research on deep tissue massage

Featured Topics

Featured series.

A series of random questions answered by Harvard experts.

Explore the Gazette

Read the latest.

Glimpse of next-generation internet

Science is making anti-aging progress. But do we want to live forever?

Epic science inside a cubic millimeter of brain

Massage helps injured muscles heal faster and stronger.

Study confirms link between mechanotherapy and immunotherapy in muscle regeneration in mice

Lindsay Brownell

Wyss Institute Communications

When injured mouse muscles were treated with mechanotherapy for three days (top), they displayed a significantly reduced number of neutrophils (in pink) compared to untreated muscles (bottom).

Credit: Wyss Institute at Harvard University

Massages feel good, but do they actually speed muscle recovery? Turns out, they do. Scientists at the Wyss Institute and Harvard John A. Paulson School of Engineering and Applied Sciences applied precise, repeated forces to injured mouse leg muscles and found that they recovered stronger and faster than untreated muscles, likely because the compression squeezed inflammation-causing cells out of the muscle tissue.

Using a custom-designed robotic system to deliver consistent and tunable compressive forces to mice’s leg muscles, researchers at Harvard’s Wyss Institute for Biologically Inspired Engineering and SEAS found that this mechanical loading (ML) rapidly clears immune cells called neutrophils out of severely injured muscle tissue. This process also removed inflammatory cytokines released by neutrophils from the muscles, enhancing the process of muscle fiber regeneration. The research is published in Science Translational Medicine.

“Lots of people have been trying to study the beneficial effects of massage and other mechanotherapies on the body, but up to this point it hadn’t been done in a systematic, reproducible way,” said  first author Bo Ri Seo, who is a postdoctoral fellow in the lab of Dave Mooney at the Wyss Institute and SEAS. “Our work shows a very clear connection between mechanical stimulation and immune function. This has promise for regenerating a wide variety of tissues including bone, tendon, hair, and skin, and can also be used in patients with diseases that prevent the use of drug-based interventions.”

A more meticulous massage gun

Seo and her co-authors started exploring the effects of mechanotherapy on injured tissues in mice several years ago, and found that it doubled the rate of muscle regeneration and reduced tissue scarring over the course of two weeks. Excited by the idea that mechanical stimulation alone can foster regeneration and enhance muscle function, the team decided to probe more deeply into exactly how that process worked in the body, and to figure out what parameters would maximize healing.

They teamed up with soft robotics experts in the Harvard Biodesign Lab, led by Wyss Associate Faculty member Conor Walsh to create a small device that used sensors and actuators to monitor and control the force applied to the limb of a mouse. The team experimented with applying force to mice’s leg muscles via a soft silicone tip and used ultrasound to get a look at what happened to the tissue in response. They observed that the muscles experienced a strain of between 10 to 40 percent, confirming that the tissues were experiencing mechanical force. They also used those ultrasound imaging data to develop and validate a computational model that could predict the amount of tissue strain under different loading forces.

“This has promise for regenerating a wide variety of tissues including bone, tendon, hair, and skin, and can also be used in patients with diseases that prevent the use of drug-based interventions.” Bo Ri Seo, Wyss Institute

They then applied consistent, repeated force to injured muscles for 14 days. While both treated and untreated muscles displayed a reduction in the amount of damaged muscle fibers, the reduction was more pronounced and the cross-sectional area of the fibers was larger in the treated muscle, indicating that treatment had led to greater repair and strength recovery. The greater the force applied during treatment, the stronger the injured muscles became, confirming that mechanotherapy improves muscle recovery after injury. But how?

Evicting neutrophils to enhance regeneration

To answer that question, the scientists performed a detailed biological assessment, analyzing a wide range of inflammation-related factors called cytokines and chemokines in untreated vs. treated muscles. A subset of cytokines was dramatically lower in treated muscles after three days of mechanotherapy, and these cytokines are associated with the movement of immune cells called neutrophils, which play many roles in the inflammation process. Treated muscles also had fewer neutrophils in their tissue than untreated muscles, suggesting that the reduction in cytokines that attract them had caused the decrease in neutrophil infiltration.

The team had a hunch that the force applied to the muscle by the mechanotherapy effectively squeezed the neutrophils and cytokines out of the injured tissue. They confirmed this theory by injecting fluorescent molecules into the muscles and observing that the movement of the molecules was more significant with force application, supporting the idea that it helped to flush out the muscle tissue.

To pick apart what effect the neutrophils and their associated cytokines have on regenerating muscle fibers, the scientists performed in vitro studies in which they grew muscle progenitor cells (MPCs) in a medium in which neutrophils had previously been grown. They found that the number of MPCs increased, but the rate at which they differentiated (developed into other cell types) decreased, suggesting that neutrophil-secreted factors stimulate the growth of muscle cells, but the prolonged presence of those factors impairs the production of new muscle fibers.

Immunofluorescence images show that when an injured muscle is treated with mechanotherapy (right), its muscle fiber type composition changes compared to untreated muscles (left). The composition of the treated muscle is more similar to that of healthy muscle, implying that treatment helps restore proper muscle function.

“Neutrophils are known to kill and clear out pathogens and damaged tissue, but in this study we identified their direct impacts on muscle progenitor cell behaviors,” said co-second author Stephanie McNamara, a former post-graduate fellow at the Wyss Institute who is now an M.D.-Ph.D. student at Harvard Medical School and the Graduate School of Arts and Sciences. “While the inflammatory response is important for regeneration in the initial stages of healing, it is equally important that inflammation is quickly resolved to enable the regenerative processes to run its full course.”

Seo and her colleagues then turned back to their in vivo model and analyzed the types of muscle fibers in the treated vs. untreated mice 14 days after injury. They found that type IIX fibers were prevalent in healthy muscle and treated muscle, but untreated injured muscle contained smaller numbers of type IIX fibers and increased numbers of type IIA fibers. This difference explained the enlarged fiber size and greater force production of treated muscles, as IIX fibers produce more force than IIA fibers.

Finally, the team homed in on the optimal amount of time for neutrophil presence in injured muscle by depleting neutrophils in the mice on the third day after injury. The treated mice’s muscles showed larger fiber size and greater strength recovery than those in untreated mice, confirming that while neutrophils are necessary in the earliest stages of injury recovery, getting them out of the injury site early leads to improved muscle regeneration.

“These findings are remarkable because they indicate that we can influence the function of the body’s immune system in a drug-free, non-invasive way,” said Walsh, who is also the Paul A. Maeder Professor of Engineering and Applied Science at SEAS and whose group is experienced in developing wearable technology for diagnosing and treating disease. “This provides great motivation for the development of external, mechanical interventions to help accelerate and improve muscle and tissue healing that have the potential to be rapidly translated to the clinic.”

The team is continuing to investigate this line of research with multiple projects in the lab. They plan to validate this mechanotherpeutic approach in larger animals, with the goal of being able to test its efficacy on humans. They also hope to test it on different types of injuries, age-related muscle loss, and muscle performance enhancement.

“The fields of mechanotherapy and immunotherapy rarely interact with each other, but this work is a testament to how crucial it is to consider both physical and biological elements when studying and working to improve human health,” said Mooney, who is the corresponding author of the paper and the Robert P. Pinkas Family Professor of Bioengineering at SEAS.

Additional authors of the paper include Benjamin Freedman, Brian Kwee, Sungmin Nam, Irene de Lázaro, Max Darnell, Jonathan Alvarez, and Maxence Dellacherie from the Wyss Institute and SEAS, and Herman H. Vandenburgh from Brown University.

This research was supported by the National Institute of Dental & Craniofacial Research under Award Number R01DE013349, the Eunice Kennedy Shriver National Institute of Child Health & Human Development under Award Number P2CHD086843, the Materials and Research Science and Engineering Centers grant award DMR-1420570 from the National Science Foundation, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institute of Health (F32 AG057135), and the National Cancer Institute (U01CA214369).

Share this article

You might like.

Physicists demo first metro-area quantum computer network in Boston

Nobel laureate details new book, which surveys research, touches on larger philosophical questions

Researchers publish largest-ever dataset of neural connections

How far has COVID set back students?

An economist, a policy expert, and a teacher explain why learning losses are worse than many parents realize

Excited about new diet drug? This procedure seems better choice.

Study finds minimally invasive treatment more cost-effective over time, brings greater weight loss

Here’s how you know

• U.S. Department of Health and Human Services
• National Institutes of Health

NCCIH Clinical Digest

for health professionals

Massage Therapy for Health: What the Science Says

Clinical Guidelines, Scientific Literature, Info for Patients:  Massage Therapy for Health

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} Low-Back Pain

Several reviews of research have found weak evidence that massage may be helpful for low-back pain. Clinical guidelines issued by the American College of Physicians in 2017 included massage as an option for treating acute/subacute low-back pain but did not include massage therapy among the options for treating chronic low-back pain.

What Does the Research Show?

• The Agency for Healthcare Research and Quality, in a 2016 evaluation of nondrug therapies for low-back pain, examined 20 studies that compared massage to usual care or other interventions and found that there was evidence that massage was helpful for chronic low-back pain but that the strength of evidence was low. The agency also looked at 6 studies that compared different types of massage but found that the evidence was insufficient to show whether any types were more effective than others.
• A 2015 Cochrane review found evidence that massage may provide short-term relief from low-back pain, but the evidence is not of high quality. The long-term effects of massage for low-back pain have not been established.
• Clinical practice guidelines issued by the American College of Physicians in 2017 included massage therapy as an option for treating acute/subacute low-back pain but did not include massage therapy among the options for treating chronic low-back pain.

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} Neck and Shoulder Pain

Massage therapy may provide short-term benefits for neck or shoulder pain.

• A 2016 review of four randomized controlled trials found that massage therapy may provide short-term benefits from neck pain. However, a 2012 Cochrane review of 15 trials on massage therapy for neck pain concluded that no recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.
• A 2013 review of 12 studies of massage for neck pain (757 total participants) found that massage therapy was more helpful for both neck and shoulder pain than inactive therapies but was not more effective than other active therapies. For shoulder pain, massage therapy had short-term benefits only.
• A 2014 randomized controlled trial involving 228 participants with chronic nonspecific neck pain found that 60-minute massages given multiple times per week was more effective than fewer or shorter sessions. The participants were randomized to 5 groups receiving various doses of massage (a 4-week course consisting of 30-minute visits 2 or 3 times weekly or 60-minute visits 1, 2, or 3 times weekly) or to a single control group (a 4-week period on a wait list).

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} Osteoarthritis

Only a few studies have examined massage therapy for osteoarthritis, but results of some of these studies suggest that massage may have short-term benefits in relieving knee pain.

• A 2017 systematic review of seven randomized controlled trials involving 352 participants with arthritis found low- to moderate-quality evidence that massage therapy is superior to nonactive therapies in reducing pain and improving functional outcomes. A 2013 review of two randomized controlled trials found positive short-term (less than 6 months) effects in the form of reduced pain and improved self-reported physical functioning. Results of a 2006 randomized controlled trial of 68 adults with OA of the knee who received standard Swedish massage over 8 weeks demonstrated statistically significant improvements in pain and physical function.

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} Headache

Only a small number of studies have looked at massage for headache, and results have not been consistent.

• Limited evidence from two small studies suggests massage therapy is possibly helpful for migraines, but clear conclusions cannot be drawn. A 2011 systematic review of these two studies concluded that massage therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine.
• A 2016 randomized controlled trial with 64 participants evaluated 2 types of massage (lymphatic drainage and traditional massage), once a week for 8 weeks, in patients with migraine. The frequency of migraines decreased in both groups, compared with people on a waiting list.
• In a 2015 randomized controlled trial , 56 people with tension headaches were assigned to receive massage at myofascial trigger points or an inactive treatment (detuned ultrasound) twice a week for 6 weeks or to be on a waiting list. People who received either massage or the inactive treatment had a decrease in the frequency of headaches, but there was no difference between the two groups.

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} Cancer Symptoms and Treatment Side Effects

With appropriate precautions, massage therapy can be part of supportive care for cancer patients who would like to try it; however, the evidence that it can relieve pain and anxiety is not strong. 2014 clinical practice guidelines for the care of breast cancer patients include massage as one of several approaches that may be helpful for stress reduction, anxiety, depression, fatigue, and quality of life.

• Clinical practice guidelines issued in 2009 by the Society for Integrative Oncology recommends considering massage therapy delivered by an oncology-trained massage therapist as part of a multimodality treatment approach in patients experiencing anxiety or pain.
• In 2017 the Society for Integrative Oncology issued guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment, recommending the use of massage therapy to improve mood disturbance in breast cancer survivors after active treatment (grade B). This recommendation is based on results from six trials.
• In clinical practice guidelines issued by the American College of Chest Physicians in 2013, massage therapy is suggested as part of a multi-modality cancer supportive care program for lung cancer patients whose anxiety or pain is not adequately controlled by usual care.
• A 2016 Cochrane review of 19 small studies involving 1,274 participants found some studies suggesting that massage with or without aromatherapy may help relieve pain and anxiety in people with cancer; however, the quality of the evidence was very low and results were not consistent.
• Another 2016 systematic review and meta-analysis of 16 studies concluded that based on the available evidence, weak recommendations are suggested for massage therapy, compared to an active comparator, for the treatment of pain, fatigue, and anxiety.

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} Fibromyalgia

Results of research suggest that massage therapy may be helpful for some fibromyalgia symptoms.

• A 2014 systematic review and meta-analysis of 9 studies (404 total participants) concluded that massage therapy, if continued for at least 5 weeks, improved pain, anxiety, and depression in people with fibromyalgia but did not have an effect on sleep disturbance.
• A 2015 systematic review and meta-analysis of 10 studies (478 total participants) compared the effects of different kinds of massage therapy and found that most styles of massage had beneficial effects on the quality of life in fibromyalgia. Swedish massage may be an exception; 2 studies of this type of massage (56 total participants) did not show benefits.

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} HIV/AIDS

There is some evidence that massage therapy may have benefits for anxiety, depression, and quality of life in people with HIV/AIDS, but the amount of research and number of people studied are small.

• A 2010 review of four studies involving a total of 178 participants concluded that massage therapy may help improve the quality of life for people with HIV or AIDS. A 2013 randomized controlled trial of 54 people suggested that massage may be helpful for depression in people with HIV; and a 2017 study of 29 people with HIV found that massage may be helpful for anxiety.

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} Infant Care

There is some evidence that premature infants who are massaged may have improved weight gain. No benefits of massage for healthy full-term infants have been clearly demonstrated.

• In a 2017 review of 34 randomized controlled trials of massage therapy for premature infants, 20 of the studies (1,250 total infants) evaluated the effect of massage on weight gain, with most showing an improvement. The mechanism by which massage therapy might increase weight gain is not well understood. Some studies suggested other possible benefits of massage but because the amount of evidence is small, no conclusions can be reached about effects other than weight gain.
• A 2013 Cochrane review of 34 studies of healthy full-term infants didn’t find clear evidence of beneficial effects of massage in these low-risk infants.

The risk of harmful effects from massage therapy appears to be low. However, there have been rare reports of serious side effects, such as blood clot, nerve injury, or bone fracture. Some of the reported cases have involved vigorous types of massage, such as deep tissue massage, or patients who might be at increased risk of injury.

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} References

• Agency for Healthcare Research and Quality. Noninvasive Treatments for Low Back Pain. AHRQ Publication No. 16-EHC004-EF. February 2016.
• Bennett C, Underdown A, Barlow J. Massage for promoting mental and physical health in typically developing infants under the age of six months . Cochrane Database of Systematic Reviews . 2013;(4):CD005038. Accessed at https://www.cochranelibrary.com on January 21, 2017.
• Boyd C, Crawford C, Paat CF, et al. The impact of message therapy on function in pain populations: a systematic review and meta-analysis of randomized controlled trials: Part II, cancer pain populations . Pain Med . 2016;17(8):1553-1568.
• Chaibi A, Tuchin PJ, Russell MB. Manual therapies for migraine: a systematic review . J Headache Pain . 2011;12(2):127-133.
• Deng GE, Rausch SM, Jones LW, et al. Complementary therapies and integrative medicine in lung cancer: Diagnosis and management of lung cancer , 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest . 2013;143(5 Suppl):e420S-e436S.
• Furlan AD, Giraldo M, Baskwill A, et al. Massage for low-back pain . Cochrane Database of Systematic Reviews . 2015;(9):CD001929. Accessed at www.cochranelibrary.com on January 26, 2017.
• Greenlee H, Balneaves LG, Carlson LE, et al. Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer . Journal of the National Cancer Institute Monographs . 2014;2014(50):346-358.
• Happe S, Peikert A, Siegert R, et al. The efficacy of lymphatic drainage and traditional massage in the prophylaxis of migraine: a randomized, controlled parallel group study. Neurological Sciences . 2016;37(10):1627-1632,
• Hillier SL, Louw Q, Morris L, et al. Massage therapy for people with HIV/AIDS . Cochrane Database of Systematic Reviews . 2010;(1):CD007502. Accessed at www.cochranelibrary.com on August 18, 2017.
• Kong LJ, Zhan HS, Cheng YW, et al. Massage therapy for neck and shoulder pain: a systematic review and meta-analysis . Evidence-Based Complementary and Alternative Medicine . 2013;2013;613279.
• Li Y-h, Wang F-y, Feng C-q et al. Massage therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials . PLoS One . 2014;9(2):e89304.
• Moraska AF, Stenerson L, Butryn N, et al. Myofascial trigger point-focused head and neck massage for recurrent tension-type headache: a randomized, placebo-controlled clinical trial . Clinical Journal of Pain . 2015;31(2):159-168.
• Nahin RL, Boineau R, Khalsa PS, Stussman BJ, Weber WJ. Evidence-based evaluation of complementary health approaches for pain management in the United States . Mayo Clinic Proceedings . September 2016;91(9):1292-1306.
• Nelson NL, Churilla JR. Massage therapy for pain and function in patients with arthritis: a systematic review of randomized controlled trials . Am J Phys Med Rehabil . 2017;96(9):665-672.
• Niemi A-K. Review of randomized controlled trials of massage in preterm infants . Children . 2017;4(4):pii:E21.
• Patel KC, Gross A, Graham N, Goldsmith CH, Ezzo J, Morien A, Peloso PMJ. Massage for mechanical neck disorders. Cochrane Database of Systematic Reviews. 2012;9:CD004871.
• Perlman AI, Ali A, Njike VY, et al. Massage therapy for osteoarthritis of the knee: a randomized dose-finding trial . PLoS One . 2012;7(2):e30248.
• Poland RE, Gertsik L, Favreau JT, et al. Open-label, randomized, parallel-group controlled clinical trial of massage for treatment of depression in HIV-infected subjects . Journal of Alternative and Complementary Medicine . 2013;19(4):334-340.
• Qaseem A, Wilt TJ, McLean RM et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians . Annals of Internal Medicine . 2017;166(7):514-530.
• Shengelia R, Parker SJ, Ballin M, et al. Complementary therapies for osteoarthritis: are they effective? Pain Manag Nurs . 2013;14(4):e274-e288.
• Sherman KJ, Cook AJ, Wellman RD, et al. Five-week outcomes from a dosing trial of therapeutic massage for chronic neck pain . Ann Fam Med . 2014;12(2):112-120.
• Shin ES, Seo KH, Lee SH, et al. Massage with or without aromatherapy for symptom relief in people with cancer . Cochrane Database of Systematic Reviews . 2016;(6):CD009873. Accessed at www.cochranelibrary.com on January 26, 2017.
• Yuan SLK, Matsutani LA, Marques AP. Effectiveness of different styles of massage therapy in fibromyalgia: a systematic review and meta-analysis . Manual Therapy . 2015;20(2):257-264.

NCCIH Clinical Digest is a service of the National Center for Complementary and Integrative Health, NIH, DHHS. NCCIH Clinical Digest, a monthly e-newsletter, offers evidence-based information on complementary health approaches, including scientific literature searches, summaries of NCCIH-funded research, fact sheets for patients, and more.

The National Center for Complementary and Integrative Health is dedicated to exploring complementary health products and practices in the context of rigorous science, training complementary health researchers, and disseminating authoritative information to the public and professionals. For additional information, call NCCIH’s Clearinghouse toll-free at 1-888-644-6226, or visit the NCCIH website at nccih.nih.gov . NCCIH is 1 of 27 institutes and centers at the National Institutes of Health, the Federal focal point for medical research in the United States.

Content is in the public domain and may be reprinted, except if marked as copyrighted (©). Please credit the National Center for Complementary and Integrative Health as the source. All copyrighted material is the property of its respective owners and may not be reprinted without their permission.

Subscriptions

NCCIH Clinical Digest is a monthly e-newsletter that offers evidence-based information on complementary and integrative health practices.

Clinical Digest Archive

• Alzheimer's & Dementia
• Asthma & Allergies
• Atopic Dermatitis
• Breast Cancer
• Cardiovascular Health
• Environment & Sustainability
• Exercise & Fitness
• Headache & Migraine
• Health Equity
• HIV & AIDS
• Human Biology
• Men's Health
• Mental Health
• Multiple Sclerosis (MS)
• Parkinson's Disease
• Psoriatic Arthritis
• Sexual Health
• Ulcerative Colitis
• Women's Health
• Nutrition & Fitness
• Vitamins & Supplements
• At-Home Testing
• Men’s Health
• Women’s Health
• Latest News
• Medical Myths
• Honest Nutrition
• Through My Eyes
• New Normal Health
• 2023 in medicine
• Why exercise is key to living a long and healthy life
• What do we know about the gut microbiome in IBD?
• My podcast changed me
• Can 'biological race' explain disparities in health?
• Why Parkinson's research is zooming in on the gut
• Health Hubs
• Find a Doctor
• BMI Calculators and Charts
• Blood Pressure Chart: Ranges and Guide
• Breast Cancer: Self-Examination Guide
• Sleep Calculator
• RA Myths vs Facts
• Type 2 Diabetes: Managing Blood Sugar
• Ankylosing Spondylitis Pain: Fact or Fiction
• Our Editorial Process
• Content Integrity
• Conscious Language
• Health Conditions
• Health Products

What to know about deep tissue massage

A deep tissue massage targets deep layers of muscle and the surrounding tissues. People may choose this type of massage to treat sports injuries or chronic pain.

In this article, we look at the benefits of deep tissue massage, as well as potential risks and side effects. We also discuss what to expect during a massage and how to find a massage therapist.

What is a deep tissue massage?

According to a 2018 review , deep tissue massage works to lengthen and relax deep tissue. This type of massage may help manage pain and increase a person’s range of motion.

Deep tissue massage may be a suitable option to treat sports injuries or chronic back pain. The technique is sometimes considered one type of therapeutic massage.

Deep tissue massage can provide many benefits for various conditions, including injury, chronic pain, and certain diseases.

May help back pain

A 2017 study looked at the effects of deep tissue massage in 31 males with ankylosing spondylitis , a form of arthritis.

The researchers divided the participants into two groups to receive either deep tissue massage or therapeutic massage without deep tissue massage techniques.

All participants had 10 massage sessions across 2 weeks, each session lasting for 30 minutes.

The study found that deep tissue massage significantly reduced pain compared to therapeutic massage.

May reduce high blood pressure

Research shows that sports massage may reduce heart rate and high blood pressure . However, there are limited studies that look at the effects of deep tissue massage on this condition.

Aids recovery after injury

Research suggests both deep and soft tissue release may aid recovery after an injury, such as an ankle injury.

Massage can help:

• relieve pain and stiffness
• improve circulation to reduce swelling or buildup of fluid around the injury
• speed up healing of muscle strains and sprains
• restore range of motion

A 2016 case study suggests deep tissue massage helped reduce lower back pain in a 28-year-old pregnant person.

After 12 sessions of deep tissue massage lasting 30 minutes each, twice a week, the participant reported a reduction in lower back pain. Massage increases serotonin , which can relieve pain in the legs and back.

Massage therapy websites also suggest deep tissue massage can support better sleep, improve sports performance, and break up scar tissue.

Therapeutic massage, including deep tissue massage, may also help with :

• Mental health: Massage may help reduce symptoms of stress , anxiety , and depression . It can also offer relaxation and improve coping mechanisms.
• Chronic lung disease: Massage may help improve respiratory function.
• Digestion: In addition to other therapies, massage may help with chronic constipation .
• Pain relief: Massage may help manage pain in conditions such as fibromyalgia , arthritis , and sciatica . It may also help treat headaches and control pain during childbirth.

Side effects

People may experience discomfort during a deep tissue massage, particularly if a therapist targets problem areas. They can let their massage therapist know if a massage becomes too painful.

Although massage has a low risk of harm, deep tissue massage may not be suitable for everyone. People may want to first check with their doctor if they have any of the following:

• a blood clotting disorder
• increased risk of injury, such as bone fractures
• nerve injury
• any recent surgery or chemotherapy
• wounds or skin conditions

How it is different

Deep tissue massage targets deep areas of muscle, while other massage techniques may focus on superficial body regions.

Certain types of massage are best suited to treat certain conditions as an additional treatment method.

Examples of massage techniques include :

• Swedish massage: Suitable for general relaxation and tension release. Uses a kneading approach to increase circulation and stimulate nerve endings in superficial layers of muscle.
• Reflexology: Targets pressure points to release areas of pain or tension.
• Neuromuscular massage: For treating chronic pain and injury, and improving posture and muscular imbalances.
• Craniosacral therapy: A light massage to deeply relax the body and promote natural healing and alignment.
• Lymph drainage therapy : A therapist applies light pressure to increase lymph fluid movement and support the immune system. People may use this massage as an additional treatment for autoimmune disorders, cancer, and surgery.
• Reiki: Light pressure to aid healing , reduce pain, and ease symptoms.
• Hot stone massage: A therapist places heated stones on the body to relieve stress and tension, which deeply relaxes the body.

What to expect

A therapist may ask people to lie on their side or their front on a massage table, depending on the massage area.

The therapist may first warm up the muscles with light pressure, before massaging the targeted area with slow strokes and applying deep pressure with the hands, arms, or elbows. This works to release contracted muscles and tissues.

People may require repeat treatments to see improvements in areas of deep muscle tension or injury.

They may also need other techniques alongside massage therapy, such as physical therapy and exercise.

Finding a massage therapist

To find a suitable massage therapist, people may want to consider the following:

• asking a healthcare provider for a recommendation or referral
• searching a recognized database, such as the American Massage Therapy Association
• researching a massage therapist’s experience, training, and qualifications
• checking that a massage therapist is willing to work alongside other healthcare professionals, especially when a person is undergoing treatment for a health condition
• making sure a massage therapist understands any health conditions or concerns people may have, and checking their experience of treating those specific needs
• checking to see if health insurance covers the type of massage treatment and if restrictions apply

A person might also want to ensure good communication between themselves, their massage therapist, and their healthcare team to make sure all treatments align.

Deep tissue massage can be an effective treatment method for various conditions, including sports injuries and back pain.

Therapeutic massage may also relieve stress and help with health conditions such as fibromyalgia and high blood pressure.

Deep tissue massage works to relax the body and relieve tension. However, it may initially be uncomfortable due to the pressure on the deep muscle areas.

A person can check with a healthcare provider to ensure it is safe for them to receive a deep tissue massage.

Last medically reviewed on November 24, 2020

• Pregnancy / Obstetrics
• Rehabilitation / Physical Therapy
• Sports Medicine / Fitness
• Complementary Medicine / Alternative Medicine

How we reviewed this article:

• 6 things to know when selecting a complementary health practitioner. (n.d.). https://www.nccih.nih.gov/health/tips/things-to-know-when-selecting-a-complementary-health-practitioner
• Find a massage therapist. (n.d.). https://www.amtamassage.org/find-massage-therapist/
• Koren, Y., et al. (2018). Deep tissue massage: What are we talking about [Abstract]? https://pubmed.ncbi.nlm.nih.gov/29861215/
• Kushartanti, B. M. W., et al . (2020). Deep tissue massage and soft tissue release in the management of chronic ankle injury. http://www.sportmont.ucg.ac.me/clanci/SM_February_2020_Kushartanti_53-56.pdf
• Majchrzycki, M., et al . (2014). Deep tissue massage and nonsteroidal anti-inflammatory drugs for low back pain: A prospective randomized trial. https://www.hindawi.com/journals/tswj/2014/287597/
• Massage therapy: What you need to know. (2019). https://www.nccih.nih.gov/health/massage-therapy-what-you-need-to-know
• Pystupa, T. D. (2013). Effect of partial sports massage on blood pressure and heart rate. https://www.sportedu.org.ua/index.php/PES/article/view/237
• Romanowski, M. W., et al . (2017). Comparison of deep tissue massage and therapeutic massage for lower back pain, disease activity, and functional capacity of ankylosing spondylitis patients: A randomized clinical pilot study. https://www.hindawi.com/journals/ecam/2017/9894128/
• Therapeutic massage. (n.d.). https://www.hopkinsmedicine.org/integrative_medicine_digestive_center/services/therapeutic_massage.html
• What is deep tissue massage? (n.d.). https://fremont.edu/deep-tissue-massage/

Share this article

Latest news

• Can sleep really clear toxins from the brain? New study offers clues
• Regularly adding table salt to food linked to 41% higher risk of gastric cancer
• Vegan and vegetarian diets provide a vast array of health benefits, study says
• How semaglutide drugs such as Ozempic can help with long-term weight loss and heart health
• Is a flu vaccine with long-term effectiveness on the horizon?

Related Coverage

There are several types of massage, such as hot stone, deep tissue, and sports massages. Benefits include relief from muscle aches and relaxation…

Swedish massage and deep tissue massage are two popular forms of massage therapy. Read on to learn about their differences and intended uses.

Thai massage is an ancient practice wherein a practitioner will bend a person's body into different poses. Learn about the benefits and possible side…

When a massage is not possible, an acupressure mat can deliver similar results. Research suggests that it can ease pain and reduce nausea. Learn more…

Muscle dysmorphia can cause a preoccupation with building muscle and the belief that a person's muscles are smaller than they are. Learn more in this…

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest Content
• For authors
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Volume 6, Issue 1
• Effect of sports massage on performance and recovery: a systematic review and meta-analysis
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

This article has a correction. Please see:

• Correction: Effect of sports massage on performance and recovery: a systematic review and meta-analysis - April 01, 2021

• Holly Louisa Davis ,
• Samer Alabed ,
• http://orcid.org/0000-0002-7458-5481 Timothy James Ainsley Chico
• Infection, Immunity and Cardiovascular Disease , University of Sheffield , Sheffield , South Yorkshire , UK
• Correspondence to Dr Timothy James Ainsley Chico, Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, South Yorkshire, UK; t.j.chico{at}sheffield.ac.uk

Objective Massage is ubiquitous in elite sport and increasingly common at amateur level but the evidence base for this intervention has not been reviewed systematically. We therefore performed a systematic review and meta-analysis examining the effect of massage on measures of sporting performance and recovery.

Design and eligibility We searched PubMed, MEDLINE and Cochrane to identify randomised studies that tested the effect of manual massage on measures of sporting performance and/or recovery. We performed separate meta-analyses on the endpoints of; strength, jump, sprint, endurance, flexibility, fatigue and delayed onset muscle soreness (DOMS).

Results We identified 29 eligible studies recruiting 1012 participants, representing the largest examination of the effects of massage. We found no evidence that massage improves measures of strength, jump, sprint, endurance or fatigue, but massage was associated with small but statistically significant improvements in flexibility and DOMS.

Conclusion Although our study finds no evidence that sports massage improves performance directly, it may somewhat improve flexibility and DOMS. Our findings help guide the coach and athlete about the benefits of massage and inform decisions about incorporating this into training and competition.

• physiotherapy
• performance

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjsem-2019-000614

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Summary box

What is already known.

A previous smaller meta-analysis found that massage gave small and inconsistent improvements in performance recovery.

A previous smaller meta-analysis found that massage gave no significant improvement in pain or delayed onset muscle soreness (DOMS).

Previous studies have shown inconsistent effects of massage on flexibility.

What are the new findings

Our larger meta-analysis finds that massage induces no significant improvement in measures of performance (sprint, jump, strength, endurance or flexibility, or in fatigue)

Our larger meta-analysis finds that massage provides a small benefit in reducing or preventing DOMS.

Our meta-analysis shows massage induces a small but significant improvement in flexibility compared with no intervention.

Introduction

Sports massage is ubiquitous in elite sport and increasingly common at age-group and amateur level, generating a multi-million pound industry of professional therapists and massage devices. The proposed benefits of sports massage include improved recovery, performance and injury prevention 1 2 but massage is both expensive and time-consuming. Therefore, there is an important need to delineate the evidence base supporting such an intervention.

A previous meta-analysis of 22 randomised studies found a small and inconsistent benefit of massage on performance recovery after exercise. 1 This included studies using non-manual techniques such as vibration or water-jet massage that are not commonly available, and outcomes such as flexibility or delayed onset muscle soreness (DOMS) were not examined. Another meta-analysis examined the effect of several interventions including massage on DOMS but included only four studies of the effect of massage at various time points, finding no significant improvement of DOMS by massage. 3 We therefore performed a comprehensive systematic review and meta-analysis aiming to examine the benefits of manual sports massage on a range of outcomes including performance, strength or recovery to better inform the athlete and coach about whether massage justifies inclusion in training or competition.

No universally accepted definition of sports massage exists. For the purpose of this meta-analysis we defined sports massage as manual manipulation of muscles and soft tissue by a qualified professional, with the purpose of improving performance in or recovery from sport.

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed in preparing, conducting and reporting this systematic review. 3

Eligibility criteria

We searched PubMed and Cochrane for publications retrieved by searching in any field for: ‘sports massage’ (OR) ‘sports therapy’ (AND) ‘athlete’. We then refined these to those including any of the following terms: ‘strength’, ‘sprint’, ‘flexibility’, ‘jump’, ‘endurance’, ‘range of motion’, ‘DOMS’, ‘delayed onset muscle soreness’, ‘perceived recovery’, ‘psychological’, ‘fatigue’, ‘performance’, ‘recovery’. To be eligible, studies must have evaluated the effect of manual massage on human participants in a randomised study and include assessment of sporting performance or recovery. Non-randomised studies, or those using non-manual massage (eg, waterjet, foam rollers, automated massage) were excluded.

We performed separate meta-analyses examining the effect of massage on measures of sporting performance (strength, jump, sprint, endurance and flexibility) and recovery (fatigue and DOMS). Where studies analysed the effect of massage at more than one time point, we analysed the time point soonest after massage. This was to avoid bias by including the same participants multiple times in the same category (pseudoreplication) which was a potential limitation of the previous largest meta-analysis. 1 Where studies included more than two groups (for example comparing massage, control and a different type of intervention) we analysed only the data for massage and control groups.

Data collection and analysis

Data was collected and analysed by HD, SA and TC using RevMan 5.3 software. Standardised mean difference (SMD) was calculated using RevMan 5.3 software and used in the meta-analysis. Standardised mean difference (difference in mean outcome between groups/SD of outcome) is a summary statistic to assess the same outcome that has been measured in a variety of ways. This allows expression of the size of the intervention effect per study relative to the variability observed in that study, and thus allows comparison of effect sizes between studies using different outcome measures. Study heterogeneity was assessed by calculating the I 2 value. I 2 values of 25%, 50% and 75% can be considered to reflect small, moderate and large degrees of heterogeneity. A p value <0.05 was considered statistically significant.

Patients and public were not involved in the design or conduct of this study.

Description of included massage techniques

A range of massage techniques were applied in the identified studies. Where available we indicate which techniques were used in the study descriptions. ‘Effleurage’ consists of strokes delivered with the palm in the direction of lymphatic drainage and venous flow. 2 4 ‘Petrissage’ involves lifting tissue away from underlying structures, intending to improve circulation, loosen adhesions between tissues and improve drainage of lymphatics. 2 4 In ‘pincement’ the palms are placed vertically above the part to be massaged, lightly picking up the tissue with thumb and fingers. 5 6 In ‘wringing' superficial tissues are grasped in both hands and twisted in opposite directions. 6 ‘Tapotement’ involves repeated light strikes to the muscle. 2 4 ‘Vibrations’ and ‘shaking’ are delivered by trembling both hands in contact with the skin. 6 ‘Friction massage’ is a brisk, deep stroke transversely or parallel to fibre direction. 2 4 ‘Compressions’ have the same intent, but use the palm to press down on the muscle. 4

We identified 29 studies meeting our eligibility criteria; 12 randomised controlled trials (RCTs) and 17 randomised crossover studies ( figure 1 ). A total of 1012 participants were included, substantially exceeding the 270 participants in the largest previous meta-analysis. 1 Many studies assessed multiple outcomes. We analysed these in separate meta-analysis of; strength, jump, sprint, endurance, fatigue, flexibility and DOMS. Due to the variability in study design and massage interventions, we briefly describe each study to allow assessment of the potential explanations for the effects observed. Studies are described in order of negative to positive effects on outcomes.

• Download figure
• Open in new tab
• Download powerpoint

A flowchart demonstrating the search strategy used to identify eligible studies for the meta-analyses.

The effect of sports massage on strength performance

Twelve studies examined whether sports massage influences recovery of strength after exercise.

Arroyo-Morales et al randomised 60 participants to 20 min pre-event massage, consisting of effleurage, petrissage and tapotement, or placebo (detuned ultrasound). 7 This found a significant decrease in peak isokinetic torque of the quadriceps after massage but not placebo, suggesting massage could negatively affect strength.

The same group conducted a further study evaluating the effect of 40 min massage on strength after high intensity exercise in 62 students. 8 A placebo (sham ultrasound) was used and participants fatigued by 3×30 s Wingate tests. This study found massage reduced electromyography (EMG) amplitude and vigour (EMG amplitude was used as an indicator of muscle force) compared with passive recovery after the Wingate tests. 9

Jönhagen et al examined the effect of massage on recovery of quadriceps strength and function after 300 maximal strength contractions in 16 participants. 10 Twelve min of massage, including effleurage and petrissage, was administered immediately after exercise, then daily for 3 days to one leg with the other used as control. Massage had no significant effect on subsequent maximal strength.

Hemmings et al tested the effect of massage on boxing strength in eight amateur boxers using a counter-balanced design with participants undergoing passive rest or 20 min, including effleurage and petrissage between repeated performances. 11 This found no difference in strength between groups.

Dawson et al examined the effect of repeated massage on strength recovery after a half marathon in 10 recreational runners. 12 They received 30 min massage including effleurage, petrissage and passive stretching, 1, 4, 8 and 11 days post-race on a single leg with the other leg used as a control. Massage had no effect on rate of return to baseline strength.

Hunter et al examined the effect of massage including effleurage and petrissage on maximal voluntary contractions using electromyography in a crossover study with 10 participants. Massage induced no significant difference in maximal voluntary contractions compared with passive rest. 13

Dawson et al also examined the effect of regular massage over a longer period on novice recreational runners. 14 Participants took part in a 10-week running preparation clinic and received massage (‘individualised to each participant’) or no massage for 30 min weekly for 10 weeks. There were no significant differences between groups in indices of strength.

Zainuddin et al examined the effects of 10 min massage including effleurage, petrissage and friction after eccentric elbow flexor exercise in a crossover study using 10 participants 15 and found no significant improvement in muscle strength after massage.

Hilbert et al investigated the effects of 20 min of massage (including effleurage, petrissage and tapotement) on muscle strength of 18 participants in a crossover trial where the control condition was sham massage. Hamstring peak torque, muscle soreness and range of motion (ROM) were measured after eccentric muscle contractions. This study found no improvement in muscle strength with massage. 16

In contrast to the above studies reporting negative or neutral effects of massage on strength, others have found massage may improve strength recovery. Sykaras et al examined the effect of brief (2 min) massage (effleurage, petrissage, friction, tapotement, pincement and wringing) on 12 female Tae Kwon Do athletes’ knee extensor peak torque after concentric/eccentric contractions. 5 One leg was massaged, and the non-massaged leg used as control. Massaged limbs performed significantly better after exhaustive exercise.

Brooks et al studied the immediate effects of 5 min manual forearm massage on power grip performance after 3 min of maximal exercise. 17 Fifty-two participants were randomised to 5 min massage (including effleurage and friction massage), passive rest or passive shoulder movement. Massage was associated with a significantly greater strength recovery.

Farr et al investigated the effects of massage including effleurage and petrissage on muscle strength after 40 min of downhill walking on a treadmill in eight male participants. Isometric and isokinetic strength and single leg vertical jump were measured. This study found that 30 min of massage after 40 min downhill walking was associated with a significant benefit in strength recovery. 18

Meta-analysis of these studies found that massage had no overall effect on strength with low study heterogeneity (SMD 0.17, 95% CI −0.08 to 0.42; participants=346; studies=12, I 2 =23% ( figure 2A ).

Forest plot demonstrating the results of the meta-analysis of the effects of manual massage (with 95% CIs) on (A) strength performance (overall effect: p=0.17) and (B) jump performance (overall effect: p=0.39). Std., standardised.

The effect of sports massage on jump performance

Five studies examined whether sports massage affects jump performance. Jönhagen et al examined the effect of massage on recovery of jumping performance after 300 maximal strength contractions in 16 participants. 10 Twelve min massage was administered immediately after exercise then daily for 3 days to a single leg with the other used as control. Massage had no significant effect on one-legged jump performance.

Delextrat et al recruited eight male and eight female basketball players to a crossover trial testing the effect of 30 min of massage including effleurage and petrissage, water immersion or passive rest on outcomes including jump performance after a match. 19 This found post-match massage had no effect.

Mancinelli et al recruited 22 female volleyball and basketball players. After baseline measurements of vertical jump height, timed shuttle run, quadriceps femoris length and pressure pain threshold were obtained, participants were fatigued by pre-season training for 2 days before being given 17 min effleurage, petrissage and vibration on each quadriceps, or passive rest, and repeating the tests. Massage did not significantly affect vertical jump height. 20

Farr et al found no significant difference in standing vertical jump performance after massage compared with passive rest in the study described above. 18

One study did find favourable effects of massage on jump performance. Kargarfard et al randomised 30 male body builders to 30 min massage (including effleurage, petrissage and vibration) of the exercised muscle group or passive rest after a fatigue-inducing protocol 21 and then assessed vertical jump performance of 30 male body builders. The control group showed worsening vertical jump performance at 48 and 72 hours, whereas the massage group performance returned to baseline by 48 hours.

Meta-analysis of these studies found that massage had no overall effect on jump performance with very low heterogeneity (SMD 0.16, 95% CI −0.20 to 0.51; participants=132; studies=5; I 2 =5%) ( figure 2B ).

The effect of sports massage on sprint performance

Seven studies examined the effect of sports massage on sprinting. Fletcher et al examined the effect of effleurage and petrissage as ‘warm up’ before a 20 m sprint test. 22 This found 9 min massage alone was associated with the slowest sprint times, and there was no significant difference compared with control when massage was combined with a ‘traditional warm up’ (4×30 s laps of a sports hall plus 1×10 s passive stretching).

Goodwin et al studied the effect of massage on 30 m sprint performance in a counterbalanced crossover design. 23 The conditions included 15 min of lower limb massage including effleurage, petrissage and tapotement, 15 min of placebo ultrasound and passive rest. There were no significant differences between any groups on any measure of sprinting.

Delextrat et al also found no difference between passive rest and massage in sprint times after competitive basketball. 19

Mancinelli et al found no significant difference on post intervention sprint times after massage in basketball and volleyball players. 20

Robertson et al also investigated the effects of massage or passive rest on cycling sprint performance recovery. 24 Nine males were fatigued by 6×30 s high intensity efforts with 30 s active recovery. Subjects received either 20 min massage (including effleurage, petrissage, wringing, picking up) or supine passive rest before a 30 s Wingate test. Massage had no effect on maximum or mean power in this test.

Ogai et al performed a crossover study 25 of 11 females who performed high intensity cycle sprints (5 s repeated eight times with recovery intervals of 20 s). This was repeated after 35 min of either passive rest or 10 min massage (petrissage and compressions). In this study sprint performance recovered significantly better in the massage group. 25

Meta-analysis found that massage had no overall effect on sprint performance, with high study heterogeneity (SMD −0.35, 95% CI −0.98 to 0.28; participants=257; studies=7; I 2 =82%) ( figure 3A ).

Forest plot demonstrating the results of the meta-analysis of the effects of manual massage (with 95% CIs) on (A) sprint performance (overall effect: p=0.27), (B) endurance performance (overall effect=p=0.91) and (C) fatigue (overall effect: p=0.22). Std., standardised.

The effect of sports massage on endurance performance

We identified three studies examining the effects of massage on endurance.

Lane and Wenger examined the effects of active recovery, massage, cold water immersion or passive rest on repeated cycling performance 24 hours apart. 26 The cycling test lasted 18 min with high intensity intervals, thus using both anaerobic and aerobic systems. Massage included effleurage, petrissage and tapotement. Only the passive rest group showed a significant decline in the second performance, but there was no significant difference between groups.

Monedero and Donne studied the effect of massage on endurance performance with pre-intervention and post-intervention 5 km bike trials. Eighteen male cyclists were randomised to either active recovery (gentle cycling), massage (effleurage and tapotement), passive recovery (lying down) or a combination of active recovery and massage in a crossover study. 27 Active recovery improved post-intervention time trial times more than massage or passive recovery.

Rinder and Sutherland recruited 13 males and 7 females in a randomised crossover study who were fatigued using an ergometer, ski squats and leg extensions followed by 6 min effleurage and petrissage or passive rest. 28 Participants then performed their maximum number of leg extensions against half maximum load. The massage group performed significantly more leg extensions post intervention compared with the control group.

Meta-analysis of these studies found that massage had no overall effect on endurance with very high study heterogeneity (SMD 0.21, 95% CI −3.45 to 3.87; participants=96; studies=3; I 2 =97%) ( figure 3B )

The effect of sports massage on muscle fatigue

Muscle fatigue is defined as loss of muscle power due to a decline in force and velocity which is both measurable and reversible by rest, which distinguishes muscle fatigue from muscle weakness or damage. 29 30 Perceived muscle fatigue is a subjective assessment.

Hemmings et al (discussed above) examined the effect of massage on performance on amateur boxers and found that this significantly increased perceived fatigue compared with control. 11

Nunes et al conducted a double-blind RCT testing whether massage reduces pain and perceived fatigue in the quadriceps of 74 athletes after an Ironman Triathlon. 31 Massage techniques used were effleurage, petrissage and tapotement. The massage group had significantly lower subjective pain and fatigue ratings, but there was no difference between the groups for pressure pain threshold.

Conversely, Mancinelli et al found that although massage had no effect on performance (described above) it reduced perceived muscle fatigue 20 as did Ogai et al . 25

Hoffman et al examined the effect of massage and pneumatic compression for perceived fatigue and pain after an ultramarathon. 32 Seventy-two finishers of the 161 km Western States Endurance Run were randomised into three groups: control, massage (effleurage, compressions and tapotement) and pneumatic compression. Those receiving massage had significantly reduced perceived fatigue ratings compared with control.

Meta-analysis found no significant effect of massage on fatigue with high study heterogeneity (SMD 0.47, 95% CI −0.28 to 1.22; participants=171; studies=5; I 2 =86%) ( figure 3C ).

The effect of sports massage on flexibility

Flexibility is defined as the range of motion available to a joint or joint series. 33 Some sports benefit from extreme ROM, such as ballet and gymnastics, while it is suggested that for sports such as running, too much flexibility can be detrimental and increase injury risk. 33 34 Seven studies examined the effect of massage on flexibility.

Barlow et al investigated the effect of a single hamstring massage on a ‘sit and reach’ test. In a crossover design, 11 males received 15 min effleurage and petrissage or control (supine rest) with a pre-intervention and post-intervention sit and reach test. There was no significant difference between the massage and control groups. 35 Similarly, Zainuddin et al (discussed above) found no significant effect of massage on range of motion of the elbow joint. 15

Huang et al studied the effect of massage on ROM of the hamstring musculotendinous junction. 36 Ten active females were randomised to 30 s massage, 10 s friction massage or passive rest. There were significant increases in hip flexion ROM with 30 s of massage at the musculotendinous junction of the distal portion of the hamstrings, but no difference in passive leg tension or EMG findings.

Hopper et al evaluate the effects of two different massage techniques on hamstring length in 39 female hockey players. 37 These were classic massage (effleurage, petrissage, shaking and picking up) and dynamic soft tissue mobilisation (DSTM) (dynamic movement contraction of target muscles with focussed deep strokes on areas of tension). There were significant increases in hamstring length in both massage groups compared with passive rest, but no differences between the different massage types. In a further study, Hopper et al also evaluated the effect of DSTM and classic massage on 45 male hockey players. 38 Hamstring length was significantly greater after DSTM compared with classic massage (including effleurage, petrissage, shaking and picking up), and hamstring lengths after either massage type were greater than after passive rest. It is noteworthy that DSTM differs from classic massage as it involves mobilisation of the joints and is therefore also a form of flexibility intervention. 38

McKechnie et al examined whether 3 min of petrissage and tapotement would influence plantar flexor flexibility and power of the lower leg in 19 participants. 39 Ankle joint flexibility was significantly increased with both massage techniques, but there was no difference between the two techniques.

Crosman et al studied the effects of hamstring massage or passive rest on ROM in 34 females. 40 Massage (including effleurage, petrissage and friction massage) significantly increased all ROM tests immediately after massage, but this was not maintained, suggesting an immediate but not long-term effect of massage on flexibility.

Meta-analysis of these studies found that massage significantly increased flexibility scores by 7%, with very high heterogeneity (p=0.01, SMD 1.07, 95% CI 0.21 to 1.93; participants=246; studies=7; I 2 =90%) ( figure 4A ).

Forest plot demonstrating the results of the meta-analysis of the effects of manual massage on (A) flexibility (overall effect: p<0.01) and (B) delayed onset muscle soreness (DOMS) (overall effect: p<0.05).

The effect of sports massage on delayed onset muscle soreness

DOMS is separate from though often co-exists with perceived muscle fatigue. DOMS is muscular discomfort following exercise experienced by athletes of all levels. 41 The intensity of discomfort increases within 24 to 72 hours post exercise, subsiding after 5 to 7 days. 42 43 A hypothesised benefit of sports massage is that it helps recovery from both fatigue and DOMS. 2 Ernst conducted a systematic review looking at the effect of post-exercise massage treatment on the effect of DOMS. 44 They included seven studies and concluded that most of these were burdened with methodological flaws, and results were inconsistent. However, most suggested that post-exercise massage may help alleviate DOMS symptoms. In our review, we included 10 studies examining the effect of massage on DOMS. All studies relied on subjective rating scales to assess DOMS.

Dawson et al studied the potential for repeated massage to influence muscle recovery following an endurance race in a field setting. 12 Ten recreational runners who completed a half marathon received 30 min massage days 1, 4, 8 and 11 post-race on one leg, while the other was used as control. Muscle strength, pain and leg swelling were assessed after each massage. Massage had no effect on rate of return to baseline levels of DOMS and swelling. Another study by the same group also found no difference in DOMS between runners who received regular massage compared to those that did not. 14 Zainuddin et al similarly found massage did not alleviate DOMS or muscle swelling. 15

Hilbert et al investigated the physiological and psychological effects of 20 min of massage on DOMS after eccentric contractions of the hamstring compared with a sham massage. 16 They found that massage did not decrease DOMS compared with placebo.

Conversely, other studies have suggested that massage may reduce DOMS. Kargarfard et al found massage had no effect on performance (described in previous section), but did significantly decrease perceived muscle soreness 24, 48 and 72 hours post exercise. 21

Hoffman et al (discussed above) examined the effect of massage and pneumatic compression for DOMS after an ultramarathon. 32 They found that both massage and pneumatic compression provided immediate pain relief compared with control.

Similarly, Delextrat et al investigated the effect of 30 min of massage, water immersion and passive rest on DOMS after a competitive basketball match. 19 Both massage and cold-water immersion improved perception of recovery and reduced DOMS, especially in females. Mancinelli et al also found massage induced significant reduction of muscle soreness in female collegiate basketball and volleyball players, with 80% of those receiving massage reporting decreased soreness. 20

Farr et al (discussed above) found that massage significantly aided alleviation of DOMS significantly. 18 Nunes et al (discussed above) also found that athletes who received massage after the Ironman Triathlon experienced significantly lower DOMS compared with control. 31

Meta-analysis of these studies found massage was associated with a statistically significant 13% improvement in measures of DOMS after exercise, with high study heterogeneity (SMD 1.13, 95% CI 0.44 to 1.82; participants=311; studies=10; I 2 =86%) ( figure 4B ).

Athletes and coaches often believe sports massage improves performance. 1 However, our meta-analysis find no conclusive empirical evidence for benefits on the outcomes of performance examined. Our meta-analysis highlights the difficulty of defining such benefits; most studies recruited small numbers of participants and the effect size of massage (if such exists) may be too small to be easily detected with low numbers, particularly if there is variability in results. The array of different massage protocols we describe makes defining optimum treatment protocols highly complex. We found no evidence of improvement in performance measures (strength, jump, sprint or endurance), even though some studies might have been expected to be affected by placebo effects. There were also two studies that suggested massage may have a detrimental effect on performance. 7 8 Our review therefore finds no evidence to justify inclusion of massage with the expectation of direct improvement of performance in strength, sprint or endurance.

We did find that massage induced a small but statistically significant improvement in flexibility, although the large heterogeneity of these studies findings (I 2 =90%) reflects the fact that this was influenced by a single outlier study, 30 with others showing a consistently smaller benefit. Athletes that require flexibility may therefore benefit from massage based on these findings, although further research into specific sports is required to confirm this. It is worth noting that the studies included compared massage to no intervention, rather than other interventions such as passive stretching, which also have the potential to improve flexibility.

We found that massage statistically significantly reduced pain/DOMS by 13%, although again these studies were highly heterogeneous (I 2 =86%) driven by a single outlier 17 so the true magnitude of any benefit remains uncertain. These findings would imply that sports more likely to induce DOMS have more to gain from inclusion of massage, especially when repeated performance before DOMS has recovered is required, such as multi-day events. This benefit may be more important in sports where analgesic use is restricted. However, given the cost and time implications of massage, head-to-head randomised control comparisons with other preventative and analgesic strategies such as ice baths or compression would be required to understand the magnitude of the benefit over other approaches. It is important to recognise that studies on DOMS use subjective rating assessments that are susceptible to placebo effects.

As well as direct effects on performance and recovery, massage has been suggested to induce physiological effects. 45 46 Cambron et al 47 studied the effect of different forms of massage on blood pressure in non-athletes. Effleurage and petrissage were associated with no significant change in blood pressure, while potentially painful massage techniques, such as trigger-point therapy, were associated with a significant rise in either diastolic or systolic blood pressure. The applicability of these findings to sports performance and recovery is unclear.

Zebrowska et al 48 investigated the effectiveness of different lymphatic drainage methods on the forearms of mixed martial arts athletes after fatiguing exercise. Drainage techniques included manual lymphatic drainage (MLD), electro stimulation and deep oscillation (DO), with a control group being exposed to non-therapeutic light. This found a significant increase in blood velocity associated with both MLD and DO although the effect on performance and recovery was not examined.

Some studies have examined the effect of massage on the autonomic nervous system, though none in a sporting context. Fazeli et al , 49 Guan et al 50 and Lee et al 51 have all suggested that massage may reduce heart rate variability and reduce cortisol levels, potentially demonstrating the wider effects of massage.

The lactic acid theory suggests that lactic acid produced during exercise contributes to pain, although this is disputed, 41 Zebrowska et al 48 found that massage was associated with a significant decrease in blood lactate with MLD. Lactic acid decreased to baseline after 20 min of MLD, whereas it remained elevated in the control group. Further research is required to examine the clinical significance of this effect.

Hemmings et al 11 also measured the effects of massage on blood lactate. As discussed above, massage was associated with better perceived recovery compared with control. However, the massage group had significantly higher blood lactate levels at the time of the second exercise. The authors suggested that increased perceived recovery may have led to a greater effort and thus increased blood lactate. 11 45 Conversely, Robertson et al 24 found no difference in blood lactate between massage and passive rest interventions. Massage did not alter blood lactate levels in Monedero and Donne, 27 Hart et al 52 or Dolgener and Morien. 53 In all these studies, active recovery was superior to massage in decreasing blood lactate levels.

Our study has several limitations, particularly the wide range of different study designs and protocols, and the lack of statistical power for the metrics examined due to the small size of the studies examined. However, our work does represent the largest review of sports massage so far conducted.

Our meta-analysis leaves many unanswered questions. These include uncertainty over the optimum duration of massage and the lack of studies testing the effect of regular repeated massage, which might have more benefit. Given the huge number of potential massage regimens and timing, it is impossible to conclude that massage cannot improve performance if the correct timing and indication could be defined. However, our findings should make athletes and coaches cautious about claims that massage will provide benefits for which there is little or no evidence.

• Poppendieck W ,
• Wegmann M ,
• Ferrauti A , et al
• Gong Y , et al
• Sykaras E ,
• Mylonas A ,
• Malliaropoulos N , et al
• Arroyo-Morales M ,
• Fernández-Lao C ,
• Ariza-García A , et al
• Martínez MM , et al
• Narayan Y ,
• Jönhagen S ,
• Ackermann P ,
• Eriksson T , et al
• Hemmings B ,
• Graydon J , et al
• Dawson LG ,
• Dawson KA ,
• Hunter AM ,
• Watt V , et al
• Thomas A , et al
• Zainuddin Z ,
• Sacco P , et al
• Hilbert JE ,
• Sforzo GA ,
• Brooks CP ,
• Woodruff LD ,
• Wright LL , et al
• Nosaka K , et al
• Delextrat A ,
• Calleja-González J ,
• Hippocrate A , et al
• Mancinelli CA ,
• Aboulhosn L , et al
• Kargarfard M ,
• Shariat A , et al
• Fletcher IM
• Goodwin JE ,
• Glaister M ,
• Howatson G , et al
• Robertson A ,
• Galloway SDR
• Matsumoto T , et al
• Monedero J ,
• Rinder AN ,
• Sutherland CJ
• Noakes TD ,
• St Clair Gibson A ,
• Bender PU ,
• de Menezes FS , et al
• Hoffman MD ,
• Badowski N ,
• Chin J , et al
• Stachenfeld NS ,
• Nicholas JA
• Johnson N , et al
• Di Santo M ,
• Wadden KP , et al
• Conneely M ,
• Chromiak F , et al
• Das S , et al
• McKechnie GJB ,
• Crosman LJ ,
• Chateauvert SR ,
• Byrnes WC ,
• Clarkson PM
• Armstrong RB
• Callaghan MJ
• Cambron JA ,
• Dexheimer J ,
• Zebrowska A ,
• Trybulski R ,
• Roczniok R , et al
• Fazeli MS ,
• Pourrahmat M-M ,
• Liu M , et al
• Collet J-P ,
• Yuskiv N , et al
• Swanik CB ,
• Dolgener F ,

Twitter @timchico

Contributors HD and TC conceived and conducted the study. All authors wrote the manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement Datasets and results of analysis are available upon request.

Read the full text or download the PDF:

Effectiveness of deep tissue massage therapy, and supervised strengthening and stretching exercises for subacute or persistent disabling neck pain. The Stockholm Neck (STONE) randomized controlled trial

Affiliations.

• 1 Musculoskeletal and Sports Injury Epidemiology Center, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Naprapathögskolan - Scandinavian College of Naprapathic Manual Medicine, Stockholm, Sweden.
• 2 Musculoskeletal and Sports Injury Epidemiology Center, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden. Electronic address: [email protected].
• 3 Faculty of Health Sciences and UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology, Toronto, Canada.
• 4 Unit of Intervention and Implementation Research for Worker Health, Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
• 5 Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
• 6 Musculoskeletal and Sports Injury Epidemiology Center, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
• PMID: 31655314
• DOI: 10.1016/j.msksp.2019.102070

Objective: To compare the effectiveness of deep tissue massage, supervised strengthening and stretching exercises, and a combined therapy (exercise followed by massage) (index groups), with advice to stay active (control group).

Methods: Randomized controlled trial of 619 adults with subacute or persistent neck pain allocated to massage (n = 145), exercise (n = 160), combined therapy (n = 169) or advice (n = 147). Primary outcomes were minimal clinically important improvements in neck pain intensity and pain-related disability based on adapted questions from the Chronic Pain Questionnaire. Secondary outcomes were perceived recovery and sickness absence. Outcomes were measured at seven, 12, 26 and 52 weeks.

Results: We found improvement in pain intensity favouring massage and combined therapy compared to advice; at seven weeks (RR = 1.36; 95%CI:1.04-1.77) and 26 weeks (RR = 1.23; 95%CI:0.97-1.56); and seven (RR = 1.39; 95%CI:1.08-1.81) and 12 weeks (RR = 1.28; 95%CI:1.02-1.60) respectively, but not at later follow-ups. Exercise showed higher improvement of pain intensity at 26 weeks (RR = 1.31; 95%CI:1.04-1.65). Perceived recovery was higher in the index groups than in the advice group at all follow-ups. We found no consistent differences in pain related disability or sickness absence.

Conclusions: In this study, at 12-months follow-up, none of the index therapies were more effective than advice in terms of pain intensity in the long term or in terms of pain-related disability in the short or long term. However, the index therapies led to higher incidence of improvement in pain intensity in the short term, and higher incidence of favorable perceived recovery in the short and in the long term than advice.

Trial registration: ISRCTN01453590. Registered 3 July 2014.

Keywords: Complementary therapies/methods; Manual therapies; Musculoskeletal manipulations; Neck pain; Patient education; Treatment outcome.

Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.

Publication types

• Comparative Study
• Randomized Controlled Trial
• Aged, 80 and over
• Chronic Pain / therapy*
• Exercise Therapy
• Massage / standards*
• Middle Aged
• Neck Pain / therapy*
• Practice Guidelines as Topic*
• Surveys and Questionnaires
• Treatment Outcome

• Faculty Portal
• Reserve Rooms
• Giving Back
• Digital Marketplace
• Schedule Appointment
• Clinic Locations
• Our Services
• Community Outreach

Deep Tissue Massage

Deep tissue massage targets chronic tension in muscles that lie far below the body’s surface. Deep muscle techniques involve slow strokes, direct pressure or friction movements that go across the muscle grain. When there is chronic muscle tension or injury, there are usually adhesions (bands of painful, rigid tissue) in muscles, tendons, and ligaments. Adhesions can block circulation and cause pain, limited movement, and inflammation. Deep tissue massage works by physically breaking down these adhesions to relieve pain and restore normal movement.

Massage therapists will use their fingers, thumbs or occasionally even elbows to apply the needed pressure. It is especially helpful for chronically tense and contracted areas such as stiff necks, low back tightness, and sore shoulders. Some of the same strokes are used as classic massage but the movement is slower and the pressure is deeper and concentrated on areas of tension and pain.

• Web Resources
• Telemedicine

Research: Massage for Neck Pain

Can massage therapy improve neck pain in the short or long term?

 By Martha Brown Menard, PhD, LMT, November 1, 2021

Neck pain is a leading cause of disability that affects workers all over the world and results in high economic costs to individuals, businesses and governments due to absenteeism and productivity losses. Psychosocial factors play a role in its development and resolution, making the clinical management of neck pain challenging.

While earlier research focused on pain relief, more recent research has included patient-centered outcomes as well. This randomized controlled study compared the effectiveness of three active therapies: deep tissue massage, supervised strengthening and stretching exercises, and a combined therapy consisting of exercise followed by massage, with advice to stay active as a control group.

The Study Methods

Six hundred and nineteen adults with subacute or persistent neck pain were recruited using ads in a free daily Stockholm newspaper. Participants were aged 18–70 years, and reported subacute (30–90 days duration) or chronic (more than 90 days duration) non-specific disabling neck pain with or without headache and/or radiating symptoms.

Those with pain intensity less than 2/10 and disability less than 1/10 on a numerical rating scale (NRS) were excluded. Also excluded were those with a history of cancer, severe skin disorders, recent neck surgery, prolapsed disc, spondylolisthesis, fracture, spinal stenosis, arthritis, osteoporosis, recent neck trauma, severe neck pain, steroids use, drug abuse, treatment by a manual therapist for the current complaint, signs of infection, no access to a smartphone with connection to the internet, or inability to communicate in Swedish. Baseline questionnaires were completed prior to randomization, and treatment began immediately following random assignment to a group.

Participants were allocated to massage (n = 145), exercise (n = 160), combined therapy (n = 169) or advice (n = 147). Treatment duration was six weeks, and the number of visits was limited to six for massage, exercise and combined therapy, and three for the advice group.

Treatments were provided by multiple trained and experienced therapists who were not part of the research team and used a manualized protocol. Treatment and protocol fidelity were regularly assessed. Participants allocated to the advice control group received an educational booklet and attended up to three visits with a therapist. The booklet included evidence-based information about back and neck pain, the psychology of the condition, misconceptions about back and neck pain and the importance of returning to normal activities.

Primary outcomes were minimal clinically important improvements in neck pain intensity and pain-related disability based on adapted questions from the Chronic Pain Questionnaire. Secondary outcomes were perceived recovery and work absence. Outcomes were measured at 7, 12, 26 and 52 weeks.

The Results

Out of 1,514 individuals screened, 621 participants were enrolled. The average age of the sample was 46 years, and 69 percent were female. Most participants reported pain duration of more than 12 months, and 77 percent used medication for their pain. The average number of visits was 2.4 for advice to stay active, 5.8 for massage, 5.0 for exercise, and 5.5 for massage and exercise combined. The 52-week follow-up rate was highest for massage therapy (94 percent) and lowest for advice to stay active (79 percent).

At 7 and 12 weeks follow-up, participants in the massage and the combined therapy groups had lower mean pain intensity than participants in the advice group. Pain-related disability for combined therapy and exercise were lower compared to advice after 12 weeks. At 26 weeks, massage and exercise were more likely to show a minimal clinically important improvement in pain intensity compared to advice. At 52 weeks, there were no consistent differences among groups in pain intensity or pain-related disability.

In terms of secondary outcomes, the incidence of perceived recovery at 52 weeks was 20 percent in the advice group, 27 percent in the exercise group, 35 percent in the massage group, and 40 percent in the combined therapy group. There was no difference in the number of visits to additional health care providers at 52 weeks across groups. However, 23 percent of the participants in the advice group visited a massage therapist during the first three months compared to 12 percent, 14 percent and 13 percent in the massage, exercise and combined therapy groups, respectively.

Limitations of the Study

In this study, double blinding was not possible, so expectation may explain some of the differences in results among the interventions. The advice group received a maximum of three sessions of therapy compared to six sessions in the other groups, and the reduced frequency of patient-therapist interaction may have affected the results.

Implications for Evidence-Informed Practice

These results show that massage alone or with exercises was more effective in the short term than advice to reach a clinically meaningful improvement in pain intensity, and that massage and exercise alone were more effective in the mid-term.

The authors note that the short- and mid-term improvement and long-term lack of any significant difference among groups are not inconsistent. In individuals with persistent pain, self-perceived recovery may not equal complete resolution of the pain. Instead, it may be that the person has learned to cope with pain, redefined what it means to be healthy or reached an acceptable quality of life as they define it.

Massage, exercise or a combination of both may encourage these kinds of reframing based on mechanisms beyond the immediate effects of deep tissue manipulation. The sense of empathy and care provision offered by massage therapy may increase patient satisfaction, reduce anxiety and distress, and facilitate a sense of self-efficacy.

Related Resources

Continuing education reading a research article.

Learn to read, evaluate and critique research, and to adapt these skills to write your own article.

Massage Therapy Journal A Real Pain in the Neck

The physical effects of hunching over tablets and cell phones have led to a chronic condition called tech neck.

1. Skillgate E, Pico-Espinosa OJ, Côté P, Jensen I, Viklund P, Bottai M, Holm LW. " Effectiveness of deep tissue massage therapy, and supervised strengthening and stretching exercises for subacute or persistent disabling neck pain. The Stockholm Neck (STONE) randomized controlled trial ." Musculoskelet Sci Pract . 2020 Feb;45:102070.

Experience Healing and Restoration with deep-tissue massage

D eep tissue massage is a form of massage therapy that is often mentioned but not completely understood. In fact, it has a long history, dating back to ancient China and Egypt. In ancient Chinese medicine, massage was considered a vital practice for restoring balance and alleviating various ailments by addressing energy blockages, and some experts propose that this was deep tissue massage. In this article, we are going to take a deep dive into deep tissue massage, its benefits, risks, and everything else in between.

What is Deep Tissue Massage?

Deep tissue massage (DTM) is a form of specialised massage therapy that targets the deeper layers of muscles, tendons, and fascia. It involves applying sustained pressure and slow strokes targeting the underlying tissues to relieve tension. Unlike Swedish massage, which focuses on relaxation, this type of massage aims to address specific musculoskeletal problems and provide therapeutic benefits. With Body Alignment Deep Tissue Massage , the emphasis is not only on targeting deep layers of tissue but also on aligning the body for optimal wellness and posture.

What are the Benefits of deep-tissue massage?

1. Pain Relief

Deep-tissue massage is shown to be more effective at alleviating persistent chronic pain compared to other medical measures or medications. It aims to release muscular restrictions by targeting root causes like muscle tension, inflammation, and adhesions. Examples of conditions that benefit from deep tissue massage in this regard include fibromyalgia and plantar fasciitis.

2. Alleviate Stress

While deep tissue massage focuses on the deep layers, it can provide a profound sense of relaxation and alleviate stress. The slow, deliberate strokes stimulate the parasympathetic nervous system (PSNS), promoting calmness and relaxation.

3. Improve Range of Motion

Deep-tissue massage helps break down scar tissue and adhesions that limit movement. By lengthening or stretching muscles, this type of massage therapy boosts flexibility and enhances joint mobility as well as range of motion.

4. Boosts Mood and Happiness

Deep tissues are also referred to as therapeutic tissues, harbouring chemicals used on the nerves and also supporting muscle relaxation. These hormones are responsible for an individual’s happiness and overall mood. By soothing the tense muscles using deep tissue massage, you can expect an improved state of calmness and happiness.

5. Muscle Recovery for Athletes

Deep-tissue massage is also extremely beneficial for both athletes and fitness enthusiasts. It helps reduce muscle soreness, prevent injuries, and enhance athletic performance. It also boosts blood circulation and tissue oxygenation and speeds up the muscle recovery process.

What are the Risks of deep-tissue massage?

Generally, there’s little risk in undergoing deep tissue massage. The only issues reported after a session are soreness and, in some cases, bruising. Of course, muscle soreness is a result of manipulating connective tissues at that deep level. Bruising is rare and can be avoided by adjusting the techniques to cater to an individual’s sensitivity.

As with any form of therapy, it is always advisable to consult your therapist or doctor to ensure that it is safe and effective for your needs.

Who is a Good Candidate for Deep Tissue Massage?

(i) People with Chronic Pain: This type of therapy can provide much-needed relief for individuals experiencing chronic conditions like arthritis, back pain, and fibromyalgia. It targets deep-rooted muscle tension and knots to alleviate pain.

(ii) People with Postural Issues: Individuals with postural imbalances, like those who have poor posture or sit for extended periods, can benefit from deep massage therapy. The therapy can help realign the muscles, correct imbalances, and improve posture.

(iii) People with high stress levels: This form of therapy also provides an effective way to manage stress. By targeting muscle tension and promoting relaxation, deep massage therapy can help get rid of stress-related symptoms.

(iv) Athletes: Athletes who are usually involved in intense physical activities can benefit from this form of therapy.

What are the Common Techniques Used in Deep Tissue Massage? 

Your practitioner may apply one or a combination of the following techniques, depending on your needs:

Stripping: This technique involves applying deep, gliding pressure along the muscle fibres in order to release tension.

Friction: This technique involves applying pressure across the grain of the muscles to target the specific spots experiencing tension.

Trigger Point Therapy: This focuses on releasing trigger points, which are hyperirritable spots in the muscles that cause referred pain. Sustained pressure is applied to these points in order to alleviate tension and pain.

The Takeaway

Whether you’re seeking relief from chronic pain, healing from an injury, or just want a way to relax and unwind, deep tissue massage can be a valuable therapeutic option. Consult with a qualified massage therapist to determine if deep tissue massage is suitable for your individual needs and experience the transformative benefits it has to offer.

The post Experience Healing and Restoration with deep-tissue massage appeared first on Sunny Sweet Days .

Breathe Salt Spa

Services Offered

Verified by Business

Deep Tissue Massage in 2 reviews

Acne Treatments

Back Treatments

Body Treatments

Body Massages in 1 review

Anti-aging Treatments

Body Scrubs

Location & Hours

Suggest an edit

Atlantic City, NJ 08401

You Might Also Consider

Just Braggin’ Salon

Erin A. said "I recently just relocated down to Manahawkin and I was in desperate need of finding a new hair stylist, I am very picky so it was very nerve racking. I did my research and Just Braggin Salon had the very best ratings and amazing…" read more

in Hair Salons

Lunar Massage

We are a team of Licensed Massage Therapists with a passion for massage and self care. Located inside the brand new Sola Salon in Forked River’s Lakeside Plaza, we provide Swedish, chair, oncology, prenatal, Reflexology, deep… read more

in Massage, Reflexology, Massage Therapy

Amenities and More

4 More Attributes

About the Business

Atlantic City's first Resort Medical Spa located right in the Tropicana Quarter! With 10,000 sq. ft. Breathe is a one of a kind location with a Medi-Spa twist, offering IV Therapy, Luxurious Massages, Skin and Body Treatments, Nails and Halo Therapy! …

Ask the Community

Ask a question

How do I make an appointment?

People also searched for

acne treatments

anti-aging treatments

back treatments

body massages

body scrubs

body treatments

Recommended Reviews

• 1 star rating Not good
• 2 star rating Could’ve been better
• 3 star rating OK
• 4 star rating Good
• 5 star rating Great

Select your rating

Overall rating

My girl Azhana killed it. She made sure I was so comfortable and so relaxed, we ended up talking the whole time and connected on another level I was telling her secrets by the end and wishing I lived closer so I could hang out. She was amazing highly highly recommend

Services at the spa were amazing! Tracy, therapist, was soooo good! I needed a massage badly and walked out feeling amazing. Love the ambiance of the spa and all its amenities, as well.

FINALLY a spa in Atlantic City that offers I.V. Vitamin infusions to cure your hangover or make sure u don't have a bad one! Omg I wish this was available to me all those yrs ago haha & comfortably an actual Nurse gave me a vitamin b shot. Massages & facials are always great. Amy is the best! I recommend the halotherapy.

See all photos from Jen D. for Breathe Salt Spa

Breathe salt spa is by far the cleanest and best salon I have ever visited. It is located in the Tropicana casino at Atlantic City. Massage therapist Sandra was hands down the very best therapist I have ever had. I can't begin to say enough good things about her. If you are ever in Atlantic city and wanting a massage, please visit Sandra at Breathe, you won't be disappointed

I've gotten a lot of massages in my life and this way by far the worst. I got a CBD massage and the woman haphazardly rubbed oil on my body and when I asked her for actual pressure she said that was a deep tissue massage. as if I wanted to pay $200 for an 80 year old woman to rub me with oil. I spent the whole 55 minutes wondering when it was going to start. horrendous.

Very clean place & they're all super friendly!! With the holidays right around the corner it would be a great present to a loved one!

My sister and I had massages at Breathe Salt Spa as a birthday gift. It was so easy to book online and we found the spa with no problem. As soon as we arrived we felt relaxed. Everyone was so friendly and the atmosphere was bright and calm. The locker room was clean and all the amenities were such a nice touch. The massages were FANTASTIC. We felt so pampered the entire time we were there. The fun & quality items for sale made the experience even better. We can't wait to go again!

4 other reviews that are not currently recommended

Hair Cuttery

Barry G. said "I had been going to the same hairdresser off and on for 20 years. Although she only charged $35, which is still reasonable, I could no longer afford that due to tight finances. Plus, she was giving me the same boring, blah,…" read more

in Hair Stylists, Men's Hair Salons

The Training Room

6.7 miles away from Breathe Salt Spa

The highly skilled therapists at The Training Room, located at 3324 Bargaintown Rd in Egg Harbor Township are here to help you get back to feeling your best again! The Training Room is a proud member of the Ivy Rehab Network, a… read more

in Physical Therapy, Sports Medicine, Orthopedists

People Also Viewed

Worlds Of Wellness

A Bella Salon & Spa

Abella Salon And Spa

Drift Day Spa

Awaken Aesthetics

Tomorrow’s Wellness Center

Fabiana Edwards Studio Salon

Makeup By Catrina

Island Wellness Center

Browse Nearby

Restaurants

Things to Do

Other Places Nearby

Find more IV Hydration near Breathe Salt Spa

Find more Massage near Breathe Salt Spa

Find more Skin Care near Breathe Salt Spa

Service Offerings in Atlantic City

Body Massages

Facial Massages

LED Light Treatments

Mask Treatments

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Int J Gen Med

The effectiveness of massage therapy for the treatment of nonspecific low back pain: a systematic review of systematic reviews

Saravana kumar.

1 International Centre for Allied Health Evidence, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia

Kate Beaton

Tricia hughes.

2 Australian Association of Massage Therapists, Adelaide, South Australia, Australia

Introduction

The last decade has seen a growth in the utilization of complementary and alternative medicine therapies, and one of the most popular and sought-after complementary and alternative medicine therapies for nonspecific low back pain is massage. Massage may often be perceived as a safe therapeutic modality without any significant risks or side effects. However, despite its popularity, there continues to be ongoing debate on the effectiveness of massage in treating nonspecific low back pain. With a rapidly evolving research evidence base and access to innovative means of synthesizing evidence, it is time to reinvestigate this issue.

A systematic, step-by-step approach, underpinned by best practice in reviewing the literature, was utilized as part of the methodology of this umbrella review. A systematic search was conducted in the following databases: Embase, MEDLINE, AMED, ICONDA, Academic Search Premier, Australia/New Zealand Reference Centre, CINAHL, HealthSource, SPORTDiscus, PubMed, The Cochrane Library, Scopus, Web of Knowledge/Web of Science, PsycINFO, and ProQuest Nursing and Allied Health Source, investigating systematic reviews and meta-analyses from January 2000 to December 2012, and restricted to English-language documents. Methodological quality of included reviews was undertaken using the Centre for Evidence Based Medicine critical appraisal tool.

Nine systematic reviews were found. The methodological quality of the systematic reviews varied (from poor to excellent) although, overall, the primary research informing these systematic reviews was generally considered to be weak quality. The findings indicate that massage may be an effective treatment option when compared to placebo and some active treatment options (such as relaxation), especially in the short term. There is conflicting and contradictory findings for the effectiveness of massage therapy for the treatment of nonspecific low back pain when compared against other manual therapies (such as mobilization), standard medical care, and acupuncture.

There is an emerging body of evidence, albeit small, that supports the effectiveness of massage therapy for the treatment of non-specific low back pain in the short term. Due to common methodological flaws in the primary research, which informed the systematic reviews, recommendations arising from this evidence base should be interpreted with caution.

Recent times have witnessed dramatic changes to health care. There is now an overt recognition for quality to inform health care practices and this recognition for change has been driven by an increasingly well-informed consumer of health service, the patient, and other stakeholders who strive to underpin their service delivery within the quality health care framework. The key components of this framework include safety, effectiveness, patient centeredness, timeliness, efficiency, and equity. 1 Much of the drive towards quality health care has been championed by evidence-based practice, which recognizes the need for health care practices to be underpinned by an integration of research evidence, clinical expertise, and patient values. 2

Low back pain is one of the most common musculoskeletal disorders in modern society and is a major reason for health care utilization. 3 , 4 The impact of low back pain is widespread, including physical, social, psychological, and economic aspects of an individual’s life. Low back pain can include discomfort in any area of the spine from the 12th rib to the inferior gluteal fold, and is only considered to be specific if its etiology is known (such as diagnoses of degenerative or other disease, infection, fracture, etc). 3 – 5 Low back pain is usually reported as self-limiting (acute or subacute durations), but it is estimated that approximately 10% of this population will develop chronic pain. 3 , 4 , 6 However, it has been suggested that this may be an underestimation, with the true number of low back pain sufferers who progress to chronic pain ranging from 16–62% at 6–12 months post injury. 7 This imposes a large burden on the health care system. 4 – 8 In spite of a large body of research evidence and a plethora of interventions being available in this area, how best to manage this condition continues to pose a challenge.

The last decade has seen a growth in the utilization of complementary and alternative medicine (CAM) for a variety of health conditions, including musculoskeletal disorders such as nonspecific low back pain. 3 – 9 Awareness in the general public about CAM therapies is growing and their use is becoming increasingly widespread. 3 , 4 The total extrapolated cost in Australia of CAMs and CAM therapists in 2004 was AUD1. 8 billion. 9 Common CAM therapies for nonspecific low back pain include acupuncture, massage, and manipulation. 4

One of the most popular and sought-after CAM interventions for nonspecific low back pain is massage. 4 There are many types of massage, including but not limited to Swedish massage; Thai massage (a form of body work involving assisted stretching); Shiatsu (a Japanese form of massage utilizing finger and palm pressure and stretching techniques); reflexology (the application of pressure to the zones of the feet, hands, or ears, which are thought to correspond to various body parts); and myofascial release (a manual therapy involving deep tissue work). Massage may often be perceived as a safe therapeutic modality without any significant risks or side effects 3 and has been recommended by the Chartered Society of Physiotherapy for the management of various pain-related conditions, especially those of musculoskeletal origin. 10 Despite its popularity, there continues to be ongoing debate on the effectiveness of massage in treating nonspecific low back pain. While there is a large body of primary research evidence, such as randomized controlled trials (RCTs), historically, secondary research evidence such as systematic reviews often fail to draw any clear conclusions with which to inform health care practice and policies. With a rapidly evolving research evidence base, and access to innovative means of synthesizing evidence, it is time to reinvestigate this issue.

This systematic review of systematic reviews (umbrella review) sets out to provide a synthesis of the best available research evidence for the effectiveness of massage therapy for adults suffering from nonspecific low back pain. Systematic reviews are considered to be the highest level of evidence for intervention questions. 11

Review question

This review determined the effectiveness of various forms of massage therapy on nonspecific low back pain in adults by answering the question “What is the evidence for the effectiveness of massage therapy in adults with nonspecific low back pain?”

Types of participants

Included participants were adults (≥18 years) suffering from non-specific acute, sub-acute or chronic low back pain (low back pain is defined as pain that is localized from the 12th rib to the inferior gluteal fold). 3 , 4 “Non-specific” means that there is no specific cause of the low back pain such as neoplasms, infection, osteoporosis, arthritic conditions, fracture, radicular syndrome or inflammatory processes. 3 , 12 , 16

Types of exposure

The treatment of interest in this review was massage therapy. For the purpose of this review, massage is defined as the manual manipulation of the soft tissues of the body for therapeutic purposes. 3 , 5 , 12

Types of comparators

Comparators included but were not limited to: sham or placebo treatment, medical interventions, physical therapy, electrical therapy (transcutaneous electrical nerve stimulation, ultrasound, etc), pharmaceutical interventions, and other forms of alternative therapy.

Types of outcomes

Outcomes included but were not limited to: patient self-report/subjective change of symptoms, assessment of pain, functional status as measured by validated tools, and assessment of range of motion.

Search strategy

A systematic search was conducted in the following databases: Embase, MEDLINE, AMED, ICONDA, Academic Search Premier, Australia/New Zealand Reference Centre, CINAHL, HealthSource, SPORTDiscus, PubMed, The Cochrane Library, Scopus, Web of Knowledge/Web of Science, PsycINFO, and ProQuest Nursing and Allied Health Source, investigating systematic reviews and meta-analyses from January 2000 to December 2012, and restricted to English-language documents. The key words used to develop the search terms used can be found in Table 1 . The appropriate truncation symbols and Boolean operators were used for each database searched and MeSH terms were used where applicable. Two researchers independently conducted the search with cross-checking of random databases to ensure consistency across the search.

Concepts searched and the keywords related to these concepts

Reference lists of any umbrella reviews returned in this search were also pearled for additional systematic reviews or meta-analyses that may not have been found in the original search.

Selection process

Articles were included if they were systematic reviews or meta-analyses that addressed massage therapy for the treatment of nonspecific low back pain, as defined in this umbrella review. Massage could have been administered in either the treatment or control group, but information regarding massage groups had to be reported separately to any other complementary medicines or placebo treatments administered. Articles that did not meet the PRISMA 13 definition of a systematic review or meta-analysis were excluded, as were any previous versions of updated systematic reviews. Articles that investigated massage therapy as applied by chiropractors or physiotherapists were also excluded, as these practitioners are not classified as massage therapists and therefore do not fit the criteria for this umbrella review.

Methodological quality assessment

Once relevant publications were identified, two reviewers independently evaluated the methodological quality using the Centre for Evidence Based Medicine (CEBM) critical appraisal tool. 14

Data extraction

The data were extracted into a custom-built table based on the CEBM questions. At this point, further exclusions were made based on the full text of the articles.

Search findings

A total of 1,854 articles were returned in the initial search of the abovementioned databases, and two new systematic reviews were found by pearling the reference lists of other umbrella reviews. Of these 1,856 articles, 262 were duplicate articles and 1,393 were removed based on title, abstract, and study descriptors. The full text of the remaining 201 articles was assessed by two independent researchers for relevance, resulting in the exclusion of a further 192 articles that did not match the inclusion criteria. Any disputes were sent to a third researcher for arbitration. The remaining nine systematic reviews were included in this umbrella review. Figure 1 provides an overview of the selection process using the PRISMA flowchart format. 13

Flowchart of study selection.

Note: Flowchart is as per the PRISMA flowchart format. 13

Methodological quality of included reviews

The nine included systematic reviews were critically appraised with the CEBM critical appraisal tool. 14 The overall quality scoring of the nine included systematic reviews ranged from poor to excellent. Table 2 provides an overview of critical appraisal scores for individual reviews.

Score of included articles as per the Centre for Evidence Based Medicine review validity appraisal sheet 14

Abbreviations: N, does not fulfill criteria; NA, not applicable to the paper; Q, question; U, unclear if it fulfills criteria; Y, fulfills criteria.

The identified systematic reviews classified their findings into three categories of low back pain: acute, chronic, or mixed (where acute and chronic were reported together). In order to maintain standardization and keep true to the research evidence, the following section summarizes the findings based on these three categories.

Category one: the effectiveness of massage therapy for acute/subacute nonspecific low back pain in adults

Furlan et al 4 identified ten trials, comprising 1,424 participants, that focused on the effectiveness of massage for low back pain. Of these, two trials were on acute/subacute nonspecific low back pain and included 158 participants. These trials showed significant short-term posttreatment benefits on pain and disability measures after massage when compared to placebo or no treatment. The assessment of methodological quality was only reported overall and the potential bias in massage-specific studies cannot be reported. However, it was reported that, overall (ie, in studies of acupuncture, massage, mobilization, and spinal manipulation), the quality of the studies was poor.

Pengel et al 15 identified two high quality RCTs, comprising 164 participants, which compared the use of massage to spinal manipulative therapy and corsets to treat non-specific low back pain. It was reported that spinal manipulative therapy and corsets both improved disability scores in comparison with massage (effect size 1.5, confidence interval [CI]: 0.8,2.2; effect size -0.9 CI -1.6, -0.1) when using the Roland Morris Disability Questionnaire (RMDQ).

Therefore, to summarize this research evidence, it is likely that massage therapy may offer some positive benefits in terms of reduction in pain and disability in the short term, when compared to placebo or no treatment. However, this was not the case when massage therapy was compared with spinal manipulative therapy and corsets.

Category two: the effectiveness of massage therapy for chronic nonspecific low back pain in adults

Bronfort et al 16 identified one RCT, comprising 164 participants, which investigated spinal manipulation therapy and various forms of massage therapy for the treatment of chronic low back pain. The findings from this RCT, of low methodological quality (38%), indicated that massage therapy was less effective than spinal manipulative therapy applied by a chiropractor for disability outcomes (statistically significant), but not for pain improvement (statistically nonsignificant).

Ernst et al 17 identified two trials, comprising 249 participants, investigating reflexology for chronic low back pain. The authors assessed the methodological quality of the two trials they found using the Jadad scale and found that one of the RCTs was moderate (3/5) and the other was high quality (5/5). Results from both included trials were similar with no significant change found between groups in either trial. While effects were found in one of the two included trials, this was not significant for reflexology in the treatment of low back pain. This systematic review failed to provide evidence that reflexology has benefits beyond that of a placebo effect. Ernst et al state: “In conclusion, the notion that reflexology is an effective treatment option is currently not based on the evidence from independently replicated, high-quality, clinical trials.” 17

Furlan et al 4 identified ten trials, comprising 1,424 participants, which focused on the efficacy of massage for low back pain. Of these ten trials, eight investigated chronic nonspecific low back pain in 1,266 participants. The evidence indicated that massage was either no different or better than mobilization in terms of immediate and intermediate pain intensity (Short Form-36 pain scale, McGill Pain Questionnaire [two trials]) and disability (two trials), determined using the Oswestry Disability Index and RMDQ. According to two meta-analyses, massage was significantly better in terms of pain reduction (using the visual analog scale [VAS]) in comparison with relaxation and physical therapy (defined by Furlan et al 4 as exercise and/or electrotherapy) immediately following treatment, for those with chronic nonspecific low back pain. In terms of the intermediate effect of massage for patients with chronic nonspecific low back pain, there were no significant differences in disability (according to RMDQ) or pain (VAS) when compared with usual care (exercise and advice). Furlan et al 4 also found one trial indicating that massage significantly reduced pain intensity and disability in both immediate and long-term follow-ups compared to acupuncture. The assessment of quality was only reported overall; the potential bias in massage-specific studies cannot be reported. However, it was reported that, overall (ie, in studies of acupuncture, massage, mobilization, and spinal manipulation), the quality of the studies was poor.

Kim et al 18 identified two RCTs, comprising 275 participants, which reported on the use of acupressure (pressing acupuncture points with a finger or device) for the treatment of chronic low back pain compared to routine physical therapy. Both trials showed significant effects on pain reduction compared to the routine physical therapy. A meta-analysis was conducted for the two RCTs reporting pain intensity posttreatment (4 weeks) and at 6-month follow-up for acupressure versus routine physical therapy for participants with chronic low back pain. This revealed that acupressure was more effective than physical therapy at 4 weeks. The authors state:

… meta-analysis demonstrated acupressure to be superior to physical therapy in terms of pain [N = 275; SMD −0.71; 95 per cent CI −0.96 to −0.47; P < 0.00001; heterogeneity: χ 2 = 0.15, P = 0.70, I 2 = 0 per cent] after four weeks post-treatment. 18

At the 6-month follow-up, acupressure had a significant effect on pain, but the authors report presence of heterogeneity in the data analysis.

van Middelkoop et al 19 identified three low-quality RCTs, comprising 163 participants, which indicated that there was no statistically significant reduction in pain when the massage groups were compared with the control groups (relaxation therapy and acupuncture; pooled weighted mean difference was −0.93 [95% CI −8.51] [sic]). They conclude there is insufficient good-quality data with which to come to a firm decision on the efficacy of massage therapy in the treatment of chronic low back pain.

Therefore, to summarize this research evidence, massage therapy may offer some positive benefits in terms of reduction in pain and disability in the short term, when compared to relaxation. However, this was not the case when massage therapy was compared with spinal manipulative therapy. There is equivocal evidence of effectiveness of massage therapy when compared to mobilization and usual care (advice and exercise).

Category three: the effectiveness of massage therapy for mixed acute, subacute, and chronic nonspecific low back pain in adults

Bronfort et al 16 identified three RCTs, comprising 197 participants, which investigated spinal manipulation therapy and various forms of massage therapy for the treatment of both acute and chronic low back pain. They found evidence to suggest that spinal manipulative therapy may be more effective in reducing pain (nonsignificant findings) than placebo massage, and a single session of spinal manipulative therapy resulted in fewer sick-leave days than friction massage. The final study found a nonsignificant advantage of spinal manipulation therapy over myofascial therapy for pain and disability reduction. All three studies had low- to moderate-quality scores (13%, 25%, and 63%).

Brosseau et al 20 identified eleven trials regarding massage for the treatment of acute, subacute, or chronic non-specific low back pain. However, the authors reported on only four trials, comprising 954 participants, which scored 3 or more on the Jadad scale 21 (high methodological quality). They found statistically significant results in favour of pain reduction in comparison to sham laser treatment but only “clinically important” 20 results in decreased disability and symptoms for massage (structural, therapeutic, and relaxation massage) in comparison to usual care and sham laser treatment.

Lewis and Johnson 10 identified seven relevant studies, with a total of 787 participants. These studies were critically appraised using the Centre for Reviews and Dissemination methodological scale. 22 The included studies scored between 3 and 7 out of a maximum score of 9. The Centre for Reviews and Dissemination methodological scale was modified to a maximum score of 9 (rather than the original maximum score of 11) by Lewis and Johnson, as they recognized the inability to blind practitioners and clients for this type of intervention (loss of 2 points). 10 There was considerable variation between the studies, limiting the ability to compare the findings. Therapeutic massage resulted in better pain and disability scores by end of trial than sham laser, and was found to be superior to self-care, acupuncture, exercise and education, and muscle relaxation. Soft tissue manipulation (six sessions, over a 1-month period) was more effective in terms of reducing disability and pain than exercise with posture education or treatment with sham laser for people with subacute low back pain. Massage (three 30-minute sessions per week for 3 weeks) was better than mental relaxation, while massage (two 30-minute sessions per week for 5 weeks) reduced pain in comparison with standard medical care (pharmacology and chronic pain education). The authors concluded that, as therapeutic massage was superior to comparison groups in only three of seven studies, the effectiveness of massage to relieve low back pain was inconclusive.

Lin et al 23 identified one RCT with low risk of bias, comprising 579 participants, which investigated the cost-effectiveness of massage therapy as compared to general practice (GP) health care. This study indicated that massage alone was less effective and more expensive from the health care sector’s perspective than GP care. However, when exercise and behavioral counseling were added to massage, it was more cost-effective than GP care.

Therefore, to summarize this research evidence, massage therapy may offer some positive benefits in terms of reduction in pain and disability in the short term, when compared to sham and placebo interventions. However, this was not the case when massage therapy was compared with spinal manipulative therapy. There is equivocal evidence of effectiveness of massage therapy when compared to acupuncture, exercise and education, and relaxation. There is limited evidence on the cost-effectiveness of massage therapy when compared to other standard interventions for nonspecific low back pain.

The aim of this umbrella review was to provide a synthesis and judgment of best available research evidence related to the effectiveness of massage therapy for the treatment of nonspecific low back pain. With increasing consumption of CAM therapies, in an era of evidence-based practice, it is only appropriate to investigate the evidence underpinning the effectiveness of CAM therapies.

The systematic reviews included in this umbrella review ranged from poor methodological quality 10 , 16 to moderate, 18 , 19 good, 4 , 15 , 20 or excellent methodological quality. 17 , 23 Therefore, we recommend that caution be used when interpreting the conclusions of these reviews, as the primary research relating to massage and non-specific low back pain, for the most part, had a high risk of bias.

While there are a number of systematic reviews investigating the effectiveness of massage therapy for nonspecific low back pain, there is mixed and conflicting evidence on outcomes from massage therapy. There is emerging evidence that massage may be an effective treatment option for treating low back pain when compared to placebo or sham therapies and other interventions (such as relaxation techniques) in improving short-term pain and disability. The role of massage as a moderately effective nonpharmacological treatment option has also been discussed by Chou et al 24 and Imamura et al 8 as a recommendation for chronic low back pain therapy.

The evidence is contradictory for the effectiveness of massage when compared to other popular treatment options, such as standard medical care, mobilization, and acupuncture in improving short-term pain and disability. Spinal manipulative therapy seems consistently to provide better outcomes when compared to massage therapy. There was no evidence found for the long-term (beyond 6 months) effectiveness of massage therapy.

The methodology underpinning the primary research, which informed the systematic reviews, was, for the most part, classified as weak. This is a significant issue that has plagued the evidence base for massage therapy and has also been acknowledged by other researchers (Airaksinen et al 25 ). The methodological issues reported by the systematic reviews include small sample size, lack of adequate blinding of assessors, and varied intervention parameters and outcome measures. This is demonstrated by the finding that only one of the nine included systematic reviews was able to undertake a meta-analysis of the included primary literature. 18 This was due to the variability in the description of intervention parameters, operational definition of massage therapy, comparators, and outcome measures utilized in the remaining eight included systematic reviews.

The poor quality of the primary research evidence base may be partly due to the conflict between what occurs in clinical practice and rigorous standards required within research settings. In a clinical practice context, massage therapy may often be offered as a “package of care” in addition to advice and education and using a combination of modalities. However, in a research context, a package of care is rarely offered in order to avoid cointervention bias. Therefore, the primary research undertaken may not truly capture and replicate what occurs in a clinical practice context. This is a challenge and a limitation when undertaking and interpreting findings of research evidence for massage therapy.

Limitations of this review

This umbrella review, like any other research, has its limitations, and these need to be acknowledged in the context of the findings. Firstly, while all attempts were made to interrogate and access all relevant literature, it is possible some publications may have been missed in the search process. This is especially relevant for CAM topics, as publications in other languages, originating from countries where English may not be a first language, such as the People’s Republic of China and India, may not be captured in Western databases. Secondly, as there was a lack of clarity around the type, use, and comparators of massage therapy in these systematic reviews, the heterogeneity made it impossible to combine the findings across all included systematic reviews and come to an absolute conclusion. Thirdly, one of the recurrent issues when interpreting these systematic review findings was the imperfect primary research designs included in these reviews. Several of the primary research studies had poor evaluations with several methodological issues (such as lack of adequate descriptions of interventions and poor long-term follow-up).

Implications for practice

The findings of this umbrella review indicate that massage may be an effective treatment option in the short term when compared to placebo and some active treatment options (such as relaxation). However, there are conflicting and contradictory findings for the effectiveness of massage therapy for the treatment of nonspecific low back pain when compared against other manual therapies (such as mobilization, standard medical care, and acupuncture). Given that there were no reported side effects or adverse events as a result of massage therapy, it may be considered as a viable treatment option, provided that cost implications are considered.

The diversity and complexity of the evidence base for the effectiveness of massage therapy for the treatment of nonspecific low back pain underscores the importance of a collaborative, patient-centered decision making process between the patient and the health professional, which is informed by best available evidence. In addition to this, sound clinical reasoning, expertise of individual health professionals, and health outcome data, collected using rigorous outcome measures, should underpin the integration of the findings from this umbrella review into clinical practice. These processes build on the philosophy of evidence-based practice in health care.

Implications for research

Massage therapy seems to be a well-researched field of therapy within CAMs. However, there are key knowledge gaps in the literature that need to be addressed. Further research is required to unpack the “black box” of massage therapy, as there is ambiguity on the operational definition of massage therapy. Various systematic reviews defined and searched for many different types and modalities of massage, with some discussing massage techniques as a separate modality and some considering massage therapy as part of a suite of interventions. This variability extended to massage therapy parameters such as dosage, duration, and intervention protocols. There is a scarcity of data on the cost-effectiveness of massage therapy for the treatment of nonspecific low back pain. As there is currently a dearth of high-quality/low risk of bias primary research on the effectiveness of massage for the treatment of nonspecific low back pain, further research, such as RCTs, with sound methodological rigor, are required. While there are a number of systematic reviews investigating the effectiveness of massage therapy for nonspecific low back pain, the mechanism underlying its action remains elusive. While physiological and psychotherapeutic models have been proposed, the precise mechanism of action continues to be debated, requiring ongoing further research.

Acknowledgments

The authors gratefully acknowledge Ms Khushnum Pastakia for her assistance and feedback during the preparation of this manuscript.

The funding for the conduct of this umbrella review was provided by the Australian Association of Massage Therapists. The authors report no other conflicts of interest in this work.