A Literature Review on Compression Garments and their Effects On Muscle Pain and Inflammation

Here below is a research report conducted last year, in the interests of gathering Evidence Based Research for a phenomenon I have found fascinating over the past few years. The phenomenon I wanted to look into is the mostly positive effects on recovery, that I had observed, from the use of muscle compression garments (MCG) on recovery and performance. One notable observation is it's seeming effect to reduce pain and inflammation in a short amount of time and another is that when elite athletes, whom I treat, have used it during a game (for example), it seems to support their musculo-skeletal structure in a way that helps them perform well, even when injured. It will take me a while to explain my experiences with these, albeit subjective, phenomena. So I'll leave it to your imagination for now and if you're interested in some more of a scientific take on the subject, please feel free to continue reading below,

May you be free from pain, happy and healthy as can be today,

M.

Compression Garments on Trained and Untrained Individuals and the effects on Pain and Inflammation after EIMD (Exercise Inducsed Muscle Damage)

by Michelle Bautista - July 2021

This study analyses the current literature on the effects of Compression Garments (CG) on recovery and subsequent performance after the stimulation of Exercise Induce Muscle Damage (EIMD). It focuses primarily on the positive effects on pain reduction (perceived levels of soreness) and inflammation (swelling/oedema) during recovery. Using electronic databases found via google search, such as PubMed, MEDLINE and PMD, 10 articles were selected for this research. The studies assessed were carried out on trained (highly fit) and untrained individuals and each study rendered measurable muscle damage after the samples competed intense training protocols. The results from both trained and untrained participants provide evidence to support the positive effects of CG on recovery. Reduced soreness, swelling of the limbs, Creatine Kinase (CK), lactates and improved haemodynamics (such as bloodflow) and performance are some of the measured variables that groups that wore CG experienced more rapidly compared to groups who did not wear CG. Out of the 10 articles, only 2 concluded that CG did not have significant positive effects and their studies are evaluated herein. This literature review concludes that there is substantial evidence to support the use of CG for expediting recovery in damaged muscles. One can assume that CG worn on areas of soft-tissue injury for a certain duration (at least 12 hours or more>EIMD) could help reduce the most salient symptoms of pain and inflammation. The implications of CG positively impacting recovery could help individuals and therapists alike to consider using or promoting CG as a means of therapy for themselves and/or for their clients.

INTRODUCTION

History of Compression Garment Use

Compression Garments (CG) are garments which have properties that provide external pressure on limbs and other body areas. Made from different materials which elicit the pressure, CG has traditionally been used in hospital settings as a prophylactic for immobile or sedentary patients to reduce the risk of stroke or heart attack (venous blockages) caused by issues such as DVT and also as a medical aid for burn patients [3]. The basic premise is that the CG improves blood flow and reduces swelling, in that the external compression supports the venous structures which have been affected by inefficient blood flow which leads to stretching of the veins and blood pooling. The compression helps reduce the diameter of the stretched out veins and thus enhances blood flow to the heart and prevents blood pooling and embolisms (blood clot formations) [6,7,10].

CG use outside of the strict medical realm has risen in the general population, especially with athletes [2,3,4,6,8,9,10,11,12,14]. CG first started becoming popular with athletes in the 1980s after (Berry, et al, 1987) published a highly popular scientific journal article stating that CG had positive effects on recovery based on reduced lactate levels found in blood samples of CG group vs Control [13]. The use of CG has seemingly grown exponentially across demographics over the last few decades and it’s added prolific use by the general public, especially by professional athletes, inadvertently serves as anecdotal evidence/advocacy of the positive effects of CG.

Recent literature reviews and meta-analyses conclude that there is evidence supporting the efficacy of CG on recovery after Exercise Induced Muscle Damage (EIMD) protocols were administered [2,4]. For example, CG use for the lower body in recovery showed significant reduction in Delayed Onset Muscle Soreness (DOMS) in a shorter recovery timeframe [2]. Improved performance, decrease in swelling, more efficient removal of free radicals such as Creatine Kinase (CK) and Lactase in the blood (both which are markers for muscle injury) also indicated to have enhanced recovery after EIMD [4]. Historically, however, overall the studies do not provide unequivocal direction as to the usage of CG, as there are also studies which contest the efficacy of CG [5,12].

Pain and Inflammation

Muscle damage or muscle injury often leads to pain and inflammation. These symptoms are common health complaints and can lead to a general decline in an individual’s health - from physiological (such as decreased ability in performing daily tasks) and psychological (perceived level of soreness and mood) (Kraemer et al, 2010). Recovery from muscle injury is therefore a major goal in treatment of many health practitioners, including massage therapists and physiotherapists. There is also lots of anecdotal evidence of the benefits of CG from blog posts on products websites [1,5,7] to athletes, such as NBA players, who promote them through their use [15]. These sources are easily available online, but generally do not provide scientific evidence to support their claims purporting the benefits of CG. It would be beneficial for manual therapists, such as physiotherapists and remedial massage therapist, medical practitioners and those who wish to use CG to have a firm understanding of scientifically backed CG benefits to

determine whether to use/or prescribe the use of CG as an adjunct treatment for pain and inflammation from muscle/soft-tissue injuries.

Heterogenous Study Variables

Meta-analyses often highlight the lack of homogeneity in CG studies [2,4]. For example, in comparison, there are wide variances in the study designs, areas of the body tested, CG materials and pressures, measured effects, duration of wear, sample types, sizes and the requirements of pre-test dietary and lifestyle requirements. [2,3,4,6,8,9,10,11,12,14]. The heterogeneity of the research protocols may result in the unequivocal nature of results in regards to CG efficacy.

Study Objectives

The purpose of this study is to summarise the information and results provided by selected literature across various test types and to analyse any trends, especially in regards to the effects of CG on pain and inflammation. As mentioned above, the results of this study could provide better treatment outcomes in practical use of CG in the recovery of muscle injuries.

Hypotheses:

1. CG reduces pain and inflammation more rapidly after EIMD and facilitates recovery and performance.

METHOD

Using electronic databases found via Google search engine, such as PubMed, MEDLINE and PMD, 10 articles were selected for this research. Examples of words included in the searches are “Effects of compression on pain and inflammation”, “Effects of compression in athletes”, “How does compression work to improve performance and recovery”. Other sources, including some non-CG specific research articles were also utilised attain further information, but not included in the critique. The 10 studies were selected based on the criteria that CG was tested after muscle damage had been induced via intense exercise protocols. The studies were carried out on either trained (highly fit) and untrained individuals. Each article was reviewed, charted and analysed. The results of the effects on pain and inflammation of each study was summarised on an Excel spreadsheet and plotted on a pivot table (Figure 1 below).

RESULTS

Trend of Support for the Positive Effects of Compression Garments

From 10 of the articles in question, 8, (or 8.5) provided confirmation of positive effects of CG on recovery. The study which merits the 0.5 support rating was one by French, et al. (2008) which had found evidence to suggest that CG supresses oedema, as there was no increase in thigh circumference in their CG group compared to the Control (CONT), but soreness is not reduced.

In this match-paired, between group design, 26 resistance-trained individuals were not given any specified diet or lifestyle restrictions besides no exercise or caffeine 48 hours before testing. They underwent an intense training regimen where they had 5 lab visits in 3 weeks. They were familiarised, tested at baseline with some physical performance measure included, made to perform a robust resistance exercise challenge (REC), provide a blood sample 24 hours after the REC and then after 48 hours post-REC they were to repeat the exercises taken at baseline. After REC the 26 participants were divided into 3 groups, compression garment (CG) – this group wore a Skins full-length ankle-waist graduated CG (with 10-12mmHg) for 12 hours overnight, contrast bathing (CB) – where the subjects immersed in hot and cold baths intermittently for 20- 30minutes after REC and CONT – with no therapy administered. The results were that CG and CB had no hierarchy of effects over no treatment at all, therefore stipulating that the commercially available Skins CG may be inadequate of providing any benefit in recovery.

It could be said however that the test battery was of an extreme level and the length of treatment with the CG may not have been sufficient for the effects of the garments to work.

The one other study which did not support the hypothesis was a self-as-control study which had a sample size of n=6 “healthy males” who also were not required to prepare with

specific instructions. Here they used Sigvaris shorts as their CG (hip to knee; 37mmHg). From this early observation, the sample size is relatively small and so are the shorts, however the pressure is greater than all of the other CG pressure levels included in this study. It asserts that the CG used for recovery from a highly intense cycling exercise did not promote better haemodynamic function, but instead, decreased blood flow to the superficial and deep areas of the quadriceps. It is also interesting to not that they compared each subjects’ one leg, to the other. They had the participants wear the shorts and then they cut one side out from above the hip and used this leg as the CONT. One can assume that because the shorts on that same leg still are compressed proximally, it may still be garnering the effects of CG and thus their results may prove biased.

The evaluation of the CG’s effects on lower limbs consisted of the majority of the studies (also 8 out of 10). Apart from the 2 mentioned above, the following studies found positive results. A study by Hettchen, et al (2019) used a cross-over design which focused on CG effects on performance of CG on the hip, thigh and calf. 19 German Handball players were enlisted to test CG efficacy (7.7-26.2mmHg graduated). They were tested in 2 phases. The 1st they would be split into either CG or CONT group, then after a “washout period” of 6-7 weeks, they were to return for Phase 2, this time they were to have the opposite group condition to what they had in Phase 1. E.g if 1 had started in CG group, at the end they would be tested in the CONT group. They had the participants draw lots from Kinder Surprise eggs at the outset to confirm which group they would start in and the CG group would wear CG for 24 hours after the REC and then 24 hours off and then on again for a period of 96 hours (4 days). The results they found in CG groups were that the participants felt “better” with reduced perception of pain and they also felt

‘stronger’ in their perceived physical state vs their CONT counterparts [7]. Their performance was enhanced with CG improving max dynamic hip/leg extension strength after intense muscular loading, lower leg power loss was less pronounced and Creatine Kinase (CK) levels dropped faster. The CG group had to use the CG for recovery for 2 days out of the 4 and it may appear to be redundant or at least inconvenient. However, its author suggest that in high performance sports, like German Handball, minimal advantages may just be what is required to have the upper hand against one’s opponent (Hettchen, et al, 2019).

Interestingly, one study enlisted 32 physically active women with no prior weight training to use either CG only (using full-length Skins leggings), CGRM – CG for 12 hours with 30m Remedial Massage directly after REM and no extra treatment with CONT after REC using

intense sets and repetitions of plyometric box jumps (Jakeman, et al, 2010). There results concluded that pain and inflammation was significantly reduced in the combined treatment group CGRM, over CG alone and no treatment. This indicates that using CG and Remedial Massage together could be an effective strategy in recovery [9].

Lastly, 2 studies which are conducted by Kraemer, et al (2001 and 2010) both provide results which supports the hypothesis of pain and inflammation decreasing in the recovery period faster in CG groups to CONT. They support the use of CG as therapeutic treatment for soft tissue injury. In the 2010 study by Kraemer, et al., an arm sleeve (10mmHg from armpit to mid forearm) was used on the participants’ dominant forearm for 5 days after the REC. The subjects were 20 untrained females. The CG group was reported to return to their normal daily activities quicker due to the quicker reduction of pain, the are circumference stayed the same indicating no

swelling to the area and prevented the loss of elbow motion compared to the CONT group. This study suggested that a Dynamic Casting effect, in which the CG reduced movement and supported normal muscle alignment, could have greatly influenced the quicker healing in recovery and performance. [10].

Kraemer, et all (2010) provided the only article in the study to test CG (Under Armour Recharge whole body compression suit) on the whole body They used a sample consisting of resistance-trained men (n=11) and women (n=9) who were their own CONT. They had been given specific dietary and lifestyle changes for a time before the tests. Once completing a baseline performance test and using the CG for 24 hours after, they were re-tested again with no CG (CONT) and then 72 hours after that were tested again. The authors stipulated that pressures that enhance optimal skin contact and proprioception would bring about the best outcomes in CG and that using CG for 24 hours post intense workout would be beneficial for athletes who want to retrain or compete within a similar timeframe [11]. The authors also stated that their sample was indicative of the population most in need of ‘recovery enhancements’ (Kraemer, et al. 2010).

No Standard Test Battery

There does not appear to be 1 standard of testing which has been completely replicated in other studies that have been accurately repeated and tested with each individual garment on different areas of the body. There are some similarities, but as noted above the conditions and criteria differs, especially in terms of the study designs, exercise regimes used to elicit EIMD, pre-test dietary and lifestyle limitation and also the duration that the CG is worn by the participants.

Some other notable differences are the measuring criteria and methods, test conditions, sample sizes, sample characteristics (e.g Trained and Untrained - where there may be difference in magnitude of effects on resistance-trained vs non-resistance trained sample groups), the CG itself and its material, areas of the body tested, control groups (such as self as control) and so on.

Any discord in the literature for and against CG use for recovery could be attenuated by the lack of homogeneity in the research thus far.

Interesting Find - The Influence of Pressure

In most of the studies, like the one by Kraemer, et al (2001 and 2010) pressure is an important factor in the “success” of CG. As mentioned above, there were vast differences in the pressure levels used for CGs and some studies did not mention the pressure they used at all. Apart from French, et al. (2008) and Sperlich, et al (2013), which used the pressures 10-12mmHg and

37mmHg respectively, and ultimately refutes that CG has any significant benefits. The other 8 studies used pressure values between the range of (1.1mmHg-26.2mmHG) [2,3,4,8,9,10,11,12]. This indicates that pressure may not be an essential factor to elicit the positive effects on recovery.

This posit is supported by the meta-review by Beliard, et al (2015) which, in their results, also found that the positive impacts of CG were found in various CG pressure levels across multiple studies. They concluded that, because of this, the CG pressure may not determine it’s efficacy. It is interesting to note that (Kraemer, et al, 2010) warns that too much compression is more harmful than good, citing a case where CG with high pressure elicited pain when applied to

an area of extreme muscle damage. Therefore, caution should be taken in administering/recommending compression.

Effects on Pain and Inflammation

Row Labels Count of Authors

N (not pain) 1

NT 2

Y 7

Grand Total 10

Figure 1.

Out of the 10 studies, 7 resulted in significant decreases in pain and inflammation in CG groups compared to Controls [2,4,8,9,10,11,12]. In 2 studies, these variables were not measured as part of the tests [3,14] and in 1 [6], only a reduction in oedema was noted and did not rate pain perception.

This observable pattern gives support to the hypothesis that the use of CG for recovery and performance reduces pain and inflammation and this claim is supported by at least 80% of the literature reviewed in this study.

DISCUSSION

The bulk of the evidence provided in this literature review shows to be mainly supportive of the efficacy of CG on pain and inflammation > EIMD. The mechanisms of enhanced recovery from CG is still largely unclear. The use of external compression from CG reduces swelling and perceived muscle pain as demonstrated in the majority of studies in this review. In addition, reductions in cellular trauma and muscle oscillations, enhanced circulation, blood lactate removal, decreased cortisol levels and increases in body temperature all point to the positive effects of Compression Garments on recovery and in turn performance. Still, the promotion of CG use may be hampered by conflicting evidence, the vast differences in testing conditions, and lack of guidance around which pressures, brands, types, etc of CG would best work. This could be assuaged in future by a replication of more homogenous EIMD and CG conditions and protocols across the various types of CG available. This could lead to higher confidence in the choice of future users to select the most effective and economical CG for their needs. Some may argue that the results are minimal, and the recommended minimum 24-hour wear of CG to take full-effect after EIMD can be tedious and constraining [14]. However, as Hettchen, et al. (2019) states, “Small differences in performance might decide a narrow match”[8].

This study is simple and does miss a few of the finer details of explaining, in more depth, the concepts and mechanisms of the said positive effects. However, from the results of this study, one could conclude that there is definite merit in using CG to facilitate recovery from muscle injury and help reduce pain and inflammation. The notable effects of CG in reducing pain and inflammation helps to reinforce the assumption that CG can be used as an adjunct treatment for

muscle injuries, along with manual therapy and other rehabilitation exercises. In addition, this review will provide valuable information and evidence based research to help manual therapists make a more informed decision in utilising CG in their practice, either for their clients or for themselves.

For massage therapists and other manual therapists in particular, the implications of the positive benefits of CG for their own use (e.g. on tired/swollen/injured forearms or whole body) could be one of longevity. CG use for pain and inflammation may effect in one practising their craft for decades more to come.

References

1. 2xu Website – information on the benefits of their product’s compression garments - https://2xu.com/pages/2xu-compression-education

2. Beliard S, Chauveau M, Moscatiello T, Cros F, Ecarnot F, Becker F. Compression garments and exercise: no influence of pressure applied. J Sports Sci Med. 2015 Mar 1;14(1):75-83. PMID: 25729293; PMCID: PMC4306786.

3. Berry MJ, McMurray RG. Effects of graduated compression stockings on blood lactate following an exhaustive bout of exercise. Am J Phys Med. 1987 Jun;66(3):121-32. PMID: 3605315. 4. Born DP, Sperlich B, Holmberg HC. Bringing light into the dark: effects of compression clothing on performance and recovery. Int J Sports Physiol Perform. 2013 Jan;8(1):4-18. doi: 10.1123/ijspp.8.1.4. PMID: 23302134.

5. Finch, M – Blog on RunnersWorld website on the benefits of compression on running 6. French, Duncan & Thompson, Kevin & Garland, Stephen & Barnes, Christopher & Portas, Matthew & Hood, Peter & Wilkes, Graeme. (2008). The Effects of Contrast Bathing and Compression Therapy on Muscular Performance. Medicine and science in sports and exercise. 40. 1297-306. 10.1249/MSS.0b013e31816b10d5.

7. Gatlin, T – The Science Behind Compression Garments

www.apexfoot.com/blog/the-science-behind-compression-garments

8. Hettchen, Michael & Gloeckler, Katharina & Stengel, Simon & Piechele, Andrea & Lötzerich, Helmut & Kohl, Matthias & Kemmler, Wolfgang. (2019). Effects of Compression Tights on Recovery Parameters after Exercise Induced Muscle Damage: A Randomized Controlled Crossover Study. Evidence-Based Complementary and Alternative Medicine. 2019. 1-11. 10.1155/2019/5698460.

9. Jakeman, John & Byrne, Chris & Eston, Roger. (2010). Efficacy of Lower Limb Compression and Combined Treatment of Manual Massage and Lower Limb Compression on Symptoms of Exercise-Induced Muscle Damage in Women. Journal of strength and conditioning research / National Strength & Conditioning Association. 24. 3157-65. 10.1519/JSC.0b013e3181e4f80c.

10. Kraemer WJ, Bush JA, Wickham RB, Denegar CR, Gómez AL, Gotshalk LA, Duncan ND, Volek JS, Putukian M, Sebastianelli WJ. Influence of compression therapy on symptoms following soft tissue injury from maximal eccentric exercise. J Orthop Sports Phys Ther. 2001 Jun;31(6):282-90. doi: 10.2519/jospt.2001.31.6.282. PMID: 11411623.

11. Kraemer WJ, Flanagan SD, Comstock BA, Fragala MS, Earp JE, Dunn-Lewis C, Ho JY, Thomas GA, Solomon-Hill G, Penwell ZR, Powell MD, Wolf MR, Volek JS, Denegar CR, Maresh CM. Effects of a whole body compression garment on markers of recovery after a heavy resistance workout in men and women. J Strength Cond Res. 2010 Mar;24(3):804-14. doi: 10.1519/JSC.0b013e3181d33025. PMID: 20195085.

12. Lee DCW, Sheridan S, Ali A, Sutanto D, Wong SHS. Wearing compression tights post-exercise enhances recovery hemodynamics and subsequent cycling performance. Eur J Appl Physiol. 2021 Jul;121(7):2091-2100. doi: 10.1007/s00421-021-04661-0. Epub 2021 Apr 9. PMID: 33835198.

13. Parsons, T. - How Compression Sportswear Acutally Works - Web Blog, GQ Magazine - https://www.gq-magazine.co.uk/lifestyle/article/compression-sportswear

14. Sperlich B, Born DP, Kaskinoro K, Kalliokoski KK, Laaksonen MS. Squeezing the muscle: compression clothing and muscle metabolism during recovery from high intensity exercise. PLoS One. 2013 Apr 17;8(4):e60923. doi: 10.1371/journal.pone.0060923. PMID: 23613756; PMCID: PMC3629206.

15. Zhang, L – Website Blog – 4 Reasons why NBA Players Wear Tights Under Their Shorts - https://www.gq-magazine.co.uk/lifestyle/article/compression-sportswear

16. Sachdeva A, Dalton M, Lees T. Graduated compression stockings for prevention of deep vein thrombosis. Cochrane Database of Systematic Reviews 2018, Issue 11. Art. No.: CD001484. DOI: 10.1002/14651858.CD001484.pub4. Accessed 10 July 2021.