– Derek M. Hansen –
I am fortunate enough to speak with strength and conditioning coaches and performance directors from many sports on a weekly basis on their involvement with their teams. In-season preparations are some of the most interesting discussions, as all staff are scrambling to do anything and everything to get their players ready for the next game. This is certainly true in American football circles, where a combination of injury management, recovery protocols, strength maintenance, physiological readiness adjustments and tactical preparations are assembled in various manners to elicit an optimal performance on the weekend.
One question that has come up more recently is how to effectively integrate massage therapy into an in-season recovery and preparation schedule for American football. Massage therapy is typically considered to be a positive input given the perceived benefit from athletes. However, proper application for sport performance is somewhat of a mystery for many, particularly given the many commitments of players and support staff during a week of preparation. Frankly, I am surprised more teams are not employing a full compliment of manual therapists to work with teams in-season through the week of game preparation. When implemented appropriately, the benefits far outweigh the costs, particularly when teams are weighing the costs of having players sit out from week to week or perform well below their potential. I have accumulated experience on advising teams on how to best integrate all types of recovery techniques at the NBA, NFL and NCAA Division 1 levels and all situations present unique challenges. I am not a registered massage professional, but have worked closely with some very skilled professionals in an effort to maximize performances in both training and competition.
Most of this discussion will focus on preparations for American Football at the NFL and NCAA level. Football in these scenarios presents an interesting case study because of the relatively long duration between games (as opposed to basketball, ice hockey and baseball) and the significant output intensity and physical toll on game days. While the research on the benefits of massage for hastening recovery may be inconclusive, I know from personal experience that the readiness of athletes can be significantly enhanced by a skilled manual therapist.
Scheduling and Prioritization of Work
One of the most common questions I’m asked with regard to recovery and game preparation in relation to massage therapy in-season is, “When is the best time to do it?” Often, teams will have finite resources to bring in a group of therapists for a few times per week. Because they are eager to maximize the impact of their investment, they want to make sure the treatments are performed at the right time. Some feel that the best time for treatments is the day before a game, while others want to keep the sessions as far away from game day as possible. The answer is much more complex than simply when should a massage be provided. It is highly dependent upon the circumstances that are presented to the therapist and the method or methods they choose to employ.
Provided in Figure 1 below are sample weeks for pro and collegiate football teams, assuming that the pros are playing on Sunday and the college teams are playing on Saturday. In this particular example, I am using a “ramped up” game preparation approach where the intensity of work is double-periodized to peak mid-week, dropped down and then built up again to activate players for the game the next day (the vertical bars representing training load from practice and other training activities). As I mentioned in one of my previous articles, a ramped-up approach, assuming the right volumes are chosen, can enhance the readiness of a player heading into a game. In these figures, I have ranked the days and type of treatment from “1” to “6”, with “1” being the first priority. If you only had enough resources to dedicate to one day, then a deep tissue session no earlier than 48 hours after game day would be your first priority. Any sooner would not allow for enough recovery following an intense game, and any later would risk fatigue and soreness leading into the next game. However, a thorough manual therapy session would ensure that muscle fiber adhesions and any hypertonic muscle issues would be addressed appropriately. My second priority would be a circulatory massage of moderate intensity two days out from the game. Thirdly, I would have massage staff implement a stimulatory shaking or slapping massage one day before a game, prior to their training session, to assist with the ramping up of muscle tone and the nervous system prior to game day. The session would be short but active. Other sessions could be added to improve circulation, lengthen muscle and improve fascial extensibility if resources permitted. It is unlikely that six sessions would be employed, but it does provide some context for the type of work that could be done. As you can see, the number of aggressive sessions is limited because of the need to minimize tissue trauma and fatigue during the week. Regenerative and restorative approaches are much more common for in-season circumstances.
Figure 2 illustrates an alternative approach for a more traditional “tapered” game preparation week. The first priority will still be the deeper tissue massage 48 hours following the previous game day. A second priority is a circulatory massage later in the week 48 hours prior to game day. I’ve also added a game day stimulatory massage as my third priority to ensure players’ muscles are ”woken-up” for their pre-game warm-up. This can occur 3-4 hours prior to the game so that the actual pre-game warm-up does not require as much energy to achieve readiness. As with the previous example, most days will be of a lighter nature to enhance recovery and restoration.
It is important to note that the scenarios identified above depict an approach with relatively healthy players. There will always be cases where acute conditions must be addressed through what I would deem more aggressive and invasive, but skilled, techniques. If a player is having difficulty with achieving range of motion in a joint the day before the game, and the team and player deem that a more targeted approach is warranted, some of the guidelines I have identified may go out the window. Fatiguing a spastic muscle through an aggressive technique may be required, and the resulting fatigue may not be significant enough to negatively impact this player’s relative value to his team on game day. This is common with the quarterback position, where skill and recognition skills far outweigh linear speed and maximal strength. In these cases, an individualized approach to manual therapy must be applied at the discretion of the medical and performance staff, with full communication with the head coach, and relevant coordinators and position coaches.
Other Factors to Consider When Integrating Massage
When adding a massage program into your in-season preparations, there are number of other important factors to consider:
1. Skill and Experience of Your Massage Therapists
More experienced massage therapists with a high degree of skill will have greater latitude to perform more comprehensive and more aggressive treatments at various times throughout the week. It is assumed that experience manual therapists fully understand the impacts of their treatments and will make good decisions on treatment choices for each player they treat, ensuring close communication with medical and performance staff. Less experienced massage staff will have more strict guidelines for treatments, with the bulk of work being superficial and more circulatory in nature. It is not uncommon for sport teams to have massage school students helping with their large rosters. In these cases, explicit guidelines for treatments must be provided to ensure athletes are not put at risk.
2. Athlete History with Massage Treatments
A number of athletes on a given team will have more advanced experience with manual therapy than others. These athletes will have been exposed to more aggressive techniques and their muscles will have adapted and become accustomed to the treatment intensity and protocol. Thus, if an aggressive technique is required a few days before a game, the decision to go ahead with that treatment may heavily depend on the athlete in question. If the athlete has consistent experience with more aggressive techniques, a treatment in close proximity to a game may be warranted. An athlete with little to no experience with an aggressive technique may not respond with positive results. It would be similar to a strength training scenario. An athlete who is accustomed to squatting 500lbs in the off-season, would not be phased by a 375lb squat during an in-season maintenance program. However, putting 375lbs on the back of an athlete with a 400lb off-season squat personal best could be a recipe for disaster. The same loading parameters must be followed for manual therapy techniques in-season.
3. Therapist Familiarity with Your Athletes
A massage therapist that has been working with your athletes for the last few years will always be in a better position to make appropriate treatment decisions, all things being equal, than a person who is new to the team. Elite athletes can be like snowflakes – every one is different. A therapist’s knowledge of an athlete’s history and tissue tolerances is absolutely essential for optimal treatment results. If you have a rotating list of massage therapists and it is not guaranteed that the same therapists will be working with the same athletes in a given week, it is imperative that communication within the pool of therapists is close and comprehensive through both detailed charting and verbal communication. In addition, manual therapists must have a good relationship with the athletes they are treating. This does not mean that they need to establish a friendship with the athlete, but there should be a level of comfort and respect between parties that creates a positive environment.
4. Number of Therapists at Your Disposal
Having a large number of massage therapists on staff can be a benefit for a football team with 53 players. More players can be treated at any given time and a higher frequency of treatments can be had throughout the week. However, as with any team, the larger number of players, the greater the difficulty to keep track of their performance and keep them on the same page. I would say there is likely a critical mass for number of massage therapists in your pool, and this may vary from organization to organization. A team of 53 athletes should have five to six therapists in place for a given massage session so that athletes are not waiting too long to be seen. These may also involve some strategic scheduling and prioritization of athletes, with players with more pressing needs seen first in the queue. In any event, it is never a good idea to make professional athletes wait, as they will easily get restless, irritated and question the need to get a massage. I would suggest that teams have two full time therapists on staff for immediate needs, with other therapists brought on board on a contract or hourly basis to address larger team needs.
5. Coordination with Performance and Medical Staff
All athletic trainers and performance staff should be communicating in an ongoing capacity with the massage therapy team. Medical and performance staff can provide invaluable information to massage therapists on the current status of an athlete and the type, duration and depth of work deemed appropriate at any given time. Conversely, the massage therapy team can relay important information to coaching and performance staff on the status of an athlete’s muscle tone and overall fatigue levels. Such information may determine how much work an athlete can perform safely in the next practice or training session. It may also determine the progression of work through the week to prepare an athlete for the next game. Massage therapists and other manual therapists are an important means of gathering subjective data on the status of athletes, and teams may consider maintaining a database of therapist feedback for future reference and determining potential patterns of overuse and fatigue in specific muscle groups.
6. Be Cautious of Significant Changes in Mobility and Function
Earlier in my career, I had some involvement in working with NBA players and addressing significant soft-tissue restrictions, mostly lower body related. The treatments that were used with these athletes took them from being in pain with limited range of motion to having no pain and feeling more mobile than ever. However, when such treatments were done prior to a practice, game or even a game-day shoot-around, some of the feedback from players was concerning. Some players complained that while the treatments made them feel better, the changes negatively impact their shooting accuracy. Other players felt that their movement coordination on the floor was significantly thrown off kilter. As such, we developed guidelines for treatment that moved significant treatment sessions at least 24-32 hours away from a game, and 12-18 hours away from a lighter practice. We also integrated some movement drills post-treatment to re-orient the players with their new-found range-of-motion. I would suggest the same precautions be taken for all manual therapy techniques that effect significant changes in range-of-motion and reduced fascial restrictions. Elite athletes are like fine-tuned race cars that need to be re-calibrated before hitting the track at full speed again.
Many people will continue to debate the efficacy of massage for recovery. I am more in favor of lobbying for good practitioners rather than argue over whether or not massage, in general, is useful. A good manual therapist will be able to individualize treatments for each player, depending on that player’s immediate and specific needs. Once a consistent, trusting relationship is developed between the athletes and service providers, tremendous results can be achieved in-season. Teams that over-rely on ice, modalities and anti-inflammatory medication will not be getting the most out of their players week-to-week. The value of human touch and interaction with patients has been recognized for thousands of years. While this article provides some general insight into the scheduling of massage therapy sessions, I encourage all medical and performance team members to find the best fit for their situation based on available resources and the factors identified above.