The purpose of this article is to examine the evidence on the effectiveness of massage therapy in the management of pain across populations, conditions, and settings.
Learning Objectives/Outcomes:After participating in the CME/CNE activity, the provider should be better able to:
1. Describe the basis for 3 types of massage and demonstrate the techniques.
2. Explain current understanding of the biological basis of massage as used for relief of pain.
3. Compare the evidence on the effects of massage in patients with postoperative and musculoskeletal pain.
Massage is the systematic manipulation of the skin, muscles, and fascia to promote relaxation, relieve stress, restore energy, and reduce pain.1 Various types of massage have been used throughout time, with the history of massage found in pictures and writings from ancient Babylonia, China, and Egypt.2 A Chinese text that describes massage, The Yellow Emperor's Class Book of Internal Medicine, is named after the Yellow Emperor who died in 2598 BCE. The text also includes other forms of therapy, including acupuncture, acupressure, and herbology. Egyptian tomb paintings presumed to be from 2500 BCE depict massage as part of their healing practices, and written accounts of Ayurvedic medicine, originating in ancient India, describe massage as a routine modality used to promote health and relieve suffering.2
Overtime, various types of massage have evolved, with variations rooted in cultural healing practices. However, some similar stroking patterns exist across various types of massage (Table 1).
The 5 specific patterns of Swedish massage are likely the most well known:
1. Effleurage: to skim or touch lightly; involves a circular motion performed with the palm of the hand;
2. Petrissage: slow, rhythmic, kneading movements in which there is pressure applied that compresses the tissue;
3. Tapotement: rhythmic percussion applied with the edge of the hand, a cupped hand or the fingertips;
4. Vibration, also called shaking: therapist gently shakes or trembles the flesh with the hand or fingertips to release tension in small-muscle areas, such as the face; and
5. Friction: pressure is applied in a circular motion over a small area or transversely, moving across the tissues and muscles to break up adhesions.1
These 5 patterns are systematically applied during a whole-body massage or to a specific body region, such as a hand or foot massage.
Massage in Health Care
Massage was a fundamental skill of nursing promoted by the pioneer of modern nursing, Florence Nightingale. Throughout the 18th to early 19th centuries, massage was part of the nursing process taught in US nursing schools and administered routinely in hospitals.3 However, with increasing emphasis on monitoring and documentation, greater reliance on analgesics and drug therapies, and time demands on nurses to fulfill additional roles and tasks, massage is typically only covered briefly in the curriculum if at all.1 Physicians, chiropractors, and physical therapists may also use massage in their practice after appropriate training.
A massage therapist has specific training and clinical hours spent on learning, practicing, and providing massage and may choose to become certified by the National Board for Therapeutic Massage and Bodywork. Most states regulate the massage therapy profession, requiring education from an accredited school and passing a licensure examination administered by the Federation of State Massage Therapy Boards.
Biological Basis of Massage
Psychological and physical effects of massage include stress reduction, muscle relaxation, and relief of pain. Massage has been shown to positively influence brain development and maturation of brain electrical activity, measured by visual evoked potentials or VEPs, in rat pups and human infants.4 Insulin-like growth factor was also higher in massaged infants and higher expression levels were found in the cortex of rat pups.
To further investigate the physical effects of massage, a small, randomized controlled trial (RCT) was conducted in which 25 women who had a child with attention-deficit hyperactivity disorder were randomized to a 4-week aromatherapy massage treatment (n = 13) or a control group (n = 12).5 Subjects in the treatment group received the aromatherapy massage for 40 minutes after taking a bath, twice per week for 4 weeks.
During each massage, 20 mL of jojoba oil containing mixed essential oils of 2% lavender and 2% geranium was used, and the effleurage, friction, petrissage, and vibration techniques were applied to the neck, shoulders, arms, back, and legs at moderate pressure.
Anxiety measured by the State-Trait Anxiety Index, depression measured by the Beck Depression Inventory, and stress measured by the Psychosocial Well-Being Index were all significantly lower in the treatment group after the 4-week intervention, compared with the control group (P < 0.05 for all).
In addition, brain rhythms of alpha, beta, theta, and delta waves were measured by encephalogram (EEG) and salivary cortisol was measured before and after one session of massage and at the completion of the 4-week treatment. Salivary cortisol was significantly reduced (P < 0.001) after the 1-time treatment but not at 4 weeks.
Mean activities of alpha and beta were significantly enhanced (P < 0.05) whereas delta was significantly reduced (P < 0.05) after the 1-time massage but not after the 4 weeks, suggesting a short-term potential in modulating the EEG pattern.
Plasma brain-derived neurotrophic factor was significantly higher in the treatment group compared with preintervention levels (P < 0.03) and the control group (P < 0.05) after the 4-week treatment, suggesting that massage facilitated adaptive coping. Massage has also been shown to increase noncontact skin temperature, an indirect measure of peripheral blood flow, in 2 small studies.6,7
In a study to examine the neurobiological correlates of massage, 40 participants were randomly assigned to receive a foot massage with a wooden object, a Swedish foot massage, reflexology, or the control condition (rest), while performing a cognitive task, and at rest.8 The Swedish foot massage activated the subgenual anterior and retrosplenial/posterior cingulate (RSC/PCC) cortices, 2 important regions of the default mode network that are involved in self-awareness and arousal, during the rest period and the RSC/PCC during the cognitive task, whereas reflexology selectively affected the RSC/PCC only modestly.
In contrast, massage with an object did not differ significantly from control. The study suggests that qualitative aspects of massage can selectively modulate the activity of specific regions of the default mode network.
Another study that evaluated the mechanisms of massage in a rodent model found that Tuina massage reduced the level of peripheral nociceptor C-fiber activity as measured by electrical sciatic nerve stimulation.9
Collectively, the evidence surrounding the analgesic effects of massage suggests that massage may influence tissue temperature, levels of chemical mediators in circulation, brain-wave activity specifically in regions of the brain that regulate self-awareness and arousal, and decrease peripheral C-fiber activity.
To date, however, there have been few studies comprehensively evaluating the effects of massage on the mechanisms of pain, and variability in the analgesic effects across pain conditions or types of massage. To examine current research on the effects of massage for pain, a nonexhaustive literature review was performed as described later.
Literature Review on the Effects of Massage on Pain Intensity in Various Populations
A nonexhaustive review of the literature was completed using the databases PubMed/Medline and CINAHL, with the key words massage and pain, to identify key trends in this body of research. Articles were limited to primary research that focused on the evaluation of massage as a means of providing pain relief in a specific population, published in the last decade (2008-2018) and that were written in the English language.
Descriptions of these studies are listed in Table 2, with a brief summary of the study findings. Most of the studies identified in the review were focused on acute pain (labor pain, postsurgical pain), were short-term, and had relatively small samples sizes. Other common challenges for research on the effects of massage include the wide variety of massage types, selection of a specific population (ie, participants undergoing anterior cervical discectomy and 1-level fusion vs all postoperative patients), inclusion of an adequate active control group that receives a similar intervention but not the study intervention, in addition to an a control group, and blinding the research team members who perform data collection. These issues affect the generalizability of study findings and the study risk of bias.
In addition to single studies, systematic reviews and meta-synthesis of published studies were identified and are summar-ized below.
Preterm Infants and Women in Labor
Massage therapy has been used to relieve pain and stress, promote neurodevelopment and weight gain in preterm infants. In this review, 34 RCTs were included, with most focusing on the effects of massage on weight gain.21 The author writes that, although some trials reported improvements in developmental scores, stress behaviors, and pain tolerance, positive effects on the immune system and earlier discharge from the hospital, the number of such studies is small and requires further evidence. In a meta-synthesis of massage for managing pain in labor, a total of 14 trials (including 1329 women) were analyzed.22 The authors found that there was low-quality evidence for greater reduction in pain during the first stage of labor and evidence for greater reduction of pain during the second and third stages of labor.
Postoperative Pain
In a systematic review and meta-analysis of the effects of massage therapy on postoperative pain and anxiety, the authors identified 10 RCTs that collectively included a total of 1157 participants.23 Among 6 of the studies that evaluated the effect of a single dose of massage on postoperative pain and 4 studies that evaluated pain from sternal incisions, there was a significant improvement in pain [standardized mean difference (SMD), -0.68; 95% confidence intervals (CIs), -0.91 to -0.46; P < .00001]. Although moderate effect sizes were found for massage, the effects were not long-lasting.
A previous study on the effects of massage on pain in an acute care setting reported that most patients experience benefits for 1 to 4 hours.24
Another systematic review on the effects of massage on acute postthoracic surgery pain included 12 RCTs. Of the 12 trials, 9 evaluated massage in addition to standard analgesia, 2 compared massage to an attention control/sham massage in the intensive care unit (ICU), 6 compared massage to standard analgesia alone on early post-ICU discharge, and 1 compared massage to both attention control and standard care in the ICU.25 The review found that participants who received massage with analgesia reported less pain compared with attention control/sham massage (3 RCTs, n = 462; SMD, -0.80; 95% CI, -1.25 to -0.35; P < 0.001) and standard care (7 RCTs, n = 1087; SMD, -0.85; 95% CI, -1.28 to -0.42; P < 0.001). The authors concluded that, in addition to pharmacologic analgesia, massage can help reduce postcardiac surgery pain intensity.
Cancer Pain
A meta-analysis on the effects of massage for cancer pain identified 12 studies (559 participants) of which 9 were rated as high quality.26 Using data from the 12 studies, the authors reported a significant effect of massage on pain reduction compared with no massage treatment or conventional care (SMD, -1.25; 95% CI, -1.63 to -0.87; P < 0.00001). In a subgroup analysis based on the cause of cancer pain, they found significant effects of massage in patients with treatment-related effects (eg, surgery and chemotherapy) and metastases, and in those with co-occurring symptoms. The results suggest that massage is effective for cancer pain, including surgery-related pain. They also reported that foot reflexology seemed to be more effective than whole-body or aroma massage.
A Cochrane review on the same subject consisted of 19 studies with a total of 1274 participants. Of the 19 studies, 14 studies were included in the qualitative review and 5 studies in the quantitative review.27 Of the studies, 13 compared massage to no massage; 6 compared aromatherapy massage to no massage; 2 studies compared aromatherapy massage to massage without aromatherapy. Short-term pain relief was greater for the massage group compared with the no-massage group (1 RCT, n = 72; SMD, -1.60; 95% CI, -2.67 to -0.53). There was some indication of benefit in the aromatherapy-massage group, but this benefit was not considered to be clinically significant. The authors concluded that there was a lack of evidence on the clinical effectiveness of massage for symptom relief in people with cancer and that future studies in this area need to address risk of bias in sample size and blinding the outcome assessment.
Musculoskeletal Pain
The effects of deep transverse friction massage for treating lateral elbow or knee tendonitis was reviewed, with 2 studies identified (57 participants).28 The first study compared deep transverse friction massage combined with therapeutic ultrasound and placebo ointment (n = 11) versus therapeutic ultrasound and placebo ointment only (n = 9) and deep transverse friction massage combined with phonophoresis (n = 10) versus phonophoresis only (n = 10) for patients with lateral elbow tendonitis (n = 40). There was no statistically significant difference noted within 5 weeks for mean change in pain.
In the second study, deep transverse friction massage with physical therapy was compared with physical therapy alone at 2 weeks in patients with knee tendonitis (n = 17). There were no statistically significant differences between groups in the 3 measures of pain assessed.
In a Cochrane review assessing the effects of massage for low back pain, a total of 25 trials (3096 participants) were included.29 For acute low back pain, massage provided greater pain relief compared with inactive controls in the short-term (1 RCT, n = 51; SMD, -0.50; 95% CI, -1.85 to -0.64); however, there was no effect on function. For subacute and chronic low back pain, massage provided significantly more pain relief and increased function than inactive controls in the short-term but not in the long-term. Massage provided a significant improvement in pain in the short- and long-terms compared with active controls, but no differences were found for function.
HIV-Related Pain
In a systematic review on the effects of massage therapy for HIV-related pain, 4 studies were included in the analysis.30 Overall, the authors reported that there was some evidence to support the use of massage therapy to improve quality of life for people living with HIV, particularly in combination with other stress management modalities. However, further studies with rigorous design and reporting, and larger sample sizes are needed to evaluate the effects on pain and other symptoms.
A series of systematic reviews were completed by the Samueli Institute and funded by the Massage Therapy Foundation through the support of the American Massage Therapy Association. These research studies addressed the impact of massage therapy on function in patients with pain in the general population, cancer populations, and surgical populations.31-33
In studies that included the general population, 60 RCTs of high quality and 7 RCTs of low quality were included in the review. The results of the analysis support that massage therapy effectively treats pain compared with sham, no treatment, and active comparators.31 The authors provided a strong recommendation for massage therapy compared with no treatment and a weak recommendation for massage compared with other sham or active comparators.
In cancer populations, 12 high-quality and 4 low-quality studies were included in the review.32 The results demonstrated that massage therapy is effective for treatment of cancer pain compared with no treatment and to active comparators. The results also demonstrated that massage therapy was beneficial for treating fatigue and anxiety. The authors provided a weak recommendation for massage therapy compared with an active comparator, whereas no recommendation was suggested for massage therapy compared with no treatment or sham.
In surgical populations, 12 studies of high quality and 4 studies of low quality were included in the analysis.33 The authors found that massage therapy is effective for treating pain and anxiety compared with active comparators and provided weak recommendations for massage therapy for reducing pain and anxiety in patients undergoing surgical procedures.
Contraindications to Massage and Potential Adverse Effects
Massage is associated with a low incidence of adverse events34; however, a thorough medical and surgical history should be obtained to prevent injury or complications. Patients with bleeding disorders or prior surgical procedures should be carefully evaluated. Massage should be avoided near open wounds or incisions, on or around pressure ulcers, thrombosis, or areas of compromised skin integrity/rash, bony prominences, or reddened/swollen areas.1
For patients with IV lines, drains, or other devices, special care should be taken to avoid the area and protect the lines. Careful attention should be paid when positioning women who are pregnant, patients with injuries, and older adults. To prevent adverse effects, patient preferences should be elicited before the massage regarding the use of oils, lotions, or other substances placed on the skin, and use of aromatherapy or other fragrances. Allergies should also be noted to avoid irritants. Adverse effects such as rash, bruising, or increased pain should be documented with appropriate follow-up.
In a systematic review evaluating the incidence of adverse events after massage over an 11-year period, complications included disc herniation, soft-tissue trauma, dissection of the vertebral arteries, spinal cord injury, and neurologic impairments.34 Thus, although the incidence of adverse effects from massage are low, when they occur, they can be very serious.
Conclusion
Massage therapy has been used for thousands of years to relieve pain, reduce suffering, and improve quality of life. Various types of massage can be used, depending on the preference of the patient and access to certified, licensed massage therapists or other health care providers adequately trained to provide massage therapy. Although a full understanding of how massage causes its analgesic effects remains to be elucidated, research has shown that it can modulate peripheral and central pathways connected to the experience of pain. Many recent studies, systematic reviews, and metasyntheses have been conducted in various populations. Overall, the evidence supports positive effects of massage in providing pain relief over the short-term and can be used safely as a complementary therapy in pain management.
References