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Massage therapy is one of the oldest methods in the gallery of health care practices. References to massage are found in Chinese medical texts 4,000 years old. Massage has been advocated in Western health care practices in an almost unbroken line since the time of Hippocrates, the "father of medicine." In the 4th century B.C., Hippocrates wrote, "The physician must be acquainted with many things and assuredly with rubbing" (the ancient Greek and Roman term for massage).
Some of the greatest physicians in history advocated massage, including Celsus (25 B.C.-50 A.D.), who wrote De Medicinia, an encyclopedia of Roman medical knowledge that dealt extensively with prevention and therapeutics using massage; Galen (131-200), the most influential physician in the ancient, medieval, and Renaissance worlds, who addressed techniques and indications for massage in his book De Sanitate Tuenda (which is translated as The Hygiene, meaning prevention); and Avicenna (980-1037), a Persian physician who wrote extensively about massage in his Canon of Medicine, which was considered the ~authoritative medical text in Europe for several centuries. A sampling of other noted advocates includes Ambrose Parι, who wrote the first modern textbook of surgery; William Harvey, who demonstrated the circulation of the blood; and Herman Boerhaave, who introduced the clinical method of teaching medicine.
Modern, scientific massage therapy was introduced in the United States in the 1850s by two New York physicians, brothers George and Charles Taylor, who had studied in Sweden. The first massage therapy clinics in this country were opened by two Swedes after the Civil War: Baron Nils Posse ran the Posse Institute in Boston, and Hartwig Nissen opened the Swedish Health Institute near the U.S. Capitol in Washington, DC. Several members of Congress and U.S. Presidents, including Benjamin Harrison and Ulysses S. Grant, were among the massage therapy clientele.
As the health care system in the United States became more influenced by biomedicine and technology in the early 1900s, physicians began assigning massage duties (which were also labor-intensive, requiring more time to be spent with patients) to assistants, nurses, and ~physical therapists. In turn, in the 1930s and 1940s, nurses and physical therapists lost interest in massage therapy, virtually abandoning it. However, a small number of massage therapists carried on until the 1970s, when a new surge of interest in massage therapy revitalized the field, albeit in the realm of alternative health care. That interest has continued to the present.
Basic approach. Massage therapy is the scientific manipulation of the soft tissues of the body to normalize those tissues. It consists of a group of manual techniques that include applying fixed or movable pressure, holding, and/or causing movement of or to the body, using primarily the hands but sometimes other areas such as forearms, elbows, or feet. These techniques affect the musculoskeletal, circulatory-lymphatic, nervous, and other systems of the body. The basic philosophy of massage therapy encompasses the concept of vis medicatrix naturae--that is, aiding the ability of the body to heal itself--and is aimed at achieving or increasing health and well-being.
Touch is the fundamental medium of massage therapy. While massage methods can be ~described in terms of a series of techniques to be performed, it is important to understand that touch is not used solely in a mechanistic way in massage therapy; there is also an artistic component. Because massage usually involves applying touch with some degree of pressure, the massage therapist must use touch with sensitivity to determine the optimal amount of pressure appropriate for each person. Touch used with sensitivity also allows the massage therapist to receive useful information about the body, such as locating areas of muscle tension and other soft-tissue problems. Because touch is also a form of communication, sensitive touch can convey a sense of caring--which is an essential element in the therapeutic relationship--to the person receiving massage. Using the wrong kind of touch--sometimes thought of as "toxic touch"--is counterproductive, tending to render a technique ineffective and to cause the body to defend or guard itself, which in turn introduces greater tension.
Demographics. The advancement of higher standards and the development of a system of professional credentials have paralleled the dynamic growth of the massage therapy profession. Massage therapists are currently licensed by 19 States and a number of localities; additional States are expected to adopt licensing acts in the near future. Most ~States require 500 or more hours of education from a recognized school program and a licensing examination. While some States require continuing education, most massage therapists voluntarily take additional courses and workshops on a regular basis during their careers.
The National Certification Exam, a professional certification program accredited by the National Commission for Certifying Agencies in December 1993 and currently administered by the Psychological Corporation, was inaugurated in June 1992. More than 9,000 people nationwide were certified as of July 1994. Six States have already adopted the exam as their licensing exam, and more States are expected to follow suit.
The Commission on Massage Training Accreditation/Approval, a national accreditation agency that was set up in accord with the guidelines of the U.S. Department of Education, currently recognizes 60 school programs. Curriculums must consist of 500 or more hours and include specified hours of anatomy, physiology, massage theory and practice, and ethics.~The primary sponsor of the national certification and accreditation programs is the American Massage Therapy Association (AMTA), the largest and oldest national professional membership association for massage professionals. AMTA currently has more than 20,000 members and publishes the Massage Therapy Journal. The association recently founded the public, charitable AMTA Foundation to fund projects for research, education, and outreach; the foundation awarded its first grants in June 1993.
Each of a number of other national nonprofit membership associations for massage professionals has between 200 and 1,500 members. These groups usually are formed for practitioners of specific methods. To alleviate the competition and infighting that are sometimes found among various professional groups, an innovative coalition known as the Federation of Therapeutic Massage and Bodywork Organizations was formed in 1991 by the AMTA, the American Oriental Bodywork Therapy Association, the American Polarity Therapy Association, the Rolf Institute, and the Trager Institute. The federation fosters greater communication and cooperation among its members.
~The number of massage therapists in the United States can only be estimated, because no formal census has been taken. Furthermore, a census or estimate would be affected by the criteria for inclusion, which would involve such variables as extent of training, number of hours worked, and whether methods used by an individual are considered forms of massage. It is estimated that there are approximately 50,000 qualified massage therapists in the United States, providing some 45 million 1-hour massage sessions per year. The number of massage therapists appears to be increasing rapidly along with a corresponding increase in use by the American public. An estimated 20 million Americans have received massage therapy. Indeed, in the study by Eisenberg and colleagues (1993)--which found that 34 percent of the American public used alternative health care--relaxation techniques, chiropractic, and massage were the most frequently used forms of alternative health care.
Methods. Some 80 different methods may be classified as massage therapy, and approximately 60 of them are less than 20 years old. There are several reasons why this is the case.
~The period of the 1940s to the mid-1970s was relatively dormant for the massage therapy profession. Little standardization was established in the field. Then in the 1970s, stimulated by changes in society such as greater interest in fitness, healthier lifestyles, personal improvement, and alternative methods of health care to complement conventional medicine, interest in massage therapy increased. An influx of new practitioners brought with them a wave of new ideas and creativity regarding ways to use hands-on techniques. Since there was little standardization, these techniques sometimes developed into freestanding methods rather than being incorporated into an existing system of classification.
Another source of new techniques was the various forms of massage native to most cultures around the world but not previously described outside each culture. For example, many of the forms of massage that come from Asia are based on concepts of anatomy, physiology, and diagnosis that differ from Western concepts.
The proliferation of methods has slowed. It is expected--as has happened in the development of other professions--that as the development of standards and credentials ~continues, there will be some consolidation and integration of methods.
The forms of massage therapy described in this section are either among the most widely used or representative of a group of similar practices. Several forms that include additional techniques besides massage are listed briefly here and discussed in more detail in the following sections. In actual practice, many massage therapists use more than one method in their work and sometimes combine several.
Swedish massage uses a system of long gliding strokes, kneading, and friction techniques on the more superficial layers of muscles, generally in the direction of blood flow toward the heart, sometimes combined with active and passive movements of the joints. This system is used to promote general relaxation, improve circulation and range of motion, and relieve muscle tension. Swedish massage is the most common form of massage.
Deep-tissue massage is used to release chronic patterns of muscular tension using slow strokes, direct pressure, or friction directed across the grain of the muscles with the fingers, ~thumbs, or elbows. It is applied with greater pressure and to deeper layers of muscle than Swedish massage.
Sports massage uses techniques that are similar to Swedish and deep-tissue massage but are specially adapted to deal with the needs of athletes and the effects of athletic performance on the body.
Neuromuscular massage is a form of deep massage that is applied specifically to individual muscles. It is used to increase blood flow, release trigger points (intense knots of muscle tension that refer pain to other parts of the body), and release pressure on nerves caused by soft tissues. It is often used to reduce pain. Trigger point massage and myotherapy are similar forms.
Manual lymph drainage improves the flow of lymph by using light, rhythmic strokes. It is primarily used for conditions related to poor lymph flow, such as edema, inflammation, and neuropathies.~The reflexology, zone therapy, tuina, acupressure, rolfing (structural integration), Trager, Feldenkrais, and Alexander methods are addressed in the following sections.
The various methods of massage therapy can be divided into two major groupings:2
1. Traditional European methods based on traditional Western concepts of anatomy and physiology, using five basic categories of soft-tissue manipulation: effleurage (gliding strokes), petrissage (kneading), friction (rubbing), tapotement (percussion), and vibration. Swedish massage is the main example.
2. Contemporary Western methods based on modern Western concepts of human functioning, using a wide variety of manipulative techniques. These may include broad applications for personal growth; emotional release; and balance of the mind, body, and spirit in addition to traditional applications. These methods go beyond the original framework of Swedish massage and include neuromuscular, sports, and deep-tissue massage; and myofascial release, myotherapy, Bindegewebsmassage, Esalen, and manual Lymph ~Drainage.
In addition, there are structural, functional, and movement integration methods that organize and integrate the body in relationship to gravity through manipulating the soft tissues or through correcting inappropriate patterns of movement; methods that bring about a more balanced use of the nervous system through creating new, integrated possibilities of movement. Examples are Rolfing, Hellerwork, Aston patterning, Trager, Feldenkrais, and Alexander.
Current research. From 1873, when the term massage first entered the Anglo-American medical lexicon, through 1939, more than 600 journal articles appeared in mainline English language journals of medicine, including the Journal of the American Medical Association, Archives of Surgery, and the British Medical Journal. During the past 50 years, reports on nearly 100 clinical trials have been published in the medical and allied health literature. Many well-designed studies have documented the benefits of several methods of massage therapy for the treatment of acute and chronic pain; acute and chronic inflammation; chronic ~lymphedema; nausea; muscle spasm; various soft-tissue dysfunctions; grand mal epileptic seizures; anxiety; and depression, insomnia, and psychoemotional stress, which may aggravate significant mental illness. A larger number of studies also have been carried out in Europe, particularly in the former Soviet Union and East Germany. Unfortunately, the published reports on most of these have not been translated into English.
Research base. The following studies reflect the versatility of massage therapy and its broad and diverse range of applications.
Premature infants treated with daily massage therapy gain more weight and have shorter hospital stays than infants who are not massaged. A study of 40 babies with low birth weight found that the 20 massaged babies had 47-percent greater weight gain per day and stayed in the hospital an average of 6 fewer days than 20 similar infants who did not receive massage; the cost saving was approximately $3,000 per infant (Field et al., 1986). Cocaine-exposed preterm infants given massages three times daily for a 10-day period showed significant improvement. Results indicated that massaged infants had fewer postnatal complications and ~exhibited fewer stress behaviors during the 10-day period, had 28-percent greater daily weight gain, and demonstrated more mature motor behaviors at the end of the 10-day course of massage therapy (Field, 1993).
A study comparing 52 hospitalized depressed and adjustment-disorder children and adolescents with a control group that viewed relaxation videotapes found that the massage therapy subjects were less depressed and anxious and had lower saliva cortisol levels (an indicator of less depression) (Field et al., 1992).
Another study showed that massage therapy produced relaxation in 18 elderly subjects. This study demonstrated physiological signs of relaxation in measures such as decreased blood pressure and heart rate and increased skin temperature (Fakouri and Jones, 1987).
A combination of Swedish massage, shiatsu, and trigger point suppression in 52 subjects with traumatically induced spinal pain led to significant alleviations of acute and chronic pain and increased muscle flexibility and tone. This study also found massage therapy to be ~extremely cost-effective in comparison with other therapies, with savings ranging from 15 percent to 50 percent (Weintraub, 1992a, 1992b). Massage has also been shown to stimulate the body's ability to control pain naturally; in one study, massage stimulated the brain to produce endorphins, the neurochemicals that control pain (Kaarda and Tosteinbo, 1989). Fibromyalgia, a painful type of inflammation, is an example of a condition that may be favorably affected by this mechanism.
A pilot study of five subjects with symptoms of tension and anxiety found a significant response to massage therapy based on one or more psychophysiological parameters, including heart rate, frontalis and forearm extensor electromyograms, and skin resistance; these changes denote relaxation of muscle tension and reduced anxiety (McKechnie et al., 1983).
Another study found that massage therapy can have a powerful effect on psychoemotional distress in persons suffering from chronic inflammatory bowel disease. Stress can worsen the symptoms of ulcerative colitis and Crohn's disease (ileitis), which can cause great pain and ~bleeding and even lead to hospitalization or death. Massage therapy was effective in reducing the frequency of episodes of pain and disability in these patients (Joachim, 1983).
Lymph drainage massage has been shown to be more effective than mechanized methods or diuretic drugs to control lymphedema (a form of swelling) secondary to radical mastectomy (removal of breast tissues). It is expected that using massage to control lymphedema will significantly lower treatment costs (Zanolla et al., 1984).
Research opportunities. The pace of research in the United States involving massage therapy appears to be increasing, and the activities of OAM may play a supportive role. A list of studies (directed by Tiffany Field) under way at the Touch Research Institute of the University of Miami Medical School illustrates the range of possibilities for research:
Infant studies--infants exposed to human immunodeficiency virus (HIV), depressed infants, infant colic, sleep disorders, and pediatric oncology.
~ Child studies--asthma, autism, posttraumatic stress disorder following natural disasters, neglected and abused children in shelters, preschool behavior, pediatric skin disorders, diabetes, and juvenile rheumatoid arthritis.
Adolescent studies--depressed adolescent mothers, adolescent mothers after childbirth, and eating disorders.
Adult studies--job performance and stress, eating disorders, pregnancy and neonatal outcome, hypertension, HIV-positive adults, spinal cord injuries, fibromyalgia syndrome, rape and spouse abuse victims, and couples therapy.
Elderly studies--volunteer foster grandparents giving and receiving massage, and arthritis.
Research recommendations. The preceding section indicates the diversity and breadth of applications of massage therapy and suggests the range of possibilities for future research.~General studies of the efficacy and effectiveness of massage therapy are still needed. Outcome studies are recommended that would allow massage therapists to work in a manner and setting that approximate actual working conditions as much as is possible. Cost-effectiveness studies also are needed. Several of the studies cited in this report have indicated that massage therapy provides substantial cost savings; this is a critical issue related to health care reform. To verify the savings, some of the more recent studies should be replicated as part of this approach.
There are numerous possibilities for studying effects of massage on many health conditions:
Since massage therapy is especially effective with soft-tissue problems, studies involving muscle strains, sprains, tendinitis, problems related to acute and chronic muscle tension, and other such conditions would be useful, as would studies of the effect of massage on the tissue healing process.
Because research offers mounting evidence that a significant percentage of health ~problems can be attributed to stress and that stress reduction can be a powerful means of preventing or treating such problems, studies of the stress-reduction effects of massage therapy would be valuable.
Another question that needs to be addressed is whether massage can cause cancerous tumors to metastasize.
The various subject areas under investigation at the Touch Research Institute are also examples of areas that merit further study.
Barriers and key issues. Several barriers and key issues need to be addressed to make research on massage therapy more productive:
Study design. A key issue related to research is the need for researchers to collaborate with massage therapists during the design stage of a study. Some previous studies used massage in an inappropriate or ineffective manner. For example, the duration of massage is ~an important factor; a common error is use of massage sessions that are too brief to be effective. Another error is the choice of techniques that are not effective.
Appropriate use of therapists. Properly qualified and skilled massage therapists should be used in each study. Some studies have been carried out in which individuals who were untrained or undertrained applied massage; it then became impossible to discern whether any negative results meant that massage was ineffective or that it was not applied properly.
Collaborations. Since few individuals are both doctorate-level researchers and massage therapists, it is recommended that NIH facilitate collaboration between researchers and massage therapists. Researchers would benefit by knowing more about interesting and promising possibilities for research, resources available from the massage therapy profession, and massage therapy itself. Massage therapists would benefit by being able to locate researchers with whom to collaborate (1) to pursue study ideas and (2) to have a better understanding of the needs of researchers and the research process itself.
~ Translations. Because many studies are in foreign languages, translations of such studies are needed.
Regulatory barriers. Another key issue is the existence of barriers to practice that hinder massage therapists; these must be removed. In some States, regulatory boards use powers granted through licensing laws to limit the practice of legitimate massage therapy by qualified massage therapists. These barriers also restrict the ability to conduct research on massage therapy in traditional settings, such as clinics and hospitals, thereby hampering research efforts.
If regulatory, insurance payment, and research barriers are not removed, they will inhibit progress regarding massage therapy, along with other forms of alternative health care.