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Immunological Effects of Massage Therapy During Academic Stress

University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Department of Psychiatry, Newark, NJ, Center for Research in Complementary and Alternative Medicine, West Orange, NJ
Kessler Medical Rehabilitation Research and Education Corporation

Studies have shown evidence for many of the physiological effects of massage, such as its ability to relax skeletal muscle (1), increase blood and lymph circulation (2), and reduce anxiety (3). The immunological effects of massage therapy, however, particularly in healthy individuals, have received little attention. One study with healthy men (4) found no significant change in the number of white blood cells (WBCs) associated with massage; however, immune assessment was limited to total leukocyte count. A more recent study with HIV+ and HIV- men (5) found significant increases in natural killer (NK) cell number and function and a number of other immune parameters after a series of massages. Given evidence from psychoneuroimmunologic (PNI) studies showing associations between stress and immune suppression (6, 7) and between stress-reduction interventions and immune enhancement (8, 9), we reasoned that massage might be a useful stress-reduction tool capable of inhibiting, or even reversing, potentially detrimental PNI effects. The present study examined for the first time the immunological effects of massage therapy as a stress-reduction intervention in a medically healthy population.

Nine medically healthy first- and second-year female medical students (age range 21–25) received a 1-hour full body massage 1 day before an academic examination that was causing them considerable anxiety. Subjects were excluded or postponed if they had any symptoms or conditions for which massage is contraindicated. Subjects were also excluded if they had received a full body massage within the past 6 months or had a history of anxiety associated with venipuncture. Individuals routinely taking medications with possible immune system effects (eg, oral contraceptives) were included because any immune reactions to these medications would be stable during the 1-hour interval between pre- and postblood draws.

Blood samples, self-report psychosocial data, and vital signs were obtained immediately before and immediately after the massage treatment. Cell phenotypes of the major cells of the immune system, natural killer cell activity (NKCA) and mitogen-induced lymphocyte stimulation were assessed by standard techniques the same day as venipuncture.

Scales measuring current anxiety and perceived stress included the State component of the State Trait Anxiety Inventory (S-STAI) (10) and a visual analogue scale of perceived stress. The massage protocol was developed to encourage relaxation and increase circulation and included the application of standard strokes of Swedish massage: effleurage, pétrissage, and friction. The therapist (D.Z.) used an unscented lotion to massage the subjects with light to moderate pressure in the following sequence: subjects prone—back, posterior legs, feet; subjects supine—anterior legs, arms, neck.

The results showed a significant decrease in respiratory rate from pre- to post-massage from a mean of 12.9 (SD = 4.8) to a mean of 10.4 (SD = 3.1) (t = -2.63; p < .05). No significant differences between pre- and postmeasures of blood pressure, pulse, or temperature were found. Mean score on the S-STAI decreased from 52.8 (SD = 7.8) premassage to 26.7 (SD = 4.6) postmassage (t = -8.10; p < .01). On the visual analogue scale, mean score decreased from 75.6 (SD = 12.9) premassage to 34.6 (SD = 22.4) postmassage (t = -4.49; p < .01). Comparisons of pre- to postperipheral WBC count measures revealed an increase in the total number of WBCs postmassage (t = 3.64; p < .01) and a decrease in the percentage of T cells postmassage (t = -2.64; p < .05). There was, however, no significant difference in the absolute number of T cells. There were no significant differences from pre- to postmassage in the percentages or absolute numbers of the other circulating lymphocyte subsets.

Analysis of variance of the lymphocyte responses to the mitogens revealed no significant time (pre—post) effect or dose-by-time interaction for any of the mitogens (p>.1). Analysis of variance of NKCA revealed a significant time (pre—post) effect (F = 12.47; df = 1,8; p < .008), indicating a significant increase in killing activity after the massage.

To assess whether the changes in both perceived stress and anxiety were mediators of the increase in NKCA after the massage, Pearson correlations were calculated between the stress and anxiety measures and NKCA. Surprisingly, change in NKCA was found to be negatively correlated with changes in both perceived stress and S-STAI: greater increases in NKCA were correlated with smaller changes in perceived stress (r = -0.76; p = .02) and in anxiety (r = -0.78; p = .02). No significant associations were found between changes in perceived stress and S-STAI and changes in WBC count and percentage of T cells.

As expected (3), the massages reduced subjective and somatic signs of anxiety. The increased WBCs after massage suggests that massage might have brought more WBCs into peripheral circulation, consistent with reported effects of massage on blood and lymph circulation (2). Aside from sampling issues, the discrepancy between our WBC findings and previous ones may relate to the different massage techniques used (ie, "fairly vigorous" in the study by Arkko et al. (4) vs light to moderate pressure, aimed at encouraging relaxation and increasing circulation, in ours). This is the first report that massage results acutely in a decreased percentage of T cells, an effect that might not have been reflected in the absolute number of T cells due to the overall increase in the number of WBCs. Our results confirm previous findings in a clinical sample of enhanced NKCA after massage (5). The present study is the first to demonstrate an association between enhanced NKCA and massage therapy in a healthy sample undergoing acute stress.

The counterintuitive associations found for anxiety and NKCA suggest that subjective experiences of anxiety reduction do not mediate the increase in NKCA, and that reduced subjective anxiety may even blunt the effect of another (unknown) factor associated with the increase in NKCA. These correlational findings may possibly reflect effects associated with the different immune compartments (eg, anxiety reduction may be associated with NKCA changes in spleen with reciprocal effects on blood NKCA). Distress related to venipuncture and/or hormonal changes associated with the menstrual cycle may, alternatively, be influencing factors, which was supported by anecdotal evidence in the current study. That the changes in WBCs and T cells were not correlated with the changes in perceived stress and S-STAI also suggests mediation by other mechanisms, such as those related to peripheral circulatory changes.

These preliminary findings have potential importance in validating and expanding the therapeutic uses of massage, since they suggest that massage may have health benefits beyond and unrelated to its stress-reduction potential. They need to be replicated, however, because of the small sample size and lack of a control group. Additionally, it would be important to clearly distinguish cumulative effects from those from a single treatment and to demonstrate long-term effects, if any, on immunity and subsequent health status.

ACKNOWLEDGMENTS

This project was funded by a grant from the American Massage Therapy Association Foundation and supported in part by National Institutes of Health Grant U24HD32994. The authors thank Haftan Eckholdt, Hong-Lin Niu, John Martinez, Kathe Trilling, Fereshteh Salimian O’Brien, Dolores Anthony, and Laurie Parsons for their support on various aspects of this project. We also thank the Swedish Institute Inc. for their loan of a massage table.

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