Massage therapy: more than a modality.
Abstract: Whilst massage therapy techniques are still used within physiotherapy, massage therapy has developed as a specific complementary and alternative medicine (CAM) health service, distinct from physiotherapy, and is one of the fastest growing areas of this sector of the health industry in the United States. New Zealand consumers are also choosing a range of complementary and alternative therapeutic approaches, including massage therapy, to satisfy their primary healthcare needs. This paper discusses the development of massage therapy in New Zealand; explores the approaches and characteristics of massage therapy as a CAM practice; outlines the evidence for massage therapy; and identifies information relevant to the physiotherapist wishing to engage in interprofessional collaboration with a massage therapist.

Key words: Massage, Massage therapy, Physiotherapy, Complementary & Alternative Medicine
Article Type: Report
Subject: Physical therapy (Practice)
Therapeutics, Physiological (Practice)
Massage (Supply and demand)
Massage (Usage)
Massage (Health aspects)
Authors: Smith, Joanna M.
Sullivan, S. John
Baxter, G. David
Pub Date: 07/01/2010
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: July, 2010 Source Volume: 38 Source Issue: 2
Topic: Event Code: 200 Management dynamics; 600 Market information - general
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 263992600
Full Text: BACKGROUND

Landmarks and influences in the development of massage therapy in New Zealand

In many countries of the ancient world, massage was considered to be a medicinal practice and was practised in many forms (Calvert 2002; Fritz 2006). Hippocrates advocated anatripsis which means 'to rub up' and suggested, 'the physician must be acquainted with many things and assuredly with anatripsis, for things that have the same name have not the same effects, for rubbing can bind a joint that is loose and loosen a joint that is too hard (Beard 1964 cited in Tuchtan et al 2004, p.17). Within Aotearoa New Zealand, mirimiri (massage therapy) was part of daily life in pre-European times (Calvert 2002), and is still practised by Maori healers today (Gregg et al 2006).

Massage therapy developed differently in the East and the West during the Middle Ages. In the West, massage therapy became associated with supernatural experiences and folk medicine, but later regained some of its "respectability" in the sixteenth century (Fritz 2006). By the 1880s, massage was undergoing a revival in Britain; Swedish massage became an important feature of nursing work and a 'diverse array of variously trained massage therapists were practising throughout the country' (Nicholls and Cheek 2006, p.2340). However, the inconsistent system of education and questionable quality of some massage therapists, false advertising claims by some massage therapists (Fritz 2006), along with the implication that 'massage establishments were merely a front for brothels' (Nicholls and Cheek 2006, p.2340) during the massage scandals of 1894, eroded the legitimacy of massage therapy.

The legitimisation of massage therapy in the 20th century was enhanced through the use of a 'biomechanical discourse' (Nicholls and Cheek 2006), and the Society of Trained Masseuses (STM) association with the medical fraternity; STM became the practising foundation of physiotherapy. Within New Zealand, the Otago Medical School established the School of Massage in 1913, and offered an 18-month Certificate in Massage; this School has since evolved into the current University of Otago School of Physiotherapy. The Physiotherapy Act of 1949 supported the right of the physiotherapist to practise therapeutic massage.

In recent years the demand for therapeutic massage services by the New Zealand public has increased and massage therapists have taken this opportunity to respond to this need. In the late 1980s and early 1990s, two voluntary associations were established in New Zealand to support massage therapists: the Massage Institute of New Zealand Incorporated (MINZI) and the New Zealand Association of Therapeutic Massage Practitioners (NZATMP). These played a role in raising the educational standards and profile of massage therapists. In 1992, the first 'formal' massage diploma (to meet the educational standards advocated by NZATMP) was delivered by a private training establishment in Auckland, and the practice of massage therapy as a stand alone therapy for health and wellness, distinct from physiotherapy, became more evident. With the adoption of the Health Professional Competency Assurance Act in 2003, the 1949 Physiotherapy Act was repealed, and the requirements of the Physiotherapy Act imposed on massage therapy educators and massage therapists to clearly identify that they were not training students in physiotherapy nor practising physiotherapy respectively was removed. The introduction of massage therapy unit standards and a National Certificate and National Diploma by the New Zealand Qualifications Authority in 2000 also stimulated growth in the number of massage therapy training providers, especially in the Polytechnic sector. Today, the education of massage therapists commonly involves a six-month Certificate in Relaxation Massage or a one to two year Diploma in Therapeutic Massage. More recently, baccalaureate degree based education for massage practitioners was implemented at Southern Institute of Technology (SIT) in 2002 in the form of a Bachelor of Therapeutic and Sports Massage. Subsequently a second provider (private training establishment) has been approved and now also offers a three-year Bachelor's Degree in Massage Therapy.

However, the practice of massage therapy in New Zealand is unregulated (Massage New Zealand 2009a) and there is a range of educational standards and levels, including non-accredited massage education providers offering massage therapy training. In the last 20 years, a number of self-regulating bodies for massage in New Zealand have been established. Today, Massage New Zealand (MNZ) is the only voluntary national association specifically for massage therapists. Members of MNZ are bound by a code of ethics, a scope of practice, a complaints procedure, and have requirements for continuing professional development. Two levels of membership exist: the Certified Massage Therapist (CMT) who practices relaxation massage, and who holds a National (NZQA) Certificate or equivalent in Relaxation Massage (most commonly representing 600 hours of training); and the Remedial Massage Therapist (RMT) who practices remedial, deep tissue or other advanced clinical styles of massage, and who holds a National (NZQA) Diploma/Degree or equivalent in Therapeutic Massage, which can vary from 1500-3600 hours of training (Massage New Zealand 2009b). Whilst MNZ members are the only nationally recognised group of massage professionals, only 250 massage therapists (CMT and RMT) are members; but based on the 2006 employment data (Department of Labour 2009), over 80% of NZ massage therapists do not belong to MNZ.

MASSAGE AS A CAM PRACTICE

Massage therapy is used as an adjunct or standalone therapy by a number of health care providers such as nurses (Grealish et al 2000; Remington 2002), physiotherapists (Foster et al 1999; Galloway et al 2004), other complementary and alternative medicine (CAM) providers (Fellowes et al 2004; Mehling et al 2007) and massage therapists (Cherkin et al 2002a). Whilst massage therapy techniques are still used within physiotherapy (Foster et al 1999; Galloway et al 2004), massage therapy has developed as a specific CAM health service, distinct from physiotherapy, and is one of the fastest growing areas of this sector of the health industry in the United States (US) (Cherkin et al 2002b). In New Zealand, massage therapy, separate from physiotherapy, is also among the many growing CAM modalities and is considered part of the manipulative and body-based CAM therapies (Ministerial Advisory Committee on Complementary and Alternative Health 2004). This section focuses on the practice of massage therapy delivered as a stand-alone therapy by a massage therapist.

Definitions and approaches

Massage therapy may be defined as 'the use of the hands to physically manipulate the body's soft tissues for the purpose of effecting a desirable change in the individual' (Tuchtan et al 2004, p.5). Other definitions add elements such as the application of purposeful and systematic touch, a collection of skills, and a variety of styles or approaches (Yates 2004). Professional bodies such as the American Massage Therapy Association (AMTA) defines 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' (American Massage Therapy Association 2009a), thereby, incorporating into massage therapy the scopes of health and wellbeing. Within New Zealand, MNZ does not define massage therapy but does position massage therapy within health and wellness in its mission statement, i.e. 'to promote health and wellness in New Zealand (Aotearoa) through quality massage' (Massage New Zealand 2009c), thereby mirroring the scope advocated by AMTA. Instead, MNZ lists a number of massage therapy techniques, energy based massage techniques, and posture related treatments (Massage New Zealand 2009d). Massage therapy techniques noted by MNZ include neuromuscular therapy (NMT), therapeutic massage, trigger point therapy, sports massage, myofascial release (MFR), chair massage, and Swedish massage (relaxation massage).

Massage therapy incorporates a variety of approaches (Moyer et al 2004; Sherman et al 2006). Some massage therapists subscribe to a single approach or school of thought, while others choose from a range of available techniques and styles depending on their skill base, scope of practice, and the needs of the client (i.e., condition and principal goal of treatment). Sherman and colleagues (2006) have recently presented a classification system (goal of treatment, styles, techniques) to assist with standardising the reporting of massage application to patients with musculoskeletal pain. Four categories described the principal goal of treatment; these were relaxation massage, clinical massage, movement re-education, and energy work. A number of different styles, for example, Swedish massage, myofascial release, proprioceptive neuromuscular facilitation, could be used for each principal goal of treatment, and each style consisted of a number of specific techniques, for example, gliding, skin rolling, kneading (Sherman et al 2006). However, the lack of consistency in the definition of massage therapy (Menard 2002), as well as the lack of consistent terminology for describing the techniques used by massage therapists are two of the challenges in conducting research in the field of massage and bodywork (Sherman et al 2006).

The practice of massage therapy is considered to be more than the applications of one or more massage therapy techniques. Massage therapy is aligned with the wellness paradigm, and places importance on addressing the client's physical, psychological and emotional needs to maximise the client's capacity to achieve mental and physical balance (Alexander 2006; Cassidy 2002; Yates 2004). In addition, an essential element of massage therapy is an interactive and relatively egalitarian therapeutic relationship (Smith 2009a), and massage therapy-related health outcomes (Smith 2009b) are more closely associated with the wellness paradigm of CAM (Alexander 2006; Cassidy 2002; Yates 2004) rather than those associated with biomedicine (Schuster et al 2004).

In summary, contemporary massage therapy in its simplest form equates to anatripsis (to rub) reflecting its origin; however, the range and descriptions of its associated techniques and practices are expansive, and variable, and only recently have there been attempts to illustrate the intentionality and integrity of massage therapy through systematic definitions and best practice frameworks (Grant et al 2008; Sherman et al 2006). The practice of massage therapy is more than a modality or an application of techniques--it is a dynamic, whole systems approach to care. The philosophy of massage therapy practice is holistic in nature and differs from the 'body-as-machine' approach (Nicholls and Larmer 2005) often used in contemporary physiotherapy practice.

The use of massage therapy

Massage therapy is used to treat symptoms associated with a wide range of chronic (Cherkin et al 2002b), clinical (Furlan et al 2002; Lawler 2004; Moyer et al 2004) and sporting (Ernst 1998; Moraska 2005; Weerapong et al 2005) conditions. It seems that more people recognise massage therapy as an important element in their overall health and wellness, with clients seeking benefits such as relaxation, feelings of well-being (Back et al 2009; Grant et al 2008; Sharpe et al 2007), improved circulation, and reduction in anxiety and pain (Moyer et al 2004). Although massage can be provided for a number of reasons, its general goal is to help 'the body achieve or increase health and well-being' (Sherman et al 2006, p.1). Some contraindications for massage therapy exist, such as, deep vein thrombosis or localised conditions such as skin injuries or burns (Sherman et al 2005). However, many conditions previously considered contraindications (e.g., metastatic cancer) are no longer considered as such (Batavia 2004); indeed, the common forms of massage, tailored appropriately, are considered very low risk (Ezzo et al 2007; Sherman et al 2005) and serious adverse events are rare (Ernst 2003).

One of the earliest surveys of massage therapy use in the general population in the US reported an increase in use of massage therapy from 6.9% in 1990 to 11.1 % in 1997; visits were primarily for back and neck problems and fatigue (Eisenberg et al 1998). A 1998-1999 survey based on patient visit data for massage therapy from two US states (Cherkin et al 2002b) reported the five primary reasons for visits were: back symptoms (20.220.4%), wellness (18.7-19.5%), neck symptoms (13.0-18.7%), anxiety or depression (5.2-8.8%), and shoulder symptoms (7.4-8.4%); and 71.5 % of users were not covered by insurance. Most visits were for chronic problems, and about a quarter to a third of all visits were for non-illness care (Sherman et al 2005). Since 2003, annual AMTA consumer surveys indicate that an average of 32% of adult Americans received a massage in the previous five years (American Massage Therapy Association 2009b). Similarly, a 2005 population based survey of CAM use in Australia (Xue et al 2007) reported western massage therapy as the second most popular form of CAM, with 27.2% of the population using western massage therapy, and, of those, 73.7% visited a practitioner, with a mean of 6.3 visits per user.

Within New Zealand, consumers are now choosing a range of complementary and alternative therapeutic approaches to satisfy their primary healthcare needs, and massage therapy is a popular treatment choice: during a 12-month period in 2002/3, 9.1% of adult New Zealanders reported having visited a massage therapist (Ministerial Advisory Committee on Complementary and Alternative Health 2004). Patterns of massage use by New Zealand-based clients show similarities with other CAM and massage surveys. Massage users tended to be female, NZ European, employed in professional careers, and almost always paid for massage privately; they sought massage therapy for symptoms of 'muscle tightness / stiffness / tension' and 'pain' (Smith 2009c). Massage users employed a proactive and health conscious approach; the massage experience as well as outcomes from massage therapy were important to clients and contributed to a healthier and more productive life (Smith 2009a, Smith 2009b, Smith 2009c).

Massage therapy practice in New Zealand

Unlike physiotherapy (Reid and Larmer 2007), massage therapy is not an established part of the health care system and is not funded by the Accident Compensation Corporation. However, the Department of Labour recently reported 1272 people employed as massage therapists in 2006, a 54% growth since 2001, and a 451% growth since 1996; 85% were female, 78% were NZ European, and 10% were Ma-ori (Department of Labour 2009). The definition used for a massage therapist for the Census survey was 'massage therapists perform therapeutic massage and administer body treatments for health, fitness and remedial purposes' (Statistics New Zealand 2009) categorising massage therapists by their self-reported activity rather than by 'registration' or 'qualification'. This employment growth perhaps reflects the growth in awareness in massage therapy, and the growing number of educational providers and graduates. The major industries serviced by massage therapy were health services (51%) and the qualifications of massage therapists ranged from none (6%) to degree/higher degree (17%) (Department of Labour 2009). The New Zealand Government Career Services website (Career Services, 2009) reports that therapists work on average 21 hours per week, charging from between $30 to $80 an hour, and that job opportunities for massage therapists in New Zealand are good.

However the census data does not necessarily represent the practice of massage therapy in New Zealand by qualified massage therapists. A recent study 66 New Zealand-based massage therapists, who were also members of MNZ, were surveyed using a random, nationwide sample. Most therapists were female (83%), NZ European (76%), and held a massage diploma (89%). Massage therapy was both a full (58%) and part time (42%) occupation, and two-thirds of therapists (66%) reported typically having between 10 and 29 client visits per week. The most frequent client fee per treatment was $60 per hour in a clinic and $1 per minute at a sports event or in the workplace. The majority of massage therapists practised in a 'solo practice' (58%) but used a wide and active referral network, including referral to and from physiotherapists (Smith 2009c). Commonly used techniques and most frequent issues or conditions seen by massage therapists, as well as therapist and practice characteristics were similar to that reported in US studies (Cherkin et al 2002b; Sherman et al 2005), suggesting some cross-national congruency.

THE EVIDENCE FOR MASSAGE THERAPY

The previous sections have indicated that the practice of massage therapy is very old, and massage therapy is widely used and expanding rapidly as a CAM practice. However, scientific research on massage therapy has only a short history (about twenty years) and although the quantity of massage therapy research has increased, the research infrastructure is still developing, and massage therapy research is still in its infancy (Moyer et al 2009). In the US, the Massage Therapy Foundation and the National Center for Complementary and Alternative Medicine are major funders for massage therapy research. Although scientific research on massage therapy is limited, there is evidence that massage may benefit some patients (National Center for Complementary and Alternative Medicine 2009); a view supported by Ernst and colleagues (2007) who suggest the evidence base is getting stronger for massage therapy.

Established effects of massage therapy

Some of the early massage therapy research reviewed the effectiveness of massage therapy in treating symptoms associated with a variety of clinical conditions (e.g., pregnancy, migraine headache) and concluded that massage therapy has received 'empirical support for facilitating growth, reducing pain, increasing alertness, diminishing depression, and enhancing immune function' (Field 1998, p.1270). Other reported changes brought about by massage include: improvements in blood and lymph flow, reduction in muscle tension and blood pressure, increase in pain threshold, improvement of mood, and relaxation of the mind (Aourell et al 2005, Coelho et al 2008, Ernst et al 2006, Frey Law et al 2008, Ouchi et al 2006, Sullivan et al 1991). A number of systematic reviews have also been conducted for massage therapy since 2004; these are summarised in Table 1. Some reviews indicate evidence for massage therapy, others conclude that more evidence is required; and conclusions cannot yet be drawn about the effectiveness for specific health conditions (Ernst et al 2007).

More recently, a well designed randomised controlled trial (RCT) (Sherman et al 2009) comparing the efficacy and safety of therapeutic neck massage with a self-care book for patients whose neck pain had persisted at least 12 weeks (n=64) showed therapeutic massage had clinically important benefits at least in the short term. Donoyama and Shibasaki (2009) in a study of massage interventions for chronic neck and shoulder stiffness (n=8) reported that the effectiveness of massage therapy for neck and shoulder muscle stiffness was dependent upon the experience of the massage practitioner. This suggestion mirrors that of Imamura and colleagues (2008) that training and experience of the massage therapist might influence outcomes; an important point when choosing a therapist.

Common gaps in massage therapy research include heterogeneous populations, non-comparable outcome measures, and poorly described treatments. For massage therapy, the situation is further complicated by the multiple professionals who use the therapy, the multimodality treatment package which may be used, the styles of massage therapy in use, and because massage is provided in many different contexts (Sherman 2008). In addition, little is known about what constitutes 'massage therapy' or the nature of the therapeutic encounter.

Models and mechanisms underlying massage therapy

As highlighted in the research discussed, massage therapy potentially offers promise for some conditions; however, there is still uncertainty about the effectiveness and mechanisms of action of massage therapy. Some of the mechanisms offered to explain massage therapy effects include: gate control theory of pain reduction, promotion of parasympathetic activity, influence on body chemistry, mechanical effects, promotion of restorative sleep, and interpersonal attention (Field 1998, Imamura et al 2008, Moyer et al 2004, Weerapong et al 2005). However, Weerapong and colleagues reviewed the literature to evaluate the evidence for the possible mechanisms of massage (biomechanical, physiological, neurological and psychological) and concluded that in general, studies were methodologically flawed or results were limited or inconclusive. Moyer et al (2004) also found that the theories commonly offered to explain massage therapy (gate control theory, parasympathetic response) were the least supported by the meta-analysis they conducted. There was support for the body chemistry, mechanical effects, and the promotion of restorative sleep mechanisms.

Moyer and colleagues further suggest that in addition to the benefits of a massage therapy intervention occurring through physiological mechanisms and the physical nature of the therapy, a psychotherapeutic, common-factors model may be applicable to massage therapy (Moyer et al 2004). Taking this approach, the positive expectations for treatment, therapist factors, the client-therapist alliance, and the interpersonal contact and communication that takes place throughout the treatment session, may be more important to the effects of massage than the purely physical ingredients of treatment (Sharpe et al 2007), i.e., the active ingredient is unknown and may be a result of more than the soft tissue manipulation (Moyer et al 2004). A recent exploration of the valued elements of the massage therapy experience (Smith 2009a, Smith 2009c) has begun the process of describing the psychosocial context of massage therapy treatment, to determine some of the specific ingredients and common factors (e.g., communication, therapist and patient expectations) noted by Moyer and colleagues (2004). These findings inform researchers of the potential active ingredients of a massage therapy intervention, and may allow practitioners to enhance the placebo effects through optimising caregiver-patient interactions (Price et al 2008). The descriptions of the massage therapy encounter and clients' reasons for returning to massage therapy also suggest that massage therapists practise within a distinctive massage therapy culture, which is potentially different from other allied health practitioners (Fellowes et al 2004, Galloway et al 2004, Remington 2002) who provide massage therapy techniques.

AN OPPORTUNITY FOR AN INTEGRATED HEALTH COLLABORATION

Massage therapy as a stand-alone therapy is widely used; its growth is partially attributed to consumer demand and an increase in awareness. New Zealanders are using massage therapy for the purposes of musculoskeletal condition management and prevention, stress and relaxation, and wellness (Smith, 2009b). It is used as a treat and as a treatment. However, legitimisation is still an issue for some therapists; the unfortunate association of massage therapy with the sex industry is still influencing the credibility of massage therapy in New Zealand. There have been significant developments in formalised massage therapy training in New Zealand, but formal registration or self-regulation through organisations such as MNZ is far from complete. In addition, research infrastructures are beginning to develop internationally (e.g., Massage Therapy Foundation sponsored case report competitions, massage specific research conferences and journals) and within New Zealand (i.e., the New Zealand Massage Therapy Research Centre at SIT), and interest and productivity in research by the massage community is growing (Moyer et al 2009). The evidence for massage therapy practice is getting stronger in some areas; however, the potential value of massage as a treatment will not be known until methodological weaknesses are addressed, and the context of treatment is sufficiently defined to enable concrete discussions and review (Grant et al 2008, Moyer et al 2009).

Whilst some physiotherapists still utilise a number of massage therapy techniques as part of their physiotherapy practice, the potential for stronger interprofessional collaboration with massage therapists exists. Some networking between massage therapists and physiotherapists is occurring for the benefit of patients. Physiotherapists choosing to adopt the integration approach (incorporating a holistic approach to health) to better position and strengthen the future for physiotherapy (Nicholls and Larmer 2005) may look to include a massage therapist into their practice ('in house' or 'outsourced').

Clients using CAM-related massage therapy value the holistic nature of the intervention, the person-centered approach taken by massage therapists, and the environmental aspects of the therapy encounter; outcomes are important to clients but so is a positive experience. The quality of massage therapy providers varies; establish the credentials of the massage therapist with whom you wish to collaborate. Useful strategies include: word of mouth, MNZ membership (relaxation therapist or remedial therapist), or qualification and qualification provider.

Key Points

* Massage therapy as a health care service, distinct from physiotherapy, is growing in popularity.

* The philosophy of massage therapy care is holistic in nature and differs from the 'body-as-machine' approach within contemporary physiotherapy practice.

* Specific massage therapy education ranges from none to Bachelor's degree level, and the practice of massage therapy is unregulated.

* Quality assurance is supported through MNZ membership or higher level qualifications--ask for the credentials of a massage therapist.

* Massage therapy research is in its infancy--but the evidence of the effectiveness of massage therapy for certain conditions is growing.

* Networking between massage therapists and physiotherapists is occurring and the potential for interprofessional collaboration is promising.

ACKNOWLEDGEMENTS

A University of Otago Postgraduate Scholarship and a University of Otago Postgraduate Publishing Bursary supported Dr Smith's research,

ADDRESS FOR CORRESPONDENCE

Jo Smith, New Zealand Massage Therapy Research Centre, Southern Institute of Technology, Private Bag 90114, Invercargill 9840, New Zealand. Phone: (+643 2112699 ext 8803) Fax: (+643 2112621). Email: jo.smith@sit.ac.nz

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Joanna M Smith BTSM, BHSc(Physio), PhD

Programme Manager & Lecturer, Massage Department, Southern Institute of Technology, New Zealand

S John Sullivan Dip Ph Ed, MSc, PhD

Professor, Centre for Physiotherapy Research, School of Physiotherapy, University of Otago

G David Baxter TD BSc(Hons), DPhil(Ulster), MBA (Lond)

Professor & Dean, School of Physiotherapy, University of Otago
Table 1: Summary of systematic reviews for massage therapy: 2004-2009

Authors           Purpose for            Number
                  massage therapy        of
                  (MT)                   studies

(Lewis &          Symptomatic            20
Johnson,          relief of
2006)             musculoskeletal
                  pain

(Imamura          Management of          13
et al., 2008);    chronic low back
(Furlan,          pain
Imamura,
Dryden, &
Irvin, 2008)

(Ezzo et          Massage for            19
al., 2007);       mechanical
(Haraldsson       neck disorders

et al., 2006)

(Wilkinson,       Massage for            10
Barnes, &         symptom relief
Storey, 2008)     In patients with
                  cancer

(Coelho et        Massage therapy        4
al., 2008)        for the treatment
                  of depression

(Ernst, 2009)     MT for cancer          14
                  palliation and
                  supportive care

Authors           Findings

(Lewis &          Therapeutic massage was:
Johnson,
2006)             Superior to no treatment in 5/10
                  comparisons;

                  Superior to sham (laser) treatment in 1/2
                  comparisons;

                  Superior to active treatment in 7/22
                  comparisons;

                  Superior to comparison groups in 6/11
                  studies using patients with
                  musculoskeletal pain; 3/7 studies using
                  patients with low back pain.

                  Superior to comparison groups in 4/9
                  studies using healthy participants
                  experiencing post-exercise pain and
                  soreness.

                  There were no relationships between study
                  outcome and the TM regimen used

(Imamura          Strong evidence that massage is effective
et al., 2008);    for nonspecific CLBP
(Furlan,
Imamura,          The effects of massage are improved if
Dryden, &         combined with exercise and education and
Irvin, 2008)      if a licensed therapist delivers massage.

(Ezzo et          Six trials examined massage as a
al., 2007);       stand-alone treatment; 14 examined massage
(Haraldsson       as part of a multimodal intervention.

et al., 2006)     Did not find a strong or moderate level of
                  evidence for massage alone relative to a
                  control

                  Relative contribution of massage could not
                  be determined in multimodal interventions

(Wilkinson,       Massage might reduce anxiety in patients
Barnes, &         with cancer in the short term, and
Storey, 2008)
                  May have a beneficial effect on physical
                  symptoms of cancer, such as pain and
                  nausea.

(Coelho et        Three of these RCTs compared massage
al., 2008)        therapy with relaxation therapies, but
                  provided insufficient data and analyses to
                  contribute meaningfully to the evaluation;

                  In the early stages of treatment, massage
                  therapy

                  Is less effective than acupuncture for
                  treating depression.

(Ernst, 2009)     Massage can alleviate a wide range of
                  symptoms: pain, nausea, anxiety,
                  depression, anger, stress and fatigue

Authors           Conclusions            Problems or
                                         recommendations

(Lewis &          The available          Inadequate
Johnson,          evidence is            sample sizes, low
2006)             inconclusive.          methodological
                                         quality and
                                         Insufficient dosing
                                         information

(Imamura          Supports
et al., 2008);    massage
(Furlan,          therapy for
Imamura,          management
Dryden, &         of CLBP
Irvin, 2008)

(Ezzo et          Results                Describe massage
al., 2007);       inconclusive:          Intervention
(Haraldsson       effectiveness          (frequency,
                  of massage             duration, number
et al., 2006)     for neck               of sessions,
                  pain remains           and massage
                  uncertain              technique).
                                         massage
                                         professional's
                                         credentials, or
                                         experience.
                                         Improve reporting
                                         of the adverse
                                         events.

(Wilkinson,       The lack               More well-
Barnes, &         of rigorous            designed large
Storey, 2008)     research               trials with longer
                  evidence               follow-up periods
                  precludes              are needed
                  drawing
                  definitive
                  conclusions.

(Coelho et        Currently
al., 2008)        a lack of
                  evidence
                  to support
                  massage
                  therapy as
                  an effective
                  treatment for
                  depression

(Ernst, 2009)     Evidence is            Methodological
                  encouraging;           quality of the
                  warrants               Included studies
                  further                was poor
                  investigations
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