After unaccustomed exertion, or activity that is eccentrically biased, individuals often experience symptoms of exercise-induced muscle damage (EIMD). The nature of eccentric muscle actions, where a muscle lengthens while generating tension, has been shown to be a causative factor in EIMD, because overextension of muscle sarcomeres leads to mechanical disruption of muscle fibers, compromising contractile ability. Symptoms of EIMD include increases in circulating myoproteins (26); increases in perceived soreness (16); a reduced time to volitional exhaustion (3); and decrements in muscle strength, power and endurance (2,29). These symptoms are problematic for individuals engaged in regular competition, and consequently, a number of strategies attempting to manage the symptoms of EIMD are currently employed, particularly in athletic populations.
Sports massage is a common feature of many athletes' training and recovery programs, with perceived outcomes including decreased feelings of soreness, decreased tissue tension, increased local blood flow facilitating the removal of cellular debris, and an influence on the inflammatory process to expedite recovery (4,24). Scientific evidence supporting these contentions is equivocal, though a number of review and experimental papers have indicated potentially beneficial effects of sports massage treatments (4,12,20,24). Recently, the use of clothing with specific compressive properties has become increasingly popular among competitive athletes. The use of compressive clothing is supported by encouraging scientific evidence, which indicates that the treatment can facilitate limb blood flow, reduced muscle oscillation, provide a ‘dynamic cast’ facilitating muscle recovery, and influence the inflammatory process after exercise (9,17,34).
In applied fields, strategies to manage the training and recovery of athletes to maintain performance through consecutive cycles of physical activity (i.e., training and competition cycles) are common, though few scientific studies have been completed to assess the effectiveness of these treatments on the symptoms of EIMD. It is important to recognize that although the symptoms of EIMD are consistent, different forms of exercise can cause muscle damage. It is currently unclear whether the effectiveness of a recovery strategy on EIMD is exercise type dependent or not. The aim of this study was to determine whether a combined treatment involving sports massage and compression immediately after damaging exercise was an effective strategy to manage the symptoms of EIMD induced by strenuous plyometric exercise. Data from a previous study (15) that indicated that compressive clothing used independently, reduced decrements in muscle strength loss and function in comparison with a passive recovery group, were used to determine whether sports massage had an additive effect on recovery from EIMD. Additional passive recovery data were collected to increase the sample size of this study.
Experimental Approach to the Problem
In this study, a randomized mixed-model experimental design was used. Subjects were required to complete strenuous plyometric exercise designed to induce muscle damage, followed by either a passive recovery, compression, or combined treatment intervention. Biochemical, perceptual, and performance changes were monitored pre and postexercise.
Thirty-two physically active (minimum 3 occasions per week) female volunteers (Age = 21.4 ± 1.7 years, stature = 1.66 ± 0.047 m, mass = 66.7 ± 6.8 kg) who had not engaged in specific lower limb weight or eccentric exercise training and had no recent history of musculoskeletal injury were randomly allocated to a passive recovery (n = 17), compression treatment (n = 8), or combined compression and massage intervention group (n = 7). Participants provided signed, informed consent to participate in the study that received ethical approval from the School of Sport and Health Sciences ethics committee. No significant differences between groups were observed for age, height, or weight (p > 0.05). Volunteers were asked to maintain normal levels of food intake and hydration, to refrain from ingesting alcohol, nutritional supplements or nonsteroidal anti-inflammatory drugs for the duration of the test, and to avoid any exercise or therapeutic treatments such as massage, which may have affected a normal recovery pattern.
After collection of baseline data, all participants completed a plyometric drop jump exercise protocol designed to induce low-level muscle damage similar to that which may be expected after training or competition in a number of sports. The plyometric exercise protocol was used to localize muscle damage to the quadriceps to facilitate reliable testing and to replicate the types of muscle injury that occur to athletes in applied settings. Volunteers in the combined treatment group were then given a 30-minute sports massage from a qualified masseur and a pair of commercially available compression tights to wear for a period of 12 hours after damaging exercise. Participants in the compression treatment group were given an identical pair of compression tights to wear for the same period. Participants were instructed to refrain from taking nutritional supplements, alcohol and from engaging in physical activity during the testing period. A priori calculations of statistical power indicated that this sample size was appropriate to satisfy power at or above 80% (6).
Participants completed 10 × 10 plyometric drop jumps to induce muscle damage. Volunteers were instructed to stand on a 0.6-m box, step off with 1 foot, land with both feet together, and attempt to achieve a 90° knee angle upon landing, before performing a maximal vertical jump (21) though jump height was not recorded. Jump frequency was standardized so that participants completed 1 jump every 10 seconds and were permitted 1-minute rest between sets. The plyometric exercise protocol was demonstrated and monitored by an experienced strength and conditioning coach.
Assessment of Muscle Damage
Indices of muscle damage were collected in the same order on each occasion: perceived soreness, creatine kinase activity, isokinetic muscle function, countermovement jump performance and squat jump performance. Indices of muscle damage were assessed before and after 24, 48, 72, and 96 hours damaging exercise. Data were also collected 1 hour after damaging exercise to quantify the magnitude of muscle damage immediately after exercise avoiding the influence of acute fatigue following the plyometric exercise protocol. To minimize the time delay between completion of the damaging exercise and the treatment intervention, no assessment of muscle damage was completed immediately after plyometric exercise. Random allocation of participants to groups limits the likelihood of differences in response to plyometric exercise. Therefore, any between group variations in response to damaging exercise can confidently be attributed to the treatment intervention.
Perceived soreness was assessed using a 10-cm visual analog scale, with 0 indicating no pain and 10 indicating the worst soreness experienced after exercise. Participants were instructed to complete an unweighted squat, holding a knee angle of approximately 90° for a period of 2 seconds, and mark perceived soreness on the visual analog scale (35).
Creatine Kinase Activity
Plasma creatine kinase activity was assessed using fingertip capillary blood sampling. The finger was cleaned using a sterile alcohol swab, and a capillary puncture was made using a Haemocue lancet (Haemocue, Sheffield, United Kingdom). Thirty microliters of sampled blood was separated by using a centrifuge and refrigerated at 4°C until analysis. Spectrophotometry (Jenway, Dunmow, United Kingdom) was used to analyze creatine kinase activity in accordance with the manufacturer's guidelines (Randox, Co. Antrim, United Kingdom). All samples were analyzed in duplicate.
Squat and countermovement jump performances were assessed to give a further indicator of functional strength. For assessment of squat jump performance, participants were instructed to adopt a squat with a 90° knee angle and hands placed on hips. This position was held for approximately 3 seconds before volunteers performed a maximal vertical jump, maintaining a straight leg position and hand placement on the hips during flight (2).
T assess countermovement jump performance, participants stood fully erect and upon verbal command performed a maximal vertical jump (2). The average height of 3 jumps of both squat and countermovement jump was measured using an infrared jump system (Microgate, Bolzano, Italy) and was taken as an indicator of jump performance. Indicators of muscle function and performance were converted to values relative to baseline for analysis.
Isokinetic Muscle Function
Muscle function was assessed by isokinetic dynamometry (Biodex 3 Medical Systems, New York, NY, USA). Participants were seated upright with the torso and experimental leg secured to reduce extraneous movement. The axis of rotation of the knee was aligned with that of the dynamometer and was standardized during the testing period. Participants completed 5 maximal voluntary extensions of the dominant leg knee extensor muscles on each occasion through 80° range of movement from full knee extension, at 60°·s−1. The best of 5 gravity corrected knee extensions was taken as the criterion measure of muscle strength.
Strength and performance measures such as these are typically reliable (intraclass correlation coefficients ≥ 0.82 [21,36]) and have been used successfully in a number of previous investigations (2,16,23)
After completion of the plyometric jump protocol, participants in the combined treatment group received a 30-minute manual massage from a professional sports masseur. Massage was completed using an oil medium and consisted of effleurage, petrissage, tapotment, and hacking to the whole of both legs and was standardized for each participant through the use of stopwatch and cue cards for the masseur who performed all treatments. Upon completion of the massage treatment, volunteers were given a pair of hip to ankle compression tights (Skins, Sydney, Australia; Figure 1) to wear for a period of 12 hours to replicate contemporary treatment methodologies and previously investigated protocols (7,9). Compression tights of this type are composed of 76% nylon tactel microfiber and 24% elastane and have been reported to exert an average compression of 17.3 mm Hg at the calf and 14.9 mm Hg at the thigh (33). Compression tights were removed for approximately 10 minutes for the 1 hour assessment of muscle damage. Participants in the compression treatment group wore identical compressive tights for 12 hours after plyometric exercise.
Data were analyzed using a repeated-measures analysis of variance (ANOVA) (3 × 6, group × time), with significance set at p ≤ 0.05 a priori. The Mauchly sphericity test was used to test assumptions of homogeneity of variance. Where this was violated, the Greenhouse-Geisser value was used to adjust degrees of freedom to increase the critical value of the F-ratio. Where appropriate, modified Tukey's post hoc tests were applied to determine the location of between group differences (SPSS 15.0).
Analysis of covariance was used to remove baseline variance in perceived muscle soreness. Significant time (F = 28.3, p < 0.01), group (F = 17.1, p < 0.01), and group by time interaction (F = 4.8, p < 0.01) effects were observed after damaging exercise. Muscle soreness was significantly higher in the passive recovery group 24, 48, and 72 hours after damaging exercise in comparison with both treatment groups (p < 0.01). Soreness was also elevated 1 hour after exercise in comparison with the compression treatment group. No significant differences in muscle soreness between the treatment groups were observed 24 and 96 hours after muscle damage. Significantly higher soreness was observed in the combined treatment group 1 hour after muscle damage, though this trend reversed 48 and 72 hours after exercise, with the compression group reporting higher perceptions of soreness at these time points (p < 0.01; Figure 2).
Countermovement Jump Performance
No significant group differences were observed at baseline in absolute terms for countermovement jump height (passive recovery 0.28 ± 0.03 m, combined 0.28 ± 0.02 m, compression 0.26 ± 0.05 m, p > 0.05). Significant time (F = 15.4, p < 0.01) and group × time interaction effects were observed (F = 4.0, p < 0.01). Significant differences between the passive recovery and treatment groups were observed at 24 and 48 hours after plyometric exercise (p < 0.01), with a further significant difference between the passive recovery and compression group present 72 hours after exercise. No significant differences between treatment groups were observed at any time (Figure 3).
Squat Jump Performance
No significant group differences were observed at baseline in absolute terms for squat jump height (passive recovery 0.23 ± 0.03 m, combined treatment 0.23 ± 0.02 m, compression 0.22 ± 0.05 m, p > 0.05). Significant time (F = 28.4, p < 0.01) group (F =18.8, p < 0.01), and group × time interaction effects (F = 7.5, p < 0.01) were observed on squat jump height. Follow-up analysis indicated significant performance differences between the control and treatment groups 24, 48, 72, and 96 hours after damaging exercise (p < 0.01). Strength decrements were also greater in the passive recovery group in comparison with the compression group, 1 hour after plyometric exercise. There were no significant differences between treatments, with the exception of 48 hours after damaging exercise, where jump performance was significantly worse in the compression group in comparison with the combined treatment group (p < 0.01; Figure 4).
Isokinetic Muscle Function
Absolute peak torque at baseline was not significantly different between groups (passive recovery 158.4 ± 25.2 N·m−1, combined treatment 168.3 ± 33.5 N·m−1, compression clothing 165.7 ± 21 N·m−1, p > 0.05). Significant time (F = 26.2, p < 0.01), group (F = 8.0, p < 0.01), and group × time interaction effects were observed (F = 5.1, p < 0.01). Significant differences in isokinetic muscle function 24, 48, 72, and 96 hours after damaging exercise (p < 0.01) between the passive recovery and treatment groups were observed. A significant difference in relative muscle strength was observed between treatment groups at 48 hours, with muscle strength of the combined treatment group being significantly lower than that of the compression group (p < 0.01). Isokinetic muscle function returned to baseline 72 hours after muscle damage in both treatment groups (Figure 5).
Creatine Kinase Activity
No significant difference between absolute baseline levels of creatine kinase activity was observed between groups (Table 1), with baseline creatine kinase activity within normal resting limits (25). Creatine kinase activity data were transformed to natural log values to satisfy assumptions of sphericity associated with repeated-measures ANOVA. A significant main effect of time (F = 9.1, p < 0.01) was observed on creatine kinase activity, but no group (F = 0.7, p > 0.05), or group × time interaction effects (F = 1.7, p > 0.05) were present.
Data from a previous investigation (15) had indicated that the use of lower limb compression significantly reduced decrements in muscle strength loss and performance, and moderated increases in perceived soreness following EIMD. Data from the first investigation were used to determine whether combining the use of lower limb compression with a sports massage immediately after damaging exercise had an additive beneficial effect on symptoms of EIMD. A significant main effect for time was observed on all indices of EIMD, indicating that the exercise protocol was successful in inducing muscle damage. Though previous investigations (18) have used more aggressive damage exercise protocols, plyometric jumping of this nature has been used successfully to induce muscle damage and was selected for its appropriateness for athletes as this level of damage is likely to occur during the course of a normal training and competition schedule.
Information pertaining to the performance of female athletes following EIMD is relatively sparse, with the majority of studies using either male or mixed gender samples. There is currently some debate as to whether there is an effect of gender on symptoms of EIMD in human subjects (13,33). Therefore, this study was designed to both contribute to the limited literature regarding female recovery responses following EIMD and eliminate the potential for a gender effect. Participants were individuals training and competing regularly and were selected from competitive university sports teams to ensure a similarity of training status. Several studies have observed a protective effect of previous training on responses to EIMD (see  for review). Therefore, individuals were excluded if they had engaged in specific plyometric or weight training programs in the 3 months preceding data collection.
Perceived muscle soreness significantly increased immediately after plyometric exercise in both groups. Soreness in all groups peaked 24-48 hours after muscle damage and returned to baseline values 96 hours after initial muscle damage, a temporal pattern consistent with both specifically and nonspecifically trained individuals, as in this case (38). Perceived soreness was significantly higher in the passive recovery group 24, 48, and 72 hours after muscle damage and was also significantly higher in comparison with the compression treatment group, 1 hour after exercise (p < 0.01). One hour after plyometric exercise, the perceived soreness of individuals in the combined treatment group was significantly higher than those in the compression treatment group. This difference was reversed 48 and 72 hours after damaging exercise, with greater perceived soreness reported in the compression treatment group in comparison with the combined treatment. Sports massage intentionally seeks to affect deep muscle tissue, and individuals often experience pain during the treatment. In this case, the significantly higher reported soreness 1 hour after damage (∼30 minutes after treatment), may be because of residual discomfort as a result the treatment. Perceived soreness was significantly higher in the compression treatment group 48 and 72 hours after muscle damage, indicating that the sports massage had an additive positive effect on soreness beyond that of lower limb compression alone.
Muscle soreness following damaging exercise has often been referred to as delayed onset muscle soreness, because significant increases in perceived soreness tend to be observed several hours after exercise. In this case, though peak soreness followed a typical temporal pattern, occurring between 24 and 48 hours after damage, significant increases in muscle soreness were observed 1 hour after damaging exercise and is consistent with previous research in this area (3,35). Practically, athletes and coaches should be aware that soreness associated with muscle damage can be present immediately after exercise and is not solely a delayed effect. Studies where increases in perceived muscle soreness have not been observed immediately (≤ 1 hour) after damaging exercise have typically used less aggressive damaging exercise protocols (14) or have not assessed measures of soreness ≤ 1 hour after damage (27). In this study, and those by Twist and Eston (35) and Davies et al. (3), the magnitude of strain is likely to be greater than the strain elicited by other eccentrically biased exercise protocols, consequently increasing the magnitude of muscle damage, as evidenced by large functional strength decrements, and causing mechanical disruption that is likely to increase in soreness soon after exercise.
Consistent with previous research, muscle strength was significantly affected by the plyometric exercise protocol (2,23). Countermovement jump height was affected to a lesser extent than squat jump height following the damaging protocol (11.4 vs. 15.6% 1 hour after damage) as a result of the contribution of the stretch-shortening cycle in the countermovement jump action. Though there were some variations in response, there were typically no significant differences in jump performance between treatments.
Muscle function was also assessed using isokinetic dynamometry at a slow speed of isokinetic muscle contraction (60°·s−1). Previous research has indicated that strength decrements following damaging exercise are greater at slow contractile speeds (30). The slow contraction speed was used to provide the greatest opportunity to observe any treatment effect and to reduce the incidence of artifact associated with this type of assessment. Isokinetic muscle strength decreased 18.2% after damaging exercise in the passive recovery group, and 15.7 and 17.6% in the combined and compression treatment groups, respectively. Strength decrements in the passive recovery group continued to fall to 69.9% of baseline values 48 hours after damaging exercise, before beginning to recover 72 and 96 hours after damage. The temporal pattern and magnitude of strength decrement observed in this study is consistent with those of previous research investigating the effects of EIMD (2).
It has been suggested that sports massage treatments applied soon after muscle injury can have a positive effect on the inflammatory process, reducing emigration of neutrophils to the cell wall, subsequently decreasing localized edema (1,32). Further muscle damage caused by neutrophil and macrophage free radical production may also be moderated by the massage process (1). Friden et al. (8) have indicated that swelling following muscle damage may lead to increased intracellular pressure, which in turn can result in increased perceptions of soreness. A reduction in soreness observed by Zainuddin et al. (39) was linked to a reduction in swelling following damaging exercise consistent with the suggestion of Friden et al. (8) that swelling can lead to soreness. This is supported by Farr et al. (5) who observed decreased soreness after a massage treatment administered 2 hours after a downhill walking exercise.
The ability for compressive clothing to significantly affect edema after damaging exercise has also previously been demonstrated (7). Limb constriction following damaging exercise has been shown to decrease localized edema, promote limb blood flow, expedite the removal of cellular debris, and reduce perceived soreness (17). The combination of these treatments may explain the significant differences in perceived soreness between the passive recovery and experimental groups in this study. Soreness has been associated with neuromuscular inhibition following damaging exercise. Westing et al. (38) indicated that soreness could result in reduced neural drive to protect the musculoskeletal system from further injury under high tension loading conditions. Reductions in soreness, such as in this study, may subsequently explain the differences in functional muscle capability between the passive recovery and treatment groups. However, the influence of soreness on subsequent muscular contraction capability following muscle damage however is unclear. Although soreness may be associated with reduced neural drive following damaging exercise (38), studies which have superimposed electrical stimulation on maximum voluntary muscle contractions have indicated that subjects are able to fully activate muscles despite the presence of soreness (30). Soreness may or may not be a limiting factor in the ability to produce a maximal voluntary muscle action, but recovery methods moderating perceived soreness are pertinent in holistic treatment strategies.
Mechanical disruption to muscle fibers after EIMD is well documented (14,28), though the effects of massage and compression treatments are rarely considered in these terms. Limb constriction associated with compressive garments of this nature have been described as creating a dynamic cast (17), promoting normal alignment of muscle fibers after EIMD, and the benefits in terms of perceived soreness previously discussed. The mechanical action of massage may also promote a return to more normal muscle fiber alignment, while decreasing passive tension within the muscle fibers and positively affecting perceptions of soreness and mood state (11,12,20). It is possible that the promotion of muscle fiber alignment, afforded by both compression and massage treatments, may facilitate recovery of muscle function and explain alterations in muscle function observed. The failure of massage to subsequently affect recovery of muscle function may indicate that there is a limit to the potential for immediate recovery after EIMD, though this suggestion must be examined. Compressive clothing has previously been investigated in regard to its ability to promote tissue repair. Trenell et al. (34) investigated the effects of compressive clothing on the inflammatory response and observed an increase in phosphodiester on a 31P-MRS spectra, suggesting that this represented an altered inflammatory response and accelerated muscle repair.
The timing and duration of intervention seem to play an important part in determining the effectiveness of a treatment when using massage and compression treatments. Butterfield et al. (1) and Smith et al. (32) observed positive effects of massage-type actions on recovery from EIMD where treatment was administered within 2 hours of damaging exercise. Butterfield et al. (1) observed that the beneficial effects associated with their cyclic compression intervention were lost when the treatment was applied 48 hours after damage. The duration of intervention is similarly important. Moraska (24) suggested that to be effective, a massage treatment should last at least 10 minutes per body part. This may go some way to explaining the lack of effect observed in other studies that used a shorter massage duration (10,11). Lambert et al. (19) have previously indicated that compression garments of this type should be worn for a minimum of 3 hours after strenuous exercise, and this appears to be consistent with current practice in some elite athletic fields.
After damaging exercise, increased creatine kinase activity is often observed and is considered to indicate an increase in cellular permeability caused by muscle damage. Although creatine kinase activity increased significantly after damaging exercise, there were no differences between groups across time. This would indicate that the treatments had no protective effect on creatine kinase activity. Although a good indicator of the occurrence of muscle damage, creatine kinase activity responses after EIMD typically track poorly with other markers of muscle damage (37).
This study examined a treatment strategy using sports massage and lower limb compression to moderate the symptoms of, and promote recovery from EIMD in young, nonspecifically trained women. Data from a previous study (15) were included to determine whether the combined treatment offered any additional benefits in terms of moderating symptoms of EIMD. The compression and combined treatment strategies were successful in moderating functional strength losses and increases in perceived soreness following strenuous plyometric exercise in comparison with a passive recovery group. Although perceptions of soreness were moderated by the combined treatment, the practicality of using sports massage as a treatment strategy is questionable given the lack of effect of the combined treatment on functional performance. Though this study observed that the combination of lower limb compression and sports massage was effective in ameliorating some of the deleterious symptoms of EIMD, the additional benefits of sports massage are unlikely to be great enough to warrant widespread use, especially if lower limb compression is available.
The application of lower limb compression immediately after exercise, which may be damaging in nature, reduces perceptions of soreness and decrements in performance in comparison with a passive recovery. Combining this treatment with a manual massage immediately after exercise can further benefit recovery in terms of perceived soreness but offers no additional benefit on muscle function. However, because no additional performance benefits were offered, the cost and time constrictions associated with manual massage are likely to limit its feasibility for use with groups of athletes, especially if lower limb compression is an available treatment.
The authors declare no conflict of interest and no grant support was provided for this study.
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