The short-term effects of myofascial TrPTs massage therapy on cardiac autonomic tone in healthy subjects

Abstract

To investigate the effects of myofascial trigger-point massage therapy to the head, neck and shoulder areas on cardiac autonomic tone.Background. No studies have reported on the effect of back massage on autonomic tone as measured by heart rate variability. This is especially relevant to the nursing profession, as massage is increasingly available as a therapy complementary to conventional nursing practice.
An experimental study in which subjects were initially placed in age- and sex-matched groups and then randomized to treatment or control by alternate allocation. The study involved 30 healthy subjects (16 female and 14 male, aged 32.47 +/- 1.55 years, mean +/- standard error). A 5-minute cardiac interbeat interval recording, systolic and diastolic blood pressure and subjective self-evaluations of muscle tension and emotional state were taken before and after intervention. Autonomic function was measured using time and frequency domain analysis of heart rate variability.
Following myofascial trigger-point massage therapy there was a significant decrease in heart rate (P < 0.01), systolic blood pressure (P=0.02) and diastolic blood pressure (P < 0.01). Analysis of heart rate variability revealed a significant increase in parasympathetic activity (P < 0.01) following myofascial trigger-point massage therapy. Additionally both muscle tension and emotional state, showed significant improvement (P < 0.01).
In normal healthy subjects myofascial trigger-point massage therapy to the head, neck and shoulder areas is effective in increasing cardiac parasympathetic activity and improving measures of relaxation.

Full text

ISSUES AND INNOVATIONS IN NURSING PRACTICE
The short-term effects of myofascial trigger point massage therapy
on cardiac autonomic tone in healthy subjects
Joseph P.A. Delaney FIBMS
Lecturer in Behavioural Sciences, Wirral Metropolitan College, and Department of Medicine, Clinical Sciences Centre,
University Hospital Aintree, Liverpool, UK
King Sun Leong BMedSc BMBS MRCP
Consultant, Diabetes Centre, Whiston Hospital, Prescot, Merseyside, UK
Alan Watkins BSc MBBS
Honorary Research Fellow, Department of Medicine, University Hospital Southampton, Southampton, UK
and David Brodie BEd MSc PhD
Professor, Research Centre for Health Studies, Buckinghamshire Chilterns University College, Chalfont St Giles, UK
Submitted for publication 18 April 2001
Accepted for publication 19 November 2001
364 Ó2002 Blackwell Science Ltd
Correspondence:
David Brodie,
Research Centre for Health Studies,
Buckinghamshire Chilterns University
College,
Chalfont St Giles,
HP8 4AD,
UK.
E-mail: david.brodie@bcuc.ac.uk
DELANEYDELANEY JJ.PP .AA ., LEONGLEONG KK.SS ., WATKINSWATKINS AA.&&BRODIEBRODIE DD.(2002)(2002) Journal of
Advanced Nursing 37(4), 364±371
The short-term effects of myofascial trigger point massage therapy on cardiac
autonomic tone in healthy subjects
Aim of the study. To investigate the effects of myofascial trigger-point massage
therapy to the head, neck and shoulder areas on cardiac autonomic tone.
Background. No studies have reported on the effect of back massage on autonomic
tone as measured by heart rate variability. This is especially relevant to the nursing
profession, as massage is increasingly available as a therapy complementary to
conventional nursing practice.
Design/Methods. An experimental study in which subjects were initially placed in
age- and sex-matched groups and then randomized to treatment or control by
alternate allocation. The study involved 30 healthy subjects (16 female and 14 male,
aged 32á47 1á55 years, mean standard error). A 5-minute cardiac interbeat
interval recording, systolic and diastolic blood pressure and subjective self-evalu-
ations of muscle tension and emotional state were taken before and after
intervention. Autonomic function was measured using time and frequency domain
analysis of heart rate variability.
Results. Following myofascial trigger-point massage therapy there was a signi®cant
decrease in heart rate (P<0á01), systolic blood pressure (P0á02) and diastolic
blood pressure (P<0á01). Analysis of heart rate variability revealed a signi®cant
increase in parasympathetic activity (P<0á01) following myofascial trigger-point
massage therapy. Additionally both muscle tension and emotional state, showed
signi®cant improvement (P<0á01).
Conclusions. In normal healthy subjects myofascial trigger-point massage therapy
to the head, neck and shoulder areas is effective in increasing cardiac parasympa-
thetic activity and improving measures of relaxation.

Introduction
Nursing in a number of contexts (such as palliative care,
oncology and cardiac rehabilitation) is increasingly exposed
to complementary therapies. A PUBMED Medline search
using the combined terms `nursing' and `complementary
therapies' revealed 527 citations between 1980 and 1990
and 1653 citations between 1990 and 2000. More partic-
ularly, the use of therapeutic massage is re-emerging as a
popular nursing modality as evidenced by an increase in
journal articles. Again using the PUBMED Medline, data-
base, the terms `nursing' and `therapeutic massage' revealed
54 citations between 1981 and 1991 compared with 248
citations between 1991 and 2001. The evidence base for
these is increasing, but clinical governance requires further
information on the ef®cacy of such interventions. In general,
the present status of certain complementary therapies is that
they are offered in conjunction with conventional nursing
practice. It would be acceptable, for example, to see the
opportunity for re¯exology, autogenic training and aroma-
therapy advertised in conjunction with a coronary care unit.
Nurses may be unsure of the merits of such therapies because
it is not part of their training and the scienti®c validity is
currently in its infancy. Massage is used across the entire age
range and in many different nursing settings. For instance,
massage has been used to reduce symptoms and improve
quality of life in children with quadriplegic cerebral palsy
(Stewart 2000). It is also among the battery of nonpharma-
cological methods commonly used to relieve children's
postoperative pain (Polkki et al. 2001). In the ®eld of cancer
care, massage has been shown to provide meaningful relief
from suffering and a relatively short period of massage has
been shown to result in physical and emotional bene®ts for
cancer patients (Billhult & Dahlberg 2001). Back massage as
a form of intervention has been reported previously in this
journal (Fraser & Kerr 1993), but no study has previously
reported the impact of massage on cardiac autonomic tone.
As autonomic tone is implicated in so many common
diseases including diabetes, peripheral vascular disease and
coronary artery disease, it will be bene®cial to appreciate the
measurement, implications and potential of heart rate vari-
ability as a measure of autonomic tone. Massage therapy
was chosen because it is known to the nursing profession as
a prospective form of relaxation but it is not commonly
practised within mainstream nursing. The selection of
healthy subjects, in the ®rst instance, was to ensure quality
baseline data before including the confounding variables of
disease and types of medication. It is intended to undertake
further work on speci®c patient groups, such as diabetes and
recent postmyocardial infarction, now the speci®c bene®ts of
massage therapy on cardiac autonomic tone for normal
subjects has been established.
Therapeutic massage is the manipulation of the soft tissue
of body areas to bring about generalized improvements in
health (Vickers & Zollman 1999). A number of studies have
reported on the subjective effects of massage on muscle
relaxation and psychological state. In an evaluation of the
use of massage on the well-being of cancer patients, Corner
et al. (1995) reported that patients found massage to be
bene®cial in assisting relaxation and reducing physical and
emotional symptoms. Wilkinson et al. (1999) reported that
patients in a palliative care setting considered massage to be
bene®cial in reducing anxiety, tension, pain and depression.
Similarly, Fraser and Kerr (1993) reported that patients
perceived back massage as relaxing. In her article `Massage
Therapy Effects,' Tiffany Field gave a history of massage
and described many studies researching the numerous effects
of massage in various populations and in many different
settings (Field 1998). Relaxation appears to be the most
important bene®t of massage (Wilkinson 1996). Research
into massage therapy is increasing yet the number of studies
documenting objective physiological changes following
therapeutic massage still remains limited. Several nursing
studies examined various massage techniques on heart rate
and blood pressure variables but the results of these studies
are equivocal (Fakouri & Jones 1987, Reed & Held 1988,
Ferrell-Torry & Glick 1993, Fraser & Kerr 1993, Meek
1993, Stevenson 1994). To the best of the authors' know-
ledge the present study is the ®rst to examine the effects of
myofascial trigger-point massage on cardiac autonomic tone
using analysis of heart rate variability to assess effects of
treatment.
Myofascial trigger-point massage therapy (MTPT) is an
advanced neuromuscular technique commonly used in the
®eld of sports therapy for the alleviation of pain and to
induce muscle relaxation following injury (Peppard 1983). It
combines a variety of massage strokes with deeper more
focused pressure at myofascial trigger-points (MTrP). As
such, it is similar to acupressure which involves applying
pressure or massage to traditional acupuncture points (Filshie
Keywords: massage, heart rate variability, autonomic tone, muscle tension,
emotional state, relaxation, myofascial trigger point, parasympathetic, sympathetic,
healthy subject
Issues and innovations in nursing practice Trigger-point massage and cardiac autonomic tone
Ó2002 Blackwell Science Ltd, Journal of Advanced Nursing,37(4), 364±371 365

& Abbot 1991). When combined with exercise, MTPT has
been shown to reduce the number and intensity of MTrP and
to be effective in treating MTrP in the neck and shoulder
areas (Gam et al. 1998).
Myofascial trigger-points are small discrete hyperirritable
areas within a taut band of muscular tissue or fascia. They are
painful on compression and can evoke characteristic referred
pain in areas far away from their actual location (Travell &
Simmons 1983). Melzack et al. (1977) reported a remarkably
high degree (71%) of correspondence between MTrP and
acupuncture points associated with pain. Stimulation of these
MTrP can cause changes within the peripheral autonomic
nervous system, such as local excessive perspiration, pilo-
erection, local vasodilation, and erythema (Travell &
Simmons 1983).
Heart rate variability (HRV) is the beat-to-beat variation
of the R-R interval of the electrocardiogram. This variability
is modulated by the sympathetic and parasympathetic
components of the autonomic nervous system (Task Force
1996). Within the last decade, and as the result of new and
more powerful computer-based analysis systems, HRV
measurement has rapidly expanded in the ®eld of autonomic
nervous system research. Analysis of HRV is a sensitive,
noninvasive, indirect technique, which can be used to
identify cardiac autonomic disturbances, such as in the
early subclinical detection of autonomic dysfunction in
diabetes mellitus (Pagani et al. 1988) and following myocar-
dial infarction (Kleiger et al. 1987). A reduction in HRV is
associated with an increased risk of coronary heart disease
(Liao et al. 1997) cardiac sudden death (Singer et al. 1988)
and all-cause mortality (Tsuji et al. 1994). Heart rate
variability analysis has also been used to assess changes in
sympathovagal tone in various mental (Carney et al. 1995)
and emotional states (Rechlin et al. 1994, McCraty et al.
1995).
Heart rate variability can be assessed in two ways: as a
time domain analysis or in the frequency domain using power
spectral analysis (PSA). Time domain measures are the
simplest to calculate and include the standard deviation of
normal-to-normal R-R intervals (SDNN), root mean square
of successive differences (RMSSD) and the proportion of
differences between adjacent normal interbeat intervals that
are >50 ms (pNN50). These measurements of short-term
variability estimate rapid variations in heart rate and are
generally associated with parasympathetic nervous system
activity (Kleiger et al. 1987).
In the frequency domain, the PSA of HRV is generally used
to identify three discrete frequency components. High
frequency (HF; 0á15±0á40 Hz), low frequency (LF; 0á04±
0á15 Hz), and very low frequency (VLF; 0á00±0á04 Hz). The
HF range re¯ects rapid changes in the beat-to-beat variability
and is associated with ¯uctuations in vagal tone, and the LF
region corresponds to blood pressure oscillations around
0á1 Hz. (Mayer waves) (Pomeranz et al. 1985). The HF and
LF bands are indirect measures of cardiac parasympathetic
and sympathetic activity, respectively, and the LF/HF ratio is
frequently used as an indicator of sympathovagal balance.
The VLF range is still poorly understood but oscillations in
this band are generally attributed to thermoregulation
(Hyndman et al. 1971) and the renin±angiotensin±aldo-
sterone system (Akselrod et al. 1985). Figure 1 shows a
typical spectrum with the speci®c frequency bands clearly
marked.
Using PSA, a spectral graph is obtained with peaks at the
frequency bands previously mentioned. The area under the
curve represents the power attributed to each particular band
(Task Force 1996). Total Power (TP) is the sum of the power
contained within the VLF, LF and HF bands.
Analysis of heart rate variability has been used to highlight
the importance of the autonomic nervous system in health
and disease (Kristal-Boneh et al. 1995, Sleight 1997). It has
also been used to provide insights into the possible cardio-
protective effects of physical activity in postmenopausal
women (Davy et al. 1996), to test the effects of dynamic
exercise in athletes (Shin et al. 1995), and to test the effects of
different lifestyles (smokers, sedentary and aerobically ®t
persons) on cardiovascular regulatory mechanisms (Galla-
gher et al. 1992).
The study
In this study we investigated the effects of MTPT to the head,
neck and shoulder areas on cardiac autonomic tone and
evaluated the psychological outcomes of the treatment.
Figure 1 Very low frequency (VLF) band 0á00±0á04 Hz, low
frequency band (LF) 0á04±0á15 Hz and high frequency (HF) band
0á15±0á4 Hz.
J.P.A. Delaney et al.
366 Ó2002 Blackwell Science Ltd, Journal of Advanced Nursing,37(4), 364±371

Method
Participants
Thirty normal, healthy volunteers [16 females, 30á94 
1á72 years, mean standard error (SESE); 14 males,
34á42á74 years, mean SESE] were recruited in the year
2000 via e-mail, bulletin boards, posters and from verbal
requests for volunteers. They comprised 22 students and ®ve
staff all from a further education college in the north-west of
England, as well as three friends who were not part of the
college. Most of the subjects engaged in a modest amount of
physical activity weekly. None were involved in regular high
intensity physical activity. Ethical committee agreement and
informed consent was obtained prior to testing.
All subjects were in good general health with no medical
conditions known to affect HRV. No subject was taking any
prescription drugs known to affect the cardiovascular system.
Subjects were randomly assigned into two age- and sex-
matched groups (eight females, seven males in each). They
were requested to refrain from smoking or drinking any
caffeine-containing beverages for at least 8 hours prior to
testing but were allowed a light breakfast at least 2 hours
before the test. Throughout the study subjects were requested
to refrain from making any exaggerated body movements or
intentionally altering their respiration.
Protocol
Subjects in Group One received MTPT to the head, neck and
shoulder areas for 20 minutes while the subjects in Group
Two relaxed by sitting quietly for the same time period thus
acting as controls. Data acquisition took place between 09á30
and 11á30 hours in a quiet, warm, temperature-controlled
environment (22±24°C). Subjects were seated in a straight,
high-backed chair to minimize postural changes. The chair
was positioned adjacent to a Polar Advantage Interface (Polar
Electro Oy, Kempele, Finland) that received signals from the
transmitter.
Subjects were allowed to rest comfortably for at least
10 minutes prior to the baseline recording procedure. During
this time they were ®tted with an elasticated electrode belt,
which incorporated a Polar Coded Transmitter (Polar Electro
Oy, Kempele, Finland). The `ribbed' electrodes were coated
in electrode gel to ensure maximum conduction and the
transmitter was positioned centrally, directly below the
xiphisternum. The belt was attached tight enough to
minimize movement of the electrodes but did not cause any
discomfort. Heart rate data acquisition took place for
5 minutes at baseline and for 5 minutes immediately
following treatment. Systolic and diastolic blood pressure
recordings were also taken at baseline and following treat-
ment using an automated blood pressure recorder (Omron
Healthcare, Europe). They were measured twice on the right
arm and the mean of the duplicate results was recorded.
Measurements of emotional state and muscle tension
Self-reports of emotional state and feelings of muscle tension
were measured before and after treatment using a 100-mm
visual analogue scale (VAS) with verbal anchors at either end
(Figure 2). Visual analogue scales have been used previously
by Grunberg et al. (1996), Wright (1987), Kaplan and
Camacho (1983) and Maddox and Douglass (1973) to
examine self-assessment of health and quality of life.
Massage procedure
Subjects were not required to undress for the massage therapy
and wore light cotton T-shirts. Following baseline recordings
they remained seated in the upright chair. In order to
maintain consistency, the same therapist, a fellow of the
International Council of Health, Fitness and Sports Thera-
pists, performed all massages. The massage procedure, which
took 20 minutes, employed the techniques of ef¯eurage,
petrissage, cross-®bre stroking and tapotement as described
by Goats (1994). Deeper more focused pressure and circular
frictions were applied to myofascial trigger-point areas in the
upper, middle and lower trapezius muscle region and the
suboccipitalis region. Gentle circular frictions and palmar
kneading was also applied in the areas of the frontalis and
temporalis muscles together with linear stroking to the
sternocleidomastoid muscles. The anatomical locations of
the MTrP used in this study can be found in detail in The
Trigger Point Manual (Travell & Simmons 1983).
Data analysis
The methods of data collection and analysis used in this study
have been described in detail previously (Delaney & Brodie
2000). Brie¯y, HRV was calculated following removal of any
abnormal beats. This consisted of an automatic default
®ltering procedure contained within the Polar Precision
Performance Software package (Polar Electro Oy, Kempele,
Finland) and also a careful inspection of the cardiac interbeat
(R-R) interval tachogram. The tachogram was visually
Figure 2 Examples of visual analogue scales for muscle tension and
emotional state.
Issues and innovations in nursing practice Trigger-point massage and cardiac autonomic tone
Ó2002 Blackwell Science Ltd, Journal of Advanced Nursing,37(4), 364±371 367

scanned to ensure complete removal of abnormal data. If
required any further `aberrant' beats were removed manually.
Measurements in the time domain consisted of the mean
R-R interval, SDNN, RMSSD and pNN50. The following
frequency domain indices of heart rate variability were
calculated: (1) very low frequency power from 0á00 to
0á04 Hz; (2) low frequency power from 0á04 to 0á15 Hz; and
(3) high frequency power from 0á15 to 0á40 Hz. An autore-
gressive model, which has been suggested as the optimal
method for short-duration recordings (Task Force 1996), was
used to generate the heart rate spectra.
Statistical analyses
Data are given as mean SESE. All variables were tested for
normality using the Kolmogorov±Smirnov test. The LF/HF
ratios alone did not have a normal distribution and therefore
were log-transformed prior to statistical analysis. An F-test
was used to compare test and control groups for differences
in variance. An unpaired t-test was used to compare the test
and control groups for all variables at baseline. A paired t-test
was used to compare values before and after treatment for
test and control groups. A two-tailed probability of P<0á05
was considered statistically signi®cant.
Results
At baseline there were no statistically signi®cant differences
between both groups for all variables in the time and
frequency domains (Table 1) or for self-perceived measures
of emotional and muscle tension (Table 2). The P-value for
emotional tension approached signi®cance at 0á06, thus the
results for this variable may represent a type-2 statistical
error. Additionally, no signi®cant gender differences were
observed at baseline or following treatment.
In the time domain, the results show that MTPT caused an
overall decrease in heart rate as indicated by an increase in
average R-R interval length (P<0á01). (Table 1). SDNN
increased by 26á8% (P<0á01), RMSSD by 46á8% (P<0á01)
and pNN50 by 55á8% (P<0á01) following MTPT. There
were no signi®cant changes observed in the time domain
measures in the control group (Table 1).
In the frequency domain a 73á5% increase was observed in
TP (P<0á01) along with an 84á5% increase in VLF power
(P0á03), and a 90% increase in HF power (P0á02). No
signi®cant changes in LF power were seen in both groups. A
17% decrease in LF to HF ratio (P0á04) was observed in
the massage group. There were no signi®cant changes in the
control group for any frequency domain measures.
Additionally there was a 39% reduction in muscle tension
and emotional state improved by 32% following MTPT
(P<0á01) (Table 2). No signi®cant differences were observed
in the control group for muscle or emotional tension. In the
massage group systolic blood pressure was signi®cantly
reduced (P0á02), as was diastolic blood pressure (P0á01).
Discussion
To the best of the authors' knowledge this is the ®rst study to
examine the effects of myofascial trigger-point massage
therapy to the head, neck and shoulders using HRV analysis
Table 1 Time and frequency domain results for baseline and treatment conditions in experimental and control groups. Data are given as
mean SESE
Experimental group Control group
Baseline Post-MTPT P-value Baseline Postrelaxation P-value
Time domain variables
Heart rate (beats/minute) 71á92á466á52á5<0á01 73á92á871á72á50á10
R-R interval (ms) 845 25á5 918 31á6<0á01 825 27á4 848 26á10á12
Standard deviation of
interbeat intervals (ms)
60á85á377á17á2<0á01 58á65á262á96á10á15
Root mean square of
successive differences (ms)
36á54á153á67á0<0á01 32á34á032á34á60á99
PNN50 (%) 5á21á58á12á0<0á01 6á01á45á51á30á34
Frequency domain variables
Total power (ms
2
) 2485 521 4311 1011 <0á01 2490 612 2947 592 0á12
Very low frequency power (ms
2
) 1248 280 2303 638 0á03 1195 321 1508 290 0á15
Low frequency power (ms
2
) 910 221 1390 489 0á12 1003 286 1177 335 0á16
High frequency power (ms
2
) 327 121 618 219 0á02 292 75 262 49 0á49
Low frequency to high frequency
ratio (log transformed)
1á52 0á28 1á26 0á26 0á04 1á36 0á21 1á49 0á23 0á43
J.P.A. Delaney et al.
368 Ó2002 Blackwell Science Ltd, Journal of Advanced Nursing,37(4), 364±371

to measure cardiac autonomic tone. The results of the study
suggest that MTPT to the head, neck and shoulder areas for
20 minutes is highly effective in increasing HRV and cardiac
parasympathetic activity in normal subjects. This is demon-
strated in the time domain by a decrease in heart rate and an
increase in SDNN, RMSSD, and also pNN50. In the
frequency domain this is shown by an increase in TP and
HF power and a reduction in LF/HF ratio.
A simple decrease in heart rate by itself may be considered
a sign of relaxation although the exact mechanisms causing
the decrease would be unknown. An increase in parasympa-
thetic activity or a decrease in sympathetic activity would
cause a decreased heart rate. The purpose of using analysis of
HRV is to try to determine the exact change in sympath-
ovagal balance.
It is generally accepted that the power of the HF oscilla-
tions found between 0á15 and 0á4 Hz, is an indirect marker of
efferent parasympathetic (vagal) input to the heart. In this
study, following MTPT, a signi®cant increase in HF power
was observed. An increase in parasympathetic nervous system
activity has been associated with the relaxation response
(Benson et al. 1974).
In the range between 0á04 and 0á15 Hz there was a
nonsigni®cant increase in LF power following treatment. The
LF range is generally accepted as a marker of sympathetic
nervous system activity associated with ¯uctuations around
0á1 Hz corresponding to blood-pressure control oscillations
known as Mayer waves (Pomeranz et al. 1985).
Increases in LF and HF power have been reported
following sensory stimulation by acupuncture needling
(Haker et al. 2000). Sensory stimulation in healthy persons
may be associated with changes in both the sympathetic and
parasympathetic nervous system depending on the site of
stimulation. This may account for the increases in both LF
and HF power in the present study, although the increase in
HF power is signi®cantly greater following MTPT. Hence, the
reduction in LF/HF ratio seen in this study (P0á04) again
suggests a shift toward cardiac parasympathetic activity.
Interestingly, the VLF component, which is generally
associated with thermoregulatory mechanisms (Hyndman
et al. 1971) and the renin±angiotensin system (Akselrod et al.
1985) shows a signi®cant increase following MTPT. Previous
studies in humans have shown that the VLF component may
be mediated by cardiac parasympathetic activity (Taylor
et al. 1998), therefore the signi®cant increases in HF power
following MTPT may have mediated the increase in VLF
power. Care must be taken in the interpretation of these
results as only a 5-minute data acquisition period was used in
this present study. Further investigation using longer
recording periods is needed to explore this particular area
of research.
In this study MTPT was also shown to be effective in
signi®cantly reducing both SBP (P0á02) and DBP
(P0á01). Felhendler and Lisander (1999) have demon-
strated that noninvasive stimulation of acupressure points
also signi®cantly in¯uences the cardiovascular system by
reducing SBP, DBP and heart rate.
As previously mentioned, acupressure points and MTrP are
thought to represent the same phenomena and the techniques
used in this study may be activating similar mechanisms to
produce blood pressure reduction. It should be pointed out
that in addition to deep focused pressure at trigger-point
sites, the massage procedure used in this study did addition-
ally contain some general ef¯eurage strokes. It has been
previously shown that these less complicated massage proce-
dures alone can be effective in lowering blood pressure (Cady
& Jones 1997).
With reference to quality of life measures, subjects reported
feeling less muscle tension and signi®cant improvement in
mood following MTPT. These ®ndings are probably the
result of an increased relaxation response and an overall
reduction in the defence-arousal (stress) response and are
possibly mediated by increased parasympathetic activity.
Although there was a nonsigni®cant difference in the
groups at baseline, the values for emotional tension of
P0á06 recognize the possibility of type-2 error. This
limitation is appreciated and future studies would bene®t
from larger group sizes or matching baseline groups for
psycho-physiological variables. A further limitation to this
study is that any effect could potentially be because of some
Table 2 Emotional state, muscle tension and blood pressure results for baseline and treatment conditions in experimental and control groups.
Data are given as mean SESE
Experimental group Control group
Baseline Post-MTPT Pvalue Baseline Postrelaxation Pvalue
Self-perceived muscle tension (mm) 41 3á0254á4<0á01 35 5á0333á10á27
Self-perceived emotional tension (mm) 47 3á2323á9<0á01 38 5á2353á40á49
Systolic blood pressure (mmHg) 125 3á5 119 3á40á02 122 2á7 120 2á70á06
Diastolic blood pressure (mmHg) 79 2á3762á50á01 76 2á9742á50á14
Issues and innovations in nursing practice Trigger-point massage and cardiac autonomic tone
Ó2002 Blackwell Science Ltd, Journal of Advanced Nursing,37(4), 364±371 369

type of exchange between the therapist and the subject,
irrespective of MTPT. Sham treatments to control for this
effect have been incorporated in our subsequent studies and
we recommend that future researchers consider a sham
massage, perhaps using unskilled or random massage,
avoiding myofascial trigger points. The limited number of
blood pressure measurements may limit the conclusions. We
were concerned that regular measurements using a pressure
cuff could be a confounding variable because of the level of
discomfort. Future studies would be advised to take more
frequent recordings using a less intrusive system such as a
®nger cuff.
The present study shows that MTPT is a safe, noninvasive
technique that is effective in inducing a relaxation effect in
normal subjects. It is a relatively simple technique to learn
and under correct instruction could be taught to the partners
or spouses of patients who could bene®t from massage
therapy.
It is imprudent to generalize from a healthy population to
those with disease processes. However, certain conditions are
characterized by increased sympathetic tone and reduced
HRV. It is possible to speculate that these conditions could
show a relaxation response following massage that may
bene®t the sympathovagal balance.
Patients who may bene®t include those recovering from a
myocardial infarction (MI). These patients are usually in a
high state of anxiety and tension and generally have increased
sympathovagal tone as the result of reduced cardiac para-
sympathetic activity (Task Force 1996). Heart failure patients
also have reduced HRV and increased levels of stress as
indicated by increased levels of circulating catecholamines
(Saul et al. 1988). MTPT could help reduce stress and
improve autonomic function by increasing HRV and para-
sympathtic activity.
Patients with uncomplicated essential hypertension may be
another group that could bene®t from the effects of MTPT.
These patients have elevated blood pressure and increased
sympathovagal balance (Guzzetti et al. 1988, Manolis et al.
1995). In previous studies, treatment using beta-blockade
(Liao et al. 1996) and ACE inhibitors (Kontopoulos et al.
1997) has been shown to improve prognosis in these patients.
MTPT may prove a useful adjunct to conventional treatment
by enhancing cardiac vagal tone and leading to restoration of
sympathovagal balance.
A further group who may bene®t from MTPT are diabetic
patients with autonomic neuropathy. These patients
commonly have reduced autonomic function as indicated by
decreased HRV (Mackay et al. 1980). They may also have pain
as the result of peripheral neuropathy, thereby increasing levels
of stress and anxiety thus further exacerbating the condition.
Additional studies using MTPT in these patient groups need to
be performed to con®rm these hypotheses.
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