v
evaluation was
* Positive on pain conducted.
4. Subjective visual analog scale evaluation was conducted.

[Ober’s test]
[Ober’s test]<break/>1. The subject lay in the lateral position
1. The subject lay in the lateral position with the test leg up.
[Link].<break/>2. Thewas
The subject’s knee subject’s
flexed at knee
90◦ andwas flexed
the ankle andatknee
90° and th
supported.<break/>3. When the support was released, the degree
supported. degre
[Link]
the the support
knee waswas released, the
measured degree of abduction
*.<break/>* Negative for adduc
(cm) of the knee was measured *.
abduction
* Negative for adduction, positive for abduction

2.2.2. Visual Analog Scale to2.2.2.

Self-Evaluate the Pain
Visual Analog Scale to Self-Evaluate the Pain
VAS was conducted to self-evaluate
VAS was theconducted
pain felt while cycling afterthe
to self-evaluate thepain
1st cycling andcycling a
felt while
the 2nd cycling. VAS required
andthe degree
the of pain felt
2nd cycling. VAS during the first
required the and second
degree cycling
of pain felttoduring th
be directly recorded immediately
cyclingafter
to beeach cycling
directly session.
recorded The range of
immediately 1–10
after wascycling
each used, session
with 0 representing absencewas
of pain and 10 extreme pain.
used, with 0 representing absence of pain and 10 extreme pain.

2.2.3. Bicycle and Exercise Performance

2.2.3. Bicycle and Exercise Performance
Zwift (Zwift Inc., Long Beach, CA,
Zwift USA),Inc.,
(Zwift a bicycle simulation
Long Beach, software,
CA, USA), and a simulation
a bicycle roller sof
fixture (Tacx NEO T2 Smart Trainer, Garmin Korea Ltd., Seoul, Republic of Korea) were
fixture (Tacx NEO T2 Smart Trainer, Garmin Korea Ltd., Seoul, Ko
used to eliminate external factors that might affect the research results, such as weather,
eliminate external factors that might affect the research results, such
wind, traffic, and road conditions, and to provide the same cycling environment [28,29].
traffic, and road conditions, and to provide the same cycling enviro
The cumulative altitude per 10 km cycling was 62 m, the longest uphill section was 1.5 km,
cumulative altitude per 10 km cycling was 62 m, the longest uphill s
and the cumulative altitude was 18 m. The participants cycled 10 km each during the first
and the cumulative altitude was 18 m. The participants cycled 10 km e
and second cycling sessions. Cadence, power, and record results were collected per second
and second cycling sessions. Cadence, power, and record results w
via Zwift to analyze their performance. An HR measuring device (Polar H-10, Polar Electro
second via Zwift to analyze their performance. An HR measuring d
Inc., Kempele, Finland) was used for HR analysis [30].
Polar Electro Inc., Kempele, Finland) was used for HR analysis [30].
2.2.4. Self-Myofascial Release
2.2.4. Self-Myofascial Release
The SMR applied in a previous study [31] was modified and supplemented to fit the
The SMRfor
purpose of this study. It was constructed applied in a previous
the triceps studyanterior,
surae, tibialis [31] wasquadriceps
modified and supp
femoris, tensor fasciae latae, and gluteus maximus (Table 3). A hard type 66 × 14 cmsurae,
purpose of this study. It was constructed for the triceps foamtibialis a
femoris, tensor fasciae latae, and gluteus
roller, made of Ethylene Vinyl Acetate Copolymer, was used as the SMR tool. maximus (Table 3). A hard ty
roller, made of Ethylene Vinyl Acetate Copolymer, was used as the SM
 Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 5 of 13
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Int. J. Environ.
Int. J. Environ. Res. Public
Res. Public HealthHealth
2022,2022, 19, x FOR PEER REVIEW
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Table
Table 3.
3. Self‐myofascial
Self‐myofascial release
release programs.
programs.
Table 3. Self‐myofascial release programs.
TableTable
Table 3. Self‐myofascial
3. Self‐myofascial
3. Self-myofascial releaseprograms.
release
release programs.
programs.
Target
Target
Target Self‐Myofascial Release
Self‐Myofascial Release
Release Protocol
Protocol Frequency
Frequency Time
Time
Target
Muscle
Target
Muscle Self‐Myofascial Protocol Frequency Time
Muscle Self‐Myofascial
Self‐Myofascial Release
Self-Myofascial
Release Protocol
Protocol Frequency
Frequency TimeTime
Target Muscle
Muscle 1. Protocolbackward at the trigger Frequency Time
Release 1. Apply
1. Apply forward
Apply forward and
forward and backward
and backward at at the
the trigger
trigger
1. Apply
point
1. Apply
point forward
forward and
and backward
backward at the trigger
at the trigger
point
1. Apply forward and backward at the 1.1. 444 times
times
point
2. Apply
point
2. Apply left
left and
and right
right at
at the
the trigger
trigger point
point 1. times
Triceps
Triceps trigger
2. point
Apply left and right at the trigger point 1.
2.
1. 44 times
times
Triceps 2.
3. Apply left
3. Apply leftandandrightrightafter
at the
the trigger
ankle pointat
rotation at the
the 1. 3. [Link]
2. 4 times
times 44 min
Triceps
surae
Triceps
surae
2.
2. Apply
3. Apply
Apply left
leftleftand and
andright right
right
right at
after
at after
the trigger
ankle
trigger
ankle pointpoint
rotation
rotation at the 2.
2.3. 444 times
4 times
times 44 minmin
Triceps
surae 3. Apply
trigger left
point and right after ankle rotation at the 2. 4
3. times
4 times min
surae 3. 3.
ApplyApply
trigger left
point
left and andrightright after
after ankle
ankle rotation
rotation at at the 3. 4 min
4 min
surae
surae trigger
trigger
4. Repeat point
point at the downward, middle, and, 44.
3. 3.4. 44111times
[Link] times
time
time
time
thetrigger
trigger
4. Repeat point
point at the downward, middle, and, 4.
4.
4.
upwardRepeat
Repeat at the
atdownward,
atpositions theof downward,
downward,
the middle,
middle, and,
and, 4. 4. 1 time11 time
time
4. Repeat
4. Repeat
upward
upward
theat
positions
positions the of the triceps
ofdownward,
the
middle,
triceps
triceps
surae
and,
middle,
surae
surae and,
upward
1. positions of the triceps surae
1. Apply
upward
upward
1. Apply
Apply
forward
positions
positions
forward
forward
of theand
of
and
and
thebackward
triceps
triceps
backward
backward
surae at
at the
surae
at the trigger
the trigger
trigger
1. Apply
point
1. Apply
point
1. Apply forward
forward
forward and and
and backward
backward
backward at at
at
the the
the trigger
trigger
point 1.1. 444 times
times
point
2.
2. Apply
trigger
point pointleft
Apply left and
and right
right at at the
the trigger
trigger pointpoint 1. times
Tibialis
Tibialis 2. Apply left and right at the trigger point 1. 1.
2.
4
1.2. 44 times
times
4 times
times
Tibialis 2.
3.
2. ApplyApply left
left
leftleft and
andandand
right right
right at the
after
at the trigger
ankle
trigger point
flexion
point and 2. 44 min
Tibialis
anterior
Tibialis
Tibialis
anterior
2.
3. Apply
3. Apply
Apply left
left and
and right
right
right atafter
the
after trigger
ankle
ankle point and
flexion
flexion and 2. 3. 2. 444 times
[Link]
2. 4
times
times
times
min
44 min
anterior 3.
3. Apply
extension
3. ApplyApply
extension left
leftleftat
and
at and
the
and
the right
trigger
right right
trigger after
point
afterafter
ankle
point ankle
flexion
ankle flexion
and and
flexion and 3. 4 times 4 min
4 min
min
anterior
anterior
anterior extension at the trigger point 3.
3. 3.
44. 44111times
[Link] times
time
time
extension
extension
4. Repeat
extension at theatat
at trigger
the
the trigger
the
trigger point
point
downward,
point middle, and, 4. time
4. Repeat at the downward, middle, and, 4. 4.
1 time
4.
4. Repeat
4.
upwardRepeat
Repeat theat
atpositions the
atdownward,
theof downward,
middle, middle,
downward,
the and,
middle, and,
and, 4. 11 time time
4. Repeat
upward
upward at
positions
positions the of the tibialis
the tibialis anterior
ofdownward,
tibialis middle,
anterior
anterior and,
upward
upward
1. positions
positions of theof tibialis
the anterior
tibialis anterior
1. Apply
upward
1. Apply
forward
Applypositionsforward of
forward
and
and
and
thebackward
tibialis
backward
backward
at
at the
anterior
at the trigger
the trigger
trigger
1.
1. Apply
point
1. ApplyApply
point forward
forward
forward and and backward
backward
and backward at at
the
at the
the trigger
trigger
point 1.1. 444 times
times
trigger
point
2. pointleft and right at the trigger point
Apply 1. times
Quadriceps point
2.
2. Apply
Apply left
left and
and right
right at
at the
the trigger
trigger point
point 1. 4
1.
2. times
44 times
times
Quadriceps 2. Apply
2.
3. Apply left and
left
left right
and
and rightat
right the trigger
atafter
the trigger
trigger
knee pointpoint and 1.2. 4 times
Quadriceps
Quadriceps
Quadriceps
femoris 2.
3. Apply
3. Applyleft
Apply leftand
left andright
and rightat
right the
after
after knee flexion
knee point
flexion
flexion and 2. 3.
and
2.
2. 444 times
4 times times
times
44 minmin
44 min
Quadriceps
femoris 3. Apply
3. Apply
extension left and
left
at right
and
the after
right
trigger knee
after
point flexion
knee and
flexion and 2.3. 4 times 4 min
min
femoris
femoris
femoris 3. Apply
extension left
at and
the right
trigger after
point knee flexion and 3. 3.
4
3.4. 4
times
41 times
times
time 4 min
femoris extension
extension at theat trigger
the trigger point
point 3. 4. 4 1 times
time
extension
4.
4. Repeat atatthethe trigger point
downward, middle, and,
and, 4. 4. 1 time
extension
4. Repeat
4. Repeat
Repeatat theat the
at
at trigger
the
downward,
the point
downward, middle,
middle, middle,
downward, and, and, 4. 11
4.
time
1 time
time
4.
upward
4. Repeat
Repeat
upward at
positions
at
positions the
the of
of downward,
the quadriceps
downward,
the quadriceps middle,
femoris
middle,
femoris and,
and,
upward
upward positions
positions of the
of quadriceps
the quadriceps femoris
femoris
upward
1. positions of thebackward
quadriceps femoris
1. Apply
upward
1.
1. ApplyApply
Apply
forward
positions
forward
forward
forward and
and
of
and
and
the quadriceps
backward
backward
backward at
at
at
the
the
the trigger
at femoris
the trigger
trigger
1.
1. Apply
point
Apply
point forward
forward and
and backward
backward at
at the
the trigger
trigger
trigger
point point 1. 44 times
point
2.
2. Apply left and right at
at the trigger point [Link]
1. 1. times
Tensor
Tensor 2. point
Apply
2. Apply
Apply left left
and
left and
right
and right
rightat the
at the trigger
trigger
the trigger point point
point 1.
2.
1.2. 444 times
4
times
times
times
Tensor
Tensor 2.
3. Apply left
left and
and right
right at the
after trigger
knee point
flexion and 2. 4
2. times 44 min
fasciae Tensor
fasciae
Tensor
fasciae latae
latae
latae
2.
3. Apply
3. Apply
3. Apply
Apply leftleftandand
left
left and
right
and right
right
right atafter
after the trigger
after
knee knee
flexion
knee point
flexion
and and
flexion and
3. 2.
3.
2.
43. 444 times
4
times
times
times
times
min
4 min
44 min
fasciae latae 3.
3. Apply
extension
Apply
extension
extension at left
at
left
the
at and
the
and
trigger
the right
trigger
right
trigger pointafter
point
after
point knee
knee flexion
flexion and
and 3. 4 times 4 min
min
fasciae latae
fasciae latae extension at the trigger point 3.
4.3.4. 411times
14.4time times
time
time
extension
4.
4. Repeat
4. Repeat
extension
Repeatat the atat
at the
at trigger
the
downward,
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downward,
middle, middle,
point
downward, and,
middle, and,
and, 4. 1 time
4. Repeat at the downward, middle, and, 4. 1
4. 1 time time
4.
upward
upward
4. Repeat
Repeat
upward at
positions
positions
positions the
of
at theof of
the downward,
the tensor
tensor
ofdownward,
the tensor fasciae
tensor fasciae middle,
fasciae latae
middle,
fasciae latae and,
lataeand,
upward
upward positions
positions of the
thebackward
tensor fasciae
fasciae latae
latae
1.
1.
1. ApplyApply
upward
Apply forward
positions
forwardforward and and
of
andthe tensor
backward
backward at at
theat the
the trigger
latae
trigger
1.
1. Apply
Apply
point forward
forward and
and backward
backward at
at the
the trigger
trigger
trigger
1. pointforward and backward at the trigger
Apply
point
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point
2. 1. 1. 44 times
[Link] times
Gluteus 2. Apply
2. Apply
point
2. Apply
Apply
leftleftandand
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3. ApplyApply after left
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abduction at the
and trigger
adduction point of the 1.2. 4 times 44 min
Gluteus
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maximus 2.
3. Apply
3. Apply
Apply left
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at the
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times 4
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hip Apply
jointat the
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point and adduction of the 3. 44 times
times 4 min
maximus 3. Apply
hip joint
joint at after
at the abduction
the trigger
trigger point and
point adduction of the 4. 4.
4 times
3. 4 min
maximus hip
4. Apply
hip
4. joint
Apply afterat flexion
the flexion
after andand
trigger extension
point extension of the of hip
the hip 3.
4.4. 4444 times
times
times
times
hip
4.
4. joint
Apply
Apply at the
after
after trigger
flexion
flexion point
and
and extension
extension of
of the
the hip
hip 4. 4 times
joint
4. at the
Apply
joint at trigger
after point
flexion and extension
extension of of the
the hiphip 4. 4 times
4. Apply
joint
joint at the
at the
the
trigger
after
trigger
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point
point and
joint at
joint at the
the trigger
trigger point point
2.3. 2.3.
2.3.
2.3.
Statistical
Statistical
Statistical
Statistical
Analyses
Analyses
Analyses
Analyses
2.3. Statistical
All the Analyses
data collected during this study
2.3. Statistical
All
All All the
thethe data Analyses
data
data collectedduring
collected
collected duringthis
during this study are
this study
study are expressed
expressed
areexpressed
are expressedas
as mean
asas
mean
mean
mean
±± SEM.
± SEM.
± SEM.
SEM.
The
The statistical
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statistical
analyses
analysesAll
All were
the
were
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data collected
performed
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used to
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and 2nd cycling
compare
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mean differences
during
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in the special
period.
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specialA Atests
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tests
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(Renne’s
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VAS)
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and in thein
exercise
differences the
special special
inperformance tests(heart
the special
special tests
tests (Renne’s
(Renne’s
rate,
(Renne’stest,test,
cadence, Noble’s
test,
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Noble’stest compression
was used
compression to test,
test, Ober’s
compare
Ober’s test,
the
test, VAS)
mean
VAS) and exercise
differences
and exercise inperformance
the
performance (heart
tests
(heart rate,
(Renne’s
rate, cadence,
cadence,test,
compression
power, and test, Ober’s
record) between test, VAS)
the and
control exercise
and SMR performance
groups. (heart
Statistical rate,rate,
significance cadence,
was power,
Noble’s
power, and
Noble’s
power,
compression
and record) between
compression
record)
test,
between Ober’s
test, Ober’s the
test,
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control
VAS)
VAS) and
and
and
and SMR
SMR
exercise
groups.
exercise
groups.
performance
Statistical (heart
performance
Statistical
(heart
significance was set
cadence,
rate, cadence,
significance was set
set
andpower,
record)
at p
power,< and record) between the control and SMR groups. Statistical significance was set< 0.05.
[Link]
and
at pp << 0.05.
0.05. record) the control
between the and SMR
control groups.
and SMR Statistical
groups. significance
Statistical was
significance set
was at p
set
at
at p < 0.05.
at p < 0.05.
3. Results
3.1. Visual Analog Scale and Iliotibial Band Flexibility
Comparative analysis of the difference between VAS felt while cycling, and ITB
flexibility confirmed in the special test, revealed that no significant difference was observed
in Renne’s VAS test results between control (p = 0.9352) and SMR group (p = 0.9982) in
each cycling session. Renne’s test results for pre-1st and post-2nd cycling of the control
showed no difference (p = 0.9912), and the SMR group showed a slight decrease after
SMR application, but there was no significant difference (Figure 2A; p = 0.2860). In the
 Comparative analysis of the difference between VAS felt while cycling, and ITB
flexibility confirmed in the special test, revealed that no significant difference was
observed in Renne’s VAS test results between control (p = 0.9352) and SMR group (p =
0.9982) in each cycling session. Renne’s test results for pre‐1st and post‐2nd cycling of the
Int. J. Environ. Res. Public Health 2022, 19, 15993showed no difference (p = 0.9912), and the SMR group showed a slight decrease
control 6 of 13
after SMR application, but there was no significant difference (Figure 2A; p = 0.2860). In
the case of VAS through Nobel’s compression test, the result of the SMR pre‐1st cycling
was significantly higher than that of the control pre‐1st cycling (p = 0.0088), the control
case of VAS through Nobel’s compression test, the result of the SMR pre-1st cycling was
post‐2nd cycling (p = 0.0023), and the SMR post‐2nd cycling (Figure 2B; p < 0.0001). No
significantly higher than that of the control pre-1st cycling (p = 0.0088), the control post-2nd
significant difference was observed in ITB flexibility in pre‐1st cycling through Ober’s test
cycling (p = 0.0023), and the SMR post-2nd cycling (Figure 2B; p < 0.0001). No significant
between each group (p = 0.9917). However, the ITB flexibility of the SMR group
difference was observed in ITB flexibility in pre-1st cycling through Ober’s test between
significantly increased post‐2nd cycling and was more than that observed in pre‐1st
each group (p = 0.9917). However, the ITB flexibility of the SMR group significantly
cycling (Figure 2C; p < 0.05). Regarding the VAS of pain felt while cycling, no significant
increased post-2nd cycling and was more than that observed in pre-1st cycling (Figure 2C;
difference was observed between the two groups after the 1st cycling (p = 0.8835).
p < 0.05). Regarding the VAS of pain felt while cycling, no significant difference was
However, the SMR group’s VAS of pain significantly decreased compared to those of the
observed between the two groups after the 1st cycling (p = 0.8835). However, the SMR
post‐1st cycling and the post‐2nd cycling of the control (p < 0.01). In addition, the SMR
group’s VAS of pain significantly decreased compared to those of the post-1st cycling and
group experienced
the post-2nd cyclinga of
more
the significant
control (p <decrease
0.01). Ininaddition,
the 2nd the
cycling
SMRthan in the
group 1st cycling
experienced a
(Figure 2D; p < 0.0001).
more significant decrease in the 2nd cycling than in the 1st cycling (Figure 2D; p < 0.0001).

Figure 2. Comparison of iliotibial band flexibility and visual analog scale. Comparison of iliotibial
band flexibility
flexibilityand
andvisual
visualanalog
analogscale.
scale.
(A)(A) Results
Results of the
of the Renne’s
Renne’s test;test; (B) Results
(B) Results ofNoble’s
of the the Noble’s
com-
pression test; (C) Results of the Ober’s test; (D) Results of the visual analog scale test. * Superscripts*
compression test; (C) Results of the Ober’s test; (D) Results of the visual analog scale test.
Superscripts denotesignificant
denote statistically statistically significant
values values
(* p < 0.05; ** p(*<p 0.01;
< 0.05;
*****pp<< 0.001;
0.01; *** p <p 0.001;
**** **** p < 0.0001).
< 0.0001).

3.2. Exercise
3.2. Exercise Performance
Performance
HR results
HR results presented
presented the
the physiological response of
physiological response of the
the heart
heart according
according to
to exercise
exercise
intensity. The
intensity. The post-2nd
post‐2nd cycling
cycling HR
HR of
of the
the SMR
SMR group
group was 150.3 ±
was 150.3 5.9, which
± 5.9, which was
was rather
rather
high compared to the results observed after 1st cycling (132.4 ± 5.9) and 2nd
high compared to the results observed after 1st cycling (132.4 ± 5.9) and 2nd cycling (138.9cycling
± 6.1) ±
(138.9 of6.1)
theofcontrol
the control
and and
the the
SMRSMR1st 1st cycling
cycling (141.1± ±8.9);
(141.1 8.9);however,
however, no
no significant
significant
difference was observed. Regarding cadence, in which the number of pedals per
difference was observed. Regarding cadence, in which the number of pedals min was
per min was
measured, the 2nd cycling of the SMR group was 83.1 ± 3.1, which was slightly higher
than that observed after 1st cycling (80.2 ± 2.4) and 2nd cycling (81.1 ± 2.8) of the control,
and the SMR 1st cycling (82.4 ± 3.3); however, no significant difference was observed
(Figure 3B). On analyzing the pedaling power while cycling, no significant difference was
observed between the groups in the 1st cycling results; however, the SMR group displayed
significantly higher pedaling power than the control group in the 2nd cycling results
(103.4 ± 8.7 vs. 140.3 ± 8.9; p < 0.01; Figure 3C). The 2nd cycling record time of the SMR
group was 1320.7 ± 48.2 s for 10 km cycling, which was slightly decreased compared
to that observed among the control 1st cycling (1472.5 ± 92.8), the control 2nd cycling
(1547.2 ± 98.5), and the SMR 1st cycling (1351.2 ± 47.1); however, no significant difference
 and the SMR 1st cycling (82.4 ± 3.3); however, no significant difference was observed
(Figure 3B). On analyzing the pedaling power while cycling, no significant difference was
observed between the groups in the 1st cycling results; however, the SMR group
displayed significantly higher pedaling power than the control group in the 2nd cycling
results (103.4 ± 8.7 vs. 140.3 ± 8.9; p < 0.01; Figure 3C). The 2nd cycling record time of the
Int. J. Environ. Res. Public Health 2022, 19, 15993 7 of 13
SMR group was 1320.7 ± 48.2 s for 10 km cycling, which was slightly decreased compared
to that observed among the control 1st cycling (1472.5 ± 92.8), the control 2nd cycling
(1547.2 ± 98.5), and the SMR 1st cycling (1351.2 ± 47.1); however, no significant difference
was observed.
was observed. OnOnthetheother
otherhand,
hand,ononanalyzing
analyzingeach section
each of the
section longest
of the uphill
longest roadroad
uphill
(distance: 1.5 km;
(distance: km; cumulative
cumulative altitude: 18 m) in thethe 2nd
2nd cycling,
cycling, aa significant
significant difference
difference was
was observed
observed between
between the groups
the groups in500
in the the m,
500600
m, m,
600900
m, m,
9001000
m, 1000
m, 1200m, 1200 m sections,
m sections, and the
and the average
average value ofvalue of the accumulated
the accumulated power power
in eachinsection
each section also significantly
also significantly differed
differed between
between
the groups the(Table
groups4).(Table 4).

Figure 3. Comparison
Figure Comparisonofofexercise
exerciseperformance.
performance. (A)(A)
Results of the
Results Heart
of the rate;rate;
Heart (B) Results of the
(B) Results of the
Cadence; (C)
Cadence; (C) Results
Resultsof ofthe
thePower;
Power;(D)
(D)Results
Resultsofof
thethe
Record. ** Superscripts
Record. denote
** Superscripts statistically
denote statistically
significant values (** p < 0.01).
significant values (** p < 0.01).
Table 4. Power in the longest uphill section.
Table 4. Power in the longest uphill section.
Power (watt)
Distance (m) Power (watt) p
Distance (m) Control SMR p
100 Control
106.8 ± 12.9 SMR
116.5 ± 8.5 ns
100
200 106.8 ±
109.6 12.9
± 8.9 123.2±± 8.5
116.5 8.5 nsns
300
200 114.8
109.6 ±±6.9
8.9 138.2±± 8.5
123.2 8.3 nsns
400
300 110.4 ± 6.8
114.8 ± 6.9 139.0 ± 9.0
138.2 ± 8.3 nsns
500 105.9 ± 6.6 146.1 ± 8.5 ** <0.01
400 110.4 ± 6.8 139.0 ± 9.0 ns
600 108.8 ± 7.7 144.8 ± 6.8 * <0.05
500 105.9 ± 6.6 146.1 ± 8.5 ** <0.01
700 109.1 ± 7.5 138.5 ± 6.0 ns
600
800 108.8 ±±6.1
104.0 7.7 133.5±±6.8
144.8 8.6* <0.05
ns
900
700 96.0 ±±6.2
109.1 7.5 135.6
138.5 ±± 9.4
6.0 * <0.05
ns
1000
800 97.9 ± 6.3
104.0 ± 6.1 138.5
133.5 ± 8.6**
± 7.5 <0.01
ns
900 96.0 ± 6.2 135.6 ± 9.4 * <0.05
1000 97.9 ± 6.3 138.5 ± 7.5 ** <0.01
1100 104.0 ± 8.9 132.2 ± 8.1 ns
1200 95.8 ± 6.1 136.3 ± 7.4 ** <0.01
1300 102.9 ± 7.8 135.2 ± 7.0 ns
1400 104.6 ± 6.6 137.7 ± 7.3 ns
1500 105.0 ± 7.4 137.2 ± 6.3 ns
Mean power 105.0 ± 5.2 135.5 ± 7.2 * <0.05
All data are represented as mean ± SEM. * Superscripts denote statistically significant values (* p < 0.05;
** p < 0.01).
Int. J. Environ. Res. Public Health 2022, 19, 15993 8 of 13

4. Discussion
This study aimed to investigate the effect of one-time SMR on pain and exercise
performance in individuals diagnosed with ITBFS who cycled regularly over one year
among adult male cycling club members. We found that the one-time SMR program
was effective in relieving pain and improving motor performance by enhancing VAS,
ITB flexibility, and pedaling power during cycling. In addition, we tried to control other
environmental factors that could affect the study results using the latest smart sports
software and equipment. No participant complained of side effects or suffered injuries
during the study’s special tests, cycling, and SMR.
Among the special tests in this study, Renne’s test showed no difference between
groups in pre-1st cycling, so it was possible to clearly evaluate the SMR effect after the
second cycling. On the other hand, in Noble’s compression test, a significant difference
was observed in the pre-cycling results between both groups; therefore, it was difficult
to clearly interpret the effect of SMR in the results after the second cycling. Due to the
nature of the special test, direct stress (such as elevation, pressure, and palpation) was
applied to the damaged tissue in a specific posture vulnerable to pain; therefore, it was not
feasible to expect pain relief from a one-time SMR in Noble’s compression test. There was
no significant difference between groups in the VAS measured after the first cycling due to
appropriate pre-cycling control; however, significant differences within and between groups
were confirmed in the SMR group’s VAS after the second cycling. Therefore, SMR was
effective in relieving pain while cycling. Physical compression by SMR using a foam roller
mediates the sensitivity of a nociceptor that transmits pain to the central nervous system
and a mechanoreceptor that detects physical deformation, such as pressure, elongation, and
flexion. SMR relieves pain by inducing the rearrangement of muscles, ligaments, tendons,
and fascia through artery expansion and increased blood flow at the injured site [32,33].
Particularly, the sensory neurons of the fascia are more densely innervated than other
tissues and, thus, play an essential role in determining the degree of pain. However, strong
stimulation is required to effectively relax the fascia because it has to penetrate the thick
skin and muscle resistance. SMR using a foam roller can apply a pressure of approximately
7 VAS [32]; therefore, the SMR applied in this study would have relaxed the adhesion of the
fascia to the damaged area. The mechanism of diffuse noxious inhibitory control (DNIC)
might be related to these results [34,35]. DNIC is a phenomenon in which monoamines,
such as noradrenaline and serotonin, are expressed by specific stimuli to counter-irritate
pain signals from the spinal cord to the brain [32]. This may temporarily relieve the pain
caused by ITBFS [34,35]. Furthermore, this study’s SMR was performed for 20 min, which
was longer than the SMR performed in previous studies (30 s–15 min) [21,32,36]. This
suggests the applicability of the DNIC mechanism, as it delivered high physical pressure to
the SMR group.
On the other hand, this pain relief mechanism might be closely associated with the
increased ITB flexibility identified in the SMR group [31,37]. ITB originates from the gluteus
maximus proximal outside the hip joint and is structured such that the bifurcated fascia, the
“iliotibial tract”, crosses the musculus biceps femoris and vastus lateralis and connects the
lateral Gerdy’s tubercle of the tibia [38]. ITB has a thick structure in a complex combination
with the tensor fasciae latae in the gluteus maximus proximal; therefore, it is not feasible to
expect the optimal effect from traditional stretching alone [16]. Thus, to secure flexibility
through ITB elongation, SMR application using a foam roller is recommended. This study
confirmed a significant difference within the SMR group in investigating ITB flexibility
through Ober’s test. ROM restriction, due to decreased flexibility, induces an imbalance
of muscles, ligaments, tendons, and fascia surrounding the joint, leading to stiffness,
adhesions, trauma, inflammation, and decreased venous and lymphatic system function
between connective tissues [39]. Consequently, motor function decreases in efficiency,
leading to various musculoskeletal injuries and diseases. Many studies on sports have
conducted research on various stretching exercises to increase athletes’ ROM; previous
studies have reported that static stretching can negatively affect athletic performance
Int. J. Environ. Res. Public Health 2022, 19, 15993 9 of 13

temporarily [40–44]. SMR using a foam roller does not affect muscle strength and is,
therefore, recommended as an effective intervention method that can increase ROM [45].
However, conflicting results were reported in related studies. Richman et al. reported
that the effect of SMR on flexibility was not significant when comparing 6-min SMR and
flexibility in dynamic stretching in adult women [46]. Conversely, Bradbury-Squires et al.
reported that the flexibility of the SMR group increased by 16% compared to the control
group after 5 min of SMR in adult men [47]. SMR studies using foam rollers have significant
limitations compared to previous studies due to the demographic characteristics of partici-
pants and the diversity of sports events, environments, tools, and SMR programs. However,
compared to previous studies mentioned above, the different delivery of the foam roller’s
physical pressure, according to weight differences (69.3 ± 10.9 vs. 84.4 ± 8.8 kg) based on
the participant’s sex, is essential to determining the results of both studies. In addition, SMR
application time is also important. In previous studies, 30 s of SMR application had no
significant effect on flexibility and exercise capacity [48,49]; nonetheless, a 90-s SMR study
showed improved flexibility [22,50]. In particular, Monteiro et al. suggested that ‘more than
90 s’ could be a criterion for inducing improved flexibility with SMR, and establishing a
systematic SMR program with extended time was required to obtain a better effect [51].
The mean body weight of the SMR group in this study was 77.2 ± 7.7 kg, and SMR was
performed for a longer time (20 min) than in other previous studies. Therefore, the ITB
flexibility increase observed in this study was due to the SMR program, consisting of a
large body weight and a relatively long time, and this increase in ITB flexibility might affect
cycling athletic performance [52].
In the cadence, power, and record analyzed as motor ability variables of cycling in this
study, no significant difference was observed in the variables, excluding power. However,
since a minimal difference of <1% or 1 s in cycling capacity is essential to determine race
outcome [52,53], we could reach some conclusions to guide follow-up studies. Cadence
is the number of pedals per unit of time, increasing with high power output [54]. A
previous study suggested 3.4–5.5% as a significant difference (p < 0.05) determining cycling
performance [55]. In this study, while the cadence between both cycles of the control
group increased by 0.4% (1st cycling: 80.2 ± 2.4 vs. 2nd cycling: 80.5 ± 2.6 RPM), in
the SMR group, the cadence increased by 1.3% (1st cycling: 82.0 ± 3.1 vs. 2nd cycling:
83.1 ± 3.1 RPM) in the second cycle compared to the first. When this was compared
with the 2nd cycling results between groups, the cadence of the SMR group increased
by 3.2% compared to the control group (p = 0.9201). While cycling, ITBFS caused more
pain on inclines than on leveled ground and lowered exercise capacity; therefore, power
was analyzed by dividing the values into units of 100 m during the longest uphill section
in the 2nd cycling. Consequently, the power of the SMR group was significantly higher
than that of the control group in the 500 m, 600 m, 900 m, 1000 m, and 1200 m sections. A
significant difference was observed between the groups in the cumulative average results.
The power displayed an increasing pattern in the SMR group and a decreasing pattern
in the control group from the 300 m section. There were some limitations in scientific
interpretation because the statistical differences were not confirmed in all the sections.
However, there were some interesting previous results [56] that confirmed the maximum
torque increase in the quadriceps and hamstrings by applying SMR to cross-country skiers
with varying inclinations of the cycling course. The longest significant difference in some
sections of the uphill road resulted from improved exercise capacity due to SMR. Overall,
the increased cadence and power confirmed in the SMR group also affected the record
time(s). No significant difference was observed between the groups as regards the record
time; however, the 2nd cycling record time increased by 74.64 s compared to the 1st cycling
in the control group. In contrast, the 2nd cycling record decreased by 30.91 s compared to
the 1st cycling in the SMR group. Reducing pain in ITBFS using SMR could reduce the
burden of bicycle pedaling and offer a quick return to pre-ITBFS levels [57]. ITBFS pain is
likely to reduce with repeated knee movement at a higher speed than at a slow speed [57].
In elite table tennis players, dynamic stretching and self-myofascial release using a foam
Int. J. Environ. Res. Public Health 2022, 19, 15993 10 of 13

roller significantly improved flexibility, power, ball speed, and agility. It was suggested
that the use of these protocols could improve performance [58]. In addition, other studies
reported a decrease in pain perception after acute rolling massage [59,60]. It was reported
that foam rolling reduced pain perception for exercise-induced delayed onset of muscle
soreness recovery, which resulted in decreased pain perception by restoring soft tissue
extensibility and/or activating the central pain control system [32]. However, more studies
are needed on the mechanisms and interaction involved in SMR and pain relief.
A limitation of this study was that it was conducted on adult male cycling club
members diagnosed with ITBFS, so there was a limit to generalizing all the results. However,
in the future, interesting results can be drawn if a follow-up study on pain and exercise
performance is conducted on other populations, such as adolescents, the elderly, women,
and other athletes, while considering the application time, duration, and diversity of SMR
applications. In addition, it will be necessary to add data by recruiting more subjects to
secure the high reliability of the results of this study.

5. Conclusions
This study aimed to verify the effects of special tests, VAS, and exercise ability based
on one-time SMR in adult male cycling club members with ITBFS. Significant differences
were observed in the SMR group in VAS through Nobel’s compression test, ITB flexibility
through Ober’s test, and VAS and power while cycling. No significant difference was
observed in HR, cadence, and record time; however, the post-cycling cadence of the SMR
group increased by 3.2% compared to the control group, and the record time decreased
by 30.91 s. Considering that a minimal difference of 1% and 1 s can determine cycling
ability and results, one-time SMR relieved pain and improved the exercise ability of cyclists
suffering ITBFS. Considering the confirmative effect of SMR in the current study, it is
expected that a systematic SMR program consisting of at least 4 min for each body part and
a total of 20 min or more would help relieve pain and improve exercise performance when
applied to relevant field and clinical practice situations.

Author Contributions: J.J.P., H.S.L., and J.-H.K. conceptualized and designed the research; J.J.P.,
H.S.L. and J.-H.K. performed experiments; J.J.P., H.S.L. and J.-H.K. analyzed data; J.J.P., H.S.L. and J.-
H.K. interpreted experimental results; J.J.P., H.S.L. and J.-H.K. wrote the first draft of the manuscript;
J.J.P., H.S.L. and J.-H.K. edited and revised the manuscript. This manuscript was prepared by
extracting part of master’s thesis of J.J.P. The results of the present study are presented ethically,
without plagiarism, tampering, or manipulation by the researchers. All authors have read and agreed
to the published version of the manuscript.
Funding: This study was performed with the support of the BK21 FOUR (Human-Tech Convergence
Program of Hanyang university) through the National Research Foundation funded by the Ministry
of Education of Korea and Hanyang University (HY-2021).
Institutional Review Board Statement: Institutional Review Board of Hanyang University (HYUIRB–
008; Approval date: 25 October 2021).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study. All data used to support the findings of this study are included in the article.
Data Availability Statement: All data used to support the findings of this study are included in the
article. The analyzed data during the current study are available from the corresponding author upon
reasonable request.
Conflicts of Interest: The authors declare no conflict of interest.
Int. J. Environ. Res. Public Health 2022, 19, 15993 11 of 13

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