As Licensed Massage Therapists, we feel it important to be hypercritical of the field. Like many areas in the health and fitness fields, sometimes the lines between what massage has been proven to do and what people claim it can do can be blurred.
We at Uplift Wellness find it important to provide an evidence-based approach while keeping in mind certain novel and anecdotal aspects of the field when we treat. One of the benefits that are talked about with massage therapy is its effect on recovery from exercise.
Let's talk about research done in this realm, what it says, what it means, and how you can apply this information for yourself. We will be using MASS as a reference for our information. MASS stands for Monthly Applications in Strength Sports. The MASS team offers this subscription at a reasonable price of $30 a month and offers its readers a comprehensive and digestible review of 10 articles that come out monthly in the strength and conditioning world. They also provide videos and podcasts in this subscription going in-depth speaking about some of those topics. Thank you, Greg Nuckols and the MASS team for providing this service for everyone in the strength and conditioning world.
Massage Therapy is well known for many things, but one of the reasons that people seek it out is for the purposes of recovery. The study that MASS looked at (original study) was a meta-analysis that compiled 99 studies that had to meet their inclusion criteria of studies that assessed DOMS, perceived fatigue, inflammatory markers, and proxies of muscle damage. They included other modes of recovery that are often used, the ones of most importance that we'll include here are massage, active recovery, and stretching. All of the modalities looked at had some improvement in perceived fatigue and DOMS. The exception is that stretching had virtually no effect on either perceived fatigue nor on DOMS. Also, active recovery actually showed to increase in perceived fatigue the day after.
In this meta-analysis, massaged showed to actually decrease perceived fatigue and DOMS the most compared to the other modalities of recovery. It should also be noted that in these studies, massage was given directly after training. In a close second place came compression garments and submerged ice baths.
The mechanisms of which this happened weren't explored and are mainly speculative at this point, but knowing what we know about what certain strokes do and the benefits of massage therapy in general, there’s some room for speculation to be had.
While the mechanism of DOMS and how it works isn't fully concise, there are some theories of which we can work with. One theory is that there are micro-tears in the myofibrils of muscles (specifically in the z-line of the sarcomere, for those anatomy buffs out there). These tears in the sarcomere affect the actin-myosin cross-bridges by causing them to disconnect, putting more tension and stress onto the remaining motor units that still have the cross-bridge intact. These micro-tears have the potential to activate nociceptors, causing some pain.
Another theory that is floating around is the enzyme efflux theory. This theory basically states that calcium that is supposed to be stored inside the sarcoplasmic reticulum is instead left in the muscle itself. This activates certain enzymes to be activated that can break down the muscle proteins. In response to that, inflammation ensues because of an increase in inflammatory mediators, which can cause some swelling and pain. Knowing this, it’s probably safe to assume that both of these contribute a significant amount to DOMS.
Now that we have that, let’s talk about how massage can influence DOMS:
First let’s talk about massage and nociception, or the perception of pain. As a disclaimer: We are well aware that pain is a multifaceted monster, and one that I am not going to tackle here, but let’s agree that it’s incredibly complex and a lot of factors contribute to it.
Research has shown that massage is pretty good at helping managing pain, even outside the realms of training-induced pain. There are a few ways that this can happen based on what we know about the physiological effects of massage strokes. At the base level of things, we can look at the gate control theory of pain. This theory states that there is a neurological "gate" that is present in the nervous system that will either allow pain to pass through to the brain or not.
When non-painful stimuli, such as massage, are introduced to the equation, that stimulus can in a sense “override” the pain signal, decreasing the sensation of pain. These strokes are coming in direct contact with the nervous system, sometimes on a systemic level if you’re doing full-body on someone. If done right, rhythmically, and strategically, those non-painful stimuli can potentially override the pain response for the person, helping to regulate the pain someone may be feeling. The conversation can get more in-depth about how neurodynamics works with the varying nerve fiber types, but for our purposes here that’s all we need to know. Staying on the subject of massage strokes, certain strokes in massage, such as effleurage and petrissage, are known to help flush muscles out by increasing the blood flow in and out of muscles. When this happens, any metabolites or chemicals in the area that chemoreceptors would be sensitive to, potentially increasing the sensation of pain. The increased flow of blood will also alleviate any hypoxia that may be forming, as well as help to deliver nutrients to the area.
Now let’s take a look at something that I came across, that I believe needs much more research done to be able to declare a definitive answer if it’s a true mechanism of how massage can influence recovery and pain, especially in the context of exercise. The paper we are looking at is an investigation paper, and by no means perfect and needs to be replicated and built upon, but it’s nonetheless interesting and seemed like it would be fun to explore. The topic is the immunomodulatory effects of massage. Upon injury and trauma, there typically is an inflammatory response that happens to try and heal the area as quickly as possible. This idea states that massage can have an influence over the inflammatory process, encouraging a more regenerative and healing state. To understand and create a good base to work off of, some knowledge of inflammation and what happens may be helpful to appreciate this thought process.
To keep things basic, when you have an injury your body kicks in the inflammatory response to help heal the area. This can be broken up into 3 stages. The acute, subacute, and chronic phases. Because DOMS is more of an acute/subacute issue, we’ll only be talking about those 2 phases here. During the acute phase, there are 2 events that occur: vascular changes and cellular changes. For the vascular changes, what happens is an increase in blood flow to the area, along with increased blood vessel permeability. In terms of cellular changes, things like leukocytes pavement to the cell walls and other WBC’s come in and arrive at the scene to do their jobs. For today's topic of conversation, we are going to be talking about macrophages, which is largely what the research looks at.
The word macrophage can be broken down into two parts - Macro= big, and phage or phago = things that devour. So basically it's a big cell that devours things, which is an essential part of the cell-mediated response of healing, as well as general inflammation. To make things more interesting, there are two kinds of macrophages which we’ll call M1 and M2. M1 macrophages encourage a pro-inflammatory response and the main job is to eat pathogens and necrotic tissue in the area. The M2 macrophages are an anti-inflammatory cell that also encourages wound healing and tissue repair along with the deactivation of M1 cells. Now that we talked about these cells let's take a look at how massage may influence the inflammatory process.
To further understand what may be going on we have to talk about something called mechanotransduction first. Mechanotransduction is defined in the investigation as “the transformation of a mechanical stimulus into a chemical signal or the resulting cellular signaling cascade after an external mechanical deformation of tissue”. In other words, when you apply force or mechanical pressure to a tissue that initiates some sort of chemical response in the tissue. The hypothesis that the investigation uses is that the application of compressive loading is a potent immunomodulator after damaging exercise.
In their laboratories, the researchers developed a device that acts like a massage mimetic. It is a machine that can be calibrated on how much force they would like to apply to a surface. The paper references another paper by Butterfield et al, which observed a large influence of massage on skeletal muscle inflammation and function. The caveat is that they did it on an eccentrically damaged rabbit tibialis anterior, which obviously has different physiologic considerations compared to human skeletal muscle, but it’s a start. They found after 30 minutes of application of their massage device for 4 consecutive days that the muscle not only recovered mechanical function at a faster rate than non-massaged and exercised muscles, but it also looked histologically similar to non-exercised tissues, which is interesting nonetheless.
They also found that the timing of this application seemed to influence the immunomodulatory efficacy, being that the further after exercise the application, the less effect it has on inflammation. So when massage is applied mechanotransduction seems to have a microenvironmental effect on the area, which in turn creates a cascade of effects that eventually helps turn M1 cells into the regenerative M2 cells, promoting reparation.
Reflection on what we’ve learned:
From what research is showing, it's fairly well supported that massage helps to improve the rate of recovery and decrease pain. That being said massage isn’t the end-all cure-all. Us as LMT’s should be responsible and honest to those we treat and should recognize that we provide a great service that can 100% benefit people, but that doing it solely won’t be the only thing that a patient or client needs to recover optimally or get out of any sort of pain. Things like nutrition, sleep, and managing life stressors are also major things to look at when dealing with recovery from training. In terms of pain, we are also aware that we are a supportive factor in helping with dealing with pain, especially in terms of MSK disorders/pathologies.
Massage certainly can help with dealing with pain amongst a whole other slew of therapeutic benefits, but doing things like physical therapy or other movement-based modalities will also play a major role in the healing process.
One way I always liked to look at it was like this: Massage does a really good job at helping you be more able to go and do your movement-based therapies by helping decrease pain and making you more comfortable and confident in how you feel and your ability to move. The biopsychosocial viewpoint of pain encompasses, well, the biology, psychology, and societal factors of pain, so helping to deal with any of those factors, like described, can be a major player in someone’s journey to becoming pain-free.
More research is needed in the field all in all. The research that is coming out is great and is doing great things for the field, but there's still a lot to be done. For these studies we talked about today, there will need to be more considerations for performance after the work has been done on the subjects to see how performance is affected. Also, more understanding of the mechanisms of how massage actually influences recovery in every application of it, not just immediate post-training, needs to be gained. Especially because most people get massaged the day after training, or have it interspersed between multiple consecutive training days. We should use the anecdotal evidence as guidance for research. If it didn’t have some positive elements on recovery or performance I assume that the gym warriors would’ve stopped it a while ago because it was preventing them from getting that sweet godly nectar of gains.
The inflammatory process is an important process for healing all in all, and there is a lot of talk lately of how skipping parts of it or limiting certain aspects of it may be negative due to a hindrance in the natural healing process, which I understand. On the other hand, if muscle function can be reintroduced in a healthy way at a quicker rate, as well as the perception of pain and fatigue is reduced alongside it, then that may promote a good psychological benefit for athletes to get back into training quicker. The field of sports psychology is coming out with amazing things in mindset and how you psychologically feel influencing your performance, so it wouldn't surprise me if that even decreasing the perception of these symptoms of DOMS would help to increase performance. But this is just based on postulation, my own experience receiving manual work, and my experience delivering it to people. Again, I cannot stress it enough, more research is needed in the field for therapists to best apply their skills everywhere we can.
Butterfield TA, Zhao Y, Agarwal S, Haq F, Best TM. Cyclic compressive loading facilitates recovery after eccentric exercise.Med Sci Sports Exerc.2008;40(7):1289–1296.
Crawford C, Boyd C, Paat C, et al. The Impact of Massage Therapy on Function in Pain Populations – A Systematic Review and Meta-analysis of Randomized Controlled Trials: Part I, Patients Experiencing Pain in the General Population. Pain Medicine, first published online: 10 May 2016.
Dupuy O, Douzi W, Theurot D, Bosquet L and Dugué B (2018) An Evidence-Based Approach for Choosing Post-exercise Recovery Techniques to Reduce Markers of Muscle Damage, Soreness, Fatigue, and Inflammation: A Systematic Review With Meta-Analysis.Front. Physiol. 9:403. doi: 10.3389/fphys.2018.00403
Waters-Banker, C., Dupont-Versteegden, E. E., Kitzman, P. H., & Butterfield, T. A. (2014). Investigating the mechanisms of massage efficacy: the role of mechanical immunomodulation.Journal of athletic training,49(2), 266–273. https://doi.org/10.4085/1062-6050-49.2.25