Pregnancy is a natural process of approximately forty weeks that begins with fertilization and ends with the birth of the fetus. Physiological, anatomical, and hormonal changes occur throughout the body to maintain physical and metabolic balance during pregnancy. These adaptive changes appear as pain due to the change in the center of gravity, musculoskeletal disorders, and soft tissue edema [1, 2].

Pain during pregnancy is mostly seen in the waist, pelvic, and leg regions. Lumbar lordosis and increased anterior pelvic tilt of the pelvis cause knee and ankle extension. Knee problems manifest as ligament laxity in the knee increases in the second trimester of pregnancy [2]. In a study, it is stated that the risk of musculoskeletal problems during pregnancy is increased by changes in hormones and physiology changes on by pregnancy. While this pain causes pain in all lower extremity muscle groups, the gastrocnemius muscle is often affected [3]. Studies indicate that pregnant women experiencing pain in their lower extremities and lower back who receive education and physical therapy during their pregnancy experience reduced pain and impairment [4]. Stretching, self-mobilization techniques, back strengthening, and postural changes are all included in physical therapy. By stimulating certain body areas, soft tissue massage is a type of physiotherapy that helps relieve a variety of aches and pains, as well as tension, exhaustion, and illnesses, intending to revive the body’s vital energy circulation [5].

Another important condition frequently encountered during pregnancy is edema. During pregnancy, the body physiologically retains water and sodium due to the increase in circulating plasma volume, decrease in osmolarity, and changes in hormones. The resulting increase in extracellular fluid causes pathological edema [6]. In addition, as the uterus grows, it puts pressure on the inferior vena cava, causing edema in the lower extremities. One-third of the edema is in the lower extremities and they encounter this complaint more in the last trimester [7]. Gimunová et al. [8] reported that 95.5% of 140 pregnant women had foot edema. Also, an increase in lower extremity and ankle circumference due to edema was observed in 83% of pregnant women [8]. In pregnant women, the severity of symptoms such as night cramps, bloating, pain, and fatigue may increase due to edema in the lower extremities [9]. Women with leg and foot edema can be treated non-pharmacologically using leg elevation, relaxing, immersion in water, bandaging, compression stockings, foot massage, intermittent pneumatic compression, reflexology, and interstitial fluid movement monitoring [10]. Foot massage is a typical non-pharmacological technique used by medical professionals [11]. Research by Rahimikian et al. [12] demonstrated the efficacy of foot massage therapy in lower extremity physiological edema in pregnant women. The therapy of physiological lower leg edema during pregnancy is not well supported by research at this time.

Pregnancy fatigue may occur due to physiological and psychological factors. Stress and sudden mood changes can cause psychological fatigue. In a psychological context, the working environment and socioeconomic factors affect the level of fatigue [13]. Fatigue, which is excessive in the first trimester of pregnancy, decreases in the second trimester and recurs in the third trimester. Fatigue, edema, and pain during pregnancy play an important role in the quality of life. These symptoms negatively affect the quality of life of pregnant women by restricting their daily life activities and functionality [14].

Percussion massage therapy (PMT) combines traditional massage and vibration therapy principles and provides rhythmic movement and pressure application to the body [15]. Percussion massage therapy produces various results such as increasing body temperature, increasing joint range of motion, accelerating blood and lymphatic flow, and reducing muscle tension and/or stiffness. In percussion massage therapy, proprioceptive stimuli are increased by stimulating the Golgi tendon organ with vibration [16]. Studies have emphasized that percussion massage is a new treatment method that is effective for lower extremity pain and has become widely used recently [15, 16, 17]. In a study, it was stated that individuals who received percussion massage therapy experienced a decrease in perceived pain level and that the use of PMT in addition to the treatment increased the effectiveness of the treatment [17]. There are studies on percussion massage therapy, but they are limited in number [18]. There are almost no studies using PMT on pregnant women. Also, studies on methods used to reduce lower extremity pain and edema in pregnant women are very limited. We believe that percussion massage therapy applied to the lower extremities is an important practice as it can be an alternative approach to symptoms such as pain, edema, and fatigue problems that may occur in the lower extremities during pregnancy. The study aimed to examine the effect of percussion massage therapy applied to the lower extremities on pain, edema, fatigue, and quality of life in pregnant women.

The study was completed by including thirty participants in the PMT group and thirty participants in the control group. Participants were similar in terms of demographic characteristics (p $>$ 0.05). The maternal age of the PMT and the control group is 30.44 and 34.24, respectively. Their gestational ages are 27.38 and 25.66 years, respectively. An overview of the distribution included variables is provided in Table 1. When comparing pre-treatment and post-treatment results within each group, statistically significant differences were found in both groups in terms of right/left ankle, knee, and thigh circumference measurements, and SF-36 physical function (p 0.05). Additionally, significant differences were observed in VAS (p = 0.013), FSS (p = 0.003), SF-36 mental health (p = 0.009) and SF-36 general health (p = 0.009) parameters in the PMT group. A statistically significant difference was found between the pre and post-treatment values of the SF-36 role physical (p = 0.009) and body pain parameters (p = 0.045) of the control group. When the differences of pre and post treatments between the groups are compared, VAS value (p = 0.000), right/left ankle (p = 0.006/p = 0.002) and right/left hip circumference measurements (p = 0.008/p = 0.006), FSS (p = 0.009), and SF-36-role emotional (RE) (p = 0.000), mental health (MH) (p = 0.005), social function (SF) (p = 0.005), and body pain (BP) (p = 0.003) measurements of the PMT group showed more statistically improvement than the control group (Table 2). The PMT group had statistically more significant results than the control group.

This study showed that the PMT group was significantly more effective than the control group in terms of pain status, ankle, and thigh circumference measurements, severity of fatigue, and quality of life parameters such as RE, MH, SF, and BP in pregnant women. It is uncertain what mechanism explains the efficacy of percussion massage therapy on pregnancy problems. The fact that most studies on percussion massage have only been conducted on men and have mostly concentrated on musculoskeletal diseases and sports performance is one factor contributing to the paucity of information in this field [26]. Almost no research has been done on the effects of percussion massage therapy on pregnancy-related lower limb discomfort, edema, and fatigue. This study showed significant improvements were observed in the parameters of pain, edema, and fatigue in the PMT group compared to the control group.

Not only is there little data regarding the benefits of percussive massage for pain relief and recuperation, but less is known about the physiological processes that underlie the treatment’s purported mechanisms of action. Despite this dearth of research, it is still believed that percussion massage works similarly to soft tissue massage, which is a type of massage in which a therapist applies pressure to a patient’s muscles with their hands, ultimately boosting blood flow, encouraging healing, and lessening pain [15]. Percussion massage therapy attempts to lessen pain by suppressing nociceptive pain fibers and activating afferent alpha and beta motor neurons [27]. One study showed a significant reduction in subjective pain sensations in the lumbar spine with vibration therapy. It has also been stated that as pain decreases, quality of life decreases [28]. Games and Sefton [29] noted that vibration treatment offers a technique that might raise tissue blood perfusion and temperature for women who might not be able to finish the activity due to an injury (such as reduced range of motion, discomfort, or swelling). In pregnant women of the PMT group who received vibration, a decrease in pain, edema, and fatigue and an increase in quality of life were observed in our study. We consider that the stimulation created by vibration on the muscular system through the tonic vibration reflex on the lower extremity contributes positively to the analgesic effect.

A common and painful side effect of pregnancy is dependent physiological lower leg edema, or water retention in the lower limbs’ interstitial space. The condition may result in pain, a heavy feeling, cramping at night, and painful paraesthesia [30]. Massage therapy applied to the feet can be beneficial for some disorders like edema in the legs and feet because it transfers extravascular fluid without disturbing intravascular fluid in pregnant women. In a study, the experimental group had a 20 min foot massage daily for 5 days whereas the control group did not receive any intervention beyond standard prenatal care. The result of this study showed that women in the experimental group had a significantly smaller lower leg circumference (right and left, ankle, instep, and metatarsal-phalanges joint) after 5 days of massage compared with the control group [31]. A study conducted determined that pregnancy therapeutic massage has many benefits in increasing blood flow and circulation. Additionally, it causes the brain to release opioids, which are naturally occurring medications that reduce pain [32]. One systematic review determined that foot massage and stockings reduced leg edema and leg symptoms respectively in pregnancy [33]. In our study as well, it was found that the application of PMT was effective in controlling pain and edema. Percussion massage therapy provides the manipulation of the soft tissue of the foot and it may decrease the physiological edema in the lower extremity in pregnant women.

Common physical symptoms such as edema, muscle cramps, and fatigue, may lead to a decrease in the quality of life in the second and third trimesters of pregnancy. There are studies in the literature about the effect of massage and soft tissue mobilization on reducing pain and edema, but as far as we know, there is no study examining the effect of PMT on pregnant women [31]. It was concluded that these results are likely because massage aids in the healing process from muscle exhaustion by promoting blood and lymph circulation, eliminating waste, and supplying nourishment and oxygen [34]. The biggest influence on women’s perceptions of their quality of life is pregnancy fatigue. Consequently, lowering the perceived levels of weariness should be the main goal of initiatives to enhance women’s quality of life [35]. In one study, women who were depressive throughout pregnancy were randomized to either the control group or the group that received moderate massage therapy twice a week from their spouses from 20 weeks of gestation until the conclusion of the pregnancy [36]. Compared to the control group ladies, the pregnant women who had massages had higher quality of life and fewer self-reported cases of leg discomfort, back pain, despair, and anxiety. According to a systematic review, the data regarding the impact of conservative therapy, such as massage or mild pressure, on pain, disability, and quality of life during both short- and long-term pregnancy is highly ambiguous [37]. Acupressure, aromatherapy, and massage were found to be the most effective non-pharmacological approaches in relieving pain in laboring and pregnant women when compared to standard care, according to a meta-analysis conducted by Hu et al. [38]. The authors concluded that the use of nonpharmacological methods reduces the possibility of adverse effects resulting from the use of pharmaceutical therapies. Another study showed the value of back massage in lowering discomfort during the initial stages of labor in primipara mothers when compared to those receiving routine treatment, and it might be implemented as a regular practice in primary care [39]. In our study, we observed an increase in fatigue and quality of life with the reduction of pain and edema. We believe that the application of PMT enhances blood circulation, thus relaxing the muscles in pregnant women, and reducing the sensation of pain and fatigue. Additionally, it was noticed an improvement in their quality of life, particularly in general body pain, mental health, and general health parameters. It can be stated that PMT applied to the lower extremities is one of the methods of coping with some difficulties (pain, edema, fatigue) experienced in pregnant women. With this study, a different perspective was gained from the current literature regarding pain and edema management in pregnant women. It has been shown that pregnancy complications can be reduced with PMT, which is easy to use in daily routine.

The strengths of the present study are the use of PMT, which has not been used before in pregnant women, and examining its effects on the most common pregnancy symptoms. Another strength is that PMT, which is one of the most popular alternative physiotherapy methods, reveals a different way of using it in pregnant women. The short duration of treatment and the inability to follow up on the long-term results of pregnant women are the limitations of the study.

In pregnant women, PMT was observed to be more effective than the control group in parameters such as pain, ankle and thigh circumference measurements, fatigue, and some sub-parameters of quality of life. PMT is not only an easy and effective method for orthopedic problems but also an alternative method for controlling pain and edema in pregnant women. PMT can be preferred to enhance the quality of life of pregnant women by improving parameters like pain, edema, and fatigue. The use of the Hypervolt device, commonly used by physiotherapists for pain control, is more limited in pregnant women. We anticipate that PMT will be a technological and innovative treatment method for the primary issues experienced by pregnant women. Additionally, the ability of PMT to create a larger impact in short treatment durations and its non-invasive nature will also facilitate its use among pregnant women. We consider that it would be good to conduct more studies on how PMT use will affect the quality of life of pregnant women in future studies.

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

MYM and AKK: protocol/project development, data analysis, validation of data analysis, manuscript writing. MYM: data collection, manuscript editing. Both authors contributed to editorial changes in the manuscript. Both authors read and approved the final manuscript. Both authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

The research protocol was approved by the Non-interventional Ethics Committee at Istanbul Medipol University, Turkey (File number: E-10840098-772.02-5416, Number:783, date:13/09/2022), and all participants provided signed informed consent.

The authors sincerely thank all the individuals of the Clinics of Obstetrics and Gynecology, Istanbul Camlica Medipol Hospital.

This research received no external funding.

The authors declare no conflict of interest.