There are a number of different types of treatments and recovery strategies South African rugby players and teams use whilst training to lower their risk of sports injuries.
These are some of the most common and the research surrounding them.
Cryotherapy is a term which describes a range of therapeutic treatments aimed at lowering tissue temperature by the withdrawal of heat from the body. Treatment can be applied either in the form of ice packs, ice massage, ethyl chloride, cold air, or cold water immersion.
These treatments have a long history in medicine, with their use ranging from the removal of warts, to more conventional applications aimed to reduce swelling after tissue trauma, and the treatment of pain.
More recently, it has been used as an ergogenic aid, as whole-body immersion in cold water before exercise in the heat has been associated with an improvement in performance.
Various forms of cryotherapy are used as an intervention for post-exercise recovery, particularly after exercise which raises body temperature, and causes inflammation of muscles.
The basis for using cryotherapy is on the assumption that it is effective in decreasing metabolic rate, inflammation, blood flow and skin, muscle and intra-articular temperatures.
Cryotherapy increases pain threshold and pain tolerance possibly as a consequence of a significant decrease in nerve conduction velocity. However, prolonged exposure to cold may have negative effects, from a recovery perspective, because blood flow increases in the muscles when the muscle temperature reaches about 10° C.
Furthermore, the permeability of the lymph vessels increases at prolonged low temperatures, resulting in increased subcutaneous swelling.
2. Contrast temperature therapy
Contrast temperature therapy consists of alternative cold and hot treatment through contrast temperature baths or warm and cold packs.
The mechanism of action is however unclear as studies have shown that contrast therapy had little effect on deep muscle temperature. Therefore the theory that the effects of contrast therapy can be attributed to fluctuations in tissue temperature is not founded on experimental evidence.
The data supporting the efficacy of this therapy is equivocal. For example, 20 rugby players performed a repeated sprint test and then were either allocated to a contrast temperature water therapy or active recovery.
The therapy consisted of three one-minute immersions in cold water (8 - 10°C) up to hip height, alternated with three one-minute hot water (38°C) showers.
The active recovery consisted of six minutes of slow jogging. The contrast temperature group had a decrease in blood lactate concentration three minutes after the procedure and also had lower heart rates after the procedure and later when the subjects did a further set of exercise. There were no meaningful differences in sprinting performance one hour after either recovery treatment.
Another study has also shown a reduction in plasma lactate after intense exercise, following contrast water immersion.
Although recommendations have been made about the ratio of warm to cold exposure and duration of treatment, there is a lack of scientific evidence to support the efficacy of any of these combinations. At best it can be said that any protocol involving contrast temperature therapy is based on anecdotal experience.
Massage is widely used by athletes to prepare for exercise and accelerate recovery from training and competition. Data collected from 12 major national and international athletic events between 1987 and 1998 showed that physiotherapists spend between 24% and 52% of their time using massage.
The premise upon which massage treatment exerts its effects are thought to be through decreasing oedema and reducing pain, enhancing blood lactate removal, and promoting healing by increasing muscle blood flow.
These proposed mechanisms are not always supported by the scientific evidence, suggesting that the effects may be psychological. Some studies have found that massage does not reduce symptoms of muscle pain.
Other studies have found to the contrary. For example, ten healthy subjects performed eccentric exercise of the elbow flexors designed to induce muscle soreness.
The arm which underwent exercise received 10 minutes of massage therapy three hours after the exercise.
Massage was effective in reducing inflammation and the symptoms of pain by 30% but it had no effect on muscle function. These results show once again that pain and muscle function are disassociated and that muscle pain should be used with caution as a clinical marker of how a muscle has recovered.
It is understandable why the results of the studies that have used massage to alleviate symptoms of muscle damage are quite varied. This can be explained because there are many different types of massage therapy, while therapy duration and frequency can also influence the results.
Furthermore, it is quite difficult to do a completely blinded study using massage as an intervention therapy, making the results difficult to interpret.
A review of all the published studies on massage showed that most studies contain methodological limitations, including inadequate training of the massage therapists, insufficient duration of treatment, too few subjects in the experiment, or over- or under-working of muscles that limits the practical conclusions which can be derived.
However, it may be concluded from all these studies that generally muscle soreness arising from delayed-onset muscle soreness (DOMS) is reduced with massage.
The main goal of stretching is to increase the range of motion around joints. The data showing that this indeed occurs is convincing.
Stretching is commonly advocated as a technique for reducing the risk of injury although the research does not necessarily support this. The evidence supporting stretching as part of a recovery protocol is less convincing. A mechanism by which stretching may enhance the recovery process has yet to be identified.
Furthermore, there do not appear to be any studies that have investigated the effect of stretching between exercise sessions/matches on performance during post-recovery exercise/competition.
Stretching exercises have been shown to be ineffective in reducing the symptoms of muscle damage.
A comprehensive review of studies which had used stretching after exercise (total stretching time ranging from 300 to 600 seconds) with the goal of reducing muscle soreness, showed that 72 hours after exercise, pain had only reduced by 2%, which was not regarded as meaningful.
5. Compression gear
Compression is a therapeutic technique whereby external compression is applied following exercise or an injury.
The theory behind this modality suggests that the external pressure reduces oedema by creating an external pressure gradient, thereby reducing the efflux of fluid from capillaries. Furthermore, the space available for fluid leakage is reduced, minimising haemorrhage and haematoma formation.
Certain types of compression treatments involve a dynamic immobilisation that reduces movement during the recovery process. Although the evidence for the efficacy of this treatment was largely anecdotal, recent studies suggest that compression can be effective in minimising swelling, improving the alignment and mobility of soft issue, and improving proprioception in an injured joint.
The only study on compression garments and recovery from rugby showed that the players who wore lower-body compression garments for 12 hours after the match showed similar signs of recovery (defined by clearance of creatine kinase from transdermal exudate) to players treated with active recovery and contrast temperature water immersion.
All these treatments were better than no treatment at all.
Unlike cold therapy, which should be applied intermittently, compression treatment should be applied constantly for at least 72 hours. Furthermore, it is important that the pressure of the compression garment does not exceed diastolic pressure, which is about 40 to 60 mmHg for the upper limbs and 60 to 100 mmHg for the lower limbs.
If the pressure exceeds these values, blood flow will be impeded.
Ideally, the garment should create a distal to proximal pressure gradient to facilitate the removal of metabolites from the periphery towards the central circulation. This encourages fluid to move away from the high-pressure areas (site of injury) to the lower pressure areas.
The commercial production of garments with these characteristics, designed to fit both the upper and lower body, has popularised this form of recovery treatment among rugby players.
6. Active recovery
Active recovery enhances the removal of high levels of circulating lactate. However the link between high levels of circulating lactate and impaired muscle function is dubious.
It follows then that if active recovery has beneficial effects, the mechanism of action is then through other mechanisms.
Despite the lack of understanding of the mechanisms of active recovery, there are several studies which show that this method has some positive effects.
For example, a recent study on rugby players showed that recovery rates (using creatine kinase in transdermal exudate as a marker) were similar for active recovery, contrast temperature water immersion, and wearing lower-body compression garments – and were significantly better than passive recovery.
However, not all studies show that active recovery has a beneficial physiological effect.
Active recovery needs to be an integral part of the training programme and implemented immediately after a training session (cool down), or after a match. Active recovery can also be structured into the programme on days of “easy” training. Active recovery needs to incorporate aerobic-type activity with stretching exercises included.
The activity should be of a sufficiently low intensity as to not induce further fatigue, but also assist with a psychological recovery, particularly after a tense match.
Active recovery should always be performed in a non-competitive environment. A popular form of active recovery, particularly the day after a match, is a pool session.
There are compelling reasons for embarking on a rehydration and refuelling strategy immediately after a training session or match. The basis for this started over 40 years ago when it was shown that exercise performance (moderate to high intensity) is related to muscle glycogen availability and that fatigue during such an activity is often associated with a depletion of muscle glycogen.
It can be assumed that muscle glycogen decreases during a rugby match, and that for complete recovery these stores need to be replenished.
There is evidence to suggest that ingesting carbohydrates immediately after exercise results in higher glycogen levels six hours later compared to if the carbohydrate was only ingested two hours after exercise.
Muscles that are damaged from the exercise do not restore their glycogen as efficiently as undamaged muscles, possibly as a result of transient insulin resistance.
There is evidence to suggest that exercise capacity will be restored more effectively when a mixture of carbohydrate and protein is ingested during recovery, compared to the same amount of carbohydrate alone.
Further studies are needed to develop more definitive guidelines on the recommendations of ingesting carbohydrate and protein immediately after exercise, as the results seem to be influenced by the magnitude of muscle damage.
Excessive alcohol consumption during the evening following a rugby match may have some detrimental effects on peak power and cognitive recovery the next morning.
Another reason for avoiding alcohol in the acute period after a match or training session is that alcohol promotes diuresis, which will delay rehydration.
The relationship between sleep and recovery after exercise, particularly relating to performance, is receiving more attention as the link between sleep cognitive function and metabolic function becomes better understood.
It has been recommended that athletes should have at least seven to nine hours of sleep a night. Based on the understanding of sleep and how it contributes to recovery and restoration, there is reason to believe that “power naps” during the day will be beneficial for a rugby player.
Research has shown that “power naps”, defined as a brief period of daytime sleep lasting less than an hour, improves alertness, productivity and mood, and may contribute to consolidating learning and improved performance of tasks involving visual discrimination.
9. Non steroidal anti-inflammatory drugs (NSAIDS)
NSAIDS relieve pain and have anti-inflammatory properties. These properties make them an attractive modality for the treatment of athletes after training and competition to possibly enhance recovery, and are the most widely used medications for treating muscle injury.
Studies on strains and contusions suggest that the use of NSAIDS can result in a modest inhibition of the initial inflammatory response and the associated symptoms. However, the inhibition of the biological steps may cause negative effects later in the healing phase.
Many studies have examined the acute affects of NSAIDS on muscle injury and the diverse findings suggest that NSAIDS have a dosage-dependent effect that may also be influenced by the time of administration.
Animal studies suggest that whilst NSAIDS may have a short-term positive effect on muscle repair, the long-term effects (four weeks) may be negative and associated with ineffectual or delayed muscle regeneration.
SA Rugby: Recovery techniques and practical guidelines by Professor Mike Lambert and David Van Wyk; Division of Exercise Science and Sports Medicine. Reviewed by Professor Mike Lambert (September 2015)