The Study Question
Fibromyalgia affects 2 to 3 percent of the population worldwide and is a condition commonly treated by massage therapists. Although the condition is diagnosed based on self-reported muscular pain, recent evidence points to the source of the pain as originating from the nervous system, via the process of central sensitization—the abnormal amplification of pain signals in the spinal cord. Is one massage therapy approach more effective in relieving fibromyalgia symptoms of general and localized muscular pain compared to another?
Review the results of a pilot study conducted at Oregon Health & Sciences University in Portland, Oregon, that compared myofascial release (MFR) to Swedish massage in a head to head contest. While Swedish massage is often used by massage therapists to address fibromyalgia symptoms, the fascia surrounding skeletal muscle tissue is highly innervated and contains fibroblasts that can regulate inflammation. The researchers hypothesized that these pain-generating characteristics of fascia might play a role in maintaining fibromyalgia symptoms, and reasoned that a technique that specifically targets fascia, such as myofascial release, might show greater benefits in reducing symptoms compared to a more general Swedish massage.
A secondary goal of this pilot study was to see whether it was possible to measure improvement in localized areas of pain in conditions that result in widespread pain and central sensitization—conditions that include fibromyalgia, low back pain and temporomandibular disorder.
The Study Methods
The study authors recruited a convenience sample of 12 women between 21-50 years of age who had a verified diagnosis of fibromyalgia. The participants were allowed to continue any existing treatment, either pharmacological or nonpharmacological, as long as they had been on it for the previous three months and agreed to not make any changes to the existing treatment during the study period. Exclusion criteria were concurrent pain conditions such as diabetic neuropathy, cervical or lumbar disc disease, or severe depression. People who were already receiving any form of manual therapy—including massage, Rolfing, chiropractic or physical therapy—were also excluded, as were those who preferred not to be touched, or who were involved in any litigation or applying for disability.
Measures were assessed at baseline, before each session, and at two weeks post treatment. All participants received 90-minute sessions once a week for four consecutive weeks. Eight women received MFR and four women received Swedish massage. The method of allocation to the type of massage therapy participants received was not specified.
The primary outcome measure was the Fibromyalgia Impact Questionnaire-Revised (FIQ-R), a 21-item self-report instrument that assesses primary symptoms of fibromyalgia, physical functioning and quality of life. Higher scores indicate more severe symptoms and decreased physical functioning and quality of life. A secondary measure, the Nordic Musculoskeletal Questionnaire (NMQ) was used to measure localized pain in seven body regions: the neck, shoulders, upper and lower back, arms, and upper and lower legs. Higher scores on a 0-3 scale indicate greater pain. All outcomes were measured by a single examiner who was blinded to treatment group.
The study intervention consisted of either Swedish massage applied to the back, neck, arms and legs with moderate pressure stroking, or MFR performed on the same regions, using prolonged assisted stretching applied to painful areas. Three different licensed massage therapists delivered the intervention, and each had prior experience working with people with fibromyalgia using both techniques. The therapists also had received advanced training in MFR.
There were no pre-existing demographic or baseline differences between the two groups. The majority (90 percent) had tried Swedish massage previously and 70 percent reported some immediate but short-term improvement as a result of prior massage, generally lasting a few hours.
Five of the eight participants in the MFR group reported clinically significant improvement in their FIQ-R scores, compared to one participant in the Swedish massage group. NMQ scores improved in both groups, but showed consistent improvement in the neck and upper back regions for the MFR group, while no local areas of improvement were observed in the Swedish massage group.
Limitations of the Study
The sample size was small, so the study did not have sufficient statistical power to estimate an effect size or determine efficacy, and participants were not randomized to the two treatment groups. The dose of massage was relatively small when compared to other studies of massage and fibromyalgia, and the longer term effects were not measured. The sample was also limited to only women, so the results cannot be generalized to men, minorities or severely depressed people with fibromyalgia. However, it was designed as a pilot for a larger study.
Implications for evidence-informed practice: Previous research shows that Swedish massage can provide at least temporary relief of general pain for people living with fibromyalgia. At the same time, addressing local muscle pain is a critical therapeutic goal in working with people with fibromyalgia.
The results of this study are intriguing because they suggest a possible mechanism for how MFR might reduce pain, and hold some promise for further investigation of MFR as a longer lasting treatment for reducing localized pain and tenderness in fibromyalgia. MFR may also have potential as an intervention to address central sensitization, but this hypothesis will require more research to determine.
Practitioners who frequently see patients or clients with pain conditions involving central sensitization may want to consider adding MFR to their therapeutic repertoire.