exhaustive and/or unaccustomed exercises ( particularly those involving high intensity 
 muscle contractions ) are known to induce temporary muscle damage .
it causes damage to the sarcolemma and the muscle cell membrane . 
 this damage results in the release of biochemical markers of muscle damage including ( e.g. 
 lactate dehydrogenase ( ldh ) , creatine kinase ( ck ) , and myoglobin ( mb)1 , 2 .
coaches , athletic 
 trainers , and athletes should seek scientific support for therapeutic interventions which 
 claim to help reduce the effects of muscle damage and speed of recovery from exercise and 
 athletic endeavors2 .
therefore , improving 
 muscle recovery after physical exercise is an important topic in sports medicine .
many researchers investigated various intervention to treat muscle damage such as active 
 recovery , massage , cryotherapy , electrotherapy , hydrotherapy , supplementation and 
 compression garments3,4,5,6,7,8,9,10 .
however the effect of 
 massage after delayed onset muscle soreness ( doms ) is still not clear12 . a recently review and meta - analysis demonstrated that 
 therapeutic massage is the only intervention that has a positive effect on the recovery of 
  muscle soreness  and function ; however , its mean effect is too small to be considered 
 clinically relevant1 .
the potential 
 benefits of massage on recovery include increased blood circulation and venous return , 
 greater lactate clearance , decreased pain sensation , and general well - being13 .
manual lymph drainage ( mld ) is a massage technique that involves the skin surface only and 
 follows the anatomic lymphatic pathways of the body . unlike other types of massage , it 
 produces neither blush nor pain and promotes lymph flow14 , 15 .
some biochemical 
 markers , such as ck , ldh , aspartate aminotransferase ( ast ) and mb are particularly 
 significant in the evaluation of tissue damage16 .
creatine kinase , a dimeric enzyme with a particularly large 
 molecule ( 80,000 da ) can not penetrate enter into the bloodstream following muscular injury . 
 and under injury conditions , it passes into the lymphatic system from the intercellular 
 fluid and is transferred to the general circulation from the thoracic lymph nodes .
this has 
 led to the hypothesis of an inverse relationship between lymphatic circulation and ck 
 levels17 .
havas et al . studied the 
 effect of peripheral lymphatic flow reduction , achieved by bed rest , on serum ck after 
 exercise .
they concluded that physical inactivity of short duration reduces the lymphatic 
 transport of ck and the secretion of muscle enzymes18 .
currently , there is a lack of controlled research to support the 
 efficacy of manual lymph massage in accelerating the rate of post - exercise blood clearance 
 of lactate and biochemical markers such as ck , ldh , and ast19 .
although acute submaximal exercise ( se ) may induce tissue damage 
 in trained individuals , mld applied immediately after exercise can reduce tissue or muscle 
 damage and also help the removal of blood lactate . in this study , we have investigated the 
 effect of mld on reducing tissue or muscle damage and removing blood lactate and muscle 
 enzymes after se in moderately trained individuals was investigated .
the subjects 
 were randomly divided into two groups , an mld group and a control group .
none of the subjects had any history of cardiovascular , metabolic or 
 musculoskeletal injury , or disease .
this study was approved by the human research ethics 
 committee of the faculty of medicine , abant izzet baysal university , bolu , turkey .
subjects were instructed to 
 avoid heavy exercise in the 72 hours before coming on all occasions .
the physical 
 characteristics of the subjects are shown in table 
 1table 1.physical characteristics of the subjectsmld ( n=10)cg ( n=8)xsdxsdage ( years)21.1  1.121.9  1.2height ( m)1.77 
01.78  0.1body weight ( kg)69.2  769.4  6.6anaerobic threshold ( km - hr)13.1  0.912.4  1.3mld : manual lymph drainage group , cg : control group .
mld : manual lymph drainage group , cg : control group the subjects performed a graded exercise test on a treadmill ergometer ( hp mercury , 
 germany ) under standardized conditions to determine the anaerobic threshold .
the exercise 
 test began at 8  kmhr and increased by 1  kmhr every three 
 minutes .
blood lactate levels 
 were measured in capillary blood drawn from a hyperemic ear lobe , at rest and at the end of 
 each exercise level .
the subjects ran until their blood lactate levels exceeded 5  mmol / l . 

seven days after the graded exercise test , all subjects ran 30 minutes on the same treadmill 
 ergometer , at a running velocity equivalent to the iat .
capillary blood samples to determine 
 the lactate concentrations were taken from a hyperemic earlobe before the beginning of each 
 test procedure .
mld was applied by a trained physiotherapist , who used specialized hand movements in a 
 range of different sequences .
the treatment was carried out as very light , completely 
 pain - free , rhythmical translational movements of the skin in the flow direction of the lymph 
 vessels .
the mld started with 
 abdominal lymph drainage after which central lymph stimulation was performed .
mld was 
 consecutively applied to the right and left lower extremities ( leg ) consecutively .
serum and plasma 
 were separated by centrifugation at 1,500  g for 15 minutes .
all serum and the plasma 
 samples were stored at 80  c until analysis .
serum levels of ast , ldh , ck and plasma levels 
 of lactate were determined by an autoanalyzer ( architect c8000 , abbott inc . , abbott park il , 
 usa ) , using test kits by the same manufacturer .
serum myoglobin level was determined by a 
 chemiluminescentce immunoassay analyzer ( architect i2000 , abbott laboratories , abbott park , 
 illinois , usa ) using the commercial kits recommended by the manufacturer .
the blood samples 
 were taken : 1 ) directly before the submaximal exercise ( b - se ) ; 2 ) directly after the 
 submaximal exercise ( a - se ) ; 3 ) after 30  min rest / after the mld application ( a - mld - r ) ; 4 ) 2 
 hours after the submaximal exercise ( 2ha - se ) 5 ) ; 24 hours after the submaximal exercise 
 ( 24ha - se ) and 6 ) 48 hours after the submaximal exercise ( 48ha - se ) the spss 16 statistical package was used for statistical analyses .
the mann and whitney 
 u - test for two independent samples was performed for intergroup comparisons
. differences 
 between the groups and over time were examined by repeated measurements analysis of variance 
 and stepwise multivariate tests . the probability level ( p - value ) for significance
there were no significant differences in the physical characteristics of two groups 
 ( p>0.05 ) ( table 1 ) .
changes in la and the 
 muscle enzymes , ( ldh , myoglobin and ck ) are presented in table 2table 2.changes in lactic acid ( la ) and muscle enzymes ( ldh , mb , ck)measuregroupla ( iuml)ldh ( iuml)mb ( iuml)ck ( iuml)b - semld13.16151.214.14021190.187.3cg11.41.7156.518.434.17.2275.7312.2a - semld71.228.6182.123.180.746.9235.8111.2cg54.310.1185.521.460.314.5325320.6a - mldmld21.37.715533.2120.963.7196.695.7cg29.67.5185.115.688.434.3310.7306.2**2ha - semld12.54.3143.621.7193.3190.4192.241.6cg19.97.5174.424.894.338347.5279.5***24ha - semld11.41.9153.416.869.551.2145.138.8cg19.110.615612.152.628.6235.789.9 * 48ha - semld13.97.314218.664.486.6182.494cg158.2152.68.644.114.9208.2139.4 * significant difference between the mld group and cg ( p < 0.05 ) . before submaximal 
 exercise ( b - se ) , after submaximal exercise ( a - se ) , after manual lymph drainage 
 ( a - mld ) , two hours after submaximal exercise ( 2ha - se ) , 24 hours after submaximal 
 exercise ( 24ha - se ) , 48 hours after submaximal exercise ( 48ha - se ) , lactic acid ( la ) , 
 lactate dehydrogenase ( ldh ) , myoglobin ( mb ) , creatine kinase ( ck ) .
statistically significant differences from baseline data were found at the 
 repeated measurements over time of la , ldh , myoglobin and ck in both groups ( p<0.05 ) , 
 except for ck in the control group , which showed no significant differences . * significant difference between the mld group and cg ( p < 0.05 ) . before submaximal 
 exercise ( b - se ) , after submaximal exercise ( a - se ) , after manual lymph drainage 
 ( a - mld ) , two hours after submaximal exercise ( 2ha - se ) , 24 hours after submaximal 
 exercise ( 24ha - se ) , 48 hours after submaximal exercise ( 48ha - se ) , lactic acid ( la ) , 
 lactate dehydrogenase ( ldh ) , myoglobin ( mb ) , creatine kinase ( ck ) significant differences were found between the two groups in baseline la ( p=0.027 ) and ldh 
 ( p=0.016 ) ; two hours after se in la ( p=0.034 ) , ldh ( p=0.012 ) and myoglobin ( p=0.034 ) ; and 
 24  h after se in ck ( p=0.043 ) .
the increase was followed by a 
 significant decrease in the mld group after mld , a difference that remained significant two 
 hours after se .
change in the myoglobin level was 
 only significant at 2  h after se , and in ck only 24  h at se .
this study was performed to assess the effect of mld on the reduction of tissue or muscle 
 damage and the removal of blood lactate and muscle enzymes after se , in moderately trained 
 individuals .
the importance of this study is in its being the first to show the influence of 
 mld on la .
the results demonstrate that mld might be effective at removing blood lactate and 
 some muscle enzymes after se .
mld is a type of massage 
 used to increase lymph flow and reabsorption without increasing ultrafiltration ; and it 
 requires special training .
it is hypothesized that the specific handling at the skin level 
 causes contraction of the superficial lymph vessels , increasing lymphatic drainage20 .
it was reported that mld application not 
 only speeds up the blood circulation but may also lead to faster elimination of metabolic 
 waste from the body and increase oxygen transport to the muscle21 .
another study of the effect of mld , not too familiar a concept in sport medicine , on muscle 
 injury arising during se and the disposal of metabolic waste , has been published .
two 
 important aspects differentiate this study from the former : first our evaluation of la 
 levels in addition to the muscular enzymes ( ldh , ck , myoglobine ) , and second , the drawing of 
 blood samples immediately after the mld application .
thus , evaluated both la levels and the 
 immediate effect of mld were evaluated .
blood samples were drawn 2  h after the mld 
 application in the study of schillinger et al.19 ; however , it was reported that mld effect peaks within 30 minutes 
 following mld22 . we observed a 
 significant fall in both la and ldh immediately after mld , and their application , with 
 levels remained low at the end of the second hour .
the first sign of 
 fatigue that follows is a loss of strength in voluntary muscle contraction23 . according to dierking and bemben
, la is 
 also responsible for the muscle pain accompanying delayed fatigue , which continues for 2448 
 hours after exercise24 .
this results in increased cellular permeability and in increases in 
 the serum concentrations of skeletal muscle enzymes such as ck , ldh and ast17 , an increase which are also affected also 
 by the type and intensity of exercise and the duration of muscular activity .
the overall 
 serum ck evolution shows an increase especially at 24  h after exercise , and the effect that 
 may persist for more than 4 days25 .
while 
 schillinger s study did not establish a significant difference in ck levels , the present 
 study showed that mld was followed by a decrease in ck within 24 hours , and a reduction in 
 delayed muscular fatigue .
the results of both studies suggested that mld contributed to 
 mitigation of muscular damage and enhanced the regenerative process of muscle cells . in our 
 opinion , such a contribution is significant , especially for athletes who have to strive 
 daily to present their best performance in competition .
analyzed ck 
 before and ( except ck ) , 24 h , 48 h , 72  h and 96  h after an exercise protocol .
they 
 classified individuals as  low  and  high  responders at the peak of maximum voluntary 
 concentric muscle contraction .
the classification of the subjects into low and high 
 responders groups was important for demonstrating that the most responsive group to strength 
 decrease after eccentric exercise also showed higher doms levels .
different methods including massage , cold application , tensing and light exercise are used 
 to help recovery after exercise .
studies of these methods are as yet insufficient for the 
 purpose of drawing definitive conclusions . published studies considering massage performed 
 post - exercise have investigated its effect on variables such as delayed muscle pain , 
 sensitivity , and muscular function and performance .
reported there was no effect 
 of post - exercise massage on delayed muscle pain reduction27 ; farr et al .
indicated that massage has no effect on muscle 
 performance and function , it does diminish pain intensity28 .
investigated the effect of massage on 
 post - exercise symptoms of 22 trained women using the pressure pain threshold , shuttle race 
 times and vertical leaps as outcome measures , and reported it resulted in muscular pain and 
 an improvement in vertical leaps29 . 

performed a study comparing the effects of deep / superficial massage with 
 those of passive tension and active to passive recovery on the lactate level in the blood . 

they concluded that neither of the two massage methods ( deep vs superficial ) or the passive 
 static tension application was correlated to a significant change in lactate levels ; in 
 other words , that they could be used as an alternative to active recovery ( at 50% 
 vo2max)30 .
these 
 contradictory results can be explained by the absence of a standard procedure for the 
 different techniques used under the description of  massage  and the small numbers of 
 subjects in the different studies31 .
another application thought to be potentially useful for recovery is intermittent pneumatic 
 compression ( ipc ) . a study performed by draper investigated the contribution of intermittent 
 pneumatic compression on the muscle inflammation marker c - reactive protein ( crp ) and doms in 
 trained athletes after long distance running .
the results indicated statistically there was 
 no significant difference in crp or pain levels between the control run and treatment 
 run2 .
however , the data suggests the test subjects recovered one day after 
 receiving ipc than to the control , and a full day recovery for a professional athlete is 
 very important .
studies with greater numbers of subjects comparing mld to different recovery 
 methods , following up values , especially ck serum levels , up to 120 hours are still needed 
 in order to proceed to a further advance our understanding of muscular recovery .
 [ purpose ] it has been well - established that exercise - induced muscle damage occurs 
 following intense exercise . 
 massage is commonly used to manage muscle damage resulting 
 from exercise . 
 however the effect of massage after exercise is still not clear . 
 the 
 purpose of this study was to examine the effect of manual lymph drainage on muscle damage 
 and on the removal of blood lactate following submaximal exercise ( se ) , as part of a 
 solution to the challenging problem in sports medicine of muscular recovery after 
 exercise . 
 [ subjects and methods ] eighteen healthy male students , with moderate exercise 
 training , were randomly assigned to either receive manual lymph drainage ( mld ) or serve as 
 controls . 
 both groups were subjected to a graded exercise test , performed on a treadmill 
 ergometer , to determine each subject s individual anaerobic threshold ( iat ) . 
 seven days 
 later , all subjects were made to run for 30 minutes on the same treadmill ergometer , at a 
 running speed equivalent to the iat . 
 one group received mld treatment , while the control 
 subjects received no treatment . 
 [ results ] following an increase immediately after 
 exercise , lactic acid ( la ) and lactate dehydrogenase ( ldh ) serum levels dropped rapidly 
 and significantly at the end of mld application and two hours after se in the subjects 
 receiving mld . 
 the course of creatine kinase ( ck ) and myoglobin levels was comparable , and 
 with myoglobin showing a significant difference at 2  h after se , and ck at 24  h after se . 
 
 [ conclusion ] manual lymph drainage after se correlated with a more rapid fall in la and of 
 the muscular enzymes of ldh , ck and myoglobin , and may have resulted in an improvement in 
 the regenerative processes elicted by structural damage to the muscle cells . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION