INTRODUCTIONMassage has been utilized in the treatment of illness and injury for thousands of years by health care practitioners. Chinese writings dating back to 2500 BC describe the use of this modality for a variety of medical purposes.
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– Massage has been promoted as a treatment of choice for numerous conditions such as musculoskeletal injuries, cancer, stress, relaxation, and pregnancy. –Physical therapists who specialize in sports medicine often utilize massage techniques to aid an athlete's recovery from intense exercise or as a treatment option when performing clinical rehabilitation. Selection of PapersThe following electronic databases were used to identify papers relevant to this review: Medline (from 1950-present), CINAHL (1982-present), PsycINFO (1985-present), Cochrane Database of Systematic Reviews, and SPORTDiscus (1830-present). Presents the Medical Subject Headings (MeSHs) and textwords (tw) utilized in the search strategy for this paper.
If fewer than 300 articles were identified by a search strategy, the study abstracts were reviewed from that category in order to identify potentially relevant papers. The reference list of each of the selected papers was also reviewed in order to identify additional relevant publications. Exclusion Criteria.Papers that were not published within a peer-reviewed scientific journal.Reports that detailed the use of massage for non-sports related injuries or functions.The rationale for these inclusion and exclusion criteria was to identify papers that investigate the use of massage in all facets of athletic care. The massage techniques included for review in this paper were based upon their prevalence within the literature and their preference among physical therapists. In specific situations where there was paucity in the literature, complementary paper(s) were presented (but not included in the overall review). Massage protocols investigating efficacy for non-sports related injuries or chronic conditions were considered beyond the scope of this review. Description of Selected Massage TechniquesSports massage is defined as a collection of massage techniques performed on athletes or active individuals for the purpose of aiding recovery or treating pathology.
Three forms of massage are frequently reported in the sports medicine literature: effleurage, petrissage, and deep transverse friction massage (DTFM).Effleurage techniques are performed along the length of the muscle, typically in a distal to proximal sequence. –, These techniques are executed throughout a massage routine, with the strokes performed slowly utilizing light or gentle pressure. –, The petrissage techniques include kneading, wringing, and scooping strokes. –, These techniques are generally performed with deeper pressure to patient tolerance. –, Deep transverse friction massage (also known as cross-friction massage) is performed by using the fingers to apply a force moving transversely across the target tissue.
EFFICACY OF A PRE-EVENT MASSAGEAthletes routinely prepare both physically and psychologically prior to competition. Athletes typically incorporate one or more of the following pre-competition preparation strategies: static stretching, dynamic stretching, warm-up drills, game simulations, and mental imagery. A pre-event massage has been suggested as a strategy to decrease pre-competition anxiety and to prepare the muscles for competition.
Currently a paucity in the literature exists addressing the effects of a pre-event massage in order to reduce injury risk or enhance psychological readiness ( ). Effect on Blood PressureCamborn et al investigated the effect of massage on a recipient's blood pressure (BP). Twenty five massage therapy students provided massage treatments to 150 current massage therapy clients.
The length of the massage and the techniques performed by the students were not controlled, but were instead based upon the students' perception of the clients' needs. The massages ranged in time from 30 to 90 minutes. Six different massage techniques were used including Swedish, deep tissue, myofascial release, sports, trigger point, and craniosacral. The authors defined sports massage as “a more vigorous type of massage used to prepare athletes for peak performance and uses a combination of techniques including joint mobilization, stretching and/or postisometric relaxation, cross-fiber friction, and pressure point massage.”The authors found that clients receiving Swedish massage (effleurage and petrissage) experienced the greatest reduction in blood pressure, whereas those who had received trigger point therapy and sports massage experienced an increase in blood pressure. While this research provides findings that may have clinical significance, the study design challenges the overall strength of the findings. A large sample size was collected (n = 150), but 25 massage therapy students performed the non-uniform interventions to clients who were already receptive to this form of treatment.
The study also lacked controls for the duration of the massage (30 to 90 minutes) and the massage techniques performed.Although this study did not directly focus on an athletic population, a vigorous massage may be less desirable than a “Swedish” (or relaxation) type of massage in specific situations. Theoretically, an athlete who is experiencing pre-game anxiety or stress may increase his or her risk of sustaining an injury or of having a sub-par performance. Future investigations should be performed with specific athletic populations receiving massages just prior to participating in a stressful simulation or actual competition. Massage Effects on FlexibilityA common perception held by athletes and coaches is that adequate flexibility will decrease the risk of injury and enhance performance. While these claims may be debatable (and beyond the scope of this paper), massage has been investigated as a strategy to increase range of motion.Barlow et al investigated the immediate effects of massage on hamstring flexibility in physically active young men. Eleven active men (mean age 21 ± 3 years) were randomly assigned to attend two testing sessions each separated by one week.
The subjects either received a 15-minute massage (performed by a massage therapist) consisting of effleurage and petrissage strokes to the hamstring muscles bilaterally or a 15-minute supine rest. Three pre-test and post-test sit and reach measurements were performed with the best one recorded. Investigators were blinded to who had received which intervention.
The subjects were also blinded when performing the sit and reach test to avoid subject bias threats to validity. The authors concluded that a single bout of hamstring massage did not have a significant effect upon sit and reach scores. Although the authors found no significant change among the small sample size, they did find that those who had low pre-test reach scores (less than 15 cm) had a higher percentage of change in reach versus those who had a 15-cm or greater reach. This led the authors to suggest a larger sampling should be performed with a “tighter” population. Also, future studies should investigate the effect on flexibility when massage is applied both proximally and distally to the target tissue.While Barlow et al failed to demonstrate a statistically significant change in flexibility, Hopper et al found massage made significant short term changes in hamstring flexibility. Female field hockey players from Western Australia's Premier League were recruited for the study.
Thirty-nine players met the study's inclusion criteria of experiencing a stretching sensation on the posterior thigh at an angle less than 70° during a straight leg raise (SLR), having full knee extension range of motion, and having full ankle plantarflexion.Athletes were randomized into one of two treatment groups; a group receiving a “classic” massage and a group receiving dynamic soft tissue mobilization (DSTM). The classic massage consisted of effleurage, kneading (petrissage), and shaking techniques for an 8-minute treatment. The DSTM treatment consisted of classic massage strokes and a dynamic treatment approach.
The dynamic technique was performed using a “long slow stroke” with a fisted hand applied both longitudinally and across the muscle fibers. This technique was applied while first passively extending the subject's knee, then while the subject actively extended their own knee, and finally while the therapist passively extended the knee while the subject performed an eccentric contraction of their hamstring muscle. The DSTM program was also performed for 8-minutes. The passive straight leg raise (PSLR) and passive knee extension (PKE) tests were used to measure hamstring length prior to the treatment intervention, immediately after the massage, and 24 hours later.
Both techniques immediately created statistically significantly changes in hamstring lengths as measured by the PKE test. The flexibility changes though were not maintained at 24 hours in either group.In a subsequent investigation by Hopper et al, they reported significant increases in hamstring flexibility after performing the DSTM program when compared to a classic massage approach or a control group. In this investigation, the subject sample was 45 healthy males (mean age = 23.7 years, SD = 4.6, range = 18 to 35 years), whereas, the previous study's population consisted of female athletes. The “classic” massage protocol utilized effleurage, kneading, picking up, and shaking techniques performed for 5-minutes. The DSTM program was similar to the one described in Hopper et al. The DTSM group demonstrated significantly greater increases in hamstring flexibility as compared to the classic approach or the control group. While the DTSM protocol had a greater effect on immediate hamstring flexibility gains (post-test measurements conducted 90-seconds after treatment), the clinical significance of these results is difficult to extrapolate.While it appears that some athletes may experience improvements in hamstring flexibility after one massage, these changes appear to be transient.
If a short term goal is to increase an athlete's flexibility, more efficient methods may exist (especially in the absence of an adequately staffed sports medicine team). Future research should investigate which athletes are ideal candidates for massage intervention, how long each massage intervention should be performed, and what duration is necessary to establish permanent flexibility changes. Massage Effects on StrengthBrooks et al assessed the effects of massage on power grip performance after maximal exercise in healthy adults. The authors conducted a pre-test and post-test study design with subjects randomized to one of four intervention groups.
The testing protocol consisted of a pre-test grip strength measurement, the exercise protocol to fatigue the muscles of the hand, the intervention, a 5-minute rest period, and the post-test strength measurement. To fatigue the muscles of the hand and the forearm, participants isometrically squeezed a hand exerciser until performance had declined to 60% of their baseline measurement. After the exercise period, the subjects were randomized to one of the following treatment groups: a 5-minute standardized massage to the dominant hand, a 5-minute standardized massage to the non-dominant hand, 5-minutes of passive shoulder and elbow range of motion, or 5-minutes of rest. The 5-minute massage protocol, consisting of effleurage and circular friction strokes, was performed by two senior therapeutic massage students.
The authors found the massage intervention to be significantly superior to the non-massage interventions for post exercise grip performance. It was also observed that grip performance after massage was significantly greater in the non-dominant versus the dominant arm.The most clinically relevant outcome was that the massage intervention demonstrated better results than the natural recovery of the control group. The authors surmise that applying massage (in this case for 5-minutes) shortly after fatiguing exercise is beneficial.Mancinelli et al investigated the effects of massage on female collegiate athletes when performed at the beginning of the basketball and volleyball seasons. Twenty-two NCAA division I women's basketball or volleyball players were recruited (11 allocated to the treatment group and 11 serving as controls). A 17-minute massage consisting of effleurage, petrissage, and vibration techniques was performed on the day of predicted peak soreness (as predicted by the strength coach). The authors found that the massage intervention helped to significantly increase vertical jump, led to a significant increase (a slowing) of shuttle run times, and significantly decreased the athlete's perceived soreness.
While the results suggest that performing a massage at an opportune time will have positive functional outcomes, the results of this study are in question due to significant design flaws. These flaws include a small sample size, the inability to control for the pre-season conditioning levels of the athletes, and the reliance upon the subjective prediction by the strength coach as to the date of expected peak muscle soreness. Effects on Delayed Onset Muscle SorenessDelayed onset muscle soreness (DOMS) is a common physiological response experienced by athletes after initiating or resuming an exercise routine, after increasing exercise intensity, or after performing eccentric forms of training (i.e. Downhill running). Delayed onset muscle soreness has been associated with minor to severe pain occurring 24 to 72 hours after the exercise bout.
Athletic performance may be hampered due to DOMS, loss of range of motion, and decreased muscle strength., While these symptoms may be temporary and part of the natural process of strength and conditioning training, the ramifications for sports performance during competition may be staggering. Theoretically, it would be beneficial to prescribe modalities that could either prevent the onset or decrease the impact of DOMS.Six theories have been proposed to explain the mechanisms of DOMS. The six theories are: lactic acid, muscle spasm, connective tissue damage, muscle damage, inflammation, and enzyme efflux. Researchers have specifically investigated the effects of massage upon blood lactate levels and changes in blood flow ( ). Study (Year)Study DesignLevel of EvidenceParticipantsProfessional(s)Conducting theInterventionTechniquesTreatment TimeResults and Authors' ConclusionsHemmings et alWithin subjects experimental design with counterbalanced design3Eight amateur boxers (mean age 24.9 years, SD 3.8)Sports massage therapistEffleurage, petrissage20-minute standardized protocol consisting of 8-minutes for the legs, 2-minutes for the back, and 10-minutes for the shoulders and arms.No significant difference. Effect of Massage on Blood FlowMassage has been proposed as a treatment modality to increase blood flow., Proponents of massage argue that local circulatory changes occur as evidenced by the changes in skin temperature and superficial hyperemia. Initial studies measuring Xe-133 isotope clearance and venous occlusion plethysmography indicated that massage had an effect on blood flow, whereas more recent studies using Doppler ultrasound techniques have found that massage had no effect on arterial or venous blood flow.
Blood Lactate ClearanceThe rationale behind the lactic acid theory is that lactic acid produced after exercise contributes to the pain and soreness experienced by the athlete. Massaging a muscle or muscle group experiencing DOMS could, theoretically, help to facilitate the removal of lactic acid from those areas.Many amateur sports (such as track and field, boxing, and swimming) may require athletes to participate in several events or matches during a short period of time. Hemmings et al studied the effects of massage on both physiologic and perceived recovery in eight amateur boxers. The investigators designed a testing protocol to examine if massage performed between bouts of simulated boxing matches would help to improve physiologic variables (blood glucose and lactate concentrations), performance, and the athlete's perception of recovery. The experimental design consisted of a 10-minute active warm up period, five 2-minute rounds of simulated boxing matches with 1-minute rest periods between each round, an intervention period (20-minute massage or no massage), a 35-minute rest period (a time period representative of the period of time between events or matches), a second 10-minute active warm up period, and a repeat of the aforementioned boxing simulation.
Four of the eight boxers served as controls during the first round of testing. During the second round of testing, the boxers switched groups.During the intervention period, the athlete either received a massage or rested lying on a mat. The 20-minute massage (effleurage and petrissage) protocol consisted of 8 minutes of treatment performed on the legs, 2 minutes on the back, and 10 minutes on the shoulders and arms. Blood lactate testing was performed before and after each boxing simulation and after the intervention. During the rest period, each boxer completed a perceived recovery scale. The authors chose to measure performance by comparing mean peak punching force per round.The authors found that regardless of whether the athlete received a massage or had rested in a supine position, the mean punching force decreased during the second boxing simulation.
As previously indicated the authors found that the massage intervention had a statistically significant effect on the boxers' perception of recovery. Massage intervention also did not affect blood lactate concentrations and, surprisingly, boxers who had received the massage intervention presented with significantly higher lactate concentrations during the second simulation. This finding was unexpected, for which the authors proposed that the perceived psychological recovery might have affected the boxers' later effort and energy expenditure.Robertson et al examined the effects of massage on lactate clearance, muscular power output, and fatigue after bouts of high intensity training. Nine male athletes (rugby, football, or field hockey) were recruited for the study. A testing protocol began with a standardized warm up period consisting of 5-minutes of cycling and 3-minutes of static stretching for the hamstrings, calf, and quadriceps muscles.
Six 30-second bouts of high intensity training were performed on a cycle ergometer (with 30 seconds of active recovery between sets). Upon completition of the high intensity repetitions, the athletes performed 5-minutes of active recovery followed by a 20-minute intervention. Subjects were randomized into one of two interventions: a 20-minute massage or 20-minutes of “passive supine rest.” The massage intervention was performed each time by the same physiotherapist. The massage sequence consisted of effleurage and petrissage techniques performed in a standardized protocol sequence of 5 minutes to the back of the left leg, 5 minutes to the back of the right leg, 5 minutes to the front of the right leg, and 5 minutes to the front of the left leg. After the intervention period, the athlete performed the same 8-minute warm up (5-minutes of cycling and 3-minutes of static stretching) followed by one 30-second high intensity bout (Wingate test).
Blood samples were collected prior to testing, after the first high intensity training, after 10- and 20-minutes of the intervention time period, and 3 minutes after the final high intensity test.The authors found no statistical difference between the massage and passive rest interventions for blood lactate concentrations and power. A significant difference did occur between the massage intervention and the rest group for the fatigue index. The fatigue index is the percentage change in power output between the first 5-seconds and the last 5-seconds in a 30-second period.
The authors suggested that additional investigations were necessary to identify the role of massage on an athlete's fatigue profile.Jonhagen et al recruited 16 people (8 men and 8 women, mean age 28 years) in order to assess if sports massage can improve recovery after an eccentric exercise protocol. Subjects performed 300 maximal eccentric quadriceps contractions with each leg on a Kin-Com dynamometer (Harrison, TN). A massage program was initiated 10 minutes after exercise, with one leg from each subject randomized to receive the massage treatment. The massage program consisted of 4-minutes of effleurage and 8-minutes of petrissage. The massage protocol was also performed daily each of the next two days.
Testing was performed before the exercise protocol, after exercise, and on the third day. Strength testing was performed on the KinCom dynamometer, a vertical long jump was performed to measure functional changes, and a visual analog scale (VAS) was used to measure a subject's pain. The VAS was performed before and after exercise and before and after the massage treatment. Microdialysis was also performed in the vastus lateralis muscle to analyze levels of the neuropeptide Y (NPY) and calcitonin gene-related peptide (CGRP). Both NPY and CGRP are neuropeptides involved in the vasodilatation of skin tissue and the modulation of pain.
The authors found that sports massage failed to influence any of the dependent variables. Resultant strength loss was significant in both treatment groups, even on the third day.
Sports massage also failed to impact functional recovery. Both groups' demonstrated significantly lower long jump scores, with a normalization of scores occurring by day three. Massage Effects on Creatine Kinase and Neutrophil LevelsSmith et al designed a study to investigate the effects of massage on variables other than lactic acid. The authors theorized a massage intervention performed two hours after exercise interferes with neutrophil emigration which may reduce the intensity of pain due to inflammation. Initial results indicated that the 30-minute massage protocol applied two hours after the exercise program helped to reduce DOMS and creatine kinase levels. This particular protocol appeared to demonstrate promising results, but the results are challenged by a small sample size (n=14).
Although the authors called for continued studies, to date, no further clinical studies have been published on this aspect. Paucity of Sports Massage ReportsDespite the prevalence of low back pain, a review of the literature was unable to identify any randomized controlled trials or quasi-experimental studies investigating the role of massage in the treatment of sports-related back injuries.
Two “non-sports” massage papers are presented here to demonstrate the challenges in interpreting the literature.Preyde researched the application of massage in the treatment of patients with subacute low back pain. In this study, subjects were randomized to one of four groups: a comprehensive massage therapy group (CMT), a soft tissue mobilization only group, a remedial exercise and postural education only group, and a placebo group who received a sham ultrasound.
Subjects in the CMT group experienced a statistically significant improvement in function, reported less intense pain, and experienced a decrease in the quality of pain as compared to the other three groups.Even though the author concluded that patients with subacute low back pain benefited from massage therapy, the CMT group received massage (utilizing a nonstandardized treatment protocol), exercise prescription consisting of a lower extremity stretching program, were encouraged to walk, swim, do aerobics, and strengthening exercises, and received education on posture and body mechanics. While at the 1-month follow up period, a significant number of patients in the CMT group had no pain; it would be a leap to attribute all of this to the massage (only 27% of subjects in the massage only group were pain free at one month). Rather this research may demonstrate that those who receive posture/body mechanics education, perform exercises, and receive massage have better outcomes versus those who only receive one treatment modality.A recent Cochrane Collaboration Back Review has concluded that the use of massage might benefit patients with subacute and chronic nonspecific low back pain, especially when the massage is combined with patient education and exercise prescription. Despite this conclusion, the panel highlights the need for additional studies to confirm the efficacy of massage for subacute and chronic LBP and to assess the effect of massage on returning-to-work.Pettitt et al reported the use of massage in the management of a 19-year old female middle distance runner suffering from sport-related chronic knee pain.
The patient underwent an iliotibial band release after initial failure of conservative treatment. Despite a course of postoperative therapy, the patient continued to experience symptoms. The authors implemented a treatment program consisting of joint and soft tissue (massage) mobilization, therapeutic exercise, and neuromuscular electric stimulation. The massage protocol consisted of effleurage strokes. The authors reported that the subject was able to return to running and complete an entire season of indoor track and field after receiving this 10-week course of rehabilitation.
While massage was one component of the rehabilitation program, the authors acknowledge the fact that the unique role of any one treatment can not be known.Blackman et al investigated the effects of massage on chronic exertional compartment syndrome (CECS). This study again highlighted the design challenges that researchers investigating massage effects have experienced. Athletes suffering from CECS complain of cramping or aching pain that develops with exercise and resolves with cessation of activity., The authors recruited seven athletes (age range 21 to 29 years) with a confirmed diagnosis of anterior CECS. Each athlete participated in a 5-week rehabilitation program. A standard massage intervention consisted of various techniques for 15-minutes each session.
Massage was performed two times a week during the first two weeks and one time a week for the remaining three weeks. Patients were also instructed to perform a standard stretching program for both anterior and posterior musculature twice a day. After the 5 week course of therapy, no significant changes were found in compartment pressures after exercise. The authors did find a significant change in the amount of exercise that could be performed prior to pain onset. Study limitations included the small sample size and the prescription of multiple treatments.
DISCUSSIONDespite the fact that massage has been used as a treatment modality for centuries, a poor appreciation for its clinical effectiveness exists. Although several unique studies have been designed to investigate the effects of sports massage, further investigations are warranted.Indirect evidence exists suggesting that massage may be beneficial on factors related to an individual's psychological state. While these investigations demonstrated improvements in blood pressure, mood states, and perception of recovery, – study design flaws limit the strengths of the conclusions.
Future research should investigate the application of massage immediately prior to stressful sports performance situations, the effects of massage on an athlete's perception of recovery between bouts or events, and the effects of massage on an athlete's mood state throughout an entire season.Massage has generally failed to demonstrate positive effects upon sports performance., One study utilizing massage at the beginning of the season demonstrated an increase in the experimental groups' vertical jump, but the study's conclusions are threatened by several design flaws. Researchers have demonstrated an association between massage and temporary changes in hamstring flexibility – and grip performance. While the results from these studies do not predict future sports performance, these studies should provide guidance in the development of future investigations. Additional research should be directed at performing a massage prior to immediate athletic performance (e.g. CONCLUSIONResearch evidence has generally failed to demonstrate massage significantly contributing to the reduction of pain associated with delayed onset muscle soreness, or significantly enhancing sports performance and recovery, or playing a significant role in the rehabilitation of sports injuries. Design flaws in research have challenged some of the positive outcomes. Additional studies examining the physiological and psychological effects of sports massage are necessary in order to enhance the sports physical therapists' ability to develop and implement clinically significant evidence based programs or treatments.