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174 Volume 40
•
Number 3
•
September 2005
Journal of Athletic Training 2005;40(3):174–180
q by the National Athletic Trainers’ Association, Inc
www.journalofathletictraining.org
Effects of Massage on Delayed-Onset
Muscle Soreness, Swelling, and Recovery
of Muscle Function
Zainal Zainuddin*†; Mike Newton*; Paul Sacco*; Kazunori Nosaka*
*Edith Cowan University, Joondalup, Western Australia, Australia; †University Technology of Malaysia, Johor,
Malaysia
Zainal Zainuddin, MS, contributed to conception and design; acquisition and analysis and interpretation of the data; and
drafting, critical revision, and final approval of the article. Mike Newton, MS, contributed to conception and design and critical
revision and final approval of the article. Paul Sacco, PhD, contributed to conception and design; analysis and interpretation of
the data; and critical revision and final approval of the article. Kazunori Nosaka, PhD, contributed to conception and design;
acquisition and analysis and interpretation of the data; and drafting, critical revision, and final approval of the article.
Address correspondence to Kazunori Nosaka, PhD, School of Exercise, Biomedical and Health Sciences, Faculty of
Computing, Health and Science, Edith Cowan University, 100 Joondalup Drive, Joondalup, Western Australia 6027, Australia.
Address e-mail to k.nosaka@ecu.edu.au.
Context:
Delayed-onset muscle soreness (DOMS) describes
muscle pain and tenderness that typically develop several
hours postexercise and consist of predominantly eccentricmus-
cle actions, especially if the exercise is unfamiliar. Although
DOMS is likely a symptom of eccentric-exercise–induced mus-
cle damage, it does not necessarily reflect muscle damage.
Some prophylactic or therapeutic modalities may be effective
only for alleviating DOMS, whereas others may enhance re-
covery of muscle function without affecting DOMS.
Objective:
To test the hypothesis that massage applied after
eccentric exercise would effectively alleviate DOMS without af-
fecting muscle function.
Design:
We used an arm-to-arm comparison model with 2
independent variables (control and massage) and 6 dependent
variables (maximal isometric and isokinetic voluntary strength,
range of motion, upper arm circumference, plasma creatine ki-
nase activity, and muscle soreness). A 2-way repeated-mea-
sures analysis of variance and paired
t
tests were used to ex-
amine differences in changes of the dependent variable over
time (before, immediately and 30 minutes after exercise, and
1, 2, 3, 4, 7, 10, and 14 days postexercise) between control
and massage conditions.
Setting:
University laboratory.
Patients or Other Participants:
Ten healthy subjects(5men
and 5 women) with no history of upper arm injury and no ex-
perience in resistance training.
Intervention(s):
Subjects performed 10 sets of 6 maximal
isokinetic (908·s
21
) eccentric actions of the elbow flexors with
each arm on a dynamometer, separated by 2 weeks. One arm
received 10 minutes of massage 3 hours after eccentric exer-
cise; the contralateral arm received no treatment.
Main Outcome Measure(s):
Maximal voluntary isometric
and isokinetic elbow flexor strength, range of motion, upper arm
circumference, plasma creatine kinase activity, and muscle
soreness.
Results:
Delayed-onset muscle soreness was significantly
less for the massage condition for peak soreness in extending
the elbow joint and palpating the brachioradialis muscle (
P
,
.05). Soreness while flexing the elbow joint (
P
5 .07) and pal-
pating the brachialis muscle (
P
5 .06) was also less with mas-
sage. Massage treatment had significant effects on plasma cre-
atine kinase activity, with a significantly lower peak value at 4
days postexercise (
P
, .05), and upper arm circumference,
with a significantly smaller increase than the control at 3 and 4
days postexercise (
P
, .05). However, no significant effects of
massage on recovery of muscle strength and ROM were evi-
dent.
Conclusions:
Massage was effective in alleviating DOMS by
approximately 30% and reducing swelling, but it had no effects
on muscle function.
Key Words:
elbow flexors, muscle strength, range of motion,
creatine kinase
E
xercise consisting of predominantly eccentric muscle
actions has the potential to cause greater injury to mus-
cles than that involving largely isometric or concentric
actions, especially if the exercise is unfamiliar.
1–3
Muscle pain
and tenderness generally develop 24 hours after such exercise
and are usually described as delayed-onset muscle soreness
(DOMS).
2,4,5
Undoubtedly, DOMS is one of the symptoms of
eccentric-exercise–induced muscle damage; however, DOMS
does not necessarily indicate muscle damage.
5
The level of
DOMS does not reflect the extent of muscle damage, and the
course of DOMS does not correspond to the course of changes
in other indicators of muscle damage.
5,6
In this context, it is
necessary to separate DOMS from other symptoms of eccen-
tric-exercise–induced muscle damage, especially when inves-
tigating prophylactic or therapeutic modalities. It may be that
some interventions are effective only for alleviating DOMS,
but others enhance recovery of muscle function without af-
fecting DOMS. Thus, when a treatment is found to alleviate
DOMS without any effects on recovery of muscle function,
the treatment is still effective if DOMS is the main concern.
A number of prophylactic or therapeutic measures have
been examined for their efficacy in preventing or reducing
Journal of Athletic Training 175
DOMS and other outcomes of eccentric-exercise–induced
muscle damage.
6,7
Massage is widely used as a therapeutic
modality for recovery from muscle fatigue and injury
8–11
and
is probably one of the most popular treatments after sports
activities. Although physiologic theory to support how mas-
sage facilitates recovery from eccentric-exercise–inducedmus-
cle damage is obscure,
8
a massage is often recommended by
coaches and therapists to alleviate or prevent DOMS after a
sporting activity.
6,8–10
A number of authors have examined the effects of massage
on DOMS and indirect markers of muscle damage such as
impairment of muscle function, swelling, and changes in mus-
cle proteins in the blood. Doubt has been cast on the effec-
tiveness of massage therapy in aiding DOMS and recovery of
muscle function.
8,10
In fact, an 8-minute massage immediately
postexercise has no effect on DOMS and recovery of muscle
strength.
12
Another author
9
concluded that massage therapy
might be a promising intervention for reducing DOMS if mas-
sage treatment enhances local blood and lymph flow and stated
the necessity of further research. In line with the positive effect
of massage on DOMS, a 30-minute massage, applied 2 hours
after eccentric exercise of the elbow flexors and extensors,
reduces DOMS.
13
A recent group
14
reported that a 30-minute
therapeutic massage of one leg 2 hours after downhill running
was effective in attenuating DOMS compared with the contra-
lateral limb with no treatment, but it caused declines in muscle
strength and power. Other researchers
15,16
have also found that
massage attenuates DOMS to varying degrees but does not
affect muscle function. Furthermore, combining warm-up,
stretching, and massage has been reported to have some effect
on DOMS and muscle function; however, it is not clear how
much of the effect was associated with massage.
17
The find-
ings about the effects of massage on DOMS and muscle func-
tion are inconclusive or contradictory in nature.
8–10
One reason for the controversy seems to stem from the dif-
ferent eccentric exercise models used in the studies, which
result in different magnitudes of damage to different muscles.
A second possible confounding factor is the fact that individ-
uals show wide variations in their responses to the same ex-
ercise protocol.
2,5,18
The large variability in responses among
individuals to the effects of eccentric exercise has made com-
parison with control conditions difficult. Most of the previous
authors of massage studies
12,13,15,17
have compared massage
and control groups composed of different populations of sub-
jects. The inconsistency among subjects in response to eccen-
tric exercise is likely to act as a confounding factor, reducing
the likelihood of exposing any positive effects the massage
therapy may have provided. One solution to this problem is
to use a ‘‘limb-to-limb’’ comparison model, in which a treat-
ment limb is compared with responses from the contralateral
(untreated) limb of the same subject. Two groups
14,16
used a
leg-to-leg comparison model by assigning one leg to massage
and the contralateral leg to the control condition. No investi-
gators have used an arm-to-arm comparison model to inves-
tigate the effects of massage on DOMS and other markers of
muscle damage after eccentric exercise. Because of the sub-
jective nature of pain sensation, comparing the massage and
control conditions in the same subject would be preferable.
Therefore, our purpose was to examine the effects of mas-
sage on DOMS, muscle strength, range of motion (ROM),
swelling, and a biochemical marker of muscle damage in the
blood using the arm-to-arm comparison model. We expected
that the arm-to-arm comparison model would offer a better
indication of whether massage is effective in alleviating
DOMS and enhancing recovery of muscle function after ec-
centric exercise.
METHODS
Subjects
Ten healthy subjects (5 men and 5 women) with no history
of upper arm injury and no experience in resistance training
were recruited after approval from the Institutional Ethics
Committee. The number of subjects was determined by a pow-
er analysis with 80% power and a 1-tailed level of significance
of P , .05 based on the data from our pilot study. The mean
6 SEM age, height, and mass of the subjects were 23.0 6 1.3
years, 163.2 6 4.8 cm, and 63.7 6 3.8 kg, respectively. Dur-
ing the experimental period, subjects were requested not to
take any medication, change their diet, or perform any stren-
uous exercise.
Experimental Design
We used an arm-to-arm comparison model: one arm was the
control, and the other arm was assigned to a treatment con-
dition. Subjects performed an identical, maximal eccentric ex-
ercise of the elbow flexors with each arm, separated by 2
weeks. For the treatment condition, subjects received a 10-
minute massage on the exercised arm 3 hours postexercise.
Therefore, the independent variables were the 2 conditions:
control and treatment (massage). Dependent variables consist-
ed of maximal isometric and isokinetic voluntary strength,
ROM, upper arm circumference, plasma creatine kinase (CK)
activity, and muscle soreness. Subjects reported to the labo-
ratory on 9 occasions, including one familiarization session
before the baseline measurements. Measurements were taken
before, immediately after and 30 minutes after the exercise,
and on days 1, 2, 3, 4, 7, 10, and 14 postexercise. Changes in
the measures over time were compared between the control
and experimental arms.
Exercise
The exercise protocol consisted of 60 maximal voluntary
eccentric contractions of the elbow flexors against the lever
arm of the isokinetic dynamometer (Cybex 6000; Lumex Inc,
Ronkonkoma, NY) moving at constant velocity of 908·s
2
1
.
Subjects were seated on an arm-curl bench with the forearm
in a supinated position and the elbow aligned with the axis of
rotation of the dynamometer lever arm. The movement began
at an elbow joint angle of 908 (the extended elbow is consid-
ered as 08). The elbow joint was forcibly extended from the
flexed position (908) to the extended position (08) in 1 second
while the subject was asked to resist maximally against the
motion. After each eccentric action, the lever arm of the iso-
kinetic dynamometer returned to the starting point at the ve-
locity of 98·s
2
1
while the subject was relaxing the arm, so that
a 10-second passive recovery period was allowed between ec-
centric repetitions. The 60 maximal eccentric actions were di-
vided into 10 sets of 6 repetitions, with a 3-minute rest be-
tween sets. Torque output was recorded and displayed in real
time for each eccentric action, and the data were saved in a
desktop computer with AMLAB data-acquisition software
(version II; AMLAB Technologies, Lewisham, Australia).
176 Volume 40
•
Number 3
•
September 2005
Massage
A standard 10-minute sports massage was applied to the
exercised arm by a qualified massage therapist 3 hours post-
exercise for the massage condition. The therapist was a pro-
fessional masseuse who had been working for an Australian
football club for several years. The 3-hour time point was cho-
sen based on a previous study.
13
The massage protocol used
deeply applied clearing techniques with palmar and finger
stroking to the muscles. Massage was applied as the subject
lay on his or her back on a massage table. The 10-minute
massage consisted of effleurage (stroking) of the hand (30 sec-
onds), wrist to elbow (1 minute), and elbow to shoulder (1
minute); petrissage (kneading) of the wrist to the elbow (30
seconds) and elbow to shoulder (30 seconds); frictions to the
forearm (1 minute), biceps, triceps, and deltoids (1 minute);
thumb petrissage of the wrist to the elbow (1 minute) and
elbow to shoulder (1 minute); and repeat effleurage of the hand
(30 seconds), wrist to elbow (1 minute), and elbow to shoulder
(1 minute). Under verbal instruction recorded on an audiocas-
sette, the same therapist performed the massage protocol
throughout. The therapist was requested to keep the depth and
rate of massage as consistent as possible.
Criterion Variables
Maximal voluntary isometric and isokinetic elbow flexor
strength, elbow joint angles and ROM, upper arm circumfer-
ence, plasma CK activity, and muscle soreness were measured
for the exercised arm. All measurements were taken twice dur-
ing the familiarization session. Measurements were taken be-
fore, immediately and 30 minutes after, and 1, 2, 3, 4, 7, 10,
and 14 days postexercise. Plasma CK activity and muscle sore-
ness were measured at the same time points as those described
previously except for immediately and 30 minutes postexer-
cise.
Muscular Strength. We used an isokinetic dynamometer to
record isometric and isokinetic concentric torque during max-
imal voluntary contractions of the elbow flexors. Verbal en-
couragements were given during the measurements. For the
isometric contractions, subjects were asked to sustain maximal
effort for 3 seconds at fixed elbow joint angles of 908 and 308,
where 08 was referred to as a full extension angle. The 908
position has been used in previous studies
2,5,17
to measure iso-
metric strength of the elbow flexors, and the 308 position was
added to examine a possible effect of an optimal angle shift.
Two measurements were performed for each angle, and the
highest peak torque value was used for subsequent analysis.
The rest between maximal isometric contractions was 30 sec-
onds, and a 1-minute recovery period was allowed between
tests at different joint angles.
We assessed concentric maximal voluntary torque of the
elbow flexors isokinetically at 5 velocities (30, 90, 150, 210,
and 3008·s
2
1
) with the same subject positioning as in the iso-
metric assessment, with 908 ROM identified as extension (08)
to flexion (908). The isokinetic strength testing was performed
in order of increasing velocity from 308·s
2
1
to 3008·s
2
1
, with
the highest peak torque from 2 trials being accepted. A 5-
second period was provided between attempts at a given ve-
locity and a 1-minute recovery period between different ve-
locities.
Range of Motion. A plastic goniometer (Sammon Preston
Rolyan, Bolingbrook, IL) was used to measure the total active
ROM for the elbow joint. The ROM was determined as the
difference between the actively flexed and extended elbow
joint angles. The active flexion angle was defined as the angle
at the elbow when attempting to fully flex the elbow joint to
touch the shoulder with the palm, and the active extended
angle was the angle when attempting to extend the elbow joint
as much as possible. To measure the elbow joint angles, we
used a semipermanent ink pen to create landmarks on the skin
and obtain consistent measurements. These measurements con-
sisted of the lateral epicondyle of the humerus, the acromion
process, and the midpoint of the styloid process of the ulna
and radius. Two measurements were taken for each angle, and
the mean value of the 2 measurements was used for analysis.
Upper Arm Circumference. A constant tension tape mea-
sure was used to measure the upper arm circumference of 5
marked sites: 3, 5, 7, 9, and 11 cm from the elbow crease.
The marks were maintained using a semipermanent ink marker
during the experimental period. Measurements were taken
while the subject’s relaxed arm was hanging by the side. Two
measurements were taken from each marked site and averaged.
The mean value of the 5 sites was calculated and used for
further analysis.
Plasma Creatine Kinase Activity. Approximately 50 mL
of blood was collected from a finger of the exercised arm in
a heparinized tube from a finger prick made with a spring-
loaded lancet. The blood sample was immediately analyzed
using a Reflotron spectrophotometer (Boehringer-Manheim,
Pode, Czech Republic) for plasma CK activity. The normal
reference range for CK using this method is 50 to 220 IU·L
2
1
,
and the assay can accurately detect values between 20 and
2000 IU·L
2
1
, according to the manufacturer’s manual. When
the value exceeded 2000 IU·L
2
1
, another blood sample was
taken and diluted to obtain a value within the range, and the
actual value was calculated.
Muscle Soreness. Muscle soreness was rated with a visual
analog scale that incorporated a 100-mm line, with 0 indicat-
ing no pain and 100 representing extremely painful. Subjects
were asked to mark their perceived soreness on the 100-mm
line when the elbow joint was forcibly flexed and extended
by an investigator and when an investigator palpated the bra-
chialis and brachioradialis. The pressure applied to the muscles
during the palpation was kept as similar as possible between
days by consistently matching the indentation of the palpated
sites. Distance from the left edge of the line (0) to the marked
point was measured in millimeters, and this value was used
for the analysis.
Reliability of the Measurements. The same investigator
took all the measurements. We used the intraclass correlation
coefficient to analyze the reliability of the measurements with
data from the 10 subjects for the 2 pre-exercise measurements
taken during the familiarization session and before exercise.
The formula for the intraclass correlation coefficient was R 5
(MS
S
2 MS
E
)/MS
S
, where MS
S
was the mean square for sub-
jects and MS
E
was the mean square for error, which is com-
puted as follows: (sums of squares for trials 1 sums of squares
for interaction)/(df for trials 1 df for interaction). The R values
for isometric and isokinetic strength, ROM, upper arm circum-
ference, plasma CK activity, and muscle soreness were 0.91,
0.90, 0.89, 0.98, 0.94, and 0.95, respectively.
Data Analysis
Changes in muscle strength, ROM, circumference, plasma
CK activity, and muscle soreness over time were compared
Journal of Athletic Training 177
Figure 1. Changes in maximal voluntary isometric torque from
baseline (pre), immediately after (0), and 1 to 14 days postexercise
for the massage and control arms expressed as a percentage of
baseline. # Indicates a significant difference from baseline.
Table 1. Changes in Peak Isokinetic Torque Before, Immediately After, and 1 to 14 Days After Exercise for the Control and Massage
Conditions (N 5 10)
Torque and
Condition
Mean (SEM) Peak Isokinetic Torque, Nm
Pre-exercise Postexercise
Days After Exercise
123471014
308·s
21
Control
Massage
25.8 (4.8)
25.6 (4.4)
17.3 (3.2)
17.7 (2.9)
14.8 (2.8)
18.9 (4.4)
16.0 (2.5)
19.5 (3.9)
19.0 (3.9)
21.0 (4.5)
20.2 (4.2)
23.0 (4.3)
21.6 (4.1)
23.1 (3.9)
22.2 (4.1)
25.7 (4.2)
23.3 (4.5)
25.4 (4.7)
3008·s
21
Control
Massage
19.8 (4.2)
19.3 (4.2)
14.8 (3.8)
13.2 (3.2)
14.5 (2.9)
13.9 (3.9)
15.0 (3.4)
15.2 (3.7)
14.2 (3.2)
17.2 (3.7)
14.8 (3.3)
16.7 (3.9)
16.2 (3.6)
17.0 (4.1)
19.2 (3.5)
19.4 (4.1)
18.1 (3.7)
18.3 (3.6)
between the massage and control conditions using a 2-way
repeated-measures analysis of variance. When the analysis of
variance showed a significant difference between conditions,
we applied a Tukey post hoc test to find the location of the
significance. Peak soreness (extension, flexion, and palpation)
was compared between conditions by a paired t test. Paired t
tests were also used to examine differences between conditions
for peak plasma CK activity and change in arm circumference.
Data analysis was performed using a statistical software pack-
age (SPSS version 11.0; SPSS Inc, Chicago, IL). Statistical
significance was set at P , .05 for all analyses. Data are pre-
sented as mean 6 SEM unless otherwise stated.
RESULTS
Exercise
All subjects performed 2 bouts of maximal eccentric exer-
cise. Baseline values for the maximal isometric and isokinetic
strength showed no significant differences (P 5 .93 and .95,
respectively) between the massage and control arms. Also,
peak torque and total work values recorded during the eccen-
tric exercise protocol were similar for the 2 conditions, and
no significant differences between the arms were evident.
Muscular Strength
Maximal isometric torque was significantly larger at an el-
bow angle of 908 (37.2 6 6.6 Nm) than at 308 (27.3 6 4.6
Nm) before exercise and throughout the measurements; how-
ever, the magnitude of decrease in torque postexercise was
similar between the 2 angles. No significant differences (P 5
.74) in maximal isometric torque at 2 different angles were
observed between the massage and control arms. As shown in
Figure 1, isometric torque decreased to approximately 60% of
pre-exercise values immediately postexercise and remained at
this level for 2 days, after which the torque returned to the
pre-exercise level by 10 days postexercise. The treatment and
control arms displayed a similar degree of strength loss post-
exercise, and no significant difference (P 5 .64) between arms
was evident for the changes in isometric torque over time.
The isokinetic torque at 5 velocities showed similar changes
postexercise, although some differences among the velocities
were evident for the absolute values. The largest difference
among the velocities was observed between 308·s
2
1
and
3008·s
2
1
(Table 1). Changes in maximal voluntary isokinetic
torque were similar to those in the isometric torque during the
postexercise period. Furthermore, no significant difference (P
5 .82) between the treatment and the control arms for any of
the velocities tested was evident. The isokinetic torque recov-
ered to the pre-exercise level by 10 days postexercise for both
conditions.
Range of Motion
No significant difference in the pre-exercise ROM values
was evident between the control and massage arms (P 5 .70).
The ROM decreased significantly (P 5 .04) immediately post-
exercise by approximately 30% from baseline and did not re-
cover for the next 4 days. Changes in ROM postexercise were
similar between conditions (Table 2).
Upper Arm Circumference
The baseline upper arm circumference was not significantly
different between the arms (P 5 .74). Upper arm circumfer-
ence increased significantly (P 5 .04) postexercise in both
conditions, and the massaged arm showed a significantly
smaller increase than the control arm (P 5 .04) (see Table 2).
Significant differences in circumference between the massage
and control arms were recorded at 3 (P 5 .04) and 4 days (P
5 .03) postexercise.
178 Volume 40
•
Number 3
•
September 2005
Table 2. Changes in Range of Motion and Upper Arm Circumference From the Pre-exercise Level to Immediately After and 1 to 14
Days After Exercise for the Control and Massage Conditions (N 5 10)
Variable
and
Condition Postexercise
Days After Exercise
123471014
Mean (SEM) range of motion, 8
Control
Massage
215.2 (1.9)
216.6 (4.3)
216.4 (3.2)
214.3 (3.9)
215.1 (3.6)
211.8 (3.5)
217.4 (4.6)
210.2 (2.2)
219.0 (4.1)
27.8 (2.0)
210.3 (3.7)
21.6 (2.4)
22.8 (3.4)
20.5 (1.8)
0.8 (2.1)
0 (1.8)
Mean (SEM) upper arm circumference, mm
Control
Massage
2.3 (1.3)
1.0 (1.2)
5.2 (1.6)
1.1 (1.6)
5.9 (1.5)
4.1 (2.1)
7.8 (1.4)
2.5 (1.2)*
10.4 (2.0)
3.3 (1.3)*
10.9 (2.1)
6.8 (1.8)
6.5 (1.8)
2.8 (1.8)
4.8 (2.0)
0.7 (1.0)
* Significant difference from the control (
P
, .05).
Figure 2. Changes in plasma creatine kinase (CK) activity before
(pre) and 1 to 14 days postexercise for the massage and control
arms. * Indicates a significant difference between arms; #, a sig-
nificant difference from baseline.
Table 3. Peak Muscle Soreness With Palpating the Brachialis and
Brachioradialis Muscles and Flexing and Extending the Elbow
Joint After Exercise for the Control and Massage Conditions
(N 5 10)
Condition
Mean (SEM) Peak Soreness, mm
Brachialis Brachioradialis Flexing Extending
Control
Massage
P
value
46.7 (6.6)
35.0 (7.9)
.06
51.6 (6.9)
33.0 (8.1)
.01
42.1 (6.5)
25.1 (7.5)
.07
52.8 (7.0)
42.9 (5.6)
.02
Plasma CK Activity
No significant difference in plasma CK activity between
arms was evident before exercise (P 5 .90). Plasma CK ac-
tivity increased significantly postexercise for both conditions
(P 5 .01); however, significantly smaller CK increases oc-
curred for the massaged arm than for the control (P 5 .02)
(Figure 2). The CK peak value for the massage condition (982
6 356 IU·L
2
1
) was 36% lower than that for the control con-
dition (2704 6 637 IU·L
2
1
).
Muscle Soreness
Muscle soreness developed after both exercise bouts. The
course of development of soreness differed, depending on the
type of measurement. Peak soreness for palpation of the bra-
chioradialis and brachialis and elbow joint flexion was report-
ed 1 to 3 days postexercise, whereas peak soreness on elbow
joint extension occurred 4 days postexercise. All reports of
soreness resolved by 7 days postexercise. As shown in Table
3, the highest peak soreness score was observed for extension,
followed by palpation of the brachioradialis. Significant dif-
ferences between the massage and the control conditions were
found for peak soreness with palpation of the brachioradialis
and extending the elbow joint (P 5 .01 to .02), with peak
values for the other 2 soreness variables showing borderline
significance (P 5 .06 to .07). The massage resulted in a 20%
to 40% decrease in the severity of soreness compared with no
treatment in the same individuals.
DISCUSSION
We investigated the effects of a 10-minute massage per-
formed 3 hours after an eccentric exercise on DOMS and other
indicators of eccentric-exercise–induced muscle damage. We
used a self-report visual analog scale to quantify the magnitude
of muscle soreness for palpation, extension, and flexion of the
elbow flexors; this scale has been reported to be the most
satisfactory means of assessing pain sensation.
19
Because the
perception of pain is highly subjective and varies widely
among individuals, the use of soreness as a quantifier of mus-
cle injury is problematic.
5
Yet it is the most widely experi-
enced negative consequence of eccentric exercise, making it
an important variable to consider. To minimize the confound-
ing effects associated with difference in individual responses,
we used the arm-to-arm comparison model to compare mas-
sage and control conditions.
The arm-to-arm comparison model is advantageous when
comparing 2 conditions in a relatively small number of sub-
jects; however, it may produce a carryover effect, especially
for the blood markers of muscle damage, if the time between
the bouts is short. We avoided this potential problem by pro-
viding an adequate interval between the bouts based on pre-
vious studies, which was more than 2 weeks.
2,18
Yet a possible
placebo effect should also be considered, because it is difficult
to eliminate a possible placebo effect in the arm-to-arm com-
parison model. Practically, people expect to have some effects
of massage when they receive it, and psychological effects
may always exist to some degree. We did not include a placebo
treatment such as touching, because subjects might have no-
ticed a difference if they had received a placebo treatment for
one arm and actual treatment for the other arm. However, sub-
jects were randomly grouped by test order (control-treatment
or treatment-control), and dominant and nondominant arms
were equally balanced over the 2 conditions. Moreover, the
changes in muscle strength (see Table 1 and Figure 1), ROM,
and upper arm circumference (see Table 2) immediately post-
Journal of Athletic Training 179
exercise were not significantly different between the control
and massage arms, and the massage was performed 3 hours
postexercise and before DOMS developed. It seems unlikely
that the changes in the criterion measures were altered by the
psychological effects of massage, because the placebo effect
would not account for the differences in upper arm circum-
ference or CK values. This suggests that the reduction in
DOMS for the massage condition was a real and not a placebo
response. It seems reasonable to assume that differences be-
tween arms, if any, were due to the effects of massage. Mas-
sage was effective in reducing the magnitude of DOMS (see
Table 3), swelling (see Table 2), and plasma CK activity (see
Figure 2). In contrast, no positive effects of massage were
found for muscle strength (see Figure 1 and Table 1) and ROM
(see Table 2).
In this study, the subjects included both sexes to generalize
the findings. Although there may be sex-based differences in
responses to eccentric-exercise–induced muscle damage,
20
controversies exist concerning the effects of sex on the mag-
nitude of muscle damage, inflammatory response, and change
in plasma CK activity after eccentric exercise.
18,22
Even if
there is a sex effect, the arm-to-arm comparison model could
minimize the effect, because the comparisons between the con-
trol and treatment conditions are made within the same subject.
Because the influence of the menstrual cycle on eccentric-ex-
ercise–induced muscle damage is small,
23
the menstrual cycle
was not considered in this study. Therefore, it seems unlikely
that the choice of subjects affected the findings.
Delayed-onset muscle soreness is a symptom of eccentric-
exercise–induced muscle damage and occurs 8 to 12 hours
postexercise, when the affected muscle contracts or stretches
or is palpated; it peaks at 2 to 3 days and slowly dissipates by
8 to 10 days postexercise.
1,6,7
The course of muscle soreness
development is different from changes in muscle strength and
ROM, upper arm circumference, and plasma CK activity.
5
Al-
though the underlying mechanism of DOMS remains uncer-
tain, it is generally accepted that DOMS is caused by inflam-
mation of the damaged muscle and/or connective tissue and
the efflux of substances from the damaged tissue to the extra-
cellular space that sensitize the free nerve endings.
1,6,24
De-
layed-onset muscle soreness is thought to be the result of ac-
tivation of the group IV pain receptors, which are responsible
for the transmission of dull, aching pain signals.
1
These re-
ceptors can respond to pressure and shear stress and/or chem-
ical substances, such as bradykinin, serotonin, and histamine,
that accumulate in the interstitium.
1
The responses of group
IV receptors to any one stimulus may be sensitized and po-
tentiated if the chemical environment of the interstitium is al-
tered. This is a possible mechanism for the development of
DOMS after eccentric exercise.
1,6,24
Our findings support previous results regarding the positive
effects of massage on DOMS. In addition, we found significant
effects of massage on muscle swelling and CK response. The
massage protocols used in previous studies have varied widely
in terms of the timing, duration, and frequency. Most have
consisted of one session of massage at 2 to 4 hours postex-
ercise.
12–15
Only Tiidus and Shoemaker
16
repeated the 10-min-
ute massage 2 and 4 days postexercise. Massage duration has
been between 8 and 30 minutes in previous studies.
12–17
All
groups except Weber et al
12
reported that massage had a pos-
itive effect on DOMS. We also found that massage interven-
tion reduced soreness more than 30% compared with the con-
trol (see Table 3). This suggests that a massage performed
postexercise but before DOMS develops can alleviate sore-
ness, no matter how the massage is performed.
It is difficult to explain how massage reduces DOMS, be-
cause no authors have yet described the effects of massage on
cellular events or pathophysiologic changes in the muscle or
connective tissue after eccentric exercise. Increasing blood
flow appears to be a major consequence of massage.
8,10
In-
creases in blood and lymph flow may enhance removal of pain
substrates that start to accumulate in the injured area, reducing
edema. We found smaller increases in upper arm circumfer-
ence 3 and 4 days postexercise for the massage condition com-
pared with the control (see Table 2). This may explain why
DOMS was attenuated by massage, if indeed edema is asso-
ciated with muscle soreness. Smith et al
13
showed that circu-
lating neutrophil levels were elevated from baseline for several
hours after massage compared with the control condition and
speculated that this was due to a reduced emigration of neu-
trophils into tissue spaces. However, no authors have yet
shown that massage can decrease the migration of neutrophils
or other leukocytes (ie, macrophages) to the injured sites. Mas-
sage to sore muscles could increase discharge from other low-
threshold sensory fibers and block pain sensation temporarily
1
;
however, the massage in our study was performed before
soreness occurred.
Cardinal signs of acute inflammation include redness, heat,
swelling, pain, and impairment of function.
25
Among these
signs, swelling, pain, and impairment of muscle function ap-
pear in eccentric-exercise–induced muscle damage.
2,25
Our
findings of reduced muscle swelling in the massage condition
may support the concept of an ameliorated inflammatory re-
sponse after treatment, as does the smaller CK efflux observed.
Because we did not measure direct indicators of inflammation,
it is not possible to state that the severity of DOMS is linked
to the processes of inflammation and/or subsequent muscle
edema. Further study is necessary to investigate how massage
affects the inflammatory responses induced by eccentric ex-
ercise.
It is interesting that increases in plasma CK activity were
significantly smaller for the massage condition than the control
(see Figure 2). The blunted CK response for the massaged arm
could be explained either by smaller CK efflux from the dam-
aged muscle or increased clearance of CK from the circulation.
It may be that massage enhanced the transport of CK from the
damaged muscle to the circulation via the lymph fluid and
increased CK clearance from the blood by increasing blood
and lymph flow.
13
It is also possible to assume that massage
assists in flushing neutrophils and macrophages from the in-
jured area, thus avoiding fiber necrosis and CK efflux.
26
How-
ever, no concrete evidence to support these speculations is
available at this time.
Although massage had positive effects on DOMS, swelling,
and plasma CK activity, no significant protective effects oc-
curred against losses in muscle strength and ROM. These find-
ings are consistent with those of previous authors,
12,13,15,16
who did not note beneficial effects of massage on either loss
or recovery of muscle function. It might be more important
for athletes and coaches to enhance recovery of muscle func-
tion after eccentric exercise than reduce DOMS and swelling.
If this is the case, massage will not fulfill that purpose. In-
creasing blood flow by massage to deliver oxygen and other
substances necessary for the regeneration of the damaged tis-
sue is apparently not effective enough. The actual physiologic
mechanisms by which massage could influence the regenera-
180 Volume 40
•
Number 3
•
September 2005
tion process are obscure.
10
Our findings thus support the idea
that DOMS should be treated with caution as an indicator of
muscle damage and may be more associated with individual
responses to the sensations eliciting pain than the mechanisms
responsible for muscle injury per se. This possibility makes it
all the more important to consider such variations in the design
and interpretation of studies such as this one.
In summary, using an arm-to-arm comparison model to
quantify the effects of a therapeutic massage after high-inten-
sity eccentric exercise, we found reductions in muscle soreness
and muscle swelling and a lowered CK efflux compared with
responses in the contralateral arm. However, massage had no
protective effect on muscle strength and ROM. Our findings
suggest that massage, used appropriately, is beneficial in re-
ducing DOMS and swelling associated with high-intensity ec-
centric exercise, but recreational athletes and sports profes-
sionals who use massage should be cognizant of the fact that
no positive effects of massage on recovery of muscle function
can be expected.
REFERENCES
1. Armstrong RB. Mechanisms of exercise-induced delayed onset muscular
soreness: a brief review. Med Sci Sports Exerc. 1984;16:529–538.
2. Clarkson PM, Nosaka K, Braun B. Muscle function postexercise-induced
muscle damage and rapid adaptation. Med Sci Sports Exerc. 1992;24:512–
520.
3. Keskula DR. Clinical implications of eccentric exercise in sports medi-
cine. J Sport Rehabil. 1996;5:321–329.
4. Gulick DT, Kimura IF. Delayed-onset muscle soreness: what is it and how
do we treat it? J Sport Rehabil. 1996;5:234–243.
5. Nosaka K, Newton M, Sacco P. Delayed-onset muscle soreness does not
reflect the magnitude of eccentric-exercise–induced muscle damage.
Scand J Med Sci Sports. 2002;12:337–346.
6. Cheung K, Hume P, Maxwell L. Delayed-onset muscle soreness: treat-
ment strategies and performance factors. Sports Med. 2003;33:145–164.
7. Connolly DA, Sayers SP, McHugh MP. Treatment and prevention of de-
layed onset muscle soreness. J Strength Cond Res. 2003;17:197–208.
8. Tiidus PM. Manual massage and recovery of muscle function following
exercise: a literature review. J Orthop Sports Phys Ther. 1997;25:107–
112.
9. Ernst E. Does post-exercise massage treatment reduce delayed-onset mus-
cle soreness? A systematic review. Br J Sports Med. 1998;32:212–214.
10. Tiidus PM. Massage and ultrasound as therapeutic modalities in exercise-
induced muscle damage. Can J Appl Physiol. 1999;24:267–278.
11. Robertson A, Watt JM, Galloway SD. Effects of leg massage on recovery
from high intensity cycling exercise. Br J Sports Med. 2004;38:173–176.
12. Weber MD, Servedio FJ, Woodall WR. The effects of three modalities
on delayed onset muscle soreness. J Orthop Sports Phys Ther. 1994;20:
236–242.
13. Smith LL, Keating MN, Holbert D, et al. The effects of athletic massage
on delayed onset muscle soreness, creatine kinase, and neutrophil count:
a preliminary report. J Orthop Sports Phys Ther. 1994;19:93–99.
14. Farr T, Nottle C, Nosaka K, Sacco P. The effects of therapeutic massage
on delayed onset muscle soreness and muscle function following downhill
walking. J Sci Med Sport. 2002;5:297–306.
15. Hilbert JE, Sforzo GA, Swensen T. The effects of massage on delayed
onset muscle soreness. Br J Sports Med. 2003;37:72–75.
16. Tiidus PM, Shoemaker JK. Effleurage massage, muscle blood flow and
long-term post-exercise strength recovery. Int J Sports Med. 1995;16:
478–483.
17. Rodenburg JB, Steenbeek D, Schiereck P, Bar PR. Warm-up, stretching
and massage diminish harmful effects of eccentric exercise. Int J Sports
Med. 1994;15:414–419.
18. Nosaka K, Clarkson PM. Variability in serum creatine kinase response
after eccentric exercise of the elbow flexors. Int J Sports Med. 1996;17:
120–127.
19. Ohnhaus EE, Adler R. Methodological problems in the measurements of
pain: a comparison between the verbal rating scale and the visual ana-
logue scale. Pain. 1975;1:379–384.
20. Tiidus PM. Estrogen and gender effects on muscle damage, inflammation,
and oxidative stress. Can J Appl Physiol. 2000;25:274–287.
21. Stupka N, Tarnopolsky MA, Yardley NJ, Phillips SM. Cellular adaptation
to repeated eccentric-exercise–induced muscle damage. J Appl Physiol.
2001;91:1669–1678.
22. Stupka N, Lowther S, Chorneyko K, Bourgeois JM, Hogben C, Tarno-
polsky MA. Gender differences in muscle inflammation after eccentric
exercise. J Appl Physiol. 2000;89:2325–2332.
23. Clarkson PM, Hubal MJ. Are women less susceptible to exercise-induced
muscle damage? Curr Opin Clin Nutr Metab Care. 2001;4:527–531.
24. Stauber WT, Clarkson PM, Fritz VK, Evans WJ. Extracellular matrix
disruption and pain after eccentric muscle action. J Appl Physiol. 1990;
69:868–874.
25. Smith LL. Acute inflammation: the underlying mechanism in delayed-
onset muscle soreness. Med Sci Sports Exerc 1991;23:542–51.
26. Cannon JG, Orencole SF, Fielding RA, et al. Acute phase response in
exercise: interaction of age and vitamin E on neutrophils and muscle
enzymes release. Am J Physiol. 1990;259(6 pt 2):R1214–1219.
