Effects of compression tights on recovery parameters after exercise induced

muscle damage – a randomized controlled crossover study

Michael Hettchen1, Katharina Glöckler2, Simon von Stengel1, Andrea Piechele1, Helmut Lötze-
rich2, Matthias Kohl3, and Wolfgang Kemmler1
1
Institute of Medical Physics, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Erlangen,
Germany
2
Institute of Outdoor Sports and Environmental Science, German Sports University Cologne, Cologne,
Germany
3
Department of Medical and Life Sciences University of Furtwangen, Schwenningen, Germany

Running title: Effects of compression tights on recovery parameters

() Professor Dr. Wolfgang Kemmler, Institute of Medical Physics,

Friedrich-Alexander University Erlangen-Nürnberg, Germany,
Henkestrasse 91
91052 Erlangen
Tel: 0049 9131-8523999
Fax: 0049 9131-8522824

Emails:

[email protected]
[email protected]
simon.von.stengel@@imp.uni-erlangen.de
[email protected]
[email protected]
[email protected]
[email protected]

None of the authors had any advisory board or financial interests.

Abstract

Introduction: Recent meta-analyses on compression garments have reported faster recovery

of muscle function particularly after intense eccentric power or resistance exercise. However,
due to the complex interaction between cohort included, exercises involved and compression
applied, recovery length and modalities and outcome parameters selected, only limited prac-
tical recommendations can be drawn from these studies. Thus, our aim was to determine the
effect of compression tights on recovery from high mechanical and metabolic stress moni-
tored over a longer recovery period. We hypothesized, that compression tights significantly
increase regeneration of lower extremity performance parameters.

Material and Methods: Using a crossover design, 19 resistance-trained handball players were
randomly assigned at start of the project to the compression tight group (recovery pro tights,
cep, Bayreuth, Germany) or the control group. Immediately after a combined lower extremity
resistance training with calf raises, lunges and squats (2 sets of 8-10 reps to momentary fail-
ure) and electromyostimulation (calf, thigh, hip), participants had to wear compression tights.
Compression was applied initially for 24 h, and further 12 h intermitted by 12 h of nonuse for
a total of 96 h. Primary study endpoint was maximum isokinetic hip/leg-extensor strength
(MIES) as determined by a leg-press. Core secondary endpoint was lower extremity power as
assessed by a counter movement jump on a force plate. Follow-up assessments were con-
ducted 24, 48, 72, 96 h post exercise, consistently without compression garment. Endpoints
were analyzed using a linear mixed effect model with spherical symmetric within-group cor-
relation.

Results: All 19 participants underwent their allocated treatment and passed through the pro-
ject strictly according to the study protocol. In summary, the effect of compression tights on
MIES and lower extremity power was significant (p=.003 and p<.001 respectively).

Conclusion: Based on our results we recommend athletes wear compression tights for faster
recovery, particularly after intense exercise with a pronounced eccentric aspect.

Key words: compression garments, recovery, exercise, performance parameters, electromo-

stimulation
Introduction

In the last fifteen years, the wearing of compression garments in various amateur and profes-
sional sports has become ever more frequent. A milestone was set by Paula Radcliffe winning
the London Marathon in 2003. She won in world record time wearing medical knee-high com-
pression socks. However, although a limited number of studies indicate some evidence that
physical performance might be increased by compression garments (review in [1, 2]), current
focus of research is increasingly on regeneration after intense muscular performance (review
in [3-5]). In summary, recent reviews and meta-analyses reported faster recovery of muscle
function [3] after exercise particularly muscle damage induced by power or resistance exercise
(EIMD) [5, 6]. However, considering the heterogeneity of the few studies in this area, we are
not convinced whether meta-analysis might be able to conclude the effect of compression
garment on recovery from exercise-induced muscle soreness or damage. Indeed, reviewing
the underlying trials there are some methodical flaws that might seriously confound and/or
impede proper interpretation of the results. First, many corresponding studies applied exer-
cise protocols unable or at least suboptimal to generate EIMD or even profound muscular sore-
ness (overview in [3]). Correspondingly, compression-induced effects on only slightly affected
parameters might be negligible. Further, study outcomes often focus on parameters (e.g. lac-
tate, creatine kinase [7, 8]) less constructive for validating regeneration. Additionally, the mi-
nority of trials monitor regeneration periods >48 h. Thus, the aim of the study was to deter-
mine the effect of compression tights on relevant parameters of recovery applying a consci-
entious methodological and biometrical approach. In summary, we hypothesize that perfor-
mance parameters, perceived physical state and blood parameters related to EIMD were pos-
itively affected during recovery from a single bout of strenuous resistance-type exercise by
wearing compression tights. Our primary hypothesis was that compression tights significantly
increase regeneration of performance parameters after EIMD-generating exercise compared
with control, as validated by maximum isokinetic hip- and leg-extensor strength.

Materials and Methods

The study was designed and realized by the Institute of Medical Physics, Friedrich-Alexander
University of Erlangen-Nürnberg (FAU), Germany, in close cooperation with the German
Sports University Cologne, (DSHS), Cologne, Germany. All parts of the project were conducted
between December 2017 and February 2018 and complied with the Helsinki Declaration “Eth-
ical Principles for Medical Research Involving Human Subjects”. The ethics committee of the
German Sports University Cologne, Germany approved this study (registration number:
024/2016). After detailed information, all participants gave their written informed consent.
The study was fully registered under clinicaltrials.gov NCT03417323. In this article, we follow
the Consolidated Standards of Reporting Trials (CONSORT) guideline for reporting parallel
group randomized trials [9].

Study design

Using a crossover design, participants were randomly assigned to the compression garment
condition that started with the treatment condition during phase 1 or to the control condition
group that started without compression garment after the intervention. In parallel, partici-
pants who started with the control condition during phase 1 then switched to the treatment
condition in phase 2 and vice versa. Correspondingly, the study was structured into two inter-
ventions, one in December 2017 and one in January 2018 separated by a 6-7 week wash-out
period (Fig. 1).

4 weeks 2 weeks 6 weeks 2 weeks

Recruitment, informa- Intervention 1 & Washout period, cross- Intervention 2 &

tion & allocation first test period over between conditions second test period

Fig. 1: Study design

Participants

Using personal contacts to handball teams playing in the 4th and 5th German Division, we gave
detailed study information including the most relevant eligibility criteria (e.g. training, health
status) during two information meetings. Twenty-eight healthy male adults 20-50 years old,
living in the area of Erlangen-Nürnberg, Germany were interested and were further assessed
for eligibility. Applying the inclusion criteria: (a) more than 5 years of experience in competi-
tion ball sports with corresponding discipline-specific resistance exercise once a week and ex-
clusion criteria: (a) diseases and medication affecting muscle metabolism; (b) contraindication
for WB-EMS application (i.e. cardiac pacemaker) or heavy resistance exercise (e.g. knee/hip
arthrosis); (c) application of WB-EMS during the last 6 months; (d) absence during the testing
periods and (e) the intention to apply types of exercise known to induce severe muscle pain
(i.e. marathon run) during the study period, finally 19 participants were included in the study.

Fig. 2: Flow-chart of the study

Intervention

Due to the very intense muscular strain induced by the exercise protocol [10] the exercise test
and the recovery period was closely supervised by medical staff.

Exercise intervention

The exercise interventions were conducted between 8:00 and 10:00 on Sunday or Monday
morning at the Institute of Medical Physics, FAU under close medical supervision. In both pe-
riods (i.e. December and January), the identical high intensity resistance exercise with special
emphasis on the eccentric part of the movement was applied. Exercises (Fig. 3) focus on lower
extremities, further WB-EMS application for the gluteus, thigh and calf muscles superimpose
the voluntary load on the corresponding regions. In detail, using a circuit mode, two sets of 8-
10 repetitions of lunges (both sides immediately in succession), unilateral calf raises (both
sides immediately in succession) and squats were prescribed. Using dumbbells, participants
were required to increase the load to realize the prescribed work to momentary failure per
exercise [11] in the range of 8-10 reps. We scheduled a time under tension with 4 sec eccentric
– 1 s isometric – and an explosive concentric phase. We set a break of 2 s between the reps in
order to synchronize exercises with the impulse phase of the EMS. Recovery between exer-
cises average 60 s; time between the two rounds of the circuit averaged 2 min. Participants
were carefully instructed on how to conduct the exercises before the tests.

The EMS equipment (miha bodytec GmbH, Gerstenhofen, Germany) used in this project con-
sisted of various vest, hip, leg and arm electrodes that allowed a simultaneous stimulation of
all the main muscle groups with an stimulation area of up to 2,800 cm2 with regionally dedi-
cated specification. However, as reported in this project we focus on the gluteus, thigh and
calf regions (Fig. 3) i.e. the scope of application of the compression tights. Using our standard
WB-EMS protocol [12], impulse frequency was set at 85 Hz with an impulse width of 350 µs.
We applied an intermitted rectangular impulse pattern with 6 s impulse and 2 s impulse break.
During the impulse phase the single repetitions of the voluntary exercises were performed.
(Current) intensity was individually adapted for each lower body region in close interaction
between the participant and the instructor. We aimed to achieve a current intensity that just
allowed proper conducting of the voluntary movements under the premise of work to mo-
mentary failure. In order to quantify this specification we asked for the participants' perceived
exertion rating immediately after the exercise tests using the Borg CR 10 scale of perceived
exertion (RPE) [13].

Participants who underwent the control condition after the exercise intervention were asked
to maintain their habitual lifestyle without any attempt to reduce muscle pain or discomfort
by recognized methods.

Further, all the participants were instructed not to exercise 72 h prior to the exercise inter-
vention or during the 96 h testing phase.
Fig. 3: Lower extremity exercises with adjuvant WB-EMS application.
Recovery intervention

As reported, participants were randomly assigned to start with the treatment (i.e. compres-
sion tights) or control condition. Participants of the treatment condition started to wear the
compression tights immediately after the exercise intervention for 24 h. After this period, 12
h of wearing compression tights (800-1000 to 2000-2200) were intermitted by 12 h phases with-
out compression tights (2000-2200 to 800-1000). Of importance, compression garments were not
worn during the 24, 24, 72, 96 h follow-up tests.

Compression garments

We used compression tights (recovery pro tights, cep, Bayreuth, Germany) that cover hip,
thigh and calf from the proximal end of the iliac crest to the distal end of the metatarsus.
Tights consisted of 75% polyamide and 25% spandex.

In order to realize the prescribed compression, participants were invited prior to the interven-
tion to determine circumferences at the narrowest point ankle, the widest point of the calf
and the mid-thigh. Using these specifications the corresponding compression tight was se-
lected out of four conventional sizes. However, in eight cases lower leg physiognomy of the
participant required customized compression tights which were provided by the manufacturer
(cep, Bayreuth, Germany).

Using the HOSYcan System (Hohenstein System, Bönnigheim, Germany), compression within
the lowest and highest circumference of the suggested size are reported (Hohenstein System,
Bönnigheim, Germany) to vary between 18.1 – 23.4 mmHg for the most narrow size above
the ankle; 19.0-26.2 mmHG for the onset of the calf muscle; 16.3-23.5 mmHg for the highest
calf circumference, 9.9-18.1 mmHg two fingerbreadths beneath the fossa poplitea; 7.7-14.3
mmHg at the mid-knee; 9.9-13.9 at mid-thigh and 8.0-12.2 for the region two fingerbreadths
beneath the crotch. Due to our failure to determine the compression with completely and
properly drawn compression tights at these ankle, calf and thigh landmarks (see also “Euro-
pean Standards for testing medical hosiery”) using a pneumatic sensor (Kikuhime, MediGroup,
Melbourne, Australia), we are unable to validate these data on an individual base.

Outcome
Primary study endpoint:
 changes of maximum isokinetic hip and leg extensor strength as determined by an iso-
kinetic leg-press
Secondary study endpoints:
Core secondary study endpoint
 changes of lower leg power (jumping height) as determined by a counter movement
jump on a force plate
Subordinate secondary study endpoints
 changes of perceived physical state dimensions as determined by the Perceived Phys-
ical State (PEPS) scale.
 changes of creatine kinase, and myoglobin serum concentration.
Testing
Primary and secondary study outcomes were assessed immediately before (baseline) and 24h,
48h, 72h and 96 hours after the exercise intervention. We conducted all tests in a blinded
fashion i.e. research assistants were unaware of the status/condition and were not allowed to
ask . Baseline and follow-up assessments of the participants were conducted at the same time
of day (± 1 h).

Demographic parameters, health risk factors, diseases, medication, lifestyle habits, physical
activity and exercise were sampled by validated baseline questionnaire [14, 15]. In order to
determine the self-rated present general condition / perceived physical state of the partici-
pants we used the Perceived Physical State (PEPS) questionnaire suggested by Kleinert [16].
Briefly the 20-item version of the PEPS scale were structured into four factors that explained
the four dimensions activation ), training level , health and flexibility using a scale from 0 (not
at all) to 5 (completely). The same questionnaire also asked about acute physical pain sensa-
tion and ailments [16].

Height was determined by a stadiometer, (Holtain, Crymych Dyfed., Great Britain); body mass
and composition were determined via multi-segmental, multi-frequency Bio-Impedance Anal-
ysis (DSM-BIA, InBody 770, Seoul, Korea) immediately before the first exercise intervention.

Maximum isokinetic strength of the hip/leg extensors and flexors, was tested using a ConTrex
isokinetic leg-press (Physiomed, Laipersdorf, Germany). Bilateral hip/leg extension and flexion
was performed in a sitting, slightly supine position (15°), supported by hip and chest straps.
Range of motion was selected between 30° to 90° of the knee angle, with the ankle flexed 90°
and positioned on a flexible sliding footplate. The standard default setting of 0.5 m/s was used.
After familiarization with the movement pattern, participants were asked to conduct five rep-
etitions with maximum voluntary effort. Participants conducted two trials intermitted by two
minutes of rest. We consistently included the highest value for hip/leg extension and hip/leg
flexion of the five repetitions and both trials in the data analysis. Applying this approach, reli-
ability for the maximum leg-press test (Test-Retest-Reliability; Intra Class Correlation) was
0.88 (95%-CI: 0.82–0.93) as established in a previous study with men 30-50 years old [17].

Power of the lower extremities was tested by counter movement jump (CMJ) with hands on
the hips (no arm swing) during the test. Starting in an upright position participants were asked
to jump as quickly and explosively as possible in order to perform the highest possible jump.
We did not restrict countermovement depth, however, we ask participants to maintain exten-
sion in the hip, knee, and ankle joints to prevent any additional flight time by bending their
legs. Tests were performed on a force platform (KMP Newton GmbH, Stein, Germany). The
software provided by the manufacturer automatically calculates jumping height based on
ground reaction forces.

Blood was sampled under non-fasting condition from an antecubital vein before exercise and
24 h, 48 h, 72 h and 96 h post exercise. In summary, CK, myoglobin and LDHD were analyzed
using the Beckmann Coulter Inc. device and test kits (Brea, Ca, USA). The same research assis-
tant consistently conducted procedures of blood sampling and analysis.

Changes of trial outcomes after trial commencement

No changes of trial outcomes were conducted after trial commencement.

Sample size analysis

Based on our primary study endpoint “maximum dynamic hip-/leg extensor strength”, we con-
sidered a difference of percentage changes between compression and non-compression con-
dition (NCC) after 96h of 7.5% (SD 7.5%) as functionally relevant. Applying α=0.05 and β-1=0.8,
in total 16 participants were required to achieve this assumption. However, due to the ex-
hausting test protocol and the post exercise testing in the morning over 4 days that have to
be performed twice (with and without compression garments), we anticipated a drop-out rate
of about 20%, thus we included all the eligible men (n=19).

Randomization procedures and enrollment

Nineteen eligible men were randomly assigned to two groups that started with or without
compression tights during the first test period. Due to the crossover design of the study, we
used only a simple but balanced random (1-1) allocation. Supervised by the researcher re-
sponsible for the randomization process (SvS), the participants drew lots, and allocated them-
selves to the two conditions. Lots were put in opaque plastic shells (“kinder egg”, Ferrero,
Italy) and were drawn by the participants from one bowl in the order of their appearance. Of
importance, neither participants nor researchers knew the allocation beforehand. Finally, nine
men started with and 10 men started without compression garment during the first study
period. Subsequently, group status of the participants was listed by the primary investigator
(MH) who enrolled participants and instructed them in detail about their status including cor-
responding dos and don’ts.

Blinding

While participants and investigators are aware of the actual status (with or without compres-
sion), research assistants were kept blind to this allocation of the participants and were not
allowed to ask, either.

Statistical Analysis

All the eligible participants who were randomly allocated to the two groups were included in
the analysis independently of compliance with the protocol. Primary and secondary endpoints
were analyzed using a linear mixed effect model with spherical symmetric within-group cor-
relation also allowing for heteroscedasticity between time-points. The full model included
treatment, timepoint and period as well as their respective two and three-way interactions as
fixed effects and subject as random effect. Significance was accepted at p <0.05.

Results

Fig. 2 shows participant flow through the study. None of the participants quit the study or was
unable to attend a testing session. Further, all 19 participants underwent their allocated treat-
ment and passed through the project strictly according to the study protocol. Tab. 1 gives
baseline characteristics of the participants.

Participant test compliance averaged RPE 8.3±0.6 (December) and RPE 8.5±0.7 (January)
(“7”=really hard, “9”=really, really hard) on the Borg CR-10 scale; furthermore, all the partici-
pants completed the prescribed exercise sessions.

Tab. 1 Baseline characteristics of the cohort

Variable Participants (n=19) min - max
MV ± SD
Age [years] 31.3 ± 7.7 20 - 49
Body Height [cm] 183.5 ± 8.6 170 - 202
Body weight [kg] 81.1 ± 7.6 67.6 – 96.8
Lean Body Mass [kg]a 69.3 ± 8.5 56.2 - 87.5
Percent Body Fat [%]a 14.6 ± 8.5 7.7 – 26.3
Physical activity [Index]g 4.26 ± 1.56 1-6
Training volume [min/week] 176 ± 64 120 - 300
Smoker [n] 0 ----------
Vegetarians [n] 2 ---------

Table 2 gives the effect of compression and time after exercise intervention for the primary
study endpoint “changes of maximum isokinetic hip- and leg extensor strength” as determined
by an isokinetic leg-press. Of importance, we did not observe any carry-over or phase effects
(ie. December vs. January) for performance and PEPS parameters, thus we did not adjust for
this parameter. In summary, the effect of compression tights on exercise-induced changes of
maximum isokinetic hip and leg strength was significantly positive (p=.003). As a detail and
non-significant for the compression condition (p=.160), however, pre-exercise maximum
strength values were still not reached after 96 h of recovery.

Tab. 2: Fixed effect results for maximum hip/leg extension strength (in [N]). MV: mean value, SE:
standard error; DF: degrees of freedom; 95-CI: 95% confidence interval.

Variable MV SE DF 95%-CI p
Intercept 3955 179 157 3601 to 4309 -----
Compression 155 51 157 54 to 256 .003
24 h post -358 72 157 -216 to -499 <.001
48 h post -303 78 157 -149 to -457 <.001
72 h post -228 78 157 -73 to 383 .004
96 h post -180 75 157 -32 to -327 .017
Thus, we confirmed our primary hypothesis that wearing compression tights significantly im-
proves maximum dynamic hip/leg extensor strength after very intense muscular loading.

In parallel to the results on leg extension strength, exercise-induced changes of lower extrem-
ity power as determined by a counter movement jump (CMJ) using a force plate were signifi-
cantly increased (p<.001) by compression tights (Tab. 3). Again non-significant for the com-
pression condition (p=.113), full recovery for lower extremity muscle power was still not
reached 96 h post exercise.

Tab. 3: Fixed effect results for lower extremity power (in [cm]). MV: mean value, SE: standard error;
DF: degrees of freedom; 95-CI: 95% confidence interval.

Variable MV SE DF 95%-CI p
Intercept 35.6 1.3 157 32.9 to 38.2 -----
Compression 1.21 0.31 157 0.60 to 1.82 <.001
24 h post -2.59 0.48 157 -1.64 to -3.53 <.001
48 h post -3.32 0.57 157 -2.20 to -4.43 <.001
72 h post -2.87 0.60 157 -1.70 to -4.05 <.001

96 h post -2.10 0.50 157 -1.12 to -3.09 <.001

In general, “Perceived Physical State” (PEPS) was positively affected by the compression gar-
ment. However, results vary between the four dimensions of the PEPS. While significant re-
sults for “training level”1 (p=.017) and “Flexibility” (p=.024) were observed, the positive effect
of compression did not reach significance (=.05) for “activation”2 (p=.239) and health
(p=.622).

Pain sensation and ailments significantly differ (p=.002 and p=.004 respectively) between the
conditions with significantly more favourable data for the CG.

Tab. 4: Raw data for creatine kinase (IU/l) at baseline and 24 h, 48 h, 72 h and 96 h post-exercise.

compres- baseline 24 h 48 h 72 h 96 h Peak

sion MV ± SD; MV ± SD; MV ± SD; MV ± SD; MV ± SD; MV ± SD
Creatine kinase (CK) [IU/l]
Without 228 ± 86 4910±6941 12735±14637 29878±24096 31755±24136 34828±24807
With 214 ± 82 2310±3599 7018±7531 15453±12940 14700±9722 17593±13086

Finally, serum parameters related to EIMD (i.e. CK and myoglobin) significantly increased
(p<.001) during both periods with peak values after 72 h (myoglobin) and 72-96 h (CK) respec-
tively. Peak-CK indicated a severe rhabdomyolysis (i.e. >50-fold increase of baseline values)
independently of the condition (Tab. 4). Due to the enormous variation for CK and myoglobin,
the data was logarithmized for further analysis. In summary, we observed a significant positive
effect of compression on CK (p<.001), however not on myoglobin (p=.669).

Discussion

This randomized controlled crossover study clearly determined the positive effects of com-
pression tights on maximum lower extremity muscle strength and power. Less decided, only
two (Training level, Flexibility) out of four PEPS dimensions [16] were significantly impacted
by wearing compression tights. Also remarkable, the positive effect of compression on CK ki-
netics during recovery was very pronounced, while no significant effect was observed for my-
oglobin concentration.

1
German version: „Trainiertheit“
2
German version: "Aktiviertheit"
A considerable number of studies (review in [1-4] focus on the effect of compression garment
on performance parameters during recovery from exercise-induced muscle soreness/DOMS
and EIMD. However, due to differences in garment type (i.e. knee socks, calf/thigh/arm
sleeves, shorts tights, leggings), compression parameters, exercise intervention, follow-up pe-
riods and outcomes, definitive evidence of a significantly favorable effect of compression gar-
ments on recovery from exercise, (or) muscle soreness/DOMS (and/or) EIMD has yet to be
provided. A recent meta-analysis [3], however, concluded a positive effect of compression
garments on “recovery” particularly after resistance exercise and prior strength performance,
while the effect of endurance exercise protocols remained non-significant (Brown, 2017
#15050). Indeed, intense eccentric resistance exercise [18] and, to a much higher degree,
(very) intense WB-EMS3 [10] are known to induce severe muscle soreness/DOMS and/or EIMD
particularly in novices. Further, in order to determine the effect of compression on recovery,
it is crucial to induce relevant muscle soreness or even EIMD4 with corresponding impact on
muscular performance. Correspondingly, eccentric resistance training combined with WB-
EMS might be an optimum stimulus particularly when unusual for the applicant. Apart from
differences in compression garment, regeneration parameters and study endpoints, we think
the ability to induce relevant muscle soreness, EIMD and sustained reductions of muscle per-
formance might be the reason for the heterogeneous study results in this field [1-4]. Applying
conventional endurance exercise intervention with endurance athletes (e.g. [21, 22]) might
be too weak a stimulus for generating significant exercise-induced changes of the outcomes
addressed. Correspondingly, the power of the predominately low to medium sample size stud-
ies in this domain might be too low to determine the slight effects of compression (compared
to control) on recovery parameters. One may argue that the quantitative reviews and meta-
analyses recently published might overcome this issue [2-4]. However, although important for
providing proof of principle of the favorable effect of compression on recovery from exercise,
due to the complex interaction of cohort, exercise, compression, recovery and outcome pa-
rameters, only limited practical recommendations for athletes can be drawn from a meta-
analysis5.

3
WB-EMS stimulates all the main muscle group simultaneously with dedicated intensity per muscle group.
Considering that muscles can also be stimulated with supramaximal intensity, WB-EMS is ideally suitable [18, 19]
for generating very high concentrations of serum parameters related to EIMD.
4
However, DOMS does not reflect the magnitude of eccentric exercise-induced muscle damage [20]
5
See also Gentil et al. [23] who addressed this issue for resistance exercise protocols.
Due to the above-mentioned complexity, the proper comparison of our results with results of
the literature is a daunting task. However, simplifying our approach, a comparison with re-
sistance (or power) exercise trials [24-33] that focus on maximum voluntary contraction (MVC)
and/or jump performance as a study outcome might be productive. In summary, conflicting
results were reported, with significant faster recovery from resistance exercise [28-32], or fail-
ure to observe relevant effects of compression garment [25-28]. Even studies with compara-
ble exercise protocols (i.e. 50-100 maximum eccentric elbow flexions) compression garment
(i.e. arm sleeves, 10 to 17 mmHG), and duration of monitoring (72-96 h post) did not report
consistent results [24, 25, 30-32]6. Of importance, results were independent of compression
provided by the sleeves ([24, 30] or duration of wearing compression post-exercise [24, 25].

Most similar to our study, Goto et al. [28], who applied intense resistance exercise7 with men
experienced in resistance training and using whole-body-compression garments worn 24 h
immediately post exercise, reported significant effects (compression vs. control) on maximum
knee extensor strength for the final 24 h post-exercise assessment. In parallel, Jakeman et al.
[29], who applied intense jumping exercises8 with moderately exercising women using com-
pression tights worn for 12 h immediately post exercise, determined significant positive ef-
fects of compression on leg extension strength and jump performance. In detail, the authors
reported significant group differences in favor of compression for squat jump height and max-
imum isokinetic leg extensor strength following all assessments (24, 48, 72, 96 h post) while
the effect on CMJ height was less pronounced and significant at 48 h post-exercise only.
Shimokochi et al. [33] also observed significant effects of compression tights9 on maximum
isokinetic leg extension strength 24 h post exercise (10x 10 reps of maximal isokinetic knee
extension contractions, 30 sec of rest). However, the authors did not observe differences in
electromyogram (EMG) related variables between the two conditions, thus they concluded
neurological factors did not relevantly contribute to the favorable effect of compression tights

6
The three latter authors observed significant positive effects, while the first two authors did not report
differences between compression and control group.
7
inter alia 5 sets of 10 reps with 70% 1 RM with 90s of recovery for bilateral leg-press and knee extension, 3 sets
10 reps with 70% 1 RM for calf raises without adjuvant compression; compression not given.
8
1x 10 reps of plyometric drop jumps (60 cm box) with 10 s between jumps and 1 min between sets without
adjuvant compression; 17mmHG at the calf, 15 mmHG at the thigh.
9
 20 mmHG at the calf and 10 mmHG at the hip. Data given by the manufacturer; not validated by the
researcher. Compression tights were worn 8 h during overnight sleep.
worn during night sleep on recovery from quadriceps muscle fatigue. In contrast to these pos-
itive results, French et al. [27] did not observe significant results on muscular performance
(CMJ) 24 or 48 h after an exhausting squat exercise protocol (6x 10 reps with a focus on ec-
centric movement). Compression tights (12 mmHG at the calf, 10 mmHG at the thigh)10 were
worn 12 h overnight.

Despite being only secondary study endpoints, CK and myoglobin responses warrant brief con-
sideration. Predominately, we determined both parameters to appraise the exercise-induced
mechanical and metabolic stress of our protocol and, to a lesser extent, to determine meta-
bolic changes during recovery from exercise. Based on our experience with WB-EMS novices
[10] and considering the enhanced training status of the participants11, we expected CK and
myoglobin concentrations in the area of a moderate (i.e. 10-50-fold increase of resting con-
centration) rhabdomyolysis [35] after our exercise/lower body EMS protocol that focused ex-
clusively on gluteus, thigh and calf muscles. However, peak CK and myoglobin concentration
in this consistently and closely medically supervised study averaged 34828±24807 IU/l for CK
und 3163±2105 µg/l for myoglobin12 and did thus not relevantly differ from whole body appli-
cation [10]. Although, the delayed CK and myoglobin peaking after 9613 and 72 h respectively
might be a specific feature of WB-EMS application [36] and/or eccentric resistance exercise
(e.g. [37]) the need for observational periods longer than 24 or 48 h was supported by this
result. Summarizing the effect of compression tights on recovery from mechanical and meta-
bolic stress, our results of positive effects on CK but absence of effects on myoglobin concen-
tration is noteworthy. We are unable to provide a robust explanation of this scenario. We
speculate that differences might be due to myoglobin kinetics, specifically the shorter half-life
(2–3 hours) and more rapid renal clearance [38]. Further, apart from its (controversial dis-
cussed) role as a marker of muscle damage [19], CK plays a vital role in energy control pro-
cesses [19]. However, considering the long recovery period of 96 h without adjuvant exercise,
we do not think that this aspect might have relevance for our results.

Some features and study limitations might decrease the evidence of this trial or at least ag-
gravate its proper interpretation. (1) One main limitation of the project might be that we were

10
Data from the manufacturer; not validated by the researcher
11
Compared to untrained, CK-increase of athletes were much lower [19, 34]
12
However, without any other symptoms as cola colored urine or abnormalities for electrolyte balance.
13
However, due the termination of FU-assessment 96 h post exercise we are unable to decide whether CK-
concentration peaked after 96 h or had still increased….
unable to validate the correct fit and individual compression gradients using the recognized
Kikuhime pressure monitoring device (MediGroup, Melbourne, Australia). However, this was
not an aspect of the general validity and reliability of this device [39], but to the proper posi-
tioning at the six ankle calf and thigh landmarks proposed. Positioning the device with tape at
the anatomical landmark (see [40]) before working the tights higher towards the hip resulted
regularly in a displacement of the device. However, this failure to check the proper size of the
compression garment based on circumference measurements and correspondingly sugges-
tions of the manufacturer might provide a “real world scenario” for the application of com-
pression tights. (2) Another limitation might be the rather short washout period of 6 weeks.
Indeed, we observed a significant phase effect for serum parameters (CK, myoglobin) with
higher concentration during phase 1. Although we are aware of the pronounced repeated
bout effect [18] of WB-EMS on CK [10], we (a) still underestimated this effect and (b) had to
consider the short, only 8-week transitional phase during the two handball seasons to conduct
the project. (3) Another study limitation might be the somewhat artificial exercise intervention
within the project. Eccentric exercise is a frequent component of handball training; however
adjuvant WB-EMS application in handball players is still an experimental approach [41]. Nev-
ertheless, applying intense WB-EMS in EMS novices ensures severe muscle soreness and EIMD
independently of the training status of the applicants [10]. As discussed above, the need for
relevant intervention effects on muscle is crucial for the subsequent effect on recovery. (4)
We applied an intermitted protocol with 24 h compression immediately post exercise, FU as-
sessments and subsequent 12 h without compression followed by wearing compression tights
overnight for 12 h upwards. This differs from most studies which either applied continuous
compression over the whole study period of 24-72 h [24, 26, 28, 31, 32] or limited wearing
compression garment to 8-12 h (e.g. [25, 29, 33]) or 24h ([30]) of their 24 [33] to -96 h [25, 29,
30] observational period14. (5) Finally, the linear mixed effect model effect applied in this study
generated more statistical power to determine group differences compared with the simple
between group comparisons for the specific follow-up assessments (e.g. 24, 48, 72, 96 h post
exercise), predominately used in the present studies. However, due to this approach we are
unable to deduce the time course of compression induced recovery from exercise.

14
Unfortunately, not all the authors reported whether FU performance tests were conducted with or without
compression garments.
Conclusion

In summary, we observed a significant positive effect of compressive tights on performance

parameters after resistance-type exercise induced muscle damage (EIMD). Based on our re-
sults we recommend athletes to wear compression tights for faster recovery, particularly after
intense exercise with a pronounced eccentric aspect.

Data availability

The datasets generated and analyzed during the present study are available from the corre-
sponding author (M.H.) on reasonable request.

Conflict of interest

The authors declare that there are no conflicts of interest regarding the publication of this
manuscript.

Funding statement

The study was predominately funded by own resources of the Institute of Medical Physics
(IMP), University of Erlangen-Nürnberg (FAU). The manufacturer (cep, Bayreuth, Germany)
provided the compression garments and funded non-(IMP) institutionalized research assis-
tants for the study, who were however blinded to the condition of the participants. The IMP,
FAU did not receive any funding from the manufacturer (cep Bayreuth, Germany).

Acknowledgement

We acknowledge the support of University Hospital Erlangen, Germany for the close scientific
collaboration and the medical monitoring and supervision of the participants.
References

1. MacRae BA, Cotter JD, Laing RM (2011) Compression garments and exercise: garment
considerations, physiology and performance. Sports Med 41:815-843
2. Engel FA, Holmberg HC, Sperlich B (2016) Is There Evidence that Runners can Benefit from
Wearing Compression Clothing? Sports Med 46:1939-1952
3. Brown F, Gissane C, Howatson G, van Someren K, Pedlar C, Hill J (2017) Compression
Garments and Recovery from Exercise: A Meta-Analysis. Sports Med 47:2245-2267
4. Hill J, Howatson G, van Someren K, Leeder J, Pedlar C (2013) Compression garments and
recovery from exercise-induced muscle damage: a meta-analysis. Br J Sports Med
5. Marques-Jimenez D, Calleja-Gonzalez J, Arratibel I, Delextrat A, Terrados N (2016) Are
compression garments effective for the recovery of exercise-induced muscle damage? A
systematic review with meta-analysis. Physiol Behav 153:133-148
6. Hill KD, Hunter SW, Batchelor FA, Cavalheri V, Burton E (2015) Individualized home-based
exercise programs for older people to reduce falls and improve physical performance: A
systematic review and meta-analysis. Maturitas 82:72-84
7. Berry MJ, McMurray RG (1987) Effects of graduated compression stockings on blood
lactate following an exhaustive bout of exercise. Am J Phys Med 66:121-132
8. Rimaud D, Messonnier L, Castells J, Devillard X, Calmels P (2010) Effects of compression
stockings during exercise and recovery on blood lactate kinetics. Eur J Appl Physiol
110:425-433
9. Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, Elbourne D, Egger
M, Altman DG (2010) CONSORT 2010 explanation and elaboration: updated guidelines for
reporting parallel group randomised trials. BMJ 340:c869
10. Teschler M, Weissenfels A, Bebenek M, Frohlich M, Kohl M, von Stengel S, Kemmler W
(2016) Very high creatine kinase CK levels after WB_EMS. Are there implications for
health. Int J Clin Exp Med 9:22841-22850
11. Steele J, Fisher J, Giessing J, Gentil P (2017) Clarity in Reporting Terminology and
Definitions of Set End Points in Resistance Training. Muscle Nerve 368-374:368-374
12. Kemmler W, Weissenfels A, Willert S, Shojaa M, von Stengel S, Filipovic A, Kleinöder H,
Berger J, Fröhlich M (2018) Efficacy and safety of low frequency Whole-Body
Electromyostimulation (WB-EMS) to improve health-related outcomes in non-athletic
adults. A systematic review. Frontiers of Physiology online first:
13. Borg E, Kaijser L (2006) A comparison between three rating scales for perceived exertion
and two different work tests. Scand J Med Sci Sports 16:57-69
14. Kemmler W, Roloff I, Baumann H, Schöffl V, Weineck J, Kalender W, Engelke K (2006)
Effect of exercise, body composition, nutritional intake in male elite climbers.
International Journal of Sportsmedicine 27:653-659
15. Kemmler W, Bebenek M, von Stengel S, Kohl M, Bauer J (2015) Increases of
cardiometabolic risk in young adults. Impact of exercise reductions during the college
years. BJMMR 8:485-494
16. Kleinert J (2016) Adjektivliste zur Erfassung der Wahrgenommenen Körperlichen
Verfassung (WKV). Zeitschrift für Sportpsychologie 13:156-164
17. Wittke A, von Stengel S, Hettchen M, Frohlich M, Giessing J, Lell M, Scharf M, Bebenek M,
Kohl M, Kemmler W (2017) Protein Supplementation to Augment the Effects of High
Intensity Resistance Training in Untrained Middle-Aged Males: The Randomized
Controlled PUSH Trial. Biomed Res Int 2017:3619398
18. Koch AJ, Pereira R, Machado M (2014) The creatine kinase response to resistance
exercise. J Musculoskelet Neuronal Interact 14:68-77
19. Baird MF, Graham SM, Baker JS, Bickerstaff GF (2012) Creatine-kinase- and exercise-
related muscle damage implications for muscle performance and recovery. J Nutr Metab
2012:960363
20. Nosaka K, Newton M, Sacco P (2002) Delayed-onset muscle soreness does not reflect the
magnitude of eccentric exercise-induced muscle damage. Scand J Med Sci Sports 12:337-
346
21. Ali A, Caine MP, Snow BG (2007) Graduated compression stockings: physiological and
perceptual responses during and after exercise. J Sports Sci 25:413-419
22. Bieuzen F, Brisswalter J, Easthope C, Vercruyssen F, Bernard T, Hausswirth C (2013) Effect
of Wearing Compression Stockings on Recovery Following Mild Exercise-Induced Muscle
Damage. Int J Sports Physiol Perform
23. Gentil P, Arruda A, Souza D, Giessing J, Paoli A, Fisher J, Steele J (2017) Is There Any
Practical Application of Meta-Analytical Results in Strength Training? Front Physiol 8:1
24. Carling J, Francis K, Lorish C (1995) The effects of continuous external compression on
delayed onset muscle soreness (DOMS). Int J Rehabil Health 1:223-235
25. Cerqueira MS, Borgesa LS, dos Santos Rocha JA, Andradea HB, Pirôpoa UA, Lupato LA,
Pereira RC (2014) Twelve hours of a compression sleeve is not enough to improve the
muscle recovery of anexercise-damaged upper arm. Apunts Med Esport 50:23-28
26. Davies V, Thompson KG, Cooper SM (2009) The effects of compression garments on
recovery. J Strength Cond Res 23:1786-1794
27. French DN, Thompson KG, Garland SW, Barnes CA, Portas MD, Hood PE, Wilkes G (2008)
The effects of contrast bathing and compression therapy on muscular performance. Med
Sci Sports Exerc 40:1297-1306
28. Goto K, Morishima T (2014) Compression garment promotes muscular strength recovery
after resistance exercise. Med Sci Sports Exerc 46:2265-2270
29. Jakeman JR, Byrne C, Eston RG (2010) Lower limb compression garment improves
recovery from exercise-induced muscle damage in young, active females. Eur J Appl
Physiol 109:1137-1144
30. Kim J, Kim J, Lee J (2017) Effect of compression garments on delayed-onset muscle
soreness and blood inflammatory markers after eccentric exercise: a randomized
controlled trial. J Exerc Rehabil 13:541-545
31. Kraemer WJ, Bush JA, Wickham RB, Denegar CR, Gomez AL, Gotshalk LA, Duncan ND,
Volek JS, Putukian M, Sebastianelli WJ (2001) Influence of compression therapy on
 symptoms following soft tissue injury from maximal eccentric exercise. J Orthop Sports
Phys Ther 31:282-290
32. Kraemer WJ, Bush JA, Wickham RB, Denegar CR, Gomez AL, Gotshalk A.L., Volek JS,
Newton RN, Putukian P, Sebastianelli WJ (2001) Continuous Compression as an Effective
Therapeutic Intervention in Treating Eccentric-Exercise-Induced Muscle Soreness. J Sport
Rehabil 10:11-23
33. Shimokochi Y, Kuwano S, Yamaguchi T, Abutani H, Shima N (2017) Effects of Wearing a
Compression Garment During Night Sleep on Recovery From High-Intensity Eccentric-
Concentric Quadriceps Muscle Fatigue. J Strength Cond Res 31:2816-2824
34. Malone S, Mendes B, Hughes B, Roe M, Devenney S, Collins K, Owen A (2018) Decrements
in Neuromuscular Performance and Increases in Creatine Kinase Impact Training Outputs
in Elite Soccer Players. J Strength Cond Res 32:1342-1351
35. Visweswaran P, Guntupalli J (1999) Rhabdomyolysis. Crit Care Clin 15:415-428
36. Kemmler W, Teschler M, Bebenek M, von Stengel S (2015) [(Very) high Creatinkinase
concentration after exertional whole-body electromyostimulation application: health
risks and longitudinal adaptations.]. Wien Med Wochenschr 165::427–435
37. Rodenburg JB, Bar PR, De Boer RW (1993) Relations between muscle soreness and
biochemical and functional outcomes of eccentric exercise. J Appl Physiol (1985) 74:2976-
2983
38. Berridge RB, Bolon BE, Herman E (2018) Chapter 10: Skeletal Muscle System. In Wallig
MA, Bolon B, Haschek WM, Rousseaux CG, Mahle BW (eds) Fundamentals of Toxicologic
Pathology 3rd Edition edn. Academic Press/Elsevier, London, pp 195-212
39. Brophy-Williams N, Driller MW, Halson SL, Fell JW, Shing CM (2014) Evaluating the
Kikuhime pressure monitor for use with sports compression clothing. Sports Eng 17:50-
60
40. Brophy-Williams N, Driller MW, Shing CM, Fell JW, Halson SL (2015) Confounding
compression: the effects of posture, sizing and garment type on measured interface
pressure in sports compression clothing. J Sports Sci 33:1403-1410
41. Kemmler W, Teschler M, Bebenek M, von Stengel S (2011) Effekt von Ganzkörper-
Elektromyostimulation auf die übergreifende sportmotorische Leistungsfähigkeit im
Handball. Dtsch Z Sportmed 62:271