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Including Stretches to a Massage Routine Improves Recovery From Official Matches in Basketball Players

Delextrat, Anne1; Hippocrate, Audrey2; Leddington-Wright, Sheila3; Clarke, Neil D.3

The Journal of Strength & Conditioning Research: March 2014 - Volume 28 - Issue 3 - p 716–727
doi: 10.1519/JSC.0b013e3182aa5e7c
Original Research

Delextrat, A, Hippocrate, A, Leddington-Wright, S, and Clarke, ND. Including stretches to a massage routine improves recovery from official matches in basketball players. J Strength Cond Res 28(3): 716–727, 2014—The aim of this study was to investigate the effect of incorporating stretches into a massage recovery treatment after a competitive basketball match on perceptual and physical markers of recovery. Nine men (age: 22 ± 3 years; stature: 191.2 ± 8.5 cm; body mass: 90.9 ± 10.1 kg; and body fat: 12.4 ± 4.7%) and 8 women (age: 21 ± 3 years; stature: 176.4 ± 8.1 cm; body mass: 73.9 ± 9.7 kg; and body fat: 21.9 ± 5.5%) who are national-level basketball players received a massage, a massage and stretching, or no treatment immediately after a competitive match. The perception of overall fatigue and leg soreness was assessed immediately after the treatment and 24 hours later, whereas countermovement jump (CMJ) and repeated sprint ability (RSA) were tested 24 hours after the treatment. Compared with massage, massage and stretching induced lower perception of leg soreness immediately only in women (p ≤ 0.001;

= 0.86), whereas a longer lasting effect was observed in men, with a difference between treatments reported after 24 hours (p ≤ 0.001;

= 0.94). Furthermore, both treatments resulted in a better CMJ performance compared with the control condition in men only (p = 0.0001;

= 0.33), and massage and stretching involved a lower performance decrement during RSA compared with massage in women only (p = 0.015;

= 0.29). The results suggest that women benefit slightly more from the combination treatment than men, and therefore this type of recovery intervention should be adopted by physiotherapists working with women teams in particular.

1Department of Sport and Health Sciences, Oxford Brookes University, Oxford, United Kingdom;

2Faculty of Life Sciences, London Metropolitan University, London, United Kingdom; and

3Department of Biomolecular and Sport Science, Faculty of Health and Life Sciences, Coventry University, Coventry, United Kingdom

Address correspondence to Dr Anne Delextrat,

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Elite basketball players experience high training loads and often train or play matches on consecutive days. Repeated eccentric exercise typical of team sport has been associated with muscle damage that can result in decreased strength, sprint, and jump performance lasting until up to 7 days postexercise (11,26,28). Therefore, enhancing recovery is crucial for these athletes to allow optimal adaptation to training and maximize match performance (34). However, recovery processes in basketball are not well understood as only few experimental studies focused on these aspects (10,26,28). In addition, although the recovery literature on other team sports is more abundant, findings from these studies cannot be extrapolated to basketball, given the specificity of eccentric loading induced by the extensive amount of jumps performed in this sport (11,26).

Among the recovery procedures used by elite basketball teams, lower limb massage is commonly applied after training or competition (10,24,26,28). The potential benefits of massage on recovery include increased blood circulation and venous return, greater lactate clearance, decreased pain sensation, and general well-being (12,17,35). Although the positive effects of massage on perceived pain or well-being are well established, there are contrasting results in the literature on other aspects such as physical performance (5,30,35). Mancinelli et al. (24) demonstrated that a 34-minute lower limb massage performed after a basketball training session improved vertical jump height in women National Collegiate Athletic Association players. In contrast, a recent study (10) reported no significant effect of a 30-minute lower limb massage performed immediately after an official match on vertical jump and repeated sprint performance in men and women. In addition, this latter study also showed that, although massage improved the perception of fatigue and leg soreness in men and women, these effects were less evident in women (10). A sex effect on recovery responses has been previously suggested by other authors (17). In particular, women were characterized by a greater drop in arterial pressure and slower circulatory adjustments after exercise, which could make them more or less sensitive to specific recovery interventions. However, most recovery studies focused on either men or women (21,24,28,30), and it is necessary to investigate recovery responses in men and women within the same study design.

Recently, studies have shown that the combination of recovery interventions might be more efficient than single modalities to help recovery. Jakeman et al. (21) reported an improvement in jump performance 48 hours after plyometric exercise when athletes received a massage combined with lower leg compression, compared with compression alone (21). It has also been shown that massage is more beneficial for recovery when combined with active recovery (27). These authors explained the larger benefits of the combined treatments by the additive effects of both interventions on local muscle blood flow (21,27). Stretching has been suggested to have analgesic effects and helps disperse the edema created by the inflammatory response to microlesions of the muscle after eccentric exercise (2,36). However, these effects have not been clearly established, and the isolated effects of stretching on recovery from basketball training or competition were found to be trivial to moderate (19,22,28). Within this context, combining massage and stretching might induce a greater physiological stimulus and accelerate recovery processes. This type of combination is found for, example, in the practice of Thai massage therapy (combination of deep massage and passive stretching), renowned for its benefits on muscle tension and psychological stress in clinical populations (4,32). However, to our knowledge, no scientific study has investigated the effects of Thai massage on the recovery of performance in athletes.

Therefore, the aim of the present study was to compare the effects of massage and massage combined with stretching on perceptual and performance markers of recovery in men and women basketball players after competitive matches. It was hypothesized that (a) massage and stretching would result in lower perception of fatigue and improved physical performances, compared with massage only, and (b) the perceptual and physical recovery effects of massage and massage and stretching will be different between men and women.

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Experimental Approach to the Problem

The aim of the present study was to investigate if adding stretching to a massage routine would improve the recovery from basketball competition in men and women. The experimental design used to address this question was a mixed-model intervention design with repeated measures. Because massage was the main recovery mode considered, it was present in both intervention conditions, with the comparison between “massage only” and “massage and stretching,” evaluating the potential benefits of the combined treatments (hypothesis 1). A control condition was added to increase the validity of the study and interventions were randomized to prevent any learning effect. As mentioned in the introduction, it was crucial to compare the response of men and women within the same experimental design to address hypothesis 2. Ecological validity of the study was ensured by considering official matches, known to induce physical and psychological stress, and testing physical performance 24 hours later to replicate real competition conditions. Psychological assessments of recovery included overall fatigue and leg soreness, in accordance with previous recovery studies (24,30). The 2 performance assessments, countermovement jump (CMJ) and repeated sprint ability (RSA) were selected for their specificity to basketball (26,28) and their widespread use in recent basketball research.

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Nine men (age: 22 ± 3 years; stature: 191.2 ± 8.5 cm; body mass: 90.9 ± 10.1 kg; and body fat: 12.4 ± 4.7%) and 8 women (age: 21 ± 3 years; stature: 176.4 ± 8.1 cm; body mass: 73.9 ± 9.7 kg; and body fat: 21.9 ± 5.5%) who are basketball players from 4 top ranking teams in the University Premier League volunteered to participate and provided written informed consent. Exclusion criteria were injury in the previous 6 months, and the presence of current medical treatment or nutritional supplements that could affect muscle function and recovery. Inclusion criteria involved being a starting player and have a match playing time greater than 25 minutes. Because of these inclusion criteria, only 5 men and 4 women could be tested during the 2010–2011 season. Therefore, an additional 4 men and 4 women were tested during the following season (2011–2012) to ensure a satisfactory sample size for analysis. All subjects had at least 3 years of playing experience at this standard or higher and no background in heavy weightlifting or heavy plyometric training. The men's group comprised 4 guards, 3 forwards, and 2 centers, whereas the women's group comprised 4 guards, 3 forwards, and 1 center. For both seasons, participants were involved in 3 120-minute basketball practice sessions and 1 match per week. The same coach trained all teams, and training sessions were standardized during the testing period. Details about each training session is shown in Figure 1. The project was approved by the university Ethics Committee and undertaken in accordance with the Declaration of Helsinki.

Figure 1

Figure 1

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Each subject was tested on 5 occasions, separated by at least 48 hours, with a maximal time of 4 weeks between the first and fifth sessions. The first session included familiarization trials and determination of the criterion score for RSA. The second session was to obtain baseline measurements of performance in a nonfatigued state (refrained from exercise in the preceding 48 hours). The remaining 3 sessions consisted in 1 of 3 recovery treatments (massage, massage and stretching, or control) presented in a random order and performed immediately after a competitive match. Perceptual measures of recovery and physical performance were then assessed at different time intervals until 24 hours after treatment (Figure 1). Testing took place during the first phase of the competitive season (October to December). The time between the first and fifth sessions did not exceed 4 weeks to minimize training-induced influences on performance (20).

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Practice and Determination of the Criterion Score (Session 1)

Three shuttle-run sprints of 30 m (15 + 15 m) separated by 3 minutes of passive recovery were performed by each subject (6). This allowed players to become accustomed to the RSA test. In addition, the best time was used as a reference (criterion score) for baseline testing (6).

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Physical Performance Measurements (Sessions 2, 3, 4, and 5)

Physical performance was assessed in a nonfatigued state (baseline), and 24 hours after each treatment. It involved a CMJ followed by RSA test. Each testing session was preceded by a controlled warm-up that comprised 5 minutes of jogging with the ball, 2 minutes of joint mobility exercise, 2 minutes of neuromuscular exercise (i.e. a cycle of 3 seconds of skipping followed by a 10-m sprint and 3 CMJ followed by another 10-m sprint, repeated for 2 minutes), and 2 minutes of passive recovery (free throws). No stretching was performed after the warm-up to avoid any interaction with the recovery treatments provided.

The CMJ test was conducted on a rubber-coated contact mat connected to a digital timer (Ergojump; Globus Inc., Treviso, Italy). Subjects started in a standing position with both feet together and were asked to jump as high as possible with a rapid countermovement, whereas keeping their hands on the hips. The depth of the countermovement was self-selected, and they were asked to land as close as possible to their point of takeoff. Flight time was used to calculate the change in the height of the body's center of mass (3). Three trials were performed, separated by 2-minute recovery, and the highest jump was recorded. Jump performance has a low variability between tests (coefficient of variation of 3.0%) (25).

The RSA test comprised 10 shuttle-run sprints of 30 m (15 + 15 m) separated by 30 seconds of passive recovery. This RSA protocol is characterized by good test-retest reliability (14). During the first sprint of the baseline session, each player was required to achieve at least 95% of his or her criterion score (6). If this was not achieved, the first sprint was repeated until achievement of the criterion score after 3 minutes of recovery (9). This score was not applied in the other sprint tests because of the potential effects of residual fatigue or possible benefits of treatments. However, participants were instructed to avoid pacing during the RSA test and produce a maximal effort during each sprint. Verbal encouragement was provided throughout to help achieve this goal.

During the sprint and criterion score tests, sprint times were recorded using photocells (Wireless Speedtrap 2; Brower timing systems, Draper, UT, USA) located at the starting line. Players were asked to start each sprint from a line placed 50 cm before the starting line, and timing started when they broke the light beam. The following measures were calculated from the RSA test as follows:

  • Total time (seconds), defined as the sum of the 10 sprint times.
  • Ideal time (seconds), calculated as the best sprint time multiplied by 10.
  • Performance decrement (%), determined according to the following equation (14):
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Perceptual Measures of Fatigue and Recovery (Sessions 3, 4, and 5)

A visual analogue scale (VAS) was used to record subjects' perception of overall fatigue (VAS general) and leg soreness (VAS legs) at the following times: immediately after the match, immediately after treatment, and 24 hours after treatment. The scale consisted of a 100-mm line labeled with “no soreness” on the left and “extremely sore” on the right. Participants rated their perceived pain by placing a mark on the line that best corresponded to their soreness. Perceived pain was quantified by measuring to the nearest 1 mm from the left end of the line to the mark. This type of perceptual rating has been previously used to assess the efficacy of massage on recovery from high-intensity intermittent exercise (24).

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The 2 massage treatments were conducted immediately after a competitive match and were presented in a random order for each participant. The same qualified (5 years experience) massage therapist performed both types of massage on each participant to increase treatment reliability. Participants were required to lay prone on a massage plinth to allow massage of the back of the thigh and leg and then to lay supine for massage of the anterior part of the thigh. A maximum of 2 players received a massage after a given match because of time constraints. Indeed, it has been established that massage is beneficial for recovery when applied within 2 hours of the end of exercise (1). The total duration of both massages was 30 minutes (15 minutes on each leg). In both massage conditions, the western massage techniques of effleurage (light stroking with the palm of the hand) and petrissage (kneading, wringing, skin rolling, and pick-up-and-squeeze performed with the palm of the hands, fingers, knuckles, or thumbs) were used (29). In the massage and stretching condition, static stretches were applied for 60 seconds, 6 times during the massage. However, in contrast with Thai massage, stretches and massage were performed in succession (4,32), massage was applied on the stretched leg in the present study to induce a greater mechanical stimulus. The body parts targeted were the gastrocnemius, gluteal muscles, and iliotibial band (ITB) because these structures are extensively used in jumping and running activities (26). Although the quadriceps is also highly involved in basketball (11), it was not convenient to stretch and massage this muscle group at the same time, and thus no quadriceps stretching was applied in the present study. The other difference between the 2 massage treatments was that some of the petrissage bouts of the massage routine were replaced by interventions on the connective tissue in the massage and stretching condition, such as cross-fiber friction (pressure applied through the fingertips perpendicular to the tissue fibers) on the Achilles tendon and stripping of the ITB (pressure applied along the muscle fibers, with fingertips, the ulnar border of the hand, the thumb, or the elbow). These types of strokes are only used in specific types of massages, or for specific treatments (i.e., tendinopathies), but they were used in the present study because similar to stretching they affect the connective tissue (12,19,35). Therefore, the aim of adding these techniques was to increase the mechanical stimulus on the connective tissue. Details about the exact type and duration of the various strokes included in each type of massage are presented in Table 1. Overall, the differences between the 2 massage techniques accounted for 10 minutes of massage duration, whereas the remaining 20 minutes was similar between massages (Table 2). In the control condition, participants lied down for 30 minutes in an ambient temperature of 20° C.

Table 1

Table 1

Table 2

Table 2

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Diet Control

Participants were requested to refrain from consuming alcohol from 24 hours before the match until the end of the testing session. Other fluid and food intake were controlled by asking participants to fill in a 2-day food diary (match day and the day after). The diary was subsequently photocopied and returned to the participant so that they could follow similar diets during the remaining trials. In addition, a meal rich in carbohydrate (1.0 g·kg−1) and protein (0.4 g·kg−1) was given to each participant 60 minutes after each match.

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Seventeen official matches (8 for women and 9 for men) over 2 competitive seasons were used. Match outcomes (scores) were recorded, and matches were not included in the analysis if the final score difference was greater than 20 points (either win or loss), or if a particular participant's playing time was less than 25 minutes. These constraints were included to decrease the likelihood of major differences in exertion experienced by the participants during the 3 matches preceding recovery treatments. The perception of overall fatigue recorded immediately after matches were another means to compare the physical and psychological load brought about by each match. Given these constraints, 2 women and 3 men were removed from the sample (the initial sample comprised of 10 women and 11 men). In addition, each match was videotaped, and a manual time motion analysis was performed to identify the frequency of jumps, sprints, and high-intensity shuffles performed by each player during each match (26).

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Statistical Analyses

Data are reported as the mean ± SD. Shapiro-Wilk tests assessed the normality of distribution. All statistical analyses were completed with SPSS version 19.0 software. One-way analyses of variance (ANOVAs) were used to compare match movement frequencies for the 3 conditions (control vs. massage vs. massage and stretching). Subsequently, the main analysis consisted in mixed-design factorial ANOVAs to assess the effects of sex (men vs. women), treatment (baseline vs. control vs. massage vs. massage and stretching), and time (immediately after the match vs. after intervention vs. 24 hours after). If an effect of sex or interaction between sex and other factors was identified, separate 2-way ANOVAs with repeated measures for each sex were conducted to test the effects of treatment and time. Where significant differences were identified, a post hoc Bonferroni test was undertaken to reveal where they lay. Estimates are shown as 95% confidence limits (CLs) with corresponding p values. An alpha of p ≤ 0.05 was considered statistically significant. Effect sizes were calculated using partial eta squared (

). Because this measure is likely to overestimate effect sizes, values were interpreted according to Ferguson (13) as no effect if 0 ≤

≤ 0.05; a minimum effect if 0.05 ≤

≤ 0.25; a moderate effect if 0.25 ≤

≤ 0.65; and a strong effect if

≥ 0.65.

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Match Variables

Mean playing times were 31.4 ± 5.0 minutes and 30.6 ± 6.6 minutes, respectively, for women and men. There were no differences between the perception of fatigue and leg soreness immediately after the matches corresponding to the 3 experimental conditions (p = 0.901; Figures 2 and 3). Likewise, no difference was observed between the 3 matches for the frequency of jumps (men's frequencies of 45.8 ± 10.8 vs. 48.6 ± 9.6 vs. 48.9 ± 10.4; and women's frequencies of 36.8 ± 9.6 vs. 38.1 ± 10.7 vs. 34.9 ± 9.3, respectively, for the control, massage, and massage and stretching conditions, p = 0.608), sprints (men's frequencies of 68 ± 17.8 vs. 65.0 ± 18.6 vs. 71.1 ± 16.9; and women's frequencies of 46.9 ± 13.9 vs. 50.1 ± 14.7 vs. 47.7 ± 12.3, respectively, for the control, massage and massage and stretching conditions, p = 0.552), and high-intensity shuffles (men's frequencies of 77.9 ± 21.2 vs. 86.8 ± 25.6 vs. 84.4 ± 20.4; and women's frequencies of 58.9 ± 17.9 vs. 62.3 ± 18.7 vs. 55.9 ± 19.3, respectively for the control, massage, and massage and stretching conditions, p = 0.596).

Figure 2

Figure 2

Figure 3

Figure 3

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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).

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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).

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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).

Figure 4

Figure 4

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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).

Figure 5

Figure 5

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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.

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Practical Applications

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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repeated sprint ability; vertical jump; fatigue; leg soreness

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