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Connective Tissue Reflex Massage for Type 2 Diabetic Patients with Peripheral Arterial Disease: Randomized Controlled Trial

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The objective of this study was to evaluate the efficacy of connective tissue massage to improve blood circulation and intermittent claudication symptoms in type 2 diabetic patients. A randomized, placebo-controlled trial was undertaken. Ninety-eight type 2 diabetes patients with stage I or II-a peripheral arterial disease (PAD) (Leriche-Fontaine classification) were randomly assigned to a massage group or to a placebo group treated using disconnected magnetotherapy equipment. Peripheral arterial circulation was determined by measuring differential segmental arterial pressure, heart rate, skin temperature, oxygen saturation and skin blood flow. Measurements were taken before and at 30 min, 6 months and 1 year after the 15-week treatment. After the 15-week program, the groups differed (P < .05) in differential segmental arterial pressure in right lower limb (lower one-third of thigh, upper and lower one-third of leg) and left lower limb (lower one-third of thigh and upper and lower one-third of leg). A significant difference (P < .05) was also observed in skin blood flow in digits 1 and 4 of right foot and digits 2, 4 and 5 of left foot. ANOVA results were significant (P < .05) for right and left foot oxygen saturation but not for heart rate and temperature. At 6 months and 1 year, the groups differed in differential segmental arterial pressure in upper third of left and right legs. Connective tissue massage improves blood circulation in the lower limbs of type 2 diabetic patients at stage I or II-a and may be useful to slow the progression of PAD.
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Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 2011, Article ID 804321, 12 pages
doi:10.1093/ecam/nep171
Original Article
Connective Tissue Reflex Massage for Type 2 Diabetic Patients
with Peripheral Arterial Disease: Randomized Controlled Trial
Adelaida Mar´
ıa Castro-S´
anchez,1Carmen Moreno-Lorenzo,2
Guillermo A. Matar´
an-Pe˜
narrocha,3Belen Feriche-Fern´
andez-Castanys,4
Genoveva Granados-G´
amez,5and Jos´
e Manuel Quesada-Rubio6
1Department of Nursing and Physical Therapy, University of Almeria, 04120 Almer´ıa, Spain
2Department of Physiotherapy, University of Granada, Spain
3Health District of La Vega, Andalusian Health Service (M´alaga), Spain
4Department of Physical Education, University of Granada, Spain
5Department of Nursing and Physical Therapy, University of Almeria, Spain
6Department of Statistics, University of Granada, Spain
Correspondence should be addressed to Adelaida Mar´
ıa Castro-S´
anchez, adelaid@ual.es
Received 23 April 2009; Accepted 2 October 2009
Copyright © 2011 Adelaida Mar´
ıa Castro-S´
anchez 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.
The objective of this study was to evaluate the ecacy of connective tissue massage to improve blood circulation and intermittent
claudication symptoms in type 2 diabetic patients. A randomized, placebo-controlled trial was undertaken. Ninety-eight type 2
diabetes patients with stage I or II-a peripheral arterial disease (PAD) (Leriche-Fontaine classification) were randomly assigned to
a massage group or to a placebo group treated using disconnected magnetotherapy equipment. Peripheral arterial circulation was
determined by measuring dierential segmental arterial pressure, heart rate, skin temperature, oxygen saturation and skin blood
flow. Measurements were taken before and at 30 min, 6 months and 1 year after the 15-week treatment. After the 15-week program,
the groups diered (P<.05) in dierential segmental arterial pressure in right lower limb (lower one-third of thigh, upper and
lower one-third of leg) and left lower limb (lower one-third of thigh and upper and lower one-third of leg). A significant dierence
(P<.05) was also observed in skin blood flow in digits 1 and 4 of right foot and digits 2, 4 and 5 of left foot. ANOVA results were
significant (P<.05) for right and left foot oxygen saturation but not for heart rate and temperature. At 6 months and 1 year, the
groups diered in dierential segmental arterial pressure in upper third of left and right legs. Connective tissue massage improves
blood circulation in the lower limbs of type 2 diabetic patients at stage I or II-a and may be useful to slow the progression of PAD.
1. Introduction
Peripheral arterial disease (PAD) is a common disease world-
wide and is associated with a high rate of disability [1,2].
Diabetes is one of the main causes of PAD. The development
of vascular complications in diabetics depends on the length
of time with the disease and their glycemia control [3]. At
endothelial level, diabetic vascular complications can lead to
luminal changes, aecting fibrinolysis, plasma coagulation,
platelet function, and to parietal changes in contractile and
secretory functions [4,5]. Diabetics also have a diminished
endothelium-dependent arterial relaxation capacity, due
to self-generating changes in the generation, release, and
association of self-produced vasodilatory substances [6].
Nitric oxide-mediated vasodilation is also aected, since
nitric oxide is deactivated by free radicals and advanced
glycation end products [7,8].
Intermittent claudication (IC) is a transient ischemia
caused by the inability of the vascular system to meet
muscle metabolic requirements. It usually clinically mani-
fests as a constrictive pain in the lower leg, although this
pain can also be reported in the thigh or foot in pre-
claudication conditions [9]. The pain can appear earlier
during steep or fast walks or at low temperatures. Other
symptoms associated with IC are cold feet and mottled
hairless skin with dryness or ulcerations. IC symptoms can
remain stable, heal spontaneously, or develop into chronic
ischemia of the lower limbs. It is well documented that
2 Evidence-Based Complementary and Alternative Medicine
around 5% of men and 2.5% of women aged >60 years
have IC symptoms [1]. Leriche-Fontaine established a four-
stage clinical classification of chronic lower limb ischemia.
Stage I is characterized by atheroma plaque symptoms, but
blood vessel obstruction is incomplete and compensatory
mechanisms have developed. In stage II, pain in lower limb
muscle groups, mainly calf muscles, is triggered by walking
and eases after rest: symptoms appear after a distance of
>150 m in stage II-a and after <150 m in stage II-b. In stage
III, the patient experiences pain while resting that worsens
when the limb is raised; the pain is mainly localized in the
feet, which become sensitive and cold and take on a pale
or red (erythematous) appearance. In stage IV, the patient
has ulcerations and limb necrosis and finds walking dicult
[10]. In stages III and IV, chronic lower limb ischemia is
mainly treated surgically by thrombectomy, embolectomy,
fasciotomy, thromboendarectomy, bypass or amputation
along with pre- and post-surgical drug treatments [11].
In stage II, treatment largely consists of diabetic control
[12], non-pharmacological methods (physiotherapy, Yoga
programs, antioxidant plants) [1318], genetic therapy,
and/or medication [1921]. Patients with stage I disease
receive no therapy because they show no symptoms. It is
therefore important to implement measures to detect initial
stages of PAD and to control risk factors [22]. A review of
the literature on subclinical PAD diagnosis concluded that
individuals with risk factors (obesity, cholesterol, sedentary
lifestyle, smoking, dyslipemia) and positive family history
should undergo vascular Doppler examination (to calculate
ankle/brachial index (ABI)) and arterial plethysmographic
examinations (arterial neumoplethysmography and photo-
plethysmography) [2327].
Connective tissue massage (CTM) may reduce symptoms
and improve IC by increasing blood circulation to the
musculature. This is achieved by massaging along reflex
lines on areas of the skin connected (at a distance) with
deep tissue and internal organs, known as Head zones
[28,29]. The hypertonic muscle region is known as the
McKenzie zone, while tissues linked to internal organs
via nerve connections are called Dicke’s connective zones.
Stimulation of these areas generates a neuro-vegetal balance
that produces a relaxed and analgesic state in the patient
and a regulation of vasomotricity in areas distantly linked
via nerve connections. CTM always begins in areas away
from hyperalgic points in aected methameric muscles to
avoid painful reactions. Loose connective tissue is stretched
and stimulated by the massage to produce a neurovegetal
balance, which skin-muscle reflex massage mainly achieves
via the autonomous or vegetal nervous system. The stimulus
produced at subcutaneous connective tissue level relaxes
contracted tissues and improves the circulation due to
vasodilation mediated by the vegetal nervous system [30,31].
To our best knowledge, however, no specific evaluation has
been published on the eects of CTM in patients with PAD.
With this background, the objective of this study was to
determine the ecacy of a CTM program to improve blood
circulation and IC symptoms in the lower limb and to serve
as a preventive measure against the progression of PAD in
type 2 diabetic patients. This approach may be of special
interest for patients unable to take part in physical exercise
programs.
2. Methods
2.1. Setting and Participants. This randomized, placebo-
controlled trial initially recruited all accessible patients with
medical records on the computer database of a Health-
care District in Southern Spain who were diagnosed with
and undergoing treatment for type 2 diabetes: a total of
146 patients. Study enrolment was from September 1 to
December 20, 2005. The 146 patients underwent an initial
examination (see below), and their consent was obtained
to review their clinical records to gather clinical data,
including medication history and date of type 2 diabetes
mellitus diagnosis, defined by oral glucose tolerance test of
>200 mg/dL or fasting blood glucose test of >126 mg/dL on
two separate occasions during the previous year.
The physical examination was conducted after >3h
without food intake and >4 h without medication [32],
measuring the ABI with the patient in supine position after
a Stradness test (10% gradient treadmill at 3 km h1up
to maximum tolerated walking distance) [33]. An 8 MHz
Doppler probe (Hadeco Smartdop SD-20) and mercury
sphygmomanometer were used for this measurement, deter-
mining systolic blood pressure (SBP) first in the right and
left brachial arteries and then in the right and left posterior
tibial arteries. The ABI was obtained by dividing the SBP
of the posterior tibial artery in each extremity by the
SBP of the brachial artery [25,34]. The examination also
yielded glycosylated hemoglobin and BMI values, calculated
as weight (kg) divided by height squared (m2).
Study inclusion criteria were: diagnosis of type 2
diabetes; ABI of 0.6–0.9 on post-procedural Strandness
test (declared equivalent to stages I and II-a of Leriche-
Fontaine classification by the American Diabetes Association
and American College of Cardiology) [35]; glycosylated
hemoglobin of 7–10%; age of 18–65 years, and BMI of 27–35.
Exclusion criteria were: PAD stage II-b or higher; peripheral
venous insuciency; cardiac, renal, or hepatic insuciency;
uncontrolled hypertension (SBP >165/95 mmHg); central
or peripheral nervous system disorders; or myopathic or
neurologic damage that impaired mobility. These criteria
were satisfied by 98 patients (58 females and 40 males), who
gave their written consent to participation after being fully
informed about the study and told that they would be able
to choose the days and times of measurement and treatment
sessions. The study was approved by the ethics committees
of our university (University of Almeria) and hospital
(Andalusian Health Service). Patients were assigned to one
of two groups by using a randomized balanced (stratified)
selection process. The groups were balanced for type of
medication received and Leriche-Fontaine stage (I or II-a),
using a stratification system that generates a sequence of
letters (from table of correlatively ordered permutations) for
each category and combination of categories. The assessor,
massage and magnotherapy therapists, and patients were not
blinded to the treatment allocation of patients. The trial was
Evidence-Based Complementary and Alternative Medicine 3
conducted between January 15, 2005 and March 30, 2008.
The participants were asked to make no significant changes
in diet, therapy, or daily activities during the course of the
study [36].
2.2. Measurements. The data gathered for the selection
process were considered the baseline measurements. The
maximum interval between baseline data collection and start
of the program was one day. The same data were collected
at 30 min, 6 months, and one year after the program. At
these evaluation sessions, we always took the following
measurements in the order given below:
2.2.1. Walking Impairment. This was assessed by administer-
ing a validated Walking Impairment Questionnaire for PAD
patients that contains items on diculties to walk a given
distance and at a given speed during the previous month and
on symptoms associated with walking impairment [32]. The
degree of diculty was scored as none (3 points), some (2
points), great (1 point) or as no walking activity (0 point).
The walking distance score was the sum of the following
points: 20 points for walking indoors, 50 points for walking
50, 150 for 150, 300 for 300, 600 for 600, 900 for 900,
and 1500 points for walking 1500. The walking speed score
was the sum of the following points: 1.5 for walking slowly,
2 for walking at average speed, 3 for walking quickly, and
5 for running or jogging. Each distance walked is used as a
weighting factor in the estimation of the walking diculty.
Walking distance scores range from 0 to 34.5 and walking
speed scores from 0 to 6.60 [32].
2.2.2. Dierential Segmental Arterial Blood Pressure. This
was estimated in both lower limbs using a plethysmograph
(MOD-PGV-20, Smart-V-Link, Quermed, Madrid) at the
proximal and distal thirds of thigh and leg; values were
expressed in mmHg. Briefly, a blood pressure cuwas placed
on the corresponding lower limb segment, and a pressure
transducer in the plethysmograph was used to record BP
changes (for 60 s) after occlusion of the venous system at
75 mmHg. The dierential segmental arterial pressure is the
dierence between systolic and diastolic arterial pressures
[27]. Figure 1 shows the plethysmography results for the limb
segments.
2.2.3. Dierential Voltage in Skin Blood Flow. Blood flow
changes were measured on each digit of both feet by photo-
plethysmography (MOD-PGV-20, Smart-V-Link, Quermed,
Madrid), with mV/V as the unit of measurement. Photo-
plethysmography is based on the principle that the infrared
range of light-emitting energy reflects the blood flow in
subcutaneous arteries. The source of infrared transmission
is the diode, which is placed next to the cadmium-selenium
photosensor receiver at a pressure of 5–40 mmHg. Most of
the light emitted by the diode is absorbed by the tissues,
and only 5–10% reaches the subcutaneous blood vessels. The
magnitude of light reflected by these blood vessels increases
with higher red blood cell density [37]. The reflected energy
is amplified and converted into a voltage dierential. The
apparatus was calibrated such that a 1% increase in blood
flow corresponded to two squares on the plethysmograph
thermographic paper [3841](Figure 2).
2.2.4. Heart Rate and Oxygen Saturation. These measure-
ments were taken with a pulseoxymeter (Megos 3300 Oxi-
pulso) placed on the second digit of right and left foot after
patients had rested (in supine) for 5 min. In connective tissue
reflex massage, changes in heart rate (bpm) and oxygen
saturation (%) are produced by the vasodilation produced.
2.2.5. Skin Temperature. Skin temperature (in C) was
measured for 5 min in the inguinal region and right and
left popliteal spaces using a thermographic scan (Emergen
dermatempt).
2.3. Intervention. The massage group received a 1-h session
of CTM twice a week for 15 weeks. The placebo group
received a 30-min session of sham magnetotherapy in the
lower back and popliteal regions (15 min per zone) twice
a week for 15 weeks using disconnected equipment; these
patients were instructed on the use of the magnetotherapy
equipment and were unaware that it was switched o.
Because all patients were treated in prone position on a
massage bed with a face hole, placebo patients were unable to
see the equipment during sham treatment. The therapy room
was maintained at a temperature of 29.8–34.5C(Oregon
scientific model 299N) and relative humidity of 39–42%
(Oregon scientific model 299N).
2.3.1. Massage. The therapists applied standard therapeutic
CTM, using the Dicke approach 42. The massage protocol
consisted of reflex-massaging the skin with the third and
fourth fingertips to stretch the subcutaneous connective
tissue to the maximum. The massage must not cause pain
or enter deep into structures under the connective tissue,
avoiding overstimulation. The therapist flexes the elbow away
from the body, rotates the shoulder internally and applies a
light radial twist to the wrist. The patient should experience
the massage as a “switching-o” feeling.
Before the massage, patients remained in a relaxed prone
position for 30 min. At each therapy session, the full massage
protocol was applied as follows. After an initial “base build-
up” with lumbosacral and pelvic massage strokes [42,43],
alternate strokes from left to right were applied to the
spinal axis, always in the following order [44]: five short
curving movements from fifth to first lumbar vertebra, five
movements at angle of lumbosacral joint, five short curving
movements from intercostal proximal third to dorsal axis
and up to spinal apophysis, seven light strokes in intercostal
spaces, seven short curving movements from intercostal
proximal third to dorsal axis and up to spinal apophysis (DVI
to DVII), five transverse intercostal movements from spine
to inner edge of scapula, one deep upward movement along
inner edge of scapula, one light stroke along axillary edge of
scapula and a final movement along anterior side of scapular
spine. The following sequence of massage strokes was then
applied to the lower limbs: three strokes at origin and
4 Evidence-Based Complementary and Alternative Medicine
Derecha
Muslo superior
Izquierd Imprimir Volver
To b i l l o
Dedo grodo
Cambios (mmHg)
Cambios (mmHg)
Cambios (mmHg)
Cambios (mmHg)
Muslo superior
To b i l l o
Dedo grodo
Cambios (mmHg)
Cambios (mmHg)
Cambios (mmHg)
Cambios (mmHg)
Cambios (mmHg) Cambios (mmHg)
4.06 mmHg
4.37 mmHg
5.6 mmHg
3.24 mmHg
2.09 mmHg
4.62 mmHg
4.41 mmHg
2.93 mmHg
Smart-V-Link
HADECO
PV arterial
∗∗∗.mmHg ∗∗∗ .mmHg
1.6
0
1.6
1.6
0
1.6
1.6
0
1.6
1.6
0
1.6
1.6
0
1.6
1.6
0
1.6
1.6
0
1.6
1.6
0
1.6
PVPVPVPV
PVPVPVPV
Encima de la rodilla
Debaio de la rodilla
Encima de la rodilla
Debaio de la rodilla
Figure 1: Dierential segmental arterial blood pressure in lower limbs is the dierence between systolic and diastolic arterial pressures in
the segment under study. The wider the dierence, the greater is the arterial blood flow.
Systolic peak
Diastolic peak
1
0
1
2
(mV/V)
PPG
AC
PP: 0.5 mV/V HR: 80 BPM
(a)
Systolic peak
Diastolic peak
(mV/V)
4
0
4
8PP: 9.5 mV/V HR: 89 BPM
PPG
(b)
Figure 2: Voltage dierential in skin blood flow is the dierence
between the voltage reached at systolic versus diastolic arterial
peaks.Thewiderthevoltagedierence, the greater is the supply of
arterial blood to the skin, as a consequence of vasodilation upper
panel (a) shows a lower skin blood flow than that observed in lower
panel (b).
insertion of ischiotibial muscles, three short strokes on both
sides of tensor fascia latae muscle, one lateral stroke from
distal region of iliotibial band to lateral side of knee, three
long strokes in triceps surae area towards each lateral side of
popliteal space, three long strokes on foot from lateral edge
of the calf muscles to lower edge of malleolus, three short
strokes upwards from lateral edges of vastus externus and
internus towards muscle fibers, two upward lateral strokes
on lateral outer side of vastus externus and lateral inner
side of vastus internus, four short strokes towards patella,
three transversal strokes from right to the left side under
tibial crest, one downward stroke from outer side of knee
to fibular malleolus, five short strokes in tibioastragalar area,
five short strokes on lateral outer edge of foot towards the
plantar cushion, four short strokes on interosseous muscles
and, finally, one long stroke from calcaneus to metatarsus-
phalanx joint in plantar area. After the massage, the patient
remained in a relaxed supine position for 30 min.
2.4. Statistical Analysis. SPSS statistics software (version
17.0) was used for statistical analyses. The reliability and
validity of the model was studied by analyzing residual inde-
pendence, normality, and variance homogeneity. Residual
independence was analyzed by plotting the values obtained
against residues, resulting in randomly distributed points
showing no specific trend and therefore verifying the residual
independence assumption. Residual normality was studied
by using a Q-Q graph, finding the dots to be located close
to the line and therefore confirming the residual normality
assumption. Variance homogeneity was tested with the
Levene test, obtaining a 95% confidence level and P-value
>.05, confirming variance equality. The normal distribution
of variables was determined by using the Kolmogorov-
Smirnof test, expressing continuous data as means with
standard deviation (SD) in the text and tables. Changes in
Evidence-Based Complementary and Alternative Medicine 5
Assessed for eligibility (n=146)
Randomized (n=98)
Allocated to intervention (n=49)
Perceived allocated intervention (n=48)
Did not receive allocated intervention (n=1)
Reason: Need for bed rest
Followed up at 30 min, 6 months and 1 year
Analyzed (n=48)
Allocated to intervention (n=49)
Received allocated intervention (n=46)
Did not receive allocated intervention (n=3)
Reasons: Need to care for severely ill or
disabled relatives
Followed up at 30 min, 6 months and 1 year
Analyzed (n=46)
Intervention
group Placebo
group
Excluded (n=48)
Didnotmeetinclusioncriteria(n=39)
Refused to participate (n=6)
Other reasons (n=3)
Figure 3: Flow chart of study participation None of the 98 randomized patients withdrew because of adverse events.
variables within each group were measured using the paired
t-test for independent samples. Temporal changes in the
scores were examined using a two-way repeated measures
ANOVA (group (massage group, placebo group) ×time
(baseline, 30 min, 6 months, 1 year)). Treatment ecacy was
analyzed by using a t-test for paired samples. Independent
t-tests were applied to baseline scores to determine whether
the random assignment to groups adequately controlled for
baseline demographic dierences.
Relationships between variables at baseline and post-
treatment were assessed by calculating the Pearson correla-
tion coecients, considering a 95% (α=0.05) confidence
level.
3. Results
3.1. Participants. The 98 patients (58 women and 40 men)
in the study group had a mean age of 53.57±11.69 years
(range 41–65 years). One patient dropped out of the massage
group and three from the placebo group (Figure 3) due to
mandatory bed rest (n=1) or the need to care for severely
ill relatives (n=3). No patient withdrew from the study due
to adverse eects of the intervention.
No significant dierences in baseline characteristics
were observed between the massage and placebo groups
(Figure 4).
3.2. 30-Min Outcomes. At 30 min after the 15-week program,
mean dierential segmental arterial pressure values (by
plethysmography) were significantly (P<.05) improved
versus baseline values (right and left leg) in the massage
group, with the greatest improvements in upper third of
the right thigh (1.69 (0.83) mmHg; P<.035), lower third
of right thigh (2.09 (0.64) mmHg; P<.031), upper third
of right leg (3.22 (1.15) mmHg; P<.029), upper third of
left thigh (1.54 (0.47) mmHg; P<.004), lower third of left
thigh (1.62 (0.94) mmHg; P<.021), and upper third of left
leg ( 2.57 (1.08) mmHg; P<.024). No significant pressure
changes were observed in the placebo group. Significant
dierences were found between massage and placebo group
in dierential arterial pressure values in the lower third of
right thigh, upper third of right leg, lower third of right
leg, lower third of left thigh, and upper third of left leg
(Tab l e 1). Repeated-measures ANOVA showed a significant
time ×groups interaction for dierential arterial pressure
values in lower third of right third (F=8.289; P<.03),
upper third of right leg (F=7.321; P<.03), lower third
of right leg (F=11.201; P<.04), lower third of left thigh
(F=7.323; P<.05), and upper third of left leg (F=9.321;
P<.01).
A similar pattern was observed for the dierential voltage
in digits. Significant (P<.05) improvement from baseline
in the massage group was observed in dierential voltage in
right first digit (3.10 (3.37) mV/V; P<.014), right second
6 Evidence-Based Complementary and Alternative Medicine
47.88
49.25
47
47.5
48
48.5
49
49.5
Age
Mean
(a)
Mean
25.96
26.16
25.85
25.9
25.95
26
26.05
26.1
26.15
26.2
Body mass index
(b)
159
155
153
154
155
156
157
158
159
160
Systolic blood pressure (mmHg)
Intervention group
Placebo group
(c)
Intervention group
Placebo group
88
87
87.5
90
88
88.5
89
89.5
90
90.5
Dyastolic blood pressure (mmHg)
(d)
Figure 4: P<.05 between intervention and placebo groups.
digit (3.93 (2.77) mV/V; P<.024), right fourth digit (6.50
(2.82) mV/V; P<.017), right fifth digit (6.30 (3.77) mV/V;
P<.014), left second digit (6.27 (2.54) mV/V; P<.022),
left fourth digit (5.36 (4.81) mV/V; P<.003) and left fifth
digit (6.58 (6.13) mV/V; P<.001). In the placebo group,
no significant change in dierential voltage was observed
in any digit (Ta b le 2). ANOVA showed a significant time ×
groups interaction for dierential voltage in right first digit
(F=7.984; P<.03), right fourth digit (F=8.321; P<.01),
left second digit (F=7.224; P<.04), left fourth digit
(F=6.932; P<.05), and left fifth digit (F=8.846; P<.01).
No significant changes in heart rate values were observed
in either group between baseline and post-treatment
(Figure 5). In the massage group, skin temperature signifi-
cantly (P<.05) diered between baseline and the end of
the 15-week treatment in right inguinal fold (35.52 (0.78)C;
P<.037), left inguinal fold (35.99 (0.47)C; P<.048), right
popliteal space (35.82 (0.39)C; P<.039), and left popliteal
space (35.13 (0.75)C; P<.042). Significant dierences
were also found (baseline versus 15 wks) in oxygen saturation
values in right foot (97.92 (2.93)C; P<.026) and left
foot (98.09 (2.64)C; P<.008). The placebo group showed
Evidence-Based Complementary and Alternative Medicine 7
Tab le 1: Dierences between groups in dierential segmental arterial pressure in lower limbs.
Variable
(mmHg)
Baseline M(SD) Pvalue
Pre-T
30 min post-program
M(SD) Pvalue
1st-PT
6monthsM(SD) Pvalue
2nd-PT
1yearM(SD) Pvalue
3rd-PT
IG PG IG PG IG PG IG PG
UTRT 1.09
(0.44)
1.17
(0.32) .32 1.69
(0.83)
1.21
(0.76) .07 1.50
(0.49)
1.24
(0.29) .09 1.48
(0.33)
1.19
(0.41) .11
LTRT 1.49
(0.06)
1.22
(0.12) .10 2.09
(0.64)
1.15
(0.51) .031.87
(0.55)
0.89
(0.83) .041.56
(0.94)
1.06
(0.36) .07
UTRL 2.31
(0.97)
1.79
(0.72) .07 3.22
(1.15)
1.88
(0.67) .032.91
(1.05)
1.87
(0.58) .042.49
(0.61)
1.86
(0.90) .04
LTRL 0.90
(0.06)
0.60
(0.97) .99 1.21
(0.11)
0.57
(0.06) .051.18
(0.99)
0.69
(0.64) .08 1.03
(0.43)
0.64
(0.96) .09
UTLT 1.05
(0.34)
1.12
(0.82) .35 1.54
(0.47)
1.09
(0.71) .08 1.31
(0.58)
1.11
(0.45) .15 1.26
(0.23)
1.08
(0.55) .23
LTLT 1.39
(0.73)
1.13
(0.79) .10 1.62
(0.94)
0.99
(1.01) .051.54
(0.88)
0.86
(0.72) .051.41
(0.62)
0.98
(0.34) .08
UTLL 1.66
(2.57)
1.32
(0.99) .98 2.57
(1.08)
1.33
(0.92) .012.21
(0.83)
1.35
(0.64) .041.98
(0.51)
1.29
(0.63) .04
LTLL 0.89
(0.31)
0.92
(0.87) .67 1.12
(0.57)
0.97
(0.56) .18 1.07
(0.46)
0.94
(0.38) .25 0.99
(0.712)
0.90
(0.57) .36
Values are presented as mean (SD). RMG, reflex massage group; PG, placebo group; 1st PT, post-treatment (30 min after 15-week treatment ends); 2nd PT,
6 months post-treatment; 3rd PT, 1 year post-treatment; UTRT, upper third of right thigh; LTRT, lower third of right thigh; UTRL, upper third of right leg;
LTRL, lower third of right leg; UTLT, upper third of left thigh; LTLT, lower third of left thigh; UTLL, upper third of left leg; LTLL, lower third of left leg.
P<.05 was considered significant.
Tab le 2: Dierences between groups in dierential voltage in skin blood flow.
Variable
(Digits)
(mV/V)
Baseline M(SD) Pvalue
Pre-T
30 min post-program
M(SD) Pvalue
1a-PT
6monthsM(SD) Pvalue
2a-PT
1yearM(SD) Pvalue
3a-PT
IG PG IG PG IG PG IG PG
Right first 2.19
(2.60)
2.23
(4.23) .35 3.10
(3.37)
2.18
(3.89) .033.04
(6.55)
2.29
(5.60) .042.59
(4.13)
2.24
(4.97) .06
Right second 3.10
(1.94)
3.42
(2.35) .07 3.93
(2.77)
3.56
(2.27) .06 3.41
(4.73)
3.48
(2.11) .30 3.21
(5.03)
3.33
(3.01) .27
Right third 2.63
(0.12)
2.87
(1.45) .10 2.96
(3.19)
2.76
(2.03) .14 2.24
(5.24)
2.80
(1.63) .05 2.38
(6.04)
2.71
(1.98) .08
Right fourth 4.73
(1.08)
4.67
(2.13) .29 6.50
(2.82)
4.62
(1.99) .015.73
(4.46)
4.58
(4.32) .035.02
(3.12)
4.52
(3.12) .05
Right fifth 5.57
(2.69)
6.01
(2.56) .06 6.30
(3.77)
6.15
(3.11) .08 6.59
(4.80)
6.23
(2.88) .06 6.01
(5.32)
6.08
(2.97) .29
Left first 3.84
(0.37)
4.12
(1.35) .07 4.17
(2.53)
4.09
(1.41) .31 4.55
(4.32)
4.21
(1.57) .08 4.11
(5.32)
4.01
(1.22) .22
Left second 5.20
(1.50)
5.39
(3.78) .16 6.27
(2.54)
5.55
(3.88) .046.12
(4.17)
5.45
(3.92) .045.88
(4.01)
5.39
(3.61) .05
Left third 4.06
(2.89)
4.23
(2.57) .21 4.44
(2.31)
4.17
(2.78) .09 4.52
(2.95)
4.29
(2.65) .09 4.48
(1.12)
4.25
(2.82) .10
Left fourth 4.88
(4.03)
4.92
(4.99) .35 5.36
(4.81)
4.89
(4.83) .055.44
(3.73)
4.98
(5.32) .045.24
(2.39)
4.96
(5.05) .09
Left fifth 4.72
(5.01)
4.51
(4.57) .12 6.58
(6.13)
4.49
(4.68) .015.04
(4.13)
4.57
(4.08) .044.69
(3.13)
4.52
(4.14) .13
Values are presented as mean (SD). RMG, reflex massage group; PG, placebo group; 1aPT, post-treatment (30min after 15-week treatment ends); 2aPT, 6
months post-treatment; 3aPT, 1 year post-treatment).
P<.05 was considered significant.
8 Evidence-Based Complementary and Alternative Medicine
Heartrate(bpm)
68.39
70.36
71.03 71.12
70.76
70.73
70.66
70.76
67
67.5
68
68.5
69
69.5
70
70.5
71
71.5
Baseline 25 weeks 6 months 1year
Time point
Mean
Intervention group
Placebo group
Figure 5: Comparisons between study groups in levels of depres-
sion, anxiety and pain. P<.05 (95% confidence interval). Values
are presented as means.
no significant dierence in any variable between baseline
and 15 weeks. The massage group showed a significantly
(P<.05) greater improvement versus the placebo group
in temperature at right and left popliteal spaces (Figure 6).
ANOVA showed a significant time ×groups interaction for
skin temperature at right popliteal space (F=5.825; P<.04)
and left popliteal space (F=4.139; P<.05) and for oxygen
saturation in right foot (F=20.034; P<.03) and left foot
(F=21.938; P<.01).
The mean (SD) maximum walking distance score sig-
nificantly improved between baseline and 10-min post-
treatment (20.03 (4.32) versus 26.85 (4.26); P<.029) in
the massage group. There were also significant dierences
between groups in this score at the end of the 15-week
treatment (baseline: 20.03 (4.32) versus 21.19 (3.94), P<
.063; 15 weeks: 26.85 (4.26) versus 21.77 (3.67), P<.034).
However, no significant change was observed versus baseline
or between groups in relation to the maximum walking speed
score (baseline: 3.97 (1.10) versus 3.89 (1.25), P<.319; 15
weeks: 4.46 (0.97) versus 3.99 (1.08), P<.087) (Figure 7).
ANOVA showed dierences in maximum walking distance
score (F=19.347; P<.03).
Although both dierential segmental arterial pressure
and heart rate responded significantly to CTM therapy, there
were no statistically significant correlations (Pearson corre-
lation coecient) between the increase in skin temperature
values and the decrease in heart rate values in the massage
group (r=0.334; P=.188) or the placebo group (r=0.319;
P=.721). However, there were significant correlations in
the massage group between the increase in skin temperature
and oxygen saturation values (r=0.346, P=.045) and
between the increase in skin temperature and dierential
segmental arterial pressure values in the upper third of the
thigh (r=0.496; P=.031), lower third of thigh (r=0.511;
P=.027), upper third of leg (r=0.436; P=.025), and lower
third of leg (r=0.392; P=.046).
3.3. Six-Month Outcomes. At 6 months post-treatment,
dierential arterial pressure remained high in the CTM in
segments with larger muscular mass, that is, lower third of
the right thigh (P<.048), upper third of right leg (P<
.045), and upper third of left leg (P<.039). No significant
change (versus baseline) was observed in the placebo group.
At 6 months, the groups significantly (P<.05) diered in
dierential pressure in lower third of right thigh, upper third
of right leg, lower third of left thigh, and upper third of left
leg (Tab l e 1). There were also statistically significant (P<
.05) dierences between the groups in dierential voltage
in right first digit, right fourth digit, left second digit, left
fourth digit, and left fifth digit (Tab l e 2). Repeated-measures
ANOVA showed a significant time ×groups interaction for
dierential arterial pressure values in lower third of right
third (F=7.321; P<.04), upper third of right leg (F=
7.146; P<.04), lower third of left thigh (F=6.852; P<.05),
and upper third of left leg (F=7.049; P<.04) and for
dierential voltage in right first digit (F=8.129; P<.04),
right fourth digit (F=7.646; P<.03), left second digit
(F=8.731; P<.04), left fourth digit (F=8.427; P<.04),
and left fifth digit (F=8.633; P<.04).
In the massage group, significant dierences were found
between baseline and six months post-treatment in skin
temperature of right inguinal fold (P<.046) and in oxygen
saturation of right (P<.045) and left foot (.043). The
placebo group showed no significant dierence between
baseline and two months in any variable. The massage group
showed a significantly greater improvement versus placebo
group in maximum walking distance (P<.049) but not
in maximum walking speed (P<.073) (Figure 7). ANOVA
analysis showed significant dierences for oxygen saturation
in right foot (F=3.821; P<.04) and left foot (F=4.053;
P<.03) and for maximum walking distance (F=17.721;
P<.04).
3.4. One-Year Outcomes. At the 1-year follow-up, the
improvements observed in the massage group at 6 months
largely persisted, with significant dierences versus baseline
in: dierential pressure in upper third of right leg (P<.041)
and upper third of left leg (P<.039); dierential voltage in
right first digit (P<.045) and left second digit (P<.046);
and oxygen saturation in right (P<.047) and left (P<.049)
feet. The placebo group again showed no dierences with
baseline values. The massage group showed a significantly
greater improvement versus placebo group (P>.05) in
dierential pressure in upper third of right leg and upper
third of left leg and in oxygen saturation in both feet (Ta b le 1
and Figure 6). No significant changes were observed versus
baseline or between groups in maximum walking distance or
maximum speed scores (Figure 7). ANOVA analysis showed
significant interaction for dierential arterial pressure values
in upper third of right leg (F=7.124; P<.04) and upper
third of left leg (F=6.993; P<.04) and for oxygen
saturation in right foot (F=3.747; P<.04) and left foot
(F=4.236; P<.03).
4. Discussion
In a group of type 2 diabetes patients with stage I or II-a
PAD, the application of a CTM protocol (Dicke approach)
Evidence-Based Complementary and Alternative Medicine 9
Baseline 30 min
post-
program
6months 1year
34.7
34.8
34.9
35
35.1
35.2
35.3
35.4
35.5
35.6
Skin temperature (right inguinal fold)
Mean
35.11
35.23
35.01
35.52
35.4
35.16
35.09
35.46
(a)
34.6
34.8
35
35.2
35.4
35.6
35.8
36
36.2
Baseline 30 min
post-
program
6months 1year
Skin temperature (left inguinal fold)
Mean
35.33
35.48
35.29
35.99 35.9
35.14
35.12
35.97
(b)
Baseline 30 min
post-
program
6 months 1 year
92
93
94
95
96
97
98
99
Mean
Oxygen saturation (%) right foot
95.9
96.5
94.56
97.92
94.67 94.67
94.56
95.04
(c)
Intervention group
Placebo group
Baseline 30 min
post-
program
6months 1year
Mean
33
33.5
34
34.5
35
35.5
36
Skin temperature (right popliteal space)
34.36
34.32
34.26
35.82
34.67
34.91
34.26
34.98
(d)
Intervention group
Placebo group
Baseline 30 min
post-
program
6 months 1 year
Mean
0
5
10
15
20
25
30
Skin temperature (left popliteal space)
22.89
21.17
25.96
20.53
22.4
22.42
24.43
26.16
(e)
Intervention group
Placebo group
Baseline 30 min
post-
program
6 months 1 year
Oxygen saturation (%) left foot
Mean
92
93
94
95
96
97
98
99
91
95.79
96.56
94.53
98.09
94.93 94.93
94.53
93.98
(f)
Figure 6: Comparisons between study groups in skin temperature and oxygen saturation. P<.05 (95% confidence interval). Values are
presented as means.
twice a week for 15 weeks increased dierential segmental
pressure in leg as measured by plethysmography, improved
skin blood flow as determined by photoplethysmography,
and increased pulse volume according to Doppler studies.
The improvement observed in the massage group after CTM
was in line with the results obtained by Castro et al. [43]
applying a massage protocol to healthy subjects. Massage of
the connective tissue reduces peripheral vascular resistance
at microcirculation level [2830]. The vascular structure
facilitates the work of increasing the blood flow from ter-
minal arterioles until it progressively reaches the large blood
vessels. A contribution to this ascending vasodilatation may
be made by the endothelium from flattened squamous cells
on the contact surface between vessel wall and circulating
blood. These cells respond to changes in humoral conditions
in the cardiovascular system, translating these changes into
vasoactive signals that regulate the blood flow [44,45].
We measured variations in skin blood flow by photo-
plethysmography based on techniques studied by Didier et al.
[46], Allen et al. [27]andBertinoetal.[47], who all stressed
the usefulness of digital photoplethysmographic evaluation
at the dierent Leriche-Fontaine stages of the disease. This
method allows qualitative variations in wave morphology
(dierences between systolic and diastolic peaks) to be
measured before and after therapy. The presence of arterial
ischemia produces qualitative changes in curve morphology
recorded by the photoplethysmograph as a dierential
voltage decrease versus the contralateral foot.
At the first post-therapeutic evaluation (at 30min), a
slight temperature increase due to skin vasodilation was
detected, likely due to a combination of both neuronal and
localized processes [48]. Previous studies [4951] found no
dierence between high- and normal-blood pressure groups
in the internal body temperature at which vasodilation
begins.
Oxygen saturation (by pulseoxymetry) and digit ABI are
good screening tools for diagnosing and monitoring PAD in
type 2 diabetic patients [52]. One study found no significant
improvements in oxygen saturation values in these patients
after 5 min of foot massage, which may be too brief to achieve
benefits; the massage produced a downward trend in the
heart rate due to vasodilation [53]. In the present study,
10 Evidence-Based Complementary and Alternative Medicine
Instantly
1 year
2 months15 weeksBaseline
95% IC variable
26.00
25.50
25.00
24.50
24.00
23.50
23.00
Maximum walking distance score RMG
(a)
Instantly
1 year2 months15 weeksBaseline
25.50
24.50
95% IC variable
26.00
25.00
Maximum walking distance score PG
(b)
Instantly
1 year
2 months15 weeksBaseline
95% IC variable
24.50
24.00
23.50
23.00
22.50
Maximum walking speed score RMG
(c)
Instantly
1 year2 months15 weeksBaseline
95% IC variable
23.75
23.50
23.25
23.00
22.75
Maximum walking speed score PG
(d)
Figure 7: Error bars in Walking Impairment Questionnaire. RMG, reflex massage groups, PG, placebo group. P<.05.
heart rate values were significantly lower versus baseline in
the massage group but not in the placebo group.
It has been reported in general terms that CTM may
causepatientssomediscomfort[54]. None of our patients
described any such feelings during our application of the
Dicke method. Patients were instructed to tell the therapist
immediately pain was felt, and this never proved necessary.
Nevertheless, discomfort may have gone unreported by some
patients, and it would be useful to explore this aspect in
greater depth in future studies.
4.1. Study Limitations. Among study limitations, the patients
with type II-a PAD continued to receive their usual medi-
cation during the massage program, for ethical reasons. A
further limitation is that the therapists were not blinded to
the group to which the patients belonged, which may have
influenced outcomes.
5. Conclusion
CTM increases blood circulation in the lower limbs of type
2 diabetic patients at stage I and II-a (Leriche-Fontaine)
of the disease, with improvements in dierential segmental
pressure in leg and greater skin blood flow. At 30 min
after this massage, the heart rate lowered and oxygen
saturation and temperature values rose, confirming the role
of the parasympathetic nervous system in the eects of this
treatment. CTM is a treatment option for asymptomatic
patients suspected of being in Leriche-Fontaine stage I,
that is, having the main risk factors for developing the
disease. This type of massage may also be useful to improve
Evidence-Based Complementary and Alternative Medicine 11
symptoms and perhaps slow the progression of the disease in
stage II-a PAD patients who have diculties in taking part in
any kind of exercise, including walking programs.
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... Peningkatan saturasi oksigen juga terjadi pada peningkatan saturasi oksigen perifer kaki setelah dilakukan perlakuan berupa connective tissue reflex massage selama 30 menit terjadi peningkatan sirkulasi darah yang diukur dengan hasil saturasi oksigen perifer pada kaki. Ratarata saturasi oksigen perifer kaki kanan 94,56% menjadi 97,92% dan dari rata-rata saturasi oksigen perifer kaki kiri 94,53% menjadi 98,09% 22 <0,05). Hal ini menunjukkan bahwa terdapat perbedan yang signifikan antara saturasi oksigen kaki kelompok kontrol pada pengukuran awal dan akhir, hal ini sesuai dengan manfaat senam kaki diabetik yaitu dapat memperbaiki sirkulasi darah dan mampu memperkuat otot -otot kecil. ...
... Hal ini sejalan dengan penelitian yang dilakukan Mar et al. (2011), bahwa terjadi peningkatan saturasi oksigen perifer kaki setelah dilakukan perlakuan berupa connective tissue reflex massage selama 30 menit terjadi peningkatan sirkulasi darah yang diukur dengan hasil saturasi oksigen perifer pada kaki. Rata-rata saturasi oksigen perifer kaki kanan 94,56% menjadi 97,92% dan dari rata-rata saturasi oksigen perifer kaki kiri 94,53% menjadi 98,09%. ...
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Chronic hyperglycolia in people with diabetes results in changes in intra-cell biochemical homeostasis so that the selendothel and nerves are disturbed. Disorders of blood vessels and nerves result in decreased blood supply to the legs. Decreased blood supply to the legs is characterized by a decrease in the value of oxygen saturation. Efforts are needed to improve oxygen saturation in people with diabetes to prevent diabetic foot disease. The purpose of this study was to determine the effect of Foot SPA with the help of wood reflection on oxygen saturation in people with diabetes in South Denpasar. The study was conducted with a quasi-experimental method, pre-test post test with control group design. The study used 2 (two) groups, group I was given treatment in the form of Foot SPA with the help of wood reflection every 2 days 15-30 minutes for 6 weeks, group II (control group) were given foot exercises every 2 days 15-30 minutes for 6 weeks. Saturation data were collected with digital oximetry at the beginning of the study and one day after the treatment period ended. Data were analyzed by paired and unpaired different tests. The results of the statistical independent test of the t test that have been done show that the value of p value is 0,000 (p value <0.05). This shows that there is a significant difference in oxygen saturation of the legs in the diabetics between the treatment groups that are given SPA reflective wooden foot SPA with a control group that is only given diabetic foot exercises. This can also be seen from the difference in the average oxygen saturation of the feet with diabetes in the treatment group by 4.52% and the control group by 0.28%. The results of the analysis showed that the administration of reflex wooden aids on foot was more effective in increasing oxygen saturation of the feet compared to only foot exercises in the control group.
... Subjects in the group B [ vascular massage therapy] reported that they find reduced the feeling of pain after 12 weeks of intervention periods. It was like the finding of Molski et al., manual lymphatic drainage is a similar form of massage found that influences the systemic blood flow function, reduced the swelling, and improve QOL [19] . Mar. ...
Article
OBJECTIVE: The aim of the study was to analyze the effectiveness of vascular exercises versus vascular massage therapy for the patient with the chronic venous insufficiency. BACKGROUND OF STUDY: Chronic venous insufficiency is a common condition in the elder person, pregnancy women, obesity etc., The symptoms are pain, swelling, loss of ankle joint range of movement. Earlier studies have shown the benefits of exercise in the patients. The purpose of this study was to analyze the effectiveness of vascular exercises and vascular massage therapy among the chronic venous insufficiency patients. METHODOLOGY: This is an experimental study of comparative type. This study was carried out in the faculty of physiotherapy department, Dr. M.G.R. educational and research institute after the approval from institution review board for 12 weeks. 20 subjects were included in the study based on the inclusion and exclusion criteria after getting their consent for participation. The subjects were divided into two groups by random sampling method. Ankle brachial pressure index [ABPI] and lower extremity functional scale [LEFS] is used for pre and post assessment. The subjects in group A performed vascular exercises for 30 mins/day for 3 days/week for 12 weeks. The subjects in group B performed vascular massage therapy in lower extremity for 30mins/day for 3day/week for 12 weeks RESULT: On comparing pre-test and post-test within group A and group B on Ankle Brachial Pressure Index and lower extremity function scale score. Group A shows highly significant difference in mean values at P ≤ 0.001 CONCLUSION: The study revealed that vascular exercises was more effective in the treatment of chronic venous insufficiency compared to vascular massage therapy. Key words: Chronic venous insufficiency, vascular massage therapy, vascular exercises.
... Sixteen clinical trials evaluated the effects of other interventions in treatment of PAD. [27][28][29][30]33,39,43,52,54,67,81,86,94,95,97,103 . These studies included the electrical or electromagnetic field stimulation, GaAlAs Laser Acupuncture, Remote Ischemic Preconditioning (RIPC), heat therapy, Extracorporeal Shock-Wave Therapy (ESWT), vibration therapy, T'ai Chi Chuan Exercise, intermittent mechanical compression, intermittent negative pressure, Waon therapy, cardiac rehabilitation programs, and chelation therapy. ...
... In addition to the potential positive effects of relaxation massage on blood glucose levels, there is evidence of other beneficial effects. Massagestudies report less neuropathic pain (Gok Metin et al. 2017) and improved blood flow to the skin (Castro-Sánchez et al. 2011) in patients with type 2 diabetes. Repeatedly, positive effects on the physical and emotional quality of life have also been shown (Wändell et al. 2012;Gok Metin et al. 2017). ...
Chapter
A wide variety of physiological processes can be set in motion through interpersonal touch or massage. For example, relaxation massages can reduce depression, anxiety, and fatigue, improve sleep, reduce stress, regulate blood sugar, blood pressure, and the immune system. These effects are in line with extensive research showing that psychological factors such as anxiety or relaxation influence the nervous system, the immune system, and the endocrine system. Accordingly, relaxation induced by interpersonal touch and massage has the potential to be used as a complementary therapy in medicine for both physical and mental disorders. The chapter also contains information on the effects of weighted blankets and vests and on contraindications and adverse side effects of massage.
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Diabetes mellitus is a group of metabolic diseases characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Alternative therapies with antihyperglycemic effects are increasingly sought after by patients with diabetes. Some potential alternative treatments for diabetes include yoga and naturopathy, which encompass hydrotherapy, massage therapy, mud therapy, acupuncture, and more. While there are review articles on various alternative therapies for diabetes individually, no known reviews have reported the collective effect of naturopathy therapies, including acupuncture, on diabetes. This comprehensive review was conducted using PubMed/Medline and Google Scholar electronic databases, aiming to provide evidence-based effects of naturopathy therapies such as hydrotherapy, mud therapy, fasting therapy, diet therapy, massage therapy, magnetotherapy, acupuncture, and reflexology, commonly practiced in India, on the management of diabetes. The literature suggests that these treatment modalities significantly improve type 2 diabetes mellitus (T2DM). However, more studies are needed to understand the comprehensive effects of administering these treatments, either individually or in combination, in effectively treating T2DM.
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Full-text available
This study investigated the effects of a spinal thermal massage device on physical and mental relaxation in office workers. Fifteen participants in their 30s and 40s used the device at home for 40 minutes, five times a week, for one month. Subjective measures, including fatigue, stress, muscle pain, blood circulation, dyspepsia, and insomnia, were assessed using the Visual Analog Scale (VAS) before and after the intervention. Objective measures included blood pressure (diastolic/systolic) and pulse pressure. The results showed significant reductions in fatigue (-51.5%), muscle pain (-49.6%), blood circulation difficulties (-23.1%), and stress (-20.9%), with trends suggesting reductions in insomnia (-20%) and dyspepsia (-7.4%). Systolic blood pressure significantly decreased, with tendencies for reductions in diastolic blood pressure and pulse pressure. In conclusion, the spinal thermal massage device appeared to promote physical and mental relaxation by combining thermotherapy and massage, likely activating the parasympathetic nervous system.
Article
Diabetes is a chronic, long-term, incurable, but controllable condition. Diabetes mellitus (DM) is a group of metabolic disorders characterized by hyperglycemia that results from defects in insulin secretion, insulin action, or both. People who have diabetes often experience a variety of symptoms, including blurry vision, excessive thirst, fatigue, frequent urination, hunger, and weight loss. This review article includes a discussion on diabetes types, symptoms, diagnostic tests, and various therapies for treating, controlling, and managing blood glucose levels, with a focus on its most recent innovation of therapies and medications. Diabetes management will also be reviewed, along with clinical pharmacodynamics, bioavailability, advantages, and complications of combined drugs/medications.
Article
Objective Traditional Thai massage is one of the alternative treatments for diabetic feet. However, the specific amount of pressing pressure applied to the foot during Thai foot massage is unknown. This study aimed to evaluate the effect of light pressing pressure on foot skin blood flow in type 2 diabetic patients. Methodes A single-arm repeated measures was conducted. Forty-three participants were recruited via the subjective examination and screening using the Michigan Neuropathy Screening Instrument. To obtain foot skin blood flow by laser doppler blood flowmetry, a probe was pasted on the 1st distal phalange of the big toe. Light pressure at a single point was applied on the plantar skin fold between the bases of the second and third toes by using the digital algometer. The pressure was applied gently, then increased slightly until the participant started to feel some minor discomfort. Patients were asked to rate their pain intensity using the visual analogue scale. Results The average pressing pressure without discomfort was 3.55 ± 1.04 Kg/cm². The foot skin blood flow increased significantly immediately after the pressing pressure, and this increase represented about 1.9 times when compared with the baseline (p < 0.001). Conclusion The application of light pressing pressure could be used as a basic standard criterion for massage to improve the foot skin blood flow in type 2 diabetic patients.
Article
Full-text available
Background Improved blood-glucose control decreases the progression of diabetic microvascular disease, but the effect on macrovascular complications is unknown. There is concern that sulphonylureas may increase cardiovascular mortality in patients with type 2 diabetes and that high insulin concentrations may enhance atheroma formation. We compared the effects of intensive blood-glucose control with either sulphonylurea or insulin and conventional treatment on the risk of microvascular and macrovascular complications in patients with type 2 diabetes in a randomised controlled trial. Methods 3867 newly diagnosed patients with type 2 diabetes, median age 54 years (IQR 48-60 years), who after 3 months' diet treatment had a mean of two fasting plasma glucose (FPG) concentrations of 6.1-15.0 mmol/L were randomly assigned intensive policy with a sulphonylurea (chlorpropamide, glibenclamide, or. glipizide) or with insulin, or conventional policy with diet. The aim in the intensive group was FPG less than 6 mmol/L. in the conventional group, the aim was the best achievable FPG with diet atone; drugs were added only if there were hyperglycaemic symptoms or FPG greater than 15 mmol/L. Three aggregate endpoints were used to assess differences between conventional and intensive treatment: any diabetes-related endpoint (sudden death, death from hyperglycaemia or hypoglycaemia, fatal or non-fatal myocardial infarction, angina, heart failure, stroke, renal failure, amputation [of at least one digit], vitreous haemorrhage, retinopathy requiring photocoagulation, blindness in one eye,or cataract extraction); diabetes-related death (death from myocardial infarction, stroke, peripheral vascular disease, renal disease, hyperglycaemia or hypoglycaemia, and sudden death); all-cause mortality. Single clinical endpoints and surrogate subclinical endpoints were also assessed. All analyses were by intention to treat and frequency of hypoglycaemia was also analysed by actual therapy. Findings Over 10 years, haemoglobin A(1c) (HbA(1c)) was 7.0% (6.2-8.2) in the intensive group compared with 7.9% (6.9-8.8) in the conventional group-an 11% reduction. There was no difference in HbA(1c) among agents in the intensive group. Compared with the conventional group, the risk in the intensive group was 12% lower (95% CI 1-21, p=0.029) for any diabetes-related endpoint; 10% lower (-11 to 27, p=0.34) for any diabetes-related death; and 6% lower (-10 to 20, p=0.44) for all-cause mortality. Most of the risk reduction in the any diabetes-related aggregate endpoint was due to a 25% risk reduction (7-40, p=0.0099) in microvascular endpoints, including the need for retinal photocoagulation. There was no difference for any of the three aggregate endpoints the three intensive agents (chlorpropamide, glibenclamide, or insulin). Patients in the intensive group had more hypoglycaemic episodes than those in the conventional group on both types of analysis (both p<0.0001). The rates of major hypoglycaemic episodes per year were 0.7% with conventional treatment, 1.0% with chlorpropamide, 1.4% with glibenclamide, and 1.8% with insulin. Weight gain was significantly higher in the intensive group (mean 2.9 kg) than in the conventional group (p<0.001), and patients assigned insulin had a greater gain in weight (4.0 kg) than those assigned chlorpropamide (2.6 kg) or glibenclamide (1.7 kg). Interpretation Intensive blood-glucose control by either sulphonylureas or insulin substantially decreases the risk of microvascular complications, but not macrovascular disease, in patients with type 2 diabetes. None of the individual drugs had an adverse effect on cardiovascular outcomes. All intensive treatment increased the risk of hypoglycaemia.
Article
The reeducation arterial occlusive disease of the lower limbs must lean on non-invasive vascular explorations which can give objective parameters about arterial and microcirculatory state of the patients and its evolution with physical therapies. The authors, due to their own experience, describe three of the available techniques: the arterial systolic pressure measurement on the ankle, giving a total estimation of hemodynamic position, the digital plethysmography (at rest and during an ischemic reflex of vasodilation), exploring the arteriolo capillar stage, the TcPO2 lying in a standing and walking position, measuring local oxygen flow, its variations during the setting of the vasomotor reflex and the increase of metabolic muscular requirements. The approach of both mechanic and bioenergetic conditions is possible with walking area measurement of which the limits are given, and above all with submaximal tests which evaluate adaptation possibilities and myocardic risk (very frequent in this patient population).
Article
BACKGROUND Long-term microvascular and neurologic complications cause major morbidity and mortality in patients with insulin-dependent diabetes mellitus (IDDM). We examined whether intensive treatment with the goal of maintaining blood glucose concentrations close to the normal range could decrease the frequency and severity of these complications. METHODS A total of 1441 patients with IDDM -- 726 with no retinopathy at base line (the primary-prevention cohort) and 715 with mild retinopathy (the secondary-intervention cohort) were randomly assigned to intensive therapy administered either with an external insulin pump or by three or more daily insulin injections and guided by frequent blood glucose monitoring or to conventional therapy with one or two daily insulin injections. The patients were followed for a mean of 6.5 years, and the appearance and progression of retinopathy and other complications were assessed regularly. RESULTS In the primary-prevention cohort, intensive therapy reduced the adjusted mean risk for the development of retinopathy by 76 percent (95 percent confidence interval, 62 to 85 percent), as compared with conventional therapy. In the secondary-intervention cohort, intensive therapy slowed the progression of retinopathy by 54 percent (95 percent confidence interval, 39 to 66 percent) and reduced the development of proliferative or severe nonproliferative retinopathy by 47 percent (95 percent confidence interval, 14 to 67 percent). In the two cohorts combined, intensive therapy reduced the occurrence of microalbuminuria (urinary albumin excretion of ≥ 40 mg per 24 hours) by 39 percent (95 percent confidence interval, 21 to 52 percent), that of albuminuria (urinary albumin excretion of ≥ 300 mg per 24 hours) by 54 percent (95 percent confidence interval, 19 to 74 percent), and that of clinical neuropathy by 60 percent (95 percent confidence interval, 38 to 74 percent). The chief adverse event associated with intensive therapy was a two-to-threefold increase in severe hypoglycemia. CONCLUSIONS Intensive therapy effectively delays the onset and slows the progression of diabetic retinopathy, nephropathy, and neuropathy in patients with IDDM.
Article
In an attempt to simplify the pre-operative assessment of amputation level in patients with severe occlusive arterial disease of the legs the skin perfusion pressure (SPPi) on calf and/or thigh was determined photo-electrically in 38 patients, aged 41–85 years and compared to the pressure values (SPPi) determined by the widely used but cumbersome isotope washout technique. SPPi was determined as the minimal external counter pressure (applied by a blood pressure cuff) sufficient to stop the washout from an intracutaneous depot of Na131I- mixed with histamine. SPPP was determined as the minimal external counter pressure required to prevent skin reddening after blanching of the skin. The systolic blood pressure, determined indirectly by strain gauge technique at the same level of the leg, was used for reading the SPPP as that counter pressure at which the photo-electric tracing moves away from a straight line placed on the tracing through the counter pressure corresponding to the systolic blood pressure. In the studied range 18–88 mmHg there was no significant difference between SPPP and SPPi. The total day-to-day variation of SPPP, determined from ten double determinations in eight patients was 6-6 mmHg (range of SPPP: 23–80 mmHg). The present results indicate that assessment of amputation level from SPPp using the standardized reading should offer a reliable alternative to the isotope washout method. The photo-electric technique is simple and fast, and gives only negligible discomfort to the patient.
Article
This chapter is devoted to antithrombotic therapy for peripheral artery occlusive disease as part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see the "Grades of Recommendation" chapter by Guyatt et al, CHEST 2008; 133:123S-131S). Among the key recommendations in this chapter are the following: We recommend lifelong antiplatelet therapy in comparison to no antiplatelet therapy in pulmonary artery disease (PAD) patients with clinically manifest coronary or cerebrovascular disease (Grade 1A), and also in those without clinically manifest coronary or cerebrovascular disease (Grade 1B). In patients with PAD and intermittent claudication, we recommend against the use of anticoagulants (Grade 1A). For patients with moderate to severe disabling intermittent claudication who do not respond to exercise therapy, and who are not candidates for surgical or catheter-based intervention, we recommend cilostazol (Grade 1A). We suggest that clinicians not use cilostazol in those with less-disabling claudication (Grade 2A). In patients with short-term (< 14 days) arterial thrombosis or embolism, we suggest intraarterial thrombolytic therapy (Grade 2B), provided they are at low risk of myonecrosis and ischemic nerve damage developing during the time to achieve revascularization. For patients undergoing major vascular reconstructive procedures, we recommend IV unfractionated heparin (UFH) prior to the application of vascular cross clamps (Grade 1A). For all patients undergoing infrainguinal arterial reconstruction, we recommend aspirin (75-100 mg, begun preoperatively) [Grade 1A]. For routine autogenous vein infrainguinal bypass, we recommend aspirin (75-100 mg, begun preoperatively) [Grade 1A]. For routine prosthetic infrainguinal bypass, we recommend aspirin (75-100 mg, begun preoperatively) [Grade 1A]. In patients undergoing carotid endarterectomy, we recommend that aspirin, 75-100 mg, be administered preoperatively and continued indefinitely (75-100 mg/d) [Grade 1A]. In nonoperative patients with asymptomatic carotid stenosis (primary or recurrent), we suggest that dual antiplatelet therapy with aspirin and clopidogrel be avoided (Grade 1B). For all patients undergoing lower-extremity balloon angioplasty (with or without stenting), we recommend long-term aspirin, 75-100 mg/d (Grade 1C).