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In the pursuit of wellbeing, relaxation, and health, mankind has resorted to massage since prehistoric times. The term “massage”, probably derived from the Greek word “massein” (to knead), today indicates a wide range of therapeutic or relaxing techniques which uses body manipulation, alone or in combination with herbs, water, salts, and muds. Aromatherapy massage (shortened to “aroma massage”) or massage with essential oils that are plant-derived oily substances with volatile and fragrant properties, has been practiced for many years too, mostly by diluting essential oils into a massage carrier oil or diffusing them in the environment during the treatment.
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C O M M E N T A R I E S
In the pursuit of wellbeing, relaxation, and health, mankind has resorted to mas- sage since prehistoric times. (1)^ The term “massage”, probably derived from the Greek word “massein” (to knead), today indicates a wide range of therapeutic or relaxing techniques which uses body manipulation, alone or in combination with herbs, water, salts, and muds. (1)^ Aromatherapy massage (shortened to “aroma massage”) or massage with essential oils that are plant-derived oily substances with volatile and fragrant properties,(2)^ has been practiced for many years too, mostly by diluting essential oils into a massage carrier oil or diffusing them in the environment during the treatment.(3) In particular, among essential oils de- rived from plants with sedative and calm- ing properties, lavender has always been known in traditional medicine as a remedy which helps to achieve psychophysical re- laxation. Evidence from in vitro and in vivo laboratory studies indicates that lavender essential oil, whose main bioactive com- ponents are linalool and linalyl acetate, can interact with several neuropharma- cological targets, including the serotonin transporter and the MAO-A, GABA-A, and NMDA ionotropic receptors, thus exerting a central anxiolytic, antidepressive, and relax- ing action.(3)^ From a pharmacokinetic point of view, the two main bioactive compounds (linalool and linalyl acetate) of lavender es- sential oil administered through massage are absorbed both through inhalation and through skin penetration. Their blood con- centrations can be detectable 5 minutes after the massage, they tend to peak after 20 minutes, and they are usually eliminated within 90 minutes after the end of the treatment.(4) In general, aromatherapy massage is quite popular as a relaxing technique and
has been reported to be one of the most commonly used complementary therapy in the UK.(5)^ However, evidence on its efficacy is not fully clear to date, and some reports have cast doubts on its clinical safety. (6) The aim of the present work is to outline the efficacy, safety, and tolerability profile of aromatherapy massage with topically applied lavender essential oil, based on a critical overview of available scientific evi- dence on the topic.
The quantitative findings of a recently published systematic review and meta- analysis underscore the potential efficacy of massage with lavender essential oil in the reduction of anxiety levels, with a signifi- cant result in favor of intervention (Hedges’ g = -0.66 [95% CI -0.97 to -0.35], p < .0001, 448 participants) after pooling data from six randomized controlled trials.(3)^ The main limitations of this result was the low aver- age quality of evidence from included stud- ies mostly due to the inherent difficulty in blinding this type of research, and the pres- ence of confounding factors, which didn’t allow to quantify the exact contribution to the observed anxiolytic effect of each component of the treatment (body ma- nipulation, lavender essential oil inhalation and skin absorption, useful placebo effects like the rituality of the treatment). (3)^ How- ever, considering that lavender essential oil administered orally has a significant effect on anxiety levels(3)^ and that, after massage, its bioactive compounds (linalool and lin- alyl acetate) can also be detected into the subject’s bloodstream,(4)^ it is plausible to assume that a useful anxiolytic and relaxing
Michele Antonelli, MD,1,2,3*^ Davide Donelli, MD1,
(^1) Terme di Monticelli, Parma, 2 Department of Medicine and Surgery, University of Parma, 3 Servizio di Consulenza in Medicina Integrativa e Complementare, Reggio Emilia, Italy
lavender aromatherapy hand massage.(17) Moreover, massage with lavender oil has been demonstrated to be useful, along with routine treatment, for symptomatic relief of 70 patients with restless leg syndrome due to chronic kidney failure.(18) Overall, aromatherapy massage with lavender essential oil appears useful for symptomatic improvements of benign health conditions characterized by chronic or subacute pain and impaired quality of life. It is interesting to notice that evidence obtained from a randomized controlled trial underscores that lavender aroma massage can provide a significant addi- tional benefit if compared with massage alone in the symptomatic amelioration of musculoskeletal pain due to osteoarthri- tis.(12)^ The potential role of lavender aroma massage in pain control of gynecological or pediatric conditions must be taken into account, given that such intervention could be useful to limit the administration of common painkillers and, therefore, the incidence of adverse events in these cat- egories of patients. In general, it is plausible to hypothesize that the analgesic action of lavender application follows its systemic absorption and may be due to its role as a sedative compound with relaxing and anti-nociceptive properties. (3,13)
A recently published systematic review has explored the potential role of aroma massage in palliative care of cancer pa- tients, and data from five included studies suggest that aromatherapy, reflexology, and massage, as well as building a sup- portive relationship with the therapist who delivers such treatments, can enhance the subjects’ well-being and may help them to cope psychologically with the individual disease burden. (19)^ In the same work, it is also highlighted that, although the level of evidence for the clinical ef- ficacy of aromatherapy and massage in cancer palliative care may not be high, such interventions are generally safe, and they are subjectively regarded as valuable and beneficial for quality of life by patients involved in qualitative studies.(19)^ In a pre- viously published Cochrane Systematic Review on the same topic, similar conclu- sions were drawn by the authors, thus sug- gesting that aromatherapy massage can exert some short-term benefits on cancer
pharmacological role of this essential oil in aroma massage exists beyond the sole ac- tion of other treatment components. Clinical trials involving elderly patients affected by cardiovascular diseases under- score the activity of aromatherapy massage with lavender essential oil not only for anxi- ety, but also for depression, mood status, and sleep quality. (7,8)^ Results of another controlled study also report beneficial ef- fects of lavender aromatherapy hand mas- sage on emotional status and aggressive behavior in subjects with dementia, (9)^ thus highlighting, along with evidence from the previously mentioned trials, an interesting role of this intervention for elderly individu- als with an impaired quality of life due to typical age-related diseases. With regard to early-life health condi- tions, in a pilot study involving 12 children affected by autism, aroma massage with lavender oil didn’t result in any signifi - cant amelioration of their sleep pattern and quality.(10)^ In this case, although the very limited number of recruited patients might have biased study results, further investigation is needed to assure the real effect of aroma massage with lavender oil in pediatric patients with neurodevelop- mental disorders.
As demonstrated by a meta-analytical work, aromatherapy can prove useful for pain management in adjunct to conven- tional therapies.(11)^ In particular, evidence from a clinical trial involving 90 patients with knee osteoarthritis indicates the ben- eficial effect of massage with lavender es- sential oil in terms of pain and functional status, if compared to massage with a more inert substance like almond oil. (12)^ Results of two trials involving 32 patients with non-specific subacute cervical pain and 61 patients with lumbar pain, respectively, suggest that eight sessions of manual acu- pressure with lavender oil can significantly reduce pain and improve spine mobility.(13) Other pain-related conditions for which lavender aroma massage appears to be signif icantly benef icial with regard to their symptomatic management are infantile colic, (14)^ dysmenorrhea, (15)^ and labor-induced pain. (16)^ In another study, a significant decrease in pain intensity has been experienced by a cohort of 118 el- derly patients with chronic pain of various non-malignant origin when treated with
followed. However, more attention should be paid by future trial investigators in de- scribing all adverse events experienced by participants during the study period and in the follow-up after intervention, in order to avoid any under-report of safety data.
Aroma massage with lavender essential oil may be beneficial as a complementary and integrative therapy for the symptom- atic management of various conditions, mainly psychological disturbances and pain-related benign disorders, and pos- sibly, in palliative care of advanced incur- able life-limiting illnesses. Some evidence interestingly underscores significant ad- ditional benefits when aroma massage is compared with massage alone, especially in the help of anxiety management and be- nign musculoskeletal pain control. In gen- eral, studied intervention appears safe and well tolerated by patients, provided that all precautions are followed by therapists. Further studies on the topic are encour- aged to understand better the therapeutic properties of lavender aroma massage, especially in the pediatric population for whom available efficacy and safety data are scarce and controversial. Like for other CAM-based (Complementa- ry and Alternative Medicines) interventions, evidence is not sufficient to draw definitive conclusions on their efficacy, nor to suggest their systematic adoption in clinical prac- tice. The present overview on the topic sup- ports the usefulness and safety of lavender aroma massage in the above-listed condi- tions, and, when patients look for it, they are not to be discouraged. However, available evidence doesn’t allow to affirm with cer- tainty that this intervention is significantly more effective than massage alone and, to date, since the potential additional benefits remain unquantified, lavender aroma mas- sage cannot be actively recommended to patients. Further randomized clinical trials ought preliminarily to assess the efficacy of lavender when topically applied and trans- cutaneously absorbed without massage, possibly adopting a condition like anxiety as a testing ground. Then, if signif icant benefits are observed, it would be possible to assume that lavender aroma massage is superior to massage alone, thus justifying future attempts to quantify precisely these effects in dedicated trials.
and any contact with irritated or damaged skin must be avoided. (2)^ Particular atten- tion should be paid to subjects with a past history of contact skin allergies (lavender aroma massage must be avoided in sub- jects who are allergic to lavender) and, in general, with allergic diathesis and skin irritability. (13)^ When externally applied, es- sential oils should be adequately diluted at a concentration of 1.5%–3.0% in a car- rier oil. (2)^ If the contact also involves the subject’s face, the dilution should be aug- mented to 0.2%–1.5% in order to prevent adverse reactions on the more sensitive face skin. (2)^ Contact or inhalation exposure to large amounts of oils are to be avoided too, because of potential triggering of seizures and bronchospastic episodes in predisposed individuals; as well, excessively long exposures should be avoided in order to prevent hypersensitivity phenomena. (2) Evidence from trials investigating the use of all lavender-based interventions (inhalation, oral administration, and aroma massage) for anxiety and relaxation sug- gests that safety data are poorly reported or not reported at all by most study authors. However, based on available information, lavender administration can generally be considered as safe, with only non-severe and reversible side effects mainly reported for oral consumption of encapsulated es- sential oil. (3)^ In the scientific literature, a highly discussed and controversial report describes the case of three prepubertal male subjects (aged 7 to 10 years old) who, after local applications of products contain- ing both lavender and tea tree oils, devel- oped gynecomastia, which resolved after discontinuation of intervention.(6)^ Further studies are needed to better investigate the safety profile of lavender in pediatric patients. Caution is also advised in preg- nant women due to lack of safety data and unknown risk to the fetus. Moreover, strict controls by local health authorities should prevent the production and marketing of natural remedies contaminated by en- docrine disruptors and toxic substances, or adulterated for commercial purposes, to guarantee the best quality standards for consumers.
Existing evidence substantially outlines a good safety profile of lavender aroma mas- sage, which appears to be well tolerated by patients when all general precautions are
Corresponding author: Michele An- tonelli, MD, Terme di Monticelli, Via Basse, 5, 43022 Monticelli Terme, Parma, Italy E-mail: ricerca@termedimonticelli.it
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