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Massage: a touchy-feely approach for a 2022 PB?

What are the performance benefits of sports massage, and should you consider adding massage to your 2022 training schedule? SPB looks at the evidence

The practice of massage as a therapeutic technique to relieve pain and promote relaxation and well-being is as old as human civilization. Hippocrates wrote papers recommending the use of rubbing and friction for joint and circulatory problems, while Chinese records dating back 3,000 years have documented the use of massage as a physical therapy(1). Although there more than 200 variations of massage, most forms include stroking, kneading, compression, friction, and applying pressure to the muscular structure or soft tissues of the human body in order to produce positive physical and mental benefits. It’s a fact that that many top athletes incorporate massage into their regular training routines – indeed, most of the top cycling teams participating in stage races such as the Tour de France employ masseurs, whose job it is to ready the cyclist for another grueling day in the saddle! However, what makes massage different to some other passive therapeutic treatments, the benefits of massage, particularly for active people, are supported by hard scientific evidence (as we shall see later).

Different types of massage

As mentioned above, massage comes in various forms and guises. The type of massage an athlete selects should reflect his/her needs and goals. Some of the more common types of massage include:

  • Relaxation massage – where the therapist massages the muscles using smooth, gentle and flowing strokes, which help to promote general relaxation, improve circulation and also to relieve muscular tension.
  • Remedial (Swedish) massage – this is a more vigorous treatment designed to help restore function to aching or injured muscles, tendons and ligaments. Strokes are applied more vigorously and with more kneading and pressure applied at certain locations. Although it can still be relaxing, it is not always completely comfortable.
  • Sports massage – this combines different massage techniques to enhance sports performance and recuperation. However unlike remedial massage, there’s less emphasis on massaging all the muscles with smooth stroking techniques; instead the therapist homes in and works almost exclusively at specific locations.
  • Aromatherapy massage – this combines the therapeutic properties of essential oils (for example invigorating, healing relaxing etc.) with specific massage techniques to promote general health and well-being.
  • Reflexology – This uses thumb and finger pressure on the reflex points of the feet (which correspond to certain areas of the body) to assist in achieving ‘balance’ within the body.
  • Oriental massage therapies – this is based on oriental massage techniques such as acupressure and Shiatsu, which treat points along the ‘acupressure meridians’, aiming to release discomfort and rebalance energy.

It’s important to realize however that these forms of massage are not mutually exclusive. A well trained and experienced therapist may incorporate one of more of these techniques into a single treatment session depending on the needs of the client.

Evidence for massage benefits

As mentioned above, the evidence for the benefits of massage in the context of sport performance (and general improved well being) is wide ranging and robust. Let’s take a look at what some of the research says, starting with general health benefits:

*Massage and general health

The general health benefits of massage are well documented, especially when it comes to helping to relieve stress-related tension and lowering blood pressure(2), which experts believe play a significant role in the development cardiovascular disease. Research also shows that massage can help in the treatment of fatigue, sleep disorders and low back pain(3). In addition, there’s a potentially even more beneficial aspect of massage – that of tactile stimulation or more simply, touch.

In today’s hectic-paced world, humans probably are touched less by other humans than at any time in our evolution. Yet we know that tactile stimulation is important; more than 30 years ago, groundbreaking research on the effects of massage on premature babies showed that preterm babies who received massage therapy showed a 47% greater weight gain and six-day shorter hospital stays than those who did not(4,5). This early research has been confirmed in numerous subsequent studies, and many clinicians now routinely recommend the use of massage therapy to improving the growth and developmental parameters of pre-term infants(6).

Many adults who try massage experience a huge psychological benefit. It’s not just that having tired or tight muscles massaged can help you unwind and release pent-up emotions accumulated through the day – the feeling of being touched in a safe, caring and compassionate manner can be a very powerful experience, reminding you that you’re not alone in the world. In the era of COVID-19 and the huge sense of isolation felt by many as a combined result of different day-to-day behaviors and government restrictions, this particular benefit perhaps cannot be overstated!

*Massage and DOMS

Studies show that massage can be useful for reducing the onset of DOMS – delayed onset muscle soreness. DOMS frequently occurs following unusually vigorous exercise, especially exercise that emphasizes eccentric movements (where muscles lengthen under tension). DOMS is related to muscle damage and typically occurs 12+ hours after exercise, with peak soreness and tenderness experienced 24-36 hours following exercise. For athletes who have to perform repeated bouts of vigorous exercise without the opportunity for full recovery (eg soccer players during a period of fixture congestion – see this article), DOMS can present a real challenge; not only is it very hard to perform optimally with sore muscles, any muscle movements that require skill and coordination are likely to be compromised by the discomfort experienced.

In a key study on this topic, researchers looked at the effects of massage applied after intense eccentric exercise to see whether it could effectively alleviate DOMS(7). In this study, subjects performed ten sets of 6 reps of maximal-intensity eccentric contractions of the elbow flexors (biceps) with each arm on a dynamometer. Starting in a flexed (elbows bent) position, the participants had to resist the machine as it applied force to straighten the arm. Two trials were performed – one for each arm – separated by two weeks. In one trial however, the arm received ten minutes of massage three hours after the intense eccentric exercise bout, while in the other trial, the other arm received no treatment. As well as measuring subjective muscle soreness, the researchers also measured levels of a compound called creatine kinase – a marker of muscle damage.

The key finding was that the delayed-onset muscle soreness was significantly less for the massage condition for peak soreness, both in extending the elbow joint and when palpating (squeezing) the brachioradialis muscle of the forearm. Soreness while flexing the elbow joint and palpating the brachialis muscle of the upper arm was also less with massage. Moreover, massage treatment significantly reduced creatine kinase activity, with a lower peak value at four days post-exercise. Exercise-induced swelling of the upper arm was also significantly reduced three and four days post-exercise (see figures 1 and 2). Overall, the researchers concluded that massage was effective in alleviating DOMS by approximately 30% and reducing swelling.


Figure 1: Creatine kinase activity following exercise

The rise in creatine kinase activity (a marker for muscle damage) was markedly lower over the day 3-7 period when massage was given compared to no massage.


Figure 2: Maximal isometric strength with and without post-exercise massage

Maximal isometric strength was significantly higher from days 3-7 in the massage condition compared to no massage.


The above findings have since been confirmed in a number of other studies. A 2017 meta-review study (a study that pools all the data from previous studies on a topic) on DOMS and massage analyzed the data from eleven previous studies involving 504 participants(8). It found the following:

  • Muscle soreness rating at 24 hours post-exercise decreased significantly when the participants received massage intervention compared with no intervention.
  • Massage therapy improved maximal isometric force and peak force after 24 hours compared with no post-exercise massage.
  • Levels of creatine kinase were reduced when participants received massage intervention.

*Massage as an adjunct to a new exercise program

Massage could improve the adaptation capacity to a new exercise program. In a very recent study, researchers compared the outcomes of an unfamiliar 7-week circuit-training type program with and without added regular weekly massage sessions(9). The subjects who were all students were split into two groups: those who performed the training sessions without massage and those who performed the same training but with added weekly massage sessions. As well as exercise testing, the outcomes in the students were measured with psychological profiling questionnaires. At the end of the intervention, it was found that (compared to no massage) the training program results were enhanced with added massage, with additional improvements in sit-up and standing long jump performance, lower blood pressure and improved measures of self confidence.

*Massage compared to vibration therapy

The use of vibration therapy using high-tech vibration platforms for improving recovery and reducing post-exercise muscle soreness has become very popular in recent years. But how does it compare to old-school massage? In a large study on this topic, researchers compared the two modes of therapy to see if vibration therapy was more effective than the standard treatment of stretching and massage for improving recovery of muscle strength and reducing muscle soreness after muscle damage induced by eccentric exercise(10).

Fifty men aged 18 to 30 years performed 100 maximal eccentric muscle actions of the right knee extensor muscles to induce DOMS and severe muscle fatigue. For the next seven days, the subjects were divided into two groups:

  • Vibration – 25 participants applied vibration therapy to the knee extensors twice daily.
  • Traditional – 25 participants performed sports massage (with some additional stretching) twice daily.

Before and after the intervention, all the subjects were monitored for changes in markers of muscle damage (using creatine kinase), muscle soreness, levels of inflammation (using a marker called C-reactive protein or CRP) and peak isometric torque. In all respects, they found no difference between the two interventions – ie the vibration therapy was no more effective than the standard practice of stretching and massage to promote muscle recovery after the performance of muscle-damaging exercise.

The following year, another study was published looking into the topic of massage and recovery from intense exercise(11). However, this study was extremely authoritative being a meta-study that reviewed the data from 22 previous studies on massage and recovery. In particular, it sought to identify how the type and duration of massage, type of exercise and performance test, duration of recovery period, and training status of subjects affected the outcomes from massage. It found the following:

  • There was a tendency for shorter massage (5-12 minutes duration) to have larger effects (+6.6%) than massage lasting more than 12 minutes (+1.0%)
  • The beneficial effects of massage were larger for short-term recovery of up to 10 minutes than for recovery periods of over than 20 minutes.
  • The greatest benefits from massage were observed after high-intensity mixed exercise, massage yielded medium positive effects (+14.4%), whereas the effects after strength exercise (+3.9%) and endurance exercise (+1.3%), while significant, were smaller.
  • A tendency was found for untrained subjects to benefit more from massage (+6.5%) than trained athletes (+2.3%).

Overall, these results suggest that the greatest benefits of massage are likely to occur when undertaking mixed, high-intensity exercise, or where the exercise is not routine in nature but unusually hard for the person undertaking it. An interesting and useful observation is that short periods of massage seems to be as equally effective as longer massages – if not even more so!


A competitor receives a massage after she completed the Bolivia Sky Race on the “Death” from Yolosa to Chuspipata, Bolivia


*Massage and injury

As we have seen, massage can benefit DOM and recovery in athletes, sportsmen and woman and fitness enthusiasts. However, there’s solid evidence that regular massage can also help prevent injuries mobility by keeping muscles elastic and promoting joint mobility(12). And when injuries do occur, massage is known to be a useful therapeutic treatment to help decrease pain and speed recovery(13). This is because we now know that (particularly in chronic injuries problems involving the back and neck) the pain experienced is often as a result of over-sensitized nerve tissue in the area. This pain tends to limit movement in the affected area, which both increases stiffness and prevents nerve tissue from ‘relearning’ normal pain-free movements, thus setting up a vicious cycle – see this article for more information.

However, studies have shown that massaging such an affected area can help to deactivate these pain signals, allowing more normal movement, which in turn helps the desensitise the nerve tissue. This is especially the case when the massage is directed toward ‘myofascial release’ – where the sheaths separating muscle bundles are worked to help break down any ‘sticky’ areas where adhesions may occur(14). Once this cycle is broken, recovery can begin. In short, regular massage may help athletes train harder and better, for longer with less chance of injury. There are also other physiological explanations as to why massage benefits an active body:

  • The stroking movements in massage increase the pressure in front of the stroke and create a vacuum behind, which helps suck fluid through blood and lymph vessels. Deep massage also causes pores in tissue membranes to open, enabling fluids and nutrients to pass through. The combined effect is to help flush out waste products and debris from muscles and encourage fresh oxygen-carrying blood and nutrients to enter, thereby speeding recovery and healing.
  • Massage stretches tissues that cannot be stretched by usual methods. Bundles of muscle fibers are stretched lengthwise as well as sideways, and the sheath or fascia that surrounds the muscle is also stretched, helping to release tension and pressure. Together this leads to more elastic muscle tissue, which helps counteract the tendency to tight/stiff muscles that hard training can produce.
  • Massage can help break down scar tissue that has resulted from previous injuries or trauma. Scar tissue is prone to re-injury because it is less flexible.

England’s Andrew Flintoff receives treatment from massage therapist Mark Saxby (L) during a World Cup cricket practice session


Massage practicalities

So you’re tempted to try massage as part of your training routine – where do you go from here? Below are some guidelines for sportsmen and women seeking practical advice:

  • Which massage? – Everybody is different and responds differently to different types of massage, so there are no hard and fast rules. However, as a rough guide, a relaxation or aromatherapy massage is a good introduction for those without specific ailments. Remedial massage is also relaxing, but is more effective at treating tired or aching muscles, or chronic injury conditions. Sports massage is very specific and may not always be comfortable or ‘enjoyable’. It can be very effective however at treating a particular problem.
  • Choosing a therapist – there are a number of massage schools, each with their own directory of therapists. Probably the best way to choose is by recommendation of a friend or colleague who’s tried a particular therapist experienced in the type of massage you’re seeking. If this isn’t possible, asking on social media is worth a try and don’t forget you can ask at your local sports centre or gym to see if anyone comes highly recommended. However, bear in mind that massage is not like medicine or personal training. It’s all about touch, and while any therapist can be competent with suitable training, some therapists are truly gifted. Speaking from personal experience, I’d rather cut off my right arm than lose my own therapist, so gifted is she! Once you find a really good therapist, stick with him or her.
  • When – massage is great for alleviating tired aching muscles, so by far the best time to have it is within 24-48 hours after training. Also, because immediately after massage you can feel very relaxed (almost to the point of feeling drained), it is not recommended on the same day before exercise. An evening massage is great for promoting a good night’s sleep!
  • How often – this will depend on how tight/stiff your muscles are and whether you have any injuries that need working on. For an acute problem, 1-2 massages per week may be needed initially; as things settle, one massage every 7-14 days is sufficient to make progress. The evidence suggests that shorter massage sessions are likely to be just as beneficial as longer sessions. After a few months you’ll almost certainly have developed improved muscle condition; provided you’re keeping physically active, a massage every month or so is often all that is needed to keep you in tip-top condition.
  • What improvements will I notice? – immediately after a massage, you may feel tired or energized, but you’ll certainly feel relaxed! If you’re suffering pain from an injury, or tightness/stiffness, the next 3-4 days should result in a significant improvement in symptoms and you’ll generally feel more mobile and flexible. Muscles also feel fresher and ready to work hard! In the longer term, persistent and chronic aches, pains and niggles often fade away completely, and you’ll become more resilient against further injury.

References

  1. Evid Based Complement Alternat Med. 2017; 2017():9519285
  2. J Hum Hypertens. 2021 Jul;35(7):627-637
  3. Complement Ther Med. 2015 Feb; 23(1):1-6
  4. Res Nurs Health. 1988 Feb;11(1):31-9
  5. J Dev Behav Pediatr. 1993 Jun;14(3):176-80
  6. Eur J Pediatr. 2021 Jan;180(1):207-215
  7. J Athl Train. Jul-Sep 2005;40(3):174-80
  8. Front Physiol. 2017; 8():747
  9. Int J Environ Res Public Health. 2021 May; 18(9): 5013
  10. Clin J Sport Med. 2015 Jul;25(4):332-7
  11. Sports Med. 2016 Feb;46(2):183-204. doi: 10.1007/s40279-015-0420-x
  12. Musculoskelet Sci Pract. 2021 Oct;55:102417
  13. J Physiother. 2015 Jul; 61(3):106-16
  14. J Bodyw Mov Ther. 2021 Jul;27:16-25

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