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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 favor 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 a
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, Zollman, 1999). However, in more recent history, massage has
become an important tool for athletes. Sports massage is now considered
a 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 around
500 B.C. Another famous Greek medical practitioner, Asclepiades, 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-Fou 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 Hendrik 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 lymp 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, Zollman, 1999)
Historically, the interest in massage has been cyclical. Massage fell
out of favor, only to once again regain acceptance, many times over the
last 500 years. Currently, massage has become far less important to
our 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 Tui 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. Meahger 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. Meahger 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 massage
is 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 to
warm-up the body by boosting circulation. This is an early form of
pre-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 (Latona, 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 Faylo. Goalkeeper Tracy Ducar said, “Clinton and Jim
Faylo, who worked with him during the World Cup, were invaluable in the
treatment they provided for us," testified Tracy Ducar, a goalkeeper on
the team. "We could not have been at our best without their help every
day." Goalie Saskia 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” (Hudd, 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 fueled 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
a 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 to
go away a lot faster” (Sports Massage: Taking the Field). Canadian
National Swim Team member, Marianne Limpert, 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 Marjoirie Albohm, 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
a 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 a
1997 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 Center
for 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 (Barnes
et 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 interest
in 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 in
2000. In 2001, massage schools turned out an estimated 30,000 new
graduates (Luscombe, p. 49).
There are other significant signs that the perceived benefits of
massage is having a strong affect 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 Blue
Shield also cover some forms of massage (Luscombe, 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 (Helwig, 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 Hannum 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. In
2004, 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" (Luscombe, 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" (Latona, 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 a
massage center in Connecticut bluntly states, “Massage is beneficial
when starting a conditioning program because it helps you get into good
shape faster” (Buckland Massage & Neuromuscular Center). 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 a
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
a 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 is
a 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. Meager was strong advocate of
pre-event massages. In his book, Sportsmassage, he wrote:
"Whatever sport you play, Sportsmassage will give you 20 per cent
extra---extra performance, extra protection, (and) extra time per game,
per season, (and) per career.......With Sportsmassage 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…. Sportsmassage 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 and
petrissage 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 is
a reduction in tension, but not total relaxation. Sports massage
therapist, James Waslaki, 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
hypertonicity 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 injures 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 that
pre-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 (Voliantis, 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 in
other performance-driven industries. Robert King, president and
co-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 postactivity 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 Renyonds, the
400 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 electrostim, massaging and heat treatments really loosened things
up" (How Massage Aides Athletic Performance).
Despite skepticism 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 byproduct 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 LeSuer, said he uses
post-event massage in the same way a detective might search for clues.
LeSuer 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 a
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. Maintence 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 fibers together, which makes
using them more difficult. These locked fibers are called “knots” and
can be extremely painful. Knots can also be caused by daily stresses.
Massage therapists believe that separating the fibers through massage
will “break-up” the knots and create free muscle movement and increased
range of motion (Pike, p. 21).
When American marathon runner Meb 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 jewelry 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" (Latona, 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. Dr. 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. Dr. 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 a
sense of well-being (Sheynin p. 63).
Another study by Donavon Reimche 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 (Sheynin, 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. Maintence
massage advocates claim that a skilled therapist 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 kinesthetic artist can turn when viewing massage
as an interaction and communication. Beyond this, we can address the
tension to which they might unconsciously cling" (Vanderbilt, 2003).
Meanwhile, LeSuer 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 LeSure, 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 affects of sports massage was also summed up by Tritton, (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 Tritton, 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, Callagahan concluded that more research
is 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 a
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 (Hemmings 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, Tiidus and Shoemaker acknowledged that there is a
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, Tiidus
and 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 (Tiidus 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 (Leivadi, 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.D
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 (Helwig, 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
a history of cardiac problems talk to their doctor before receiving a
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 tumor (Vickers
et 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
et al.).
Part of the problem of determining the effectiveness of sports massage
comes from the widely varying skills of its practitioners (Moyer et
al., 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 can not 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 it’s
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, et
al., 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 a
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 (Balke 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 opinoids. However, gentler types of stoke
technique appeared to have no impact on pain relief. After looking at a
total of seven studies, Dr. Edward Ernst of the University of Exeter
conducted a systematical review and concluded that massage therapy may
be a promising treatment for DOMS (1998). However, in 2004, Moyer,
Rounds, and Hannum 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 that
pre-event and post-event sports massage have no significant impact on
DOMS 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 (Tiidus, 1997).
A Swedish study in 2004 further confirmed Tiidus’ theories on the
actual benefits (versus perceived benefits) of sports massage. The
researchers 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” ( Jönhagen 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. Labyak 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. In
fact, 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
a 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” (Labyak 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
Hannum (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 20
to 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
a 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 a
long-lasting solution. Most notably, the study’s authors also stated,
“Massage might be an effective alternative to conventional medical care
for persistent back pain” (Cherkin, 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 Tritton 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 Hannum’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 affect 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% percent 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 Hannum (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 counseling for mental health problems or
addiction. Another perceived affect 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 Hannum 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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