Vol.2, No.8, 919-926 (2010)
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Openly accessible at
A combination therapy of massage and stretching
increases parasympathetic nervous activity and
improves joint mobility in patients affected by
Laura Bazzichi1*, Marco Dini2, Alessandra Rossi3, Silvia Corbianco2, Elisa Giovannoni2,
Arianna Consensi1, Camillo Giacomelli1, Francesca De Feo1, Francesca Sernissi1, Bruno
Rossi2, Stefano Bombardieri1
1Department of Internal Medicine, Division of Rheumatology, University of Pisa, Pisa, Italy; *Corresponding Author:
2Department of Neuroscience, University of Pisa, Pisa, Italy
3Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa, Pisa, Italy
Received 9 December 2009; revised 1 February 2010; accepted 3 February 2010.
Objective: to investigate how therapeutic mas-
sage, combined with stretching, can really con-
tribute to the treatment of fibromyalgia (FM)
symptoms. Design: Feasibility study. Setting: A
single center. Participants: Twenty women hav-
ing a preexisting diagnosis of FM based on
American College of Rheumatology criteria were
recruited. Intervention: Subjects received a total
of 18 sessions of light massage administered by
a physical therapist twice a week and then per-
formed passive stretching exercises. Main out-
come measures: heart rate (HR) and Heart Rate
variability (HRV), the assessment of joint flexi-
bility through elettrogoniometer, the Fibromyal-
gia Impact Questionnaire (FIQ), the Pittsburgh
Sleep Quality Index (PSQI), and the Borg scale
or Rating of Perceived exertion (RPE). Evalua-
tions were conducted at the screening visit (T0),
immediately at the end of the session of mas-
sage (T1) and after completion of 18 sessions
(T2). Results: HRV showed an improvement in
terms of decreased sympathetic tone and in-
crease of parasympathetic tone at the end of
treatment. Also joint flexibility showed a sig-
nificant improvement at T2 compared with the
screening. FIQ, PSQI, RPE did not change.
Conclusions: the findings highlight the excel-
lent compliance of FM patients to the combined
therapy of massage and stretching, showing an
amelioration of muscle stiffness and an im-
provement of autonomic nervous system with a
decrease of sympathetic tone and an increase
of parasympathetic tone. The questionnaires did
not show any ameliorations, probably because
in these patients the perception of quality of life
is distorted compared with more objective pa-
rameters, such as muscle rigidity, the articular
mobility and the autonomic nervous system.
Keywords: Fibromyalgia; Massage Therapy;
Stretching; Heart Rate Variability; Stiffness
Fibromyalgia syndrome (FM), as defined in the 1990
American College of Rheumatology (ACR) criteria [1],
is a chronic, generalized pain condition with characteris-
tic tender points on physical examination, often accom-
panied by a number of associated symptoms such as
fatigue, sleep disturbance, headache, irritable bowel syn-
drome and mood disorders. The pathophysiology and
aetiology of FM still remain unclear. FM has a high
prevalence in the general population (2-3%) [2] and the
condition is more common amongst women than men,
while representing 30% of rheumatic diseases.
The development of FM often leads to a premature re-
tirement, to limitation of physical activity and waste of
years with an acceptable quality of life, as well as high-
est rate of medical consultations. For such reasons, FM
represents a major socio-economic problem and, there-
fore efforts should be directed towards the identification
of specific diagnostic tests and specific treatment to re-
duce pain and disability.
In the last decade, significant improvements have
been made in the knowledge of the mechanisms in-
L. Bazzichi et al. / HEALTH 2 (2010) 919-926
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volved in the altered pain threshold of FM patients and
new strategies of treatment have been developed or pro-
posed. Different medical treatments are used to treat
fibromyalgia and beside pharmacological compounds
non-pharmacological interventions include psychother-
apy, chiropractic, acupuncture, physical therapy and
massage [3-12].
There are many studies showing the effect of massage
or massage combined with other treatments as progres-
sive muscle relaxation or transcutaneous electrical nerve
stimulator (TENS), in reducing anxiety, depression, cor-
tisol and Corticotropin Releasing Factor-Like Immuno-
reactivity levels, pain perception, and stiffness in pa-
tients affected by fibromyalgia [13,14]. Moreover it has
been showed that massage therapy may increase the
number of sleep hours, decrease the sleep movements,
reduce substance P levels [15] and improves pain and
quality of life related to health (HRQOL) [16].
Other studies confirm only in part these results high-
lighting also that benefits of massage in FM are of short
term [17], or that the obtained results, even if positive,
may not be considered realistic given the low number of
the patients studied [18].
These evidence supporting the use of massage for FM
are controversial; some works suffers from methodo-
logical limitations such as small sample size, inadequate
blinding of assessors and an absence of follow-up as-
sessments, others found no benefits for massage or
short-term benefits.
Given these premises and the great request of massage
therapy by FM patients, we designed a study to better
understand how therapeutic massage can really contrib-
ute to the treatment of FM symptoms and how it can
affect the quality of life of these patients. For this goal a
treatment protocol of rehabilitative massage and stretch-
ing exercises has been developed at the Division of
Neurorehabilitation of the University of Pisa, for the FM
patients recruited by the Division of Rheumatology of
the same University.
In healthy individuals it has been showed that trigger
point massage may have effects on autonomic tone
measured by heart rate variability [19], in particular
heart rate variability (HRV) analysis revealed a signifi-
cant increase in parasympathetic activity, and a decrease
in heart rate, systolic blood pressure and diastolic blood
pressure have been observed. Some authors [20-22] re-
ported that FM patients have hyperactivity of sympa-
thetic tone and hypoactivity of parasympathtetic tone,
which may be related to the symptomatology, physical
and psychological aspects of FM.
In light of these evidence a single-center feasibility
study was carried out to investigate whether a combined
treatment of light massage and stretching, performed by
us, could be helpful in treating fibromyalgia. The main
outcome measures to verify it were HRV recording, joint
flexibility assessing and clinical evaluation.
This protocol treatment allowed us to conduct a study
for the evaluation and standardization of the effective-
ness of massage therapy on such patients.
2.1. Subjects
Twenty women affected by primary FM (aged between
45 and 70 years) were enrolled in the study. Patients,
with diagnosis of at least 1 year, were recruited accord-
ing to the 1990 American College of Rheumatology cri-
teria (ACR criteria) [1].
The concomitant presence of other rheumatic diseases
was an exclusion criteria.
Patients had not taken any medications known to alter
autonomic activity. All patients gave their written con-
sent to participate in the study.
2.2. Experimental Protocol
The treatment program was carried out 2 time a week for
9 weeks, for a total of 18 sessions.
Each session began with the measurement of joint
flexibility and continued with the electrocardiographic
(ECG) recording for the assessment of heart rate (HR)
and heart rate variability (HRV).
After these evaluations we proceeded with the mas-
sage: it was a light massage, (stroking, effleurage), with
the passage of the hands over a large part of the body
with constant pressure. This pressure was evaluated by
strain gauge, according to about 300-400 gr/cm2.
Massage treatment, lasting about 30 minutes, was
performed with the patient in “discharge”, or keeping the
affected joints in flexion-extension, abdo-adduction and
/or intra-extrarotation in order to reduce muscle tension.
It began in front of legs, with touch in cauda-cranial di-
rection, towards the area of the inguinal lymph nodes,
firstly those surface and then deeper. Subsequently mas-
sage continued behind the legs, in the same manner and
time. In this case however, moving from the area of the
calf to the thigh, there were also slight manoeuvres to
empty the popliteus lymph nodes of the cable, keeping
the knee passively flexed slightly.
The last part of massage was devoted to the back and
shoulders, with manoeuvres that do not include the area
of the spine in the direction of the axillary lymph nodes.
Immediately after the massage ECG recording and the
measurement of joint flexibility were repeated. After the
massage session, passive stretching exercises were ad-
ministered to patients, with the aim of assessing the per-
ception of stress of these patients, using the Borg scale
for the perception of effort (Rating of Perceived exertion,
RPE) [23].
Passive stretching is a form of static stretching in
L. Bazzichi et al. / HEALTH 2 (2010) 919-926
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which an external force exerts upon the limb to move it
into the new position [24]. Passive stretching resistance
is normally achieved through the force of gravity on the
limb or on the body weighing down on it. It can also be
achieved with the help of a partner, stretch bands, or
mechanical devices [25,26].
The exercises of passive articular mobilization ado-
pted by us can be represented as reported in Table 1.
3.1. Electrocardiogram Recording
HR and HRV were recorded for assessing the changes in
autonomic nervous system consequent to the treatment.
Heart rate can be defined as the number of heart beats
per minute. This number is an average value, because the
time between one heart beat and the other, is not con-
stant, but changes. The HRV [27-30] is a measure of the
beat-to-beat variations in heart rate. Several scientific
studies in recent years have demonstrated its importance
as a reliable indicator in other areas of application such
as psychology, psychiatry, psychotherapy, holistic medi-
cine, sports medicine and the number of applications is
growing continuously [31-35].
Table 1. Exercises of passive articular mobilization utilized in
the treatment protocol.
Biceps, major
and minor pec-
toralis, anterior
Major and minor
pectoralis, ante-
rior deltoid.
Little Round,
triceps (long
head), Rear
Major and minor
pectoralis, front
teeth, inferior
Square of Lombi,
Internal and Ex-
ternal Oblique
Elevator of the
scapula, Upper
Small and Large
Round, Sotto-
scapolare, Great
Backbone, Cor-
Femoral Quadri-
Femoral biceps,
Sartorio, frail,
The ECG recordings were obtained by connecting the
subjects to a Holter monitor in a supine position during
complete rest. Patients were instructed to breathe nor-
mally, and the respiratory rate was measured. Five min-
ute segments of lead ECG were recorded via telemetry
(Polar Team System), then processed through a software.
Further processing of the data was carried out with
MatLab algorithm.
ECG data were digitized at rate of 250 Hz (width pass,
0.05 to 35 Hz). The ECG signals were converted into an
event series, which required the measurement of R-R
intervals. Premature beats and noise were excluded both
automatically and manually, and only segments with
greater than 90% qualified beats were included in the
analysis. Finally, analysis of HRV, fast-Fourier transform,
PSD (calculated as s/Hz), were performed using signal
processing software as described by others [36]. We di-
vided the power spectrum into 2 major frequency ranges:
low-frequency (LF) band (0.04 to 0.15 Hz) and high-
frequency (HF) band (0.15 to 0.5 Hz).
Because in our sample there were no differences in
respiratory rate between the measurements, any signifi-
cant difference in HF can be mainly attributed to changes
in parasympathetic tone.
ECG recordings were made immediately before and
after each massage session in order to highlight the im-
mediate effects of treatment. Moreover, data obtained at
each session were further compared with each other in
order to assess the effects of massage on the autonomic
nervous system throughout the treatment period.
3.2. Physical Function Assessment.
Patients have been evaluated at screening (T0) and at the
end of treatment (T2).
The Fibromyalgia Impact Questionnaire [37,38] was
administered for the assessment of the quality of life of
patients according to the treatment.
The quality of sleep was determined by using the Pit-
tsburgh Sleep Quality Index (PSQI) [39], an index that
distinguishes a poor quality of sleep from a good sleep
through the measurement of seven different areas.
To assess the subjective perception of effort in relation
to the effort was assessed by means of the Borg scale or
perception of effort (Rating of Perceived exertion, RPE)
To assess the effects of massage on joint flexibility we
have used a parallelogram elettrogoniometer (DEM-Italy)
to measure the range of motion (ROM) on shoulder, hip
and knee. Data are expressed in percentage and in angu-
lar degrees, calculated on the basis of joint flexibility of
healthy subjects [40] with a resolution of 0.5°, related to
each patient and to each articular measurement.
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3.3. Data Analysis
Student’s t tests were used to compare means of quanti-
tative variables, and proportions were compared by chi-
square tests. Because of the skewness of the data, loga-
rithmic transformation was performed on the absolute
units of the spectral components of HRV before the sta-
tistical analysis. A p value < 0.05 was taken as the level of
statistical significance. All statistical analyses were per-
formed using SPSS statistical software, Version 9.
We found a mean decrease of the HR at baseline of
about 7 ± 2 bpm (mean ± DS), and a diversity in patterns
over time in the HR route (Figures 1 and 2).
At the beginning of the protocol FM patients exhibited
significant higher heart rate, with higher LF component
and lower HF component (Table 2), compared to the end
of protocol (Figure 3) (p < 0.05).
Table 3 shows the results of FIQ, RPE, and PSQI. No
significant variation was found between T0 and T2.
Figure 4 shows the range of motion (ROM) calcu-
lated as mean of begin-end treatment, in percentage and
in angular degrees, with a resolution of 0.5°, on each
patient and refereed to each joint measured. We high-
lighted improvements in all joints at the end of treatment,
shoulder showed the highest values.
There are no significant modifications in HRV or joint
flexibility immediately after the massage session (data
not shown).
Our aim was to evaluate the effects of a massage treat-
Figure 1. Tacogram of heart rate data (HR) beat to beat as time
domain before the treatment. (The figure refers to a FM patient).
Table 2. Results of Power Spectrum Analysis in FM patients at
baseline and after treatment.
Absolute power values of
the frequency bands (msec2)
LF 1.16 ± 0.79 0.67 ± 0.37
HF 0.11 ± 0.08 0.30 ± 0.18
LF: low- frequency band (0.04 to 0.15 Hz), Hz: high-frequency band
(0.15 to 0.5 Hz). Data are expressed as mean ± SD. All differences are
statistically significant (p < 0.05).
Table 3. Results of tests and questionnaire. Data are expressed
as mean ± SD.
After treat-
ment (T2)
FIQ Fibromyalgia Im-
pact Questionnaire 70.08 ± 3 65.27 ± 5
RPERating Perceived
Exertion 11 ± 2 10 ± 1
PSQI Pittsburgh Sleep
Quality Index 12 ± 2 11 ± 3
Figure 2. Tacogram of heart rate data (HR) beat to beat as time
domain at the end of the treatment. (The figure refers to a FM
ment, “effleurage” or “light stroking”, combined with
passive stretching exercises on a group of fifteen women
affected by fibromyalgia.
The results are encouraging concerning the improve-
ment of joint mobility and hence the state of contraction,
as all patients showed an overall improvement of joint
We showed a significant reduction in HR and HRV,
vagal tone, and augmented sympathetic activity in FM
before treatment. These results reflect a basal autonomic
L. Bazzichi et al. / HEALTH 2 (2010) 919-926
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state of hyperactivation characterized by increased sym-
pathetic and decreased parasympathetic tone. These find-
ings are in accordance with those of other researchers
who have shown that FM patients have hyperactivity of
the sympathetic nervous system [41,42] and elevated HR
at rest [21].
After the massage and stretching treatment program
we observed a tendency to inversion characterized by
decreased sympathetic and increased parasympathetic
tone. This is an interesting result showing an improve-
ment in the balance of the autonomic nervous system
after the combined treatment of massage and stretching
and reflecting the beneficial effects of the treatment.
It has been postulated that sympathetic autonomic
system over activity at rest could be related, in part, to
symptoms such as fatigue, sleep disturbances, paresthe-
siae, and irritable bowel syndrome, all typical symptoms
of fibromyalgia. Nevertheless, the abnormal autonomic
response to sympathetic challenger could explain the
low muscle oxygen [43], the abnormal muscle phosphate
metabolism [44], the decreased threshold for pain, and
increased fatigue in patients with FM [45].
Figure. 3. Spectral analysis of R-R interval variability in FM patients before (red) and after (black) treatment. (The figure refers to a
FM patient).
1) Shoulder extension. 2) Shoulder flexion. 3) Shoulder abduction. 4) Shoulder adduction. 5) Shoulder abduction (horizontal). 6) Shoulder adduction
(horizontal). 7) Hip extension. 8) Hip flexion. 9) Hip abduction. 10) Hip adduction. 11) Knee flexion.
Figure 4. Medium improvement of range of motion (ROM). Medium, max and min values and interquartile range are indicated in
each box (referred to 20 patients). Data are expressed in percentage and on angular degrees calculated on the basis of joint flexibility
of healthy subjects (Ryf and Weyman 1999). The numbers (1-11) indicate the joints.
Openly accessible at
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Reduction in parasympathetic tone was found at rest
also in some HRV studies on patients affected by panic
disorder [46], generalized anxiety disorder [47], depres-
sion [48] and post traumatic stress disorder [49]. Perhaps
this finding is characteristic of anxiety disorders or de-
pression in general and is not specific for FM, reflecting a
non specific anxiety-related response in patients with FM.
In summary, at rest FM patients exhibit sympathetic
hyperactivity and concomitantly reduced parasympa-
thetic activity.
We found the maximum improvement of joint flexi-
bility in shoulder, this is an interesting finding consider-
ing that FM patients often say “they have the world on
their shoulders”.
While we found that the combined treatment of mas-
sage and stretching FM patients improved the articular
mobility and autonomic nervous system, other authors
[50] suggest no consistent immediate or long-term ef-
fects on the autonomic nervous system of healthy mid-
dle-aged and elderly subjects after connective tissue
Unexpectedly the FIQ, Borg RPE and PSQI ques-
tionnaire did not show any improvements. This discrep-
ancy may be explained considering that, as reported in
the literature [51], in these patients is amplified the per-
ception of quality of life in its various components and
relationships, with respect to more objective parameters,
such as muscle rigidity, articular movement and the
sympatho-vagal balance.
We must make a consideration regarding to the Borg
questionnaire: the perception of fatigue did not change
after treatment, but we must consider the fact that at T2
patients joint flexibility increased, then they are able to
perform wider movements with equal effort, then the
effort is indeed decreased.
The limitations of the present study are the lack of psy-
chiatric evaluations of FM patients, given that HRV al-
teration has been found in mood disorders, and the lack
of a control sample.
In conclusion our protocol has highlighted the excellent
compliance of patients suffering from fibromyalgia with
a combined treatment of massage and stretching; pa-
tients show an amelioration of muscle stiffness and of
the parasympathetic component. The questionnaires did
not show any ameliorations, probably because in these
patients the perception of quality of life is distorted
compared with more objective parameters, such as mus-
cle rigidity, the joint flexibility and the autonomic nerv-
ous system.
Our research highlights the need for a standardization
of treatment, both in terms of method (technique) and
application (pressure of operator).
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