PPS0705 Massage Ther2 1

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Evidence-based massage therapy
Edzard ErnstComplementary MedicinePeninsula
Medical SchoolUniversities of Exeter Plymouth,
UKEmail Edzard.Ernst_at_pms.ac.ukWebsite
www.pms.ac.uk/compmed
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OK Mr. Hook. Seems youre trying to decide
between pirating or massage therapy. Well, maybe
we can help you narrow it down.
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EBM integrating individual clinical experience
with the best available external clinical
evidence from systematic research
D Sackett 1997
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Evidence-based medicine a new trend?
Our work is an incessant collection of evidence,
weighing of evidence and judging upon the
evidence
Sir William Osler. 1907
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Myth
Massage therapy cannot be evaluated according to
EBM because placebo-controlled double-blind
studies are not possible
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Hierarchy of evidence
Systematicreviews of RCTs
Randomisedclinical trials
Controlled clinical trails
Uncontrolled data (e.g. case reports, case
series,observational studies)
Ernst E. Complementary Medicine, Peninsula
Medical School
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Observational data

• Surveys
• Uncontrolled / observational studies

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Massage - what for?
Design Sample Response rate Results
Survey 223 CAM organisations worldwide 34 Indi
cated for

• anxiety/stress
• headache/migraine
• back pain
• respiratory problems
• insomnia
• menstrual problems
• arthritis/rheumatism
• depression
• skin problems

• chronic fatigue/ME
• neck/shoulder pain
• IBS
• sports injuries
• constipation
• MS
• cancer
• HIV/AIDS

Long, Huntley, Ernst. Complementar Ther Med
20019178
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Practice patterns of US massage therapists
Design Sample Results
interview study record of 20 patients/therapists
226 massage therapists from Connecticut or
Washington

• conditions treated- musculoskeletal (59/63)-
  wellness care (20/29)- psychological complaints
  (9/6)
• treatments used- Swedish massage (81/77)- deep
  tissue massage (63/65)- trigger point
  techniques (52/46)

Sherman KJ, et al. BMC CAM 2005513
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Massage in an acute care setting
Design Sample Result
post treatment questionnaire 113 hospitalised
patients receiving 1-4 massage treatments

• response rate 62
• 99 felt increased relaxation
• 93 expressed a sense of well being
• 88 had positive mood changes
• 75 experience improvements in mobility, energy,
  participation in treatment recovery

Smith M, et al. Alt Ther 1999564
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Massage in hospice care
Design Sample Intervention Results
0bservational study 32 cancer patients 1
session of individualised massage therapy
(average 58 min) Self-rating showed
improvement pain 4.2 2.0 anxiety 3.8 1.8 pea
cefulness 4.0 1.9
Polubinski, West. JPSM 200530104
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Massage for symptom control in cancer
Design Sample Intervention Results

• 0bservational study with 48-hour follow-up
• 1290 patients with various types of cancer
• One single massage session
• Symptoms scores were reduced by approximately 50
• Out-patients improved more than in-patients
• Benefit persisted throughout follow-up

Cassileth et al. JPSM 200428244
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Consider this case

• Patient is ill, say, with back pain
• Patient opts for massage therapy
• Patient recovers

Does that prove that massage is effective?
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treatment
assumption treatment caused pain reduction
alternative explanations time (natural history
of disease) expectation empathy
placebo regression towards the mean
undeclared therapies being kind to
therapist, etc
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therefore we need controlled studies,
preferablyRCTs
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Principle of the RCT
experimental intervention
R
compare results
sample
control intervention
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Massage for rheumatic pain
Design Sample Intervention Results
RCT with two parallel groups 29 patients with
non-inflammatory rheumatic pain A) 10 sessions
of Swedish massage B) usual GP care for 5 weeks,
follow-up 3 months

• pain and depressive mood improved in both groups
• analgesic effect was only notable at follow-up in
  A

Güthlin, Walach Phy Therapie 200021717
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Massage vs acupuncture for LBP
Design Patients Interventions Endpoints
Results

• RCT with 3 parallel arms
• 262 patients with persistent LBP
• A) TCM acupuncture
• B) massage
• C) exposure to educational material
• pain, function
• massage superior to acupuncture and control
• effects lasted up to 52 weeks
• acupuncture not effective

10 x / 10 weeks
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Cherkin et al Arch Intern Med 20011611081
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Massage for shoulder pain of stroke patients
Design Sample Intervention Results
RCT with 2 parallel groups and 3 days
follow-up 102 stroke patients with shoulder
pain A) Daily slow stroke back massages (as a
nursing intervention) B) No such adjuvant
treatment
Pain perception and anxiety improved in A
compared to B
Moke et al Compl Ther Nursing Midwifery
200410209
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Massage for childhood asthma
Design Patients Interventions Results

• RCT
• 32 children with asthma
• Parents were instructed to apply
• Massage
• Relaxation
• A) Younger children anxiety, cortisol, pulmonary
  function
• B) Older children anxiety

20 minutes before bedtime for 30 days
Feld T, et al. J Paediatr 1998132654
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Self-massage for smoking cessation
Design Sample Intervention Result

• RCT
• 20 adult smokers
• self-massage of hand or ear during craving
• No such treatment
• Less craving less cigarettes smoked in group A

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Hernandez R, et al. Preventive Med 19992828
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Consider this case
There are 20 RCTs of massage for condition x 10
have a positive result and 10 have a negative one
proponent
opponent
summary of 10 positive RCTs conclusion clearly
positive
summary of 10 negative RCTs conclusion clearly
negative
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Systematic reviews
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Principle of systematic reviews
Evaluate totality of data (of certain,
pre-defined nature) Minimize random
errorMinimize selection bias
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Massage for LBP
Design Result Conclusions
systematic review of all RCTs

• only 4 RCTs were found
• in all 4 RCTs massage was used in the control arm

massage might have some potential and, in view
of the popularity of massage for LBP, rigorous
studies are urgently needed
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Ernst E. J Pain Symp Man 19991765
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Abdominal massage for chronic constipation
Design Source Sample Result
systematic review searches in 4 databases 4
controlled clinical trials

• numerous methodological flaws
• heterogeneity in design
• some promising hints

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Ernst E. Forsch Komplementarmed 199961
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Massage for DOMS

• systematic review
• 7 controlled trials
• serious methodological flaws
• no consensus on outcome
• majority suggests that massage alleviates
  symptoms of DOMS

Design Sample Result
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Ernst E. Br J Sports Med 199832212
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Safety
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Adverse effects of massage therapy
Design Aim Inclusion Result

• systematic review
• evaluate the potential for harm of any type of
  massage therapy
• any type of clinical evidence
• 16 case reports 4 case series were found
• majority of AEs were associated with exotic
  types of massage delivered by lay people
• AEs included - CVAs
• - embolisation of a kidney
• - haematoma
• - nerve damage
• - pulmonary embolism
• - ruptured uterus

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Ernst E. Rheumatol 2003421101
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Summary of clinical evidence for massage
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Weight of evidence

• Level
• Quality (max 000)
• Volume

Direction of result clearly positive
clearly negative
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Summary of clinical evidence for massage
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Future studies (RCTs)

• adequate sample size
• optimal intervention
• validated outcome measures
• reasonable follow-up
• more than one therapist
• Clearly described intervention
• blinded evaluator

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Conclusions
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• EBM is not a threat but an opportunity for
  massage therapy
• current trial data are encouraging

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