**E**ff**ect of Psycho-Regulatory Massage Therapy on Pain and Depression in Women with Chronic and**/**or Somatoform Back Pain: A Randomized Controlled Trial**

#### **Sabine B.-E. Baumgart 1,\*, Anja Baumbach-Kraft <sup>2</sup> and Juergen Lorenz <sup>3</sup>**


Received: 9 September 2020; Accepted: 30 September 2020; Published: 12 October 2020

**Abstract:** Chronic unspecific back pain (cBP) is often associated with depressive symptoms, negative body perception, and abnormal interoception. Given the general failure of surgery in cBP, treatment guidelines focus on conservative therapies. Neurophysiological evidence indicates that C-tactile fibers associated with the oxytonergic system can be activated by slow superficial stroking of the skin in the back, shoulder, neck, and dorsal limb areas. We hypothesize that, through recruitment of C-tactile fibers, psycho-regulatory massage therapy (PRMT) can reduce pain in patients with cBP. In our study, 66 patients were randomized to PRMT or CMT (classical massage therapy) over a 12-week period and tested by questionnaires regarding pain (HSAL= Hamburger Schmerz Adjektiv Liste; Hamburg Pain adjective list), depression (BDI-II = Beck depression inventory), and disability (ODI = Oswestry Disability Index). In all outcome measures, patients receiving PRMT improved significantly more than did those receiving CMT. The mean values of the HSAL sensory subscale decreased by −51.5% in the PRMT group compared to −6.7% in the CMT group. Depressive symptoms were reduced by −55.69% (PRMT) and −3.1% (CMT), respectively. The results suggest that the superiority of PRMT over CMT may rely on its ability to activate the C-tactile fibers of superficial skin layers, recruiting the oxytonergic system.

**Keywords:** massage therapy; chronic back pain; depression; oxytocin; C-tactile fibers; somatoform pain (ICD 10); somatic symptom disorder (DSM-5)

#### **1. Introduction**

Chronic back pain (cBP) has a leading position worldwide in disease-related disability and loss of quality of life [1]. It represents a common health problem, especially among women. According to a GEDA ("Gesundheit in Deutschland Aktuell", current state of health in Germany) survey from 2009/2010, one in four women reported suffering cBP (lasting >3 months) within the last 12 months [2]. Modern recommendations by national and international health organizations focus on non-drug therapy options in the treatment of chronic (non-specific) back pain. A variety of treatment modalities are suggested, including physical and rehabilitation interventions [3] and instrument-based techniques such as transcutaneous electrical nerve stimulation (TENS) [4], acupuncture [5], low-level laser therapy (LLLT) [6], and shock wave therapy [7]. Additional treatment with pain-relieving medication is recommended. Surgery is not recommended because there is little evidence of its effectiveness [5,8,9]. Chou et al. [10] underlined these recommendations and showed that psychological impairments, e.g.,

sleep disorders, mood fluctuation, depression, and listlessness, are frequent co-morbidities of chronic pain. A central characteristic of patients with chronic pain is their negative body perception [11], inhibiting cognitive access to therapy [12–14].

In the 1980s, Groddek and Dogs integrated massage therapy as a form of body therapy into the treatment of chronic pain to gain direct access to the patient's emotions via their skin and its nervous system, thus facilitating positive body perception and cognitive-behavioral treatment [15,16]. Berg et al. and Listing et al. [17,18] showed how professional therapeutic touch in the form of massage can reduce the physical and psychological symptoms of patients with pain and/or depression. A reduction in pain, mood disorders, and listlessness and fatigue was reported. Furthermore, general psychological tension was reduced, and well-being was increased. Baumgart et al. reviewed randomized controlled trials (RCTs) published from 1996 to 2009 that investigated the effectiveness of massage for patients with depression both as the main diagnosis and a co-morbidity [16]. The authors concluded that the effectiveness of massage therapy depends on the design of the parameters of (a) pressure, (b) speed, (c) direction, and (d) rhythm [14,18–22]. Studies on the effects of oxytocin and its interactions with the neuro-physiological system have provided possible explanations for the effect of touch or massage therapy in chronic pain (with and without depression) [23]. In their study, Walker and McGlone illustrated the connection between the type of touch (effect parameters: pressure and time), its neurological transmission of stimuli via C-tactile fibers, and the significance of oxytocin with regard to pain-relieving effects [24]. C-tactile afferent fibers mediate pleasantness of touch and serve a fundamental role in the hedonic function of tactile sensation [25]. Kane and Terrel emphasized the role of touch for child development and propagated the integration of touch into the treatment of developmental trauma [26]. Experimental evidence indicates that activation of C-tactile fibers can significantly alleviate muscle pain [27]. The stimulus of a gentle or moderate touch, transduced in the skin by C-tactile fibers, is transmitted via ascending spinothalamic pathways to the insular cortex, an area of the limbic system. Through connections with the paraventricular nucleus, the thalamus stimulates the synthesis of oxytocin when a touch is perceived as pleasant [23,28,29].

Based on these considerations, we hypothesize that pain experience and depressive symptoms can be reduced and physical capacity can be improved by gentle massage that is optimized to activate C-tactile skin afferents. The aim of this study is to examine the effect of both classical and psycho-regulatory massage in patients with cBP on pain experience, depressive symptoms, and physical capacity.

#### **2. Materials and Methods**

The study was conducted as a double-blind RCT. The study is registered in the German Registry for Clinical Studies (DRKS00006876), and the protocol was approved by the ethics committee of the University of Halle (Saale), Germany (Nr. 2014-22).

#### *2.1. Eligibility Criteria*

The eligibility criteria and baseline data were assessed prior to randomization. The inclusion and exclusion criteria can be found in Table 1 and were defined via extensive literature research. The diagnosis M54 in the ICD-10 (International Statistical Classification of Diseases and Related Health Problems) represents a composite of diagnoses related to back pain.


**Table 1.** List of eligibility criteria for study participation.

Clear diagnosis of chronic pain is difficult, since 90% of the diagnoses do not reveal any apparent clinical findings [30,31]; thus, chronic pain is primarily defined by the duration of the pain [32,33]. Since chronic pain can lead to psychological co-morbidity [34], the diagnostic group of somatoform disorders (ICD-10, F45) was also included. These disorders are generally defined by the occurrence of physical problems without a clear somatic diagnosis.

#### *2.2. Participants*

We conducted 107 recruitment interviews. Of these, 41 patients did not participate for the following reasons: *n* = 16 did not meet eligibility criteria, *n* = 3 stated that the number of interventions was too high, *n* = 11 were not comfortable with the nudity required for massage therapy, *n* = 8 found that the questionnaires were too complicated, and *n* = 3 did not want to use massage oil. Overall, *n* = 66 patients were randomized into either the intervention or control group using hidden lots covered in envelopes. One patient was excluded prior to the first treatment due to acute illness; 61 patients completed the treatment. Two patients in each treatment group discontinued the treatments without giving any reason (see Figure 1).

#### *2.3. Interventions*

Interventions took place in the physiotherapy practice operated by the principle investigator (SB). The outpatient setting was chosen to maximize external validity. The intervention group received psycho-regulatory massage therapy (PRMT) and the control group received classical massage therapy (CMT). Patients were blinded towards the type of massage they received. However, they were aware of the study's aim to compare the two types of massage. Data analysis was blind towards a patient's treatment method. All therapists employed in the practice participated in the study (*n* = 7). The design of effect parameters differed between the intervention and control groups in terms of pressure, speed, direction, and rhythm [12,14], as shown in Table 2. The interventions also differed in respect to the target organ and body areas treated. PRMT targets the skin and the superficial fascia, whereas CMT targets all layers of the tissue, including the periosteum. The PRMT unfolds from three partial massages to a full body massage. It is applied with warm oil in both supine and prone body positions and involves soft to moderate intensities of continuous slow strokes. They are uninterrupted throughout the entire session except during the change from supine to prone body position. The therapist does not touch the different body parts in separate sequences, but moves in harmonious transitions from limbs to trunk to create a whole-body experience. An extended description of the PRMT technique is added as supplemental material. In contrast, CMT is applied to the back alone and extends from the sacrum to the neck.

**Figure 1.** CONSORT (Consolidated Standards of Reporting Trials) flow chart of participants in this study comparing PRMT (psycho-regulatory massage therapy) and CMT (classical massage therapy).


**Table 2.** Effect parameters of the interventions.

PRMT, psyochregulatory massage therapy; CMT, classical massage therapy.

The intervention group was treated by seven therapists who received professional training to standardize the performance of PRMT, which was applied for 30 to 60 min [35,36]. The control group received 20 min of CMT, which was not standardized but applied individually, reflecting standard care within the German statutory health insurance scheme. All treatments were applied non-verbally in a closed therapy room with only the patient and therapist present. Patients were treated by the same therapist during the whole study period, for optimal therapeutic effectiveness [18,21]. Each group received 10 treatments overall, which were scheduled twice a week.

#### *2.4. Data collection*

After 3 months, follow-up data were collected. Figure 2 shows the structure and course of the study. Data were collected via questionnaires, handed out by the therapists and filled by the patients themselves. Baseline data (T0) were collected prior to randomization and the first intervention. At T1 (5th treatment), T2 (10th treatment), and at follow-up (T3), data were collected after the interventions.

**Figure 2.** Study timeline (T, time of measurement; PRMT, psychoregulatory massage therapy; CMT, classical massage therapy).

Pain was assessed using the Hamburg Pain Adjective List (Hamburger Schmerz Adjektiv Liste, HSAL), a multi-dimensional questionnaire for pain experience in adults with acute or chronic pain. The HSAL consists of 37 adjectives, 21 of those describing the affective experience of pain (pain suffering + pain anxiety) and 16 describing the sensory experience of pain (pain rhythm + pain acuity). Each item can be answered on a scale from 0 (not correct at all) to 6 (completely correct), and the answers are added up to create a total score (maximum of 222, corresponding to a maximum of pain) [37]. The validity of the HSAL has been assessed by several studies in different clinical situations (Cronbach's alpha of the primary scales is between 0.80 and 0.90) [38]. The HSAL questionnaire is especially suitable in connection with psychiatric scales (depression, anxiety) and also has good applicability for monitoring patient health.

Depressiveness was measured using the Beck Depression Inventory (BDI-II), scaling 0–3 for each item; the maximum overall score is 63 points [39,40]. The severity of depression is categorized into five groups:

0–8 no depression;


The clinical relevance of the respective changes in depression was assessed according to the criteria of Hiroe et al. [42]. Accordingly, a 5-point change in BDI-II score indicates minimal relevance, 10–19 points is moderate, and more than 20 points corresponds to a strong effect.

Quality of life was measured using the Oswestry Disability Index (ODI), a self-rating questionnaire about disability in patients with back pain [43]. The questionnaire consists of 10 items, which are categorized into (1) physical complaints (or disability), (2) activity, and (3) participation according to the International Classification of Functioning, Disability and Health (ICF). A maximum score of 50 indicates maximum impairment. The scores are then converted into percentages depending on the number of questions answered. Mannion et al. [44,45] and Hooff et al. [46] investigated the validity of the German version. Their results showed that the ODI is a good measurement tool for assessing a patient's disability due to back pain (Cronbach's alpha = 0.90). The total ODI score represents a percentage and is interpreted as follows:

0–2 minimal disability (all activities of daily living (ADL) are mostly possible, often no therapy necessary, activation of life is enough);

21–40 moderate disability (participation is already limited and incapacity to work often occurs, conservative treatment);

41–60 severe disability (pain is the main problem and ADL are affected, intensive diagnostics are necessary);

61–80 crippled (all areas of life are affected);

81–100 bedridden or the patient exaggerates [47,48].

#### *2.5. Sample Size and Randomization*

For sample size calculation on the basis of overall pain experience as the primary outcome, alpha was set to 5%, statistical power should be at least 90% (SD 2.0), and the drop-out rate was expected to be 20%, resulting in a group size of *n* = 33. Block randomization was carried out with a block size of 10 by an independent statistician from University of Halle, Saale (Germany).

#### *2.6. Statistical Analysis*

Given the ordinal data type of all questionnaires (HSAL-total, HSAL-affective, HSAL-sensory, BDI-II-score, and ODI (%)) that were, in at least one session, not normally distributed, as tested with the Kolmogorov–Smirnov test, we applied the Wilcoxon rank-sum test for two independent samples to analyze group differences (CMT vs. PRMT) at baseline (T0) and to test the magnitude of change from baseline to the T1, T2, and T3 time points (SPSS, Version 26). A significant difference (two-tailed test) was accepted at *p*-values below 0.05. To test the effect of sessions, we applied the Friedmann ANOVA test separately for CMT and PRMT. In case of significance, we used the Wilcoxon test for paired samples. According to the total of six comparisons, we used Bonferroni correction, resulting in a *p*-value of 0.008 as the threshold for significance.

#### **3. Results**

The results of the non-parametric comparison using the Wilcoxon rank-sum test for two independent samples are summarized in Table 3 for all study parameters. The baseline condition (T0) yielded non-significant differences for all questionnaire scores.

HSAL total, affective, and sensory scores for pain: The total scores and the affective and sensory subscores of HSAL were significantly smaller in the T2 and T3 sessions in the PRMT group compared to the CMT group. No difference appeared in session T1. The Friedmann ANOVA yielded a non-significant effect of treatment session for CMT in HSAL-Total (*p* = 0.56), weak significance for HSAL-Affective that failed to reach the significance criterion in any of the six comparisons, and an absence of significance for HSAL-Sensory (*p* = 0.127). In contrast, all HSAL parameters were statistically significant for the effect of treatment session in PRMT (*p* < 0.001). Post hoc Wilcoxon testing revealed significant decreases in all HSAL parameters for comparisons T3 vs. T0, T4 vs. T0, T3 vs. T2, and T4 vs. T2 (*p* < 0.001; Bonferroni-corrected).

BDI-II score for depression: PRMT reduced the intensity of depression more than CMT already during T1, but more strongly during sessions T2 and T3. The Friedman ANOVA resulted in a significant session effect in CMT (*p* = 0.03); however, no post hoc comparison reached the Bonferroni-corrected threshold criterion. In contrast, PRMT had a significant effect of session with statistically significant post hoc Wilcoxon testing in all six comparisons (*p* < 0.001): T0 vs. T1, T0 vs. T2, T0 vs. T3, T1 vs. T2, T1 vs. T3, and T2 vs. T3. Thus, the BDI-II score continuously decreased over the three months of treatment. Overall, the severity of depression decreased by 55.69% with PRMT, from a moderate to minimal level of severity on average [45]. Under CMT, the mean BDI-II score changed by −3.1% over the whole study period.


**Table 3.** Results (mean and SD) for pain experience (HSAL total score and affective and sensory subscales), depressive symptoms (BDI-II), and disability (ODI); results of the Wilcoxon rank-sum test for independent samples tested for effect of treatment (PRMT vs. CMT) and *p*-values for two-tailed comparisons.

BDI-II: Beck Depression Inventory, 2nd version; ODI: Oswestry Disability Index; PRMT: Psycho-regulatory massage therapy; CMT: classical massage therapy; n.s.: not significant.

ODI (%) score for disability: The progression of improvement in functional status achieved by PRMT in comparison to CMT is quite similar to that for depression. A weak, yet significantly better improvement in PRMT than in CMT occurred in T1, but much greater treatment differences appeared in T2 and T3. The Friedmann ANOVA showed non-significant change by CMT (*p* = 0.56). In contrast, there was a significant change in ODI (%) by PRMT (*p* < 0.001) with significant post hoc differences in all comparisons, except for T3 vs. T2. Table 4 shows the distribution of patients within the different levels of disability (reflecting limitations in quality of life, daily activities, and participation) at baseline and follow-up measurements. Before intervention, the vast majority (90.62%) of the PRMT group had a moderate to severe level of disability. At follow-up, 86.66% of the patients had minimal to moderate levels of disability. On average, the degree of disability improved by at least one level in 90% of the PRMT group, while CMT did not lead to any substantial change. The effect size according to Cohen, ƒ = 0.47, corresponds to a strong effect.


**Table 4.** Distribution of patients at baseline (T0) and follow-up (T3) according to the respective levels of disability.

#### **4. Discussion**

The primary aim of this study was to examine the effect of two forms of massage therapy in patients with chronic back pain (cBP). According to the general consensus about pain as a multidimensional experience [49,50] pain was assessed via HSAL (the Hamburg Pain Adjective List). In the group receiving PRMT, the decrease in the HSAL total score was statistically significant (−57.7 points), relating to an improvement of 46%. In contrast, the HSAL total score improved only by 5.6% in the group receiving CMT, failing to reach statistical significance and indicating no clinical relevance. In terms of decrease in symptoms of affective and sensory pain experience, PRMT thus shows strong superiority over CMT. Consistent with our results, Cherkin et al. [51] investigated 10 massage applications with a duration of 50–60 min and compared "structural" massages with relaxing massages. Relaxing massages were superior to structural massages, the latter being comparable to CMT. The follow-up at 10 weeks showed that the results persisted in both groups; thus, a long-term effect analogous to the results of the present study could also be observed. Without emphasizing different techniques, Wallach et al. [52] observed a sustained long-term effect of CMT after three months involving 10 applications of massage therapy of 20 min each over 10 weeks. Hamre et al. [53] investigated the effect of rhythmic massage therapy in a four-year prospective cohort study. They examined 85 chronically ill patients, 45 of whom suffered from chronic back or neck pain. Eighteen of the patients also suffered from depression and fatigue. The disease and symptom scores used in that study, each on a scale of 0 to 10, improved significantly. The disease score decreased from 6.3 to 2.77 points, and the symptom score decreased from 5.76 to 3.13 points. The SF-36 questionnaire also showed an improvement in the physical component score and the mental score. Thus, the symptoms of chronic disease were reduced, and at the same time, the quality of life of the patients improved.

Models from neuro-biological research might explain the positive effects of massage and the role of their specific techniques. Studies using microneurography have indicated the existence of low-threshold slowly conducting C-fibers in superficial skin layers that are predominantly activated by soft and low-velocity (3 cm/s) stroking stimuli [27]. In contrast, stronger pressure stimuli penetrating into deeper subepidermal skin layers activate rapidly conducting A-tactile afferents. A-tactile and C-tactile afferents are regarded as important for discriminant and affective dimensions of touch perception, respectively [28]. Accordingly, A-tactile fibers are predominantly abundant in the glabrous skin of the hands, whereas C-tactile fibers predominate in the hairy skin of the limbs and back. Several authors have pointed to the importance of the type of touch to be applied: slow, harmonic, and rhythmic with moderate pressure [24,54–57].

Boehme et al. compared patients suffering from fibromyalgia with healthy controls by using functional magnetic resonance imaging (fMRI) imaging of brain activity in response to selective C-tactile stimuli and additionally analyzed the voxel-based morphometry in areas of the limbic cortex [58]. They observed an abnormal pattern of deactivation and activation within the posterior insula during pleasantness and pain ratings, respectively, and a reduced grey matter density in the hippocampus and anterior insula. The authors interpreted their results as indications of anhedonia to gentle touch in fibromyalgia. Notably, classical massage is reported to worsen pain, whereas soft skin stroking,

lymphatic drainage, and superficial vacuum massage alleviate pain in fibromyalgia patients [59]. Liljencrantz and Olausson [56] also reported anxiety-reducing effects of stimulating C-tactile afferents.

Craig [60] and Devue et al. [61] identified a functional network between the anterior insula and the cingulate gyrus, which serves primarily for self-recognition and awareness of one's own body. External impulses like touch and their subjective processing are thus integrated into emotional experiences. Older studies identified interoceptive afferents of primates as correlates of a so-called "gut feeling", which represents a complex integration of sensory perceptions and corresponding emotional responses. In the early 1990s, Damasio demonstrated that emotional and mental responses to stimuli mediate spino-thalamic and insular impulses that are integrated into body perception [62]. Paulsen and Stein reported that patients with depression and/or anxiety disorders experience significantly altered interoceptive signal processing. Signals are passed on blurred and amplified, so that homeostatic states are difficult to predict [63].

Several studies have shown an interaction of C-tactile afferents with the oxytonergic system in reducing pain and improving body perception [24,54,55]. Pfeifer et al. [64] and Uvnäs-Moberg and Peterson [23] postulated a positive influence on pain memory via the limbic system and activation of the oxytonergic system. This hypothesis was confirmed by follow-up data. A long-term effect was shown in both groups at three months post-intervention. This is coherent with the neuro-biologic findings by Lund et al. [65], who reported a long-term pain-reducing effect of soft massage-like touch through interaction of the oxytonergic system with the opioid system and activation of periaqueductal grey neurons. Miranda-Cardenaz et al. [66] and DeLaTorre [67] detected oxytocin receptors in the laminae of the dorsal horns. By micro-stimulation of the paraventricular nucleus and intrathecal administration of oxytocin, they were able to demonstrate an inhibited stimulus response of the wide dynamic-range neurons in the spinal horn in chronic pain syndrome. The authors considered this to be a descending oxytonergic control mechanism that influences chronic pain perception. Oxytocin also plays an antagonistic role in the glutamatergic spinal sensory conduction of acute pain stimuli [68]. Oxytocin inhibits the conduction of pain in the protopathic ascending pathways and plays a role in the function of the opioid system and gate control mechanism [64,65]. Thus, oxytocin can inhibit acute and chronic pain stimuli at different levels of the central nervous system (CNS).

The results on depression severity in our study, as measured by the BDI-II questionnaire, lend further strong support for the importance of C-tactile stimulation underlying the superior efficacy of PRMT over CMT. In the PRMT group, improvements on the BDI-II correspond to a moderate clinical effect [46]. In contrast, the severity of depression did not change significantly following CMT. These results support findings from a systematic review by Baumgart et al. that found massage therapy to be effective for depression and anxiety as a primary diagnosis and a co-morbidity, respectively [16]. Finally, disability and activity improved significantly within the PRMT group. Inter-group analysis also showed a significant effect in favor of PRMT compared to CMT. The PRMT group showed an improvement rate of 37.76%—the CMT group, only 3.46%. Changes of at least 18% are considered clinically relevant [46]. In this study, an important aim of chronic pain treatment (increase in function and activity) was achieved with PRMT [61]. Positive psycho-emotional effects, including a decrease in depressive symptoms, increase the motivation to maintain physical integrity, which is associated with an increase in personal activity [20,69,70]. Perceiving the back as a pleasant body part might reduce negative self-referential processing and open the patients towards treatments aiming at cognitive emotion regulation, e.g., mindfulness training [71].

There are limitations of our study. Since this study was conducted in the outpatient setting of a physiotherapy practice, the level of treatment standardization was low. Factors such as the patient's daily routine; sleep, waking, and eating rhythm; and time of intervention were not standardized to increase external validity. Treatment prescription was done by private orthopedic surgeons and general practitioners using the ICD-10 codes M54 and F45, which qualified the patients for study inclusion. There might have been variability among doctors in the use of these diagnoses. Yet, no patient had indication of specific back diseases causing their pain. Use of the term "somatoform" might be debatable, and it differs between the DSM (Diagnostic and Statistical Manual of Mental Disorders) and ICD classifications. During the update to DSM-5, the class of "somatoform disorders" was changed to "somatic symptom disorder", whereas the term is still used in the ICD-10. Furthermore, patients were allowed to use their pain medication as usual and receive other therapies, introducing a certain risk of bias to our results. Future studies could examine how the use of analgesics can be reduced by PRMT. Standard regulations of health care insurances allow 20 to 30 min of treatment duration for CMT, but 60 min for PRMT, because the latter involves a whole-body massage. Thus, longer treatment sessions might have contributed to the superiority of PRMT over CMT. The follow-up period of our study was three months, to increase comparability with other studies [16]. However, future studies could choose a longer follow-up period to better assess the long-term effects of PRMT intervention. Although the BDI-II score yielded no significant group differences at baseline, there was no stratification of patients according to the severity of depressive symptoms by an expert in psychiatry. Our results strongly suggest that patients with indications of depressive comorbidity benefit the most from PRMT. Although our a priori concept and conduct of PRMT aimed at an optimization of recruiting C-tactile afferent activity, we have no physiological proof of its importance in our study. Heart rate variability analysis has been found to be sensitive to the pleasantness of C-tactile stimulation [72] and appears to be compatible with study designs such as the one presented here.

#### **5. Conclusions**

Our results indicate that psycho-regulatory massage therapy (PRMT) is more effective than classical massage therapy (CMT) in reducing pain and depression and enhancing physical capacity and activity in patients suffering from chronic unspecific back pain. Unlike CMT, PRMT characterizes a massage technique by which the therapist applies soft and slow strokes upon the skin of the back, neck, shoulders, and upper arms that specifically activate C-tactile fibers. Future studies should examine the importance of individual differences of co-morbidity with depression in patients suffering from chronic unspecific back pain for the superiority of PRMT over CMT. This knowledge would improve the selection of individualized physical therapy options for these patients.

**Author Contributions:** S.B.-E.B.: Conceptualization, formal analysis, resources, writing—original draft. A.B.-K.: writing—review and editing, visualization. J.L.: Supervision, statistical analysis, writing—review and editing. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

### *Review* **Keeping in Touch with Mental Health: The Orienting Reflex and Behavioral Outcomes from Calatonia**

#### **Anita Ribeiro Blanchard 1,\* and William Edgar Comfort <sup>2</sup>**


Received: 8 February 2020; Accepted: 20 March 2020; Published: 22 March 2020

**Abstract:** Physical and psychological therapy based on touch has been gradually integrated into broader mental health settings in the past two decades, evolving from a variety of psychodynamic, neurobiological and trauma-based approaches, as well as Eastern and spiritual philosophies and other integrative and converging systems. Nevertheless, with the exception of a limited number of well-known massage therapy techniques, only a few structured protocols of touch therapy have been standardized and researched to date. This article describes a well-defined protocol of touch therapy in the context of psychotherapy—the Calatonia technique—which engages the orienting reflex. The orienting reflex hypothesis is explored here as one of the elements of this technique that helps to decrease states of hypervigilance and chronic startle reactivity (startle and defensive reflexes) and restore positive motivational and appetitive states.

**Keywords:** orienting reflex; motivational system; touch therapy; integrative psychotherapy; somatic psychology

#### **1. Introduction**

The limitations of verbal psychotherapy have become more evident in the past thirty years [1], giving rise to a large number of somatic and body-based modalities aimed to address treatment-resistant disorders [2–4]. Recently, there has been an interest in developing somatically informed research methods to support a wide range of these integrative practices [5,6]. Accordingly, this article discusses the significance of integrating a structured touch therapy (Calatonia) into psychotherapy to facilitate an orienting reflex (OR) [7]. The OR leads the individual to direct their motivational system towards appetitive and exploratory states, which can, in turn, positively influence affective and cognitive states.

Motivation—a concept derived from the biological sciences—has not been explored for its potential strength in mental health treatments, although motivation as a cognitive concept was well developed by Miller [8]. Affective responses comprising an organism's underlying motivational state have been broadly categorized in terms of defensive and appetitive systems, evolving either separately or in conjunction to engage with environmental stimuli indicative of threat or opportunities for survival, respectively [9]. In this perspective, emotional experiences occur within a range of appetitive-pleasant or defensive-unpleasant valence and have levels of arousal that indicate the degree of activation in response to that emotional valence [10]. These two basic dimensions of affective responses support mobilization for action, attention and social communication, according to the motivational system that is engaged (defensive or appetitive), its intensity of activation and its emotional context [9–13].

While several findings have identified distinct brain networks for approach/avoidance behavior and pleasant or aversive affect in healthy subjects [14,15], mental health continues to be studied primarily from a symptomatological perspective, with little research into long-term behavioral outcomes linked to the patient's motivational state.

As an illustration, depressive disorders—from their biological symptoms to their emotional and cognitive expression—can be understood as dysfunctions of the motivational system, in which (appetitive) motivation is reduced. Anxiety disorders may also be viewed from a motivational system perspective, in which there is either strong behavioral inhibition or impulsivity, based on aversive, defensive or avoidant motivation [16]. In such cases, touch therapies may prove useful to redirect the individual's motivational state toward more approach-oriented behavior, in conjunction with conventional psychotherapy and/or pharmacological treatment.

It is in this context that we introduce the therapeutic potential of Calatonia, a long-standing technique of touch therapy which aims to re-orient the individual toward a more open behavioral approach through activation of the appetitive motivational system and concomitant inhibition of startle and defensive states. This integrative approach has been used to treat disorders unresponsive to verbal psychotherapy alone, such as PTSD and other forms of trauma.

The primary mechanism through which Calatonia is thought to exert changes in the individual's motivational states is by eliciting an orienting reflex (OR) within the context of psychotherapy [17]. The OR is activated through touch experienced as a novel, sustained and non-threatening stimulus. Calatonia (described in Section 3) is a therapeutic technique based on a structured sequence of touches applied bilaterally to distinct regions of the body [18–20]. Since its inception, Calatonia has purported to induce a state of deep relaxation and increased unconscious processing with a net result of altering the patient's motivational and affective states [19–21].

However, Calatonia has yet to be submitted to rigorous scientific testing for the direct therapeutic benefits accrued from its application. One potential avenue for such research is the Research Domain Criteria (RDoC) framework for evaluating novel treatments for mental health put forth by the National Institute of Mental Health (NIMH) [22]. Within the RDoC framework, an upward level of analysis constitutes mapping functional measures of neural activity to variation in clinical symptoms on a distinct spectrum of mental health such as anxiety [22]. In line with this approach, a study utilizing near-infrared spectroscopy (fNIRS) to investigate alterations in neural markers of anxiety following Calatonia is currently under preparation.

#### **2. History of the Technique**

During WWII, the Hungarian physician Pethö Sándor (1916–1992) structured a sequence of ten light touches while treating the psychological and physical suffering of refugees and other displaced persons at Red Cross refugee camps. This sequence of touches emerged from the combined biomedical knowledge and feedback from patients about the points of tactile contact that appeared to balance their sympathetic and parasympathetic responses and foster autonomic regulation [18–20].

After being treated with this technique—then named Calatonia—patients spontaneously shared their feelings, thoughts, worries, memories and traumatic experiences with a scale of trust and openness that had not happened before the treatment—a clear validation of its usefulness in psychotherapy [19,20]. Following a few applications of Calatonia, patients showed decreased symptoms of traumatic stress (shell shock), anxiety, depression, pain and other ailments that afflicted most war survivors at the time. Patients' improvements manifested in terms of increased morale, acceptance, well-being, hope, will to live, overall motivation and resilience [21], defined as the ability to adequately adapt and respond to homeostatic disturbances [23]. These touches seemed to promote global changes, which led Sándor [19,20] to describe Calatonia as a technique for psychophysical regulation and reorganization.

After the end of the war, Sándor worked for two years in the psychiatric wards of German hospitals, using Calatonia to successfully treat depression, suicide ideation, post-traumatic stress disorder, anxiety, catatonic states and other mental disorders [18,21,24,25]. Later, in São Paulo, Brazil [26], he expanded the repertoire of techniques to include many other "light touch" sequences, grouped under the name subtle touch (ST) [27–30]. Another ST technique, Fractional Decompression, works by gradually releasing pressure from a touch applied to hairy skin on the back, arms or legs [27]. Fractional decompression is thought to primarily target the affective-affiliative touch system associated with hairy non-glabrous skin [31]. Calatonia continues to be the most widely used ST technique. At times, subtle touch and Calatonia are used interchangeably to denote the whole gamut of techniques developed by Sándor and subsequently expanded by other clinical psychologists [32]. Sándor's subtle touch method has produced numerous qualitative studies published over the past four decades (reviewed in [32]), as well as quantitative research in the past fifteen years [32–34].

Sándor had previously hypothesized [19,20] that the experience of physiological regulation, mood stabilization, inflow of adaptive cognition and neuromuscular relaxation induced by Calatonia were linked to the associative activation of somatosensory representations in the frontotemporal cortex, the engagement of peripheral proprioceptive nerve fibers, particularly in the skin and cortical mediation by the ascending reticular activating system. Furthermore, he associated its effects with psycho-affective elements mobilized by the configuration of dyadic regulation through the touch therapy protocol.

Given the barriers to many forms of social and affiliative touch in social interactions, particularly in the context of psychotherapy, it can be useful to compare the touch sequence employed in Calatonia with other common forms of "pleasant" touch found in everyday encounters. In particular, a recently discovered category of slow-response unmyelinated nerve fiber, C-tactile afferents, have been implicated in many forms of innocuous touch [35], as well as touch in social contexts [31]. C-tactile afferent projections terminate in the ventral medial nucleus of the thalamus and posterior insular cortex [36,37], associated with the contextual and affective components of touch [38]. While the primary areas of contact in Calatonia are to the glabrous skin areas of the feet or hands (see below), the sequence employed also includes contact to hairy skin containing C-tactile afferent connections. Several other ST techniques similarly activate CT connections by contact with the arms, calves, back and head. As such, Calatonia may act on both a common affiliative system for social touch as well as on more discriminative neural pathways in glabrous areas of the hands and feet. However, the perceptual characteristics of touch in these regions are specifically modulated in Calatonia to induce large-scale novelty-related activation in addition to more familiar responses to CT touch primarily in thalamic and insular regions.

#### **3. The Calatonia Technique**

Touch therapies differ in their goals. Some focus on achieving body awareness, structural readjustment, functional improvement, emotional-affective regulation, release of pent up energy, healing of trauma, among other issues [2]. Calatonia has an open-ended goal, in contrast to more narrowly defined ST techniques: one geared toward spontaneous adaptive adjustments in one's idiosyncratic psychophysical needs and imbalances, prompted by the sequence of touches. As an example, for some, stress will manifest as insomnia or excessive worrying; for others, it will manifest as addiction, overeating or overreacting emotionally in relationships. Each maladaptive style will lead to different responses to Calatonia's applications, despite being caused by the same underlying problem—stress.

A description of this technique (Figures 1–5) may be useful to integrate the elements that will be discussed in this article. Calatonia is performed in silence (unless the patient feels discomfort or the need to speak) after the patient has been briefed on the steps of the protocol [19,20]. The patient removes his or her shoes and socks and lies on a massage table in a supine position, with his or her eyes closed, fully dressed (Figure 1). Preferably, the therapist applies the technique on the lower limbs, or, alternatively, on the hands and forearms. Excluding the tenth point (the head), the first nine points of tactile contact are bilateral (the same tactile stimulus is simultaneously held on each side of the body). The seven first touches (Figure 2) are extremely light (as if the therapist were holding a "soap bubble") and sustained in place for one to three minutes (preferably three minutes on the few initial applications). The eighth, ninth and tenth tactile contacts (respectively Figures 3–5) are supported and held in place for one to three minutes on the heels, calves and head (in that order). At the end, patients are coached back to awareness of the environment and themselves and instructed to sit up and walk

back to their seat, at which point they are invited to share their observations or impressions, if any, which may have manifested during or after the application of the technique.

**Figure 1.** Resting state (task-free) supine position.

**Figure 2.** Sequential order of bilateral points of tactile contact.

**Figure 3.** Ankle support, eighth bilateral touch.

**Figure 4.** Calf support, ninth bilateral touch.

**Figure 5.** Head support, tenth and last touch.

#### **4. Touch to the Feet or Hands**

While it appears unusual to propose tactile contact with the patient's feet or hands in psychotherapy, there is strong empirical support for doing so. Contact is made to these specific sites, as nowhere else on the body is there found a similar configuration of neurobiological and physiological variables, including the distinctive dermo-mechanical features and receptors found on the glabrous skin of the feet and hands [35–44]. This combination of features frequently results in the activation of an orienting response by eliciting a pattern of neural activation associated with novelty, of either a neutral or pleasant nature, through both conscious and unconscious perceptual pathways.

The glabrous (non-hairy) skin of the hands and feet is indirectly connected to several perceptual subsystems involved in the detection of vibration, temperature changes and differences in texture and pressure, as well as somatosensory and proprioceptive responses [43,44]. The areas targeted in Calatonia contain the most numerous populations of skin receptors, collectively known as the discriminative–spatial system [41–46], distinct from receptors of the affective–affiliative system found primarily in non-glabrous skin. Glabrous skin is a dedicated site of very precise tactile perception geared toward the exploration of and adaptation to novel stimuli, as well as the evaluation and appraisal of a spectrum of touch pleasantness and roughness mediated by the somatosensory cortex [47–49].

For example, to read and attribute meaning to the raised dots of the Braille system requires language, touch and spatial coding to be transformed into semantic, lexical and haptic processing. This in turn engages highly associative areas of the brain to produce concrete and abstract thinking, symbols and ultimately communication [50].

Hands are also especially involved in the formation of procedural memory, which makes them potential "roads" for the emotional retrieval of such implicit memories—in particular, early childhood memories linked to independence, mastery, self-care, reaching out and so forth. These memories may be accompanied by emotional and relational contexts of frustration, impatience, among many other emotions and behavioral patterns [51,52]. Similarly, the locomotor system is in many ways involved in early childhood developmental milestones (standing, walking, running, bike riding, etc.).

The feet bear the total gravitational force imposed on the body and function as an integrated system with the cerebellum and vestibular system to control posture, coordination, equilibrium and the generation of locomotor rhythm; the proprioceptive control of posture is chiefly initiated in the feet [53]. Drew, Prentice and Schepens [54] state that these essential mechanisms of control of postural muscle tone and locomotion "are located in the brainstem and spinal cord, in which a range of locomotor behaviors are achieved by the projections from the forebrain structures (cerebral cortex, basal ganglia and limbic-hypothalamic systems) and cerebellum to the brainstem-spinal cord". As such, despite the role of these mechanisms in voluntary movement and locomotion, a significant portion of the adjustment of balance is made involuntarily, based on information that does not require conscious attention to be processed. When the feet are in an unloaded position (i.e., lying down), there is no background discharge activity in any of the cutaneous receptors unless there is intentionally applied stimulation [49,53–55]. This may be indicative of how Calatonia on the feet facilitates the reorganization of the individual's global posture and muscle tension.

#### **5. Novel Stimuli in Psychotherapy**

There are several common elements to Sándor's many ST techniques, yet two elements can be immediately perceived as fundamental: (a) their non-invasiveness, by respecting an individual's boundaries and even their resistance to therapy, while gently supporting the individual towards gaining resilience toward the integration of crucial personal issues; (b) their novelty, through the application of atypical sensory stimuli—not merely an oddball protocol for the sake of novelty itself, but a meaningful stimulus that engages global responses and multidimensional aspects of a person's life.

The combination of these two aspects, non-invasiveness and novelty, is hypothesized as generating an orienting reflex or an orienting response [7], also known as the 'what is it response?' or the exploratory response. The OR is an involuntary response of an organism to a stimulus that is 'out of the ordinary' but not alarming or menacing. ORs are an adaptive feature of cognition present since infancy [56] that play a major role in many aspects of motivation, emotion and attention [57–62].

Sándor purposefully developed different methods for creating ORs by using an unusually light and static form of touch or other forms of stimulation in his techniques. These included passive movements that were mechanically impossible for the patient to perform voluntarily (e.g., rotating the patient's finger sideways); atypical but non-threatening sounds directed towards specific parts of the body, small vibrations applied to bone projections and protuberances, such as the spinous processes [27] and many others. His approach was geared toward the enhancement of neural plasticity and the generation of 'dedicated neural circuitries' for experiencing well-being, leading to increased self-confidence and a sense of safety within one's own body [17,18].

#### **6. The Orienting Reflex in Calatonia**

An orienting reflex is triggered when a sensory stimulus is perceived as novel, innocuous or pleasant [58,63]. This may be seen in opposition to defensive reflexes initiated when a sensory stimulus is perceived as painful, aversive and potentially dangerous—or startle reflexes activated in response to abrupt, unexpected or overly intense stimuli. All of these responses, whether defensive/startle or orienting, will activate the executive network for regulation or action if necessary [64,65].

In animals, the OR is a survival reflex that does not burden the organism with a full-blown alert response but entices them to explore the environment. Pavlov [66] saw the OR as the biological basis for the highest form of curiosity, imagination, science and knowledge of the world around us. At the basic end of this spectrum, the OR encourages human curiosity, which drives child development and "involves an indissoluble mixture of cognition and motivation" [67]—a key prerequisite for learning and the formation of top-down predictions in perceptual processing. To achieve this level of exploration, the OR tunes the organism toward a specific stimulus by enhancing perceptual awareness [68–70]. In contrast, the defensive and startle reflexes limit the impact of the stimulus on the organism by functionally raising perceptual thresholds [68–70].

The OR halts all non-essential brain activity to allow the individual to orientate their primary senses towards the source of stimulation, focusing on possible means of interaction with the stimulus through the activation of the autonomic nervous system (ANS) [68,69]. It produces an unintentional shift of attention that interrupts the ordinary flow of awareness and leads us to attend to the novelty of a stimulus for the appraisal of its meaning and/or significance. This phase of the reflex has been classified by researchers as an "information-gathering", "analyzing", "modelling" or simply "sensory" phase [7]. One of the key physiological markers of an OR is the initial deceleration in the heartbeat, which is a sign of enhanced perceptual processing and is mediated by the parasympathetic branch of the ANS [71,72]. This initial slowdown allows the organism to more easily detect the potential significance of stimulus features to estimate 'uncertainty'. An OR is triggered if uncertainty is detected concerning the biological value or perceptual features of the stimulus [73].

As mentioned above, Calatonia triggers an OR due to its non-invasive nature (experienced as either of a neutral or pleasant affect), extended duration of passive tactile stimuli and the novelty of its touch. Sustained attention to a body location results in the enhanced processing of the tactile stimuli presented at that location compared to other unattended locations [74]. A light touch is often a strange sensory perception, particularly on the feet, accustomed to supporting the individual's body weight and rough contact with stimuli on the ground. The palms of the hands and the soles of the feet are instruments of self-agency [75–77] and rarely the object of passive interaction. Receiving a passive gentle touch in these areas may easily throw the organism into a state of perceptive, emotional and cognitive surprise yet still feel innocuous within a safe context. The neutral affect associated with the surprise response works to reset attentional processes [78]—with attention defined in cognitive terms as the ability to selectively attend to some stimuli while ignoring others [79].

Individuals have different forms of appraisal and emotional responses to touch based on their personal history and cultural biases [80]. However, it is highly likely that most people will experience an OR in response to an unexpectedly static, sustained and light touch that conveys neither personal meaning nor affection. Such a response is dependent on the therapist adopting an appropriately responsive but neutral affective state during the application of Calatonia.

#### **7. Brain Areas Associated with the Orienting Reflex**

Sándor's hypothesis concerning reticular formation mediation in the large-scale neural response activated during Calatonia has been borne out by subsequent research based on brain imaging (fMRI-PET, EEG, NIRS). Here, we articulate an updated argument in the light of this evidence for the therapeutic benefit of engaging the orienting reflex through novel stimulation and the cognitive re-evaluation this may engender.

The functional circuitry of the reticular formation (RF), known as the reticular activating system (RAS), has long been recognized as a central component within a multitude of subcortical and cortical neural circuitry [81]. The RAS has been implicated in cognitive functions such as the orienting reflex to novel stimuli [7], attention, sleep, homeostatic regulation, as well as the transmission and modulation of pain, alongside other brain structures [82–85]. Essentially, the RF plays a major role in the modulation of attention to the extremely light sensory stimuli of Calatonia, which takes the organism by surprise and induces an orienting reflex, with extensive engagement of the RF and related networks in this process.

The OR triggers an extensive search for possible associations to previous contexts and meanings within the individual's history, beginning with short-term memories and moving on to those that may be embedded in implicit memory. With the aim of associating the new stimulus to previous memory representations, the brain quickly 'explores' the memory via the hippocampus and sensory association areas in the central-parietal cortex. In this process, a set of neocortical limbic interactions occur to resolve the significance of the stimulus [73,86,87].

Uddin and colleagues [88] note that the insula is commonly involved in detection of novel stimuli across sensory modalities. The insula, dorsal anterior cingulate (dACC) and other subcortical structures form part of the 'salience network' (SN), which is activated in response to out-of-the-ordinary or "oddball" stimuli. The function of the SN is to identify "the most homeostatically relevant among multiple competing internal and external stimuli" [88]. Most importantly, for the higher-order cognitive processes produced with Calatonia [17] where more complex stimuli require greater cognitive processing, the dorsal anterior insula will be recruited. Insular activation primarily functions "to integrate external sensory information with internal emotional and bodily state signals to coordinate brain network dynamics and to initiate switches between the default mode network (DMN) and central executive network (CEN)" [88].

If no associations are formed between the tactile stimuli in Calatonia and previous experiences recorded as memories, then the significance of the event will be assessed primarily by the amygdala. The amygdala plays an important role in encoding, storing and retrieving emotionally charged events and controlling the hormonal cascade triggered by defensive responses [89]. Amygdalar structures are activated by both emotionally salient and novel stimuli. This activation may occur regardless of whether the stimuli are emotionally valent and/or pleasant or unpleasant. In addition, the salience of the emotion is central to determining whether either a fight-or-flight or other motivational or appetitive response is triggered [90–94].

#### **8. The Appraisal of New Stimuli**

A stimulus or event is significant if it is helpful in satisfying a need, reaching a goal, or sustaining an internal value. The opposite holds true for negative significance, whereupon the stimulus is unhelpful for achieving any of the aforementioned goals. In ANS terminology, significance can be equated to homeostasis, whereby a stimulus or event positively influences homeostatic mechanisms, leading to that stimulus being attributed a high level of significance [92,95,96].

Scherer [97] asserts that the appraisal of significance is defined by one's needs, goals, values and general wellbeing, which leads to a cascade of motivation-related changes. In particular, emotionally-laden appraisals of pleasantness and well-being (or the opposite valence) lead to somatovisceral changes via the ANS and changes in motor facial expression, as well as voice and bodily tensions, conveyed through the somatic nervous system [97–99]. Over the course of Calatonia, adjustments in body tension are frequently reported in the form of twitching, sudden jerks, spontaneous jolts felt in the diaphragm, lung expansion (a respiratory reflex) and fluttering eyelids, while at the end of Calatonia, the facial muscles are often notably relaxed [17–20,32].

In the presence of a pleasant OR, several somatic responses may occur, such as a deceleration in heart rate, salivation, pupillary responses, pharyngeal expansion and a relaxation of the tract walls ('wide voice') [97]. These many somatic reactions are conducive to a trophotropic response (a relaxation response for resting and replenishing energy) and increased stability. This may in turn lead to a decrease in respiration rate, a slight decrease in heart rate, sphincter relaxation, a decrease in general muscle tone, relaxation in facial muscle tone and overall relaxation of the vocal apparatus ('relaxed voice'), comfort and resting posture. If this relaxation response leads to changes in one's motivational state and plans for action, an ergotropic shift (the activation response and usage of energy) may occur as a result of experiencing well-being [97]—in this way, one feels motivated to become proactive. This fact may explain why Calatonia is a method of psychophysiological regulation and not exclusively a relaxation technique because, ultimately, it takes the organism where it needs to go. Whether positively activated (ergotropic) or relaxed (trophotropic), Calatonia fosters the organism's optimal state [17–20].

#### **9. ORs in Clinical Practice**

The emotional significance of a stimulus, defined by its level of pleasantness and importance, can frequently affect OR intensity when focusing one's attention on a stimulus [7,100,101]. One example of the use of OR in clinical practice is a simple technique designed by Sándor: a sequence of three slow and sustained 'insufflation (blowing) on and above the seventh cervical vertebra (C4–C7)'. The therapist applies the technique while the patient remains in a sitting or standing position. This somatosensory contact at C4–C7 affects the entirety of the brachial plexus, which innervates the arm muscles, thus affecting a large area of the brain, as well as cervical vagus branching [102], causing an immediate and involuntary shift in attention with a pleasant affective tone. This is an effective way of peacefully redirecting disruptive behavior in children in less than a couple of minutes and one that has been applied on many previous occasions to institutionalized children in foster care when they felt themselves unable to engage in emotional regulation [17]. For these children, the novelty of tactile stimulation diverted their attention from an overwhelming state of emotional reaction, offering them a state of adaptive relief directly proportional to this initial state.

The process of neocortical-limbic connectivity and integration linked to an OR is not a standard occurrence in children and adults with histories of abuse and/or PTSD [103–105]. These patients frequently show symptoms of excessive limbic system activity (particularly an abnormally overactive amygdala) with less activity in the neocortex, which causes them to react impulsively to the minor triggers of daily life [106]. However, in several cases of PTSD, the opposite pattern of activation is observed, with over-activation of the prefrontal systems and over-inhibition of the amygdala and insula, leading these patients to experience flat affective states and anhedonia.

When the amygdala is chronically activated in response to trauma, stress and/or overwhelming fear, the individual's emotional response to sensory inputs becomes compromised and often requires re-setting [68,69,83]. The effects of exposure to traumatic events on brain structure and function are extensive and very specific brain regions have been implicated in trauma and PTSD [107–111]. Significant research has been dedicated towards investigating a variety of psychological treatments to address specific types of such neural dysregulation [3,112–117].

In the treatment of trauma, by prompting a neutral/pleasant OR, Calatonia shifts the patient's experience away from defensive states, leading to the re-setting of vigilant states and attentional processes and facilitating the reinstatement of neocortical–limbic interactions.

By enhancing the perception of a stimulus, Calatonia also activates motivational (or appetitive) systems that support survival, adaptation and tending to one's needs and, consequently, attentional processes based on 'interest', 'curiosity' and 'well-being'. This seemingly simple process conceals a complex reorganization of the individual on physical, emotional and cognitive levels—a process of great psychotherapeutic utility [28–30,32–34,112].

In terms of its general application in psychotherapy, the OR has been hypothesized as one of the key drivers for successful clinical outcomes following eye movement desensitization and reprocessing (EMDR) [117]. This technique aims to gradually expose the patient to the stimuli underlying PTSD and other trauma disorders, similar to other forms of cognitive-behavioral therapy. Hypothetically, EMDR pairs the recall of a traumatic event with a supposedly emotionally-neutral motor stimulus—eye movements. EMDR appears to show similar improvements in post-therapy

outcomes to other cognitive-behavioral therapies particularly for the treatment of PTSD, however the functional mechanisms underlying its action remain unclear [117–120].

To many patients who suffer from PTSD, the idea of re-experiencing the trauma as proposed in EMDR is unbearable. Unlike EMDR, Calatonia does not target a specific event or memory. Consequently, there is no resetting of new homeostatic values based on previous traumatic experiences, thus amplifying the effects of Calatonia beyond specific trauma memories. Instead, there is a decrease in startle and defensive reflexes and a reinforcing of the "benign present", allowing the individual to be spontaneously released into a 'stream of consciousness' state corresponding to the emergence of the default mode network (DMN) of broad frontoparietal activation in the brain [17]. In this context, high-priority psychological issues may emerge spontaneously and rescript themselves in light of this new experience, producing the myriad of idiosyncratic reports that demonstrate the nonlinearity of psychological processes, followed by a sense of well-being [30].

#### **10. Habituation: Does Repeated Calatonia Cease to Generate an OR?**

What happens when Calatonia is repeated on a weekly basis? Does it lose its novel impact and stop triggering an OR response?

First, a description of the technique and the consent given by the patient are always requirements to minimize the possibility of a startle or defensive response by making the technique 'cognitively safe' and, evidently, this technique is offered only once a good therapeutic relationship is formed. However, a description of this technique does not prevent an OR from occurring as the OR is a result of the direct tactile stimulus and frequently resistant to top-down modulation.

In time, the sequence of touches becomes predictable and thus provides a sense of safety to the patient. Most importantly, what happens within one's mind, body and emotions during each Calatonia session may become an element of significance for an OR. The route taken towards eliciting an OR may be the same, but the journey is always different. This approach places emphasis on the significance of the event and its capacity to continue to generate a significant OR response. It is very common for patients who receive regular Calatonia to say, "today was different, I didn't feel the same way I felt last week", "today the touch seemed much lighter", "the left side of my body seemed to be heavier", or similar such observations. These comparisons can be accounted for by Friston's free energy principle [121], in which the brain is constantly trying to predict events to minimize errors. In this hypothesis, bottom-up processes are thought to compare previous events (memories) to current perceptual inputs to estimate the error in deviation between the internal model and novel input, thus recognizing minimal differences in deviation. Any changes in the representation or original "neural model" of an event that triggered an OR will retrigger the OR by establishing a comparison to what was previously experienced [122,123].

#### **11. A Clinical Vignette**

The reorganization of the (appetitive) motivational system prompted by Calatonia can be seen in action in a clinical case presenting a dysfunction of the primary motivational behavior for survival, eating. For three consecutive sessions, a fifteen-year-old female patient suffering from anorexia nervosa reported that she "knew exactly what she was going to eat for dinner". She proceeded to describe to the therapist the meal that came to her mind during the session of Calatonia.

She spontaneously sent pictures of her meals to the therapist shortly following these sessions. These included pictures of her breakfast on the mornings following therapy, revealing nutritious and complete meals. It can be hypothesized that the neurobiological mechanisms set in motion by ORs bypassed her voluntary resistance to homeostatic self-regulation and allostatic behaviors [17], restoring a biological imperative, via "neural circuits in the mammalian brain that prompt specific somatic and autonomic responses associated with motivated behavior" [9].

As the sessions of Calatonia progressed, the sadness and depression she felt surrounding her self-destructive behavior emerged—and her menstrual periods returned, along with these emotions. In her ninth session, she reported a dream in which she "had been kidnapped by a skinny and weak man, from whom she escaped to a shopping mall together with a beautiful girl of the same age who was also his hostage".

The attentional and motivational processes set in motion during Calatonia seemed to have redirected her perception of her physical needs, revealing the pain she inflicted on herself. In the dream, the self-destructive dynamics that required her awareness were depicted by the skinny and weak man (anorexic thought patterns) and the beautiful girl (her idealized version of herself). She also began to go out more often instead of staying at home watching videos of other anorexic girls. This process suggests what Schomaker and Meeter [124] describe as an "attentional response to novelty, possibly mediated by the amygdala, an arousal-like response to deviance, which could be mediated by the noradrenergic system and a slower upregulation of exploration, motivation and learning, mediated by the dopaminergic system", as well as a possible reorganization of thalamic functional connectivity [125,126].

#### **12. Conclusions**

Calatonia and other ST techniques appear to function through the re-calibration of a subset of attentional processes. These include a reduction in the startle response to anxiety- and fear-inducing stimuli and may help to orient the patient towards novel unknown stimuli in a context of adaptation. The redirection of alerting and defensive responses towards motivational and appetitive states through innocuous, pleasant and unusual touch sequences allows the patient to implicitly process past states of trauma. A necessary prerequisite for this technique to be considered a safe psychotherapeutic approach is for the psychotherapist to have adequate training and observe strict adherence to the established protocol of touch and engagement with the patient.

Many studies discuss whether the novelty or significance of an event is the actual trigger of an OR and the consensus is that both novelty and significance are involved in the generation of an orienting response. However, significance was found to be a key factor in sustaining engagement in an OR [7,127], only a relevant/significant novel stimulus will continue to trigger an OR.

In summary, novelty-driven stimulation can support reward processes, drive exploration and other adaptive cognitive processes and enhance perception and sharpen its responses. Most importantly, an OR has a lasting and strong impact on memory and on the attentional system mediated by the amygdala, resulting from neural plasticity and deep changes to the motivational system [124].

#### **13. Final Considerations**

Beyond the impact of orienting reflexes, there are several other neurobiological, neuro-cognitive and neuro affective-emotional elements that influence the results and responses to the complex stimuli proposed in Calatonia, as listed in a previous publication [30] and briefly mentioned below.

Among these elements, dyadic regulation proposes a fine-tuned, non-verbal, inter-brain synchronization, whereby inter-brain synchronization between two individuals is defined as a natural occurrence that impacts interpersonal communication [128–132].

The importance of establishing a conscious pace of communication in therapeutic relationships cannot be emphasized enough [133–135] as several physiological systems follow a preset tempo or rhythm (heartbeat, respiration, thalamo-cortical oscillations) and "rhythms are a prominent signature of brain activity" [136]. The modulation of cortical oscillation via paced somatosensory stimuli may also facilitate integration of the individual's basic notion of selfhood. From early infancy to adulthood, selfhood is built through physical contact and proximal interaction with others via skin-to-skin interactions—before one develops the ability to share mental states in distal face-to-face interactions [137–140].

Other hypotheses about the possible elements involved in the complex mental stimuli and contexts observed in Calatonia include:

*Brain Sci.* **2020**, *10*, 182

The use of (task-free) resting-state functional connectivity to facilitate access to spontaneous and pertinent (to psychotherapy) self-reflective cognitive processes [141,142];


In conclusion, there is significant support for the importance of integrating the orienting reflex in psychotherapy through both physical and non-physical cues. ORs appear to play a mediating role in the improved behavioral outcomes from Calatonia, by initially restoring psychophysical regulation and well-being—and eventually leading to a more positive sense of self. In patients with a history of trauma or attachment issues, this may mean establishing a context of safety within individual boundaries first, through dyadic regulation, before addressing psychological issues that may lead to more feelings of vulnerability [1,167].

**Author Contributions:** Conceptualization, A.R.B.; writing—original draft preparation, A.R.B.; writing—review and editing, W.E.C.; visualization, A.R.B and W.E.C.; supervision, W.E.C.; project administration, A.R.B. and W.E.C.; funding acquisition, N/A. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

## *Article* **Does the Therapist's Sex A**ff**ect the Psychological E**ff**ects of Sports Massage?—A Quasi-Experimental Study**

#### **Bernhard Reichert 1,2**


Received: 18 May 2020; Accepted: 13 June 2020; Published: 16 June 2020

**Abstract: Objectives**: The aim of this study was to determine the influence of the sex of the therapist and of the athlete on the athlete's current emotional state after a sports massage. The assumption was that the effect of a massage on the current mood was independent of the sex of the therapists or athletes. **Background**: Sports massages are an integral part of the support given to athletes during training or competition and are a commonly used method for promoting athletes' physical and mental recovery. Few studies have measured the mental characteristics or even the nonspecific effects of sports massages. Sexual attraction or dislike are among the nonspecific effects of a treatment. **Materials and methods**: One hundred and sixty-eight high-performance male and female amateur athletes received a sports massage from 15 male and female trained therapists. The current emotional state of the athletes was measured before and after intervention using the BSKE-EA17 adjective scale, whose items can be assigned to five categories of the current emotional state. ANOVAs (analysis of covariances) were carried out to calculate the interactions between the sexes. Cohen's d for similar group sizes and similar group variances were determined. **Results**: Neither the sex of the therapist nor the sex of the athlete had any influence on the mental effect of a sports massage. The only exception was when male athletes were treated by female therapists, where an increase in "elevated mood" was observed. Sports massages resulted in an increase in the responses in the categories "elevated mood" (d = 1.1) and "level of activation" (d = 0.3) and a decrease in the responses for "low mood" (d = 0.3), "level of deactivation" (d = 0.6) and "level of excitation" after the massage compared to before the massage (d = 0.9). **Conclusions**: Sports massages appear to increase the positive dimensions of the athletes' current emotional state and reduce the negative dimensions. The self-reported mood changes from before the massage to after the massage were not influenced by other prognostic variables, including wait time, age of the athlete or the duration of the run. The results suggest that the specific effects of sports massages on the mental status are supported. Disregarding the aspect of the therapists' sex, sports officials, trainers and athletes therefore can be more independent in the personnel planning of sports therapists.

**Keywords:** sports massage; current emotional state; mood; therapist's sex; athlete's sex

#### **1. Introduction**

Massage is the manipulation of soft tissue by a trained therapist as a component of a holistic therapeutic intervention [1,2].

Sports massage is defined as a set of massage techniques that enhance athletes' recovery and help treat pathological conditions [3]. Depending on the time a sports massage is performed in relation

to exercise, the terms "pre-event", "pre-exercise", "inter-event", "post-event", "post-exercise" and "training" massage are used [4].

The specific forms of a massage are broken down further into the overall duration, intensity and selection of techniques used. In most studies, technical elements of Swedish, classic or Western massage are used in sports massages: strokes, kneading, petrissage, frictions and vibrations. In the literature, the term "recovery massage" is used to describe a massage delivered after intense exercise [4]. The best outcomes of massages for muscular recovery were achieved when the treatment was applied within the first two hours of exercise [5].

The particular significance of a recovery massage is especially evident in athletes performing repeated exertions within a short period. In athletes competing in multidiscipline events, as well as those participating in various disciplines, top performances must be delivered multiple times on the same day or several days in a row. For this reason, a quick recovery is an important factor for ensuring top performances for the duration of the competition [1].

A sports massage plays a valuable role in the health system [6]. It is an integral component of support for athletes during training or competition. Athletes, those supporting them and individuals associated with sports worldwide recognize sports massages as an effective means of boosting recovery and reducing pain and discomfort [3]. Sports massages are often offered to support athletes at large-scale events. Galloway and Watt reported in 2004 that physical therapists devoted 24.0% to 52.2% of the time they spent supporting athletes at large national and international sports events to massages [7].

Scientific aspects of sports massages are of interest to athletes, their trainers and sports physicians [8]. Schilz and Leach (2020) surveyed 100 endurance athletes about their knowledge regarding the effects of sports massage therapy. Of the athletes surveyed, 93% felt that sports massage therapy could be seen as a form of injury prevention, 92% felt that it was a valuable method of resolving a wide variety of muscular problems and 90% indicated that they felt that sports massage therapy improved their quality of life.

Very few studies have addressed sports massages following endurance performances [9] and very few address psychological factors [9–11]. The latest relevant review by Poppendieck (2016) described the benefits of post-exercise sports massages in detail. These positive effects were observed for strength and endurance exercises, as well as for high-intensity mixed exercises. Since the physiological mechanisms of the performance recovery were unclear for the authors, they described the mental effects as more significant [12].

In general, the study objects, outcomes and results of the different (physiological, in particular) effects of sports massages vary widely, and unequivocal statements are rare [8,13]. Very few studies have measured mental characteristics.

Each therapeutic intervention can be assumed to have an effect component that is directly dependent on the intervention (specific effect) and an effect component that is independent of the intervention (nonspecific effect) [14]. These nonspecific effects include the presence, voice and sex of the therapist; trust; therapeutic alliance [15] and space-related conditions. In order to better classify the value of massage therapy (specific effects), the influences of nonspecific effects on, e.g., mental outcomes should be investigated. No studies are available in the well-known medical databases that investigate the nonspecific effects of a massage with respect to psychological effects [14].

Experience has shown that athletes rarely perceive physical contact occurring during manually applied massages to be unpleasant or anticipate that it will be unpleasant [16]. During the application, one could assume that massage therapy may result in an improved mental status, depending on the sex of the therapist or the athlete, through some kind of sexual stimulation. Culturally formed attitudes may prohibit heterosexual contact between the therapist and the athlete. Negative experiences with heterosexual contact in the personal history of athletes could also lead to preferring a certain sex of the therapist. Therefore, one question that may arise is whether the sex of the therapist or the athlete can

contribute to a change in the perception and, thus, contribute to the athlete's assessment of his or her current emotional state. This possible influence has not been investigated in previous studies to date.

The aim of this study was therefore to determine the influence of the sex of the therapist and of the athlete on the athlete's current mental state after a sports massage. The assumption is that the effects of a massage on the current mood is independent of the sex of therapists or athletes. The following research questions led through the study:


#### **2. Materials and Methods**

#### *2.1. Participants and Setting*

The participants in this quasi-experimental study design were recruited on the day prior to the 19th Stuttgart half-marathon in the city of Stuttgart, Germany. Some 19,000 athletes participated in the race. All of the study participants were ambitious amateur athletes. They were personally approached and encouraged to participate in the study. Recruiting took place in the Hanns-Martin-Schleyer-Halle, a large sports and entertainment venue in Stuttgart. The participants were informed in writing, gave their consent after having read the information and completed a questionnaire to clarify the inclusion/exclusion criteria.

Included in the study were participants in the half-marathon who were between the ages of 18 and 70 and who did not meet any of the exclusion criteria.

Any health condition that negatively impacted the athletes' overall performance capacity—in particular, their running performance, their recovery and the perception of tactile stimuli—were defined as exclusion criteria. They included the following medical criteria:


The following variables were recorded as additional prognostic factors:


#### 2.1.1. Sample size Calculation

The maximum number of participants was determined based on the number of therapists delivering massages simultaneously (15) and the average duration of the massage therapy. All therapists gave massages continuously and treated as long as there was demand from athletes. All included test persons who visited the massage area were treated.

#### 2.1.2. Assignment of Participants and Blinding

Whenever a massage table freed up, a new athlete was assigned to it, regardless of the sex of either the athlete or the therapist. This means that the male and female athletes were assigned to the male and female therapists in a random fashion, albeit not in the conventional sense. Both male and female athletes participating in the study and male and female athletes not participating in the study underwent massage in the same setting. The participants knew that they were part of a study. The subjects were instructed not to tell the therapists that they were participating in the study, so the therapists were unable to identify these athletes as study participants. The athletes were assigned an ID number, so that the individuals evaluating the questionnaires and those analyzing the data were blinded.

#### *2.2. Study Procedure and Intervention*

The participants were requested to come to the massage area on the day of the half-marathon as soon as possible after crossing the finish line. Immediately after they had checked in and before the massage, they filled out a sociodemographic questionnaire and completed a questionnaire about their current emotional state. Immediately after the massage, they completed a second questionnaire about their current emotional state. In terms of the mental outcome variables, there were no differences between the pre-massage and post-massage questionnaires. The participants completed the questionnaires in a separate waiting area within the massage area.

The massages were delivered near the finish area of the half-marathon in a separate area in which 15 massage tables were set up next to each other without any partitions. Participants and athletes not participating in the study were treated identically and were assigned to a free massage table.

The massage therapists (8 male and 7 female) were students enrolled in the physical therapy school in Fellbach, Germany and were trained for several hours to perform the sports massage standardized in duration, techniques, sequence and intensity. The massage length was set at 15 to 20 min. The massage entailed the treatment of two legs only with the techniques used in classic massage therapy: strokes, kneading, petrissage and frictions, with the balls of the hands on the front and back of the legs. This corresponds to the way a sports massage is performed on endurance athletes [16] and the way sports massages were conducted in previous studies by the author [17]. A neutral commercially available massage oil without any additives was used for the massage. All of the sports massages took place on the same day between approximately 11:00 a.m. and 4:00 p.m.

#### *2.3. Measurement Instruments*

In addition to a sociodemographic questionnaire with additional prognostic variables, a questionnaire for describing the athlete's current mental state was used. The latter questionnaire comprised a short form of the adjective list compiled by Janke, Erdmann and Hüppe (BSKE-EA 17), which was used in various previous studies [18]. This 17-item scale was suitable for recording the respondents' current emotional states and any short-term changes. The items were assigned to different categories:


Mood in psychology is a form of pleasant or unpleasant feeling that forms the background of human experiences. Mood depends on the (biological) overall constitution of the individual and the individual's current emotional state [19].

Janke and Debus described some of these categories in their manual [20] as follows:

Activation: "State-of-mind feature characterized by pleasure-oriented activity that is primarily performance-oriented but also environmentally oriented [...] and encompasses holistically somatic and psychological aspects of activity." A high rating for activation describes a state of the highest possible performance efficiency and wellbeing.

Deactivation: "State-of-mind feature characterized by reduced activity with respect to performance and the environment (relation to introversion!). This reduced activity is closely connected to the feeling of overall impaired willingness and ability to perform in the sense that the individual feels a lack of ability and lack of willingness to do anything."

Excitement: "State-of-mind feature characterized by motor restlessness and tension characterized by lack of desire and emotional disequilibrium (emotional lability), combined with performance inefficiency."

Each description of the current emotional state (item) could be evaluated using a Likert scale in seven gradations. These items were coded between 0 = "not at all" and 6 = "very strong". The participants used this instrument to evaluate themselves and indicate to what extent certain feeling states corresponded to their current emotional states. Each scale is marked by a noun and two exemplary adjectives (see example in Figure 1).


**Figure 1.** Example of an item from the BSKE-EA 17 scale with gradation and coding.

This yields the following point ranges for each category: elevated mood (0 to 18 points), low mood (0 to 30 points), activation (0 to 12 points), deactivation (0 to 12 points) and excitement (0 to 24 points). Totaling the scores of these scales would not be expedient, which is why the items were evaluated by category.

#### *2.4. Objectives and Outcomes*

The primary outcome of this study was to describe the influence of the therapist's sex and of the participant's sex on the psychological effects of a sports massage. It was assumed that neither the sex of the therapist nor that of the athlete would have an effect.

The secondary research question was as follows: What general effect does a sports massage have on an athlete's current state of mind? Do any other prognostic factors (wait time until the massage, age of the athlete or duration of the race) have an influence?

A positive influence on the part of the sports massage on the athlete's current state of mind is considered to be an increase in the responses in the categories "elevated mood" and "activation" and a decrease in the responses for "low mood", "deactivation" and "excitement".

#### *2.5. Statistical Methods*

The data were recorded in MS Excel [21] and prepared for analysis in IBM SPSS 19.0 [22]. A questionnaire was excluded if more than one item of the outcome variables was not filled out. All other missing values were replaced by mean values. Calculating a total score for the multidimensional emotional state questionnaire (BSKE\_EA 17) would not be expedient, which is why the items were

evaluated by category. The Kolmogorov-Smirnov test was used to test the metric variables for normal distribution.

*T*-tests for dependent samples were calculated to statistically test the before-and-after differences. The differences in effects between men and women were calculated using the *t*-test for independent samples. To analyze the effects of the sex of the therapist and the effects of the sex of the athlete on the change in the five scales of T1 (pre-massage) to T2 (post-massage), the effect size for mean differences (Cohens d) between two groups (before and after the sports massage) was calculated with similar group sizes and similar group variances. The interpretation of the effect size was based on [23]: low effect size = 0.1 to 0.2, medium effect size = 0.3 to 0.5 and large effect size >0.5.

Mixed ANOVAs were conducted to evaluate the effects of the therapist's sex and the athlete's sex on the changes in the five dependent categories (scales). Furthermore, ANOVAs (analysis of covariances) were carried out. In this context, the following hypotheses were tested:


To study the influence of the interval-scaled variables "wait time", "running performance" (in minutes) and "age" on the change from T1 to T2, multiple regression analyses were performed with the difference values of T2 and T1 as dependent variables. This thus allowed us to investigate whether, for example, shorter wait times were associated with higher difference values (= stronger changes from before to after the massages).

#### **3. Results**

#### *3.1. Deviations from the Protocol*

No motivated participants were excluded for health-related reasons before inclusion in the study. No participants discontinued their participation in the study, and no adverse effects of the massages were observed.

#### *3.2. Participants' Characteristics*

In all, 200 athletes were recruited—of whom, 185 athletes were included in the study and underwent a sports massage as planned. Seventeen questionnaires were excluded from evaluation owing to missing responses. The responses of 127 male athletes and 41 female athletes were evaluated. Table 1 shows the athletes' characteristics. They were, on average, 37 years old, approx. 178 cm tall and had a BMI of approx. 23. They had trained for an average of 32 km a week in the previous three months and achieved an average race time of 1:50:55 (h:mm:ss) for the half-marathon distance on the race day. The participants estimated the optimum time taken for a sports massage after a half-marathon at an average of 21 min and estimated the perceived duration of the massage they underwent at 12 min. They waited six minutes on average from the time they entered the massage area to the onset of the sports massage (see Table 1). Seventy-two point two percent reported that the wait time prior to the onset of the sports massage did not negatively influence their current emotional state. Nine athletes (5.7%) took medication prior to the competition that could have an influence on their recovery and current state (e.g., aspirin or diclofenac). The participants received 80 massages by male therapists and 88 massages by female therapists.


**Table 1.** Participant characteristics. MV = mean value, Med = median, SD = standard deviation, Min = minimum, Max = maximum and BMI = body mass index.

#### *3.3. Results of the Outcome Variables*

Table 2 shows the descriptive analysis for the outcome variables or the before-after comparisons differentiated by group. Sports massages resulted in an increase in the responses in the categories "elevated mood" (d = 1.1) and "activation" (d = 0.3) and a decrease in the responses for "low mood" (d = 0.4), "deactivation" (d = 0.6) and "excitation" after the massage compared to before the massage (d = 0.9). Testing the differences in the results of women and men before and after applications with the two-tailed *t*-test for independent samples revealed a *p*-value <0.05 only for the category "excitement" after the treatment. Table 3 presents the results of the analytical statistics for the outcome variables for the before-after comparisons, differentiated by group.

**Table 2.** Descriptive data for the outcome variables. Mean value (standard deviation) and Diff = difference.


**Table 3.** Analytical statistics for the outcome variables; d = Cohen's d and *p* = *P*-value.


ANOVAs were conducted to evaluate the effects of the therapist's sex and the athlete's sex on the changes in the five dependent categories (scales) between T1 and T2 (Table 4). The resulting design was a 2 (therapist's sex: male vs. female) × 2 (athlete's sex: male vs. female) × 2 (time: T1 vs. T2) mixed factorial, with time as a repeated measures factor.


**Table 4.** Results of the mixed ANOVA.

Time: main effect of time, sex A: effect of sex of the athlete, sex T: effect of sex of the therapist, time x sex T: two-way interaction of time and sex of the therapist, sex A x sex T: two-way interaction of sex of the therapist and sex of the athlete and time x sex A x sex T: three-way interaction of time, sex of the therapist and sex of the athlete. *F*: test of equality of variances, ηp2: Partial Eta Squared.

Some comments on some dependent categories:

• Activation

Of all the other effects, only the main effect of sex of the athlete was significant, *F*(1.163) = 4.4, *p* = 0.04 and η<sup>p</sup> <sup>2</sup> = 0.03, indicating that males reported overall higher levels of "activation" than females.

• Deactivation

Paired post-hoc (LSD) comparisons showed that the decrease in "deactivation" was significant for almost all combinations of the sex of the athletes and sex of the therapists, all *p* < 0.01, but not for female athletes who received a massage from a male therapist (*p* = 0.59).

• Excitement

Paired post-hoc (LSD) comparisons showed that the male and female athletes did not differ in their levels of "excitement" before the massage, *p* = 0.36, but after the massage, male athletes reported significantly higher levels of "excitement" than female athletes, *p* < 0.01, albeit lower than before the massage.

• Effects of wait time, athlete's age and duration of the run To analyze the effects of wait time, age of the athlete and duration of the run (time in minutes), regression analyses were conducted with these variables, as prognostic variables and difference scores of the questionnaire scales before and after the massage were used as dependent variables. None of the five regression analyses yielded a significant effect of any of the three prognostic variables.

The hypotheses set out above can be answered as follows:

**Hypothesis 1:** *In general, the current mood changed from T1 to T2 (main e*ff*ect of time). This hypothesis can be accepted. The low mood decreased significantly from the time before to the time after the massage, regardless of the sex of the therapist or athlete. The feeling of activation increased significantly from the time before to the time after the massage and was greater in men than in women, regardless of the sex of the therapist or athlete.*

*In summary, almost all athletes showed a significant decrease in the feeling of deactivation from the time before to the time after the massage, with the exception of the group of female athletes who were massaged by male therapists. In this group, the feeling of deactivation after the massage was no di*ff*erent. The level of arousal decreased significantly as a result of the sports massage, although male athletes reported significantly higher "arousal levels" than female athletes, although lower than before the massage.*

**Hypothesis 2:** *The sex of the therapist had a (main) e*ff*ect on changes in the current mood. This hypothesis must generally be rejected.*

**Hypothesis 3:** *The change in the current mood depended on the sex of the athlete ("interaction e*ff*ect"). This hypothesis must generally be rejected. The only relevant di*ff*erence found in the study regarding the influence of the sex of the therapist or the athlete was that both before and after the massage, male athletes reported significantly better moods than female athletes when the male athletes received a massage from a female therapist. All other interactions between the sex of the therapist and the sex of the athlete were not significant.*

#### **4. Discussion**

A total of 185 recruited athletes in the study—of whom, the data of 168 ambitious amateur athletes were evaluated. Fifteen trained students performed the post-exercise massages after a half-marathon. The participant characteristics data corresponded to a survey conducted in 2011 that recorded the data at the same location as the same event and with the same intervention [17].

The aim of this research was to show whether the sex of the therapist or the athlete had an influence on the mental effects of a sports massage and whether the mental state improved with the treatment. In summary, the athletes reported a significantly higher positive and decreased negative mental state after the massage than prior to the massage, and this effect was, in general, identical regardless of the sex of either the therapist or the athlete. The only exception was when male athletes were treated by female therapists, where an increase in "elevated mood" was observed. These results are nearly all congruent with the results of studies addressing the mental recovery of athletes undergoing post-exercise sports massages [9–11,16,17]. Hemmings et al. (2000) employed a pre-/post-design to study the physiological and psychological effects of recovery massages in boxers. They showed that the boxers reported a significantly increased perception of recovery after a massage than after passive resting [11]. In a randomized, controlled design involving 108 half-marathon participants, Reichert, 2011 showed that a sports massage significantly increased the elevated mood and reduced the low mood compared to passive resting [17].

In general, too few studies have been conducted with mental outcomes to attest to a fundamental unequivocal effect of sports massages, regardless of athletic discipline. The present study showed that the influence of sex plays, at most, a negligible role with regards to short-term mental outcomes.

#### **5. Conclusions**

To our knowledge, this was the first study of the nonspecific effects of the sex of therapists and athletes during a massage treatment on their mental status. The study showed that neither the therapist's sex nor the athlete's sex influenced the mental effects of the sports massage. Sports massages appear to increase the positive dimensions of the athletes' current emotional states and reduce the negative dimensions. The self-reported mood changes from before the massages to after the massages were not influenced by other prognostic variables, including the wait time, age of the athlete or the duration of the run. The results suggest supporting the specific effects of sports massages on the mental status. The question of sex is clearly irrelevant to the outcome. Sports officials, trainers and athletes can therefore be more independent in the personnel planning of sports therapists.

In the future, additional studies with a similar study design should be carried out that include control groups and focus on other sports disciplines, as well as on professional athletes. The influence of the therapist's/athlete's sex on the mental outcomes should also be investigated for other types of massage (e.g., classic massage) and treatment settings (e.g., rehabilitation). Furthermore, the other nonspecific effects of treatments on these outcomes must also be examined.

#### **6. Limitations**

Cohen's d was calculated in the study because no comparable data for classifying the effect size was available from previous studies. For the differences between T1 (pre-massage) and T2 (post-sports massage), however, it should be noted that the lack of a control group meant that, principally, no causal interpretation was possible that would allow the difference to be attributed to the massage. However, in a similar study with a randomized controlled design by Reichert (2011), a significant advantage of sports massage vs. passive rest with regards to the current mental state was suggested [17].

**Author Contributions:** Conceptualization, methodology, formal analysis, resources, writing, supervision by the autor. The author have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Acknowledgments:** I would like to thank the students at the VPT Akademie staatl, anerk, Massageschule Fellbach for their hands-on support and the Württembergische Leichtathletik Verband (track and field association) for logistical support with implementing this study.

**Conflicts of Interest:** There are no conflicts of interest. The entire study protocol and all data may be obtained from the author.

#### **References**


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