Massage - an introduction to the evidence

Research Evidence in Massage

Massage involves the manipulation of soft tissues of the body (1), especially muscles, tendons, ligaments and fascia (2). Massage can be adapted to treat athletes and non-athletes alike for many reasons. Massage can be used to treat various musculoskeletal injuries or conditions, ranging from acute to chronic. Massage is thought to improve circulation, cell metabolism, venous and lymphatic flow, removal of chemical irritants, stretch superficial scar tissue, and alleviate adhesion. As a result, relaxation, pain relief, oedema reduction, increased range of movement, enhanced recovery, and injury prevention can be achieved (3). The growing use by elite athletes suggests there is belief that massage works (4, 5), and has an important role to play in prevention, preparation, rehabilitation, and recovery of athletes (6).

This belief reflects, and supports, my own positive experiences of massage; i) as a retired race cyclist, ii) as an ex-masseur to the GB cycling team, iii) working as a sports therapist. Surprisingly the research literature has yet to demonstrate any clear benefits.

Characteristics of a good massage therapist

Like all interventions, massage needs to be based on sound scientific ‘essential principles’. A good therapist, in addition to being competent in manual therapy should have an understanding of human anatomy, physiology, pathology; and the ability to apply this knowledge when practising massage (15). Frequently cited by many authors, therapists must acquire adequate knowledge of the pathophysiology of soft tissue injury and the healing process (15, 16, 17, 18). Because, an understanding of tissue healing is fundamental to effective massage as the phases of healing guide clinical decision-making with respect to what, when, and how to apply appropriate massage (3, 15). Otherwise, massage may result in poor performance and cause further tissue damage (19). Experience is an essential component in any profession and massage is no exception. For example, a pre-requisite for masseurs applying for major sporting events e.g. Olympics and Commonwealth games require a minimum of 500 hours practical sports massage. In a recent study by Moraska (20), the level of therapist training was shown to impact effectiveness of massage as a post-race recovery tool following a 10-Km run. A greater reduction in muscle soreness was achieved by therapists with 950 hours of training as opposed to those with 450 hours. Interestingly, Bramah (5) believes the reason why chartered physiotherapists fail to understand ‘massage’ is because they only receive approx 6 hours of massage training throughout their entire university degree.

What the research literature says

Massage is not without its critics and the lack of robust research on the benefits or otherwise leaves the discipline open to criticism. Research evidence is scarce (6) and when it does exist produces equivocal findings (7). In many studies, authors cite the lack of positive findings is down to flawed methodology and poor design (6, 7, 8), in some studies, lack of therapist experience (9). Furthermore, within the literature, treatment styles and descriptions use conflicting or inconsistent terminology (10), which creates more confusion, further adding to the research dilemma.
 

In support of the continued use of massage

Although often frowned upon by some professions for its poor evidence-base, the lack of robust evidence is not just confined to massage. Watson (11) reports if one looks critically at the full range of physiotherapy treatments, there is simply insufficient evidence to support or reject many of them in all known circumstances. Furthermore, the absence of evidence does not always mean that there is evidence of absence (11). Although we should strive for evidence-based practice, the lack of sound evidence doesn’t mean a treatment doesn’t work in practice (12), or, shouldn’t be used. However, when sound evidence is lacking, treatment should be guided by experience and clinical reasoning (13). Crucially, treatment outcomes can be enhanced by taking opportunity to compliment massage using other suitable interventions, thereby adopting a multi-factorial and/or multi-disciplinary approach (4, 12, 14). Modern therapy encourages a wider approach.
 

Conclusion

Although relatively few robust randomised controlled studies exist and much of the research is flawed, a strong belief remains that massage has significant therapeutic benefits. If massage failed to produce benefits, it is unlikely that experienced therapists would have continued its use throughout the decades.

References:

1. Westland G. (1993). Massage as a therapeutic tool. British Journal of Occupational Therapy, 56(4), 129-134.
2. Brukner P, Khan K. (2001). Clinical sports medicine. 2nd edition. Sydney: The McGraw-Hill Companies.
3. Anderson MK, Hall SJ, Martin M. (2004). Foundations of athletic training. Prevention, assessment, and management. 3rd edition. USA: Lippincott Williams & Wilkins.
4. Cash M. (2003). Sports massage - hands on help. sportEX Health 18, 28-29.
5. Bramah B. (2006). Massage training and the physiotherapy BSc degree. sportEX dynamics, 9, 9-10.
6. Galloway S, Hunter A. (2005). Mind or Body? Research into sports massage. sportEX dynamics 4, 12-14.
7. Robertson A, Watt JM, Galloway SD. (2004). Effects of massage on recovery from high intensity cycling exercise. British Journal of Sports Medicine, 38,173-176.
8. Heymanson N, Hiskins B. (2006). Delayed onset muscle soreness and soft tissue therapy - what makes good research? sportEX dynamics, 10, 8-11.
9. Hilbert J, Sforzo G, Swensen T. (2003). The effects of massage on delayed onset muscle soreness. British Journal of Sports Medicine. 37, 72-75.
10. Dixon MW, Sherman KJ, Thompson D, Cherkin DC. (2007). Massage terminology - it’s all in the name. sportEX dynamics 11, 14-21.
11. Watson T. (2000). The role of electrotherapy in contemporary physiotherapy practice. Manual Therapy, 5, 132-141.
12. Patel K, Patel S. (2007). Low back pain - a multidisciplinary symposium and debate. sportEX dynamics 13, 19-22.
13. Naylor CD. (1995). Grey zones of clinical practice: some limits to evidence-based medicine. Lancet, 345, 840-842.
14. Bury T, Mead J. (1998). Evidence-based healthcare: a practical guide for therapists. Oxford: Butterworth Heinemann.
15. Holey E, Cook E. (2003). Evidence-Based Therapeutic Massage. Edinburgh: Churchill Livingstone.
16. Glasgow P. (2007). Sports rehabilitation: principles and practice. sportEX medicine. 32, 10-16.
17. Kannus P, Parkkari TL, Jarvinen T., et al. (2003). Basic science and clinical studies coincide: active treatment approach is needed after a sports injury. Scandinavian Journal of Medicine and Science in Sports. 13, 150-154.
18. Clark N. (2004). Principles of injury rehabilitation. sportEX medicine. 19, 6-10.
19. Hunter G. (1998). Specific soft tissue mobilisation in the management of soft tissue dysfunction. Manual Therapy. 3(1), 2-11.
20. Moraska A. (2007). Therapist education impacts the massage effect on postrace muscle recovery. Medicine & Science in Sports & Exercise, 39 (1), 34-37.