Soft Tissue Techniques For Athletic Recovery

In my last article I discussed a new paper looking at Massage and Exercise Induced Muscle Damage. At the end of the article I discussed some of the ways massage can be thought of as a modality to use within the recovery process from competition or during intense training phases. I thought it would be good to put together some more formal thoughts on the topic as recovery is different for everyone and athletes often have individual complaints or needs that have to be met. By altering your treatment approach you may have a better chance of meeting these needs and helping to play a more significant role in the recovery process.

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In the left hand column we see a variety of different complaints that an athlete may have and reasons that they may be seeking out massage. In the right hand column there are a few different options for treatment. This is by no means and absolute list. It is just a few ideas to get the therapist thinking of potential treatment effects. Unfortunately, most therapists have a one-size-fits-all approach to therapy and, no matter what your complaint or need is, you are going to come in, lie on the table and get a deep tissue massage (oftentimes leaving the individual more sore the next day). By trying to vary our treatment approach and be aware of the athlete’s complaint, we can (a) meet the athlete’s needs and (b) alter our soft tissue inputs from treatment to treatment, preventing the body from adapting to the exact same thing every time.

Briefly looking at the different types of complaints:

  • In the first group, we are dealing with athletes who have a high level of fatigue and exhaustion. This may come from a period of overreaching or overtraining. Additionally, within this bucket are athletes that have a high level of anxiety (and perhaps may show a higher amount of sympathetic dominance). For the athletes with these complaints our treatment options are to help them attain a more relaxed state. For this, I favor longer massage sessions (60-90min) with a lot of slow compression and long holds of skin stretching. These techniques tend to be very relaxing and provide a therapeutic effect. The suggestion of placing the athlete prone is to decrease the amount of visual input (as well as the urge to talk or speak) and to attempt to get them to shut down for a moment and maybe even fall asleep on the table. Additionally, working on the neck and paraspinals in this prone position seems to evoke a sense of relaxation and have a calming effect on the system. The therapist should resist the urge of trying to go too deep with their compressions, to a point where the athlete becomes very engaged in the session and is trying to fight against your pressure. Work to the athlete’s tolerance level. Much of the ideas in this section came from some of the research I have discussed a few years ago on Massage and HRV and Massage and Stress as well as some of the concepts I took from Robert Schleip’s text, Fascia: The Tensional Network of the Human Body, which I discussed in THIS article.
  • In the second group we see one of the most common reasons why athletes seek out massage – soreness. The massage technique suggestions for this complaint come from some of the research discussed on my last article as well as the research I discussed in an article two years ago from Crane et al. Both articles explained a massage approach for muscle damage dealing with 5-10min of gliding strokes to the affected muscle region. I also put into this section things like contract relax stretching or pin and stretch modalities as method to engage the athlete, get them to move around a little bit, and, in the process of creating movement with human touch, allow them to perceive themselves as “less sore”.
  • The final group is one of mobility or “tightness” as well as treatments geared towards maintenance of mobility and tissue quality. The aim of dealing with the athletes in this group is to have a good understanding of where their movement system is currently (what is their baseline) and then determining when they are below their norm (oftentimes, following intense competition or training, the individual may tighten up or stiffen up and lose some of their normal movement). Also, knowing what is normal for the athlete in the sense of tissue quality (tone) and what is abnormal, for that individual, can be extremely important and helpful in guiding your treatment approach. Within this group the modalities selected are more active, engaging the athlete to move and be a participant in the treatment. Thus, things like pin and stretch techniques or active stretching/mobility techniques can be very valuable. Additionally, Dr. Andreo Spina’s work, Functional Range Release, can be extremely helpful for engaging the resistance barrier, applying tension to the tissue, and using things such as PAILs and RAILs to actively engage the athlete with movements into and out of their limited range (Dr. Spina also has an approach called Functional Range Conditioning, which is a nice follow up to the hands on treatment as it is a movement based approach to re-teach the system how to move into certain ranges of motion). Other ideas for the treatment approaches in this group came from articles and sources on Foam Rolling and increases in joint ROM, muscle stripping with eccentric contraction (gliding techniques with active movement), ischemic compression (trigger point compression) and increases in joint ROM, the work for Travell and Simons, as well as others discussing trigger point theories, and the fascial manipulation work of Stecco.

Wrapping Up

As I stated earlier, the treatment approach/modalities in the right column are by no means an exhaustive list. The goal of this article was to provide a framework for therapists to begin to think about and consider how their treatment techniques impact the athlete/client and perhaps can (and should) be modulated based on what the athlete’s symptoms/complaints are. In this way, the therapist can approach treatment with the athlete and hopefully better meet their needs and facilitate a positive recovery outcome.

Massage and Exercise Induced Muscle Damage

A number of studies over the years have evaluated the potential role massage plays in recovery following exercise or competition, looking at factors such as lactate clearance and delayed onset muscle soreness (DOMS). Commonly, the studies looking at massage and DOMS base their outcome on the subjects’ perception of how the muscle feels following the exercise protocol and then how it feels following massage at different time points (immediately following, +12hrs, +24hrs, +48hrs, etc) in comparison to a control group. A recent paper by Shin and Sung took the investigation a step further in order to try and understand how massage affects recovery with regard to muscle strength and proprioception.

Subjects

Twenty one subjects, who did not regularly perform strength training exercises for the lower extremities, were randomly divided into two groups. Eleven subjects were in the massage-treatment group, while 10 subjects were in the control group.

Exercise Protocol

The EIMD protocol consisted of the subjects going up and down a five-story building 20 times. Following the 20 reps, the subjects rested for 5min and then had their lactate levels measured. Lactate levels were measured pre- and post-exercise in order to confirm that the subjects sustained an adequate level of muscle fatigue.

Measurements of Proprioception & Strength

Strength was measured using surface EMG over the gastrocnemius during resting and isometric contractions (pushing against a wall without ankle movement for 5sec while in a prone position). Ultrasonography of the gastrocnemius during the same 5sec isometric contraction was also assessed. Proprioception was evaluated using a dual inclinometer, which measured knee and ankle proprioception via passive-to-active angle reproduction. The subjects completed three trials, lying prone, and proprioception was measured as the difference between the targeted angle and the reproduced angle in the ankle and knee joints.

Intervention

The experimental group in this study received a 15 minute massage to the gastrocnemius, which consisted of light stroking, milking, friction, and skin rolling – all commonly used massage techniques. The control group received sham transcutaneous electrical nerve stimulation (TENS) to the gastrocnemius for 15min.

Findings

> EIMD was confirmed in both subject groups via a significant increase in pre- to post-lactate levels.

> Massage to the gastrocnemius increased activation of the medial gastrocnemius head during isometric contraction following the EIMD protocol.

> Massage appeared to have a positive effect on pennation angle of the superficial layer of the gastrocnemius.

> The massage treatment group increased proprioception at the ankle joint, following EIMD, however the changes in the knee joint were not found to be significant.

My Comments

Massage and soft tissue therapy continue to be recovery modalities sought out by athletes, sports physios, and coaches. While a large part of the result an individual gets from massage following intense exercise may come in the way of psychological relaxation or perception that the treatment is doing something favorable (IE, placebo – which is not a bad thing!), this paper does appear to suggest that there may be other benefits at play. The tests used in the paper are not dynamic in nature, so it would be hard to suggest that perhaps those in the massage group could get off the table and go for another run up and down the stairs; however, it would be interesting to evaluate their ability to repeat their performance, following the protocol, 24hrs later, as this would be similar to what an athlete may be asked to do during a competitive season or during the rigors of a training camp.

As mentioned above, the psychological aspects of any form of touch therapy cannot be understated. The idea of placing your hands on an individual and them producing a response of overall relaxation and them believing in the overall effect is a massive win in terms of shifting that athlete to a more recovered state. That being said, from a more physiological perspective, this is not the first study to look at massage and potential improvements in joint range of motion following treatment. MacDonald and colleagues (J Strength Cond Res, 2013) looked at self-myofascial release massage, using a foam roller, and increases in knee joint range of motion and Forman and colleages (J Body Work Mov Thera, 2014) showed an increase in hamstring range of motion following deep stripping massage with eccentric contraction. Additionally, using trigger point pressure to the gastrocnemius and soleus, Grieve and colleagues (J Body Work Mov Thera, 2013) showed improved ankle joint dorsiflexion in recreational runners.

Finally, looking at the massage intervention in this study – 15min of treatment to the gastrocnemius is a long time to spend on one single muscle. A 2012 study by Crane and colleagues, evaluated the attenuation of inflammation following EIMD using massage therapy. They found that a 10min massage, using effleurage (gliding strokes), petrissage (kneading strokes), and slow stripping strokes to the quadriceps muscle were effective for mitigating the inflammatory response following an intense bike protocol. Perhaps the duration of time spent on one single muscle is a key aspect to attaining certain results when there is excessive soreness or exercise induced muscle damage.

In my next article I will lay out a few ideas surrounding common athlete symptoms, when it comes to high amounts of training, and different massage modalities that may be effective in order to positively influence those symptoms.

A Scale of Perception for Bar Velocity

Questionnaires have been around for a long time and been found to be valid and reliable once the athlete is properly anchored to the scale. While it may sound simple, there is actually a lot of complexity within the simplicity of just asking a person a few questions regarding how they feel today or how hard they felt a particular activity was (RPE). However, once the individual understands what they are being asked, and gains some experience rating themselves, usually about 4 weeks,  questionnaire data can be very helpful in planning training. (I have been a fan of using questionnaire data as a method of understanding how an athlete is tolerating training for several years and wrote about the daily questionnaire I use in a previous blog article.)

Recently, Bautista and colleagues (2014), have attempted to create a new scale, which allows the athlete to rate their perception of bar velocity in the bench press (CLICK HERE for full paper).

Measuring bar velocity is incredibly helpful and is done by attaching some sort of linear position transducer to the bar to objectively measure the speed at which the bar is moving through various lifts (E.g., bench press, squat, deadlift). The 1RM of the subjects in the study was established prior to using the rating scale, during an incremental load protocol. A linear position transducer was used to understand bar velocity at various percentages of the individual’s 1RM during the incremental load test:

  • Light = < 40%
  • Medium = 40% – 70%
  • Heavy = > 70%

Over a 5 day testing period, the subjects performed each set in a random order, using the intensity parameters above, and were blinded to the amount of load on the bar via partial occlusion pads, which prevented them from seeing the weight. The subjects performed 2-4 repetitions with a given load and then provided their perception of bar velocity using a scale developed by the authors, based on bar velocity during the incremental load 1RM test:

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The verbiage below the numbers, used to anchor the subjects during the experimental portion of the test, was established using the corresponding bar speed form the incremental load 1RM test and the verbal qualification provided by the subjects following each of their lifts during the initial test.

A high correlation was found between the actual bar velocity and the perception of bar velocity provided by the subjects, particularly as their use of the scale increased. Thus, greater exposure and time using the scale improved their ability to properly classify their lift.

Practical Use

As stated earlier, I am a big fan of questionnaires. While they are especially helpful when combined with other objective data (GPS, HR, Fitness Testing, Bar Velocity, etc) as a stand alone they can provide rich information once the athlete is properly anchored to the scale.

I see the Rating of Bar Velocity scale used in this study being practical in a few ways:

  1. Not all strength and conditioning programs have funds to provide a linear position transducer unit at each lifting platform. However, if athletes gain an understanding and awareness of how to rank their bar velocity, this method can be useful as an inexpensive means of determining individual percentages for power training. (NOTE: I do think it would be of value to at least have one or two linear position transducers available to allow the athletes to initially understand how fast they are moving the bar, as well as to have available on testing days.)
  2. Not all athletes will move the same relative intensity at the same speed. This will allow the coach to adjust the training intensity up or down for the athlete, in order to stay in their ideal zone of bar speed, depending on the training goal for the day.
  3. Similar to using a Rating of Perceived Exertion on a fitness test, the Rating of Perceived Velocity can be used on a strength test or Rep Max test and charted over time to show improvement with the same load or the same relative intensity.
  4. Finally, having athletes rank their efforts like this, I find, increases their awareness of the training session and engages them more in what they are doing. Rather than going through the motions, the athlete has to now be conscious of what (s)he is trying to do.

 

Product Review: Dan Baker – High Powered Performance Video

I recently had the pleasure of going through Dan Baker’s High Powered Performance Videos.

This series is a 7 video set of a workshop Dan Baker put on in the UK. For those that don’t know, Dan Baker is a PhD and strength coach, who served as the Director of Strength and Conditioning for the Brisbane Broncos Rugby Club for just under 20 years.

I was excited to check this video set out, as Dan Baker has published a lot of great strength and conditioning research and articles around power training, periodization, and energy system training. I have read much of his work over the years and one of the things I admire the most about Dan is that he is a strength coach who honors a scientific approach. He isn’t a scientist who sits in a lab and pontificates about what people in the field should be doing. He is a doer himself, not only serving as a strength coach at the highest level but also competing as a powerlifter, who takes a scientific approach to developing his programs – always testing, always objectifying, and always trying to understand how to do things better.

The video set is excellent. The first video goes into the long term athletic development approach Dan set up at the Brisbane Broncos. Unlike sports in America, where players get to the highest level by playing through high school and college, with different teams, the athletes in the National Rugby League are part of a club and they work through the ranks of that club. As they develop it is ultimately determined whether or not they will make it to the highest level team. This process allows the strength coach to take a multi-year approach to developing strength and fitness. Dan lays out his plan and explains how they move athletes through the process, the ways they test the athletes, and the strength markers that athletes need to hit in order to transition into the next stage.

Other videos in the collection go into topics such as:

> Periodization
> Power training with bands, chains, and lifting complexes
> Program design
> Energy system development (particularly around Max Aerobic Speed utilization in the training process)

Dan shows a lot of video footage of his athletes and shows their actual training programs from year to year. He talks about what they did, why they did it, what results it produced, what errors he made, and what changes were made each year to ensure that the athletes were constantly improving. Dan shows and discusses data on his athletes dating back to 1995 and talks about how guys developed and the sort of capacities the athletes at the highest level were able to attain.

I recommend the High Powered Performance Video Set to any strength coach in the field as Dan clearly discusses how he blends the science and the practical in order to take an objective approach to establishing a high level strength and conditioning program.

Life Stress, Training, & Recovery

Recovery from training and competition is dependent on many systems (E.g., endocrine, hormonal, musculoskeletal, etc) to coordinate the appropriate responses to the stress placed on the body. Just like your bank account – you withdraw money and then (hopefully) you put money back in, attempting to not allow the account to drop below a certain point – there is a cost on the body that is paid every time we train and compete and we have to do things to try and repay that cost. As I say, “there is always a cost of doing business.”

Currently, coaches are rushing to find various methods of monitoring their athletes within the training environment (IE, GPS, HR, Force Plates, etc); however, one critical aspect that may often get overlooked is the athlete’s life stress. As I discussed in a previous article, Your Stress Account, understanding both specific (the things we have control over as coaches) and non-specific (the external stressors, outside of the competitive environment, that the athletes have to deal with) is essential to ensuring that we know how much we can push and how much we may need to back off.

While the above methods of monitoring training are helpful, quantifying the amount of stress being placed on the athlete is a cost effective way of understanding how they are adapting. I discussed the questionnaire I have used in the past in a previous article, Doing Simple Things Well, and while many coaches will often say to me, “We ask the athletes every day how they are doing when they come into the gym”, I do believe that putting a number on it, documenting it, and following the responses over time can be beneficial, not only for the coach to track the athlete’s trend, but also to educate the athlete about how they are doing.

Life Stress and Training

Life stress plays a key role in how we adapt (or don’t adapt) to training. A 2008 study by Bartholomew et al., evaluated 135 undergraduate students grouping them into either low or high stress groups based on a series of psychological measures. What they found was that those who were considered “high stress” subjects had a more difficult time adapting to the 12-week, periodized resistance training program. These high stress individuals saw lower scores on both bench press and squat as well as girth measurements (hypertrophy) in post program testing.

More recently (2014), Stults-Kolehmainen and colleagues  evaluated the effects that chronic mental stress had on the recovery of muscle function and somatic sensations (E.g., perceived energy, fatigue, and soreness) over a four day period. To quantify life stress, the Perceived Stress Scale and the Undergraduate Stress Questionnaire were completed by the subjects. The subjects completed a leg press training session of 6 sets x 10 reps at 80-100% of their individual 10RM. Maximal isometric force, jump height, cycle power, perceived energy, fatigue, and soreness were assessed at 24hr intervals following the training session. Interestingly, it was found that chronic stress had an impact on muscle recovery following the leg press training session, with low recovery curves being seen in those reporting high levels of stress. The subjects with lower levels of stress saw more efficient recovery curves. Perhaps the low stress individuals are in a position to tolerate and adapt to training more efficiently.

What About Injured Athletes?

Often, when an athlete sustains an injury, they will stop doing things like daily questionnaires because they feel that these questionnaires are only for those who are “training”. This becomes problematic because understanding an athlete’s psychological state can impact their recovery and rehabilitation. While injuries often have typical recovery time lines (E.g., 3-4 weeks), the goal should be to try and speed up the recovery process as much as possible without compromising the athlete’s health. One of the best ways to speed up this process and “drive in the fast lane”, so to speak, is to create an optimal environment for healing to take place. Educating the athlete on things like sleep, nutrition, hydration, and rest are essential.¬† Additionally, it is helpful to understand the athlete’s psychological state and do whatever you can to create an environment that allows the athlete to continue training in some capacity, as well as fuels optimism and decreases the negativity that some athletes can have once they get injured. Ford et al., (2000) found that an athlete’s psychological state can impact their time lost due to injury. Those that were less optimistic and didn’t cope well with stress had greater time loss following injury compared to those who were more optimistic and had better self-esteem. Finally, a meta-analysis conducted by Walburn and colleagues (200), found that wound healing was actually impaired due to stress, emphasizing the need for a better understanding between stress and healing.

Summary

The stress that athletes face outside of the competitive environment has the potential to impact their ability to train, adapt, recover from injury, and heal. While there are many methods of assessing athletes within the training environment, a simple questionnaire evaluating the athletes psychological status (discussed in a previous article on this site) can provide the coach with a better understanding of how the athlete is psychologically coping and can drive interventions and program changes to ensure that the athlete gets the appropriate attention they need.