Essentials of Complementary and Alternative Medicine (June 1999)

CHAPTER 22. M
ASSAGE
 T
HERAPY
Tiffany Field
Background
 
Definition
 
History and Review of Literature
Principal Concepts
Provider–Client Interaction
Therapy and Outcomes
 
Treatment Options
 
Types of Massage Techniques
 
Treatment Evaluation
Use of the System for Treatment
 
Major Indications
 
Major Contraindications
Organization and Training
Prospects for the Future
Chapter References
BACKGROUND
Definition
The word massage has its origins in many languages, including the French word  masser (literally meaning to shampoo), a Greek word that means to knead, a Hindu 
word that means to press, and an Arabic word that means to press softly. Massage is defined as the hand manipulation of body tissues to promote wellness and to 
reduce stress and pain. The therapeutic effects of massage are from its impact on the muscular, nervous, and circulation systems.
Massage therapy sessions usually combine several techniques, including Swedish massage (stroking and kneading), Shiatsu (pressure points), and neuromuscular 
massage (which generally involves pressure by the therapist in all areas of the body, not just tender pressure points) (
1
). Oils are typically used, and aromatic 
essences are often added for an additional effect. Massage sessions may also feature soft background music to enhance relaxation.
History and Review of Literature
The practice of massage has been used for thousands of years, before recorded time. The word  massage can be found in many classic texts, including the Bible and 
the Vedas. As early as 400 
BC
, Hippocrates talked about the necessity for physicians to be experienced in rubbing. Ancient records from China and Japan refer to 
massage therapy. Massage was also widely used by other early cultures, including by Arabs, Egyptians, Indians, Greeks, and Romans. During the Renaissance, 
massage spread throughout Europe. Swedish massage was developed in the early nineteenth century by Henry Lind.
Key published works include volumes by M. Beck,  A Theory and Practice of Therapeutic Massage (
2
); L.J. Chaitow, Soft Tissue Manipulation (
3
); T. Field, Touch (
4
); 
N. Hollis, Massage for Therapists (
1
); L. Lidell, The Book of Massage: The Complete Step by Step Guide to Eastern, Western Techniques  (
5
); and C. 
Maxwell-Hudson, A Complete Book of Massage (
6
). Most of the books provide directions for performing various massage techniques, with accompanying photographs 
or drawings.
PRINCIPAL CONCEPTS
Many people in the field of massage therapy assume that the world is a stressful place, and that the stress experienced manifests in the body from tense muscles to 
unhealthy postures to disorganized physiology, all of which lead to sleep problems, mental illness, immune dysfunction, and other chronic diseases. Massage therapy 
is believed to alleviate these problems by reducing stress, improving depressed mood states, improving sleep, and reducing pain. Recently, discussions about 
massage therapy have centered on wellness and how massage therapy can be used to prevent many stress-related problems and illnesses. Aside from taking a 
physical and medical history, massage therapists are not involved in diagnosing clients. Generally, the client presents to the massage therapist's office with a 
diagnosis already made by a physician.
Therapeutically, massage is believed to affect all body systems, from circulation to metabolism. Massage therapists claim that massage improves the elasticity and 
tone of the skin, relaxes muscles, alleviates aches and pains in muscles and joints, facilitates respiration, enhances digestive processes, decreases blood pressure, 
and increases circulation of blood and lymph (
1
). Recently, based on research data, massage therapy was noted to enhance wellness by reducing stress hormones 
and, in turn, improving immune function (
7
).
PROVIDER–CLIENT INTERACTION
The optimal massage therapist–client interaction is brief and nonverbal. Aside from history-taking and inquiring about the patient's diagnosis or complaint, the 
therapist typically only needs to rule out contraindications and to request feedback from the clients as to how much pressure they prefer. Most therapists then 
discourage verbal interaction; it is not their specialty, and quiet massage sessions are often more relaxing.
Most types of massage feature standard techniques that can be presented as a package to most clients. Occasionally, therapists will need to shift from techniques 
that involve pressure (e.g., Swedish, Shiatsu) to nonpressure techniques (e.g., the Trager method, which involves moving the limbs). For example, if the patient has 
fibromyalgia (pain all over the body with an unknown etiology), massage techniques involving pressure may exacerbate the pain of the condition.
THERAPY AND OUTCOMES
Treatment Options
There are many options for massage therapy. There are different types of therapists, different types of massage, and different places to get massage therapy. The 
client makes all of these decisions and, if unsatisfied, can make other choices. Most massage therapy practices are run by trained massage therapists, physical 
therapists, and nurses who offer massage therapy (now called nurse massage therapists). Typically, people go to a therapist who has been recommended and who 
practices the client's technique of choice. Determining the technique of choice is probably best done by simply trying a massage in various techniques. Research will 
also help document the specific techniques that are effective for the client's specific condition.
Many practitioners work out of private clinics; some have treatment rooms in their own homes. Massage therapists may also work in spas, athletic clubs, hair salons, 
hotels, airports, and even at car washes in some cities. Finally, massage therapists are often hired to come to a client's home with a portable table or chair. Massage 
therapy used to be practiced routinely in hospitals (as recently as the 1950s); unfortunately, it is rarely seen in hospitals today.
Types of Massage Techniques
Treatment options include choosing the type of massage (e.g., Swedish or Shiatsu); typically, several techniques are combined. Many techniques are similar and 
involve stroking, kneading, stretching, and relaxation. Generally, the client has some choice about the type of music used during the session and the type of aroma to 

be added to the massage oil. In some wellness centers and commercial programs—The Great American Backrub in New York and Unwind in Miami—clients can 
choose between table massage, which typically involves removing clothing and applying oils, or chair massage, which can be done without removing clothing.
S
WEDISH
 M
ASSAGE
There are five basic techniques in Swedish massage:
1. Effleurage is stroking, which can be superficial or deep and of varying pressure. Deep stroking is usually done in a direction toward the heart, reputedly to help 
circulation; a more superficial stroking is done on the return motion away from the heart.
2. Petrissage is a kneading motion in a circular pattern using the fingers and thumbs. It is intended to stimulate the muscle tissue and the deeper circulation of the 
limbs as well as venous flow, which is made possible by its vigorous movement.
3. Friction involves deeper muscle stimulation by using rolling, ringing, and compression movements. The therapist uses the palm or the heel of the hand and 
sometimes even the elbow and forearm to accomplish these movements. A variation of this technique is practiced in China. The therapist is suspended from a 
bar above the client, enabling him or her to use his or her feet for these friction movements.
4. Tapotement is percussion that involves rhythmic movements, such as slapping, beating, and tapping in a quick vigorous fashion. It is designed to stimulate 
deeper muscles.
5. Vibration is accomplished by the therapist's hands or an electric vibrator to facilitate relaxation.
Swedish massage techniques are typically found in spas, hotels, and athletic clubs. Swedish massage is usually performed with the client on a massage table, on the 
floor, or on a chair. Typically, baby oil, vegetable oil, or an aromatic natural oil is used. These oils are stroked and kneaded on all parts of the body. The various 
movements (e.g., effleurage, petrissage) are done up and down the back, and across the shoulder and neck muscles, the backs of the legs, feet, arms, and hands. 
Stroking on the front of the client is done across the stomach, the front of the legs and arms, and the face and forehead. Therapists will generally inquire if there is a 
body part the client prefers is not touched; that part as well as the private parts are covered, typically with a towel or sheet, at all times.
A
CUPRESSURE
 (S
HIATSU
)
Acupressure, or Shiatsu (shi for finger, atsu for pressure), is a prolonged and heavy pressure that is often combined with Swedish massage. Usually the therapist 
uses only the balls of his or her thumbs and occasionally the palms or the elbows. The therapist's movements follow a diagram of key pressure points called  tsubos. 
These points are reputedly located along meridians in which the energy flows.  Yang meridians flow down the body from head to foot; ying meridians flow up the body 
from the feet to the head. The therapist reputedly makes an assessment to determine if the client has more ying or yang, and then applies pressure along the opposite 
meridian as indicated (e.g., the yang meridian if the client has more ying).
Various mechanisms have been described for the Shiatsu effect, including an increase in vagal activity (the slowing of the heart caused by the vagus nerve), which 
also slows circulation and relaxes the patient. Others say that stress and muscle spasms are reduced by the increase in glucose released in the body (
1
).
N
EUROMUSCULAR
 M
ASSAGE
In neuromuscular massage, the therapist applies even more pressure than in the other types of massage. Neuromuscular massage is intended to reach the deeper 
connective tissues, tendons, ligaments, and nerves. The therapist typically performs this technique using the pads of his or her thumbs, fingers, or both. This 
technique requires greater strength on the part of the therapist.
Treatment Evaluation
Based on existing research, clients normally show immediate effects, including improved mood state and affect and decreased anxiety and stress hormone levels 
(e.g., salivary cortisol). These effects have been highly significant and based on observations of the client, self-reports by the client, and saliva assays of cortisol. In 
addition, changes in EEG recorded before and after the session suggest increased alertness (
8
). Longer-term changes have also been evaluated after 4 to 6 weeks of 
treatment. These changes include a decrease in depression; improved sleep patterns; lower stress, as measured by urinary cortisol, norepinephrine, and epinephrine 
levels (
9
); and enhanced immune function (e.g., an increase in natural killer cells) (
7
).
The effects of massage have also been noted on clinical measures that are specific to different conditions or considered by clinicians to be good measures of 
improved clinical condition. For example, increases in pulmonary function, including peak airflow, have been noted in children with asthma (
10
), and decreased blood 
glucose levels have been reported in children with diabetes after a month of massage (
11
). Another example is significant weight gain in premature infants who are 
given 10 days of massage (
12
). These changes are unique to the given conditions and are not expected to occur generally across medical conditions.
Many of these noted changes are reported in research that compares treatment and control groups or that compares massage with other forms of treatment. Massage 
therapists are more likely to assess treatment effects based on the presence or absence of various obvious symptoms or from the client's reporting a decrease in 
symptoms. Currently, massage therapists are not collecting physiological or biochemical measures, although they are being encouraged to do so. Usually therapists 
alter their treatment if there is no therapeutic effect. However, usually the client elects to discontinue the treatment or seek treatment elsewhere if desired changes do 
not occur, unless the client feels the treatment was indicated just for making him- or herself feel better.
USE OF THE SYSTEM FOR TREATMENT
Major Indications
The primary indications of massage therapy are for wellness and stress and pain reduction. However, there are many other ways in which massage therapy is 
clinically useful.
P
AIN
 R
EDUCTION
Pregnancy and Labor
In many countries, such as India, pregnant women are massaged several times daily for relaxation and to reduce their anxiety levels (
13
). This therapy is considered 
beneficial for both the woman and her fetus. We have been teaching the partners of pregnant women to massage the women during pregnancy and labor (
14
). 
Ultrasound images taken after the massages show positive responses from the fetus. Most of them “like the massage,” as is seen by their smiles on ultrasound. When 
we coded fetal movements, we found a normalization of activity level. This may be associated with reduced anxiety and depression in the mothers.
Burn Patients
Debridement (i.e., skin brushing) is an extremely painful medical procedure used for severe burn patients. Patients usually have significant anxiety in anticipation of 
the pain. Massage therapy is being used to reduce anticipatory anxiety before debridement and to indirectly alleviate pain during the procedure. Following a 5-day, 
30-minute treatment before debridement, burn patients experienced lower anxiety and an associated decrease in cortisol levels (
15
). Pain had also decreased by the 
fifth day of massage treatment, as had depression (probably because of the decrease in pain). Postburn patients, who experience not only pain but itching, reported a 
decrease in both (
15
).
Chronic Pain: Fibromyalgia
In a study on fibromyalgia syndrome, subjects were randomly assigned to one of three therapies—massage therapy, transcutaneous electrical stimulation (TENS), or 
transcutaneous electrical stimulation with no current (SHAM TENS)—for 30-minute treatment sessions, twice weekly for 5 weeks (
16
). The subjects receiving 
massage therapy reported lower anxiety and depression, and their cortisol levels were lower immediately after the therapy sessions on the first and last days of the 
study. The TENS subjects showed similar changes, but only after therapy on the last day of the study. The massage therapy group improved on a dolorimeter 

measure of pain, and they reported less pain, less stiffness and fatigue, and fewer nights of difficult sleeping. Thus, massage therapy was the most effective therapy 
with these fibromyalgia patients.
M
ODELS FOR
 U
NDERLYING
 M
ECHANISMS OF
 T
OUCH AND
 P
AIN
 R
ELIEF
Pain alleviation has most frequently been attributed to the “gate theory” (
17
). This theory suggests that pain can be alleviated by pressure or cold temperature 
because pain fibers are shorter and less myelinated than are pressure and cold temperature receptors. The pressure or cold temperature stimuli are received before 
the pain stimulus, the “gate” to the brain is closed, and thus the pain stimulus is not received.
Another potential theory for pain alleviation through massage therapy relates to quiet (restorative) sleep deprivation. There seems to be a connection between quiet 
sleep deprivation and pain. During quiet sleep, somatostatin is normally released. In the absence of quiet sleep, somatostatin is not released and pain is experienced. 
Also, substance P, which is notable for causing pain, is released in the absence of restorative sleep. One of the leading theories for the pain associated with 
fibromyalgia syndrome is the production of substance P because of restorative sleep deprivation (
16
). With this in mind, it is interesting that the subjects in a 
fibromyalgia syndrome study experienced more quiet sleep and less pain following the massage therapy treatment period (
16
).
A
LLEVIATING
 D
EPRESSION AND
 A
NXIETY
Bulimia in Adolescents
Adolescents with the eating disorder bulimia (overeating and self-induced vomiting) also experience severe depression. After 1 month of massage, bulimic 
adolescents had fewer depressive symptoms, lower anxiety levels, and lower urinary cortisol levels (
18
). Their eating habits also improved, and they had a less 
distorted body image in the short term; long-term effects need to be assessed in a follow-up study.
Chronic Fatigue Syndrome
In one study, chronic fatigue syndrome subjects who had high scores on the Beck Depression Inventory were randomly assigned either to a massage therapy or to a 
SHAM TENS control group (
19
). On the first and last days of the study, the massage therapy group had lower depression and anxiety scores and lower salivary 
cortisol levels than did the SHAM TENS group. Longer-term effects (last day versus first day) indicated that the massage therapy group had lower depression, fewer 
somatic symptoms, more hours of sleep, lower urinary cortisol levels, and elevated urinary dopamine levels than did the SHAM TENS group.
S
TRESS
 R
EDUCTION
Job Stress
In a job-stress study, medical school staff and faculty were give a 15-minute massage during their lunch periods in massage chairs in their offices (
8
). These sessions 
involved the massage therapist applying deep pressure in the back, shoulders, neck, and head regions. Rather than being more sleepy than usual after their midday 
massage, the subjects reported that they experienced heightened alertness, similar to a “runner's high.” EEG recordings before, during, and after the massage 
sessions showed that alpha waves significantly decreased during massage, which is in contrast to the significant increase in alpha levels that occurs during relaxation 
and sleep. This decrease in alpha waves, combined with increased theta and decreased beta waves, suggested a pattern of heightened alertness. A math 
computation task showed that computation time was significantly reduced and the computation accuracy increased following the massages, suggesting that 15-minute 
massages during the lunch period enhance alertness and cognitive performance.
“Grandparent” Volunteers Massaging Infants
Elderly people are noted to suffer from touch deprivation. In an attempt to decrease this situation, volunteer “grandparents” were recruited to massage abused infants 
(
20
). The grandparents also benefited from giving the massages. Their depressed mood decreased following a 1-month period of massaging the infants; they also 
experienced increased self-esteem and decreased cortisol levels. The effects these volunteers experienced from  giving massage were compared with the effects they 
experienced when receiving massage themselves. In a counterbalanced design, these volunteers gave infants massages for 1 month and then received massages for 
1 month. The volunteers benefited more from giving the massage than from receiving the massage. Their affect and self-esteem improved, as did their lifestyle habits: 
they reported drinking fewer cups of coffee daily, they made more social phone calls, and they made fewer trips to the doctor's office.
M
ODELS
 U
NDERLYING
 T
OUCH
 A
LLEVIATING
 S
TRESS AND
 D
EPRESSION
In all of the above studies, the participants' depressed mood was decreased and anxiety levels and stress hormones (e.g., norepinephrine, epinephrine, cortisol) were 
reduced. One potential mechanism is suggested by a recent study measuring frontal EEG activation following massage in depressed adolescents (
21
). The 
individual's shift to a more positive mood is notably accompanied by shifts from right frontal EEG activation (normally associated with sad affect) to left frontal EEG 
activation (normally associated with happy affect) or at least to symmetry (midway between sad and happy affect). In this study on depressed adolescent mothers and 
their infants, right frontal EEG activation (noted in chronically depressed adults and also observed in the depressed mothers and infants in our study) was shifted 
towards symmetry following a 20-minute massage (
21
). The many chemical and electrophysiological changes previously discussed may underlie the decrease in 
depression noted following massage therapy.
An associated potential mechanism may be the increase noted in vagal activity following massage therapy. The nucleus ambiguous branch of the vagus (i.e., the 
“smart” vagus) stimulates facial expressions and vocalizations, which could contribute to less depressed affect and in turn could feedback to effect less depressed 
feelings.
I
MMUNE
 D
ISORDER
: HIV-P
OSITIVE
 A
DULTS
In a study on HIV-positive adults, natural killer cells and natural killer cell cytotoxicity increased following 20 days of massage (
7
). Twenty-nine gay men, 20 of whom 
were HIV-positive and 9 of whom were HIV-negative, were massaged for 1 month; 11 of the HIV-positive men served as their own controls by being compared when 
they were receiving versus not receiving massage. Major immune findings for the effect of the month of massage included a significant increase in the number of 
natural killer cells, natural killer cell cytotoxicity, and subsets of CD8 cells. There was no change in HIV disease progression markers (i.e., CD4; CD4 to CD8 ratios), 
possibly because the HIV-positive men were already severely immunocompromised. Major neuroendocrine findings, measured via 24-hour urines, included a 
significant decrease in cortisol and nonsignificant trends showing decreased catecholamines. Significant decreases in anxiety and increases in relaxation were 
significantly correlated with increases in the number of natural killer cells. Elevated stress hormones (e.g., catecholamines, cortisol) are noted to negatively affect 
immune function. The increase in cytotoxic capacity associated with massage therapy probably derives from the decrease in these stress hormones following 
massage therapy.