Chapter 13 Massage in Sport
Sports massage has gained popularity since the 1980s with the increased participation of all ages in aerobics and the worldwide visibility of sport. However, it is insufficient to define sports massage simply as massage applied to athletes. Often the term sports massage is used synonymously with the term deep tissue massage to justify the use of painful pressures on athletes. This usage is often based on the misconception that the muscular bulk of an athlete necessitates abuse to the connective tissues to deliver an effective intervention. This generalization is also an inaccurate description of sports massage. Sports massage is the use of soft tissue mobilization to enhance performance among individuals who are placed in physical achievement situations. An achievement situation is one in which (1) there is public verifiability of performance (an audience), (2) there is a known criteria of success, (3) an individual is responsible for the outcome, and (4) there is a challenging task. Athletes spend most of their time in physical achievement situations during training or competition.
The idea that sports massage differs from therapeutic massage applied to nonathletes may be misleading. It is not that the techniques used with sports massage are so radically different; rather, the difference lies in the ability of the practitioner to vary the dosage, timing, and amount of pressure based on the needs of the athlete to best enhance performance outcomes. This requires an understanding of periodization for a sport (Mayhew, 1995); specifically, the therapist must know the repetitive cycle that an athlete will undertake several times during a year in order to prepare for peak performance during competition. The knowledgeable practitioner is aware of what point in this cycle an athlete or team is in order to apply the appropriate skills and, thereby, assist the athlete with preparation and recovery.
The additional value that sports massage provides to athletes when compared with other populations is in the psychological effects that can be attained to enhance performance. A positive adjustment in mood, an acquired sense of well-being, a decrease in anxiety, and a decrease in fatigue—all of these are reported and demonstrated psychological responses associated with massage intervention (Hernandez-Reif et al., 2001; Robertson et al., 2004; Stock et al., 1996). The athlete can benefit from these effects before competition or between bouts of training to manage the associated stressors of sport (Loehr, 1994).
Sports massage based on the timing of performance or in response to injury is applied to attain different goals, such as to promote relaxation, increase circulation, diminish adhesion formation, or decrease pain (Farr et al., 2002). It is adjustment based on the demands of the sport and to best enhance performance that distinguishes sports massage from another clinical therapeutic intervention. It is the skilled ability on the part of the therapist that adds the psychological and anxiety management effects for performance that contribute to positive functional outcomes.
Sports massage, as with any therapeutic treatment, must begin with a comprehensive evaluation to ascertain the source of the problem and construct a treatment plan. For any population requiring therapeutic intervention, one treatment modality is insufficient to fully restore full function or treat disability. Similarly, with an athletic population, massage is but part of a regimen of treatment that also includes resistance or flexibility exercises; physical agents such as ice, ultrasound, or electrical stimulation; and other manual therapy interventions such as joint manipulation. It is this combination of applied therapeutic intervention to address imbalances that will promote healing and performance, thus enhancing functional movement for the elite athlete. Although the body of knowledge regarding the mechanisms through which these effects occur continues to expand with scientific investigations, it is important to remember that sports massage is not a new intervention and has been in existence since early civilizations (Callaghan, 1993; Hemmings, 2000).
HISTORY OF SPORTS MASSAGE
Massage as a form of treatment for athletes has existed for thousands of years. The Greeks may have been the first to use massage for athletes as a precompetition and postcompetition intervention. In truth, the original writings regarding massage are from the works of Hippocrates dated around 400 bc (De Domenico & Wood, 1997; Schoitz, 1958). Wrestling was a popular sport in ancient Greece, as were track and field events. Early manuscripts describe manual therapy intervention to treat trauma as well as promote recovery. Historical accounts describe the treatment for a wrestler who has finished a wrestling match and sustained a dislocated shoulder by stating that, “The physician must be experienced in many things, but assuredly also in rubbing; for things that have the same name have not the same effect. For rubbing can bind a joint that is too loose and loosen a joint that is too hard” (De Domenico & Wood, 1997). Also, Hippocrates describes that “it is necessary to rub the shoulder gently and smoothly; but the joint should be moved about, not violently but so far as it can be done without producing pain” (Paris & Loubert, 1990). This account describes the intervention for shoulder realignment by different manual maneuvers and the use of massage to coax the tissues to respond to realignment. Thus, sports massage—that is, massage applied to enhance performance for athletes—has existed as one of the early applications of soft tissue mobilization intervention.
The different professionals who use massage techniques were described in Chapter 1. As these practitioners continue to apply and advocate the value of massage therapy, sports massage continues to gain validity among athletes and administrators. Athletic trainers are constantly bombarded with participants in aquatic and athletic events clamoring for massage techniques to manage musculoskeletal concerns (Bell, 1999). In present-day competition, the medical teams as part of the United States delegations to the Atlanta (1996) and Sydney (2000) Olympic Games were responsible for administering daily comprehensive massage and specific soft tissue mobilization to the more than 100 athletes of the United States Olympic team. The delegation for Great Britain administered more than 1000 soft tissue treatments during the Atlanta Olympic Games in 1996. An investigation performed in the United Kingdom to quantify the use of massage by physiotherapists at athletic events revealed important findings. Specifically, the study found that the percentage of time devoted to providing massage therapy treatment to athletes ranged from 24% to 52.2%, and the overall median percentage of total treatments for massage was 45.2% (Galloway & Watt, 2004). More and more athletes seek this treatment from qualified professionals with positive results. These statistics demonstrate that it is becoming common for elite competitors to require soft tissue massage as part of their training and competition regimen. Why are massage techniques in such high demand? Why do therapists apply them so frequently? This may be due both to the perceived and validated effects of massage.
THERAPEUTIC EFFECTS OF MASSAGE FOR AN ATHLETE
The effects of massage for athletes are similar to those for nonathletes as listed in Box 13-1 and discussed in Chapter 5. Although limited conclusive investigations have been performed regarding the mechanisms of action to date, specific massage techniques continue to be used to induce specific change within athletic populations.
Delayed Onset Muscular Soreness
Athletes are at high risk for delayed onset muscular soreness (DOMS). DOMS is the soreness and stiffness in the exercised joints and muscles that occurs with a new physical activity or with strenuous activity undertaken after an extended rest period. Although often associated with eccentric exercise because of the hypothesized microtearing of fibers associated with these activities (Connolly et al., 2003), DOMS occurs after other forms of training activities as well. Temporary soreness can last for several hours after any unaccustomed exercise; however, a distinguishing characteristic with DOMS is that pain appears later and can last from 24 to 96 hours after activity (MacArdle et al., 2001). DOMS can vary from muscle tenderness to debilitating pain and affects athletic performance by causing reduced joint motion, shock attenuation, and reduction in peak torque (Cheung et al., 2003). Compensatory mechanisms can place an athlete at increased risk of further injury. To date, there is not one definitive documented cause of DOMS; however, various hypotheses exist as to the manifestation of DOMS. These are listed in Box 13-2. It is most probable that the cause of DOMS is a combination of these factors rather than any one factor.
BOX 13-2 Potential Causes of Delayed Onset Muscular Soreness (DOMS)
Researchers have hypothesized that massage intervention can decrease soreness and promote recovery to facilitate continued training and competition for an athlete. The mechanical pressure applied with massage techniques can increase muscle compliance, decrease passive and active stiffness, and thereby increase joint and muscular range of motion (Weerapong et al., 2005). The mechanical pressure can also help to increase blood flow and promote increased tissue temperature through rubbing (Hinds et al., 2004).
Investigative results have varied because of differences in investigative rigor and methodologies. However, in a randomized clinical trial with a control group (N = 7) and an experimental group (N = 7), Smith et al. (1994) demonstrated positive results. This group found that 30 minutes of soft tissue massage administered 2 hours after isokinetic eccentric exercise of the upper extremity resulted in decreased reported levels of DOMS and decreased measures of serum creatine kinase levels within the massage group. An investigation was conducted with 8 male subjects performing downhill walking to induce DOMS followed by a 30-minute massage therapy intervention on one leg of each subject (Farr et al., 2002). Significantly higher levels of pain and tenderness were measured in the nonmassaged limb 24 hours after activity with a significant difference between limbs. There was also a demonstrated decrease in isometric strength compared with baseline 1 hour after the walk. These findings support the hypothesis that sports massage following activity can promote recovery and thereby facilitate continued training and competition at peak performance.
DOMS has been incorrectly attributed to an accumulation of lactic acid or elevated serum lactate levels (MacArdle et al., 2001). Some argue that massage can mechanically promote lactate removal. Hemmings et al. (2000) found no significant difference in blood lactate levels between two groups of boxers that performed two bouts, of upper-body ergometry. The groups were measured between bouts, with the control group (N = 8) performing passive rest and the experimental group (N = 8) receiving massage therapy. The blood lactate level was higher in both groups following the second bout of exercise performance without massage intervention; therefore, there was no significant difference in blood lactate levels after maximal activity. A significant difference was found with a higher perception of recovery level reported by the massage intervention group, suggesting that DOMS can manifest without elevated lactate levels and can be relieved with massage treatment.
Conclusive evidence regarding the effectiveness of massage on DOMS is lacking (Jonhagen et al., 2004). It appears that for each investigation that demonstrates positive physiological effects of massage on DOMS recovery, there is another with findings to the contrary. Robertson et al. (2004) demonstrated no significant difference in the physiological effects of massage when compared with pas-sive recovery in a group (N = 9) performing high-intensity cycling. A systematic review by Ernst (1998) failed to generate a meta-analysis because of variations in methodologies of included investigations. Investigations with larger samples, greater methodological rigor, and a comparison of standard treatment protocols are needed to arrive at a definitive conclusion. Results of this systematic review emphasized the potential systemic effects of massage therapy with emphasis on the fact that massage intervention need not be an extended full-body session but that benefits are attained by the direct and local mechanical pressure effects on the muscles treated.
Therefore comprehensive or full-body massage as well as spot work, as the abbreviated specific tissue treatment has been called, continue to be used on athletes regularly (Galloway & Watt, 2004). These techniques, which are used to promote recovery for DOMS, allow continued intensive training with lower levels of pain and fatigue reported by elite and novice athletes (Hinds et al., 2004; Hemmings et al., 2000; Robertson et al., 2004; Smith et al., 1994).
Technique and Dosage for DOMS
When treating DOMS, the primary goal is to decrease pain. Treatment can vary from an extended full-body massage that can be 1 hour in length to an abbreviated 15- to 20- minute session for the extremities or a specific body part. To begin a treatment session, effleurage such as stroking with light pressure should be used to promote circulation, stimulate superficial blood flow, and facilitate local and general relaxation. This gentle introduction of the therapist’s hands to the athlete’s tissues will begin to allow relaxation of the mind and body and thereby decrease any protective spasm that might be present as a result of pain. The pressure should be light to accommodate the tissue tenderness that is the hallmark of DOMS. The therapist should pay particular attention to signals denoting relaxation by the athlete. These signs could include deep, rhythmic breathing; decreased tension within the superficial tissue being stroked; or closed eyes with relaxation of facial muscles. If any of these signs do not begin to occur within 5 minutes, the pressure may be too deep and an adjustment must be made to decrease the force applied.
Following initial relaxation, which can begin to occur within 4 to 5 minutes, the therapist can then progress to moderate compression with pétrissage such as gentle kneading and wringing. This is a deeper application of massage but should not cause the athlete to perform sustained muscle contractions or increase tension in the tissues. If this begins to occur, the pressure is too deep and should either be modified or the technique adjusted. Pétrissage could be discontinued and only effleurage used for the entire treatment dose. To avoid inducing pain and causing further tissue damage, pétrissage techniques should not be applied with deep pressure or long duration when treating DOMS. No more than half of the entire duration of the massage intervention should be used for pétrissage. This is then followed by moderate-pressure effleurage. Active range of motion exercise without resistance has been demonstrated to facilitate recovery from DOMS in combination with massage (Lane & Wenger, 2004). Therefore, active assisted range of motion (AAROM) can be incorporated within a treatment session before the final transition to light pressure effleurage to conclude the treatment. One can envision the treatment session as one-third initial light effleurage, one-third moderate pétrissage, and a final one-third with moderate effleurage to include AAROM concluding with light effleurage.
DOMS can last for 96 hours (4 days), so that repetitive treatments can be applied over a period of days to alleviate symptoms. Multiple treatments with massage appear to be more effective than a single dose of treatment (Tidus & Shoemaker, 1995). Also, just as DOMS is most likely caused by a combination of factors, it appears that the ideal treatment is a combined approach that includes massage therapy, active recovery, and even cryotherapy (Cheung et al., 2003).
Massage for Acute Injury
Initial Inflammation
Acute injuries frequently occur during sport competitions, or so it may appear. Most of us can remember seeing an athlete sustain a strained hamstring while running a 400-meter sprint, a cyclist take a tumble when racing in a pack, or a quarterback receive a blow to the trunk and double over to the ground in pain. This initial acute stage of an injury results in obvious pain and short-term dysfunction; however, this initial stage also results in physiological changes beyond the dysfunction. These include electrolyte imbalance and fluid imbalance as well as local and general circulation alterations (Cailliet, 1996).
The acute phase of an injury with the initial inflammatory reaction lasts from onset of the injury to 4 to 6 days later and is characterized by tissue sensitivity. Pain results from vascular and cellular responses with the altered chemical state irritating nerve endings (Cailliet, 1996). There can be increased edema, muscle guarding, and increased tissue tension. The initial inflammatory reaction occurs with the signs of inflammation including heat, redness, and loss of function. Pain at rest is also present and can be can be exacerbated with movement. Some argue that massage should not be undertaken during this stage because of the potential for greater harm. This greater harm can occur if the therapist is not skilled with the application of massage and is not attuned to tissue response and tissue texture changes. The view that massage is absolutely contraindicated with acute injury is negated with findings by Stearns (1940). In a classic work regarding the effect of movement on fibroblastic activity, the researcher concluded that fibrils form almost immediately during the healing process and external forces are responsible for the physical arrangement of these fibers. Therefore, skilled massage with passive movement of the traumatized tissues can enhance the healing process.
Rhythmic effleurage strokes with light to moderate pressure can convey calm in the midst of an injury situation that may appear out of control to an athlete. There is an invaluable sense of confidence that the therapist can help instill in the athlete (Moritz et al., 2000) through this therapeutic touch. The repetitive movement can contribute to relaxation and diminish the anxiety or sense of threat felt by an athlete when confronted with an injury (Brewer, 1994). Massage can also be a helpful means to convey support. The athlete who receives manual massage treatment may also acquire a sense of support and empathy from the therapist providing care. Adherence to rehabilitation has been associated with social support (Duda et al., 1989; Prochaska & Marcus, 2001
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Massage in Palliative Care
Connective Tissue Massage
Massage for the Baby and Infant
Classification, Definitions, and Descriptions of the Basic Massage Strokes and Relaxed Passive Movements
Decongestive Therapy for the Treatment of Lymphedema
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