Massage Therapy for Musculoskeletal Disorders

Is it effective?

By Jerrilyn Cambron
[Somatic Research]

According to the 2010 Global Burden of Disease Study, musculoskeletal disorders are the fourth largest health problem worldwide, affecting 20–50 percent of the population at any given time.1 The most commonly affected areas include the low back, neck, shoulders, and knees. In fact, of all injuries presenting to emergency departments in the United States, 36 percent are sprains and/or strains of the lower extremity and 16 percent are sprains and/or strains of the upper extremity.2 Many treatments are utilized for these conditions, including massage therapy.
A recent review article by D. C. Bervoets and others tried to answer this question: “Is massage therapy effective for people with musculoskeletal disorders compared to any other treatment or no treatment?”3 In order to answer this question, the authors searched scientific literature databases, including CINAHL, PEDro, and PubMed for clinical trials that included massage therapy for adults with musculoskeletal disorders, excluding those who had severe pathology such as fracture, nerve damage, psychological disorders, or sports injuries.
In this article, massage was defined as “systematic manual manipulation of the soft tissues of the body with rhythmical pressure and stroking.” Articles with treatment defined as joint manipulation, energy manipulation, or mechanical devices were excluded from the review. Also, massage therapy could not be combined with any other form of care, but rather needed to be a stand-alone treatment, and the comparison therapy could not be an alternative form of massage. Common musculoskeletal disorders were defined by the International Classification of Primary Care (ICPC) codes and mainly included diagnoses for low back, neck, shoulder, and knee pain.
Included articles were assessed for quality using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) analysis approach, which scores an article based on factors such as flawed design, high degree of study dropout, and publication bias.
A total of 26 clinical trials were included in the review with the following conditions: low-back pain (8 articles), shoulder pain (4), fibromyalgia (3), knee osteoarthritis (3), chronic musculoskeletal pain (2), neck pain (2), chronic patellar tendinopathy (1), carpal tunnel syndrome (1), hand pain (1), and hand osteoarthritis (1).
Massage techniques included Swedish massage (5 articles), Thai massage (4), self-massage (1), or a combination of massage techniques (12). Four studies did not clearly describe the type of massage used. All reviewed articles included outcome measures that focused on either pain (22 articles) or dysfunction (14 articles). Data included in the review were mainly from short-term studies (post-treatment up to 12 weeks) with very few including long-term follow-up.

The Results
The results of the review included a total of 2,565 participants within the 26 studies. For reduction in pain in the short term, the data demonstrated evidence in favor of massage compared to no treatment in people with shoulder pain and osteoarthritis of the knee, but not in those with low-back pain or neck pain. For improvement in function in the short term, the data also showed evidence in favor of massage compared to no treatment in people with low-back pain, knee arthritis, or shoulder pain. However, when massage was compared to acupuncture, joint mobilization, manipulation, or relaxation therapy, there were no clear outcomes for which one treatment type was more beneficial than another.
As in all review articles, there are limitations to the results. For example, the majority of clinical trials (16 out of 26) had a high risk of bias based on the GRADE analysis, leading to weakened overall results. Also, the type of massage, diagnosis, sample size, outcome measures utilized, data collection time points, and comparative group differed from study to study, making it difficult to combine the data.
A similar review article was also recently published on the effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and injuries of the upper and lower extremities of adults and children.4 Six scientific databases were searched and the articles were critically appraised using the Scottish Intercollegiate Guidelines Network (SIGN) criteria rather than the GRADE analysis, but with similar study characteristic assessments. To be included in this review article, studies had to be in English; published after 1989; be a clinical trial, cohort, or case-control design; and have a minimum of 30 subjects per treatment arm.
In this review, musculoskeletal disorders and injuries were based on the US Centers for Disease Control and Prevention definition and defined as “grade I–II sprains or strains; nonspecific shoulder, elbow, wrist, hip, knee, ankle, and/or foot pain; tendonitis; tendinopathy; tendinosis; and other musculoskeletal disorders and injuries (including nerve injuries/neuropathies).” Studies were excluded if subjects had pathologies such as dislocations, fractures, infections, neoplasms, or systemic disease.
The definition of soft-tissue therapy used in this study was “a mechanical form of therapy where soft-tissue structures are passively pressed, kneaded, or stretched, using physical contact with the hand or mechanical device.” Forms of massage that focused on acupuncture points were excluded.
Because articles were only focusing on upper and lower extremities, and because there were many exclusion criteria for this review, only six articles were included. All six had a low risk of bias, demonstrating strong study designs. The six articles focused on lateral epicondylitis (2 articles), shoulder impingement syndrome (1), carpal tunnel syndrome (1), and plantar fasciitis (2).
The results demonstrated that myofascial release therapy was beneficial for lateral epicondylitis and plantar fasciitis. Movement reeducation was also beneficial for lateral epicondylitis. Localized relaxation massage combined with other forms of care provided short-term benefit for carpal tunnel syndrome.
The main limitation of this review was that the authors were searching for articles on a variety of conditions being treated with a variety of soft-tissue techniques, while using very narrow acceptance criteria, such as the stipulation that articles must be in English with a strong study design. Only six articles were chosen, and they were very different in content, making it difficult to come to any conclusion.

Conclusions
Overall, the two systematic review articles demonstrated that massage therapy appears to reduce pain and improve function in some musculoskeletal conditions. Because the articles included in the reviews were so divergent, we do not have strong conclusions on what treatment is most effective for what specific condition. However, we do have a better understanding that more high-quality research is needed on specific conditions using consistent treatment methods. Once that occurs, future review articles may elicit stronger conclusions. The results found in these review articles may not translate to your clients, so be sure to discuss your proposed treatment plan with your clients and their health-care teams.

Notes
1. The Lancet, “Global Burden of Disease Study 2010,” accessed February 2016, www.thelancet.com/global-burden-of-disease.
2. Ibid.
3. D. C. Bervoets et al., “Massage Therapy Has Short-Term Benefits for People With Common Musculoskeletal Disorders Compared to No Treatment: A Systematic Review,” Journal of Physiotherapy 61, no. 3 (July 2015): 106–16, doi: 10.1016/j.jphys.2015.05.018.
4. S. Piper et al., “The Effectiveness of Soft-Tissue Therapy for the Management of Musculoskeletal Disorders and Injuries of the Upper and Lower Extremities: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration,” Manual Therapy 21 (February 2016): 18–34, doi: 10.1016/j.math.2015.08.011.

Jerrilyn Cambron, DC, PhD, MPH, LMT, is an educator at the National University of Health Sciences and president of the Massage Therapy Foundation. Contact her at jcambron@nuhs.edu.