Mechanical massage and mental training programs effect employees’ heart rate, blood pressure and fingertip temperature : An exploratory pilot study

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This is the published version of a paper published in European Journal of Integrative Medicine.

Citation for the original published paper (version of record):

Muller, J., Ekström, A., Harlén, M., Lindmark, U., Handlin, L. (2016)

Mechanical massage and mental training programs effect employees’ heart rate, blood pressure

and fingertip temperature: An exploratory pilot study.

European Journal of Integrative Medicine, 8(5): 762-768

https://doi.org/10.1016/j.eujim.2016.06.002

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Research

paper

Mechanical

massage

and

mental

training

programs

effect

employees

’

heart

rate,

blood

pressure

and

fingertip

temperature

—An

exploratory

pilot

study

Jasmin

Muller

a

,

Anette

Ekström

a

,

Mikael

Harlén

a

,

Ulrika

Lindmark

b

,

Linda

Handlin

a,

*

a

SchoolofHealthandEducation,UniversityofSkövde,Box408,54128Skövde,Sweden b

SchoolofHealthSciences,JönköpingUniversity,Box1026,55111Jönköping,Sweden

ARTICLE INFO

Articlehistory:

Received15December2015

Receivedinrevisedform31March2016 Accepted4June2016 Keywords: Heartrate Bloodpressure Temperature Massage Workplace Stress ABSTRACT

Introduction:Inabilitytorelaxand recoveris suggestedtobe akeyfactorforstress-relatedhealth problems.Thisstudyaimedtoinvestigatepossibleeffectsofmechanicalmassageandmentaltraining, usedeitherseparatelyorincombinationduringworkinghours.

Methods:Employeeswererandomlyassignedtooneofthefollowinggroups:i)Mechanicalmassage combinedwithmentaltraining(n=19),ii)Mechanicalmassage(n=19),iii)Mentaltraining(n=19),iv) Pause(n=19),v)Control(n=17).Thestudylastedforeightweeks.Heartrate,bloodpressureand fingertiptemperatureweremeasuredatstart,afterfourandaftereightweeks.

Results:Between-groupanalysisshowedthatheartratedifferedsignificantlybetweenthegroupsafter4 weeks(p=0.020)andtendedtodifferaftereightweeks(p=0.072),withlowestlevelsdisplayedinthe massagegroupandthecontrolgroup.Bloodpressureandfingertiptemperaturedidnotdifferbetween thegroups.Within-groupanalysisshowedthatmechanicalmassagedecreasedheartrate(p=0.038)and bloodpressure(systolicp=0.019,diastolicp=0.026)andincreasedfingertiptemperature(p=0.035). Mentaltrainingprogramsreducedheartrate(p=0.036).Combiningthetwomethodsincreaseddiastolic bloodpressure(p=0.028)and decreasedfingertiptemperature(p=0.031).Thecontrolgrouphada significantdecreaseinsystolicbloodpressureduringthefirstfourweeksofthestudy(p=0.038) Conclusion:Receivingmechanicalmassageandlisteningtomentaltrainingprograms,eitherseparatelyor incombination,duringworkinghourshadsomepositiveeffectsontheemployees’heartrate,blood pressureandfingertip temperature.Theeffectswereespeciallystrongforemployeeswhoreceived mechanicalmassageonly.

ã2016TheAuthors.PublishedbyElsevierGmbH.ThisisanopenaccessarticleundertheCCBYlicense (http://creativecommons.org/licenses/by/4.0/). 1.Introduction

AccordingtotheWorldHealthOrganization(WHO)healthisa stateofcompletephysical,mental,andsocialwell-beingandnot merelytheabsenceofdiseaseorinfirmity[1].Healthpromotionis theprocess of enabling people toincrease control over – and improve–theirhealth.Theresponsibilityforhealthpromotionlies not only on the health sector but also employers have a responsibilityfortheiremployees[2].

Stress-relatedhealthproblemshaveincreasedinindustrialized countries during recent years and they are often strongly in_fluencedbytheworkingenvironment(althoughsomecultural differencesexist).Stress-relatedillnesses,suchascardiovascular

disorders,type2diabetes,reducedimmunefunctionandcognitive impairment, typicallydevelop over a verylong time and cause muchsufferingfortheaffectedindividualsandcanresultinlong periodsofinabilitytoworkandinextendedsickleave[3–5].

Aninabilitytorelaxandrecover,andtherebytheinabilityto reducestresslevels,hasbeensuggestedtobeakeyfactorforthe increasinglevelsofstress-relatedhealthproblemsin industrial-izedcountries.Peopleseemtobeabletoworkveryhardwithout problemsiftheyareabletorestandrecover,butiftheydecreaseor losethisability,theybecomemoresensitivetostressanddevelop stress-relatedhealthproblems[5,6].

Twocommonactivitiesperformedbyindividualstoincrease theirabilitytorelaxandrecover,andhencepromotetheirhealth, aremassageandmentaltraining.Previousresearchhasshownthat several positive effects accompanymassage treatment, such as decreasedlevelsofanxiety,increasedperceptionofwellbeingand decreasedperceptionofpainand,inaddition,bothheartrateand

*Correspondingauthor.

E-mailaddress:linda.handlin@his.se(L.Handlin).

http://dx.doi.org/10.1016/j.eujim.2016.06.002

1876-3820/ã2016TheAuthors.PublishedbyElsevierGmbH.ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

ContentslistsavailableatScienceDirect

European

Journal

of

Integrative

Medicine

blood pressure are decreased [7–10]. Repeated massage treat-mentsareassociatedwithlong-termexpressionofalltheseeffects

[11,12].Non-noxioussensorystimulation,suchasmassage,results in a release of the neuropeptide oxytocin and many of the physiologicaleffectsinducedbymassage,arepartlymediatedby oxytocin[13].

Mental training has been shown to help a person reach a relaxedmentalstate,astatethatseemstobelinkedtoreductionof stressand tensionandbetterhealth[14,15].Inaddition,mental relaxationalsocanhelptodecreaseheartrateandbloodpressure

[16].

Anincreasednumberofemployershavestartedtoworkwith variousmethodstohelpreducetheiremployees’stressandhelp themtostayhealthy.Onesuchmethod,whichhasbeenusedby several companies in Sweden, is an armchair with massage capabilitiesandaudioprogramsformentaltraining.Ourresearch grouphasrecentlyshownthatemployeeswhousedthisarmchair duringworkinghoursexperiencedpositivepsychologicaleffects onself-reportedlevelsof anxietyand stress susceptibility[17]. However, the physiological effects of the mechanical massage and/orthemental training programsprovided bythe armchair havenotyetbeeninvestigated.

Theaimofthispilotstudywastoinvestigatepossibleeffectson theemployees’heartrate,bloodpressureandfingertip tempera-ture when using mechanical massage and mental training programs,both separately and in combination, during working hours.

2.Methods

2.1.Settingandstudydesign

The studywas performed in thesouthwest partof Sweden during2013.Fourdifferentworkplaceswerestrategicallyselected basedontheirgeographicallocationandworkingareasincluding bothsmallandlargetownswithemployeeslivinginbothurban and rural districts, and workplaces in both private and public sectors.Theparticipatingemployeeshadavarietyofpositionsand responsibilities and both workers and people in management positionswereincludedinthestudy.

Intotal,93employeesparticipatedinthestudy.Randomization occurredateachworkplacewhereeachparticipantwasrandomly assignedtooneofthefollowingfivestudygroups:i)Massageand mentaltraining(sittinginthearmchairandreceivingmechanical massagewhilelisteningtothementaltrainingprograms,n=19); ii) Massage (sitting in the armchair and receiving mechanical massageonly,n=19);iii)Mentaltraining(sittinginthearmchair and listeningtothe mental training programs only, n=19);iv) Pause (sitting in the armchair but not receiving either the mechanicalmassageorlisteningtothementaltrainingprograms, n=19);andv)Control(notsittinginthearmchairatall,n=17).

Thestudylastedforatotalofeightweeks.Duringtheseweeks, theparticipantsingroupsi–iiitookabreakfromtheirregularwork and sat in the armchair for 15min three times each week, preferablybetween1pmand4pm.Theparticipantswhousedthe massageprogram(i.e.,groupsiandii)allusedthesameprogram, but were able to make individual adjustments regarding the strength of the massage. The participants who listened to the mentaltraining(i.e.,groupsiandiii)listenedtodifferentprograms in thefollowingorder: ”Recovery”– weekone, “Mindfulness– learntoliveinthepresent”–weektwo,”Thewaytoabetterand deepersleep”–weekthree,“Reducethenegativestress”–week four,“Learntothinkpositively”–weekfive,“Increaseyourmental strength”–weeksix,“Howtogetagreaterenjoymentoflife”– weeksevenand”Recovery”–weekeight.Theparticipantsingroup ivtooka breakfromtheirregularworkandsatinthechairfor

15min three times each week; however, they didnot use the massageprogramorlistentothementaltrainingprograms.Group vservedasacontrolgroupandcontinuedtheirworkasusual,with nobreak.Inoneoftheworkplaces,duetoahecticschedule,the participants wereassigned specifictimes to usethe chair. The participants wrote in a journal each time they used the intervention.Attheendofthestudythisjournalwashandedin totheresearcherstoallowforfollowupwhethertheparticipant haddonetheactivitiesassignedtothem.

2.2.Participants

2.2.1.Inclusionandexclusioncriteria

2.2.1.1.Workplaces. Onlycompanieswhohadnopriorexperience ofthearmchairwereincludedinthestudy.

2.2.1.2. Employees. Employees without self-reported serious and/or chronicillnesses (physical ormental) who wereableto perform their work assignment were asked if they wanted to participate in the study. The employees should work 75–100% within their own organizations. If working less than 100% the reasonfornotworkingfulltimeshouldbestressrelatedissues.

Employeeswithpreviousexperienceofusingmechanicalchair massageand/orthementaltrainingprogramswereexcludedfrom thestudy.Inaddition,employeeswhowerepregnant,orwhowere sufferingfrominfluenza,colds,or feversat thetime,werealso excludedfromthestudyduetohealthrisks.Employeesworking lessthethen75%wereexcludedfromthestudy.

2.3.Thearmchair

ThearmchairusedinthepresentstudywastheRecoveryChair included in the Promas MethodTM_{, provided by Promas AB,}

Sweden. The armchair is equipped with the ability to give mechanicalmassagetotheneck,shoulders,back,andcalves.This isperformedthroughacombinationofmotors,gears,rollersand vibratingmechanisms.Thechairhasamotorizedrecliningsystem sotheusercanchangethechair’spositionbypressingabuttonon thechair'scontrolsystemandtheuserareallowedtoadjustthe intensityofthemassage.Whiletheusergetsa massage,he/she maysimultaneouslylistentoamentaltrainingprogramdeveloped and producedbyLars-Eric Uneståhl(ScandinavianInternational University)[14,15].Thementaltrainingprogramsincludeverbal instructions, mental exercises and soft music. The aim of the programs are to help the user achieve mental relaxation. The mechanical massageprogramsorthemental trainingprograms canalsobeusedseparately.Attheworkplaces,allthearmchairs werelocatedinaroomwherethedoorcouldbeshut,sothatuser couldbecompletelyseparatedfromotheractivitieswhilesittingin thechair.

2.4.Datacollection

The participants’ heart rate, blood pressure and fingertip temperatureweremeasuredthreetimesduringthestudyperiod: atthestartofthestudy(immediatelybeforetherandomization), after4weeks,andafter8week(endofstudy).Themeasurements wereperformedduringanindividualmeetingattheworkplace duringregularworkinghoursbyanurseandaresearcherwhohad experienceofandwerewelltrainedinthiskindofmeasurements. Heart rate, Systolicblood pressure(SBP) and diastolicblood pressure (DBP) were measured with an automatic manometer (Omron M6 Comfort, Omron Healthcare, Hoofddorp, the Netherlands). Themanometer wasattachedtotheparticipant’s leftarmandplacedinlinewiththeheart.Fingertiptemperature

wasmeasuredwithalaserthermometer(Digital-Laser Thermom-eter,Esska.deGmbH,Hamburg,Germany).Theparticipantswere inaseatedpositionduringallmeasurements.

2.5.Statisticalanalyses

StatisticalcalculationswereperformedusingtheIBMStatistical PackagefortheSocialSciences(SPSS,version22.0).Background dataarepresentedasmeansandstandarddeviation(SD).Totest forthedifferencesbetweengroupsonseparateoccasions(start, four weeks, and eight weeks) the Kruskal Wallis Test for independent samples, as well as the Mann-Whitney Test for independentsampleswereused.Totestfordifferenceswithineach studygroupduringtheentirestudyperiodFriedman’sTwo-way Analysis of Variance by Rankwas used. To test for differences betweentwo occasions within each study groupthe Wilcoxon Signed-RankTestwasused.Changeswereanalyzedbetweenstart andfourweeks,betweenfourandeightweeks,andbetweenstart and eight weeks.Since this was anexploratory pilotstudy we chosetoperformthepairedtestindependentlyoftheresultsfrom theFriedmantest.P-values0.05wereconsideredsignificantand P-values<0.1wereinterpretedastendencies[18].

2.6.Ethicalconsiderations

The study was approved by the Local Ethics Committee in Gothenburg,Sweden(ref.nr:980-12)andtheHelsinkiDeclaration wasfollowed[19].Theemployeeswereinformedand giventhe opportunitytoaskquestionsaboutthestudyandtheirpossible participation. They were also informed that all collected data wouldonlybeavailabletotheresearchers,nottotheiremployers, and that their workload would not be affected by their

participation.Allemployeeswhochosetoparticipateinthestudy signedwrittenconsent.

3.Results

ACONSORTflowchartofparticipantrecruitmentisshownin

Fig. 1. Baseline data for the participants is shown in Table 1. Baselinedataandtheexternaldropoutdidnotdiffersignificantly betweenthefivegroups(datanotshown).

3.1.Heartrate

Asignificantdifferencewas observedbetweenthefivestudy groups after 4 weeks (p=0.020) and this difference tended to remainaftereightweeks(p=0.072)(Fig.2)(Table2).

Afterfourweeks,themassagegroup,thementaltraininggroup andthecontrolgrouphadsignificantlylowerheartratescompared tothepausegroup(p=0.026,p=0.007andp=0.006,respectively). Inaddition,themassagegrouptendedto,andthecontrolgroup had,significantlylowerheartratescomparedtothemassageand mentaltraininggroup(p=0.057andp=0.008,respectively)(Fig.2) (Table2).

Attheendofthestudy,boththemassagegroupandthecontrol grouphadsignificantlylowerheartratescomparedtothemassage andmentaltraininggroup(p=0.024andp=0.009,respectively). Bothgroupsalsotendedtohavelowerheartratecomparedtothe pausegroup(p=0.073andp=0.080,respectively)(Fig.2)(Table2). Wheneachgroupwasanalyzedseparately,boththemassage groupandthementaltraininggroupshowedsignificantdecreases inheartratewhencomparingthestartwithweek4(p=0.039and p=0.036, respectively). For the massage group, this decrease

remainedand was significantwhen comparingthestart of the studywiththeendofstudyaswell(p=0.038)(Fig.2)(Table2). 3.2.Systolicbloodpressure(SBP)

Whenallfivestudygroupswerecomparedwitheachotherno significantdifferenceswerenotedbetweenthegroupsduringthe study.

However, when each group was analyzed separately it was found that SBP decreased significantly during the entire study period (p=0.019) in the massage group. This decrease was particularlystrongduringthefirstfourweeks(p=0.002)(Fig.3) (Table2).

Inthepausegroup,SBPtendedtodecreasewhencomparing SBP atthestart of thestudy withSBPat theend of thestudy (p=0.051). The controlgrouphad a significantdecrease in SBP duringthefirstfourweeksofthestudy(p=0.038)(Fig.3)(Table2). Fortheotherstudygroups,SBPremainedunchanged.(Fig.3) (Table2).

Table1

Baselinedataforallgroups.

MassageandMentaltraining(n=19) Massage(n=19) Mentaltraining(n=19) Pause(n=19) Control(n=17) p-value

Age ns Mean(SD) 50.4(8.37) 46.5(12.1) 49.3(14.1) 47.9(9.24) 46.6(10.5) Sex ns Women;n(%) 16(84) 15(79) 13(68) 13(68) 12(71) Men;n(%) 3(16) 4(21) 6(32) 6(32) 5(29) Maritalstatus ns Single,n(%) 4(21) 3(16) 2(11) 2(11) 2(12) Partner/married,n(%) 15(79) 16(84) 17(89) 17(89) 14(82) Livingapart/other,n(%) 0 0 0 0 1(6) Education ns CompulsorySchool,n(%) 1(5) 1(5) 1(5) 0 1(6)

Seniorhighschool,n(%) 5(26) 3(16) 2(11) 4(21) 2(12)

Highereducation,n(%) 2(11) 3(16) 2(11) 3(16) 1(6)

University,n(%) 11(58) 12(63) 14(74) 12(63) 13(76)

Fig.2.Heartrate(bpm)(medianlevels)forthefivestudygroups.Massageand mental traininggroup (n=19),Massage group(n=19),Mental traininggroup (n=19),Pausegroup(n=19),andControlgroup(n=17).

Table2

Heartrate,BloodpressureandFingertiptemperatureforallgroups.

Heartrate(bpm)Median (Q25–Q75)

Diastolicbloodpressure (mmHg)Median(Q25– Q75)

Systolicbloodpressure (mmHg) Median(Q25–Q75) Fingertiptemperature(_C) Median(Q25–Q75) Start 4w£ 8w$

Start 4w 8w Start 4w 8w Start 4w 8w

Massage

&MentalTraining (n=19) 68 (64– 75) 71 (62– 79) 73 (66– 78) 84 (75– 101) 85 (79–90) 87^ (77– 96) 130 (118– 137) 127 (116– 139) 129 (114– 141) 26 (24.8–28) 26,3 (24.6–28.3) 24.6* (22.6–26.2) Massage(n=19) 68 (60– 73) 65* (58– 71) 65* (56– 69) 83 (77–94) 77* (75–86) 79* (74– 86) 125 (116– 137) 113,* (109– 120) 120 (111– 126) 26.2 (25.4– 28.9) 24.5,*(23.6– 25.3) 25.2,^(23.9– 28.9) MentalTraining(n=19) 69 (58– 79) 64* (56– 74) 64 (57– 81) 84 (78–92) 80 (76–93) 82 (74– 95) 125 (113– 145) 120 (111– 140) 117 (112– 141) 25.5 (24.3– 27.6) 25.7 (24.8–29.5) 24.9 (22.1–27.3) Pause(n=19) 71 (64– 85) 72 (66– 81) 71 (63– 81) 87 (75–93) 87 (72–94) 76 (74– 89) 123 (108– 144) 126 (103– 140) 115 (104– 133) 25.8 (24.9– 27.4) 25.3 (23.8–27.4) 24.7 (22.5–27.3) Control(n=17) 64 (57– 71) 61 (59– 70) 65 (59– 71) 80 (74–91) 77 (71– 91.5) 82 (72– 88) 125 (106– 135) 119 (115– 125) 121 (106– 135) 26 (24.6– 27.7) 25 (23.2–27.9) 25.8 (24.8–27.4) £ _{Significantdifferencebetweenthestudygroups(p<0.05).}

$_{Tendencytodifferencebetweenthestudygroups(p<0.1).} *

Significantdifferencecomparedtostart(p<0.05). ^ _Significant

differencecomparedtoweek4(p<0.05). _{Significantdifferenceovertheentirestudyperiod(p<0.05).}

3.3.Diastolicbloodpressure(DBP)

Whenallfivestudygroupswerecomparedwitheachotherno significantdifferenceswerenotedbetweenthegroupsduringthe study.

However, when each groupwas analyzed separately it was found that the massage and mental training group showed a significantincreaseinDBPduringthelastfourweeksofthestudy (p=0.028)(Fig.4)(Table2).

The massage group showed a signi_ficant decrease in DBP betweenthestartand4weeksaswellasbetweenthestartand8 weeks(p=0.031andp=0.026,respectively)(Fig.4)(Table2).

Fortheotherstudygroups,DBPremainedunchanged(Fig.4) (Table2).

3.4.Fingertiptemperature

Whenallfivestudygroupswerecomparedwitheachotherno significantdifferenceswerenotedbetweenthegroupsduringthe study.

However,whentheeachgroupwasanalyzedseparatelyitwas found that the massage and mental training group showed a significant decrease in fingertip temperature when comparing startwithendofstudy(p=0.031)(Fig.5)(Table2).

Forthemassagegrouptherewasasignificantchangeovertime (p=0.003)withasigni_ficantdecreaseduringthe_firstfourweeks (p=0.001)followedbyasignificantincreaseduringthenextfour weeks(p=0.035)(Fig.5)(Table2).

For the otherstudygroups, Fingertiptemperatureremained unchanged(Fig.5)(Table2).

4.Discussion

The aim of the present pilot study was to investigate if mechanicalmassageandmentaltraining,usedbothseparatelyand in combination, during working hours could affect employees’ heart rate, blood pressure and fingertip temperature. These variablesgiveagoodrepresentationofanindividual_’s physiologi-calhealth.Stress-relatedillnessisoftenassociatedwith hyperten-sion,henceblood pressureandheart ratearegood variablesto studyeffectsonthecardiovascularsystem.Stressisalsoassociated withanincreasedactivityinthesympatheticnervoussystemand hence fingertip temperature can be used as an indicator of sympatheticresponses[20].

The results suggests that mechanical massage and mental trainingmight havepositive physiologicaleffectsforemployees withthemechanicalmassagesignificantlydecreasingthe employ-ees’heartrateaswellastheirsystolicanddiastolicbloodpressure, andincreasedtheirfingertiptemperature.Inaddition,themental trainingprogramssignificantlyreducedtheemployees’heartrate. Heartratedifferedsigni_ficantlybetweenthe_fivestudygroups afterfourweeksandtendedtodifferalsoaftereightweeks.Itwas shownthattheemployeeswhoreceivedmechanicalmassageor listenedtothementaltrainingprogramsseparatelyweretheones with the lowest heart rate. When these groups were studied separatelyareductioninheartratewasseenforbothgroups,andit thereforeseemsthatthesetwomethods,whenusedseparately, canhelptoreducetheemployees’heartrate.

For blood pressureand fingertip temperaturethere wereno differences betweenthe groupsfor any of the three occasions, however,sincethiswasanexploratorypilotstudywealsolooked ateachgroupseparately.Thisanalysisshowedthatthemechanical massageprovidedbythearmchairmightbeeffectiveindecreasing the employee’s systolic and diastolic blood pressure. Manual massage/massagetherapyhaspreviouslybeenshowntodecrease blood pressure [12] and the present study shows that also mechanical massage might induce similar effects. The _finding thatmechanicalmassagecaninducedecreasesinbloodpressure couldbeespeciallyimportantforpeoplewhodislikebeingtouched

[21].

Thewith-ingroupanalysisfromthepausegroupindicatedthat also a 15-min break taken during working hours might have positiveeffectsonemployee’ssystolicbloodpressure.

Fingertip temperature can be used as an indicator of sympatheticresponses [20] and althoughthere wereno differ-encesbetweenthegroupsatanyoftheoccationsthemassageand mental training group and the massage group still displayed changesin theirfingertiptemperatureduringthestudyperiod. However, thechanges differed somewhat in thesetwo groups.

Fig.3.Systolicbloodpressure(mmHg)(medianlevels)forthefivestudygroups. Massageandmentaltraininggroup(n=19),Massagegroup(n=19),Mentaltraining group(n=19),Pausegroup(n=19),andControlgroup(n=17).

Fig.4. Diastolicbloodpressure(mmHg)(medianlevels)forthefivestudygroups. Massageandmentaltraininggroup(n=19),Massagegroup(n=19),Mentaltraining group(n=19),Pausegroup(n=19),andControlgroup(n=17).

Fig. 5.Fingertip temperature (_{C) (median levels)for thefive study groups.} Massageandmentaltraininggroup(n=19),Massagegroup(n=19),Mentaltraining group(n=19),Pausegroup(n=19),andControlgroup(n=17).

During the last four weeks of the study the massage group displayedsignificantincreasedfingertiptemperaturewhereasthe combination groupshoweda decrease infingertip temperature throughoutthestudyperiod.Theincreaseintemperatureseenin themassagegroupmightbebecauseofanincreasedcirculation outtothefingersduetoadecreasedsympatheticactivityandan increasedparasympatheticactivity.

Theparticipantsinthisstudychangedtrainingprogrammeeach weekduringthestudyperiod.Howthisaffectedtheresultscanonly bespeculatedupon,butitmightbethatthechangescausedsome confusionand theresults mighthavebeenstronger ifthesame trainingprogrammehadbeenusedthroughouttheentirestudy.

Basedontheresultsfromthepresentpilotstudywecanonly speculate on the mechanism underlying the observed effects inducedbythemechanicalmassage,andtosomeextentbythe mentaltrainingprograms,buttheymightbelinkedtoanincreased function in alpha 2-adrenoreceptors. These receptors, located presynapticallyonnoradrenergicneuronsemanatingfromtheLC andNTS,exertinhibitoryeffectsonthereleaseofnoradrenaline, whichthenleadstodecreasedstresslevelsandlessreactivityto stress[22,23].

Manualmassage/massagetherapycaninduceoxytocinrelease

[24] and has been linked to stress reducing effects such as decreasedheartrateandbloodpressure[13].Sincethemechanical massageusedinthepresent studyappearstoinducethesame effectsasmanual massage/massagetherapydoes, itmostlikely also causes oxytocin release. Oxytocin is produced in the paraventricular nucleus (PVN) and the supraoptical nucleus (SON) withinthe hypothalamus. During the massage,the oxy-tocinergicfibersemanatingfromthePVNcauseanendogenous releaseofoxytocinintodifferentbrainareas,includingthenucleus ofthesolitarytracts(NTS)andlocusceroleus(LC),whichareof central importance for regulation of blood pressure and stress reactivity [25–27]. This increase in endogenous oxytocin levels maythenincreasethenumberofalpha2-adrenoreceptorsinthe brainandthusexcertstress-reducingeffects.Inaddition,oxytocin canalsodecreasetheactivitywithintheHPA-axis[13].Therefore, oxytocin releasedin connectionwithmechanical massage may haveinducedthestress-reducingeffectsseenintheemployeesin themassagegroupinthepresentstudy.

Thecontrolgroupcontinuedwiththeirworkasusualanddid not use any functions of the armchair or take a break in the armchair during working hours. However, they still displayed some stress-reducing effects such as lower heart rate and decreasedbloodpressure.Thepositiveeffectsseenforthisgroup of employees might be due to the “Hawthorne Effect”, i.e., individualsmaychangetheirbehaviorduetotheattentionthey are receiving from researchers rather than because of any manipulation of independent variables [28]. Since it has been shownthatpositivesocialinteractionscanberelatedto health-promotingeffects[29]thepositiveeffectsobservedforthecontrol groupmightalsobearesultofpositiveinfluencesfromthe co-workersassignedtotheothergroups.

4.1.Limitations

Thisexploratory pilotstudy includedfourdifferent typesof workplaces, since the purpose was to include a variety of workplacesand duties. In total, 93 participantswererandomly assignedtooneoffivedifferentstudygroups(includingacontrol group).Evenifthestudypopulationwassmall,therandomization canberegardedasamethodologicalstrength.

Based on the results prom this exploratory pilot study it’s possibleto drawsome conclusionaboutsample size. In future studiesitwouldbeinterestingtomeasurealsotheparticipants’ salivarycortisollevelsandifitshouldbepossibletodetecta30%

reduction of the individual’scortisol levels in the intervention groups compared with the controls (

b

=0.8 and

a

=0.05) each groupshouldinclude100individuals.Withanadequatepowered studyitwouldalsobepossibletoconsiderdifferentbackground variablesinthestatisticalanalysis,e.g.,gender,typeofpositionsin thecompanies,leisureactivitiesetc.

Duetofinancialaswellastimelylimitationsforthepresentstudy itwasnotpossibletoperformanadequatelypoweredstudy,hence thelowernumberofparticipantsthanrecommended.Therefore,the resultsfromthisexplorativepilotstudyshouldbeseenasafirststep towardsalargerrandomizedstudywithinthestudyarea.

It seems that there is a time difference for the different techniquestogenerateeffects.Itmightbethatthe8weekperiodin thepresentstudywasatooshorttimeperiodtobeabletodetect changes.Infuturestudiesitwouldbesuggestedtoincreasethe timeperiodandalsototakemoremeasurementsoverthecourseof thestudy, andtakeseveralmeasurementsat baseline,sinethis mightaddtovalidity.

Stress-related health problems have become an increasing problemintoday’ssocietyandthereisaneedfordevelopmentof evidence-basedtreatmentsforrecoveryandhealthpromotionin workplaces.Thecomplexnatureofstress-relatedillnessincreases theneedformoretechniquesthatcanaddressbothsomaticand psychicparametersofhealthatthesametime.Thearmchairusedin thepresentstudywasequippedwiththeabilitytogivemechanical massageandtoplaymentaltrainingprograms.Employeeswhouse thisarmchair hadpreviouslyshowedimprovementintheir self-reportedpsychichealth[17].Theresultspresentedinthispaper showsthatthearmchairmightalsogeneratepositivephysiological effects. However, further research with a larger number of participantsisneededtoinvestigatethelong-termeffectsofusing the armchair and especially when combining the mechanical massagewiththementaltrainingprograms.

5.Conclusions

Receivingmechanicalmassageandlisteningtomentaltraining programs, either separately or in combination, during working hourshadsomepositiveeffectsonemployees’heartrate,blood pressure and fingertip temperature.Theeffects were especially strong for employees who received mechanical massage only. However, the effects generated when combining mechanical massageandmentaltrainingprogramsneedfurtherinvestigation. Conflictofinterest

None.

Acknowledgments

We want toexpress our appreciation to all employees and employerswhoparticipatedinthisstudy.Wealsothanksprofessor KerstinUvnäsMobergforhervaluableinputforthisstudy.

This study was funded by the The Knowledge Foundation, Sweden, www.kks.se, (reference number:20110142). The study was a co-production project including: University of Skövde, PromasAB(providedthearmchairwithmechanicalmassage)and Scandinavian International University (provided the mental relaxationprogram).

Nofinancialdisclosureswerereportedbytheauthorsofthis paper.

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