SOCIETY. INTEGRATION.

EDUCATION
Proceedings of the International Scientific Conference. Volume VI, May 22th -23th, 2020. 445-455

SIGNIFICANCE OF INTENSITY OF SWEDISH

MASSAGE COURSE IN IMPROVEMENT OF HEALTH
STATUS
Una Veseta
Red Cross Medical College of Riga Stradiņš University, Latvia
Antra Gulbe
Red Cross Medical College of Riga Stradiņš University, Latvia
Oskars Onzevs
Red Cross Medical College of Riga Stradiņš University, Latvia

Abstract. The aim of the study is to compare the immediate and cumulative effects of Swedish
massage on the physiological, emotional, and biochemical factors of healthy individuals, as
well as the sustainability of the effects depending on the intensity of the course.The study
subjects were 30 healthy young women. The subjects were randomly assigned into two groups.
Subjects got in total ten Swedish back massages: twice and once a week. At the research the
complete blood count was performed, salivary cortisol level, total antioxidant capacity were
checked with the resources of laboratory “E. Gulbja Laboratorija” (www.egl.lv) Emotions
were tested by using the FaceReader 6.0™. Body composition analysis was performed by using
Tanita SC 330, blood pressure and heart rate were also measured (Omron M7–IT). The
collected data was analyzed by using methods of mathematical statistics. Regression testing
was performed by using the Fisher criterion. Analysis of the obtained data allows us to observe
positive trends in Swedish massage to the improvement of health status. Differences in some
summary results of massage effects were identified.
Keywords: course intensity, healthy individuals, health status, Swedish massage.

Introduction

Massage therapy is a purposeful, widely recognized medical technology,

which applies dosed mechanical influence to the soft tissues of the human body -
skin, tendons, ligaments, fascia, and muscles (Fritz, 2014). The effect produced
by massage in the human's organism is a complicated physiological process,
which involves numerous systems and organs, but the leading role belongs to the
nervous system (Fritz, 2014; Moraska, Pollini, Boulanger, Brooks, & Teitlebaum,
2010).
Despite the growing popularity of massage, most of the published research
materials have very cautiously formulated conclusions: massage may reduce pain,
stress, symptoms of depression and insomnia, it can improve certain parameters

© Rēzeknes Tehnoloģiju akadēmija, 2020

http://dx.doi.org/10.17770/sie2020vol6.5087
Veseta et al., 2020. Significance of Intensity of Swedish Massage Course in
Improvement of Health Status

of immunity. There isn't much research that has addressed the issue of how
massage helps, i.e. it's mechanisms of action, instead of whether it helps. Research
on the immediate effects of massage and the effects of repeated influence of
massage on the body is lacking and the significance of the “dosage” of influence
(interval between sessions) is a completely new research direction (Moyer,
Rounds, & Hannum, 2004).
The aim of the study is to compare the immediate and cumulative effects of
Swedish massage on the physiological, emotional, and biochemical factors of
healthy individuals, as well as the sustainability of the effects depending on the
intensity of the course.

Literature review

In the most of researches, massage is done twice a week (Fielda, 2016).

According to the results of Fateme, Mojtaba, & Hojatollah research, it is
recommended that massage, as a valuable non-invasive method, is used for nurses
in intensive care units to reduce their stress, promote mental health and prevent
the decrease in quality of nursing work life. Swedish massage was performed on
participants of the experimental group for 25 min in each session, twice a week
for four weeks (Fateme, Mojtaba, & Hojatollah, 2015).
The findings of another research indicate that massage therapy enhances
positive well-being and reduces stress perception among community-dwelling
older adults. Participants (n=54) got 50 min massage or guided relaxation sessions
twice weekly for four weeks. The massage included Swedish, neuromuscular and
myofascial techniques (Sharpe, Williams, Granner, & Hussey, 2007).
The effect of a single Swedish massage session (45 min) on the oxytocin
level of a healthy adult, hypothalamic–pituitary–adrenal activity and
improvement in immunity was researched at the University of Atlanta in 2009.
The study did not confirm a significant increase in oxytocin levels, but a minor
decrease in cortisol level was observed and the overall conclusion was made that
a single massage session cannot significantly reduce the factors that characterize
stress (Rapaport, Schettler, & Breese, 2010). Therefore, the researchers at the
University of Atlanta conducted another study in 2011, where the effect of a 5-
week massage course (once or twice a week), where the factors characterizing
stress and immunity of a healthy adult were researched. The researchers
concluded that the cumulative effect of massage may differ, depending on the
intensity of massage sessions, as well as stated that further research is required
(Rapaport, Schettler, & Breese, 2012).
Cortisol has been indicated as a stress characterizing factor in several studies
on the effect of massage (Bunker et al., 2003; Dickerson & Kemeny, 2004; Field,
Hernandez-Reif, Diego, Schanberg, & Kuhn, 2005). For example, Field, et al.

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(1996), twenty-six adults got a chair massage and 24 control group adults were
asked to relax in the massage chair for 15 minutes, two times per week for five
weeks. Group by repeated measures and post hoc analyses revealed the following:
1) frontal delta power increased for both groups, suggesting relaxation; 2) the
massage group showed decreased frontal alpha and beta power (suggesting
enhanced alertness); while the control group showed increased alpha and beta
power; 3) the massage group showed increased speed and accuracy on math
computations while the control group did not change; 4) anxiety levels were lower
following the massage, but not the control sessions, although mood state was less
depressed following both - the massage and control sessions; 5) salivary cortisol
levels after the massage were lower only for one day, but not after the control
sessions; 6) at the end of the five-week period depression scores were lower for
both groups, but job stress score were lower only for the massage group
(Field et al., 1996).
Seven weeks course massage therapy consisted of a 20 min massage therapy
session offered daily to patients (a young adult psychiatric inpatient) during the
period of hospitalization. There was a significant reduction in self-reported
anxiety (p<0.001), resting heart rate (p<0.05) and cortisol levels (p<0.05)
immediately following the initial and final massage therapy sessions
(Garner et al., 2008).
Two similar design studies in Givi (2013) and Moeini, Givi, Ghasempour, &
Sadeghi (2011) shows the effects of massage on blood pressure (BP). It was
performed on women with pre-hypertension. The study consisted of two groups -
test group (25 patients) getting 10 sessions of Swedish massage (10-15 min) three
times a week, and the control group (25 patients), which was offered a relaxation
in the same environment without getting any massage. The results indicated that
mean systolic and diastolic blood pressure in the massage group was significantly
lower in comparison with the control group (p<0.001). Evaluation of durability of
the massage effects on BP also indicated, that even 72 hours after finishing the
study there was still a significant difference between the test and control groups
in systolic and diastolic BP (p<0.001). Findings of the study indicated that
massage therapy was a safe, effective, applicable and cost-effective intervention
in controlling BP of the pre-hypertension women and it can be used in the health
care centers and even at home (Givi, 2013; Moeini, Givi, Ghasempour, &
Sadeghi, 2011).
A study conducted in Japan included 12 elderly people requiring long-term
care, who were randomly divided into two groups (A and B). Group A got hand
massage and group B got foot massage -for 15 min each. After one week, group
A got foot massage and group B got hand massage - for 15 min each. Results
showed that the degree to which participants felt pleasant, relaxed and refreshed
was high after both kinds of massage. This study suggests that hand and foot

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Improvement of Health Status

massage modulate psychological factors in elderly people requiring long-term

care and can be used more regularly to support the well-being of elderly people
(Nakano et al., 2019).
In general, the findings of studies carried out so far have shown that massage
effectively improves health and well-being, both in virtually healthy subjects and
in people with different diseases. Massage has been performed twice a week in
most of studies. The effect of massage on different health parameters has been
demonstrated, but did not find any studies of the immediate and cumulative
effects of massage and the residual effects of course exposure depending on the
intensity of the massage course.

Methodology

This was a 5 and 10 weeks randomized open-type comparative study that

compared the immediate and cumulative effects of Swedish massage to the
physiological, emotional and biochemical factors of healthy individuals, as well
as the sustainability of massage impact depending on the intensity of the course.
The study was conducted the Red Cross Medical College of Riga Stradiņš
University (hereinafter – RSU RCMC) scientific activities development project
“The importance of classical massage course intensity in improving health status”
No 1.), which took place in the for ten months in accordance with generally
accepted standards of good scientific practice and ethical principles provided by
the Helsinki Declaration. The protocol was reviewed and approved RSU RCMC
ethical committee. Before being included in the study, each participant signed the
informed consent to participate in the study.
The main inclusion criteria of the study participants were: a physically and
psychologically healthy person aged 18 to 35 who did not smoke, has not taken
within the last six months more than a glass of wine or its equivalent (another
alcohol) per day, has not used drugs, has not worked night shifts, denied
pregnancy, failed to follow a special diet, the body mass index (BMI) was within
the normal range of 18.5 to 24.9 and the results of a full blood test were consistent
with the generally accepted normal values of a healthy person.
The main exclusion criteria were:
• serious medical problems with recent history of medical interventions;
• participant prepares to follow some health-affecting program during the
study;
• risk of not completing the study (it was previously known that
participant will not be able to attend all massage and test sessions).

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Assessed as appropriate (n=40)

Excluded (n=4)
Inclusion (n=40) • did not met inclusion criteria (n=3)
• cancelled participation (n=1)
• other reasons (n=0)

Trial participants divided into groups randomly (n= 36)

Grouping

Grouped for intervention Grouped for intervention

Intervention received (n=17) Intervention received (n=17)
• did not use intervention received (n=1). Not • did not use intervention received (n=1) -
able to attend massage session twice per week. started night shift

Followed – up

Lost for post-control (n =0) Lost for post-control (n =2) Got ill, discontinued
Stopped intervention (n =1). Disliked massage massages. Stopped intervention (n =0)

Analysis
Analyzed (n =16) Analyzed (n =16)
• excluded from analyses (n =1) Mistakenly • excluded from analyses (n =1) Mistakenly
entered indicators entered indicators

Figure 1 Study Flow Scheme

Following the first anthropometric and laboratory assessments, the

participants were divided into groups (randomly) using the drawing lots
(Figure 1). Group A members were massaged twice a week, i.e., they had a five-
week course, while group B members were massaged once a week and had a
10-week course.
Methods. The weight was determined using professionally calibrated scales
and the analyser Tanita SC 330 (N 11030184 TANITA 545 N 510426) to the
nearest 100 g. The participants were wearing lightweight clothing, no shoes.
The clinical blood test was conducted to assess the actual health status of the
study participants: (Hb, WBC, RBC, HT, PLT) + WBC differential + ESR
(capillary photometry method). The results of the analysis showed the results of
the patient's blood composition and generally recognized reference ranges for the
healthy person.
Full blood counts were detected, cortisol levels in saliva and total antioxidant
capacity measured at the beginning of the study, after the fifth massage, after the
last massage and two weeks after the last massage. The levels of cortisol in the

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Improvement of Health Status

blood vary depending on stress and correlate with the levels of cortisol in saliva
(Kirschbaum & Hellhammer, 1994).
Photometric method was used for the determination of cortisol in saliva.
Cortisol has a diurnal rhythm: under normal conditions the level of cortisol
increases 1–2 hours before waking up and reduces during the day until it reaches
the minimum at midnight. Laboratory “E. Gulbja Laboratorija” has determined
the following reference ranges of salivary cortisol: from 2.30 p.m. – 3.30 p.m.
<11.9 nmol/L. Samples were taken at 3.00 p.m. – 3.30 p.m. The total amount of
antioxidants was determined by the photometric method in heparinized blood
plasma. In normal, antioxidant levels in a healthy person range from 1.3 to 1.77
nmol/L. All tests were carried out in an accredited laboratory, which performed
testing in accordance with the international standard (LVS EN ISO 15189: 2008).
Before and after each massage session the study participants were filmed, all
video - analysed, using the FaceReader 6.0 ™ software to perform an analysis of
their emotional condition and define which of the six basic feelings (happy, angry,
sad, surprised, frightened, disgust or neutral) prevail (Ekman & Cordaro, 2011).
In the study FaceReader 6.0 was used to test well-being by measuring the levels
of positive and negative feelings. Video analysis and results` mathematical
statistics were performed Noldus Information Technology BV (Netherlands),
www.noldus.com.
The study analysed BP parameters, particularly changes in systolic and
diastolic pressure, and their progression to normal intervals. BP measurements
were performed before each massage using the automatic BP measurement
apparatus Omron M7 – IT. A remeasurement on the same arm was performed
after the massage.
Back massage was performed in accordance with the following principles:
• positioning of the customer according to his individual needs before
starting a massage;
• massage duration - 25 minutes;
• massage is performed for the back part from C7 to S5;
• massage is performed using the following sequence of techniques:
gliding, rubbing, kneading and vibration.
Statistical analysis was performed using the statistical software package
SPSS 17.0 for Windows. Data were expressed as mean and standard deviation.
The differences in the distribution of qualitative variables were assessed by the
Chi-square test. The difference considered to be significant when p<0.05.
Regression testing was performed by using the Fisher criterion.

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Research results

The results of the study showed no significant differences between the two
groups (p<0.01) (Table 1). Repeated analysis of total blood scenes and body
composition allowed an assessment of the effects of the procedure. The analyses
were conducted four times during the study. The results showed that the subjects
were generally healthy, and therefore the results were not analysed.
Table 1 Descriptive statistics of the anthropometry of the A group and B group

Mann-Whitney test for p=0.01 and n =15

Parameters A group B group U Ukrit
Age (years) 25.0±5.3 23.7±5.3 86 51
Weight (kg) 63.5±9.0 65.2±7.6 79 51
Height (m) 170.7±6.6 169.5±8.4 87 51
BMI (kg/m2) 21.7±2.2 22.6±1.2 84 51
BMI=body mass index. Values are expressed as mean ± standart deviation n=15

Before intervention both groups were almost similar in regard to total

antioxidant capacity, salivary cortisol level and BP levels, with the exception, that
the salivary cortisol level was slightly higher for group A; in any case - all rates
were within normal limits and all differences between both groups were
statistically insignificant (p>0.05) (Table 2).
Table 2 Descriptive statistics of the Cumulative Change of the A group and B group

Before After the 5th After the 10th Two weeks

massage massage massage after massage
course session session course
A Mean 1.58 1.37 1.61 1.63
Total SD 0.13 0.13 0.13 0.12
antioxidant B Mean 1.59 1.56 1.76 1.63
SD 0.09 0.13 0.05 0.08
A Mean 16.07 11 14.8 14.27
Salivary SD 10.5 4 6.53 5.46
cortisol B Mean 13.57 10.21 10 15.21
SD 5.73 2.75 3.4 5.67
A Mean 120.27 117.73 119.8 121.27
Systolic
SD 5.56 6.5 5.09 7.1
BP
B Mean 119.27 116.87 116.6 117.93
(mmHg)
SD 7.74 6.82 6.81 7.53
A Mean 73.47 71.33 72.47 73.07
Diastolic
SD 4.91 5.02 4.03 6.1
BP
B Mean 72.8 69.4 72.47 70.73
(mmHg)
SD 4.31 5.79 5.1 5.97

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Improvement of Health Status

Salivary cortisol levels, decreased after the first five massage sessions in
both groups, but the data are not statistically significant (p˃0.05). The effects of
Swedish massage on the physiological and biochemical factors of healthy
individuals were irrelevant, excluding heart rate.

Figure 2 Heart rate of the A group and B group

Before intervention, the heart rates for group A and B did not differ
significantly (p>0.05). Slope position was determined by Fisher criterion. With a
5% reduction in probability will be all the time. Statistically significant (p˂0.05)
(Figure 2, Table 3).
Table 3 Descriptive statistics of the heart rate of the A group and B group

For Slope
Interce
Slope F Significance F Lower 95.0% Upper 95.0%
pt
A before 72.984 -0.0602 5.43 0.04808 -0.1198 -0.000647
A after 66.005 -0.0697 8.25 0.02078 -0.1257 -0.013728
23.2
B before 74.543 -0.0779 0.00132 -0.1152 -0.040633
1
24.0
B after 67.902 -0.0560 0.00119 -0.0823 -0.029635
2

The students’ independent t-test results showed that the average score of
neutral and happy emotions was different between the A and B groups before and
after intervention (p>0.05) (Figure 3).

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60
Intensity of facial expression
*
50 Group A before
* Group A after
40 Group B before
Group B after
30

20

10

0
Neutral Happy Sad Angry Surprised Scared
* significant differences compared to before massage course (p ≤ 0.05)

Figure 3 Induced emotions before and after massage of the A group and B group

Conclusions and discussion

This was a 5 and 10 weeks randomized open-type comparative study that

compared the immediate and cumulative effects of Swedish massage to the
physiological, emotional and biochemical factors of healthy individuals, as well
as the sustainability of massage impact depending on the intensity of the course.
Blood pressure, pulse and emotion measurements were performed before and
after each massage session to determine the immediate effects of massage. The
results of the study showed that there were no significant differences between the
two groups (p<0.01), while average physiological parameters were close to the
upper limit of norm. The study data showed that the effect of a single massage
was weak, similar to that of Rapaport, Schettler, & Breese (2010) study. The
impact analysis of each massage session showed minor changes in determinations
of physiological and emotional factors, but before each following massage there
were positive determination trends.
The analysis of these determinants of group A (a massage course twice a
week) showed higher fluctuations in results, which generally ensured less
stabilization of physiological and emotional factors. Data of group B (a massage
course once a week) showed higher stabilizing effects of the results. The
proportion of neutral and happy feelings increased during the course and heart
rate decreased, which is statistically significant (p<0.05).
While massage therapy lacks evidence-based research, its popularity is
rising. It's important to consider the availability of massage. Massage is performed
twice a week in most studies (Fielda, 2016). For example, the study of Fateme,
Mojtaba, & Hojatollah (2015) demonstrated the importance of twice a week
massage in health maintenance and in work quality of intensive therapy units’

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Improvement of Health Status

nurses. Similar studies analysing the effect's sustainability would be required for
massage course with sessions performed once a week.
Another study (Sharpe, Williams, Granner, & Hussey, 2007) shows that
massage therapy improves positive well-being and reduces stress perception
among older adults. It would be necessary to carry out once per week massage
session studies for this target group in order to consider the possibility to ensure
broader availability of massage. As mentioned above, our study concluded that in
practically healthy young adults, massage provided on once per week basis
increased positive feelings during a massage course (p<0.05).
As in the Field et al. (1996) study, the results of this study showed a tendency
to impact the levels of saliva cortisol. Saliva cortisol levels decreased after the
first five massage sessions in both groups, but the data is not statistically
significant (p˃0.05). Saliva cortisol level is a good indicator for analysing the
immediate effects of Swedish massage.
Givi (2013) and Moeini, Givi, Ghasempour, & Sadeghi (2011) examine the
effect of massage on blood pressure. The study was conducted three times a week
in women with pre-hypertension. In our study participated healthy subjects, and
the effect of massage on blood pressure is not statistically significant (p˃0.05).
Nor did the study confirm a significant increase in total antioxidant levels.
Comparing heart-rate scores in both groups heart rates declined regardless
of whether massage was performed two or once per week. This expected finding
is supported by earlier studies (Garner et al., 2008) as well.
Based on the findings of this study, it may be concluded that a once per week
massage course is recommended to improve the health status of practically
healthy people. Similar studies in older people and people with increased levels
of workplace stress would be recommended in future.

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