Bo-Yang Pan,Tian Chen,Long-Ming Lei

1Liuzhou Hospital of Traditional Chinese Medicine,Liuzhou,China.2The first Affiliated Hospital of Guangxi University of Traditional Chinese Medicine,Nanning,China.

Abstract

Keywords: Massage therapy,TCM,Sub-health,Review

Introduction

In recent years,sub-health state refers to a state between health and disease,and is also known as the third state.As it can transform into health or disease,it is often called a “gray state,” “pre-disease state,” or “sub-clinical stage.” This includes a state of absence of clinical symptoms or mild sensation of symptoms,but presence of underlying pathology [1].The most common symptoms of sub-health are fatigue,poor sleep quality,forgetfulness,pain,sore throat,increased incidence of infections,and decreased immunity [2-4].Fatigue is considered as one of the most typical clinical symptoms of sub-health [5].When a person is chronically fatigued,some energy molecules may be converted into acids during physical activity,and as a result,the pH value of body fluids decreases,affecting the functions of the cardiovascular system,gastrointestinal system,liver and kidney,central nervous system,as well as mental health [6].Studies have found that mice are more irritable and restless under a variety of short-term stressors such as swimming in cold water,sleep deprivation,and clip-on tail stimulation.When the interventional factors were applied for more than two weeks,the mice showed more mental fatigue,fur shedding,loss of luster,weight loss,reduced independent activities,memory loss,and so on.These effects are consistent with the basic characteristics of human sub-health status [7-11].When the body is in a state of sub-health for a long time,the individual is more likely to progress in the direction of disease,such as insomnia,depression,impotence,sexual dysfunction,and so on [12].Therefore,choosing the effective therapy to scientifically regulate sub-health has become a common concern in Chinese and western medicine [13].

There is no definite qualitative diagnosis of the disease,nor an abnormality in the laboratory investigations.It is difficult to adopt specific methods or drugs for targeted treatment in western medicine.Therefore,more and more people are inclined to seek traditional Chinese medicine (TCM) treatment.Chinese medicine believes that sub-health state is similar to “weakness.” Suwen (B.C.220～211,Han Dynasty) said: “when the spirit is gone,the body is weak” [14].In TCM,it is believed that long term disease could result in the loss of vital essence,and this is the main reason for weakness.Massage therapy has been used to treat chronic diseases since ancient times.As early as in Yannianjiuzhuanfa (A.D.1636～1912,Qing Dynasty),it has been recorded that massage of the abdomen could supplement the body's insufficiency,excrete the body's waste matter,and probably increase the life span.This paper reviews literature to analyze the effect of massage treatment for the sub-health state in the recent 10 years,so as to provide more credible clinical research data.

Modern medical theory research on massage therapy for the treatment of the sub-health state

Sub-health state includes physical sub-health,psychological sub-health,and social adaptability sub-health.At present,there are many in-depth clinical studies on the application of massage therapy for sub-health,but most of them focus on physical sub-health.However,the available basic research on the use of modern medical theories and means to explain its mechanism of action is relatively weak [15].In recent years,more and more scholars have begun to reveal the mechanism of action of massage therapy on the sub-health state from the perspective of modern medicine.

Huang CLet al.believe that manipulation through massage to stimulate the receptors from the outside can make the receptors excited and exert a benign regulatory effect on the body through nerve reflex [16].A mild microcirculation disorder may be the physiological and pathological basis of the sub-health state.Massage can significantly improve the microcirculation index of patients in the sub-health state [17].Lei LMet al.adopted animal studies to demonstrate that a back massage can up-regulate the expression level of BDNF mRNA and protein in the hippocampal neurotrophic factor of rats that were reduced due to bondage stress,reduce the damage of chronic binding stress to the hippocampal neurons and synapses of model rats,and down-regulate the serum levels of ACTH and CORT and restore them to the normal level [19,20].Moreover,massage intervention can down-regulate CRH mRNA expression in the hypothalamus,antagonize the hyperfunction of HPA axis,and improve physical and mental symptoms in the sub-health state [21].Liu HZet al.observed the effects of massage on spleen deficiency type sub-healthy elderly individuals [22].Serum levels of nitric oxide,malondialdehyde,and superoxide dismutase were measured.At the end of the experiment,the level of nitric oxide increased significantly in the experimental group when compared to the control group (P＜ 0.05).Malondialdehyde content was significantly decreased (P＜ 0.01).Superoxide dismutase level was significantly increased (P＜ 0.05).These results suggest that massage has positive effects on nitric oxide,malondialdehyde,and superoxide dismutase levels in the peripheral blood of the sub-healthy middle-aged and elderly subjects,and may regulate their immune balance.Moreover,in response to the constant changes in the external environment,the human body has a systematic regulatory mechanism to maintain the stability of the internal environment,namely the neuro-humoral-endocrine system.Among these,neuromodulation plays an important role.Its basic mechanism is nerve reflex; the massage is the stimulation applied to the receptors on the body surface that makes the receptors excited,and modulates the nerve reflex to produce adjustment effect to body eventually,improve subhealth state [23].Liu YLet al.explained the disease prevention and health care obtained from massage,from the perspective of psychology [18].They believe that massage therapy has a good psychological adjustment effect on patients.From the perspective of psychology,touching,pressing,and kneading can relieve mental tension,release tension and pressure,and help in establishing patients' trust in doctors.Compared to other therapies,health massage offers obvious advantages in fostering a good doctor-patient relationship.Therefore,health massage is not only a kind of body massage,it also provides the effect of psychological therapy.

The clinical thinking method and concrete method of massage to treat the sub-health state

Pay attention to the whole concept and the guiding role of syndrome differentiation in treatment

The overall concept of TCM holds that the human body is centered on organs,which are connected with limbs and tissues through the meridian system.The physiological functions of tissues and organs are related to each other,and influence each other in the pathological state as well.Niu HSet al.performed whole body massage on the neck,shoulder,waist,abdomen,foot,and head of sub-healthy patients under the guidance of this concept [24].Through the use of different massage techniques and point stimulation of different parts in order to promote blood circulation,accelerate metabolism,and enhance immunity,they achieved a satisfactory therapeutic effect.Zhou HFet al.studied the effect of health massage on the sub-health status,and performed whole-body health massage treatment on 200 patients with sub-health status [25].The results indicated that 44 cases were cured,110 cases were obviously effective,40 cases were effective,6 cases were ineffective,and the total effective rate was 97%.The results show that massage can significantly improve fatigue,weakness,physical and mental discomfort,and emotional symptoms of the sub-health status.

Treatment based on syndrome differentiation (a basic principle of TCM to understand diseases and treat diseases) implies that doctors make a note of the patients' medical history,symptoms,and other clinical data through the four diagnostic methods of TCM (inspection,auscultation,inquiry and palpation) to analyze and judge the diseases,and to establish the therapeutic method [26,27].It closely follows the main pathogenesis of the disease,thus improving the clinical efficacy.Wang Qet al.used massage to treat the sub-healthy state.In addition to a systemic massage,they also differentiated TCM syndromes [28].Based on the results of syndrome differentiation,they selected additional treatment sites: (1) deficiency of both the heart and spleen: the main symptoms are difficulty in falling asleep,high frequency of dreams,easily woken from sleep,palpitations,forgetfulness,and dizziness.Management: press and knead the acupoints of Xinshu (BL15),Ganshu (BL18),Pishu (BL20),Weishu (BL21),and Xiaochangshu (BL27),each for two minutes.Straight rub the back of the Du Meridian and both sides of the bladder until the affected parts is heated; (2) insufficiency of the spleen: symptoms include eczema,erosions,and exudation with skin damage,loose stools,etc.Management: rub the acupoints of Zhongwan (CV12),Zhangmen (LR13),Tianshu (ST25),Qihai (CV6),and Guanyuan (CV4),each acupoint for five minutes.Rub Pishu (BL20) and Weishu (BL21) acupoints until the affected parts is heated.Press and knead the acupoints of Zusanli (ST36) and Fenglong (ST40) for three minutes until the affected part achieve a feeling of sore and pain; (3) stagnation of liver Qi: emotional depression or irritability,abdominal pain,and breast pain and irregular menstruation in women.Management: rub the bilateral ribs until the affected parts is heated.Press and knead the acupoints of Zhangmen (LR13),Qimen (N13),Xingjian (LR2),Neiguan (PC6),Ganshu (BL18),Danshu (BL19),and Geshu (BL17),each acupoint for one minute,until the affected part achieves a feeling of sore and extension; (4) deficiency of liver and kidney: symptoms include dizziness,tinnitus,forgetfulness,insomnia,weakness in waist and knee,flank pain,etc.Management: press and knead the acupoints of Ganshu (BL18),Shenshu (BL23),and Mingmen (GV4),each acupoint for one minute.Rub Shenshu (BL23),and Mingmen (GV4) with the whole palm until the affected parts is heated.Press and knead the acupoints of Yongquan (KI1) from 6 to 8 times.Tang HLet al.randomly divided sub-healthy people with liver depression and spleen deficiency into two groups,and treated them with liver soothing and spleen strengthening massage and conventional massage,respectively [29].The results showed that the main symptoms (fatigue and insomnia) were improved in both groups.However,the improvement of fatigue and insomnia in the liver soothing and spleen strengthening massage groups were better than that in the conventional massage group.At the same time,the liver and spleen massage group showed significant improvement in the scores of interpersonal sensitivity,depression,anxiety,hostility,psychosis,and five other symptom factors in the 90-item symptom scale.

Pay attention to the therapeutic functions of meridians and acupoints

Massage works on the body through different ways: stimulation of the body surface,conduction to the relevant meridians and viscera,improvement in the viscera function,and balance in the functions of Yin and Yang,so as to achieve the purpose of treatment [30].The occurrence of somatic sub-health state is related to the dysfunction of Zang-Fu organs,and the Du meridian,bladder meridian,and viscera are closely related [31,32].The main meridians in the circulation of the human back and waist are the Du meridian and bladder meridian.There are also important acupoints such as Huatuojiaji (EX-B2) acupoint and back Shu point.Du meridian is the sea of Yang meridian,and is closely connected with the brain through the meridians.Stimulation of the Du meridian could awaken the brain and open the orifices and play an important role in regulating the balance of Qi and blood in the meridians of Yin and Yang throughout the body.Huatuojiaji (EX-B2) acupoint near the Du meridian,which have the function of awakening the brain,adjust the mind and clear the collaterals.Therefore,clinical research used the Du meridian and bladder meridian as the main areas for treatment.Li QB used massage along bladder channel originated from Emei traumatology (originated from the ancient town of Fuxi in the Emei Mountain,Sichuan Province,China,it is a genre system for treating traumatic diseases by means of Sichuan TCM orthopedics,massage,internal medicine prescription,external application plaster,smoked and medicated wine) to treat fatigue in sub-health has achieved good results [33-35].Chen BM used chiropractic therapy combined with conventional massage to treat 30 patients with sub-health,with a total effective rate of 95.83% [36].It is believed that chiropractic therapy combined with conventional massage therapy can effectively improve the somatic symptoms of sub-healthy patients.Lei LMet al.considered psychological sub-health to be closely related to the heart,liver,and brain.Du meridian intersects the foot Jueyin liver meridian at the top,the Du meridian goes into the brain,and branches of Du meridian connect with heart [37-39].Therefore,the back is selected as the operating site for the treatment of mental sub-health state,and the resultant effect is very good.

Pay attention to the idea of the unity of man and nature,massage treatment should also comply with the four seasons

The holistic view of TCM attaches great importance to the integrity of human beings and the external environment,and emphasizes that the life process is influenced by society and nature at any time.Moreover,massage therapy also emphasizes on the unity of nature and man in the treatment of the sub-health state,and advocates following the four seasons.Ziwuliuzhu was born of Huangdineijing (B.C.220～211,Han Dynasty),and develop in the Song dynasty (A.D.960～1279),in the Ming dynasty (A.D.1368～1644) with a relatively complete theoretical system.It refers to the method of selecting acupoints based on the rise and fall of Yin and Yang at different times,the flow of human Qi and blood,and the rules of opening and closing of acupoints at different times [40].Lingguibafa was found as early as Yijing (B.C.1046～771,Xizhou Dynasty),and the theoretical system was perfected in the complete works of Zhenjiudaquan in the Ming dynasty (A.D.1368～1644).It takes time as the main condition,combines with the alternating flow of Ganzhi (a kind of astronomical calendar originated from ancient China),and uses mathematical deduction to determine the method of taking points [41].Ziwuliuzhu and Liuguibafa were guided by the theory of “unity of man and nature,” and explained the law of flow of Qi and blood in the human body,which is consistent with the natural circadian rhythm.It is believed that the changes of Qi and blood in the meridians and the opening and closing of meridians vary with the time of day.Therefore,in the treatment of sub-health state by massage,Ziwuliuzhu and Lingguibafa are adopted as the guiding methods for selecting meridians and acupoints,which can often promote manipulation to achieve more ideal therapeutic effects.

Wang JHet al.used massage depending on the method of Lingguibafa to treat 50 cases with physical symptoms of sub-health [42].According to the date and time of patient visiting,the main acupoints and meridians should be selected for treatment.The main point is pressed,kneaded,pinched,or plucked to obtain Qi; the main meridians were treated by percussion and massage along the surface of the meridians.At last,the palm-rubbing method were used along the meridians of the body surface.The results showed that the curative effect here was better than that of manipulation in the control group and TCM treatment group.Huang XH performed acupoint selection by the Ziwuliuzhu method,and adopted massage methods following the theory of Ziwuliuzhu to treat physical symptoms of sub-health,and the curative effect was good [43].

Massage treatment according to the different clinical classifications of sub-health state

Massage for sub-health of bodyPang Jet al.found that massage therapy for the treatment of physical pain in sub-health had satisfactory clinical efficacy.They believe that massage can stimulate the meridians of the body to a certain extent through a variety of manipulations,so as to stimulate the local and systemic reactions of the body reflexively [41].Thus,massage could dredge the channels and meridians,promoting Qi to activate blood to alleviate and eliminate pain.Therefore,massage therapy for pain in sub-health of the body results in a good curative effect [34,44].Liu JR combined chiropractic therapy with massage to observe the intervention effect of pain in sub-health of the body [45].After the treatment,the patients' quality of life (whoqol-brief),the McGill pain questionnaire,and changes in the scores of the main symptoms and signs were observed.They assumed that Chiropractic massage therapy could significantly improve the clinical symptoms of the patients with physical pain in the sub-health state.

Massage for mental sub-healthA large number of clinical studies have shown that massage has a good clinical effect on mental sub-health.Lei LMet al.randomly divided 200 patients with social stress sub-health depression into two groups.The treatment group was treated with peppermint essential oil and the control group was given psychological counseling [38].By comparing the scores on the 24-item Hamilton depression scale (hamd-24),and the improvement of the main symptoms of sub-health depression before and after treatment in the two groups,the intervention effect of massage with essential oil on social stress sub-health depression was determined.The results showed that massage with essential oil had an ideal intervention effect on social stress sub-health depression.Another study also showed that back meridian massage could regulate the functional activities of the whole body and viscera through manipulation on the back Shu points,so as to achieve the purpose of fulfilling deficiency and purging,harmonizing Qi and blood,and balancing Yin and Yang [33].It is believed that massage therapy can effectively relieve the tension of the body,so as to make people feel happy and energetic.Hence,it can effectively improve the psychological symptoms of sub-healthy people.

Conclusion

In conclusion,massage therapy can effectively improve patients' physical pain,fatigue,and discomfort.At the same time,massage has greatly improved the psychological discomfort caused by sub-health,such as depression,anxiety,insomnia,and other symptoms.Therefore,it is deeply favored by people.However,as far as literature is concerned,although there are many reports on relevant clinical observations,laboratory observations on massage treatment for sub-health is relatively scarce,which makes it difficult to provide good and credible theoretical support.In summary,the existing problems can be roughly divided into the following categories: (1) there are no unified diagnostic criteria for sub-health status,and there are differences in the inclusion criteria in different studies.(2) Clinical studies on massage therapy for sub-health lack relevant reports on large samples and multi-center randomized controls,and the mechanism is not clear.(3) At present,a subjective scale is mostly used to evaluate the effect of treatment,and there is no standard objective evaluation.(4) There are great differences in acupoint selection,manipulation,stimulation intensity,and frequency of massage for treating people in the sub-health state,and no standardized operation has been formed.(5) There are relatively few studies on the modern mechanism of massage in the treatment of the sub-health status.Therefore,in future research,we should strengthen the research on the pathogenesis involved in status of sub-health,and combine the theory of TCM with modern experiments and clinical research.Further exploration of more convenient and effective methods will gradually improve the theoretical system of massage intervention for the people with a sub-health status.