First this article was published at the Jornal of Massage Science in the October issue, 2010
In the times of Internet it is difficult sometimes to follow all the professional news. We greatly appreciate Sue Hitzmann, LMT from www.massageprofessionals.com who started an important discussion on the recently published article in New York Times about sports massage and its impact on blood flow and post-exercise muscle soreness. (http://well.blogs.nytimes.com/2010/06/02/phys-ed-does-massage-help-after-exercise/).
This article is based on the interview with Michael Tschakovsky, an associate professor in the School of Kinesiology and Health Studies at Queen's University in Kingston, Ontario.
Prof. Tschakovsky and his colleagues recently published an article in the Journal Medicine & Science in Sports & Exercise (Wiltshire et al., 2010) ,which presented results of the study, examined the impact of massage on post-exercise muscle blood flow and lactic acid removal.
The study showed that
"'...sports massage results in severe impairment to blood flow during the massage stroke, and this impairment has a net effect of decreasing muscle blood flow early in the recovery period after strenuous exercise.' and '...sports massage would not be indicated for optimal lactic acid removal from exercised muscle...'."
These results and interview with Prof. Tschakovsky allowed the author of the article in the New York Times to conclude:
'The results, published in the latest issue of the Journal Medicine & Science in Sports & Exercise, are a blow, at least to those of us who justify our massages as medicinal (bold by JMS)'.
In fact, these results, if they are correct, are a professional blow to the entire industry and science of sports massage.
The situation is even more complicated by the fact that this data was published in such a respected media publication as the New York Times, which has more than 18 million subscribers.
Considering the grave importance of this study and the following article we decided to do our own investigation. Through the Journal Medicine & Science in Sports & Exercise we obtained the copy of the original article and methodically examined it in great details. This article is our response to the both publications and we are encouraging our readers to read it through despite the fact that it is long piece. However, it will give you information of great importance when dealing with the consequences of these and future similar publications on this subject.
For this study Canadian scientists recruited 12 healthy male subjects. Subjects were asked to perform three maximal isometric handgrips with 1 minute between efforts. Next, they continuously hand gripped a dynamometer at 40% of maximum voluntary contraction for 2 minutes. In a clinical group subjects laid quietly for 30 seconds and this was the time when massage began which consisted of effleurage and kneading. In the control group after initial 30 seconds of rest subjects began 10 minutes of rhythmic forearm contractions at 10% of maximum voluntary contraction. The authors of the article started to monitor central hemodynamic, forearm oxygen uptake, forearm blood flow, forearm lactic acid removal after initial 30 seconds rest. The statistical analysis of the obtained data allowed the authors to conclude that
"'...sports massage actually impairs removal of lactic acid from exercised muscle and that this is due to a mechanical impairment to postexercise muscle blood flow from rhythmic compression of muscle tissue'."
However detailed analysis of this article showed us that despite of correct statistical analysis of obtained data this is one of the most weak and outdated study we encounter so far on subject of sports massage. The study concentrated on two major aspects - lactic acid removal and blood circulation in muscle tissue. Here is why the authors are dead wrong on each point of their study.
LACTIC ACID REMOVAL
At the beginning of the article the authors specified that there is a split in the medical community about the impact of lactic acid on muscle fatigue and recovery. They have clearly sided with the view that lactic acid is one of the important factors in muscle fatigue and soreness after intense exercise. The stated that
"...it still remains that early lactic acid removal from the muscle may be advantageous to improve athletic performance..."
However, this is an old and outdated view which is abandon by the great majority of the sports medicine scientists. The current view is the complete opposite. The muscles during eccentric exercises use lactic acid as an easily accessible burning fuel while their own ATP storage is depleted and production is strained. We can provide great number of studies which justify this fact. Conveniently enough the authors of this article didn't even mentioned the most important publications which showed complete unsustainability of the lactic acid theory.
To save readers time we will use one of the most comprehensive reviews on this subject published in Sports Medicine (Cheung, et al., 2003). Let us quote part of the article which addresses the lactic acid theory:
"The lactic acid theory is based on the assumption that lactic acid continues to be produced following exercise cessation. For the lay public, the accumulanous of toxic metabolic waste product is thought to cause a noxious stimulus and the perception of pain at a delayed stage.
However, this theory has largely been rejected as the higher degree of metabolism associated with concentric muscle contractions have failed to result in similar sensations of delayed soreness. In addition, lactic acid levels return to pre-exercise levels within 1 hour following exercise and blood lactate levels measured before, during and sporadically up to 72 hours after level and downhill running have failed to show a relationship between lactic acid levels and soreness ratings.”
Here is another quote from one of the most respected publication for sports coaches (Sharkey and Gaskill, 2006):
"This fallacy (i.e., lactic acid theory, JMS) has been around for years, even though it lacks any basis in fact. The lactic acid isn't direct cause of the soreness."
So what are the causes of muscle soreness after the exercise? At this point we have 5 theories. We will use publication of Cheung, et al (2003) to discuss this subject:
Muscle Damage Theory (Hough, 1902)
Despite the fact that this is the oldest of all theories it has large following among current scientists. According to this theory eccentric exercise disrupts the contractile apparatus of skeletal muscles especially along Z-lines which are its weakest link.
Muscle Spasm Theory (deVries, 1966; Cleak et al., 1992)
Increase in the resting muscle tone leads to compression of the capillaries, local ischemia, insufficient drainage and accumulation of waste products and finally activation of pain receptors as results of local changes in pH.
Inflammation Theory (Smith, 1991)
The author and proponents of this theory argue that pathophysiologically intense exercise trigger in the skeletal muscle the response identical to basic inflamation: interstitial edema, increased permeability of small blood vessels, infiltration of the muscle tissue with macophages, etc.
Connective Tissue Damage Theory (Sydney-Smith et al., 1992)
Excessive strain of the connective tissue structures leads to muscle soreness. This theory is backed by the fact that there is significant increase of components of mature collagen and individual amino acids in urine after eccentric exercises. This is a sign of connective tissue damage because the collage is main protein these structures build from.
Enzyme Efflux Theory (Gulick, Kimura, 1996)
When muscle tissue is damaged as a result of eccentric exercise the calcium leaks from cysterns and it slows the ATP production as well as activates enzymes and ferments which additionally damage muscle tissue.
Studies these theories are based on showed that yes each theory is correct and currently scientists start to see each of five theories as a reflection of different steps of the same process triggered by the intense exercise. In such cases there is no single elusive factor which we are trying to find since 1902 which is responsible for the muscle soreness after exercise, but it is rather combination of causes. The idea of accumulation of lactic acid as a primary factor in muscle soreness and fatigue is simply the outdated and confusing notion.
Thus, it is completely irrelevant for science in general and for sports massage in particular if it has any effect on lactic acid removal, because we need lactic acid to be used for the effective muscle contraction.
The impact of massage strokes on the blood flow of exercised muscle is where this study gets especially interesting and let us say mildly puzzling. Please follow us now. The authors asked their subjects to conduct eccentric exercise of the forearm muscles. What will the first outcome of this event be? The heart rate will continuously rise to satisfy oxygen demands. In 30 seconds after the subject has stopped exercising the heart rate is still elevated and the authors started to conduct the effleurage and kneading strokes on the muscles. At the same time they started to measure the blood flow though obviously forearm.
Anyone who knows the basics of anatomy and physiology will predict that massage strokes at this time (i.e. 30 seconds after cessation of muscle contractions) will indeed decrease blood flow because the blood rushes through the arteries faster as a result of the increased heart rate.
If one opens the most respected and comprehensive textbook on Medical Physiology (Ganong, 2009) which every medical school in the world refers to, he or she will find that during the eccentric exercises the blood flow through the muscles increases by 30 fold. How can massage strokes additionally increase the blood flow even if the muscle stopped to contract just 30 seconds ago? There is no way that massage strokes even with greatest speed of application will be able to additionally speed up the blood flow. They may only block it and this very well predicted fact was registered by the authors.
According to the article in the New York Times the blood flow through the muscles is an area of great interest for Prof. Tschakovsky and his colleagues. We simply don't understand how such educated group of scientists may even consider the necessity of scientific examination of this obvious issue. The design of this experimental protocol simply looks amateurish. If we will make an analogy with astronomy study of the same principles will try to prove us that the Earth is a globe rather than flat disk despite the of obviousness of this scientific fact. The impact of sports massage on muscle soreness and fatigue is a very controversial issue, because a lot of studies have shown that sports massage failed to show any positive outcomes. The problem of all these studies is not sports massage but rather incorrectly designed protocol of the studies. Unfortunately, this study unintentionally or intentionally falls into the same trap.
A little history first. The incredible success of the Soviet Olympic team during the peak of the Cold War is historical fact (1972, 1976, 1980, 1988, 1992). We can provide an even more striking example. The East German Olympic Team ended up second in team medal counts in the 1976, 1980 and 1988 Olympic Games and it always beat Western Germany despite the fact that Eastern Germany was smaller in size and population. In these and other Easter European countries sports massage was one of the cornerstone of athlete's training and at the same time it was a very well kept secret.
After the fall of the Soviet bloc this information became available on the West. The several studies (Cafarell, et al., 1990, Drews, 1990, Wenos, et al., 1990, Rodenberg, et al., 1994) showed that sports massage doesn't have any impact on the muscle soreness and fatigue. However, this controversy was solved in 1994 by a study conducted by Dr. L.L. Smith and his colleagues who by the way is the father of the Inflammation Theory we discussed above and one of the main proponents of the unified theory which looks on muscle soreness and fatigue as being the result of several sequence events.
Dr. Smith and his colleagues from East Carolina University decided to do a very simple thing no one among Western scientists had done before. They designed a study protocol which re-created in every small detail the recommendations of their colleagues from former Eastern bloc countries. The clinical results of this study showed that, yes indeed, the muscle soreness and fatigue is dramatically reduced by sports massage when it is conducted correctly. One of the critical components is time of massage application. If massage is conducted less than 2 hours and later than 3 hours after the intense exercise it doesn't affect the muscle soreness or fatigue. Lin (1999) reported similar results of reduction in plasma CK level after exercise massage group received the 15-minute massage 2 hours after the exercise. This allowed Cheung, et al., (2003) to conclude that: 'This time table (i.e., 2-3 hours, by JMS) may suggest that the timing of massage intervention may be a very influential factor.'
The study conducted by Smith, et al. (1994) is widely known and cited among the professionals around the world and there is very small chance that the authors didn't know about its existence and impact. However they choose to design their own completely ridiculous protocol or they didn't bother to do proper research before the study protocol was designed. As you remember the authors started to apply sports massage 30 seconds (!) after the end of eccentric exercise.
If you would like to find out why the 2-3 hour window after eccentric exercise is so important please click here. This is why we consider the initial article published in the Journal Medicine & Science in Sports & Exercise (Wiltshire et al., 2010) as the weakest scientific study so far which has tried to examine the benefits of sports massage. The following publication in the New York Times is based on this study and it is obvious that the correspondent who didn't have enough expertise in sports medicine was mislead by the results of this study and Prof. Tschakovsky' opinion. A couple of final thoughts. The New York Times is a very respected media publication and it always gives the other side the choice to respond. The author of the article gave this choice to the massage community to comment on the published study and interview with Prof. Tschakovsky.
M. K. Brennan, a licensed massage and bodywork therapist registered nurse and former President of the American Massage Therapy Association' comments are quoted in the article. Let us cite single comment of M.K. Brennan was able to make as a response to the article: "The main takeaway" of Mr. Tschakovsky's study, Ms. Brennan says, "is that far more research about exercise and sports massage is needed."
This is the most ridiculously toothless comment in regard to the published study American Massage Therapy Association was able to generate! We, as well as many of our colleagues think this is simply outrageous. From our perspective the article in New York Times greatly harmed and undermined the entire profession. We suggest our readers simply type 'Tschakovsky and sports massage' in the search window of any major search engine and see how much fuss the publication in New York Times has generated on the Internet. These are clients you lost! We are living in different times now and this article as well as lack of official reaction to it will be on the Internet forever.
Where is the official response and detailed analysis of the study from any massage therapy professional associations, foundations or chapters. Where are all these presidents, vice presidents, former presidents, experts on sports massage and countless continued educational providers who are supposed to analyze and defend this profession from groundless and frequently unscientific claims?
If massage officials don't have enough professional expertise they must hire scientists who be able to independently analyze information and this analysis must be used as a part of an official response. Instead it seems that our supposed leaders run for the woods and simply wait until the situation calms itself. Unfortunately, they again weren't able to stand up and firmly defend the profession in general and those they are suppose to officially represent and this is a very sad situation.
Maybe we are wrong and this matter upsets only us and our colleagues, so we give our readers the chance to reach their own conclusions. Send us your opinion and we will publish it in the next issue of Journal of Massage Science.
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