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Delayed onset muscle soreness: Is massage effective?
Nicole Nelson, MS, LMT,
Despite the widespread occurrence of delayed onset muscle soreness (DOMS), there is little consensus as to the exact cause or which treatments may be most effective at alleviating symptoms. Greater understanding of DOMS can give sports medicine and fitness professionals an opportunity to help prevent or speed recovery of this performance limiting condition. This article will review the DOMS literature, including the potential role of psychosocial factors and explore studies which involve massage therapy as a treatment modality. Articles from PubMed, MEDLINE, Google Scholar, and references from articles are included in this review. Search words and phrases included delayed onset muscle soreness, repeated bout effect, massage effectiveness, exercise induced muscle damage, and eccentric exercise.
Any individual engaging in a new physical activity, or those that have suddenly increased exercise volume and intensity, has likely experienced DOMS. DOMS is frequently associated with ballistic stretching and eccentric exercises such as downhill running, the lowering phase of weight training and plyometrics. Although there is a lack of consensus as to the precise mechanism behind DOMS, its presentation is fairly consistent. DOMS generally begins 12–24 h after unaccustomed exercise and is marked with tenderness upon palpation and a sense of stiffness while moving (Cheung et al., 2003). Soreness tends to peak around the 48 h time frame; however, complete resolution of symptoms can take up to 10 days. Soreness can vary from mild discomfort to incapacitating pain; this is largely dependent on the intensity and volume of training, as well as the novelty of the DOMS inducing event. Peak strength deficits usually occur within 24–48 h after activity, and generally curtails within 10 days. While DOMS is not considered a major threat to an individual’s overall health, intense exercise during the DOMS symptomatic period can potentially cause harm, as shock absorption capability, strength output, force steadiness and overall coordination is believed to be compromised (Vila-Cha et al., 2012). Furthermore, compensatory movement patterns may also occur as the body will self protect against the discomfort of DOMS (Cheung et al., 2003; Vila-cha et al., 2012). These findings suggest that exercise programming that involves explosive force generation and shock absorption capability be used with caution during peak DOMS soreness. Although programming adjustments may need to be made during peak DOMS soreness, repeated bouts of similar movements have been shown to induce a protective and potentially analgesic effect. This adaptive effect, termed “the repeated bout effect” (RBE), is believed to provide significant protection against future injury. Additional benefits of the RBE include decrease losses in contractile force, less soreness and a reduction in the amount of muscle proteins in the blood (DiPasquale et al., 2011; Aldayel et al., 2010). Although the exact mechanism of this protective effect is uncertain, many credit improved motor unit activation where more fibers are recruited in subsequent bouts of the same activity (Gabriel et al., 2006). It has also been suggested that the formation of protective proteins and repair of the sarcoplasmic reticulum may be responsible for the reduction of DOMS after similar exercise exposure (Nosaka et al., 1991). The RBE has been shown to remain high for 14 days, lessen by 28 days and completely diminish within 42 days after the initial DOMS event (DiPasquale et al., 2011). Considering the benefits of the RBE, clinicians and sports performance professionals are well advised to emphasize preseason conditioning involving sports specific movement drills as early as two months in advance.
Proposed mechanisms of DOMS
While research has yet to offer a definitive explanation as to the cause, most are in agreement that lactic acid, once believed to be linked to muscle pain after exercise, is not involved. In fact, lactic acid has been shown to dissipate within an hour of cessation of exercise, long before the symptoms of DOMS arise. Muscle damage is believed to occur during repeated eccentric contractions, where the sarcomeres are progressively overstretched. This structural disruption can spread to adjacent areas of the muscle and lead to damage of the membranes of the sarcoplasmic reticulum, transverse tubules or the sarcolemma. During this time of structural vulnerability, Ca2+ moves freely into the sarcoplasm, where it activates pathways related to muscle fiber degradation and repair (Proske and Allen, 2005).
Serum creatine kinase (CK) has been used as a measure of muscle damage in DOMS studies; however, some individuals are found to have higher levels of serum CK compared to other similar individuals when exposed to the same exercise protocol. Likewise, CK activity is also influenced by other factors other than tissue damage, including genetic factors, age and gender (Baird et al., 2012). This has led many researchers to question if changes in CK activity are a consequence of normal metabolic activity, rather than a marker of muscle damage and a loss of muscle cell integrity (Baird et al., 2012).
Many researchers have questioned if muscle soreness actually corresponds with muscle damage. Crameri compared the effect of voluntary muscle contractions to the effects of electrical stimulation contraction in humans (Crameri et al., 2007). He discovered markedly less muscle damage in the voluntary muscle contractions group, despite the fact that each group experienced similar levels of muscle soreness. Crameri theorized that muscle damage does not necessarily correlate to soreness, and that high intensity, eccentric contractions actually induces changes to the extracellular matrix (ECM). These changes then result in an increase in interstitial inflammation, followed by a nociceptive response. The level of actual muscle damage has also been questioned by Yu in 2004. Yu proposes that there is an adaptive remodeling of the myofibril proteins rather than myofibril damage (Yu et al., 2004). Although DOMS is clearly a symptom of eccentrically induced muscle damage, it is important to note that there are instances where individuals can experience DOMS without the presence of muscle damage (Nosaka et al., 2002). This distinction is critical, as treatments for DOMS may be unique from other symptoms of exercise induced muscle damage (Zainuddin et al., 2005).
Inflammation and edema
Connolly et al. (2003) explained that eccentric exercise causes damage to the muscle cell membrane, which sets off an inflammatory response. This inflammatory response leads to the formation of metabolic waste products, which act as a chemical stimulus to type III and IV nerve afferents that directly cause the sensation of pain. These metabolic waste products also increase vascular permeability, and attract neutrophils and cytokines to the site of injury. Once at the site of injury, neutrophils generate free radicals, which are thought to damage the cell membrane, and attract additional neutrophils and cytokines. Edema results from the movement of these cells, and the resultant accumulation of fluid is thought to contribute to the further sensations of pain (Connolly et al., 2003; Dessem et al., 2010). Evidence suggests that the level of inflammation is directly dependent on the type of eccentric activity, the RBE, age and gender (Peake et al., 2005).
Researchers note that DOMS and the RBE may have a more systemic outcome, known as cross-transfer or cross education, where the strength gains and reduced soreness seen in conjunction with the RBE, carry over to seemingly uninvolved areas of the body. In a review of 13 studies, Munn et al., 2004 reported that an average increase in strength of 35% in the trained limb was accompanied by a significant 7.8% increase in the untrained limb. The results of this meta-analysis were further supported by Starbucks and Eston (2012). Subjects performed bicep exercises of one arm to induce DOMS and the RBE. Researchers discovered the strength increases associated with the RBE did carryover to the contralateral arm (Starbuck and Eston, 2012). This suggests that DOMS may be centrally mediated and implies some degree of neural adaptation, as there was no direct training stimulus to the untrained muscles.
Recently, pain research has recognized the interplay of psychosocial factors and physiological factors in the pain experience (Gatchel et al., 2007). It follows that these psychosocial factors may contribute to the perceived severity of DOMS symptoms. Biopsychosocial proponents suggest that the pain experience does not necessarily result from tissue damage; rather each individual’s pain is dependent upon their genetics, history, current mental status, patient expectations, and socio-cultural influences (Gatchel et al., 2007; George et al., 2007). In one study, researchers took 19 males and 23 females with no history of shoulder pain, and naïve to exercise. Subjects were asked to complete surveys which measured fear of pain, pain catastrophizing and anxiety. Pain catastrophizing has been defined as an unrealistic interpretation of bodily sensations, which leads to the preoccupation that one has a serious problem, and is doomed for the worst outcome (Gatchel et al., 2007). The volunteers underwent shoulder external rotation exercises to induce DOMS and were evaluated 24 h post exercise. Those that demonstrated a high fear of pain had more pronounced DOMS symptoms (George et al., 2007). This study was supported in 2008, as George and others investigated the role of fear and a specific gene associated with chronic pain. Subjects completed self-report pain questionnaires and were screened for having the COMT genotype (an enzyme linked to pain modulation). DOMS was induced by having participants perform shoulder exercises and were assessed 24, 48, and 72 h post exercise. Those demonstrating high pain catastrophizing beliefs and having the gene associated with low COMT enzyme activity (higher pain sensitivity), were more likely to have elevated pain intensity (George et al., 2008). Trost and colleagues demonstrated a connection between fear avoidance beliefs and DOMS symptoms. Trost induced DOMS to the trunk extensors of 30 participants. The researchers found that fearful participants had lower strength production and were hypervigilant to pain sensations (Trost, 2011). It should be noted that the induction of DOMS in theses studies served as an experimental model of pain. Inducing DOMS provides more control over the mechanism of injury in comparison to clinical pain. Intent notwithstanding, these studies indicate that psychological factors, including catastrophizing and fear, can influence the perceived severity of DOMS.
Effectiveness of massage
Theoretical mechanisms of massage
It is still unclear why massage might improve DOMS. It has been suggested that massage helps decrease cytokine levels, which in turn, can mitigate the inflammatory response that is expected from intense exercise. A recent study examined the effects of one 45 min Swedish massage on the body’s hormonal response and immune function (Rapaport et al., 2010). Blood samples were taken before and after the sessions. Significant decreases in cytokines (interleukin 4 and interleukin 10) were found for the massage group compared to those receiving a sham massage. In another study, Crane and colleagues had healthy subjects exercise to exhaustion on a stationary bicycle. After exercise, the subjects received a 10 min massage to one leg, while the other leg received no treatment. The researchers took biopsies of the quadriceps muscles 2.5 h after the massage and discovered a significant dampening in the expression of inflammatory cytokines in the experimental leg compared to the control leg (Crane et al., 2012). Although the findings of Crane and Rapaport are intriguing, it is still unclear if the dampening in the expression of cytokines will result in less perceived tenderness and improved performance among DOMS sufferers.
Many suggest that massage increases local circulation, thereby evacuating the pain attenuating factors and increasing the delivery of nutrients that may speed recovery (Wiltshire et al., 2010; Zainudden et al., 2005). To the contrary, others have shown little or no increase in muscular blood flow (Hinds et al., 2004; Shoemaker et al., 1997). Hinds postulates that massage actually increases blood flow to the skin, diverting circulation from skeletal muscle, thus deleting any positive effects on muscle recovery (Hinds et al., 2004).
Massage has been associated with positive effects on nervous system activity. Depending on the massage technique, mechanical pressure on the muscle is thought to increase or decrease neural excitability; these neural changes are believed to effect muscular tensions, potential for spasms and pain (Lee et al., 2009). Evidence does suggest that massage may decrease the Hoffman or H-reflex, which is used to measure the excitability of the motor neuron pool. A recent study demonstrated reductions of H-reflex measures among study participants that received a 60 min, full-body massage (Sefton J et al., 2012). It is unclear how long lasting these effects may be, as the researchers assessed the subjects 60 min after the intervention. Future study is needed to fully understand whether the mechanical pressure of massage is directly responsible for the reductions in the H-reflex, or if these reductions are a product of the subject relaxing during the therapy.
It has been suggested that massage results in the reduction of the stress hormone cortisol, and an increase in the levels of serotonin and dopamine (Rapaport et al., 2010; Field et al., 2005). These positive changes in biochemistry are believed to result in reductions of pain. There is still much debate however, as to the direct influence massage has on cortisol levels (Moyer et al., 2011), and if these biochemical changes would influence DOMS intensity.
Possibly the most well established benefits of massage within the literature are psychological (Krohn et al., 2011; Beider and Moyer, 2007; Moyer et al., 2004; Hemmings et al., 2000). Trost and George have shown that fearful beliefs and pain catastrophizing can impact perceived pain intensity, which reveals the subjectivity of pain (Trost et al., 2011; George et al., 2007, 2008). Theoretically, if massage can reduce levels of anxiety and worry, it may provide some relief of DOMS symptoms.
Massage and DOMS
Although massage is a commonly used treatment for DOMS, little scientific evidence exists as to its overall effectiveness in improving strength and performance outcomes after exercise (Best et al., 2008; Cheung et al., 2003; Torres et al., 2012). There is however, a growing body of evidence to suggest that massage can reduce the pain and soreness associated with DOMS. The following is a collection of studies investigating the effectiveness that massage may have on pain, markers of inflammation and muscular breakdown, strength and power production, and is summarized in Table 1.
• Micklewright and colleagues examined 20 male subjects, new to strength training. The participants were asked to perform eccentric elbow extensions in order to induce DOMS. One group received soft tissue release (STR) while the other received no treatment. DOMS was assessed at 24 and 48 h after exercise. Researchers did not find any statistical reduction in the level of soreness between groups (Micklewright, 2009).
• Mancinelli and colleagues examined 22 female basketball and volleyball players, a group accustomed to exercise. Subjects were asked to perform quadriceps exercises to induce DOMS. 11 subjects received a massage to the quads which included effleurage, petrissage, skin rolling and vibration, while the other 11 received no treatment. The participants that received the massage had increased vertical jump displacement, and lower perceived soreness (Mancinelli et al., 2006).
• A study conducted by Zainuddin suggested massage might be beneficial for DOMS. Researchers studied 10 subjects; 5 men and 5 women. Participants were asked to perform eccentric bicep curls to induce DOMS. One arm received a 10 min massage, 3 h post exercise, while the other arm received no treatment. The massaged arm was found to have reduced activity of CK, as well as decreased soreness compared to the arm that did not receive the massage (Zainuddin et al., 2005).
• Rodenburg and colleagues separated 50 subjects into 2 groups after inducing DOMS. Group 1 performed a dynamic warm-up and stretching before exercise, and received a 15 min massage after exercise. Group 2 did not perform the warm up or receive a massage. Group 1 experienced less pain during the 96 h evaluation period (Rodenburg et al., 1994).
• Smith and colleagues had 14 participants perform elbow extension and flexion exercises to induce DOMS. Two hrs after exercise, the intervention group received a 30 min massage, which included effleurage and petrissage, while the control group received no treatment. Smith noted a reduction in soreness in the massage group from 24 to 96 h post exercise (Smith et al., 1994).
• Wenos and colleagues had participants perform eccentric knee extensions to induce DOMS. One leg received a massage, while the other leg received no treatment. Soreness was evaluated by a pain questionnaire 24, 48, and 72 h after exercise. The researchers found no significant difference between the massaged leg and the control leg (Wenos et al., 1990).
• Hilbert had 18 volunteers perform hamstring exercises to induce DOMS. The participants were then separated into two groups. The first group received a massage consisting of 5 min of effleurage, 1 min of tapotement, 12 min of petrissage, followed by 2 min of effleurage. The second group received a sham massage, which involved the therapist rubbing lotion on the participants’ legs and having them rest for the remaining 20 min. The massage was performed 2 h after exercise. Researchers found no significant differences in ROM, inflammatory markers or mood. They did discover that the group receiving the real massage reported a decrease in the intensity of soreness 48 h after exercise (Hilbert and Kimura, 2003).
• Farr and colleagues investigated the effects of a 30 min massage to 8 participants after walking downhill for 40 min. One leg received the treatment 2 h after exercise, while the other leg received no treatment. Muscle soreness, strength, and single leg vertical jump height were measured at multiple points in time after exercise. The intervention group had reduced soreness and tenderness; measures of strength showed no improvement compared to the control leg (Farr et al., 2002).
• Jakeman and others studied the effect of combining massage and the use of compressive clothing. Subjects performed 100 plyometric drop jumps and were assigned to one of three groups; a passive recovery group, a group which received a 30 min massage (performed immediately after exercise) followed by wearing compression stockings for 11.5 h, and a compression group which wore the stockings for 12 h after exercise. The combination group showed significantly less soreness at 48 and 72 h after exercise compared to the compression group and the passive recovery group. Both treatment groups had similar positive effects on isokinetic muscle strength, squat jump performance, and countermovement performance compared to the passive group (Jackeman et al., 2010).
Discussion of disparity
The majority of the studies included in this review do indicate that massage reduces perceived levels of soreness. In spite of this, drawing conclusions from this collection of work should be with caution, as there is a great amount of variance in study methods and designs. For example, massage techniques varied, as did the time spent performing different strokes. The overall consensus might be that massage reduces soreness; however, it remains unclear which techniques and dosages are optimal. The experience of the therapists was another inconsistency among the above listed studies. Some of the practitioners were physical therapy students; others were licensed massage therapists, while others were physiotherapists. Years of experience among the practitioners also varied within the mentioned studies. Backgrounds ranged from student status, to multiple years of professional experience. It is difficult to draw any firm conclusions in view of the discrepancy in practitioner type and years of practice within the bodywork field. The way in which DOMS was induced was another inconsistency among these studies. The muscle groups, exercises performed, angles of contraction, contraction velocity, and volume of exercise all varied. It is well documented that these factors can result in differing degrees of DOMS (Connolly et al., 2003; Paddon-Jones et al., 2005). It stands to reason, that if induction methods affect the expression of DOMS, these methods may also impact treatment success. For example, if DOMS was induced by performing 100 plyometric jumps, massage may have a very different result than if the subjects had performed 6 sets of 5 maximal, voluntary knee extensions.
Finally, the RBE might well be the most difficult variable to control within these studies. It is difficult to imagine that the researchers were able to account for all similar physical exposures among individual participants for up to two months prior to testing.
Difficulties of massage study
The human element in massage delivery and reception opens the door for study issues. Despite similar training, each therapist develops unique method of performing certain strokes. Likewise, the manner in which a therapist performs a treatment is dependent on several factors, such as mood, time of day, room temperature etc. If a massage can not be precisely duplicated, reliability becomes an issue. Along these same lines, there are certain intangibles that speak to the efficacy of massage, such as the therapist’s intention, depth of pressure, and speed of stroke. These critical components of therapy are difficult to quantify, measure and control.
With regard to study participants, an individual’s expectations may have a considerable influence on performance. Most individuals participating in these studies understand that decreased performance is likely after undergoing vigorous training. These expectations may have a confounding influence on the individual’s strength and power expression. This was evidenced when researchers used rabbits to investigate the effect that a machine that administered “massage-like compressive loading” has on strength. The researchers stimulated the hind legs of the rabbits to simulate eccentric exercise, after which the rabbits were divided into three groups. One group received four-15 min treatments beginning immediately after exercise; the second group began receiving the same 4 treatments, 48 h after exercise, and the third group received no treatment. Interestingly enough, the group that immediately received the massage, performed significantly better in strength and power tasks than the other two groups. The researchers concluded that immediate massage was more beneficial than delayed massage in restoring muscle function. They did note that the delayed massage group still outperformed the rabbits that did not receive any treatment (Haas et al., 2012). This research reveals that humans may assume that intensive exercise and muscle soreness naturally leads to temporary limitations in strength output. By using rabbits, the researchers were able to demonstrate that several doses of massage, performed immediately following exercise, can significantly improve strength and power expression.
Human expectation must also be considered in studies that compare subjects that receive massage to those that do not receive massage. Those in the intervention groups most likely recognize that they are recipients of a treatment, and naturally hold some expectation of change. This would suggest that massage studies involving limb vs limb analysis may be more revealing.
It is well documented that pain is a result of many factors and varies considerably among individuals (Gatchel et al., 2007; Vlaeyen and Linton, 2000). Understandably, the purpose of these studies required the need to isolate and measure the impact massage may have on DOMS; however, this may be impractical as the complexity of pain may call for varied interventions. This was indicated in the studies which combined treatments of dynamic warm-ups with massage and the use of compression garments with massage.
The possibility that subjects may attach different meaning to soreness, and how this subjective interpretation of pain can affect performance, would be worth investigating. The rabbit study by Haas and others clearly showed enhanced recovery of muscle function, a result that is not consistent with most studies involving humans. These findings, along with the research of Trost and George, indicate that psychosocial factors influence the pain experience. A greater understanding of why certain individuals exhibiting fear and catastrophizing beliefs perceive more pain would be helpful, not only to those within the strength and performance fields, but to those working with chronic pain sufferers.
Although studies by Hilbert, Farr, Zainuddin and Smith have all indicated that massage received between 2 and 3 h after exercise might be an ideal treatment window for the reduction of soreness, questions remain regarding dosage of massage. Along these same lines, it is unclear what depth of pressure and techniques therapists should use when working with DOMS sufferers. Repeated study of one specific massage protocol is needed to develop any potent conclusions.
Most studies have investigated the effects of local massage on DOMS symptoms. Given the established benefits that full-body massage has on chronic pain, it is likely the same systemic effects can help minimize the symptoms of DOMS.
Although debate continues, the general consensus is that DOMS is a combination of several mechanisms beginning with micro-trauma of muscles and connective tissues which is followed by an inflammatory process and edema. These events, along with genetic factors, exercise history, age and psychosocial factors will likely account for the varying degrees of DOMS symptoms. Massage has been studied as a treatment option for DOMS with promising results in reducing soreness, yet limited results in performance enhancement. As pain has been recognized as an integration of biopsychosocial events, future study of a more comprehensive treatment approach may be warranted.
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