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The mechanisms of massage and effects on performance, muscle recovery and injury prevention

Weerapong P, Hume PA, Kolt GS

Many coaches, athletes and sports medicine personnel hold the belief, based on observations and experiences, that massage can provide several benefits to the body such as increased blood flow, reduced muscle tension and neurological excitability, and an increased sense of well-being. Massage can produce mechanical pressure, which is expected to increase muscle compliance resulting in increased range of joint motion, decreased passive stiffness and decreased active stiffness (biomechanical mechanisms). Mechanical pressure might help to increase blood flow by increasing the arteriolar pressure, as well as increasing muscle temperature from rubbing. Depending on the massage technique, mechanical pressure on the muscle is expected to increase or decrease neural excitability as measured by the Hoffman reflex (neurological mechanisms). Changes in parasympathetic activity (as measured by heart rate, blood pressure and heart rate variability) and hormonal levels (as measured by cortisol levels) following massage result in a relaxation response (physiological mechanisms). A reduction in anxiety and an improvement in mood state also cause relaxation (psychological mechanisms) after massage. Therefore, these benefits of massage are expected to help athletes by enhancing performance and reducing injury risk. However, limited research has investigated the effects of pre-exercise massage on performance and injury prevention. Massage between events is widely investigated because it is believed that massage might help to enhance recovery and prepare athletes for the next event. Unfortunately, very little scientific data has supported this claim. The majority of research on psychological effects of massage has concluded that massage produces positive effects on recovery (psychological mechanisms). Post-exercise massage has been shown to reduce the severity of muscle soreness but massage has no effects on muscle functional loss. Notwithstanding the belief that massage has benefits for athletes, the effects of different types of massage (e.g. petrissage, effleurage, friction) or the appropriate timing of massage (pre-exercise vs post-exercise) on performance, recovery from injury, or as an injury prevention method are not clear. Explanations are lacking, as the mechanisms of each massage technique have not been widely investigated. Therefore, this article discusses the possible mechanisms of massage and provides a discussion of the limited evidence of massage on performance, recovery and muscle injury prevention. The limitations of previous research are described and further research is recommended.

Sports Medicine – 2005;35(3):235-56 – abstract

Full text available in  through MTABC member only website (link) under the research tab and then library.

Effects of leg massage on recovery from high intensity cycling exercise

Robertson A, Watt JM, Galloway SD

BACKGROUND: The effect of massage on recovery from high intensity exercise is debatable. Many studies on massage suffer from methodological flaws such as poor standardisation of previous exercise, lack of dietary control, and inappropriate massage duration. OBJECTIVE: To examine the effects of leg massage compared with passive recovery on lactate clearance, muscular power output, and fatigue characteristics after repeated high intensity cycling exercise, with the conditions before the intervention controlled and standardised. METHODS: Nine male games players participated. They attended the laboratory on two occasions one week apart and at the same time of day. Dietary intake and activity were replicated for the two preceding days on each occasion. After baseline measurement of heart rate and blood lactate concentration, subjects performed a standardised warm up on the cycle ergometer. This was followed by six standardised 30 second high intensity exercise bouts, interspersed with 30 seconds of active recovery. After five minutes of active recovery and either 20 minutes of leg massage or supine passive rest, subjects performed a second standardised warm up and a 30 second Wingate test. Capillary blood samples were drawn at intervals, and heart rate, peak power, mean power, and fatigue index were recorded.

RESULTS: There were no significant differences in mean power during the initial high intensity exercise bouts (p = 0.92). No main effect of massage was observed on blood lactate concentration between trials (p = 0.82) or heart rate (p = 0.81). There was no difference in the maximum power (p = 0.75) or mean power (p = 0.66) in the subsequent Wingate test, but a significantly lower fatigue index was observed in the massage trial (p = 0.04; mean (SD) fatigue index 30.2 (4.1)% v 34.2 (3.3)%).

CONCLUSIONS: No measurable physiological effects of leg massage compared with passive recovery were observed on recovery from high intensity exercise, but the subsequent effect on fatigue index warrants further investigation.

Br J Sports Med.2004; 38: 173-176 - full text PDF

doi: 10.1136/bjsm.2002.003186

Massage after exercise–responses of immunologic and endocrine markers: a randomized single-blind placebo-controlled study

Arroyo-Morales, M; Olea, N; Ruíz, C; Castilo, J; Martínez, M; Lorenzo, C; Díaz-Rodríguez, L

The effectiveness of massage for postexercise recovery remains unclear, despite numerous studies on this issue. The aim of this study was to determine the effect of massage on endocrine and immune functions of healthy active volunteers after intense exercise. After repeated Wingate tests, the effects of whole-body massage and placebo on salivary cortisol, immunoglobulin A (IgA), and total protein levels were compared using a between-group design. Sixty healthy active subjects (23 women, 37 men) underwent 2 exercise protocol sessions at least 2 weeks apart and at the same time of day. The first session familiarized participants with the protocol. In the second session, after a baseline measurement, subjects performed a standardized warm-up followed by three 30-second Wingate tests. After active recovery, subjects were randomly allocated to massage (40-minute myofascial induction) or placebo (40-minute sham electrotherapy) group. Saliva samples were taken before and after the exercise protocols and after recovery. In both groups, the exercise protocol induced a significant increase in cortisol (p < 0.001), decrease in salivary IgA (sIgA) (p < 0.001), and increase in total proteins (p = 0.01) in saliva. Generalized estimating equations showed a significant effect of massage on sIgA rate (p = 0.05), a tendency toward significant effect on salivary total protein levels (p = 0.10), and no effect on salivary flow rate (p = 0.55) or salivary cortisol (p = 0.39). The sIgA secretion rate was higher after the recovery intervention than at baseline among women in the massage group (p = 0.03) but similar to baseline levels among women in the placebo group (p = 0.29). Massage may favor recovery from the transient immunosuppression state induced by exercise in healthy active women, of particular value between high-intensity training sessions or competitions on the same day.

Journal of Strength & Conditioning Research – Volume 23(2), March 2009, pp 638-644 – abstract

Full text available in  through MTABC member only website (link) under the research tab and then library.

Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial

SE Lamb , JL Marsh, JL Hutton, R Nakash , MW Cooke

Background

Severe ankle sprains are a common presentation in emergency departments in the UK. We aimed to assess the effectiveness of three different mechanical supports (Aircast brace, Bledsoe boot, or 10-day below-knee cast) compared with that of a double-layer tubular compression bandage in promoting recovery after severe ankle sprains.

Methods

We did a pragmatic, multicentre randomised trial with blinded assessment of outcome. 584 participants with severe ankle sprain were recruited between April, 2003, and July, 2005, from eight emergency departments across the UK. Participants were provided with a mechanical support within the first 3 days of attendance by a trained health-care professional, and given advice on reducing swelling and pain. Functional outcomes were measured over 9 months. The primary outcome was quality of ankle function at 3 months, measured using the Foot and Ankle Score; analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN37807450.

Results

Patients who received the below-knee cast had a more rapid recovery than those given the tubular compression bandage. We noted clinically important benefits at 3 months in quality of ankle function with the cast compared with tubular compression bandage (mean difference 9%; 95% CI 2·4—15·0), as well as in pain, symptoms, and activity. The mean difference in quality of ankle function between Aircast brace and tubular compression bandage was 8%; 95% CI 1·8—14·2, but there were little differences for pain, symptoms, and activity. Bledsoe boots offered no benefit over tubular compression bandage, which was the least effective treatment throughout the recovery period. There were no significant differences between tubular compression bandage and the other treatments at 9 months. Side-effects were rare with no discernible differences between treatments. Reported events (all treatments combined) were cellulitis (two cases), pulmonary embolus (two cases), and deep-vein thrombosis (three cases).

Interpretation

A short period of immobilisation in a below-knee cast or Aircast results in faster recovery than if the patient is only given tubular compression bandage. We recommend below-knee casts because they show the widest range of benefit.

The Lancet, Volume 373, Issue 9663, Pages 575 – 581, 14 February 2009 – abstract

doi:10.1016/S0140-6736(09)60206-3

Contrast therapy – A systematic review

WA Hing, SG White, A Bouaaphone, P Lee

Abstract

Contrast therapy is a strategy that is widely utilised in a number of sporting codes to aid recovery. This wide use might suggest that contrast therapy is an effective recovery modality however support for this assumption appears to be mainly anecdotal.

The purpose of this paper is to review the efficacy of contrast therapy. To achieve this objective, a systematic review of randomised controlled trials (RCTs) that have specifically evaluated the therapeutic efficacy of contrast therapy was performed. A search to identify appropriate literature was conducted across a number of electronic databases. The titles and abstracts of the papers identified were reviewed to select papers specifically relating to contrast therapy. Twelve RCTs met the inclusion and exclusion criteria. The PEDro Scale, a systematic tool used to critique RCTs, was employed to critique the methodological quality of these studies

This review highlights both the lack in quantity and quality of research regarding the efficacy of contrast therapy for sports recovery. There appears to be insufficient evidence that contrast therapy aids in recovery and the limited methodological quality of the reviewed studies makes it difficult to draw clear conclusions about this form of therapy. Future research needs to re-examine the use of contrast therapy and in particular whole body immersion recovery strategies within the appropriate sports setting. This research will need to be of sufficient quality to enable appropriate conclusions to be made with regards to its use as a recovery strategy.

Physical Therapy in Sport
Volume 9, Issue 3, August 2008, Pages 148-161- abstract

doi:10.1016/j.ptsp.2008.06.001

Preventing Hamstring Injuries in Sport

Brughelli M, Cronin  J

Summary
Hamstring injuries can be devastating for athletes and sports teams. Recent advances in technology have greatly enhanced our understanding of how and why hamstring injuries occur. Based on this information, professional sports teams have implemented various training interventions in an attempt to reduce the rate of hamstring injuries with varying success. Reviewing the recent literature on hamstring injuries and the studies that have reported decreases in injury rates could give further insight into how hamstring injures can be prevented and thus is the focus of this article.

CONCLUSIONS

Hamstring injury rates can be reduced if an appropriate eccentric exercise protocol is followed. The exercises presented in this article have been developed based on the current literature that has shown increases in optimum length of tension development and reductions in hamstring injury rates. In addition to the reductions in injuries, a few studies have reported that hamstring injuries were less severe after an eccentric exercise protocol. Furthermore, the inclusion of such eccentric exercises may accelerate the recovery from hamstring injury and return to play. Both contentions, however, must be monitored in some fashion to be certain of the efficacy of the inclusion of eccentric exercises. These new and alternative exercises are not meant to replace any other modes or methods of training. Instead, they can simply be added to current training programs. The addition of 2 eccentric exercises per week (1 per session) should be an easy adjustment to the training program, which could lead to dramatic decreases in muscle strain injury rates.

Strength and Conditioning Journal:Volume 30(1)February 2008pp 55-64 – abstract

Full text available in  through MTABC member only website (link) under the research tab and then library.

Is ice right? Does cryotherapy improve outcome for acute soft tissue injury?

N C Collins

Aims: The use of ice or cryotherapy in the management of acute soft tissue injuries is widely accepted and widely practised. This review was conducted to examine the medical literature to investigate if there is evidence to support an improvement in clinical outcome following the use of ice or cryotherapy.

Methods: A comprehensive literature search was performed and all human and animal trials or systematic reviews pertaining to soft tissue trauma, ice or cryotherapy were assessed. The clinically relevant outcome measures were (1) a reduction in pain; (2) a reduction in swelling or oedema; (3) improved function; or (4) return to participation in normal activity.

Results: Six relevant trials in humans were identified, four of which lacked randomisation and blinding. There were two well conducted randomised controlled trials, one showing supportive evidence for the use of a cooling gel and the other not reaching statistical significance. Four animal studies showed that modest cooling reduced oedema but excessive or prolonged cooling is damaging. There were two systematic reviews, one of which was inconclusive and the other suggested that ice may hasten return to participation.

Conclusion: There is insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries.

Emergency Medicine Journal 2008;25:65-68; doi:10.1136/emj.2007.051664 – abstract

The Use of Ice in the Treatment of Acute Soft-Tissue Injury A Systematic Review of Randomized Controlled Trials

C Bleakle, S McDonough, D MacAuley

Background: There are wide variations in the clinical use of cryotherapy, and guidelines continue to be made on an empirical basis.

Study Design: Systematic review assessing the evidence base for cryotherapy in the treatment of acute soft-tissue injuries.

Methods: A computerized literature search, citation tracking, and hand searching were carried out up to April 2002. Eligible studies were randomized-controlled trials describing human subjects recovering from acute soft-tissue injuries and employing a cryotherapy treatment in isolation or in combination with other therapies. Two reviewers independently assessed the validity of included trials using the Physiotherapy Evidence Database (PEDro) scale.

Results: Twenty-two trials met the inclusion criteria. There was a mean PEDro score of 3.4 out of of 10. There was marginal evidence that ice plus exercise is most effective, after ankle sprain and postsurgery. There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft-tissue injury, and there was no evidence of an optimal mode or duration of treatment.

Conclusion: Many more high-quality trials are needed to provide evidence-based guidelines in the treatment of acute soft-tissue injuries.

Am J Sports Med January 2004 vol. 32 no. 1 251-261 – abstract

Transversus abdominis and core stability: has the pendulum swung?

G T Allison, S L Morris

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In the past decade there has been a focus on isolated transversus abdominis activation and how it contributes to lumbo-pelvic stability. This rationale has not only influenced the management of chronic low back pain (LBP); it has also been included in exercises for many other pathologies of the lower and upper limb and also for prophylaxis in pain-free subjects

The rationale that the feedforward bilateral muscle activation of the transversus abdominis stabilises the segmental lumbar spine is based on the reports that, unlike other trunk muscles, transversus abdominis is activated independently of the direction of any spinal perturbation.^{1 2} This finding implies that it plays an important role in spinal stability. The finding that individuals with low back pain or normal subjects with anxiety and stress appear to have altered timing of feedforward onsets of transversus abdominis reinforces the case for the presence of a motor control dysfunction.^3–6 It is often inferred that such a dysfunctional pattern corresponds to less than optimal core stability.

Such an inference – that altered timing of the transversus abdominis leads to poor core stability – is popular in the literature but on further inspection fundamental evidence is lacking.

Firstly, the literature very quickly generalises the research findings of unilateral transversus abdominis activation to a bilateral pattern. In rapid unilateral arm raising (the preferred research model) this assumption is not valid. The contra lateral side preactivates the deltoid but in most normal controls the ipsilateral side is significantly lagging.¹ This critical finding suggests that, although some studies show that bilateral activation of transversus abdominis is able to stiffen the spine,⁷ such findings do not correspond to the unilateral arm-raising task. That is, although they may provide some evidence that the bilateral activation of the transversus abdominis provides some degree of spinal stiffening (albeit mostly in flexion), bilateral feedforward activation of transversus abdominis is not the normal activation pattern for unilateral arm raising.^{1 2}

Secondly, when arm flexion is performed using alternate arms, the transversus abdominis (left and right) are clearly directionally specific.^{1 8} The previous reports that transversus abdominis (left) is not directionally specific refers to the comparison of flexion and extension of the same (right) arm. This may reflect the difference in the strategy of arm movement, not the actual perturbing force acting on the spine due to the different directions of arm movement. The feedforward activation of the transversus abdominis on the contralateral side to arm movement is related to the rotatory torque acting on the spine and the degree of asymmetry between sides is related to the magnitude of this torque.²

As the name infers, transversus abdominis holds true to the concept of form and function since it is most sensitive to torques parallel to the muscle fibres. Transversus abdominis shows directional specificity based on the direction of the perturbation,^{1 2} and under certain types of movement it is likely to be synergistically active with other leg and trunk muscles in a diagonal rather than the corset action.^{1 2} Bilateral arm raising that generates a sagittal plane torque (ie, no significant rotatory torque) makes the transversus abdominis activation more symmetrical (corset-like) but also delays the activation.² Hodges et al⁹ demonstrated that three of eight normal pain-free control subjects did not have feedforward responses in 70% of trials during bilateral arm raising. We propose that this is not due to “less than optimal stability” but rather a normal variation of motor control related to the lack of trunk rotation perturbation. Delayed activation of transversus abdominis in patients with low back pain may be more related to the lack of trunk rotation used in the arm raise by these subjects than to specific motor control problems with transversus abdominis. The activation pattern and onsets of this muscle just may be a better marker of this change in movement strategy than other trunk muscles. The isolated bilateral transversus abdominis activation training strategy, if it does provide a mechanical stiffness of the spine in pathological populations, is therefore more likely to be a compensatory control strategy than a correction of normal patterns of activation. This compensatory training strategy may be a cortical process to normalise movement control. This then re-establishes a normal asymmetrical transversus abdominis action during rotation tasks within a complex muscle synergy rather than correcting a single dysfunctional muscle.

It follows that, although bilateral transversus abdominis isolation has demonstrated some clinical utility, the assumption that it plays a significant and direct mechanical role in stability of the spine is unclear. Furthermore, the bilateral feedforward response is not a normal pattern in predictable rotation perturbations. The idea that this isolated muscle pattern should be taught prophylactically in normal pain-free athletes is at best controversial.¹⁰ Whatever the clinical utility of the intervention, the mechanistic rationale cannot be based on the presumption that the directional invariant bilateral feedforward response of transversus abdominis is acting as a corset stabiliser and is the normal pattern for all spinal perturbations. Similarly, care has to be taken in the interpretation that all other activation patterns represent motor control dysfunction and that this can be translated into a mechanical inference that these individuals have less than optimal core stability. The evidence is just not there.

British Journal of Sports Medicine 2008;42:930-931 (abstract only)

doi:10.1136/bjsm.2008.048637