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. 2023 Feb;77(1):24–28. doi: 10.5455/medarh.2023.77.24-28

Effect of Massage Therapy with Lime (Citrus Aurantifolia) Essential Oil on the Recovery of Delayed Onset of Muscle Soreness in Athletes

Novita Sari Harahap 1, Nimrot Manalu 2, Nurhamidah Sari Siregar 1, Yetty Machrina 2,3
PMCID: PMC10008347  PMID: 36919127

Abstract

Background:

Physical exercise is a systematic exercise to increase muscle strength achieve goals such as improving the athlete’s physical and preventing injury. Athletes must do is massage therapy to prevent muscle fatigue and pain due to physical exercise or during competition. The increase of lactic acid levels affects the maximum working ability of muscle fibers, decreases physical performance, and is fatigue in which the onset of pain. Lime essential oil as a topical oil contains high ester substances that have pharmacological effects such as natural analgesic effects to relieve pain.

Objective:

The purpose of this study was to determine the effect of massage therapy with lime essential oil as a topical oil on the recovery of delayed-onset muscle soreness (DOMS) in athletes.

Methods:

The participants are boxing athletes, 30 men, 20–22 years old, and non-smokers. Participants were divided into three groups. The exercise group (E) was doing exercises and was not given massage therapy; the exercise massage (EM) group, namely, doing exercises and being massaged with ordinary lotion as a topical oil; and the EM lime (EMC) group did exercises and was given a massage with lime essential oil as the topical oil.

Results:

The results showed that there was a significant difference in the average levels of lactic acid (p = 0.000) and the athlete’s pain intensity (p = 0.000) in the three groups, namely, the exercise group (E), the exercise and massage group (EM), and the exercise and massage with lime essential oil (EMC).

Conclusion:

This study finds that lime essential oil used as topical massage therapy oil is better for accelerating the DOMS.

Keywords: Delayed onset of muscle soreness, Lime essential oil, Massage therapy

1. BACKGROUND

In realization sports, athletes will receive exercises that can improve their performance, including fitness exercises that are useful for maintaining physical fitness and muscular strength. Exercise requires intensive and continuous energy so that the muscle's need for oxygen is very large. During strenuous and exhausting physical exercise, relative hypoxia occurs so that the amount of oxygen in the tissues is reduced. Muscles will contract under anaerobic conditions so that the energy supply is met through the anaerobic glycolysis process. As a result, muscle glycogen during physical exercise is reduced and has the potential to produce lactic acid (1).

Increased lactic acid levels, can affect the maximum working capacity of muscle fibers, reduce physical performance, and is one of the factors causing tiredness in athletes. The result of fatigue has an impact on the onset of pain in contracting muscles called Delayed Onset Muscle Soreness (DOMS). Pain can be caused through an inflammatory process in physical activity, which includes numerous eccentric muscle contractions (2). Exercise without adequate control can lead to muscular damage and inflammation. Pain measurement is very important for determining the intensity or quality of pain a person is experiencing (3).

DOMS is the pain that happens within 24-72 hours of physical activity, and recovery happens within 4-6 days. DOMS will provoke people suffering from pain which the experience in the days following the event of exercise. Muscular pain is a physiological effect upon tissues wich reacts to muscle activity (4). The pain in the muscle has an impact on the decrease in muscle force that can affect the athlete's performance. One of the treatments often used by athletes is massage therapy, which aims to reduce muscular tension caused by physical exercise or competition (5).

Lime (Citrus aurantifolia) is a plant of the rutaceous family that may produce essential oils on the skin of the fruit. The pharmacological effect of lime essential oil can cause physical and psychological relaxation effects because it contains the bioactive substances linalool and linalyl acetate. Lime essential oil also contains high ester substances so that has pharmacological effects such as natural analgesic effects to relieve muscle pain. This is related to the anti-stress and antidepressant effects which give the body a response to be over when the pain. In some studies, massage therapy usually uses lotion for topical massage therapy (6). The difference in this study is that the topical ingredients for massage therapy use lime essential oil. Recovery must be carried out after each physical activity aimed at removing lactic acid in the muscles.

Recovery and immediately the following exercise is essential to improving an athletes’ performance. The muscle recovery mechanism may be achieved by increasing the removal of lactic acid through increased microcirculations. Massage therapy can facilitate in removing of lactic acid from tissues by increasing the flow of lymphatic fluid or blood, so that lactic acid can diffuse out of the muscles and into the blood (7).

The findings of the study using the visual analog Scala measuring instrument (scale 1-10) showed that in the group that received the massage there was a decrease in pain (8). Research shows that massage after exercise can reduce the time to recuperate and prevent muscle pain after exercise. The study showed that the arm that received a recovery in the form of massage experienced a 10% -20% reduction in pain (9).

Based on the previously mentioned considerations, the purpose of the study is to determine the impact of massage therapy with lime essential oil as a topical oil on the recovery of DOMS in athletes.

2. OBJECTIVE

The purpose was to determine the effect of massage therapy with lime essential oil as a topical oil on the recovery of delayed-onset muscle soreness (DOMS) in athletes.

3. MATERIAL AND METHODS

Ethical approval

This research procedure is in accordance with the principles of the Declaration of Helsinki (World Medical Association, 2002) and has been approved by the Ethics Committee for the Implementation of Health Research at the University of North Sumatra (reference number: 523/KEPK/USU/2022). Participants accepted to be part of the study by signing an informed consent form. Massage therapy was conducted by three female masseurs and three male masseurs and trained and tested prior to the study.

Participants

The participants are boxing athletes, 30 men, 17 to 19 years old, and non-smokers. Participants were divided into 3 groups, the exercise group (E) was doing exercises and was not given massage therapy; the exercise massage (EM) group, namely doing exercises and being massaged with ordinary lotion as a topical oil; the exercise massage lime (EMC) group did exercises and was given a massage with lime essential oil as the topical oil.

Protocol exercise

The exercises are given according to the training program from the trainer with a frequency of 3 times a week for 4 weeks. Massage is given to the arms and legs, every 30 minutes after exercise. Before and after treatment, lactic acid levels and pain intensity were examined. Then the data were analyzed using the Anova test statistic

Lactic acid and pain intensity assessment

This study made use of a research instrument known as accutrend lactate with the market brand Roche type 3012522, and the Visual Analogue Score (VAS) a pain scale for measuring the severity of muscular pain. Assessment of pain intensity can be measured using The Visual Analog Scale (VAS). VAS is a valuable approach to measure the severity of pain as described by the subjects, with maximum repeatability among observers (10). VAS is a scale in the form of a straight line which usually has 100 mm long with verbal markings on each end that indicates the intensity of pain felt by the patient, such as at indicate “no pain” and the other end indicates no pain intolerable. Next, the patient is give instruction to put a cross in the range of the lines to describe the pain you are experiencing (11). This instrument's primary purpose is to measure the amount of lactic acid. This instrument has been proven to be valid for use in the manipulation of lactic acid levels.The method for the accutrend test begins with the participant's fingertip being pierced with lancets in order to draw blood. The blood is then dripped onto the lactic acid BM Strip, after which the lactate strip is inserted and monitored with an accutrend lactate monitor (lactate meter).

Statistical analysis

The data were shown using mean and standard error of the mean representations (SEM). The data were analysed using either a one-way analysis of variance (Anova), followed by the relevant post-hoc tests, so that numerous comparisons could be made. GraphPad Prism, version 8.0.2, was used for the statistical analyses (GraphPad Software, Inc., USA). For statistical significance, a P-value of less than 0.05 was used.

4. RESULTS

The Body Mass Index (BMI) of the participants is shown in table 1. There were 27 people in the normal weight category, which had a percentage of 90%, 2 people in the underweight category, which had a percentage of 6.67%, and 1 person in the overweight category, which had a percentage of 3.33%.

Statistical analysis results from the Anova test revealed a significant difference in mean lactic acid levels (p=0.000) and the athlete's pain intensity (p=0.000) in all groups, namely the exercise group (E), the exercise and massage group (EM), and the exercise group (EM). exercise and massage with lime essential oil (EMC), as indicated in Table 2. In Figure 1, according to the Tukey follow-up test, there is a significant in mean lactic acid level between the E group and the EM group (p=0.013; p<0.05); E group with EMC group (p=0,000; p<0,05) and EM group with EMC group (p=0,043; p<0,05). This indicates that the EMC group was more effective in reducing lactic acid than the E group and the EMC group. In Figure 2, according to the Tukey follow-up test, there is a significant in mean pain intensity between the E group and EM group (p=0.000; p<0.05); E group with EMC group (p=0.001; p<0.05) and EM group with EMC group (p=0.001; p<0.05). This indicated that the EMC group was more effective in reducing pain intensity than the E group and the EMC group.

Table 2. The differences mean of lactic acid and pain intensity in the exercise (E), exercise and massage (EM), and exercise and massage with lime essential oil (EMC). Note: *= significant (p<0,05), Sd: standar deviation, E: the exercise group, EM: the exercise and massage group, EMC: the exercise and massage group with lime essential oil.

Variable E group
(mean ± Sd)		 EM group
(mean ± Sd)		 EMC group
(mean ± Sd)		 Anova
P
Lactat acid (mmol/L) Pre test
Post test
t-dependent		 4.15 ± 0.24
5.0 ± 0.45
0.00		 4.74 ± 0.37
4.24 ± 0.46
0.003*		 4.7 ± 0.41
3.6 ± 0.69
0.000*		 0,000*
Pain intensity Pre test
Post test
t-dependent		 3.5 ± 0.52
3.1 ± 0.32
0.037*		 3.6 ± 0.52
1.9 ± 0.32
0.000*		 3.6 ± 0.52
1.3 ± 0.48
0.000*		 0,000*
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Figure 1. Differences in mean lactic acid levels before and after treatment.

Figure 1.

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Figure 2. Difference in mean pain intensity before and after treatment.

Figure 2.

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Table 1. Frequency Distribution of BMI Athletes.

BMI f %
Underweight (< 18,5 kg/m2) 2 6.67
Normoweight (18,5-24,9 kg/m2) 27 90
Overweight (25-29,9 kg/m2) 1 3.33
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5. DISCUSSION

The results showed that massage using lime essential oil as a topical oil after exercise in athletes accelerated the DOMS recovery process. It may prevent fatigue because it reduces lactic acid levels and pain intensity compared to other groups. Decreased lactic acid levels and pain intensity in the EMC group was caused by the influence of massage therapy as an active form of recovery. Indeed, the use of lime essential oil as a topical oil, it has a greater effect on reducing lactic acid and pain intensity. Thus it may increase the tolerance to lactic acid and increase the buffering capacity of bicarbonate and phosphate in the muscle (12). Massage therapy with lime essential oil as the topical oil is an efficient effort to eliminate lactic acid in athletes so as to prevent DOMS. There is some evidence that massage therapy performed after intense exercise can help reduce delayed onset muscle soreness and boost muscle performance (13). Another advantage is the relief of muscle pain by increasing the pain threshold, due to an increase in the production of endorphins (14). Recovery may reduce muscle pain, this happens because of the elimination of lactic acid by increasing microcirculation in muscles (15). Athletes are usually given high-intensity and continuous training to improve their performance. The condition of fatigue and muscle pain in these athletes should be avoided, because DOMS conditions can interfere with athlete performance. Athletes must have excellent physical condition, which can always be beneficial to maintain muscle fitness. Fatigue is a physiological phenomenon, a process of decreasing tolerance to physical work. The cause is very specific depending on the characteristics of the work. As a solution, massage therapy using lime essential oil as the topical oil can be used for athlete care, especially after exercise (16). Increase in lactic acid levels in the E group was caused by hypoxia in muscle resulting in anaerobic metabolism that produces lactic acid (17). The increased need for oxygen, especially by contracting muscles, causes ischemic reperfusion and can trigger the formation of free radicals. The increased in lactic acid can stimulate reactive oxygen compounds to become more reactive, thus disrupting athletic performance (18). Free radicals that are formed during strenuous and exhausting physical exercise will cause tissue damage, including liver muscle tissue, blood, and other tissues (19).

The pain can be caused by the dose of exercise and the intensity of the exercise given is not in accordance with the individual's ability or excessive muscle training or overtraining. If in someone who is not an athlete, the damage can be caused by muscle activity that exceeds the ability to carry out activities and movements that are wrong. Other factors are stiffness, speed of contraction, muscle fatigue, and position at the time of movement. One of the treatments that is often done by athletes is massage therapy which aims to reduce muscle tension due to physical exercise or during competition (20).

Many studies have pointed to Citrus aurantifolia as a significant natural flavonoid source. Citrus aurantifolia has potent antioxidant and antinociceptive properties, which can be found in fruit, peel, essential oil, and isolated components (21). Flavonoids are classes of phytochemicals that are regarded to be essential due to the different pharmacological effects they display (22). The activity of flavonoids does not rely on the elimination of a single mechanism, but rather on the reduction of numerous mechanisms, thereby affecting multiple targets in the neurological processes that underlie the manifestation of pain (23). Flavonoids are multi-target chemicals, and their anti-inflammatory and analgesic activities have attracted a growing amount of interest (24) In different animal models of pain, flavonoids have been shown to have strong antinociceptive effects (25). The results of previous studies stated that flavonoids contained in citrus have the potential to have an antinociceptive effect on pain in post-operative conditions (26).

Lime essential oil which is applied when the massage may also accelerate the healing process in time of inflammation. Pain is one of the signs of inflammation, with decreasing inflammation, there will be a decrease in muscle pain. The addition of massage therapy will provide physiological effects in the form of a relaxing effect, increase blood flow, and lymphatic flow, stimulate the nervous system, and increase venous return so that it can reduce pain due to spasm muscle shortening, or due to fibrosis (27).

Lime essential oil contains several active compounds such as flavonoids, saponins, alkaloids, tannins, steroids, phenols, limonene, linolyl acetate, and citronella. Lime essential oil has an antioxidant effect because it contains flavonoids. Flavonoids have the ability to protect lipid membranes from damage and inhibit the expression of the enzyme Cyclooxygenase-2 (COX-2) so that the biosynthesis of pain mediators such as prostaglandins is inhibited. Thus it will reduce the production of prostaglandins by arachidonic acid thus reducing pain (28). These flavonoids effectively inhibit the production of nitric oxide (NO), interleukin (IL)-10, IL-6, and TNF-α. Flavonoids are able to inhibit the production of inflammatory prostaglandin E2 and pro-inflammatory cytokines (29). The results of previous research stated that flavonoid antioxidants as anti-inflammatories in red dragon fruit can inhibit cyclooxygenase-2 (COX-2) and at the same time inhibit inflammatory processes (30-31). Flavonoids have been shown to reduce the production of pro-inflammatory cytokines including TNF- (32), according to studies by Harahap et al., (2021).

Lime essential oil can cause physical and psychological relaxation effects because it contains the bioactive substances linalool and linalyl acetate (33). Pharmacokinetically, the two main bioactive compounds (linalool and linalyl acetate) in lime essential oil administered through massage are well absorbed through skin penetration. The essential oil will be absorbed directly into the bloodstream when applied during massage, affecting the muscles directly and the effect can last long after the massage (34).The natural analgesic effect of lime essential oil is safe because its components can penetrate the skin as well as penetrate the lower layers of the skin. After being applied to the skin, essential oils and their components are metabolized rapidly, do not accumulate in the organism, and are excreted rapidly (35). Massage therapy using essential oils is easier, cheaper, and without side effects. Massage therapy is effective for reducing pain and allowing athletes to easily perform physical exercises. The results of this study prove that massage therapy can increase the elimination of lactic acid during the recovery period after high-intensity exercise (36).

6. CONCLUSION

This study finds that lime essential oil used as topical massage therapy oil is better for accelerating the DOMS recovery process. This is evidenced by the decrease in lactate levels and reduced pain after exercise.

Acknowledgments:

The researchers are grateful to all participants who accepted to be part of the study. This research was funded by the Ministry of Education, Culture, Research and Technology, the State University of Medan with study contract number 0008/UN33.8/PPKM/PTI/2022.

Participant Consent Form:

Before the study, first, explain to the participants about the purpose and objectives of the study and the treatment that will be given while participating in the study. If agreed then the participant signed the informed consent agreement.

Authors contribution:

Each author provides a contribution starting from observing a condition that occurs in athletes, then creating conception and research design, analyzing and interpreting data for the article. Each author has a role in compiling articles and revising them.

Conflict of interests:

None declared.

Financial support and sponsorship:

Funding by DIPA Medan State University.

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