Compression garments: Just placebo? - Sportsmith

Compression garments: Just placebo? - Sportsmith

Compression garments: The most effective placebo in sports performance?

By Jonathon Weakley

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Compression garments. We have all seen them. We see them on our favourite athletes, on recreational runners as they jog past us and, more commonly, as casual wear when we go get our pumpkin spiced lattes. But what are they? Do they improve performance? And does the hype surrounding them reflect their value?

First, it is important to understand what compression garments are. Simply, they’re a type of clothing (often made of spandex) which apply mechanical pressure to the body. People use them before, during or after exercise in a bid to improve performance or enhance recovery. The most common compression garments are tights that cover the legs (Figure 2), but we also often see versions of compression garments that cover the arms, chest and even the entire body. Compression garments are also used for medical purposes – indeed, this is where their translation to sport began. However, for this article, we will only discuss compression garments and how they relate to exercise in healthy individuals.

Compression garments have received considerable attention over the years, with advocates touting a range of mechanisms for their potential efficacy. Improvements in biomechanical, physiological and perceptual outcomes are commonly put forward to support their use. With the growing interest in compression garments, naturally there has been an increase in research trying to understand any changes that occur when athletes wear them (Figure 3). Additionally, there are regularly efforts to understand how we can optimise their use. While an exhaustive overview of their use and effects is not possible here (but you can read this open access manuscript at Sports Medicine ), I will touch upon some of their uses in performance and recovery, and provide some of the current available evidence and my personal experiences.

Performance-related effects of compression garments

In sport, performance is often the most important outcome. Jumping higher, running faster and further, and being stronger are fundamentals of “good performance.” Interestingly, despite their widespread use, the majority of research does not support the use of compression garments for improving performance. Should we be throwing all our compression garments out? Not so fast. Performance is multifaceted and isolating individual elements of performance, as we do in research, can sometimes be overly simplistic.

Despite their widespread use, the majority of research does not support the use of compression garments for improving performance.

When thinking about compression garments and performance, the first question we should ask might need to be “is this item going to harm my performance?” The research is clear that the garments rarely, if ever, have negative effects on an athlete’s performance [1]. Therefore, if an athlete wears tights or an under layer that provides compression, there probably is no downside and we shouldn’t be telling the athlete to take it off.

Strength and power with compression garments

The effects of compression garments on muscle strength and power production has been relatively mixed, with garments either providing negligible or a small positive effect.

Most of the studies that have investigated compression’s effect on strength have used isometric tests. On the surface, this may seem a fair method of measuring strength, as these tests have reliable peak force values and can be easily implemented. However, if compression garments were to have an ergogenic effect on force production, dynamic exercises that include the stretch-shortening cycle (SSC) and the need for rapid force development have the greatest likelihood of improvement. This is due to compression garments:

having relatively strong evidence suggesting they can improve the filtering of non-specific sensory information, which can enhance joint proprioception and repositioning [2-4];

potentially supporting the SSC through greater elastic energy, depending on the pressure the garment provides.

When recently speaking to two elite Olympic weightlifting athletes regarding their decision to use compression garments, they both expressed that they feel more “supported” when wearing them. I can understand this and feel it makes sense, as compression garments help improve proprioception and have similar properties to knee wraps, which the weightlifting and powerlifting communities commonly use to improve concentric lifting performance. While the evidence is scarce when assessing acute strength and power changes, it is feasible that very small favourable changes could occur [5,6]. However, it’s important to temper any expectations, as the changes would be very small and likely will not affect strength endurance [5].

Compression garments and aerobic performance

Cardiovascular and cardiorespiratory outcomes are commonly touted as the beneficiaries of wearing compression garments. These changes may be of particular benefit for endurance exercise or exercise that has a considerable aerobic component.

Compression garments likely have very little influence on heart rate, although some evidence suggests they may affect cardiac output, which could be advantageous to the athlete [7-9]. Conversely, stroke volume is likely unaffected [8,10,11] and, at the muscular level, peripheral blood flow and muscle oxygenation likely do not benefit with compression use [10,12].

Naturally, these contradictory results lead to conflicting evidence to support their use during endurance exercise. Multiple studies have shown that compression garments can improve incremental aerobic performance [13,14], but one study demonstrated that time to fatigue may be negatively impacted by compression use (although metabolic cost may also be lower) [15]. During more sport specific testing, when completing circuits that mimic exercise (e.g., netball), the results showed enhanced performance [16]. But in real-life sporting scenarios, evidence is scarce for actual improvements in prolonged aerobic performance (e.g., triathlon) or when exercise includes an oppositional component (e.g., playing a football match) [17,18].

Again, this makes sense: sporting competition is more heavily influenced by extrinsic variables such as pacing strategies and tactical positioning, rather than by spandex covering an athlete’s legs!

Finally, for athletes who complete repetitive exercise (e.g., running, cycling), one benefit that isn’t reported within the literature is compression garments’ ability to minimise chafing. While something that we often don’t consider in the performance world, chafing can be extremely painful, and I’ve seen it remove players from training sessions. Therefore, when working with athletes who are prone to chafing, particularly during preseasons where there are higher volumes and athletes are getting back into the groove of things, having this trick up your sleeve may keep them in training!

Improvements in localised temperature

One clear effect that compression garments exert is increasing and maintaining skin temperature at the point of coverage. Compression garments increase skin temperature faster relative to control conditions during warm-ups [19], and the athletes maintain these temperatures to a greater extent throughout and following exercise [20-23]. This may be particularly beneficial in cold environments. Interestingly, despite localised changes in skin temperature, overall changes in body temperature, sweat rate and fluid loss are not observed [24-26]. These findings may be important for players who participate in intermittent sports, such as rugby union or American football, where there are prolonged periods of repositioning, organizing and waiting between plays.

Physiotherapists and strength & conditioning coaches are often terrified of players completing explosive exercise in the cold. The thought of wingers or wide receivers maximally sprinting and evading opponents on a cold winter day where the game has been stop-start gives me nightmares. Therefore, I have often recommended that players in those circumstances consider wearing compression garments to help keep important body parts (like the thighs) warm.

Compression garments for recovery

Enhancing recovery is frequently the aim of wearing compression garments. However, like performance, despite their common use, there is little evidence to suggest that they do indeed support the restoration of muscle function and the return to homeostasis.

Following exercise, compression garments largely demonstrate no benefit on commonly reported measures of muscle damage like creatine kinase and c-reactive protein [22-24], while evidence of a positive effect on muscle damage and swelling is scarce. There is some evidence to suggest that compression garments may facilitate recovery between high intensity bouts when there is limited recovery time [25], but the magnitude of change is small and the likelihood of this effect is borderline.

So, are compression garments beneficial for recovery? Well… it depends on what you consider as recovery.

Outside of changes in skin temperature, one of the most consistent positive findings in the literature (~57% of the time [1]) is that athletes perceive compression garments to reduce muscle soreness and pain. This is important because an athlete’s perception of how they are feeling can make a considerable difference to their actual performance. When an athlete feels good, they often perform better. Therefore, an athlete’s belief in the garment may play a substantial role in it benefitting the athlete. The literature backs this up, with compression garments having a greater effect in those who believed they were beneficial [26]. This information may be useful for the practitioner as it can help you identify which athletes should use compression garments. Alternatively, if recovery is the main goal, using some creative storytelling and emphasising how good compression garments “could” be may help improve perceptions of pain and muscle soreness following training and match play.

When an athlete feels good, they often perform better. Compression garments seem to have a greater effect in those who believed they were beneficial

Role of pressure in compression garments

Evidence for compression garments has been hampered by the broad implementation of garments, different exercises and times that the athlete is wearing the garment. But perhaps the most important yet poorly reported consideration is the pressure of the garment.

It is ironic that a substantial proportion of the literature has investigated compression garments and either:

not reported the pressure across points of the body;

not considered how different anthropometry can alter the pressure the garment applies;

cited generic information from manufacturer specifications; or,

estimated from indirect modelling techniques.

This has resulted in some research having wildly different levels of compression within the same studies! However, when we are a bit more selective of the data and consider studies that have compared the effects of different compression pressures on recovery, we start to see a slightly clearer story.

Hill et al., [27] showed improved recovery of jump performance when athletes wore stockings with higher pressure (applying 14.8 ± 2.2 mmHg at the thigh and 24.3 ± 3.7 mmHg at the calf ) compared to lower pressure (8.1 ± 1.3 mmHg and 14.8 ± 2.1 mmHg) for 72 hours following damaging exercise. Additionally, Mizuno and colleagues [28] showed decreased fatigue and muscle damage responses immediately following two hours of uphill running, when the athletes wore garments with “moderate” levels of compression (16.1 ± 2.0 and 17.9 ± 3.5 mmHg at the thigh and calf, respectively) throughout the exercise bout, compared to “high” pressure levels (26.9 ± 3.3 and 29.2 ± 3.8 mmHg) and a control (<5 mmHg).

These findings suggest the existence of an optimal pressure for recovery, and that going beyond this level of pressure may exert negative effects. This makes sense, as very high levels of pressure can induce perceptions of discomfort which, in turn, could mitigate any functional benefit. Considering these findings and the excellent review by Brown et al. [29], a pressure somewhere in the region of 14 – 19 mmHg at the thigh and 19 – 24 mmHg at the calf may provide the greatest benefit. But note, changes in anthropometry between individuals, chronic use of the same garment (i.e., stretching of the material) and generic information supplied by brands can be hurdles in finding the most efficacious fit.

One final consideration regarding pressure and how it is applied is whether “graduated pressure” is a necessary characteristic of your compression garment. While there is little literature available, evidence suggests that graduated compression is not necessary, with one study even suggesting that graduated compression was less effective than uniform compression at mitigating perceptions of calf pain [30]. Instead, the absolute pressure around the ankle or calf may play a more important role in facilitating recovery.

Future considerations for improving our understanding of compression garments

Clearly, there are still a lot of unknowns about compression garments. While there’s been some excellent research so far, there’s also been some less than satisfactory efforts that probably do more harm than good in helping us understand what compression garments actually do. Therefore, here are some key considerations to help push our understanding forward.

Due to the considerable effects belief in a product can have, before any intervention it is important to assess whether individuals indeed think that compression garments work. This can help the interpretation and delineate between the true effects of the garment and any placebo effects.

Report the material type and blend so the research and practitioner communities can assess whether certain properties are beneficial to performance or recovery.

Actually measure garment pressure across multiple sites, and reduce the variation between participants within the same group so we can make valid comparisons. This is essential to elucidating whether compression has any benefits. While some research suggests differential effects of garment pressure, due to the questionable level of reporting that is rampant within the literature, it’s difficult to making conclusive statements about beneficial effects.

Poor sampling practices by researchers has probably led to a lot of the inconclusive and ambiguous findings. Over 90% of the studies in this area have failed to report statistical power. That indicates that most studies are failing by design. Therefore, I would love to see more people practising good science and reporting the statistical power of their study, so the reader can be confident in the results they are reading.

When assessing changes in fatigue, muscle damage and recovery, it’s important to ensure that there was actually fatigue and muscle damage! Without pointing fingers, some research has suggested that improved recovery occurs with compression garments but failed to actually show that there was indeed any change in physical function following the exercise!

Recommendations for the use of compression garments

Compression garments come in all shapes and sizes, and this simple fact may well be the reason why we see such conflicting evidence throughout the literature. While evidence around compression garments will always be conflicting, evidence of performance and recovery gets more favourable when the sizing of the garment is appropriate and when there is sufficient pressure (e.g., 14 – 19 mmHg at the thigh and 19 – 24 mmHg at the calf [24,27]). The simple fact that compression garments should provide compression to the muscle is often overlooked. This may also mean that, after some use, you may need to replace the garment with a new set to maintain adequate levels of pressure.

Evidence of performance and recovery gets more favourable when the sizing of the garment is appropriate and when there is sufficient pressure (e.g., 14 – 19 mmHg at the thigh and 19 – 24 mmHg at the calf)

Weakley J, Broatch J, O’Riordan S, Morrison M, Maniar N, Halson SL. Putting the Squeeze on Compression Garments: Current Evidence and Recommendations for Future Research: A Systematic Scoping Review. Sports Medicine. 2021. Ahead of Print.

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