Clinical Interventions in Aging
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Clinical Interventions in Aging 2014:9 1311–1319
. 2014 Thanakiatpinyo et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0)
License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further
permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on
how to request permission may be found at: http://www.dovepress.com/permissions.php
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http://dx.doi.org/10.2147/CIA.S66416
The efficacy of traditional Thai massage
in decreasing spasticity in elderly stroke patients
Thanitta Thanakiatpinyo1
Supakij Suwannatrai2
Ueamphon Suwannatrai2
Phanitanong Khumkaew2
Dokmai Wiwattamongkol2
Manmas Vannabhum2
Somluck Pianmanakit1
Vilai Kuptniratsaikul1
1Department of Rehabilitation
Medicine, 2Center of Applied Thai
Traditional Medicine, Faculty of
Medicine Siriraj Hospital, Mahidol
University, Bangkok, Thailand
Correspondence: Vilai Kuptniratsaikul
Department of Rehabilitation Medicine,
Faculty of Medicine Siriraj Hospital,
Mahidol University, 2 Prannok Road,
Bangkok 10700, Thailand
Tel +66 2 419 7511
Fax +66 2 411 4813
Email vilai.kup@mahidol.ac.th
Purpose: To study the efficacy of traditional Thai massage (TTM) versus conventional physical
therapy (PT) programs in treating muscle spasticity, functional ability, anxiety, depression, and
quality of life (QoL) in Thai stroke patients.
Methods: This randomized controlled trial with a blinded assessor was carried out at the
Department of Rehabilitation Medicine, Siriraj Hospital (Bangkok, Thailand). The study
included 50 stroke (onset .3 months) outpatients experiencing spasticity at the elbow or knee
muscles at a grade of .1+ on the modified Ashworth Scale who were .50 years old and able
to communicate. The subjects were randomly allocated to the treatment group receiving TTM
(24 subjects) or the control group receiving the PT program (26 subjects). Both groups received
treatment (either TTM or PT) twice a week for 6 weeks. Spasticity grade, functional ability,
anxiety, depression, and QoL were measured at Week 0 and Week 6.
Results: At Week 6, the percentage of patients whose modified Ashworth Scale score had
decreased by at least one grade was not statistically significant between the two groups. Both
TTM and PT groups experienced a significant increase in functional ability and QoL, but no
difference was found between the groups. Anxiety and depression scores showed a decreasing
trend in the TTM group.
Conclusion: This preliminary report showed no evidence that TTM differed from the PT
program in decreasing spasticity. However, both interventions may relieve spasticity, increase
functional ability, and improve QoL after 6 weeks. Only TTM can decrease anxiety and depression
scores. Further studies with adequate sample size are necessary.
Keywords: stroke, massage, spasticity, anxiety, depression
Introduction
Worldwide, stroke is one of the common ailments among the elderly. It is the third-
ranking cause of death, and therefore affects the health care system in Thailand.1 One
of the common consequences of stroke is spasticity. It is defined as a motor disorder
that is characterized by a velocity-dependent increase in tonic stretch reflexes (muscle
tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch
reflexes.2 The prevalence of post-stroke spasticity has ranged from 19%3 to 39%4 of
stroke patients at 3 months and 12 months after experiencing stroke, respectively. In
Thailand, the prevalence of post-stroke spasticity during rehabilitation was 41.6%.5
However, recent studies reported that the increased resistance of muscles with spasticity
to passive movement is due not only to hyperexcitability reflexes, but also to
altered properties of the muscle tissue.6,7 Spasticity can cause pain, abnormal posture,
and joint contracture. It may interfere with functional recovery and the ability to
perform daily activities, resulting in decreasing quality of life (QoL) and increasing
caregiver burden.
Dovepress
Thanakiatpinyo et al
submit your manuscript | www.dovepress.com
1312
Clinical Interventions in Aging 2014:9
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Currently, many methods for decreasing spasticity are
available, including pharmacological and nonpharmacological
treatments. The pharmacological therapies, such as oral
anti-spastic drugs,8,9 botulinum toxin injection,9–11 phenol
injections,9,12 alcohol injection,13 and intrathecal baclofen,14,15
usually focus on reducing reflex hyperexcitability. Nonpharmacological
treatments, which aim to inhibit neural activity,
reduce muscle stiffness, and improve the surrounding
connective tissue, include heat modalities, cryotherapy,
electrical stimulation, stretching, splinting, acupuncture,
and massage.16,17
The mechanisms of massage on spasticity vary depending
on technique. Goldberg et al found that petrissage massage
above the lumbar area can reduce H-reflex amplitude in the
calf muscles of people with traumatic spinal cord injury.18
This result reflects a reduction in motor neuron excitability.
Deep massage can stretch the muscle that experiences spasticity
and reset sarcomere lengths to a more optimal state.
It helps to break down subcutaneous adhesions and prevent
fibrosis,19 and may lead to improved sensory feedback from
muscle spindle receptors. Moreover, the repetitive cutaneous
stimulation provided by massage may reduce pain through
the gate control theory.20
There have been a few study reports related to massage
and spasticity. Unfortunately, these studies were reported
in local languages. Only one randomized control trial was
found, which reported the efficacy of rehabilitation exercise
therapy in decreasing post-stroke hemiplegia limb
muscle spasticity compared with traditional Chinese massage
therapy.21 Their curative effects on patients were evaluated
4 weeks after treatment using the modified Ashworth Scale
(MAS) and limb motor function integration scale, and by
measuring the changes in activities of daily living. The
researchers concluded, by examining total effective rates,
that rehabilitation exercise therapy could improve muscle
spasticity significantly more than traditional Chinese massage
therapy. However, this study was published in Chinese. Thus,
it cannot clearly be stated how the previous study measured
the total effective rate and the details of the massage technique
and dosage used.
Traditional Thai massage (TTM) is the most popular
alternative medicine in Thailand. People have been
acquainted with this massage for over a century. Currently,
it is well recognized and regulated by the Thai government.
Although massage is found worldwide in clinical practice, the
scientific evidence that supports the effectiveness of massage
in decreasing spasticity is limited. Therefore, a randomized
controlled trial with a single-blinded assessor was performed
to compare the effects of TTM and conventional physical
therapy (PT) on spasticity, functional ability, anxiety, depression,
and QoL in stroke patients.
Methods
The current study was a randomized trial. The study protocol
was conducted in accordance with the ethical principles
stated in the most recent version of the Declaration
of Helsinki. After the study protocol was approved by the
Institutional Review Board of Siriraj Hospital, stroke patients
were recruited from the outpatient unit of the Department of
Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital
(Bangkok, Thailand) from August 2011 through July 2013.
Chronic stroke (onset .3 months) patients with moderate-
to-severe spasticity of the elbow or knee in at least one limb
(grade .1+), as evaluated by the MAS, who were aged .50
years and able to communicate, were eligible to participate.
Subjects who had contraindications for massage, eg, fever
38.C or greater, uncontrolled blood pressure, bleeding
tendencies, taking anticoagulant drugs, unhealed fractures,
contact dermatitis, skin infections, or severe osteoporosis,
were excluded. Additionally, fixed joint contracture, a history
of botulinum toxin injection within the last 6 months, a
history of nerve block within the past year, severe dementia,
or uncontrolled psychological disorders were excluded. The
study would be terminated if severe adverse events occurred,
including fractures or hematomas in the muscle or soft tissue
of the patients.
After providing consent, subjects were randomly assigned
to undergo TTM or the conventional PT program. A computer-
generated randomization number was used, and the allocation
codes were kept in opaque envelopes. An external
investigator selected consecutive allocation envelopes for
consecutive participants.
Patients who were randomized into the treatment group
received court-type TTM, two nonconsecutive days per week
for 6 weeks. Five certified personnel who performed massage
for the duration of the study were standardized according
to a Thai massage organization. Therapists performed the
massage with the same procedure over the hemiplegic side for
1 hour per session. The basic massage lines and major signal
points were the main massage treatment using only thumb
and hand pressing at the point without traction or stretching.
The basic massage lines were pressed for 10 seconds and the
major signal points were pressed for 30 seconds per point.
Massage points included in this study were located in the leg,
back, abdomen, arm, sho
Clinical Interventions in Aging
Dovepress
open access to scientific and medical research
Open Access Full Text Article
Original Research
1311
submit your manuscript | www.dovepress.com
Clinical Interventions in Aging 2014:9 1311–1319
. 2014 Thanakiatpinyo et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0)
License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further
permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on
how to request permission may be found at: http://www.dovepress.com/permissions.php
Dovepress
http://dx.doi.org/10.2147/CIA.S66416
The efficacy of traditional Thai massage
in decreasing spasticity in elderly stroke patients
Thanitta Thanakiatpinyo1
Supakij Suwannatrai2
Ueamphon Suwannatrai2
Phanitanong Khumkaew2
Dokmai Wiwattamongkol2
Manmas Vannabhum2
Somluck Pianmanakit1
Vilai Kuptniratsaikul1
1Department of Rehabilitation
Medicine, 2Center of Applied Thai
Traditional Medicine, Faculty of
Medicine Siriraj Hospital, Mahidol
University, Bangkok, Thailand
Correspondence: Vilai Kuptniratsaikul
Department of Rehabilitation Medicine,
Faculty of Medicine Siriraj Hospital,
Mahidol University, 2 Prannok Road,
Bangkok 10700, Thailand
Tel +66 2 419 7511
Fax +66 2 411 4813
Email vilai.kup@mahidol.ac.th
Purpose: To study the efficacy of traditional Thai massage (TTM) versus conventional physical
therapy (PT) programs in treating muscle spasticity, functional ability, anxiety, depression, and
quality of life (QoL) in Thai stroke patients.
Methods: This randomized controlled trial with a blinded assessor was carried out at the
Department of Rehabilitation Medicine, Siriraj Hospital (Bangkok, Thailand). The study
included 50 stroke (onset .3 months) outpatients experiencing spasticity at the elbow or knee
muscles at a grade of .1+ on the modified Ashworth Scale who were .50 years old and able
to communicate. The subjects were randomly allocated to the treatment group receiving TTM
(24 subjects) or the control group receiving the PT program (26 subjects). Both groups received
treatment (either TTM or PT) twice a week for 6 weeks. Spasticity grade, functional ability,
anxiety, depression, and QoL were measured at Week 0 and Week 6.
Results: At Week 6, the percentage of patients whose modified Ashworth Scale score had
decreased by at least one grade was not statistically significant between the two groups. Both
TTM and PT groups experienced a significant increase in functional ability and QoL, but no
difference was found between the groups. Anxiety and depression scores showed a decreasing
trend in the TTM group.
Conclusion: This preliminary report showed no evidence that TTM differed from the PT
program in decreasing spasticity. However, both interventions may relieve spasticity, increase
functional ability, and improve QoL after 6 weeks. Only TTM can decrease anxiety and depression
scores. Further studies with adequate sample size are necessary.
Keywords: stroke, massage, spasticity, anxiety, depression
Introduction
Worldwide, stroke is one of the common ailments among the elderly. It is the third-
ranking cause of death, and therefore affects the health care system in Thailand.1 One
of the common consequences of stroke is spasticity. It is defined as a motor disorder
that is characterized by a velocity-dependent increase in tonic stretch reflexes (muscle
tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch
reflexes.2 The prevalence of post-stroke spasticity has ranged from 19%3 to 39%4 of
stroke patients at 3 months and 12 months after experiencing stroke, respectively. In
Thailand, the prevalence of post-stroke spasticity during rehabilitation was 41.6%.5
However, recent studies reported that the increased resistance of muscles with spasticity
to passive movement is due not only to hyperexcitability reflexes, but also to
altered properties of the muscle tissue.6,7 Spasticity can cause pain, abnormal posture,
and joint contracture. It may interfere with functional recovery and the ability to
perform daily activities, resulting in decreasing quality of life (QoL) and increasing
caregiver burden.
Dovepress
Thanakiatpinyo et al
submit your manuscript | www.dovepress.com
1312
Clinical Interventions in Aging 2014:9
Dovepress
Currently, many methods for decreasing spasticity are
available, including pharmacological and nonpharmacological
treatments. The pharmacological therapies, such as oral
anti-spastic drugs,8,9 botulinum toxin injection,9–11 phenol
injections,9,12 alcohol injection,13 and intrathecal baclofen,14,15
usually focus on reducing reflex hyperexcitability. Nonpharmacological
treatments, which aim to inhibit neural activity,
reduce muscle stiffness, and improve the surrounding
connective tissue, include heat modalities, cryotherapy,
electrical stimulation, stretching, splinting, acupuncture,
and massage.16,17
The mechanisms of massage on spasticity vary depending
on technique. Goldberg et al found that petrissage massage
above the lumbar area can reduce H-reflex amplitude in the
calf muscles of people with traumatic spinal cord injury.18
This result reflects a reduction in motor neuron excitability.
Deep massage can stretch the muscle that experiences spasticity
and reset sarcomere lengths to a more optimal state.
It helps to break down subcutaneous adhesions and prevent
fibrosis,19 and may lead to improved sensory feedback from
muscle spindle receptors. Moreover, the repetitive cutaneous
stimulation provided by massage may reduce pain through
the gate control theory.20
There have been a few study reports related to massage
and spasticity. Unfortunately, these studies were reported
in local languages. Only one randomized control trial was
found, which reported the efficacy of rehabilitation exercise
therapy in decreasing post-stroke hemiplegia limb
muscle spasticity compared with traditional Chinese massage
therapy.21 Their curative effects on patients were evaluated
4 weeks after treatment using the modified Ashworth Scale
(MAS) and limb motor function integration scale, and by
measuring the changes in activities of daily living. The
researchers concluded, by examining total effective rates,
that rehabilitation exercise therapy could improve muscle
spasticity significantly more than traditional Chinese massage
therapy. However, this study was published in Chinese. Thus,
it cannot clearly be stated how the previous study measured
the total effective rate and the details of the massage technique
and dosage used.
Traditional Thai massage (TTM) is the most popular
alternative medicine in Thailand. People have been
acquainted with this massage for over a century. Currently,
it is well recognized and regulated by the Thai government.
Although massage is found worldwide in clinical practice, the
scientific evidence that supports the effectiveness of massage
in decreasing spasticity is limited. Therefore, a randomized
controlled trial with a single-blinded assessor was performed
to compare the effects of TTM and conventional physical
therapy (PT) on spasticity, functional ability, anxiety, depression,
and QoL in stroke patients.
Methods
The current study was a randomized trial. The study protocol
was conducted in accordance with the ethical principles
stated in the most recent version of the Declaration
of Helsinki. After the study protocol was approved by the
Institutional Review Board of Siriraj Hospital, stroke patients
were recruited from the outpatient unit of the Department of
Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital
(Bangkok, Thailand) from August 2011 through July 2013.
Chronic stroke (onset .3 months) patients with moderate-
to-severe spasticity of the elbow or knee in at least one limb
(grade .1+), as evaluated by the MAS, who were aged .50
years and able to communicate, were eligible to participate.
Subjects who had contraindications for massage, eg, fever
38.C or greater, uncontrolled blood pressure, bleeding
tendencies, taking anticoagulant drugs, unhealed fractures,
contact dermatitis, skin infections, or severe osteoporosis,
were excluded. Additionally, fixed joint contracture, a history
of botulinum toxin injection within the last 6 months, a
history of nerve block within the past year, severe dementia,
or uncontrolled psychological disorders were excluded. The
study would be terminated if severe adverse events occurred,
including fractures or hematomas in the muscle or soft tissue
of the patients.
After providing consent, subjects were randomly assigned
to undergo TTM or the conventional PT program. A computer-
generated randomization number was used, and the allocation
codes were kept in opaque envelopes. An external
investigator selected consecutive allocation envelopes for
consecutive participants.
Patients who were randomized into the treatment group
received court-type TTM, two nonconsecutive days per week
for 6 weeks. Five certified personnel who performed massage
for the duration of the study were standardized according
to a Thai massage organization. Therapists performed the
massage with the same procedure over the hemiplegic side for
1 hour per session. The basic massage lines and major signal
points were the main massage treatment using only thumb
and hand pressing at the point without traction or stretching.
The basic massage lines were pressed for 10 seconds and the
major signal points were pressed for 30 seconds per point.
Massage points included in this study were located in the leg,
back, abdomen, arm, sho
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