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What Do We Know About Recovery Interventions For Delayed-Onset Muscle Soreness?

Understanding recovery interventions for delayed-onset muscle soreness involves exploring the intricate mechanisms that contribute to its development and persistence.

Alexander McCaslin
Jan 19, 2024388 Shares12932 Views
Studying recovery interventions for delayed-onset muscle soreness(DOMS) is crucial.
In the pursuit of physical fitness and athletic excellence, individuals often encounter the unwelcome companion of DOMS, which can:
  • impede performance
  • hinder training progress
  • even discourage individuals from maintaining an active lifestyle
Looking for recovery interventions may pave the way for enhanced post-exercise recuperation.


Since the pioneering work of Hough in 1902, the term “delayed-onset muscle soreness (DOMS)” has dominated the field of athletic recovery.
DOMS typically occurs after exercise-induced muscle damage (EIMD), particularly if the exercise is unaccustomed or involves a large amount of eccentric (muscle lengthening) contractions.
The symptoms of EIMD include:
  • temporary reduction in muscle force
  • disturbed proprioceptive acuity
  • increases in inflammatory markers both within the injured muscle and in the blood
There is also increased in muscle:
  • soreness
  • stiffness
  • swelling
The intensity of discomfort and soreness associated with DOMS increases within the first 24 hours, peaks between 24 and 72 hours, before subsiding, and eventually disappears 5 to 7 days after the exercise.
Consequently, DOMS may interfere with athletic training or competition, and several recovery interventions have been utilized by athletes and coaches in an attempt to offset the negative effects.
Although there has been a proliferation of research into the etiology of DOMS following EIMD, little is known regarding the effective management of the condition.
To reduce DOMS and augment recovery, recent systematic reviewsand meta-analyses have examined:
  • the benefits of using cold water immersion (CWI)
  • contrast water therapy(CWT)
  • stretching
  • hyperbaric oxygen therapy
  • compression garments
Two other interventions are currently being reviewed by the Cochrane Collaboration but have yet to be published. They are:
  • antioxidant supplementation
  • whole-body cryotherapy
Although the physiological and biochemical rationale for using many of these interventions remain elusive, elite athletes and coaches have incorporated them as part of their training and performance schedules.
Previous research has suggested the hydrostatic pressure experienced during both CWI and CWT may reduce inflammationby creating a displacement of fluids from the periphery to the central cavity.
Moreover, it has also been proposed that CWT and CWI could enhance recovery by:
  • altering tissue temperature and blood flow
  • aiding in the removal of waste products and muscle metabolites
Compression garments are purported to alter blood flow and create a pressure gradient that reduces the space for inflammation following EIMD.
In their study published in 2011 by Cochrane Database of Systematic Reviews, Robert D. Herbert, Marcos de Noronha, and Steven J. Kamper eloquently describe how the theory of the pain-spasm-pain cycle was incorrectly used in early investigations examining the justification for using stretching before and after exercise.
This theory, which has since been discredited, suggested that stretching the exercised muscle created a restoration of blood flow to the muscle to interrupt this pain spasm-pain cycle.
It is worth highlighting that one of the most commonly used outcome measures of athletic recovery is the subjective assessment of muscle soreness.
Therefore, all of these interventions have the potential to improve an individual’s psychological recovery following exercise, and the importance of this placebo effect should not be discounted.
Three of these reviews compared CWI, compression garments, hyperbaric oxygen therapy, and stretching to a passive or control (no) treatment.
Two of the remaining reviews compared CWI and CWT to active recovery, warm water immersion, and compression garments in addition to a placebo/control and the other treatment (i.e., CWT vs. CWI).
To study the efficacy of the treatments, these reviews have examined multiple outcome measures that are associated with recovery, including:
a. Objective measurements
  • strength
  • power recovery
  • functional performance
  • hematological markers of muscle damage
  • inflammation
b. Subjective measurements
The assessment of muscle soreness using a visual analogue scale or similar.
It has previously been suggested that exercise-induced hemoconcentration and/or hemodilution and alterations of tissue clearance can affect creatine kinase (CK) and myoglobin (Mb) concentration in the blood. Also, the relevance of using blood biomarkers to quantify the severity of EIMD has been questioned.
Therefore, the current editorial focuses predominantly on the recovery of soreness, strength, and power after the use of the different interventions.
There was a high degree of heterogeneitywithin the reviews in termsof the study design, including the:
  • treatment intervention
  • dosage
  • outcome measures
  • type of exercise
  • participants
Although a study published in 2013 by the journal PLOS One, the authors, with Francois Bieuzen as lead author, has previously noted that gender differences have been observed in serum CK activity, inflammatory cell infiltration and activation of protein degradation pathways following exercise, both male and female participants were included in these meta-analyses.
In addition, the classification of participants from sedentary to elite (untrained individuals experience greater levels of DOMS following exercise compared to their trained peers) made meta-analysis and interpretation of collated evidence difficult.
The following is a summary of the current evidence:

Muscle Soreness

Compared to a passive/control treatment, the following were effective in alleviating DOMS post exercise:
  • cold water immersion (CWI)
  • contrast water therapy (CWT)
  • compression garments
Two studies reported that muscle soreness was not significantly different after either CWI or CWT:
  • Cold-water Immersion (Cryotherapy) for Preventing and Treating Muscle Soreness after Exercise (2012), with Chris M. Bleakley as lead author and Cochrane Database of Systematic Reviews as publisher
  • Contrast Water Therapy and Exercise Induced Muscle Damage: A Systematic Review and Meta-Analysis (2013), with Francois Bieuzen as lead author and PLOS Oneas publisher
However, CWT tended to be better than warm water immersion.
Conversely, these two were ineffective in reducing muscle soreness:
  • stretching (before or after exercise)
  • hyperbaric oxygen therapy
In fact, some evidence suggests that hyperbaric oxygen therapy might actually hinder recovery from muscle soreness after laboratory-based eccentric exercise protocols.

Muscle Strength

CWI was not effective in improving the rate of recovery of muscle strength post exercise.
Pooled results tended to favor the passive condition in the immediate period following the treatment.
The use of these two appeared to have a positive effect on the recovery of muscle strength post exercise when compared to a passive treatment:
  • compression garments
  • contrast water therapy (CWT)
Moreover, Bieuzen and his fellow authors reported that two small studies found CWT more beneficial than CWI in strength recovery.
A study published in 2005 by Cochrane Database of Systematic Reviews, with Michael Bennett as lead author, reported no significant difference in strength between hyperbaric oxygen therapy and a control treatment while Robert D. Herbert and his fellow authors did not include strength as an outcome measure in the stretching review.


Rate of recovery of muscle power post exercise appears unaffected after either CWI or CWT compared to a control treatment.
Conversely, a study published in 2013 by the British Journal of Sports Medicine, with Jessica Hill as lead author, reported that the use of compression garments has a moderate effect on the recovery of muscle power following exercise.
Unfortunately, there were no data provided on power related outcome measures in the stretching or the hyperbaric oxygen treatment reviews.

Limitations And Future Research

These reviews have undoubtedly enhanced the evidence base and informed the sports medicine community regarding the management of DOMS.
However, we must recognize that the quality and strength of recommendations in a review are only as strong as the quality of studies that it analyzes.
All of the reviews discussed in this editorial have unanimously highlighted the brevity of high-quality randomized controlled studies that incorporated an adequate sample size.
These reviews have also indicated a risk of bias with respect to the:
  • blinding of the participants, personnel, and outcome assessors
  • allocation concealment in the existing studies
While it is worth acknowledging that blinding participants to the treatment provided in these studies is difficult, particularly those employing water immersion and stretching, future studies should endeavor to blind the assessors recording the post-treatment outcome measures.
Future research should also:
  • consider the use of an effective sham therapy
  • give careful consideration (and report) any adverse effects
  • examine the cost utility of the therapies being examined
The current evidence regarding the effect on DOMS, and subsequent recovery strategies, is predominantly derived from young healthy active males, and more research incorporating female and master athletes is warranted.
Finally, few authors have considered the impact of the chronic use of these recovery interventions, and research addressing the implications for over-training and training maladaptation is required.
Therefore, the quest for recovery interventions for delayed-onset muscle soreness should continue.
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