A physiotherapist reached out the other day after reading the chiropractic adjustment truths blog post. We had a bit of discussion on manual therapy and I dismissed manual therapy as ineffective for musculoskeletal conditions (back pain, shoulder pain, knee pain, etc). He somewhat disagreed. He thinks there’s value in manual therapy.
I realised I have not blogged much about other forms of manual therapy beyond spinal manipulation. So, I have decided to start with the all-time popular sports massage.
What is a sports massage?
So if you look up “sports massage” as a search term in pubmed, you’ll realise there aren’t many results. Most of the studies are also quite old. Which makes me think maybe sports massage is more of a marketing gimmick for massage targeted at athlete rather than a standalone, unique therapy.
I am not sure.
From the available literature, sport massage is a type of manual therapy aimed at enhancing athletic performance, helping athlete recover, or as an treatment intervention for musculoskeletal injuries.
Top Five Sports Massage Articles: Square One’s Edition
So it’s really hard to debunk a topic you don’t know at the back of your hand.
For sports massage, not so much. Largely because I am not a massage therapist or a physiotherapist. So, let’s do a literature review on the evidence for sports massage.
Study 1: Using Pressure Massage for Achilles Tendinopathy: A Single-Blind, Randomized Controlled Trial Comparing a Novel Treatment Versus an Eccentric Exercise Protocol (2019)
I just blogged about Kingsley’s Achilles tendinitis so this paper court my attention. Does pressure massage work for tendinopathy?
(I have never heard anyone recommending pressure massage for tendinopathy so I guess, it is indeed, a novel treatment.)
The paper compared pressure massage vs. eccentric exercise vs. combination of both massage and eccentric exercise. In the abstract, it was published the pressure massage group improved significantly more than the eccentric exercise group in their Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A-IS) scores.
The score difference was … unknown. They published numbers for all their other outcome measures but no numbers for the only outcome that was able to demonstrate. Fishy much?
The minimal clinically important difference (MCID), which is the minimum change you need for a patient to be able to perceive a difference, score is 6.5. Just by eyeballing (that’s all we can do), there’s a possibly MCID at week 4. Who knows.
But that is not the only problem with the study you know?
In their pressure massage group, the participants received 18 massages across 12 weeks. The eccentric exercise group, on the only hand, had one session with the physiotherapist in the whole 12 weeks.
The exercise group were given written instructions and also videos explaining the exercises. They didn’t even measure if the participants actually did the exercises. So, they could have done zero times. That’s terrible, terrible trial design.
- Pressure massage doesn’t improve pain and ankle range of motion for Achilles tendinopathy
- Pressure massage improves pain at four weeks but the change may not be clinically meaningful for patients
- The trial design doesn’t allow for fair comparison between the massage group and treatment groups: 16 visits vs. 1 visit over 12 weeks, no record if the exercise group even performed the exercises
- Data was not available for the outcome that improved even though data was available for other outcome measurements
Study 2: Massage therapy slightly decreased pain intensity after habitual running, but had no effect on fatigue, mood or physical performance (2019)
The title kinda gave it all away.
Participants were given a 10-minute massage or a sham joint mobilisation to the quadriceps after running for 10 kilometres.
The massage group showed a 0.7 point improvement on a 0 to 10 numerical rating scale.
Bottom line: There’s no improvement in pain intensity because the minimal clinically important difference (i.e. the minimum difference you need to perceive a change) for this is two points.
Study 3: The effect of massage technique plus thoracic manipulation versus thoracic manipulation on pain and neural tension in mechanical neck pain (2019)
At this stage we quickly realised there’s not a lot of research on sports massage. We wanted to stick to the latest research so we expanded our search to massage in general (i.e. not sports specific).
Essentially the study compares a chiropractic adjustment to the middle back vs. chiropractic adjustment plus massage. The spinal manipulation plus massage group did improve better. Quite impressive change actually. For the manipulation alone group, pain at rest was 45.27 (out of 100) and pain after treatment was 20.71. For manipulation plus massage, pain at rest was 42.33 and a whopping 9.67 after treatment.
All participants received six treatments – twice a week across three weeks.
Interestingly, no mention of how long was the duration of each massage for.
Bottom line: massage + manipulation is better than manipulation alone. Sorry chiropractors who only adjust.
Study 4: Effect of Post-Exercise Massage on Passive Muscle Stiffness Measured Using Myotonometry – A Double-Blind Study (2018)
This study measured muscle stiffness with myotonometry, which is a handheld device that can be used to measure various properties of a muscle.
Participants ran downhill on a treadmill for 40 minutes and received a Swedish-style massage (effleurage, wringing, kneading, and tapotement) on the quadriceps, hamstrings, tibialis anterior, and gastrocnemius. Measurements were taken before, immediate after, 24, 48, 72, and 96 hours after the treatment.
Guess what? Massage was not superior to the placebo treatment at reducing muscle stiffness.
This is interesting because a study in 2015 a study also looking at muscle stiffness found massage reduced calf muscle stiffness immediately after the treatment but not after three minutes.
Bottom line: No, massage doesn’t decrease muscle stiffness.
Study 5: The effect of massage on acceleration and sprint performance in track & field athletes (2018)
This is the paper most of you will hate.
The massage treatment was straightforward enough: 10 to 15 minutes of effleurage, petrissage, tapotement, circular friction, and jostle by a licensed athlete trainer. The other treatments are: dynamic warm up, combination of dynamic warm up + massage, lastly sham ultrasound.
Results? The massage group athletes had poorer performance in the 60-meter sprint compared to the dynamic warm-up group. However, there is no difference in acceleration and sprint performance between all four groups.
The authors also said, “Many of the studies regarding sports massage and its proposed benefits have lacked the necessary controls and population to apply results to sports performance.”
Bottom line: Massage doesn’t improve athletic performance and may possibly have a detrimental effect
It does seem like we are cherry picking studies that are against sports massage. You are kinda right. There are two studies that posted results in support of sports massage. We left them out because they were confusing to interpret.
Confusing study A: ‘Recover quicker, train harder, and increase flexibility’: massage therapy for elite paracyclists, a mixed-methods study
The study published that massage therapy improved recovery for paraathletes via means of reducing muscle tightness and in improving sleep.
The outcome measures used to measure sleep and muscle tightness is a 10-point scale. I am not sure if that is a validated outcome measure.
We know there are validated questionnaires for sleep such as Pittsburgh Sleep Quality Index or Athens Sleep Questionnaire. To measure sleep quality via a 10-point scale doesn’t sound legit at all.
Measuring muscle tightness with a 10-point scale would actually measure perception of muscle tightness instead of actual muscle tightness. This would contribute to perceived recovery than true recovery .
Confusing case study B: 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
So I was initially super excited about this study because of the title. When I looked into it, I realised the study design is strange. They included repeated-measure studies, which rank very low in the hierarchy of evidence.
I am also sure repeated-measure studies doesn’t contribute to generalisability.
I did look through the actual review and a few coming across several questionable studies, I decided to leave it out.
Debunking sports massage claims
#1 Pressure massage doesn’t reduce pain or increase range of motion
#2 Pressure massage is not an effective treatment for tendinitis
#3 Sports massage doesn’t improve performance
#4 Post-sports massage doesn’t help with pain to a clinically meaningful difference
#5 When it comes to neck pain, massage + manipulation is better than manipulation alone
#6 Sports massage doesn’t reduce muscle stiffness
#7 Sports massage decrease performance
#8 There are studies that show positive outcomes for sports massage but they are poorly designed
I acknowledge this is by no means a full picture of the benefits to sports massage. However, based on my research over the past few days, it doesn’t seem like there are reasonable-quality studies out there to support the efficacy of sports massage.
I also acknowledge that most of the studies here look at the effects of massage on sports/exercise. I will look into the effect of massage on musculoskeletal pain at a later date.
At the end of the day, research supporting sports massage seems to be lacking despite what physiotherapists and massage therapists claim.
If you have a question or know of a study I missed out on, please reach out to us via the contact form below.