The Hierarchy of Recovery

The relationship between training recovery and fatigue has significant impact on performance. An adequate balance between stress (training and competition loads, other life demands) and recovery is essential for athletes to achieve continuous high-level performance (1). Research has focused on the examination of physiological and psychological recovery strategies to compensate external and internal training and competition loads. A systematic monitoring of recovery and the subsequent implementation of recovery routines aims at maximising performance and preventing negative developments such as under-recovery, overreaching, overtraining syndrome, injuries, or illnesses. In a world where there are countless recovery ‘strategies’ it is important not to get lost in the 1%’s and ensure the most important aspects of recovery are done right.

1. A Well Structured Training Program

You can’t ice bath, nap, foam roll and or massage you way out of a poorly designed training plan. A training plan that doesn’t include enough rest days, spikes loads too quickly or has too high intensity places the athlete at an increased injury risk. A well designed program will include a large amount of low intensity running and a small amount of high and moderate intensity running strategically placed throughout the week. Consider the 80/20 rule (blog/ podcast). High intensity days should generally be followed by rest days or easy days. Consistent gradual increases in training load reduce injury risk and over time can allow someone to reach high training volumes, which in themselves are protective against injury. A well structured training program includes the right balance of high versus low intensity training, cross training, rest days, recovery weeks and consistent gradual loading.

2. Sleep

Sleep is an important part of recovery for any and every athlete (2). Finestone and Milgrom (2008) found that sleep has a role in the development of stress fractures. By reducing marching load and introducing a recommended minimum 6 hours of sleep a night, there was a 60% reduction in stress fracture incidence. A review by Watson (2017) emphasised accumulating evidence towards increased sleep duration and improved sleep quality in athletes are associated with improved performance and competitive success. In addition, better sleep may reduce the risk of both injury and illness in athletes, not only optimising health but also potentially enhancing performance through increased participation in training. A systematic review by Bonnar et al. (2) looked at several interventions to improve performance, including sleep extension and napping, sleep hygiene, and post-exercise recovery strategies. Evidence suggests that sleep extension had the most beneficial effects on subsequent performance. Further information on the importance of sleep can be found here.

3. Nutrition

What and when you fuel is important for recovery. Nutrition is far from my speciality and to do this area justice is well beyond the scope of the post. To read more on nutrition may I suggest you start here and here. An important aspect of nutrition is hydration and monitoring fluid loss and rehydrating appropriately particularly for exercise in the heat or longer durations.

4. Mental and Emotional Stress

Stress is stress. When trying to recover from the physical stressors of training, it is important to reduce and or manage other stress. Athletes who possess higher psychological distress are more likely to get injured (5). Athletes who experience anxiety in preseason are 2.5 times more likely to be injured compared to those who have not experienced anxiety (4). Stress can cause attentional changes, distraction and increased self-consciousness that all can interfere with performance and predispose an athlete to injury (6-11). Stress increases muscle tension and coordination that can increase the risk for injury; decreasing stress can actually decrease injury and illness rates (6, 10, 12).

Psychological skills of relaxation, goal setting, imagery, and self-talk have emerged as particularly helpful in influencing the competitive anxiety response in athletes. The use of qualified professionals in this area are of great value (see Optimisation Hub). Use of relaxation techniques prior to bed such as positive suggestion, and visualization are recommended as part of the sleep routine to ensure a clear mind and relaxed state when going to bed. Mobile apps that help people practice mindfulness skills, for instance, might prove to be effective in enhancing mental recovery (Birrer et al., 2012).

5. Physiotherapy and Massage

As we move further along the hierarchy we reach Physiotherapy and massage. These can be valuable tools to manage recovery. Firstly it is important to distinguish between what is pain, injury, soreness, signs of increasing fatigue or overtraining. Physiotherapy can be used to help identify when an athlete is experiencing these and help modify training and other aspects of recovery accordingly. Physiotherapy and massage can help to ensure strength, power, range of motion, tone, balance and neuromuscular control are staying consistent.

Massage is believed to benefit athletes through its biomechanical, physiological, neurological and psychological mechanisms.It is believed that one of the greatest advantages of sport massage is to overcome fatigue and reduce fatigue and recovery, especially during periods of competition, and consequently, enhance performance at the next event. Massage can improve some physiological markers but some studies have shown no effect on any recovery parameters. There is however multiple studies that report significant reductions in soreness perception of DOMS after massage.

6. Ice Cold/Cryotherapy

Muscle soreness commonly results after sports and exercise activity. A priority for clinicians and athletes is to encourage full recovery between exercise bouts using an effective intervention programme. Multiple systematic reviews have been conducted on cryotherapy. These provide some evidence that cold-water immersion reduces delayed onset muscle soreness after exercise when compared with passive interventions involving rest or no intervention. However, it is not possible to draw definitive conclusions on pain or recovery because of the poor methodological quality, and small sample sizes. (14, 15, 16).  The results also demonstrated the presence of a dose–response relationship, indicating that CWI with a water temperature of between 11 and 15 °C and an immersion time of 11–15 min may provide the best results (15). Other than reported reductions in soreness there is not consistent findings amongst the literature for change in other markers of inflammation or fatigue.

7. Everything Else

Everything else is summed in together not to belittle the various evidence that exists for other recovery modalities, but rather to draw ones focus to those with the most bang for your buck. Individual needs and preferences play a role, so If you get a great reduction in soreness from foam rolling, yoga or mobility routines great please keep it up. Other recovery tools may include compression garments, float tanks, stretching and mobility routines, active recovery or walking.

Lewis Craig (APAM)
POGO Physiotherapist
Masters of Physiotherapy

Featured in the Top 50 Physical Therapy Blog

References:

1. Kellmann, M., Bertollo, M., Bosquet, L., Brink, M., Coutts, A. J., Duffield, R., … & Kallus, K. W. (2018). Recovery and performance in sport: consensus statement. International journal of sports physiology and performance, 13(2), 240-245.
2. Bonnar, D., Bartel, K., Kakoschke, N., & Lang, C. (2018). Sleep Interventions Designed to Improve Athletic Performance and Recovery: A Systematic Review of Current Approaches. Sports Medicine, 48(3), 683–703. doi:10.1007/s40279-017-0832-x
3. Samuels, C. (2009). Sleep, Recovery, and Performance: The New Frontier in High-Performance Athletics. Physical Medicine and Rehabilitation Clinics of North America, 20(1), 149–159.doi:10.1016/j.pmr.2008.10.009
4. Li, H., Moreland, J. J., Peek-Asa, C., & Yang, J. (2017). Preseason anxiety and depressive symptoms and prospective injury risk in collegiate athletes. The American journal of sports medicine, 45(9), 2148-2155.
5. Putukian, M. (2016). The psychological response to injury in student athletes: a narrative review with a focus on mental health. Br J Sports Med, 50(3), 145-148.
6. American College of Sports Medicine, American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, et al. Psychological issues related to injury in athletes and the team physician: a consensus statement. Med Sci Sports Exerc 2006;38:2030–4. doi:10.1249/mss.0b013e31802b37a6
7. Wiese-Bjornstal EM. Psychology and socioculture affect injury risk, response and recovery in high-intensity athletes: a consensus statement. Scan J Med Sci Sports 2010;20(Suppl 2):103–11. doi:10.1111/j.1600-0838.2010.01195.x
8. Walker N, Thatcher J, Lavallee D. Psychological responses to injury in competitive sport: a critical review. J of Royal Soc Promot Health 2007;127:174. doi:10.1177/146642400707949
9. Nippert AH, Smith AM. Psychological stress related to injury and impact on sport performance. Phys Med Rehabil Clin N Am 2008;19:399–418. doi:10.1016/j.pmr.2007.12.003
10. Williams JM, Andersen MB. Psychological antecedents of sport and injury: review and critique of the stress and injury model. J Appl Sport Psychol 1998;10:5–25. doi:10.1080/10413209808406375
11. Ivarsson A, Johnson U, Lindwall M, et al. Psychosocial stress as a predictor of injury in elite junior soccer: a latent growth curve analysis. J Sci Med Sport 2014;17:366–70. doi:10.1016/j.jsams.2013.10.242
12. Kerr G, Goss J. The effects of a stress management program on injuries and stress levels. J Appl Sport Psychol1996;8:109–17. doi:10.1080/10413209608406312
13. Weerapong, P., Hume, P. A., & Kolt, G. S. (2005). The Mechanisms of Massage and Effects on Performance, Muscle Recovery and Injury Prevention. Sports Medicine, 35(3), 235–256. doi:10.2165/00007256-200535030-00004
14. Bleakley, C., McDonough, S., Gardner, E., Baxter, G. D., Hopkins, J. T., & Davison, G. W. (2012). Cold-water immersion (cryotherapy) for preventing and treating muscle soreness after exercise. Cochrane Database of Systematic Reviews.doi:10.1002/14651858.cd008262.pub2
15. Machado, A. F., Ferreira, P. H., Micheletti, J. K., de Almeida, A. C., Lemes, Í. R., Vanderlei, F. M., … & Pastre, C. M. (2016). Can water temperature and immersion time influence the effect of cold water immersion on muscle soreness? A systematic review and meta-analysis. Sports Medicine, 46(4), 503-514.

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