I went to massage school in 2001 with the intention of getting my credentials and working with my parents, who led bicycle tours across the United States. My plan was to provide massage to my parents’ tour clients after they rode 60–110 miles per day and start a career that would have me working with cyclists whose knots I would ease and whose performance I would help improve. Clearly that didn’t become my path, thanks to a chance meeting in a grocery store right before I finished massage school (that’s a story for another time), but it does help explain why this edition’s highlighted research article stood out to me for the Somatic Research column.
With the 2018 Winter Olympics and Paralympics behind us, some of us are already thinking about the 2020 Summer Games and the 2020 participant hopefuls who are gearing up for a long and intense training cycle. Massage therapy has long been thought to enhance athletic performance, whether it be applied between exercise bouts, in preparation for an event, or postevent for recovery benefit.1 While a lot of research exists on massage for sports performance, these studies are often choked with inconclusive outcomes, small sample sizes, or outcomes that, while potentially physiologically or psychologically meaningful to the athlete, do not meet the statistical significance often sought in peer-reviewed literature. A recent editorial in the British Journal of Sports Medicine highlights some of the emerging evidence for massage and postexercise recovery, including massage’s reduction of inflammatory cells and agents, as well as reduction of tissue damage.2 Much of the research highlighted in the editorial are animal studies, but the authors point to the importance of human studies and the need for research examining multiple rounds of massage sessions and usage over athletes’ training seasons.3 Researchers out of the University of South Carolina anticipated this research literature gap with their recently published study that looks at multiple massage therapy sessions over the course of a training cycle in elite cyclist athletes.4 In addition, this study addresses another gap in the related literature by focusing on disabled athletes training for Rio’s 2016 Paralympics; prior to now, virtually no research specific to massage for disabled athletes was available.
The massage for paracyclists study used a mixed-methods research design, meaning they collected both quantitative (numbers, measures, scales, and counts) and qualitative (words, comments, notes, and open-answer responses) data to understand how a long-term massage therapy program administered over the course of an Olympic training cycle affected quality of life, function and performance goals, stress, sleep, and pain.
A unique feature of this study was that participants resided and trained in various states from coast to coast and were able to identify a practicing massage therapist of their choice to provide the allotted massage treatments, given the therapist was willing to complete study training, follow the study protocol, and complete and submit study-specific data collection (i.e., assessment and treatment notes). The article is open access, meaning anyone can read it, but I’ll briefly outline the methods used and the outcomes before highlighting some discussion points and practice-relevant implications.

Study Methodology

The study began in January 2015 and ran through August 2016, allowing for up to 18 months of study time. Participants were to receive one massage per week for the first month for what the study team termed a loading phase. After those first four weekly massages, participants were to receive a massage every other week until the end of the study. The approach intended to both reflect real-world practice and to minimize related time burden.
Study duration (18 months or less) varied for participants depending on when they joined the study. Five guiding massage session protocols were developed for study therapists to integrate into their clinical massage treatment delivery, based on a study-specific intake assessment survey that included participant session goals:
(1) general relaxation, (2) muscle relaxation, (3) combined general and muscle relaxation, (4) injury rehabilitation, and (5) injury rehabilitation integrated into general and muscle relaxation. Study outcomes were: quality of life as measured by the modified SF-36 for nonambulatory individuals; stress, sleep, and muscle tightness; pain; and spasticity measured with a 10-point scale.
Data were collected at pre- and one-day posttreatment for the first, 14th, and final massage session. Additionally, qualitative data were derived from massage intake and completion forms, treatment notes, a study exit questionnaire, and feedback emails.
Thirteen paracyclists participated in the study overall, with seven men and two women completing enough of the program and data collection to be included in analysis. The program and study participation were open to members of a specific paracycling team based in Greenville, South Carolina (Greenville Health Systems Team Roger C. Peace), which had members who resided and trained in states from coast to coast. Not all members of the team participated and participation timelines varied based on when cyclists joined the team.
Muscle tension reduction was identified most often by participants as treatment goals, while mention of pain occurred with regard to session goals more often for therapists. Participants attributed recovery assistance, symptom relief, and sleep benefit to their massage sessions, which they believed led to improved performance. Quantitative measures indicated no change in quality of life measures, but indicated sleep and muscle tightness improved before and after massage, and over the course of the study. In addition to reporting these results, the article is also able to frame the findings within the context of participant experience with the mixed-methods approach and the collected qualitative data.

The massage for paracyclists study shares the small sample size weakness of earlier massage for sports performance research, limiting the study’s generalizability. However, other methodological and study aspects (e.g., use of mixed methods, repeated measures, and 18-month timeframe) strengthen the impact and importance of the work and provide several practice and future research implications. Aspects I find particularly striking include the study’s demonstration of human research challenges (which its mixed-methods approach helps), its reflection of real-world massage practice and epistemology, and what can immediately be taken away from this study and applied to practice.

The Messiness of Human Research

I have been heard upon occasion lamenting my decision to do research with humans per its conflict to my desire to set a detailed plan (with low likelihood to change), have control, and keep structure, structure, structure. The statement that “human research is messy” should not surprise anyone who’s ever worked with or interacted with a human. It’s one thing to collect data on a group of people at a single time point or before and after a single intervention; this sort of schedule effort is minimal, relatively speaking. It is a whole other bucket of pickles when scheduling needs span an extended period of time and when each appointment requires the alignment of multiple schedules. Granted, this study’s researchers were not yoked with the task of intervention schedule management for each participant; however, study viability and completion did rely on these aspects. The study’s results speak a bit to these challenges in the program implementation section, and also when study participants are described.
Some readers may have noted, as I did, the 31 percent decrease in those who participated (13 people) to those who completed enough of the program and data collection to be included in the analysis (nine people). While little specifics are reported in this regard, the paper does note athletes leaving and joining the team through study duration, as well as scheduling conflicts due to busy training plans and clinical practices, travel, life events, and transportation issues. In addition, due to the small sample size and the long study duration, it was necessary for all three time points to have data so participants would have had to complete at least 14 massage sessions, be in the study for at least 4–6 months, and completed pre- and one-day postmassage data collection at the three collection time points. These needs have a lot of contingencies that are reliant on multiple people, schedules, and follow-through, which (no matter how it’s looked at) equal the potential for messy.
Additional mess in this and other massage therapy research is the challenge of pointing to the specific elements of massage responsible for potentially related effects. While there were general protocols for therapists to follow, these served more as treatment frameworks rather than something fidelity (exactness of replication) could be measured on. There is also the fact that all manner of other elements in participants’ lives could have had an impact on the study’s outcomes. After all, participants were doing a lot of exercise, were “out in the elements” quite a bit, and potentially had other condition- and sport-related aspects impact study outcomes. All this being said, the fact remains, and will always remain, that the messy discussed here is inherent to massage therapy practice and therefore we should expect that practice-reflective research will include it as well. Still, it is important these aspects are understood when therapists or others consider and apply these sorts of research findings. The mixed-methods study design helps in this regard because it provides an opportunity for qualitative data to assist in the interpretation of study results.

Real-World Reflection: Loading and Maintenance Treatment Phases, Epistemology, and Quality of Life Measures

The study’s use of treatment “loading” in its design is interesting, and reflects the massage and bodywork notion that frequent visits at the start of a therapeutic treatment regimen set the potential for the work to “hold” for longer periods of time. In other words, clients are recommended to attend weekly sessions (for example) until treatment effects are holding to subsequent sessions. Additional time between sessions is added as long as treatment effects hold for the between-session duration. This principle is reinforced by the law of facilitation, which essentially states that once a neurological impulse has traversed a particular path, the resistance to travel that path again gets smaller.5 This concept is not often used in research studies, but is an approach often used in practice. This study did not make an assessment related to the loading treatment period, but the fact it was included in the intervention delivery design is an important reflection of real-world practice. I think this is a ripe topic for elucidation in future research.
Epistemology is essentially how we know what we know—the means through which knowledge is gleaned in a particular field, practice, or situation. Massage therapists base what they know about their client on what their client tells them, interpretation of their client observation, and prior experience with similar situations. It goes without saying that all of these means have the potential for bias, but for practical purposes, these are the ways we know what we know about our clients. To that end, this study’s mixed-methods approach and qualitative data collection and reporting reflects key field epistemology methods, in addition to enriching the quantitative outcomes. The participant quotes highlighted in the study could easily be those coming from sports massage clients anywhere in the world.  
Quality of life is an incredibly important study measure, regardless of population. While no statistically significant changes were reported with regard to this study’s quality of life measure, it is important to point out inherent measure-related challenges for this study, because I think it is erroneous to conclude from these findings that massage was ineffective for quality of life. The SF-36V measure used in this study is a standardized and reliable measure for functional health-related quality of life that has been adapted specifically for nonambulatory individuals.6 While completely appropriate for the population, two key considerations are important to keep in mind. First, the study’s population are elite athletes, which indicates a certain high level of functioning relative to their particular situation. When looking at the baseline SF-36V scores for these paracyclists, domain means started in the 70s and 80s for all but two of the eight domain and perceived change scores. The lower baseline domain scores were for pain and energy/fatigue, which began at 68.9 and 58.9, respectively; still relatively high and reasonable considering their continuous sport involvement. These high scores at the start of the study potentially (and likely) set the stage for a ceiling effect. There essentially isn’t very much room for these domains to improve to begin with. Second, exercise is known to be directly linked to positive quality of life outcomes.7 To try and parcel out changes and/or benefit “credit” between an athlete’s exercise regimen and simultaneous massage is for all intents and purposes impossible, at least with a measure such as the SF-36V; and this challenge is irrespective of my first challenge point above.
The bottom line is that the quality of life measure in this study is not well poised to assess massage therapy effects; rather, the measure provides meaningful descriptive information about study participants at key time points in the study.

Immediate Takeaways for Practice Implementation

The quantitative study results about massage’s potential benefit for sleep and muscle tightness reinforce what many tend to believe and see in practice for their massage clients, athletes or not. While these study results don’t necessarily offer new ways of applying massage to this population, there is a key takeaway regarding practice process that is ripe for practice implementation. In my brief results outline, you may have noticed the subtle disconnect between what participants indicated as their treatment goals compared to what therapist treatment notes seemed to focus on. Specifically, the paracyclists most often mentioned loosening tight restrictions in their treatment goals, but pain reduction was the most frequently indicated client goal for therapists. Both are certainly closely related, and treatment intended to decrease pain will likely also address muscle tightness. However, client-centered practice only stands to improve when therapist focus and documentation align with client goals. The study authors suggest “verbal intakes may be important when compared with written intake forms to help elucidate goals and improve treatment,” and I could not agree more, whether your client is a paracyclist, general athlete, or nonathlete. It’s easy to get caught up in what we think is best, what we want for a client, or even in what we think our client wants, but everyone will always be better served when client goals and therapist intention and understanding of client goals align.  


From a practice standpoint, sport-focused massage is a field cornerstone and one can hardly imagine organized walks, runs, or other events without massage tables and chairs for pre- and postevent sessions. While it is logical to think that massage would be just as well received and beneficial for para-athletes, research focus in this population has not been robust, and this long-term study is the first to focus on this population. The massage for paracyclists study provides many discussion considerations for massage therapists and practitioner researchers to consider. The study is unique in its long-term quasi-experimental mixed-methods approach and gives insight into practical challenges inherent in real-world massage research. While results have limited generalizability due to its size, narrow focus, and less controlled aspects, the study provides a foundation on which future work can build examining massage’s impact on performance and recovery for athletes of all ability, function, and level. I look forward to more practice-reflective research in the years to come, as well as research focused across the various ranges of function, health, and social determinants of health.

Notes

1. P. Weerapong, P. A. Hume, and G. S. Kolt, “The Mechanisms of Massage and Effects on Performance, Muscle Recovery and Injury Prevention,” Sports Medicine 35, no. 3 (2005): 235–56.
2. T. M. Best and S. K. Crawford, “Massage and Postexercise Recovery: The Science is Emerging,” British Journal of Sports Medicine 51 (2017): 1386–7; C. Haas et al., “Massage Timing Affects Postexercise Muscle Recovery and Inflammation in a Rabbit Model,” Medicine & Science in Sports & Exercise 45, no. 6 (June 2013): 1105–12, https://doi.org/10.1249/MSS.0b013e31827fdf18; C. Haas et al., “Dose-Dependency of Massage-Like Compressive Loading on Recovery of Active Muscle Properties Following Eccentric Exercise: Rabbit Study with Clinical Relevance,” British Journal of Sports Medicine 47, no. 2 (2013): 83–8. https://doi.org/10.1136/bjsports-2012-091211.
3. T. M. Best and S. K. Crawford, “Massage and Postexercise Recovery: The Science is Emerging.”
4. A. B. Kennedy, N. Patil, and J. L. Trilk, “‘Recover Quicker, Train Harder, and Increase Flexibility’: Massage Therapy for Elite Paracyclists, a Mixed-Methods Study,” BMJ Open Sport & Exercise Medicine 4, no. 1 (January 1, 2018):e000319, https://doi.org/10.1136/bmjsem-2017-000319.
5. Sandy Fritz, “The Scientific Art of Therapeutic Massage,” chap. 4 in Mosby’s Fundamentals of Therapeutic Massage, 4th ed. (Maryland Heights, Missouri: Elsevier, 2013).
6. S. L. Luther et al., “A Pilot Study to Modify the SF-36V Physical Functioning Scale for Use with Veterans with Spinal Cord Injury,” Archives of Physical Medicine and Rehabilitation 87, no. 8 (August 1, 2006): 1059–66.
7. R. Bize, J. A. Johnson, and R. C. Plotnikoff, “Physical Activity Level and Health-Related Quality of Life in the General Adult Population: A Systematic Review,” Preventive Medicine 45, no. 6 (December 2007): 401–15.

Niki Munk, PhD, LMT, is an assistant professor of health sciences at Indiana University’s School of Health and Rehabilitation Sciences, a Kentucky licensed massage therapist, a visiting research fellow with the Australian Research Centre in Complementary and Integrative Medicine, and mother of two young daughter-scientists. Munk’s research explores real-world massage therapy for chronic pain, trigger point self-care, massage for amputation-related sequelae, and the reporting and impact of massage-related case reports.