Does Sports Massage Contribute to Post-Workout Recovery?
By Ross Turchaninov, M.D., Ph.D.
Boris Prilutsky, M.A.
Oleg Bouimer, M.A.

According to Sven Jonhagen, M.D., of the Institutionen Sodersjukhuset in Stockholm, Sweden, Post-Event Sports Massage has no positive therapeutic impact on post-workout recovery in athletes.  The results of this study were published in the American Journal of Sport Medicine, (September, 2004).  The following is an excerpt from the paper:  “In this study, participants worked out for 30 minutes, giving their leg muscles intense eccentric exercise which emphasizes extending muscles, not contracting them.  Within 10 minutes after their workout, each volunteer received sports massage on only one leg.  The benefits of sport massage in which muscles are kneaded harder than regular massage were recently tested by Sven Jonhagen, M.D.  Researchers saw no sign that sport massage helps in post workout recovery.  Strength tests taken before, directly after, and 2 days after the exercise session showed similar results for the massaged and unmassaged legs.  Both legs were sore for roughly the same lengths of time, the participants report.”

We found Dr. Jonhagen’s protocol design to be flawed.  One such design flaw was the emphasis on flexion of muscles and not extension.  Clearly, exercise is not possible without the use of antagonist muscle groups responsible for flexion and extensions.  In order to understand the importance of Post-Event Rehabilitative Massage Therapy for professional athletes as well as for the general gym-going enthusiast, we would like to discuss the side-effects of vigorous exercise.  Vigorous, intense, exercise overloads the skeletal-muscular apparatus and the cardiovascular system, causes accumulation of metabolic waste products in tissues (some of which are toxic), strains the endocrine system, and much more.  When overloaded, the muscular system reacts by accumulating tension in muscles.  This, in turn, disturbs metabolic processes in the skeletal and muscular systems.  A higher muscular tonus (especially in the extremities) contributes to an increase in the peripheral vascular resistance, which is the main opposition mechanism for left-side cardiac work.  In such a case, the cardiovascular system is not only overloaded during vigorous exercise, but also is prevented from resting due to higher peripheral vascular resistance.  Given the facts described above, the endocrine system cannot function in its normal physiological regime.  Additionally, over-tensed muscles produce pain, soreness, and fatigue.  Understandably, if an athlete is not rehabilitated from the side-effects of vigorous exercise, we can assume that in some cases, the athlete can possibly do more harm than good to the body.  The athlete can, as a matter fact, achieve less than his or her physiological potential with lack of proper rehabilitation.

As you know, from 1960s to the mid 1980s, most of the Olympic gold medals used to go to the former Soviet Union, Eastern Germany, Bulgaria, Romania, and other countries in the Soviet block.  We do not believe that these athletes had a greater physiological potential.  However, we know that protocols of Medical and Sports Massage that were developed through extensive research in these countries greatly contributed to the athletes’ achievements, as well as to the prevention of sports-related injuries.  Discussions about the benefits of Sports Massage to athletes have been ongoing for a while.

The possibility of speeding up the athlete’s recovery by massage captured the attention of Western European and American scientists working in the field of Sports Medicine.  However, authors of numerous studies in different centers mostly concluded that massage does not have any significant impact on the process of recovery after maximal exercises (Drews, et al., 1990; Carfarelli, et al., 1990; Rodenberg, et al., 1994; Tiidus, et al., 1995; Gupta, et al., 1996, and more).  All these studies were conducted by very responsible scientists and published in respected professional journals.  Thus, everyone who became familiar with this matter deserves the clear answer to the question: Who is right? After analysis of Western European and American sources we concluded that the problem is a significant misunderstanding and misrepresentation.  First of all, Russian scientists always pointed out the importance of four equally important components of rehabilitative massage treatment after vigorous exercises.  Failure to include even one of them will ruin all efforts:

1. TIME OF THE TREATMENT 
All Eastern-European authors agreed that massage has to be started no earlier than 2-2.5 hours after vigorous exercises.  

2. DURATION OF THE TREATMENT
The massage session has to last from 30-40 minutes to 1 hour.  During this time the massage therapist works on the athlete’s whole body with special attention to the muscular groups which were overloaded during the exercises or competition. 

3. MASSAGE TECHNIQUES
It is best to use the combination of effleurage, kneading, permanent vibration, compression, stretching and long range shaking.  However, 40-50% of massage time has to be spent on kneading.  With the proper execution of this technique the operator is able to alternate stimulation and relaxation of the massaged muscles.  Thus, kneading is the best tool for restoring muscular strength.

4. PRESSURE
The applied pressure has to be significant but without the activation of the pain analyzing system.  The threshold of pain varies from one part of the body to another, or even within the borders of the same massaged segment.  Thus, the pressure has to be continually adjusted.

All Western articles which reported about the failure of massage therapy to speed up the recovery process were united by one striking similarity.  Despite a truly scientific approach to the evaluation of treatment and its duration, these studies neglected to follow the proper protocol:

AUTHOR			TIME OF THE TREATMENT		DURATION

Cafarell, et al., 1990			immediately after exercise			4 min
Drews, 1990				immediately after exercise			30 min
Wenos, et al., 1990			48 hours after exercise			N/A
Rodenberg, et al., 1994		15 minutes after exercise			15 min
Tiidus, 1995				48 hours after exercise			10 min
Gupta, 1996				48 hours after exercise			10 min

However, in our opinions, one published article on this matter puts everything in the correct perspective.  In this study, a group of North Carolina and Virginia authors (Smith, L.L et al., 1994) formulated a protocol based on that of Russian scientists, proving its value.  The authors examined the effect of massage on delayed onset of muscle soreness, and creatine kinase (an enzyme indicator of muscle damage) and neutrophil (an inflammatory white blood cell) count.  The authors adjusted their experimental protocol according to the practical recommendations of Russian authors.  These authors considered that vigorous exercises damage muscular tissue with the development of aseptic (non-infectious) inflammation and interstitial edema.  The body reacts to these events by mobilizing neutrophils to the affected area.  Neutrophils enter tissues and start their cleaning job (i.e., phagocytosis) to remove the waste products produced by the muscular injury and inflammation.  Their increased concentration also attracts other types of phagocytic cells, macrophages.  In the process of phagocytosis, catabolic enzymes are released from neutrophils, additionally damaging already injured muscular fibers.  Dr. Smith and associates, through their research, noticed that two major events indirectly support this theory: temporary reduction of neutrophil count and increased concentration of creatine kinase in local blood vessels, and their following emigration into soft tissues as critical elements responsible for the long lasting muscle soreness after vigorous exercises.  This study showed that this process precisely matches the 2 hour time limit after vigorous exercise
	 
This is what Smith, et al., had to say in their conclusion:
“During acute inflammation, blood flow slows as vessels dilate in an area of injury.  When this occurs, the white blood cells, including neutrophils, are displaced from the central, axial zone of blood flow to the peripheral, plasmatic zone and subsequently marginate along the vessel walls.  Since sport massage appears to increase blood flow through the vascular bed, we theorized that this increased flow rate in the area of microtrauma could prevent the typical outward displacement of neutrophils.  In addition, we speculated that the mechanical action of sports massage could shear marginated cells from vessel walls and thus hinder emigration of cells from the circulation into tissues spaces.  …control group exhibiting a more rapid and steeper increase CK (i.e. creatine kinase) values than the massage group.  …sports massage rendered hours after termination of unaccustomed eccentric exercise reduces the intensity of delayed onset muscle soreness and reduces serum creatine kinase levels.”

As we stated above, the reduction and elimination of muscular soreness are not the only goals of Post-Event Sports Massage.  The objectives and goals of Post-Event Sport Massage are:  

1. To reduce the tension in muscles and connective tissue.
2. To reduce peripheral vascular resistance.
3. To accelerate drainage of venous blood as well as lymphatic fluid.  

And ultimately: 
4. To balance, to the extent possible, the activities of the sympathetic and parasympathetic divisions of the nervous system.

Working in the “Inhibitory Regime” (massaging while gradually increasing pressure), we awaken reflexes to the original stimuli.  These are expressed in vasodilation (reduction of peripheral vascular resistance, reduction of left cardiac work, etc.)  As a matter of fact, with Post-Event Sports-Massage, we also prevent the enlargement of the heart muscles (hypertrophy), balance the biomechanics that prevent sports-related injuries, as well as improve the performance of the athlete.  

In 1981, Professor Dembo, M.D., Ph.D. (of the Leningrad Medical School), following extensive research, shed more light on how Post-Event Sports Massage rehabilitation can prevent hypertrophic heart syndrome.  He tested 20 healthy male athletes ages 17-23 for the effects of Post-Event Sports Massage.  Dr. Dembo recorded a decrease in peripheral vascular resistance and a decrease in left cardiac work following the administration Post-Even Sports Massage protocol.  Among other machinery, Dr. Dembo used electroencephalograph (reflecting electrical activity in the brain) in this study.  He also performed 24-hour hemodynamic studies.  The athletes were observed over a 6-week period during their regular professional workout routine.  Prior to the administration of massage treatments, the athletes have undergone sleep studies, where it was shown that they experienced abnormal peripheral vascular resistance and high levels of left cardiac work (particularly between 1am and 4am).  Based on the database of the electroencephalograph it was evident that the quality of sleep was disturbed.  During the next six weeks, following the same workout regimen, and having received Post-Event Sports Massage twice a week, there was a significant reduction in peripheral vascular resistance, left cardiac work, and an increase in deep sleep.  In his conclusion, Professor Dembo stated that during the day normal hemodynamic study readings included heart rate, blood pressure, and other cardiovascular parameters.  During the nighttime the data indicated a worsening due to the overload of skeletal muscles (expressed mostly at nighttime) and in turn leading to the abnormalities mentioned above.

At this point, we would like to refer you again to the article of Dr. Sven Jonhagen.  As we already quoted, Dr. Jonhagen, like many other scientists, did not follow the guidelines presented in this article (time of the treatment, duration of treatment, massage techniques, and pressure).  Additionally, in our opinion, he set up the wrong objectives, such as coming to the conclusion that massage therapy does not contribute to the strength of muscles.  To the best of our knowledge, no European or American massage therapy organizations ever claimed that massage therapy directly increases muscular strength.  It is, however, an accepted fact that by reducing the tension in a muscle, we contribute to its return to the normal physiological potential.  Another problem with Dr. Jonhagen’s study is that instead of having a real control group, he used the contralateral leg as a control.  This made us think that this doctor started researching massage therapy with no knowledge of the physiological effects of massage on the human body.  The scientifically proven fact is that massaging one extremity awakens the vasomotor reflex which leads to significant increase of arterial blood supply to both the massaged and unmassaged extremity.  There’s no doubt that articles such as Dr. Jonhagen’s are very confusing and lack any benefit for the general public as well as for massage therapists.  Therefore, we are happy to take this opportunity to once and for all shed a light on this controversy by presenting a correct Post-Event Sports Massage protocol based on scientific and clinical evidence.


For additional reading, refer to:
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 of Delayed Onset Muscle Soreness. Creatine Kinase and Neutrophil Count: Preliminary report. J. Orthp. Sports Phys. Ther., 19(2): 93-99, 1994.

Dr. Dembo’s study was published in “Physical Culture & Sports” from the book series “Science for Sports.” (1981)


A note from Boris Prilutsky: As you can understand from this article, using proper protocols is what makes the difference between proper and improper utilization of Sports Massage.  Scientifically-proven protocols are designed through extensive research and thorough analysis of data on efficacy and safety of any treatment.  The methods and techniques I present in my Medical Massage video series are proven safe, and in most cases can lead to rapid results.