In the age of the Internet, it can be not easy to keep up with all the professional news. We greatly appreciate Sue Hitzmann, LMT, from www.massageprofessionals.com, who started a meaningful discussion about the recently published New York Times article on sports massage and its impact on blood flow and post-exercise muscle soreness. (http://well.blogs.nytimes.com/2010/06/02/phys-ed-does-massage-help-after-exercise/).
This article is based on the interview with Michael Tschakovsky, an associate professor in the School of Kinesiology and Health Studies at Queen’s University in Kingston, Ontario. Prof. Tschakovsky and his colleagues recently published an article in the Journal of Medicine & Science in Sports & Exercise (Wiltshire et al., 2010), which presented results of a study examining the impact of massage on post-exercise muscle blood flow and lactic acid removal.
The study showed that:
‘…sports massage results in severe impairment to blood flow during the massage stroke, and this impairment has a net effect of decreasing muscle blood flow early in the recovery period after strenuous exercise.’ and ‘…sports massage would not be indicated for optimal lactic acid removal from exercised muscle…’.
These results and an interview with Prof. Tschakovsky allowed the author of the article in the New York Times to conclude:
‘The results, published in the latest issue of the Journal Medicine & Science in Sports & Exercise, are a blow, at least to those of us who justify our massages as medicinal (bold by JMS)’.
In fact, if these results are correct, they are indeed a professional blow to the entire industry and science of sports massage. The situation is further complicated by the fact that this data was published in the New York Times, a respected media outlet with more than 18 million subscribers.
Considering the grave importance of this study to the massage profession, we decided to do our own investigation. Through the Journal Medicine & Science in Sports & Exercise, we obtained a copy of the original article and methodically examined it in great detail.
This article is our response to both publications, and we encourage our readers to read it through, despite its length. However, it will provide you with important information when dealing with the consequences of these publications and future similar publications on this subject.
For this study, Canadian scientists recruited 12 healthy male subjects. Subjects were asked to perform three maximal isometric handgrips with 1 minute between efforts. Next, they continuously handgripped a dynamometer at 40% of maximum voluntary contraction for 2 minutes.
In a clinical group, subjects lay quietly for 30 seconds, during which the massage began with effleurage and kneading. In the control group, after the initial 30 seconds of rest, subjects began 10 minutes of rhythmic forearm contractions at 10% of maximum voluntary contraction.
The authors started monitoring central hemodynamics, forearm oxygen uptake, forearm blood flow, and forearm lactic acid removal after an initial 30-second rest. The statistical analysis of the obtained data allowed the authors to conclude that
‘…sports massage actually impairs removal of lactic acid from exercised muscle and that this is due to a mechanical impairment to postexercise muscle blood flow from rhythmic compression of muscle tissue’.
It seems this case is closed, and the authors are correct that sports massage actually harms the athlete’s recovery. However, a detailed analysis of this article showed that, despite an accurate statistical analysis of the data, it is one of the weakest and most outdated studies we have encountered so far on the subject of sports massage.
The study focused on two significant aspects: lactic acid removal and blood circulation in muscle tissue. Here is why the authors are dead wrong on each point of their study.
At the outset, the authors noted that the medical community is divided over the impact of lactic acid on muscle fatigue and recovery. They have clearly sided with the view that lactic acid is a critical factor in muscle fatigue and soreness after intense exercise. They stated that
‘…it still remains that early lactic acid removal from the muscle may be advantageous to improve athletic performance…’
However, this is an outdated view abandoned by the great majority of sports medicine scientists. The current view is the complete opposite. During eccentric exercises, muscles use lactic acid as an easily accessible fuel while their ATP stores are depleted and production is strained. We can provide numerous studies that support this claim. Conveniently enough, the authors of this article didn’t even mention the most essential publications that showed the complete unsustainability of the lactic acid theory.
To save readers’ time, we will use one of the most comprehensive reviews on this subject published in Sports Medicine (Cheung et al., 2003). Let us quote part of the article which addresses the lactic acid theory:
‘The lactic acid theory is based on the assumption that lactic acid continues to be produced following exercise cessation. For the lay public, the accumulation of toxic metabolic waste products is thought to cause a noxious stimulus and the perception of pain at a delayed stage.
However, this theory has largely been rejected, as the higher metabolic rate associated with concentric muscle contractions has failed to elicit delayed-onset muscle soreness. In addition, lactic acid levels return to pre-exercise levels within 1 hour following exercise, and blood lactate levels measured before, during, and sporadically up to 72 hours after have failed to show a relationship between lactic acid levels and soreness ratings.’
Here is another quote from one of the most respected publications for sports coaches (Sharkey and Gaskill, 2006):
“This fallacy (i.e., lactic acid theory, JMS) has been around for years, even though it lacks any basis in fact. The lactic acid isn’t the direct cause of the soreness”.
So what are the causes of muscle soreness after exercise? At this point, we have five theories. We will use the publication of Cheung, et al (2003) to discuss this subject:
1. Muscle Damage Theory (Hough, 1902)
Although this is the oldest theory, it has a large following among current scientists. According to this theory, eccentric exercise disrupts the contractile apparatus of skeletal muscles, especially along Z-lines, which are its weakest link.
2. Muscle Spasm Theory (deVries, 1966; Cleak et al., 1992)
An increase in resting muscle tone leads to compression of capillaries, local ischemia, impaired drainage, accumulation of waste products, and, finally, activation of pain receptors due to local changes in pH.
3. Inflammation Theory (Smith, 1991)
The author and proponents of this theory argue that pathophysiologically intense exercise triggers a response in skeletal muscle identical to basic inflammation: interstitial edema, increased permeability of small blood vessels, infiltration of the muscle tissue with macrophages, etc.
4. Connective Tissue Damage Theory (Sydney-Smith et al., 1992)
Excessive strain of the connective tissue structures leads to muscle soreness. This theory is supported by a significant increase in the components of mature collagen and individual amino acids in urine after eccentric exercise. This is a sign of connective tissue damage because collagen is the main protein from which these structures are built.
5. Enzyme Efflux Theory (Gulick, Kimura, 1996)
When muscle tissue is microdamaged during eccentric exercise, calcium leaks from the sarcoplasmic reticulum, slowing ATP production and activating enzymes and fermentative pathways, which further damage muscle tissue.
Studies of these theories showed that each is correct, and scientists are now beginning to see the five theories as reflections of different stages of the SAME PROCESS triggered by intense exercise. In such cases, there is no single elusive factor we have been trying to find since 1902 responsible for muscle soreness after exercise; rather, it is a combination of causes. The idea of lactic acid accumulation as a primary factor in muscle soreness and fatigue is simply an outdated and confusing notion. If you would like to read the entire chain of events that contribute to muscle soreness after eccentric exercise, please click here: Medical Massage Courses & Certification | Science of Massage Institute » United We Will Stand!
Thus, it is entirely irrelevant to science in general and to sports massage in particular whether it affects lactic acid removal, because we need lactic acid for effective muscle contraction.
The impact of massage strokes on the blood flow of exercised muscle is where this study gets especially interesting and, let us say, mildly puzzling. Please follow us now. The authors asked their subjects to perform eccentric forearm muscle exercise. What will the first outcome of this event be? The heart rate will continuously rise to satisfy oxygen demands. Thirty seconds after the subject stopped exercising, the heart rate remained elevated, and the authors began performing effleurage and kneading strokes on the muscles. At the same time, they started measuring blood flow through the forearm.
Anyone who knows the basics of anatomy and physiology will predict that massage strokes at this time (i.e., 30 seconds after cessation of muscle contractions) will indeed decrease blood flow because the blood rushes through the arteries faster as a result of the increased heart rate.
If one opens the most respected and comprehensive textbook on Medical Physiology (Ganong, 2009), which every medical school in the world refers to, he or she will find that during the eccentric exercises, the blood flow through the muscles increases by 30-fold. How can massage strokes additionally increase the blood flow even if the muscle stopped contracting just 30 seconds ago? There is no way that massage strokes, even at the fastest possible rate of application, can speed up blood flow. They may only block it, and the authors noted this very well-predicted fact.
The impact of sports massage on muscle soreness and fatigue is a highly controversial issue, because many studies have shown that it fails to produce positive outcomes. The problem with all these studies is not sports massage but rather the poorly designed protocols—unfortunately, this study, whether intentionally or unintentionally, falls into the same trap.
A little history first. The incredible success of the Soviet Olympic team during the peak of the Cold War is a historical fact (1972, 1976, 1980, 1988, 1992). We can provide an even more striking example. The East German Olympic Team finished second in medal counts at the 1976, 1980, and 1988 Olympic Games, and it always beat West Germany despite East Germany’s smaller size and population. In these and other Eastern European countries, sports massage was one of the cornerstones of athletes’ training, yet it was also a closely guarded secret.
After the fall of the Soviet bloc, this information became available in the West. Several studies (Cafarell et al., 1990; Drews, 1990; Wenos et al., 1990; Rodenberg et al., 1994) showed that sports massage does affect muscle soreness or fatigue. However, this controversy was solved in 1994 by a study conducted by Dr. L.L. Smith and his colleagues, who, by the way, is the father of the Inflammation Theory we discussed above, and one of the leading proponents of the unified theory, which looks at muscle soreness and fatigue as being the result of several sequential events.
Dr. Smith and his colleagues from East Carolina University decided to do something straightforward that no Western scientist had done before. They designed a study protocol that re-created in every small detail the recommendations of their colleagues from former Eastern Bloc countries. The clinical results of this study showed that, yes indeed, the muscle soreness and fatigue are dramatically reduced by sports massage when it is conducted correctly. One of the critical components is the time of massage application. If massage is performed less than 2 hours or more than 3 hours after the intense exercise, it doesn’t affect the muscle soreness or fatigue.
Lin (1999) reported similar results: a reduction in plasma CK levels after the exercise massage group received a 15-minute massage 2 hours after the exercise. This allowed Cheung, et al., (2003) to conclude that:
‘This timetable (i.e., 2-3 hours, by JMS) may suggest that the timing of massage intervention may be a very influential factor.’
The study by Smith et al. (1994) is widely known and cited among professionals worldwide, and there is little chance that Prof. Tschakovsky and his colleagues were unaware of its existence and impact. However, they either chose to design their own completely ridiculous protocol or didn’t bother to conduct proper research before developing it. As you remember, the authors began applying sports massage 30 seconds (!) after the eccentric exercise ended. If you would like to find out why the 2-3 hour window after eccentric exercise is so essential, please click here.
This is why we consider the initial article published in the Journal Medicine & Science in Sports & Exercise (Wiltshire et al., 2010) as the weakest scientific study so far that has tried to examine the benefits of sports massage. The following New York Times article is based on this study, and it is evident that the journalist, who lacked sufficient expertise in sports medicine, was misled by the study’s results and Prof. Tschakovsky’s personal opinion.
A couple of final thoughts. The New York Times is a very respected media publication, and it always gives the other side the choice to respond. The author of the article gave the massage community the option to comment on the published study and interview with Prof. Tschakovsky.
Here is the toothless response of the American Massage Therapy Association to the New York Times article:
“The main takeaway of Mr. Tschakovsky’s study is that far more research about exercise and sports massage is needed.”
Where is the detailed analysis of the study from any massage therapy professional associations, foundations, or chapters? Where are all these presidents, vice presidents, former presidents, experts on sports massage, and countless continuing education providers who are supposed to analyze and defend the sports massage from groundless and frequently unscientific claims?
If massage officials lack sufficient professional expertise, they must hire scientists who can independently analyze information, and this analysis must be used as the official response. Instead, it seems that massage leaders run for the woods and wait until the situation calms down. Unfortunately, they again weren’t able to stand up and firmly defend the profession in general and those they are supposed to represent officially.
Cafarelli E., Sim J., Carolan B., Liebesman J. Massage and Short Term Recovery From Muscle Fatigue. Int J Sports Med, 1990, 11:474-478.
Cheung, K., Hume1 P.A., Maxwell L. Delayed Onset Muscle Soreness Treatment Strategies and Performance Factors. Sports Med, 2003; 33 (2): 145-164.
Cleak M.J., Eston R.G. Muscle soreness, swelling, stiffness and strength loss after intense eccentric exercise. Br. J. Sports Med, 1992, 26(4): 267-272.
deVries H.A. Quantitative EMG investigation of the spasm theory of muscle pain.Am J Phys Med, 1966; 45:119-134.
Drews T., Kreider R.B., Drinkard B., Cortes C.W., Lester C., Somma C.T., Shall L.M., Woodhouse M. Effects of Postevent Massage on Repeated Ultra-Endurance Cycling. Int J Sports Med, 11:407, 1990.
Ganong W.F. Review of Medical Physiology. ‘Lange’, Norwalk, Connecticut, 2009.
Gulick D.T., Kemura I.F. Delayed onset muscle soreness: what is it and how do we treat it? J. Sports Rehab, 1996, 5: 234-243.
Hough T. Ergographic studies in muscular soreness. Am J Physiol, 1902; 7:76-92.
Lin WH. The effects of massage, stretch and meloxicam on delayed onset muscle soreness. Taoyuan: National College of Physical Education and Sports, 1999.
Reynolds G. Phys Ed: Does Massage Help After Exercise? New York Times, 2010, June 2.
Sharkey B.J., Gaskill S.E. Sport Physiology For Coaches. Human Kinetics. Windsor, Champaign, Ill. 2006.
Rodenberg J.B., Steenbeek D., Schiereck P., Bar P.R. Warm-up, Stretching and Massage Diminish Harmful Effects of Eccentric Exercises. Inter J Sports Med, 1994, 15:414-419.
Smith L.L. Acute inflammation: the underlying mechanism in delayed onset of muscle soreness. Med Sci Sports Exerc, 1991, 23(5):542-551.
Smith L.L., Keating M.N., Holbert D., Spratt D.S., McCammon M.R., Smith S.S., Israel R.G. The Effect of Athletic Massage on Delayed Onset Muscle Soreness. Creatine Kinase and Neutrophil Count. J. Orthop Sports Phys Ther, 1994, 19(2):93-99.
Sydney-Smith M., Quigley, B. Delayed onset muscle soreness: evidence of connective tissue damage, liquid peroxidation and altered renal function after exercise. Report to Australian Sports Comission’s Applied Sport Research, Canberra: Australian Sports Commission, 1992:77.
Wiltshire EV, Poitras V, Pak M, Hong T, Rayner J, Tschakovsky ME. Massage impairs postexercise muscle blood flow and “lactic acid” removal. Med Sci Sports Exerc, 2010 Jun; 42(6):1062-71.
Wenous J.Z., Brilla L.R., Morrison M.D. Effect of Massage on Delayed Onset Muscle Soreness. Med Sci Sports Exerc, 1990, 22:S34.
Category: Sport Massage