The Study Question
Does massage therapy offer any benefit for addressing pain in general?
Pain is a significant problem that often triggers a visit to a health care provider, and it is estimated that approximately 80 percent of physician visits are prompted by pain. Pain affects an individual on multiple levels, including interfering with daily activities and negatively affecting work performance, family activities and relationships, mental health and overall quality of life.
Previous research has shown a close correlation between pain and other functional outcomes such as sleep, and often these challenges reinforce and compound one another. To be effective, pain management must address the whole person.
Massage therapy is rooted in a holistic, biopsychosocial model that appears to be well-suited to manage pain. This study employs systematic review and meta-analysis to assess existing massage therapy research for treating pain and function-related and health-related quality of life outcomes across all pain populations.
The Study Methods
A systematic review and meta-analysis was conducted using the Samueli Institute’s systematic review process known as the Rapid Evidence Assessment of Literature (REAL). A stakeholder group contributed to defining the review’s protocol to maximize the meaning and impact, and the systematic review team followed the protocol to independently evaluate the quantity and quality of the available English, peer-reviewed literature. The protocol for the study is registered with PROSPERO under CRD42014008867. This collaborative meta-analysis of research on massage therapy for pain conducted by Samueli Institute was commissioned by the Massage Therapy Foundation, with support from the American Massage Therapy Association.
Four databases, PubMed, CINAHL, Embase and PsycInfo, were searched from database inception through February 2014. Articles were included if they met all of the following criteria: (a) human population experiencing pain; (b) massage therapy administered alone as a therapy, as part of a multi-modal intervention where massage effects can be separately evaluated, or with the addition of techniques commonly combined with massage, such as the external application of water, heat, cold, lubricants, background music, aromas, essential oils, and with the addition of tools that may mimic the actions that can be performed by the hands; (c) sham, no treatment or active comparison; (d) assessment of at least one relevant functional outcome, and; (e) a peer-reviewed randomized controlled trial (RCT) study design published in the English language. Additionally, interventions were included if they were not necessarily labeled as massage or massage therapy but included the use of manual forces and soft-tissue deformation as well as gliding, torsion, shearing, elongation, oscillating, percussive and joint movement methods (touch, compression, gliding, percussion, friction, vibration, kneading, movement, positioning, stretching or holding). Mechanical interventions such as chair massage were excluded.
The Consolidated Standards of Reporting Trials (CONSORT) Statement lists standards for describing study interventions, and facilitates the analysis of combined studies in meta-analyses and systematic reviews. One formal extension of these standards has been established for acupuncture trials: STRICTA, the Standards for Reporting Interventions in Clinical Trials of Acupuncture. These criteria address design elements such as the intervention’s rationale, technique, treatment regimen and dosing; other elements of treatment; practitioner background; and control/comparison interventions. A noteworthy feature of this study is the development of a proposed Standards for Reporting Interventions in Clinical Trials of Massage (STRICT-M) Checklist.
For each study, the sample size, mean or pre-post difference, and standard deviation for each treatment group was extracted. Effect sizes were calculated for each comparison (i.e., massage vs. active comparator, massage vs. sham, and massage vs. no treatment) for the following outcomes: pain intensity/severity, activity, stress, mood (i.e., anxiety), sleep (i.e., fatigue), and health-related quality of life (HrQoL) where available. For pain intensity/severity, a clinical translation into the Visual Analogue Scale (VAS), 0-100, was conducted for clinical interpretation using a standard deviation of 25 points. The authors considered a 20-mm difference on the VAS to be clinically relevant. Meta-analyses were conducted with Comprehensive Meta-analysis version 2.2.
The stakeholder group and systematic review team together reviewed the evidence and graded across three areas: confidence in the estimate of the effect, magnitude of the effect, and safety as reported. They then provided an overall recommendation of the benefit/risk for massage therapy.
Out of the 3,678 articles yielded from the search strategy, 67 articles met the systematic review’s inclusion criteria and included general pain populations. Studies involving surgical pain and pain related to cancer were excluded from this study and analyzed separately.
Articles were published between 1999–2013 and evaluated the use of massage therapy on musculoskeletal pain, headache, visceral pain, and chronic pain, including fibromyalgia and spinal cord pain. Massage was performed by at least one practitioner and primarily consisted of massage therapy, myofascial release therapy, traditional Thai massage and ischemic compression compared to a variety of active, sham or no treatment controls.
Active controls included joint manipulation, physical therapy and acupuncture. Outcomes measured included pain, activity, sleep, mood, stress, HrQoL and pain pressure threshold. Treatment dosage varied from a single 1.5-minute session to a total of 40–60-minute daily sessions over the course of 20 weeks. Across the studies, 32.2 percent of the participants were male and 67.8 percent were female, with an average age of 42.7 years (range of 20–83 years).
Limitations of the Study
One limitation noted was that many of the 67 studies did not describe blinding procedures, an essential component of clinical trials. Regardless of whether or not blinding is possible in a given study, authors should discuss attempts made toward blinding or why blinding was not possible, and if employed, who was blinded and whether they remained so for the duration of the study.
Implications for evidence-informed practice: Overall, this systematic review and meta-analysis found that massage therapy may be beneficial for treating pain and functional outcomes in general pain populations, and it is safe with little risk of adverse events. Massage therapy was also beneficial for treating anxiety and health-related quality of life.
Massage Therapy Journal
Massage Therapy Journal
Massage for Functional Pain
1. Crawford C, Boyd C, Paat CF, Price A, Xenakis L, Yang, EM, Zhang W, Evidence for Massage Therapy (EMT) Working Group. “The Impact of Massage Therapy on Function in Pain Populations—A Systematic Reviewand Meta-Analysis of Randomized Controlled Trials: Part I, Patients Experiencing Pain in the General Population.” Pain Med. 2016 Jul; 17(7): 1353–1375.
2. Boyd C, Crawford C, Paat CF, Price A, Xenakis L, Zhang W, “Evidence for Massage Therapy (EMT) Working Group. The Impact of Massage Therapy on Function in Pain Populations—A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part II, Cancer Pain Populations.” Pain Med. 2016 Aug; 17(8):1553-1568.
3. Boyd C, Crawford C, Paat CF, Price A, Xenakis L, Zhang W, Evidence for Massage Therapy (EMT) Working Group. “The Impact of Massage Therapy on Function in Pain Populations—A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part III, Surgical Pain Populations.” Pain Med. 2016 Sep; 17(9):1757-1772.