Made to Measure Compression Garments for Recovery in Rugby Players
Condition: Muscle Damage
Study type: Interventional

Summary: 
      Aims

        -  To compare the compression pressures exerted by made-to-measure compression garments
           (CG) with those from standard sized garments

        -  To assess the efficacy of custom fitted, high pressure CG for facilitating the recovery
           of strength, muscular power and sprint performance, and to compare the effects with
           those of garments exerting lower pressures and a sham treatment

      Rationale for study design

      The results of a recent meta-analysis (unpublished data) have informed the design of this
      study. The conclusions of the meta-analysis were that CG are most effective for the recovery
      of:

        -  Force and power performance following eccentric/plyometric exercise

        -  Maximal force production, at least 24 hours post-exercise (for example in strength and
           power athletes undertaking resistance training programmes)

        -  Additionally, the recovery of high-intensity cardiovascular performance may also be
           enhanced by the used of CG, when tested 24 hours following exercise which incurs
           metabolic stress Accordingly, the current study was designed to investigate the effects
           of CG on the recovery of force, muscular power and sprint performance in rugby players
           over a 48 hour period following damaging exercise. The exercise protocol chosen
           (detailed below) provided both mechanical and metabolic recovery demands.
    

Detailed description: 
      Study 1) A comparison of the pressures exerted by different compression garments Participants
      were assessed for anthropometry; including height and body-mass, as well as waist, hip thigh,
      calf, ankle and gluteal circumferences. All limb measurements were taken from the right side,
      in accordance with guidelines set by the International Society of Anthropometry and
      Kinanthropometry (ISAK). Skinfold measurements were taken according to the ISAK 8 site
      protocol by a level 1 anthropometrist.

      Thirty-two of the initially recruited 48 participants (see Study 2, below) were randomly
      selected and fitted for custom fitted compression garments (CG - stockings), after taking
      real-time 3D images using the manufacturer's proprietary, digitised method (Isobar,
      Manchester, UK). The custom fitted stockings (CF) were manufactured to apply pressures of 35
      mmHg and 20 mmHg for the calf and mid-thigh respectively. Using a crossover design, applied
      pressures were compared to those from standard sized CG (SSG) which provided lower pressures
      (5-15 mmHg) for each athlete. Garments were provided in small, medium or large, dependent on
      athletes' size and fitted according to the manufacturer's guidelines based upon height and
      body-mass (2XU, Campbelltown, Australia). Pressures at the skin-garment interface were
      measured for both garments, worn in a randomised order, using a pressure monitor. Pressures
      applied at three sites were recorded: font-thigh and medial calf landmarks as defined by The
      International Society for the Advancement of Kinanthropometry (ISAK), and 2 cm above the
      centre of the median malleolus of the ankle. This visit to the laboratory took approximately
      30 minutes per participant. Means and standard deviations were calculated from the pressure
      data to ascertain the average pressure exerted by the garments, as well as the variation in
      pressure across this population. Differences in measured pressures between garments were
      assessed using a paired-samples t-test (SPSS Statistics 22, IBM, New York, USA).

      Study 2) An investigation into the effects of the pressures applied by different compression
      garments in facilitating the short term recovery of strength and power performance The full
      cohort of 48 athletes originally recruited participated in a randomised clinical trial
      (parallel design) to assess the effects of CG on recovery from a standardised eccentric
      exercise protocol. Athletes were required to avoid strenuous exercise for 48 hours before the
      start of the study, and then throughout 48 hours recovery. The first session included
      assessment of performance followed by a bout of damaging exercise and re-assessment, lasting
      approximately 90 minutes. Recovery was assessed in 2 further sessions, at 24 hours and at 48
      hours after exercise (each lasting approximately 30 minutes).

      Initial assessment Following a standardised warm up (400 m jogging, 20 leg swings in both the
      horizontal and sagittal planes on either leg, and any individual stretches usually
      performance by an athlete), maximal force production (using a strain-gauge - MIE Medical
      Research Ltd., Leeds, UK) was assessed by measuring the best of three attempts of maximal
      knee extension. Participants will be seated on a plyometric box, starting from a flexed
      position of 90o, as measured with a goniometer. In addition, 30 m sprint time (timing gates
      by Brower, Utah, USA) and vertical jump performance, using a jump mat (FSL electronics,
      Cookstown, UK), were assessed (best of 3 attempts). Soreness (200 mm visual analogue scale)
      and swelling (spring loaded tape measure - Lafayette Instrument Co, Lafayette, Indiana, USA)
      were also assessed. Muscle damage was also be quantified by creatine kinase analysis (RX
      Monza, Kearneysville, West Virginia, USA) from venous blood samples taken from the arm at
      baseline and at each time-point throughout recovery.

      Eccentric muscle-damage protocol Following initial assessment, participants completed 20 sets
      of 20 m sprints with a 5 m deceleration phase, followed by 100 drop jumps. Sprints were
      separated by 60 s intervals. This combined protocol represents a novel and ecologically valid
      stimulus which combines the mechanical and metabolic stressors faced by Rugby Union players
      from competition and training. Sprints were timed to provide real-time feedback and encourage
      maximal effort, and sprints repeated if deceleration continued past the 5 m zone permitted.
      Subsequent drop jumps were performed from a 0.6 m platform, while athletes were encouraged to
      achieve the maximum height possible following a down-phase that resulted in the hips dropping
      below the level of the knee.

      In a randomised, parallel-group design, athletes undertook either a sham treatment (CON), or
      wore CG immediately from the cessation of exercise for 48 hours recovery, removing them only
      to wash. Garments were manufactured to apply the pressures below, with no differences in
      physical appearance between garments. Athletes were allocated to one of the following three
      conditions:

        -  Custom fitted stockings (Isobar, Manchester, UK) applying over 35 mmHg and 20 mmHg at
           the calf and mid-thigh respectively (CF)

        -  Standard sized garments (2XU, Campbelltown, Australia) applying lower pressures (SSG -
           applying 5-15 mmHg, at both the calf and thigh)

        -  A sham ultrasound treatment (CON) The CON group received 15 minutes (5 minutes of
           quadriceps, 5 minutes of hamstrings, and 5 minutes of gastrocnemius) of sham ultrasound
           therapy (Combined therapy ultrasound/inferential; Shrewsbury Medical, Shropshire, United
           Kingdom) within 1 hour of the completion of performance testing. Pressures at the
           skin-garment interface were measured for both garments using a pressure monitor.

      Performance measures - dependent variables Recovery was quantified by repeating the initial
      assessment and comparing to baseline values. Recovery of performance and recovery of markers
      of muscle damage were measured at the following time-points: pre-exercise, post-exercise, 24
      hours post-exercise, 48 hours post-exercise. Between-group differences in the recovery of
      performance and physiological factors were assessed over time using a 2 way (time by
      condition) mixed-measures analysis of variance (SPSS Statistics 22, IBM, New York, USA).

      All equipment used and methods employed made use of validated measures of strength, power,
      muscle damage and compression pressures.
    

Intervention name(s): Custom fitted compression garments (CF); Standard-sized compression garments (SSG); Sham ultrasound (CON)
Intervention type(s): Device; Device; Procedure
Intervention description(s): Custom fitted compression garments (Isobar, Manchester, UK) designed to provide 35 mmHg at the ankle and >20 mmHg at the mid-thigh (equivalent to European class 2 compression garments); Off-the-shelf, standard-sized garments (2XU, Campbelltown, Australia), typically providing pressures equivalent to European grade 1 compression or below (5 - 10 mmHg at both the ankle and thigh); Sham ultrasound using an unplugged machine. Sham treatment for 5 minutes on each of the thighs, calves and hamstrings
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Randomised, controlled, parallel trial
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: exercise induced muscle damage; recovery; rugby