the use of female human resources is highlighted as an important factor in the aging korean 
 society , especially as married women have started entering the labour market .
in addition , a 
 wide range of fields utilize female labour and the distribution ratio of women in each field 
 is increasing , with female participation in social and economic activities reaching 50.2% in 
 2013 , 51.3% in 2014 and 51.8% in 20151 . 
 office jobs
in particular are experiencing a greater influx of female resources than any 
 other area , accompanied by the risk of various diseases due to poor working posture and 
 environments , long - term use of computers , task over - load , mental stress , etc2 . the stress that female office workers 
 experience in the male - centred organizational culture in korea seems to have more 
 significant implications3 .
in general , moderate stress plays a positive role in physical and mental vitality while 
 achievement motivation elicits feelings of tension
. however , undue stress caused by task 
 over - load might have negative effects on the mind and body , for example , personal anxiety , 
 reduced concentration , loss of drive to work , stress - related diseases , etc .
it might also 
 have direct or indirect negative effects on organizational performance , for example , 
 occurrence of negligent accidents , expansion of healthcare expenses , a decrease in 
 productivity and loss of employment4 . 

thus , a stress therapy program with easy applicability during busy business hours can 
 improve the health of female office workers .
one of the easily applicable stress therapy 
 options , in terms of time and space , is massage .
not only does it have therapeutic effects 
 on various bodily functions including the nervous , musculoskeletal , cardiovascular and 
 integumentary systems , it is also recognized as a type of aerohydropathy as it helps to 
 promote local and general circulation , increases immunologic function , optimizes natural 
 healing ability and helps maintain body balance and harmony .
massage is the oldest method 
 used to resolve tiredness in the mind and body , and can treat and prevent illness5 .
massage on the neck muscles extends the 
 range of cervical spine rotation7 and 
 improves neck flexor muscles8 . in 
 addition
, massage after total knee arthroplasty decreases pain and increases the 
 diarthrodial range9 . in the current study , 

in addition to the extension of diarthrodial range , it influences stress hormones 
 ( epinephrine and norepinephrine ) , which can trigger the activation of sympathetic nerves 
 such as an increase in heart rate , contraction of blood vessels and muscle tension , as well 
 as circulation throughout the body via blood10 .
thus , massage has been confirmed to have positive effects on 
 changes in hormones11 , 12 , blood pressure13 , 
 14 and heart rate15 .
this study was performed to provide a theoretical 
 rationale for the application of massage as stress therapy in female office workers . with 
 the goal of improving health and quality of life ,
this study is based on the analysis of the 
 effects of massage on stress hormones , including blood pressure and heart rate .
the target population of this study was female office workers ; 2049 year old female office 
 workers at 3 institutions located in city g were randomly recruited as an accessible 
 population .
11 were placed in experimental ( exp ) group 
 ( i ) , 11 in experimental ( exp ) group ( ii ) and 12 in the control group ; their physical 
 features are provided in table 1table 1.physical characteristics of the subjectsage ( years)height ( cm)weight ( kg)exp ( i ) ( n=11)42.6  2.0158.1  3.159.2  4.5exp ( ii ) ( n=11)43.1  1.8158.1  2.359.1  1.2cont ( n=12)42.6  1.7158.0  1.258.9  1.2exp : experimental group , cont : control group .
exp : experimental group , cont : control group this study was approved by the ethics committee at dongguk university of korea and written 
 consent to participate in the study was obtained from all of the subjects in accordance with 
 the declaration of helsinki .
scalp massage was performed for 15 minutes / session for exp ( i ) and 25 minutes / session for 
 exp ( ii ) , twice a week , for a total of 20 times over 10 weeks in both groups .
the scalp 
 massage room was maintained at a humidity of 4060% and a temperature of 2627c .
the 
 investigator trained one sub - investigator with scalp care experience on the necessity and 
 purpose of this study in order to maintain the accuracy and validity of experimental 
 procedures .
the sub - investigator performed the scalp massage under the supervision of the 
 investigator .
details of the program are presented in table 2table 2.scalp massage program for 10 weeksweeksordertimecontentsfrequencyexp ( i)exp ( ii)110warm - up3  min2  minstretching before massagemain program19  min11  min .
massage in shoulder ( 3 times)2 times /week compression by a thumb compression by a wrist grasp and squeeze by a finger champi compression under down [ ed : unclear] massage in neck grasp and pull down in the muscle of neck massage under the larynx massage in the occiput massage in a zig - zag wave exercise flip by a finger effeurage by a finger tapotement by a finger pull up a hair grasp up by head rolling and massage a circle in the temples of one s head massage in a ear massage a hole in a facecool - down3  min2  minstretching after massage .
blood collection to measure the levels of stress hormones ( epinephrine , norepinephrine and 
 cortisol ) was performed in the subjects following at least 12 hours of fasting .
the 
 collected blood was centrifuged for 10 minutes at 3,000  rpm using a centrifuge ( model 
 hc-16a , korea ) ; the post - centrifugal plasma was stored at 73  c and referred to laboratory 
 n for hemanalysis .
blood collection was conducted before the first scalp massage and at 9 am 
 the following day .
blood 
 pressure was measured before the first scalp massage and after 10 weeks , for a total of two 
 times , using a mercury sphygmomanometer ( omron hem-770a , japan ) .
the mean value of the 2 measurements was used as 
 the average blood pressure .
the subjects heart rates were also measured before the program 
 and after 10 weeks at a stable status using the sport tester pe 3000 ( polar electro co. 
 finland ) ; each measurement was conducted for 5 minutes and the mean value of the 2 
 measurements was used as the heart rate .
the 
 primary effect and interaction effect on the time interval and between groups were evaluated 
 using a two - way repeated anova , and a post - hoc test was conducted using the duncan test .
a scalp massage was performed for 15 
 minutes / session for exp ( i ) and 25 minutes / session for exp ( ii ) , for 10 weeks .
there was no significant difference in the time 
 interval and interactions between groups for epinephrine ( p>0.05 ) . however , there were 
 significant differences in the time interval and interactions between groups for 
 norepinephrine and cortisol . in an assay of primary effects caused by the time interval
, 
 significant differences were found among epinephrine , norepinephrine and cortisol , leading 
 to a meaningful difference in exp ( ii ) for epinephrine in the post - hoc test as well as in 
 exp ( i ) and exp ( ii ) for norepinephrine and cortisol with prior and post - hoc tests . 

significant differences between groups were also found for norepinephrine and cortisol , 
 leading to meaningful differences between exp ( i ) and the control group and between exp ( ii ) 
 and the control group for both norepinephrine and cortisol ( table 3table 3.the influence of stress hormones according to group by 10 weeks , before and 
 aftervariablespre massagepost massageexp ( i)exp ( ii)contexp ( i)exp ( ii)contepinephrine263.8  63.1254.0  7.9262.9  60.1212.4  37.0222.6  33.1**254.1  35.4norepinephrine751.6  92.5680.5  110.2739.1  117.8450.0  127.9499.5  126.2655.1  189.3cortisol23.4  2.724.2  3.824.6  2.916.3  2.015.3  2.223.9
 1.8values are expressed as mean  sd , * p<0.05 , * * p<0.01 : significance different 
 between pre and post massage
. significance different between exp ( i ) and 
 cont , significance different between exp ( ii ) and cont ) .
values are expressed as mean  sd , * p<0.05 , * * p<0.01 : significance different 
 between pre and post massage
. significance different between exp ( i ) and 
 cont , significance different between exp ( ii ) and cont there was a significant difference in systolic blood pressure and diastolic blood pressure 
 in terms of the interaction effect between time intervals and by group . in an assay of 
 primary effects caused by time intervals ,
a significant difference was found in systolic 
 blood pressure and diastolic blood pressure , leading to a meaningful difference in exp ( i ) 
 and exp ( ii ) for both systolic blood pressure and diastolic blood pressure with prior and 
 post - hoc tests . a significant difference between groups
was also found for systolic blood 
 pressure and diastolic blood pressure , leading to a meaningful difference between exp ( i ) 
 and the control group and between exp ( ii ) and the control group for both systolic blood 
 pressure and diastolic blood pressure ( table 
 4table 4.the influence of blood pressure and heart rate according to group by 10 weeks , 
 before and aftervariablespre massagepost massageexp ( i)exp ( ii)contexp ( i)exp ( ii)contsystolic blood pressure157.6  3.7150.1  2.9152.5  2.1139.8  3.0135.4  1.7147.4  1.8diastolic blood pressure99.9  3.695.9  2.0101.8  2.289.6  2.684.8  2.498.9  2.0heart rate80.0  7.281.1  9.181.5  2.273.3  7.177.1  12.880.1  2.9values are expressed as mean  sd , * p<0.05 , * * p<0.01 : significance different 
 between pre and post massage.significance different between exp ( i ) and 
 cont , significance different between exp ( ii ) and cont ) .
values are expressed as mean  sd , * p<0.05 , * * p<0.01 : significance different 
 between pre and post massage.significance different between exp ( i ) and 
 cont , significance different between exp ( ii ) and cont for heart rate , there was no significant difference in terms of interaction between time 
 interval and by group ( p>0.05 ) .
additionally , no significant difference in the primary 
 effect caused by time intervals and between groups was found ( p>0.05 ) ( table 4 ) .
there are two different neuroendocrine systems associated with stress : one is the 
 sympathetic system - adrenal medulla axis involved in the secretion of epinephrine and 
 norepinephrine and the other is the hypothalamus - pituitary - adrenal medulla ( hpa ) axis 
 involved in the secretion of cortisol16 . 

the physiological effect of massage in general can be divided into a relaxation effect and a 
 stimulation effect .
the relaxation effect involves hypothalamic reactions associated with 
 the decline of sympathetic system activity and an increase in parasympathetic system 
 activity .
there are two types of stimulation effects : one is reflexive and the other is 
 mechanical .
the reflex effect is refreshing and relaxing due to delivering stimulation at 
 the cutaneous peripheral nerve to the cerebrum .
peripheral cutaneous stimulation promotes 
 circulation through stimulation of the parasympathetic nerve , relaxation of muscles and 
 extension of capillary vessels .
ultimately , massage reduces sympathetic nerve activity while 
 increasing parasympathetic nerve activity17 . in this study ,
15-minute and 25-minute scalp massages had a 
 significant effect on norepinephrine and cortisol while the 25-minute scalp massage had a 
 significant effect on epinephrine .
this suggests that a scalp massage decreases the 
 activation of the sympathetic nerve while increasing the activation of the parasympathetic 
 nerve , resulting in a decrease in the secretion of norepinephrine and cortisol , or in other 
 words , stabilization of hormone levels .
however , only in the case of the 25-minute scalp 
 massage was there a significant difference in the level of epinephrine .
this seems to be caused 
 by either personal sensitivity differences and time variance18 or as a result of personal differences between subjects and time 
 variance .
in addition , the study demonstrated that the levels of epinephrine were 
 unpredictable and could increase in uncontrolled noise environments19 .
a previous study demonstrated that the low frequency ( lf ) sympathetic nerve activity marker 
 significantly decreased whereas the high frequency ( hf ) parasympathetic nerve activity 
 marker significantly increased after 15 minutes of scalp massage20 .
another study demonstrated the effects of a 20 minute 
 scalp massage on norepinephrine and cortisol21 .
the results of our study were in agreement with these existing 
 studies , suggesting that a>15 minute scalp massage has a positive effect on stress 
 hormones .
the results also suggested that stress increases cardiac output and blood pressure by 
 influencing the sympathetic nerve , resulting in the increase of peripheral blood pressure by 
 epinephrine , leading to the relaxation of blood vessels and increased blood flow rate in the 
 liver , heart muscles and brain tissues .
in addition , norepinephrine is known to cause 
 vasoconstriction , increase blood pressure , general peripheral resistance22 , and pulse due to rising blood cortisol 
 concentration levels during mental stress .
there was a significant decrease in both systolic and diastolic blood pressure after 15 and 
 25 minute scalp massages , which seems to be a result of the stabilization of hormone levels 
 caused by an increase in the activation of sympathetic nerves and parasympathetic nerves and 
 the subsequent decrease in the concentration of norepinephrine and cortisol hormone .
this is 
 probably because the scalp massage promoted blood circulation , resulting in a positive 
 effect on the neck muscles and the relaxation of blood vessels7 , 8 . after performing scalp 
 massage in adults at the normotensive or prehypertensive stage
additionally , 4 weeks of massage at work was shown to significantly decrease strain and 
 blood pressure14 . under the control of the autonomic nervous system , the heart rate increases when the 
 reaction of the sympathetic nerve system is accentuated . in this study ,
the heart rate did 
 not seem to decrease significantly despite a decrease in the level of norepinephrine and 
 cortisol hormones controlling the sympathetic nerve system .
however , the heart rate showed a 
 tendency to drop slightly . in a previous study involving carotid sinus massage in aged 
 subjects ,
blood pressure and heart rate were shown to decrease24 and a significant decrease in heart rate was confirmed 
 after 4560 minutes of muscle massage in middle aged men and female performed at different 
 intensities25 . in a study using massage 
 ( at moderate and mild intensity ) and a vibrator , massage treatment at moderate intensity was 
 shown to significantly reduce the heart rate26 .
these differences from the existing study might be because massage 
 in this study was not performed frequently ( twice a week ) and the intensity was relatively 
 mild .
in general , only the heart rate did not show a significant difference and the scalp 
 massage had positive effects in terms of hormones and blood pressure .
we recommend active utilization of a scalp massage program with no spatial or time limits 
 in female office workers , as the use of a scalp massage lasting 15 minutes or less as a 
 stress control program could have a positive effect .
furthermore , better results are 
 expected in future studies if the intensity of the massage is varied while considering the 
 physical condition of the subjects .
 [ purpose ] a scalp massage was conducted on female office workers divided into a 15 minute 
 group and 25 minute group and its effect on stress hormone , blood pressure and heart rate 
 was analyzed in order to provide a theoretical rationale to apply scalp massage as stress 
 therapy . 
 [ subjects and methods ] a scalp massage was applied to 34 female office workers 
 twice a week for a total of 10 weeks ; the subjects were classified into 15  min . 
 , 25  min . 
 
 and control groups , and their stress hormone levels , blood pressure and heart rate were 
 evaluated . 
 [ results ] significant differences in norepinephrine , cortisol and blood 
 pressure ( sbp & dbp ) were found in terms of interaction by time interval and between 
 groups . 
 [ conclusion ] as a result of applying scalp massage to female office workers for 15 
 and 25 minutes , positive effects were observed on stress hormone , blood pressure and heart 
 rate . 
 therefore , scalp massage can be used for stress control with no spatial or time 
 limit . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION