'Recover quicker, train harder, and increase flexibility': Massage therapy for elite paracyclists, a mixed-methods study

Abstract

Objectives
Massage therapy (MT) enhances recovery by reducing pain and fatigue in able-bodied endurance athletes. In athletes with disabilities, no studies have examined similar MT outcomes, yet participation in sport has increased by >1000 athletes from 1996 to 2016 Olympic games. We examined the effect of MT on pain, sleep, stress, function and performance goals on the bike, as well as quality of life off the bike, in elite paracycling athletes.

Methods
This is a quasi-experimental, convergent, parallel, mixed-methods design study of one team, with nine paracycling participants, in years 2015 and 2016. One-hour MT sessions were scheduled one time per week for 4 weeks, and then every other week for the duration of the time the athlete was on the team and/or in the study. Closed and open-ended survey questions investigating athlete goals, stress, sleep, pain and muscle tightness were gathered pre and post each MT session, and every 6 months for health-related quality of life. Quantitative analysis timepoints include baseline, 4–6 months of intervention and final visit. Additional qualitative data were derived from therapists’ treatment notes, exit surveys, and follow-up emails from the athletes and therapists.

Results
Significant improvement was found for sleep and muscle tightness; quantitative results were reinforced by athlete comments indicating MT assisted in their recovery while in training. There were no improvements in dimensions measuring quality of life; qualitative comments from athletes suggest reasons for lack of improvement.

Conclusion
This real-world study provides new information to support MT for recovery in elite paracyclists.

Full text

KennedyAB, etal. BMJ Open Sport Exerc Med 2018;4:e000319. doi:10.1136/bmjsem-2017-000319 1
Open Access Original article
‘Recover quicker, train harder, and
increase exibility’: massage therapy
for elite paracyclists, a mixed-
methods study
Ann Blair Kennedy,1 Nirav Patil,2 Jennifer L. Trilk1
To cite: KennedyAB, PatilN,
TrilkJL.. ‘Recover quicker,
train harder, and increase
exibility’: massage therapy
for elite paracyclists, a mixed-
methods study. BMJ Open
Sport & Exercise Medicine
2018;4:e000319. doi:10.1136/
bmjsem-2017-000319
Accepted 22 December 2017
1Department of Biomedical
Sciences, University of South
Carolina School of Medicine
Greenville, Greenville, South
Carolina, USA
2Department of Quality
Management, Greenville Health
System, Greenville, South
Carolina, USA
Correspondence to
DrAnn BlairKennedy,
University of South Carolina
School of Medicine Greenville;
kenneda5@ greenvillemed. sc.
edu
ABSTRACT
Objectives Massage therapy (MT) enhances recovery
by reducing pain and fatigue in able-bodied endurance
athletes. In athletes with disabilities, no studies have
examined similar MT outcomes, yet participation in sport
has increased by >1000 athletes from 1996 to 2016
Olympic games. We examined the effect of MT on pain,
sleep, stress, function and performance goals on the bike,
as well as quality of life off the bike, in elite paracycling
athletes.
Methods This is a quasi-experimental, convergent,
parallel, mixed-methods design study of one team, with
nine paracycling participants, in years 2015 and 2016.
One-hour MT sessions were scheduled one time per week
for 4 weeks, and then every other week for the duration of
the time the athlete was on the team and/or in the study.
Closed and open-ended survey questions investigating
athlete goals, stress, sleep, pain and muscle tightness
were gathered pre and post each MT session, and every
6 months for health-related quality of life. Quantitative
analysis timepoints include baseline, 4–6 months of
intervention and nal visit. Additional qualitative data were
derived from therapists’ treatment notes, exit surveys, and
follow-up emails from the athletes and therapists.
Results Signicant improvement was found for sleep
and muscle tightness; quantitative results were reinforced
by athlete comments indicating MT assisted in their
recovery while in training. There were no improvements in
dimensions measuring quality of life; qualitative comments
from athletes suggest reasons for lack of improvement.
Conclusion This real-world study provides new
information to support MT for recovery in elite paracyclists.
BACKGROUND
In the past 20 years, the number of disabled
athletes competing at elite levels has increased,
as is witnessed in the number of participants
at the 1996 Summer Paralympics in Atlanta
(n=3255) compared with the number of
participants in 2016 in Rio (n=4328).1 The
Paralympics is not the only venue for disabled
athletes, as positive health and social benefits
have been noted for those who participate
in both professional and recreational adap-
tive sports.2–5 Yet studies demonstrate that
para-athletes also have higher incidence and
prevalence of injures compared with able-
bodied athletes.6–9
The increasing number of disabled
athletes, as well as increased risk of injuries,
gives credence for investigation into ways
to support disabled athletes during their
training and sport competition. Massage
therapy (MT) has been shown to improve
recovery by reducing pain and fatigue in
endurance able-bodied athletes.10 11 Addition-
ally, a recent analysis of treatments pursued
by athletes at the Pan American games indi-
cates that MT was the most sought treatment,
and more than half of MTs were performed
by massage therapists.12 Reports suggest MT
availability for para-athletes6 13 14; however,
to our knowledge, outcomes of MT treat-
ment have not been tracked for athletes with
disabilities. While no identifiable evidence
exists to support MT for disabled athletes,
there is evidence for MT benefiting those with
health conditions seen in para-athletes, such
as spinal cord injury,15–17 cerebral palsy18 19
and amputation.20 21
Best and Crawford,22 as well as Poppend-
ieck et al,23 suggest the need to investigate
multiple bouts of massage during an athletic
season for athletes to advance the science of
massage and sport recovery.22–26 The purpose
of this paper is to examine the effect of MT
on pain, sleep, stress, function and perfor-
mance goals on the bike, as well as the quality
Key messages
►Massage therapy aids able-bodied athlete recovery.
Until now, no studies have investigated the effects of
massage therapy in a para-athlete population.
►Massage therapy, however, showed no improvement
in health-related quality of life for a small sample of
elite paracyclists.
►Our study showed that massage therapy assisted
in para-athletes’ recovery, particularly in the area of
reducing muscle tightness and in improving sleep.
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2KennedyAB, etal. BMJ Open Sport Exerc Med 2018;4:e000319. doi:10.1136/bmjsem-2017-000319
Open Access
of life off the bike, in elite paracycling athletes in training
from January 2015 until the Rio Olympics in 2016.
METHODS
Participants
All members of Greenville Health System Team Roger C
Peace (Greenville, South Carolina, USA), an elite para-
cycling team, were invited to join the study in 2015 and
2016. In 2015, a total of 9 of the team’s 11 athletes began
the programme; two athletes left the team in 2015 and two
athletes dropped from the study prior to completing the
intervention. At the beginning of 2016, four new athletes
joined the team and began the study protocol. While a
total of 13 athletes completed the study visits; the data
from only of nine athletes were used for this analysis after
reviewing study visit timeline due to lack of consistent
survey completion by the athletes and massage therapists.
All participants signed a written informed consent.
Study design and intervention description
A quasi-experimental, convergent, parallel, mixed-
methods design was used.27 Both qualitative and
quantitative data were gathered in one phase of the
research, analysed separately and then merged to find
where the results converged. Merging the quantitative/
qualitative data strengthened the overall outcome by
providing more comprehensive results.27
In 2014, a standardised MT programme was designed
with the intention to help a decentralised team of elite
paracyclists to improve recovery, rest, performance and
quality of life both on and off the bike. The decentralised
nature of the paracycling team allowed for athletes to
be on the same team and also to live across the country.
Development of the programme is described elsewhere28
and included input from relevant stakeholders including
athletes, coaches and massage therapists. In brief,
the intervention allows for five different protocols (1,
general relaxation; 2, muscle relaxation; 3, combination
of general and muscle relaxation; 4, injury rehabilitation;
and 5, integrated injury rehabilitation and general and/
or muscular relaxation) to be integrated into clinical MT
treatment based on an intake assessment survey, which
also specified the athlete’s specific goals for the session.28
This type of flexible and adaptive protocol allows for indi-
vidualised treatment of athletes based on their treatment
goals and allows for the programme implementers (ie,
massage therapists) to work within their strengths and
skillsets.29–31 Massage therapists used to implement the
programme were identified either by the athlete, through
a search through a locator service, or through local and
national contacts. For massage therapists to be qualified
as implementers, they had to practise sports MT, be willing
to be trained in and follow study protocols, and be willing
to work with their assigned athlete. A total of 17 massage
therapists were recruited and trained as implementers via
online live webinar; more therapists were recruited than
athletes, as some athletes worked with multiple massage
therapists. Of the 17 massage therapists, 11 (64.71%)
were female and all therapists had an average of 14 years
(SD 8.59) in practice. Ten of the 17 therapists (58.8%)
held a bachelor’s degree or higher; 58.8% had more
than 600 hours of initial MT education. All massage ther-
apists were paid their standard fees for their services and
provided MT treatment in either their offices or in the
athlete’s home.
On entering the study and signing informed consent,
athletes were asked to schedule a 1-hour MT sessions
one time per week for 4 weeks (eg, loading phase) and
then every other week for the duration of the time (eg,
maintenance phase) they were on the team and/or in
the study. This schedule was chosen to try to minimise
time burden on the athletes, as well as mirror ‘real-world’
clinical implementation. The maximum amount of MT
sessions an athlete could obtain if they remained on the
team and in the study over the 18-month period was 39
MT sessions.
Outcome measures
Quantitative data were gathered from the RAND Medical
Outcomes Survey MOS Short Form Health Survey
36 (SF-36),32 33 or SF-36V34 (for non-ambulatory athletes),
and on an MT session intake and exit questionnaires to
measure stress, sleep, muscle tightness, spasticity and
pain on a 10-point scale, with higher numbers indicating
greater impairment.28 Qualitative data were obtained
from open-ended questions on the massage intake and
exit questionnaires, from the massage therapists’ treat-
ment notes, from the programme exit questionnaire,
as well as programme feedback emails provided by the
athletes.
Data collection
On entering the programme, the athletes completed
a health history form as well as either the SF-36 V.2 or
SF-36V. The athletes subsequently filled out the SF-36
(or SF-36V) after the 14th MT session (approximately
6 months into the programme) and at the end of the
programme. The MT session intake surveys were emailed
to each athlete on the morning of their scheduled MT
session; once the survey was completed, an email noti-
fication was sent to their massage therapist. Massage
therapists also received an email link to their treatment
notes on the morning of the scheduled session with
their athlete. The morning after the MT session, athletes
received the session exit survey to follow up on progress
after treatment. All surveys were managed through the
REDCap system, a secure and Health Insurance Porta-
bility and Accountability Act (HIPAA)-compliant system
for survey and database development.35
Data analysis
Quantitative analysis (SAS Enterprise Guide Software,
V.7.1) included comparing the nine dimensions of SF-36
questionnaire and the 10-point scales for pain, sleep,
function, spasticity and stress before, during and after
the intervention. Repeated-measures analysis of variance
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KennedyAB, etal. BMJ Open Sport Exerc Med 2018;4:e000319. doi:10.1136/bmjsem-2017-000319
Open Access
(ANOVA) was used to analyse the differences in compar-
ison variables at three timepoints: baseline, at 4–6 months
and at final visit. Further, multiple pairwise comparison
was performed using Tukey’s test whenever a significant
difference was revealed by repeated-measures ANOVA.
The difference between intake and exit outcome vari-
ables was analysed at each timepoint separately using
paired t-test. P values less than 0.1 are considered signifi-
cant for this feasibility study.
Qualitative analysis (NVivo V.11 qualitative data anal-
ysis software; QSR International, Doncaster, Victoria,
Australia) began with data immersion by reading and
rereading the text provided by the athletes and thera-
pists. Next, word count queries were performed for each
qualitative survey question, athlete feedback emails and
the therapists’ notes to begin to understand potential
patterns in the data.36 Then initial codes were created
from the textual data through an iterative thematic anal-
ysis process of reading the data and highlighting text
and assigning a code identifier.37 Once all the data were
coded, emergent themes were identified by gathering
similar codes together.37 The coding scheme evolved to
have four major themes: goals for MT sessions, perceived
benefits of MT sessions, beliefs and expectations about
MT, and the interaction and importance of the thera-
peutic relationship with their massage therapist. These
themes are mentioned here, in the Methods, as they then
guided the integration of the quantitative and qualita-
tive data. The quantitative results tables were integrated
with athlete and therapist comments from the represen-
tative themes. These qualitative quotations were used to
explore and expand the understanding and of the quan-
titative findings.38 39
RESULTS
Participants
Seven male and two female athletes of the Roger C Peace
paracycling team (analysis n=9) with an average age of
39.14 (SD 9.23) years and an average time since injury/
impairment of 19.09 years (SD 12.02) provided sufficient
data for analysis. Figure 1 indicates the states where the
athletes lived; it should be noted that one athlete split his
time living in two separate states (Ohio and Florida) and
received the intervention in both locations.
The athletes presented with varying impairments that
limited activity: three with spinal cord injuries, two with
amputations, one with stroke, one with traumatic brain
injury, one with a lower limb crush injury leading to
neuromuscular impairment, and one with cerebral palsy.
In the sport of paracycling, an athlete’s level of impair-
ment is evaluated and graded to allow athletes of similar
abilities to compete against each other. Of the grades
(1–5), a lower grade represents a greater physical impair-
ment and limitation for activity; an athlete with a grade of
2 has a greater impairment and a higher level of disability
than an athlete with a grade of 5.40 Additionally, there
are four types of sport class categories in which athletes
can compete: handcycle, tricycle, tandem and upright
bicycle.40 The categories in which the athletes compete
include three handcyclists (two H3, one H4), one tricycle
(T1), and five cyclists (three C5, one C4, one C2).
Athlete perceptions of quality of life
Athletes’ quality of life was quantitatively assessed with
the SF-36 and confirmed with qualitative data (figure 2).
The dimensions within the SF-36 are created by aver-
aging items together, each scale totalling up to 100, with
higher scores indicating higher quality of life. Athletes’
comments (figure 2) point to other indicators for lack
of improvement, including the level of disability of the
athletes, less than desired frequency of MT, amount of
intense training and continued health issues for many of
the athletes.
Athlete goals point to benets and outcomes
The athletes indicated that reducing muscular tension
was their most often sought goal for treatment, while
pain reduction was mentioned less often on the session
intake form (figure 3). However, within the therapist’s
notes, pain reduction was mentioned as an athlete’s
session goal (figure 3).
In figures 4 and 5, it should be noted that pain is not
included in the outcome variable comparison, as the
athletes did not sufficiently answer both intake and exit
questions for this variable. Figure 4 looks at each variable
longitudinally by pre-MT or post-MT. Figure 5 exam-
ines the variables pre-MT and post-MT to each other
and longitudinally. The athletes report several benefits
of treatment, with the most often reported benefit of
assisting in recovery from training and racing including
relief from symptoms and helping with sleep. These
benefits from recovery led to improved training and
racing performance.
Programme implementation
Programme implementation data and programme exit
survey data indicated that the recommended protocol of
one massage per week for 4 weeks and then every other
week for the length of the study appeared to be difficult
to follow. Athlete travel, life events, transportation issues
Figure 1 State residence of athletes.
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4KennedyAB, etal. BMJ Open Sport Exerc Med 2018;4:e000319. doi:10.1136/bmjsem-2017-000319
Open Access
and busy athlete schedules were indicated as barriers to
maintaining the protocol. Additionally, while surveys were
delivered electronically to both athletes and therapists,
and therapists were expected to check the completion of
the surveys prior to initiation of therapy session, survey
completion for all sessions (intake, exit and therapist’s
notes) was not consistently completed by all athletes or
massage therapists.
DISCUSSION
In this quasi-experimental, mixed-methods design study,
elite paracycling athletes reported an improvement in
muscular tension and sleep after MT treatment. This
study found three noteworthy results: (1) Athletes’
expectations and programme implementation may
have impacted the expected improvement in athletes’
quality of life. (2) Verbal intakes may be important when
compared with written intake forms to help elucidate
goals and improve treatment. (3) The athletes’ percep-
tions of the benefits of MT, mainly assisting in recovery,
support the quantitative improvement in reduced muscle
tightness and sleep.
MT improves the quality of life in many popula-
tions.41–45 Yet MT did not significantly improve quality of
Figure 2 Athletes’ perceptions of quality of life. Integration of quantitative and qualitative data. Results of SF-36 and quotes
from athletes from quality of life and massage expectations themes.ANOVA, analysis of variance.
Figure 3 Word frequencies displayed in a word cloud exploring the athlete’s goals for sessions from the athlete reported goal
on the intake form and from the athlete report (verbal) to therapist as indicated by the therapist in their notes.
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Open Access
life as measured by the SF-36 instruments for the paracy-
clists. This could be because some of the expectations of
treatment did not lead to the desired outcomes (as noted
by the athletes’ comments from the qualitative data) or
it could result from the inconsistent programme imple-
mentation.
The scarcity of reporting pain reduction as a goal
of treatment in written form by the athletes versus the
Figure 4 Athletes’ goals point to perceived benets and outcomes. Integration of quantitative and qualitative data. Outcome
variables comparison from intake (pre-MT) and exit forms (post-MT) and quotes from athletes and from therapist notes.
ANOVA, analysis of variance; MT, massage therapy.
Figure 5 Athletes’ perceived benets and outcomes. Integration of quantitative and qualitative data. Comparison at each
timepoint from intake exit (pre-MT and post-MT) forms and quotes from athletes and from therapist notes. MT, massage
therapy.
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6KennedyAB, etal. BMJ Open Sport Exerc Med 2018;4:e000319. doi:10.1136/bmjsem-2017-000319
Open Access
greater indication of pain reduction as a goal as indicated
in the therapists’ notes may indicate the importance of
communication between the therapist and the patient.
Communication within an MT practice has not yet
been investigated, but it has been mentioned as a crit-
ical component of care within the MT setting.46 47 Other
healthcare literature indicates improved outcomes for
patients with good healthcare provider communica-
tion48–51 and findings could be similar for MT treatment.
Additionally, while MT did not significantly improve
pain or stress, another hypothesis could be an actual
focus of the athletes to shift more from relieving pain
to improving function, as is indicated by their most indi-
cated goals of reducing muscle tightness/tension. This
shift, from pain management to functional improvement,
is mentioned as a new suggestion in the management
of subacute and chronic pain in elite athletes by the
International Olympic Committee (IOC); the IOC also
suggests that treatment should take a multidisciplinary
approach.52 In the IOC report, the committee does take
special note of Paralympic athletes indicating they may
have more pain than able-bodied athletes and therefore
may have higher usage of pain medications, yet there is
not mention of the multidisciplinary approach for these
athletes.52 This lack of mention of additional approaches
could be due to the current lack of evidence for MT
benefiting Paralympic athletes.
Our study extends previous studies in various non-ath-
lete and athlete populations (including those with breast
cancer, pregnant women, older individuals, patients with
fibromyalgia, osteoarthritis, athletes and healthy individ-
uals) indicating MT can aid in improving sleep44 53 54 and
muscle tightness.45 55–57 Ours is the first study to investigate
these outcomes in a para-athlete population. Integrating
the qualitative results indicates that athletes felt that MT
helped with recovery and training. The athletes clearly
indicated in the qualitative data that they felt MT helped
them to train harder, rest better and possibly perform
better. These results mirror previous studies showing MT
assisting in recovery from exercise in able-bodied individ-
uals.11 58–60
Limitations and future directions
Results should be viewed with caution as the limitations
include a small sample size with no comparison group.
Furthermore, the measures used to evaluate change in
the population are largely subjective, and the athletes and
therapists did not consistently supply data via forms or
consistently follow the recommended protocol. However,
this study was implemented in real-world settings, and
lack of consistent survey completion still led to positive
outcomes.
Additionally, this is the first known study to follow
decentralised athletes for this length of time, as most
massage studies are short in duration (one to six sessions
generally). This study shows continued improvements in
muscle tightness and sleep over time. Further research
is needed to explore the impact of MT on pain in this
population, as well as investigate the effect of MT on
para-athletes in other adaptive sports.
CONCLUSION
Previous work reported MT as a common technique for
athletes to use to reduce recovery time,11 25 26 although
to date no literature has explored the effects of MT in
a para-athlete population. This real-world implemented
study provides new information to support MT for
recovery in elite paracyclists.
Acknowledgements The authors would like to thank and acknowledge the
massage therapists who implemented the study throughout the country. Their work
and willingness to engage in the training and research process made this project
possible. We would also like to thank the athletes of Team Roger C Peace, the team
manager Jerry Page and the Director Sportif Jim Cunningham for their tireless
efforts to train harder, recover quicker and nd the best ways to support each other
in the sport of paracycling as well as in life.
Contributors ABK designed the intervention, analysed the qualitative data and
prepared the manuscript. NP analysed the quantitative data and helped to prepare
the manuscript. JLT helped to design the intervention and helped to prepare the
manuscript.
Funding This project was funded by the generous sponsorship of Team Roger C
Peace by the American Massage Therapy Association.
Competing interests None declared.
Patient consent Obtained.
Ethics approval This study was approved by the Institutional Review Board at
the Greenville Health System Ofce of Research Compliance and Administration
(Pro00036860).
Provenance and peer review Not commissioned; externally peer reviewed.
Open Access This is an Open Access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited and the use is non-commercial. See: http:// creativecommons. org/
licenses/ by- nc/ 4. 0/
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2018. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
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paracyclists, a mixed-methods study
flexibility': massage therapy for elite
'Recover quicker, train harder, and increase
Ann Blair Kennedy, Nirav Patil and Jennifer L. Trilk
doi: 10.1136/bmjsem-2017-000319
2018 4: BMJ Open Sport Exerc Med
http://bmjopensem.bmj.com/content/4/1/e000319
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