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The short-term effects of myofascial TrPTs massage therapy on cardiac autonomic tone in healthy subjects

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To investigate the effects of myofascial trigger-point massage therapy to the head, neck and shoulder areas on cardiac autonomic tone.Background. No studies have reported on the effect of back massage on autonomic tone as measured by heart rate variability. This is especially relevant to the nursing profession, as massage is increasingly available as a therapy complementary to conventional nursing practice. An experimental study in which subjects were initially placed in age- and sex-matched groups and then randomized to treatment or control by alternate allocation. The study involved 30 healthy subjects (16 female and 14 male, aged 32.47 +/- 1.55 years, mean +/- standard error). A 5-minute cardiac interbeat interval recording, systolic and diastolic blood pressure and subjective self-evaluations of muscle tension and emotional state were taken before and after intervention. Autonomic function was measured using time and frequency domain analysis of heart rate variability. Following myofascial trigger-point massage therapy there was a significant decrease in heart rate (P < 0.01), systolic blood pressure (P=0.02) and diastolic blood pressure (P < 0.01). Analysis of heart rate variability revealed a significant increase in parasympathetic activity (P < 0.01) following myofascial trigger-point massage therapy. Additionally both muscle tension and emotional state, showed significant improvement (P < 0.01). In normal healthy subjects myofascial trigger-point massage therapy to the head, neck and shoulder areas is effective in increasing cardiac parasympathetic activity and improving measures of relaxation.
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ISSUES AND INNOVATIONS IN NURSING PRACTICE
The short-term effects of myofascial trigger point massage therapy
on cardiac autonomic tone in healthy subjects
Joseph P.A. Delaney FIBMS
Lecturer in Behavioural Sciences, Wirral Metropolitan College, and Department of Medicine, Clinical Sciences Centre,
University Hospital Aintree, Liverpool, UK
King Sun Leong BMedSc BMBS MRCP
Consultant, Diabetes Centre, Whiston Hospital, Prescot, Merseyside, UK
Alan Watkins BSc MBBS
Honorary Research Fellow, Department of Medicine, University Hospital Southampton, Southampton, UK
and David Brodie BEd MSc PhD
Professor, Research Centre for Health Studies, Buckinghamshire Chilterns University College, Chalfont St Giles, UK
Submitted for publication 18 April 2001
Accepted for publication 19 November 2001
364 Ó2002 Blackwell Science Ltd
Correspondence:
David Brodie,
Research Centre for Health Studies,
Buckinghamshire Chilterns University
College,
Chalfont St Giles,
HP8 4AD,
UK.
E-mail: david.brodie@bcuc.ac.uk
DELANEYDELANEY JJ.PP .AA ., LEONGLEONG KK.SS ., WATKINSWATKINS AA.&&BRODIEBRODIE DD.(2002)(2002) Journal of
Advanced Nursing 37(4), 364±371
The short-term effects of myofascial trigger point massage therapy on cardiac
autonomic tone in healthy subjects
Aim of the study. To investigate the effects of myofascial trigger-point massage
therapy to the head, neck and shoulder areas on cardiac autonomic tone.
Background. No studies have reported on the effect of back massage on autonomic
tone as measured by heart rate variability. This is especially relevant to the nursing
profession, as massage is increasingly available as a therapy complementary to
conventional nursing practice.
Design/Methods. An experimental study in which subjects were initially placed in
age- and sex-matched groups and then randomized to treatment or control by
alternate allocation. The study involved 30 healthy subjects (16 female and 14 male,
aged 32á47 1á55 years, mean standard error). A 5-minute cardiac interbeat
interval recording, systolic and diastolic blood pressure and subjective self-evalu-
ations of muscle tension and emotional state were taken before and after
intervention. Autonomic function was measured using time and frequency domain
analysis of heart rate variability.
Results. Following myofascial trigger-point massage therapy there was a signi®cant
decrease in heart rate (P<0á01), systolic blood pressure (P0á02) and diastolic
blood pressure (P<0á01). Analysis of heart rate variability revealed a signi®cant
increase in parasympathetic activity (P<0á01) following myofascial trigger-point
massage therapy. Additionally both muscle tension and emotional state, showed
signi®cant improvement (P<0á01).
Conclusions. In normal healthy subjects myofascial trigger-point massage therapy
to the head, neck and shoulder areas is effective in increasing cardiac parasympa-
thetic activity and improving measures of relaxation.
Introduction
Nursing in a number of contexts (such as palliative care,
oncology and cardiac rehabilitation) is increasingly exposed
to complementary therapies. A PUBMED Medline search
using the combined terms `nursing' and `complementary
therapies' revealed 527 citations between 1980 and 1990
and 1653 citations between 1990 and 2000. More partic-
ularly, the use of therapeutic massage is re-emerging as a
popular nursing modality as evidenced by an increase in
journal articles. Again using the PUBMED Medline, data-
base, the terms `nursing' and `therapeutic massage' revealed
54 citations between 1981 and 1991 compared with 248
citations between 1991 and 2001. The evidence base for
these is increasing, but clinical governance requires further
information on the ef®cacy of such interventions. In general,
the present status of certain complementary therapies is that
they are offered in conjunction with conventional nursing
practice. It would be acceptable, for example, to see the
opportunity for re¯exology, autogenic training and aroma-
therapy advertised in conjunction with a coronary care unit.
Nurses may be unsure of the merits of such therapies because
it is not part of their training and the scienti®c validity is
currently in its infancy. Massage is used across the entire age
range and in many different nursing settings. For instance,
massage has been used to reduce symptoms and improve
quality of life in children with quadriplegic cerebral palsy
(Stewart 2000). It is also among the battery of nonpharma-
cological methods commonly used to relieve children's
postoperative pain (Polkki et al. 2001). In the ®eld of cancer
care, massage has been shown to provide meaningful relief
from suffering and a relatively short period of massage has
been shown to result in physical and emotional bene®ts for
cancer patients (Billhult & Dahlberg 2001). Back massage as
a form of intervention has been reported previously in this
journal (Fraser & Kerr 1993), but no study has previously
reported the impact of massage on cardiac autonomic tone.
As autonomic tone is implicated in so many common
diseases including diabetes, peripheral vascular disease and
coronary artery disease, it will be bene®cial to appreciate the
measurement, implications and potential of heart rate vari-
ability as a measure of autonomic tone. Massage therapy
was chosen because it is known to the nursing profession as
a prospective form of relaxation but it is not commonly
practised within mainstream nursing. The selection of
healthy subjects, in the ®rst instance, was to ensure quality
baseline data before including the confounding variables of
disease and types of medication. It is intended to undertake
further work on speci®c patient groups, such as diabetes and
recent postmyocardial infarction, now the speci®c bene®ts of
massage therapy on cardiac autonomic tone for normal
subjects has been established.
Therapeutic massage is the manipulation of the soft tissue
of body areas to bring about generalized improvements in
health (Vickers & Zollman 1999). A number of studies have
reported on the subjective effects of massage on muscle
relaxation and psychological state. In an evaluation of the
use of massage on the well-being of cancer patients, Corner
et al. (1995) reported that patients found massage to be
bene®cial in assisting relaxation and reducing physical and
emotional symptoms. Wilkinson et al. (1999) reported that
patients in a palliative care setting considered massage to be
bene®cial in reducing anxiety, tension, pain and depression.
Similarly, Fraser and Kerr (1993) reported that patients
perceived back massage as relaxing. In her article `Massage
Therapy Effects,' Tiffany Field gave a history of massage
and described many studies researching the numerous effects
of massage in various populations and in many different
settings (Field 1998). Relaxation appears to be the most
important bene®t of massage (Wilkinson 1996). Research
into massage therapy is increasing yet the number of studies
documenting objective physiological changes following
therapeutic massage still remains limited. Several nursing
studies examined various massage techniques on heart rate
and blood pressure variables but the results of these studies
are equivocal (Fakouri & Jones 1987, Reed & Held 1988,
Ferrell-Torry & Glick 1993, Fraser & Kerr 1993, Meek
1993, Stevenson 1994). To the best of the authors' know-
ledge the present study is the ®rst to examine the effects of
myofascial trigger-point massage on cardiac autonomic tone
using analysis of heart rate variability to assess effects of
treatment.
Myofascial trigger-point massage therapy (MTPT) is an
advanced neuromuscular technique commonly used in the
®eld of sports therapy for the alleviation of pain and to
induce muscle relaxation following injury (Peppard 1983). It
combines a variety of massage strokes with deeper more
focused pressure at myofascial trigger-points (MTrP). As
such, it is similar to acupressure which involves applying
pressure or massage to traditional acupuncture points (Filshie
Keywords: massage, heart rate variability, autonomic tone, muscle tension,
emotional state, relaxation, myofascial trigger point, parasympathetic, sympathetic,
healthy subject
Issues and innovations in nursing practice Trigger-point massage and cardiac autonomic tone
Ó2002 Blackwell Science Ltd, Journal of Advanced Nursing,37(4), 364±371 365
& Abbot 1991). When combined with exercise, MTPT has
been shown to reduce the number and intensity of MTrP and
to be effective in treating MTrP in the neck and shoulder
areas (Gam et al. 1998).
Myofascial trigger-points are small discrete hyperirritable
areas within a taut band of muscular tissue or fascia. They are
painful on compression and can evoke characteristic referred
pain in areas far away from their actual location (Travell &
Simmons 1983). Melzack et al. (1977) reported a remarkably
high degree (71%) of correspondence between MTrP and
acupuncture points associated with pain. Stimulation of these
MTrP can cause changes within the peripheral autonomic
nervous system, such as local excessive perspiration, pilo-
erection, local vasodilation, and erythema (Travell &
Simmons 1983).
Heart rate variability (HRV) is the beat-to-beat variation
of the R-R interval of the electrocardiogram. This variability
is modulated by the sympathetic and parasympathetic
components of the autonomic nervous system (Task Force
1996). Within the last decade, and as the result of new and
more powerful computer-based analysis systems, HRV
measurement has rapidly expanded in the ®eld of autonomic
nervous system research. Analysis of HRV is a sensitive,
noninvasive, indirect technique, which can be used to
identify cardiac autonomic disturbances, such as in the
early subclinical detection of autonomic dysfunction in
diabetes mellitus (Pagani et al. 1988) and following myocar-
dial infarction (Kleiger et al. 1987). A reduction in HRV is
associated with an increased risk of coronary heart disease
(Liao et al. 1997) cardiac sudden death (Singer et al. 1988)
and all-cause mortality (Tsuji et al. 1994). Heart rate
variability analysis has also been used to assess changes in
sympathovagal tone in various mental (Carney et al. 1995)
and emotional states (Rechlin et al. 1994, McCraty et al.
1995).
Heart rate variability can be assessed in two ways: as a
time domain analysis or in the frequency domain using power
spectral analysis (PSA). Time domain measures are the
simplest to calculate and include the standard deviation of
normal-to-normal R-R intervals (SDNN), root mean square
of successive differences (RMSSD) and the proportion of
differences between adjacent normal interbeat intervals that
are >50 ms (pNN50). These measurements of short-term
variability estimate rapid variations in heart rate and are
generally associated with parasympathetic nervous system
activity (Kleiger et al. 1987).
In the frequency domain, the PSA of HRV is generally used
to identify three discrete frequency components. High
frequency (HF; 0á15±0á40 Hz), low frequency (LF; 0á04±
0á15 Hz), and very low frequency (VLF; 0á00±0á04 Hz). The
HF range re¯ects rapid changes in the beat-to-beat variability
and is associated with ¯uctuations in vagal tone, and the LF
region corresponds to blood pressure oscillations around
0á1 Hz. (Mayer waves) (Pomeranz et al. 1985). The HF and
LF bands are indirect measures of cardiac parasympathetic
and sympathetic activity, respectively, and the LF/HF ratio is
frequently used as an indicator of sympathovagal balance.
The VLF range is still poorly understood but oscillations in
this band are generally attributed to thermoregulation
(Hyndman et al. 1971) and the renin±angiotensin±aldo-
sterone system (Akselrod et al. 1985). Figure 1 shows a
typical spectrum with the speci®c frequency bands clearly
marked.
Using PSA, a spectral graph is obtained with peaks at the
frequency bands previously mentioned. The area under the
curve represents the power attributed to each particular band
(Task Force 1996). Total Power (TP) is the sum of the power
contained within the VLF, LF and HF bands.
Analysis of heart rate variability has been used to highlight
the importance of the autonomic nervous system in health
and disease (Kristal-Boneh et al. 1995, Sleight 1997). It has
also been used to provide insights into the possible cardio-
protective effects of physical activity in postmenopausal
women (Davy et al. 1996), to test the effects of dynamic
exercise in athletes (Shin et al. 1995), and to test the effects of
different lifestyles (smokers, sedentary and aerobically ®t
persons) on cardiovascular regulatory mechanisms (Galla-
gher et al. 1992).
The study
In this study we investigated the effects of MTPT to the head,
neck and shoulder areas on cardiac autonomic tone and
evaluated the psychological outcomes of the treatment.
Figure 1 Very low frequency (VLF) band 0á00±0á04 Hz, low
frequency band (LF) 0á04±0á15 Hz and high frequency (HF) band
0á15±0á4 Hz.
J.P.A. Delaney et al.
366 Ó2002 Blackwell Science Ltd, Journal of Advanced Nursing,37(4), 364±371
Method
Participants
Thirty normal, healthy volunteers [16 females, 30á94
1á72 years, mean standard error (SESE); 14 males,
34á42á74 years, mean SESE] were recruited in the year
2000 via e-mail, bulletin boards, posters and from verbal
requests for volunteers. They comprised 22 students and ®ve
staff all from a further education college in the north-west of
England, as well as three friends who were not part of the
college. Most of the subjects engaged in a modest amount of
physical activity weekly. None were involved in regular high
intensity physical activity. Ethical committee agreement and
informed consent was obtained prior to testing.
All subjects were in good general health with no medical
conditions known to affect HRV. No subject was taking any
prescription drugs known to affect the cardiovascular system.
Subjects were randomly assigned into two age- and sex-
matched groups (eight females, seven males in each). They
were requested to refrain from smoking or drinking any
caffeine-containing beverages for at least 8 hours prior to
testing but were allowed a light breakfast at least 2 hours
before the test. Throughout the study subjects were requested
to refrain from making any exaggerated body movements or
intentionally altering their respiration.
Protocol
Subjects in Group One received MTPT to the head, neck and
shoulder areas for 20 minutes while the subjects in Group
Two relaxed by sitting quietly for the same time period thus
acting as controls. Data acquisition took place between 09á30
and 11á30 hours in a quiet, warm, temperature-controlled
environment (22±24°C). Subjects were seated in a straight,
high-backed chair to minimize postural changes. The chair
was positioned adjacent to a Polar Advantage Interface (Polar
Electro Oy, Kempele, Finland) that received signals from the
transmitter.
Subjects were allowed to rest comfortably for at least
10 minutes prior to the baseline recording procedure. During
this time they were ®tted with an elasticated electrode belt,
which incorporated a Polar Coded Transmitter (Polar Electro
Oy, Kempele, Finland). The `ribbed' electrodes were coated
in electrode gel to ensure maximum conduction and the
transmitter was positioned centrally, directly below the
xiphisternum. The belt was attached tight enough to
minimize movement of the electrodes but did not cause any
discomfort. Heart rate data acquisition took place for
5 minutes at baseline and for 5 minutes immediately
following treatment. Systolic and diastolic blood pressure
recordings were also taken at baseline and following treat-
ment using an automated blood pressure recorder (Omron
Healthcare, Europe). They were measured twice on the right
arm and the mean of the duplicate results was recorded.
Measurements of emotional state and muscle tension
Self-reports of emotional state and feelings of muscle tension
were measured before and after treatment using a 100-mm
visual analogue scale (VAS) with verbal anchors at either end
(Figure 2). Visual analogue scales have been used previously
by Grunberg et al. (1996), Wright (1987), Kaplan and
Camacho (1983) and Maddox and Douglass (1973) to
examine self-assessment of health and quality of life.
Massage procedure
Subjects were not required to undress for the massage therapy
and wore light cotton T-shirts. Following baseline recordings
they remained seated in the upright chair. In order to
maintain consistency, the same therapist, a fellow of the
International Council of Health, Fitness and Sports Thera-
pists, performed all massages. The massage procedure, which
took 20 minutes, employed the techniques of ef¯eurage,
petrissage, cross-®bre stroking and tapotement as described
by Goats (1994). Deeper more focused pressure and circular
frictions were applied to myofascial trigger-point areas in the
upper, middle and lower trapezius muscle region and the
suboccipitalis region. Gentle circular frictions and palmar
kneading was also applied in the areas of the frontalis and
temporalis muscles together with linear stroking to the
sternocleidomastoid muscles. The anatomical locations of
the MTrP used in this study can be found in detail in The
Trigger Point Manual (Travell & Simmons 1983).
Data analysis
The methods of data collection and analysis used in this study
have been described in detail previously (Delaney & Brodie
2000). Brie¯y, HRV was calculated following removal of any
abnormal beats. This consisted of an automatic default
®ltering procedure contained within the Polar Precision
Performance Software package (Polar Electro Oy, Kempele,
Finland) and also a careful inspection of the cardiac interbeat
(R-R) interval tachogram. The tachogram was visually
Figure 2 Examples of visual analogue scales for muscle tension and
emotional state.
Issues and innovations in nursing practice Trigger-point massage and cardiac autonomic tone
Ó2002 Blackwell Science Ltd, Journal of Advanced Nursing,37(4), 364±371 367
scanned to ensure complete removal of abnormal data. If
required any further `aberrant' beats were removed manually.
Measurements in the time domain consisted of the mean
R-R interval, SDNN, RMSSD and pNN50. The following
frequency domain indices of heart rate variability were
calculated: (1) very low frequency power from 0á00 to
0á04 Hz; (2) low frequency power from 0á04 to 0á15 Hz; and
(3) high frequency power from 0á15 to 0á40 Hz. An autore-
gressive model, which has been suggested as the optimal
method for short-duration recordings (Task Force 1996), was
used to generate the heart rate spectra.
Statistical analyses
Data are given as mean SESE. All variables were tested for
normality using the Kolmogorov±Smirnov test. The LF/HF
ratios alone did not have a normal distribution and therefore
were log-transformed prior to statistical analysis. An F-test
was used to compare test and control groups for differences
in variance. An unpaired t-test was used to compare the test
and control groups for all variables at baseline. A paired t-test
was used to compare values before and after treatment for
test and control groups. A two-tailed probability of P<0á05
was considered statistically signi®cant.
Results
At baseline there were no statistically signi®cant differences
between both groups for all variables in the time and
frequency domains (Table 1) or for self-perceived measures
of emotional and muscle tension (Table 2). The P-value for
emotional tension approached signi®cance at 0á06, thus the
results for this variable may represent a type-2 statistical
error. Additionally, no signi®cant gender differences were
observed at baseline or following treatment.
In the time domain, the results show that MTPT caused an
overall decrease in heart rate as indicated by an increase in
average R-R interval length (P<0á01). (Table 1). SDNN
increased by 26á8% (P<0á01), RMSSD by 46á8% (P<0á01)
and pNN50 by 55á8% (P<0á01) following MTPT. There
were no signi®cant changes observed in the time domain
measures in the control group (Table 1).
In the frequency domain a 73á5% increase was observed in
TP (P<0á01) along with an 84á5% increase in VLF power
(P0á03), and a 90% increase in HF power (P0á02). No
signi®cant changes in LF power were seen in both groups. A
17% decrease in LF to HF ratio (P0á04) was observed in
the massage group. There were no signi®cant changes in the
control group for any frequency domain measures.
Additionally there was a 39% reduction in muscle tension
and emotional state improved by 32% following MTPT
(P<0á01) (Table 2). No signi®cant differences were observed
in the control group for muscle or emotional tension. In the
massage group systolic blood pressure was signi®cantly
reduced (P0á02), as was diastolic blood pressure (P0á01).
Discussion
To the best of the authors' knowledge this is the ®rst study to
examine the effects of myofascial trigger-point massage
therapy to the head, neck and shoulders using HRV analysis
Table 1 Time and frequency domain results for baseline and treatment conditions in experimental and control groups. Data are given as
mean SESE
Experimental group Control group
Baseline Post-MTPT P-value Baseline Postrelaxation P-value
Time domain variables
Heart rate (beats/minute) 71á92á466á52á5<0á01 73á92á871á72á50á10
R-R interval (ms) 845 25á5 918 31á6<0á01 825 27á4 848 26á10á12
Standard deviation of
interbeat intervals (ms)
60á85á377á17á2<0á01 58á65á262á96á10á15
Root mean square of
successive differences (ms)
36á54á153á67á0<0á01 32á34á032á34á60á99
PNN50 (%) 5á21á58á12á0<0á01 6á01á45á51á30á34
Frequency domain variables
Total power (ms
2
) 2485 521 4311 1011 <0á01 2490 612 2947 592 0á12
Very low frequency power (ms
2
) 1248 280 2303 638 0á03 1195 321 1508 290 0á15
Low frequency power (ms
2
) 910 221 1390 489 0á12 1003 286 1177 335 0á16
High frequency power (ms
2
) 327 121 618 219 0á02 292 75 262 49 0á49
Low frequency to high frequency
ratio (log transformed)
1á52 0á28 1á26 0á26 0á04 1á36 0á21 1á49 0á23 0á43
J.P.A. Delaney et al.
368 Ó2002 Blackwell Science Ltd, Journal of Advanced Nursing,37(4), 364±371
to measure cardiac autonomic tone. The results of the study
suggest that MTPT to the head, neck and shoulder areas for
20 minutes is highly effective in increasing HRV and cardiac
parasympathetic activity in normal subjects. This is demon-
strated in the time domain by a decrease in heart rate and an
increase in SDNN, RMSSD, and also pNN50. In the
frequency domain this is shown by an increase in TP and
HF power and a reduction in LF/HF ratio.
A simple decrease in heart rate by itself may be considered
a sign of relaxation although the exact mechanisms causing
the decrease would be unknown. An increase in parasympa-
thetic activity or a decrease in sympathetic activity would
cause a decreased heart rate. The purpose of using analysis of
HRV is to try to determine the exact change in sympath-
ovagal balance.
It is generally accepted that the power of the HF oscilla-
tions found between 0á15 and 0á4 Hz, is an indirect marker of
efferent parasympathetic (vagal) input to the heart. In this
study, following MTPT, a signi®cant increase in HF power
was observed. An increase in parasympathetic nervous system
activity has been associated with the relaxation response
(Benson et al. 1974).
In the range between 0á04 and 0á15 Hz there was a
nonsigni®cant increase in LF power following treatment. The
LF range is generally accepted as a marker of sympathetic
nervous system activity associated with ¯uctuations around
0á1 Hz corresponding to blood-pressure control oscillations
known as Mayer waves (Pomeranz et al. 1985).
Increases in LF and HF power have been reported
following sensory stimulation by acupuncture needling
(Haker et al. 2000). Sensory stimulation in healthy persons
may be associated with changes in both the sympathetic and
parasympathetic nervous system depending on the site of
stimulation. This may account for the increases in both LF
and HF power in the present study, although the increase in
HF power is signi®cantly greater following MTPT. Hence, the
reduction in LF/HF ratio seen in this study (P0á04) again
suggests a shift toward cardiac parasympathetic activity.
Interestingly, the VLF component, which is generally
associated with thermoregulatory mechanisms (Hyndman
et al. 1971) and the renin±angiotensin system (Akselrod et al.
1985) shows a signi®cant increase following MTPT. Previous
studies in humans have shown that the VLF component may
be mediated by cardiac parasympathetic activity (Taylor
et al. 1998), therefore the signi®cant increases in HF power
following MTPT may have mediated the increase in VLF
power. Care must be taken in the interpretation of these
results as only a 5-minute data acquisition period was used in
this present study. Further investigation using longer
recording periods is needed to explore this particular area
of research.
In this study MTPT was also shown to be effective in
signi®cantly reducing both SBP (P0á02) and DBP
(P0á01). Felhendler and Lisander (1999) have demon-
strated that noninvasive stimulation of acupressure points
also signi®cantly in¯uences the cardiovascular system by
reducing SBP, DBP and heart rate.
As previously mentioned, acupressure points and MTrP are
thought to represent the same phenomena and the techniques
used in this study may be activating similar mechanisms to
produce blood pressure reduction. It should be pointed out
that in addition to deep focused pressure at trigger-point
sites, the massage procedure used in this study did addition-
ally contain some general ef¯eurage strokes. It has been
previously shown that these less complicated massage proce-
dures alone can be effective in lowering blood pressure (Cady
& Jones 1997).
With reference to quality of life measures, subjects reported
feeling less muscle tension and signi®cant improvement in
mood following MTPT. These ®ndings are probably the
result of an increased relaxation response and an overall
reduction in the defence-arousal (stress) response and are
possibly mediated by increased parasympathetic activity.
Although there was a nonsigni®cant difference in the
groups at baseline, the values for emotional tension of
P0á06 recognize the possibility of type-2 error. This
limitation is appreciated and future studies would bene®t
from larger group sizes or matching baseline groups for
psycho-physiological variables. A further limitation to this
study is that any effect could potentially be because of some
Table 2 Emotional state, muscle tension and blood pressure results for baseline and treatment conditions in experimental and control groups.
Data are given as mean SESE
Experimental group Control group
Baseline Post-MTPT Pvalue Baseline Postrelaxation Pvalue
Self-perceived muscle tension (mm) 41 3á0254á4<0á01 35 5á0333á10á27
Self-perceived emotional tension (mm) 47 3á2323á9<0á01 38 5á2353á40á49
Systolic blood pressure (mmHg) 125 3á5 119 3á40á02 122 2á7 120 2á70á06
Diastolic blood pressure (mmHg) 79 2á3762á50á01 76 2á9742á50á14
Issues and innovations in nursing practice Trigger-point massage and cardiac autonomic tone
Ó2002 Blackwell Science Ltd, Journal of Advanced Nursing,37(4), 364±371 369
type of exchange between the therapist and the subject,
irrespective of MTPT. Sham treatments to control for this
effect have been incorporated in our subsequent studies and
we recommend that future researchers consider a sham
massage, perhaps using unskilled or random massage,
avoiding myofascial trigger points. The limited number of
blood pressure measurements may limit the conclusions. We
were concerned that regular measurements using a pressure
cuff could be a confounding variable because of the level of
discomfort. Future studies would be advised to take more
frequent recordings using a less intrusive system such as a
®nger cuff.
The present study shows that MTPT is a safe, noninvasive
technique that is effective in inducing a relaxation effect in
normal subjects. It is a relatively simple technique to learn
and under correct instruction could be taught to the partners
or spouses of patients who could bene®t from massage
therapy.
It is imprudent to generalize from a healthy population to
those with disease processes. However, certain conditions are
characterized by increased sympathetic tone and reduced
HRV. It is possible to speculate that these conditions could
show a relaxation response following massage that may
bene®t the sympathovagal balance.
Patients who may bene®t include those recovering from a
myocardial infarction (MI). These patients are usually in a
high state of anxiety and tension and generally have increased
sympathovagal tone as the result of reduced cardiac para-
sympathetic activity (Task Force 1996). Heart failure patients
also have reduced HRV and increased levels of stress as
indicated by increased levels of circulating catecholamines
(Saul et al. 1988). MTPT could help reduce stress and
improve autonomic function by increasing HRV and para-
sympathtic activity.
Patients with uncomplicated essential hypertension may be
another group that could bene®t from the effects of MTPT.
These patients have elevated blood pressure and increased
sympathovagal balance (Guzzetti et al. 1988, Manolis et al.
1995). In previous studies, treatment using beta-blockade
(Liao et al. 1996) and ACE inhibitors (Kontopoulos et al.
1997) has been shown to improve prognosis in these patients.
MTPT may prove a useful adjunct to conventional treatment
by enhancing cardiac vagal tone and leading to restoration of
sympathovagal balance.
A further group who may bene®t from MTPT are diabetic
patients with autonomic neuropathy. These patients
commonly have reduced autonomic function as indicated by
decreased HRV (Mackay et al. 1980). They may also have pain
as the result of peripheral neuropathy, thereby increasing levels
of stress and anxiety thus further exacerbating the condition.
Additional studies using MTPT in these patient groups need to
be performed to con®rm these hypotheses.
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... In previous massage studies conducted with patients [2][3][4] and healthy people [5][6][7][8][9][10], evaluations were based on pre-and postintervention comparisons, and few evaluations were based on continuous measurements. Some of these previous studies [2][3][4] reported a signi cant decrease in heart rate and noted a distress relief effect. ...
... Signi cant reductions in HR have been observed pre-and post-intervention. Although the effects on the autonomic nervous system have been shown to some extent, such as the activation of the parasympathetic nerve by moderate massage [11], the number of participants examined remains small, and the evidence comparing pre-and post-intervention measurements is insu cient [2][3][4][5][6][7][8]. ...
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Background: Few studies have provided detailed analyses of sustained evaluations during manual interventions, and their physiological and psychological effects are not well known. Moreover, no studies have evaluated the effects of conversation in combination with intervention. We investigated the effects of conversation and hand-mediated therapy on the autonomic nervous systems and moods of both recipients and practitioners. Methods: Participants were university students (n=30). Two different interventions were included: one in which conversation was maintained during massage, and the other without conversation. Outcomes were heart rate variability (HRV) measurements and the Profile of Mood States Second Edition (POMS2), which were analyzed using repeated-measures analysis of variance, multiple comparisons, the difference between means test, the Friedman test, and the Wilcoxon signed-rank test. Intervention I data measured was from October 2016 to September 2017 whereas Invention II data was measured from January 2019 to March 2019. The study data was analyzed from October 2017 to October 2019. Results: After 15 min of rest, both negative and positive mood states were significantly reduced. In the presence of conversation, sympathetic nerve activity significantly increased, and a significant decrease in negative mood states was observed in POMS2, as well as a rising tendency for positive mood states. In massage recipients, a significant increase in parasympathetic nervous activity was noted when conversation was absent; however, when conversation was present, there was an increase in sympathetic nervous activity and a decrease in parasympathetic nervous activity, but only the decline in the mean heart rate (MHR) was significant. All negative items significantly declined in POMS2. The mean value of sympathetic activity in the group of practitioners was significantly higher after the intervention than before, regardless of the presence or absence of conversation. In the presence of conversation, all negative POMS2 items significantly declined. Conclusion: Hand-mediated therapies suppressed conversation-mediated sympathetic nervous system activity. The absence of conversation produced a more pronounced relaxation effect in the massage recipient. In terms of mood, the relaxation effect was more powerful in the presence of conversation. Furthermore, in the presence of conversation, a mood-based relaxation effect on the practitioner was confirmed. Trial registration: None
... According to previous studies, massage therapy increased the HF component and decreased the LF/HF component. These results show that massage therapy is effective for psychological relaxation [25,26]. Another report indicated that, when healthy participants listened to quiet music or inhaled the vapor of bergamot oil for a certain period of time, there were significant changes to the LF, HF, and the LF/HF ratio, as well as a shifting of the autonomic nerve balance in the direction of parasympathetic dominance, causing a relaxation effect [27]. ...
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This cross-sectional study aimed to examine the effects of being swayed in a sway bed on children with severe motor and intellectual difficulties by examining potential differences in their autonomic and emotional responses, as well as their muscle hardness, and by comparing them with “a control condition without any stimulation”. Children’s heart rate variability, rectus femoris hardness, and passive hip abduction range of motion (ROM) were measured in two experimental conditions, differentiated by the presence of a 5-min sway stimulus. In each condition, the children’s faces were video-recorded and retrospectively rated subjectively by their homeroom teacher concerning the visible expression of eight emotions. Significant intervention-related effects were observed on the heart rate variability and the “Relax” item of the emotional response indicators but not on muscle hardness or hip ROM. Our findings provide evidence that using a motorized sway bed can promote relaxation in children with severe motor and intellectual disabilities by influencing their autonomic response.
... For example, Pohl et al. [46] identified positive impacts of a horse-riding intervention on partic-ipants' physical, psychological and social abilities, general mood, QoL and future beliefs. Notably, integral to NBIs is relaxation, reducing immediate stressors for the individual and akin to other non-pharmacological interventions, such as massage, decreasing blood pressure and HRV [76]. In this review, both heart rate and HRV were seen to improve following NBIs [49,51,53,55], suggesting a relaxation effect akin to previous forest therapy interventions that do not measure psychological outcomes [77,78]. ...
Background: With the global burden of disease increasing, particularly in relation to often preventable chronic diseases, researchers and clinicians are keen to identify interventions that can mitigate ill health and enhance the psychological wellbeing of people living with long-term conditions (LTCs). It is long established that engagement with nature can support human health and wellbeing, and in recent years, nature-based interventions (NBIs) have been advanced as of potential benefit. This review thus sought to systematically appraise published evidence of the application of NBIs to address psychological wellbeing for those living with LTCs. Methods: A systematic search of three databases, PsycINFO, MEDLINE and SCOPUS, was undertaken, and the BestBETs quality assessment checklist was used to appraise methodological quality of elicited studies. Results: Of 913 studies identified, 13 studies (12 using quantitative methods, one qualitative) were used. Included papers reported use of a variety of psychological outcomes alongside more circumscribed physiological outcomes. Quality appraisal showed modest robustness, some methodological weaknesses and a dominance of application in developed countries, yet synthesis of studies suggested that reported psychological and physiological outcomes present a strong argument for NBIs having a promising and positive impact on psychological wellbeing. Conclusions: NBIs have positive psychological and physiological impacts on people with LTCs, suggesting they may be a suitable addition to current maintenance treatment. Future research should focus on minimising study bias and increasing the potential for cross-cultural applications.
... [31] Following MTrP massage therapy significant decrease in heart-rate, SBP, DBP was found due to the significant increase in parasympathetic activity. [32] However, this was not reproduced in other studies which showed that massage type and areas massaged were the main factors affecting change in BP. Increases in BP were noted for potentially painful massage techniques, including trigger point therapy. ...
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... (9) Moreover, there is great interest in lifestyle behaviors and interventional strategies to mitigate physical stress via activation of the parasympathetic nervous system, reflected by an increase in HRV. (10) Massage is an intervention conventionally used to decrease muscle tension (11) that has shown promise as a means to modulate autonomic stress via stimulation of cardiac-parasympathetic activity under resting (12,13) or postexercise conditions. (14) However, massage may be inaccessible for many due to prohibitive costs or exorbitant time requirements. ...
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... From these results, it can be concluded that comfort and relaxation are related. A reduction in heart rate (HR) by itself considered a sign of relaxation, caused either by an increase in parasympathetic nervous system (PNS) activity or a decrease in sympathetic nervous system (SNS) activity [26]. Generally, a high-frequency (HF) component is a marker for pure cardiac PNS activity, while the low-frequency/highfrequency (LF/HF) ratio reflects SNS activity [27]. ...
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Background Bed baths are a daily nursing activity to maintain patients’ hygiene. Those may provide not only comfort but also relaxation. Notably, applying a hot towel to the skin for 10 s (AHT10s) during bed baths helped to reduce the risk of skin tears and provided comfort and warmth in previous studies. However, it is still unclear whether autonomic nervous system is affected by bed baths. Thus, this study investigated the effect on the autonomic nervous activity of applying hot towels for 10 s to the back during bed baths. Methods This crossover study had 50 participants (25 men and women each; average age 22.2 ± 1.6 years; average body mass index 21.4 ± 2.2 kg/m ² ) who took bed baths with and without (control condition: CON) AHT10s on their back. Skin temperature, heart rate variability (HRV), and blood pressure (BP) were measured. Subjective evaluations and the State-Trait Anxiety Inventory in Japanese were also performed. Results A significant interaction of time and bed bath type on skin surface temperature was observed ( p < .001). Regarding the means of skin surface temperature at each measurement time point, those for AHT10s were significantly higher than those for CON. Although the total state-anxiety score significantly decreased in both the bed bath types after intervention, the mean values of comfort and warmth were higher for bed baths with AHT10s than for CON ( p < .05) during bed baths; AHT10s was significantly higher in warmth than CON after 15 min ( p = .032). The interaction and main effects of time on HRV and BP and that of bed bath type were not significant. Conclusion Bed baths that involved AHT10s caused participants to maintain a higher skin temperature and warmer feeling than under the wiping-only condition; they also provided comfort during the interventions. However, the bed baths with AHT10s did not allow participants to reach a relaxed state; moreover, there was no change in autonomic nerve activity. This may be due to participants’ increased anxiety from skin exposure and the intervention being limited to one part of the body.
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Joint hypermobility (JH) conditions suggest dysfunction in the autonomic nervous system (ANS) (dysautonomia), associated with multifactor non-articular local musculoskeletal pain, and remains a complex treatment. This study aims to determine the effects of musculoskeletal interfiber counterirritant stimulation (MICS) as an innovative treatment of myofascial trigger points (MTrPs) on the upper trapezius muscle in JH patients. We evaluate the ANS activity by wavelet transform spectral analysis of heart rate variability (HRV) in sixty women, equally divided: MTrP, MTrP + general joint hypermobility (GJH), and MTrP + joint hypermobility syndrome (JHS). The protocol phases were rest, stimulation, and recovery, with clinical and home treatment for three-days. All groups show a significantly decreased in pain perception during and post-treatment, and an increased parasympathetic ANS activity under MICS in the GJH and JHS groups. The variables low-frequency (LF) vs. high-frequency (HF) showed significant differences during the protocol phases, and the LF/HF ratio maintained a predominance of sympathetic activity (SA) throughout the protocol. The new MICS technique reduces the pain perception and modulates the ANS activity by an increase in vagal tone, and a decrease in sympathetic tone. This modulation was followed by an increase in the HRV in JH patients after treatment with MICS. Clinical Trials: RBR-88z25c5.
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Early sports specialization, increased professional load, technical complexity of motor elements, lack of adequate means of rehabilitation in the training process have become the main triggers in the emergence of MNPS. The aim of the study was to study the mechanisms of development, clinical manifestations and development of the etiological system of treatment of cervical myofascial pain in the absence of actual organic pathology of the spine. Promising treatment is the use of reflexology. Effects of reflexology: analgesia, psychiatric (depression, sedation), nutrition, recovery, muscle relaxation. Conclusions: Athletes are mainly characterized by pain in the muscles that provide static work, as well as different options for the distribution of MNPS, depending on the sport. The upper and lower extremities are involved in performing active motor functions characteristic of sports. In general, local symptoms of pain were observed in 52.5% of athletes, and common - in 40.6%. At the same time, MNPS was most common in 63.4% of cases of cervical wrestlers and 58.4% of cases of lumbosacral region; in athletes, the development of myofascial disorders increases the bioelectrical activity of muscles at rest; Athletes with common symptoms have reduced control processes in the central nervous system [1]. It is characterized by an increase in multisynaptic reflex excitability at the level of the brain stem; emotional disorders in athletes in the presence of myofascial pain are characteristic in the presence of the third stage of the pathological process; the occurrence of general symptoms of MNPS according to the study leads to an increase in the average time of sensorimotor response, deterioration of motor processes and increased fatigue when performing a series of tests; MNPS treatment, which includes reflexology and PIR programs based on clinical and instrumental studies, significantly improves the athlete's condition during 12 months of follow-up.
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Background Heart rate variability (HRV) is one of the tools that can assess autonomic activities during exercise or recovery. Massage is an often-used recovery method with varying recovery outcome. This study was to investigate the effect of lower limb massage on recovery HRV following repeated knee flexion and extension exercise-to-exhaustion. Methods Nine healthy men aged between 20-30 years old were recruited and randomly assigned to a control group (n = 5) and massage group (n = 4). The HRV spectral analysis was performed at baseline, pre-exercise, post-exercise and immediately post-intervention. For intervention, the participants in the massage group received a 10-min massage on the quadriceps and hamstring muscles of the dominant leg whereas the control group received none. The HRV was presented as low-frequency (LF) peak (Hz), power (ms²), power (normalised unit; n.u.) and high-frequency (HF), peak (Hz), power (ms²), power (n.u.) as well as LF/HF ratio. Results Spectral power analysis showed there were no significant differences in the LF indices and LF/HF ratio with massage. HRV normalisation data revealed a within-subject difference with massage. Conclusions Massage caused an immediate parasympathetic activation during recovery from a single exhaustive muscle contraction exercise. Hence, massage may be used to potentiate recovery.
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Coronary heart disease (CHD) and cardiac sudden death (CSD) incidence accelerates after menopause, but the incidence is lower in physically active versus less active women. Low heart rate variability (HRV) is a risk factor for CHD and CSD. The purpose of the present investigation was to test the hypothesis that HRV at rest is greater in physically active compared with less active postmenopausal women. If true, we further hypothesized that the greater HRV in the physically active women would be closely associated with an elevated spontaneous cardiac baroreflex sensitivity (SBRS). HRV (both time and frequency domain measures) and SBRS (sequence method) were measured during 5-min periods of controlled frequency breathing (15 breaths/min) in the supine, sitting, and standing postures in 9 physically active postmenopausal women (age = 53 +/- 1 yr) and 11 age-matched controls (age = 56 +/- 2 yr). Body weight, body mass index, and body fat percentage were lower (P < 0.01) and maximal oxygen uptake was higher (P < 0.01) in the physically active group. The standard deviation of the R-R intervals (time domain measure) was higher in all postures in the active women (P < 0.05) as were the high-frequency, low-frequency, and total power of HRV. SBRS also was higher (P < 0.05) in the physically active women in all postures and accounted for approximately 70% of the variance in the high-frequency power of HRV (P < 0.05). The results of the present investigation indicate that physically active postmenopausal women demonstrate higher levels of HRV compared with age-matched, less active women. Furthermore, SBRS accounted for the majority of the variance in the high-frequency power of HRV, suggesting the possibility of a mechanistic link with cardiac vagal modulation of heart rate. Our findings may provide insight into a possible cardioprotective mechanism in physically active postmenopausal women.
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Spectral analysis of spontaneous heart rate fluctuations were assessed by use of autonomic blocking agents and changes in posture. Low-frequency fluctuations (below 0.12 Hz) in the supine position are mediated entirely by the parasympathetic nervous system. On standing, the low-frequency fluctuations increase and are jointly mediated by the sympathetic and parasympathetic nervous systems. High-frequency fluctuations, at the respiratory frequency, are decreased by standing and are mediated solely by the parasympathetic system. Heart rate spectral analysis is a powerful noninvasive tool for quantifying autonomic nervous system activity.
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Clinically based studies have indicated that patients who have suffered myocardial infarction (MI) exhibit lower heart rate variability (HRV). Such associations have not been reported at the population level. To investigate whether MI is related to lower HRV in the general population, the authors examined a stratified random sample of 2,243 men and women aged 45–64 years, of whom 260 had had MI and 1,983 were free of any coronary heart disease manifestations. All were part of the biracial cohort of the Atherosclerosis Risk in Communities study sampled from four United States communities. Resting, 2-minute supine heart rate data were analyzed using spectral analysis to estimate high-frequency (0.16–0.35 Hz) and low-frequency (0.025–0.15 Hz) spectral powers as conventional indices of HRV. The mean levels of high-frequency powers were 1.02 and 1.23 (beats/min)2 for MI and non-MI groups, respectively (P < .05), and the low-frequency means were 2.46 and 3.11 (beats/min)2 for MI and non-MI groups, respectively (P < .01). Age, race, and sex-adjusted odds ratios (95% confidence interval) of lower high-frequency and low-frequency powers contrasting MI to non-MI individuals were 1.52 (range, 1.09–2.10) and 1.54 (range, 1.12–2.10), respectively. After adjustment for use of beta-blocker medication, the odds ratios (95% confidence interval) were 1.26 (range, 0.88–1.81) and 1.22 (range, 0.87–1.69) for lower high-frequency and low-frequency powers, respectively. The findings from this first population-based study of prevalent MI and HRV provide support for an inverse association between MI and lower HRV. However, adjusting for beta-blocker use eliminates the statistical association. These findings confirm that impaired HRV is found in individuals with prevalent MI, even when drawn as a sample of community-dwelling individuals. This impaired HRV may contribute to the increased risk of subsequent cardiovascular events previously observed in survivors of acute MI. The cross-sectional data also suggest that use of beta-blockers diminishes the odds of lower HRV associated with MI.
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The experience of massage in an oncology ward was the focus of this study. Eight female cancer patients were given massage for 10 consecutive days and then interviewed using phenomenology as a theoretical framework. The essential meaning of getting massage as part of the daily care for female cancer patients was described as getting a meaningful relief from suffering. The findings identified five themes: the relief is meaningful because it offers the patient an experience of being “special.” The massage contributes to the development of a positive relationship with the personnel, to feeling strong, and to a balance between autonomy and dependence. The massage also brings about a meaningful relief from suffering because it just “feels good.” The findings of this study can be of use to health care professionals as it shows that the relatively short period of massage can result in physical and emotional benefits for cancer patients.
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Nonpharmacological methods in relieving children’s postoperative pain: a survey on hospital nurses in Finland Aim of the study. The aim of this study was to describe nurses’ use of selected nonpharmacological methods in relieving 8–12-year-old children’s postoperative pain in hospital. Methods. The convenience sample consisted of 162 nurses working on the paediatric surgical wards in the five Finnish university hospitals. An extensive questionnaire, including a five-point Likert-scale, on the nurses’ use of selected nonpharmacological methods and demographic data was used as a method of data collection. The response rate was 99%. Descriptive statistics as well as nonparametric Kruskall–Wallis ANOVA and the chi-squared test were used as statistical methods. Results. The study indicates that emotional support, helping with daily activities and creating a comfortable environment were reported to be used routinely, whereas the cognitive-behavioural and physical methods included some less frequently used and less well known strategies. The results also show that attributes, such as the nurses’ age, education, and work experience, the number of children the nurses had, the nurses’ experiences of hospitalization of their children as well as the hospital and the place of work, were significantly related to the use of some nonpharmacological methods. Conclusions. The nurses used versatile nonpharmacological methods in children’s postoperative pain relief, although some defects could be observed. More research is needed on the methods used by nurses to relieve children’s pain in different patient groups and the factors which hinder or promote nurses’ use of pain alleviation methods in the clinical practice.
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The influence of five background variables (age-group. sex. work status. smoking status. household income) on four health ratings (current self-rating. estimated age/sex average rating, best possible self-rating. health satisfaction self-rating) was investigated in the context of a local survey with 377 respondents. Main effects of age-group. smoking status and work status on current health self-ratings were obtained as predicted. Age-group was also found to affect age/sex average ratings. health satisfaction and best possible health self-ratings, with smoking status also influencing the last of these. Mediation of the obtained effects was also examined by controlling for three independent self-report measures of health status in the analyses. Two relevant theoretical notions were examined in analysing the data. The health satisfaction findings as a function of age-group proved consistent with Multiple Discrepancies Theory. Strong support was obtained for a social representations approach. particularly through the direct effects (unmediated by the independent health status measures) of age-group on age/sex average health ratings and best possible health self-ratings. This suggests the contribution of a social consensus about age as having a negative influence on health status. Directions for further research are briefly outlined.