Comparison of the Immediate Effect of Petrissage Massage and
Manual Lymph Drainage Following Exercise on Biomechanical
and Viscoelastic Properties of the Rectus Femoris Muscle in Women
Nilüfer Kablan, Nuray Alaca, and Yaşar Tatar
Journal of Sport Rehabilitation, 2021, 30, 725-730
https://doi.org/10.1123/jsr.2020-0276
© 2021 Human Kinetics, Inc. ORIGINAL RESEARCH REPORT
Comparison of the Immediate Effect of Petrissage Massage and Manual Lymph Drainage Following Exercise on Biomechanical and Viscoelastic Properties of the Rectus Femoris Muscle in Women
Nilüfer Kablan, Nuray Alaca, and Yaşar Tatar
Context: Fast and adequate recovery after exercise and activity is important for increasing performance and preventing injuries. Inadequate recovery usually causes changes in the biomechanical and viscoelastic properties of the muscle. Objective: To compare the immediate effect of petrissage massage (PM) and manual lymph drainage (MLD) following submaximal exercise on the biomechanical and viscoelastic properties of the rectus femoris muscle in healthy women. Design: Cross-sectional, repeated- measures. Setting: Marmara University. Participants: 18 healthy female students. Intervention(s): Following the submaximal quadriceps strengthening exercise performed in 3 sets of 8 repetitions with intensity of 75% of 1 maximum repetition, participants’ right leg received a 5-minute PM (PM group) and the contralateral leg received a 5-minute MLD application (MLD group). Main Outcome Measures: Skin temperature was measured using P45 thermographic thermal camera (Flir System; ThermaCAM, Danderyd, Sweden), and muscle tone, biomechanical, and viscoelastic features were measured with a myometer (Myoton AS, Tallinn, Estonia) at baseline, immediately postexercise, post-PM/MLD application, and 10 minutes postexercise. Results: In the PM group, the tonus (P = .002) and stiffness (P < .001) values measured after the massage and at the end of the 10-minute resting period were found to be statistically different than those measured right after the exercise (P < .05). Relaxation time and creep values at all measurement times were significantly different (P < .05). In the MLD group, it was observed the tonus (P < .001), stiffness (P = .025), and relaxation time (P < .01) values decreased significantly after the MLD compared with the values measured after the exercise; however, the creep value was found to be significantly different in all measurements (P < .05). Conclusion: PM and MLD reduce passive tissue stiffness and improve the extent of muscle extensibility over time against the muscle tensile strength. PM and MLD are therapeutic methods that can be used to support tissue recovery after exercise and prevent injuries.
Keywords: manual lymphatic drainage, stiffness, creep, cutaneous temparature
Fast and adequate recovery after exercise and activity is important for increasing performance and preventing injuries. Inadequate recovery usually causes delayed muscle pain, which changes the biomechanical1,2 and viscoelastic3 properties of the muscle. Changes in viscoelastic properties are closely related to overuse and overtraining injuries, and abnormal stiffness increase was noted to cause muscle pain, microinjuries, and abnormal tissue repair responses.4 Therefore, gaining insight into the intrinsic properties of the muscle is needed, not only for the evaluation of healthy tissue, but also for the prevention of injuries, to detect changes in pathological tissues, and the tissue’s response to treatment.5
It is important to have an efficient recovery process in order for the biomechanical and viscoelastic properties, which change dur- ing exercise, to go back to normal as soon as possible. Massages have been reported to assist in different aspects in the recovery of tissues after exercise, training, and competition.6 Although there are studies investigating the effect of massage on the biomechani- cal2,7,8 and viscoelastic properties3 of the muscle, the results are not consistent.
Kablan is with the Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, University of Health Sciences, Istanbul, Turkey. Alaca is with the Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey. Tatar is with the Faculty of Sports Sciences, Marmara University, Istanbul, Turkey. Kablan (niluferkablan@yahoo.com) is corresponding author.
Petrissage (kneading) massage (PM), as a sequence of com- pression and release from compression exerted on muscle tissue, is a technique of traditional Swedish massage, and is applied from distal to proximal.8 It is effective in improving muscle blood flow and reducing muscle tone, local edema, and muscle soreness. In studies which PM was applied in combination with other Swedish massage techniques (such as effleurage, wringing, tapotement, and deep circular friction), changes in the biomechanical properties of the muscle were found be contradictory.2,7 But, the study, which only applied PM, showed that PM improved recovery from muscle stiffness following the intensive exercise.8
Manual lymph drainage (MLD) is a gentle manual technique, which is based on the 4 basic Vodder strokes; the “Stationary Circle,” “Pump,” “Rotary,” and “Scoop.’’ It is administered on the skin surface with moderate pressure (30–50 mm Hg), following the anatomical lymph collector pathway and flow direction. Due to the elastic deformation of the cutaneous and subcutaneous tissue by MLD, the amplitude and frequency of the lymphangiomotor activity increase and ensure the removal of metabolic waste, espe- cially macromolecules from the tissue. MLD also supports the superficial and deep venous return without increasing ultrafiltration.9 It has been reported that MLD after submaximal exercise decreases lactic acid and biochemical marker levels indicating muscle damage, such as lactate dehydrogenase, creatine kinase, and myoglobin,6 accelerates recovery, and reduces muscle pain.10 Despite these known effects, no study exists investigating the effect of MLD on muscle biomechanical and viscoelastic properties. The aim of this study was
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to compare of immediate effect of PM and MLD performed after submaximal exercise on biomechanical and viscoelastic properties of the rectus femoris muscle in healthy women. It was hypothesized that MLD has similar effect with PM following submaximal exercise on biomechanical and viscoelastic properties of the muscle.
Methods
Participants
This study was carried out at Marmara University, Sports Science and Athletes Health Research and Implementation Center in February 2020. In the present study, 18 sedentary, healthy women (mean age = 21.90 [1.59] y), studying at Health Sciences Univer- sity, were included. Approval for the study was obtained from the Ethics Committee of Non-interventional Clinical Research, Mar- mara University Faculty of Medicine (09.2019.968). The study group was informed about the purpose and content of the study and written informed consent was obtained from all participants. The study was conducted in accordance with the principles of the Declaration of Helsinki (clinical trial record: 04324775).
Volunteers with no systemic, orthopedic, or neurological dis- abilities, who were 18–25 years old, with body mass index ≤ 25 and skinfold thickness of 5 to 15 mm were included in the study. Participants with a history of injury/surgery/pain involving the lower extremities in the last 6 months, or with a disease that would affect their myofascial properties and body temperature were excluded from the study. Similar research data11 were used to calculate (power =
.978) the sample size (Power and Sample Size Calculation 3.1.6; http://biostat.mc.vanderbilt.edu/wiki/Main/PowerSampleSize) and the total number of participants required was calculated as 15. Eighteen individuals were evaluated against the possibility of dropout rate, and the study was completed with 18 women.
The participants were asked not to use any stimulant drugs in the previous 24 hours, not to apply any substances (moisturizer, etc) onto the skin area to be evaluated, and to stay away from any strenuous activities. In addition, they were not allowed to consume liquids and
food from 2 hours before the measurements till the end. The patients rested for 30 minutes and were then taken to the evaluation room, and body mass index (in kilogram per meter squared), skinfold thickness (in millimeters), and 1-repetition maximum (1RM) value (in kilo- grams) were obtained. Skinfold thickness was measured on the midpoint of the line between the anterior superior iliac spine and the patella, with a skinfold caliper (Saehan Electronic, Gyeonggi-do, South Korea), while the participant was standing and body weight was transferred to the limb not to be measured, and the average of the 3 measurements taken was recorded.
For the right and left quadriceps muscles, 1RM value was calculated using a computer program called Weightlifting 1RM Lift Log Calculator-Vandersoft, and 75% of this value was accepted as the exercise weight.
The right extremity of the participants was included in the PM group and the left extremity in the MLD group. Skin temperature, passive tone, and biomechanical (passive stiffness, decrement) and viscoelastic (relaxation time [RT], creep) properties of the rectus femoris muscle were measured 4 times: baseline, immediately postexercise, post-PM/MLD application, and 10 minutes after the end of the exercise sessions to see the effect of the greater relaxation period.4,11All measurements were carried out by the same physiotherapist at normal room temperature (22°C–24°C) and relative humidity < 50%,12 with the room condition monitored by a thermohygrometer (PCE-HVAC 3; PCE Instruments, Deutsch- land, Germany). The protocol of the study is shown in Figure 1.
Exercise Protocol
Following quadriceps/hamstring stretching exercises (for each muscle = 2 × 20 s), submaximal eccentric quadriceps strengthening exercise was performed in 3 sets of 8 repetitions with intensity of 75% of 1RM and a recovery interval of 30 seconds13 was taken between the series in which participants used weights in the seated position. The ProMetronom (EUMLab-Xanin Technology GmbH, Berlin, Germany) computer program was used to maintain a standardization in exercise pace.
Figure 1 — Study design: (A) PM and (B) MLD. 1RM indicates 1-repetition maximum; MLD, manual lymphatic drainage; PM, petrissage massage.
PM and MLD
Manual techniques were performed by the same physiotherapist with 22 years of experience (first author), who was certified in manual technique applications. In order not to affect the tempera- ture measurements, moisturizer (cream, oil, etc) was not used in either of the applications. The applications were performed for 5 minutes from the patella to the inguinal region, through the rectus muscle, while the patient was in a supine position and the rectus femoris muscle was relaxed. PM consisted of high-pressure knead- ing (petrissage) movements supported by 3 repetitions stroking both at the beginning and end.14 MLD consisted of dynamic alternating stationary circles, supported by 3 repetitive effleurages both at the beginning and end, following the stimulation of the inguinal lymph nodes with 5 repetitions.
Thermal Imagining of Cutaneous Temperature
While the participant was in an anatomical position, the thermal photo of the thigh region was taken with a P45 thermographic camera (Flir System, Danderyd, Sweden; ThermaCAM, Sweden) at a distance of 1 m. Photographs were analyzed using the FLIR Quick-Report 1.2 software, and the minimum and maximum skin temperature (in degree Celsius) values of a 1.5-cm2 perimeter of the myometer measurement point were calculated. In skin temperature calculation, the emissivity value of the human skin was accepted as 0.98.12
Measurement of Biomechanical and Viscoelastic Properties
The biomechanical and viscoelastic properties of the muscles were measured using a myometer (MyotonPro; Myoton AS, Tallinn, Estonia), which can measure up to 2 cm depth of the subcutaneous tissue,4 with established validity and reliability.15 Measurements were made in a supine position, with the rectus femoris relaxed, from the midpoint of the line extending between the anterior superior iliac spine and the patella.2 By taking the average of the oscillator responses generated by the tissue against 3 repetitive mechanical stimuli (0.40 N, 15 ms), tonus (in Hertz), stiffness (in newton per meter), decrement, RT (in milliseconds), and creep were calculated by myometer.4
Statistical Analysis
In this study, the significance level was set at P < .05 for all evaluations, and statistical analyses were performed using SPSS
(version 21.0; SPSS Inc, Chicago, IL) for Windows. Descriptive statistical techniques (mean [SD]) were used to describe the groups. The compliance of the data with the normal distribution was evaluated using the Shapiro–Wilk test. Variance analysis was used in the analysis of data for intragroup repeated measurements. Paired-samples t test and independent samples t test were used in post hoc tests. The relationship between parameters was examined with the Pearson correlation test. Effect size was examined to reveal a clinically significant difference. It was calculated by taking the ratio between the averages to the SD before the application. As defined by Cohen, ≤0.20 was taken as small effect, 0.20 to 0.50 as moderate effect, 0.50 to 0.80 as large effect, and >0.80 as very large effect.16
Results
Mean body mass index value of the participants was 21.50 (2.54). The groups were similar in terms of skinfold thickness (right = 11.56 [2.29]; left = 12.05 [2.03]) and 1RM value (right = 26.22
[7.20]; left = 26.33 [8.30]) (P > .05).
In the PM group, skin temperature minimum values at all measurement times were found to be similar (P > .05); however, in the MLD group, it was changed significantly postexercise (P = .002) compared with preexercise, and post-MLD compared with postexercise (P = .013). Skin temperature maximum values increased significantly in both groups after manual applications compared with postexercise (P < .05). At the end of the 10-minute rest period in the MLD group, skin temperature maximum was still significantly higher than that of postexercise (P = .01) (Table 1).
The effect sizes of both groups were similar in terms of skin temperature effect values (Table 1).
It was observed that, in the PM group, tonus and stiffness changed significantly after massage application and 10-minute rest period, and in the MLD group after drainage application compared with postexercise (P > .05). RT values were found to be signifi- cantly different in the PM group in all measurement periods, and in the MLD group after drainage compared with postexercise (P < .05). In both groups, it was determined that the creep values of all measurement periods were significantly different (P > .05). In terms of the decrement values, there was no statistically significant difference in both groups (P > .05) (Table 2).
In terms of biomechanical and viscoelastic properties, PM and MLD groups were similar (P > .05). It was observed that the effect value of PM on the biomechanical and viscoelastic proper- ties of the muscle was higher than that of MLD (except tonus; Table 2).
Table 1 Thermal Imagining of the Participants
Abbreviations: MLD, manual lymphatic drainage; PM, petrissage massage; post-exer, immediately postexercise; post-exer10 min, 10 minutes after the end of the exercise sessions; post-PM/MLD, post-PM/MLD application; pre-exer, baseline. Note: Values are presented as mean (SD).
aThe effect size of post-exer–post-PM/MLD difference. bThe effect size of post-exer–post-exer10min difference.
*Pre-exer–post-exer. **Post-exer–post-PM/MLD. ***Post-exer–post-exer10min. Bold denotes significanceP < .05.
Table 2 Tone, Biomechanical, and Viscoelastic Properties of Rectus Femoris of the Participants
Abbreviations: MLD, manual lymphatic drainage; PM, petrissage massage; post-exer, immediately postexercise; post-exer10 min, 10 minutes after the end of the exercise sessions; post-PM/MLD, post-PM/MLD application; pre-exer, baseline; RT, relaxation time. Note: Values are presented as mean (SD).
aThe effect size of post-exer–post-PM/MLD difference. bThe effect size of post-exer–post-exer10min difference.
*Pre-exer–post-exer. **Post-exer–post-PM/MLD. ***Post-exer–post-exer10min. Bold denotes significance P < .05.
No statistical relationship was observed between skin temper- ature and myoton values (P > .05)
Discussion
In the present study, the immediate effect of PM and MLD performed after submaximal exercise on the biomechanical and viscoelastic properties of the rectus femoris muscle were examined. It was found that skin temperature decreased in both groups after exercise and increased after PM/MLD. In myotone measurements, following PM and MLD application, tonus and stiffness decreased significantly and creep and RT increased. At the end of the 10- minute rest period, RT and creep remained at a high level compared with postexercise. In myotone measurements, PM application was observed to be slightly more effective than MLD in all values (except tonus)Blood circulation is involved in the transport of body temper- ature and responds to increased body temperature during exercise with large hemodynamic changes. The role of the cutaneous thermoregulator system in balancing body temperature, especially during exercise, results in changes in blood flow toward the cutaneous area during exercise.17 In this study, it was observed that skin temperature values decreased in both groups following exercise and this decrease was significant at the minimum value of the MLD group. The findings are consistent with studies reporting that skin temperature decreases with exercise.18 This decrease in skin temperature has been reported to be the result of cutaneous vasoconstriction due to released catecholamine and other vasocon- strictor hormones to increase muscle blood flow.19 In this study, skin temperature following PM/MLD applications values increased significantly in both groups compared with postexercise. The findings obtained in the present study are consistent with the results of study showing that massage increases peripheral blood flow and causes an increase in skin temperature.20
High tone is associated with increased intramuscular pressure due to increased tension and increased contraction.5,21 The increase in intramuscular pressure prevents blood flow,22 decreases the strength of muscles, causes pain, yields early onset of muscle
fatigue, and delays muscle recovery. Various massage methods have been reported to decrease muscle tone.5,23 In the present study, there was a slight increase in tonus following exercise in both groups, while it decreased significantly after PM/MLD. The findings of the study are in line with the results of the studies showing that PM24 and MLD10 reduced muscle tone following exercise.
High stiffness causes more energy to be consumed to create deformation in the muscle, and increases the risk of injury.5,21 Although it was reported that increased tissue temperature by exercise decreases the connective tissue stiffness and increases the extensibility of the tissue and range of motion,25 there are also studies reporting that exercise and activity do not always lead to a decrease in stiffness, but sometimes, on the contrary, result in an increase in stiffness.3,8 Similarly, it was observed in the present study that stiffness increased following the exercise (although not at a significant level) in parallel with the increased tonus. Following PM/MLD, stiffness decreased significantly, to a degree below preexercise level.
While a study has shown that massage has no effect on stiffness,2 others have reported its reducing effect on stiffness.7,8 It has been stated that the decrease in stiffness may be due to the cross-bridge breakage effect of PM via pressure and stretching,7 decreasing motor neuron excitability,26 creating local reflex inhibi- tion,23 and increasing intramuscular temperature.27 In addition, the stiffness-reducing effect of the massage was observed to disappear shortly after,7 and it was claimed that the reason for this was that the cross-bridges separated before gradually reconnect.28 In the study29 investigating changes in stiffness after eccentric exercise in untrained males, it has been found that increased stiffness values measured immediately after exercise continues for 5 days. In this study, a high stiffness level measured following exercise decreased significantly after PM/MLD application and a low level also continued for up to 10 minutes following exercise.
Although there are reports advocating otherwise,1 it has been stated that MLD performed after submaximal exercise is an important therapeutic method10 that reduces biochemical markers which are indicators of muscle damage, such as lactate dehydrogenase, creatine kinase, and myoglobin,6 and accelerate
recovery after exercise. However, there are not enough studies on the effects of these features of MLD on stiffness.
Muscle tissue has a viscoelastic structure, and viscoelastic properties show time-dependent behaviors.30 In animal experi- ments, mechanical stimuli mimicking the deep effleurage tech- nique have been shown to restore the viscoelastic properties of the tissue following exercise.3 The study results showed that exercise significantly reduced creep values in both groups, and RT significantly decreased in the PM group and almost decreased significantly in the MLD group. Despite the decreased RT value, the decrease in creep values shows that the deformation in the original length of the muscle is low. This result is consistent with the increase in stiffness value, which represents the resistance of tissue to deformation. PM/MLD caused a significant increase in creep and RT values. The increase in the creep value shows that the length of tissue under the same tension increases with time. This result is in line with the view that as a result of the decrease in the resistance of the tissue against the change of the length of the tissue with decreasing stiffness, it increases the extensibility of the tissue against the same tensile force overtime.30 In addition, the increase in creep values despite the increase in RT is an indication of high deformation in the tissue. On the other hand, the approach of creep and RT to the preexercise level in the 10 minutes following the exercise shows that the exercise and PM/ MLD activity on the viscoelastic properties of the muscle disappeared.
The rapid recovery of the muscle after exercise is important for
increasing performance and preventing injuries. In this study, we originally hypothesized that MLD has a similar effect to PM on recovery of biomechanical and viscoelastic properties of the muscle following submaximal exercise, and the results of the study supported this hypothesis. However, because of higher effect size values in the PM group, it can be considered that PM has a slightly greater effect on these characteristics compared with MLD. This study has shown that MLD reduces passive tissue stiffness and improves the extent of muscle extensibility over time against the muscle tensile strength. When considered together with other positive effects on tissue, it is clear that MLD contributes to recovery of tissue in different ways, so MLD and PM can be used as a therapeutic method to support tissue recovery after exercise and prevent injuries.
The studies in this field have been conducted using different massage techniques, different time periods, and following different exercises. For this reason, there is no consensus on the technique and time duration that reveals the therapeutic effects of the massage. Limitations of the study are the absence of a control group in which no PM/MLD was applied, and the evaluation of the muscle only at rest. In addition, since only healthy tissue was evaluated, no data on the effects of applications on pathological tissues and healing were obtained. This constitutes another serious limitation of our study. It is suggested that further studies should be planned to investigate the responses of the pathological tissue other than the healthy and the active tissue.
Conclusion
The PM and MLD decrease passive tissue stiffness after exercise and increase the extensibility of the muscle against tensile strength over time. Although the effect of PM was higher and much more lasting on biomechanical and viscoelastic properties compared with MLD, both are therapeutic methods that can be used to support tissue recovery after exercise and prevent injuries.
Acknowledgments
The authors report no conflicts of interest.
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