Recommendations from a leading sport scientist

We pride ourselves on the scientific integrity of Isobar compression garments. Dr Jonathan Leeder (Lead Physiologist British Cycling, and Lead Physiologist and Lab Director at English Institute of Sport) has weighed up the scientific evidence on compression garments for us. He comments on the following 7 topics:  

1. Recovery – What is it and why is it important?

2. How can compression garments enhance recovery?

3. What is the evidence that compression garments work for athletes?

4. Compression versus other recovery techniques

5. Specifics of the Isobar compression garment

6. Recommendations for using compression garments

7. Travel

 

 

1. Recovery – What is it and why is it important?

It is well established that to get to better at your sport, you need to train. Training places a stress on the body, and given adequate recovery, the body will positively repair and adapt to that session (Figure 1). If the balance between training and recovery is optimal, super-compensation occurs and performance levels improve. Decades of research have focussed on optimising training, yet without sufficient recovery, training gains will not occur. By focussing effort onto recovery, it is possible to recover faster, potentially enabling greater volumes/intensities of training, leading to greater performance gains.

Figure 1. Graph showing the basic pattern of stress, recovery and adaptation. Source: www.strengthrunning.com


Figure 1. Graph showing the basic pattern of stress, recovery and adaptation. Source: www.strengthrunning.com

Whether you are a marathon runner, a rugby player or a swimmer, you will have experienced the sensation of pain in the days following hard training sessions or competitions. This is frequently termed ‘delayed onset muscle soreness (DOMS)’ and is the result of ‘exercise-induced muscle damage (EIMD)’[1-3]. Whilst it might not feel like it, EIMD is an athlete’s friend, as it is part of the stress that causes the body to adapt. DOMS isn’t the only symptom of hard training, athletes also experience short term reductions in muscular function, swelling of damaged muscles and reduced range of movement[4].

The cause of EIMD and DOMS is highly specific to the type of exercise and its intensity/duration. EIMD is predominantly caused by ‘eccentric muscle contractions’, which is when the muscle lengthens whilst still under tension[5, 6]. For example when exercising in the gym, the down phase of a squat places extreme loads on a variety of muscles of the leg as they lengthen. This mechanical tension causes micro damage at a cellular level in the muscle/tendon. To repair this damaged tissue, the body’s natural repair system (the inflammatory response) is activated. It is the inflammatory response which causes swelling around the damaged areas and concomitantly places pressure on pain receptors, hence the feeling of DOMS. This is not a bad a thing, as it is an essential part of the body repairing itself. Clearly the load of the squat and the number of reps will directly influence the magnitude of EIMD, and hence the level of DOMS in the days following. 

Running is a sport commonly associated with EIMD and DOMS[7]. Whilst the eccentric loads in running are considerably less than lifting heavy weights, the number of eccentric contractions experienced by the legs is considerably more. Runners commonly run ~180 strides per minute, which over 2 hours, would equate to over 20,000 eccentric contractions collectively. This a mechanical stress, however another source of stress exists called ‘metabolic stress’[1].  EIMD caused by metabolic stress in long duration exercise is due to ‘oxidative stress’. This is a highly complex system related to energy metabolism but, in brief, as exercise intensity increases, highly damaging ‘reactive oxygen species’ are released as an essential component of energy metabolism. During exercise, damage to muscles will occur if there is an imbalance between the body’s anti-oxidant system and the level of reactive oxygen species released[8]. 

Sports such as cycling and swimming fall under the category of metabolic stress more than mechanical stress as the number and load of eccentric contractions is very low (non-weight bearing), yet metabolic stress can be very high when exercising at high intensities and high volumes. Field sports such as football, hockey and rugby are associated with high levels of mechanical stress due to the frequent high speed changes of direction and decelerations[9], and also a high metabolic stress due to the high intensities and long game durations[10]. An additional form of stress in contact sports such as rugby are contusions, which are caused in a very different way, yet still add to the feeling of DOMS in the days following an intense training session or competition.

In summary, the type and severity of exercise determines how long it will take the body to recover. As the next sections describe, compression garments are potentially able to increase the rate of recovery compared to just resting alone. This is however on the assumption that athletes are sleeping, eating and hydrating adequately. 

 

 

2. How can compression enhance recovery?

Compression garments have 3 main mechanisms to help athletes recover[11-13]:

  1. Following EIMD, the inflammatory response causes swelling around the damaged area, which in turns place pressure on pain receptors. Compression garments are believed to reduce swelling by stimulating lymphatic outflow and transporting fluid from the muscle back into the blood. This will reduce the amount of pain athletes feel in the days following hard training, and potentially increase how fast they can return to training.
     
  2. Compression garments are well established to increase blood flow (venous return) in the lower legs. The importance of blood flow in recovery cannot be overstated. When a short turnaround between rounds in competition is required, increasing blood flow can remove certain muscle metabolites which are associated with reduced performance (pH, H+, lactate and K+). 
     
  3. Athletes often have to travel, which is a form of stress in itself. Compression garments are able to reduce the magnitude of lower leg swelling and discomfort following long haul travel, hence enabling athletes to recover faster from the flight, and get back into training faster than if they wore no garments.
 

 

3. What is the evidence that compression garments work for athletes?

A plethora of research has focused on the effectiveness of compression garments to manage clinical conditions such as DVT. However it is only in the last 10 years that research has focused on the effectiveness of compression garments in sport (Figure 2). 

Figure 2. Number of publications per year found in PubMed database that include the terms ‘compression + garments + sport’.


Figure 2. Number of publications per year found in PubMed database that include the terms ‘compression + garments + sport’.

There is a considerable mixture of results. Some studies show very positive effects of compression garments on recovery, yet others show no effect at all. The most scientifically valid way to make an evidence based opinion about the effectiveness of any intervention is called a ‘meta-analysis’. This process collates all the research data together to increase the sample size, enabling a higher powered statistical inference[14]. 
A recent review [13] has collated all of the scientifically peer reviewed data on the effectiveness of compression garments (Table 1). The main findings were:

  • The study collated research from 12 studies, which included a total of 205 athletes, average age 22 years.
     
  • The research utilised a range of brands of compression garments and exercise types.
     
  • The study measured recovery markers of DOMS, muscle strength, muscle power and creatine kinase (CK; blood based marker of muscle cell damage)
     
  • Conclusion: ‘The use of compression garments appears to reduce the severity of DOMS, accelerate the recovery of muscle function and attenuate the concentration of CK following strenuous exercise’. These findings indicate that wearing a compression garment may improve recovery following intense training and competition; this has implications for both elite athletes and recreational populations.
     

Table 1. Summary table from Hill et al (2013) of studies included for systematic review.

Figure 3. below shows the data collated from the 12 studies measuring DOMS. Called a ‘forest plot’, it shows each individual study and each time point post-exercise it measured DOMS compared to a control group. If the square data points fall to the right of the centre line, it suggests the average of the group favoured wearing compression garments compared to control. As with any research, there is some variance associated with the response of the group, depicted by the lateral line which crosses through the square. The summary of all the studies is the diamond at the bottom, which in this case, defines scientifically that compression garments had a ‘moderate’ statistical effect on reducing DOMS.

Figure 3. Forest plot taken from Hill et al (2013) illustrating DOMS responses.


Figure 3. Forest plot taken from Hill et al (2013) illustrating DOMS responses.

 

 

4. Compression versus other recovery techniques

It is recognised that a range of recovery strategies exist that are available to athletes[15-17]. Whilst there are pros and cons to all of these, there is little gain from using such strategies unless athletes are getting sufficient sleep and appropriate nutrition for their sport. An athlete who is training hard, but not refuelling and sleeping poorly will eventually burn out[18], irrespective of whether they utilise additional recovery strategies. Once these basics have been achieved, further performance gains can be sought from using targeted recovery strategies.

The most popular recovery strategy used by athletes in general is hydrotherapy, in the form of contrast bathing or ice bathing[19, 20]. These strategies have been in use for many years, hence specific research investigating the effectiveness is fairly substantial. The mechanisms of how ice baths are purported to work are opposite to that of compression garments. When an athlete immerses in an ice bath, the temperature of the muscle drops and blood flow is reduced[21]. This is suggested to reduce the magnitude of the inflammatory response immediately after exercise. However two recent meta-analyses have shown the predominant effect of water immersions is to reduce the perception of soreness, and had limited effect on functional recovery, suggesting the placebo effect may be responsible[19, 20].

An additional concern to exercise professionals is the effect some recovery strategies, namely ice baths and anti-inflammatory medication, have on the adaptive response to training. As alluded to in the first section, the stress of training is what causes the body to adapt over time. If the magnitude of that stress is blunted too much by a recovery strategy, it is possible the positive adaptive responses may be reduced. There is a growing body of evidence to support this view[22-24], however further evidence is required before any firm conclusions can be made.

Currently only compression garments and hydrotherapy have sophisticated meta-analyses supporting their use[13, 19, 20]. Although commonly adopted by athletes, there is very little evidence to support stretching or active warm downs to aid recovery[1]. Given the logistical convenience of utilising compression garments, and the fact there is no evidence that they have negative effects on adaptation, compression garments are a highly ranked strategy for recovery for athletes [17]. For a review of a range of recovery strategies, see Howatson et al (2008).

 

 

5. Specifics of the Isobar compression garment

From an applied sports science perspective, there are two main pro’s of the Isobar garment:

  1. The 3D scan guarantees a perfect fit and;
  2. The garment provides an effective level of compression to reduce venous transit time and reduce leg volume 

At a consumer level, this is reassuring as you know the garment will fit well (particularly if athletes are not considered of ‘normal’ anthropometry) and will provide effective compression. 

 

 

6. Recommendations for Using the Garment

Below are some guidelines describing how to use compression garments in a few different situations that many athletes will associate with.
 

Competing twice in one day

In situations where athletes are required to perform twice in a day (competitions or double training days), athletes are recommended to do the following:

  1. Upon finishing exercise, athletes should complete usual warm down activity. This will often involve light exercise and stretching
     
  2. During this period, athletes should commence nutritional recovery specific to the demands of their training. This will often comprise of carbohydrate, protein, electrolyte and rehydration.
     
  3. In the time between completing the warm down from session 1 and starting to warm up for session 2, compression garments should be worn.
     
  4. Increased blood flow can aid nutrient delivery to assist in replenishing the muscles, and also assist in removal of muscle metabolites that could have negative implications for the second session. Compression could manage any swelling induced from muscle damage from the first session.
     

Greater than 24 hours until next needed to train/compete

  1. Upon finishing exercise, athletes should complete usual warm down activity. This will often involve light exercise and stretching
     
  2. During this period, athletes should commence nutritional recovery specific to the demands of their training. This will often comprise of carbohydrate, protein, electrolyte and rehydration.
     
  3. If the session was highly damaging / intense, athletes should aim to ice bath. This may reduce the magnitude of the initial damage. This should be completed within 2 hours of exercise.
     
  4. Upon leaving the ice bath, muscle temperature and blood flow continue to stay reduced for at least 1 hour [21]. During this time compression garments should not be used as they could have the opposite effect.
  5. 1 hour after the ice bath, compression garments should be worn. These should be worn for up to 72 h following the damaging exercise bout. 
     
  6. Compression can and should be worn when you sleep. This should be trialled before wearing garments during a competition, just to ensure sleep disturbance doesn’t occur as a result of the garment. 
     
  7. Compression garments can be worn 24/7 for up 3 days after the exercise bout to aid recovery.
 

 

7. Travel

Whilst it is always possible to argue the evidence for or against elite athletes using compression garments as recovery strategies, the evidence to support their use during long haul travel is unequivocal – it’s a no brainer.

It is commonplace for athletes to train or compete abroad. The stress on the body during long haul travel is known as travel fatigue[25]. If unmanaged, athletes can experience heavy swollen legs for a number of days, negatively impacting the quality of training. The use of compression garments has been shown to systematically reduce the incidence of DVT on flights, but also the level of swelling and leg discomfort[26]. Whilst it is common for athletes to think about managing travel fatigue when they fly, athletes shouldn’t forget that any situation which involves them being on their feet or sat down for a prolonged period of time can cause heavy legs and discomfort. Therefore compression garments shouldn’t just get worn on a flight, but also when waiting in lounges or when travelling in cars/coaches etc.

 

Report by Dr Jonathan Leeder

PhD (Recovery and Muscle Damage). CSci. BASES Accredited. 
Lead Physiologist British Cycling. 
Lead Physiologist and Lab Director at English Institute of Sport, Sportcity, Manchester.


 

References

  1. Howatson, G. and K.A. van Someren, The prevention and treatment of exercise-induced muscle damage. Sports Med, 2008. 38(6): p. 483-503. 
  2. Friden, J., Delayed onset muscle soreness. Scand J Med Sci Sports, 2002. 12(6): p. 327-8. 
  3. Lieber, R.L. and J. Friden, Morphologic and mechanical basis of delayed-onset muscle soreness. J Am Acad Orthop Surg, 2002. 10(1): p. 67-73. 
  4. Pyne, D.B., Exercise-induced muscle damage and inflammation: a review. Aust J Sci Med Sport, 1994. 26(3-4): p. 49-58. 
  5. Chen, Y.W., et al., Molecular responses of human muscle to eccentric exercise. J Appl Physiol, 2003. 95(6): p. 2485-94. 
  6. Nosaka, K. and P.M. Clarkson, Muscle damage following repeated bouts of high force eccentric exercise. Med Sci Sports Exerc, 1995. 27(9): p. 1263-9. 
  7. Howatson, G., et al., Influence of tart cherry juice on indices of recovery following marathon running.Scand J Med Sci Sports, 2010. 20(6): p. 843-52. 
  8. Nikolaidis, M.G., et al., The effect of muscle-damaging exercise on blood and skeletal muscle oxidative stress: magnitude and time-course considerations. Sports Med, 2008. 38(7): p. 579-606. 
  9. Akenhead, R., et al., Diminutions of acceleration and deceleration output during professional football match play. J Sci Med Sport, 2013. 
  10. Ascensao, A., et al., Biochemical impact of a soccer match - analysis of oxidative stress and muscle damage markers throughout recovery. Clin Biochem, 2008. 41(10-11): p. 841-51. 
  11. MacRae, B.A., J.D. Cotter, and R.M. Laing, Compression garments and exercise: garment considerations, physiology and performance. Sports Med, 2011. 41(10): p. 815-43. 
  12. Sperlich, B., et al., Squeezing the muscle: compression clothing and muscle metabolism during recovery from high intensity exercise. PLoS One, 2013. 8(4): p. e60923. 
  13. Hill, J., et al., Compression garments and recovery from exercise-induced muscle damage: a meta-analysis. Br J Sports Med, 2013. 
  14. Moher, D., et al., Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol, 2009. 62(10): p. 1006-12. 
  15. Barnett, A., Using recovery modalities between training sessions in elite athletes: does it help? Sports Med, 2006. 36(9): p. 781-96. 
  16. Cheung, K., P. Hume, and L. Maxwell, Delayed onset muscle soreness : treatment strategies and performance factors. Sports Med, 2003. 33(2): p. 145-64. 
  17. Nedelec, M., et al., Recovery in soccer : part ii-recovery strategies. Sports Med, 2013. 43(1): p. 9-22. 
  18. Meeusen, R., et al., Prevention, diagnosis, and treatment of the overtraining syndrome: joint consensus statement of the European College of Sport Science and the American College of Sports Medicine. Med Sci Sports Exerc, 2013. 45(1): p. 186-205. 
  19. Bleakley, C., et al., Cold-water immersion (cryotherapy) for preventing and treating muscle soreness after exercise. Cochrane Database Syst Rev, 2012. 2: p. CD008262. 
  20. Leeder, J., et al., Cold water immersion and recovery from strenuous exercise: a meta-analysis. Br J Sports Med, 2012. 46(4): p. 233-40. 
  21. Gregson, W., et al., Influence of cold water immersion on limb and cutaneous blood flow at rest. Am J Sports Med, 2011. 39(6): p. 1316-23. 
  22. Yamane, M., et al., Post-exercise leg and forearm flexor muscle cooling in humans attenuates endurance and resistance training effects on muscle performance and on circulatory adaptation. Eur J Appl Physiol, 2006. 96(5): p. 572-80. 
  23. Toumi, H. and T.M. Best, The inflammatory response: friend or enemy for muscle injury? Br J Sports Med, 2003. 37(4): p. 284-6. 
  24. Trappe, T.A., et al., Effect of ibuprofen and acetaminophen on postexercise muscle protein synthesis.Am J Physiol Endocrinol Metab, 2002. 282(3): p. E551-6. 
  25. Samuels, C.H., Jet lag and travel fatigue: a comprehensive management plan for sport medicine physicians and high-performance support teams. Clin J Sport Med, 2012. 22(3): p. 268-73. 
  26. Clarke, M., et al., Compression stockings for preventing deep vein thrombosis in airline passengers.Cochrane Database Syst Rev, 2006(2): p. CD004002