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54
EFFECT OF TRADITIONAL THAI MASSAGE ON MUSCLE
OXYGEN SATURATION IN LOW BACK PAIN PATIENTS:
A PRELIMINARY STUDY
* Ketsarakon Oatyimprai1, Wichai Eungpinichpong2, Orawan Buranruk3, Kurusart Konharn4
and Kukiat Tudpor5
1 Research and Training Center for Enhancing Quality of life of working Age People, Thailand
2,3,4 Faculty of Associated Medical Sciences, Khon Kaen University, Thailand
5Faculty of Public Health, Mahasarakham University, Thailand
*Corresponding Author, Received: 29 Sept. 2019, Revised: 22 Nov. 2019, Accepted: 14 Feb 2020
ABSTRACT: Low Back Pain (LBP) is a common disease found in every age that affects daily life. LBP may
cause poor posture of the lumbar spine, and decrease muscle performance which leads to muscle fatigue, reduce
blood circulation and reduce muscle oxygen saturation. Traditional Thai Massage (TTM) has been used to treat
patients with LBP for a long time with some evidence that it could increase muscle flexibility, improve blood
circulation and decrease pain. However, its effect on muscle oxygen saturation has not been explored. This
study uses one group pretest-posttest design to preliminary determine this effect. Twenty-three subjects (6
males and 17 females) who had non-specific LBP participated. Each of them was measured on muscle oxygen
saturation, visual analog scale (VAS) and Sorensen’s test before and immediately after having a 15-minute
session of TTM. These measures were compared before and after those of a 15-minute rest period. The results
showed significantly increase in muscle oxygen saturation (p < 0.01), increase endurance of back extension (p
< 0.05), decrease pain intensity (3.46±2.65) (p < 0.01) and decrease anxiety level (4.04±2.30) (p < 0.01) after
received TTM. In conclusion, TTM could improve muscle oxygen saturation level, decrease pain intensity,
decrease anxiety level and increase the duration of hold while performing back muscle endurance tests.
Keywords: Low back pain, Muscle oxygenation, Thai massage, Anxiety, Muscle blood circulation
1. INTRODUCTION
Lower back muscles are the part of body
structure that used to stabilize the body in upright
position where the main muscle that acts in this
position is erector spinae (ES) muscle. ES muscle is
responsible for thoracic and lumbar flexion from the
upright position since it acts as antagonists to
gravity [1]. Low back pain (LBP) is one common
disease resulting from disorder of lower back
muscle and lumbar spine [2]. LBP has high
prevalence in adult population (70-85 %),
especially rate of incidence in females was higher
than males in all age groups [3][4][5].
The individual with LBP which effects on daily
life can develop chronic low back pain (CLBP) [6].
LBP could be divided into two types as specific and
non- specific base on pathology where most of the
cases are non-specific LBP [7][8]. CLBP can affect
poor posture of lumbar spine, poor balance in sitting
position. Causes of LBP may induce inefficient
muscular stabilization of spine, psychological
distress and prolong workload is promoting muscle
fatigue, reduce blood flow and reduce muscle
oxygenation [9][10][11][12] Nowadays, many
kinds of treatments have been suggested to treat low
back pain such as massage, stretching exercise,
strengthening exercise, etc., because they could
improve muscle flexibility, muscle activity, blood
circulation, and oxygen saturation.
Oxygen is the most important to bodywork in
each working process. Oxygen is transported in
hemoglobin and myoglobin. Therefore, oxygen
saturation separated two types as arterial oxygen
saturation and muscle oxygen saturation. From the
previous study, Murthy, G. [13] reported that the
importance of muscle oxygen saturation when
muscle ischemia that affects to decrease blood
volume and muscle oxygenation, it causes muscle
fatigue. The study of Bengtsson, A. [14] reported
that “hypoxia in combination with muscle work
causes pain as well as energy depletion” and when
oxygen is raising, it can delay the onset of muscle
fatigue [15].
At present, there are several studies that show
therapeutic evidence base about traditional Thai
massage, but none of the studies has provided the
level of muscle oxygen saturation of TTM on lower
back muscle. Thus, TTM still needs more evidence
to support beneficial effects such as treatment
guidelines. Therefore, this study will preliminarily
determine the effects of traditional Thai massage on
level of muscle oxygen saturation and muscle
endurance of lower back muscles in low back pain
International Journal of GEOMATE, Aug., 2020, Vol.19, Issue 72, pp. 54 - 61
ISSN: 2186-2982 (P), 2186-2990 (O), Japan, DOI: https://doi.org/10.21660/2020.72.5636
Special Issue on Science, Engineering and Environment
International Journal of GEOMATE, Aug., 2020, Vol.19, Issue 72, pp. 54 - 61
55
patients.
2. METHODOLOGY
This study used one group pretest-posttest
design, conducted in the department of Physical
therapy, faculty of Associated Medical Sciences,
Khon Kaen University, Khon Kaen Province,
Thailand. This study was approved by Ethics
Committee of Khon Kaen University.
2.1 Participants
Male and female participants with LBP age
between 20 – 45 years old were recruited by using
bulletin boards and oral requests. They were
screening by researcher according to the inclusion
criteria; subacute (3 weeks to 3 months) or chronic
low back pain of non-specific low back pain (> 3
months), body mass index (BMI) = 18.5-24.9 kg/m2
[16], visual analog scale ≥ 3/10, good
communication and cooperation, no contraindica-
tion to either TTM, no fracture, non-smoking [17]
and adipose tissue thickness (ATT) ≤ 6.7 mm. All
participants must refrain from drinks containing
alcohol and caffeine before attending in 24 hours.
Twenty-three participants (26.70 ± 6.18 years of
age; height 1.63 ± 0.09 m.; weight 56.14 ± 8.99 kg.;
BMI 20.88 ± 1.71 kg/m2; ATT 4.37 ± 1.49 mm.)
were signed informed consent before joining in this
study.
2.2 Procedure
Twenty-three participants were measured
physical examination (e.g. heart rate, blood pressure,
the severity of pain and level of exhausted at that
time), anxiety level by STAI-Y1, Visual analog
scale (VAS), muscle oxygen saturation (SmO2) and
endurance of back extension by Sorensen’s test for
baseline. After that, they received TTM for 15
minutes per session on lower back muscle in prone
position. The participants rest 15 minutes before
receiving TTM.
Massage points including 2 lines and in this
study performed along energy lines or Sen-sib
which is call “Ping-kha-la” or “Ei-tha” [18] depends
on pain side. The massage therapist was measure 2
fingers base from the spine and pressed at T1 to S1
to apply gentle, gradually increasing, pressure
through the massage therapist's thumb or palmar.
Pressure applied until the participants begin to feel
slight uncomfortable then hold 5-10 seconds per
time. The massage therapist applied several times
until 15 minutes [19]. The participants can request
to stop the massage therapists or researchers at any
time if they feel pain. And re-measured in the same
baseline after finished TTM (Fig.1).
Fig.1 Overview of study design
2.3 Measurements
2.3.1 Muscle oxygen saturation (SmO2) using
MOXY
Muscle oxygen saturation chooses as a primary
outcome measure in this study and used MOXY to
measure muscle oxygen saturation. The participants
were lying in prone position; the researcher cleans
up on lower back at L1 to L5. Then the researcher
palpated L3 for place MOXY monitor on the center
of erector spinae [20] (Fig.2). The data recorded in
peripedal (software of MOXY) and exported in
Microsoft excel. The validity of this tool is
consider-ably strong (ICC; r = 0.773–0.992) [21].
The researcher has an intra-class correlation
coefficient at 0.98.
Fig.2 The location of Moxy monitor placed on low
back muscle
Recruited eligibility subjects
Baseline assessments
Traditional Thai Massage (TTM)
15 minutes
Post-test assessments
Data analysis
L1
L2
L3
L4
L5
International Journal of GEOMATE, Aug., 2020, Vol.19, Issue 72, pp. 54 - 61
56
2.3.2 Endurance of back extension using Sorensen’s
test
The participants were prone by the lower part of
the body on the bed and anterior superior iliac spine
place on edge of the bed after that the researcher
strapped to the three-point: level of greater
trochanter of the femur, knee creases and level of
lateral [22]. The chair placed in front of the
participant to support the upper part of the body and
the participant placed both hands on the chair for the
starting position. Beginning the participant lift the
upper part and hand from the chair and both arms
crossed on the chest. The upper part of the body was
horizontal to the bed. They hold the horizontal
position until fatigue or the body can’t lift to
horizontal (Fig.3). The researcher measured the
time by stopwatch. [23] [22] [24]. The validity of
the Biering-Sorensen test has 0.77 [22]. This
assessment time was 5 minutes approximately.
Fig.3 Endurance of back extension by Sorensen’s
test
2.3.3 Pain intensity using Visual analog scale (VAS)
The pain intensity was assessed by 10 cm. visual
analog scale. Range 0-10 which 0 is “no pain” and
10 is “most pain”. The participants were marked on
the scale of pain intensity.
2.3.4 Anxiety level by STAI-Y1 (Thai version)
The participants requested to state-trait anxiety
inventory Y1 has 20 item State anxiety items
include: ‘Not at all; I fell a little bit; I fell quite a lot”
and I fell very so much’. Higher scores mean greater
anxiety. The score of STAI-Y1 separate to 3 levels
of anxiety, there are including; 20-39 scores: Low
anxiety, 40-59 scores: Moderate anxiety and 60-80
scores: High anxiety.
2.4 Statistical analysis
Data analysis was used by SPSS version 23 in
this study. Descriptive data of continuous data such
as age, weight, etc., are presented in terms of mean
and standard deviation. The categorical data such as
gender, occupation, etc., are presented in proportion
and percentages. Demographic data are presented as
mean ± standard deviations (SD) and percentage.
Mean and standard deviations of the values were
calculated for each variable. This study aimed to
analyze each outcome in the period before and after
treatment, the different times by the immediate
effect of each outcome. Paired t-test and Wilcoxon
used to compare outcome variables at baseline with
outcome variables after received treatment
immediately within the group. Friedman’s 2-way
ANOVA used to compare the change of outcome
measure at different times within group. This study
estimates the adjusted mean difference and the 95
percentages confidence interval for each outcome
measure.
3. RESULTS
3.1 Muscle oxygen saturation
Table 1 showed that the immediately after
received TTM had significantly increased between
Soren1-Recovery, TTM-Recovery and Base5M-
Recovery (p-value < 0.01). In addition, there are
three pairs that have significantly different at p-
value < 0.05: Rest1-Recovery, Soren2-Recovery,
and Rest2-Recovery. Table 2 showed SmO2 was
significantly improved after receiving TTM where
was 8.17% increased.
Figure 7 showed that changes in muscle oxygen
saturation in each period with the following
changes: In Soren1 when the participant extends
back in Sorensen’s test, the muscle oxygen
saturation was decreasing from baseline and
increasing after resting 15 minutes. Next, the
massage therapist applied massage on the affected
side, the muscle oxygen saturation was decreasing
again and increasing after resting 15 minutes. In the
same result of Soren1 in Soren2 but the muscle
oxygen saturation decreased lower than Soren1.
The last recovery period was increasing more than
all period and significant increasing after received
the treatment.
3.2 Endurance of back extension muscle
Table 2 showed the endurance of back extension
was also significantly improved about 0.11 min
after receiving TTM, significantly improved at p-
value < 0.05.
Endurance of back extension muscle has
significantly increased after received TTM and it’s
not normal distribution because some participants
had decreasing of time when doing Sorensen test 2
(Fig.4).
International Journal of GEOMATE, Aug., 2020, Vol.19, Issue 72, pp. 54 - 61
57
3.3 Pain intensity and anxiety level
Pain intensity was significantly decreased at p-
value < 0.01 and anxiety level was significantly
improving at p-value < 0.01 after received TTM
from baseline (Fig.5) (Fig.6).
Fig.4 The change after received TTM of the
endurance of back extension
Fig.5 The change after received TTM of pain
intensity
Fig.6 The change after received TTM of anxiety
level
4. DISCUSSIONS
This study was preliminarily determining the
immediate effects of traditional Thai massage
(TTM) on level of the muscle oxygen saturation
(SmO2), Visual analog scale (VAS), State trait
anxiety Y1 (STAI-Y1) and muscle endurance of
lower back muscle in low back pain (LBP) patients.
The results showed that SmO2, muscle
endurance, VAS, and STAI-Y1 had significant
increasing. The result showed that traditional Thai
massage can increase level of the muscle oxygen
saturation and muscle endurance of lower back
muscles in low back pain patients immediately after
received treatment. Beside pain scale and anxiety
levels have improved in the same way.
Table 1 Participants outcome of Muscle oxygen
saturation (SmO2)
Note: * p value < 0.05, ** p value < 0.01 and S.E.:
Standard error
4.1 Immediate effect on increasing muscle
oxygen saturation level
This study found muscle oxygen saturation
increased after receiving TTM. Changes in muscle
oxygenation depend on the exertion level, blood
flow, myoglobin, and hemoglobin dissociation
curve. The muscle had myoglobin that was carrying
oxygen to the muscle which will be transmitted
through the capillaries and changes the amount of
myoglobin depend on the concentration in skeletal
muscle fibers. [27]
Item
S.E.
P-value
Baseline-Sorensen 1
0.637
1.000
Baseline – Resting 1
0.637
1.000
Baseline – TTM
0.637
1.000
Baseline – Resting 2
0.637
1.000
Baseline – Sorensen 2
0.637
1.000
Baseline – Recovery
0.637
0.001**
Sorensen 1 – Resting 1
0.637
1.000
Sorensen 1 – TTM
0.637
1.000
Sorensen 1– Resting 2
0.637
0.510
Sorensen 1 – Sorensen 2
0.637
0.785
Sorensen 1 – Recovery
0.637
0.001**
Resting 1 – TTM
0.637
1.000
Resting 1 – Resting 2
0.637
1.000
Resting 1 – Sorensen 2
0.637
1.000
Resting 1 – Recovery
0.637
0.003**
TTM – Resting 2
0.637
1.000
TTM – Sorensen 2
0.637
1.000
TTM – Recovery
0.637
0.001**
Resting 2 – Sorensen 2
0.637
1.000
Resting 2 – Recovery
0.637
0.022*
Sorensen 2 – Recovery
0.637
0.012*
International Journal of GEOMATE, Aug., 2020, Vol.19, Issue 72, pp. 54 - 61
58
Table 2 Comparison outcome of all outcomes
Note: * p value < 0.05, ** p value < 0.01
Fig.7 The change of muscle oxygen saturation (SmO2) baseline until recovery.
Baseline measurement was measured 5 minutes
and the SmO2 level was high or low depending on
the muscle tension and blood flow on the lower
back in each person. According to the previous
study, who had a myofascial trigger point or muscle
spasm often had vasoconstriction that affects poor
blood circulation, poor oxygenation, and fatigue
easily [26]. Next, Sorensen’s test 1 showed SmO2
was decreasing for baseline because they had
muscle contraction when performed back
extension, causing the vessels were occluded. So,
the SmO2 level was increasing after resting 15
minutes in period 1. After that, the massage
therapist applied the pressure and while doing
massage had changes of SmO2 rise and fall because
when she applied the pressure, had compress to
vessel in the muscle and then the massage therapist
slowly released pressure, causing the blood vessels
to gradually relaxed and increased blood circulation
[25]. Then, the participants were resting 15 minutes
showed the SmO2 level was higher than the
baseline, causing muscle relaxation that improved
blood circulation and improved oxygenation [26].
In Sorensen’s test, 2 showed the SmO2 level had
decreased while doing back extension but it’s
decreasing less than Sorensen’s 1.
The last recovery period showed that the SmO2
level had significantly increased with each period.
Since, there were both relaxing massage and
increasing strength of isometric back extension the
effect of the possible mechanism might be
promoted parasympathetic to relaxation and
Items
Baseline
(Mean ± SD)
Post-test
(Mean ± SD)
Difference
(95% CI)
P-value
Muscle oxygen saturation 78.88 ± 14.11 87.05 ± 8.95
8.17
(60.52 to 98.33)
0.001**
Endurance of back extension 0.34 ± 0.38 0.45 ± 0.28
0.11
(0.010 to 0.21)
0.015*
Pain intensity 5.67 ± 1.52 2.22 ± 2.04
3.46
(2.65 to 4.27)
0.001**
Anxiety level 33.61 ± 5.46 29.57 ± 4.83
4.04
(2.30 to 5.78)
0.001**
70.00
72.00
74.00
76.00
78.00
80.00
82.00
84.00
86.00
88.00
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Muscle oxygen saturation: SmO2
(percentage)
Duration
(minute)
Baseline
1st Sorensen
ì
s test 2nd Sorensen
ì
s test
Resting
Resting
TTM
Recovery
International Journal of GEOMATE, Aug., 2020, Vol.19, Issue 72, pp. 54 - 61
59
improve vasodilation by reducing heart rate, blood
pressure, and endorphins as relaxation substances.
Parasympathetic is part of the autonomic nervous
system that controls the body rest and balance
homeostasis cause muscle relaxation. While
massage in the prone position on erector spinae, it
involved pressure on the muscle tissue which may
decreased muscle tension and increase skin
temperature. Consequently, it may induce
vasodilation, improve circulation. Since oxygen in
the muscles is bined to myoglobin in capillaries,
massage could increase SmO2 level immediately
after applying TTM on the tight back muscles.
4.2 Immediate effect on improving endurance of
back extension
This study found that endurance of back
extension was significantly improved after received
TTM according to massage could be decreased
muscle spasm, muscle tension, and improved
flexibility, causing there was improved blood flow
[25] [29] and improved oxygen saturation. The
previous study reported repetitive exercise could
improve circulation after knee flexion and
extension. In addition, Sorensen’s test was the
isometric exercise of back extension, it could be
improved strengthening the cause of participants
could hold the upper body longer from baseline.
Isometric exercise could improve blood circulation
in 2004 reported massage group with isometric
exercise has muscle blood volume higher than
isometric without massage. While muscle contrac-
tion that affects to squeeze vessel after slowly
released muscle contraction the vessel will dilate
that improved blood flow on localizing muscle [32].
4.3 Immediate effect reducing pain intensity
This study showed that the level of pain
intensity was significantly decreased after the
treatment. Mechanism of pain is some part of the
body received pain signal after that refers to dorsal
horn in the spinal cord, that sends to the brain and
first transmission cell (T cell). Substantia gelatinosa
in spinal cord functions as the gate control system,
which consists of small fiber, densely packed cells
that form a functional unit extending the length of
the spinal cord. Gate control theory of pain
mechanism is substantia gelatinosa on the afferent
fiber stimulated large fiber (L-fiber) and decrease
the activity of small fiber (S-fiber) that effect to
close gate control of pain. [30]. In addition, TTM
promoted vasodilation, exchanges oxygen and
decreased lactic acid cause of fatigue
4.4 Immediate effect on improving anxiety level
The study found that after the participants
received the massage, there was a better anxiety
condition before a received massage. Anxiety will
fluctuate with various substances in the body and
the work of that receptor or hormone, found that
noradrenergic (NA) and serotonergic receptors (5-
HT) play an important role in anxiety. Concerns
about changes in NA also depend on the function of
the endocrine glands. Normally, NA releases
secretion of noradrenaline, but in anxiety, triggering
locus coeruleus (LC) results in a decrease in the rate
of signaling. NA stimulation, including after
noradrenaline. There is also an increase of
corticotropin-releasing factor (CRF) and adreno-
corticotropic hormone (ACTH, corticotropin) in the
body, resulting in increased heart rate, increased
blood pressure and neophobic behaviors that people
with this condition will have fear to do somethings
result in a decrease in the activity. Traditional Thai
massage will be stimulation parasympathetic effect
that causes the body to release noradrenaline,
serotonin (5HIAA), dopamine and reduce cortisol
CRF, ACTH, and corticotropin.
The results of this study were consistent with
previous studies, that showed the immediately TTM
on back muscle 30 minutes could improve pain
intensity and improve the level of anxiety which
accordance with this study [19]. TTM was
promoted relaxation, activated parasympathetic and
decreased sympathetically. Moreover, massage the
whole body in pregnancy could increase serotonin
(5HIAA), increased dopamine, decreased cortisol
that might be explained about improving anxiety
level [31]
5. FOLLOW UP
The researcher followed up the participants
about pain intensity for 1 day after receiving the
massage and found no adverse effect.
6. LIMITATIONS AND FURTHER STUDY
This study has some limitations. Firstly, this
study has small sample size because it was a
preliminary study without a control group for
comparison. Secondly, the study has no blinded
assessor and patients which could be prone to be
bias. Thirdly, data collection in some patients was
failed due to excessive sweating after performing
Sorensen’s test that caused unfirmed skin contact
during measurement of muscle oxygenation. The
lastly, results of this study could be explained only
the immediate effects of TTM on the observed
parameters. Long-term effects have not yet to be
explored.
To validate the effects of TTM on muscle
oxygen saturation and muscle endurance, a
randomized control trial using either parallel or
International Journal of GEOMATE, Aug., 2020, Vol.19, Issue 72, pp. 54 - 61
60
crossover design is recommended for further study.
Moreover, long-term effects of it should be
explored for clinical practice.
7. CONCLUSION
The aim of this study was to preliminarily
determining the immediate effects of traditional
Thai massage on level of the muscle oxygen
saturation and muscle endurance of lower back
muscles in low back pain patients. Based on the
results of the study, it is concluded that muscle
oxygenation could be improved after receiving a
single session of 15-minute traditional Thai
massage on lower-back muscles in low back pain
patients. Moreover, it could also have decreased
pain intensity, decreased anxiety level and
improved back muscle endurance.
This study is the first research regarding
traditional Thai massage on muscle oxygen
saturation in low back pain patients. The treatment
technique of traditional Thai massage used in this
study could produce beneficial results without any
adverse effect either immediately on one day after
receiving the massage session. Thus, this protocol
of 15-minute of traditional Thai massage could be
an alternative treatment for pain management of
low back pain patients.
8. ACKNOWLEDGMENTS
Financial support in this research was
authorized by the Research and Training Center for
Enhancing Quality of life of working Age People.
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