Massage Therapy As an Option in Supportive Care

(NCCAM) Massage therapy, a form of hands-on healing, has been used since ancient times and across many cultures. Today, it's a popular form of complementary and alternative medicine (CAM) in the United States, especially as a supportive therapy to help manage symptoms such as pain, sleep problems, and the negative effects of stress. In the 2007 National Health Interview Survey (NHIS), massage was the fifth-most-used CAM therapy. The NHIS also found that Americans paid about $4.18 billion out-of-pocket for roughly 95.3 million visits to massage practitioners in the year before the survey.

"The leading reason Americans use CAM is to help relieve pain, especially in musculoskeletal conditions," says Josephine P. Briggs, M.D., Director of the National Center for Complementary and Alternative Medicine (NCCAM). "A growing body of research suggests that certain CAM health practices, including massage, hold promise as supportive, nonpharmacologic care for difficult symptoms such as chronic pain. That's why research exploring the use of CAM for symptom management is a strategic priority for NCCAM."

Janet Kahn, Ph.D., N.C.T.M.B., is a member of NCCAM's national advisory council, a practicing massage therapist, executive director of the Integrated Healthcare Policy Consortium, and a research assistant professor at the University of Vermont School of Medicine. Dr. Kahn says, "Patients most often use massage therapy as a complementary health care approach, as an approach to maintaining well-being, or for specific complaints. I see massage increasingly recommended by the medical community as part of integrative care plans."

Potential Applications

Massage has been included in a number of clinical practice guidelines, including the National Cancer Institute's PDQ supportive care treatment summaries (cancer pain, lymphedema); the American Pain Society (fibromyalgia, low-back pain); the American College of Physicians (low-back pain); the American College of Chest Physicians (lung cancer); the American College of Occupational and Environmental Medicine (low-back disorders); and the Commission of the Council on Chiropractic Guidelines and Practice Parameters (fibromyalgia, tendinopathy).

Chronic low-back pain (LBP) is one of the pain conditions for which massage is used, and "one of the most prevalent, expensive, and poorly treated conditions seen by primary care clinicians," says Dr. Briggs. "Treatment approaches are often based on a relatively thin foundation of evidence. Most interventions have not been rigorously tested, and many back pain studies are limited by design issues. Thus, little is known about what treatments are or are not effective."

"We have evidence from several studies," she continues, "suggesting that massage is among those CAM therapies that might make useful contributions for managing chronic back pain. We need more insight, however, on the best management strategies for back pain."

Fibromyalgia is another pain condition frequently seen by health care providers, and one in which there often is no universally effective treatment. Studies have found that up to 91 percent of people with fibromyalgia use some form of CAM, and up to 75 percent use massage therapy.

Ruth Werner, president of the Massage Therapy Foundation, is a massage therapist, educator, and author. "I think that the most important message about massage for fibromyalgia," she says, "is that patients have good days and bad days. Their tolerance for depth, speed, and pressure in massage can vary greatly day to day; the therapist must always stay within individual pain tolerance. Patients with fibromyalgia live with an 'invisible' condition. Massage as practiced by a therapist who is sensitive to their diffuse pain and their feedback can help them not only with pain, stress, and sleep, but through listening and through understanding their situation."

The scientific evidence on massage for fibromyalgia is limited. A review published in July 2010 included six randomized controlled trials and two single-arm studies. This review concluded that there is modest evidence of short-term benefit from massage therapy for fibromyalgia, but noted that the evidence is not conclusive, there were unsolved methodological issues in all the studies, and additional rigorous research is needed.

Massage and Integrative Care in Hospitals

According to an American Hospital Association survey, the number of hospitals offering CAM grew from 7.7 percent in 1998 to 37.3 percent in 2007. Of the hospitals offering CAM, about 71 percent offered massage therapy. Hospitals offered massage most often for:

Stress reduction (71%)
Pain management (66%)
Cancer patient support (57%)
Pregnancy massage (55%)
As part of physical therapy rehabilitation (53%)
Mobility/movement training (45%)
Palliative care (41%)

Survey reported in "2010 Massage Therapy Industry Fact Sheet," American Massage Therapy Association.

Among other diseases/conditions in which massage is used to help manage symptoms is cancer. Many people with cancer (survey figures vary widely) have used at least one form of CAM, and they do so to address symptoms such as pain and fatigue; manage side effects from treatment; lessen depression, anxiety, and sleep problems; and support quality of life.

Martha Brown Menard, Ph.D., C.M.T., is a massage therapist, researcher, and author who focuses most of her work on cancer patients and survivors. She finds massage useful "throughout the continuum [in cancer], including to address the side effects of treatment such as pain and range of motion—even years after treatment—and to help with sleep. Manual lymphatic drainage1 can be very helpful with lymphedema following breast cancer treatment. Massage can also help with some of the adhesions and restrictions in scar tissue."

"Patients with any kind of chronic pain," she continues, "tend to tense up and tighten their muscles around the pain, feel anxious, and have more trouble with restorative sleep. That sets up a cycle that will make the pain worse. If you can use massage to break that cycle, it really helps…. I think that the biggest impact of massage is on anxiety, however. When you can manage anxiety, you can manage a lot of other symptoms as well."

Several lines of evidence from both observational studies and randomized trials suggest that massage may provide short-term relief of pain from a variety of cancer-related symptoms. While not definitive, this body of work indicates the need for further investigation of massage as a reasonably safe nonpharmacologic CAM approach.

1 Manual lymphatic drainage is a technique used to reduce lymphedema (swelling caused by a buildup of lymph fluid in tissue). Massage is used to move the fluid away from areas where lymph vessels are blocked, damaged, or removed by surgery, in order to remove extra fluid. Another name for this technique is manual lymphedema therapy.

Research Directions

"Massage is a subject that merits investigation," says Dr. Briggs. "It is also a good example of an area where the application of research on CAM therapies to the problems of pain is potentially valuable. The long history of massage, its popularity, and 'common sense' all point in this direction."

Reviews of the scientific literature to date have largely been based on a limited number of clinical studies that have been very small, uncontrolled, or with other flaws in design or reporting. Also, it is difficult to "mask" massage, and it is challenging to develop comparison treatments that do not overlap with existing massage techniques. More standardization and consistency (for research purposes) in treatment regimens and in the language about massage are needed and have been called for. Among current areas of interest are ways to meet the challenges in clinical studies; longer-term assessment of massage; and dose-response studies.

Ask About Credentials

Before beginning any CAM therapy, it is important to talk to the practitioner about education, training, licenses, and certifications.

Most states (43 at this writing, plus the District of Columbia) regulate the profession of massage therapy, through a license, certification, or registration. Specific requirements for training, testing, and continuing education may vary. One detailed listing of state regulations on massage is at www.amtamassage.org/about/lawstate.html . In some areas, regulation may be by local ordinance.

In addition to massage therapists, some other health care providers, such as chiropractors and physical therapists, have training in massage.

Dr. Kahn finds massage to be "an incredibly rich field for research. On the one hand, you have at least preliminary indications of massage prompting a wide range of effects, from fairly sustained pain reduction for people with chronic back pain, to relief of nausea and anxiety in cancer patients, to improved weight gain in premature infants. The range of effects and consistent data on massage for stress reduction suggests fruitful investigation into possible underlying mechanisms. At the same time, findings that massage provides relief for multiple forms of musculoskeletal pain call for more research focused particularly on tissue-level effects."

At the preclinical level, there is some early evidence that massage and other manual therapies engage physiological processes that are important in pain. Among avenues being investigated are the following:

Massage may facilitate the relaxation response by shifting the balance of sympathetic and parasympathetic nervous system response.
Massage may shift neurochemistry through stimulating release of serotonin, endorphins, or other chemicals, and may inhibit the secretion of cortisol.
Massage may cause beneficial biomechanical changes in the soft tissue, connective tissue, and/or at the cellular level.
Massage may invoke pleasurable sensations in the brain, thus pre-empting pain signals (the "gate control theory").
Massage may involve other aspects of patient-practitioner interaction and the therapeutic context involved in pain or in emotion regulation.

Using Massage Safely

Massage has few serious risks when administered appropriately by a well-trained massage professional. Side effects may include temporary discomfort, bruising, swelling, and a sensitivity or allergy to massage oils. Among cautions are that:

Open communication and information-sharing among the patient and all members of the care team is very important for safe and best use of massage.
In cancer, practices that should be avoided include massage of areas with the following: known tumors; predictable sites for metastasis; acute deep venous thrombosis; fractured or weakened bones; open wounds, hematomas, or skin breakdown; stents and other prosthetic devices; and soft tissue following radiation therapy when the skin is sensitive.
Vigorous massage should be avoided by people with bleeding disorders or low blood platelet counts, and by people taking blood-thinning medications such as warfarin.
Massage should not be done in any area of the body with blood clots, fractures or weakened bones, open or healing wounds, skin infections, or where there has been a recent surgery.
Women who are pregnant should consult their health care provider before using massage therapy.

Tailoring Massage Treatments Safely

According to NCCAM's fact sheet on massage therapy, massage has few serious risks when used appropriately and delivered by a well-trained therapist who is familiar with issues in the patient's condition(s) and able to modify treatment accordingly. For more information on the safe use of massage, see list above.

References

American College of Occupational and Environmental Medicine. Low back disorders. In Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers, 2nd ed. Elk Grove Village, IL: American College of Occupational and Environmental Medicine; 2007.
American Massage Therapy Association. 2010 Massage Therapy Industry Fact Sheet. American Massage Therapy Association Web site. Accessed at www.amtamassage.org/news/MTIndustryFactSheet2010.html on July 19, 2010.
American Massage Therapy Association. Credentials for the Massage Therapy Profession. American Massage Therapy Association Web site. Accessed at www.amtamassage.org/findamassage/credential.html on July 19, 2010.
Barbour C. Use of complementary and alternative treatments by individuals with fibromyalgia syndrome. Journal of the American Academy of Nurse Practitioners. 2000; 12(8):311–316.
Barnes PM, Bloom B, Nahin R. Complementary and alternative medicine use among adults and children: United States, 2007 *. CDC National Health Statistics Report #12. 2008.
Bernas M, Witte M, Kriederman B, et al. Massage therapy in the treatment of lymphedema. Rationale, results, and applications. IEEE Engineering in Medicine and Biology Magazine. 2005;24(2):58–68.
Buckhardt CS, Goldenberg D, Crofford L, et al. Guideline for the Management of Fibromyalgia Syndrome Pain in Adults and Children. Clinical practice guideline no. 4. Glenview, IL: American Pain Society; 2005.
Cassileth BR, Deng GE, Gomez JE, et al. Complementary therapies and integrative oncology in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3 Suppl):340S–354S.
Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine. 2007;147(7):478–491.
Coe AB, Anthony ML. Understanding bodywork for the patient with cancer. Clinical Journal of Oncology Nursing. 2005;9(6):733–739.
Council on Chiropractic Guidelines and Practice Parameters. Chiropractic management of Fibromyalgia Syndrome: Summary of Clinical Practice Recommendations From the Commission of the Council on Chiropractic Guidelines and Practice Parameters. Council on Chiropractic Guidelines and Practice Parameters. Accessed at www.ccgpp.org/downloads/chiropractic_management_fibromyalgia.pdf * on July 20, 2010.
Council on Chiropractic Guidelines and Practice Parameters. Chiropractic Management of Tendinopathy: Summary of Clinical Practice Recommendations From the Commission of the Council on Chiropractic Guidelines and Practice Parameters. Lexington, SC: Council on Chiropractic Guidelines and Practice Parameters; 2009.
Ernst E. Musculoskeletal conditions and complementary/alternative medicine. Best Practice and Research: Clinical Rheumatology. 2004;18(4):539–556.
Ernst E. The safety of massage therapy. Rheumatology (Oxford). 2003:42(9):1101–1106.
Field T. Massage therapy. Medical Clinics of North America. 2002;86(1):163–171.
Harris RE, Clauw DJ. The use of complementary medical therapies in the management of myofascial pain disorders. Current Pain and Headache Reports. 2002;6(5):370–374.
Hassett, AL, Gevirtz RN. Nonpharmacologic treatment for fibromyalgia: patient education, cognitive-behavioral therapy, relaxation techniques, and complementary and alternative medicine. Rheumatic Diseases Clinics of North America. 2009;35(2):393–407.
Holdcraft LC, Assefi N, Buchwald D. Complementary and alternative medicine in fibromyalgia and related syndromes. Best Practice and Research: Clinical Rheumatology. 2003;17(4):667–683.
Kalichman L. Massage therapy for fibromyalgia symptoms. Rheumatology International. 2010;30(9):1151–1157.
Massage. Natural Standard Database Web site. Accessed at http://www.naturalstandard.com on April 21, 2010.
Miaskowski C, Cleary J, Burney R, et al. Guideline for the Management of Cancer Pain in Adults and Children. Clinical practice guideline no. 3. Glenview, IL: American Pain Society; 2005.
Moyer CA, Dryden T, Shipwright S. Directions and dilemmas in massage therapy research: a workshop report from the 2009 North American Research Conference on Complementary and Integrative Medicine. International Journal of Therapeutic Massage and Bodywork: Research, Education, and Practice. 2009;2(2):15–27.
Moyer CA, Rounds J, Hannum JW. A meta-analysis of massage therapy research. Psychological Bulletin. 2004;130(1):3–18.
Nahin RL, Barnes PM, Stussman BJ, et al. Costs of complementary and alternative medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007 *. CDC National Health Statistics Report #18. 2009.
National Cancer Institute. Lymphedema PDQ® (health professional version). National Cancer Institute Web site. Accessed at www.cancer.gov/cancertopics/pdq/supportivecare/lymphedema/HealthProfessional on July 20, 2010.
National Cancer Institute. Pain PDQ® (health professional version). National Cancer Institute Web site. Accessed at www.cancer.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional on July 20, 2010.
National Cancer Institute, National Center for Complementary and Alternative Medicine. Thinking About Complementary and Alternative Medicine: A Guide for People with Cancer. National Cancer Institute Web site. Accessed at www.cancer.gov/cancertopics/thinking-about-CAM on July 20, 2010.
National Center for Complementary and Alternative Medicine. Cancer and CAM: At a Glance *. Bethesda, MD: National Center for Complementary and Alternative Medicine. NCCAM publication no. D453.
National Center for Complementary and Alternative Medicine. Fibromyalgia and CAM: At a Glance. Bethesda, MD: National Center for Complementary and Alternative Medicine. NCCAM publication no. D413.
National Center for Complementary and Alternative Medicine. Massage Therapy: An Introduction. Bethesda, MD: National Center for Complementary and Alternative Medicine. NCCAM publication no. D327.
Pioro-Boisset M, Esdaile JM, Fitzcharles MA. Alternative medicine use in fibromyalgia syndrome. Arthritis Care and Research. 1996;9(1):13–17.
Sagar SM, Dryden T, Myers C. Research on therapeutic massage for cancer patients: potential biologic mechanisms. Journal of the Society for Integrative Oncology. 2007;5(4):155–162.
Sim J, Adams N. Systematic review of randomized controlled trials of nonpharmacological interventions for fibromyalgia. Clinical Journal of Pain. 2002;18(5):324–336.
Tsao JC. Effectiveness of massage therapy for chronic, non-malignant pain: a review. Evidence-Based Complementary and Alternative Medicine. 2007;4(2):165–179.
Weerapong P, Hume PA, Kolt GS. The mechanisms of massage and effects on performance, muscle recovery and injury prevention. Sports Medicine. 2005;35(3):235–256.
Weiger WA, Smith M, Boon H, et al. Advising patients who seek complementary and alternative medical therapies for cancer. Annals of Internal Medicine. 2002;137(11):889–903.
Yates JS, Mustian KM, Morrow GR, et al. Prevalence of complementary and alternative medicine use in cancer patients during treatment. Supportive Care in Cancer. 2005;13(10):806–811.