Massage & Muscle Stiffness

One of the main reasons that athletes seek out massage is to decrease the muscle stiffness they feel due to intense training and competing. A recent paper by Crommert and colleagues (Scand J Med Sci Sport, 2014) evaluated the effects of massage on muscle stiffness in the medial gastrocnemius of eighteen healthy volunteers.

Methods

Seven minutes of massage was performed on the gastrocnemius of one leg for each subject – 2min of effleurage, 2min of petrissage, 2min of deep circular friction, and 1min of effluerage – while the non-massaged lower leg served as the control. Immediately following massage, the subjects rated their level of pain experienced during the massage on a 0 to 10 scale (0 = no pain, 10 = worst imaginable pain).

Muscle stiffness was measured using shear wave elastography to quantify the shear elastic modulus (stiffness) at the midpoint of the medial gastrocnemius muscle belly at three time points: before massage (baseline), immediately following massage (follow-up 1), and after 3min of rest following follow-up 1 (follow-2), in both the massaged and non-massaged legs.

Findings

  • Medial gastrocnemius stiffness was significantly lower immediately following massage (follow-up 1) compared with baseline and following rest (follow-up 2).
  • There were no significant differences found between baseline and follow-up 2 in the massaged leg, indicating a return to normal muscle stiffness.
  • Average level of pain rating was 1.3 +/- 1.6 and there was no correlation found between perceived pain level and a reduction in muscle stiffness in the massaged leg at follow-up 1.

Conclusion

Massage appears to reduce muscle stiffness; however the results are short lived with a rapid return back to baseline levels.

Practical Applications

The authors suggested four potential mechanisms that may lead to a decrease in muscle stiffness from massage:

  1. A decrease in motoneuron excitability due to general relaxation.
  2. Manual pressure and stretching leading to a breaking apart of stable cross-bridges between actin and myosin filaments, which are spontaneously formed while the muscle is at rest.
  3. Increased intramuscular temperature from the massage.
  4. The possibility that all of these mechanisms are working together, rather than any one of them working in isolation.

These theoretical mechanisms for why manual/touch therapy works are interesting and most likely not the only mechanisms at play. I’d be inclined to think that #4 above is the most likely scenario, along with other potential influences.

The fact that massages influence on muscle stiffness was short lived is interesting. From a practical standpoint, when applying this stuff to athletes for specific purposes of addressing muscle tone and stiffness, there are a few things I think about with regard to the outcome in this study:

  • The length of treatment may have been too short to produce a more longer lasting effect. Maybe seven minutes isn’t enough? One proposed mechanisms that led to a decrease in muscle stiffness was general relaxation from massage. While not measuring stiffness, Arroyo-Morales have done some studies looking at massage therapy and autonomic changes – a shift towards a more parasympathetic state – leading to greater relaxation. The two studies they performed used 40min massages following intense cycling exercise in order to achieve this result.
  • Maybe the techniques used are to passive in order to produce longer lasting changes? As I discussed a few weeks ago, there might be different massage techniques for different recovery purposes. If the goal is to improve some sort of functional outcome (E.g., decrease muscle stiffness and/or improved ROM) maybe passive techniques, like the ones used in this study, need to be coupled with more active techniques which force the client to be an active participant in the treatment. This puts the client in the driver seat and might allow their brain to be more receptive to the changes taking place and cause them to be more longer lasting.
  • Finally, maybe the treatment needed to be followed up with active movement in order to “make it stick”? In the past, I have written about the idea that massage might be useful to “open the window”, to help decrease threat or increase awareness for the client, and then should be followed up by movement therapies in order to teach the brain to move and be strong through the new ROM on its own. Perhaps the reduction in muscle stiffness, found in this paper, would have been longer lasting with movement therapy? Certainly a short treatment time can be beneficial in certain situations, depending on your goal. Grieve and colleagues found that a 10min treatment consisting of trigger point therapy and light stretching was adequate enough to produce a significant increase in ankle dorsiflexion in recreational runners. In a situation where the goal of treatment is some sort of functional outcome, rather than more recovery based, these short bouts of massage therapy may be enough to produce a result and then should be followed up with some sort of movement based therapy.

Massage therapy appears to impact the body on different levels via different mechanisms. This study evaluated muscle stiffness and found that seven minutes of massage was effective at decreasing muscle stiffness, however, the results were short lived. From a practical standpoint, the fact that massage decreased muscle stiffness is promising and there might be other factors that could enhance the effect of the positive change in muscle stiffness seen in this study. In an actual treatment setting we rarely (or never) rely solely on one single modality or approach and usually a variety of different approaches are stacked on top of each other, depending on the intended goal of the treatment. When used in conjunction with other modalities, the findings from this study may potentially be augmented.

NBA Super Teams – “They Just Need to Learn To Play Together”

Being a life long Cavs fan, I was excited to see LeBron return to Cleveland to try and make a run at a championship. I’ll admit, in 2010, when he made the decision to leave for Miami, I was pretty upset; but, I don’t fault players for going to different teams if it means more money and better opportunities to win championships. Additionally, how can you fault a guy for wanting to play on a super team with athletes like Dwyane Wade and Chris Bosh? What makes LeBron’s second stint in Cleveland so exciting is the possibility of another super team, this time with Kevin Love and Kyrie Irving. Of course, when these teams get together and don’t automatically win 20 straight right out of the gate, fans tend to get a bit unruly and start to jump ship.

Similar to LeBron’s first year in Miami, it took some time for things to click between the players on the team. The media pundits always like to bring it back to the fact that the players need to, “Learn to play together”,  because, as some point out, they have such similar games and are all three such dominant players on the court that they have to figure out who is going to play which role (which might actually change from game to game).

With that in mind, I decided to look at some of the data of these players on the super teams to see how similar they are and, perhaps, try and understand how similar LeBron’s current super team, the Cavs, is to his former super team, the Heat.

The Data

Since I don’t have access to a ton of NBA data, I took whatever I could get a hold of from www.basketball-reference.com. I compiled the player data for all of the years LeBron was at the Miami Heat, all of the years Kevin Love was at the Minnesota Timberwolves (his entire career), and all of the years Kyrie Irving has been at the Cleveland Cavs (his entire career).

Only players who participated in more than 30 games per season where included (NOTE: Doing this removes Kevin Loves 2012-2013, as he only played in 18 games that season do to several hand injuries).

I then created a cluster analysis to evaluate how similar or dissimilar players in the data set were (you can click on the picture to make it larger).

Screen Shot 2014-12-07 at 5.14.50 PM As we see, LeBron lies on a node all to himself, and rightfully so! LeBron is a truly unique player, who can play every position on the court and is both a significant defensive and offensive threat. To the right of Lebron, we see a second node, which then breaks down into two more nodes. It is in this cluster on the tree that we see the main players we care about – those that make up LeBron’s former and current super team. Kevin Love and Chris Bosh are clustered close together while Dwyane Wade and Kyrie Irving are clustered close together, owing to the similarities in their game.

LeBron’s Supporting Cast

We see that the supporting cast for LeBron have some similarities when we evaluate their performance metrics within the data set of these three teams (Cavs, Heat, and Timberwolves). Looking deeper at LeBron’s supporting cast in both Miami and Cleveland allows us to see how each of these players compare to each other.

Screen Shot 2014-12-07 at 6.07.04 PMLooking at Field Goal Percentage, we see that LeBron’s former teammates are a clear favorite when it comes to making shots. However, it is important to remember that this data is showing us the years that Wade and Bosh also played with LeBron. Perhaps having LeBron on the team created new opportunities for Wade and Bosh to score, opportunities that Irving and Love did not have given the weaker teams they were on?

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When it comes to rebounds we see that Kevin Love has had more success in this category than the other four players, while we see that Bosh is roughly equal with James.

Below is some comparison of the four players against each other for a few of the other metrics in the data set (all graphs are showing mean +/- SD).

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Conclusions

It is interesting to compare these players against each other. I am a bit surprised to see Bosh with such a low number of assists compared to the rest of the group. Additionally, it is interesting to see how many blocks Wade and Bosh had in comparison to Irving and Love. The Heat were definitely a defensive juggernaut, while also being a huge offensive threat, making them one of the most dangerous teams in the NBA. While it appears, from the cluster analysis, that Love and Irving play similar games to Bosh and Wade, it seems like Bosh and Wade are slightly better in some of the statistical categories.

Wade was already a great player (one of the best ever) before LeBron, and Bosh was no slouch himself. I wonder if “figuring out how to play together” allowed them to improve different aspects of their game, as having a unique player like LeBron on the court tends to draw a lot of interest from the opponents defense, opening up new opportunities for Wade and Bosh. One way to evaluate that might be to look at their individual statistics during their career before LeBron and then after LeBron. Additionally, it might be interesting to compare how much LeBron’s game changed from his first years with the Cavs and then his years with the Heat, where he “figured out how to play” with the other superstars on the court.

It will be interesting watch James, Love, and Irving, figure it out over the next few seasons. They have potential to turn this into another big three and hopefully dominate the NBA. With the similarities between Bosh and Love, and Wade and Irving, perhaps LeBron can put his new teammates into a good position to elevate their game and take things to the next level.

Minimum Effective Training Dose

You hear the phrase all the time, “I’m a real minimum effective dose guy”, or, “We train only as much as we need and then no more”.

Everyone says these things, but what do they really mean? What is a “minimum effective dose”? Is the minimum effective dose different for different people? Do some people need more training and some less? While the phrases sound good on paper or when uttered at a training conference, how do we take the theory of the minimum effective dose and turn it into practice?

To be fair, these are great ideas and statements that really do resonate with me in my approach to program design. Why expend physical resources (energy) on training that are unnecessary and potentially limiting your recovery from the previous session, thus diminishing your ability to train harder the next time around? As I like to say, “There is always a cost of doing business. All training comes at a cost and in order to reap the benefits you need to make sure you pay that cost and then replenish the checking account before paying again.”

Recently, I had a great discussion with two colleagues I respect – Sam Leahey and Nate Brookreson. We were discussing concepts around an individualized training approach, and the main discussion points began with us first reading and talking over two papers by Kiviniemi, et al., Endurance Training Guided Individually by Daily Heart Rate Variability Measurements (Eur J Appl Physiol, 2007) and Daily Exercise Prescription on the Basis of HR Variability Among Men and Women (Med Sci Sports Exer, 2010).

Both studies utilized a similar type of training approach for the two training groups. One group performed a standard, predetermined training program – just like a coach would write for an athlete, dictating what should be done each day of the week (exercises, load/intensity, sets, reps, etc). The other group performed their training based on their HRV readings taken first thing in the morning, upon waking. The mode of exercise in the studies was endurance training, and days were broken into high intensity (40min at > 85% of maxHR) or low intensity (40min at 65-70% maxHR) or complete rest.

The way it worked for the HRV-dictated training group was that they would take their HRV, and based on the outcome, compared to a rolling average, they would alter their training for the day performing either a high intensity session, a low intensity session, or taking a rest day. Thus, training was guided by what the body was prepared to do.

Interestingly, the HRV-dictated training groups improved their fitness while training high intensity sessions less frequently during the study period than the predetermined training group (More is not better. Better is better). Basically, on days when their body was ready for a high intensity training session they went for it, and when their body was not ready they backed off and allowed the body time to replenish the checking out, so to speak, before repaying the cost. They gave the body what it needed.

Some of my thoughts

Heart Rate Variability is not the be-all-end-all of athlete monitoring, as some make it out to be. It is one small piece (a small piece with rather noisy data, mind you) in a much larger puzzle. That being said, I do believe it can have a role in athlete monitoring if you understand its limitations, standardize the collection process, and couple it with other methods of monitoring the athlete and evaluating their capability and capacity on a given day.

These studies seem to move us closer to understanding the concept of a minimal effective dose and perhaps offer a newer approach to program design and periodization – similar to the concept of auto-regulation. Earlier this year I put together a decision tree for training, similar to the one shown in one of the studies mentioned above, where a few factors were taken into consideration and put into the tree, and the results of those factors allowed the athlete to alter their training program based on the input they plugged in. This allowed us to adjust the program up or down on a given day based on how the athlete was responding. Instead of writing training programs that told the athlete to do “x” on Monday, “y” on Wednesday”, and “z” on Friday, the athlete was given different workouts with different training targets (2 workouts reflecting the main physiological targets of the training block, 1-2 workouts reflecting the secondary, or maintenance, physiological targets of the training block, and 1 recovery based work).

Depending on how the athlete was reporting that day, we would choose which workout to do. This would end up sometimes pushing our training week out longer than 7 days (sometimes it would take 10 days to get through the training cycle). This was apparent, particularly, in older athletes whose bodies took longer to recover from the training session or athletes who were out of shape and lacked fitness and needed the extra time to make appropriate adaptations to the training stimulus imposed upon them. If we were working on a timeline and had a set duration of time to perform a block of training (for example the athlete would only be able to train 10 weeks in an offseason), we would adjust the workout on a given day by lowering either training volume or training intensity (which of those we lowered was dependent on the physiological targets of that phase of training and what the main objective was).

What was also interesting in the studies above was that if the subject had recovered the following day from a high intensity training day they would then perform another high intensity session (although after two successive high intensity sessions they were asked to take a rest day). The high-low training concept of organizing high intensity stressors on one day and low intensity stressors on another day is a great one and one that I have used for many years; however, there are times when the athlete needs to be able to put together back-to-back days of high intensity work due to competition (i.e., basketball or hockey) or hard practices (i.e., NFL training camp) being stacked together. By using a training approach driven by monitoring the athlete’s response and adjusting the workout to suit their needs and abilities on a given day, we can slowly build up the athlete’s resilience to tolerate high intensity work to a level that allows them to train hard, recover quickly, and then train hard again. This is a key piece that ties together the stress resistance/stress tolerance and fitness components of my Physiological Buffer Zone methodology, which I discussed in THIS interview.

What it basically boils down to is that each athlete is an individual. Each athlete has a different way of responding and adapting to the training stress you apply to them (and even to the treatment stress if you are using soft tissue work!). The time it takes to recover and make favorable adaptations to a training session may differ from one athlete to the next, and an individualized approach, based on monitoring various qualities, is essential to understanding what the athlete needs. Too often coaches try and force fit an athlete into their training program without respecting these laws of individualization. Hopefully the future will allow for better methods to test athletes, monitor/evaluate athletes, and adjust training for athletes to ensure that their body receives the type of training it needs – the correct amount at the correct time.

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.