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Effects of Massage on Delayed-Onset Muscle Soreness, Swelling, and Recovery of Muscle Function


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Delayed-onset muscle soreness (DOMS) describes muscle pain and tenderness that typically develop several hours postexercise and consist of predominantly eccentric muscle actions, especially if the exercise is unfamiliar. Although DOMS is likely a symptom of eccentric-exercise-induced muscle damage, it does not necessarily reflect muscle damage. Some prophylactic or therapeutic modalities may be effective only for alleviating DOMS, whereas others may enhance recovery of muscle function without affecting DOMS. To test the hypothesis that massage applied after eccentric exercise would effectively alleviate DOMS without affecting muscle function. 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 kinase activity, and muscle soreness). A 2-way repeated-measures analysis of variance and paired t tests were used to examine 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. University laboratory. Ten healthy subjects (5 men and 5 women) with no history of upper arm injury and no experience in resistance training. Subjects performed 10 sets of 6 maximal isokinetic (90 degrees x s(-1)) 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 exercise; the contralateral arm received no treatment. Maximal voluntary isometric and isokinetic elbow flexor strength, range of motion, upper arm circumference, plasma creatine kinase activity, and muscle soreness. 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 = .07) and palpating the brachialis muscle (P = .06) was also less with massage. Massage treatment had significant effects on plasma creatine 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 evident. Massage was effective in alleviating DOMS by approximately 30% and reducing swelling, but it had no effects on muscle function.
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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
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,
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
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.
To test the hypothesis that massage applied after
eccentric exercise would effectively alleviate DOMS without af-
fecting muscle function.
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
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.
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.
Subjects performed 10 sets of 6 maximal
isokinetic (908·s
) 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
Delayed-onset muscle soreness was significantly
less for the massage condition for peak soreness in extending
the elbow joint and palpating the brachioradialis muscle (
.05). Soreness while flexing the elbow joint (
5 .07) and pal-
pating the brachialis muscle (
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 (
, .05), and upper arm circumference,
with a significantly smaller increase than the control at 3 and 4
days postexercise (
, .05). However, no significant effects of
massage on recovery of muscle strength and ROM were evi-
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
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.
Muscle pain
and tenderness generally develop 24 hours after such exercise
and are usually described as delayed-onset muscle soreness
Undoubtedly, DOMS is one of the symptoms of
eccentric-exercise–induced muscle damage; however, DOMS
does not necessarily indicate muscle damage.
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.
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.
Massage is widely used as a therapeutic
modality for recovery from muscle fatigue and injury
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,
a massage is often recommended by
coaches and therapists to alleviate or prevent DOMS after a
sporting activity.
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.
In fact, an 8-minute massage immediately
postexercise has no effect on DOMS and recovery of muscle
Another author
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.
A recent group
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
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.
The find-
ings about the effects of massage on DOMS and muscle func-
tion are inconclusive or contradictory in nature.
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.
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
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
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.
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.
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
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
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
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.
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-
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
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
) 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
to 3008·s
, 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-
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
and the assay can accurately detect values between 20 and
2000 IU·L
, according to the manufacturer’s manual. When
the value exceeded 2000 IU·L
, 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
2 MS
, where MS
was the mean square for sub-
jects and MS
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
Mean (SEM) Peak Isokinetic Torque, Nm
Pre-exercise Postexercise
Days After Exercise
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)
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.
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
(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
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)
Condition Postexercise
Days After Exercise
Mean (SEM) range of motion, 8
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
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 (
, .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)
Mean (SEM) Peak Soreness, mm
Brachialis Brachioradialis Flexing Extending
46.7 (6.6)
35.0 (7.9)
51.6 (6.9)
33.0 (8.1)
42.1 (6.5)
25.1 (7.5)
52.8 (7.0)
42.9 (5.6)
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
) was 36% lower than that for the control con-
dition (2704 6 637 IU·L
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.
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.
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.
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.
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,
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.
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,
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.
The course of muscle soreness
development is different from changes in muscle strength and
ROM, upper arm circumference, and plasma CK activity.
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.
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.
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.
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.
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-
Only Tiidus and Shoemaker
repeated the 10-min-
ute massage 2 and 4 days postexercise. Massage duration has
been between 8 and 30 minutes in previous studies.
groups except Weber et al
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.
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
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
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.
Among these
signs, swelling, pain, and impairment of muscle function ap-
pear in eccentric-exercise–induced muscle damage.
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-
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.
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.
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,
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.
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.
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... The improvement trend was better than that of the athletes who did not receive massage. Several studies have shown that massage and acupuncture can significantly decrease post-exercise creatine kinase and urea levels and promote muscle fatigue elimination in healthy volunteers (Zhou Yan and Yang Xiao-bo, 2003;Zainuddin et al., 2005). Tyka et al. (2018) also reported that vibromassage could have a positive effect on the level of a marker of muscle damage and connective tissues after long-term physical exercise in males. ...
... The mechanisms underlying the effect of massage on creatine kinase levels remain unclear. Some possible reasons for the decrease in serum creatine kinase response for massage are lower creatine kinase efflux from the damaged muscle and increased clearance of creatine kinase from the circulation through increased blood and lymph flow (Zainuddin et al., 2005;Sefton et al., 2010). A previous study demonstrated that massage significantly elevated the temperature in massage areas, as well as in adjacent non-massage areas, which may lead to changes in peripheral blood flow (Sefton et al., 2010). ...
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Objective: This study aimed to investigate the effect of a two-week machine massage on the physical properties of the erector spinae and serum biochemical indexes of adolescent athletes after training. Methods: Sixteen male adolescent wrestlers were recruited (age: 15 ± 1 year; height: 166 ± 7 cm; weight: 56 ± 7 kg) and randomly assigned to machine massage (MA, 8) and control (CO, 8) groups. Participants in the MA group received machine massage for 20 min after each wrestling training from Monday to Saturday (except on Thursday) for two weeks, while the participants in the CO group recovered naturally. Over the course of two weeks, all the participants underwent similar wrestling training program under the guidance of a professional coach. Before and after the intervention, serum urea and creatine kinase (CK) levels were measured in a fasting state. A Myoton Pro digital muscle evaluation system was used to measure the physical properties of the erector spinae, including the oscillation frequency, logarithmic decrement of a muscle’s natural oscillation, and dynamic stiffness. Results: After two weeks of machine massage treatment, the dynamic stiffness of the erector spinae in the MA group decreased by 12.90% and that in the CO group increased by 2.34%, indicating a significant difference between the two groups ( p = 0.04, ƞ ² = 0.286). The decrease in the logarithmic decrement of a muscle’s natural oscillation value in the MA was significantly greater than that in the CO ( p = 0.003, ƞ ² = 0.286). Moreover, the serum CK values decreased by 33.84% in the MA group and by 1.49% in the CO group, despite a trend of change between the groups ( p = 0.062, ƞ2 = 0.084). No significant difference was found in the improvement in serum urea levels between the two groups after two weeks of treatment. Conclusion: Results of the present study indicated that a two-week machine massage had a positive effect on the improvement of the physical properties of the erector spinae of wrestlers during training.
... Finally, the difference between the CK measurements of 72 nd and 96 th hours was also found significant and this was shown in the The CK measurements conducted due to time in the control group showed significant difference (p < 0.001). The difference between the measurements before the exercise and those for all following measurement times and urine Efflux of intramuscular ions and proteins leads to increased osmolarity of the extracellular fluid and fluid shifts out of the cell [3,7,10,16,[23][24][25][26]. ...
... The mechanisms producing delayed muscle soreness are vaguely understood,making information concerning prevention and treatment scarce. Previous studies have tried to isolatespecific mechanisms while other studies have attempted to prevent and treat the symptoms [7,22,26,30,31]. We attempted to prevent and treat muscular soreness through the use of sport drinks at dehydrate persons. ...
... Massage is widely used to promote the recovery of skeletal muscle fatigue and injury after sports training in competitive athletes. Massage can reduce the inflammation of damaged skeletal muscle and promote mitochondrial repair [2], improve DOMS [3], reduce muscle strength loss [4], and promote EIMD repair [4]. However, it is still unclear whether massage can protect skeletal muscles from injury during long-term heavy-duty exercise. ...
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Background Massage is widely used in exercise-induced skeletal muscle damage (EIMD). It has been proven that massage can improve the morphology and function of damaged skeletal muscle in multiple ways. However, whether massage can protect skeletal muscles from injury during long-term heavy-duty exercise has not yet been determined. Methods In this study, a rat model of overuse injury was established by eccentric running for 4 weeks, and pressing at constant pressure and frequency and massage were used as intervention methods to explore whether massage could protect skeletal muscle from injury through upregulating integrin and the basement membrane laminin. Results The results showed that compared with the model group, the ultrastructure of skeletal muscle in the massage group was relatively complete and clear, and the maximum isotonic and tetanic contraction forces were significantly increased (P < 0.01). In addition, in the massage group, β1 integrin expression was significantly increased, p-FAK protein expression was decreased, and the co-localization of β1 integrin and the basement membrane laminin 2 was significantly increased (P < 0.01). Conclusion Our study shows that during long-term heavy-duty exercise, massage can enhance the cell adhesion function mediated by integrin β1 and laminin 2 to protect skeletal muscle from injury and prevent the occurrence of overuse injury.
... Erden et al [42] stated that adding IASTM to the conventional physical therapy program for 8 wk was superior to conventional physical therapy alone for patients with myofascial pain with upper and mid back TrPs in the improvement of pain intensity and PPT. The effect of IASTM on pain could be explained by increasing blood flow, which removes pain substrates [43][44][45]. Furthermore, IASTM stimulates the A-beta sensory fibers and blocks the A-delta and C-fibers. ...
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Background: Active myofascial trigger points (TrPs) often occur in the upper region of the upper trapezius (UT) muscle. These TrPs can be a significant source of neck, shoulder, and upper back pain and headaches. These TrPs and their related pain and disability can adversely affect an individual's everyday routine functioning, work-related productivity, and general quality of life. Aim: To investigate the effects of instrument assisted soft tissue mobilization (IASTM) vs extracorporeal shock wave therapy (ESWT) on the TrPs of the UT muscle. Methods: A randomized, single-blind, comparative clinical study was conducted at the Medical Center of the Egyptian Railway Station in Cairo. Forty patients (28 females and 12 males), aged between 20-years-old and 40-years-old, with active myofascial TrPs in the UT muscle were randomly assigned to two equal groups (A and B). Group A received IASTM, while group B received ESWT. Each group was treated twice weekly for 2 weeks. Both groups received muscle energy technique for the UT muscle. Patients were evaluated twice (pre- and post-treatment) for pain intensity using the visual analogue scale and for pain pressure threshold (PPT) using a pressure algometer. Results: Comparing the pre- and post-treatment mean values for all variables for group A, there were significant differences in pain intensity for TrP1 and TrP2 (P = 0.0001) and PPT for TrP1 (P = 0.0002) and TrP2 (P = 0.0001). Also, for group B, there were significant differences between the pre- and post-treatment pain intensity for TrP1 and TrP2 and PPT for TrP1 and TrP2 (P = 0.0001). There were no significant differences between the two groups in the post-treatment mean values of pain intensity for TrP1 (P = 0.9) and TrP2 (P = 0.76) and PPT for TrP1 (P = 0.09) and for TrP2 (P = 0.91). Conclusion: IASTM and ESWT are effective methods for improving pain and PPT in patients with UT muscle TrPs. There is no significant difference between either treatment method.
... Therefore, it can be concluded that higher values of lactate acid cannot cause DOMS, which is formed from 24 to 48 h after intense physical activity. A detailed investigation of DOMS and intense physical activity revealed the development of muscle fibers damage, which led to the direct releasement of the enzyme creatine kinase (cK) [36,[103][104][105][106]. Only one study did not show the positive influence of massages on the reduction of the cK level [107]. ...
Full-text available
Background: A massage is a tool that is frequently used in sports and exercise in general for recovery and increased performance. In this review paper, we aimed to search and systemize current literature findings relating to massages' effects on sports and exercise performance concerning its effects on motor abilities and neurophysiological and psychological mechanisms. Methods: The review has been written following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines. One hundred and fourteen articles were included in this review. Results: The data revealed that massages, in general, do not affect motor abilities, except flexibility. However, several studies demonstrated that positive muscle force and strength changed 48 h after the massage was given. Concerning neurophysiological parameters, the massage did not change blood lactate clearance, muscle blood flow, muscle temperature, or activation. However, many studies indicate pain reduction and delayed onset muscle soreness, which are probably correlated with the reduction of the level of creatine kinase enzyme and psychological mechanisms. In addition, the massage treatment led to a decrease in depression, stress, anxiety, and the perception of fatigue and an increase in mood, relaxation, and the perception of recovery. Conclusion: The direct usage of massages just for gaining results in sport and exercise performance seems questionable. However, it is indirectly connected to performance as an important tool when an athlete should stay focused and relaxed during competition or training and recover after them.
... The result of fatigue has an impact on the onset of pain in contracting muscles called Delayed Onset Muscle Soreness (DOMS). Pain can be caused through an inflammatory process in physical activity, which includes numerous eccentric muscle contractions (2). Exercise without adequate control can lead to muscular damage and inflammation. ...
Full-text available
Background: Physical exercise is a systematic exercise to increase muscle strength achieve goals such as improving the athlete's physical and preventing injury. Athletes must do is massage therapy to prevent muscle fatigue and pain due to physical exercise or during competition. The increase of lactic acid levels affects the maximum working ability of muscle fibers, decreases physical performance, and is fatigue in which the onset of pain. Lime essential oil as a topical oil contains high ester substances that have pharmacological effects such as natural analgesic effects to relieve pain. Objective: The purpose of this study was to determine the effect of massage therapy with lime essential oil as a topical oil on the recovery of delayed-onset muscle soreness (DOMS) in athletes. Methods: The participants are boxing athletes, 30 men, 20-22 years old, and non-smokers. Participants were divided into three groups. The exercise group (E) was doing exercises and was not given massage therapy; the exercise massage (EM) group, namely, doing exercises and being massaged with ordinary lotion as a topical oil; and the EM lime (EMC) group did exercises and was given a massage with lime essential oil as the topical oil. Results: The results showed that there was a significant difference in the average levels of lactic acid (p = 0.000) and the athlete's pain intensity (p = 0.000) in the three groups, namely, the exercise group (E), the exercise and massage group (EM), and the exercise and massage with lime essential oil (EMC). Conclusion: This study finds that lime essential oil used as topical massage therapy oil is better for accelerating the DOMS.
... Delayed onset muscle soreness (DOMS) refers to the phenomenon of muscle soreness caused by micro-damage of muscle cell structure following eccentric exercise or unaccustomed high-intensity exercise, which traditionally peaks at 24-72 hours [1][2][3]. In addition to localized muscle pain, symptoms of DOMS may include swelling, joint stiffness, reduced joint range of motion, and reduced muscle strength, all of which can seriously affect athletic training [4]. ...
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Background: This study aimed to investigate the effects of cold water immersion (CWI) and contrast water therapy (CWT) on serum interleukin 6 and prostaglandin 2 levels in self-perceived exertion, and muscle soreness of elite race walkers over a 15-day high-intensity training period. Methods: Thirty elite male race walkers were randomly divided into three groups: control group (C, n = 10), cold-water immersion (CWI, n = 10) group, contrast water therapy (CWT, n = 10) group. After daily training, elite race walkers were exposed to either CWI (10 minutes at 10 °C) or CWT (4 cycles of 2.5 minutes, alternately at 12 °C and 38 °C). Elite race walkers in the control group only performed simple stretching without any additional treatment. The serum interleukin 6, prostaglandin 2, self-perceived exertion, and muscle soreness were tested at 6 training points at baseline (B), light load-1 (L1), heavy load-1 (H1), medium load (M), heavy load-2 (H2), light load-2 (L2), respectively. Results: When compared with the CWT group, the interleukin 6 level, prostaglandin 2 level, self-perceived exertion, and muscle soreness of the C group were not significantly different. When compared with the CWT group, the interleukin 6 level in the CWI group was significantly lower at the time point of L1 and H2. Similarly, CWI significantly reduced the prostaglandin 2 levels at M and L2, except for H2. Self-perceived exertion and muscle soreness were not significantly different in both groups. Conclusions: The results from this study demonstrate that CWI may be more effective than CWT for reducing inflammatory markers at certain points in a training cycle, but it does appear that this effect can be induced in a predictable fashion.
... Bu artışında; o bölgedeki hücresel matriks adezyonunu ve lokal iskemiyi azaltarak etki ettiği ileri sürülmektedir. 4 Kan akımındaki artış, ağrı substratlarını ortadan kaldırmakta ve bu şekilde yaralı doku çevresinde gelişen inflamasyonu azalttığı bildirilmiştir. 5 Yumuşak dokuya enstrüman vasıtasıyla bir uyarı verildiğinde, lokal inflamasyon yoluyla fibronektin ile fibroblastların aktivitesi ve sayısı artmaktadır. 6 Böylece, yeni kollajen sentezlenir ve yeniden düzenlenir, bu da dokunun yenilenmesini ve iyileşmesini sağlar. ...
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The use of instrument assisted soft t issue mobilization(IASTM) method is increasing. The aim of this study was to examinethe studies in the literature to evaluate the effects of the IASTM methodon which regions and populations, on which parameters, and to evalu-ate the effect of single or more session applications. For this purpose,“PubMed”, “Scopus”, “Web of Sc ience” and “CINAHL” electron icdatabases were searched between 1-15 January 2022. Stud ies carriedout between January 1, 2017 and January 1, 2022 were included in thestudy. According to the results of 29 studies meeting the inclusion cri-teria; it was observed that the effects of the IASTM method on muscu-loskeletal problems in the upper extremity, lower extremity and spineregions and the healthy population were examined. Studies examiningthe effects on many parameters such as jo int range of mot ion, pain,strength, and function have reported that IASTM application is gener-ally effective. In addition, it has been reported that both a single-sessionapplication and more applications are effective. As a result, althoughithas been reported that the IASTM method is effective in different re-gions and populations, either in a single session or in more applicationson different parameters, it is thought that more comprehensive and de-tailed studies are needed, considering that there is no standard protocolfor the method. The b iggest def iciency in the l iterature about themethod is the absence of an international standard on the appl icationangle and frequency. The development of an international standard isan important need.
... Recently, Clifford et al. [58] found a moderatemagnitude reduction in DOMS after supplementation with collagen peptides which would fit with an assumed existence of micro-damage. A plethora of studies, moreover, demonstrated that massage [59][60][61] and foam rolling [62][63][64][65] alleviated DOMS. Finally, it has been repeatedly shown that the ECT generally adapts to mechanical loading [43,66]. ...
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Background The extramuscular connective tissue (ECT) has been shown to play a significant role in mechanical force transmission between musculoskeletal structures. Due to this and owing to its tight connection with the underlying muscle, the ECT may be vulnerable to excessive loading. The present study aimed to investigate the effect of eccentric elbow flexor exercise on the morphology of the biceps brachii ECT. In view of the high nociceptive capacity of the ECT, an additional objective was to elucidate the potential relationship between ECT damage and the occurrence of delayed onset muscle soreness (DOMS). Methods Eleven healthy participants (♂ = 7; 24 ± 2 years) performed fatiguing dumbbell elbow flexor eccentric exercise (EE) for one arm and concentric exercise (CE) for the other arm in random order and with random arm allocation. Before, immediately after and 24–96 h post-exercise, maximal voluntary isometric contraction torque of the elbow flexors (dynamometer), pressure pain (algometer), palpation pain (100 mm visual analog scale), biceps brachii ECT thickness and ECT/muscle mobility during passive movement (both high-resolution ultrasound) were examined. Results Palpation pain, suggestive of DOMS, was greater after EE than CE, and maximal voluntary isometric contraction torque decreased greater after EE than CE (p < .05). Relative to CE, EE increased ECT thickness at 48 (+ 17%), 72 (+ 14%) and 96 (+ 15%) hours post-exercise (p < .05). At 96 h post-EE, the increase in ECT thickness correlated with palpation pain (r = .68; p < .05). ECT mobility was not different between conditions, but compared to CE, muscle displacement increased at 24 (+ 31%), 72 (+ 31%) and 96 (+ 41%) hours post-EE (p < .05). Conclusion Collectively, these results suggest an involvement of the ECT changes in delayed onset muscle soreness.
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Eccentric exercise continues to receive attention as a productive means of exercise. Coupled with this has been the heightened study of the damage that occurs in early stages of exposure to eccentric exercise. This is commonly referred to as delayed onset muscle soreness (DOMS). To date, a sound and consistent treatment for DOMS has not been established. Although multiple practices exist for the treatment of DOMS, few have scientific support. Suggested treatments for DOMS are numerous and include pharmaceuticals, herbal remedies, stretching, massage, nutritional supplements, and many more. DOMS is particularly prevalent in resistance training; hence, this article may be of particular interest to the coach, trainer, or physical therapist to aid in selection of efficient treatments. First, we briefly review eccentric exercise and its characteristics and then proceed to a scientific and systematic overview and evaluation of treatments for DOMS. We have classified treatments into 3 sections, namely, pharmacological, conventional rehabilitation approaches, and a third section that collectively evaluates multiple additional practiced treatments. Literature that addresses most directly the question regarding the effectiveness of a particular treatment has been selected. The reader will note that selected treatments such as anti-inflammatory drugs and antioxidants appear to have a potential in the treatment of DOMS. Other conventional approaches, such as massage, ultrasound, and stretching appear less promising.
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Muscle soreness, a familiar phenomenon to most athletes, has been differentiated into 'acute' and 'delayed onset'. The etiology of acute muscle soreness has been attributed to ischemia and the accumulation of metabolic by-products. However, the etiology of delayed onset muscle soreness (DOMS) is not so clear. Six theories have been proposed: lactic acid, muscle spasm, torn tissue, connective tissue, enzyme efflux, and tissue fluid theories. The treatment of DOMS has also been investigated. Studies in which anti-inflammatory medications have been administered have yielded varying results based on the dosage and the time of administration. Submaximal concentric exercise may alleviate soreness but does not restore muscle function. Neither cryotherapy nor stretching abates the symptoms of DOMS. Transcutaneous electrical stimulation]Ins been shown to decrease soreness and increase range of motion, but the effect on the recovery of muscle function is unknown. Therefore, the treatment of DOMS remains an enigma.
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Pain, stiffness, and indicators of muscle damage occur at different times after eccentric muscle action. After a single bout of maximal resisted lengthening of the elbow flexors, elbow position, pain perception, and indicators of cellular damage were measured. Immediately postexercise, a significant decrease in resting muscle length was observed that continued to 48 h. At this time, an increase in perceived muscle soreness was noted (P less than 0.05), and a biopsy of the biceps brachii revealed mast cell degranulation, separations of the extracellular matrix from myofibers, and increased plasma constituents in the extracellular space. It is proposed that myofiber disruption allows intracellular proteins to escape and extracellular proteins and ions to enter, causing swelling, whereas the disrupted extracellular matrix initiates the inflammatory response, which includes the release of mast cell granules seen at 48 h postexercise. Thus the delayed sensation of pain (soreness) after repeated eccentric muscle actions probably results from inflammation in response to extracellular matrix disruption.
Returning an athlete to functional activity is the primary goal of the sports medicine practitioner. Eccentric exercise may be used throughout the rehabilitation program to improve muscle performance and restore normal function. The selection and progression of eccentric exercise are contingent on treatment goals and the individual's tolerance to activity. Basic concepts of eccentric muscle performance are discussed, and general treatment guidelines with an emphasis on specificity and intensity are presented, to enable the clinician to organize and implement relevant, prudent eccentric exercise within the restrictions of the clinical setting. The use of eccentric exercise in the management of tendinitis is briefly discussed.
The effect of analgesics on pathological pain in a double-blind, complete cross-over design was assessed by means of two rating scales, a verbal rating scale (VRS) and visual analogue scale (VAS). The VRS is widely used, but has several disadvantages as compared to the VAS. The results obtained by means of the VRS showed higher F-ratios (analysis of variance and Kruskall-Wallis H-test) than those obtained by means of the VAS. The VRS, which transfers a continuous feeling into a digital system, seems to augment artificially the measurement of effects produced by analgesics, and the VAS seems to assess more closely what a patient actually experiences with respect to change in pain intensities. The correlation between the two scales was highly significant (r = 0.81, P less than 0.001). The calculated regression line (y=-29.6 + 0.55-x) was not similar to the line of identity and showed much lower values for the VAS, supporting our interpretation. The distribution of the variances of the values obtained by means of both scales was not homogenous. This indicates that the homogeneity of the distribution of variances should always be checked and a Kruskall-Wallis H-test used, if they are inhomogenously distributed.
This brief review focuses on the time course of changes in muscle function and other correlates of muscle damage following maximal effort eccentric actions of the forearm flexor muscles. Data on 109 subjects are presented to describe an accurate time course of these changes and attempt to establish relationships among the measures. Peak soreness is experienced 2-3 d postexercise while peak swelling occurs 5 d postexercise. Maximal strength and the ability to fully flex the arm show the greatest decrements immediately after exercise with a linear restoration of these functions over the next 10 d. Blood creatine kinase (CK) levels increase precipitously at 2 d after exercise which is also the time when spontaneous muscle shortening is most pronounced. Whether the similarity in the time courses of some of these responses implies that they are caused by similar factors remains to be determined. Performance of one bout of eccentric exercise produces an adaptation such that the muscle is more resistant to damage from a subsequent bout of exercise. The length of the adaptation differs among the measures such that when the exercise regimens are separated by 6 wk, all measures show a reduction in response on the second, compared with the first, bout. After 10 wk, only CK and muscle shortening show a reduction in response. After 6 months only the CK response is reduced. A combination of cellular factors and neurological factors may be involved in the adaptation process.
It is well documented in animal and human research that unaccustomed eccentric muscle action of sufficient intensity and/or duration causes disruption of connective and/or contractile tissue. In humans, this appears to be associated with the sensation of delayed onset muscle soreness (DOMS). During the late 1970's, it was proposed that this sensation of soreness might be associated with the acute inflammatory response. However, subsequent research failed to substantiate this theory. The present article suggests that the results of much of the research concerning DOMS reflect events typically seen in acute inflammation. Similarities between the two events include: the cardinal symptoms of pain, swelling, and loss of function; evidence of cellular infiltrates, especially the macrophage; biochemical markers such as increased lysosomal activity and increased circulating levels of some of the acute phase proteins; and histological changes during the initial 72 h. In the final section of this paper, a theoretical sequence of events is proposed, based on research involving acute inflammation and DOMS.
Several host defense responses and metabolic reactions that occur during infection have been observed after exercise. We hypothesized that these reactions, known as the "acute phase response," contribute to the breakdown and clearance of damaged tissue after exercise. This hypothesis was tested with 21 male volunteers representing two ranges of age (22-29 and 55-74 yr), who ran downhill on an inclined treadmill to accentuate damaging eccentric muscular contractions. The subject groups were further divided in a double-blind placebo-controlled protocol, which examined the influence of 48 days of dietary vitamin E supplementation before the exercise. All subjects were monitored for 12 days after exercise for changes in circulating leukocytes, superoxide release from neutrophils, lipid peroxidation, and efflux of the intramuscular enzyme creatine kinase (CK) into the circulation. Among those receiving placebo, the less than 30-yr-old subjects responded to exercise with a significantly greater neutrophilia and higher plasma CK concentrations than the greater than 55-yr-old subjects. Dietary supplementation with vitamin E tended to eliminate the differences between the two age groups, primarily by increasing the responses of the greater than 55-yr-old subjects. At the time of peak concentrations in the plasma, CK correlated significantly with superoxide release from neutrophils. The association of enzyme efflux with neutrophil mobilization and function supports the concept that neutrophils are involved in the delayed increase in muscle membrane permeability after damaging exercise.
Delayed-onset muscular soreness (DOMS), the sensation of pain and stiffness in the muscles that occurs from 1 to 5 d following unaccustomed exercise, can adversely affect muscular performance, both from voluntary reduction of effort and from inherent loss of capacity of the muscles to produce force. This reduction in performance is temporary; permanent impairment does not occur. A number of clinical correlates are associated with DOMS, including elevations in plasma enzymes, myoglobinemia, and abnormal muscle histology and ultrastructure; exertional rhabdomyolysis appears to be the extreme form of DOMS. Presently, the best treatment for DOMS appears to be muscular activity, although the sensation again returns following the exercise. Training for the specific contractile activity that causes DOMS reduces the soreness response. The etiology and cellular mechanisms of DOMS are not known, but a number of hypotheses exist to explain the phenomenon. The following model may be proposed: 1) high tensions (particularly those associated with eccentric exercise) in the contractile/elastic system of the muscle result in structural damage; 2) cell membrane damage leads to disruption of Ca++ homeostasis in the injured fibers, resulting in necrosis that peaks about 2 d post-exercise; and 3) products of macrophage activity and intracellular contents accumulate in the interstitium, which in turn stimulate free nerve endings of group-IV sensory neurons in the muscles leading to the sensation of DOMS.