Effect of Swedish massage Versus Progressive muscle relaxation on Blood Glucose Level of Children with Type 1 Diabetes Mellitus

Background: Swedish massage (SM) and Progressive muscle relaxation (PMR) are special techniques that recently used in many chronic disorders as type 1 diabetes mellitus (T1DM). Both techniques have a crucial role in reducing stress that can lower blood glucose level in children with T1DM. Objective : Investigate the effect of Swedish massage versus progressive muscle relaxation on blood glucose level of children with T1DM. Setting : This study was conducted at the Outpatient diabetic clinic in the Specialized University Hospital at Smouha in Alexandria. Design: A quasi experimental research design was used. Subjects: A convenient sample of 50 diabetic children who were randomly allocated to two equal study groups (study I (SM) and study II (PMR)). Tools : Two tools were used; Socio-demographic and Medical History of Diabetic Children Interview Schedule and Blood glucose level Assessment Tool Results : Swedish massage and progressive muscle relaxation were associated with significant decreases in fasting blood glucose level, random blood glucose level and consequently HbA1C after intervention (P<0.001 for all blood glucose levels) . The SM group demonstrated more decrease in fasting blood glucose level, random blood glucose level and consequently HbA1C than PMR group. Where means of HbA1C for SM and PMR were 7.88 ± 0.92 and 9.08 ± 1.08 respectively after intervention and there was a statistical significant difference (P = 0.007). Conclusion: Both techniques are effective to decrease blood glucose levels in diabetic children. While Swedish massage was more effective than PMR. Recommendations: Swedish massage and PMR techniques need to be incorporated in the care of diabetic children


Introduction
Type 1 diabetes mellitus is one of the most common endocrine and metabolic problems occurring in childhood.Type 1 diabetes mellitus (T1DM) is a chronic autoimmune disease characterized by insulin deficiency due to pancreatic β cell destruction which leads to increase blood glucose levels (hyperglycemia).Ineffective glycemic control can affect the growth and development of children and adolescents.It is usually associated with acute and chronic complications that have impact on children's quality of life (Katsarou et al., 2017;Madrigal et al., 2020).
In 2019, the International Diabetes Federation (IDF) reported that approximately 1,110,100 children are estimated to have T1DM worldwide.They reported that around 98,200 children under 15 years were diagnosed with T1DM worldwide each year (Patterson et al., 2019).The annual incidence in the United States is approximately 20 in 100,000 children.The prevalence of T1DM is highest in non-Hispanic whites followed by African Americans, Hispanics, and American Indians (Marcdante & Kliegman, 2019).The largest contribution to the total number of estimated childhood T1DM cases among Eastern Mediterranean and Middle Eastern countries comes from Egypt.It accounts for about a quarter of the region's total, 8/100 000 per year in egyptian children under the age of 15 years had T1DM (El-Ziny et al., 2014).
Stress is considered as one environmental factor contributing to the development of T1DM in children.Theoretically, the beginning of the autoimmune process could be triggered by stress and contribute to its progression.Stress results in elevated cortisol levels that may contribute to insulin resistance.Epinephrine (another hormone released during stress), inhibits also the insulin secretion and leads to an increase in the need for insulin.Stress can be controlled through behavioral intervention techniques as Swedish massage and progressive muscle relaxation which are very important to improve glycemic condition of children with T1DM (Argyropoulos et al., 2021).Swedish massage (SM) is a relaxation technique that focuses on improving blood flow to the skin, muscle and removing tension of the muscles.It was the first systematic method of therapeutic massage based on a physiological perspective.It is built around five basic superficial strokeseffleurage (sliding or gliding), petrissage (kneading), tapotement (rhythmic tapping), friction (steady pressure) and vibration or jostling (De Omena Bomfim, 2021).
Progressive muscle relaxation (PMR) is one of the best effective non-pharmacological techniques, which decreases stress in children because it influences mental and physical conditions.It can be applied by making the muscles maximally strain, and then loosening it until the muscle is relaxed.It is repeated until children acquire complete relaxation (Casman & Nurhaeni, 2018).Progressive muscle relaxation leads to regulation of autonomic nervous system activity that potentially contributes to medical management of T1DM through improving in glycosylated hemoglobin level (HbA1c) (Paschali et al., 2020).Swedish massage and Progressive muscle relaxation had an effective role in decreasing blood glucose level in children with T1DM, so that the pediatric nurse should apply and educate care giver about Swedish massage and PMR techniques (Ismaili et al., 2018).

Aim of study
This study aimed to investigate the effect of Swedish massage versus progressive muscle relaxation on blood glucose level in children with T1DM.

Research Hypothesis:
Diabetic children who are subjected to Swedish massage exhibit low blood glucose level than those who are subjected to PMR.

Design:
A quasi experimental research design was used.

Settings:
This study was conducted at the Outpatient diabetic clinic in the Specialized University Hospital at Smouha in Alexandria.

Subjects:
A convenience sampling of 50 diabetic children who fulfilled the following criteria comprised the study subjects:
• Children who live in Alexandria only.

Ethical considerations:
• Informed written consent was obtained from diabetic children's caregivers for their participation in the study after explaining the aim of the study.• The right to refuse to participate or withdraw from the study at any time was assured.• The privacy of children was ascertained.
• Confidentiality of data was maintained.

Statistical analysis:
• The collected data were coded and entered in special format to be suitable for computer feeding.o Significance of the obtained results was judged at the 5% level.

Results:
Table (1) illustrates socio-demographic characteristics of diabetic children.It revealed that 52% of each of diabetic children who received SM and those who received PMR were females.The highest percentage of each of the diabetic children who received SM and PMR groups were in the age group from 10 to 12 years (44% and 52% respectively).Regarding the child birth order, the highest percentage was for the first and second birth order in the family for Swedish massage and PMR groups (60%-92% respectively).

Medical history of diabetic children is shown in table (2).
It was clear from this table that the highest percentage of SM group (56%) was within the duration of DM from less than one to 2 years.The highest percentage in PMR group (40%) was within the duration of 3 to 4 years.The majority of SM group (92%), while nearly three quarters (72%) of PMR group were previously admitted to the hospital.The most common diabetic complications in study group I (SM) and study group II (PMR) were hyperglycemia (100% and 96%, respectively) and lack of concentration (68% and 40% respectively).

Table (3)
presents that comparison between SM and PMR groups regarding means of fasting blood glucose level before breakfast.It was clear that the mean of fasting blood glucose level of Swedish massage group at the end of 12th week was less than those at the end of first week, where means were 106.28 ± 15.43 and 166.5 ± 42.62 respectively.There was highly statistically significant difference between all weeks of the study (P1 <0.001).The mean of fasting blood glucose level of PMR group at the end of 12th week (133.28± 11.05) was less than those at the end of first week (142.16± 26.30).There was highly statistically significant difference between all the weeks of the study (P1 <0.001).It was noticed from the same table that mean fasting blood glucose level of Swedish massage group at the end of 12th week (106.28± 15.43) was less than those in PMR group at the same week (133.28± 11.05).There was a statistical significant difference between both groups (P2= 0.001).
Comparison between SM and PMR groups related to means of random blood sugar level before and after each session is highlighted in Table (4).It revealed from the table that mean of random blood sugar after 24th session in SM group (150.08 ± 19.72) was less than those before the first session (264.7 ± 82.01).There was a statistical significant difference between all of the study weeks (P1 <0.001).This table shows that the mean of random blood sugar after 24th session in PMR group (218.72 ± 46.59) was less than those before the first session (248.52 ± 35.54).There was a statistical significant difference between all the study weeks (P1 <0.001).It revealed from the same table that mean of random blood sugar level at the end of 12 th week of the study in SM group (150.08 ± 19.72) was less than those in PMR group (218.72 ± 46.59) at the same week.There was a statistical significant difference between both groups (P2 <0.001).

Table (5)
shows comparison between SM and PMR groups regarding means of HbA1c.It was noticed that the mean of HbA1c in the SM group at the end of the 12th week (7.88 ± 0.92) was less than those at the beginning of the study (9.74 ± 1.11).There was a statistical significant difference (P0<0.001).This table shows also that the mean of HbA1c in PMR group at the end of the 12th week (9.08 ± 1.08) was less than those at the beginning of the study (9.74 ± 1.12).There was a statistical significant difference (P0 <0.001).It was obvious from this table that mean at the 12th week of the study in SM group (7.88 ± 0.92) was less than those in PMR (9.08 ± 1.08).There was a statistical significant difference (P = 0.007).

Discussion
Diabetes mellitus is the most common chronic metabolic disease in childhood.Children with T1DM more frequently experience stress compared with other children.
Stress response activates sympathetic nervous system that may enhance cortisol release, increase insulin resistance and elevate blood glucose level (Nygren, 2015).So, it is important to apply complementary medicine as Swedish massage and progressive muscle relaxation (PMR) techniques, which helped in relieving stress in addition to routine care of diabetic children as, insulin injection, diet management, and exercise.(Anna et al., 2018).
The present study results showed that means of fasting blood glucose level (Table 3), random blood glucose level (Table 4) and HbA1c blood glucose level (Table 5) for SM and PMR at the end of 12th week were less than those at the end of first week.The difference was highly statistically significant.Field (2019) supported the present study as he reported that implementing massage was more effective to children and adolescents with chronic disease as T1DM.The blood glucose levels were significantly lower in the SM group by the end of the three months period of application of massage .Talakoub et al. ( 2010) results were congruent with the current study.He reported that application of PMR in children was more effective in decreasing blood glucose levels at the end of the study period.
The results related to positive effect of SM and PMR at the end of 12th week of the study may be related to the fact that children became more relaxed at the end of the study than at the beginning.They became more familiar with techniques.It is due to body release a lot of endorphins throughout the study period which can calm the central nervous system so that reduce blood glucose levels with progression in sessions (Purba et al., 2019).Rodríguez-Mansilla et al. (2017) agreed with the current study and reported that effect of SM and PMR techniques became more effective after the fourth session because the children became more relaxed.
The findings related to positive effect of SM and PMR on blood glucose levels could be explained in the light of the fact that SM and PMR techniques stimulate hypothalamus to decrease action of sympathetic nervous system and increase action of parasympathetic.These actions lead to decrease stress hormones as cortisol and glucagon, which consequently decrease blood glucose level (Purba et al., 2019).These results may be due to that around one half of children in SM group and more than half in PMR group were at age group 10-12 years (Table 1).According to Piaget cognitive developmental theory at this age, children became able to think and connect between actions in logical manner.So that they feel comfortable to connect between application of SM or PMR and sense of relaxation, which lead to decrease blood glucose level.Moreover results may be contributed to the role of mothers in children's life.Mothers are considered as the corner stone related to children.Children may be compliance with SM and PMR techniques that lead to decrease blood glucose levels because in this time they became more attached to their mothers and got great attention from them.
The findings could be explained by the fact that children in school age became more interested in using technology.So that, they were interested in watching videos that the researcher sent to them about SM and PMR techniques.Children became more curious and be stimulated to come to sessions of techniques, which produced effective results at the end of study period.Moreover, Kashaninia et al. (2015) reported that Swedish massage is easy to apply, free from risk, non-invasive, and relatively inexpensive which makes it the most common complementary medicine used in nursing.It may be another cause for commitment to techniques and decreased blood glucose levels at the end of the study due to easiness, safety, and cost-effective of techniques in decreasing and stabilizing blood glucose level, which made mothers more motivated to complete all sessions for their children.Elagamy et al. (2020) and Magor et al. (2014) supported the current study and cited that PMR technique is the easiest technique to be learned and administered to children, inexpensive, available at any time, self-induced by children, and had no side effects.
Although SM and PMR techniques had positive effect in reducing blood glucose levels.Swedish massage technique was more effective than PMR technique in reducing blood glucose level in diabetic children.Where means of fasting blood glucose level (Table 3), random blood glucose level (Table 4), and consequently HbA1c blood glucose level (Table 5) in SM group were less than those in PMR group throughout the study period.There were statistically significant differences between both groups at the end of the 12th week.These results are supported by Ghazavi et al. (2008) and Sajedi et al. (2011) who study the effect of massage therapy and muscle relaxation on blood glucose levels in diabetic children.They reported that Swedish massage technique is more effective than progressive muscle relaxation technique in decreasing the blood glucose level.These results could be contributed to that the researcher in SM technique had active role to touch children, while in PMR technique the researcher just gave instructions and motivated the children to carry it out by themselves.Touch had an important effect to help children reach state of deep relaxation that leads to decrease blood glucose levels than effect of instructions and motivation in PMR group.In addition, the role of the child in SM technique is passive role, while in PMR technique the child had an active role.He must do the technique correctly and effectively with complete attention to reach the state of deep relaxation.Children in this age may not be able to follow a lot of instructions and keep attention for a long period of time.
From the ongoing discussion, it can be noted that integrating complementary medicines as Swedish massage and progressive muscle relaxation techniques to routine nursing care are considered one of the nursing priorities for diabetic children.Swedish massage and PMR enhance children's physiological parameters related to blood glucose levels (fasting, random, and consequently HbA1c).Therefore, nurses in diabetic unit have a more meaningful and active role in teaching as well as implementing the complementary medicines including Swedish massage and progressive muscle relaxation and could integrated them in children's plan of care.

Conclusion:
Based upon the findings of the current study, diabetic children who received SM or PMR techniques had positive effect on reducing blood glucose levels (fasting, random and consequently HbA1c).There were highly statistically significant differences at the end of 12th week of the study in SM and PMR groups related to blood glucose level .
Diabetic children were subjected to Swedish massage had more positive effect in decreasing blood glucose levels (fasting, random and consequently HbA1c) than those who were subjected to Progressive Muscle Relaxation with statistically significant differences.

Recommendations:
• Inservice training program should be provided for all nurses working in diabetic units as regards SM and PMR techniques and its benefits for diabetic children.

•
Free from other medical disorders as cardiac, renal, or any other metabolic disorder.

Tool II: Blood glucose level Assessment Tool:
e.The first process of implementation of Swedish massage was Effleurage in which the researcher did long, firm gliding strokes with the whole hand or thumbs.The strokes trace the outer contours of the body.f.The second process was Petrissage, where the researcher lifted, rolled, grasped, stretched, and compressed or squeezed the underlying tissue of abdomen, back, arm, and leg of child.g.The third process was Tapotement.In this process the researcher did a rhythmic percussion, most frequently administered with the edge of her hand, a cupped hand or the tips of the fingers.h.The fourth process was Friction in which the researcher did a deep and circular movement near joints and other bony areas such as rib cage in front and backbones in the back.j.The last process of Swedish massage was Vibration, where the researcher made shaking, quivering, trembling, or rocking movements with the fingers, or full hand to all body parts from the front and from the back.k.Finally the researcher advised the children to put on their clothes.14.The Progressive muscle technique (PMR) exercise was performed by

12 th Weeks 23 th Session 24 th Session 23 th Session 24 th Session
Pairwise comparison bet. each 2 groups was done using Post F1: F for One way ANOVA test,

Hoc Test, (Tukey) F2: F test (ANOVA) with repeated measures,
Sig. bet.periods was done using Post Hoc Test (adjusted Bonferroni) p2: p value for comparing between SM and PMR groups in second session p1: p value for comparing between the studied weeks in each session in each group *: Statistically significant at p ≤ 0.05

Table ( 5): Comparison between Swedish massage and Progressive muscle relaxation groups regarding means of glycosylated haemoglobin level (HbA1c)
Pairwise comparison bet. each 2 groups was done using Post

Hoc Test, (Tukey) F2: F test (ANOVA) with repeated measures,
Sig. bet.periods was done using Post Hoc Test (adjusted Bonferroni) p: p value for comparing between the studied groups p0: p value for comparing between beginning and end value *: Statistically significant at p ≤ 0.05