A Literature Review. Types of Massage. Peter M. Tiidus, PhD ' Effect of Massage on Muscle Damage Caused by Eccentric Muscle Action

Transcription

1 R A T U R E R E V I E W Manual Massage and Recovery of Muscle Function Following ~xercise: A Literature Review Peter M. Tiidus, PhD ' t is a widely held belief among athletes, coaches, and therapists that massage is an effective therapeutic modality that can enhance muscle recovery and reduce soreness following intense physical activity (5,21). Various forms of manual massage are practiced in the belief that they may reduce exercise-induced muscle strength loss, enhance recovery rate, and reduce muscle soreness. Indeed, considerable time and money is spent by athletic teams in the provision of sports massage for athletes (7). However, the actual scientific literature does not tend to support the positive effkacy of manual massage as a postexercise therapeutic modality in the athletic setting (5-7,16,31,38). This brief review will critically examine the recent scientific literature dealing with massage and its potential relationship to the physiology of the muscle damage/recovery process. Specifically, it will discuss the potential (or lack there of) for manual massage to affect: 1) muscle damage caused by eccentric muscle action; 2) retention and recovery of muscle strength and performance following "eccentric-mechanical" muscle damage; 3) reduction of delayed onset muscle soreness following "eccentric-mechanical" muscle damage; and 4) recovery of muscle strength and performance following anaerobic exercise. JOSPT Volume 25 Number 2 February 1997 There is currently little scientific evidence that manual massage has any significant impact on the short- or long-term recovery of muscle function following exercise or on the physiological factors associated with the recovery process. In addition, delayed onset muscle soreness may not be affected by massage. Light exercise of the affected muscles is probably more effective than massage in improving muscle blood flow (thereby possibly enhancing healing) and temporarily reducing delayed onset muscle soreness. This paper reviews current scientific evidence on the use of manual massage to affect: I ) muscle damage caused by eccentric muscle action; 2) retention and recovery of muscle strength and performance following "eccentric-mechanical" muscle damage; 3) reduction of delayed onset muscle soreness following "eccentric-mechanical" muscle damage; and 4) recovery of muscle strength and performance following anaerobic exercise. Because manual massage does not appear to have a demonstrated effect on the above, its use in athletic settings for these purposes should be questioned. Key Words: massage, muscle strength, muscle soreness ' Associate Professor and Chair, Department of Physical Education, Wilfrid Laurier University, 75!lniversity Avenue W, Waterloo, Ontario, Canada, N2L 3C.5 The massage-related research has been sponsored by Wilfrid Laurier University Short Term Research Grants. Types of Massage There are numerous forms of massage which are used by therapists to attempt to promote muscle or connective tissue healing and functional recovery or to stimulate muscles in athletes. Three commonly employed massage techniques used primarily in athletic settings are emeurage, petrissage, and tapotement (21). Emeurage involves light or deep muscle stroking; petrissage involves muscle kneading and rolling manipulations; and tapotement involves a series of percussive blows administered to muscles with relaxed hands (21). The first two are used by therapists primarily for muscle "restorative" effects and the third is used for muscle "stimulation" (21). Other types of massage used in athletic settings in- clude mechanical vibratory massage (6) and massage using pressurized water (3539). Effect of Massage on Muscle Damage Caused by Eccentric Muscle Action Intense exercise, particularly involving eccentric muscle contractions, may cause the nonuniform overstretching of sarcomeres, resulting in injury and damage (12,13). These in-juries typically involve A-band disruption, Z-band streaming, misalignment of myofibrils, and disintegration of the intermediate filament system (1 3,20). Exercise-induced stress will also produce alterations to the muscle cell sarcolemma (2,4). Sarcolemma damage leads to disrup tion of muscle cell calcium homeosta-

2 sis, resulting in increased intracellular calcium concentration (2,12). Increased calcium concentration results in further muscle contractile protein and membrane degeneration over the next several days (2,4). This subsequent damage is likely caused by calcium-induced activation of muscle protease and phospholipase enzymes (4.12). In addition, reduced muscle phosphocreatine levels (as indicated by elevated inorganic phosphate to phosphocreatine ratios) may persist for up to 7 days following intense muscular exercise (23). Markers of muscle damage and membrane disruption, such as creatine kinase, will be evident in the blood at this time as well (8). The exercise-induced damage to the muscle contractile proteins and contractile-related structures may be primary factors in the prolonged reductions in muscle strength noted in individuals who have physically overexerted themselves (25). It is not immediately apparent how massage may be able to physiologically affect the time course or severity of the postexercise muscle damage/repair process. It has been postulated that various forms of massage may enhance muscle blood flow (1 4.21). Increasing blood flow could increase oxygen delivery to injured tissue and thereby, theoretically, enhance the healing/return to homeostasis process ( 19). However, the evidence for massage having an effect on muscle blood flow is at best equivocal. Typical techniques for the measurement of muscle blood flow during massage (ie., venous occlusion plethysmography and '"xe clearance) have been problematic (38). Two recent reviews on the effects of massage in athletic settings (5,7) have concluded that the previous studies have not generally supported a significant positive effect of any type of manual massage on limb blood flow. More recently, Tiidus and Shoemaker (38) employed Doppler ultrasound to determine arterial and venous blood flow during emeurage massage of the quadriceps muscles. Although no measurement technique is able to ascertain microcirculatory changes, Doppler ultrasound has the advantage of providing clear data during actual massage (38). In this study, light and deep emeurage massage had no effect on quadriceps arterial or venous blood flow at any time during the 10-minute massage duration (38). In fact, light quadriceps contractions were far more effective in improving blood flow than manual massage itself (38). In a follow-up study, Shoemaker et al (31) also found no effect of either emeurage, petrissage, or tapotement massage techniques on blood flow to quadriceps or forearm muscles, while light muscle contractions again induced significant increases in blood flow. Hence, if enhanced muscle blood flow does in fact improve the healing process, light muscle contractions may be more effective than massage. One study has, however, reported a lower postexercise serum creatine kinase activity in subjects who were massaged (30 minutes of alternating emeurage, petrissage, and shaking of the exercised limb) 2 hours after arm exercise compared with control sub jects (33). While this seems to suggest that muscle damage may have been reduced in the massaged sub jects, interpretation of serum creatine kinase activity as an absolute measure of muscle damage is problematic (17, 28). In contrast, a recent study employing minutes of whole body underwater jet massage has reported increased serum enzyme activities (possibly due to enhanced clearance from muscle) following treatment (39). Therefore, changes in blood creatine kinase activities can be highly variable and not necessarily reflective of or proportional to muscle damage alone ( 17.28). Thus, measures of the potential for massage to influence the course of muscle damage need to be validated with more precise measures of physiological damage and repair. Effect of Massage on Retention and Recovery of Muscle Strength and Performance Following "Eccentric- Mechanical" Muscle Damage It has been well documented that intense unaccustomed exercise or exercise involving a significant eccentric component will result in reduced muscle strength lasting up to 5-10 days postexercise (12,18,20,38). The greatest disruption to muscle force generation is evident immediately following eccentric exercise, with muscle strength slowly returning to normal over several days (8,18). As previously explained, the physiological mechanisms associated with prolonged reduction of muscle strength may be related to the exercise-induced mechanical disruption of muscle cell sarcomeres and sarcolemma (2,12). In addition, manual massage has not generally been demonstrated to have any positive effects on ability to perform repeated bouts of exercise nor on the long-term rate of postexercise muscle strength recovery. This is not surprising, since, as previously discussed, there is little evidence suggesting that massage has any positive effect on the physiological mechanisms associated with muscle damage. Drews et al (10) reported no effect of regular daily massages (30 minutes of unspecified manual massage) on performance or recovery of elite cyclists performing a May stage race. Tiidus and Shoemaker (38) performed 4 days of daily 10-minute superficial and deep effleurage massage on one leg of the subjects following intense eccentric quadriceps muscle contractions involving both legs. The other leg served as an unmassaged control. They demonstrated that for up to 4 days postexercise, massage did not improve the rate of recovery of quadriceps isokinetic peak torque (at 0, 60, or 180" sec-') over that of the unmassaged control leg (38). Although Rodenburg et al (29) did report some minor positive effects of a 108 Volume 25 Number 2 February 1997 JOSPT

3 combination of stretching, ice, and 15 minutes of effleurage and petrissage massage on postexercise muscle recovery, they attributed these benefits more to stretching and ice than to massage. In contrast, Viitasalo et al (39) reported slightly lower performance decrements in junior track athletes with 20-minute daily treatments of warm underwater jet massage during intense training cycles. This is in contrast to the previously cited studies which employed manual massage. The reduction in performance decrements may also have been partially attributed to muscle heating experienced during immersion in 38 C wa- Depending on the severity of exerciseinduced muscle damage, muscle soreness may peak hours postexercise and disappear within 3 to 7 days. ter (39). Overall, there is currently not enough evidence to support a positive effect of manual massage techniques on long-term postexercise muscle recovery. Effect of Massage on Reduction of Delayed Onset Muscle Soreness Following "Eccentric-Mechanical" Muscle Damage Postexercise, delayed onset muscle soreness is usually evident within 8-24 hours after exercise termination (1,36). Depending on the severity of exercise-induced muscle damage, muscle soreness may peak hours postexercise and disappear within 3 to 7 days (1,32). Delayed onset muscle soreness may be related to the types of postexercise muscle damage previously described ( 1,32). In addition, related changes associated with an acute inflammatory response, such as swelling (9), increased lysosomal activity, edema, and macrophage invasion also occur in exercisedamaged muscle (15,32). How important each of these factors are in the development of muscle soreness is currently unknown (1,l5, 36). Since nonsteroidal anti-inflammatory drugs have had equivocal effects on muscle soreness, the importance of the postexercise muscle inflammatory response to the magnitude of muscle soreness is uncertain (15). It has also been suggested that muscle soreness may be related to exercise-induced damage to muscle connective tissue (34). However, this has not been substantiated by subsequent research (37,4O). Muscle soreness sensation is transmitted to the spinal cord via muscle group 111 and IV free nerve endings (1,15,32). Group 111 and IV nerves may respond to the accumulation of prostaglandins (ie., PGE, produced by invading macrophages), kinins, histamine, and acute swelling or edema (1,32,35). These acute changes, which are similar in time course to delayed onset muscle soreness, may be associated with the acute inflammatory response which constitutes the initial stage of the muscle healing process (9,15,32). Despite popular public belief, it has been well documented that muscle lactate and hydrogen ion accumulation are in no way associated with muscle damage or delayed onset muscle soreness (l,l2,32,36). If massage is able to temporarily diminish muscle damage and the effects of the inflammatory response in muscle, it may be able to affect the later developing muscle soreness. To be able to disrupt the initial develop ment or progression of the muscle damage and the inflammatory re- sponse, massage would have to be performed within 1-2 hours postexercise. Few studies have specifically investigated the possible effects of early massage intervention on delayed onset muscle soreness (33). Smith et al (33) had hypothesized that massage (30 minutes of primarily effleurage and petrissage), if performed within 2 hours after exercise, may affect neutrophil accumulation (an indicator of the onset of the inflammatory response) in muscle. However, their experimental evidence for this effect was inconclusive (33). A recent study reported that 20 minutes of water jet massage performed after exercise had no effect on circulating lymphocytes, leucocytes, or monocytes (39). Further research is required to clarify the effects, if any, of massage on the postexercise muscle inflammatory process. The effects of massage on muscle soreness ( hours postdamage) have been reported by only a few studies, with no conclusive results. Application of a second sensation, such as massage to a sore muscle, could increase discharge from other low threshold sensory fibers and thereby temporarily block soreness sensation (1,36). It has been suggested that light exercise may temporarily diminish muscle soreness via this mechanism (1.30). Alternatively, if edema, swelling, and inflammation are significant factors in muscle soreness sensation (32,36), massage may be able to affect soreness by reducing their presence in affected muscles. Although one study has suggested that massage is able to increase skin lymph flow (24), no evidence is available on the effects of massage on muscle lymph flow or muscle edema in human subjects (7). One study using anesthetized dogs with hypoprotein-induced leg edema did report a slight increase in lymph flow as a consequence of kneading and stroking massage (11). However, the degree of lymph flow induced by massage was no different from that JOSPT Volume 25 Number 2 February 1997

4 induced by active or passive movement of the legs (7,ll). Smith et al (33) reported a trend (over 5 days) toward lower delayed onset muscle soreness in subjects receiving postexercise manual massage compared with unmassaged controls. However, Tiidus and Shoemaker (38) noted slightly reduced soreness in emeurage-massaged muscles only at 48 hours postexercise, but not at other times over a May postexercise period. Viitasalo et al (39) also reported that underwater jet massage slightly reduced muscle soreness at some but not other time points during May training cycles in junior track athletes. Others have reported no change in perceived muscle soreness or mood states consequent to various types of massage (5,7). Performing light exercise with exercisedamaged muscles has also been reported to temporarily reduce soreness (30). Thus, if massage does have any effect on muscle soreness, it is variable, small, temporary, and no greater than that which can be brought about by light exercise of the affected muscles. Recovery of Muscle Strength and Performance Following Anaerobic Work Short-term muscular fatigue, which is rectified within hours postexercise, is associated with temporary disruption of muscle cell excitationcontraction coupling (1 2). Muscular fatigue is a complex physiological process which cannot usually be attributed to a single mechanism. However, exercise-induced alterations in muscle homeostasis, including hydrogen ion accumulation, potassium loss, depletion of high energy phosphates (ATP and creatine phosphate) and glycogen, loss of calcium homeostasis, or local ischemia may be some of the causative factors associated with disruption of the muscle excitation contraction cycle during intense exercise and in postexercise muscle fatigue (12). For example, it is likely that one factor associated with loss of muscle force following very intense exercise is the increased intramuscular concentration of hydrogen ions (1 2). In addition to increased levels of intramuscular lactate, postexercise elevations in intramuscular hydrogen ion concentration are also caused by decreased muscle potassium, increased phosphocreatine breakdown, and increased muscle carbon dioxide levels (22). Hydrogen ions probably interfere with the ability of muscle contractile proteins to generate force If massage were to enhance removal of hydrogen ions from muscle cells or to improve recovery of lost muscle potassium, phosphates, or glycogen, it could conceivably improve the rate of recovery of muscle function. either by reduction of the total number of crossbridges formed or by the amount of force generated per crossbridge (12). If massage were to enhance removal of hydrogen ions from muscle cells or to improve recovery of lost muscle potassium, highenergy phosphates, or glycogen, it could conceivably improve the rate of recovery of muscle function immediately postexercise. There is at present very little data on the effect5 of massage on these parameters, and what there is does not tend to support a positive effect (5,7). By improving oxygen and nutrient delivery immediately postexercise, enhanced muscle blood flow could conceivably have a positive effect on some of the above factors associated with recovery from muscle fatigue. In addition, if improved circulation could enhance emux of lactate and hydrogen ions from muscle, this might also speed recovery. However, as previously discussed, muscle blood flow is not likely to be significantly affected by any type of manual massage (5,7,31,38). Cafarelli and Flint (5) also noted that several earlier studies had failed to consistently demonstrate any effect of various types of manual massage on blood lactate or potassium concentrations either during or after high intensity exercise. In contrast, continuing light exercise immediately after intense activity will have a positive effect on muscle blood flow (27,3138) and would therefore seem more likely than massage to enhance recovery rate via normalization of these factors. A recent study by Gupta et al (1 6) confirmed that following supramaximal cycling exercise, blood lactate was cleared faster by light exercise than by passive rest and that 20 minutes of massage (emeurage and petrissage) during passive rest did not affect the lactate clearance rate at all. As discussed in the previous section, massage has been postulated to improve lymph flow (14,21). If massage were able to enhance movement of hydrogen ions into the interstitial fluid and, from there, via enhanced lymph flow into the circulation, it is conceivable that a slight improvement in the rate of recovery could be induced. There currently is very little data on this possibility; however, the result5 of the study by Gupta et a1 (16) would suggest that it would not be an important factor. Muscle ph and lactate levels usually normalize within minutes postexercise (22,25). Therefore, any Volume 25 Number 2 February 1997 JOSPT

5 potential for massage to affect these parameters would not extend beyond this time period. It would also appear that simple warmdown exercises would potentially have a much greater effect on factors affecting short-term recovery than massage. The few studies which have examined the effects of massage on short-term recovery tend to bear this out. Cafarelli et al (6) investigated the effects of percussive vibratory massage on the rate of short-term recovery from static or dynamic muscular work. The rates of fatigue for repeated bouts of static or dynamic muscular work were the same, whether subjects received massage or no treatment during intermittent rest periods (6). In contrast, an earlier study using percussive or hand massage did claim a positive effect on postexercise work performance (3). However, the results of this study are considerably weakened by a lack of statistical evidence of a significant difference between treatments and a relatively small sample number (3,7). Thus, there is currently little evidence to support massage as an effective enhancement of recovery rate following anaerobic exercise. CONCLUSIONS There is currently very little evidence that manual massage has any significant impact on the recovery of muscle function following exercise or on any of the physiological factors associated with the recovery process. In fact, light exercise of the affected muscles is probably more effective than massage in improving muscle blood flow (thereby, possibly enhancing healing) and temporarily reducing the soreness sensation than massage. It has been recently demonstrated that exercising damaged muscles will not induce further damage (26). In addition, the types and durations of massage employed by massage therapists varies based on athlete and masseur preference and not on any scientific data (5,7). Thus, the JOSPT Volume 25 Number 2 Februay 1997 time and money spent by sports teams on the provision of sports massage may be misplaced (7). Because little evidence exists which supports manual massage as an effective therapeutic modality in affecting muscle damage, strength retention and recovery of muscle strength and performance following muscle damage, delayed onset muscle soreness reduction, and recovery of muscle strength and performance following anaerobic exercise, the use of massage for these purposes should be questioned. JOSPT REFERENCES 1. Armstrong RB: Mechanisms of exercise-induced delayed onset muscular soreness: A brief review. Med Sci Sports Exerc , Armstrong RB, Warren GL, Warren JA: Mechanisms of exercise-induced muscle fibre injury. Sports Med 12:l , Balke 6, Anthony J, Wyatt F: The effects of massage treatment on exercise fatigue. Clin Sports Med 12: , Byrd SK: Alterations in the sarcoplasmic reticulum: A possible link to exercise-induced muscle damage. Med Sci Sports Exerc , Cafarelli E, Flint F: The role of massage in preparation for and recovery from exercise. 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