The perceived effectiveness of sports massage therapy

Massage therapy has been used ancient times. There is evidence that the Chinese used therapeutic massage more than 3,000 years ago. Massage has fallen in and out of favour over time. One of the newest forms of massage therapy is sports massage. Famous athletes have publicly expressed their great satisfaction with sports massage. They claim that it has increased their athletic performance and helped speed their recovery after strenuous exercise.

Non-professional athletes and their trainers has also become increasingly interested in sports massage, partly because of the acclaim it has received from elite athletes. This has led to even more interest in the therapy by non-athletes. Some of the popularity of sports massage can be attributed to the increasing acceptance of all forms of alternative therapies. Despite all of the intense interest, there is a lack of accurate information about massage.

There are many widely held perceptions about the effectiveness of pre-event sports massage, including that it can prevent injury and provide an edge over the competition. However, there is no published research that suggests pre-event massage has a positive impact on performance or injury prevention. There is some evidence that massage after an athletic event can help reduce pain, but the results remain inconclusive. There has also been research that concluded that regular, or maintenance, massages can alleviate some symptoms.

In 2004, a research team published A Meta-Analysis of Massage Therapy, which provided comprehensive look at the actual effectiveness of sports massage. Among other findings, they concluded that massage may reduce pain. However, the study debunked many of the widely held perceptions about the effectiveness of sports massage. Massage therapy does seem to have an impressive ability to reduce anxiety and depression. While the exact science behind the benefits sports massage remains elusive, many athletes, coaches, and massage therapists continue to believe that it can have a tremendous positive effect if used both before and after sporting events and during periods of training.

Introduction

Massage is one of the oldest and widely used therapies in the history of mankind. The American Heritage Dictionary of the English Language defines massage as: “the rubbing or kneading of parts of the body especially to aid circulation, relax the muscles, or provide sensual stimulation.” These benefits have been enjoyed since ancient times and almost all cultures have used some version of therapeutic massage(Vickers, Zelman, 1999). However, in more recent history, massage has become an important tool for athletes. Sports massage is now considered powerful way to help maximize athletic performance (Davidson, 2001).

The prevalence of this type of massage has rapidly increased over the last two decades and the perceived effectiveness of sports massages given before and after athletic events has become widespread.
Massage may have become more en vogue recently, but it is certainly not new. The first evidence of massage can be seen in the Chinese Cong-Fou, written around 2700 B.C. The text makes references to the manipulation of soft tissue. The ancient Chinese massage techniques involved applying pressure to muscles and meridian points. There is evidence that the ancient Chinese practitioners believed their massage not only relaxed muscles, but also improved the function of internal organs(Calvert, 2001).

Ancient Indian texts also described various massage techniques that were believed to promote spiritual and physical healing (Pike, p.viii). Even Hippocrates taught a form of massage to his students around500 B.C. Another famous Greek medical practitioner, Asclepiads, was so impressed by the perceived benefits of massage that the stopped using all other medicines and treatments and only used massage therapy for healing. He believed that massage techniques could increase and restore nutritive fluids (Calvert, 2001). However, over time, Western cultures gradually abandoned the Greek beliefs about massage.

During the middle ages, massage was still used as a folk remedy, but established medical scientists discounted it and the use of massage was no longer considered part of regular medical treatment. (Calvert, 2001).
About 150 years ago, a French translation of the Cong-Four appeared. Historians believe the text served as the foundation for the development of the now-popular Swedish massage (Davidson, 2001). There is some dispute over the origins of Swedish massage, but many credit Per Hendrix Ling for its development during the early 18th century. Ling promoted the idea that massage could heal the body by boosting circulation of the blood and limp systems.

Ling’s massage technique was very vigorous and he prescribed a standardized treatment. He suffered from gout and developed the system to improve his condition and later to help others. He did not equate massage with relaxation or any other psychological benefit. In fact, he called it the “Swedish Movement Cure” (Cates, 1998). Current Swedish massage has evolved somewhat from Ling’s ideas and is now more gentle, although the focus is still on increasing the flow of oxygen in the blood and to assist the muscles in releasing toxins. In the last few decades, Swedish massage therapists have placed greater emphasis on the psychological benefits of massage and they strive to provide a sense of calmness and well-being.(Vickers, Zelman, 1999)

Historically, the interest in massage has been cyclical. Massage fallout of favour, only to once again regain acceptance, many times over the last 500 years. Currently, massage has become far less important tour culture than medical drugs and surgery, but it is again becoming more popular as an alternative therapy (Cates, 1998). There are still many forms of massage found throughout the world, including Hawaiian, deep tissue, and Tue. Na. One of the newest forms of massage is sports massage. Although it is considered a separate form of massage, it shares strong similarities with Swedish Massage and the most of the techniques employed in Swedish massage are used in sports massage(Davidson, 2001). However, sports massage also incorporates Shiatsu massage techniques.

Sports massage was largely developed by Jack Meagher. Meagher was the massage therapist for the US Olympic Equestrian Team. He developed sports massage based on the theory that there are a dozen body postures that form the axis of all athletic movement. Meagher said that because each sport requires that the athlete maintain certain postures, it is possible to identify potential overuse injuries before they occur and help prevent them through sports massage. Meagher wrote that athletic performance could be improved by 20% with the introduction of sports massage (Dion, 2001).
Although sports massage encompasses many techniques, all sports massages geared toward generating the maximum performance from an athlete.

The effects of sports massage are achieved through a combination of mechanical, physiological, and psychological processes. Research has demonstrated that the compression caused by correctly-applied sports massage can improve lymphatic and venous drainage in the body and boost circulation (Hollis, 1997). Under the general heading of sports massage, there are three distinctly different types of massage. Each has a different goal and employs different strokes. The three categories of sports massage are pre-event, post-event, and maintenance massage.

Although sports massage has recently become more sophisticated, modern athletics have been using forms of pre-event and post-event massage for decades. For example, baseball pitchers have long used massage as an attempt to extend the length of their career by maintaining range of motion and flexibility. For many decades, boxing coaches and trainers have been seen giving boxers “rubdowns” before a fight in an effort toward-up the body by boosting circulation. This is an early form fore-event massage (Pike, p.viii).

Modern sports massage first became integrated as part some teams ‘standard athletic training in the former Soviet Union, East Germany, and other Eastern European countries during the 1960s. Soviet teams were the first to employ dedicated massage therapists that traveled with them. In the 1970s, the trend became more widespread, as more European countries and teams in the United States began to take interest in sports massage (Davidson, 2001).

However, it is only since the 1980s that sports massage has become truly mainstream. Now, it is a common practice for teams to integrate sports massage as part of their standard training regimen. Certified sports massage therapists have been seen at many major sporting events, including Ironman competitions, the Goodwill and Pan-American games, marathons, the Olympics, and professional bike races (Latina, 2000).When the U.S women’s soccer team defeated China, winning the World Cup, the players publicly thanked their sports massage therapist, Wynn Clinton and Jim Fayola. Goalkeeper Tracy Ducat said, “Clinton and Jim Fayola, who worked with him during the World Cup, were invaluable in the treatment they provided for us," testified Tracy Ducat, a goalkeeper on the team. "We could not have been at our best without their help every day." Goalie Saki Webber agreed, saying, "Without Clinton I think that it would have been a much different story. I think that he kept us healthy and kept us together during the World Cup” (Hued, 2002).

Sports massage has also infiltrated smaller sports. For example, even some Canadian cowboys are receiving massages before and after rodeos, thanks to new mobile massage rooms are traveling with them (Visconti,p.54). Although professional sports teams have lead the way in incorporating sports massage, college, some secondary schools, and amateur teams are also exploring massage as a way to enhance performance.

The public’s perceived value of the effectiveness of sports massage has been fuelled by public statements from well-known professional athletes who say their extraordinary skills have improved after undergoing regular massage therapy. For example, tennis champion, Martina Navratilova said, “I started getting massages and realized what wonderful thing it is for your body” (Sports Massage: Taking the Field ). Former professional football quarterback, Joe Montana, has said, “I’ve been working with massage for a few years now, and I found it helps you to recover a little quicker. The bumps and bruises seem Togo away a lot faster” (Sports Massage: Taking the Field). Canadian National Swim Team member, Marianne Limpet, agrees:

“I find that massage is very beneficial in helping with a quicker recovery from hard training or racing, and it prevents me from getting tight muscles and injuring myself. I am one of few athletes at my age(30), and I'm sure that massage has played a major role in helping to keep my body in shape to continue to this level” (Warren, 2003).
Even Marjorie Album, the Chief Athletic Trainer of the 1996 Atlanta Olympic Games, once commented, “I would not provide sports medicine services for any major athletic event without massage therapists.”(Sports Massage: The Athlete’s & Trainer’s Edge ) With glowing testimonials from esteemed athletes and sports professionals, it is not surprising that more amateur and college athletes are now becoming interested in sports massage.

After all, our society places great emphasis and value on athletics, and the financial and emotional rewards can be great to those who excel in their chosen sport. It is not surprising that sports massage is popular among those searching for competitive edge.

This relatively new appreciation for sports massage has increased as part of a larger trend toward ergogenic aids to boost all types of athletic performance. Ergogenic aids include a wide variety of tools and therapies, such as visualization, meditation, and pre-event stretching. Advocates of sports massage say it is valuable ergogenic tool that can improve circulation, reduce stress, promote muscle efficiency and healing, and even prevent injuries (Pike, p. vii).

The perceived benefits of massage have also become more wide-spread as the general acceptance of alternative medicines has increased. In a1997 random sample of 1,500 households in the United States, 42% of adults reported using some type of alternative therapy in the last year. Nearly 45% said they would be willing to pay more each month for alternative care. Additionally, when choosing healthcare, nearly 70% of respondents said having access to alternative therapies is an important factor in choosing a health insurance plan (Landmark Healthcare Inc.,1997). Alternative medicine is even more popular in the United Kingdom, where in studies, nearly 47% of respondents have reported they are using alternative therapies. Also in the U.K., of those undergoing complementary medicine, nearly nine out of ten are paying for their treatment (Thomas et al. p. 2 -11 ).

Massage therapy is one of the fasting growing forms of alternative medicine. In 1999, The American Massage Therapy Association (AMTA)conducted a nationwide survey in the United States. Researchers found that 27% of adults had therapeutic massage in the last five years, compared to only 17% in a 1997 study who said they had a massage in the previous five years (Massage: Much-Kneaded Complementary Health Care). Another study conducted the previous year found that visits to massage therapists increased by nearly 36% in the years between 1990 and 1997(Eisenberg et al. p. 1569).

Furthermore, in 2004, the National Centerior Complementary and Alternative Medicine in the United States reported that massage has become the ninth most popular alternative therapy treatment. In the study, 5% of respondents said they had received massage therapy at least one time in the previous year (Boneset al.). This translates into big business for the massage industry, as American consumers are spending up to $6 billion dollars a year on massage therapy (Eisenberg et al., p. 1569). This increasing interesting massage has created a surge in massage school educational facilities and applicants. As of 2002, there were more than 950 state-licensed massage schools in the U.S., which is 14% more school than existed in2000. In 2001, massage schools turned out an estimated 30,000 new graduates (Lacombe, p. 49).

There are other significant signs that the perceived benefits of massage is having a strong effect on public policy. In the United States, The National Institutes of Health is currently sponsoring three studies in an attempt to clarify the medical benefits of massage. Additionally, a national survey of employer-sponsored healthcare plans found that 15% of HMOs cover massage therapy. Cigna and Blue Cross BlueShield also cover some forms of massage (Lacombe, p. 49).Furthermore, a 1995 study found that more than half of family doctors in the United States said they would recommend some form of massage therapy to their clients (Hedwig, p.1).

This is a concern to some researchers who wonder if the benefits of massage are worth the price of the therapy. In their meta-analysis of massage therapy research, Moyer, Rounds, and Hanno wrote, “For these trends to continue (indeed, to determine if they even should continue),what is needed is a more rigorous and quantitative examination of MT’s(massage therapy’s) effectiveness that that which currently exists”(Moyer et al.).

The perceived, yet often unexplained, effects of massage (including sports massage) have even created interested within the White House. In2004, the White House Commission on Complementary and Alternative Medicine Policy called for more research and funding for public education on massage therapy. The commission’s chairman, James Gordon, did not offer an explanation of the actual benefits of massage, but he did allude to the widespread perceived effectiveness of the alternative treatment. He said:
"We shouldn't put too much weight on its benefits, but at the same time we should make it available to everyone. Massage does decrease anxiety, reliably. It does decrease pain in a number of people with chronic-pain syndrome. It does improve mood. Exactly how it does it, I don’t think we know" (Lacombe, p. 50).
AMTA researchers say as more people accept massage therapy as a viable treatment option, more athletes are becoming interested in sports massage.

The AMATA now recognizes sports massage as a unique specialty field within the massage industry. There has also been increased interest in sports massage among the so-called “weekend warriors”(people who only exercise on the weekends) and those do not consider themselves athletes or exercise regularly. No matter how little time they spend taking part in athletics, some people want to enjoy the perceived benefits of sports massage. Licensed massage therapist John Balletto said, “Anyone who exercises or works in an active job or even has to constantly bend down to pick up a child can benefit from sports massage. This type of massage helps muscles deal with the repetitive motions inherent to these activities" (Latina, 2000).

In the past, there was a public perception that only elite athletes and wealthy, pampered women received regular massages. As sports massage becomes more mainstream and begins to be embraced by the general public, there is an increased perception that sports massage is not only a luxury, but a new necessity. This trend can be seen in many forms of mainstream media. For example, a college newspaper in Texas, The University Daily, recently ran an article that stated that more financially strained college students were paying for massages as a way to combat stress. It also explained how deep tissue massage can help relieve pain associated with carrying heavy book bags and suggested that students ask their parents to pay for a massage session.

A massage therapist in the article was quoted as saying, “It is very therapeutic. It’s not a luxury like people think. If more people think of it as therapy, then more people could justify it that way" (Aaron).
However, despite the widespread interest in sports massage, there is a lack of reliable information on its benefits and effects. Using a search engine like Goolgle.com to search under the “benefits of sports massage” will turn up hundreds of websites offering glowing testimonials about the therapy and claims that are not backed up by current scientific research.

For instance, SportsInjuryClinic.net claims that regular sports massage treatments will “maintain the body, prevent injuries and loss of mobility, cure and restore mobility to injured muscle tissue, boost performance, and extend the overall life of your sporting career” (Sports Injury Clinic). Another website for massage centre in Connecticut bluntly states, “Massage is beneficial when starting a conditioning program because it helps you get into good shape faster” (Buckland Massage & Neuromuscular Centre). With so many websites making fantastic claims about the benefits of sports massage, it is easy to understand why the perceived benefits of sports massage currently held by the general public do not always match current scientific research.

As previously mentioned, sports massage is broken down into three main categories: pre-event, post-event, and routine maintenance. Each of these forms of sports massage uses a combination of stroke techniques. In order to understand the research and perceived benefits of sports massage, it is important to understand the various stroke styles. The most common stroke strokes are effleurage, petrissage, and cupping(Davidson, 2001). Other common strokes include friction, range of motion movements, trigger point, and compression (which some massage therapists classify as a type of petrissage) (Pike, p. 26-31).

Effleurage utilizes long, gentle strokes. This is the most basic type of stroke and warms the area for the work to come by increasing blood flow to the muscle (Pike, p. 26). This is the main stroke for creating relaxation and is often used most frequently at the start and end of massage therapy session, although it is useful throughout the therapy(Cates, 1998).
Petrissage is a firmer, two handed kneading technique that includes blows to the muscle. Both hands grab the muscle and compress it. Massage therapists use petrissage to loosen tight muscles and squeeze blood out from deeper structures (Davidson, 2001).

Cupping involves hitting the muscles with cupped hands. This stroke technique is used to break down scar tissue, relieve tension and tone the muscles (Davidson, 2001).

Friction strokes are used only during deep tissue massage to relax the muscles and reduce adhesions. These circular strokes generate heat by increasing blood flow to the area being worked on (Pike, p. 32)
Range of motion movements are assisted exercises that the massage therapist uses to increase the mobility of joints. The massage therapist moves the body while the athlete stays relaxed. Massage therapists report that this technique can extremely helpful for athletes, who usually need to have the maximum range of movement possible in order to excel at their sport (Pike, p. 34).

Trigger points are parts of the muscle that are tight and painful. When massage therapist applies pressure to a trigger point, the athlete will often cry out in pain. Correctly massaging a trigger point will help release tight muscles and “break the pain cycle so the tissue can get blood and nutrients to heal and relax itself” (Pike, p. 31)
Compression strokes are used on muscle bellies, generally in large areas, like the adductors. Massage therapists use compression, which Isa squeezing movement, to feel the tissues under the skin. Compression can stimulate and warm the tissue or relax the athlete, depending on the firmness of the stroke (Pike, p. 30).

Many people mistakenly think that sports massage is beneficial because it is somehow “deeper” than other massages. However, that is not always the case. Sports massage is any massage technique that allows “active people to stay active, to keep the body in working order, and to aid rehabilitation following injury.. Thus it can also involve gentle rubbing, or even no rubbing at all. In fact, there are times when rubbing may be harmful and in this instance, stretching may be more beneficial” (Famous Therapies).

Literature Review

Many massage therapists believe that pre-event sports massage can help prevent serious injury by warming-up the muscles and improve performance during a competition. Meagre was strong advocate for-event massages. In his book, Sports massage, he wrote:
"Whatever sport you play, Sports massage will give you 20 per cent extra---extra performance, extra protection, (and) extra time per game, per season, (and) per career.......With Sports massage you can do what you do better, longer, and more easily, raising your performance level at the same time that you lower the stress level it places on your body…. Sports massage before (problems) reach the critical stage is the only sensible way to keep your entire muscular structure in top form"(Massage Before, or After?).

Pre-event massage is not intended to replace traditional warm-up methods. It is usually performed just before the athlete’s standard warm-up. Rapid effleurage stimulates and warms the muscles andpetrissage encourages the release of tension. It is common for the massage therapist to use shaking and stretching techniques. Deep tissue and friction are avoided. The part of the body that is massaged depends on the sport, but usually includes leg and back muscles (Davidson,2001).
Pre-event massage generally only lasts about ten minutes. The goal Isa reduction in tension, but not total relaxation. Sports massage therapist, James Weslaco, says that most athlete want to feel stimulated, not overly relaxed, by a pre-event massage because being too relaxed can adversely affect performance (Vanderbilt, 2001).

“(Pre-event massage) objectives are to increase circulation, increase range of motion of the joints, decrease tightness and hyper tonicity of major joints and muscles, and to relax and then invigorate the body to get it ready for the competition” (Pike, p. 19)
The perceived benefit of fully prepared muscles is important to many athletes, who are well-aware of the many career-ending injuries that have been blamed on not properly warming-up. There is a widely-held belief that overuse injuries can be avoided if the athlete is warmed-up with a combination of massage and standard warm-up practices. However, many studies have suggested that the benefits of pre-event sports massage are mostly psychological and there is no evidence theatre-event massage can decrease the risk of injuries (Harmer, p.55).

Some athletes say they perform better on the field after receiving pre-event massage. However, again, the benefits appear to be purely psychological. Research shows that massage, which is part of passive warm-up techniques that can also include saunas and hot showers, have little positive effect on performance (Volant’s, et al., 2001).

In one study, members of a group of athletes who received pre-event massage each reported feeling that they could perform better on the field because of the therapy. Yet, their performance, heart rate and arteriovenous oxygen responses were not noticeable different than those of a control group that did not receive massage (Boone, et al., 1991).
Although there are many widely embraced perceived benefits to pre-event sports massage, there has not been enough research to back up the antidotal evidence given by athletes and their massage therapists. Some studies have indicated that there can be physiological responses that result in improved outcome for the athlete.

However, much of the research has not quantified the technique and pressure used by the massage therapist.. No study to date has examined how stroke forms and pressure (light touch versus firm) as an independent variable can affect athletic performance (Moyer et al.).

Even though the benefits of pre-event massage are still unknown, it continues to increase in popularity, not just in athletics but also another performance-driven industries. Robert King, president and-founder of Chicago School of Massage Therapy, says "It's a debatable subject in terms of actual research that substantiates it.” Yet, he continues to see the demand for pre-event message grow. "I've worked on runners, actors and actresses before performances, boxers and swimmers, and again it depends on the type of muscle you're going to encounter and the condition and goals of the athlete. The approach is geared toward the needs of that particular event" (Vanderbilt, 2001).

Unlike pre-event massage, post-event massage may have measurable benefits. Post-event massage is performed one to two hours after the athlete has finished taking part in a sporting event, in order to allow time for blood vessels dilated by exercise to return to their normal state. The goal of this type of massage is to reduce the trauma caused by strenuous exercise. Light effleurage is used to minimize swelling. Practitioners believe light petrissage will promotes cellular waste removal and clear toxins from the body. (Pike, p. 20).

“The goals are to relax tight muscles, decrease muscle soreness, facilitate faster recovery time, relieve cramping, increase lymphatic circulation and removal of post activity metabolites, and relax the nervous system” (Pike, p. 20).
Other perceived benefits of post-event massage therapy include the lessening of muscle spasms and an increase in flexibility which may prevent future injuries. Although receiving a massage after a strenuous workout can feel very pleasurable, practitioners should limit sessions to under 30 minutes because tired muscles may be more prone to injury. In fact, some therapists believe that the longer the athletic event is, the shorter the post-event massage should be (Cates, 1998).

The perceived effectiveness of post-event massage is pervasive among professional athletes. There is a strong belief that the therapy can speed recovery after extreme exertion. For example, Butch Reynolds, the400 meter world record holder was quoted as saying that because of massage, “If [a muscle pull or strain] does occur, it’s easy to heal. The healing process is cut in half.”

Professional football linebacker Al Smith has also heralded the benefits of post-event massage. He said, “It helps me quite a bit. It helps my recovery time from the game. Athletes are using it quite a bit.” (Sports Massage: Taking the Field)Perhaps the most famous advocate of post-event massage is Michael Jordan. In talking about his physical problems after a performance, the basketball player said, “I was a little concerned, because I couldn’t really walk well...and my mobility was very, very limited. But two days of electros Tim, massaging and heat treatments really loosened things up" (How Massage Aides Athletic Performance).

Despite scepticism that massage has physiological benefits, Davidson advocates the use of post-event massage to speed recovery (2001). She writes that sports massage can reduce the swelling of micro-traumas. Micro-traumas are small tears that occur in muscles during strenuous exercise. Davidson claims that post-event massage will also remove lactic acid and waste build-up in the muscles, help maintain flexibility, and reduce cramping.

However, while Davidson’s theories may be popular, there are studies that dispute the claims. For instance, the blood pressure, cardiac output, heart rate, and lactic acid levels of ten men were compared during a recent study. Lactic acid is a by-product of exercise that occurs during exercise when there is a lack of oxygen in the body’s tissues. Some massage practitioners have made the claim that massage can help the body eliminate waste products, including lactic acid.

However, the men in the study who received massage had similar levels of lactic acid to the men who were not treated with a massage(Callaghan, p. 31). Furthermore, the group that received massages performed no better than the control group.

The idea the lactic acid can (and should) be flushed from the body during post-event massage is a good example of how the perceived effectiveness of massage does not always match current scientific research. For many years, massage therapists believed that they could help athletes get rid of lactic acid. They passed this belief onto clients, including many athletes, who accepted the theory as fact. The false assumptions about lactic acid were even taught in massage schools. Even though scientific studies have debunked this belief, many athletes still think they need post-event massage to rid their bodies of lactic acid (Vanderbilt, 2001).

Despite the critics, many massage therapists are convinced of the benefits of post-event massage. They say post-event massage can help determine why an athlete did not perform up to expectations. A massage therapist for the Los Angeles Dodgers, William Leisure, said he uses post-event massage in the same way a detective might search for clues. Leisure described his work not only in terms of keeping the players ‘muscles loose and relaxed, but also keeping constant watch on their bodies.

"Even if someone's not injured, if the performance wasn't quite right, I do a palpation to see if any muscles are tight. It has a lot to do with how good your hands are. Your brain and your thumbs have to be as one… It's not just a rub. It's the information I can get from the body and turn it into something else to try to make a cohesive plan. Scanning the tissue and checking for deviations is kind of diagnostic, actually. That helps them to stay at peak performance" (Vanderbilt,2001).

The third category of sports massage, maintenance, is not administered on days of competition or performance. Instead it is done between events (Pike, p. 21). Usually, maintenance massages are given once week as part of a total training regimen. However, elite athletes, who often have the resources to hire their own massage therapists, may receive daily massages.

Manteca massage uses all of the strokes common in Swedish massage, including effleurage, petrissage, and vibration. These massages take longer than pre-event massages, usually taking between 30 to 90 minutes. The goal of maintenance massage is to increase the blood flow to the muscles, reduce the chance of developing scar tissue, and increase range of motion and flexibility. (Davidson,2001). Donna Yates, PTA, CMT summed up the perceived benefits of maintenance massage:

“An effective maintenance program is based on the massage therapist’s understanding of which muscles are used in a given sport and which are likely candidates for trouble. By focusing on particular muscle groups and tissues, the therapist helps the athlete maintain or improve range of motion and muscle flexibility. A maintenance program reduces the chance of injury and helps the athlete reach better performance”(Yates).

One of the perceived benefits of maintenance massages is often referred to as “working out the knots.” After exercise, the body may repair itself in a way that locks some muscle fibres together, which makes using them more difficult. These locked fibres are called “knots” and can be extremely painful. Knots can also be caused by daily stresses. Massage therapists believe that separating the fibres through massage will “break-up” the knots and create free muscle movement and increased range of motion (Pike, p. 21).

When American marathon runner Me Keflezighi returned home after winning a silver medal at the Athens Olympics, he said we would prepare for the New York City Marathon by undergoing a serious of maintenance massages to “work out his knots.” He said, “Deep massages. It’s sometimes painful, but it’s temporary discomfort for a long-term effect” (Graham).

The president of the International Sports Massage Federation explains this theory to the general public by using an analogy. He says, "Think of a jewellery chain with a kink in it. That kink is in the muscle. Sports massage works to get the kink out so the muscle can perform optimally" (Latina, 2000). This is another example of the how the perceived effectiveness of sports massage is spread through the general public and sports community by using very general or vague descriptions.

Two Physical therapists at the Medical College of Georgia have tried to pinpoint the benefits of maintenance massages. Rd. Mary Ellen Franklin’s research was based on a popular theory that massage helps the body repair itself. She measured the levels of the stress hormone cortisol in the urine of people who had just received a massage. She found that the more their hormone levels were altered, depending on the intensity of the massage techniques used. Rd. Franklin’s studies have also left her with the belief that loosening muscles through massage may trigger the release of endorphins, which boost mood and foster sense of well-being (Sheening p. 63).

Another study by Donavon Reich at the Medical College of Georgia found that massaging of the hamstring muscle could increase the range of motion of the knee joint for a week. His study has led him to believe that massage is beneficial to people who have limited mobility because of tight muscles (Sheening, p. 63).

In addition to increasing range of motion and increases in endorphins, many massage therapists believe that maintenance massage can help prevent injuries. The theory is that the constant tension created by athletic training can build-up and cause injuries associated with over-use. Massage helps release tension, therefore reducing the risk of some types of injures (Sports Coach).

Over time, athletes can develop muscle imbalances, which increases the risk of injury. Manteca massage advocates claim that a skilled the rapist will notice changes in muscle tissue and be able to correct imbalances before they become dangerous. Each sport has its own patterns of chronic muscle imbalances and strain caused by overuse. For example, tennis players often have tight pectoral muscles on their dominant side, which can lead to rotator cuff tears. Runners are prone to injuries associated with tight calf muscles and hamstrings (Vanderbilt, 2003).

The release of tension is important in all sports. However, muscular tension is an area of serious concern for dancers because it is often associated with injury. The famed River Dance troupe has used maintenance massage to alleviate tension that the dancers themselves might not even be aware of. Massage therapist Keith Eric Grant believes that massage therapy can shorten recovery time after a performance. He explained, "We become part of the lifestyle structures of support to which an athlete and kinaesthetic artist can turn when viewing massages an interaction and communication. Beyond this, we can address the tension to which they might unconsciously cling" (Vanderbilt, 2003).

Meanwhile, Leisure said that pre-event, post-event and maintenance massages all help players understand their bodies, which ultimately can reduce the chance of injury. He believes that regular massage helps players “get in tune” with their bodies. According to Leisure, this body awareness makes athletes more sensitive to varying sensations. Therefore, potentially serious injuries are not as likely to go undetected (Vanderbilt, 2003).

These theories remain largely unproven. For example, Ernst, while on one hand concluding that massage may provide some benefits, has also sharply criticized existing studies on sports massage, calling them methodologically flawed.
“The lack of randomization and blinding in one study, and use of single-blinding in the others meant the studies were open to selection and observer bias. Inadequate definitions of massage and improvement were given in the trials and different outcomes and measurement tools were used. The studies were, therefore, of poor quality and validity and unlikely to be capable of providing a true result regarding the effectiveness of massage in low back pain” (Ernst, 1999).

This general dissatisfaction with current research on the effects of sports massage was also summed up by Triton, (1993).
"Claims about massage are sometimes outcomes of rigorous research, but more often-than-not, they are wishful thinking or hypotheses based on the anatomical structures and physiology of the body… Unfortunately, there is very little to be found in the literature on the physiological effects of massage and very few scientific studies have been undertaken in this area."

As stated by Triton, there have been relatively few scientific studies on the beneficial effects of massage. Among those studies, Callaghan could find little agreement on the most effective massage techniques, and the physiological and psychological factors involved. Because of the many conflicting results, Callaghan concluded that more researches necessary in order to understand the ramifications of sports massage and to justify its use (Callaghan, 1993).

However, this lack of evidence seems to have little effect on athletes who believe that pre-event and post-competition massage has helped them achieve their goals. During the European Cup 2000, Kevin Keegan publicly stated that his team would be receiving post-event massage immediately following the games. The Federation of Holistic Therapists, which strongly advocates all forms of massage, explains the popularity of sports massage by stating, “Whether this is for the purposes of relaxation or invigoration, and whether the effects are psychological or physiological is, in many respects, irrelevant. For many, mental preparation is as paramount as physical ability when it comes to a good performance (Sports Massage).

A study in the British Journal of Sports Medicine further explores the theory that sports massage provides a psychological benefit. In the study, eight amateur boxers were tested for levels of blood glucose, heart rate, and lactic acid before and after two fights. The fights all lasted 10 minutes and involved some 400 punches. After the first fight, some boxers simply rested. Others received a 20 minute massage by qualified therapist. After the second fight, there was no measurable difference in the two groups and both showed similar physical signs of fatigue.

Yet, the boxers who had been given the massage reported feeling better than those that had simply rested (Hemming’s et al. p.109-114). The study concluded that there is some support for the reputed psychological benefits of sports massage, but there is no evidence that massage can provide physiological benefits, including restoration and improved performance.
In a similar study, Tides and Shoemaker acknowledged that there is pervasive perception that massage can enhance long term muscle recovery from strenuous athletic training. Many athletes, coaches and trainers believe that increasing blood flow to the affected muscles through massage is a key component of recovery.

To discover if these perceived benefits could be proven by showing tangible results of massage, Tideland Shoemaker set up a study in 1995 in which subjects had their quadriceps muscles massaged every day for four days. The subjects had all previously completed an intense training session that included eccentric quadriceps work. After the workout, peak torque had declined in both the massaged group and the control group that received no massage. In both groups, recovery was evident over the four days.

Blood flow was monitored by the use of pulsed Doppler ultrasound velocimetry. The massaged quadriceps did not have significantly more blood flow. They concluded that massage was “not an effective treatment modality for enhancing long term restoration of post-exercise muscle strength and its use for this purpose in athletic settings should be questioned.” However, the perceived level of DOMS was reduced in the group that received the massages (Tides and Shoemaker, 1995). This perceived benefit of massage can be compared to a “placebo effect.”

Robert King, president and co-founder of Chicago School of Massage Therapy does not disagree with these studies and others that have reached the same conclusions. He states:

“There are some scientific studies showing that massage does elongate some muscles, but I think a large component is psychological. It's tied in with issues of confidence, self-esteem and body awareness. The feeling of getting massage expertly is a profoundly integrative experience. And if they are overly psyched out, it can assist in general relaxation” (Vanderbilt, 2003)

It is likely that the perceived psychological benefits of pre-event sports massage may actually create a situation in which the athlete is able to maximize their body’s potential. After all, much of antithetic skill is mental, so it stands to reason that calming nervous tension before an event will only benefit the athlete’s performance.

Research has shown that massage has a remarkable ability to decrease stress. In one study, 30 female dancers were randomly given either massage therapy or relaxation therapy. They received their assigned therapies twice a week for five weeks. Both groups reported feeling less depression and anxiety. However, only the massage group showed lower levels of the stress hormone, cortisol. Both groups also reported feeling less physical pain. Yet, only the massage group actually showed measurable improvements in range of motion (Levied, et al. 1999).

While soothing massages may help athletes become calmer and more relaxed before events, a brisk massage may stimulate an athlete and reduce states of apathy. This stimulation can give athletes a feeling of “mental readiness” (Davidson, 2001). Furthermore, many athletes turn to massage after events simply because it feels good. They consider it a physical and mental reward for a job well-done.

While the exact science behind the benefits of massage, including sports massage, remains elusive, many say they do not need medical research to tell them what they already know: massage has worked for them. To them, it doesn’t matter why. Robert Henley Woody, Ph.D., Sc. Wrote "There is clearly too much support for the benefits of massage for it to be left out of any health specialist's treatment repertoire, even if many of the healing properties involve the psychological effects of 'laying on of the hands'" (Cates, 1998).

In 2003, Ernst, noting the increased interest in massage, tried to determine the safety and side effects of the alternative therapy. He searched computerized literature in four databases. He did not consider injuries relating to massage oil or ice applications. His search uncovered 16 reports of negative effects, which four of them being serious. Sports massage enthusiasts seem to be comparatively safe, since most of the problems were found in more “exotic” types of massage given by people who were untrained. He concluded that while massage is not entirely without risks, serious consequences are quite rare (Ernst,2003).

While there seems to be few serious side effects from receiving sports massage therapy in the United Kingdom (Vickers et al.) and the United States, it is definitely not for everyone. Often massage is seen as “cure-all” to those who have embraced the various and sometimes farfetched misconceptions about massage. Sports massage should never be used on subjects suffering from many maladies, including burns infectious diseases, phlebitis or deep vein thrombosis, osteoporosis, and certain skin conditions (Hedwig, 2001) (Davidson, 2001).

Some research has also suggested that patients who have suffered a heart attack should not undergo massage therapy, but this has been the subject of debate. It is therefore recommended that anyone who has had history of cardiac problems talk to their doctor before receiving massage. Additionally, although there is no evidence that massage cancer patients promotes the spread of the disease, practitioners should never apply firm, direct pressure over an active tumour (Vickers al.).

In pre-event and post-event sports massage, the athletes are usually dressed. During maintenance massage, it is more common for the massage therapist to use cream or oil (Pike, p. 21). There has been concern expressed over the safety of oils used, especially those that used in aromatherapy massages. Although the safety of essential oils has not been established, adverse reactions to them are extremely rare (Vickers al.).

Part of the problem of determining the effectiveness of sports massage comes from the widely varying skills of its practitioners (Moyer teal., 2004). In the United States, true sports massage therapists must not only have a certificate in general massage from an accredited school, they must also complete further training in a program approved by the AMTA National Sports Massage Certification Program (Davidson,2001). In the United Kingdom, massage therapists can be registered by many different organizations, which can be confusing for those trying to find a qualified sports massage therapist. It is recommended that athletes chose a practitioner from an organization that is associated with the British Complementary Medicine Association (Vickers et al.)

However, academic credential vary from region to region and they do not necessarily mean that the massage therapist is fully qualified. Mastering the application of sports massage can take years of experience and a vast understanding of athletics (Vanderbilt, 2001).

Unfortunately, many of those interested in receiving therapeutic sports massage cannot turn to their physician for help or advice. Although more patients in the United States and the United Kingdom report using alternative medicine, most still visit their medical physicians. However, there is little information about how physicians discuss alternative treatments and their effectiveness with their patients.

Furthermore, physicians have reported feeling uncomfortable answering questions about alternative treatments, including massage, because they felt they did not have enough education on the subject to-do so (Winslow and Shapiro, 2002). It is therefore plausible that more athletes and those interested in sports massage could make better, more informed decisions about receiving care if their own doctors were more educated on the topic.

Methodology

Researchers at the School of Applied Sciences at the University of Glamorgan in Wales tested the perceived benefits of massage and its effects on performance. Researchers studied the effect of pre-event massaging of the hamstring muscle group on the “sit and reach” test. Before the massage, 11 men performed the sit and reach test. Then, they either received a 15 minute massage of the hamstrings or rested. They then repeated the sit and reach test. The next week the entire process was repeated, except this time the massage group rested and the rest group received the hamstring massage. No significant differences were found between the massage group and the resting group. The researchers concluded: “A single massage of the hamstring muscle group was not associated with any significant increase in sit and reach performance immediately after treatment in physically active young men” (Barlow, teal., p. 351).

A study in Scotland acknowledged that that the equivocal results of current research on the benefits of sports massage, including pre-event massage, makes it very difficult to justify the expense and effort that it takes to employ massage specialists at major athletic events(Galloway and Watt, 2004). However, despite the limited and often conflicting research on the benefits of sports massage, there is widespread perception that pre-event sports massage is beneficial. Galloway and Watt stated, “Given the popularity of massage among athletes, consideration should be given to the use of specialist sports massage staff at major athletics events. Furthermore, it would seem prudent to further investigate the efficacy of the treatment” (2004).

There is research that suggests that massage can encourage the recuperation process and reduce fatigue and pain in several ways, depending on the type of massage technique used (Blake et. al, 1989).An Australian study found that patients who had undergone operations had less perceived pain over a 24-hour period. Furthermore, the researchers at the University of Iowa found that massage can reduce the perception of a pain in anxiety by promoting relaxing. Although these studies dealt with hospitalized patients, there is reason to believe that the same calming effects could be enjoyed by athletes (Cates,1998).

Looking specifically at sports massage, researchers found that sports massage can reduce the chance of developing delayed onset muscle soreness (DOMS) if the massage is administered within two hours after the conclusion of the eccentric exercise (Smith et al., 1994). DOMS occurs when tissue is injured, resulting in inflammation and pain. The pain and swelling associated with DOMS can adversely affect an athlete’s performance by reducing his or her range of motion.

In this study men were randomly assigned to either a massage or control group. All of the men performed five sets of eccentric exercise involving the elbow flexors and extensors. Two hours after the exercise, the massage group received a 30 minute sports massage. The non-massage group simply rested. Levels of circulating neutrophils, which contribute to acute inflammation, and cortisol, a naturally occurring hormone, were tested at 30 minute intervals for eight hours after exercise. The massage group reported reduced levels of neutrophils and higher levels of cortisol, and therefore experienced reduced DOMS (Smith et al., 1994).

Massage therapists often use compression stokes, shaking, range of motion movements, and petrissage to prevent DOMs. Deep tissue work and heat applications are not recommended (Pike, p.21) In other studies, friction massage has also been shown to provide pain relief by stimulating the endogenous opioids. However, gentler types of stoke technique appeared to have no impact on pain relief. After looking at total of seven studies, Rd. Edward Ernst of the University of Exeter conducted a systematically review and concluded that massage therapy maybe a promising treatment for DOMS (1998). However, in 2004, Moyer, Rounds, and Hanno discounted Ernst’s conclusions, saying Ernst did not have a sufficient number of statistics from which to draw conclusions.

Furthermore, there have also been studies that have concluded theatre-event and post-event sports massage have no significant impact condoms or any other physiological factors that affect recovery after exercise. In fact, some research suggests that light exercise improves the flow of blood more than sports massage and therefore may be more beneficial than massage in aiding the recovery process (Tides, 1997).

A Swedish study in 2004 further confirmed Tides’ theories on the actual benefits (versus perceived benefits) of sports massage. There searchers approached the topic by acknowledging that the use of sports massage is very popular in the athletic community, but there has been very little evidence of its therapeutic effects. Sixteen participants performed 300 maximal eccentric contractions of the quadriceps muscle. Each received massage on only one leg. For the purpose of the study, their other legs served as the “control group. “Researchers tested the participants each day for three days following the exercise. They concluded that the “massage treatment did not affect the level or duration of pain or the loss of strength or function following exercise” ( Jon Hagen et al. p. 1503 ).

Athletes have also praised massage as a good way to encourage relaxation, saying that the release of tension can help the recovery process. Lab yak and Metzger (1997) compared nine studies on the effect of effleurage back massage on physiological indicators of relaxation. It should be noted this was not an analysis confined to athletes. Infect, the subjects were between 19-96 years of age, with widely varying levels of health and fitness.

They reported that “three minute effleurage led to an 11% decrease in blood pressure and heart rate and 6% decrease in respiratory rate. Ten minute effleurage led to an 11%decrease in blood pressure and heart rate and a 25% decrease in respiratory rate” (Lab yak and Metzger, 1997) . This led them to the conclusion that massage therapy is effective in inducing relaxation. However, their conclusions were later criticized by Moyer, Rounds, and Hanno (2004), who said their findings were the result of flawed methodology and left open the possibility that the relaxation effects could have been caused by a placebo effect, statistical regression, or even spontaneous recovery.

Another study that also evaluated the efficacy of massage concluded that it is a viable therapy for low back pain when compared to other alternative forms of therapy. 262 patients, with ages ranging from 20to 70 years, were randomly selected to receive acupuncture, therapeutic massage, or educational materials. Most had already received at least a year of treatment for pain and many were on medications to relieve their symptoms. They were studied for 10 weeks. The massage group received 10 massages, while the other groups received their prescribed treatments.

At the end of the study, during telephone interviews, the massage group reported less severe symptoms and less of dependency on pain medication. After one year, the massage group still reported better results over the acupuncture and self-education materials group. 10% of massage group patients visited their physicians for pain during the study period.

This compares with 18% of the acupuncture group and 21% of the self-care patients who sought medical treatment for pain. The researchers concluded that therapeutic massage was an effective treatment for low back pain and seemed to provide along-lasting solution. Most notably, the study’s authors also stated, “Massage might be an effective alternative to conventional medical care for persistent back pain” (Gherkin, et al., 2001).

Data Analysis

Yet, despite all of the previous studies, there are still many linger questions on whether the actual benefits of massage match the common public perceived benefits of the therapy. Over the last decade, as the interest in massage has increased, so has the amount of research. In the 1990’s Triton and Ernst expressed their great dissatisfaction with the then-current research on massage, especially sports massage techniques. However, a more recent and much larger review of current research has come up with some different conclusions. “A Meta-Analysis of Massage Therapy Research” was published in the January, 2004 edition of the Psychological Bulletin.

For the purpose of this analysis, massage was defined as the "the manual manipulation of soft tissue intended to promote health and well-being, a definition that encompasses the diverse nature of this form of treatment" (Moyer et al., 2004). The researchers, working with this definition, carefully examined 144 existing studies that dealt with the effectiveness of massage therapy on adults. Any therapy using self-massage, heat, ice, chiropractic treatments, or progressive relaxation treatments were generally not included (exceptions were made for those that had a specific massage group.)

Children were also eliminated from the review. This left them with 37 studies, involving more than 1,800 subjects. They looked at nine dependent variables and considered the popular theories of how massage could control pain, promote parasympathetic activity, promote sleep, and influence body chemistry. The study also looked at the mechanical effects of massage, which is of particular interest to those who practice sports massage. The researchers paid particular attention to articles concerned with sports performance, recovery after exercise, and injury management.

When it was completed, Moyer, Rounds, and Hanno’s meta-analysis delivered several blows to widely held beliefs about massage therapy. The concluded that the actual benefits of massage appear to be quite different that the perceived benefits many have. They write, “It is interesting to note that, among the theories that are commonly offered to explain MT effects, the most popular theories are the ones least supported by the present results.”

They concluded:
“Single applications of MT reduced state anxiety, blood pressure, and heart rate, but not negative mood, immediate assessment of pain, and cortisol level. Multiple applications reduced delayed assessment of pain. Reductions of trait anxiety and depression were MT’s largest effects, with a course of treatment providing benefits similar in magnitude to those of psychotherapy” (Moyer et al., 2004).
The finding that massage did not reduce cortisol levels significantly is different than the other conclusions reached by the scientific community. They also concluded that a single session of massage therapy did not have an immediate effect on the assessment of pain, which stands in sharp contrast to the beliefs held by many sports massage therapists. However, patients who received a series of massages reported lower levels of pain than those that did not receive therapy.

It was suggested that massage might help reduce pain by allowing the subject to more easily receive necessary sleep.
Also of interest, is the finding that subjects who received massage therapy had fewer incidents of anxiety and depression. In fact, trait anxiety the massage groups experienced a 77% reduction in trait anxiety and a 73% present reduction in depression (Moyer et. al, 2004). This seems to add credence to the widely held perception that sports massage can benefit an athlete’s state of mind and therefore benefit athletic performance.

However, the researchers went to great lengths at the conclusion of their study to stress that massage therapy is not limited psychological benefits. They state that massage therapy is also a physical therapy and some of its benefits appear to occur through physiological mechanisms. In fact, they say one of the most interesting aspects of massage therapy is that it seems to provide benefits in various ways. They end their meta-analysis by stating:

“However, whether researchers wish to study MT as a physical therapy, as a psychological one, or as both, new research should examine not merely the effects resulting from MT, but also the way in which these effects come about. It is only by testing MT theories that a better understanding of this ancient practice will result" (Moyer et. al,2004).

The strong psychological impact of massage found by many studies strongly correlates with the anecdotal evidence given by countless massage therapists and their clients. The perceived psychological benefits of all massage, including sports massage, include an improvement in self-image (Vickers et al.) Massage therapists speculate that more than specific techniques, the simple act of touching can be therapeutic, especially for those who have had limited physical contact with others. Patients often report feeling “cared for” after receiving massage therapy.

Moyer, Rounds, and Hanno (2004) mentioned similarities between the benefits of massage therapy and psychotherapy. Massage therapists seem to agree with these similarities, saying that massage can even serve as an important step toward counselling for mental health problems or addiction. Another perceived effect of massage is that it can help patients learn how to relax by showing them exactly what total relaxation feels like. However, these theories, while backed up by anecdotal evidence, have not been researched (Vickers et al.).

Summary

There are many perceptions, both accurate and misleading, about the effectiveness of sports massage. While all forms of sports massage, including pre-event massage, continue to grow in popularity, it is difficult for even skilled researchers to determine the exact benefits of the treatment. Therefore, it is not surprising that the general public, athletes, and even massage therapists, are often unsure about ramifications of massage therapy on the body.

There has been much anecdotal evidence about the varied benefits of sports massage in maximizing performance. It is clear that for many, massage is a pleasant tool and an additional way to warm-up, cool-down, and train. However, despite the perceived effectiveness of pre-event massage, most scientific studies continue to suggest that massage done before a strenuous exercise has no effect on performance. Research has shown that post-event massage may offer some limited benefits, but the evidence is remains contradictory. Regular massage, or maintenance massage, may also provide have a positive effect on the body, but exactly what those benefits are remains debatable.

Moyer, Rounds, and Hanno have concluded that the psychological benefits of massage may surpass the physical effects of the therapy, but there is still not enough research to support any claims. Several groups have called for more studies on massage. Continued research will be the only way to fully understand the mysteries of all massage, including sports massage. Until more is known, the public’s knowledge about sports massage will continue to be based more on widely-held perceptions than actual facts.

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