er back massages is effective to relief the physical and psychological stress of the students.
We found that the back massages of the students significantly reduce serum level of cortisol without affecting that of lactate. This observation is in accordance with our previous results obtained by use of hot pack treatments of the students  - . The importance of the removal of lactate from the exercised muscle for recovery of performance originates from the earlier studies indicating that intracellular acidosis contributes to muscle fatigue   . Recent studies indicate that lactate is an important intermediary in numerous metabolic processes rather than the direct cause of acidosis, referred as “lactic acidosis” in the muscle   . Power exercises such as sprinting, when the rate of demand for energy is high, glucose is broken down and oxidized to pyruvate, and lactate is produced from pyruvate faster than the tissue can remove it, so lactate concentration begins to rise. Therefore, blood lactate concentration reflects the balance between lactate production and clearance  . Thus, we measured the serum level of lactate as a marker for the muscle fatigue, since the students kept the same position for a long time. However, the serum level of lactate was not affected at all after the back massages as in the case of hot pack treatment   . This would be due to that the students were lying down in the bed during the treatment.
It turned out that back massages reduce the stiffness of trapezium, but did not change the skin blood flow at all, although hot pack treatments increase the skinblood flow without affecting the muscle stiffnesss. These different results may be due to the property of the stimuli, namely mechanical (massages) and heat (hot pack treatment) stimuli.
Massages have been defined as “a mechanical manipulation of body tissues with rhythmical pressure and stroking for the purpose of promotion health and well-being”  . From the view point of athletes and sports medicine personnel, it is generally believed, based on observations and experiences, that massage can provide several benefits to the body such as increased blood flow, reduced muscle tension and neurological excitability, and an increased sense of well-being, although empirical data on possible mechanisms involved are limited  . Furthermore, there are number of techniques in existence, and their use depends on the experience and skill of the therapist and intended clinical advantage desired.
The massaging maneuver used in the present study was rubbing the back with three fingers putted together, making forms of loop, at acupressure between 400 - 800 g. It is generally considered that massages evokes two types of responses, namely mechanical responses as a result of pressure and movement as the soft tissues are manipulated and reflex responses in which the nerves respond to stimulation. In the present study, it seems that mechanical massages directly relieved muscular stiffness with no change in SKBF. In addition massages also reduced the VAS value, and therefore, it seems reasonable to assume that both mechanical and reflex responses are involved in the present results obtained by back massages, although the exact mechanisms in the present observations are yet to be clarified.
Back massages of the students did not affect the skin blood flow at all in the present study. Concerning the effects of massages on the blood flow in the musculature or skin, till now there are bulk of reports, and a common belief among athletes and therapists alike has been that massage enhances muscle blood flow  . However empirical data, presented during last decade, were equivocal. Firstly, it was reported that blood flow increased by 50% after vigorous massage  ; however, later studies claimed much smaller increases  - or no increase at all  .
Recent studies performed by modern techniques with both Doppler ultrasound and laser Doppler flowmetry to integrate femoral artery blood flow (FABF) and skin blood flow (SKBF), do not support the hypothesis that postexercise massage elevates limb blood flow  . Namely, massages applied to the quadriceps significantly elevated skin blood flow (SKBF) without the increase in femoral artery blood flow (FABF), questioning the efficacy of massage as an aid to recovery in postexercise settings. Furthermore, recent study indicates that massage even impairs post exercise muscle blood flow by mechanically impeding blood flow  .
However, there is a solid physiological basis for predicting that massages could elevate muscle blood flow on the basis of recent findings of rapid vasodilatory responses of resistance vessels to repeated compression  - . Thus, further studies are definitely warranted concerning the effects of massages on the blood flow in the patients with stiffness or the athlete after the exercises.
Our previous and present studies indicate that hot pack treatment but not the massages of the back affected the skin blood flow. Hot pack treatment of the students reduced the serum level of cortisol and VAS value at the same time, indicating that the treatment could relief mainly psychological stress   . It was also observed the decrease in VAS values in response to hot pack treatment  .
From a psychological point of view, Butagat et al. also reported that hot pack treatment could increase the feeling of comfort and enhance relaxation  . However, it is unknown whether the hot pack treatment increases the arterial blood flow or not in the back. Thus, under the assumption that the some muscle blood flow diverted into the cutaneous circulation, then the increase in the skin blood flow might question the hot pack effects to cure the stiff shoulder or the neck. It is generally considered that SKBF mainly plays an important role in thermoregulation of the body (see for example  ).
Taking all these experimental facts into the account, it seems that massages may be better treatment rather than hot pack treatment of the students with physical and psychological stresses.
However, further studies are definitely warranted to understand the mechanisms involved in the effects of massage on physical and psychological responses, due to limitations of the present study.
Back massages of the students, preparing for the national license examination, significantly reduced the muscle stiffness of trapezius, serum level of cortisol without affecting that of lactate and VAS value, thereby indicating that the treatment is effective to improve the physical and psychological conditions of the students.
The authors gratefully acknowledge the critical reading of the MS, helpful comments and suggestions of Dr. K.E. Creed.
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