Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 2013, Article ID 171852, 8 pages
Effects of Swedish Massage Therapy on Blood Pressure,
Heart Rate, and Inflammatory Markers in Hypertensive Women
Izreen Supa’at,1Zaiton Zakaria,2Oteh Maskon,3
Amilia Aminuddin,2and Nor Anita Megat Mohd Nordin2
1Faculty of Biomedical and Health Sciences, Universiti Selangor, Shah Alam, Malaysia
2Physiology Department, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
3Medical Department, Cardiology Unit, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
Correspondence should be addressed to Izreen Supa’at; email@example.com
Received 23 August 2012; Accepted 21 July 2013
Academic Editor: Ka Kit Hui
Copyright © 2013 Izreen Supa’at et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
endothelial inflammatory markers. This randomized control trial measured the effects of whole body SMT (massage group) or
resting (control group) an hour weekly for four weeks on hypertensive women. Blood pressure (BP) and heart rate (HR) were
measured before and after each intervention and endothelial inflammatory markers: vascular endothelial adhesion molecules 1
(VCAM-1) and intracellular adhesion molecules 1 (ICAM-1) were measured at baseline and after the last intervention. Massage
(푃 = 0.01) after four sessions with no significant difference between groups. Reductions in HR were also seen in massage group
BP, HR, and VCAM-1 in hypertensive women.
group (푛 = 8) showed significant systolic BP (SBP) reduction of 12mmHg (푃 = 0.01) and diastolic BP (DBP) reduction of 5mmHg
after sessions 1, 3, and 4 with significant difference between groups. VCAM-1 showed significant reduction after four sessions: the
massage group showed reduction of 998.05ng/mL (푃 = 0.03) and the control group of 375.70ng/mL (푃 = 0.01) with no significant
old  with a prevalence in women higher than men . In
2004, 43% of women over 30 years old are hypertensive .
(CVD). CVD is the primary cause of death in women in
Malaysia as well as globally . In addition, more women
experienced the side effects of antihypertensive treatment
enzyme inhibitors compared to men .
The development of primary hypertension has been
in the increased expression of interleukin 6 (IL-6), inter-
leukin 1 (IL-1), tumour necrosis factor 훼 (TNF-훼), monocyte
chemoattractant protein 1 (MCP-1), VCAM-1, and ICAM-
1 in hypertensive rats [5–7]. VCAM-1 and ICAM-1 are
immunoglobulin superfamily (IGSF) molecules involved in
cell to cell adhesion. VCAM-1 is expressed on endothe-
lial, epithelial, macrophage, and dendritic cells. ICAM-1 is
expressed on endothelial, epithelial, fibroblast, leucocytes,
and tumour cells. VCAM-1 and ICAM-1 form attachments
and assist transendothelial migration of leukocytes at sites
of atherosclerosis . These molecules are upregulated in
response to inflammatory cytokines or oxidative low-density
lipoprotein(ox-LDL) . Duringan inflammationcaused by
injury, leukocytes will roll on the endothelium before firmly
adhering to the vessel wall. Stable adhesion of leukocytes
further upregulates adhesion molecules that will drive the
transmigration of leukocytes across the endothelium to the
site of injury. Leukocytes adhesion is opposed by tangential
2Evidence-Based Complementary and Alternative Medicine
ity gradient near the vessel wall .
is directly proportional to blood viscosity and velocity and
blood viscosity × blood velocity/vessel diameter). There are
andtheatherogenicoscillatoryshearstress which occurs
two types of shear stress: the atheroprotective laminar or
pulsatile shear stress which occurs in straight blood vessels
event of narrowingofthearteries, theshearstress here islow.
Consequently, blood will rush out of the narrow opening at
high velocity and create a higher shear stress on the arterial
wall, therefore inducing endothelial-dependent nitric oxide-
mediated vasodilation which brings the shear stress back to
normal. However, this effect is blunted in hypertensive and
hypercholesterolemic patients . It was found that with
increasing shear stress the expression of VCAM-1 is low
and the expression of ICAM-1 is high. There was also no
decrease in shear stress, the expression of VCAM-1 increases
and the expression of ICAM-1 decreases with leukocytes
of development of atherosclerosis [17, 18].
Swedish Massage Therapy (SMT) is a complementary
treatment that is believed to provide relaxation and therefore
able to reduce blood pressure caused by stress . It is the
and lymphatic flow. It is a painless, gentle and nonforceful
technique that is not associated with any serious adverse
pathetic activity and increase parasympathetic activity .
Therefore this therapy is able to decrease anxiety and stress
[23, 24]. In addition, massage therapy is able to reduce blood
[25–27]. It also increases skin blood flow and suppleness and
induces tissue relaxation . The long strokes in massage
compress the body tissues and when released increase blood
flow to the local area .
The present study assessed the effects of SMT versus rest
on hypertensive women. If SMT yields positive results in this
tary therapy to the conventional management of hyperten-
extends, no studies have assessed the effects of whole body
and inflammatory markers. In view of the literature stated
above, it was hypothesized that massage increases blood flow
and thus increases shear stress on the blood vessel wall. The
increase in shear stress reduces the expression of VCAM-1
and vWF and increases ICAM-1. In addition, through the
activation of parasympathetic nervous system, massage is
able to reduce BP and HR. Therefore Swedish Massage Ther-
apy is expected to reduce BP, HR, and VCAM-1 and increase
2.1. Participants. This study is an experimental randomized
control trial that has been approved by the Ethics Commit-
tee of the Universiti Kebangsaan Malaysia Medical Centre
(UKMMC) (Project Ethics Code: FF-280-2009). The par-
ticipants were 35–60-year-old women recruited from the
UKMMC records. These women must fulfil the following
(a) body mass index (BMI) of less than 35kg/m2;
or without treatment. If they are on antihypertensive
or anticholesterol medications, they must be on only
one medication of the same type and dose for at least
(c) normal liver, thyroid, and renal functions;
(d) not taking any prescribed and/or traditional medi-
cations (apart from those stated in (b)) and supple-
(e) not smoking or drinking alcohol;
(f) no other illnesses;
(g) not pregnant;
(h) have not experienced Swedish Massage Therapy.
Detailed explanation of the study was given to each
woman. All women had signed the consent form before par-
ticipating in this study.
is, BP taken before and after intervention with continuous
outcomes. The formulaused in this study is taken from Chan
2003 . The values forthis formulaare taken from another
study  with a similar topic and significant results. The
minimum number of subjects calculated is 16 with 8 subjects
Twenty-three women fulfilled the above criteria and
were screened for any health conditions that may influence
their blood pressure. Blood pressure of these women was
monitored for two weeks prior to the intervention. Blood
function and the fasting blood glucose level were normal.
Resting electrocardiogram (ECG) and stress tests were also
carried out to ensure normal cardiac function. Fasting body
composition was measured before and after the intervention
Twenty women successfully passed their screening. These
women were randomly assigned to two groups: the massage
group and the control group using random numbers gener-
ated through the SPSS version 15 software. However, only 16
women (8 per group) successfully completed the interven-
2.2. Intervention. In this study, the massage protocol is an
hour of Swedish Massage Therapy to the whole body, once a
week for four weeks. An hour of massage allows enough time
which was expected to produce positive effects on BP and
Evidence-Based Complementary and Alternative Medicine3
HR [30, 31]. Massage sessions once a week for four weeks are
considered not too frequent as they prevent the subject from
showing any signs of relaxation prior to the massage session
as would be expected if the sessions are more frequent.
whole body Swedish Massage Therapy once a week for four
weeks at the Clinical Trial Ward, UKMMC. A qualified mas-
sage therapist with a certificate in Holistic Therapy from the
Institute of Bioproduct Development, Universiti Teknologi
Malaysia, carried out the massage on each of the subjects.
The massage techniques used are a combination of petrissage
or kneading, tapotement or beating/hacking/cupping, and
effleurage or long strokes. These techniques are applied at
medium pressure. Olive oil was used as the lubricant. These
massage sessions were carried out during working days
between 8 and 10 a.m. The protocol used is described below.
(1) The subject is requested to lie prone with only the
right leg is exposed. Massage oil applied on the ex-
(2) Long strokes are applied on the posterior right leg.
(3) The gastrocnemius muscle is kneaded using both
(4) Step (2) is repeated.
(5) The medial and lateral parts of back of the thigh are
(a) kneaded using the palm of the hand;
(b) hacked or striken with the medial side of the
(6) Lymphatic drainage is then carried out by applying
long strokes along the venous or lymphatic vessels
towards the nearest lymph nodes.
(7) Step (2) is repeated.
(8) The left leg is covered and steps 1–7 are repeated on
the left leg.
(9) Massage is then carried out on the back. Massage oil
is applied on the whole back.
(10) Long strokes are carried out using the palms of
therapist hands from the lower back to the shoulders.
(11) Kneading using fingers is applied parallel to the spine
from the lower back to between the scapulae.
(12) Step (10) is repeated.
(13) Kneading using palms is applied on both loin areas
and posterior to the lungs.
(14) Lymphatic drainage was carried out from the lower
back to the axillary and subclavicular lymph nodes.
(15) Step (10) is repeated.
(16) The subject is requested to turn over and lie supine
with the right leg exposed. Massage oil is applied on
the whole leg.
(17) Long strokes are applied on the anterior right leg.
(18) The anterior tibialis muscle is kneaded using both
(19) Step (17) is repeated.
(20) The biceps femoris is kneaded using the palm of the
(21) Step (6) and Step (17) are repeated.
(22) Massage is then carried out on the abdomen where
massage oil is applied.
(23) Long strokes are applied from the umbilicus to the
xiphisternum, along the lower border of the ribs
towards lateral of the abdomen and inferior towards
the inguinal area.
(24) Strokes are applied along the ascending, transverse,
and descending colon.
(25) Small, circular kneading using tips of fingers is
applied clockwise around the umbilicus.
(26) Lymphatic drainage is carried out through long
strokes from the posterior loin area to the inguinal
(27) Step (23) is repeated.
(28) Massage is then carried out on the right arm where
massage oil is applied.
(29) Effleurage is applied using one hand to support the
subject’s arm and the other hand carrying out long
strokes from the wrist to the scapula region.
(30) The forearm is kneaded using the thumb.
(32) Step (29) is repeated.
(33) The subject is requested to sit up with her back to the
(34) The massage therapy ends with massage to the scalp,
neck, and shoulders.
(35) The scalp is kneaded from the frontal area to the
occipital area using fingers.
heel of the hands.
(37) The trapezius and deltoid muscles are kneaded ac-
cording to the orientation of the muscle fibers using
(38) BP and HR were taken. The subject is requested to
Eight women in the control group underwent an hour
of rest, once a week for four weeks at the same ward and at
the same time. They were instructed to lie supine and rest
either doing light reading or sleep. They are not allowed to
listen to any music, watch television, exercise, or carry out
any activities that may affect their BP.
4 Evidence-Based Complementary and Alternative Medicine
and after each massage and rest session and 48 hours after
the last session. Blood pressure was taken twice at five-
minute interval using the mercury sphygmomanometer and
HR through palpation.
10mL of blood was collected in normal test tubes with
no chemical preservatives at baseline, that is, before the first
massage and rest session and after the last session ended.
The blood was left to coagulate for two hours before being
centrifuged at 3000rpm for 10 minutes at 4∘C. The serum
before being analysed. The level of soluble VCAM-1 and
ICAM-1 was analysed using kits through the enzyme-linked
immunosorbent assay method (ELISA). The analysis pro-
tocols were carried out as instructed in the kits: VCAM-
1 (BMS232TEN, Bender MedSystems, Austria) and ICAM-
1 (BMS201INST, Bender MedSystems, Austria). The concen-
tration of soluble VCAM-1 and ICAM-1 of each sample was
calculated through the SOFTmaxPRO software through the
measurements of the absorbance value of the study samples,
the standard samples, and the control samples. The normal
range of soluble VCAM-1 as stated in the kit is 400.6–
1340.8ng/mL and soluble ICAM-1 is 129.9–297.4ng/mL.
is pipetted into 1mL Eppendorf tubes and stored at −70∘C
2.4. Statistical Analyses. Data were analysed using SPSS
software version 15. Due to the small number of samples
(<20), nonparametric statistical tests were used. The Mann-
used to measure the changes in each group. For BP and
HR, the difference between the preintervention readings and
postintervention readings of each session is considered to be
an acute change. The difference between the preintervention
readings of BP and HR of session 1 and preintervention
readings of subsequent sessions is considered to be chronic
the preintervention reading of BP and HR of session 1 and
reading 48 hours after session 4. All data is presented in
Whitney U test was used to compare the readings between
the two, groups, and the Wilcoxon Signed Rank test was
median (interquartile range). The value of 푃 < 0.05 is
accepted as the significant level.
3.1. Baseline Characteristics. The baseline characteristics of
the research participants are shown in Table 1. Women in the
massage and control groups were comparable in all parame-
However, this was still within the normal range. In general,
these women were overweight; resting BP showed Stage
1 hypertension, and lipid profile showed high cholesterol
and high LDL while HDL levels were normal. More than
62% were nonmenopausal. In each group, three participants
(37.5%) are on antihypertensive medications and only one
(12.5%) is on anticholesterol medication.
3.2. SBP Changes. Figure 1 shows the trend of SBP changes
for every session for both groups. During session 1, there
143.00 (9.00)mmHg to 138.00 (16.75)mmHg (푍 = −1.70,
Table 1: Baseline characteristics of the research participants.
(푛 = 8)
(푛 = 8)
On antihypertensives (%)
On anticholesterol (%)
Resting SBP (mmHg)
Resting DBP (mmHg)
Resting HR (bpm)
Fasting blood glucose
Data in median (interquartile range).∗푃 < 0.01 is significant.
137.00 (11.75)mmHg with 푍 = −2.52, 푃 = 0.01, after the
51.00 (10.00) 51.13 (11.00)0.96
푃 = 0.03). Chronic significant reduction was seen after the
second and third weeks in both groups and after the fourth
4.95 (0.25) 5.50 (0.45)0.01
first week in the control group from 140.00(23.75)mmHg to
week in the massage group only at 12mmHg (푍 = −2.54,
푃 = 0.01).TherewasnosignificantdifferenceinSBPreadings
3.3. DBP Changes. The trend in DBP changes is shown in
Figure 2. During session 1, there was an acute significant
between massage and control groups.
DBP reduction of 7mmHg in massage group (푍 = −2.38,
week (−2mmHg, (푍 = −2.21, 푃 = 0.03)), the third week
Therewere nosignificantdifferencesbetween thetwo groups
in all DBP readings.
significant HR reduction in massage group after each session
with significant differences between groups after session 1
inthecontrolgroupafterthefirstweek(푍 = −2.26,푃 = 0.02)
3.4. VCAM-1 Changes. The changes in the level of VCAM-1
are displayed in Figure 4. Significant reduction in VCAM-1
was seen in massage group from 1988.30 (911.39)ng/mL to
(602.39)ng/mL (푍 = −2.52, 푃 = 0.01). No significant change
푃 = 0.02). During session 4, there was an acute significant
(−5mmHg, (푍 = −2.52, 푃 = 0.01)) in the massage group.
(푍 = −2.22, 푃 = 0.03), session 3 (푍 = −2.07, 푃 = 0.04), and
with no significant difference between groups.
reduction in the control group from 81.50 (8.75)mmHg to
80.00 (5.25)mmHg with 푍 = −2.03, 푃 = 0.04. In addition,
(−8mmHg, (푍 = −2.54, 푃 = 0.01)), and the fourth week
session 4 (푍 = −2.03, 푃 = 0.04). Chronic reduction was seen
990.25 (675.25)ng/mL (푍 = −2.20, 푃 = 0.03) and the
was seen between groups.
control group from 1420.55 (861.07)ng/mL to 1044.85
Evidence-Based Complementary and Alternative Medicine5
Post 48 hr
Figure 1: SBP changes for each session for massage group and
control group.∗푃 < 0.05 (acute changes within groups) and㵻푃 <
0.05 (chronic changes within groups).++푃 < 0.05 (baseline versus
after session 4).
Figure 2: DBP changes for each session for massage group and
control group.∗푃 < 0.05 (acute changes within groups) and㵻푃 <
0.05 (chronic changes within groups).
3.5. ICAM-1 Changes. No significant changes were seen
within the two groups and between groups as shown in
Massage group showed chronic significant reduction in SBP
after two, three, and four weeks. These results are consistent
with Olney (2005) , Hernandez-Reif et al. (2000) ,
and Moeini et al. (2011)  which showed that massage
had long-term effects on the BP of hypertensive patients.
However, the control group of this current study also showed
chronic significant reduction in SBP after one, two, and three
weeks. These results contradict the results of the authors
Post 48 hrs
Figure 3: HR changes for each session for massage group and
control group.∗푃 < 0.05 (acute changes within groups),㵻푃 < 0.05
(chronic changes within groups), and#푃 < 0.05 (changes between
Week 0 Week 4
V-CAM 1 (ng/mL)
Figure 4: VCAM-1 changes for massage group and control group.
∗푃 < 0.05 (reduction within groups).
mentioned. Olney (2005) , Hernandez-Reif et al. (2000)
, and Moeini et al. (2011)  showed no significant
changes in SBP of their control groups. Several factors may
be able to explain these occurrences. Firstly, the rest session
of this current study is of longer duration if compared to the
studies of Olney  and Moeini et al. . Secondly, during
the resting period, the subject is free to use any relaxation
methods, and the researcher is only present during the pre-
and postintervention measurements. The combination of no
supervision and longer duration of rest may have reduced
the SBP of the control subjects. Acute reduction in SBP of
5mmHg after session 1 in the massage group was also seen,
6 Evidence-Based Complementary and Alternative Medicine
Week 0Week 4
I-CAM 1 (ng/mL)
Figure 5: ICAM-1 changes for massage group and control group.
In parallel with the results of SBP, the massage group also
and four weeks of massage therapy and acute significant
to reduce both SBP and DBP, even though there is no signifi-
cant difference between groups.
after each session, and the changes were significant between
groups after sessions one, three, and four. Even though the
duration of the massage session is different from other stud-
ies, these results are consistent with studies that measure the
effects of massage on normal individuals , breast cancer
patients , hospice patients , migraine patients ,
and critical care patients .
The reduction in BP and HR could be explained through
the comfortable feeling and relaxation, as well as the increase
(2009)  who showed that the massage applied at medium
component of HR variability which reflected an increase in
vagal activities. In addition, there was a decrease in the ratio
of low-frequency component to high-frequency component
of HR variability which indicates a change from sympathetic
activities to parasympathetic activities.
To date, there have been no studies that measure the
effects of massage on endothelial inflammatory markers. In
this current study, the massage group experienced a signifi-
cant reduction of VCAM-1 from an abnormal level to a nor-
and Simonson 2008  stated that SMT through effleurage
remains unchanged, the increase in blood flow increases
shear stress on the blood vessel wall. The increase in shear
stress decreases the expression of VCAM-1 [18, 37]. This
is supported by the studies of Ando et al., (1994) ,
Korenaga et al. (1997), and Helmlinger et al. (1995)
which showed decrease in the production of VCAM-1 at
the production of VCAM-1 at shear stress of ±0–4dyne/cm2.
studied the effects of shear stress at 10dyne/cm2on the
expression of ICAM-1 on human umbilical vein endothelial
cells (HUVEC) and Morigi et al. (1995)  who exposed
physiological shear stress of >15dyne/cm2and an increase in
It was expected that the level of ICAM-1 of the massage
group increases after the intervention. Walpola et al. (1995)
 showed that high shear stress (30.5dyne/cm2) increases
the expression of ICAM-1. Nagel et al. (1994)  who
HUVEC at shear stress of 8dyne/cm2also reported an
increase in the expression of ICAM-1. However, the current
study showed no significant changes in both massage and
control groups for ICAM-1. It may be that the shear stress
created by massage is not large enough to have effects on
ICAM-1. Further studies are warranted on the effects of
This study has shown that Swedish Massage Therapy or rest-
1 through the effects that have been discussed. However, the
to SMT. In addition, massage also reduces resting HR in
The authors would like to acknowledge all the staff at
the Physiology Department, Cardiology Unit, Clinical Trial
Ward, and the Centre for Research in Emergency Medicine,
UKMMC, for all their support during this research. This
research was funded by UKMMC Fundamental Research
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