Any time someone sustains an injury it generally goes through three stages of tissue healing. In general, massage is very effective for treating many injuries in conjunction with exercise rehabilitation.
Massage therapists take a remedial exercise course during their study of massage therapy. This is great as it helps them work with fitness and strength training professionals for injury rehabilitation.
I will look at the benefits massage therapy provides for exercise for each stage of tissue healing.
As a reminder here are the three phases of tissue healing:
- Acute (inflammatory reaction/protection phase)
- Sub Acute (repair and modeling/controlled motion)
- Chronic (maturation and remodeling/return to function).
The key here is to understand what is happening at the cellular level in order to provide the proper massage techniques followed by the appropriate exercise.
Acute Stage – #1
In the acute phase the inflammatory reaction occurs. Typical signs and symptoms of this stage may be remembered by the acronym S.H.A.R.P. This stands for swelling, heat, altered function, redness and pain.
On a functional level there is pain before tissue resistance. This usually occurs at the beginning of range of motion. Chances are your client does not want to move that injured area at all. And if they do it will be very limited.
The most common approach at this stage is RICE:
Massage therapy helps to maintain and increase blood and lymph circulation thereby decreasing the amount of swelling. This allows for clearing of the waste products caused by the inflammatory process.
Massage will also help to decrease the tension in any compensating muscles in that area or on the opposite limb. This makes it easier for you to give exercises in the acute stage. Furthermore, massage therapy also provides a psychological boost to the tissue healing process.
You can perform pain-free passive range of motion and muscle setting, or low intensity isometric resistance exercises to help maintain current range of motion and strength.
Pain-free grade one or two joint play may be performed as well. This is important because you want to maintain the movement between joints to allow for full range of motion later in the healing process.
As a friendly reminder, caution must be taken to avoid any sharp pain as this indicates tissue damage. The last thing you need is for your client to have a longer than anticipated recovery from injury.
Sub Acute Stage – #2
The next stage is the repair and healing stage. The key in this stage is to promote healing and develop mobile scar. As there is collagen formation, the tissue is fragile and easily injured.
Massage therapy is very effective in this stage for promoting circulation to the affected area, providing the appropriate nutrients for tissue healing. Massage is also beneficial for treating compensating muscles, increasing range of motion and decreasing pain.
Again massage is effective for treating the areas above and below the injury.
Massage prepares the muscles in this stage for open and closed chain exercises as well as muscular endurance exercises.
These exercises can progress in intensity and range. Again both range of motion and resistance exercises must be done pain- free.
Joint play is effective for working within a pain-free range. It is important to remember that if the joint is “stuck”, building strength through a full range will be challenging and you will also be setting your client up for another injury.
In this stage pain occurs simultaneously with tissue resistance.
It is also a “grey” area for treatment and exercise. If both the massage and the exercise are too aggressive your client may end up back in the inflammatory stage.
It is fine for your clients to work with a little discomfort. I draw the line with sharp pain.
If the massage and exercise are not adequate, there will be an increase in misaligned scar tissue leading to a decrease in range of motion and delay in tissue healing.
Generally any type of massage technique must be pain-free. Effectiveness of the massage treatment is dependent on the communication between client and therapist.
At the beginning of this stage you can start with sub maximal multi-angle resistance isolation exercises and assisted range of motion, and progress to full body resistance exercise and self-stretches.
Simple static proprioceptive and balance exercises may be included in this stage, leading to more dynamic and functionally integrated exercises towards the end of this stage, and finally leading to return to function.
Chronic Stage – #3
Next, in the chronic or return to function stage there is maturation of connective tissue, contracture of scar tissue and remodeling of the scar.
Massage is extremely beneficial both before and after exercise.
Generally there is an absence of inflammation and pain occurs after resistance.
Massage therapy is an effective tool at this time to help the individual reach full range of motion.
Massage prepares the body for any type of intense rehab/training
At this stage in the tissue healing process, the massage therapy techniques tend to be deeper and more aggressive. Techniques such as transverse friction, grade 3 or 4 joint play, muscle stripping and myofascial release manipulate the quality of tissue to prepare for more comprehensive exercises for tissue healing.
These techniques help with aligning collagen fibers and developing functional independence, and to improve the tissue quality.
Pre-exercise massage may be included as part of the warm up.
Resistance exercises progress from sub maximal multi-angle isometrics to concentric, eccentric and plyometric.
Total body, functional or activity related exercises are appropriate in this phase of injury recovery.
Post exercise massage is effective for recovery. I would recommend post massage one to two hours post exercise.
The benefits of post massage are:
- Improved circulation
- Muscular relaxation
- Separation of muscle from connective tissue
- Formation of healthy scar tissue and connective tissue normalization
- Deactivation of trigger points
In closing, injuries go through three stages of tissue healing in which a combination of massage and exercise is extremely beneficial for a quick recovery.
Treatment and exercises start with isolation and gradually progress from isolation to total body or functional integration.
As a fitness or strength training professional it is always great have contacts in the field of massage therapy as both your clients and you can benefit personally and professionally.
Mike Grafstein B.Ph.Ed, CAT©, RMT
Mike has certification as an Athletic Therapist in Canada and registration as a Massage Therapist in the province of Ontario.
He has held the position of Head Therapist for the Ontario Soccer Association, Soccer Academy Alliance of Canada (SAAC) and Bryst International.
He has traveled internationally with soccer performing treatments in many different foreign settings.
Currently he is a senior instructor and clinic supervisor at Bryan College – North York Campus faculty of Massage Therapy and Hydrotherapy where teaches physiology and remedial exercise.
He practices massage therapy at Upper Canada Sports Medicine in Newmarket, Ontario.