Perception of Overall Fatigue (Visual Analogue Scale General)
There was no effect of sex on VAS general (p = 0.257;
= 0.09). However, there was an effect of treatment (p ≤ 0.001;
= 0.69), time (p ≤ 0.001;
= 0.90), and an interaction effect between sex, treatment, and time (p ≤ 0.001;
= 0.31) on VAS general (Figure 2). Subsequent analyses for each sex revealed a treatment effect (p ≤ 0.001;
= 0.67 and 0.74, respectively, in women and men), time (p ≤ 0.001;
= 0.87 and 0.95, respectively, in women and men), and treatment by time interaction (p ≤ 0.001;
= 0.57 and 0.73, respectively, in women and men).
In women, VAS general was greater after the match than immediately after treatment (95% CL of difference: 2.84–4.36, 2.67–4.67, and 1.96–4.47, respectively, for control, massage, and massage and stretching; p ≤ 0.001) and immediately after treatment compared with after 24 hours, in the control (95% CL of difference: 0.86–3.14; p = 0.004) and massage conditions only (95% CL of difference: 0.36–2.01; p = 0.012, Figure 2A). In addition, VAS general was lower immediately after the massage (95% CL of difference: 1.29–3.08; p ≤ 0.001) and massage and stretching (95% CL of difference: 0.63–2.86; p = 0.005) compared with control, with no difference between the 2 treatments (p = 0.552). However, comparisons after 24 hours showed a difference in VAS general between the massage and control conditions only (95% CL of difference: 0.43–2.31; p = 0.008, Figure 2A).
In men, VAS general was greater after the match than immediately after treatment (95% CL of difference: 1.10–2.02, 2.24–3.76, and 2.02–4.36, respectively, for control, massage, and massage and stretching; p ≤ 0.001) and immediately after treatment compared with after 24 hours, in the massage (95% CL of difference: 0.20–2.98; p = 0.027, Figure 2B) and massage and stretching conditions only (95% CL of difference: 1.38–2.48; p ≤ 0.001, Figure 2B). Comparisons immediately after treatments showed that the massage and massage and stretching interventions were different from the control condition (95% CL of difference: 0.40–1.31 and 0.16–1.74, respectively, for massage (p = 0.002) and massage and stretching (p = 0.021). These differences persisted after 24 hours (95% CL of difference: 1.31–2.75 and 1.87–3.36, respectively, for massage and massage and stretching; p ≤ 0.001, Figure 2B).
Perception of Leg Soreness (Visual Analogue Scale Legs)
The statistical analysis did not show any effect of sex on VAS legs (p = 0.328;
= 0.07). However, an effect of treatment (p ≤ 0.001;
= 0.88), time (p ≤ 0.001;
= 0.96) and interaction between treatment, time, and sex (p = 0.003;
= 0.31) were observed (Figure 3). Subsequent analyses for each sex showed effects of treatment (p ≤ 0.001;
= 0.86 and 0.94, respectively, in women and men), time (p ≤ 0.001;
= 0.97 and 0.95, respectively in women and men), and treatment by time interaction (p ≤ 0.001;
= 0.90, and 0.83, respectively, in women and men).
In women, VAS legs was greater after the match than immediately after treatment in the massage (95% CL of difference: 3.19–5.92; p ≤ 0.001) and massage and stretching conditions (95% CL of difference: 4.89–8.17; p ≤ 0.001) only, and immediately after treatment compared with after 24 hours in the control (95% CL of difference: 1.63–3.72; p ≤ 0.001) and massage conditions only (95% CL of difference: 0.34–1.78; p = 0.007, Figure 3A). Perception of leg soreness immediately after treatment was lowest for massage and stretching, followed by massage, and control (95% CL of difference: 4.03–8.09, 2.79–6.67, and 0.92–1.74, respectively, between massage and stretching and control, massage and control, and massage and stretching and massage, p ≤ 0.001). However, after 24 hours, differences were shown only between massage and control (95% CL of difference: 2.2–4.03; p ≤ 0.001) and massage and stretching and control (95% CL of difference: 1.50–4.73; p = 0.002, Figure 3A).
In men, the effect of time on VAS legs was observed between after the match than immediately after treatment only (95% CL of difference: 0.73–0.96, 2.75–6.02, and 3.99–5.31, respectively, for control, massage, and massage and stretching; p ≤ 0.001). No difference was shown between immediately after treatment and 24 hours post for any of the 3 conditions (p = 0.133–0.995, Figure 3B). Comparisons immediately after treatment showed that the massage and massage and stretching interventions were different from the control condition (95% CL of difference: 2.23–4.17 and 2.49–4.39, respectively, for massage and massage and stretching; p ≤ 0.001). However, after 24 hours, differences were observed between all the conditions, with the lowest VAS legs reported for massage and stretching, followed by massage, and then control (95% CL of difference: 1.91–3.82 [p ≤ 0.001], 1.08–3.24 [p = 0.01], and 0.39–1.01 [p = 0.01], respectively, between massage and stretching and control, massage and control, and massage and stretching and massage; Figure 3B).
Countermovement Jump Height
There was an effect of sex (p ≤ 0.001;
= 0.992) and treatment (p = 0.001;
= 0.33) on CMJ height, but no interaction between these factors (p = 0.55;
= 0.05; Figure 4). Subsequent analyses for each gender showed a treatment effect in men only (p = 0.042;
= 0.318). Pairwise comparisons in men revealed a decrease in CMJ performance in the control condition compared with baseline (95% CL of difference: 1.82–4.69 cm; p ≤ 0.001).
Repeated Sprint Ability
There was an effect of sex on total time and ideal time (p ≤ 0.001;
= 0.99), However, no treatment effect (p = 0.128–0.564;
= 0.05–0.13) or interaction between sex and treatment (p = 0.166–0.208;
= 0.05–0.11) was observed on these variables. Women's total time values were 63.5 ± 2.2 seconds, 64.5 ± 2.8 seconds, 64.1 ± 2.1 seconds, and 64.7 ± 1.6 seconds, and ideal time values were 61.3 ± 2.1 seconds, 62.4 ± 3.0 seconds, 61.6 ± 2.4 seconds, and 63.1 ± 1.7 seconds, respectively, in the baseline, control, massage, and massage and stretching conditions. Men's total time values were 58.4 ± 2.8 seconds, 56.3 ± 4.4 seconds, 57.1 ± 4.1 seconds, and 58.0 ± 2.2 seconds; and ideal time values were 56.0 ± 3.4 seconds, 55.7 ± 1.8 seconds, 56.6 ± 2.5 seconds, and 56.4 ± 2.1 seconds, respectively, in the baseline, control, massage, and massage and stretching conditions.
The statistical analyses showed an effect of sex (p ≤ 0.001;
= 0.98) and treatment (p = 0.015;
= 0.29) on the performance decrement (Figure 5). Subsequent analyses for each sex showed a treatment effect in women only (p ≤ 0.001;
= 0.60). Pairwise comparisons in women showed that the performance decrement was smaller in the massage and stretching condition compared with massage (95% CL of difference: 0.33–2.70 seconds; p = 0.014). In addition, the massage condition resulted in a greater performance decrement compared with the control condition (95% CL of difference: 0.26–0.95 seconds; p = 0.002).
The main findings of the present study showed that incorporating stretches into a massage routine immediately after an official basketball match resulted in lower perception of leg soreness and better repeated sprint performance compared with a classical sports massage. Although both massage treatments improved CMJ performance in men, no further benefit from the combined treatment was observed. Therefore hypothesis 1 was rejected. In addition, perception of leg soreness after 24 hours was improved in men only, and the performance decrement during repeated sprint was better in women only. Therefore hypothesis 2 was accepted.
The combination of interventions is a relatively recent area of investigation into the recovery from physical exercise. Although the benefits of massage and stretching performed in isolation range from moderate to trivial in previous studies (24,28), the present investigation propose to combine these interventions, as it is classically performed during Thai massage (4,32). Both recovery procedures improved perceptions of overall fatigue and leg soreness, with greater benefits of the combination on leg soreness, in accordance with hypothesis 1. Previous studies reported lower pain perception after massage (24), whereas contrasting results were found about the effects of stretching on pain perception, with either reducing, no change, or increasing leg soreness after stretching (19,36). The present study provides evidence that adding stretches to a massage routine not only does not have any negative effects on the perception of fatigue or leg soreness but also could even lead to reduced leg soreness, compared with massage alone. Our results are associated with large effect sizes, which highlight the practical importance of recovery strategies to reduce DOMS. They are also in agreement with previous findings showing that the combination of recovery interventions was more effective at reducing DOMS symptoms compared with isolated interventions (21). Several underlying mechanisms have been suggested to justify the benefits of massage on reduced pain, such as neurological factors [pain gate theory (31)], activation of the parasympathetic system (7), and biochemical characteristics [increased removal of muscle by-products, increased serotonin and endorphin concentrations (23), or the mechanical realignment of muscle fibers (16)]. Stretching has also been associated with beneficial effects, including decreased pain and edema dispersion (2,36). However, stretching is not always recommended in the recovery from intermittent running exercises because it is likely to create microlesions within the muscle that would aggravate the disruption of the cytoskeleton of muscle fibers induced by eccentric exercise and increase leg soreness (37). The results of the present study are in disagreement with this observation because the combination of massage and stretching did not involve greater pain sensation compared with massage only, despite the fact that stretches were similar to static stretching. In practical terms, an additional benefit of combining massage and stretching in a single treatment in elite players is that it saves time in their postmatch routine, in comparison with the usual practice of stretching first, and then having a massage.
The effects of the combination of recovery treatments on physical performance observed in the present study were less strong than those shown on perceptual measures, as evidenced by only small to moderate effects sizes. Indeed, although both massage and massage and stretching were beneficial in men to achieve a post–24 hours CMJ performance similar to the levels achieved at baseline, no difference between these 2 recovery treatments were revealed by the statistical analysis. This is in contradiction with hypothesis 1. These results confirm the improvement in vertical jump performance observed in a previous study after a massage was performed postexercise, compared with no intervention (24). However, they are in contradiction with the better vertical jump performance reported after a combination of massage and compression garments in the recovery from team sport–specific exercise, compared with compression garments only (21). These authors attributed the positive effects of these various recovery interventions to their capacity to reduce the edema associated with the inflammatory process after eccentric exercise and hence improve muscle function. This could also partly explain the results of the present study. Therefore, these findings suggest that massage and massage and stretching have similar beneficial effects in the recovery of jump performance after an official match in men, and thus either of these treatments should be implemented by physiotherapists after practice sessions and matches. This is of particular importance in the context of the outcome of basketball tournaments where matches are played daily, given the crucial role of the vertical dimension in this sport, compared with other team sports (26).
There was an effect of the combined recovery intervention on RSA performance in the present study, with lower performance decrements observed in women compared with the massage alone condition. This is in agreement with hypothesis 1. To our knowledge, the present study is the first to investigate the effects of combined recovery interventions on RSA. In addition, there is very limited research on the effects of massage or stretching alone on RSA (38). A recent study found that static stretching performed in the recovery from soccer training sessions for 3 consecutive days did not affect repeated sprint performance (38). In basketball, the line-drill test is classically used to assess running performance (28). Montgomery et al. (28) studied the effects of static stretches performed every day during a 3-day tournament on basketball line-drill performance and only found a small effect of this recovery intervention compared with control conditions. Although the mechanisms responsible for the better effects of massage and stretching compared with massage only in the present study are difficult to establish, they could be linked to the stretch-shortening cycle. In particular, stretching is known to have positive effect on the series elastic components of the muscle (endomysium, perimysium, and epimysium) and the spinal reflexes involved in the stretch-shortening cycle (15,18). In the present study, these structures might have been affected by the deep tissue massage (friction and stripping) performed on the Achilles tendon and the ITB. Within this context, our results suggest that adding stretches to a massage in postmatch recovery practices induces better RSA performance 24 hours later and in particular prevents the decrease in sprint performance with time. Because it is well established that sprint and high-intensity activities decrease between the first and fourth quarter of basketball matches (10,26), practitioners should be encouraged to use the combination of these recovery techniques to improve player performances. It is important to note, however, that the effect size associated with this result in the present study was only moderate, and therefore further studies are needed to confirm these observations.
Interestingly, there was an interaction between sex, treatment and time on the perception of leg soreness in the present study, with better immediate effects of the combination intervention compared with massage alone in women, and better benefits of the combination compared with massage alone in men after 24 hours only. This is in agreement with hypothesis 2. Differences between men and women in the perceptual measures of recovery from basketball matches have been previously evidenced, with women getting a greater benefit from specific recovery treatments such as cold water therapy, but not others such as massage, compared with men (10). In addition, a recent review on sex effects during recovery from exercise offers some elements of explanation of our results (17). Indeed, these authors stated that women usually experienced an earlier postexercise inflammatory response, and that this response was overall weaker than that of men in the longer term because of slower circulatory adjustments (8,17). If we assume a direct link between the symptoms of DOMS (including pain perception) and the inflammatory response, this could partly explain why the combination of recovery interventions is more beneficial immediately in women and more beneficial 24 hours postexercise in men. However, further studies including both sexes are necessary to confirm these results because the effects sizes associated with our results are small to moderate.
Psychological perception of fatigue is an important factor to take into account because it could influence players' behavior and choices during competition if they do not feel rested. Within this context, Smith and Jackson (33) reported an inverse association between perception of leg soreness and vertical jump performance in men soccer players. This could explain the greater CMJ performance and lower perceived leg soreness observed in the present study 24 hours after the massage and stretching treatment in men and suggests that the combination treatment is slightly more beneficial than massage alone in men in the context of a succession of daily basketball practice sessions or matches. In women, the transitory psychological beneficial effects of the combination treatment did not seem to persist 24 hours later, or to translate into a better vertical jump performance. This highlights the more complex nature of recovery and performance in women and the potential link to the role played by hormonal factors at the different phases of the menstrual cycle (17). Interestingly, the performance decrement in the RSA test was lower after the massage and stretching treatment than massage alone in women only, suggesting that this recovery technique should be beneficial to avoid the decrease in sprint frequencies classically evidenced toward the end of basketball matches (10,26). The mechanisms allowing these contrasting effects on RSA across sexes are not known, and therefore additional studies involving more invasive measurements are necessary. However, these results must be interpreted with caution because they are associated with small to moderate effects sizes, and no change was observed in the 2 other RSA performance indices (total time and ideal time). In addition, it has been mentioned by several authors that repeated sprint performance is multifactorial and highly influenced by pacing and psychological factors (6,10).
The main limitations of this study are the rather small sample size, the lack of control over the task inducing fatigue, and the lack of data measurement after 24-hour postexercise. An official match was chosen to replicate real conditions, although it is difficult to ensure that all players were exhausted at the end of the match. In addition, measurements at 48 and 72-h postexercise would have been useful because the symptoms of DOMS usually peak around these times (7). However, these were chosen to increase the ecological validity of the study and its practical applications. Finally, it must be mentioned that these results can only be applied to elite level teams who possess a massage therapist.
The present study showed some positive effects of combining massage and stretching compared with massage only in the recovery from a match. This suggests that the classical sport massages currently provided to players might not optimally stimulate the recovery processes, and that physiotherapists could incorporate stretches into their massage treatments. This should be performed within 2 hours after training or matches, in particular during tournaments where matches are played daily. Another practical benefit of combining both procedures is that time is saved, compared with performing stretches and massage separately. The differential effects observed between sexes imply that, whereas the combination adds further benefits than massage alone on leg soreness in men, both treatments could be implemented by physiotherapists working with men teams to improve the recovery of jump performance. In contrast, the recovery of repeated sprint performance seems better after massage and stretching than massage in women. This strengthen findings from previous studies that a classical sports massage is not enough to improve recovery in women, and other treatments, such as massage and stretching should be used by physiotherapists working with women teams. Coaches from women teams also need to be aware of their slower recovery compared with men when planning their training programs, and in particular allow more recovery time (or more treatments) after sessions involving a large amount of muscle damage, such as plyometric training.
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Keywords:Copyright © 2014 by the National Strength & Conditioning Association.
repeated sprint ability; vertical jump; fatigue; leg soreness