Physical therapists often provide sports massage interventions during athletic events (17). Such a massage can be provided before or after athletes engage in strenuous activity. Sports massage provided before an activity is called pre-event massage, whereas massage after the activity is termed postevent massage. The hypothesized effects of pre-event massage include injury prevention because of increased muscle flexibility and decreased muscle tension, increased performance because of increased strength and efficiency of muscles and other relevant body systems, and the promotion of a mental state conducive to performance characterized by increased vigor and alertness (21).
However, evidence with regard to the effects of pre-event massage is limited and equivocal. Research has reported immediate postmassage increases in muscle length (2,12,29) but has shown no effect on postexercise muscle flexibility or muscle soreness (7,13). Preevent massage has been shown to either decrease isometric and isokinetic strength (29) or have no effect on isokinetic strength or rate of torque development (12). Research showed no effect on VO2max or lactate levels during submaximal aerobic exercise (8) or on work/time ratio and cumulative number of repetitions during strength workouts (10). Harmer (19) noted a nonsignificant trend toward a positive effect on stride frequency in sprinters, but more recent studies have shown no effect on 20- and 30-m sprint performance or 20-m sprint kinematic parameters (15,18). In contrast, Arabaci (2) reported a decrease in 10-m acceleration and 30-m sprint times and also noted decreased vertical jump performance after a pre-event massage.
The exact manner in which a massage produces its hypothesized effects also remains a topic of debate and investigation: Various, likely concurrent biomechanical, physiological, neurological, and psychophysiological mechanisms have been proposed and studied (28). Increased sympathetic nervous system activity is associated with increased readiness for activity, whereas increased parasympathetic activity indicates decreased readiness (27). Changes in (para)sympathetic activity as a result of a pre-event massage may explain effects on subsequent performance. Salivary flow rate, cortisol concentration, and α-amylase activity have been identified as indicators of sympathetic or parasympathetic activity (5,11,23,28). Previous research has indicated that cutaneous sensitivity to pain may affect muscle performance (1,14), but no research has previously studied the effect of massage on mechanical rather than pain detection threshold. With cutaneous input, one of the many summated inputs that determine motor unit activation levels, massage-induced changes in mechanical detection threshold (MDT) and concomitant changes in afferent input on α-motoneurons may also provide an explanation for effects on performance (25). Finally, mood state as measured by the Profile of Mood States (POMS) has been shown predictive of athletic performance and changes in mood state may provide yet another reason for effects on performance (6).
Therefore, the objective of this study was twofold: (a) establish the effect of a pre-event massage on muscle performance, and (b) provide information on the possible mechanisms by which pre-event massage produces its effect on performance by establishing effects on (para)sympathetic activity, MDT, and mood state.
Experimental Approach to the Problem
This study used a randomized single-blind placebo-controlled crossover design to compare the immediate effects of a pre-event massage to a sham intervention of detuned ultrasound. Sham ultrasound has been used in previous studies on the effects of massage as a placebo intervention (4,16). A crossover design was chosen to accommodate for the high interindividual variability in the outcome measures of salivary flow rate, cortisol concentration, α-amylase activity, and MDT (5).
Although admittedly not representative of performance in functional activities, isokinetic dynamometry has previously been used for assessment of muscle performance in massage research (12,29). Isokinetic peak torque assessment (Genu 3, Easytech, Firenze, Italy) for concentric knee extension and flexion was done at 60°, 120°, 180°, and 240°·s−1. After 1 warm-up contraction at each speed, subjects completed 3 maximal effort contractions at each speed. A 10-second rest was given between each contraction and a 1-minute rest between the different velocities. Assessment started with 60°·s−1 and progressed to 240°·s−1. Li et al. (22) established adequate test-retest reliability for concentric peak torque assessments of knee extension and flexion at the 2 lower speeds used in this study (ICC = 0.82-0.91).
Reduced cortisol concentrations are indicative of increased parasympathetic activity (28). In a previous study, we found no significant effect of postevent massage on salivary cortisol concentrations (5). Increased salivary flow rate is also associated with increased parasympathetic activity (11). Alpha-amylase is a salivary enzyme that inhibits bacterial adherence and growth in the oral cavity (24); its activity has been used as a marker of sympathetic activity (23). None of these outcome measures have been used in previous research on the effects of pre-event massage. In this study, stimulated saliva was collected for 3 minutes at each assessment point. Volume was calculated to the nearest 0.1 mL and saliva flow rate (ml·min−1) was determined by dividing volume by collection time. Immediately after collection, saliva samples were centrifuged at 3,000 rpm for 15 minutes to remove sediments and then stored at -70°C until analysis. Salivary cortisol concentrations and α-amylase activity were assessed in thawed samples with a commercial luminescence immune assay (Salimetrics, State College, PA, USA), reading the luminescence units with an automatic luminometer (Beckmann, Krefeld, Germany). All samples were analyzed in a single batch to eliminate interassay variance and were measured in duplicate. We established adequate interassay accuracy with a calculated coefficient of variation between 6.5 and 7%.
Mechanical detection threshold using Semmes-Weinstein monofilaments is a noninvasive method to assess cutaneous sensation threshold. With the patients unable to see their thigh, we applied the monofilaments at a right angle to the skin and increased pressure until the filament buckled. Patients were asked to indicate when they felt the pressure. Two locations were tested: (a) midway between the greater trochanter and lateral femoral epicondyle over the vastus lateralis; (b) on the medial thigh 3 cm superior to the patella over the vastus medialis. We established adequate mean intrarater reliability with an intraclass correlation coefficient (ICC) = 0.90 (range 0.77-0.96) for measurement over the vastus medialis and ICC = 0.86 (0.72-0.96) over the vastus lateralis.
The POMS questionnaire was used to evaluate subject mood state. The POMS consists of 65 items grouped into 6 subscales: Tension-Anxiety, Depression-Dejection, Anger-Hostility, Vigor, Fatigue, and Confusion. Each subscale score is evaluated on a 5-point scale (0-4), with greater scores indicating a higher mood disorder. A meta-analysis showed moderate effect sizes for increased vigor and decreased confusion and depression and small effect sizes for decreased anger and tension when predicting performance among athletes of homogenous ability (6). All versions of the POMS have been noted as reliable with good to excellent internal consistency reliability (3).
Subjects were chosen by purposive sampling from the student body of the Faculty of Health and Sports Sciences of the University of Granada between January and June of 2009. Sample size requirements were based on the primary end point of salivary flow rate established in a previous study (5). An experienced physical therapist interviewed the subjects and gathered data on clinical history, current health status, medication use, dietary intake, and habitual level of physical activity. Exclusion criteria were (a) presence of any disease; (b) level of physical activity <5 h·wk−1; (c) regular smoking habit; (d) contraindications to strength training. The study sample consisted of 23 subjects (11 women; mean age ± SD, 21.3 ± 2.3 years; weight 69.8 ± 11.2 kg; height 174.8 ± 9.7 cm; body mass index 22.6 ± 1.8). All subjects participated in training and recreational competition (soccer, handball, and athletics) for approximately 8 h·wk−1 (range 5-15 hours). The Ethics Committee of the University of Granada granted ethical approval. Informed consent was obtained from all subjects, and study procedures were consistent with the Helsinki declaration.
Subjects were required to present to the laboratory at the same time of the day on 2 occasions separated by a 1-week interval. They were asked to refrain from intense exercise on the day before the study and instructed not to consume food, caffeine, or alcohol during the 3 hours preceding the study. By way of a coin flip method, they were randomly assigned to the experimental or placebo intervention with assignment to the opposite condition for the next session. After subjects rested for 10 minutes in a supine position, an assessor blinded to treatment allocation collected baseline data for salivary flow rate, cortisol concentration, α-amylase activity, MDT, and POMS. All treatments and tests were done in a physical therapy university-clinic with a thermostatically controlled temperature (20-22°C).
Both interventions were administered by a physical therapist with >5 years of clinical experience in sports medicine, who had completed several familiarization sessions before the study to practice stroke order and rate of the massage intervention. The experimental pre-event massage intervention was designed with guidance from an experienced sports physical therapist and consisted of effleurage, then petrissage, and finally tapotement applied to the dominant-side calf, hamstrings, quadriceps, and craniofacial muscle groups. Each muscle group received 6 minutes of massage except for the craniofacial muscles, which received 2 minutes, for a total of 20 minutes. The therapist used a medium consisting of sweet almond oil mixed with an aromatherapy eucalyptus essence. The placebo intervention consisted of detuned, sham ultrasound. Participants were informed that they would be receiving an ultrasound treatment and that this was anticipated to have a similar effect to that of massage. Treated regions, patient position, and duration were the same as those used during the massage intervention.
After the intervention, the blinded assessor again collected data for salivary flow rate, cortisol concentration, α-amylase activity, MDT, and POMS. All subjects were then assessed for isokinetic peak torque as described above.
For statistical analysis, we used the R-software package (version 2.9.2, Auckland, New Zealand). We calculated means, SD, and 95% confidence intervals of the values for each variable. The Kolmogorov-Smirnov test showed a normal distribution of the data (p > 0.05). Preintervention data before each session were compared using a dependent-samples t-test. We used 2-way repeated-measures analyses of covariance (ANCOVAs) with intervention (experimental, control) as the between-group variable and time (pre-post intervention) as the within-subjects variable to examine the effects of the interventions. Separate ANCOVAs were performed with each dependent variable. The hypothesis of interest was Group * Time interaction. If a significant interaction was identified, planned pairwise comparisons were performed to examine differences from baseline to postintervention between groups to investigate if any between-group differences were statistically significant. A 1-way repeated-measures ANCOVA was used to assess for a treatment effect on the mean isokinetic peak torque measurement after each intervention. For all ANCOVAs, we introduced gender as a covariate to determine if any observed effects were gender-specific. For all analyses, a p value ≤ 0.05 was considered statistically significant.
The dependent-samples t-test showed that preintervention data on all outcome measures were not significantly different between treatment sessions: Salivary flow rate (p = 0.3), salivary cortisol concentrations (p = 0.8), α-amylase activity (p = 0.3), MDT vastus medialis (p = 0.2), MDT vastus lateralis (p > 0.1), tension (p = 0.2), depression (p = 0.9), anger (p = 0.8), fatigue (p = 0.9), vigor (p = 0.7), confusion (p = 0.5) (Table 1).
The ANCOVA found a significant session × time interaction for decreased mean peak torque of the quadriceps at 240°·s−1 (F = 5.0; p = 0.03) and 180°·s−1 (F = 3.8; p < 0.5) after the massage but not after placebo intervention. There was no significant interaction at 120°·s−1 (F = 1.6; p = 0.2) and 60°·s−1 (F = 2.6; p = 0.1) (Figure 1). No influence of gender was found at 240°·s−1 (F = 2.7; p = 0.1) or 180°·s−1 (F = 1.8; p = 0.2). The ANCOVA did not show any significant session × time interaction for mean peak torque of hamstrings at any test condition (240°s−1: F = 0.02; p = 0.8; 180°·s−1: F = 0.03, p = 0.8; 120°·s−1: F = 0.1; p = 0.7; 60°·s−1: F = 0.05; p = 0.8). Table 2 summarizes mean peak torque values for both knee flexion and extension after massage and placebo conditions.
The ANCOVA revealed a significant session × time interaction for salivary flow rate (F = 4.0; p < 0.05) but not for cortisol concentration (F = 0.2; p = 0.9) or α-amylase activity (F = 2.3; p = 0.1). Again, gender did not influence salivary flow rate (F = 0.01; p > 0.9). Pairwise comparisons revealed an increase in salivary flow rate (P = 0.03) after the massage intervention but no significant changes (p = 0.7) after the placebo. Table 3 summarizes pre and postintervention and change scores for salivary levels.
The ANCOVA showed a significant session × time interaction for MDT over the vastus medialis (F = 11.1; p < 0.001) and vastus lateralis (F = 8.3; p = 0.01) muscles. Again, no influence of gender was found (F = 0.8; p = 0.3, F = 0.01; p = 0.9, respectively). Pairwise comparisons revealed an increase in MDT over both vastus medialis (p = 0.001) and vastus lateralis (p = 0.01) muscles after the massage intervention, whereas no changes were found after the placebo intervention (vastus medialis p = 0.1; vastus lateralis p = 0.8). Table 3 details pre and postintervention and change scores for MDT levels.
The ANCOVA showed a significant session × time interaction for the tension (F = 4.1; p < 0.05) but not for depression (F = 0.3; p = 0.5), anger (F = 1.0; p = 0.3), fatigue (F = 0.4; p = 0.5), vigor (F = 1.5; p = 0.2), and confusion (F = 0.7; p = 0.4) subscales of the POMS (Figure 2). Gender did not influence the comparative analysis for the tension subscale (F = 2.0; p = 0.2). Pairwise comparisons showed a significant decrease in tension (p = 0.01) after the massage and a nonsignificant decrease (p > 0.05) after the placebo ultrasound. Table 4 summarizes pre and postintervention and change scores of each POMS subscale after each intervention.
This study showed that massage before activity negatively affected subsequent muscle performance in the sense of decreased isokinetic peak torque at higher speeds. Although it is not warranted to extrapolate these findings to stating that pre-event massage will negatively affect athletic performance, it should be noted that higher movement speeds generally are more relevant to such activities than lower speeds. This study does add to the growing body of evidence that has found that pre-event massage has negative effects on performance (2,29) or at best no effects at all (8,10,12,15,18).
Although we found no significant changes in salivary cortisol concentration and α-amylase activity, this study did find a significant increase in salivary flow rate indicative of increased parasympathetic nervous system activity (11). Increased parasympathetic activity is associated with decreased readiness for action (27). This would seem to indicate that pre-event massage does not prepare the athlete for subsequent activity and may explain to some extent the decreased muscle performance also noted in this study.
We also found an increase in MDT in both locations tested. Cutaneous afferent input is one source of afferent input on the soma of the α-motoneuron (25). Decreased afferent input as a result of increased MDT might lead to decreased motor-unit activation and a resultant decrease in performance providing us with yet another mechanism explaining the negative effects of pre-event massage noted in this study.
Finally, this study noted a significant decrease in the tension subscale of the POMS for massage as compared to placebo. In a previous study, we found a reduction in the vigor subscale with postevent massage intervention (4). Although decreased vigor has been associated with decreased athletic performance, decreased tension positively affects performance albeit that effect sizes are small (6). This finding of a positive effect of massage is consistent with psychological effects found in other studies (20,26). It should be noted that effects of mood state are greater in short duration, open skill, individual sports (6). This may mean that pre-event massage is indicated to increase performance in such sports, especially in individual athletes prone to excessive pre-event tension.
We acknowledge limitations to this study. With this study performed in a controlled laboratory setting, its findings may not apply to the athletic environment where the stress of competition and other psychological factors may be more relevant than physiological factors (9). The time required to carry out the assessment procedures in studies that use psychological, physiological, and biological outcome measures may compromise the validity of trial results. In this study, adequate training before the trial to coordinate measurements was provided to reduce the impact of this limitation. Finally, by using recreational sportspeople as our subjects, we may have limited extrapolation of results to higher-level sportspeople that commonly use pre-event massage.
Preevent massage negatively affects subsequent muscle performance. Mechanisms that may play a role in explaining the negative effects of pre-event massage include increased parasympathetic activity and decreased MDT. Effects of pre-event massage on mood state are somewhat positive and indicate that pre-event massage might be indicated to increase performance in short duration, open skill, individual sports, especially in sportspeople prone to excessive pre-event tension.
The study was funded by a research project grant (CAR-Granada, 2007) from the Spanish High Council for Sports. In memoriam of Peter Huijbregts.
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Keywords:Copyright © 2011 by the National Strength & Conditioning Association.
pre-event massage; strength; salivary cortisol; α-amylase; mechanical detection threshold; mood state