Category — Research Review

Massage therapy has gained a considerable amount of popularity over the past several years. In some occupational settings massage has been offered to employees as a potential modality for decreasing stress, boosting morale, and potentially keeping ergonomic stress, from repetitive movements (e.g., typing on a computer for 10hrs a day), to a minimum.

A recent paper (Engen DJ, et al. Feasibility and effect of chair massage offered to nurses during work hours on stress-releated symptoms: A Pilot Study. Compl Thera Clin Prac 2012; 18: 212-215.) looked at the impact that massage can have on occupational and ergonomic stress on nurses during working hours.

Subjects

Thirty-eight nurses (5 men/33 women) participated in the study. The nurses received a weekly, 15min chair massage, for 10 weeks. The subjects were assessed at baseline, 5wks, and 10wks using a self assessment scale, a perceived stress scale, an anxiety scale, and a symptom visual analog scale.

Treatment

In this particular study, the massage treatment was set up in such a way that it allowed the therapist the ability to customize the treatment to the client based on their requests. For example, if the client was seeking stress reduction then various techniques such as light strokes, slower paced massage strokes, and slow compressions might be used to help induce a more parasympathetic state. If the subject was asking for pain reduction or a decrease in tightness or stiffness then the therapist tailored the treatment towards more compression and stretching techniques, joint mobility techniques, and trigger point/accupressure compression techniques depending on how the client was responding to the therapy.

Results

Some of the interesting findings included:

• Stress and anxiety related symptoms improved over the entire study at both 5 and 10 weeks.
• Thirty-five or the thirty-eight subjects had positive comments about their massage with regard to improved sleep and reduction of pain, headaches, tension, and stress. They also noted that they felt more relaxed and re-energized.
• Thirty of the nurses felt that they had improved job satisfaction due to the massage and twenty-three of them reported that they would be willing to pay $10-25 for a 15min massage if it were regularly available at work.

Practical Applications

Interesting study and one of the biggest limitations is that it did not include a control group. That being said, it is a pilot study and hopefully more studies will look at some of the effects of massage on stress.

From a practical standpoint, even those the subjects are not athletes, I am always trying to think about what I can take away from the study and how it can be applied to the population and clientele I work with.

One thing I took away from this study was the benefits massage can have on morale, well-being, and stress reduction,  something I have discussed a number of times in previous blog articles:

Trigger Points and a Sympathetic State

Using Soft Tissue Therapy to Enhance Stress Resistance

Massage, Stress, and HRV

With athletes, especially during the competitive season when trying to be at your best for every game is paramount, finding ways to improve the athletes’ psychological well-being and decrease stress can be an essential component to keeping people healthy.

Not only is stress reduction a benefit of massage but I believe, when used appropriately, it can be helpful for enhancing stress resistance as we attempt to boost the athlete’s buffer zone and increase their ability to tolerate the stresses placed on them – obviously this is only one piece to a large puzzle of stress resistance, as enhancing fitness, nutritional intake, and sleep (as well as numerous other factors) go into developing quality stress resistance. Massage can be one tool to assist in this capacity.

What I did like about the approach used in this paper was that the therapist was given the ability to alter the treatment based on the client’s needs. Often massage research is conducted in such a way that there is a protocol being tested (IE, 5min of gliding, 5min of kneading, 2min of cross-fiber friction, 3min of gliding) which is very limiting as human beings are not protocols. Humans are living, adapting organisms and, while we all have many similarities, we are all individual and have different needs. Making changes to the session based on what the individual needs is a key component to therapy and can impact the result you get.

I do feel that a proactive approach to stress and stress resistance should be emphasized. In the sports and athletic arena, professionals often tend to be very reactive (only doing something when an athlete complains of a problem) rather than trying to build a program that heads issues off at the pass. When used properly, massage may be one potential tool that can assist in this proactive approach.

patrick@optimumsportsperformance.com

Recovering from competition is something that athletes and coaches are always looking to maximize. There are many ideas out there on how to approach the situation with everything from, “lift hard the day after the game since it is the day which is furthest away from the next game” to “take a full day of rest the day after the game to allow yourself to recover”.

A new study in the Journal of Strength and Conditioning Research by Tufano et. al. (2012), Effect of Aerobic Recovery Intensity on Delayed-Onset Muscle Soreness and Strength, set out to look at the result that different aerobic intensities had on recovery from a delayed-onset muscle soreness (DOMS) bout of resistance training.

Twenty-six women in their early to mid-twenties participated in the study. The subjects were randomly assigned to one of three groups:

1. Moderate Intensity Cycling – 20min of riding at 70% of age predicted max HR reserve at 80rpm
2. Low Intensity Cycling – 20min of riding at 30% of age predicted max HR reserve at 80rpm
3. Rest (control) – 20min of sitting on the bike without pedaling

Baseline testing consisted of a pain scale evaluation, isometric force of the right quadriceps, and dynamic strength of the right quadriceps.

Within one week of baseline testing the subjects reported back to the lab for five consecutive days. Day 1 consisted of the DOMS inducing training protocol: 6 sets x 10 reps of maximum eccentric efforts for the knee extensors. Following this protocol the subjects then performed their randomly assigned recovery protocol (listed above). The subjects were re-tested on the above variables, immediately post and then days 2-5 the subjects reported back to the lab and where assessed in the same baseline variables at 24h, 48h, 72h, and 96h.

Some of the findings:

• Pain Scale was the greatest immediately post training than any other time period.
• Dynamic strength was significantly greater pre-intervention compared to immediately post; however, it was not significantly greater at 24h, 48h, 72h, or 96h.
• While the control group and low intensity group showed no significant differences in isometric strength during any of the time periods the moderate intensity group showed no differences between baseline testing and 48h, however 72h and 96h were significantly greater than at 24h of recovery.

Practical Application

This was an interesting study. I am still trying to figure out what I can pull from it knowing that the subjects are not athletes and knowing that they performed the recovery protocol after the eccentric training protocol rather than the next day, which may have been more “real-world” for an athlete who goes out and competes one day and then comes back the next day to train. Also, the paper did not tell how much time was placed between the training protocol and the recovery protocol.

Trying to get an athlete to recover quickly following a competition is often an important goal for most coaches, especially in sports where the athlete may be required to compete multiple times a week (e.g., hockey, basketball, soccer, or baseball). The idea of going to the gym to train the day following a competition is something that many coaches place importance on and the hypothesis is that by moving around and getting blood flowing one is able to remove greater amounts of waste product and shuttle more nutrients to the cells to promote greater healing and restoration. This, of course, is still up for debate as science is still trying to understand what exactly is going on – perhaps there is also a large psychological component that goes into doing some exercise following competition and allowing the athlete to mentally get back in the game rather than sitting around and loafing, and perhaps this also can be helpful from a recovery standpoint. At any rate, it seems like doing something has benefit and the next question is always, “how much should we do?”. “Do we do a full on heavy lifting session the day after the game“. “Do we do a light foam rolling and mobility/stretch session?”

While this study did not look at doing high-intensity work following the eccentric training protocol it has been my experience that most athletes do not want to do a heavy or high-intensity session the day after the game. Most are pretty beat up, sore (pain scale was indicated in this paper), and tired – provided they played a significant role in the game – and the last thing they are thinking about is training hard. What we might be able to take away from this paper is that doing too little is simply not enough. Perhaps some medium intensity aerobic work would be the best option to keep the athletes moving following the game, get blood flowing, and prevent psychological lulls in the weekly schedule.

Of course this paper only looked at one aspect of the recovery process (training) and we should also keep in mind that recovery following intense competition is often multifaceted and often includes a variety of restorative modalities – massage, cold water therapy, nutrition, sleep, etc. Taking all of these things into consideration, as well as how we train the day following a game, can potentially further the athlete’s ability to recover.

Similar to the findings in this paper, I have been a fan of the idea that the day after a game we do some form of moderate intensity aerobic work. The modalities I often use include things such as:

• Circuit training workouts using body weight activities, light calisthenics, low resistance exercises, and even working in various cardiovascular activities into the circuit (IE, light runs of short distance during the circuit, light cycling or versa climber). HR monitors are worn to ensure the individual is in the appropriate HR zone.
• High resistance bike rides performed on  a spin bike with a high intensity (45-50rpms) for a set period of time (usually we do several rounds of 5min high resistance : 2.5min easy pedaling) and HR monitors are worn to ensure the individual is in the appropriate HR zone.
• Bodybuilder type training, which is what I call doing loads around 75% of less for 8-12 repetitions, not to failure (leaving 2-3 reps in the tank), and using total body movements (squatting, bench press, rowing movements, lunging movements, etc).

This type of work, along with soft tissue work (aimed at the individuals specific needs – both physiologically and structurally), has been useful at getting guys back on track. Of course I am always looking to refine these methods and ideas but hopefully this offers readers something to think about, consider, and play with.

patrick@optimumsportsperformance.com

The idea of programming can be a confusing one and as I discussed in a previous blog article, Concurrent Training: Strength and Aerobic Training at the Same Time?, both strength training and aerobic training apply different types of stress on the body and thus produce different molecular adaptations.

The big argument that always comes back is, “How practical is being able to always separate the two?”. Obviously we only have seven days in the week and with athletes needing to attend practice, competitions, and (if you are working with high school or college athletes) class, it can get really difficult to practically lay some of this stuff out as time is limited. Research happens in a much more controlled environment than the “real world” and sometimes we need to get creative with training structure.

What if we have to do Strength Training and Aerobic Training in the Same Session?

Performing strength training and conditioning tasks in the same session is a common way of prescribing training as it allows us to train several qualities in a time efficient manner. As I discussed in the Concurrent Training Article, the amount of focus you place on each task will be dependent on the goals of the training session, the phase of training and the athlete’s individual needs. One question that people often ask is, “Which should I do first? Conditioning or Strength Training?”. My reply to that is always, “It depends”.

A 2009 paper by Coffey and Hawley looked at successive bouts of strength and aerobic training during two different training session – one where the eight subjects performed strength training first and the other where the subjects performed aerobic training first.

Session 1

• Resistance Training: Leg Extensions – 8 sets x 5 reps @ 80% intensity; Rest = 3min
• 15min rest period
• Endurance Training: Cycling – 30min continuously at a power output of approximately 70% of the individuals VO2peak

Session 2 (2 weeks after Session 1)

• Endurance Training: Cycling – 30min continuously at a power output of approximately 70% of the individuals VO2peak
• 15min rest period
• Resistance Training: Leg Extensions – 8 sets x 5 reps @ 80% intensity; Rest = 3min

Key Findings

• When endurance training was performed before resistance training (Session 2) there was a decrease in genes specifically associated with hypertrophy; therefore, the anabolic effect of resistance training may be blunted.
• When resistance training is performed before endurance training (Session 1) there is potential to exacerbate inflammation and protein degradation
• The results of this study are consistent with other studies indicating that there is an interference effect that takes place when two types of different training modalities are performed in the same session (as discussed in the Concurrent Training Article)

Practical Application

It would appear that anyway you slice it you get some sort of negative effect. Do your conditioning before your resistance training and you blunt the anabolic response. Do your resistance training before your conditioning and you end up with greater amounts of inflammation and protein degradation.

Thus, to answer the question of, “Which should I do first?”, we have to take into consideration the individuals needs because, as I stated earlier, “It depends!”

When looking at the individual athlete and trying to understand their needs it is important to remember that most team sport athletes do not need to maximize their potential in one single area (strength or power) but rather need to be a little more well-rounded and possess the capacity to repeat explosive and powerful efforts over the course of a game.

Oftentimes, when testing an athlete, we will typically find that the athlete tends to be dominant in one physical aspect (IE, strength) and may be lacking in another (IE, conditioning or sport specific work capacity), thus, our training should reflect that athlete’s needs during certain training phases when we are trying to make improvements in specific qualities.

For example, For an athlete who is already strong, powerful, and posses a large amount of muscle mass, my goals of training may be to improve their general fitness and work capacity and maintain their strength and power. In this athlete I may choose to perform some conditioning work first in the session and follow that with a low volume strength session, as maintenance work, for a few weeks until I get the fitness changes that I want. For an athlete who possess great conditioning but lacks strength and power my goal in that first phase of training would be to perform the strength and power work first in the session, to prioritize that quality, and then perform some low volume conditioning (maintenance work) at the end of session.

Obviously the most ideal situation would be to break up the week, separate the qualities, and train them at the volumes and intensities necessary for the individual; however, this is not always possible. In the offseason, when there are less demands placed on the individual, you may be able to get away with this type of setup but as the season draws near you may need to get more creative with your programming and figure out how to prioritize specific qualities on the limited training days that are available to you.

Some of these concepts and ideas are covered in the latest DVD I recorded with Charlie Weingroff, and Joel Jamieson. The DVD comes out November 6th, but don’t forget that you can get on the pre-sale list and save $25. Sign up HERE!

patrick@optimumsportsperformance.com

Soft tissue therapy can be an important modality for enhancing stress resistance when used appropriately within the training program. Rapaport and colleagues have now published two papers looking at the effect general Swedish massage can have on the hypothalamic-pituitary-adrenal axis and immune function.

A Single Massage Session

Their first paper (2010) looked at the effects of a single Swedish massage session compared to a session of light touch therapy – both treatments lasting 45min in duration.  Fifty-three healthy subjects, aged 18-45, participated in the study and were randomly assigned to either a Swedish massage group or a light touch therapy group (control group). In both cases the subjects started the session prone and finished in supine lying. The Swedish massage session consisted of effleurage, petrissage, kneading, tapotement, and thumb friction while the light touch session consisted of the therapist lightly stroking the skin with the back of their hand. Blood samples were collected at 5 and 1 minute prior to treatment and then 1, 5, 10, 15, 30, and 60min post treatment. Salivary cortisol was collected immediately before and 20min after the massage treatment and a psychological self assessment questionnaire was taken 15min before and 15min after the treatment session.

The results of the study showed a large decrease in arginine-vasopressin for the Swedish massage group compared to the light touch group and a small decrease in cortisol. Arginine-vasopressin (aka vasopressin or anti-diuretic hormone) is a hormone released from the posterior pituitary gland which is active during the stress response to inform the kidneys to reabsorb water into the blood stream. Thus a shift in arginine-vasopressin may indicate a positive shift away from a sympathetic state and more towards a relaxed or parasympathetic state. Additionally, massage was shown to increase the number of circulating lymphocytes, indicating a potential boost in immune system function. Both massage and light touch showed small decreases in cortisol and only light touch showed a decrease in corticotropin (ACTH), a hormone released from the pituitary which signals the adrenal cortex to release glucocorticoids.

These results were interesting and show that there may be potential biological effects with Swedish massage. Of course more research needs to be conducted to determine the best application of massage and how these sort of changes are brought about in the body during a massage treatment.

The next immediate question is, “What happens when we do more frequent massage sessions?”, which is what Rapaport and colleagues set out to do with their most recent study.

Repeated Massage Sessions

In their second paper (2012) Rapaport again investigated Swedish massage therapy versus light touch therapy (using the same 45min protocol above) in 45 subjects who were assigned to either a Swedish massage or light touch therapy session performed either once or twice a week for a 5-week treatment period. The same neuroendocrine, immune, and salivary cortisol samples were collected as in the first study in the same time frequencies as well.

The results of the study indicated that weekly Swedish massage for 5-weeks was effective at increasing circulating lymphoctes and decreasing cytokine production – similar to those results seen in single massage treatment study above. Additionally, the once a week Swedish massage produced a decrease in ACTH, arginine-vasopressin, and cortisol. The result of a twice-weekly massage for 5-weekas showed a different response by increasing oxytocin levels – a hormone that may potentially explain the interpersonal relationship that forms between therapist and client – and larger decreases in salivary cortisol. Interestingly there was only a small change change seen in oxytocin levels with the once a week treatment protocol and no change in oxytocin seen in the single session of Swedish massage performed in the prior study.

Some Thoughts

Perhaps, when the athlete is asked, “Why do you get a massage every week?”, and they reply,”Because it feels good!”,there is much more going on internally than just the psychological perception of relaxation and comfort.

Hopefully more research will continue down the road of looking at the biological outcomes of massage therapy as I believe there is a lot to be understood in this field.

What these two studies do show us is that the frequency of massage matters if we are looking to influence the athlete’s physiological system and enhance stress resistance. Additionally, the duration of the massage is important as it takes time to get the athlete relaxed, wind them down, and create physiological changes. The “10min flush” is probably not going to get the job done and longer durations of massage may be needed (>/= 45min). Finally, these papers show the importance of massage therapists in the sports training environment understanding how to perform Basic Massage Therapy and general massage approaches to facilitate a specific response from the body. Instead of thinking about using soft tissue therapy only for injured athletes or when someone is complaining about something, a more proactive approach should be taken to use these modalities at the correct time in the training and competitive environment to ensure the desired result.

Patrick
patrick@optimumsportsperformance.com

References

Rapaport MH, et al. A preliminary study of the effects of a single session of swedish massage on hypothalamic-pituitary-adrenal and immune function in normal individuals. J Alter Comple Med 2010; 16(10): 1-10.

Rapaport MH, et al. A preliminary study of the effects of repeated massage on hypoathlamic-pituitary-adrenal and immune function in healthy individuals: A study mechanisms of action and dosage. Journal of Alternative and Complementary Medicine 2012; 18(8): 1-9.

In last week’s blog article I discussed the role that soft tissue therapy can play in recovery and helping to raise the athlete’s stress resistance.  In doing so, I referenced two articles that looked at trigger point therapy and its effects on the autonomic nervous system, as measured by heart rate variability.  Today, I wanted to expand a bit on trigger points and their relationship to a sympathetic state as this information is helpful to further enhance our understanding of the role soft tissue therapy can play in the training and sports performance arena.

Trigger Points – An integrated Hypothesis

Before going into how the sympathetic system and trigger points are related it is best to first explain the hypothesis of what is going on, or more appropriately, what we think is going on when there is a trigger point.  I emphasize the word think because no one is really sure and there are a variety of hypotheses out there, one of which being that there is no such thing as a trigger point at all and really all that is taking place is just entrapment of nerves (although this doesn’t completely explain many of the random referral patterns that have been known to take place when a trigger point is compressed and also, as we will see later in the article, the biochemical environment and the local sympathetic state would be a potential player in the irritation and/or compression of the nerves anyway).  I wrote trigger point 101 a little over three years ago as a way to give some basic information about what trigger points are and how we can treat them and while I may explain some of the info in there differently these days (it was three years ago!) I still think that there is some basic stuff in there that will help people better understand this phenomenon.

While there are a number of hypotheses out there probably the most accepted is the “integrated hypothesis” as explained by McPartland and Simons:

“The ‘integrated hypothesis’ regarding the etiology of myofascial trigger points states that each trigger point has a sensory component, a motor component, and an autonomic component.  The hypothesis encompasses local myofascial tissue, the CNS, and systemic biomechanical factors.”

This integrated hypothesis is all encompassing and works to explain how trigger points form, what happens when they form, why they feel painful, and how the nervous system comes into play.  This hypothesis includes many things such as:

• Excessive muscle contraction will compress local sensory nerves and blood vessels decreasing local blood supply of oxygen
• What there is pain when the trigger point is provoked
• Elevations of protons, bradykinin, serotonin, substance P, norepinephrine, calcitonin, and TNF-a in the area of the trigger point
• The localized sweating, vasoconstriction, and pilomotor activity (goosebumps) when a trigger point is provoked

Putting all of this together we begin to understand the mulifaceted nature of trigger points and understand that there is more to it than just the myofascial system.  The nervous system, the endocrine system, and in fact all systems of the body will play a role (although the nervous system is really in the driver’s seat).

Looking Further Into The Nervous System

Shah and colleagues have conducted a few studies which looked specifically at the biochemical milieu of trigger points.  When looking at trigger points in the upper trapezius of subjects in one of three groups – (1) Normal/no neck pain/no trigger points; (2) Latent/no neck pain/latent trigger points; (3) Active/cervical pain of <3 months duration/Active trigger points present – what they found was that those with active trigger points, when compared to the other two groups, had:

• A lower threshold of local tenderness (confirmed by a pressure algometer)
• Greater amounts of bradykinin, substance P, TNF-a, serotonin, norepinephrine, calcitonin gene-related peptide
• Significantly lower pH

An additional finding this group of researchers made was that a variety of inflammatory mediators (e.g., neuropeptides, catecholamines, and cytokines) were found to be elevated in the area of the active trigger point.  Also, the biochemical milieu in a site remote to the active trigger point (they used the gastrocnemius as the site remote to the active trigger point in the upper trapezius) was lower than in the active site; however, when compared to that of the latent and normal groups, it was found that the active group’s biochemical milieu was significantly higher in the remote location.  The researchers noted that this may suggest potential central sensitization.  I look at this information in the context of an athlete who is overtrainined or overstressed and pushing towards sympathetic dominance where the internal environment is reflecting this hormonal shift. 

Finally, another point that Shah et al. note is that, in association with elevated sympathetic activity, increased levels of norepinephrine have been implicated in their role of depressed feedback control of muscle length and increased spontaneous electrical activity at motor enplates, thus hinting at norepinephrine’s potential role in the pathophysiology of trigger points and myofascial pain syndromes.

Conclusions and Practical Applications

Placing this information and the information from last week’s article into context we can begin to piece together a much broader picture of the ways in which out autonomic state can have an influence over the myofascial system thus inhibiting the way we move and perform. 

Using this information we can further enhance an athlete’s recovery, either from injury or from competition/training, by figuring out ways to influence the nervous system in order to get what we want in the training or therapy program.  Soft tissue therapy may be one potential way to influence this state but it is, of course, not the only way.

Finally, another way to help athletes with their overall program is to make them aware of things that can perpetuate trigger points – and it should come as no surprise that most of these things are also nervous system irritants - such as:

• Overuse
• Overtraining
• Nutritional deficiencies
• Poor sleep
• High amounts of stress (psychological or physical)
• Drug use
• Tobacco and nicotine (getting baseball players to stop using smokeless tobacco should be a high priority)
• High amounts of caffeine intake (small amounts should not be a problem; however, high amounts of caffeine like we see in many college athletes who live on things like coffee, diet soda, and red bull is going to provoke a sympathetic environment)
• Prolonged postures (IE, sitting)…as they say, “movement is medicine”

In the end it really comes down to educating your athletes/clients/patients and developing a well rounded program that addresses their needs and is appropriately managed to ensure that the program is doing what you want it to do.

Patrick
patrick@optimumsportsperformance.com

References

McPartland JM, Simons DG. Myofascial Trigger Points: Translating Molecular Theory into Manual Therapy. J Manual & manipulative Therapy 2006; 14(4): 232-239.

Shah JP, Gilliams, EA. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: An application of muscle pain concepts to myofascial pain syndrome. JBMT 2008; 12: 371-384.

Shah JP, et al. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol 2005; 99: 1977-1984.