Sunday, September 20, 2009

DOMS Part 1: What is Delayed Onset Muscle Soreness (DOMS) and what doesn't work to reduce/eliminate it

ResearchBlogging.orgEver get sore a day or two after a workout? Muscle pain, muscle soreness or muscle stiffness that is felt 12-48 hours after exercise is usually known as Delayed Onset Muscle Soreness or DOMS. The tell tale signs of DOMS are sore muscles, unable to move such muscles in normal range of motion, reduced strength in those limbs. It usually happens after trying out a new workout or doing new type of physical activity, or if the intensity of a familiar activity goes up up.

Exactly what's happening in DOMS that creates the soreness and related effects is still speculation, but regardless of cause what might reduce or eliminate its effects has been studied from multiple approaches. This article has two parts (1) what it is and what doesn't work to reduce doms (this article); (2) what actually does seem to work to reduce or eliminate doms.

In part 1, this one, there's a summary about what is known about it. We then looks at what seems not to work at all, what actually makes DOMS worse. In Part II we look at what seems to mitigate its effects on performance but not pain, or vice versa, and what may actually really eliminate it from occurring (that part is very hair of the dog). If you'd just like the program of what works, skip to Part II, Summary, right now because a lot of suggestions on the rest of the web (like cool down or stretch after exercise) are just wrong. Knowing what doesn't work - since all the proposals are so sensible, but so useless, is interesting too.

So next time you're in a shower room argument about be sure to cool down and stretch it out or have a hot shower or get a massage, take an aspirin or vitamin c, you'll be able to say bollocks, as you are able to move freely two days after that intense training session while your peers are hobbling.

DOMS Review of the Known

DOMS is brought on by

In normal circumstances, eccentric muscle work that is either at a new intensity level or is a new eccentric-loaded movement brings on DOMS. In some studies, for instance, DOMS has been successfully induced by backwards walking down an 13 degree inclined treadmill.

DOMS effects
The most obvious effects of DOMS are that they occur 12-48 hours after the activity; DOMS hurts with the consequent effect being a decreased range of motion, increased size from swelling, and less power to work in the effected muscles. The effected muscles are most often the big leg muscles and to lesser degree, calves, but DOMS is not restricted to the lower body.

Beneath the manifested physical effects are the physiological ones that are less clear: changes in creatine kinase for instance, amount of inflammation, degree of muscle fiber damage. Whether or not an intervention mitigates the effects of DOMS is usually measured by perceived soreness, but also less subjective range of motion and force production. In some cases the physiological markers like CK levels pre and post are also checked. In some cases we'll see that treatments can decrease the DOMS effect on ROM and power, but do nothing to eliminate the duration/intensity of the pain.

DOMS physiological causes
This section is based on a great overview by sports fitness advisor of research from the 70's up to about 2006, the authors show that by about the mid-80's any thoughts that lactic acid buildup in the muscles was the cause of DOMS was put to rest. Likewise in the 80's and early 90's the main theories that seem to be still active are DOMS is either muscle cell damage (ruptured cells spilling contents into muscle fibers), muscle fiber damage, where the repair process at sensitive nerve endings is the pain signal, or an inflammatory (Tidball JG. Inflammatory cell response to acute muscle injury. Med Sci Sports Exerc. 1995 Jul;27(7):1022-32) response. The latter suggests that the 48 hour period when DOMS hits is the peak time for cell death (Armstrong RB. Mechanisms of exercise-induced delayed onset muscular soreness: a brief review. Med Sci Sports Exerc. 1984 Dec;16(6):529-38).

In other words no one knows the exact mechanism for DOMS - a review of the literature i've done to 2009 suggests this is still the case.

I cannot find the reference, alas, but my favorite hypothesis to date has been that the pain is actually the building up of the new muscle fiber material where other fibers are getting pushed out of the way as new tissue comes in. If anyone knows of the reference, please let me know.

DOMS - unpredictable degree of effect
What we do know at this point is that, as of March 2009, we don't have the appropriate scales to predict "Onset, intensity, and duration of DOMS" in 87% of a tested population. SO we can bring it on, but we don't know exactly how it's going to effect participants.
Clin J Pain. 2009 Mar-Apr;25(3):239-43.
Can muscle soreness after intensive work-related activities be predicted?
Soer R, Geertzen JH, van der Schans CP, Groothoff JW, Reneman MF.
Center for Rehabilitation, University Medical Center Groningen, University of Groningen, Haren, The Netherlands.

OBJECTIVES: It is currently unknown whether specific determinants are predictive for developing delayed onset muscle soreness (DOMS) after heavy work-related activities. The aim of this study was to analyze whether personal characteristics and performance measures are predictive for onset, intensity, and duration of DOMS after performing work-related activities during a Functional Capacity Evaluation in healthy participants. METHODS: Included in this study were 197 healthy participants (102 men, 95 women), all working within a broad range of professions. Five groups of predictors were tested in a multiple regression analysis model: personal variables, self-reported activity, self-reported health, perceived effort during the test, and objective outcomes of the test. Twenty-three independent variables were selected and tested with a backward regression analysis. RESULTS: The onset of DOMS could be explained for 7% by the variables: sex and the work index of the Baecke questionnaire. Variance of intensity of DOMS could be explained for 13% by the variables: age, sex, and VO2max. Variance in duration of DOMS could be explained for 8% by the variables: sex and reported emotional role limitations. Onset, intensity, and duration of DOMS remain unpredictable for 87% or more. CONCLUSIONS: The results demonstrate that the intensity and duration of self-reported DOMS can only minimally be predicted from the candidate predictors used in this study.
Characteristics of DOMS
While we can't yet predict how long and how intense DOMS will be, we know alot more about where it actually acts in the muscluature: the bits further away from the center of the body - the distal ends of the muscles.
Med Sci Sports Exerc. 2008 Feb;40(2):326-34.Click here to read Links
Sensory and electromyographic mapping during delayed-onset muscle soreness.
Hedayatpour N, Falla D, Arendt-Nielsen L, Farina D.

Centre for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7 D-3, Aalborg, Denmark.

PURPOSE: The aim of this human study was to apply novel topographical mapping techniques to investigate sensory and EMG manifestations of delayed-onset muscle soreness (DOMS) in multiple locations of the quadriceps. METHODS: Bipolar surface EMG signals were recorded from 11 healthy men with 15 pairs of electrodes located at 10, 20, 30, 40, and 50% of the distance from the medial, superior, and lateral border of the patella to the anterior superior iliac spine. Subjects performed sustained isometric knee extensions at 40% of the maximal force (MVC) until task failure before, 24 h, and 48 h after eccentric exercise. Pressure-pain thresholds (PPT) were assessed at the 15 locations where the EMG was recorded. RESULTS: Time to task failure was reduced after the eccentric exercise (mean +/- SD, 56.6 +/- 23 s before the eccentric exercise; 34.3 +/- 18.9 s at 24 h after exercise; and 34.3 +/- 14.4 s at 48 h after exercise). During the postexercise sustained contractions, EMG average rectified value (ARV) significantly decreased over time (P < style="color: rgb(102, 51, 0);">ONCLUSION: Novel topographical mapping of both surface EMG and PPT of the quadriceps showed site-dependent effects of eccentric exercise, probably attributable to variations in the morphological and architectural characteristics of the muscle fibers. Greater manifestations of DOMS in the distal region of the quadriceps may indicate a greater susceptibility of this region to further injury after eccentric exercise.
In case one is curious, DOMS is different in effect than muscular fatigue when muscular activity is viewed using a similar EMG set up to the above study. The power generated in muscle repair goes up in a fatigued muscle; it's totally nuked in a DOMS - effected muscle.
Scand J Med Sci Sports. 2008 Nov 3.
Effect of delayed-onset muscle soreness on muscle recovery after a fatiguing isometric contraction.
Hedayatpour N, Falla D, Arendt-Nielsen L, Farina D.

Department of Health Science and Technology, Centre for Sensory-Motor Interaction (SMI), Aalborg University, Aalborg, Denmark.

An increase to above-baseline levels of electromyography (EMG) mean power spectral frequency (MPF) has been observed previously during muscle recovery following fatiguing contractions and has been explained by membrane hyperpolarization due to increased activation of the Na(+)-K(+) pump. It is hypothesized that this membrane mechanism is impaired by muscle fiber damage following eccentric exercise. Thus, the aim of the study was to investigate surface EMG signal characteristics during recovery from fatigue after eccentric exercise. Ten healthy subjects performed sustained isometric knee extensions at 40% of the maximal torque (MVC) until task failure before, immediately after and 24 and 48 h after eccentric exercise. Bipolar surface EMG signals were recorded from six locations over the quadriceps during the sustained isometric contraction and during 3-s long contractions at 40% MVC separated by 1-min intervals for 15 min (recovery). Before the eccentric exercise, MPF of EMG signals increased to values above baseline during recovery from the fatiguing isometric contraction (P<0.001), style="color: rgb(102, 51, 0);">In conclusion, delayed-onset muscle soreness abolished the supranormal increase in EMG MPF following recovery from fatigue.
Reducing DOMS - overview from 2003 - it's better; it's worse
J Strength Cond Res. 2003 Feb;17(1):197-208.Links
Treatment and prevention of delayed onset muscle soreness.
Connolly DA, Sayers SP, McHugh MP.

Human Performance Laboratory, University of Vermont, Burlington, Vermont 05401, USA. dconnoll@zoo.uvm.ed

Eccentric exercise continues to receive attention as a productive means of exercise. Coupled with this has been the heightened study of the damage that occurs in early stages of exposure to eccentric exercise. This is commonly referred to as delayed onset muscle soreness (DOMS). To date, a sound and consistent treatment for DOMS has not been established. Although multiple practices exist for the treatment of DOMS, few have scientific support. Suggested treatments for DOMS are numerous and include pharmaceuticals, herbal remedies, stretching, massage, nutritional supplements, and many more. DOMS is particularly prevalent in resistance training; hence, this article may be of particular interest to the coach, trainer, or physical therapist to aid in selection of efficient treatments. First, we briefly review eccentric exercise and its characteristics and then proceed to a scientific and systematic overview and evaluation of treatments for DOMS. We have classified treatments into 3 sections, namely, pharmacological, conventional rehabilitation approaches, and a third section that collectively evaluates multiple additional practiced treatments. Literature that addresses most directly the question regarding the effectiveness of a particular treatment has been selected. The reader will note that selected treatments such as anti-inflammatory drugs and antioxidants appear to have a potential in the treatment of DOMS. Other conventional approaches, such as massage, ultrasound, and stretching appear less promising.
more from 2003:nothing works
In 2003, nothing that had been tried really worked - and i've found a few studies recently that show we can make it worse. And while the review abstract says that NSAIDS (ibuprofen, etc) and antioxidants have potential, that hope has been fleeting. Antioxidants like Vit C have not been shown in clinical trials to work (Close GL, Ashton T, Cable T, Doran D, Holloway C, McArdle F, MacLaren DP. Ascorbic acid supplementation does not attenuate post-exercise muscle soreness following muscle-damaging exercise but may delay the recovery process. Br J Nutr. 2006 May;95(5):976-81). Likewise, NSAIDS have been shot down again:
Int J Sports Med. 2007 Nov;28(11):909-15. Epub 2007 May 31.Click here to read Links
Effect of NSAID on muscle injury and oxidative stress.
McAnulty S, McAnulty L, Nieman D, Morrow J, Dumke C, Henson D.

Health, Leisure, and Exercise Science, Appalachian State University, Boone, NC 28608, USA.

Indirect markers of muscle damage and delayed onset muscle soreness were examined and correlated to changes in oxidative stress, plasma antioxidant potential, and use or nonuse of non-steroidal anti-inflammatory drugs in 60 ultra-marathoners following the Western States Endurance Run. Blood was collected prior to and immediately following the race and analyzed for muscle damage by creatine phosphokinase and oxidative stress by F (2)-isoprostanes, protein carbonyls, and lipid hydroperoxides and antioxidant potential by the ferric reducing ability of plasma. Subjects recorded delayed onset muscle soreness during the week following the race. Lipid hydroperoxide concentrations were unchanged, but F (2)-isoprostanes, protein carbonyls, ferric reducing ability of plasma, creatine phosphokinase, and delayed onset muscle soreness increased significantly postrace. Protein carbonyls were significantly higher postrace in nonsteroidal anti-inflammatory drug users versus nonusers.
Inrtiguingly another review in 2003 of DOMS literature seems more accurate about interpretations of the existing research at that time:
Sports Med. 2003;33(2):145-64.
Delayed onset muscle soreness : treatment strategies and performance factors.
Cheung K, Hume P, Maxwell L.

School of Community Health and Sports Studies, Auckland University of Technology, Auckland, New Zealand.

Delayed onset muscle soreness (DOMS) is a familiar experience for the elite or novice athlete. Symptoms can range from muscle tenderness to severe debilitating pain. The mechanisms, treatment strategies, and impact on athletic performance remain uncertain, despite the high incidence of DOMS. DOMS is most prevalent at the beginning of the sporting season when athletes are returning to training following a period of reduced activity. DOMS is also common when athletes are first introduced to certain types of activities regardless of the time of year. Eccentric activities induce micro-injury at a greater frequency and severity than other types of muscle actions. The intensity and duration of exercise are also important factors in DOMS onset. Up to six hypothesised theories have been proposed for the mechanism of DOMS, namely: lactic acid, muscle spasm, connective tissue damage, muscle damage, inflammation and the enzyme efflux theories. However, an integration of two or more theories is likely to explain muscle soreness. DOMS can affect athletic performance by causing a reduction in joint range of motion, shock attenuation and peak torque. Alterations in muscle sequencing and recruitment patterns may also occur, causing unaccustomed stress to be placed on muscle ligaments and tendons. These compensatory mechanisms may increase the risk of further injury if a premature return to sport is attempted.A number of treatment strategies have been introduced to help alleviate the severity of DOMS and to restore the maximal function of the muscles as rapidly as possible. Nonsteroidal anti-inflammatory drugs have demonstrated dosage-dependent effects that may also be influenced by the time of administration. Similarly, massage has shown varying results that may be attributed to the time of massage application and the type of massage technique used. Cryotherapy, stretching, homeopathy, ultrasound and electrical current modalities have demonstrated no effect on the alleviation of muscle soreness or other DOMS symptoms. Exercise is the most effective means of alleviating pain during DOMS, however the analgesic effect is also temporary. Athletes who must train on a daily basis should be encouraged to reduce the intensity and duration of exercise for 1-2 days following intense DOMS-inducing exercise. Alternatively, exercises targeting less affected body parts should be encouraged in order to allow the most affected muscle groups to recover. Eccentric exercises or novel activities should be introduced progressively over a period of 1 or 2 weeks at the beginning of, or during, the sporting season in order to reduce the level of physical impairment and/or training disruption. There are still many unanswered questions relating to DOMS, and many potential areas for future research.

In the above reference, a phase of adaptation is proposed to mitigate the effects of DOMS, while a few years on in 2006, some researchers suggest that what we know about DOMS behaviour may be biased by the population, and raises the question would the results be any different if studies were restricted to elite athlete populations?

Even while asking that question, the authors suggest there's no reason to think that what we know doesn't work in non-elite athletic populations will work in elite athletes. Really the questions these researchers want to know about are physiological effects: any way to say how much longer before elite athletes can get back to optimal work post DOMS?

Sports Med. 2006;36(9):781-96.Links
Using recovery modalities between training sessions in elite athletes: does it help?
Barnett A.

Centre of Excellence for Applied Sport Science Research, Queensland Academy of Sport, Brisbane, Queensland, Australia.

Achieving an appropriate balance between training and competition stresses and recovery is important in maximising the performance of athletes. A wide range of recovery modalities are now used as integral parts of the training programmes of elite athletes to help attain this balance. This review examined the evidence available as to the efficacy of these recovery modalities in enhancing between-training session recovery in elite athletes. Recovery modalities have largely been investigated with regard to their ability to enhance the rate of blood lactate removal following high-intensity exercise or to reduce the severity and duration of exercise-induced muscle injury and delayed onset muscle soreness (DOMS). Neither of these reflects the circumstances of between-training session recovery in elite athletes. After high-intensity exercise, rest alone will return blood lactate to baseline levels well within the normal time period between the training sessions of athletes. The majority of studies examining exercise-induced muscle injury and DOMS have used untrained subjects undertaking large amounts of unfamiliar eccentric exercise. This model is unlikely to closely reflect the circumstances of elite athletes. Even without considering the above limitations, there is no substantial scientific evidence to support the use of the recovery modalities reviewed to enhance the between-training session recovery of elite athletes. Modalities reviewed were massage, active recovery, cryotherapy, contrast temperature water immersion therapy, hyperbaric oxygen therapy, nonsteroidal anti-inflammatory drugs, compression garments, stretching, electromyostimulation and combination modalities. Experimental models designed to reflect the circumstances of elite athletes are needed to further investigate the efficacy of various recovery modalities for elite athletes. Other potentially important factors associated with recovery, such as the rate of post-exercise glycogen synthesis and the role of inflammation in the recovery and adaptation process, also need to be considered in this future assessment.
And in 2004 there's a lovely caveat to say that because we are so in the dark about the cause of DOMS we should be very careful about what we give a go as it might make things worse - especially as DOMS disappears 2-10 days (!) before "complete functional recovery"
Ann Readapt Med Phys. 2004 Aug;47(6):290-8.
Coudreuse JM, Dupont P, Nicol C.

Service de medecine du sport, CHU Salvator, APHM, 249, boulevard Sainte-Marguerite, 13009 Marseille, France.

Muscle intolerance to exercise may result from different processes.
Diagnosis involves confirming first the source of pain, then potential pathological myalgia. Delayed-onset muscle soreness (DOMS), commonly referred as tiredness, occurs frequently in sport. DOMS usually develops 12-48 h after intensive and/or unusual eccentric muscle action. Symptoms usually involve the quadriceps muscle group but may also affect the hamstring and triceps surae groups. The muscles are sensitive to palpation, contraction and passive stretch. Acidosis, muscle spasm and microlesions in both connective and muscle tissues may explain the symptoms. However, inflammation appears to be the most common explanation. Interestingly, there is strong evidence that the progression of the exercise-induced muscle injury proceeds no further in the absence of inflammation. Even though unpleasant, DOMS should not be considered as an indicator of muscle damage but, rather, a sign of the regenerative process, which is well known to contribute to the increased muscle mass. DOMS can be associated with decreased proprioception and range of motion, as well as maximal force and activation. DOMS disappears 2-10 days before complete functional recovery. This painless period is ripe for additional joint injuries. Similarly, if some treatments are well known to attenuate DOMS, none has been demonstrated to accelerate either structural or functional recovery. In terms of the role of the inflammatory process, these treatments might even delay overall recovery
Things have certainly changed in that attenuation since 2004, but what we've also improved our knowledge around: how to make DOMS worse.

Making DOMS worse? You betcha

Despite the warning above, researchers have indeed found a couple ways to indeed make the pain of DOMS worse: we can make it hurt more - in 2005 with hyperbaric chambers:
Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004713.Click here to read Links
Hyperbaric oxygen therapy for delayed onset muscle soreness and closed soft tissue injury.
Bennett M, Best TM, Babul S, Taunton J, Lepawsky M.

Prince of Wales Hospital, Department of Diving and Hyperbaric Medicine, Barker Street, Randwick, New South Wales 2031, Australia.

BACKGROUND: Soft tissue injuries (including muscle damage after unaccustomed exercise) are common and are often associated with athletic activity. Hyperbaric oxygen therapy (HBOT) is the therapeutic administration of 100% oxygen at environmental pressures greater than one atmosphere. OBJECTIVES: To assess the benefits and harms of HBOT for treating soft tissue injury, including delayed onset muscle soreness (DOMS). SEARCH STRATEGY: We searched the following in July 2004: CENTRAL, MEDLINE, EMBASE, CINAHL, DORCTIHM and reference lists from relevant articles. Relevant journals were handsearched and researchers in the field contacted. SELECTION CRITERIA: Randomised trials comparing the effect on closed soft tissue injury (including DOMS) of therapeutic regimens which include HBOT with those that exclude HBOT (with or without sham therapy). DATA COLLECTION AND ANALYSIS: Four reviewers independently evaluated study quality and extracted data. Most of the data presented in the review were extracted from graphs in the trial reports. MAIN RESULTS: Nine small trials involving 219 participants were included. Two trials compared HBOT versus sham therapy on acute closed soft tissue injuries (ankle sprain and medial collateral knee ligament injury respectively). The other seven trials examined the effect of HBOT on DOMS following eccentric exercise in unconditioned volunteers.All 32 participants of the ankle sprain trial returned to their normal activities. There were no significant differences between the two groups in time to recovery, functional outcomes, pain, or swelling. There was no difference between the two groups in knee function scores in the second acute injury trial; however, intention-to-treat analysis was not possible for this trial.Pooling of data from the seven DOMS trials showed significantly and consistently higher pain at 48 and 72 hours in the HBOT group (mean difference in pain score at 48 hours [0 to 10 worst pain] 0.88, 95% CI 0.09 to 1.67, P = 0.03) in trials where HBOT was started immediately. There were no differences between the two groups in longer-term pain scores or in any measures of swelling or muscle strength.No trial reported complications of HBOT but careful selection of participants was evident in most trials. AUTHORS' CONCLUSIONS: There was insufficient evidence from comparisons tested within randomised controlled trials to establish the effects of HBOT on ankle sprain or acute knee ligament injury, or on experimentally induced DOMS. There was some evidence that HBOT may increase interim pain in DOMS. Any future use of HBOT for these injuries would need to have been preceded by carefully conducted randomised controlled trials which have demonstrated effectiveness.
We can make it worse with soft tissue release, too (that was a surprise):
Phys Ther Sport. 2009 Feb;10(1):19-24. Epub 2008 Dec 16.Links
The effect of soft tissue release on delayed onset muscle soreness: a pilot study.
Micklewright D.

Department of Biological Sciences, The University of Essex, Wivenhoe Park, Colchester, Essex CO43SQ, UK.

OBJECTIVES: To examine soft tissue release (STR) as an intervention for delayed onset muscle soreness (DOMS). DESIGN: A mixed-subjects experimental design was used. Participants performed 4 x 20 eccentric elbow extensions at 80% of 1RM. Participants received either STR (50%) or no treatment (50%). DOMS measurements were taken before the elbow extensions and at 0, 24, and 48 h afterwards. SETTING: The study was conducted at the University of Essex exercise physiology laboratory. PARTICIPANTS: Twenty male participants, unaccustomed to strength conditioning, completed the study. MAIN OUTCOME MEASURES: DOMS was evaluated using relaxed joint angle (RJA), active range of motion (AROM), passive range of motion (PROM), and arm girth measurements. Soreness ratings were measured using a 100 mm visual analogue scale (VAS). RESULTS: In both conditions there were post-DOMS task increases in VAS ratings (p < style="color: rgb(102, 51, 0);">STR exacerbates the DOMS sensation yet does not seem to improve the rate of recovery during the first 48 h.
DOMS: what else doesn't help but doesn't make it worse.

In the realm of what doesn't help, it's intriguing to see how frequently massage of various kinds has been investigated. Sufficiently so that one might be able to say that it doesn't help. In 2005, for instance, one article claimed success for massage by saying that range of motion and perceived tenderness, as well as CK levels were all better in the massage group. It's always nice to be less sore. But what did not occur was any impact on recovery of ROM or muscle strength.
J Athl Train. 2005 Jul-Sep;40(3):174-80.
Comment in:
J Athl Train. 2005 Jul-Sep;40(3):186-90.

Effects of massage on delayed-onset muscle soreness, swelling, and recovery of muscle function.
Zainuddin Z, Newton M, Sacco P, Nosaka K.

Edith Cowan University, Joondalup, Western Australia, Australia.

CONTEXT: Delayed-onset muscle soreness (DOMS) describes muscle pain and tenderness that typically develop several hours postexercise and consist of predominantly eccentric muscle actions, especially if the exercise is unfamiliar. Although DOMS is likely a symptom of eccentric-exercise-induced muscle damage, it does not necessarily reflect muscle damage. Some prophylactic or therapeutic modalities may be effective only for alleviating DOMS, whereas others may enhance recovery of muscle function without affecting DOMS. OBJECTIVE: To test the hypothesis that massage applied after eccentric exercise would effectively alleviate DOMS without affecting muscle function. DESIGN: We used an arm-to-arm comparison model with 2 independent variables (control and massage) and 6 dependent variables (maximal isometric and isokinetic voluntary strength, range of motion, upper arm circumference, plasma creatine kinase activity, and muscle soreness). A 2-way repeated-measures analysis of variance and paired t tests were used to examine differences in changes of the dependent variable over time (before, immediately and 30 minutes after exercise, and 1, 2, 3, 4, 7, 10, and 14 days postexercise) between control and massage conditions. SETTING: University laboratory. PATIENTS OR OTHER PARTICIPANTS: Ten healthy subjects (5 men and 5 women) with no history of upper arm injury and no experience in resistance training. INTERVENTION(S): Subjects performed 10 sets of 6 maximal isokinetic (90 degrees x s(-1)) eccentric actions of the elbow flexors with each arm on a dynamometer, separated by 2 weeks. One arm received 10 minutes of massage 3 hours after eccentric exercise; the contralateral arm received no treatment. MAIN OUTCOME MEASURE(S): Maximal voluntary isometric and isokinetic elbow flexor strength, range of motion, upper arm circumference, plasma creatine kinase activity, and muscle soreness. RESULTS: Delayed-onset muscle soreness was significantly less for the massage condition for peak soreness in extending the elbow joint and palpating the brachioradialis muscle (P < .05). Soreness while flexing the elbow joint (P = .07) and palpating the brachialis muscle (P = .06) was also less with massage. Massage treatment had significant effects on plasma creatine kinase activity, with a significantly lower peak value at 4 days postexercise (P < .05), and upper arm circumference, with a significantly smaller increase than the control at 3 and 4 days postexercise (P < .05). However, no significant effects of massage on recovery of muscle strength and ROM were evident. CONCLUSIONS: Massage was effective in alleviating DOMS by approximately 30% and reducing swelling, but it had no effects on muscle function.
In 2007, in a survey of stretching/DOMS studies that looked at impact on soreness of massage, however, shows that the effects of stretching are very small (.5 on a 100 point scale)
Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004577.
Stretching to prevent or reduce muscle soreness after exercise.
Herbert RD, de Noronha M.

University of Sydney, School of Physiotherapy, PO Box 170, Lidcombe, NSW, Australia, 1825.

BACKGROUND: Many people stretch before or after (or both) engaging in athletic activity. Usually the purpose is to reduce risk of injury, reduce soreness after exercise, or enhance athletic performance. OBJECTIVES: The aim of this review was to determine effects of stretching before or after exercise on the development of post-exercise muscle soreness. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to April 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2), MEDLINE (1966 to May 2006), EMBASE (1988 to May 2006), CINAHL (1982 to May 2006), SPORTDiscus (1949 to May 2006), PEDro (to May 2006) and reference lists of articles. SELECTION CRITERIA: Eligible studies were randomised or quasi-randomised studies of any pre-or post-exercise stretching technique designed to prevent or treat delayed-onset muscle soreness (DOMS), provided the stretching was conducted soon before or soon after exercise. To be eligible studies must have assessed muscle soreness or tenderness. DATA COLLECTION AND ANALYSIS: Methodological quality of the studies was assessed using the Cochrane Bone, Joint and Muscle Trauma Group's methodological quality assessment tool. Estimates of effects of stretching were converted to a common 100-point scale. Outcomes were pooled in a fixed-effect meta-analysis. MAIN RESULTS: Of the 10 included studies, nine were carried out in laboratory settings using standardised exercise protocols and one involved post-exercise stretching in footballers. All participants were young healthy adults. Three studies examined the effects of stretching before exercise and seven studies investigated the effects of stretching after exercise. Two studies, both of stretching after exercise, involved repeated stretching sessions at intervals of greater than two hours. The duration of stretching applied in a single session ranged from 40 to 600 seconds.All studies were small (between 10 and 30 participants received the stretch condition) and of questionable quality.The effects of stretching reported in individual studies were very small and there was a high degree of consistency of results across studies. The pooled estimate showed that pre-exercise stretching reduced soreness one day after exercise by, on average, 0.5 points on a 100-point scale (95% CI -11.3 to 10.3; 3 studies). Post-exercise stretching reduced soreness one day after exercise by, on average, 1.0 points on a 100-point scale (95% CI -6.9 to 4.8; 4 studies). Similar effects were evident between half a day and three days after exercise. AUTHORS' CONCLUSIONS: The evidence derived from mainly laboratory-based studies of stretching indicate that muscle stretching does not reduce delayed-onset muscle soreness in young healthy adults.
THe findings of the survey seem to be confirmed in yet another massage oriented study that shows massage may somewhat mitigate perceived soreness, but not significantly, and there is no effect on the other key markers of ROM and swelling.
Chir Narzadow Ruchu Ortop Pol. 2008 Jul-Aug;73(4):261-5.
[Effects of massage on delayed-onset muscle soreness]
[Article in Polish]

Bakowski P, Musielak B, Sip P, Biegański G.

Studenckie Koło Medycyny Sportowej, Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu.

INTRODUCTION: Delayed onset muscle soreness (DOMS) is the pain or discomfort often felt 12 to 24 hours after exercising and subsides generally within 4 to 6 days. Once thought to be caused by lactic acid buildup, a more recent theory is that it is caused by inflammatory process or tiny tears in the muscle fibers caused by eccentric contraction, or unaccustomed training levels. Exercises that involve many eccentric contractions will result in the most severe DOMS. MATERIAL AND METHODS: Fourteen healthy men with no history of upper arm injury and no experience in resistance training were recruited. The mean age, height, and mass of the subjects were 22.8 +/- 1.2 years, 178.3 +/- 10.3 cm, and 75.0 +/- 14.2 kg, respectively. Subjects performed 8 sets of concentric and eccentric actions of the elbow flexors with each arm according to Stay protocol. One arm received 10 minutes of massage 30 minutes after exercise, the contralateral arm received no treatment. Measurements were taken at 9 assessment times: pre-exercise and postexercise at 10 min, 6, 12, 24, 36, 48, 72 and 96 hours. Dependent variables were range of motion, perceived soreness and upper arm circumference. RESULTS: There was noticed difference in perceived soreness across time between groups. The analysis indicated that massage resulted in a 10% to 20% decrease in the severity of soreness, but the differences were not significant. Difference in range of motion and arm circumference was not observed. CONCLUSIONS: Massage administered 30 minutes after exercises could have a beneficial influence on DOMS but without influence on muscle swelling and range of motion.
No change from any previous work on massage, not matter how frequently it's tested or from what angle it seems. And just to add some current studies to previous work, acupuncture doesn't help any factor:
Clin Physiol. 2000 Nov;20(6):449-56.
Lack of effect of acupuncture upon signs and symptoms of delayed onset muscle soreness.
Barlas P, Robinson J, Allen J, Baxter GD.

Physiotherapy Subject Group, School of Health and Social Sciences, Coventry University, UK.

The effect of acupuncture upon experimentally induced delayed onset muscle soreness (DOMS) was assessed in a placebo-controlled study under blinded conditions. Volunteers (n = 48; 24 M & 24 F) were randomly allocated to one of four groups: control (20 min rest), placebo (minimal needling at non-acupuncture points), treatment group 1 (acupuncture at classic acupuncture points) and treatment group 2 (acupuncture at 'tender' points). DOMS was induced in the elbow flexors of the non-dominant arm using a standardized eccentric exercise regime. Measurements of elbow range of movement (flexion, extension, relaxed angle), and pain as well as visual analogue scores (VAS), tenderness (using a pressure algometer) were employed as indices of treatment efficacy. Measurements of elbow range of movement and tenderness were made prior to DOMS induction on the first day, and repeated pre- and post-treatment on subsequent days; pain was assessed using visual analogue scales post-induction and post-treatment on the first day, and pre- and post-treatment thereafter. For all conditions, subjects rested supine for a period of 20 min, during which treatment was delivered according to group allocation. Repeated measures and one-way analysis of variance (ANOVA) demonstrated no significant interactive (AB) effects, except for visual analogue scores (P = 0.0483); one factor ANOVA on the second day of the experiment (pre-treatment) indicated significant differences between the control and all other groups. However, such differences were not found on any other day of the experiment. It is concluded that acupuncture has little effect upon the cardinal signs and symptoms of DOMS, at least under the conditions of the current experiment.
While the 2000 study seems to come up with a big fat zero, in 2008, two groups showed some relieve from DOMS pain associated with acupuncture. The second group looked at other DOMS factors like muscle force and confirmed earlier work: no effect.
Chin Med. 2008 Nov 25;3:14.
Effects of tender point acupuncture on delayed onset muscle soreness (DOMS) - a pragmatic trial.
Itoh K, Ochi H, Kitakoji H.

Department of Clinical Acupuncture and Moxibustion, Meiji University of Integrative Medicine, Hiyoshi-cho, Nantan, Kyoto 629-0392, Japan.

ABSTRACT: BACKGROUND: Acupuncture is used to reduce inflammation and decrease pain in delayed onset muscle soreness (DOMS). This study investigates the efficacy of acupuncture on the symptoms of DOMS. METHODS: Thirty subjects were assigned randomly to there groups, namely the control, non-tender point and tender point groups. Measurement of pain with full elbow flexion was used as indices of efficacy. Measurements were taken before and after exercise, immediately after treatment and seven days after treatment. RESULTS: Significant differences in visual analog scores for pain were found between the control group and tender point group immediately after treatment and three days after exercise

Really? Let's try that again, and not to put too fine a point on the null effect:
J Altern Complement Med. 2008 Oct;14(8):1011-6.
Effects of acupuncture on symptoms and muscle function in delayed-onset muscle soreness.
Hübscher M, Vogt L, Bernhörster M, Rosenhagen A, Banzer W.

Department of Sports Medicine, Goethe-University, Frankfurt/Main, Germany.

OBJECTIVE: This study was done to investigate the effects of a standardized acupuncture treatment on symptoms and muscle function in exercise-induced delayed-onset muscle soreness (DOMS). METHODS: A prospective, randomized, controlled, observer and subject-blinded trial was undertaken. Twenty-two (22) healthy subjects (22-30 years; 10 males and 12 females) were randomly assigned to three treatment groups: real acupuncture (deep needling at classic acupuncture points and tender points; n = 7), sham-acupuncture (superficial needling at nonacupuncture points; n = 8), and control (no needling; n = 7). DOMS of the nondominant elbow-flexors was experimentally induced through eccentric contractions until exhaustion. The outcome measures were pain perception (visual analogue scale; VAS; range: 0-10 cm), mechanical pain threshold (MPT; pressure algometer), and maximum isometric voluntary force (MIVF; force transducer). Treatment was applied immediately, 24 and 48 hours after DOMS induction. Measurements of MPT and MIVF were made prior to DOMS induction as well as before and after every treatment session. VAS data were acquired after DOMS induction as well as pre- and post-treatment. Final pain, MPT, and MIVF measurements were performed 72 hours after DOMS induction. RESULTS: Following nonparametric testing, there were no significant differences between groups in outcome measures at baseline. After 72 hours, pain perception (VAS) was significantly lower in the acupuncture group compared to the sham acupuncture and control subjects. However, the mean MPT and MIVF scores were not significantly different between groups. CONCLUSIONS: Although acupuncture seemed to have no effects on mechanical pain threshold and muscle function, it proved to reduce perceived pain arising from exercise-induced muscle soreness.
SO That's what doesn't work: massage, stretching, acupuncture, cool downs, vitamin C or NSAIDS.

In Part II we'll consider what does work. There is hope. There is technology, but especially, there is Heart (Rate).
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