Kanpumasatsu: A superficial self-massage with a dry towel to enhance relaxation and immune functions

Abstract

Prior to 2020, healthcare professionals in the United States already had high rate of burnout. Since 2020, the COVID-19 pandemic created an urgent need for public health measures to effectively mitigate its negative health impacts. Despite these measures including vaccination, masking, handwashing, and physical distancing, people continue to be affected by post-COVID conditions (PCC) or newly acquired infections. Promoting one's well-being and self-care, especially the methods that promote one's relaxation and immune functions will serve as valuable tools among all healthcare practitioners and educators. For example, Kanpumasatsu, a skin rubdown using a dry towel, is simple to instruct, safe, and a cost-containing self-care approach that has the potential to promote relaxation and improve one's immune functions. At the present moment, the evidence is limited and the mechanism of how kanpumasatsu improves immune functions has not been clearly documented. However, this author postulates this superficial massage causes the skin to stretch and enhances the lymphatic flow beneath the skin in a mechanism similar to that of lymphatic drainage massage. While the limited evidence of the health benefits of kanpumasatsu is available today, there is a potential for creating and enhancing instructional resources, conducting research and practice through awareness of kanpumasatsu among interprofessional educators and practitioners as a pilot self-care program to prevent burnout.

1. Introduction

According to the National Academies of Science, Engineering, and Medicine's report in 2019, before the COVID-19 pandemic, the burnout rate among nurses and doctors in the United States was already between 35 and 54%.¹ Similarly, the rate of burnout among medical students and residents was between 45 and 60%.¹ Thus, the human capital of the healthcare system had already been significantly burdened by this high rate of burnout. Among a range of factors that contribute to healthcare professionals' burnout, the most obvious to note are job demands, such as workload, time pressure, technology stress, moral and ethical dilemma, lack of job resources and support as well as lack of work-life integration.¹

In this context, the COVID-19 pandemic has created compounding burden to healthcare professionals. As of Dec. 9th, 2022, there had been 643,875,406 confirmed cases of COVID-19 globally including 6,630,082 deaths.² In the U.S. as of Dec. 12, 2022, there had been 99,241,649 confirmed cases and 1,080,472 total deaths.³ As the COVID-19 pandemic continues to pose fear and caregiver burden globally, COVID-19's physical, cognitive and mental health impacts are being researched from various perspectives. Wei et al. discovered that the adults with chronic respiratory conditions, such as asthma and chronic obstructive lung diseases (COPD) are more likely to report both physical and mental health symptoms during the COVID-19 pandemic compared to others.⁴ By exploring the plausible reasons for long-term cognitive impact of COVID-19, such as fatigue, attentional, memory, and executive processes, Dondaine et al. argue that these cognitive impacts are due to pneumonia-induced hypoxia, infection of central nervous system and microstrokes.⁵

Health care professionals have witnessed firsthand the magnitude of the pandemic and the vulnerability of people.⁶ During the early stage of the COVID-19 pandemic, healthcare professionals experienced the fear of uncertainty, lack of Personal Protective Equipment (PPE), and the perceived and real increased risk of infection to themselves and others.⁷ All these added stressors manifested more psychologically than physically among healthcare professionals, for instance, manifesting as anxiety and burnout.^{7 , 8} The U.S. Department of Health and Human Services/Center for Disease Control and Prevention reported that out of 26,174 public health workers surveyed, 52.8% indicated that they had at least one adverse mental health conditions in the past 2 weeks.⁹ One of the recommendations to prevent the high rates of mental health manifestations and burnout from chronic stress among healthcare professionals was to pilot a new preventive program that can be implemented facility-wide and assess the outcomes after its implementation.⁹ Kanpumasatsu, a self-massage using dry towel can be one of such pilot programs since it is cost and time efficient and easy to instruct.

Even after the peak of the pandemic appears to have passed, healthcare professionals experience continuous stress because chronic health concerns are being recognized after the management of acute symptoms associated with the COVID-19 pandemic. It is called post-COVID conditions (PCC) which is an umbrella term encompassing a variety of mental and physical health consequences that are present for 4 or more weeks after the initial onset of SARS-CoV-2 infection.¹⁰ According to the U.S. Census Bureau's Household Pulse Survey¹¹; 18–19% of the U.S. adults who ever had COVID currently experiencing PCC. The ongoing PCC presence adds fear and burden to healthcare professionals who are already experiencing chronic stress and its adverse impact on their health.^{9 , 12}

Due to the chronic stress described above, healthcare professionals need self-care more than ever. The primary aim of self-care for the individual is to become stress resilient and be able to attain optimal quality of life. To do so, we bring our attention back to the concept of “milieu intérieur”.¹³ Its English translation is “Internal milieu.” This concept was created by Claude Bernard, a French scientist and physician in mid 1800s, as the blood and the lymph which serve as the body of water where the organism's cells are bathed in. This internal environment is controlled by the organism and to be maintained at a desirable state for the organism, which was later called homeostasis.^{13 , 14} Unlike blood vessels, the lymphatic system is not easily visualized and thus clinicians may not pay careful attention to it unless its malfunction causes observable swelling, i.e., lymphedema. In addition to lymphedema, a malfunction of the lymphatic system has been implicated with a variety of systemic conditions, such as inflammatory disorders ²², immune tolerance⁵², metabolic conditions, such as obesity and metabolic syndrome,¹⁵ cardiovascular diseases,¹⁶ cancer growth and metastasis,17, 18, 19 infectious diseases^{20 , 21} and septic shock²². Kataru et al.'s review article concludes that the lymphatic system is an important regulator of immune responses.²³ To overcome chronic stress and its adverse effects on health, healthcare professionals must be able to benefit from exploring a cost and time effective preventive approach which is focused on the optimization of one's internal milieu.

For the optimization of our internal milieu, it is essential to relax and restore the balance of the autonomic nervous system. In the United States, relaxation methods such as yoga,²⁴ tai chi,²⁵ massage,^{26 , 27} breathing,²⁸ acupuncture, and meditation are well known, but kanpumasatsu is not yet well recognized. However, similar superficial skin stimulation, such as dry brushing has been practiced in spas to exfoliate and improve circulation and lymphatic flow.29, 30, 31, 32 One source indicates that it is practiced all over the world.³³ The tool to brush the skin vary from one tradition to another. For example, Native Americans use dried corncobs, Ayurvedic practitioners use raw-silk gloves, Europeans use bristles, and in traditional Chinese medicine, dried fruit fibers are recommended.³³ Similar to the way dry brushing practice spread, Kanpumasatsu has a potential to become a common self-care practice. By introducing kanpumasatsu, we could encourage healthcare researchers, educators, and practitioners to conduct more research in the future.

2. Kanpumasatsu and its evidence

Kanpumasatsu is an ancient health promoting technique developed and practiced in Japan. Its origin is believed to be from Ayurvedic Medicine in India⁴⁹. In the Japanese language, kanpu means dry towel and masatsu means friction. It is believed that kanpumasatsu became popular in 1940s to prevent respiratory infections in elementary schools in Japan.³⁴ This writer remembers practicing kanpumasatsu at her elementary school in Tokyo in 1960s. Typically, a soft cotton towel is used to rub the whole body from distal to proximal segments and in slow steady repetitions totaling 5–10 min in duration. It can be practiced directly against the skin or with a minimally clothed fashion. Some researchers translated kanpumasatsu in English as skin rubdown with a dry towel.^{34 , 35} It stimulates the skin in a way similar to other oriental medical practices, such as acupuncture, moxibustion and massage⁴⁹.

There is ample research evidence on these techniques' effects in preventing colds,³⁵ enhancing immunity,^{36 , 37} increasing blood flow, activating natural killer cells, and improving metabolism through the autonomic nervous system.^{38 , 39} Tactile stimulation to the skin has been known to play a critical role in animal and human growth, influencing DNA expressions, and reflexive effects on a variety of physiological functions.⁴⁰ Field et al.⁴¹ demonstrated that tactile skin stimulation increased the rate of weight gain among neonates with low birth weight who were separated from their mothers.^{41 , 42} In addition, Pauk et al.⁴³ reported that the lack of growth hormones among maternally-deprived rat pups was prevented by repeatedly brushing the skin surface. Furthermore, it is reported that rat pups who were deprived from mother's licking and grooming had lower levels of serotonin in their hippocampus region of the brain. This affects the amount of glucocorticoid production at their DNA level which may have a long-term impact on the development of the HPA axis, which results in poor stress resiliency in their future.^{26 , 27} Physical agents, in particular skin stimulation, such as acupuncture, various massage, or application of hot pack on the skin, are utilized to relieve musculoskeletal pain, reduce soft tissue stiffness by improving blood circulation, and balancing the internal organ functions.⁴⁰ Mental and physical stress and pain are known to cause secretion of catecholamine from the adrenal cortex. However, among anesthetized rat pups, brushing their chest area caused a decrease in the sympathetic nervous system drive and inhibition of catecholamine secretion.⁴⁴ Furthermore, tactile skin stimulation on abdominal region of the rats under anesthesia caused increased dopamine production.⁴⁵ All these effects of tactile skin stimulation may apply to kanpumasatsu, but it has not been fully examined by itself. Typically, a soft cotton towel is used to rub the whole body from distal to proximal segments and in slow steady repetitions totaling 5–10 min in duration. It can be practiced directly against the skin or in a minimally clothed fashion.

To respond to the lack of research on kanpumasatsu, Watanabe et al. investigated the mechanism of kanpumasatsu as a health promotion therapy³⁵. They randomly assigned 12 healthy male adults into the kanpumasatsu group and other 12 into the control group. After 5 min of kanpumasatsu, body temperature, pulse rate, blood gas (PO₂, sO₂, pH) and lactate were increased. However, they were not statistically significant changes. It was concluded that kanpumasatsu is a mild aerobic, systemic exercise that might affect immune function through the autonomic nervous system.³⁵ The Health Channel, a Japanese public TV program explored the kanpumasatsu's health benefits by interviewing participants who practiced it twice a day (upon waking up in the morning and before going to bed) for one month. They revealed that 10 out of 12 participants reported that they perceived higher quality of sleep during this practice⁴⁹.

Another study assessed the effects of kanpumasatsu applied to sixteen bed-ridden older patients in Japan.³⁴ The results showed that there were no significant changes among lymphocyte count, gamma-globulin, or C-reactive protein (CRP) levels, but neutrophil count increased after 10 days from the initial kanpumasatsu application. Furthermore, natural killer cell activity increased at 5 and 10 days after the initiation of kanpumasatsu.³⁴ The mechanism of the increase in natural killer cell activity was believed to be either through stimulation of the sympathetic nervous system or through the effect on the mediators from the T lymphocytes. The authors concluded that kanpumasatsu may be used to reduce complications associated with bed-ridden older adults.

Unlike the lesser known kanpumasatsu, complete Decongestive Therapy (CDT) is a well-integrated conservative treatment for lymphedema, a common complication after cancer treatments. A component of CDT is lymphatic drainage massage, superficial massage that stretches the skin and mobilize the lymphatic flow underneath the skin. While the efficacy of CDT and its component, lymphatic drainage massage has not been fully established due to the quality of research available to date,⁴⁶ it is worth noting that both kanpumasatsu and lymphatic drainage massage stretch the skin and therefore it stimulates the flow of lymphatic fluid underneath the skin. This author postulates that the mechanism of kanpumasatsu on enhancing immune function is due to this stimulation of the skin and lymphatic vessels. Note that the similarities and differences of lymphatic drainage massage within CDT and kanpumasatsu are summarized in Table 1 . Both are superficial massage technique without the use of massage oil. However, kanpumasatsu is easier to learn and shorter duration per body part than lymphatic drainage massage. Finally, while self-application of lymphatic drainage massage is limited to in hard-to-reach region, such as mid-back, kanpumasatsu can be applied as self-massage with a dry towel.

Table 1.

Comparing the characteristics of kanpumasatsu and lymphatic drainage massage within CDT.

	Lymphatic Drainage Massage within CDT	Kanpumasatsu
Type of massage	Superficial	Superficial
Use of Massage Oil	No	No
Single Session Duration	Longer (5–10 min for a single limb)	Shorter (5–10 min for the whole body)
Ease of Learning	Need extensive training More complex hand motions and directions of stimulation	Easy to learn
Self-Administration	Partially Yes (there are hard to reach body regions, such as mid back)	Yes with a dry towel to cover hard to reach body parts

In summary, there has been ample research examining the effects of various tactile skin stimulation during the past half century. They showed strong evidence in such modality's enhancement of immune function³⁶ and improving metabolism38, 39; In animal studies using rats, rubbing the skin showed to aid in animal growth,^{41 , 43} an increase in serotonin production in rats,^{26 , 27} a decrease in catecholamine,⁴⁴ and an increase in dopamine production.⁴⁵ In human research on kanpumasatsu's health benefits, there were some evidence of immune function enhancement³⁵ and demonstration of an increase in natural killer cells and neutrophils among bed-ridden older adults.³⁴ Anecdotal accounts exist for enhancement of immune function, prevention of cold, and improvement of sleep quality⁴⁹. Various strength of the evidence that support both tactile skin stimulation and kanpumasatsu's health benefits are shown in Table 2 .

Table 2.

Strength of Research Evidence of Tactile skin stimulation and kanpumasatsu's health benefits.

	Strong Evidence	Some Evidence	Anecdotal Accounts
Enhancing Immune Function
-ANS	36 (EA)	35 (K)	49(K)
-Improve blood circulation	34(K)
-↑ Natural Killer Cells/Neutrophil
-Improve Lymphatic Circulation		37 (M)
Preventing Cold			49(K)
Improving Sleep Quality			49 (K)
Improving Metabolism	38 (T)39 (T)
Aid in Animal Growth
-↑ Rate of Weight Gain in Rats with Low Birth Weight	41 (T)43 (B)
Maternal Licking & Glooming in Rats
-↑ Serotonin Production	26, 27 (GL)
-Influence positively on Future Stress response	26, 27(GL)
Altering Stress Reponses by brushing the skin
-↓Catecholamine Production	44 (T)
-↑Dopamine Production	45 (T)

Keys: B: Brushing, EA: Electroacupuncture, GL: Glooming/licking, K: kampumasatsu, T: Tactile skin stimulation.

3. Instructions, recommendations for use, and strategies that promotes regular practice

You can practice Kanpumasatsu for yourself or to others. It can be practiced either in sitting or standing outdoor or indoor, even though it was traditionally practiced in Japan standing outdoors. While traditionally practiced in minimum clothing, wearing a scrub suit in healthcare setting is appropriate. To move your arms comfortably, the length of the towel should be about one yard, but a shorter one can also work. Appropriate towel materials include cotton or soft gauze. The direction of rubbing is from the distal part to the proximal part (e.g., hand, forearm, then upper arm), and should be repeated multiple times until the skin becomes slightly pink. For hard-to-reach areas, such as your back and lower extremities, you can hold each end of the towel and pulled back and forth or side to side to cause friction against the skin. It is best to avoid immediately before or after taking a shower or a bath to prevent skin irritation or damage. It will take a total of 5 min to go through the head, neck, upper extremities, trunk, and lower extremities. One should be reminded to keep breathing normally without holding the breath during kanpumasatsu. It is recommended to hydrate thoroughly after this practice to facilitate toxin elimination. The contraindications include skin diseases, areas of open wound, inflammation, or lack of sensation.

Busy healthcare practitioners may excuse themselves by not having the necessary tool, such as a towel at hand. One can place a towel in multiple, commonly accessible places, such as the break room, car, and in the lunch box. Even without a towel, one can practice it by using one's own hands. To initiate this practice, you should not pressure yourself to practice multiple times a day, instead, starting with just before going to bed or inside the bed to see if your sleep quality improves or time to fall asleep shortens. At work, you may create a habit to rub down a portion of your body, such as arms or legs when you go to the bathroom. If you are applying skin lotion, capture this opportunity to rub down from hands, wrists, forearms, upper arms and shoulders. When you see yourself in a mirror, rub down with your fingers from the crown of your head to the neck to upper trapezius muscles to the tip of your shoulders. Be mindful of the sensation that comes from the rubbed area as well as your overall sense of well-being. When you complete kanpumasatsu of the entire body, you may notice how invigorating, refreshing, and simultaneously relaxing it is to your mind and body.

For healthcare organizations to implement a facility-wide burnout prevention pilot program, a simple but visually appealing infographics can be shared through the email or webpage. Such example can be found at WebMD⁵⁴, but it can be tailored to each organization⁵³. Each of the self-care strategy graphics, such as massage, sleep, or physical activity can be hyperlinked to more detailed information, such as the level of evidence, level of learning ease, tools, time it takes to practice and tips for sustainable practice. Inclusion of kanpumasatsu, self-massage with a dry towel, may empower healthcare professionals’ ability to take care of themselves without costing time or money. An added notation about the limited evidence of its effectiveness and mechanisms can help each individual to decide which practice they wish to focus.

4. Resources for continued exploration and/or practice

The following resources are all in Japanese language, however, one can appreciate the videos as well as drawings shown on the webpage. To the best of this author's knowledge, there was no resource that was written or spoken in English at the onset of this writing. This is a limiting factor for U.S. health care organizations to conduct a pilot program of kanpumasatsu. To eliminate this limitation and facilitate the pilot use of kanpumasatsu, this author created a brief instructional video in English language as shown here as the first item.

How to practice Kanpumasatsu (乾布摩擦)/https://www.youtube.com/watch?v=gDXSBL5v6vU This author created this short video to show the audience how to practice kanpumasatsu in T-shirt and pants. To keep the video short, only half of the body was massaged and instructed to repeat the same for the other side of the body. Any questions or comments are directed to the author's email address.⁵¹

Kanpumasatsu no yarikata (YouTube)/https://www.youtube.com/watch?v=NDdIVDx44BM This title of the YouTube video is translated as “How to perform kanpumasatsu.” This 3 min and 13 s video shows how to provide kanpumasatsu to a child lying on a treatment table. The acupuncturist in the video suggests finding a used cotton towel instead of a brand new one. In addition, he instructs to stop rubbing when the child's skin color changes to pink not to irritate skin.⁴⁷

Kanpumasatsu wa saikyo no serufukea (YouTube) /https://www.youtube.com/watch?v=0-9giTJwAT4 . Tobanishi Fitness. This title of the YouTube video is translated as “Kanpumasatsu is the ultimate selfcare.” One acupuncturist and his colleague show how a dry towel can be used for rubbing the neck, arms, and the trunk. This video does not show the procedure for the lower extremities. Both practitioners state that their upper extremities fatigued by repeated rubbing motion and noted that they feel warmer after completing their practice.⁴⁸

Kanpumasatsu towa? Koukateki na yarikata to odorokino kenkou kouka⁴⁹/https://www.nhk.or.jp/kenko/atc_1307.html.

This webpage article describes the results of the single group experiment of kanpumasatsu and its perceived health benefits after daily practice for 1 month. Ten out of 12 participants reported that their quality and the depth of sleep improved after kanpumasatsu practice. While it is written in Japanese language, the first graph shows that during the practice of kanpumastastu, the sympathetic nervous system activity dominates, but after completing the 5 min of kanpumasatsu, the parasympathetic nervous system drive dominates. Five diagrams show how kanpumasatsu can be performed.

5. Key takeaways

Kanpumasatsu, self-massage with a dry towel is a simple, no cost, and easy to learn self-care technique that can be piloted in healthcare organizations as a burnout prevention program. Through the stimulation of the skin surface, it has the potential to balance the autonomic nervous system, to relax, and to enhance lymphatic flow, and as a result, improving one's immune functions.

• •To prevent the high rates of mental health manifestations and burnout from chronic stress among healthcare professionals, organizations can pilot a facility-wide new preventive program and assess the outcomes after its implementation
• •Kanpumasatsu is a traditional Japanese superficial self-massage technique aimed to boost one's immune functions
• •Kanpumasatsu is simple and safe self-massage technique that has the potential for healthcare professionals and educators to learn and implement
• •Further research on Kanpumasatsu's mechanism and evidence may reveal its effects on lymphatic flow and the promotion of immune functions

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.