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ORIGINAL REPORT
Corresponding Author: Akram Abedinipoor
Department of Nursing, School of Nursing and Midwifery, Qom University of Medical Sciences, Qom, Iran, Post. Code: 3713649373
Tel: +98 251 7729595, 7715214-6, Fax: +98 251 7704234, E-mail: akabedini@yahoo.com
How Effective is Swedish Massage on Blood Glucose
Level in Children with Diabetes Mellitus?
Firoozeh Sajedi1, Zahra Kashaninia2, Samaneh Hoseinzadeh3, and Akram Abedinipoor4
1 Pediatric Neurorehabilitation Research Center, University of Social Welfare & Rehabilitation Sciences, Tehran, Iran
2 Department of Nursing, University of Social Welfare & Rehabilitation Sciences, Tehran, Iran
3 Department of Biostatistics, Tarbiat Modares University of Medical Sciences, Tehran, Iran
4 Department of Nursing, School of Nursing and Midwifery, Qom University of Medical Sciences, Qom, Iran
Received: 10 Jan. 2011; Received in revised form: 3 Feb. 2011; Accepted: 20 Feb. 2011
Abstract- This study was conducted to determine the effect of Swedish massage on blood glucose level in
children with diabetes mellitus (DM). It was prospective randomized controlled trial study that conducted on
36 children, 6-12 years old with DM, recruited from a hospital in Qom City, Iran. The children were
randomly assigned to intervention and control groups. Swedish massage was performed 15 minutes, 3 times a
week, for 3 months in intervention group. The blood glucose levels were evaluated immediately after every
session of massage in two groups. The mean ages of children in the intervention (n=18) and control (n=18)
groups were 9.05±1.55 and 9.83±2.03 years respectively. There was statistically no significant difference in
blood glucose levels before intervention between two groups (P=0.586), but the blood glucose levels were
lower significantly in intervention group in comparison with control group after intervention (P<0.0001).
Addition of Swedish massage to daily routines; exercise, diet and medication regimens, is an effective
intervention to reduce blood glucose level in diabetic children.
© 2011 Tehran University of Medical Sciences. All rights reserved.
Acta Medica Iranica, 2011; 49(9): 592-597.
Keywords: Blood glucose; Diabetes Mellitus; Massage; Child
Introduction
Diabetes mellitus (DM) is one of the most common
severe chronic childhood diseases with a variable
incidence among different ethnic groups; from
0.7/100000 per year in Karachi-Pakistan to about
40/100000 per year in Finland. The incidence of DM is
rapidly increasing and shows a trend toward earlier age
of onset. The increasingly prolonged survival of the
diabetic child is associated with an increasing
prevalence of complications (retinopathy, neuropathy).
These long term complications are related to glycemic
control. A good metabolic control is having a profound
influence on reducing the incidence and the severity of
certain complications (1). However achieving good
control can be difficult for many individuals because the
delicate hormonal balance that controls glucose
homeostasis is disrupted by the disease, before diagnosis
and easily upset by physical and psychological stress
after diagnosis even if the person is on diabetes
treatment (2).
Because of the chronic nature of diabetes many
people turn to complementary therapies (CT) to assist
them to cope and control the disease (2) Leese et al.
surveyed people with diabetes attending a diabetic
outpatient clinic in the UK and found 17% were using
CT (3). A similar survey in Canada found 25% of people
with diabetes used CT (4). The main therapies used were
nutritional and spiritual therapies, herbs, massage and
meditation (5). More than 1000 years ago, diabetes was
treated in various societies with relaxation, massage,
opium, and moderate exercise, as well as dietary
alternations (6).
There are 5 forms of massage therapy. The first is
traditional European or Swedish, the most common form
of massage in the United States. The focus is on
relaxation and improved blood circulation through
muscle massage (7,8).
Swedish massage was developed in 1914 by Per
Henrik Ling; this method is considered one of the first
scientific approaches to massage, aiming specifically to
affect the circulatory, lymphatic, and nervous systems.
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F. Sajedi, et al.
Acta Medica Iranica, Vol. 49, No. 9 (2011) 593
Long, gliding strokes (referred to as friction) are used to
enhance blood and lymph flow; kneading (called
petrissage) is used to relax muscle tension; and tapping,
cupping, and hacking movements (called tapotement)
are used to stimulate nerves. (9)
It has been shown that there are significant
correlations between poor metabolic control and
depressive symptoms, and a high level of anxiety (1).
Massage has been shown to decrease anxiety in a variety
of patient populations, including people with diabetes.
These stress reducing benefits of massage have raised
the possibility that massage may be of benefit to people
with diabetes by inducing the relaxation response,
thereby controlling the counter-regulatory stress
hormones and permitting the body to use insulin more
effectively (9-14).
Cortisol is a stress hormone associated with the
sympathetic response of the autonomic nervous system
(15,16). Massage therapy (MT) is expected to reduce
cortisol levels, a finding that would be consistent with
facilitating a parasympathetic response of the autonomic
nervous system (16-18). So massage has continued to be
found useful for lowering blood glucose levels (11,12).
This study was conducted to determine the effect of
Swedish massage on blood glucose level in children
with DM.
Materials and Methods
Subjects
Following ethical approval from the ethics committee of
the University of Social Welfare and Rehabilitation
Sciences (USWR), a prospective, randomized,
controlled trial study was conducted in 2009, at the
Clinic of Kamkar-Arabnia Hospital, Qom City, Iran.
Inclusion criteria were age between 6-12 years,
diagnosis of DM type I (based on medical file), and
parents & children cooperation. Exclusion criteria were
skin disease, osteopathy, malignancy in spinal cord,
drug consumption (except for DM), and severe sensorial
or movement disorders. Forty eight patients were
assessed for eligibility. Six patients were excluded
because of not meeting inclusion criteria and six other
patients refused to participate. All parents received
documented information about the aims and plans of the
research, and were asked to sign consent forms; those
not willing to participate would be provided with
services as usual. Finally 36 patients with DM enrolled
in this study. The subjects were randomly assigned to
intervention and control groups on the basis of random
number table.
Protocol
We focused on forms of MT that are concordant with
the traditional Swedish styles of massage; Swedish
massage is performed on a table or special massage
chair with oil and systematically starts and finishes in
the following manner. The first process is stroking
(effleurage), which consists of long, firm gliding strokes
usually done with the whole hand or thumbs. The
strokes trace the outer contours of the body. The second
is kneading (petrissage), which is the process of working
on specific muscle groups by rhythmically lifting,
rolling, kneading, or squeezing them. Third is friction.
The therapist uses circular strokes often moving
opposite to the muscle fibers to reach the deeper muscles
and for connective tissues such as tendons. Fourth is
percussion (tapotement), which uses gentle, rhythmic,
and drumming motions. Finally the therapist uses
vibration. To do this the massage therapist rapidly
relaxes and contracts his or her own muscles, which
transmits the vibrations to whatever part of the body is
being touched. A gentler technique is called jostling and
is used on the arms and legs. The therapist gently shakes
the arms back and forth to relax them. A trained
massage therapist will usually start with stroking and
then move on to kneading and friction on any areas that
seem especially tense or sore. Percussion is used to relax
the large back muscles. Vibration and jostling are used
throughout the massage, especially on the arms and legs
(7-9,19).
For the purposes of this study, MT is performed by
the manual manipulation of soft tissue by a person other
than the recipient. A nurse was trained to Swedish
massage by one of the experienced physiotherapists at
USWR. Then she trained the parents. Next, the
intervention group was given Swedish massage by
trained parents with supervision of that nurse.
Massage was implemented in quiet rooms with
appropriate temperature (20-24°C), and light at 8 am.
The parents were asked not to change their children’s
daily routines such as: exercise, diet and medication
regimens.
The children took off their clothes and were
positioned on a suitable bed in supine position and were
massaged from arms, neck and head and then progressed
to the torso, feet, and legs. The patient then lied prone,
and the legs, hip and back were massaged. Massage
lotion was applied to minimize friction on the skin. The
children received massage for 15 minutes, three times a
week for three months (totally = 540 minutes) and blood
glucose level was measured right after every MT session
by glucometre. The children did not receive any
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How effective is swedish massage on blood glucose level
594 Acta Medica Iranica, Vol. 49, No. 9 (2011)
interventions in control group but they had daily
routines such as: exercise, diet and medication regimens
and their blood glucose levels were measured at 8:30
am, three times a week, for three months by glucometer
in the hospital for comparison with the blood glucose
levels of children in intervention group.
Measurements
Data was collected by glucometre with glucomen
brand name, scale, tape-measure and demographic
questionnaire.
Demographic questionnaire included 13 questions:
age, gender, height, weight, children and their parents’
educations, the parents’ job, duration of diabetes and
diabetes medication, type and doses of insulin, and
family history of diabetes. The demographic questions
were developed by the researchers in Persian (Farsi)
language. To establish the validity of questions, using
content validity method; evaluation of questionnaire by
10 faculty members of nursing and medicine that were
experienced.
The patients’ weights were measured without shoes
and with comfortable clothes by standard scale. Their
heights were measured as they stood in front of a wall
without shoes and their heel, shoulders and buttock
touched the wall; the highest level of the head was
determined on the wall and was measured by tape.
To assess reliability of the glucometre instrument,
the blood samples of 20 individuals were sent to test to
Kamkar hospital laboratory. At the same time one drop
of the same blood samples were tested by glucometre.
Then reliability of two measurements was determined
and confirmed by pearson correlation coefficient.
Data analysis
The analyses were used in this study were: (a) linear
mixed model to determine the effect of massage on the
blood glucose level after baseline measurement in
follow up; If the F-test of linear mixed model was
significant, pairwise comparisons among all times is
performed by bonferroni post hoc test. (b) Independent
t-test was used to compare baseline blood glucose levels
and quantitative demographic variables in two groups.
(c) Chi-square and fisher’s exact test were used to
compare the categorical demographic variables in two
groups. (d) K-S test was used to assessing normality of
variables. Although we measured blood glucose level 36
times after baseline, because of the small sample size,
we analyzed 12 measurements; the mean of 3 successive
measurements. SPSS version 16 was used to statistical
analysis of data. A P≤0.05 was considered statistically
significant.
Results
Background variables
A total of 36 children were enrolled in this study: 18
children in each group. There were 7 (38.9%) and
11(61.1%) females in control and intervention groups
respectively (P=0.182).
Table 1 summarizes the demographic characteristics
of 2 groups. There were no significant differences in
age, weight, height, DM duration, medication duration,
and insulin doses (NPH & regular) between 2 groups.
There were also no significant differences in
occupations of mothers (P=0.104) and fathers (P=0.97),
educations of mothers (P=1), fathers (P=1) and patients
(P=1), and family history of DM (P=1) between 2
groups by fishers' exact test.
Blood glucose levels
The mean of baseline blood glucose levels in
intervention and control groups were 207.9 ± 70.5,
195.9± 54.6 respectively before intervention. There was
no significant difference in the mean of baseline blood
glucose levels between 2 groups by Independent test
(P=0.568).
Table 1. Demographic characteristics (quantitative) in two groups*
Intervention (n =18) Control (n=18) P
Age (year) 9.0 ±1.5 9.8 ±2.0 0.206
Weight (kg) 26.7 ±5.3 30.7±6.5 0.052
Height (cm) 129.7±8.4 126.8 ±33.0 0.342
DM duration (month) 21.6 ±13.2 27.7 ±19.6 0.278
Medication duration(month) 20.8 ±12.2 27.6 ±19.4 0.225
NPH doses (IU) 30.0 ± 5.8 32.8 ±7.0 0.198
Regular doses (IU) 14.4 ± 3.2 16.0 ±4.2 0.226
* values are expressed as mean ±SD
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F. Sajedi, et al.
Acta Medica Iranica, Vol. 49, No. 9 (2011) 595
Table 2. Repeated measurements of blood glucose levels (BGLs) in the two groups*
Time of measurements baseline first 2nd 3
rd 4
th 5
th 6
th 7
th
Intervention group BGLs 207.9± 70.5 200.3 ±61.7 187.2±58.6 174.6±58.3 171.6±46.1 167.2±42.8 159.2±41.9 153.2±41.6
Control group BGLs 195.9± 54.6 198.6±55.9 209.4±56.4 189.2±46.9 190.7±47.9 193.8±47.2 187.8±46.8 196± 60.5
Be continue Table 2.
Time of measurements 8th 9
th 10th 11th 12th Mixed ANOVA
Intervention group BGLs 146.7±38 137.9±36 134.8±32 128.8±29.2 116.9±28.8 **
Control group BGLs 193.8±49.1 193.9±53.6 190.7±58.1 195.1±51.3 191.2±50.5
*Values are expressed as mean ± SD.
**The effect of group and time were statistically significant; P, 0.05.
Linear mixed model (with first-order autoregressive
covariance matrix and random effect subject) yielded a
significant time, group, baseline blood glucose level,
time and group interaction effect (P<0.05). This
indicated that intervention was effective in reducing
blood glucose level. Bonferooni post hoc test indicated
that blood glucose levels didn’t change at successive
sessions in control group but there were significant
differences between responses at almost of pairwise
sessions except a few sessions in intervention group
(Table 2).
Also as it is shown in figure 1, the means of blood
glucose levels in intervention group is descending, but
there is no significance changes in control group.
Discussion
The results of this study demonstrated that MT (in type
of Swedish massage) is effective to reduce blood
glucose level in diabetic children.
MT effects can be divided into single-dose and
multiple-dose. Single-dose effects include MT's
influence on psychological or physiological states that
are transient in nature. Multiple-dose effects are
restricted to MT's influence on variables that are
considered to be more enduring, or that would likely be
influenced only by a series of MT sessions performed
over a period of time (19). In this study, we used
multiple-dose to benefit its continuing influences.
The potential benefits of multiple-dose MT can be
further classified to affective, physiological or
behavioral in nature. Affective refers to effects most
closely associated with the recipients' feelings and
emotions (such as anxiety). Physiological effects are
those concerned with recipients' vital organismic
processes including muscle tone and blood glucose
level.
Figure 1. Trends of blood glucose level changes in two groups.
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596 Acta Medica Iranica, Vol. 49, No. 9 (2011)
Behavioral effects are those related to the recipients'
observable responses to their environment; such as
relaxation (19). It’s seemed that our subjects benefited
from all of these effects.
Beider and Moyer showed that generally massage
therapy has resulted in lower anxiety and stress
hormones and improve clinical course in diabetic
children (20). In our study may be, MT was effective
through reduction of anxiety and stress hormones.
Hernandez et al. (21) also assessed massage effect
on blood pressure, stress hormones secreted from
salivary glands and depression. They showed that
massage reduces blood pressure (P<0.05), anxiety
(P<0.001), depression (P<0.01) and stress hormones
(cortisol) secreted from salivary glands (P<0.05). On the
other hand Dunn showed that there were no statistically
significant differences in the physiological stress
indicators following massage therapy (22).
Doctors at Duke University Medical Center have
observed small but significant improvements in
glycemic control in type 2 diabetics given stress
management training. They proposed that cost-effective
stress management training programs include muscle
relaxation, when administered in a group setting, might
benefit patients with type 2 diabetes in the long-run by
building on traditional practices used for improving
glucose levels (23).
Surwit et al. also suggested that stress management
(include muscle relaxation) can be a meaningful addition
to a comprehensive treatment program for patients with
type 2 diabetes, because stress is associated with the
release of counterregulatory hormones and energy
mobilization, often resulting in elevated glucose levels.
In addition, stress can disrupt diabetes control indirectly
through effects on diet, exercise, and other self-care
behaviors (24). Jablon et al. showed that muscle
relaxation was effective on fasting blood glucose level
reduction (P<0.0001), 2 hours blood glucose (P<0.0001)
and stress (P<0.0001) (25).
May be massage is more effective than relaxation on
blood glucose level in DM. In one study, twenty-four
children with diabetes were assigned to receive either
massage therapy or relaxation therapy. One-half of the
parents were asked to massage their children for 20
minutes before bedtime for 30 consecutive nights, and
the other half were asked to conduct progressive muscle
relaxation each night for the same time period. The
effects in the massage group were decreased parental
and child anxiety. Over a 30-day period, the mean blood
glucose decreased from 159 to 118 mg/dL in the
massage group. (26)
In conclusion, addition of Swedish massage as a
complementary treatment to daily routines; exercise, diet
and medication regimens, is an effective intervention to
reduce blood glucose level in diabetic children.
Considering that parents continue to explore and utilize
all the health care options for their children and Swedish
massage is cost-effective, easy and available, so it is
essential to be thaught to mothers and caregivers for
better metabolic control in diabetic children.
Acknowledgements
This research was supported by the University of Social
Welfare and Rehabilitation Sciences (USWR). We
would like to acknowledge Elham Mahmoudi, patients
and their parents for their sincere cooperation.
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