American Massage Therapy Association^®

AMTA Position Statement Proposal

Date received by Delegate: November 7th, 2008

Background information

According to National Center for Health Statistics:

• More than one-quarter of Americans (26%) age 20 years and over - or, an estimated 76.5 million Americans - report that they have had a problem with pain of any sort that persisted for more than 24 hours in duration. [NOTE: this number does not account for acute pain].
• Adults age 45-64 years were the most likely to report pain lasting more than 24 hours (30%). Twenty-five percent (25%) of young adults age 20-44 reported pain, and adults age 65 and over were the least likely to report pain (21%).
• More women (27.1%) than men (24.4%) reported that they were in pain¹

Pain affects the life, quality of life, and work of the American public.²  In many people, pain medications can have unpleasant side effects.³  Considering the number of people reporting pain and its effects on quality of life, and with pain medications not necessarily being the best option, the American public has become interested in examining other methods of pain relief.   In the CDC’s 2007 survey of CAM therapies the top four reasons adults used CAM therapies were to treat pain including back pain or problems, neck pain or problems, joint pain or stiffness/other joint condition, arthritis, and other musculoskeletal conditions.⁴  The most prevalent reason for children to use CAM therapies is also due to pain, back/neck pain to be specific.⁴

Research indicates that massage can reduce pain and pain intensity in patients with metastatic bone pain on an immediate, intermediate and long term time frame.⁵ Massage can reduce the incidence and frequency associated with headache pain.⁶  Massage relieves postoperative pain . ^{7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17} Massage reduced back and leg pain in pregnant women.¹⁸ Massage decreased pain, distress, tension, and anxiety in children and adolescents with chronic pain.¹⁹  Massage is recommended for children with cancer and “growing pains”.^{20, 21}   Massage relieves chronic pain, chronic pain of moderate to severe intensity and those with myalgia.^{22, 23, 24}  Massage reduces pain and improved the quality of life for adult cancer patients.^{25, 26}   Massage improves subjective perception of and function for those with Carpel Tunnel Syndrome.²⁷   Massage has a positive effect on lower back pain.^{28, 29, 30, 31, 32, 33}   Massage reduces pain for those with distal radial trauma and those receiving needle insertions.^{34, 35}

Rationale

Those patients who seek complementary methods for pain relief will benefit from the structured touch of trained massage therapists working within their scope of practice. 

The position statement supports the following AMTA Core Values:

• We believe that massage benefits all.
• We are a diverse and nurturing community working with integrity, honesty and dignity.
• We embrace excellence in education, service and leadership.

The 10-30 Year Vivid Descriptions of the AMTA are also supported by the position:

• People recognize the power of touch to affect the mind/body/spirit continuum.
• The role of massage therapy will be expanded in all practice settings
• There will be international recognition for the value of massage.  All societies will be educated and accept massage therapy and AMTA will be a global networking resource for massage therapy and therapists.

Position Statement

It is the position of the American Massage Therapy Association (AMTA) that massage therapy can aid in pain relief.

References

1. National Center for Health Statistics (2006). Health, United States, (2006): with chartbook on trends in the health of Americans with special feature on pain. Table 61. Hyattsville, MD: Centers for Disease Control and Prevention, National Center for Health Statistics. Retrieved April 7, 2007, from Centers for Disease Control Web site: http://www.cdc.gov/nchs/data/hus/hus06.pdf
   
   
2. Strine T.W., Hootman J.M., Chapman D.P., Okoro C.A., Balluz L. (2005). Health-related quality of life, health risk behaviors, and disability among adults with pain-related activity difficulty. Am J Public Health, 95(11), 2042–2048.
   
   OBJECTIVES: We examined the association between pain-related activity difficulty (PRAD) in the past 30 days and health-related quality of life, health behaviors, disability indices, and major health impairments in the general US population.
   
   METHODS: We obtained data from 18 states in the 2002 Behavioral Risk Factor Surveillance System, an ongoing, cross-sectional, state-based, random-digit-dialed telephone survey of noninstitutionalized adults aged 18 years or older.
   
   RESULTS: Nearly one quarter of people in the 18 states and the District of Columbia reported at least 1 day of PRAD in the past 30 days. PRAD was associated with obesity, smoking, physical inactivity, impaired general health, infrequent vitality, and frequent occurrences of physical distress, mental distress, depressive symptoms, sleep insufficiency, and anxiety symptoms. Moreover, a general dose-response relationship was noted between increased days of PRAD and increased prevalence of impaired health-related quality of life, disability indices, and health risk behaviors.
   
   CONCLUSION: Pain negatively influences various domains of health, not only among clinical populations, but also in the general community, suggesting a critical need for the dissemination of targeted interventions to enhance recognition and treatment of pain among adult community-dwellers.
   
   
3. Franz, J. (2004). Post-Surgical Pain. In Gale Encyclopedia of Surgery. Retrieved April 8, 2009, from Healthline Web site: http://www.healthline.com/galecontent/post-surgical-pain#definition
   
   
4. 4. Barnes, P.M., Bloom, B., Nahin, R. (2008). Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007, CDC National Health Statistics Report #12. Retrieved April 7, 2009, from Centers for Disease Control Web site: http://www.cdc.gov/nchs/data/nhsr/nhsr012.pdf
   
   
5. Jane, S.W., Wilkie, D.J., Gallucci, B.B., Beaton, R.D., Huang, H.Y., (2008). Effects of a Full-Body Massage on Pain Intensity, Anxiety, and Physiological Relaxation in Taiwanese Patients with Metastatic Bone Pain: A Pilot Study. J Pain Symptom Manage.37(4):754-63.
   
   Bone involvement, a hallmark of advanced cancer, results in intolerable pain, substantial morbidity, and impaired quality of life in 34%-45% of cancer patients. Despite the publication of 15 studies on massage therapy (MT) in cancer patients, little is known about the longitudinal effects of MT and safety in cancer patients with bone metastasis. The purpose of this study was to describe the feasibility of MT and to examine the effects of MT on present pain intensity (PPI), anxiety, and physiological relaxation over a 16- to 18-hour period in 30 Taiwanese cancer patients with bone metastases. A quasi-experimental, one-group, pretest-posttest design with repeated measures was used to examine the time effects of MT using single-item scales for pain (PPI-visual analog scale [VAS]) and anxiety (anxiety-VAS), the modified Short-Form McGill Pain Questionnaire (MSF-MPQ), heart rate (HR), and mean arterial pressure (MAP). MT was shown to have effective immediate [t(29)=16.5, P=0.000; t(29)=8.9, P=0.000], short-term (20-30 minutes) [t(29)=9.3, P=0.000; t(29)=10.1, P=0.000], intermediate (1-2.5 hours) [t(29)=7.9, P=0.000; t(29)=8.9, P=0.000], and long-term benefits (16-18 hours) [t(29)=4.0, P=0.000; t(29)=5.7, P=0.000] on PPI and anxiety. The most significant impact occurred 15 [F=11.5(1,29), P<0.002] or 20 [F=20.4(1,29), P<0.000] minutes after the intervention. There were no significant time effects in decreasing or increasing HR and MAP. No patient reported any adverse effects as a result of MT. Clinically, the time effects of MT can assist health care providers in implementing MT along with pharmacological treatment, thereby enhancing cancer pain management. Randomized clinical trials are needed to validate the effectiveness of MT in this cancer population.
   
   
6. Moraska, A., Chandler, C.(2008). Changes in Clinical Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study.J Man Manip Ther. 16(2), 106-12.
   
   Complementary and alternative medicine approaches to treatment for tension-type headache are increasingly popular among patients, but evidence supporting its efficacy is limited. The objective of this study was to assess short term changes on primary and secondary headache pain measures in patients with tension-type headache (TTH) receiving a structured massage therapy program with a focus on myofascial trigger point therapy. Participants were enrolled in an open label trial using a baseline control with four 3-week phases: baseline, massage (two 3-week phases) and follow-up. Twice weekly, 45-minute massage sessions commenced following the baseline phase. A daily headache diary was maintained throughout the study in which participants recorded headache incidence, intensity, and duration. The Headache Disability Index was administered upon study entry and at 3-week intervals thereafter. 18 subjects were enrolled with 16 completing all headache diary, evaluation, and massage assignments. Study participants reported a median of 7.5 years with TTH. Headache frequency decreased from 4.7+/-0.7 episodes per week during baseline to 3.7+/-0.9 during treatment period 2 (P<0.001); reduction was also noted during the follow-up phase (3.2+/-1.0). Secondary measures of headache also decreased across the study phases with headache intensity decreasing by 30% (P<0.01) and headache duration from 4.0+/-1.3 to 2.8+/-0.5 hours (P<0.05). A corresponding improvement in Headache Disability Index was found with massage (P<0.001). This pilot study provides preliminary evidence for reduction in headache pain and disability with massage therapy that targets myofascial trigger points, suggesting the need for more rigorously controlled studies.
   
   
7. Mitchinson, A.R., Kim, H.M., Rosenberg, J.M., Geisser, M., Kirsh, M., Cikrit, D., Hinshaw, D.B. (2007). Acute postoperative pain management using massage as an adjuvant therapy: a randomized trial. Arch Surg. 142(12), 1158-67.
   
   HYPOTHESIS: Adjuvant massage therapy improves pain management and postoperative anxiety among many patients who experience unrelieved postoperative pain. Pharmacologic interventions alone may not address all of the factors involved in the experience of pain.
   
   DESIGN: Randomized controlled trial.
   
   SETTING: Department of Veterans Affairs hospitals in Ann Arbor, Michigan, and Indianapolis, Indiana.
   
   PATIENTS: Six hundred five veterans (mean age, 64 years) undergoing major surgery from February 1, 2003, through January 31, 2005.
   
   INTERVENTIONS: Patients were assigned to the following 3 groups: (1) control (routine care), (2) individualized attention from a massage therapist (20 minutes), or (3) back massage by a massage therapist each evening for up to 5 postoperative days. Main Outcome Measure Short- and long-term (> 4 days) pain intensity, pain unpleasantness, and anxiety measured by visual analog scales.
   
   RESULTS: Compared with the control group, patients in the massage group experienced short-term (preintervention vs postintervention) decreases in pain intensity (P = .001), pain unpleasantness (P < .001), and anxiety (P = .007). In addition, patients in the massage group experienced a faster rate of decrease in pain intensity (P = .02) and unpleasantness (P = .01) during the first 4 postoperative days compared with the control group. There were no differences in the rates of decrease in long-term anxiety, length of stay, opiate use, or complications across the 3 groups.
   
   CONCLUSION: Massage is an effective and safe adjuvant therapy for the relief of acute postoperative pain in patients undergoing major operations.
   
   
8. Mehling, W.E., Jacobs, B., Acree, M., Wilson, L., Bostrom, A., West, J., Acquah, J., Burns, B., Chapman, J., Hecht, F.M. (2007). Symptom management with massage and acupuncture in postoperative cancer patients: a randomized controlled trial. J Pain Symptom Manage. 33(3), 258-66.
   
   The level of evidence for the use of acupuncture and massage for the management of perioperative symptoms in cancer patients is encouraging but inconclusive. We conducted a randomized, controlled trial assessing the effect of massage and acupuncture added to usual care vs. usual care alone in postoperative cancer patients. Cancer patients undergoing surgery were randomly assigned to receive either massage and acupuncture on postoperative Days 1 and 2 in addition to usual care, or usual care alone, and were followed over three days. Patients' pain, nausea, vomiting, and mood were assessed at four time points. Data on health care utilization were collected. Analyses were done by mixed-effects regression analyses for repeated measures. One hundred fifty of 180 consecutively approached cancer patients were eligible and consented before surgery. Twelve patients rescheduled or declined after surgery, and 138 patients were randomly assigned in a 2:1 scheme to receive massage and acupuncture (n=93) or to receive usual care only (n=45). Participants in the intervention group experienced a decrease of 1.4 points on a 0-10 pain scale, compared to 0.6 in the control group (P=0.038), and a decrease in depressive mood of 0.4 (on a scale of 1-5) compared to +/-0 in the control group (P=0.003). Providing massage and acupuncture in addition to usual care resulted in decreased pain and depressive mood among postoperative cancer patients when compared with usual care alone. These findings merit independent confirmation using larger sample sizes and attention control.
   
   
9. Kshettry, V.R., Carole, L.F., Henly, S.J., Sendelbach, S., Kummer, B. (2006). Complementary alternative medical therapies for heart surgery patients: feasibility, safety, and impact. Ann Thorac Surg. 81(1), 201
   
   BACKGROUND: Complementary therapies (touch, music) are used as successful adjuncts in treatment of pain in chronic conditions. Little is known about their effectiveness in care of heart surgery patients. Our objective is to evaluate feasibility, safety, and impact of a complementary alternative medical therapies package for heart surgery patients.
   
   METHODS: One hundred four patients undergoing open heart surgery were prospectively randomized to receive either complementary therapy (preoperative guided imagery training with gentle touch or light massage and postoperative music with gentle touch or light massage and guided imagery) or standard care. Heart rate, systolic and diastolic blood pressure, and pain and tension were measured preoperatively and as pre-tests and post-tests during the postoperative period. Complications were abstracted from the hospital record.
   
   RESULTS: Virtually all patients in the complementary therapy group (95%) and 86% in standard care completed the study. Heart rate and blood pressure patterns were similar. Decreases in heart rate and systolic blood pressure in the complementary therapies group were judged within the range of normal values. Complication rates were very low and occurred with similar frequency in both groups. Pretreatment and posttreatment pain and tension scores decreased significantly in the complementary alternative medical therapies group on postoperative days 1 (p < 0.01) and 2 (p < 0.038).
   
   CONCLUSIONS: The complementary medical therapies protocol was implemented with ease in a busy critical care setting and was acceptable to the vast majority of patients studied. Complementary medical therapy was not associated with safety concerns and appeared to reduce pain and tension during early recovery from open heart surgery.
   
   
10. Chen, H.M., Chang, F.Y., Hsu, C.T. (2005). Effect of acupressure on nausea, vomiting, anxiety and pain among post-cesarean section women in Taiwan. Kaohsiung J Med Sci. 21(8), 341-50.
    
    The purpose of this study was to examine the effectiveness of acupressure for controlling post-cesarean section (CS) symptoms, such as nausea and vomiting, anxiety perception and pain perception. A total of 104 eligible participants were recruited by convenience sampling of operating schedules at two hospitals. Participants assigned to the experimental group received acupressure, and those assigned to the control group received only postoperative nursing instruction. The experimental group received three acupressure treatments before CS and within the first 24 hours after CS. The first treatment was performed the night before CS, the second was performed 2-4 hours after CS, and the third was performed 8-10 hours after CS. The measures included the Rhodes Index of Nausea and Vomiting, Visual Analog Scale for Anxiety, State-Trait Anxiety Inventory, Visual Analog Scale for Pain, and physiologic indices. Statistical methods included percentages, mean value with standard deviation, t test and repeated measure ANOVA. The use of acupressure reduced the incidence of nausea, vomiting or retching from 69.3% to 53.9%, compared with control group (95% confidence interval = 1.65-0.11; p = 0.040) 2-4 hours after CS and from 36.2% to 15.4% compared with control group (95% confidence interval = 0.59-0.02; p = 0.024) 8-10 hours after CS. Results indicated that the experimental group had significantly lower anxiety and pain perception of cesarean experiences than the control group. Significant differences were found in all physiologic indices between the two groups. In conclusion, the utilization of acupressure treatment to promote the comfort of women during cesarean delivery is strongly recommended.
    
    
11. Wang, H.L., Keck, J.F. (2004). Foot and hand massage as an intervention for postoperative pain. Pain Manag Nurs. 5(2), 59-65.
    
    Physiological responses to pain create harmful effects that prolong the body's recovery after surgery. Patients routinely report mild to moderate pain even though pain medications have been administered. Complementary strategies based on sound research findings are needed to supplement postoperative pain relief using pharmacologic management. Foot and hand massage has the potential to assist in pain relief. Massaging the feet and hands stimulates the mechanoreceptors that activate the "nonpainful" nerve fibers, preventing pain transmission from reaching consciousness. The purpose of this pretest-posttest design study was to investigate whether a 20-minute foot and hand massage (5 minutes to each extremity), which was provided 1 to 4 hours after a dose of pain medication, would reduce pain perception and sympathetic responses among postoperative patients. A convenience sample of 18 patients rated pain intensity and pain distress using a 0 to 10 numeric rating scale. They reported decreases in pain intensity from 4.65 to 2.35 (t = 8.154, p <.001) and in pain distress from 4.00 to 1.88 (t = 5.683, p <.001). Statistically significant decreases in sympathetic responses to pain (i.e., heart rate and respiratory rate) were observed although blood pressure remained unchanged. The changes in heart rate and respiratory rate were not clinically significant. The patients experienced moderate pain after they received pain medications. This pain was reduced by the intervention, thus supporting the effectiveness of massage in postoperative pain management. Foot and hand massage appears to be an effective, inexpensive, low-risk, flexible, and easily applied strategy for postoperative pain management.
    
    
12. Piotrowski, M.M., Paterson, C., Mitchinson, A., Kim, H.M., Kirsh, M., Hinshaw, D.B. (2003). Massage as adjuvant therapy in the management of acute postoperative pain: a preliminary study in men. J Am Coll Surg. 197(6), 1037-46.   
    
    BACKGROUND: Opioid analgesia alone may not fully relieve all aspects of acute postoperative pain. Complementary medicine techniques used as adjuvant therapies have the potential to improve pain management and palliate postoperative distress.
    
    STUDY DESIGN: This prospective randomized clinical trial compared pain relief after major operations in 202 patients who received one of three nursing interventions: massage, focused attention, or routine care. Interventions were performed twice daily starting 24 hours after the operation through postoperative day 7. Perceived pain was measured each morning.
    
    RESULTS: The rate of decline in the unpleasantness of postoperative pain was accelerated by massage (p = 0.05). Massage also accelerated the rate of decline in the intensity of postoperative pain but this effect was not statistically significant. Use of opioid analgesics was not altered significantly by the interventions.
    
    CONCLUSIONS: Massage may be a useful adjuvant therapy for the management of acute postoperative pain. Its greatest effect appears to be on the affective component (ie, unpleasantness) of the pain.

13. Taylor, A.G., Galper, D.I., Taylor, P., Rice, L.W., Andersen, W., Irvin, W., Wang, X.Q., Harrell, F.E. Jr. (2003). Effects of adjunctive Swedish massage and vibration therapy on short-term postoperative outcomes: a randomized, controlled trial. J Altern Complement Med. 9(1), 77-89.     
    
    OBJECTIVE: To examine the effects of adjunctive postoperative massage and vibration therapy on short-term postsurgical pain, negative affect, and physiologic stress reactivity.
    
    DESIGN: Prospective, randomized controlled trial. The treatment groups were: (1) usual postoperative care (UC); (2) UC plus massage therapy; or (3) UC plus vibration therapy.
    
    SETTING: The University of Virginia Hospital Surgical Units, Gynecology-Oncology Clinic, and General Clinical Research Center. SUBJECTS: One hundred and five (N = 105) women who underwent an abdominal laparotomy for removal of suspected cancerous lesions.
    
    INTERVENTIONS: All patients received UC with analgesic medication. Additionally, the massage group received standardized 45-minute sessions of gentle Swedish massage on the 3 consecutive evenings after surgery and the vibration group received 20-minute sessions of inaudible vibration therapy (physiotones) on the 3 consecutive evenings after surgery, as well as additional sessions as desired.
    
    OUTCOME MEASURES: Sensory pain, affective pain, anxiety, distress, analgesic use, systolic blood pressure, 24-hour urine free cortisol, number of postoperative complications, and days of hospitalization.
    
    RESULTS: On the day of surgery, massage was more effective than UC for affective (p = 0.0244) and sensory pain (p = 0.0428), and better than vibration for affective pain (p = 0.0015). On postoperative day 2, massage was more effective than UC for distress (p = 0.0085), and better than vibration for sensory pain (p = 0.0085). Vibration was also more effective than UC for sensory pain (p = 0.0090) and distress (p = .0090). However, after controlling for multiple comparisons and multiple outcomes, no significant differences were found.
    
    CONCLUSIONS: Gentle Swedish massage applied postoperatively may have minor effects on short-term sensory pain, affective pain, and distress among women undergoing an abdominal laparotomy for removal of suspected malignant tissues.
    
    
14. Le Blanc-Louvry, I., Costaglioli, B., Boulon, C., Leroi, A.M., Ducrotte, P. (2002). Does mechanical massage of the abdominal wall after colectomy reduce postoperative pain and shorten the duration of ileus? Results of a randomized study. J Gastrointest Surg. 6(1), 43-9.
    
    The aim of this study was to determine the effectiveness of mechanical abdominal massage on postoperative pain and ileus after colectomy. We hypothesized that parietal abdominal stimulation could counteract induced pain and postoperative ileus, through common spinal-sensitive pathways, with nociceptive visceral messages. After preoperative randomization, 25 patients (age 52 +/- 5 years) underwent active mechanical massage by intermittent negative pressure on the abdominal wall resulting in aspiration (Cellu M50 device, LPG, Valence, France), and 25 patients (age 60 +/- 6 years) did not receive active mechanical massage (placebo group). Massage sessions began the first day after colectomy and were performed daily until the seventh postoperative day. In the active-massage group, amplitude and frequency were used, which have been shown to be effective in reducing muscular pain, whereas in the placebo group, ineffective parameters were used. Visual analogue scale (VAS) pain scores, doses of analgesics (propacetamol), and delay between surgery and the time to first passage of flatus were assessed. Types and dosages of the anesthetic drugs and the duration of the surgical procedure did not differ between groups. From the second and third postoperative days, respectively, VAS pain scores (P < 0.001) and doses of analgesics (P < 0.05) were significantly lower in patients receiving active massage compared to the placebo group. Time to first passage of flatus was also significantly shorter in the active-massage group (1.8 +/- 0.3 days vs. 3.6 +/- 0.4 days, P < 0.01). No adverse effects were observed. These results suggest that mechanical massage of the abdominal wall may decrease postoperative pain and ileus after colectomy.
    
    
15. Hattan, J., King, L., Griffiths, P. (2002). The impact of foot massage and guided relaxation following cardiac surgery: a randomized controlled trial. J Adv Nurs. 37(2), 199-207.
    
    BACKGROUND: Because of the widely presumed association between heart disease and psychological wellbeing, the use of so-called 'complementary' therapies as adjuncts to conventional treatment modalities have been the subject of considerable debate. The present study arose from an attempt to identify a safe and effective therapeutic intervention to promote wellbeing, which could be practicably delivered by nurses to patients in the postoperative recovery period following coronary artery bypass graft (CABG) surgery. Aim. To investigate the impact of foot massage and guided relaxation on the wellbeing of patients who had undergone CABG surgery.
    
    METHOD: Twenty-five subjects were randomly assigned to either a control or one of two intervention groups. Psychological and physical variables were measured immediately before and after the intervention. A discharge questionnaire was also administered.
    
    RESULTS: No significant differences between physiological parameters were found. There was a significant effect of the intervention on the calm scores (ANOVA, P=0.014). Dunnett's multiple comparison showed that this was attributable to increased calm among the massage group. Although not significant the guided relaxation group also reported substantially higher levels of calm than control. There was a clear (nonsignificant) trend across all psychological variables for both foot massage and, to a lesser extent, guided relaxation to improve psychological wellbeing. Both interventions were well received by the subjects.
    
    CONCLUSIONS: These interventions appear to be effective, noninvasive techniques for promoting psychological wellbeing in this patient group. Further investigation is indicated.
    
    
16. Hulme, J., Waterman, H., Hillier, V.F. (1999). The effect of foot massage on patients' perception of care following laparoscopic sterilization as day case patients. J Adv Nurs. 30(2), 460-8.
    
    This randomized-controlled study examined the effects of foot massage on patients' perception of care received following surgery. The sample of 59 women who underwent laparoscopic sterilization as day case patients were randomly allocated into two groups. The experimental group received a foot massage and analgesia post-operatively, whilst the control group received only analgesia post-operatively. Each participant was asked to complete a questionnaire on the day following surgery. This examined satisfaction, memory and analgesia taken. The 76% response rate was comparable with other patient satisfaction studies following day-case surgery. Statistical analysis showed no overall significant difference in the pain experienced by the two groups; however, the mean pain scores recorded following surgery showed a significantly different pattern over time, such that the experimental group consistently reported less pain following a foot massage than the control group. This study has attempted to explore the use of foot massage in a systematic way and is therefore a basis for further study.
    
    
17. Nixon, M., Teschendorff, J., Finney, J., Karnilowicz, W. (1997). Expanding the nursing repertoire: the effect of massage on post-operative pain. Aust J Adv Nurs. 14(3), 21-6.
    
    An equivalent groups design with a treatment group of 19 patients and a control group of 20 patients was used to investigate the impact of massage therapy on patients' perceptions of post-operative pain. Data were analysed using analysis of covariance repeated measures (within subjects) design. Controlling for age, the results indicated that massage produced a significant reduction in patients' perceptions of pain over a 24 hour period. A linear positive relationship emerged between patients' age and the duration of the massage. The study indicates that further investigation of the potential for massage to reduce pain is warranted.
    
    
18. Field, T., Figueiredo, B., Hernandez-Reif, M., Diego, M., Deeds, O., Ascencio, A. (2008). Massage therapy reduces pain in pregnant women, alleviates prenatal depression in both parents and improves their relationships. , J Bodyw Mov Ther . 12(2), 146-50.
    
    Prenatally depressed women (N=47) were randomly assigned to a group that received massage twice weekly from their partners from 20 weeks gestation until the end of pregnancy or a control group. Self-reported leg pain, back pain, depression, anxiety and anger decreased more for the massaged pregnant women than for the control group women. In addition, the partners who massaged the pregnant women versus the control group partners reported less depressed mood, anxiety and anger across the course of the massage therapy period. Finally, scores on a relationship questionnaire improved more for both the women and the partners in the massage group. These data suggest that not only mood states but also relationships improve mutually when depressed pregnant women are massaged by their partners.
    
    
19. Suresh, S., Wang, S., Porfyris, S., Kamasinski-Sol, R., Steinhorn, D.M. (2008). Massage therapy in outpatient pediatric chronic pain patients: do they facilitate significant reductions in levels of distress, pain, tension, discomfort, and mood alterations?, Paediatr Anaesth.18 (9 ),884-7 . 
    
    BACKGROUND AND OBJECTIVES: This study was designed to look at the efficacy of adjuvant massage therapy in children and adolescents who presented to a chronic pediatric pain clinic for management.
    
    METHODS: After Institutional Review Board approval and informed consent and assent was obtained, all pediatric patients who presented to the outpatient chronic pain clinic at Children's Memorial Hospital from July 2006 to May 2007 were invited to participate in a study that offered massage therapy as an adjunct to conventional pain treatment. Patients (n = 80 sessions, 57 patients) were asked to rate their levels of distress, pain, tension, discomfort, and degree of upset mood on a scale of 1-5 (e.g. for distress 1 = very calm; 5 = very distressed) before and after massage therapy. Paired t-tests were used to compare pre- and postmassage ratings and probability values were corrected for multiple comparisons using the Bonferroni procedure.
    
    RESULTS: After massage therapy, patients reported highly significant improvement in their levels of distress, pain, tension, discomfort, and mood compared with their premassage ratings (all t-values >6.1, ****P < 1 x 10(-8). To control for the possible effects of patients reporting improvements simply as a result of rating their symptoms, we collected control ratings before and after a comparable 'no intervention' time period in a subset of 25 patients. The 'no intervention' time period typically took place in the treatment room with the therapist present. Approximately 60% of the control ratings were obtained before the intervention and 40% were obtained after the massage therapy. None of the differences between the pre- and postratings associated with the 'no intervention' control time period were significant. In these same patients, the difference between the pre- and postmassage ratings were significant, all t-values >3.8, **P < 0.001.
20. Hughes, D., Ladas, E., Rooney, D., Kelly, K. (2008). Massage therapy as a supportive care intervention for children with cancer, Oncol Nurs Forum. 35 (3 ), 431-42 .
    
    PURPOSE/OBJECTIVES: To review relevant literature about massage therapy to assess the feasibility of integrating the body-based complementary and alternative medicine (CAM) practice as a supportive care intervention for children with cancer.
    
    DATA SOURCES: PubMed, online references, published government reports, and the bibliographies of retrieved articles, reviews, and books on massage and massage and cancer. More than 70 citations were reviewed.
    
    DATA SYNTHESIS: Massage therapy may help mitigate pain, anxiety, depression, constipation, and high blood pressure and may be beneficial during periods of profound immune suppression. Massage techniques light to medium in pressure are appropriate in the pediatric oncology setting.
    
    CONCLUSIONS: Massage is an applicable, noninvasive, therapeutic modality that can be integrated safely as an adjunct intervention for managing side effects and psychological conditions associated with anticancer treatment in children. Massage may support immune function during periods of immunosuppression.
    
    IMPLICATIONS FOR NURSING: Pediatric oncology nurses are vital in helping patients safely integrate CAM into conventional treatment. Pediatric oncology nurses can help maximize patient outcomes by assessing, advocating, and coordinating massage therapy services as a supportive care intervention.
21. Lowe, R.M., Hashkes, P.J. (2008). Growing pains: a noninflammatory pain syndrome of early childhood. Nat Clin Pract Rheumatol. 4 (10 ),542-9 .
    
    The term 'growing pains' has been used for almost 200 years to refer to the often severe, generally bilateral lower-extremity nocturnal pains experienced by up to one-third of all children at some time during early childhood. No clear mechanism has yet been identified that explains these pains, but there is an increasing body of evidence indicating that several factors, individually or in combination, might be responsible for this phenomenon. These include mechanical factors, such as joint hypermobility and flat feet, decreased pain thresholds, reduced bone strength, and emotional factors involving the patient's family and other social stressors. Correct diagnosis of growing pains requires a thorough patient history and physical examination. The diagnosis can be safely established without unnecessary laboratory investigations or imaging; however, identification of one or more clinical cautionary signs, such as unilateral pain, morning stiffness, joint swelling and systemic symptoms (e.g. fever, weight loss and malaise), should trigger an extended evaluation to exclude other more serious conditions that might also present with limb pain. Once the diagnosis has been established, conservative management, using symptomatic pain medications, massage and other supportive measures, should be employed until the syndrome self-resolves with time.
    
22. Walach, H., Güthlin, C., König, M. (2003). Efficacy of massage therapy in chronic pain: a pragmatic randomized trial. J Altern Complement Med. 9 (6 ),837-46.
    
    BACKGROUND: Although classic massage is used widely in Germany and elsewhere for treating chronic pain conditions, there are no randomized controlled trials (RCT).
    
    DESIGN: Pragmatic RCT of classic massage compared to standard medical care (SMC) in chronic pain conditions of back, neck, shoulders, head and limbs.
    
    OUTCOME MEASURE: Pain rating (nine-point Likert-scale; predefined main outcome criterion) at pretreatment, post-treatment, and 3 month follow-up, as well as pain adjective list, depression, anxiety, mood, and body concept.
    
    RESULTS: Because of political and organizational problems, only 29 patients were randomized, 19 to receive massage, 10 to SMC. Pain improved significantly in both groups, but only in the massage group was it still significantly improved at follow-up. Depression and anxiety were improved significantly by both treatments, yet only in the massage group maintained at follow-up.
    
    CONCLUSION: Despite its limitation resulting from problems with numbers and randomization this study shows that massage can be at least as effective as SMC in chronic pain syndromes. Relative changes are equal, but tend to last longer and to generalize more into psychologic domains. Because this is a pilot study, the results need replication, but our experiences might be useful for other researchers.
    
    
23. Seers, K., Crichton, N., Martin, J., Coulson, K., Carroll, D. (2008). A randomised controlled trial to assess the effectiveness of a single session of nurse administered massage for short term relief of chronic non-malignant pain. BMC Nurs. 7,10.
    
    BACKGROUND: Massage is increasingly used to manage chronic pain but its benefit has not been clearly established. The aim of the study is to determine the effectiveness of a single session of nurse-administered massage for the short term relief of chronic non-malignant pain and anxiety.
    
    METHODS: A randomised controlled trial design was used, in which the patients were assigned to a massage or control group. The massage group received a 15 minute manual massage and the control group a 15 minute visit to talk about their pain. Adult patients attending a pain relief unit with a diagnosis of chronic pain whose pain was described as moderate or severe were eligible for the study. An observer blind to the patients' treatment group carried out assessments immediately before (baseline), after treatment and 1, 2, 3 and 4 hours later. Pain was assessed using 100 mm visual analogue scale and the McGill Pain Questionnaire. Pain Relief was assessed using a five point verbal rating scale. Anxiety was assessed with the Spielberger short form State-Trait Anxiety Inventory.
    
    RESULTS: 101 patients were randomised and evaluated, 50 in the massage and 51 in the control group. There were no statistically significant differences between the groups at baseline interview. Patients in the massage but not the control group had significantly less pain compared to baseline immediately after and one hour post treatment. 95% confidence interval for the difference in mean pain reduction at one hour post treatment between the massage and control groups is 5.47 mm to 24.70 mm. Patients in the massage but not the control group had a statistically significant reduction in anxiety compared to baseline immediately after and at 1 hour post treatment.
    
    CONCLUSION: Massage is effective in the short term for chronic pain of moderate to severe intensity.
    
    
24. Frey Law, L.A., Evans, S., Knudtson, J. Nus, S., Scholl, K., Sluka, K.A. (2008). Massage reduces pain perception and hyperalgesia in experimental muscle pain: a randomized, controlled trial. J Pain. 9 (8 ), 714-21.
    
    Massage is a common conservative intervention used to treat myalgia. Although subjective reports have supported the premise that massage decreases pain, few studies have systematically investigated the dose response characteristics of massage relative to a control group. The purpose of this study was to perform a double-blinded, randomized controlled trial of the effects of massage on mechanical hyperalgesia (pressure pain thresholds, PPT) and perceived pain using delayed onset muscle soreness (DOMS) as an endogenous model of myalgia. Participants were randomly assigned to a no-treatment control, superficial touch, or deep-tissue massage group. Eccentric wrist extension exercises were performed at visit 1 to induce DOMS 48 hours later at visit 2. Pain, assessed using visual analog scales (VAS), and PPTs were measured at baseline, after exercise, before treatment, and after treatment. Deep massage decreased pain (48.4% DOMS reversal) during muscle stretch. Mechanical hyperalgesia was reduced (27.5% reversal) after both the deep massage and superficial touch groups relative to control (increased hyperalgesia by 38.4%). Resting pain did not vary between treatment groups. PERSPECTIVE: This randomized, controlled trial suggests that massage is capable of reducing myalgia symptoms by approximately 25% to 50%, varying with assessment technique. Thus, potential analgesia may depend on the pain assessment used. This information may assist clinicians in determining conservative treatment options for patients with myalgia.
    
    
25. Currin, J., Meister, E.A. (2008). A hospital-based intervention using massage to reduce distress among oncology patients. Cancer Nurs. 31 (3 ),214-21.
    
    The objective of this study was to assess the impact of a Swedish massage intervention on oncology patients' perceived level of distress. Each patient's distress level was measured using 4 distinct dimensions: pain, physical discomfort, emotional discomfort, and fatigue. A total of 251 oncology patients volunteered to participate in this nonrandomized single-group pre- and post design study for over a 3-year period at a university hospital setting in southeastern Georgia. The analysis found a statistically significant reduction in patient-reported distress for all 4 measures: pain (F = 638.208, P = .000), physical discomfort (F = 742.575, P = .000), emotional discomfort (F = 512.000, P = .000), and fatigue (F = 597.976, P = .000). This reduction in patient distress was observed regardless of gender, age, ethnicity, or cancer type. These results lend support for the inclusion of a complementary massage therapy program for hospitalized oncology patients as a means of enhancing their course of treatment
    
    
26. Sagar , S.M., Dryden, T., Wong, R.K. (2007). Massage therapy for cancer patients: a reciprocal relationship between body and mind. Curr Oncol. 14 (2 ),45-56
    
    Some cancer patients use therapeutic massage to reduce symptoms, improve coping, and enhance quality of life. Although a meta-analysis concludes that massage can confer short-term benefits in terms of psychological wellbeing and reduction of some symptoms, additional validated randomized controlled studies are necessary to determine specific indications for various types of therapeutic massage. In addition, mechanistic studies need to be conducted to discriminate the relative contributions of the therapist and of the reciprocal relationship between body and mind in the subject. Nuclear magnetic resonance techniques can be used to capture dynamic in vivo responses to biomechanical signals induced by massage of myofascial tissue. The relationship of myofascial communication systems (called "meridians") to activity in the subcortical central nervous system can be evaluated. Understanding this relationship has important implications for symptom control in cancer patients, because it opens up new research avenues that link self-reported pain with the subjective quality of suffering. The reciprocal body-mind relationship is an important target for manipulation therapies that can reduce suffering.
    
    
27. Moraska, A., Chandler, C., Edmiston-Schaetzel, A., Franklin, G., Calenda, E.L., Enebo, B. (2008). Comparison of a targeted and general massage protocol on strength, function, and symptoms associated with carpal tunnel syndrome: a randomized pilot study. J Altern Complement Med. 14 (3 ),259-67 .
    
    OBJECTIVE: Carpal tunnel syndrome (CTS) is a major, costly public health issue that could be dramatically affected by the identification of additional conservative care treatment options. Our study aimed to evaluate the effectiveness of two distinct massage therapy protocols on strength, function, and symptoms associated with CTS. DESIGN: This was a randomized pilot study design with double pre-tests and subjects blinded to treatment group assignment.
    
    SETTING/LOCATION: The setting for this study was a wellness clinic at a teaching institution in the United States.
    
    SUBJECTS: Twenty-seven (27) subjects with a clinical diagnosis of CTS were included in the study.
    
    INTERVENTIONS: Subjects were randomly assigned to receive 6 weeks of twice-weekly massage consisting of either a general (GM) or CTS-targeted (TM) massage treatment program.
    
     OUTCOME MEASURES: Dependent variables included hand grip and key pinch dynamometers, Levine Symptom and Function evaluations, and the Grooved Pegboard test. Evaluations were conducted twice during baseline, 2 days after the 7th and 11th massages, and at a follow-up visit 4 weeks after the 12th massage treatment.
    
     RESULTS: A main effect of time was noted on all outcome measures across the study time frame (p < 0.001); improvements persist at least 4 weeks post-treatment. Comparatively, TM resulted in greater gains in grip strength than GM (p = 0.04), with a 17.3% increase over baseline (p < 0.001), but only a 4.8% gain for the GM group (p = 0.21). Significant improvement in grip strength was observed following the 7th massage. No other comparisons between treatment groups attained statistical significance.
    
    CONCLUSIONS: Both GM and TM treatments resulted in an improvement of subjective measures associated with CTS, but improvement in grip strength was only detected with the TM protocol. Massage therapy may be a practical conservative intervention for compression neuropathies, such as CTS, although additional research is needed.
    
    
28. Quinn, F., Hughes, C.M., Baxter, G.D. (2008).. Reflexology in the management of low back pain: a pilot randomised controlled trial. Complement Ther Med. 16 (1 ), 3-8.
    
    OBJECTIVE: The current study was designed as a pilot study for a randomised controlled trial to investigate the effectiveness of reflexology in the management of low back pain (LBP).
    
    MATERIALS AND METHODS: Participants suffering non-specific LBP were recruited and randomised into either a reflexology or a sham group. Patients and outcome assessor were blinded to group allocation. Each patient received either a 40 min reflexology treatment or sham treatment (according to group allocation) once per week for six consecutive weeks. The primary outcome measure was pain (visual analogue scale), secondary outcome measures were the McGill pain questionnaire, Roland-Morris disability questionnaire, and SF-36 health survey. Outcome measures were performed at baseline, week 6, week 12 and week 18.
    
    RESULTS: VAS scores for pain reduced in the treatment group by a median value of 2.5 cm, with minimal change in the sham group (0.2 cm). Secondary outcome measures produced an improvement in both groups (McGill pain questionnaire: 18 points in the reflexology group and 11.5 points in the sham group). Results indicate that reflexology may have a positive effect on LBP.
    
    CONCLUSION: Reflexology appears to offer promise as a treatment in the management of LBP; however, an adequately powered trial is required before any more definitive pronouncements are possible.
    
    
29. Bell, J.  (2008). Massage therapy helps to increase range of motion, decrease pain and assist in healing a client with low back pain and sciatica symptoms. J Bodyw Mov Ther. 12(3), 281-9. 
    
    OBJECTIVE: This study evaluated the effectiveness of massage therapy as a component in increasing range of motion (ROM), decreasing pain and assisting in healing of a client with low back pain (LBP) and sciatica symptoms.
    
    METHODS: The client presented with an insidious onset of LBP and pain that radiated into the right lower extremity (sciatica). The client had been experiencing this pain daily for the past 9 months. Frequency, duration, and intensity of symptoms were recorded in a daily diary beginning the day after the client's first visit with the massage therapist. Manual therapy was administered once a week; each session lasted 45 min and consisted of a structured protocol directed mainly toward muscles of the lumbar spine, pelvis, thigh, and leg regions.
    
    RESULTS: The results of this study suggest that massage therapy was effective at reducing LBP intensity and increasing ROM for this particular client. LBP intensity was assessed at level one the first three assessment periods. The reduction in post-massage LBP intensity was maintained from week six until week 10 with the exception of week six (no change) and week seven (pain increase due to intense trigger point treatment). The client's activities of daily living (ADLs) steadily increased throughout the 10-week study.
    
    CONCLUSION: The distinct techniques and stretches used during the course of this study have the possibility of becoming useful, non-pharmacological interventions for reducing or eliminating pain and sciatica symptoms associated with low back pain.
    
    
30. Hsieh, L.L., Kuo, C.H., Lee, L.H., Yen, A.M., Chien, K.L., Chen, T.H. (2006).  Treatment of low back pain by acupressure and physical therapy: randomised controlled trial. BMJ. 332 (7543 ),696-700 .
    
    OBJECTIVE: To evaluate the effectiveness of acupressure in terms of disability, pain scores, and functional status.
    
    DESIGN: Randomised controlled trial.
    
    SETTING: Orthopaedic clinic in Kaohsiung, Taiwan.
    
    PARTICIPANTS: 129 patients with chronic low back pain.
    
    INTERVENTION: Acupressure or physical therapy for one month.
    
    MAIN OUTCOME MEASURES: Self administered Chinese versions of standard outcome measures for low back pain (primary outcome: Roland and Morris disability questionnaire) at baseline, after treatment, and at six month follow-up.
    
    RESULTS: The mean total Roland and Morris disability questionnaire score after treatment was significantly lower in the acupressure group than in the physical therapy group regardless of the difference in absolute score (- 3.8, 95% confidence interval - 5.7 to - 1.9) or mean change from the baseline (- 4.64, - 6.39 to - 2.89). Acupressure conferred an 89% (95% confidence interval 61% to 97%) reduction in significant disability compared with physical therapy. The improvement in disability score in the acupressure group compared with the physical group remained at six month follow-up. Statistically significant differences also occurred between the two groups for all six domains of the core outcome, pain visual scale, and modified Oswestry disability questionnaire after treatment and at six month follow-up.
    
    CONCLUSIONS: Acupressure was effective in reducing low back pain in terms of disability, pain scores, and functional status. The benefit was sustained for six months.
    
    
31. Dryden, T., Baskwill, A., Preyde, M. (2004). Massage therapy for the orthopaedic patient: a review. Orthop Nurs. 23 (5 ),327-32 .
    
    The effectiveness of massage therapy for the orthopaedic patient has not been documented; thus, a review of the published literature was warranted. A considerable proportion of the population experience orthopaedic problems, and many use massage therapy. A review and analysis of the literature between January 1973 and June 2003 yielded tentative results. It appears that massage therapy may be effective for orthopaedic patients with low back problems and potentially beneficial for patients with other orthopaedic problems. Massage therapy appears to be safe, to have high patient satisfaction, and to reduce pain and dysfunction.
    
    
32. Brady, L.H., Henry, K., Luth, J.F. 2nd, Casper-Bruett, K.K. (2001). The effects of shiatsu on lower back pain. J Holist Nurs. 19 (1 ),57-70 .
    
    Shiatsu, a specific type of massage, was used as an intervention in this study of 66 individuals complaining of lower back pain. Each individual was measured on state/trait anxiety and pain level before and after four shiatsu treatments. Each subject was then called 2 days following each treatment and asked to quantify the level of pain. Both pain and anxiety decreased significantly over time. Extraneous variables such as gender, age, gender of therapist, length of history with lower back pain, and medications taken for lower back pain did not alter the significant results. These subjects would recommend shiatsu massage for others suffering from lower back pain and indicated the treatments decreased the major inconveniences they experienced with their lower back pain.
    
    
33. Cherkin, D.C., Eisenberg, D., Sherman, K.J., Barlow, W., Kaptchuk, T.J., Street, J., Deyo, R.A. (2001) .  Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. Arch Intern Med. 161 (8 ), 1081-8 .
    
    BACKGROUND: Because the value of popular forms of alternative care for chronic back pain remains uncertain, we compared the effectiveness of acupuncture, therapeutic massage, and self-care education for persistent back pain.
    
    METHODS: We randomized 262 patients aged 20 to 70 years who had persistent back pain to receive Traditional Chinese Medical acupuncture (n = 94), therapeutic massage (n = 78), or self-care educational materials (n = 90). Up to 10 massage or acupuncture visits were permitted over 10 weeks. Symptoms (0-10 scale) and dysfunction (0-23 scale) were assessed by telephone interviewers masked to treatment group. Follow-up was available for 95% of patients after 4, 10, and 52 weeks, and none withdrew for adverse effects.
    
    RESULTS: Treatment groups were compared after adjustment for prerandomization covariates using an intent-to-treat analysis. At 10 weeks, massage was superior to self-care on the symptom scale (3.41 vs 4.71, respectively; P =.01) and the disability scale (5.88 vs 8.92, respectively; P<.001). Massage was also superior to acupuncture on the disability scale (5.89 vs 8.25, respectively; P =.01). After 1 year, massage was not better than self-care but was better than acupuncture (symptom scale: 3.08 vs 4.74, respectively; P =.002; dysfunction scale: 6.29 vs 8.21, respectively; P =.05). The massage group used the least medications (P<.05) and had the lowest costs of subsequent care.
    
    CONCLUSIONS: Therapeutic massage was effective for persistent low back pain, apparently providing long-lasting benefits. Traditional Chinese Medical acupuncture was relatively ineffective. Massage might be an effective alternative to conventional medical care for persistent back pain.
    
    
34. Lang , T., Hager, H., Funovits, V., Barker, R., Steinlechner, B., Hoerauf, K., Kober, A. (2007).  Prehospital analgesia with acupressure at the Baihui and Hegu points in patients with radial fractures: a prospective, randomized, double-blind trial. Am J Emerg Med. 25 (8 ),887-93 .
    
    BACKGROUND: Pain during transportation is a common phenomenon in emergency medicine. As acupressure has been deemed effective for pain management by the National Institutes of Health, we conducted a study to evaluate its effectiveness in prehospital patients with isolated distal radial fracture.
    
    METHODS: This was a prospective, randomized, double-blind study. Thirty-two patients were enrolled. Acupressure was performed either at "true" points or at "sham" points. Vital signs and pain and anxiety scores were recorded before and after the acupressure treatment. Normally distributed values were compared using the Student t test.
    
    RESULTS: Pretreatment scores for pain and anxiety were similar in the 2 groups (47.6 +/- 8.9 vs 51.2 +/- 8.7 visual analog scale [VAS] score for pain, 52.4 +/- 6.0 vs 47.5 +/- 9.3 VAS score for anxiety). At the hospital, patients in the true-points group had significantly lower pain (36.6 +/- 11.0 vs 56.0 +/- 13.3 VAS score, P < .001) and anxiety scores (34.9 +/- 22.2 vs 53.4 +/- 19.7 VAS score, P = .022).
    
    CONCLUSION: Acupressure in the prehospital setting effectively reduces pain and anxiety in patients with distal radial trauma.
    
    
35. Arai, Y.C., Ushida, T., Osuga, T., Matsubara, T., Oshima, K., Kawaguchi, K., Kuwabara, C., Nakao, S., Hara, A., Furuta, C., Aida, E., Ra, S., Takagi, Y., Watakabe, K. (2008). The effect of acupressure at the extra 1 point on subjective and autonomic responses to needle insertion. Anesth Analg. 107 (2 ),661-4 .
    
    BACKGROUND: Premedication with sedatives can decrease the discomfort associated with invasive anesthetic procedures. Some researchers have shown that acupressure on the acupuncture extra 1 point is effective for sedation. We investigated whether acupressure on the extra 1 point could alleviate the pain of needle insertion.
    
    METHODS: We investigated the effect of acupressure at the extra 1 point or a sham point on needle insertion using verbal rating scale (VRS) pain scores and heart rate variability (HRV). Twenty-two healthy female volunteers were randomly allocated to two groups: the extra 1 group received acupressure at the extra 1 point, and the sham group received acupressure at a sham point. After starting the electrocardiogram record, a 27-gauge needle was inserted into the skin of a forearm. Thereafter, another needle was inserted into the skin of the other forearm during acupressure.
    
    RESULTS: Acupressure at the extra 1 point significantly reduced the VRS, but acupressure at the sham increased the VRS. Acupressure at the extra 1 significantly reduced the low frequency/high frequency ratio of HRV responding to needle insertion.
    
    CONCLUSIONS: Acupressure at the extra 1 point significantly reduced needle insertion pain compared with acupressure at the sham point. Also, acupressure at the extra 1 point significantly reduced the low frequency/high frequency ratio of HRV responding to needle insertion, which implies a reduction in sympathetic nervous system activity.
    
    

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