Abstract
Background:
Diabetes mellitus is a group of metabolic diseases characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Massage with aroma oils is commonly used in the management of various diseases, including diabetes. This study aims to evaluate the effect of abdominal massage with eucalyptus aroma oil on blood glucose levels in patients with type 2 diabetes mellitus (T2DM).
Materials and Methods:
In this single group pre-post study, 50 patients with T2DM underwent only one session of abdominal massage with eucalyptus aroma oil for 20 min. Random blood glucose levels, blood pressure, pulse rate, pulmonary function, Trail Making Test A and B, state anxiety, and state mindfulness were measured before and after the intervention.
Results:
There was a significant reduction in random blood glucose level, Trail Making Test A, and state mindfulness scores and a significant increase in peak expiratory flow rate with no significant changes in blood pressure, pulse rate, Trail Making Test B, and state anxiety after the intervention compared with before the intervention.
Conclusions:
Abdominal massage with eucalyptus oil reduces blood glucose levels and improves mindfulness and cognitive task performance in patients with T2DM. A lack of control group and long-term follow-up is limiting the scope of this study. Hence, long-term randomized controlled studies are recommended to validate the results of the study.
Introduction
Type 2 diabetes mellitus (T2DM) is characterized by chronic hyperglycemia with disturbances of carbohydrate, fat, and protein metabolism, resulting from defects in insulin secretion, insulin action, or both. 1 The International Diabetes Federation estimates that 537 million people between the ages of 20 and 79 have diabetes at this time. According to the Indian Council of Medical Research—India Diabetes research, the overall estimated prevalence of diabetes in India was 11.4%, while the prevalence of prediabetes was 15.3%, with a significantly higher incidence of 16.4% in urban areas. 2 T2DM is a complex metabolic disease in which concomitant insulin resistance and beta-cell impairment led to hyperglycemia, which is the hallmark of the disease. 3 Insulin injections along with oral hypoglycemic drugs are the standard treatment for T2DM. However, these treatments have adverse effects, such as lactic acid toxicity, peripheral edema, cardiac failure, liver and kidney damage, and gastrointestinal problems. 2 Hence, there is a need for complementary and alternative medicines in the management of T2DM. Massage and aromatherapy are commonly used to treat T2DM. 4 Several studies have shown that massage improves glucose and lipid metabolism disorders by regulating muscle, inflammatory factors, and pancreatic islet function. Abdominal massage affects gastrointestinal responses by stimulating parasympathetic nerves, but its effectiveness and specific mechanism in the treatment of T2DM are not clear. 5 Psychological stress is believed to be an essential risk factor for diabetes, and stressful experiences may affect the onset and metabolic control of T2DM, 6 whereas massage has been shown to decrease anxiety in people with T2DM. 7 Among various massages, abdominal massage (also known as visceral massage in China) involves mechanical and manual manipulations that are commonly used in the treatment of obesity and prediabetes. 8 The proponents of aromatherapy lay claim to an ancient tradition of herbal medicine practiced in countries such as Egypt and India thousands of years ago. It is now commonly administered by massaging into the skin, and the term “aromatherapy” usually implies massage with a range of aromatic plant extracts known as essential oils. 9 Synergistic effects of five essential oils such as eucalyptus, rosemary, geranium, lavender, and chamomile in conjunction with massage therapy have been utilized in the management of T2DM. 10 However, no studies reported the isolated effects of eucalyptus oil massage in T2DM. Hence, the objective of the study was to evaluate the effect of abdominal massage with eucalyptus oil on blood glucose levels, blood pressure, pulmonary function, cognitive task performance, and state anxiety and mindfulness in patients with T2DM.
Materials and Methods
Study design
A single group pre-post design was adopted for this study. All the eligible patients underwent only one session of abdominal massage with eucalyptus oil for 20 min. Assessments were taken before and immediately after the intervention (Fig. 1).
Trial profile.
Participants
Participants were recruited using convenient sampling methods and willing to participate in this study. A total of 50 patients with T2DM aged 54.20 ± 10.56 were recruited from a yoga and naturopathy medical college and hospital. Both male and female participants aged between 30 and 70 years and with history of T2DM were included in the study. Subjects with pyrexia, open wounds and cuts (abdomen), hypersensitive skin, and recent surgical history such as caesarean section and abdominal and thoracic procedures and females during pregnancy, lactation, and menstrual cycle were excluded from the study.
Ethical consideration
Subjects were recruited from Government Yoga and Naturopathy Medical College and Hospital (GYNMCH). Institutional ethics committee (IEC) clearance was obtained from GYNMCH (Ref. No.: RES/IEC-GYNMC/2021/088) before recruitment of the first participant. Informed consent was obtained from each participant.
Intervention
Subjects were instructed to lie in a supine position on a massage table. All the participants underwent only one session of abdominal massage (friction, stroking, fulling, kneading, percussion) with eucalyptus oil (four drops of eucalyptus oil mixed with 50 mL of carrier oil, i.e., sesame oil) for 20 min. 11 Massage was given by the intern doctors, which was monitored by the investigator.
Outcome measures
Random blood sugar level
It was measured using instant glucometer (Accu-Chek, Roche Diabetes Care India Private Limited, India).
Blood pressure and pulse rate
It was calculated using noninvasive automatic arm type digital blood pressure (BP) apparatus (Omron-hem 7120, Kyoto, Japan).
Pulmonary function
It had been recorded using peak expiratory flow meter (Breathe O Meter Unit, Cipla Limited, Mumbai, India). The average of three readings were considered.
Trail Making Test A and B
Trail Making Test (TMT) is a neuropsychological test used for screening for cognitive impairment, which will assess psychomotor speed, visuospatial search, and target-directed motor tracking. The standardized version of the TMT comprises two task components, TMT-A and TMT-B. In TMT-A participants were required to draw lines and connect circled numbers in a numerical sequence (i.e., 1–2–3). In TMT-B, participants were asked to draw lines to connect circled numbers and letters in an alternating numeric and alphabetic order (i.e., 1-A-2-B). The performance was assessed by the total time to complete the task. 12
Spielberger State-Trait Anxiety Inventory (6 item).
State-Trait Anxiety Inventory (STAI), specifically STAI-6, is used as the principal measure for anxiety. STAI originally consists of 20 items and is the most widely used subjective measure of anxiety in health research. We used STAI-6, the short form, to improve brevity of the questionnaire. Furthermore, STAI-6 is highly correlated with the full version of STAI and has a good reliability. STAI-6 consists of 6 items, with 4-point Likert scale, from 1 = not at all to 4 = very much. To calculate the total STAI score (range 20–80), reverse score the positive items (calm, relaxed, content), so 1 = 4, 2 = 3, 3 = 2, and 4 = 1. Sum all the six scores and multiply total score by 20/6. The normal score range varies from 20 to 80. STAI scores are commonly classified as “no or low anxiety” (20–37), “moderate anxiety” (38–44), and “high anxiety” (45–80). 13
Mindfulness Attention Awareness Scale
The state Mindfulness Attention Awareness Scale (MAAS) is a 15-item scale designed to assess the short-term or current expression of a core characteristic of mindfulness, namely, a receptive state of mind in which attention, informed by a sensitive awareness of what is occurring in the present, simply observes what is taking place. MAAS originally consists of 15 items and is the most widely used subjective measure of mindfulness in health research. We used MAAS, the short form, to improve brevity of the questionnaire. The MAAS consists of 5 items, with 6-point Likert scale, from 0 = not at all to 6= very much. To calculate the total MAAS score, reverse score all items and then average all 5 values. Higher scores reflect higher state mindfulness. 14
All the outcome measures are assessed before and after the intervention.
Data analysis
All the data were checked for normality using Kolmogorov–Smirnov test. Within-group analysis was also performed using paired sample t-test and Wilcoxon signed-rank test based on the data distribution by Statistical Package for the Social Sciences, Version 16.0.
Results
A total of 65 patients were screened for eligibility. Of 65 participants, 15 did not fulfil the eligibility criteria and thus 50 patients were included in the study. All the participants underwent the intervention and none of the participants dropped out of the study. Hence, all the 50 participants (those completed the study) were included for data analysis. The basic demographic details of all the participants are provided in the Table 1.
Demographic Details of the Participants
All values are in mean ± standard deviation except gender.
Results showed a significant reduction in random blood sugar (RBS) level, TMT-A, and state mindfulness scores and a significant increase in peak expiratory flow rate (PEFR) with no significant changes in blood pressure, pulse rate, TMT-B, and state anxiety after the intervention compared with before the intervention (Table 2). No adverse events were reported by the participants during the study period.
Pre-Test and Post-Test Assessments of the Study Group
All values are presented as mean ± standard deviation.
DBP, diastolic blood pressure; PEFR, peak expiratory flow rate; PR = pulse rate; RBS, random blood sugar; SBP, systolic blood pressure; SMAAS, State Mindfulness Attention Awareness Scale; STAI, State-Trait Anxiety Inventory; t, paired samples t-test; TMT-A, Trail Making Test A; TMT-B, Trail Making Test B; z, Wilcoxon signed-rank test.
Discussion
The objective of the study was to assess the immediate effect of abdominal massage with eucalyptus oil in the management of T2DM. Results of this study reveal a significant reduction in RBS, TMT-A, and State Mindfulness Attention Awareness Scale and a significant increase in PEFR with no significant changes in BP, pulse rate, TMT-B, and STAI after the intervention compared with before the intervention.
Massage increases skin microcirculation through dilatation of blood vessels and promotes the secretion of insulin, strengthens the nervous system, enhances the body’s immune system and metabolism, and improves muscle glucose uptake, which lowers blood sugar levels. 8 Abdominal massage promotes intestinal motility and reduces colonic transport time, which can modulate the composition of gut microbiota, thereby reducing blood glucose level. 10 It produces hypoglycemic effect through the regulation of Peroxisome proliferator activated receptors (PPARs) signaling pathway. 15 It increases signaling nuclear factor kappa-light-chain-enhancer of activated B cells/Sirtuin 1 in adipose tissue indicating regulation of proinflammatory cytokines that will contribute to insulin resistance. 15 Essential oil and their constituents can penetrate through skin and even used as transdermal drug delivery enhancer by affecting skin integrity. 16 Phytochemicals of eucalyptus essential oil include 1,8-cineole (eucalyptol), carvone, citral, citronellal, geranyl acetate, α-pinene, α-pinocarvone, and β-pinene, which exhibit antidiabetic activity. 17 An increase in the level of reactive oxygen species is another pathogenic factor in T2DM. 18 Natural antioxidants that scavenge free radicals may be exhibiting a synergistic effect with their hypoglycemia impact to provide a comprehensive antidiabetic effect. 17 Eucalyptus globulus acts as an antihyperglycemic agent that is enhanced by the presence of powerful antioxidants (quercetin, chlorogenic acid, and isoquercitrin). 19 As a result, aromatherapy massage with eucalyptus oil alone serves as a useful adjunctive therapy for the management of T2DM and may be a source of complementary therapy for diabetes in future.
Strength of the study
This is the first study that evaluated the effect of abdominal massage with eucalyptus oil in T2DM. The intervention was feasible and well tolerated, and no adverse effects were reported by the participants.
Limitations of the study
The study lacks control group to compare the effects of intervention. Furthermore, the sample size was small and was not calculated based on the previous study. We have explored the immediate effect of abdominal massage with eucalyptus oil and did not access either the short-term or the long-term effects, which are very essential to study in chronic conditions such as T2DM, which is limiting the scope of this study. Hence, further well-controlled long-term studies are recommended to validate the results of our study.
Conclusions
Abdominal massage with eucalyptus oil reduces blood glucose levels and improves mindfulness and cognitive task performance in patients with T2DM. A lack of control group and long-term follow-up is limiting the scope of this study. Hence, long-term randomized controlled studies are recommended to validate the results of the study.
Footnotes
Authors’ Contributions
Writing original draft and investigations: K.P. Supervision and Conceptualization: D.Y. Writing—review and editing and formal analysis: M.A. Writing—review and editing: N.L. Supervision and validation: M.N.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.