Popular sporting literature such as health and fitness magazines, internet training, and sport sites as well as articles written by athletes, coaches, and physical therapists have endorsed the use of  techniques such as massage, hydrotherapy, and hyperbaric oxygenation as ways of speeding up the recovery process and thus improving athletic performance. However, the reality of this statement may be somewhat different to the thoughts and claims of these members of the athletic public.

There are two aspects to look at in critically assessing the value of such treatments:

  • Does a decreased recovery time actually equate to increased performance in an athlete’s chosen sport?
  • Do the aforementioned strategies actually lead to a decreased recovery period?

The initial question, whether or not decreased recovery times equal increased performance, falls outside the scope of this literature review. However, the author takes the view that a significant decrease in recovery time will allow an athlete to train with more volume or intensity while avoiding the negative effects of overtraining and as such can only be beneficial to an athlete’s performance if the training regime is specific to the skills required in the athlete’s chosen event.

The latter question—do the modalities of massage, hydrotherapy, and hyperbaric oxygenation actually speed up the recovery process—is the focus of this critical review, which is based on recent peer reviewed journal articles and textbooks.


Massage therapy has been utilized in sports for many years and has become almost standard practice for many athletes, especially those involved in contact or highly physical sports. So does massage actually decrease recovery times for athletes?

Many coaches, physiotherapists, massage practitioners, and athletes attest to the recovery related benefits associated with the use of post-exercise massage. Reaburn and Jenkins (1996) do as well, citing benefits such as increased blood flow, temporary flexibility gains, and psychological benefits. However, a large body of literature does not conclusively support these claims (Brooks, et al. 2005; Weerapong, et al. 2005; Sykaras, et al. 2003; Robertson, et al. 2004).

One possible reason for the lack of literary support from the literature given this treatment’s widespread popularity within sporting circles could be associated with the wide variance in the study methods used between researchers as well as the poor experimental control of many of the studies. There is also the difficulty of assessing which recovery variables should be measured and what performance outcomes should be used. Factors critical to the validity of these studies were often overlooked, and according to Robertson et al., included a lack of standardization of massage duration and warm-up regimens as well as basic inconsistencies in the work preceding the massage therapy (Robertson et al. 2004).

Several recent studies have lent support to the claims of enhanced recovery through the use of massage techniques. In a study utilizing elite female Tae Kwon Do athletes, Sykaras et al. (2003) showed that massage between sets of exercises significantly reduced the fatigue associated decrease related to peak isokinetic eccentric torque as measured using the Cybex Norm. However, this recovery benefit did not carry over to the athlete’s peak isokinetic concentric torque. Brooks et al. (2005) conducted a study into the effects of a five-minute forearm/hand massage between measurements of maximal grip strength. The results strongly supported the use of massage as opposed to either of the control techniques (passive range of motion and passive recovery technique) when maintaining grip strength is important. The applications of these findings could apply to a number of sports including rock climbing, powerlifting, wrestling, and racket sports.

In a well-controlled study, Robertson et al. (2004) looked at the effects of leg massage on the recovery of male athletes after high intensity cycling. They found no significant differences between blood lactate clearance times or the power generated (maximum and mean) by massaged or control (passive recovery) group athletes. They did, however, find significant support for massage as a technique for lowering the fatigue index.

Delayed onset muscle soreness (DOMS) is often cited by athletes as detrimental to their performance, although the mechanisms of DOMS and its effect on performance remain inconclusive. Some types of massage techniques are purported to reduce DOMS by increasing oxygenated blood flow to injured areas, thereby increasing recovery speed through various mechanisms including the restoration of calcium ion homeostasis and regulation of the inflammation process. Research on the effect of massage on localized blood flow rates has produced conflicting results (Cheung, et al 2003).

Zainuddin, et al. (2005) found that massage was effective at reducing DOMS and serum creatine kinase levels. However, this did not equate to decreases in the recovery time for muscular strength. This finding supports the use of massage in situations where the pain associated with DOMS is hindering performance rather than using massage to enhance the recovery of muscle function. Moraska (2005) briefly explored the possible psychological effects of massage and how these could be beneficial to athletic performance. The limited amount of studies cited suggests that this may be an area deserving further exploration.

In a review of the mechanisms of massage and its effects on performance and recovery, Weerapong et al. (2005) delineated the types of massage and their purported mechanisms and benefits to athletes. The authors summarized his findings stating, “There is no clear evidence that massage can actually improve performance, enhance recovery, or prevent muscular injury.”

Moraska’s literature review of sports massage perhaps best summarizes the findings of the available research literature in relation to massage stating, “Accurate interpretation of the sports massage research is made difficult by the large number of studies with methodological deficiencies” and that “better controlled research studies need to be conducted to confirm and extend the current understanding in this field.”


The use of water based modalities for recovery is certainly not a new practice, with the bathhouse being a regular part of life for ancient Romans. Despite this, Angie Calder, recovery and performance consultant at the Australian Institute of Sport, stated that this form of treatment is still very under-utilized in the Australasian region (www.nzrugbynet.co.nz).

Types of hydrotherapy include water based recovery sessions and thermal modalities such as hot pools, ice baths, and contrast baths. Reaburn and Jenkins (1996) stated that “these water therapies promote both physiological and neurological recovery.” So what does the research say?

Fahey and Romero (1991) stated that heated whirlpools or tubs are excellent places for the early phase rehabilitation of injuries when targeting range of motion and strength recovery. This is due to the buoyancy of the human body reducing impact as well as the ability to utilize the water to add resistance. Whether this applies to general recovery as opposed to the treatment of specific injuries was not mentioned. The authors stated that contrast water therapy (CWT) had been found to be extremely effective in treating edematous body parts such as sprained ankles due to the increased localized blood flow attributed to the alternating dilation and contraction of blood vessels. Again, whether this confers benefits in generalized recovery is not mentioned. However, in a recent study of elite male rugby players, Gill, Beaven, and Cook found that post-match, CWT facilitated a significantly faster recovery of creatine kinase levels than a passive recovery mode. There was no significant difference between CWT recovery rates and those achieved by utilizing a post-match active recovery session or post-match use of compression garments. Given the cost of the contrast baths, many athletes and coaches may opt for the cheaper options of active recovery or compression garments to achieve similar results.

In his 2004 review article, Cochrane found there was very little research on the effects of post-exercise CWT on recovery times for athletes. Often, research data from CWT use in treating acute injuries was used to support its use for athletes as a recovery method. After reviewing the literature surrounding hydrotherapy treatments in relation to athlete recovery times, it is clear that more well-controlled research is needed before it is possible to extol the virtues of these modalities as viable treatments to enhance recovery.

Hyperbaric oxygenation

Hyperbaric oxygen therapy (HBO) is the inspiration of 100 percent oxygen while the body is subjected to increased atmospheric pressure, which has the effect of hyperoxygenating the tissues. HBO is used as a treatment for a number of medical conditions including carbon monoxide poisoning, “the bends,” and soft tissue injuries. HBO acts primarily to reduce localized tissue hypoxia while reducing edema through vasoconstriction. A growing number of professional sports teams including the National Hockey League, the National Football League, and the National Basketball League have also began to utilize HBO as an injury recovery technique (Babul and Rhodes 2000).

One suggested application of HBO is to increase the rate at which lactate is removed from exercised muscles because this has been proposed to decrease muscular fatigue. In a study testing lactate clearance times, Kay, et al. (2005) found no significant differences between passive recovery with 100 percent oxygen and passive recovery with ambient breathing

A study involving the recovery from injury for professional soccer players suggested a 55 percent decrease in recovery time for those athletes utilizing HBO. However, this study was highly subjective in nature relying on a physiotherapist’s estimation of injury recovery time versus the reality of recovery time (Babul and Rhodes 2000). Other studies have produced conflicting results. Two such studies looked at the recovery from ankle sprains. The first suggested a 30 percent faster return to normal function (Potera 1995) while the second showed no significant difference between the HBO group and the control group (Borromeo, et al. 1997).

In a study focusing on recovery from DOMS, it was found that HBO treatment significantly increased recovery rates for eccentric strength, although there was no effect on the pain associated with DOMS (Staples 1996 cited in Babul and Rhodes 2000). These findings were contradicted in a subsequent study, which found that HBO was ineffective in the treatment of muscle damage as determined using magnetic resonance imaging, creatine kinase levels, perceived soreness measures, and strength testing (Harrison, et al. 2001).

Delaney and Montgomery (2001) reviewed a different aspect of the use of HBO—the use of HBO prior to competition as an ergogenic aid. They stated that “it is difficult to rationalize how prior HBO could enhance performance. Tissue retention of oxygen is unlikely because tissue autoregulation reduces O2 levels upon return to a normobaric, normoxic environment.” In summarizing current literature, it seems that the research surrounding the use of HBO to decrease recovery time and enhance athletic performance is shaky at best. Further, well-controlled studies are needed to establish whether or not HBO should become part of every elite athlete’s routine.

Elite and aspiring athletes are constantly on the lookout for the “winning edge” and often resort to methods that may confer some benefit without actually being scientifically proven. The use of massage, hydrotherapy, and hyperbaric oxygen therapies can be viewed in this light. There is not enough evidence from well-controlled studies of significant sample size to support or refute the use of such modalities in regards to improving recovery times and enhancing the athlete’s performance. The blood variables seem to be too transient to provide a clear picture, and future studies may wish to investigate anti-inflammatory markers that may be better indicators of recovery.

Given these findings, athletes should be wary of investing time and money into such therapies in an attempt to obtain faster recovery. There are, however, enough findings supporting the possible benefits of these treatments to warrant further research to clarify the role and effectiveness of massage, hydrotherapy, and hyperbaric oxygen therapies in relation to recovery.


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