Theory For Massage

Psychological Bulletin Copyright 2004 by the American Psychological Association, Inc.
2004, Vol. 130, No. 1, 3–18 0033-2909/04/$12.00 DOI: 10.1037/0033-2909.130.1.3
A Meta-Analysis of Massage Therapy Research

Christopher A. Moyer, James Rounds, and James W. Hannum
University of Illinois at Urbana–Champaign
Massage therapy (MT) is an ancient form of treatment that is now gaining popularity as part of the
complementary and alternative medical therapy movement. A meta-analysis was conducted of studies
that used random assignment to test the effectiveness of MT. Mean effect sizes were calculated from 37
studies for 9 dependent variables. Single applications of MT reduced state anxiety, blood pressure, and
heart rate but not negative mood, immediate assessment of pain, and cortisol level. Multiple applications
reduced delayed assessment of pain. Reductions of trait anxiety and depression were MT’s largest effects,
with a course of treatment providing benefits similar in magnitude to those of psychotherapy. No
moderators were statistically significant, though continued testing is needed. The limitations of a medical
model of MT are discussed, and it is proposed that new MT theories and research use a psychotherapy
perspective.
Massage therapy (MT), the manual manipulation of soft tissue physicians, who adopted his techniques and shared them with
intended to promote health and well-being, has a history extending like-minded colleagues. Soon after, in the later part of the century,
back several thousand years. Recorded in writing as far back as the Dutch physician Johann Mezger was successful in reintroduc-
2000 B.C. (Fritz, 2000, p. 13), massage was a part of many ancient ing massage to the scientific community, presenting it to his
cultures including that of the Chinese, Egyptians, Greeks, Hindus, colleagues as a medical treatment, and codifying some of its
Japanese, and Romans, and was often considered to be a medicinal elements with terms that are still in use today (Fritz, 2000, pp.
practice (Elton, Stanley, & Burrows, 1983, p. 275). The Greek 16 –17; Salvo, 1999, pp. 9 –11).
physician Hippocrates (460 –377 B.C.) advocated rubbing as a Interest in MT has continued to grow among the scientific
treatment for stiffness; later, the physicians Celsus (25 B.C.–A.D. community and consumers alike. Currently, in the United States,
50) and Galen (A.D. 129 –199) wrote extensively on the medicinal MT is one of the fastest growing sectors of the expanding com-
and therapeutic value of massage and related techniques such as plementary and alternative medical therapy movement. Visits to
anointing, bathing, and exercise. However, in Western cultures, the massage therapists increased 36% between 1990 and 1997, with
association between massage and medicine eventually diminished consumers now spending between $4 and $6 billion annually for
as Greco-Roman traditions were abandoned. Although the practice MT (Eisenberg et al., 1998), in pursuit of benefits such as im-
of massage continued as a folk medicine treatment during the proved circulation, relaxation, feelings of well-being, and reduc-
Middle Ages, its adoption by the common people served to sepa- tions in anxiety and pain, all of which are endorsed as benefits of
rate it from the scientific and medical milieu, and in this way, MT by the American Massage Therapy Association (AMTA,
massage fell out of favor with the medical establishment (Fritz, 1999b). At the same time, numerous studies across several fields
2000; Salvo, 1999). including psychology, medicine, nursing, and kinesiology support
This schism continued during the early part of the 19th century, MT’s therapeutic value. Field (1998) reviewed the effectiveness of
during which time Per Henrik Ling developed Swedish massage, MT in treating symptoms associated with a host of clinical con-
the basis of many modern forms of MT. Ling, who was not trained ditions, including pregnancy, labor, burn treatment, postoperative
in medicine, applied his ideas and techniques to the treatment of pain, juvenile rheumatoid arthritis, fibromyalgia, back pain, mi-
disease, a practice that met opposition from the Swedish medical graine headache, multiple sclerosis, spinal cord injury, autism,
community. Despite this resistance, Ling gained support from his attention-deficit/hyperactivity disorder, posttraumatic stress disor-
influential clients and was eventually able to teach his system to der, eating disorders, chronic fatigue, depression, diabetes, asthma,
HIV, and breast cancer. In addition to the beneficial outcomes that
were unique to these specific conditions, Field proposed a set of
Christopher A. Moyer, James Rounds, and James W. Hannum, Depart- common findings by indicating that “across studies, decreases
ment of Educational Psychology, University of Illinois at Urbana– were noted in anxiety, depression, [and] stress hormones (corti-
Champaign. sol)” (p. 1278).
We wish to thank Sue Duval, Carol Webber, and the Interlibrary Even the popular press has picked up on the increase in MT
Borrowing Staff at the Illinois Research and Reference Center, University
practice and research. A feature in Time suggested that MT is on
of Illinois at Urbana–Champaign, for their invaluable contributions to this
project. Patrick Armstrong and James Wardrop also contributed.
the rise, in part, because of “people’s greater awareness of the
Correspondence concerning this article should be addressed to James effect stress has on health” (Luscombe, 2002, p. 49). It is also
Rounds, Department of Educational Psychology, University of Illinois at reported that the National Institutes of Health have begun funding
Urbana–Champaign, 1310 South Sixth Street, Champaign, IL 61820-6990. MT research, and that the White House Commission on Comple-
E-mail: [email protected] mentary and Alternative Medicine Policy (2002) has called for
3
4 MOYER, ROUNDS, AND HANNUM
more research and public education on MT. The Time article ing, causing movement, and/or applying pressure to the body,” and
concludes by noting that the Commission’s chairman, physician massage therapy as “a profession in which the practitioner applies
James Gordon, indicates that MT is known to be effective in manual techniques, and may apply adjunctive therapies, with the
decreasing anxiety, reducing pain, and improving mood (Lus- intention of positively affecting the health and well-being of the
combe, 2002, p. 50). client” (AMTA, 1999a). Clearly, these definitions provide latitude
If MT can be effective in the ways indicated by the AMTA, for a variety of approaches to exist under the rubric of MT. In one
Field, and Gordon, it would represent a therapy of interest to a instance, MT may consist of a treatment lasting an hour or more,
variety of fields. One can imagine its use expanding beyond the with long, firm strokes applied to numerous sites of the client’s
private practices of massage therapists, and extending to places body, while that client lies partially disrobed on a specially de-
such as hospitals, nursing homes, psychological treatment centers, signed table in a private clinic. In another instance, an MT client
sports performance clinics, and workplaces. In addition, MT could may receive a 10-min treatment of kneading focused on the shoul-
establish itself as a treatment supported by insurance carriers and ders while seated fully clothed in a specially designed chair, in a
health maintenance organizations. These are, in fact, trends that are public space such as a shopping mall or workplace. Duration of
already occurring in a limited way. Nevertheless, for these trends treatment, types of touch and strokes administered, the sites of the
to continue (indeed, to determine if they even should continue), body where treatment is applied, the apparatus used to facilitate
what is needed is a more rigorous and quantitative examination of treatment, and where that treatment takes place can all vary con-
MT’s effectiveness than that which currently exists. siderably. In addition, there is also considerable variability in the
There are three meta-analyses of MT research, but each is very explanatory mechanisms that massage therapists (and recipients)
limited in scope. Ottenbacher et al. (1987) quantified 19 studies subscribe to. Finally, the outcomes being pursued may vary
that examined the effects of tactile stimulation on infants and widely; whereas one client may undergo MT in the hopes of
young children, and found statistically significant beneficial out- obtaining relief from backache, another may receive MT to reduce
comes for five of the six categories examined: motor–reflex, emotional tension. In the present study, we define MT as the
cognitive–language, social–personal, physiological, and overall manual manipulation of soft tissue intended to promote health and
development. Labyak and Metzger (1997) examined nine studies well-being, a definition that encompasses the diverse nature of this
that sought to measure the effect of effleurage back massage on form of treatment.
physiological indicators of relaxation, and concluded that this form Though MT can take a variety of forms, the common element
of MT was effective in promoting relaxation. However, interpre- that allows these forms to be grouped together is their use of
tation of this finding is made problematic by their decision to interpersonal touch in the form of soft tissue manipulation. This
include within-groups designs in the analysis, leaving open the element forms the basis for the predominant theories encountered
possibility that the observed effects could be attributable to spon- in MT research that are concerned with how it may provide the
taneous recovery, placebo effect, or statistical regression (Field, benefits of reductions in anxiety, depression, stress hormones, and
1998, p. 1270), and by the fact that only limited information is pain. In several of these theories, the pressure applied to the body
provided on the individual studies and their effect sizes. Ernst by means of MT is thought to trigger certain physiological re-
(1998) reviewed seven studies that assessed the effect of postex- sponses that ultimately result in beneficial outcomes. It should be
ercise MT as a treatment for delayed-onset muscle soreness, reach- noted, however, that the pressure required by these theories has not
ing the tentative conclusion that MT may be a promising treatment, been quantified, nor do existing clinical studies of MT routinely
a conclusion that is hampered, like that of Labyak and Metzger, by report on the amount of pressure administered in a way that would
a lack of sufficient statistics reported in the review itself. permit precise replication. Although at least one study utilizing
No study to date has quantitatively reviewed the range of infants as subjects observed differential effects in terms of weight
commonly reported MT effects in physically mature individuals. gain for firm versus light strokes (Scafidi et al., 1986), no study to
The present study is intended to address this problem. By means of date has examined pressure as an independent variable with a
a more exhaustive literature search than those conducted in previ- sample of physically mature participants.
ous reviews, we seek to unite the spectrum of MT studies that
appear in a range of scientific disciplines including psychology, MT Theories
medicine, nursing, and kinesiology. In addition, by limiting inclu-
sion to studies that use a between-groups design with random Unfortunately, there has been little emphasis on theory in the
assignment of participants, the present study more accurately mea- MT literature, with many researchers choosing to emphasize their
sures MT’s true effects than reviews that have included other predictions and results without testing, or in some cases even
designs that are open to bias and do not permit strong causal discussing, possible explanatory mechanisms. In other instances,
claims. theories are offered, but important details are omitted. Researchers
have rarely specified such things as whether a theory explains
Overview of MT immediate versus lasting effects, or if activation of a theoretical
mechanism requires a course of treatment as opposed to a single
In modern practice, MT is not a single technique, or even a application. For the theories that follow, we suggest that only the
single set of techniques. Rather, it is a broad heading for a range first one, the gate control theory of pain reduction, is logically
of approaches that share common characteristics, a fact that is limited to providing an immediate effect. Each of the remaining
evident in definitions provided by the AMTA. The AMTA defines theories, to various degrees, could potentially offer immediate or
massage as “manual soft tissue manipulation [that] includes hold- lasting effects, or provide benefits that accumulate over a course of
MASSAGE THERAPY META-ANALYSIS 5
treatment. However, it must be noted that these are strictly sup- which “may inhibit the transmission of noxious nerve signals to
positions and have not yet been tested. the brain” (Field, 1998, p. 1274). Others have suggested that
The order in which these theories are presented reflects their manipulations such as rubbing, or applying pressure, may stimu-
frequency in the literature. Those that appear first are most fre- late a release of endorphins into the bloodstream (Andersson &
quently cited. Lundeberg, 1995; Oumeish, 1998). In these ways, MT may pro-
vide pain relief or feelings of well-being by influencing the body
Gate Control Theory of Pain Reduction chemistry of the recipient.
Melzack and Wall (1965) theorized that the experience of pain

can be reduced by competing stimuli such as pressure or cold,
Mechanical Effects
because of the fact that these stimuli travel along faster nervous Articles concerned with sports performance, exercise recovery,
system pathways than pain. In this way, MT performed with and injury management highlight the possibility that MT may
sufficient pressure would create a stimulus that interferes with the speed healing and reduce pain by mechanical means. The manip-
transmission of the pain stimuli to the brain, effectively “closing ulations and pressure of MT may break down subcutaneous adhe-
the gate” to the reception of pain before it can be processed (e.g., sions and prevent fibrosis (Donnelly & Wilton, 2002, p. 5) and
Barbour, McGuire, & Kirchhoff, 1986; Field, 1998; Malkin, promote circulation of blood and lymph (Fritz, 2000, pp. 475–
1994). This notion, that MT may have an analgesic effect consis- 478), processes that may lead to reductions in pain associated with
tent with gate control theory, appears in the literature more than injury or strenuous exercise. However, as a group, studies con-
any other theory pertaining to MT. cerned with measuring MT’s effect on circulation have generated
inconsistent results (Tiidus, 1999).
Promotion of Parasympathetic Activity
MT may provide its benefits by shifting the autonomic nervous Promotion of Restorative Sleep
system (ANS) from a state of sympathetic response to a state of
parasympathetic response. A sympathetic response of the ANS Individuals deprived of deep sleep may experience changes in
occurs as an individual’s body prepares to mobilize or defend itself body chemistry that lead to increases in pain. In the absence of
when faced with a threat or challenge, and is associated with deep sleep, levels of substance P increase and levels of somatosta-
increased cardiovascular activity, an increase in stress hormones, tin decrease, and both of these changes have been linked with the
and feelings of tension. Conversely, the parasympathetic response experience of pain (Sunshine et al., 1996). Sunshine et al. (1996)
occurs when an individual’s body is at rest and not faced with a concluded that MT may have promoted deeper, less disturbed
threat, or is recovering from a threat that has since passed, and is sleep in a sample of fibromyalgia sufferers who experienced a
associated with decreased cardiovascular activity, a decrease in reduction in pain during the course of treatment. Chen, Lin, Wu,
stress hormones, and feelings of calmness and well-being and Lin (1999) reached the conclusion that acupressure treatment
(Sarafino, 2002, p. 40). may have been effective in improving sleep quality in a sample of
The pressure applied during MT may stimulate vagal activity elderly residents at an assisted-living facility. In this way, MT may
(Field, 1998, pp. 1273, 1276 –1277), which in turn leads to a reduce pain indirectly by promoting restorative sleep.
reduction of stress hormones and physiological arousal, and a
subsequent parasympathetic response of the ANS (e.g., Ferrell- Interpersonal Attention
Torry & Glick, 1993; Hulme, Waterman, & Hillier, 1999;
Schachner, Field, Hernandez-Reif, Duarte, & Krasnegor, 1998). The five theories previously described, the majority of which
By stimulating a parasympathetic response through physiological attempt to explain the role MT may play in reducing pain, are the
means, MT may promote reductions in anxiety, depression, and only ones that appear consistently in the scientific literature. How-
pain that are consistent with a state of calmness. This same ever, the element of interpersonal attention that may be present in
mechanism may also be responsible for several condition-specific MT must also be considered. It is occasionally noted that some
benefits resulting from MT, such as increased immune system portion of MT effects may result from the interpersonal attention
response in HIV-positive individuals (Diego et al., 2001), or im- that the recipient experiences, as opposed to resulting entirely from
proved functioning during a test of mental performance, in which the activation of physiological mechanisms (Field, 1998, p. 1270;
study participants receiving MT also displayed changes in electro- Malkin, 1994). However, although this possible effect of interper-
encephalograph pattern consistent with increased relaxation and sonal attention is acknowledged in the research literature, it is
alertness (Field, Ironson, et al., 1996). However, support for this almost universally treated as a nuisance variable, and comparison
theory is not universal, and it has even been suggested that MT treatments are selected in such a way that different groups receive
may promote a sympathetic response of the ANS (e.g., Barr & the same amount of attention. In this way it is believed that any
Taslitz, 1970). benefits demonstrated by the MT group that exceed those of the
comparison group can be attributed to a specific ingredient of MT,
Influence on Body Chemistry specifically interpersonal touch in the form of soft tissue manip-
ulation. Although many studies, including all of those in the
Two studies have linked MT with increased levels of serotonin present analysis, attempt to control for interpersonal attention, no
(Field, Grizzle, Scafidi, & Schanberg, 1996; Ironson et al., 1996), study to date has examined it as an independent variable. As such,
the role that interpersonal attention may play in MT effects is not MT may have enduring effects on other variables has gone essen-
well understood. tially unaddressed.
Effects Single-Dose Effects

The present study examines both psychological and physiolog- State anxiety. State anxiety is a momentary emotional reaction
ical effects resulting from MT. The psychological effects corre- consisting of apprehension, tension, worry, and heightened ANS
spond with those suggested by Field and Gordon and endorsed by activity. Because state anxiety can be understood as a reaction to
the AMTA, and are also of interest because MT can be considered one’s condition or environment, the intensity and duration of such
a novel way of treating these conditions, which are more routinely a state is determined by an individual’s perception of a situation as
addressed by means of psychotherapy or pharmaceuticals. The threatening (Spielberger, 1972, p. 489). Many of the samples used
physiological effects nominate themselves because MT is a phys- in MT research are drawn from populations experiencing serious
ical therapy. and chronic health problems that can lead to feelings of anxiety
We contend that MT effects can also be divided into single-dose
(Hughes, 1987; Popkin, Callies, Lentz, Cohen & Sutherland,
effects and multiple-dose effects. Single-dose effects include MT’s
1988). If MT is effective in reducing state anxiety, it may be
influence on states, either psychological or physiological, that are
doubly valuable to such patient populations, in that it could both
transient in nature and that might reasonably be expected to be
improve subjective well-being and promote physical health. In
influenced by a single session of MT. These include state anxiety,
physically healthy populations, the improvement in subjective
negative mood, pain assessed immediately following treatment,
well-being alone may be the primary benefit of a reduction in state
heart rate, blood pressure, and cortisol level. Multiple-dose effects
anxiety.
are restricted to MT’s influence on variables that are typically
Negative mood. Some studies have examined the effect of MT
considered to be more enduring, or that would likely be influenced
on mood, which may be defined as “transient episodes of feeling
only by a series of MT sessions performed over a period of time,
or affect” (Watson, 2000, p. 4). Although the primary studies do
as opposed to a single dose. These variables include trait anxiety
not specify a model for mood, virtually all the studies appear to be
and depression, as well as pain when it is assessed at a time
concerned with MT’s ability to bring about a reduction of negative
considerably after treatment has ended.
affect rather than an increase in positive affect.
Frequently, researchers elect to examine both single-dose effects
and multiple-dose effects within the same study. Diego et al. Pain. Several studies have examined MT’s immediate effect
(2001) is one such study, in which treatment group participants on pain, the unpleasant emotional and sensory experience that is
received MT twice weekly for a period of 12 weeks, and compar- associated with actual or potential tissue damage (Merskey et al.,
ison group participants engaged in progressive muscle relaxation 1979). The sources of pain in the primary studies are diverse, and
(PMR) according to the same schedule. Assessments of state include conditions such as headache (Hernandez-Reif, Dieter,
anxiety were made immediately prior to, and immediately follow- Field, Swerdlow, & Diego, 1998), backache (Hernandez-Reif,
ing, both the first and last sessions of MT or PMR in the study. Field, Krasnegor, & Theakston, 2001), and labor pain (Hemenway,
Depression, a condition expected to be more resistant to change, 1993) among others.
was assessed prior to the first session of MT or PMR, and not again Cortisol. Some MT studies have attempted to measure a
until after the 24th and last sessions of either treatment. Many change in participants’ cortisol levels. Cortisol is a stress hormone
studies, particularly those conducted by the Touch Research Insti- associated with the sympathetic response of the ANS (Field,
tute, use such a design in order to examine both single- and 1998). MT, a therapy commonly thought of as relaxing, is ex-
multiple-dose effects. pected to reduce cortisol levels, a finding that would be consistent
It must be noted that the terms single-dose effect and multiple- with facilitating a parasympathetic response of the ANS (e.g.,
dose effect are not yet in common usage. Research into MT Field et al., 1992; Ironson et al., 1996).
generated by the Touch Research Institute typically uses the terms Blood pressure. A handful of studies have examined MT’s
short-term effect and long-term effect to make a similar distinction, effect on blood pressure. Although predictions are not always
but no consistent terminology has been used among other MT offered, most commonly MT is expected to reduce blood pressure
researchers. The decision to use this terminology is motivated by consistent with a parasympathetic response of the ANS
the desire to prevent any confusion that may arise with regard to (Hernandez-Reif, Field, et al., 2000; Okvat, Oz, Ting, &
how long an effect may last following the termination of treatment. Namerow, 2002).
Very few studies have attempted to examine whether any MT Heart rate. A few studies examining MT have attempted to
effects may last beyond the final day on which a participant measure its physiological effects in terms of heart rate. Research-
receives treatment, making the use of the term long-term effect ers have not always offered clear predictions for this variable (Barr
potentially confusing. All effects in the present study, with the & Taslitz, 1970), but in cases where a prediction is evident, most
exception of one outcome variable, were assessed on the same day often a decrease in heart rate is predicted, consistent with a
that a treatment took place. The exception is MT’s effect on parasympathetic response of the ANS (Cottingham, Porges, &
delayed assessment of pain, for which assessments took place at Richmond, 1988; Okvat et al., 2002). Nevertheless, some research-
various time periods significantly after treatment had been discon- ers have noted that the opposite effect could be observed in cases
tinued. Presently, pain appears to be the only variable in the MT in which MT was a novel experience for research participants
literature that has been assessed in this way; the possibility that (Reed & Held, 1988, p. 1232).
Multiple-Dose Effects Munizza, 1999; Yyldyz & Sachs, 2001) and in psychotherapy
(e.g., Bierenbaum, Nichols, & Schwartz, 1976; Turner, Valtierra,
Trait anxiety. Several studies have examined MT’s potential Talken, Miller, & DeAnda, 1996) to examine dosage as an inde-
to reduce trait anxiety, the “relatively stable individual differences pendent variable. However, no studies concerned with MT have
in anxiety proneness as a personality trait” (Spielberger, 1972, p. done so. It is not known whether there is a minimal amount, in
482). In contrast with the transient and situation-specific nature of terms of minutes of MT administered per session, required to
state anxiety, trait anxiety is a dispositional, internalized proneness produce benefits, nor is it known whether there is an optimal
to be anxious (Phillips, Martin, & Meyers, 1972, p. 412). Persons amount of MT that produces benefits most efficiently. Fortunately,
with high levels of trait anxiety tend to perceive the world as more the studies that exist vary considerably in the amount of MT
dangerous or threatening, and experience anxiety states more fre- administered to participants in each session, from as little as 5 min
quently and with greater intensity than those with lower levels of (Fraser & Kerr, 1993; Wendler, 1999) to as much as an hour
trait anxiety (Spielberger, 1972, p. 482). (Levin, 1990). By examining the relationship between the magni-
Depression. Ingram and Siegle (2002) noted that, in the course tude of effects generated and the amount of MT administered per
of research, the concept of depression has been defined many session, the present study aims to determine whether there are
different ways, including as a mood state, a symptom, a syndrome, minimum or optimum dosages of MT.
a mood disorder, and a disease. In the current meta-analysis, Mean age of participants. Although MT research has been
studies included in this category have been chosen on the basis of performed on samples with a variety of age ranges, no study has
their utilization of a measure believed to capture something be- sought to determine whether MT offers effects of differing mag-
yond “ordinary unhappiness” or a “sad mood,” symptoms that nitude to participants who differ in age. The present study exam-
would more accurately belong to the previously discussed category ines whether there is a relationship between the mean age of the
of negative mood. Subclinical depression, likely the best descrip- participants in a study and the magnitude of effects.
tion of the type of depression most often assessed in MT research, Gender of participants. Only one study to date, using a very
consists of the aforementioned symptoms combined with symp- small sample, has examined whether MT effects might vary ac-
toms such as mild to moderate levels of motivational and cognitive cording to the gender of the recipients (Weinrich & Weinrich,
deficits, vegetative signs, and disruptions in interpersonal relation- 1990). The present study more powerfully examines the possibility
ships (Ingram & Siegle, 2002, p. 90). that the gender of the recipient might moderate MT effects by
Delayed assessment of pain. A few studies have assessed examining whether study outcomes vary according to gender.
participants’ experience of pain at one or more time points signif- Type of comparison treatment. In discussing the research find-
icantly after a course of treatment has ended. The majority of these ings for a different treatment modality (psychotherapy), Wampold
studies have done so at intervals that range from a few days to 6 (2001) noted that there is a distinction that must be made between
weeks (Cen, 2000; Dyson-Hudson, Shiflett, Kirshblum, Bowen, & absolute and relative efficacy. Absolute efficacy “refers to the
Druin, 2001; Preyde, 2000; Shulman & Jones, 1996), although one effects of treatment vis-à-vis no treatment and accordingly is best
study included an assessment that took place 42 weeks after addressed by a research design where treated participants are
treatment ended (Cherkin et al., 2001). Because of the small contrasted with untreated participants” (Wampold, 2001, p. 59).
number of studies, and the range of times at which delayed By contrast, relative efficacy “is typically investigated by compar-
assessments were made, it is not expected that the present study ing the outcomes of two treatments” when one wishes to determine
will be able to determine precisely how long an analgesic effect which, if either, is superior (Wampold, 2001, p. 73). Clearly, the
resulting from MT lasts, or the rate at which such an effect decays; type of efficacy one wishes to measure plays an important part in
rather, the aim is simply to examine whether or not MT may have determining what will be an appropriate choice for a comparison,
a lasting analgesic effect. as a study designed to measure one does not necessarily measure
the other. This issue of distinguishing absolute efficacy (does MT
Moderators work better than no treatment at all?) from relative efficacy (does
MT work better than a specific alternative treatment, such as
A number of potentially interesting moderator variables have PMR?) has not been made explicit enough in MT research. How-
gone unexamined in MT research. Primary studies, for instance, ever, a wide variety of comparison treatments have been used in
have neglected to examine whether the length of MT sessions, or MT research, some of which resemble a wait-list (no treatment)
characteristics of the therapist and the recipient, influence the condition, whereas others use active treatments (such as the afore-
magnitude of MT effects. Similarly, only a few studies have used mentioned PMR, or chiropractic care) as a point of comparison, or
more than one comparison group, making it difficult to determine placebo-type comparison treatments that are meant to account for
whether the type of treatment to which MT is compared may the effect of receiving attention (such as transcutaneous electrical
moderate its effects. Although within-study examinations of such stimulation performed with a machine that is not delivering any
moderators would permit stronger inferences to be made, their current to the participant). Logically, if MT has any effect what-
importance can be explored in the present study by means of soever, we expect the MT effects that result from comparison with
between-study comparisons. In addition, the present study also a no-treatment condition would be larger than those that result
examines a potential moderator that cannot be examined within an from comparing MT to any treatment condition, including so-
individual study, that of a laboratory effect. called placebo conditions in which the participants receive no
Minutes of MT per session. It is common for treatment studies viable treatment. Combining the results of such different studies
in medicine (e.g., Bollini, Pampallona, Tibaldi, Kupelnick, & without attempting to account for these different comparison
points could be problematic. For this reason, we have divided the placebo comparison treatments. Finally, no prediction is made
comparison treatments in the primary studies, when possible, as concerning therapist training, or the existence of a laboratory
belonging to either wait-list equivalent or active/placebo effect.
categories.
The wait-list equivalent category consists of comparison treat-
Method
ments that most closely resemble having received no treatment,
and includes wait-list controls, standard care (in studies where all Literature Search and Criteria for Inclusion
participants had a medical condition and continued to receive care
for that condition regardless of group assignment), rest, reading, or A literature search was performed by Christopher A. Moyer and a
a work break. The active/placebo category consists of all other graduate student in library and information sciences hired as a research
comparison treatments, which are grouped according to the expec- assistant. The PsycINFO, MEDLINE, CINAHL, SPORT Discus, and Dis-
tation that each could reasonably be expected to have some effect, sertation Abstracts International databases were searched using the fol-
lowing key words: massage, massotherapy, acupressure (and accupres-
including the possibility of a placebo effect. These include treat-
sure), applied kinesiology, bodywork, musculoskeletal manipulation,
ments such as PMR, acupuncture, chiropractic care, and various reflexology, relaxation techniques, Rolfing, Touch Research Institute, and
forms of attention, among others. Studies that used multiple com- Trager. Author searches were conducted within the same databases for the
parison groups that could not be included together within a single following authors associated with MT research: Burman, I.; Field, T.; Hart,
category were not included in either category. S.; Hernandez-Reif, M.; Kuhn, C.; Peck, M.; Quintino, O.; Schanberg, S.;
Therapist training. Treatment research in fields such as psy- Taylor, S.; Theakston, H.; Weinrich, M.; and Weinrich, S. The Internet
chology (Pinquart & Soerensen, 2001; Weisz, Weiss, Alicke, & Web sites of the AMTA (www.amtamassage.org), the AMTA Foundation
Klotz, 1987) and medicine (Lin et al., 1997; Tiemens et al., 1999) (www.amtafoundation.org), and the Touch Research Institute (http://www
sometimes examines the existence of training effects to determine .miami.edu/touch-research/) were inspected for references, and the Touch
whether practitioners with greater amounts of training provide Research Institute was also contacted directly to request unpublished data.
The reference lists of all studies located by these means were then manu-
greater benefit to those being treated. No MT research, however,
ally searched to yield additional studies.
has examined the training of the massage therapist as an indepen- All studies were inspected to ensure that they examined a form of MT
dent variable. However, the studies that do exist vary in regard to consistent with the present study’s operational definition, in which MT is
who performs MT on participants. The majority of studies use one defined as the manual manipulation of soft tissue intended to promote
or more fully trained and licensed massage therapists. Others health and well-being. Studies were limited to those that administered MT
utilize a layperson with only minimal training in providing mas- to human participants other than infants, and that reported results in
sage, usually just enough to facilitate the study (e.g., Fischer, English. Studies concerned with chiropractic, heat therapy, hydrotherapy,
Bianculli, Sehdev, & Hediger, 2000; Weinrich & Weinrich, 1990; passive motion, or progressive relaxation treatments were not included,
Wendler, 1999). By contrasting the results of studies that used a unless the study also included an MT group. Studies examining therapeutic
fully trained massage therapist with those that used a layperson to touch, a nursing intervention distinct from MT (in that it does not actually
require physical contact to occur), were also excluded unless they also had
provide treatment, the present meta-analysis may be able to deter-
an MT group. Several studies used more than two groups; in these cases,
mine whether a therapist’s training plays an important role in study results were combined in order to yield a between-groups compari-
providing MT benefits. son of all subjects receiving MT versus all subjects receiving non-MT
Laboratory effect. Much of the research in this area, and treatments. Studies concerned with ice massage, participants performing
especially the most recent research, is the product of a single self-massage, or massage performed with the aid of mechanical devices
laboratory, the Touch Research Institute (Field, 1998). Because were excluded, as were studies that only included MT as part of a
this one source is responsible for a large proportion of MT studies, combination treatment (e.g., MT combined with exercise and movement
it is important to determine whether the results coming from this therapy). MT administered with scented oil or MT administered with
research group differ in a significant way from those of other background music were not considered to be combination treatments, as
researchers. If a difference is found, it would be important to these are common elements of MT in clinical practice, and studies using
such treatment were included. Studies that did not explicitly label a
examine more closely what factors contribute to that difference.
treatment as “massage” or as “massage therapy,” but used a treatment that
fit the authors’ operational definition of MT, were included.
Predictions These criteria yielded 144 studies concerned with outcomes of MT. Each
study was reviewed independently by Christopher A. Moyer and James
MT is expected to promote significant and desirable reductions Rounds for possible inclusion in the meta-analysis. Studies were examined
for each of the following variables, consistent with the existing to ensure that they (a) compared an MT group with one or more non-MT
explanatory theories outlined above: state anxiety, negative mood, control groups, (b) used random assignment to groups, and (c) reported
pain (immediate and delayed assessment), cortisol, heart rate, sufficient data for a between-groups effect size to be generated on at least
blood pressure, trait anxiety, and depression. It is expected that one dependent variable of interest. These three criteria accounted for
greater reductions in these variables will be associated with higher approximately equal proportions of excluded studies.
The first two inclusion criteria were necessary to ensure that effects were
doses of MT, in the form of minutes of MT administered per
a result of treatment. When participants in MT research serve as their own
session, a relationship one would expect to observe if MT is a controls (e.g., Bauer & Dracup, 1987; Fakouri & Jones, 1987) there is no
viable treatment. MT effects are not expected to vary according to way to know whether effects are attributable to treatment or are instead the
the age or gender of participants. It is expected that MT effects result of spontaneous recovery, placebo effect, or statistical regression
generated from studies using wait-list equivalent comparison treat- (Field, 1998, p. 1270). Similarly, random assignment of participants to
ments will be larger than those generated from studies with active/ groups is necessary to control for the possibility of selection effects. Glaser
(1990) is an example of a study that is threatened in this way. Because Depression. Five of the 10 studies assessing depression utilized the
treatment participants were previously enrolled in an MT program, and Center for Epidemiological Studies—Depression Scale (CES–D; Radloff,
were compared with a group of participants who were not enrolled, it is 1977). Two used the SCL-90-R, and one combined the CES–D and the
likely that these groups differed in their predisposition toward MT in a way SCL-90-R. The remaining studies used either the Children’s Depression
that could affect results. Inventory—Short Form (Kovacs, 1992) or an investigator-constructed
When studies met all criteria apart from reporting sufficient data for measure.
calculating between-groups effects, and contact information was available, Delayed assessment of pain. The five studies assessing pain at a time
study authors were contacted in an attempt to obtain the necessary data. significantly after treatment ended relied on five different instruments.
Specifically, there were seven studies from the Touch Research Institute These were the Neck Pain Questionnaire (Leak et al., 1994), the Wheel-
for which this was the case (Field et al., 1999; Field et al., 2000; Field, chair User’s Shoulder Pain Index (Curtis et al., 1995), the McGill Pain
Peck, et al., 1998; Field, Quintino, Henteleff, Wells-Keife, & Delvecchio- Questionnaire (Melzack, 1975), a visual analogue scale, and an
Feinberg, 1997; Field, Schanberg, et al., 1998; Field, Sunshine, et al., 1997; investigator-constructed measure.
Sunshine et al., 1996). Upon our request, we were informed that the data
needed from these studies (standard deviations) were no longer available. Statistical Analysis
For this reason, these studies could not be included in the meta-analysis.
Interrater agreement for the inclusion process was 93%. The 10 studies Effect sizes. Between-groups comparisons on variables of interest were
for which there was initial disagreement, which occurred most frequently converted to Hedges’s g effect size. Hedges’s g, calculated as (Group Mean
as a result of uncertainty regarding random assignment, were then reviewed 1 – Group Mean 2) ! pooled standard deviation, estimates the number of
jointly, with the subsequent decision made to exclude 8 of these. This standard deviations by which the average member of a treatment group
resulted in a total of 37 studies meeting the inclusion criteria. differs from the average member of a comparison group for a given
outcome. In cases where a study used more than one measure to examine
the same outcome variable, results of multiple measures were standardized
Variables and Measures
and then averaged in order to result in one effect size per variable for any
The nine variables for which effect sizes were calculated, and the study. Similarly, if a study examined the immediate effects of more than
instruments used to assess them, are as follows: one application of treatment, or examined the treatment effect on delayed
State anxiety. Fifteen of the 21 studies examining MT’s effect on assessments of pain at more than one time point, the results of the multiple
anxiety used the state anxiety portion of the State–Trait Anxiety Inventory applications or assessments were standardized and then averaged in order
(Spielberger, 1983). Five studies used a visual analogue scale, and one to calculate a single effect size for that study. Effect sizes were coded such
study used an investigator-constructed measure. that positive values, for any variable, indicate a more desirable outcome
Negative mood. Seven of eight studies assessing negative mood used (e.g., a reduction in anxiety) for the participants who received MT.
the Profile of Mood States (McNair, Lorr, & Droppleman, 1971). The This process was done independently by both the first and second
remaining study used a visual analogue scale. authors for the entire set of effect sizes; these initial results were then
Immediate assessment of pain. Eight of the 15 studies assessing pain compared in order to determine agreement and eliminate errors. Agreement
immediately following treatment used visual analogue scales alone. Two rate (AR) of initial calculations for the entire set of 84 effect sizes was 88%.
studies used a visual analogue scale in conjunction with either the Short- Within outcome categories, the initial rates of agreement were as follows:
Form McGill Pain Questionnaire (Melzack, 1987) or the Menstrual Dis- state anxiety, AR " 86% (n " 21); negative mood, AR " 88% (n " 8);
tress Questionnaire (Moos, 1968). Two studies used investigator- immediate assessment of pain, AR " 87% (n " 15); cortisol, AR " 86%
constructed measures, and the remaining studies relied on the Neck Pain (n " 7); blood pressure, AR " 60% (n " 5); heart rate, AR " 100% (n "
Questionnaire (Leak et al., 1994), the revised Oswestry Low Back Pain 6); trait anxiety, AR " 86% (n " 7); depression, AR " 90% (n " 10); and
Questionnaire (Hudson-Cook, Tomes-Nicholson, & Breen, 1989), or be- delayed assessment of pain, AR " 60% (n " 5). When discrepancies were
havioral observation. observed, calculations were reviewed jointly to correct errors, and a con-
Cortisol. Of the seven studies that assessed cortisol levels, four relied sensus was reached.
on salivary samples, two on urinary samples, and one on a blood sample. Individual study effect sizes were then subjected to a correction for small
In each case, samples were collected 20 min after the application of MT, sample bias, then weighted by their inverse variance and averaged to
to account for the fact that bodily cortisol levels are indicative of responses generate a mean effect size for each outcome variable (Lipsey & Wilson,
occurring 20 min prior to sampling (Field, Hernandez-Reif, Quintino, 2001). An overall, nonspecific effect size was also calculated by averaging
Schanberg, & Kuhn, 1998, p. 233). all effects within each study, and then calculating a weighted overall effect
Blood pressure. Five studies offer data pertaining to participants’ from these effect sizes. All effect sizes were calculated according to a
blood pressure, assessed by means of a sphygmomanometer. Measures of random effects model of error estimation.
diastolic and systolic blood pressure were combined into one effect size, Statistical significance of the mean effect sizes was assessed by calcu-
because only a few studies report on this variable, and differ in regard to lating the 95% confidence interval (CI) for the population parameter. A
which values they report. significance level of .05 or better is inferred when zero is not contained
Heart rate. Of the six studies that assessed the effect of MT on heart within the CI. For effect sizes reaching statistical significance, the likeli-
rate, four used some type of automatic monitoring device, and one study hood and possible influence of publication bias—the possibility that stud-
indicated that pulse was assessed manually. One study did not specify the ies retrieved for the meta-analysis may not be a random sample of all
means by which heart rate was assessed. studies actually conducted (Rosenthal, 1998)—was assessed by means of a
Trait anxiety. Three studies of the seven assessing trait anxiety used trim and fill procedure (Duval & Tweedie, 2000), a nonparametric statis-
the Symptom Checklist-90 –Revised (SCL-90-R; Derogatis, 1983). One tical technique of examining the symmetry and distribution of effect sizes
study combined the Conners Teacher Rating Scale (Conners, 1969) and the plotted by inverse variance. This technique first estimates the number of
Revised Children’s Manifest Anxiety Scale (Reynolds & Richmond, studies that may be missing as a result of publication bias, and then allows
1985). The three remaining studies used either the Beck Anxiety Inventory a new, attenuated effect size to be calculated on the basis of the influence
(Beck, Brown, Epstein, & Steer, 1988), the trait portion of the State–Trait such studies would have if they were included in the analysis. The trim and
Anxiety Inventory (Spielberger, 1983), or an investigator-constructed fill procedure was performed with the Division of Vector-Borne Infectious
measure. Diseases library using the statistical computing program S-PLUS (Bigger-
Table 1
Individual Study Characteristics and Effect Sizes (g) by Outcome Variable
Mean Min/ Comp. Trained TRI

Study Participants N % female age session type therapist? study? g
State anxiety
Chang et al. (2002) Pregnant women 60 100 28 30 WL No No 0.45

Chin (1999) Surgery patients 85 100 42 10 WL No No #0.50
Delaney et al. (2002) Healthy adults 30 53 31 20 WL Yes No 0.20
Diego et al. (2002) Spinal cord patients 20 25 39 40 A/P Yes Yes 0.57
Diego et al. (2001) HIV$ adolescents 24 92 17 20 A/P Yes Yes 0.87
Field et al. (2002) Fibromyalgia patients 20 — 51 30 A/P Yes Yes 0.11
Field, Ironson, et al. (1996) Medical staff 50 80 26 15 A/P Yes Yes 0.48
Fischer et al. (2000) Amniocentesis patients 200 100 34 — WL No No 0.00
Fraser & Kerr (1993) Institutionalized elderly 21 — — 5 C — No 1.20
Groer et al. (1994) Healthy adults 32 69 64 10 WL No No #0.21
Hernandez-Reif, Field, et al. (1998) Multiple sclerosis patients 24 75 48 45 WL Yes Yes 1.33
Hernandez-Reif et al. (2001) Back pain patients 24 54 40 30 A/P Yes Yes 0.07
Hernandez-Reif, Field, et al. (2000) Hypertensive adults 30 53 52 30 A/P Yes Yes 0.24
Hernandez-Reif, Martinez, et al. (2000) PDD patients 22 100 33 30 A/P Yes Yes 0.84
Leivadi et al. (1999) University dance students 30 100 20 30 A/P Yes Yes 0.21
Levin (1990) Healthy adults 36 — 27 60 WL Yes No 1.30
Menard (1995) Surgery patients 30 100 52 45 WL Yes No 1.12
Mueller Hinze (1988) Healthy women 48 100 27 10 C — No 0.50
Okvat et al. (2002) Cardiac catheter patients 78 24 61 10 A/P Yes No #0.06
Richards (1993) Hospitalized elderly men 69 0 66 6 C No No 0.80
Wendler (1999) Soldiers 93 10 30 5 A/P No No 0.54
Negative mood
Abrams (1999) Children/adolescents with ADHD 30 17 13 20 WL Yes Yes 0.09

Hernandez-Reif, Field, et al. (1998) Multiple sclerosis patients 24 75 48 45 WL Yes Yes 0.32
Hernandez-Reif et al. (2001) Back pain patients 24 54 40 30 A/P Yes Yes #0.07
Hernandez-Reif, Martinez, et al. (2000) PDD patients 24 100 33 30 A/P — Yes 1.27
Leivadi et al. (1999) University dance students 30 100 20 30 A/P Yes Yes #0.49
Levin (1990) Healthy adults 36 — 27 60 WL Yes No 0.46
Immediate assessment of pain
Cen (2000) Neck pain patients 31 75 48 30 C Yes No 1.21

Chang et al. (2002) Pregnant women 60 100 28 30 WL No No 0.99
Chin (1999) Surgery patients 85 100 42 10 WL No No #0.30
Fischer et al. (2000) Amniocentesis patients 200 100 34 — WL No No #0.13
Hemenway (1993) Labor pain patients 32 100 23 10 A/P No No 0.38
Hernandez-Reif, Dieter, et al. (1998) Headache patients 26 — 40 30 WL Yes Yes 0.52
Hsieh et al. (1992) Back pain patients 63 — 34 — A/P Yes No #0.94
Okvat et al. (2002) Cardiac catheter patients 78 24 61 10 A/P Yes No 0.16
Weinrich & Weinrich (1990) Cancer patients 28 36 62 10 A/P No No #0.04
Wilkie et al. (2000) Hospice care cancer patients 29 31 63 30 WL Yes No #0.14
Cortisol

Chin (1999) Surgery patients 85 100 42 10 WL No No 0.07
Hernandez-Reif et al. (2001) Back pain patients 24 54 40 30 A/P Yes Yes #0.39
Hernandez-Reif et al. (2002) Parkinson’s disease patients 16 50 58 30 A/P Yes Yes 0.41
Table 1 (continued)
Mean Min/ Comp. Trained TRI

Study Participants N % female age session type therapist? study? g
Blood pressure
Delaney et al. (2002) Healthy adults 30 53 31 20 WL Yes No #0.06

Heart rate
Cottingham et al. (1988) Healthy men 32 0 27 45 WL Yes No 0.22

Delaney et al. (2002) Healthy adults 30 53 31 20 WL Yes No 0.53
Richards (1993) Hospitalized elderly men 69 0 66 6 C No No 0.35
Trait anxiety

Hernandez-Reif, Dieter, et al. (1998) Headache patients 26 — 40 30 A/P Yes Yes 0.52
Rexilius et al. (2002) Patient caregivers 35 72 52 30 C Yes No 0.31
Scherder et al. (1998) Alzheimer’s patients 16 — 86 30 A/P — No 0.68
Shulman & Jones (1996) Employees 33 61 40 15 WL Yes No 0.06
Depression

Diego et al. (2002) Spinal cord patients 20 25 39 40 A/P Yes Yes 0.32
Diego et al. (2001) HIV$ adolescents 24 92 17 20 A/P Yes Yes 0.74
Hernandez-Reif, Dieter, et al. (1998) Headache patients 26 — 40 30 WL Yes Yes 0.38
Rexilius et al. (2002) Patient caregivers 35 72 52 30 C Yes No 0.91
Scherder et al. (1998) Alzheimer’s patients 16 — 86 30 A/P — No 1.50
Delayed assessment of pain
Cen (2000) Neck pain patients 31 75 48 30 C Yes No 0.36

Cherkin et al. (2001) Back pain patients 262 58 45 — C Yes No 0.25
Dyson-Hudson et al. (2001) Wheelchair users 18 22 45 45 A/P Yes No 0.35
Preyde (2000) Back pain patients 73 51 45 30 C Yes No 0.49
Stratford et al. (1989) Tendinitis patients 40 50 43 10 WL — No 0.30
Note. Dashes indicate that data were not reported. Comp. " comparison; TRI " Touch Research Institute; A/P " active/placebo; C " combination; WL
" wait-list equivalent; PDD " premenstrual dysphoric disorder; ADHD " attention-deficit/hyperactivity disorder.
staff, 2000), which generates results for the three estimators of missing 31); and laboratory effect, AR " 100% (n " 34); proportion of female
studies (L0, R0, and Q0) described by Duval and Tweedie (2000). Per the participants was coded only by the first author. The influence of moderator
suggestion of these authors, the number of missing studies resulting from variables was assessed by performing a weighted regression analysis
each estimator was considered before the eventual decision was made to (Lipsey & Wilson, 2001) on the set of overall, nonspecific effect sizes for
report results according to the L0 and R0 estimators, which are considered all studies.
preferable for most situations (Duval & Tweedie, 2000).
Moderators. As with effect sizes, moderator variable data were also
coded independently by both the first and second authors. Agreement rate Results
for initial coding of all moderator data across categories was 97% (n "
158). Within moderator variable categories, initial agreement rates were as Table 1 lists the effect sizes (Hedges’s g) for each study by
follows: minutes per session, AR " 100% (n " 34); mean age, AR " 100% outcome variable, as well as important study characteristics. The
(n " 25); comparison type, AR " 97% (n " 34); training, AR " 87% (n " 37 studies included in the meta-analysis used a total of 1,802
participants, including 795 who received MT. Of the 1,007 par- analysis based on the L0 estimator yielded 10 studies missing as a
ticipants who received a comparison treatment, 49% received one result of publication bias, which result in an attenuated but still
of the five treatments categorized as wait-list equivalent, and the significant effect (g " 0.20, 95% CI " 0.06, 0.34); the funnel plot
remaining 51% received a treatment categorized as active/placebo. of actual and filled study effect sizes for this analysis is repre-
The mean number of participants for a study was 48.7 (SD " sented in Figure 1. The same analysis performed with the R0
49.0), and mean age of all participants was 40.6 years (SD " 13.9). estimator indicates no missing studies. Of the six specific outcome
Participants received an average of 21.7 min (SD " 14.0) of MT variables that generated significant effects, results of trim and fill
per application of treatment. Sixty-five percent of studies reported analyses indicated that only state anxiety and delayed assessment
using a trained massage therapist (or therapists), 22% reported of pain effects were likely overestimated due to publication bias. A
using a minimally trained person (or persons) to deliver treatment, trim and fill analysis performed on the state anxiety effect using
and 14% did not indicate the level of training of the person (or the L0 estimator yielded an estimate of four studies likely missing
persons) administering MT. Thirty-two percent of studies were as a result of publication bias. When the influence such studies
conducted by the Touch Research Institute. would have on state anxiety is calculated, the adjusted effect is
Table 2 graphically represents the distribution of overall study nonsignificant (g " 0.22, 95% CI " #0.01, 0.45). A trim and fill
effect sizes by means of a stem and leaf plot. Table 3 lists the mean analysis performed on the delayed assessment of pain outcome
effect size for each outcome variable, as well as the number of variable using the L0 estimator yielded a slightly smaller but still
studies contributing to the effect size, its 95% CI, and the results significant effect (g " 0.26, 95% CI " 0.07, 0.44). When the same
of trim and fill procedures applied to statistically significant ef- analyses were performed with the R0 estimator, no missing studies
fects. The nonspecific, overall mean effect was statistically signif- were indicated in either case.
icant (g " 0.34, p % .01). Among the nine specific outcome An analysis of potential moderator variables for the set of
variables examined, six displayed statistically significant effect overall effect sizes was not statistically significant, QR(6) " 5.80.
sizes. For the single-dose effects category, these included state Despite the nonsignificance of the regression model, the decision
anxiety (g " 0.37, p % .01), blood pressure (g " 0.25, p % .02), was made to inspect the significance of the individual moderator
and heart rate (g " 0.41, p % .01). Negative mood (g " 0.34), variables. Minutes of MT administered per session (z " 1.55, p "
immediate assessment of pain (g " 0.28) and cortisol (g " 0.14) .06, one-tailed) was the only moderator that approached the pre-
were nonsignificant. All outcome variables examined within the determined alpha for statistical significance ( p % .05). To examine
multiple-dose effects category, including trait anxiety (g " 0.75, this variable a bit further, we calculated separate weighted effect
p % .01), depression (g " 0.62, p % .01), and delayed assessment sizes for two categories of studies. Studies that administered ! 30
of pain (g " 0.31, p % .01), were statistically significant. min of MT per session generated an effect that was substantially
The results of trim and fill analyses conducted on the statisti- larger than that resulting from the entire set of studies (g " 0.54,
cally significant outcome variables indicated that the results are 95% CI " 0.32, 0.76). Studies that administered % 30 min of MT
fairly robust to the threat of publication bias. For overall effects, an per session demonstrated an effect that was slightly smaller than
that of the entire set of studies, but still significant (g " 0.30, 95%
CI " 0.08, 0.52).
Table 2
Stem and Leaf Plot of 37 Overall Study Effect Sizes Discussion
Stem Leaf This meta-analysis supports the general conclusion that MT is
effective. Thirty-seven studies yielded a statistically significant
#0.9 4
#0.8
overall effect as well as six specific effects out of nine that were
#0.7 examined. Significant results were found within the single-dose
#0.6 and multiple-dose categories, and for both physiological and psy-
#0.5 chological outcome variables. Confidence in these findings is
#0.4 bolstered by the results of trim and fill analyses, which indicate
#0.3
#0.2 14 that the results are not unduly threatened by publication bias.
#0.1 4
#0.0 47
0.0 26 Single-Dose Effects
0.1 1
0.2 2259 Three of the six single-dose effects examined were statistically
0.3 0558 significant. The magnitude of MT’s effect on state anxiety means
0.4 0114579 that the average participant receiving MT experienced a reduction
0.5 8 of state anxiety that was greater than 64% of participants receiving
0.6 17 a comparison treatment. MT was also more effective than com-
0.7 2389
0.8 013 parison treatments in reducing blood pressure and heart rate. The
0.9 average MT participant experienced a reduction in blood pressure
1.0 9 that was greater than 60% of comparison group participants,
1.1 2 whereas for heart rate, the reduction resulting from MT was greater
1.2 0
than 66% of comparison group participants, findings that are
Table 3
Mean Effect Sizes (g) and Results of Trim and Fill Analyses by Outcome Variable
Adjusted g based on
Outcome variable k g 95% CI L0 k $ L0 Adjusted 95% CI
Overall 37 0.34** 0.21, 0.48 10 0.20** 0.06, 0.34

Single-dose effects
State anxiety 21 0.37** 0.14, 0.59 4 0.22 #0.01, 0.45
Negative mood 8 0.34 #0.08, 0.76 —
Immediate pain 15 0.28 #0.01, 0.57 —
Cortisol 7 0.14 #0.10, 0.38 —
Blood pressure 5 0.25* 0.03, 0.48 0
Heart rate 6 0.41** 0.19, 0.62 0
Multiple-dose effects
Trait anxiety 7 0.75** 0.27, 1.22 0
Depression 10 0.62** 0.37, 0.88 0
Delayed pain 5 0.31** 0.10, 0.52 3 0.26** 0.07, 0.44
Note. A positive g indicates a reduction for any outcome variable. Dashes indicate data not calculated because of nonsignificance of effect size. CI "
confidence interval; L0 " estimate of missing studies resulting from trim and fill procedure.
* p % .05. ** p % .01.
consistent with the theory that MT may promote a parasympathetic may provide analgesia by competing with painful stimuli in a way
response of the ANS. Cortisol, however, another outcome variable consistent with the gate control theory of pain. MT’s effect on
that would be expected to decrease if MT promotes a parasympa- negative mood was also nonsignificant.
thetic response, was not significantly reduced, a finding that con-
trasts with the conclusion previously reached by Field (1998). Multiple-Dose Effects
Despite this inconsistent support for MT promoting a parasympa-
thetic response, the significant finding for the cardiovascular vari- Some of MT’s largest and most interesting effects belong to the
ables suggests that future research should examine whether MT multiple-dose effects category. Despite the fact that MT did not
might have an enduring effect on blood pressure such that it could demonstrate an effect on immediate assessment of pain, a signif-
be used in treating hypertension. icant effect was found for delayed assessment of pain. MT partic-
MT did not exhibit an effect on immediate assessment of pain. ipants who received a course of treatment and were assessed
This finding contrasts with the commonly offered notion that MT several days or weeks after treatment ended exhibited levels of
Figure 1. Funnel plot of 37 overall study effect sizes (g) plus the 10 effect sizes filled in by means of trim and
fill procedure using the L0 estimator; no filled studies are indicated using the R0 estimator.
pain that were lower, on average, than 62% of comparison including therapeutic touch (active/placebo), transcutaneous elec-
group participants. This finding is consistent with the theory trical stimulation without current (active/placebo), and a no-
that MT may promote pain reduction by facilitating restorative treatment control (wait-list equivalent). As a group, these contrast-
sleep, but without data on sleep patterns, this possibility is only ing results seem to agree with the nonsignificant finding in the
conjecture. meta-analysis in suggesting that whether MT is compared with an
Reductions of trait anxiety and depression following a course of active/placebo or wait-list equivalent treatment does not substan-
treatment were MT’s largest effects. The average MT participant tially influence effects. However, no primary studies that exam-
experienced a reduction of trait anxiety that was greater than 77% ined MT’s largest effects— on depression and trait anxiety— used
of comparison group participants, and a reduction of depression such a design; the influence of such a moderator may be more
that was greater than 73% of comparison group participants. These evident in relation to these more robust effects, and could be
effects are similar in magnitude to those found in meta-analyses examined in future studies by using both types of comparison
examining the absolute efficacy of psychotherapy, a more tradi- groups.
tional treatment for either condition, in which it is estimated that The prediction that effects would not vary according to the age
the average psychotherapy client fares better than 79% of un- or gender of participants was supported. Neither of these recipient
treated clients (Wampold, 2001, p. 70). Considered together, these characteristics was significantly associated with overall effects.
results indicate that MT may have an effect similar to that of Therapist training did not have a significant effect on outcome.
psychotherapy. This finding, however, should not be used to conclude that training
is of no consequence. In the present meta-analysis, this variable
Moderators could only be dummy coded according to whether a study involved
a trained massage therapist, or a layperson trained by a massage
All six moderators that were examined were nonsignificant. In therapist for the purposes of conducting the study. It was not
most cases, this was not surprising, given that we did not expect possible to differentiate the levels of experience various massage
effects to vary according to recipient characteristics and made no therapists may have had, nor was it possible to know how much
predictions concerning therapist training or laboratory effect. training laypersons involved in the studies had received. The only
However, it was unexpected that neither the minutes of MT ad- conclusion that can be definitively reached from this result is that
ministered per session nor type of comparison treatment moder- laypersons provided with some training can provide beneficial
ated effects in a way that was statistically significant. MT, information that may be valuable to researchers working with
Minutes of MT administered per session was the only moderator limited resources. No evidence of a laboratory effect was found.
that approached the predetermined alpha for statistical signifi-
cance. This, combined with the logic that if MT has an effect,
MT Theories
longer doses should likely be more potent, leads us to suspect that
our analysis failed to find a relationship because of insufficient Mixed support for existing theories. It is interesting to note
statistical power rather than the true absence of any moderating that, among the theories that are commonly offered to explain MT
effect. Nevertheless, it must be concluded that this moderator may effects, the most popular theories are the ones least supported by
not be as important as we predicted, and that even short sessions the present results. The failure to find a significant effect for
of MT can be effective. Future studies could more powerfully immediate assessment of pain contradicts the theory that MT
examine the role of session length by including two levels of this provides stimuli that interfere with pain consistent with gate con-
variable, something that does not appear to have been done in any trol theory. Reductions in blood pressure and heart rate resulting
study to date. from MT do support the theory that MT promotes a parasympa-
Whether studies used a wait-list equivalent or active/placebo thetic response, although, if this theory is true, it would also be
comparison group was not significant for overall effects. This expected that a significant reduction in cortisol levels would have
finding does not support the prediction that studies using wait-list occurred, which did not. By contrast, the remaining theories are
equivalent comparison treatments would yield larger effects. Be- not inconsistent with the current results. MT’s effects on state
cause stronger inferences can be made from within-study compar- anxiety, trait anxiety, and depression may come about as a result of
isons, we decided to compare this result with those from studies MT’s influence on body chemistry, whereas the ability of a course
that included both an active/placebo and a wait-list equivalent of MT treatment to provide lasting pain relief may result from the
comparison group within the design. Three studies fitting this mechanical promotion of circulation and breakdown of adhesions,
criterion examined state anxiety as an outcome. Richards (1993), or from improved sleep promoted by the treatment.
in a study that involved 69 participants, found that wait-list par- MT from a psychotherapy perspective. Another theory that has
ticipants improved significantly less than those who received a not previously been put forth may also account for MT effects. MT
combination of muscle relaxation, mental imagery, and relaxing may provide benefit in a way that parallels the common-factors
music. By contrast, Fraser and Kerr (1993), in a study that in- model of psychotherapy. Substantial evidence suggests that the
volved 21 participants, found no statistically significant difference considerable efficaciousness of psychotherapy results not from any
in outcome between two comparison groups, one of which re- specific ingredient of treatment, but rather from the factors that all
ceived attention in the form of conversation (active/placebo), the forms of psychotherapy share (Wampold, 2001). In this model,
other of which received no intervention (wait-list equivalent). factors such as a client who has positive expectations for treatment,
Similarly, Mueller Hinze (1988), in a study with 48 participants, a therapist who is warm and has positive regard for the client, and
found no differences in outcome for three comparison groups the development of an alliance between the therapist and client are
considered to be more important than adherence to a specific whether the psychological state of the therapist is of importance;
modality of psychotherapy. The same model can be extended to and (e) whether personality traits of the therapist, of the recipient,
MT, given the possibility that benefits arising from it may come or any interaction between those personality traits influence out-
about more from factors such as the recipient’s attitude toward comes. An examination of such personality, process, and thera-
MT, the therapist’s personal characteristics and expectations, and peutic relationship variables may reveal that benefiting from MT is
the interpersonal contact and communication that take place during just as much about feeling valued as it is about being kneaded.
treatment, as opposed to the specific form of MT used or the site Finally, the possibility that MT may provide a significant por-
to which it is applied. tion of its benefit in a way that parallels psychotherapy has a
Several of the findings in the present study are consistent with bearing on the selection of comparison treatments used in future
such a model applied to MT. The finding that MT has an effect on research. Viewed from a medical perspective, comparison treat-
trait anxiety and depression that is similar in magnitude to what ments in MT research are thought to function as placebo treat-
would be expected to result from psychotherapy suggests the ments, in that they control for incidental aspects of the treatment
possibility that these different treatments may be more similar than (most notably attention in MT research) while withholding what is
previously considered. Further support comes from the fact that thought to be the specific effective ingredient (soft tissue manip-
MT training was not predictive of effects. Possibly, MT effects are ulation). However, the same logic cannot be applied if the treat-
more closely linked with characteristics of the massage provider ment being examined is thought to be beneficial because of inci-
that are independent of skill or experience in performing soft tissue dental aspects, because the double-blind condition favored in
manipulation. medicine trials, where neither the participants nor the researchers
In addition to having similar effects, MT parallels psychother- involved in the study are aware of who is receiving viable treat-
apy in structure. Both forms of therapy routinely rely on repeated, ment and who is receiving the placebo, is logically impossible
private interpersonal contact between two persons. Studies con- (Wampold, 2001, p. 129). Those supervising and administering
tributing effects to the trait anxiety and depression outcome cate- treatment in MT research, as in psychotherapy research, are aware
gories used treatment protocols similar to those that might be of the treatment being delivered and know if it is intended to be
maintained in short-term psychotherapy, with twice-weekly meet- therapeutic. This is a critical factor to consider if the treatment
ings over a span of 5 weeks being most common; other studies being studied relies on the therapist’s beliefs and intentions in
used similar protocols. Interestingly, the length of individual ses- order to be effective. The placebo treatment, derived from medical
sions in these studies ranged from 15 to 40 min, with 30 min being trials intended to examine the effectiveness of specific ingredients,
the most common session length. Had these studies used a session cannot control for the incidental aspects of a treatment such as MT.
length equivalent to the “50-minute hour” that is routine in psy- When a common-factors model is applied to MT, the notion that a
chotherapy, it is possible that MT’s effect for these variables comparison treatment such as progressive muscle relaxation con-
would have matched or exceeded that expected of psychotherapy. trols for attention is incorrect. The attention provided to compar-
Application of such a psychotherapeutic, common-factors ison group participants is identical in quantity but not in quality,
model to MT has important ramifications for future research. and cannot be expected to function as a control for the attention
Different questions need to be asked, different moderators tested, received by participants in the MT treatment group.
and different comparisons made. Foremost among the questions is The idea that MT has significant parallels with psychotherapy,
whether MT is as effective as psychotherapy. No study has directly and that perspectives gained from psychotherapeutic research
compared these treatments, a comparison that would be justified should be applied to future research, is not meant to suggest that
given the finding that some MT effects may be very similar to MT delivers effects entirely by psychological means. Clearly MT
those of psychotherapy. Similarly, it could be interesting to deter- is at least partially a physical therapy, and some of its benefits
mine whether a combination of MT and psychotherapy could be almost certainly occur through physiological mechanisms. In fact,
significantly more effective than either alone. Another critical one of the most interesting aspects of MT is that it may deliver
issue that needs to be examined is whether these specific MT benefit in multiple ways; specific ingredients and common factors
effects are enduring. Current studies contributing to these effects may each play a role, with each being differentially important
all performed assessments on the final day of treatment, making it depending on the desired effect. However, whether researchers
impossible to know if the effects last. Studies that administer a wish to study MT as a physical therapy, as a psychological one, or
course of MT treatment should make assessments not only imme- as both, new research should examine not merely the effects
diately after treatment has ended, but also several weeks or months resulting from MT, but also the ways in which these effects come
later, to determine whether reductions of anxiety, depression, or about. It is only by testing MT theories that a better understanding
other conditions are maintained. of this ancient practice will result.
Despite the fact that MT is a treatment that relies on interper-
sonal contact, no research has attempted to manipulate, or even
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Psychological Bulletin Copyright 2004 by the American Psychological Association, Inc.

2004, Vol. 130, No. 1, 3–18 0033-2909/04/$12.00 DOI: 10.1037/0033-2909.130.1.3

A Meta-Analysis of Massage Therapy Research

Melzack and Wall (1965) theorized that the experience of pain

Effects Single-Dose Effects

Mean Min/ Comp. Trained TRI

Chang et al. (2002) Pregnant women 60 100 28 30 WL No No 0.45

Abrams (1999) Children/adolescents with ADHD 30 17 13 20 WL Yes Yes 0.09

Immediate assessment of pain

Cen (2000) Neck pain patients 31 75 48 30 C Yes No 1.21

Abrams (1999) Children/adolescents with ADHD 30 17 13 20 WL Yes Yes 0.07

Mean Min/ Comp. Trained TRI

Delaney et al. (2002) Healthy adults 30 53 31 20 WL Yes No #0.06

Cottingham et al. (1988) Healthy men 32 0 27 45 WL Yes No 0.22

Abrams (1999) Children/adolescents with ADHD 30 17 13 20 WL Yes Yes 0.94

Abrams (1999) Children/adolescents with ADHD 30 17 13 20 WL Yes Yes 0.29

Delayed assessment of pain

Cen (2000) Neck pain patients 31 75 48 30 C Yes No 0.36

Overall 37 0.34** 0.21, 0.48 10 0.20** 0.06, 0.34

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Overall 37 0.34 0.21, 0.48 10 0.20 0.06, 0.34