ORIGINAL RESEARCH
Vibration Therapy Is No More Effective Than the Standard Practice of Massage and Stretching for Promoting Recovery From Muscle Damage After Eccentric Exercise Joel T. Fuller, B. Physiotherapy, Hons,* Rebecca L. Thomson, PhD,* Peter R. C. Howe, PhD,*† and Jonathan D. Buckley, PhD*
Objective: The purpose of this study was to determine if vibration
Key Words: vibration, stretching, massage, muscle damage, muscle strength, muscle soreness
therapy is more effective than the standard treatment of stretching and massage for improving recovery of muscle strength and reducing muscle soreness after muscle damage induced by eccentric exercise.
(Clin J Sport Med 2015;25:332–337)
Design: A randomized, single-blinded parallel intervention trial design was used. Setting: Research laboratory. Participants: Fifty untrained men aged 18 to 30 years completed the study.
Interventions: Participants performed 100 maximal eccentric muscle actions (ECCmax) of the right knee extensor muscles. For the next 7 days, 25 participants applied cycloidal vibration therapy to the knee extensors twice daily and 25 participants performed stretching and sports massage (SSM) twice daily. Main Outcome Measures: Changes in markers of muscle damage [peak isometric torque (PIT), serum creatine kinase (CK), and serum myoglobin (Mb)], muscle soreness (visual analog scale), and inflammation [serum C-reactive protein (CRP)] were assessed. Results: After ECCmax, there was no difference in recovery of PIT and muscle soreness or serum CK, Mb, and CRP levels between vibration and SSM groups (P . 0.28). Conclusions: Cycloidal vibration therapy is no more effective than the standard practice of stretching and massage to promote muscle recovery after the performance of muscle-damaging exercise. Clinical Relevance: Prescription of vibration therapy after maximal exercise involving eccentric muscle damage did not alleviate signs and symptoms of muscle damage faster than the standard prescription of stretching and massage. Submitted for publication January 22, 2014; accepted July 18, 2014. From the *Nutritional Physiology Research Centre, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia; and †Clinical Nutrition Research Centre, University of Newcastle, Newcastle, Australia. The vibration therapy cushions and financial support for this study were provided by Advanced Lifestyle International (Park Ridge, Queensland, Australia) through a Researchers in Business grant (Enterprise Connect, Australia). The authors report no conflicts of interest. Corresponding Author: Jonathan D. Buckley, PhD, Nutritional Physiology Research Centre, University of South Australia, GPO Box 2471, Adelaide 5001, South Australia ([email protected]). Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
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INTRODUCTION Exercise involving eccentric muscle action can cause muscle damage, resulting in muscle soreness, swelling, and reduction in muscle strength.1 Eccentric muscle actions are an inherent component of many physical recreation and sporting activities, and if recovery from the resulting damage is not sufficient, the ensuing symptoms could increase risk of injury,2 impede subsequent exercise performance,3 and present a barrier to continued involvement in physical activity.4 As a result, to offset the potential adverse effects of muscle damage, effective recovery modalities are desirable. One potential recovery aid, currently growing in popularity, is the application of vibration.5–9 It has been suggested5–9 that increases in blood flow associated with the application of vibration10 could aid muscle recovery. Indeed, several studies have found that vibration alleviated muscle soreness after exercise-induced muscle damage.5,6,8 However, although muscle soreness is an important symptom of muscle damage that might present a barrier to continued physical activity participation,4 reductions in muscle soreness correlate poorly with the return of muscle strength, which is reported to be the best marker of recovery from muscle damage.11 The efficacy of vibration therapy for promoting recovery of muscle strength after muscle damage has only been investigated in 2 studies.8,9 Recovery of elbow flexor peak isometric torque (PIT) was unaffected by vibration in untrained participants,8 and recovery of peak eccentric torque of the knee extensor muscles was impeded by vibration in trained participants.9 Both studies used a limb-to-limb comparison crossover design with 1 limb assigned to treatment and the other to a no treatment control after a 2-week9 or 4-week washout.8 One potential problem with this design is evidence of a contralateral repeated bout effect, whereby even a single bout of eccentric exercise affords some protection against the development of further muscle damage on the contralateral limb.12 This effect has been observed as long as 14 days after exercise,12 and it is unclear what would be an appropriate washout period for studies using a limb-tolimb comparison crossover design. A further limitation is the use of no treatment as a comparator to the vibration Clin J Sport Med Volume 25, Number 4, July 2015
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intervention.6–9 It seems likely that vibration, which causes strong mechanical and auditory stimuli, would be associated with a placebo effect, and this effect could challenge the validity of conclusions drawn from comparing vibration with no treatment. Indeed, use of vibration therapy for the management of pain has been shown to be similar in efficacy to that of a placebo.13 Furthermore, the Medical Services Advisory Committee of the Australian Department of Health and Ageing, the peak body responsible for advising government on evidence relating to the effectiveness of new medical technologies and procedures to inform decisions regarding public funding, recommends that the most appropriate comparator for assessing efficacy of novel clinical therapies is the current therapy that the novel therapy is most likely to replace.14 Only in this way can it be ensured that novel therapies provide a greater benefit than current practice and thus improve therapeutic management. A recent meta-analysis of physiotherapeutic interventions used after exercise-induced muscle damage concluded that the most commonly used treatments include massage and stretching, but these and other therapies (cryotherapy and low-intensity exercise) had trivial or no effect on muscle recovery.15 Therefore, the most appropriate therapy against which to compare effects of vibration therapy for promoting recovery of muscle damage would seem to be massage and stretching. The primary purpose of the present study was to determine whether the use of vibration therapy for the treatment of muscle damage induced by eccentric exercise was more effective than the current practice of stretching and sports massage (SSM). It was hypothesized that recovery of muscle strength would be faster for vibration therapy compared with SSM.
METHODS Research Design A randomized, single-blinded parallel intervention trial was conducted. A parallel study design was undertaken to avoid the aforementioned repeat bout effect associated with eccentric muscle action. One treatment group received vibration therapy and the other received the standard treatment of SSM. Outcomes of interest were PIT of the knee extensor muscles (primary outcome), muscle soreness, serum creatine kinase (CK, biomarker of muscle damage), serum myoglobin (Mb, biomarker of muscle damage), and serum C-reactive protein (CRP, biomarker of inflammation).
Participants Ethical approval was obtained from the Human Research Ethics Committee of the University of South Australia. The project was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12610000488000). A final cohort of 50 participants (22.5 6 3.7 years, 23.1 6 3.2 kg/m2) completed the study. Participants provided written informed consent before being accepted into the study. To aid recruitment of the required sample size, participants were given the option of not providing blood samples during the study, as muscle strength was the primary outcome of interest. Twelve participants chose not to provide blood samples. Participants were aged 18 to 40 years and considered untrained. Untrained participants were chosen Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
Vibration Therapy for Muscle Recovery
because they would experience a greater degree of exerciseinduced muscle damage and soreness because of the lack of any protection afforded by the repeat bout effect16 and because soreness experienced by novice exercisers as a result of muscle damage is a barrier to continued involvement in physical activity.4 Thus, evidence of an improved ability to reduce the negative impact of muscle damage might facilitate improved exercise participation in novice exercisers. Participants were excluded if they participated in physical activity more than once per week for the purpose of improving or maintaining physical fitness or had a musculoskeletal or medical problem that interfered with their ability to perform the required exercise.
Testing Procedures Participants attended the laboratory on 6 occasions over a 2-week period, which included 1 familiarization and 5 experimental sessions. Each participant completed all sessions at the same time of day and abstained from food in the 4 hours before each session. Participants were familiarized in the week before their anticipated start date during which demographic data were collected and PIT of the knee extensor muscles of the right leg was assessed. During the first experimental visit, PIT and muscle soreness were reassessed and blood samples collected for measurement of serum CK, Mb, and CRP. Participants then performed 100 maximal eccentric muscle actions (ECCmax) of the knee extensor muscles of the right leg. Assessments of PIT and muscle soreness were repeated and blood samples collected immediately after ECCmax and at 24, 48, and 72 hours and 7 days post-ECCmax. After the assessments undertaken immediately post-ECCmax, participants were randomly allocated to either vibration or SSM treatment. Randomization was via a process of minimization17 using PIT values obtained during familiarization as the minimization variable. Allocation to treatment was performed by an independent investigator (R.L.T.), with allocation information withheld from outcome assessors for the duration of data collection.
Muscle Damage Induction Muscle damage was induced through the performance of ECCmax on a Biodex isokinetic dynamometer (Biodex System 4; Biodex Medical Systems, Shirley, New York) at an angular velocity of 45 degrees per second through a 90-degree range of motion. Participants exhibiting no reduction in knee extensor PIT after muscle damage induction (PIT post-ECCmax $ PIT at baseline) were considered to have not adhered to the maximal exercise requirements and were excluded.
Peak Isometric Torque Peak isometric torque of the right knee extensor muscles was assessed using a Biodex isokinetic dynamometer and was sampled at 1000 Hz using a PowerLab data acquisition system (PowerLab 16/30; ADInstruments, Bella Vista, New South Wales, Australia). Before the assessment of PIT, participants completed a warm-up consisting of 3 submaximal isometric contractions, with the knee positioned in 90 degrees of flexion. Muscle strength was determined from the PIT achieved during the best of three 5-second maximal isometric contractions with a 1-minute rest between each maximal effort. Body position, www.cjsportmed.com |
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approximate axis of rotation of the knee joint, and dynamometer lever arm length were standardized across assessments. Test– retest assessment of PIT 1 week apart showed a good level of reliability [intraclass correlation coefficient (ICC) = 0.80].
written instructions. Participant compliance was monitored using a treatment diary. Based on participant self-reporting in these diaries, all participants completed all treatments as prescribed.
Muscle Soreness
Statistical Analyses
Muscle soreness was evaluated using a 100-mm visual analog scale (VAS)18 with anchor points consisting of “no soreness” on the left and “worst soreness possible” on the right. Participants were seated and requested to hold their right knee in an extended position for 5 seconds while a 5-kg mass was suspended from the ankle. Participants placed a mark at the point on the VAS corresponding to their perception of the soreness in the knee extensor muscles. The test–retest reliability of VAS muscle soreness scores was excellent (ICC = 0.98).
Based on the variance from a previous study we conducted19 using the same protocol to induce muscle damage and assess changes in muscle strength, a priori power analysis determined that 50 participants would be required to detect a 50% difference in PIT between treatments with a 5% significance level and 80% power. Predictive Analytics Software (PASW version 17, SPSS, Chicago, Illinois) was used to perform all statistical analyses. Normality of data was checked using the Shapiro–Wilk test, and data that were not normally distributed were transformed using logarithmic transformations (CK, Mb, and CRP). Differences between treatment groups for dependent variables at baseline and immediately post-ECCmax were assessed using an independent t test. Changes in markers of muscle damage over time were compared between treatment groups using a linear mixed model. Independent variables were time, treatment, and treatment · time interaction. Values for each of the dependent variables obtained immediately post-ECCmax were included as covariates in the model.
Serum Biomarkers Blood samples (10 mL) were collected for assessment of serum CK, Mb, and CRP concentrations. Serum levels of CK and CRP were assayed by a clinical chemistry analyzer (Konelab 20 XTi; Thermo Fisher Scientific, Middleton, Virginia) using a CK-N-acetylcystein reagent and CRP high-sensitivity kit, respectively (Thermo Fisher Scientific). Serum levels of Mb were assayed by a biochemical analyzer (ADVIA Centaur; Bayer, Leverkusen, Germany) using a commercially available kit (Siemens Healthcare Diagnostics, Tarrytown, New York). Interassay coefficients of variation for serum levels of CK, Mb, and CRP were 0.8%, 2.8%, and 3.7%, respectively.
RESULTS TREATMENTS
Flow of participants through the stages of the study is shown in Figure 1.
Vibration treatment was applied twice daily for 20 minutes with participants seated and a vibration cushion [cycloidal vibration therapy (CVT) cushion; Advanced Lifestyle International, Park Ridge, Queensland, Australia] positioned under their right thigh. During pilot testing, it was established that, in this seated position, vibration penetrated through the whole thigh and vibrated the knee extensor muscles at a frequency of 73 Hz and peak-to-peak displacement of 0.5 mm. This treatment resulted in a 126 228 m/s vibratory load that should have been associated with a 77% increase in muscle perfusion.10 This estimated increase in muscle perfusion was comparable in magnitude with the 67% and 64% increase in muscle perfusion estimated for the vibration treatments used by Lau et al8 and Barnes et al,9 respectively. Participants were provided with a CVT cushion for the duration of the study. Stretching and sports massage treatment involved 14 minutes of self-applied sports massage techniques and 6 minutes of static stretching of the right knee extensor muscles. This combination of SSM was performed twice daily to match the duration of treatment performed by the vibration group. The massage component consisted of effleurage (4 minutes), tapotement (2 minutes), and petrissage (8 minutes). Static stretching was performed 6 times in a standing position by pulling the heel of the foot up to the buttocks and then pulling the knee back to extend the hip. Each stretch was held for 30 seconds with 30 seconds of rest between stretches. Correct application of treatments was demonstrated to all participants who were also provided with verbal and
There was no difference in muscle soreness between treatment groups at baseline (Table). Muscle soreness increased post-ECCmax for both groups (P , 0.01 for time), with a tendency for muscle soreness to be higher immediately after ECCmax in the CVT group compared with the SSM group (P = 0.05, Table). There was no significant difference in the change in muscle soreness from immediately postECCmax to day 7 between CVT and SSM groups (P = 0.83 for treatment · time interaction, Figure 3). There was no difference in serum CK, Mb, or CRP levels between groups at baseline (Table). All 3 increased after ECCmax (P , 0.05, Table). There was no significant difference between groups for change in serum CK, Mb, or CRP levels over 7 days during administration of CVT or
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Primary Outcome There was no difference in PIT between groups at baseline (Table). Peak isometric torque decreased immediately post-ECCmax in both groups (P , 0.01) and was fully recovered by 7 days post-ECCmax (Table). In terms of between-treatment differences, there was no difference in PIT between groups immediately after ECCmax and there was no difference between groups in the recovery of PIT over 7 days during administration of CVT or SSM treatment (P = 0.64 for treatment · time interaction; Figure 2).
Secondary Outcomes
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Vibration Therapy for Muscle Recovery
FIGURE 1. Flow diagram of participant progress through study. ITT, intention to treat.
SSM treatment (P . 0.28 for treatment · time interaction, Figures 4–6).
DISCUSSION
The findings of this study do not provide any evidence that vibration is more effective than the standard treatment of SSM, for recovery of muscle strength in the lower limb after muscle-damaging eccentric exercise in untrained participants. This finding is in agreement with the results of previous research that has shown, when compared with no treatment, vibration applied using a handheld device does not improve recovery of elbow flexor PIT8 and standing on a vibrating platform does not improve recovery of knee extensor PIT.9 It should be noted that in each study,8,9 including the present study, the method used to apply vibration differed and may have resulted in a different vibration stimulus, making direct comparisons difficult. However, no studies have provided evidence to support the use of vibration for recovery of muscle strength after muscle damage.
Interestingly, it has recently been suggested that rather than improving muscle recovery, vibration may induce20 and exacerbate muscle damage9 by causing additional eccentric muscle contractions. However, similar to the results of Lau et al,8 we did not observe any tendency for recovery of muscle strength, CK, or Mb to be suppressed with the use of vibration after muscle damage. One possible explanation for this difference could be the different methods of vibration application. In the studies by Barnes et al9 and De Hoyo et al,20 where vibration induced and exacerbated muscle damage, vibration was applied to participants standing in a static squat position, whereas in the present study and the study by Lau et al,8 vibration was applied to participants in a relaxed state. It has been shown previously that the response of muscle to vibration is stronger when superimposed on muscle undergoing submaximal contraction.21 This enhanced response of muscle to vibration may not be appropriate when muscle is in a damaged state. Another possible explanation for the conflicting findings could be the choice of vibration frequency and magnitude, with slower frequencies and greater displacement tending to negatively affect muscle recovery. Markers of muscle damage increased in response to vibration applied at frequencies of 26 and 30 Hz and peak-to-peak displacements of 4 and 6 mm.9,20 Conversely, recovery of muscle strength was not suppressed in response to vibration applied at frequencies of 65 and 73 Hz and peak-to-peak displacements of 0.5 and 1 mm.8 When muscle recovery, rather than muscle training stimulus, is the goal of vibration treatment, highfrequency low-magnitude vibration might be better tolerated by recovering muscle than low-frequency high-magnitude vibration. Only one combination of vibration frequency and magnitude was used in the present study; so, it was not possible to investigate this hypothesis further. However, it has been previously noted that vibration-induced increases in blood flow are dependent on the combination of vibration parameters applied,10 which suggests that muscle recovery might also be differentially affected. The effects of vibration and SSM on muscle soreness and inflammation after ECCmax did not differ. This is in contrast to previous results, which showed that vibration
TABLE. Muscle Strength, Markers of Muscle Damage, Muscle Soreness, and Inflammation in Untrained Men Before and After Performance of 100 ECCmax of the Knee Extensor Muscles Followed by Either Vibration or SSM Interventions Dependent Variable PIT, Nm VAS scores, mm Serum CK levels, U/L Serum Mb levels, mg/L Serum CRP levels, mg/L
Intervention CVT SSM CVT SSM CVT SSM CVT SSM CVT SSM
Baseline 218.0 212.5 26.7 18.7 147.5 178.6 47.6 38.3 0.58 0.71
6 6 6 6 6 6 6 6 6 6
49.5 54.2 20.5 20.1 71.7 102.5 34.1 11.5 0.46 0.86
Post-ECCmax 167.6 171.8 56.4 43.5 152.2 188.1 52.3 46.5 0.52 0.75
6 6 6 6 6 6 6 6 6 6
50.2 55.7 22.3 23.2 68.0 106.0 22.8 17.5 0.45 0.88
24 h 175.0 172.6 56.3 38.9 383.6 279.3 50.4 43.8 0.86 1.02
6 6 6 6 6 6 6 6 6 6
62.7 63.4 22.4 26.2 315.2 174.3 16.6 14.2 0.74 1.22
48 h 182.1 193.2 48.4 37.2 299.4 260.3 42.5 37.9 1.04 0.81
6 6 6 6 6 6 6 6 6 6
58.4 55.9 21.8 24.6 207.2 207.6 13.7 15.9 1.45 0.99
72 h 6 6 6 6 6 6 6 6 6 6
168 h 6 6 6 6 6 6 6 6 6 6
59.9 58.7 17.4 24.4 229.4 70.1 39.2 4.9 0.73 0.44
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192.9 210.1 36.3 29.2 298.9 228.2 65.6 41.3 0.70 0.62
63.8 59.4 22.6 25.3 170.0 175.6 43.3 18.3 1.08 0.56
212.1 226.9 21.6 19.0 298.8 151.0 55.8 31.8 0.80 0.51
Values reported are raw data mean 6 SD. h, hours post-ECCmax.
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Fuller et al
FIGURE 2. Change in muscle strength after performance of 100 ECCmax (ie, 0 = immediately after muscle damage induction). Change values were calculated relative to the values obtained immediately after muscle damage induction. Values plotted on the graph are data mean 6 95% confidence interval predicted by the random effects mixed model.
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FIGURE 4. Change in muscle tissue damage (serum CK) after performance of 100 maximal eccentric muscle contractions (ie, 0 = immediately after muscle damage induction). Change values were calculated relative to the values obtained immediately after muscle damage induction. Values plotted on the graph are data mean 6 95% confidence interval predicted by the random effects mixed model.
alleviates muscle soreness to a greater extent than no treatment6,8 and stretching5 in trained5,6 and untrained8 participants. Differences could be due to the timing of muscle soreness assessment in relation to the vibration treatment. In the present study, participants were instructed not to perform treatment in the 4 hours before each assessment, whereas in the study by Lau et al,8 muscle soreness assessment focused on acute effects and was undertaken immediately after vibration treatment.
In the 2 other studies reporting an analgesic effect of vibration after exercise-induced muscle damage, it is not clear from the reported methodology when muscle soreness assessment was undertaken in relation to the vibration treatment.5,6 Reducing postexercise soreness in novice exercisers is important to encourage ongoing participation in exercise,4 and novice exercisers represent a demographic for whom potential analgesic effects of
FIGURE 3. Change in muscle soreness after performance of 100 maximal eccentric muscle contractions (ie, 0 = immediately after muscle damage induction). Change values were calculated relative to the values obtained immediately after muscle damage induction. Values plotted on the graph are data mean 6 95% confidence interval predicted by the random effects mixed model.
FIGURE 5. Change in muscle tissue damage (serum Mb) after performance of 100 maximal eccentric muscle contractions (ie, 0 = immediately after muscle damage induction). Change values were calculated relative to the values obtained immediately after muscle damage induction. Values plotted on the graph are data mean 6 95% confidence interval predicted by the random effects mixed model.
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Vibration Therapy for Muscle Recovery
ACKNOWLEDGMENTS The authors thank Advanced Lifestyle International for providing the vibration therapy cushions and financial support for this study. The authors also thank Dr Catherine Yandell and Ms Kelsey Hibberd for assistance with laboratory analysis and data collection. REFERENCES
FIGURE 6. Change in inflammation after performance of 100 maximal eccentric muscle contractions (ie, 0 = immediately after muscle damage induction). Change values were calculated relative to the values obtained immediately after muscle damage induction. Values plotted on the graph are data mean 6 95% confidence interval predicted by the random effects mixed model.
vibration could have a strong appeal. However, for this analgesic effect to be relevant, it needs to provide long-lasting benefit. Timing of assessments in the present study was better placed to assess these longer lasting effects, avoiding acute effects, but there was no evidence of any chronic reduction in soreness. A limitation of the present study is the lack of a “true” placebo control group, which makes it difficult to determine the individual effects of vibration or SSM. Although there was no difference in recovery between vibration and SSM, it is unclear from the present results whether recovery for the vibration and SSM groups would have been different from no treatment. This question has been addressed previously, with massage and stretching having no effect or a trivial effect on recovery15 and vibration having no effect8 or a possible detrimental effect on recovery.9 It was thought that the comparison of vibration treatment with standard treatment used in the present study increased the clinical relevance of the findings by testing vibration therapy against the current therapy that it is most likely to replace.14
CONCLUSIONS The results of this study suggest that vibration is no more effective than the standard treatment of SSM for promoting recovery of muscle strength and alleviating muscle soreness after exercise-induced muscle damage in untrained men. Future research should investigate if an optimal combination of vibration frequency, magnitude, and duration exists for promoting recovery of muscle following exercise.
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1. Proske U, Allen TJ. Damage to skeletal muscle from eccentric exercise. Exerc Sport Sci Rev. 2005;33:98–104. 2. Smith LL. Tissue trauma: the underlying cause of overtraining syndrome? J Strength Cond Res. 2004;18:185–193. 3. Twist C, Eston R. The effects of exercise-induced muscle damage on maximal intensity intermittent exercise performance. Eur J Appl Physiol. 2005;94:652–658. 4. Myers RS, Roth DL. Perceived benefits of and barriers to exercise and stage of exercise adoption in young adults. Health Psychol. 1997;16: 277–283. 5. Rhea MR, Bunker D, Marín PJ, et al. Effect of itonic whole-body vibration on delayed-onset muscle soreness among untrained individuals. J Strength Cond Res. 2009;23:1677–1682. 6. Broadbent S, Rousseau J, Thorp R, et al. Vibration therapy reduces plasma IL-6 and muscle soreness after downhill running. Br J Sports Med. 2010;44:888–894. 7. Edge J, Mündel T, Weir K, et al. The effects of acute whole body vibration as a recovery modality following high-intensity interval training in well-trained, middle-aged runners. Eur J Appl Physiol. 2009;105: 421–428. 8. Lau WY, Nosaka K. Effect of vibration treatment on symptoms associated with eccentric exercise-induced muscle damage. Am J Phys Med Rehabil. 2011;90:648–657. 9. Barnes M, Perry B, Mündel T, et al. The effects of vibration therapy on muscle force loss following eccentrically induced muscle damage. Eur J Appl Physiol. 2012;112:1189–1194. 10. Fuller JT, Thomson RL, Howe PRC, et al. Effect of vibration on muscle perfusion: a systematic review. Clin Physiol Funct Imaging. 2013;33:1–10. 11. Warren GL, Lowe DA, Armstrong RB. Measurement tools used in the study of eccentric contraction induced injury. Sports Med. 1999;27:43–59. 12. Howatson G, Van Someren KA. Evidence of a contralateral repeated bout effect after maximal eccentric contractions. Eur J Appl Physiol. 2007;101:207–214. 13. Lundeberg T. A comparative study of the pain alleviating effect of vibratory stimulation, transcutaneous electrical nerve stimulation, electroacupuncture and placebo. Am J Chin Med. 1984;12:72–79. 14. Department of Health and Ageing. Technical Guidelines for Preparing Assessment Reports for the Medical Services Advisory Committee—Service Type: Therapeutic (Version 1.2). Canberra, Australia: Department of Health and Ageing, Australian Federal Government; 2013. 15. Torres R, Ribeiro F, Duarte JA, et al. Evidence of the physiotherapeutic interventions used currently after exercise-induced muscle damage: systematic review and meta-analysis. Phys Ther Sport. 2012;13:101–114. 16. Lavender AP, Nosaka K. A light load eccentric exercise confers protection against a subsequent bout of more demanding eccentric exercise. J Sci Med Sport. 2008;11:291–298. 17. Altman DG, Bland JM. Treatment allocation by minimisation. BMJ. 2005;330:843. 18. Huskinsson E. Visual analogue scales. In: Melzack R, ed. Pain Mechanisms. New York, NY: Raven Press; 1983:33–37. 19. Buckley JD, Thomson RL, Coates AM, et al. Supplementation with a whey protein hydrolysate enhances recovery of muscle-force generating capacity following eccentric exercise. J Sci Med Sport. 2010;13:178–181. 20. De Hoyo M, Carrasco L, Da Silva-Grigoletto ME, et al. Impact of an acute bout of vibration on muscle contractile properties, creatine kinase and lactate dehydrogenase response. Eur J Sport Sci. 2013;13:666–673. 21. Bongiovanni LG, Hagbarth KE. Tonic vibration reflexes elicited during fatigue from maximal voluntary contractions in man. J Physiol. 1990; 423:1–14.
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Vibration Therapy Is No More Effective Than the Standard Practice of Massage and Stretching for Promoting Recovery From Muscle Damage After Eccentric Exercise Joel T. Fuller, B. Physiotherapy, Hons,* Rebecca L. Thomson, PhD,* Peter R. C. Howe, PhD,*† and Jonathan D. Buckley, PhD*
Objective: The purpose of this study was to determine if vibration
Key Words: vibration, stretching, massage, muscle damage, muscle strength, muscle soreness
therapy is more effective than the standard treatment of stretching and massage for improving recovery of muscle strength and reducing muscle soreness after muscle damage induced by eccentric exercise.
(Clin J Sport Med 2015;25:332–337)
Design: A randomized, single-blinded parallel intervention trial design was used. Setting: Research laboratory. Participants: Fifty untrained men aged 18 to 30 years completed the study.
Interventions: Participants performed 100 maximal eccentric muscle actions (ECCmax) of the right knee extensor muscles. For the next 7 days, 25 participants applied cycloidal vibration therapy to the knee extensors twice daily and 25 participants performed stretching and sports massage (SSM) twice daily. Main Outcome Measures: Changes in markers of muscle damage [peak isometric torque (PIT), serum creatine kinase (CK), and serum myoglobin (Mb)], muscle soreness (visual analog scale), and inflammation [serum C-reactive protein (CRP)] were assessed. Results: After ECCmax, there was no difference in recovery of PIT and muscle soreness or serum CK, Mb, and CRP levels between vibration and SSM groups (P . 0.28). Conclusions: Cycloidal vibration therapy is no more effective than the standard practice of stretching and massage to promote muscle recovery after the performance of muscle-damaging exercise. Clinical Relevance: Prescription of vibration therapy after maximal exercise involving eccentric muscle damage did not alleviate signs and symptoms of muscle damage faster than the standard prescription of stretching and massage. Submitted for publication January 22, 2014; accepted July 18, 2014. From the *Nutritional Physiology Research Centre, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia; and †Clinical Nutrition Research Centre, University of Newcastle, Newcastle, Australia. The vibration therapy cushions and financial support for this study were provided by Advanced Lifestyle International (Park Ridge, Queensland, Australia) through a Researchers in Business grant (Enterprise Connect, Australia). The authors report no conflicts of interest. Corresponding Author: Jonathan D. Buckley, PhD, Nutritional Physiology Research Centre, University of South Australia, GPO Box 2471, Adelaide 5001, South Australia ([email protected]). Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
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INTRODUCTION Exercise involving eccentric muscle action can cause muscle damage, resulting in muscle soreness, swelling, and reduction in muscle strength.1 Eccentric muscle actions are an inherent component of many physical recreation and sporting activities, and if recovery from the resulting damage is not sufficient, the ensuing symptoms could increase risk of injury,2 impede subsequent exercise performance,3 and present a barrier to continued involvement in physical activity.4 As a result, to offset the potential adverse effects of muscle damage, effective recovery modalities are desirable. One potential recovery aid, currently growing in popularity, is the application of vibration.5–9 It has been suggested5–9 that increases in blood flow associated with the application of vibration10 could aid muscle recovery. Indeed, several studies have found that vibration alleviated muscle soreness after exercise-induced muscle damage.5,6,8 However, although muscle soreness is an important symptom of muscle damage that might present a barrier to continued physical activity participation,4 reductions in muscle soreness correlate poorly with the return of muscle strength, which is reported to be the best marker of recovery from muscle damage.11 The efficacy of vibration therapy for promoting recovery of muscle strength after muscle damage has only been investigated in 2 studies.8,9 Recovery of elbow flexor peak isometric torque (PIT) was unaffected by vibration in untrained participants,8 and recovery of peak eccentric torque of the knee extensor muscles was impeded by vibration in trained participants.9 Both studies used a limb-to-limb comparison crossover design with 1 limb assigned to treatment and the other to a no treatment control after a 2-week9 or 4-week washout.8 One potential problem with this design is evidence of a contralateral repeated bout effect, whereby even a single bout of eccentric exercise affords some protection against the development of further muscle damage on the contralateral limb.12 This effect has been observed as long as 14 days after exercise,12 and it is unclear what would be an appropriate washout period for studies using a limb-tolimb comparison crossover design. A further limitation is the use of no treatment as a comparator to the vibration Clin J Sport Med Volume 25, Number 4, July 2015
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intervention.6–9 It seems likely that vibration, which causes strong mechanical and auditory stimuli, would be associated with a placebo effect, and this effect could challenge the validity of conclusions drawn from comparing vibration with no treatment. Indeed, use of vibration therapy for the management of pain has been shown to be similar in efficacy to that of a placebo.13 Furthermore, the Medical Services Advisory Committee of the Australian Department of Health and Ageing, the peak body responsible for advising government on evidence relating to the effectiveness of new medical technologies and procedures to inform decisions regarding public funding, recommends that the most appropriate comparator for assessing efficacy of novel clinical therapies is the current therapy that the novel therapy is most likely to replace.14 Only in this way can it be ensured that novel therapies provide a greater benefit than current practice and thus improve therapeutic management. A recent meta-analysis of physiotherapeutic interventions used after exercise-induced muscle damage concluded that the most commonly used treatments include massage and stretching, but these and other therapies (cryotherapy and low-intensity exercise) had trivial or no effect on muscle recovery.15 Therefore, the most appropriate therapy against which to compare effects of vibration therapy for promoting recovery of muscle damage would seem to be massage and stretching. The primary purpose of the present study was to determine whether the use of vibration therapy for the treatment of muscle damage induced by eccentric exercise was more effective than the current practice of stretching and sports massage (SSM). It was hypothesized that recovery of muscle strength would be faster for vibration therapy compared with SSM.
METHODS Research Design A randomized, single-blinded parallel intervention trial was conducted. A parallel study design was undertaken to avoid the aforementioned repeat bout effect associated with eccentric muscle action. One treatment group received vibration therapy and the other received the standard treatment of SSM. Outcomes of interest were PIT of the knee extensor muscles (primary outcome), muscle soreness, serum creatine kinase (CK, biomarker of muscle damage), serum myoglobin (Mb, biomarker of muscle damage), and serum C-reactive protein (CRP, biomarker of inflammation).
Participants Ethical approval was obtained from the Human Research Ethics Committee of the University of South Australia. The project was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12610000488000). A final cohort of 50 participants (22.5 6 3.7 years, 23.1 6 3.2 kg/m2) completed the study. Participants provided written informed consent before being accepted into the study. To aid recruitment of the required sample size, participants were given the option of not providing blood samples during the study, as muscle strength was the primary outcome of interest. Twelve participants chose not to provide blood samples. Participants were aged 18 to 40 years and considered untrained. Untrained participants were chosen Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
Vibration Therapy for Muscle Recovery
because they would experience a greater degree of exerciseinduced muscle damage and soreness because of the lack of any protection afforded by the repeat bout effect16 and because soreness experienced by novice exercisers as a result of muscle damage is a barrier to continued involvement in physical activity.4 Thus, evidence of an improved ability to reduce the negative impact of muscle damage might facilitate improved exercise participation in novice exercisers. Participants were excluded if they participated in physical activity more than once per week for the purpose of improving or maintaining physical fitness or had a musculoskeletal or medical problem that interfered with their ability to perform the required exercise.
Testing Procedures Participants attended the laboratory on 6 occasions over a 2-week period, which included 1 familiarization and 5 experimental sessions. Each participant completed all sessions at the same time of day and abstained from food in the 4 hours before each session. Participants were familiarized in the week before their anticipated start date during which demographic data were collected and PIT of the knee extensor muscles of the right leg was assessed. During the first experimental visit, PIT and muscle soreness were reassessed and blood samples collected for measurement of serum CK, Mb, and CRP. Participants then performed 100 maximal eccentric muscle actions (ECCmax) of the knee extensor muscles of the right leg. Assessments of PIT and muscle soreness were repeated and blood samples collected immediately after ECCmax and at 24, 48, and 72 hours and 7 days post-ECCmax. After the assessments undertaken immediately post-ECCmax, participants were randomly allocated to either vibration or SSM treatment. Randomization was via a process of minimization17 using PIT values obtained during familiarization as the minimization variable. Allocation to treatment was performed by an independent investigator (R.L.T.), with allocation information withheld from outcome assessors for the duration of data collection.
Muscle Damage Induction Muscle damage was induced through the performance of ECCmax on a Biodex isokinetic dynamometer (Biodex System 4; Biodex Medical Systems, Shirley, New York) at an angular velocity of 45 degrees per second through a 90-degree range of motion. Participants exhibiting no reduction in knee extensor PIT after muscle damage induction (PIT post-ECCmax $ PIT at baseline) were considered to have not adhered to the maximal exercise requirements and were excluded.
Peak Isometric Torque Peak isometric torque of the right knee extensor muscles was assessed using a Biodex isokinetic dynamometer and was sampled at 1000 Hz using a PowerLab data acquisition system (PowerLab 16/30; ADInstruments, Bella Vista, New South Wales, Australia). Before the assessment of PIT, participants completed a warm-up consisting of 3 submaximal isometric contractions, with the knee positioned in 90 degrees of flexion. Muscle strength was determined from the PIT achieved during the best of three 5-second maximal isometric contractions with a 1-minute rest between each maximal effort. Body position, www.cjsportmed.com |
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approximate axis of rotation of the knee joint, and dynamometer lever arm length were standardized across assessments. Test– retest assessment of PIT 1 week apart showed a good level of reliability [intraclass correlation coefficient (ICC) = 0.80].
written instructions. Participant compliance was monitored using a treatment diary. Based on participant self-reporting in these diaries, all participants completed all treatments as prescribed.
Muscle Soreness
Statistical Analyses
Muscle soreness was evaluated using a 100-mm visual analog scale (VAS)18 with anchor points consisting of “no soreness” on the left and “worst soreness possible” on the right. Participants were seated and requested to hold their right knee in an extended position for 5 seconds while a 5-kg mass was suspended from the ankle. Participants placed a mark at the point on the VAS corresponding to their perception of the soreness in the knee extensor muscles. The test–retest reliability of VAS muscle soreness scores was excellent (ICC = 0.98).
Based on the variance from a previous study we conducted19 using the same protocol to induce muscle damage and assess changes in muscle strength, a priori power analysis determined that 50 participants would be required to detect a 50% difference in PIT between treatments with a 5% significance level and 80% power. Predictive Analytics Software (PASW version 17, SPSS, Chicago, Illinois) was used to perform all statistical analyses. Normality of data was checked using the Shapiro–Wilk test, and data that were not normally distributed were transformed using logarithmic transformations (CK, Mb, and CRP). Differences between treatment groups for dependent variables at baseline and immediately post-ECCmax were assessed using an independent t test. Changes in markers of muscle damage over time were compared between treatment groups using a linear mixed model. Independent variables were time, treatment, and treatment · time interaction. Values for each of the dependent variables obtained immediately post-ECCmax were included as covariates in the model.
Serum Biomarkers Blood samples (10 mL) were collected for assessment of serum CK, Mb, and CRP concentrations. Serum levels of CK and CRP were assayed by a clinical chemistry analyzer (Konelab 20 XTi; Thermo Fisher Scientific, Middleton, Virginia) using a CK-N-acetylcystein reagent and CRP high-sensitivity kit, respectively (Thermo Fisher Scientific). Serum levels of Mb were assayed by a biochemical analyzer (ADVIA Centaur; Bayer, Leverkusen, Germany) using a commercially available kit (Siemens Healthcare Diagnostics, Tarrytown, New York). Interassay coefficients of variation for serum levels of CK, Mb, and CRP were 0.8%, 2.8%, and 3.7%, respectively.
RESULTS TREATMENTS
Flow of participants through the stages of the study is shown in Figure 1.
Vibration treatment was applied twice daily for 20 minutes with participants seated and a vibration cushion [cycloidal vibration therapy (CVT) cushion; Advanced Lifestyle International, Park Ridge, Queensland, Australia] positioned under their right thigh. During pilot testing, it was established that, in this seated position, vibration penetrated through the whole thigh and vibrated the knee extensor muscles at a frequency of 73 Hz and peak-to-peak displacement of 0.5 mm. This treatment resulted in a 126 228 m/s vibratory load that should have been associated with a 77% increase in muscle perfusion.10 This estimated increase in muscle perfusion was comparable in magnitude with the 67% and 64% increase in muscle perfusion estimated for the vibration treatments used by Lau et al8 and Barnes et al,9 respectively. Participants were provided with a CVT cushion for the duration of the study. Stretching and sports massage treatment involved 14 minutes of self-applied sports massage techniques and 6 minutes of static stretching of the right knee extensor muscles. This combination of SSM was performed twice daily to match the duration of treatment performed by the vibration group. The massage component consisted of effleurage (4 minutes), tapotement (2 minutes), and petrissage (8 minutes). Static stretching was performed 6 times in a standing position by pulling the heel of the foot up to the buttocks and then pulling the knee back to extend the hip. Each stretch was held for 30 seconds with 30 seconds of rest between stretches. Correct application of treatments was demonstrated to all participants who were also provided with verbal and
There was no difference in muscle soreness between treatment groups at baseline (Table). Muscle soreness increased post-ECCmax for both groups (P , 0.01 for time), with a tendency for muscle soreness to be higher immediately after ECCmax in the CVT group compared with the SSM group (P = 0.05, Table). There was no significant difference in the change in muscle soreness from immediately postECCmax to day 7 between CVT and SSM groups (P = 0.83 for treatment · time interaction, Figure 3). There was no difference in serum CK, Mb, or CRP levels between groups at baseline (Table). All 3 increased after ECCmax (P , 0.05, Table). There was no significant difference between groups for change in serum CK, Mb, or CRP levels over 7 days during administration of CVT or
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Primary Outcome There was no difference in PIT between groups at baseline (Table). Peak isometric torque decreased immediately post-ECCmax in both groups (P , 0.01) and was fully recovered by 7 days post-ECCmax (Table). In terms of between-treatment differences, there was no difference in PIT between groups immediately after ECCmax and there was no difference between groups in the recovery of PIT over 7 days during administration of CVT or SSM treatment (P = 0.64 for treatment · time interaction; Figure 2).
Secondary Outcomes
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Clin J Sport Med Volume 25, Number 4, July 2015
Vibration Therapy for Muscle Recovery
FIGURE 1. Flow diagram of participant progress through study. ITT, intention to treat.
SSM treatment (P . 0.28 for treatment · time interaction, Figures 4–6).
DISCUSSION
The findings of this study do not provide any evidence that vibration is more effective than the standard treatment of SSM, for recovery of muscle strength in the lower limb after muscle-damaging eccentric exercise in untrained participants. This finding is in agreement with the results of previous research that has shown, when compared with no treatment, vibration applied using a handheld device does not improve recovery of elbow flexor PIT8 and standing on a vibrating platform does not improve recovery of knee extensor PIT.9 It should be noted that in each study,8,9 including the present study, the method used to apply vibration differed and may have resulted in a different vibration stimulus, making direct comparisons difficult. However, no studies have provided evidence to support the use of vibration for recovery of muscle strength after muscle damage.
Interestingly, it has recently been suggested that rather than improving muscle recovery, vibration may induce20 and exacerbate muscle damage9 by causing additional eccentric muscle contractions. However, similar to the results of Lau et al,8 we did not observe any tendency for recovery of muscle strength, CK, or Mb to be suppressed with the use of vibration after muscle damage. One possible explanation for this difference could be the different methods of vibration application. In the studies by Barnes et al9 and De Hoyo et al,20 where vibration induced and exacerbated muscle damage, vibration was applied to participants standing in a static squat position, whereas in the present study and the study by Lau et al,8 vibration was applied to participants in a relaxed state. It has been shown previously that the response of muscle to vibration is stronger when superimposed on muscle undergoing submaximal contraction.21 This enhanced response of muscle to vibration may not be appropriate when muscle is in a damaged state. Another possible explanation for the conflicting findings could be the choice of vibration frequency and magnitude, with slower frequencies and greater displacement tending to negatively affect muscle recovery. Markers of muscle damage increased in response to vibration applied at frequencies of 26 and 30 Hz and peak-to-peak displacements of 4 and 6 mm.9,20 Conversely, recovery of muscle strength was not suppressed in response to vibration applied at frequencies of 65 and 73 Hz and peak-to-peak displacements of 0.5 and 1 mm.8 When muscle recovery, rather than muscle training stimulus, is the goal of vibration treatment, highfrequency low-magnitude vibration might be better tolerated by recovering muscle than low-frequency high-magnitude vibration. Only one combination of vibration frequency and magnitude was used in the present study; so, it was not possible to investigate this hypothesis further. However, it has been previously noted that vibration-induced increases in blood flow are dependent on the combination of vibration parameters applied,10 which suggests that muscle recovery might also be differentially affected. The effects of vibration and SSM on muscle soreness and inflammation after ECCmax did not differ. This is in contrast to previous results, which showed that vibration
TABLE. Muscle Strength, Markers of Muscle Damage, Muscle Soreness, and Inflammation in Untrained Men Before and After Performance of 100 ECCmax of the Knee Extensor Muscles Followed by Either Vibration or SSM Interventions Dependent Variable PIT, Nm VAS scores, mm Serum CK levels, U/L Serum Mb levels, mg/L Serum CRP levels, mg/L
Intervention CVT SSM CVT SSM CVT SSM CVT SSM CVT SSM
Baseline 218.0 212.5 26.7 18.7 147.5 178.6 47.6 38.3 0.58 0.71
6 6 6 6 6 6 6 6 6 6
49.5 54.2 20.5 20.1 71.7 102.5 34.1 11.5 0.46 0.86
Post-ECCmax 167.6 171.8 56.4 43.5 152.2 188.1 52.3 46.5 0.52 0.75
6 6 6 6 6 6 6 6 6 6
50.2 55.7 22.3 23.2 68.0 106.0 22.8 17.5 0.45 0.88
24 h 175.0 172.6 56.3 38.9 383.6 279.3 50.4 43.8 0.86 1.02
6 6 6 6 6 6 6 6 6 6
62.7 63.4 22.4 26.2 315.2 174.3 16.6 14.2 0.74 1.22
48 h 182.1 193.2 48.4 37.2 299.4 260.3 42.5 37.9 1.04 0.81
6 6 6 6 6 6 6 6 6 6
58.4 55.9 21.8 24.6 207.2 207.6 13.7 15.9 1.45 0.99
72 h 6 6 6 6 6 6 6 6 6 6
168 h 6 6 6 6 6 6 6 6 6 6
59.9 58.7 17.4 24.4 229.4 70.1 39.2 4.9 0.73 0.44
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192.9 210.1 36.3 29.2 298.9 228.2 65.6 41.3 0.70 0.62
63.8 59.4 22.6 25.3 170.0 175.6 43.3 18.3 1.08 0.56
212.1 226.9 21.6 19.0 298.8 151.0 55.8 31.8 0.80 0.51
Values reported are raw data mean 6 SD. h, hours post-ECCmax.
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Fuller et al
FIGURE 2. Change in muscle strength after performance of 100 ECCmax (ie, 0 = immediately after muscle damage induction). Change values were calculated relative to the values obtained immediately after muscle damage induction. Values plotted on the graph are data mean 6 95% confidence interval predicted by the random effects mixed model.
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FIGURE 4. Change in muscle tissue damage (serum CK) after performance of 100 maximal eccentric muscle contractions (ie, 0 = immediately after muscle damage induction). Change values were calculated relative to the values obtained immediately after muscle damage induction. Values plotted on the graph are data mean 6 95% confidence interval predicted by the random effects mixed model.
alleviates muscle soreness to a greater extent than no treatment6,8 and stretching5 in trained5,6 and untrained8 participants. Differences could be due to the timing of muscle soreness assessment in relation to the vibration treatment. In the present study, participants were instructed not to perform treatment in the 4 hours before each assessment, whereas in the study by Lau et al,8 muscle soreness assessment focused on acute effects and was undertaken immediately after vibration treatment.
In the 2 other studies reporting an analgesic effect of vibration after exercise-induced muscle damage, it is not clear from the reported methodology when muscle soreness assessment was undertaken in relation to the vibration treatment.5,6 Reducing postexercise soreness in novice exercisers is important to encourage ongoing participation in exercise,4 and novice exercisers represent a demographic for whom potential analgesic effects of
FIGURE 3. Change in muscle soreness after performance of 100 maximal eccentric muscle contractions (ie, 0 = immediately after muscle damage induction). Change values were calculated relative to the values obtained immediately after muscle damage induction. Values plotted on the graph are data mean 6 95% confidence interval predicted by the random effects mixed model.
FIGURE 5. Change in muscle tissue damage (serum Mb) after performance of 100 maximal eccentric muscle contractions (ie, 0 = immediately after muscle damage induction). Change values were calculated relative to the values obtained immediately after muscle damage induction. Values plotted on the graph are data mean 6 95% confidence interval predicted by the random effects mixed model.
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Vibration Therapy for Muscle Recovery
ACKNOWLEDGMENTS The authors thank Advanced Lifestyle International for providing the vibration therapy cushions and financial support for this study. The authors also thank Dr Catherine Yandell and Ms Kelsey Hibberd for assistance with laboratory analysis and data collection. REFERENCES
FIGURE 6. Change in inflammation after performance of 100 maximal eccentric muscle contractions (ie, 0 = immediately after muscle damage induction). Change values were calculated relative to the values obtained immediately after muscle damage induction. Values plotted on the graph are data mean 6 95% confidence interval predicted by the random effects mixed model.
vibration could have a strong appeal. However, for this analgesic effect to be relevant, it needs to provide long-lasting benefit. Timing of assessments in the present study was better placed to assess these longer lasting effects, avoiding acute effects, but there was no evidence of any chronic reduction in soreness. A limitation of the present study is the lack of a “true” placebo control group, which makes it difficult to determine the individual effects of vibration or SSM. Although there was no difference in recovery between vibration and SSM, it is unclear from the present results whether recovery for the vibration and SSM groups would have been different from no treatment. This question has been addressed previously, with massage and stretching having no effect or a trivial effect on recovery15 and vibration having no effect8 or a possible detrimental effect on recovery.9 It was thought that the comparison of vibration treatment with standard treatment used in the present study increased the clinical relevance of the findings by testing vibration therapy against the current therapy that it is most likely to replace.14
CONCLUSIONS The results of this study suggest that vibration is no more effective than the standard treatment of SSM for promoting recovery of muscle strength and alleviating muscle soreness after exercise-induced muscle damage in untrained men. Future research should investigate if an optimal combination of vibration frequency, magnitude, and duration exists for promoting recovery of muscle following exercise.
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