In Defense of Massage

Review of ‘Skeletal Muscle Damage and Repair’ Peter M. Tiidus – Editor


This opening blog is intended as an information gathering or discussion device to help understand, support or counteract some of the information contained in the first edition of the recent book Skeletal Muscle Damage and Repair as published in 2008.  I found out about this book by chance while studying for my trigger point certification with the Janet G. Travell Myopain Seminar Series ( Ploughing through the book I am struck by how little I can come up with in the way of defense to statements made in it.  I invite people to read the following summary of some massage-related parts according to Tiidus and contribute any material that can confirm or deny his claims. If we can’t deny his claims then our profession is in a bit of trouble. In order to be taken seriously by the medical and sports community we can’t make claims based solely on anecdotal evidence.

Peter Tiidus; his book and his claims

Each of the 23 chapters in the book has a different author. Many chapters contain a table full of published research studies that are used to support the findings, both positive and negative for that chapter’s topic. Each chapter has a summary, often concluding that more research needs to be done.

Part 1 of the book deals with muscle damage on a physiological level.
It spends a lot of time dealing with exercise-induced injury from maximal, concentric, eccentric, isometric and prolonged exertion contractions. Other forms of muscle injury include crush, laceration, blunt impact, freezing and tourniquet-induced ischemia.

Part 2 covers muscle damage and repair in applied situations.
Examples of these are aging, gender, diabetes, workplace overuse injuries, functional gait, over-training and muscular dystrophy.

Part 3 then offers some solutions with six chapters covering treatments and interventions.
Modalities include massage therapy, ultrasound, physical therapy, antioxidant supplementation, trigger point therapy, hyperbaric oxygen and drug therapies.
(It could have been helpful at the beginning of the book to place a chapter on the latest additions in knowledge of optimal skeletal muscle anatomy and physiology, although this could be a book in itself.)

The chapters of particular interest to we massage therapists (neuromuscular therapists in particular) are found in Part 3. The two subjects are massage therapy and trigger point involvement on muscle damage and repair. They make for some gruesome reading. Firstly we’ll deal with the chapter on massage – later we’ll include trigger points as a separate blog.

And now to the Tiidus take on massage therapy

Massage has long purported to enhance post-damage muscle healing by:

  • improving blood flow in the muscle,
  • reducing muscle tension and soreness,
  • flushing out wastes and toxins,
  • reducing exercise-induced muscle damage,
  • ameliorating strength loss and swelling, and lastly
  • augmenting the speedy return of muscle function, especially strength.

What is the evidence to support these claims? Just how do you measure these factors and then re-measure after massage? What is your control group? What is massage to be compared to?

The Tiidus take on massage and skeletal muscle damage and repair

Measurements of the benefits of massage on skeletal muscle can be physiological, biochemical and or histiological.

According to Tiidus there is no data to support the positive influence of massage on muscle membrane disruption, muscle inflammation (cytokines), satellite cell activation, muscle peroxidative damage, lysosome and protease enzyme activity, and altered calcium activity.
Tiidus says substantial data actually refutes the positive effect of massage on loss of muscle force and recovery, changes in muscle blood flow, and muscle lactate clearance
Tiidus says there is mixed or minor research to support the positive influence of massage on delayed onset muscle soreness (DOMS), muscle tension, relaxation and resting length and myofascial trigger points.

Some examples of testing for and benefits of massage (according to Tiidus, 2008)

1.    Massage and muscle force recovery after damage

Muscle damage is easily incurred after eccentric activity. Lost strength is usually regained within 3-14 days. Massaging one damaged limb and not the other can monitor the effect on recovery or earlier return of strength. Various studies have failed to confirm any benefit from massage.

2.    Massage and its effects on soreness, swelling and pain

Studies have tried to crudely measure thigh or triceps circumference changes post-massage and not come up with much. Likewise, the relief of soreness shows variable, minor or mixed results. Various reviews of the literature testing the effectiveness of massage in treating musculoskeletal pain have shown promising findings but as yetunconvincing evidence (Ernst 2004).

3.    Massage and its effects on blood flow

Arterial blood flow can be measured by Xenon marked red cells, Doppler ultrasound.Massage made little difference to either. Skin blood flow, as measured by laser Doppler and ultrasound Doppler, did increase as did skin temperature (not core muscle temperature) during massage. But, if blood is diverted away from muscle and into the skin the possibility arises that massage may actually hinder healing if  the supposed benefits of increasing blood flow to promote healing are to be believed.

4.    Massage and muscle lactic acid

Anyone who still propounds that old chestnut that massage has anything to do with ‘flushing out lactic acid’ needs to know that there is absolutely no relationship with lactate and muscle soreness. See also bullet point 3 above concerning blood flow

5.    Massage and fibrosis and tension

Almost no evidence exists to back massage to affect post-damage muscle scarring or to break up unspecified ‘adhesions’. Studies regarding muscle tension may show limited evidence for reduction in sympathetic muscle activity following massage. Recent studies by Hopper (2005) show improvement in hamstring length and hip flexibility.

6.    Massage and mood

In the improvement of mood (Affective Massage) massage seems to come out comparatively better. Tiidus offers limited evidence of a relaxation benefit.

In summary, this is a call for fellow massage therapists to help defend the foundations of the massage profession with whatever evidence they have come across. We will need to address each of the numbered points above if we can. This information will form our defense.