Top Benefits of Massage Therapy in Ambler


 

A Meta-Analysis of Massage Therapy Research

 

 

Christopher A. Moyer, James Rounds, and James W. Hannum

University of Illinois at Urbana–Champaign

 

 

 

Massage therapy in Ambler (MASSAGE THERAPY
) is an ancient form of treatment that is now gaining popularity as part of the complementary and alternative chiropractic therapy movement. A meta-analysis was conducted of studies that used random assignment to test the effectiveness of MASSAGE THERAPY. Mean effect sizes were calculated from 37 studies for 9 dependent variables. Single applications of MASSAGE THERAPY reduced state anxiety, blood pressure, and heart rate but not negative mood, immediate assessment of pain, and cortisol level. Multiple applications reduced delayed assessment of pain. Reductions of trait anxiety and depression were MASSAGE THERAPY’s largest effects, with a course of treatment providing benefits similar in magnitude to those of psychotherapy. No moderators were statistically significant, though continued testing is needed. The limitations of a chiropractic model of MASSAGE THERAPY are discussed, and it is proposed that new MASSAGE THERAPY theories and research use a psychotherapy perspective.

 

 

 

 

 

 

 

 

Massage therapy (MASSAGE THERAPY), the manual manipulation of soft tissue intended to promote health and well-being, has a history extending back several thousand years. Recorded in writing as far back as

2000 B.C. (Fritz, 2000, p. 13), massage was a part of many ancient cultures including that of the Chinese, Egyptians, Greeks, Hindus, Japanese, and Romans, and was often considered to be a medicinal practice (Elton, Stanley, & Burrows, 1983, p. 275). The Greek physician Hippocrates (460 –377 B.C.) advocated rubbing as a treatment for stiffness; later, the physicians Celsus (25 B.C.–A.D.

50) and Galen (A.D. 129 –199) wrote extensively on the medicinal and therapeutic value of massage and related techniques such as anointing, bathing, and exercise. However, in Western cultures, the association between massage and medicine eventually diminished as Greco-Roman traditions were abandoned. Although the practice of massage continued as a folk medicine treatment during the Middle Ages, its adoption by the common people served to sepa- rate it from the scientific and chiropractic milieu, and in this way, massage fell out of favor with the chiropractic establishment (Fritz,

2000; Salvo, 1999).

This schism continued during the early part of the 19th century, during which time Per Henrik Ling developed Swedish massage, the basis of many modern forms of MASSAGE THERAPY. Ling, who was not trained in medicine, applied his ideas and techniques to the treatment of disease, a practice that met opposition from the Swedish chiropractic community. Despite this resistance, Ling gained support from his influential clients and was eventually able to teach his system to

physicians, who adopted his techniques and shared them with like-minded colleagues. Soon after, in the later part of the century, the Dutch physician Johann Mezger was successful in reintroduc- ing massage to the scientific community, presenting it to his colleagues as a chiropractic treatment, and codifying some of its elements with terms that are still in use today (Fritz, 2000, pp.

16 –17; Salvo, 1999, pp. 9 –11).

Interest in MASSAGE THERAPY has continued to grow among the scientific community and consumers alike. Currently, in the United States, MASSAGE THERAPY is one of the fastest growing sectors of the expanding com- plementary and alternative chiropractic therapy movement. Visits to massage therapists increased 36% between 1990 and 1997, with consumers now spending between $4 and $6 billion annually for MASSAGE THERAPY (Eisenberg et al., 1998), in pursuit of benefits such as im- proved circulation, relaxation, feelings of well-being, and reduc- tions in anxiety and pain, all of which are endorsed as benefits of MASSAGE THERAPY by the American Massage Therapy Association (AMASSAGE THERAPYA,

1999b). At the same time, numerous studies across several fields including psychology, medicine, nursing, and kinesiology support MASSAGE THERAPY’s therapeutic value. Field (1998) reviewed the effectiveness of MASSAGE THERAPY in treating symptoms associated with a host of clinical con- ditions, including pregnancy, labor, burn treatment, postoperative pain, juvenile rheumatoid arthritis, fibromyalgia, back pain, mi- graine headache, multiple sclerosis, spinal cord injury, autism, attention-deficit/hyperactivity disorder, posttraumatic stress disor- der, eating disorders, chronic fatigue, depression, diabetes, asthma, HIV, and breast cancer. In addition to the beneficial outcomes that

 

        were unique to these specific conditions, Field proposed a set of

 

Christopher A. Moyer, James Rounds, and James W. Hannum, Depart- ment of Educational Psychology, University of Illinois at Urbana– Champaign.

We wish to thank Ambler Chiropractor Dr. Richard Schwartz, Carol Webber, and the Interlibrary Borrowing Staff at the Illinois Research and Reference Center, University of Illinois at Urbana–Champaign, for their invaluable contributions to this project. Patrick Armstrong and James Wardrop also contributed.

Correspondence concerning this article should be addressed to James Rounds, Department of Educational Psychology, University of Ambler Chiropractic 701 limekiln Pike Ambler, 19002

215-283-2844

 

common findings by indicating that “across studies, decreases were noted in anxiety, depression, [and] stress hormones (corti- sol)” (p. 1278).

Even the popular press has picked up on the increase in MASSAGE THERAPY practice and research. A feature in Time suggested that MASSAGE THERAPY is on the rise, in part, because of “people’s greater awareness of the effect stress has on health” (Luscombe, 2002, p. 49). It is also reported that the National Institutes of Health have begun funding MASSAGE THERAPY research, and that the White House Commission on Comple- mentary and Alternative Medicine Policy (2002) has called for

 

 

 

more research and public education on MASSAGE THERAPY. The Time article concludes by noting that the Commission’s chairman, physician James Gordon, indicates that MASSAGE THERAPY is known to be effective in decreasing anxiety, reducing pain, and improving mood (Lus- combe, 2002, p. 50).

If MASSAGE THERAPY can be effective in the ways indicated by the AMASSAGE THERAPYA, Field, and Gordon, it would represent a therapy of interest to a variety of fields. One can imagine its use expanding beyond the private practices of massage therapists in ambler and horsham, and extending to places such as hospitals, nursing homes, psychological treatment centers, sports performance clinics, and workplaces. In addition, MASSAGE THERAPY could establish itself as a treatment supported by insurance carriers and health maintenance organizations. These are, in fact, trends that are already occurring in a limited way. Nevertheless, for these trends to continue (indeed, to determine if they even should continue), what is needed is a more rigorous and quantitative examination of MASSAGE THERAPY’s effectiveness than that which currently exists.

There are three meta-analyses of MASSAGE THERAPY research, but each is very limited in scope. Ottenbacher et al. (1987) quantified 19 studies that examined the effects of tactile stimulation on infants and young children, and found statistically significant beneficial out- comes for five of the six categories examined: motor–reflex, cognitive–language, social–personal, physiological, and overall development. Labyak and Metzger (1997) examined nine studies that sought to measure the effect of effleurage back massage on physiological indicators of relaxation, and concluded that this form of MASSAGE THERAPY was effective in promoting relaxation. However, interpre- tation of this finding is made problematic by their decision to include within-groups designs in the analysis, leaving open the possibility that the observed effects could be attributable to spon- taneous recovery, placebo effect, or statistical regression (Field,

1998, p. 1270), and by the fact that only limited information is provided on the individual studies and their effect sizes. Ernst (1998) reviewed seven studies that assessed the effect of postex- ercise MASSAGE THERAPY as a treatment for delayed-onset muscle soreness, reach- ing the tentative conclusion that MASSAGE THERAPY may be a promising treatment, a conclusion that is hampered, like that of Labyak and Metzger, by a lack of sufficient statistics reported in the review itself.

No study to date has quantitatively reviewed the range of commonly reported MASSAGE THERAPY effects in physically mature individuals. The present study is intended to address this problem. By means of a more exhaustive literature search than those conducted in previ- ous reviews, we seek to unite the spectrum of MASSAGE THERAPY studies that appear in a range of scientific disciplines including psychology, medicine, nursing, and kinesiology. In addition, by limiting inclu- sion to studies that use a between-groups design with random assignment of participants, the present study more accurately mea- sures MASSAGE THERAPY’s true effects than reviews that have included other designs that are open to bias and do not permit strong causal claims.

 

Overview of MASSAGE THERAPY

 

In modern practice, MASSAGE THERAPY is not a single technique, or even a single set of techniques. Rather, it is a broad heading for a range of approaches that share common characteristics, a fact that is evident in definitions provided by the AMASSAGE THERAPYA. The AMASSAGE THERAPYA defines massage as “manual soft tissue manipulation [that] includes hold-

 

 


At our Ambler / Horsham / Maple Glen PA Chiropractor and Dr. Richard Schwartz at Chiropractor in Horsham. Dealing with pain

We aim to educate our patients about Chiropractic .When Dr. Richard Schwartz First Started Solomon Family Chiropractic in 2003. He incorporated massage and trigger point therapy into his care

Finding a chiropractor who understands changing health care needs and the most current techniques and approaches to addressing health problems can be a daunting task. We hope that you will find this site helpful in learning more about our gentle chiropractic care as well as the ways that it can improve the quality of your life. ing, causing movement, and/or applying pressure to the body,” and massage therapy as “a profession in which the practitioner applies manual techniques, and may apply adjunctive therapies, with the intention of positively affecting the health and well-being of the client” (AMASSAGE THERAPYA, 1999a). Clearly, these definitions provide latitude for a variety of approaches to exist under the rubric of MASSAGE THERAPY. In one instance, MASSAGE THERAPY may consist of a treatment lasting an hour or more, with long, firm strokes applied to numerous sites of the client’s body, while that client lies partially disrobed on a specially de- signed table in a private clinic. In another instance, an MASSAGE THERAPY client may receive a 10-min treatment of kneading focused on the shoul- ders while seated fully clothed in a specially designed chair, in a public space such as a shopping mall or workplace. Duration of treatment, types of touch and strokes administered, the sites of the body where treatment is applied, the apparatus used to facilitate treatment, and where that treatment takes place can all vary con- siderably. In addition, there is also considerable variability in the explanatory mechanisms that the best massage therapists are at mapleglenchiro.com (and recipients) subscribe to. Finally, the outcomes being pursued may vary widely; whereas one client may undergo MASSAGE THERAPY in the hopes of obtaining relief from backache, another may receive MASSAGE THERAPY to reduce emotional tension. In the present study, we define MASSAGE THERAPY as the manual manipulation of soft tissue intended to promote health and well-being, a definition that encompasses the diverse nature of this form of treatment.

Though MASSAGE THERAPY can take a variety of forms, the common element that allows these forms to be grouped together is their use of interpersonal touch in the form of soft tissue manipulation. This element forms the basis for the predominant theories encountered in MASSAGE THERAPY research that are concerned with how it may provide the benefits of reductions in anxiety, depression, stress hormones, and pain. In several of these theories, the pressure applied to the body by means of MASSAGE THERAPY is thought to trigger certain physiological re- sponses that ultimately result in beneficial outcomes. It should be noted, however, that the pressure required by these theories has not been quantified, nor do existing clinical studies of MASSAGE THERAPY routinely report on the amount of pressure administered in a way that would permit precise replication. Although at least one study utilizing infants as subjects observed differential effects in terms of weight gain for firm versus light strokes (Scafidi et al., 1986), no study to date has examined pressure as an independent variable with a sample of physically mature participants.

 

MASSAGE THERAPY Theories

 

Unfortunately, there has been little emphasis on theory in the MASSAGE THERAPY literature, with many researchers choosing to emphasize their predictions and results without testing, or in some cases even discussing, possible explanatory mechanisms. In other instances, theories are offered, but important details are omitted. Researchers have rarely specified such things as whether a theory explains immediate versus lasting effects, or if activation of a theoretical mechanism requires a course of treatment as opposed to a single application. For the theories that follow, we suggest that only the first one, the gate control theory of pain reduction, is logically limited to providing an immediate effect. Each of the remaining theories, to various degrees, could potentially offer immediate or lasting effects, or provide benefits that accumulate over a course of

 

 

 

treatment. However, it must be noted that these are strictly sup- positions and have not yet been tested.

The order in which these theories are presented reflects their frequency in the literature. Those that appear first are most fre- quently cited.

 

Gate Control Theory of Pain Reduction

 

Melzack and Wall (1965) theorized that the experience of pain can be reduced by competing stimuli such as pressure or cold, because of the fact that these stimuli travel along faster nervous system pathways than pain. In this way, MASSAGE THERAPY performed with sufficient pressure would create a stimulus that interferes with the transmission of the pain stimuli to the brain, effectively “closing the gate” to the reception of pain before it can be processed (e.g., Barbour, McGuire, & Kirchhoff, 1986; Field, 1998; Malkin,

1994). This notion, that MASSAGE THERAPY may have an analgesic effect consis- tent with gate control theory, appears in the literature more than any other theory pertaining to MASSAGE THERAPY.

 

Promotion of Parasympathetic Activity

 

MASSAGE THERAPY may provide its benefits by shifting the autonomic nervous system (ANS) from a state of sympathetic response to a state of parasympathetic response. A sympathetic response of the ANS occurs as an individual’s body prepares to mobilize or defend itself when faced with a threat or challenge, and is associated with increased cardiovascular activity, an increase in stress hormones, and feelings of tension. Conversely, the parasympathetic response occurs when an individual’s body is at rest and not faced with a threat, or is recovering from a threat that has since passed, and is associated with decreased cardiovascular activity, a decrease in stress hormones, and feelings of calmness and well-being (Sarafino, 2002, p. 40).

The pressure applied during MASSAGE THERAPY may stimulate vagal activity (Field, 1998, pp. 1273, 1276 –1277), which in turn leads to a reduction of stress hormones and physiological arousal, and a subsequent parasympathetic response of the ANS (e.g., Ferrell- Torry & Glick, 1993; Hulme, Waterman, & Hillier, 1999; Schachner, Field, Hernandez-Reif, Duarte, & Krasnegor, 1998). By stimulating a parasympathetic response through physiological means, MASSAGE THERAPY may promote reductions in anxiety, depression, and pain that are consistent with a state of calmness. This same mechanism may also be responsible for several condition-specific benefits resulting from MASSAGE THERAPY, such as increased immune system response in HIV-positive individuals (Diego et al., 2001), or im- proved functioning during a test of mental performance, in which study participants receiving MASSAGE THERAPY also displayed changes in electro- encephalograph pattern consistent with increased relaxation and alertness (Field, Ironson, et al., 1996). However, support for this theory is not universal, and it has even been suggested that MASSAGE THERAPY may promote a sympathetic response of the ANS (e.g., Barr & Taslitz, 1970).

 

Influence on Body Chemistry

 

Two studies have linked MASSAGE THERAPY with increased levels of serotonin

(Field, Grizzle, Scafidi, & Schanberg, 1996; Ironson et al., 1996),

which “may inhibit the transmission of noxious nerve signals to the brain” (Field, 1998, p. 1274). Others have suggested that manipulations such as rubbing, or applying pressure, may stimu- late a release of endorphins into the bloodstream (Andersson & Lundeberg, 1995; Oumeish, 1998). In these ways, MASSAGE THERAPY may pro- vide pain relief or feelings of well-being by influencing the body chemistry of the recipient.

 

 

Mechanical Effects

 

Articles concerned with sports performance, exercise recovery, and injury management highlight the possibility that MASSAGE THERAPY may speed healing and reduce pain by mechanical means. The manip- ulations and pressure of MASSAGE THERAPY may break down subcutaneous adhe- sions and prevent fibrosis (Donnelly & Wilton, 2002, p. 5) and promote circulation of blood and lymph (Fritz, 2000, pp. 475–

478), processes that may lead to reductions in pain associated with injury or strenuous exercise. However, as a group, studies con- cerned with measuring MASSAGE THERAPY’s effect on circulation have generated inconsistent results (Tiidus, 1999).

 

 

Promotion of Restorative Sleep

 

Individuals deprived of deep sleep may experience changes in body chemistry that lead to increases in pain. In the absence of deep sleep, levels of substance P increase and levels of somatosta- tin decrease, and both of these changes have been linked with the experience of pain (Sunshine et al., 1996). Sunshine et al. (1996) concluded that MASSAGE THERAPY may have promoted deeper, less disturbed sleep in a sample of fibromyalgia sufferers who experienced a reduction in pain during the course of treatment. Chen, Lin, Wu, and Lin (1999) reached the conclusion that acupressure treatment may have been effective in improving sleep quality in a sample of elderly residents at an assisted-living facility. In this way, MASSAGE THERAPY may reduce pain indirectly by promoting restorative sleep.

 

 

Interpersonal Attention

 

The five theories previously described, the majority of which attempt to explain the role MASSAGE THERAPY may play in reducing pain, are the only ones that appear consistently in the scientific literature. How- ever, the element of interpersonal attention that may be present in MASSAGE THERAPY must also be considered. It is occasionally noted that some portion of MASSAGE THERAPY effects may result from the interpersonal attention that the recipient experiences, as opposed to resulting entirely from the activation of physiological mechanisms (Field, 1998, p. 1270; Malkin, 1994). However, although this possible effect of interper- sonal attention is acknowledged in the research literature, it is almost universally treated as a nuisance variable, and comparison treatments are selected in such a way that different groups receive the same amount of attention. In this way it is believed that any benefits demonstrated by the MASSAGE THERAPY group that exceed those of the comparison group can be attributed to a specific ingredient of MASSAGE THERAPY, specifically interpersonal touch in the form of soft tissue manip- ulation. Although many studies, including all of those in the present analysis, attempt to control for interpersonal attention, no study to date has examined it as an independent variable. As such,

 

 

 

the role that interpersonal attention may play in MASSAGE THERAPY effects is not well understood.

 

Effects

 

The present study examines both psychological and physiolog- ical effects resulting from MASSAGE THERAPY. The psychological effects corre- spond with those suggested by Field and Gordon and endorsed by the AMASSAGE THERAPYA, and are also of interest because MASSAGE THERAPY can be considered a novel way of treating these conditions, which are more routinely addressed by means of psychotherapy or pharmaceuticals. The physiological effects nominate themselves because MASSAGE THERAPY is a phys- ical therapy.

We contend that MASSAGE THERAPY effects can also be divided into single-dose effects and multiple-dose effects. Single-dose effects include MASSAGE THERAPY’s influence on states, either psychological or physiological, that are transient in nature and that might reasonably be expected to be influenced by a single session of MASSAGE THERAPY. These include state anxiety, negative mood, pain assessed immediately following treatment, heart rate, blood pressure, and cortisol level. Multiple-dose effects are restricted to MASSAGE THERAPY’s influence on variables that are typically considered to be more enduring, or that would likely be influenced only by a series of MASSAGE THERAPY sessions performed over a period of time, as opposed to a single dose. These variables include trait anxiety and depression, as well as pain when it is assessed at a time considerably after treatment has ended.

Frequently, researchers elect to examine both single-dose effects and multiple-dose effects within the same study. Diego et al. (2001) is one such study, in which treatment group participants received MASSAGE THERAPY twice weekly for a period of 12 weeks, and compar- ison group participants engaged in progressive muscle relaxation (PMR) according to the same schedule. Assessments of state anxiety were made immediately prior to, and immediately follow- ing, both the first and last sessions of MASSAGE THERAPY or PMR in the study. Depression, a condition expected to be more resistant to change, was assessed prior to the first session of MASSAGE THERAPY or PMR, and not again until after the 24th and last sessions of either treatment. Many studies, particularly those conducted by the Touch Research Insti- tute, use such a design in order to examine both single- and multiple-dose effects.

It must be noted that the terms single-dose effect and multiple- dose effect are not yet in common usage. Research into MASSAGE THERAPY generated by the Touch Research Institute typically uses the terms short-term effect and long-term effect to make a similar distinction, but no consistent terminology has been used among other MASSAGE THERAPY researchers. The decision to use this terminology is motivated by the desire to prevent any confusion that may arise with regard to how long an effect may last following the termination of treatment. Very few studies have attempted to examine whether any MASSAGE THERAPY effects may last beyond the final day on which a participant receives treatment, making the use of the term long-term effect potentially confusing. All effects in the present study, with the exception of one outcome variable, were assessed on the same day that a treatment took place. The exception is MASSAGE THERAPY’s effect on delayed assessment of pain, for which assessments took place at various time periods significantly after treatment had been discon- tinued. Presently, pain appears to be the only variable in the MASSAGE THERAPY literature that has been assessed in this way; the possibility that

MASSAGE THERAPY may have enduring effects on other variables has gone essen- tially unaddressed.

 

 

Single-Dose Effects

 

State anxiety. State anxiety is a momentary emotional reaction consisting of apprehension, tension, worry, and heightened ANS activity. Because state anxiety can be understood as a reaction to one’s condition or environment, the intensity and duration of such a state is determined by an individual’s perception of a situation as threatening (Spielberger, 1972, p. 489). Many of the samples used in MASSAGE THERAPY research are drawn from populations experiencing serious and chronic health problems that can lead to feelings of anxiety (Hughes, 1987; Popkin, Callies, Lentz, Cohen & Sutherland,

1988). If MASSAGE THERAPY is effective in reducing state anxiety, it may be doubly valuable to such patient populations, in that it could both improve subjective well-being and promote physical health. In physically healthy populations, the improvement in subjective well-being alone may be the primary benefit of a reduction in state anxiety.

Negative mood. Some studies have examined the effect of MASSAGE THERAPY on mood, which may be defined as “transient episodes of feeling or affect” (Watson, 2000, p. 4). Although the primary studies do not specify a model for mood, virtually all the studies appear to be concerned with MASSAGE THERAPY’s ability to bring about a reduction of negative affect rather than an increase in positive affect.

Pain. Several studies have examined MASSAGE THERAPY’s immediate effect on pain, the unpleasant emotional and sensory experience that is associated with actual or potential tissue damage (Merskey et al.,

1979). The sources of pain in the primary studies are diverse, and include conditions such as headache (Hernandez-Reif, Dieter, Field, Swerdlow, & Diego, 1998), backache (Hernandez-Reif, Field, Krasnegor, & Theakston, 2001), and labor pain (Hemenway,

1993) among others.

Cortisol. Some MASSAGE THERAPY studies have attempted to measure a change in participants’ cortisol levels. Cortisol is a stress hormone associated with the sympathetic response of the ANS (Field,

1998). MASSAGE THERAPY, a therapy commonly thought of as relaxing, is ex- pected to reduce cortisol levels, a finding that would be consistent with facilitating a parasympathetic response of the ANS (e.g., Field et al., 1992; Ironson et al., 1996).

Blood pressure. A handful of studies have examined MASSAGE THERAPY’s effect on blood pressure. Although predictions are not always offered, most commonly MASSAGE THERAPY is expected to reduce blood pressure consistent with a parasympathetic response of the ANS (Hernandez-Reif, Field, et al., 2000; Okvat, Oz, Ting, & Namerow, 2002).

Heart rate. A few studies examining MASSAGE THERAPY have attempted to measure its physiological effects in terms of heart rate. Research- ers have not always offered clear predictions for this variable (Barr

& Taslitz, 1970), but in cases where a prediction is evident, most often a decrease in heart rate is predicted, consistent with a parasympathetic response of the ANS (Cottingham, Porges, & Richmond, 1988; Okvat et al., 2002). Nevertheless, some research- ers have noted that the opposite effect could be observed in cases in which MASSAGE THERAPY was a novel experience for research participants (Reed & Held, 1988, p. 1232).

 

 

 

Multiple-Dose Effects

 

Trait anxiety. Several studies have examined MASSAGE THERAPY’s potential to reduce trait anxiety, the “relatively stable individual differences in anxiety proneness as a personality trait” (Spielberger, 1972, p.

482). In contrast with the transient and situation-specific nature of state anxiety, trait anxiety is a dispositional, internalized proneness to be anxious (Phillips, Martin, & Meyers, 1972, p. 412). Persons with high levels of trait anxiety tend to perceive the world as more dangerous or threatening, and experience anxiety states more fre- quently and with greater intensity than those with lower levels of trait anxiety (Spielberger, 1972, p. 482).

Depression. Ingram and Siegle (2002) noted that, in the course of research, the concept of depression has been defined many different ways, including as a mood state, a symptom, a syndrome, a mood disorder, and a disease. In the current meta-analysis, studies included in this category have been chosen on the basis of their utilization of a measure believed to capture something be- yond “ordinary unhappiness” or a “sad mood,” symptoms that would more accurately belong to the previously discussed category of negative mood. Subclinical depression, likely the best descrip- tion of the type of depression most often assessed in MASSAGE THERAPY research, consists of the aforementioned symptoms combined with symp- toms such as mild to moderate levels of motivational and cognitive deficits, vegetative signs, and disruptions in interpersonal relation- ships (Ingram & Siegle, 2002, p. 90).

Delayed assessment of pain. A few studies have assessed participants’ experience of pain at one or more time points signif- icantly after a course of treatment has ended. The majority of these studies have done so at intervals that range from a few days to 6 weeks (Cen, 2000; Dyson-Hudson, Shiflett, Kirshblum, Bowen, & Druin, 2001; Preyde, 2000; Shulman & Jones, 1996), although one study included an assessment that took place 42 weeks after treatment ended (Cherkin et al., 2001). Because of the small number of studies, and the range of times at which delayed assessments were made, it is not expected that the present study will be able to determine precisely how long an analgesic effect resulting from MASSAGE THERAPY lasts, or the rate at which such an effect decays; rather, the aim is simply to examine whether or not MASSAGE THERAPY may have a lasting analgesic effect.

 

 

Moderators

 

A number of potentially interesting moderator variables have gone unexamined in MASSAGE THERAPY research. Primary studies, for instance, have neglected to examine whether the length of MASSAGE THERAPY sessions, or characteristics of the therapist and the recipient, influence the magnitude of MASSAGE THERAPY effects. Similarly, only a few studies have used more than one comparison group, making it difficult to determine whether the type of treatment to which MASSAGE THERAPY is compared may moderate its effects. Although within-study examinations of such moderators would permit stronger inferences to be made, their importance can be explored in the present study by means of between-study comparisons. In addition, the present study also examines a potential moderator that cannot be examined within an individual study, that of a laboratory effect.

Minutes of MASSAGE THERAPY per session. It is common for treatment studies in medicine (e.g., Bollini, Pampallona, Tibaldi, Kupelnick, &

Munizza, 1999; Yyldyz & Sachs, 2001) and in psychotherapy (e.g., Bierenbaum, Nichols, & Schwartz, 1976; Turner, Valtierra, Talken, Miller, & DeAnda, 1996) to examine dosage as an inde- pendent variable. However, no studies concerned with MASSAGE THERAPY have done so. It is not known whether there is a minimal amount, in terms of minutes of MASSAGE THERAPY administered per session, required to produce benefits, nor is it known whether there is an optimal amount of MASSAGE THERAPY that produces benefits most efficiently. Fortunately, the studies that exist vary considerably in the amount of MASSAGE THERAPY administered to participants in each session, from as little as 5 min (Fraser & Kerr, 1993; Wendler, 1999) to as much as an hour (Levin, 1990). By examining the relationship between the magni- tude of effects generated and the amount of MASSAGE THERAPY administered per session, the present study aims to determine whether there are minimum or optimum dosages of MASSAGE THERAPY.

Mean age of participants. Although MASSAGE THERAPY research has been performed on samples with a variety of age ranges, no study has sought to determine whether MASSAGE THERAPY offers effects of differing mag- nitude to participants who differ in age. The present study exam- ines whether there is a relationship between the mean age of the participants in a study and the magnitude of effects.

Gender of participants. Only one study to date, using a very small sample, has examined whether MASSAGE THERAPY effects might vary ac- cording to the gender of the recipients (Weinrich & Weinrich,

1990). The present study more powerfully examines the possibility that the gender of the recipient might moderate MASSAGE THERAPY effects by examining whether study outcomes vary according to gender.

Type of comparison treatment. In discussing the research find- ings for a different treatment modality (psychotherapy), Wampold (2001) noted that there is a distinction that must be made between absolute and relative efficacy. Absolute efficacy “refers to the effects of treatment vis-a`-vis no treatment and accordingly is best addressed by a research design where treated participants are contrasted with untreated participants” (Wampold, 2001, p. 59). By contrast, relative efficacy “is typically investigated by compar- ing the outcomes of two treatments” when one wishes to determine which, if either, is superior (Wampold, 2001, p. 73). Clearly, the type of efficacy one wishes to measure plays an important part in determining what will be an appropriate choice for a comparison, as a study designed to measure one does not necessarily measure the other. This issue of distinguishing absolute efficacy (does MASSAGE THERAPY work better than no treatment at all?) from relative efficacy (does MASSAGE THERAPY work better than a specific alternative treatment, such as PMR?) has not been made explicit enough in MASSAGE THERAPY research. How- ever, a wide variety of comparison treatments have been used in MASSAGE THERAPY research, some of which resemble a wait-list (no treatment) condition, whereas others use active treatments (such as the afore- mentioned PMR, or chiropractic care) as a point of comparison, or placebo-type comparison treatments that are meant to account for the effect of receiving attention (such as transcutaneous electrical stimulation performed with a machine that is not delivering any current to the participant). Logically, if MASSAGE THERAPY has any effect what- soever, we expect the MASSAGE THERAPY effects that result from comparison with a no-treatment condition would be larger than those that result from comparing MASSAGE THERAPY to any treatment condition, including so- called placebo conditions in which the participants receive no viable treatment. Combining the results of such different studies without attempting to account for these different comparison

 

 

 

points could be problematic. For this reason, we have divided the comparison treatments in the primary studies, when possible, as belonging to either wait-list equivalent or active/placebo categories.

The wait-list equivalent category consists of comparison treat- ments that most closely resemble having received no treatment, and includes wait-list controls, standard care (in studies where all participants had a chiropractic condition and continued to receive care for that condition regardless of group assignment), rest, reading, or a work break. The active/placebo category consists of all other comparison treatments, which are grouped according to the expec- tation that each could reasonably be expected to have some effect, including the possibility of a placebo effect. These include treat- ments such as PMR, acupuncture, chiropractic care, and various forms of attention, among others. Studies that used multiple com- parison groups that could not be included together within a single category were not included in either category.

Therapist training. Treatment research in fields such as psy- chology (Pinquart & Soerensen, 2001; Weisz, Weiss, Alicke, & Klotz, 1987) and medicine (Lin et al., 1997; Tiemens et al., 1999) sometimes examines the existence of training effects to determine whether practitioners with greater amounts of training provide greater benefit to those being treated. No MASSAGE THERAPY research, however, has examined the training of the massage therapist as an indepen- dent variable. However, the studies that do exist vary in regard to who performs MASSAGE THERAPY on participants. The majority of studies use one or more fully trained and licensed massage therapists. Others utilize a layperson with only minimal training in providing mas- sage, usually just enough to facilitate the study (e.g., Fischer, Bianculli, Sehdev, & Hediger, 2000; Weinrich & Weinrich, 1990; Wendler, 1999). By contrasting the results of studies that used a fully trained massage therapist with those that used a layperson to provide treatment, the present meta-analysis may be able to deter- mine whether a therapist’s training plays an important role in providing MASSAGE THERAPY benefits.

Laboratory effect. Much of the research in this area, and especially the most recent research, is the product of a single laboratory, the Touch Research Institute (Field, 1998). Because this one source is responsible for a large proportion of MASSAGE THERAPY studies, it is important to determine whether the results coming from this research group differ in a significant way from those of other researchers. If a difference is found, it would be important to examine more closely what factors contribute to that difference.

 

Predictions

 

MASSAGE THERAPY is expected to promote significant and desirable reductions for each of the following variables, consistent with the existing explanatory theories outlined above: state anxiety, negative mood, pain (immediate and delayed assessment), cortisol, heart rate, blood pressure, trait anxiety, and depression. It is expected that greater reductions in these variables will be associated with higher doses of MASSAGE THERAPY, in the form of minutes of MASSAGE THERAPY administered per session, a relationship one would expect to observe if MASSAGE THERAPY is a viable treatment. MASSAGE THERAPY effects are not expected to vary according to the age or gender of participants. It is expected that MASSAGE THERAPY effects generated from studies using wait-list equivalent comparison treat- ments will be larger than those generated from studies with active/

placebo comparison treatments. Finally, no prediction is made concerning therapist training, or the existence of a laboratory effect.

 

 

Method

 

Literature Search and Criteria for Inclusion

 

A literature search was performed by Christopher A. Moyer and a graduate student in library and information sciences hired as a research assistant. The PsycINFO, MEDLINE, CINAHL, SPORT Discus, and Dis- sertation Abstracts International databases were searched using the fol- lowing key words: massage, massotherapy, acupressure (and accupres- sure), applied kinesiology, bodywork, musculoskeletal manipulation, reflexology, relaxation techniques, Rolfing, Touch Research Institute, and Trager. Author searches were conducted within the same databases for the following authors associated with MASSAGE THERAPY research: Burman, I.; Field, T.; Hart, S.; Hernandez-Reif, M.; Kuhn, C.; Peck, M.; Quintino, O.; Schanberg, S.; Taylor, S.; Theakston, H.; Weinrich, M.; and Weinrich, S. The Internet Web sites of the AMASSAGE THERAPYA (www.aMassage Therapyamassage.org), the AMASSAGE THERAPYA Foundation
(www.aMassage Therapyafoundation.org), and the Touch Research Institute (http://www

.miami.edu/touch-research/) were inspected for references, and the Touch Research Institute was also contacted directly to request unpublished data. The reference lists of all studies located by these means were then manu- ally searched to yield additional studies.

All studies were inspected to ensure that they examined a form of MASSAGE THERAPY consistent with the present study’s operational definition, in which MASSAGE THERAPY is defined as the manual manipulation of soft tissue intended to promote health and well-being. Studies were limited to those that administered MASSAGE THERAPY to human participants other than infants, and that reported results in English. Studies concerned with chiropractic, heat therapy, hydrotherapy, passive motion, or progressive relaxation treatments were not included, unless the study also included an MASSAGE THERAPY group. Studies examining therapeutic touch, a nursing intervention distinct from MASSAGE THERAPY (in that it does not actually require physical contact to occur), were also excluded unless they also had an MASSAGE THERAPY group. Several studies used more than two groups; in these cases, study results were combined in order to yield a between-groups compari- son of all subjects receiving MASSAGE THERAPY versus all subjects receiving non-MASSAGE THERAPY treatments. Studies concerned with ice massage, participants performing self-massage, or massage performed with the aid of mechanical devices were excluded, as were studies that only included MASSAGE THERAPY as part of a combination treatment (e.g., MASSAGE THERAPY combined with exercise and movement therapy). MASSAGE THERAPY administered with scented oil or MASSAGE THERAPY administered with background music were not considered to be combination treatments, as these are common elements of MASSAGE THERAPY in clinical practice, and studies using such treatment were included. Studies that did not explicitly label a treatment as “massage” or as “massage therapy,” but used a treatment that fit the authors’ operational definition of MASSAGE THERAPY, were included.

These criteria yielded 144 studies concerned with outcomes of MASSAGE THERAPY. Each study was reviewed independently by Christopher A. Moyer and James Rounds for possible inclusion in the meta-analysis. Studies were examined to ensure that they (a) compared an MASSAGE THERAPY group with one or more non-MASSAGE THERAPY control groups, (b) used random assignment to groups, and (c) reported sufficient data for a between-groups effect size to be generated on at least one dependent variable of interest. These three criteria accounted for approximately equal proportions of excluded studies.

The first two inclusion criteria were necessary to ensure that effects were a result of treatment. When participants in MASSAGE THERAPY research serve as their own controls (e.g., Bauer & Dracup, 1987; Fakouri & Jones, 1987) there is no way to know whether effects are attributable to treatment or are instead the result of spontaneous recovery, placebo effect, or statistical regression (Field, 1998, p. 1270). Similarly, random assignment of participants to groups is necessary to control for the possibility of selection effects. Glaser

 

 

 

(1990) is an example of a study that is threatened in this way. Because treatment participants were previously enrolled in an MASSAGE THERAPY program, and were compared with a group of participants who were not enrolled, it is likely that these groups differed in their predisposition toward MASSAGE THERAPY in a way that could affect results.

When studies met all criteria apart from reporting sufficient data for calculating between-groups effects, and contact information was available, study authors were contacted in an attempt to obtain the necessary data. Specifically, there were seven studies from the Touch Research Institute for which this was the case (Field et al., 1999; Field et al., 2000; Field, Peck, et al., 1998; Field, Quintino, Henteleff, Wells-Keife, & Delvecchio- Feinberg, 1997; Field, Schanberg, et al., 1998; Field, Sunshine, et al., 1997; Sunshine et al., 1996). Upon our request, we were informed that the data needed from these studies (standard deviations) were no longer available. For this reason, these studies could not be included in the meta-analysis. Interrater agreement for the inclusion process was 93%. The 10 studies

for which there was initial disagreement, which occurred most frequently as a result of uncertainty regarding random assignment, were then reviewed jointly, with the subsequent decision made to exclude 8 of these. This resulted in a total of 37 studies meeting the inclusion criteria.

 

Variables and Measures

 

The nine variables for which effect sizes were calculated, and the instruments used to assess them, are as follows:

State anxiety. Fifteen of the 21 studies examining MASSAGE THERAPY’s effect on anxiety used the state anxiety portion of the State–Trait Anxiety Inventory (Spielberger, 1983). Five studies used a visual analogue scale, and one study used an investigator-constructed measure.

Negative mood. Seven of eight studies assessing negative mood used the Profile of Mood States (McNair, Lorr, & Droppleman, 1971). The remaining study used a visual analogue scale.

Immediate assessment of pain. Eight of the 15 studies assessing pain immediately following treatment used visual analogue scales alone. Two studies used a visual analogue scale in conjunction with either the Short- Form McGill Pain Questionnaire (Melzack, 1987) or the Menstrual Dis- tress Questionnaire (Moos, 1968). Two studies used investigator- constructed measures, and the remaining studies relied on the Neck Pain Questionnaire (Leak et al., 1994), the revised Oswestry Low Back Pain Questionnaire (Hudson-Cook, Tomes-Nicholson, & Breen, 1989), or be- havioral observation.

Cortisol. Of the seven studies that assessed cortisol levels, four relied on salivary samples, two on urinary samples, and one on a blood sample. In each case, samples were collected 20 min after the application of MASSAGE THERAPY, to account for the fact that bodily cortisol levels are indicative of responses occurring 20 min prior to sampling (Field, Hernandez-Reif, Quintino, Schanberg, & Kuhn, 1998, p. 233).

Blood pressure. Five studies offer data pertaining to participants’ blood pressure, assessed by means of a sphygmomanometer. Measures of diastolic and systolic blood pressure were combined into one effect size, because only a few studies report on this variable, and differ in regard to which values they report.

Heart rate. Of the six studies that assessed the effect of MASSAGE THERAPY on heart rate, four used some type of automatic monitoring device, and one study indicated that pulse was assessed manually. One study did not specify the means by which heart rate was assessed.

Trait anxiety. Three studies of the seven assessing trait anxiety used the Symptom Checklist-90 –Revised (SCL-90-R; Derogatis, 1983). One study combined the Conners Teacher Rating Scale (Conners, 1969) and the Revised Children’s Manifest Anxiety Scale (Reynolds & Richmond,

1985). The three remaining studies used either the Beck Anxiety Inventory (Beck, Brown, Epstein, & Steer, 1988), the trait portion of the State–Trait Anxiety Inventory (Spielberger, 1983), or an investigator-constructed measure.

Depression. Five of the 10 studies assessing depression utilized the

Center for Epidemiological Studies—Depression Scale (CES–D; Radloff,

1977). Two used the SCL-90-R, and one combined the CES–D and the SCL-90-R. The remaining studies used either the Children’s Depression Inventory—Short Form (Kovacs, 1992) or an investigator-constructed measure.

Delayed assessment of pain. The five studies assessing pain at a time significantly after treatment ended relied on five different instruments. These were the Neck Pain Questionnaire (Leak et al., 1994), the Wheel- chair User’s Shoulder Pain Index (Curtis et al., 1995), the McGill Pain Questionnaire (Melzack, 1975), a visual analogue scale, and an investigator-constructed measure.

 

Statistical Analysis

 

Effect sizes. Between-groups comparisons on variables of interest were converted to Hedges’s g effect size. Hedges’s g, calculated as (Group Mean

1 – Group Mean 2) ! pooled standard deviation, estimates the number of standard deviations by which the average member of a treatment group differs from the average member of a comparison group for a given outcome. In cases where a study used more than one measure to examine the same outcome variable, results of multiple measures were standardized and then averaged in order to result in one effect size per variable for any study. Similarly, if a study examined the immediate effects of more than one application of treatment, or examined the treatment effect on delayed assessments of pain at more than one time point, the results of the multiple applications or assessments were standardized and then averaged in order to calculate a single effect size for that study. Effect sizes were coded such that positive values, for any variable, indicate a more desirable outcome (e.g., a reduction in anxiety) for the participants who received MASSAGE THERAPY.

This process was done independently by both the first and second authors for the entire set of effect sizes; these initial results were then compared in order to determine agreement and eliminate errors. Agreement rate (AR) of initial calculations for the entire set of 84 effect sizes was 88%. Within outcome categories, the initial rates of agreement were as follows: state anxiety, AR 86% (n 21); negative mood, AR 88% (n 8); immediate assessment of pain, AR 87% (n 15); cortisol, AR 86% (n 7); blood pressure, AR 60% (n 5); heart rate, AR 100% (n

6); trait anxiety, AR 86% (n 7); depression, AR 90% (n 10); and

delayed assessment of pain, AR 60% (n 5). When discrepancies were observed, calculations were reviewed jointly to correct errors, and a con- sensus was reached.

Individual study effect sizes were then subjected to a correction for small sample bias, then weighted by their inverse variance and averaged to generate a mean effect size for each outcome variable (Lipsey & Wilson,

2001). An overall, nonspecific effect size was also calculated by averaging all effects within each study, and then calculating a weighted overall effect from these effect sizes. All effect sizes were calculated according to a random effects model of error estimation.

Statistical significance of the mean effect sizes was assessed by calcu- lating the 95% confidence interval (CI) for the population parameter. A significance level of .05 or better is inferred when zero is not contained within the CI. For effect sizes reaching statistical significance, the likeli- hood and possible influence of publication bias—the possibility that stud- ies retrieved for the meta-analysis may not be a random sample of all studies actually conducted (Rosenthal, 1998)—was assessed by means of a trim and fill procedure (Duval & Tweedie, 2000), a nonparametric statis- tical technique of examining the symmetry and distribution of effect sizes plotted by inverse variance. This technique first estimates the number of studies that may be missing as a result of publication bias, and then allows a new, attenuated effect size to be calculated on the basis of the influence such studies would have if they were included in the analysis. The trim and fill procedure was performed with the Division of Vector-Borne Infectious Diseases library using the statistical computing program S-PLUS (Bigger-

 

 

Table 1

Individual Study Characteristics and Effect Sizes (g) by Outcome Variable

 

 

Study    Participants

 

N

 

% female

 

Mean age

 

Min/

session

 

Comp. type

 

Trained therapist?

 

TRI

study?

 

g

 

State anxiety

             

Chang et al. (2002)

Pregnant women

60

100

28

30

WL

No

No

0.45

Chin (1999)

Surgery patients

85

100

42

10

WL

No

No

#0.50

Delaney et al. (2002)

Healthy adults

30

53

31

20

WL

Yes

No

0.20

Diego et al. (2002)

Spinal cord patients

20

25

39

40

A/P

Yes

Yes

0.57

Diego et al. (2001)

HIV$ adolescents

24

92

17

20

A/P

Yes

Yes

0.87

Field et al. (2002)

Fibromyalgia patients

20

51

30

A/P

Yes

Yes

0.11

Field, Ironson, et al. (1996)

Chiropractic staff

50

80

26

15

A/P

Yes

Yes

0.48

Fischer et al. (2000)

Amniocentesis patients

200

100

34

WL

No

No

0.00

Fraser & Kerr (1993)

Institutionalized elderly

21

5

C

No

1.20

Groer et al. (1994)

Healthy adults

32

69

64

10

WL

No

No

#0.21

Hernandez-Reif, Field, et al. (1998)

Multiple sclerosis patients

24

75

48

45

WL

Yes

Yes

1.33

Hernandez-Reif et al. (2001)

Back pain patients

24

54

40

30

A/P

Yes

Yes

0.07

Hernandez-Reif, Field, et al. (2000)

Hypertensive adults

30

53

52

30

A/P

Yes

Yes

0.24

Hernandez-Reif, Martinez, et al. (2000)

PDD patients

22

100

33

30

A/P

Yes

Yes

0.84

Leivadi et al. (1999)

University dance students

30

100

20

30

A/P

Yes

Yes

0.21

Levin (1990)

Healthy adults

36

27

60

WL

Yes

No

1.30

Menard (1995)

Surgery patients

30

100

52

45

WL

Yes

No

1.12

Mueller Hinze (1988)

Healthy women

48

100

27

10

C

No

0.50

Okvat et al. (2002)

Cardiac catheter patients

78

24

61

10

A/P

Yes

No

#0.06

Richards (1993)

Hospitalized elderly men

69

0

66

6

C

No

No

0.80

Wendler (1999)

Soldiers

93

10

30

5

A/P

No

No

0.54

   

 

Negative mood

             

 

 

 

 

 

 

 

 

Immediate assessment of pain

 

Cen (2000)

Neck pain patients

31

75

48

30

C

Yes

No

1.21

Chang et al. (2002)

Pregnant women

60

100

28

30

WL

No

No

0.99

Chin (1999)

Surgery patients

85

100

42

10

WL

No

No

#0.30

Field et al. (2002)

Fibromyalgia patients

20

51

30

A/P

Yes

Yes

0.85

Fischer et al. (2000)

Amniocentesis patients

200

100

34

WL

No

No

#0.13

Hemenway (1993)

Labor pain patients

32

100

23

10

A/P

No

No

0.38

Hernandez-Reif, Dieter, et al. (1998)

Headache patients

26

40

30

WL

Yes

Yes

0.52

Hernandez-Reif et al. (2001)

Back pain patients

24

54

40

30

A/P

Yes

Yes

0.35

Hernandez-Reif, Martinez, et al. (2000)

PDD patients

24

100

33

30

A/P

Yes

0.81

Hsieh et al. (1992)

Back pain patients

63

34

A/P

Yes

No

#0.94

Leivadi et al. (1999)

University dance students

30

100

20

30

A/P

Yes

Yes

0.21

Mueller Hinze (1988)

Healthy women

48

100

27

10

C

No

0.81

Okvat et al. (2002)

Cardiac catheter patients

78

24

61

10

A/P

Yes

No

0.16

Weinrich & Weinrich (1990)

Cancer patients

28

36

62

10

A/P

No

No

#0.04

Wilkie et al. (2000)

Hospice care cancer patients

29

31

63

30

WL

Yes

No

#0.14

Cortisol

 

Abrams (1999)

Children/adolescents with ADHD

30

17

13

20

WL

Yes

Yes

0.07

Chin (1999)

Surgery patients

85

100

42

10

WL

No

No

0.07

Field, Ironson, et al. (1996)

Chiropractic staff

50

80

26

15

A/P

Yes

Yes

0.45

Hernandez-Reif et al. (2001)

Back pain patients

24

54

40

30

A/P

Yes

Yes

#0.39

Hernandez-Reif, Field, et al. (2000)

Hypertensive adults

30

53

52

30

A/P

Yes

Yes

0.18

Hernandez-Reif et al. (2002)

Parkinson’s disease patients

16

50

58

30

A/P

Yes

Yes

0.41

Leivadi et al. (1999)

University dance students

30

100

20

30

A/P

Yes

Yes

0.13

 

 

Table 1 (continued)

 

 

Study

 

Participants

 

N

 

% female

 

Mean age

 

Min/

session

 

Comp. type

 

Trained therapist?

 

TRI

study?

 

g

Blood pressure

 

Delaney et al. (2002)

Healthy adults

30

53

31

20

WL

Yes

No

#0.06

Hernandez-Reif, Field, et al. (2000)

Hypertensive adults

30

53

52

30

A/P

Yes

Yes

0.29

Mueller Hinze (1988)

Healthy women

48

100

27

10

C

No

0.49

Okvat et al. (2002)

Cardiac catheter patients

78

24

61

10

A/P

Yes

No

0.16

Wendler (1999)

Soldiers

93

10

30

5

A/P

No

No

0.34

Heart rate

 

Cottingham et al. (1988)

Healthy men

32

0

27

45

WL

Yes

No

0.22

Delaney et al. (2002)

Healthy adults

30

53

31

20

WL

Yes

No

0.53

Mueller Hinze (1988)

Healthy women

48

100

27

10

C

No

0.82

Okvat et al. (2002)

Cardiac catheter patients

78

24

61

10

A/P

Yes

No

0.16

Richards (1993)

Hospitalized elderly men

69

0

66

6

C

No

No

0.35

Wendler (1999)

Soldiers

93

10

30

5

A/P

No

No

0.52

   

 

Trait anxiety

             

 

 

 

 

 

 

 

Depression

 

Abrams (1999)

Children/adolescents with ADHD

30

17

13

20

WL

Yes

Yes

0.29

Diego et al. (2002)

Spinal cord patients

20

25

39

40

A/P

Yes

Yes

0.32

Diego et al. (2001)

HIV$ adolescents

24

92

17

20

A/P

Yes

Yes

0.74

Field et al. (2002)

Fibromyalgia patients

20

51

30

A/P

Yes

Yes

0.63

Hernandez-Reif, Dieter, et al. (1998)

Headache patients

26

40

30

WL

Yes

Yes

0.38

Hernandez-Reif et al. (2001)

Back pain patients

24

54

40

30

A/P

Yes

Yes

0.80

Hernandez-Reif, Field, et al. (2000)

Hypertensive adults

30

53

52

30

A/P

Yes

Yes

0.82

Hernandez-Reif, Martinez, et al. (2000)

PDD patients

24

100

33

30

A/P

Yes

0.28

Rexilius et al. (2002)

Patient caregivers

35

72

52

30

C

Yes

No

0.91

Scherder et al. (1998)

Alzheimer’s patients

16

86

30

A/P

No

1.50

Delayed assessment of pain

 

Cen (2000)

Neck pain patients

31

75

48

30

C

Yes

No

0.36

Cherkin et al. (2001)

Back pain patients

262

58

45

C

Yes

No

0.25

Dyson-Hudson et al. (2001)

Wheelchair users

18

22

45

45

A/P

Yes

No

0.35

Preyde (2000)

Back pain patients

73

51

45

30

C

Yes

No

0.49

Stratford et al. (1989)

Tendinitis patients

40

50

43

10

WL

No

0.30

 

Note. Dashes indicate that data were not reported. Comp. comparison; TRI Touch Research Institute; A/P active/placebo; C combination; WL

wait-list equivalent; PDD premenstrual dysphoric disorder; ADHD attention-deficit/hyperactivity disorder.

 

 

 

staff, 2000), which generates results for the three estimators of missing studies (L0, R0, and Q0) described by Duval and Tweedie (2000). Per the suggestion of these authors, the number of missing studies resulting from each estimator was considered before the eventual decision was made to report results according to the L0 and R0 estimators, which are considered preferable for most situations (Duval & Tweedie, 2000).

Moderators. As with effect sizes, moderator variable data were also coded independently by both the first and second authors. Agreement rate for initial coding of all moderator data across categories was 97% (n

158). Within moderator variable categories, initial agreement rates were as

follows: minutes per session, AR 100% (n 34); mean age, AR 100% (n 25); comparison type, AR 97% (n 34); training, AR 87% (n

31); and laboratory effect, AR 100% (n 34); proportion of female participants was coded only by the first author. The influence of moderator variables was assessed by performing a weighted regression analysis (Lipsey & Wilson, 2001) on the set of overall, nonspecific effect sizes for all studies.

 

 

Results

 

Table 1 lists the effect sizes (Hedges’s g) for each study by outcome variable, as well as important study characteristics. The

37 studies included in the meta-analysis used a total of 1,802

 

 

 

participants, including 795 who received MASSAGE THERAPY. Of the 1,007 par- ticipants who received a comparison treatment, 49% received one of the five treatments categorized as wait-list equivalent, and the remaining 51% received a treatment categorized as active/placebo. The mean number of participants for a study was 48.7 (SD

49.0), and mean age of all participants was 40.6 years (SD 13.9).

Participants received an average of 21.7 min (SD 14.0) of MASSAGE THERAPY

per application of treatment. Sixty-five percent of studies reported

using a trained massage therapist (or therapists), 22% reported using a minimally trained person (or persons) to deliver treatment, and 14% did not indicate the level of training of the person (or persons) administering MASSAGE THERAPY. Thirty-two percent of studies were conducted by the Touch Research Institute.

Table 2 graphically represents the distribution of overall study effect sizes by means of a stem and leaf plot. Table 3 lists the mean effect size for each outcome variable, as well as the number of studies contributing to the effect size, its 95% CI, and the results of trim and fill procedures applied to statistically significant ef- fects. The nonspecific, overall mean effect was statistically signif- icant (g 0.34, p % .01). Among the nine specific outcome variables examined, six displayed statistically significant effect sizes. For the single-dose effects category, these included state anxiety (g 0.37, p % .01), blood pressure (g 0.25, p % .02), and heart rate (g 0.41, p % .01). Negative mood (g 0.34), immediate assessment of pain (g 0.28) and cortisol (g 0.14) were nonsignificant. All outcome variables examined within the multiple-dose effects category, including trait anxiety (g 0.75, p % .01), depression (g 0.62, p % .01), and delayed assessment of pain (g 0.31, p % .01), were statistically significant.

The results of trim and fill analyses conducted on the statisti-

cally significant outcome variables indicated that the results are fairly robust to the threat of publication bias. For overall effects, an

 

 

Table 2

Stem and Leaf Plot of 37 Overall Study Effect Sizes

 

Stem    Leaf

 

#0.9    4

#0.8

#0.7

#0.6

#0.5

#0.4

#0.3

#0.2    14

#0.1    4

#0.0    47

0.0    26

0.1    1

0.2    2259

0.3    0558

0.4    0114579

0.5    8

0.6    17

0.7    2389

0.8    013

0.9

1.0    9

1.1    2

    1.2    0

analysis based on the L0 estimator yielded 10 studies missing as a result of publication bias, which result in an attenuated but still significant effect (g 0.20, 95% CI 0.06, 0.34); the funnel plot of actual and filled study effect sizes for this analysis is repre- sented in Figure 1. The same analysis performed with the R0 estimator indicates no missing studies. Of the six specific outcome variables that generated significant effects, results of trim and fill analyses indicated that only state anxiety and delayed assessment of pain effects were likely overestimated due to publication bias. A trim and fill analysis performed on the state anxiety effect using the L0 estimator yielded an estimate of four studies likely missing as a result of publication bias. When the influence such studies would have on state anxiety is calculated, the adjusted effect is nonsignificant (g 0.22, 95% CI ” #0.01, 0.45). A trim and fill analysis performed on the delayed assessment of pain outcome variable using the L0 estimator yielded a slightly smaller but still significant effect (g 0.26, 95% CI 0.07, 0.44). When the same analyses were performed with the R0 estimator, no missing studies were indicated in either case.

An analysis of potential moderator variables for the set of overall effect sizes was not statistically significant, QR(6) 5.80. Despite the nonsignificance of the regression model, the decision was made to inspect the significance of the individual moderator variables. Minutes of MASSAGE THERAPY administered per session (z 1.55, p

.06, one-tailed) was the only moderator that approached the pre-

determined alpha for statistical significance ( p % .05). To examine this variable a bit further, we calculated separate weighted effect sizes for two categories of studies. Studies that administered ! 30 min of MASSAGE THERAPY per session generated an effect that was substantially larger than that resulting from the entire set of studies (g 0.54,

95% CI 0.32, 0.76). Studies that administered % 30 min of MASSAGE THERAPY

per session demonstrated an effect that was slightly smaller than

that of the entire set of studies, but still significant (g 0.30, 95% CI 0.08, 0.52).

 

Discussion

 

This meta-analysis supports the general conclusion that MASSAGE THERAPY is effective. Thirty-seven studies yielded a statistically significant overall effect as well as six specific effects out of nine that were examined. Significant results were found within the single-dose and multiple-dose categories, and for both physiological and psy- chological outcome variables. Confidence in these findings is bolstered by the results of trim and fill analyses, which indicate that the results are not unduly threatened by publication bias.

 

Single-Dose Effects

 

Three of the six single-dose effects examined were statistically significant. The magnitude of MASSAGE THERAPY’s effect on state anxiety means that the average participant receiving MASSAGE THERAPY experienced a reduction of state anxiety that was greater than 64% of participants receiving a comparison treatment. MASSAGE THERAPY was also more effective than com- parison treatments in reducing blood pressure and heart rate. The average MASSAGE THERAPY participant experienced a reduction in blood pressure that was greater than 60% of comparison group participants, whereas for heart rate, the reduction resulting from MASSAGE THERAPY was greater than 66% of comparison group participants, findings that are

 

 

Table 3

Mean Effect Sizes (g) and Results of Trim and Fill Analyses by Outcome Variable

 

 

 

Outcome variable    k    g    95% CI    L0

Adjusted g based on

k $ L0     Adjusted 95% CI

 

 

 

Overall

 

37

 

0.34**

 

0.21, 0.48

 

10

 

0.20**

 

0.06, 0.34

Single-dose effects

           

State anxiety

21

0.37**

0.14, 0.59

4

0.22

#0.01, 0.45

Negative mood

8

0.34

#0.08, 0.76

   

Immediate pain

15

0.28

#0.01, 0.57

   

Cortisol

7

0.14

#0.10, 0.38

   

Blood pressure

5

0.25*

0.03, 0.48

0

   

Heart rate

6

0.41**

0.19, 0.62

0

   

Multiple-dose effects

           

Trait anxiety

7

0.75**

0.27, 1.22

0

   

Depression

10

0.62**

0.37, 0.88

0

   

Delayed pain

5

0.31**

0.10, 0.52

3

0.26**

0.07, 0.44

 

Note. A positive g indicates a reduction for any outcome variable. Dashes indicate data not calculated because of nonsignificance of effect size. CI

confidence interval; L0 estimate of missing studies resulting from trim and fill procedure.

* p % .05. ** p % .01.

 

 

 

consistent with the theory that MASSAGE THERAPY may promote a parasympathetic response of the ANS. Cortisol, however, another outcome variable that would be expected to decrease if MASSAGE THERAPY promotes a parasympa- thetic response, was not significantly reduced, a finding that con- trasts with the conclusion previously reached by Field (1998). Despite this inconsistent support for MASSAGE THERAPY promoting a parasympa- thetic response, the significant finding for the cardiovascular vari- ables suggests that future research should examine whether MASSAGE THERAPY might have an enduring effect on blood pressure such that it could be used in treating hypertension.

MASSAGE THERAPY did not exhibit an effect on immediate assessment of pain. This finding contrasts with the commonly offered notion that MASSAGE THERAPY

may provide analgesia by competing with painful stimuli in a way consistent with the gate control theory of pain. MASSAGE THERAPY’s effect on negative mood was also nonsignificant.

 

Multiple-Dose Effects

 

Some of MASSAGE THERAPY’s largest and most interesting effects belong to the multiple-dose effects category. Despite the fact that MASSAGE THERAPY did not demonstrate an effect on immediate assessment of pain, a signif- icant effect was found for delayed assessment of pain. MASSAGE THERAPY partic- ipants who received a course of treatment and were assessed several days or weeks after treatment ended exhibited levels of

 

 

 


 

Figure 1. Funnel plot of 37 overall study effect sizes (g) plus the 10 effect sizes filled in by means of trim and fill procedure using the L0 estimator; no filled studies are indicated using the R0 estimator.

 

 

 

pain that were lower, on average, than 62% of comparison group participants. This finding is consistent with the theory that MASSAGE THERAPY may promote pain reduction by facilitating restorative sleep, but without data on sleep patterns, this possibility is only conjecture.

Reductions of trait anxiety and depression following a course of treatment were MASSAGE THERAPY’s largest effects. The average MASSAGE THERAPY participant experienced a reduction of trait anxiety that was greater than 77% of comparison group participants, and a reduction of depression that was greater than 73% of comparison group participants. These effects are similar in magnitude to those found in meta-analyses examining the absolute efficacy of psychotherapy, a more tradi- tional treatment for either condition, in which it is estimated that the average psychotherapy client fares better than 79% of un- treated clients (Wampold, 2001, p. 70). Considered together, these results indicate that MASSAGE THERAPY may have an effect similar to that of psychotherapy.

 

Moderators

 

All six moderators that were examined were nonsignificant. In most cases, this was not surprising, given that we did not expect effects to vary according to recipient characteristics and made no predictions concerning therapist training or laboratory effect. However, it was unexpected that neither the minutes of MASSAGE THERAPY ad- ministered per session nor type of comparison treatment moder- ated effects in a way that was statistically significant.

Minutes of MASSAGE THERAPY administered per session was the only moderator that approached the predetermined alpha for statistical signifi- cance. This, combined with the logic that if MASSAGE THERAPY has an effect, longer doses should likely be more potent, leads us to suspect that our analysis failed to find a relationship because of insufficient statistical power rather than the true absence of any moderating effect. Nevertheless, it must be concluded that this moderator may not be as important as we predicted, and that even short sessions of MASSAGE THERAPY can be effective. Future studies could more powerfully examine the role of session length by including two levels of this variable, something that does not appear to have been done in any study to date.

Whether studies used a wait-list equivalent or active/placebo comparison group was not significant for overall effects. This finding does not support the prediction that studies using wait-list equivalent comparison treatments would yield larger effects. Be- cause stronger inferences can be made from within-study compar- isons, we decided to compare this result with those from studies that included both an active/placebo and a wait-list equivalent comparison group within the design. Three studies fitting this criterion examined state anxiety as an outcome. Richards (1993), in a study that involved 69 participants, found that wait-list par- ticipants improved significantly less than those who received a combination of muscle relaxation, mental imagery, and relaxing music. By contrast, Fraser and Kerr (1993), in a study that in- volved 21 participants, found no statistically significant difference in outcome between two comparison groups, one of which re- ceived attention in the form of conversation (active/placebo), the other of which received no intervention (wait-list equivalent). Similarly, Mueller Hinze (1988), in a study with 48 participants, found no differences in outcome for three comparison groups

including therapeutic touch (active/placebo), transcutaneous elec- trical stimulation without current (active/placebo), and a no- treatment control (wait-list equivalent). As a group, these contrast- ing results seem to agree with the nonsignificant finding in the meta-analysis in suggesting that whether MASSAGE THERAPY is compared with an active/placebo or wait-list equivalent treatment does not substan- tially influence effects. However, no primary studies that exam- ined MASSAGE THERAPY’s largest effects— on depression and trait anxiety— used such a design; the influence of such a moderator may be more evident in relation to these more robust effects, and could be examined in future studies by using both types of comparison groups.

The prediction that effects would not vary according to the age or gender of participants was supported. Neither of these recipient characteristics was significantly associated with overall effects. Therapist training did not have a significant effect on outcome. This finding, however, should not be used to conclude that training is of no consequence. In the present meta-analysis, this variable could only be dummy coded according to whether a study involved a trained massage therapist, or a layperson trained by a massage therapist for the purposes of conducting the study. It was not possible to differentiate the levels of experience various massage therapists may have had, nor was it possible to know how much training laypersons involved in the studies had received. The only conclusion that can be definitively reached from this result is that laypersons provided with some training can provide beneficial MASSAGE THERAPY, information that may be valuable to researchers working with limited resources. No evidence of a laboratory effect was found.

 

 

MASSAGE THERAPY Theories

 

Mixed support for existing theories. It is interesting to note that, among the theories that are commonly offered to explain MASSAGE THERAPY effects, the most popular theories are the ones least supported by the present results. The failure to find a significant effect for immediate assessment of pain contradicts the theory that MASSAGE THERAPY provides stimuli that interfere with pain consistent with gate con- trol theory. Reductions in blood pressure and heart rate resulting from MASSAGE THERAPY do support the theory that MASSAGE THERAPY promotes a parasympa- thetic response, although, if this theory is true, it would also be expected that a significant reduction in cortisol levels would have occurred, which did not. By contrast, the remaining theories are not inconsistent with the current results. MASSAGE THERAPY’s effects on state anxiety, trait anxiety, and depression may come about as a result of MASSAGE THERAPY’s influence on body chemistry, whereas the ability of a course of MASSAGE THERAPY treatment to provide lasting pain relief may result from the mechanical promotion of circulation and breakdown of adhesions, or from improved sleep promoted by the treatment.

MASSAGE THERAPY from a psychotherapy perspective. Another theory that has not previously been put forth may also account for MASSAGE THERAPY effects. MASSAGE THERAPY may provide benefit in a way that parallels the common-factors model of psychotherapy. Substantial evidence suggests that the considerable efficaciousness of psychotherapy results not from any specific ingredient of treatment, but rather from the factors that all forms of psychotherapy share (Wampold, 2001). In this model, factors such as a client who has positive expectations for treatment, a therapist who is warm and has positive regard for the client, and the development of an alliance between the therapist and client are

 

 

 

considered to be more important than adherence to a specific modality of psychotherapy. The same model can be extended to MASSAGE THERAPY, given the possibility that benefits arising from it may come about more from factors such as the recipient’s attitude toward MASSAGE THERAPY, the therapist’s personal characteristics and expectations, and the interpersonal contact and communication that take place during treatment, as opposed to the specific form of MASSAGE THERAPY used or the site to which it is applied.

Several of the findings in the present study are consistent with such a model applied to MASSAGE THERAPY. The finding that MASSAGE THERAPY has an effect on trait anxiety and depression that is similar in magnitude to what would be expected to result from psychotherapy suggests the possibility that these different treatments may be more similar than previously considered. Further support comes from the fact that MASSAGE THERAPY training was not predictive of effects. Possibly, MASSAGE THERAPY effects are more closely linked with characteristics of the massage provider that are independent of skill or experience in performing soft tissue manipulation.

In addition to having similar effects, MASSAGE THERAPY parallels psychother- apy in structure. Both forms of therapy routinely rely on repeated, private interpersonal contact between two persons. Studies con- tributing effects to the trait anxiety and depression outcome cate- gories used treatment protocols similar to those that might be maintained in short-term psychotherapy, with twice-weekly meet- ings over a span of 5 weeks being most common; other studies used similar protocols. Interestingly, the length of individual ses- sions in these studies ranged from 15 to 40 min, with 30 min being the most common session length. Had these studies used a session length equivalent to the “50-minute hour” that is routine in psy- chotherapy, it is possible that MASSAGE THERAPY’s effect for these variables would have matched or exceeded that expected of psychotherapy. Application of such a psychotherapeutic, common-factors model to MASSAGE THERAPY has important ramifications for future research. Different questions need to be asked, different moderators tested, and different comparisons made. Foremost among the questions is whether MASSAGE THERAPY is as effective as psychotherapy. No study has directly compared these treatments, a comparison that would be justified given the finding that some MASSAGE THERAPY effects may be very similar to those of psychotherapy. Similarly, it could be interesting to deter- mine whether a combination of MASSAGE THERAPY and psychotherapy could be significantly more effective than either alone. Another critical issue that needs to be examined is whether these specific MASSAGE THERAPY effects are enduring. Current studies contributing to these effects all performed assessments on the final day of treatment, making it impossible to know if the effects last. Studies that administer a course of MASSAGE THERAPY treatment should make assessments not only imme- diately after treatment has ended, but also several weeks or months later, to determine whether reductions of anxiety, depression, or

other conditions are maintained.

Despite the fact that MASSAGE THERAPY is a treatment that relies on interper- sonal contact, no research has attempted to manipulate, or even measure, the kind of psychological interactions that undoubtedly take place between the provider and recipient of MASSAGE THERAPY. Details worth examining include (a) the amount and types of communication, both verbal and nonverbal, that take place between massage ther- apist and recipient; (b) the recipient’s and therapist’s expectations for whether treatment will be beneficial; (c) the amount of empa- thy perceived by the recipient on behalf of the therapist; (d)

whether the psychological state of the therapist is of importance; and (e) whether personality traits of the therapist, of the recipient, or any interaction between those personality traits influence out- comes. An examination of such personality, process, and thera- peutic relationship variables may reveal that benefiting from MASSAGE THERAPY is just as much about feeling valued as it is about being kneaded.

Finally, the possibility that MASSAGE THERAPY may provide a significant por- tion of its benefit in a way that parallels psychotherapy has a bearing on the selection of comparison treatments used in future research. Viewed from a chiropractic perspective, comparison treat- ments in MASSAGE THERAPY research are thought to function as placebo treat- ments, in that they control for incidental aspects of the treatment (most notably attention in MASSAGE THERAPY research) while withholding what is thought to be the specific effective ingredient (soft tissue manip- ulation). However, the same logic cannot be applied if the treat- ment being examined is thought to be beneficial because of inci- dental aspects, because the double-blind condition favored in medicine trials, where neither the participants nor the researchers involved in the study are aware of who is receiving viable treat- ment and who is receiving the placebo, is logically impossible (Wampold, 2001, p. 129). Those supervising and administering treatment in MASSAGE THERAPY research, as in psychotherapy research, are aware of the treatment being delivered and know if it is intended to be therapeutic. This is a critical factor to consider if the treatment being studied relies on the therapist’s beliefs and intentions in order to be effective. The placebo treatment, derived from chiropractic trials intended to examine the effectiveness of specific ingredients, cannot control for the incidental aspects of a treatment such as MASSAGE THERAPY. When a common-factors model is applied to MASSAGE THERAPY, the notion that a comparison treatment such as progressive muscle relaxation con- trols for attention is incorrect. The attention provided to compar- ison group participants is identical in quantity but not in quality, and cannot be expected to function as a control for the attention received by participants in the MASSAGE THERAPY treatment group.

The idea that MASSAGE THERAPY has significant parallels with psychotherapy, and that perspectives gained from psychotherapeutic research should be applied to future research, is not meant to suggest that MASSAGE THERAPY delivers effects entirely by psychological means. Clearly MASSAGE THERAPY is at least partially a physical therapy, and some of its benefits almost certainly occur through physiological mechanisms. In fact, one of the most interesting aspects of MASSAGE THERAPY is that it may deliver benefit in multiple ways; specific ingredients and common factors may each play a role, with each being differentially important depending on the desired effect. However, whether researchers wish to study MASSAGE THERAPY as a physical therapy, as a psychological one, or as both, new research should examine not merely the effects resulting from MASSAGE THERAPY, but also the ways in which these effects come about. It is only by testing MASSAGE THERAPY theories that a better understanding of this ancient practice will result.

 

 

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Received August 8, 2002

Revision received June 3, 2003

Accepted June 4, 2003 !

 

 

 

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