Introduction

The problem of complex somatic and mental stress reactions is one of the important modern aspects of fundamental and clinical research in neurology, psychology and biology. Despite made medical efforts to reduce the level of mental stress in various social and nosological groups over the past decades, the stress level is still very high [1, 2].

One of the most remarkable stress markers is an increased tonic activity i.e. the excessive muscle tension that is considered a psychological defense reaction to stress [3]. Many authors noted a high correlation of neurotic disorders with the functional status of the facial muscles. The greatest “emotional determinants” of experiencing negative affect is pointed to the muscles of mastication (m. masseter) and the muscle of the facial expression such as the circular muscles of the mouth (m. orbicularis oris), the muscle lowering the angle of the mouth (m. depressor anguli oris), and the “frowning” muscle (m. corrugator supercilii) [4—6].

There was found that increasing of the bioelectric activity of the facial muscles is triggered by the limbic-reticular complex and is realized through the function of facial — trigeminal nerves [7].

As a result, the status of chronic stress or low mood leads to physiological accumulation of the facial muscle tension forming contractions and spasms in the muscles [8].

According to the facial feedback hypothesis (FFH), under prolonged stress the facial muscles become an independent hyperactive system, which not only supports but also enhances negative emotional experiences [9]. Therefore, besides the descending central nervous influence on the status of the facial muscles, there is an ascending way passing the afferent information from the facial muscles to the emotional brain centers. Accordingly, mutual reinforcement of negative emotional state and facial muscles tone forms a vicious circle of emotion experiencing [10].

At present, modern scientific society is developing the concept of emotional proprioception, which presents itself the approach to persistent muscle relaxation, which helps to break the vicious circle between the facial muscles tension and the emotional brain centers and gives a positive psycho-emotional correction of depressive disorders. [11].

In 2012—2014, the first randomized control trials of using botulinum toxin type A (BTA) were showed that a single injection of BTA into the “frowning” muscle (m. corrugator supercilii) leading to the long-term relief of symptoms of depression and post-traumatic stress disorder for a period about 3 to 6 months [12, 13].

In 2016, the performed studies, using magnetic resonance imaging, demonstrated that BTA injections generated peripheral denervation of the facial muscles and reduction of afferent signals from the facial muscles to the brain emotion centers [14]. BTA injection into the glabellar sites produced the decreased reaction of the amygdala to negative outer stimuli. When the action of BTA ceased, the amygdala activity returned to its original functional status, hence there is a confirming evidence of positive aspects of BTA denervation in forming afferent feedback from m. corrugator supercilii to the amygdala. The authors noted that muscle denervation, involved in negative facial expression (grief, sadness, soreness), disrupted “SOS signal of the brain” loop which had a beneficial effect on mood [11-14].

However, all treatment methods of psychological stress reactions are highly ambiguous. Thus, we should note, that after BTA injections into m. corrugator supercilii, patients experienced decreased emotional and sexual state due to low efferent impulses from the amygdala [15, 16].Taken all mentioned above into account, we might introduce the highly affordable method for solving this problem with more positive and safe effects on the facial feedback.

Currently, medical facial massages are a new developing correction facial muscles activity method. As a rule, these methods are used in strong connection with pain treatment in neurological dysfunctions (parafunctional activity of the masticatory muscles, myofascial face pain, prosopalgia, trismus, temporomandibular joint dysfunction), since the problem evolved, the tone of the facial muscles and its role in experiencing chronic stress are more than just a cosmetic issue.

Often hypertonic facial muscles are an incidental finding during cosmetic or dental procedures. In this regard, we assumed that using cosmetic and medical massage techniques to reduce the hyperactive tone of the facial muscles could be a psycho-corrective breaking tool for muscle tension and patient’s negative emotional state.

The aim of this study is to evaluate the effectiveness of using massage methods based on facial feedback, to study the possibility of their use as a correction tool of psychoemotional state.

Materials and methods

The study involved 67 females aged 30 to 50 years (mean age 41.5±6.7 years), their application for help was a cosmetic change/correction appearance. All women made through psychological tests, by the tests results using method of random numbers, three groups were generated.

The 1^st (control) group was 12 females (mean age 40.5±6.5 years), who received basic recommendations, including information on a healthy lifestyle, impact of stress on human health, general recommendations of a balanced diet, moderate physical activity, sleep hygiene, cleansing skin advices, information about harmful postures and habits that increase tension in the facial and skeletal muscles.

In the 2^nd group included 25 females (average age 40.8±6.9 years) with the background of basic recommendations, a course of cosmetic facial massage (V.I. Dubrovsky modification) was performed [17]. Each patient had 10 massage procedures, the procedures were carried out once a week, and session lasted 60 minutes. The duration of correction treatment was 2.5 months.

The group 3 made up of 30 females (mean age 42.6±6.7 years) with basic recommendations as in the 1^st and the 2^nd groups, treated with a course of myofascial facial massage targeting the inactivation of the facial muscle hypertension. The following massage techniques were used: pinch palpation, ischemic compression, stretching. The massage was performed in accordance with the licensed program No. 2705237 “Method of neuromuscular relaxation of facial muscle.” Total amount of massage procedures was 10, lasted 60 minutes. The procedures were carried out once a week. The correction duration was 2.5 months.

Inclusion criteria: female sex, age 30—50, no contraindications to massage.

Exclusion criteria: plastic surgery, botulinum toxin injections, the presence of facial volume correction.

Exclusion criteria in study performing: study protocol violation.

Before and after the course of correction all women were tested psychologically and neurophysiologically.

The psychological testing included The Beck depression inventory to assess the presence and degree of subjective severity of depression, the state-trait anxiety inventory (Ch.D. Spielberger, modified by Yu.A. Khanin) to measure of trait and state anxiety, the visual analogue scale (VAS) to study of self-esteem using subscales “Feelings”, “Self-confidence” and “Assessment of appearance”.

The neurophysiological study included electromyography (EMG) performed on the Neuro-MEP-Neurosoft machine. The degree of bioelectrical activity of the muscles the most involved in the manifestation of negative emotional state was assessed in following muscles: m. corrugator supercilii, m. masseter, m. depressor anguli oris, and m. nasalis.

The studies were carried out on the both face sides together. Two tests were performed — at rest and at maximum stress. The results were interpreted using the standards of J. Clam myography [18].

The analysis of the long-term results of a massage course correlating to the psychological features of all females was made up out after 4 months.

Statistical data processing was undertaken using the licensed statistical software package Statistica 10. The results are presented as the arithmetic mean and the standard deviation (M±SD). Differences were considered statistically significant at p<0.05.

Results

The data analysis of the Beck depression inventory of all 65 females showed that 55% of them did not have any signs of depressive disorder symptoms. At the same time, 45% of females had varying depressive disorders symptoms: in 30% of cases — subdepression, in 6% — moderate and 9% — a severe level of depression.

Analysis of the level of situational anxiety showed 75% of cases with a low level of situational anxiety associated with great expectations of upcoming procedures. 22.4% of women was corresponded to a moderate level of anxiety, 3% — to a low level.

However, 100% of studied females were diagnosed with moderate and high levels of individual anxiety.

May be noted that the high prevalence of depressive and anxiety states in almost healthy-look women was a result of the targeted search of this study, whilst females, applied for cosmetic or dental correction for aesthetic issue, usually have no signs of bad mood.

Self-esteem on the subscales “Assessment of appearance”, “Self-confidence”, “Feelings” may be assessed as a quite high. In this case, analyzing the available data variation, expressed through the minimum and maximum ratio, the marker “Assessment of appearance” was the most variable — the average score on the VAS placed from 16 to 100, characterizing female self-assessment as one of the most susceptible and society-influenced esteem features.

Based on the initial EMG data, a significant elevation of the standard markers of the bioelectrical activity of all facial muscles was found. Thus, EMG markers of m. masseter on the right and left sides of the face were 9.3±11.7 and 9.0±10.0 μV, m. corrugator supercilii — 7.9±7, and 9.0±8.0, m. depressor anguli oris — 11.1±7.1 and 11.2±7.3, m. nasalis — 11.8±6.6 and 12.2±5.6 μV, respectively.

Considering all said above, according to the clinical guidelines of standard EMG, normal numbers should not elevated 3 µV for masticatory muscles and 5 µV for mimic muscles, in this study, we concluded statement to initial high levels of muscle tension due to stress hyperactivity [18].

Based on the study data, we noted, that almost ¹/₂ (45%) of female cases applied for aesthetic correction was characterized with a high bioelectric activity of the facial muscles. Varying signs of depressive disorders, high to medium level of individual anxiety (100%) and in the overwhelming majority of cases (75%) of a low level of situational anxiety due to positive expectations of upcoming procedures were concluded.

Effectiveness assessment of various techniques influence on the female psycho-emotional state

We found, during analyzing the markers of statistical depression severity, a significant positive variation dynamic. The control group displayed the decreased average depression score about 24.7%, the 2^nd group showed 31.4%, and the 3^rd group — 45.6%. The study data emphasized that all 3^rd group females with a previous high and medium depression level corrected severity after the performed myofascial massage course (Table 1).

Note. *p<0.05; **p<0.01 — significance of differences with respect to baseline; *p<0.05 — significance of differences in relation to the control group.

All groups with using manual impact on the facial muscles (groups 2^nd and 3^rd), revealed a significant decrease of situational anxiety level. However, decreasing average score of situational anxiety did not play an important role due to the initial normal data. The control group showed no significant dynamics in terms of situational anxiety level (p>0.05).

The assessment of individual anxiety dynamics demonstrated no valuable variation in the 1^st control and in the 2^nd groups (p>0.05). The 3^rd group showed decreasing personal anxiety level from 47.5±6.7 to 44.1±7.6 points (p<0.05) after the procedure ended, all females were no high degree of individual anxiety.

The analysis of self-esteem markers according to VAS revealed a significant positive dynamics in all tested groups, apart from the 1^st control. The 3^rd group demonstrated a high score of the scale markers — “Assessment of appearance”, “Feelings”, “Self-confidence” (p<0.01), and the average subscale marker levels in the 3^rd group were significantly higher than in the 1^st control group.

VAS self-esteem dynamics in the 2^nd group registered increasing score in the “Assessment of appearance” levels after the course ended. By contrast, the control group showed a significant decrease of the “Assessment of appearance” level (p<0.05). Subscales “Feelings” and “Self-confidence” in the 1^st control group were no change at all.

The assessment of the neurophysiological data dynamics during testing at rest in the 3^rd group revealed the most noticeable decrease of EMG markers on facial muscles. As a result, all tested females with the originally increased tone of m. corrugator supercilii on the both sides of face registered an average level decrease by 39%, m. masseter on the right side — by 53%, and m. depressor anguli oris — by 25% (p<0.05).

The 2^nd group had no strong changes compared to the original data, which might pointed to the insufficient effect of cosmetic massage to reduce facial muscle tone. The basic recommendations for the control group were not enough to an adequate correction method shifting the average amplitude of bioelectrical activity of masticatory and facial muscles on the left face side. Thus, we registered the increase biopotential amplitude of m. masseter, m. corrugator supercilii, and m. nasalis (p<0.05).

Conclusion

The study results indicate a considerable effect of the cosmetic and myofascial massage types on the psychological female health state. However, in the group of cosmetic massage, the improvement of psychoemotional state was not grounded by statistically significant positive dynamics of decreasing muscle tone, hence it might be explained with more superficial effect techniques, although much deeper procedures on the facial muscles using myofascial massage directly provided normal tonic activity and better functionality of the facial muscles.

The follow-up data analysis confirmed tension-reducing effect of the facial muscles using deeper myofascial massage technique to maintain the long-term positive dynamics of female psychological state.

During the study, the considerable positive psychological effect on the neurophysiological markers of female health state made possible evidence to manifest the myofascial massage as an effective tool of psychoemotional correction treatment.

The neurophysiological dynamics in different tested groups at maximum stress is presented in Table 2. The EMG data analysis revealed a significant decrease of functional activity of the masticatory and facial muscles in the 3^rd group. The control group stated the notable functional activity increase of m. masseter on the both sides during voluntary activity status (p<0.05). There were no statistically remarkable differences in the other tested muscle. The cosmetic massage group (the 2^nd group) revealed no reliable data in changing neurophysiological muscle state (p>0.5).

Note. *p<0.05; **p<0.01 — significance of differences with respect to baseline.

In the long-term period, analysis of the psychological status during the myofascial massage procedures showed a strong preservation of achieved positive results in the 3^rd group (n=18) in terms of “Depression” and “Self-confidence” subscales (p<0.05). Nonetheless, the 2^nd group (n=20), stable positive results were not noted. The 1^st group (n=12) manifested a great deterioration of self-esteem according to the VAS subscale “Self-confidence” (p<0.05). Other psychological status markers in all groups did not show any significant changes.