Massage therapy (MT), as one of the complementary and alternative treatments, is defined as a therapeutic manipulation using the hands or a mechanical device, which includes numerous specific and general techniques that are often used in sequence, such as effleurage (stroking), petrissage (kneading), and percussion [
With its popularity in pain relief, MT has become a widely accepted treatment for neck and shoulder pain. There are, however, inconsistent conclusions on effects of MT for neck and shoulder pain. Most prior reviews maintained that there was inconclusive evidence on effects of MT for neck and shoulder pain [
Therefore, we performed an updated systematic review of all currently available data that included English and Chinese publications and conducted quantitative meta-analyses of MT on pain and functional status of patients with neck and shoulder pain to determine whether MT is a viable complementary and alternative treatment for neck and shoulder pain.
We performed comprehensive computerized searches of the medical literature in 7 databases and reference lists through December 2011. English databases included PubMed, EMBASE, OVID-MEDLINE, and SPRINGLINK, and Chinese databases included China Knowledge Resource Integrated Database (CNKI), Weipu Database for Chinese Technical Periodicals (VIP), and Wan Fang Data. The main search terms were massage, manual therapy, Tuina, neck pain, neck disorders, cervical vertebrae, shoulder pain, and trapezius muscle. No restrictions on publication status were imposed. In addition, we performed hand searches at the library of Shanghai University of Traditional Chinese Medicine.
Randomized controlled trials (RCTs) of MT for patients with neck and/or shoulder pain were included. There were no limitations on the participant’s age, gender, or nationality. The focused intervention was MT using the hands or mechanical devices. The control intervention included placebo, a wait list control, no treatment, standard care, and any active treatments not related to MT. The main outcomes of interest were pain and functional status. We did not set any restriction on the type of tool used in the studies to measure these outcomes as there were no universally accepted tools available. We found various validated tools for these outcomes in different countries. The effects of MT included immediate effects (immediately after treatments: up to one day) and followup effects (short-term followup: between one day and three months, intermediate-term followup: between three months and one year, and long-term followup: one year and beyond).
Trials were excluded if any of the following were identified: (1) if neck and/or shoulder pain was caused by fractures, tumors, infections, rheumatoid arthritis, and so forth; (2) if MT was combined with other manual therapies including spinal manipulation, mobilization, chiropractic, and; (3) if controlled interventions also contained MT, since it would be impossible to evaluate the specific effect of MT; and (4) if the language was neither English nor Chinese.
Two reviewers extracted data independently according to predefined criteria including the first author, the original country of the study, year of the study, pain location, pain duration, the sample size, the mean age of participants, the duration of treatments, the followup time, main outcome assessments, the intervention of experimental and control group, and main conclusion (mean improvement on pain). Any discrepancies were discussed until the authors reached consensus.
The methodological quality of RCTs was assessed independently by two reviewers based on PEDro scale, which is based on the Delphi list and has been reported to have a fair-to-good reliability for RCTs of the physiotherapy in systematic reviews. This scale consists of 11 criteria: (1) study eligibility criteria specified, (2) random allocation of subjects, (3) concealed allocation, (4) measure of similarity between groups at baseline, (5) subject blinding, (6) therapist blinding, (7) assessor blinding, (8) less than 15% dropouts, (9) intention-to-treat analysis, (10) between-group statistical comparisons, and (11) point measures and variability data. Criteria (2)–(11) were used to calculate the PEDro score. Each criterion was scored as either 1 or 0 according to whether the criteria was met or not, respectively. The scores are summed, and a higher score represents a better methodological quality. A cut point of 6 on the PEDro scale was used to indicate high-quality studies as this has been reported to be sufficient to determine high quality versus low quality in previous studies [
The mean change in outcomes between the end of final intervention and the baseline was used to assess the difference between experimental group and control group in the meta-analyses. Standardised mean difference (SMD) was used because the studies included in meta-analyses assessed the outcome based on different scales (e.g., VAS 0–10 and VAS 0–100). And the SMD and 95% confidence intervals (CI) were calculated in the meta-analyses. For studies with insufficient information, the reviewers contacted the primary authors to acquire and verify the data when possible. In studies that involved more than one control group, the reviewers restricted our analyses to MT and each control group. In order to get more accurate heterogeneity we used random effects model employing variation factors among studies as correction weight. The
We identified 865 abstracts from 7 English and Chinese databases. After initially screening 108 potentially relevant abstracts, we excluded 90 because they did not meet the inclusion criteria (e.g., systematic reviews, commentary, case report, technical report, not MT as a stand-alone treatment, participants were healthy, using psychosocial or biochemical outcome measures, and not in English or Chinese). We retrieved and reviewed 18 full articles. 12 RCTs [
Study selection process. RCTs: randomized controlled trials.
Twelve eligible studies included 757 subjects with mean age of
Of twelve RCTs, 8 RCTs [
Randomized controlled trials evaluating the effect of massage therapy for neck and shoulder pain.
First authors, year, country | Pain location, pain duration | Sample size, mean age (year), | Duration weeks | Follow-up weeks | Main outcome assessments | Experimental group intervention* | Control group intervention* | Main conclusion |
---|---|---|---|---|---|---|---|---|
Irnich 2001, Germany [ |
Neck pain |
177 |
3 | 12 | Pain VAS (0–100) |
Massage therapy (MT) |
(1) Acupuncture (AC) |
MT (12.70) < AC (25.30); |
| ||||||||
Dyson-Hudson 2001, US [ |
Shoulder pain |
18 |
5 | 5 | Pain WUSPI |
MT |
AC |
MT (28.80) > AC (26.70) |
| ||||||||
Cen 2003, US [ |
Neck pain |
31 |
6 | 6 | Pain NPQ (0–100) |
Chinese traditional massage |
(1) Exercise (EX) |
CTM (19.22) > EX (7.78) |
| ||||||||
van den Dolder 2003, Australia |
Shoulder pain |
29 |
2 | — | Pain VAS (0–100) |
Soft tissue massage (STM) (15–20 min/6 sessions) | Waiting list (WL) | STM (26.60) > WL (0.10) |
| ||||||||
Mok 2004, Hong Kong [ |
Shoulder pain |
102 |
1 | 3 days | Pain VAS (0–100) |
Slow-stroke back massage |
SC | SBM (14.60) > SC (7.61) |
| ||||||||
Fryer 2005, Australia [ |
Neck pain |
37 |
1 day | — | PPT | Manual pressure release |
Sham myofascial release |
MPR (2.05) > SMR (−0.08) |
| ||||||||
Meseguer 2006, Spain [ |
Neck pain |
54 |
1 day | — | Pain VAS (0–10) | Classical strain/counterstrain technique (CST) |
SC | CST = MST (2.60) |
| ||||||||
Blikstad 2008, UK [ |
Neck pain |
45 |
1 day | — | Pain VAS (0–10) |
Myofascial band therapy |
(1) Activator trigger point therapy (ATPT) |
MBT < ATPT |
| ||||||||
Zuo 2008, China [ |
Neck pain |
60 |
2 | — | Pain VAS (0–10) |
CTM |
Traction (TR) |
CTM (5.47) > TR (4.87) |
| ||||||||
Sherman 2009, US [ |
Neck pain |
64 |
10 | 16 | NDI |
MT |
SC | MT > SC (NDI) |
| ||||||||
Buttagat 2011, Thailand [ |
Shoulder pain |
20 |
3 | 2 | Pain VAS (0–10) |
Traditional Thai massage (TTM) (30 min/9 sessions) | Physical therapy (PT) |
TTM (4.50) > PT (1.60) |
| ||||||||
Zhang 2011, China [ |
Neck pain |
120 |
10 days | 24 | Pain VAS (0–10) |
CTM |
TR |
CTM (5.56) > TR (3.85) |
VAS: visual analog scale; WUSPI: wheelchair user’s shoulder pain index; ROM: range of motion; NR: no reported; NPQ: Northwick park neck pain questionnaire; STAI: state-trait anxiety inventory; PPT: pressure pain threshold; NDI: neck disability index; CNFDS: Copenhagen neck functional disability scale; ASCS: Assessment scale for cervical spondylosis.
The quality scores are presented in Table
PEDro scale of quality for included trials.
Study | Eligibility criteria | Random allocation | Concealed allocation | Similar at baseline | Subjects blinded | Therapists blinded | Assessors blinded | <15% dropouts | Intention-to-treat analysis | Between-group |
Point measures and variability data | Total |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Irnich et al. [ |
1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 7 |
Dyson-Hudson et al. [ |
1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 7 |
Cen et al. [ |
1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 6 |
van den Dolder and Roberts [ |
1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 8 |
Mok and Woo [ |
1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 6 |
Fryer and Hodgson [ |
1 | 1 | 0 | 0 | 1 | 0 | 1 | 0 | 1 | 1 | 1 | 6 |
Meseguer et al. [ |
1 | 1 | 0 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 8 |
Blikstad and Gemmell [ |
1 | 1 | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 0 | 6 |
Zuo et al. [ |
1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 7 |
Sherman et al. [ |
1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 8 |
Buttagat et al. [ |
1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 8 |
Zhang et al. [ |
1 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 7 |
0 = not meet the criteria; 1 = meet the criteria.
Eight RCTs examined the immediate effect of MT for neck pain versus inactive therapies or active therapies. Six of them were included in the meta-analysis [
Four trials tested the immediate effect of MT for shoulder pain versus inactive therapies [
Three RCTs [
Two RCTs [
Forest plot of the immediate effect of massage therapy for (a) neck pain and (b) shoulder pain.
Neck pain
Shoulder pain
Four RCTs assessed the immediate effect of MT for neck pain compared with acupuncture [
Two RCTs tested the immediate effect of MT for shoulder pain compared with acupuncture [
In studies with followup, two RCTs assessed short-term effects of MT for neck pain. The authors reported that MT did not experience significant improvements on pain compared with acupuncture after a 12-week followup [
Forest plot of the followup effect of massage therapy for neck and shoulder pain.
Three trials tested short-term effects of MT on shoulder pain compared with acupuncture [
Two studies tested the effectiveness of MT for shoulder range of motion compared with acupuncture [
Forest plot of the effect of massage therapy in improving functional status related to shoulder pain.
Six trials reported the effectiveness of MT on functional status of patients with neck pain; however, the quantitative meta-analysis had not been conducted due to the serious heterogeneity in assessment methods and ineligible reported data. Four of these studies reported favourable immediate effects compared with standard care [
The results suggested that MT may have been more beneficial than inactive therapies in immediate effects for neck and shoulder pain, but there were no differences between MT and other active therapies. On followup effects, the meta-analysis only showed the short-term benefit of MT for shoulder pain. With regard to the improvement of functional status, there was not valid evidence of MT for neck and shoulder pain.
We analyzed studies comparing MT with inactive therapies and active therapies separately because different control comparators address different questions. In addition, each control has advantages and limitations that must be considered in interpreting the analysis results. The inactive therapy control is intended to address the following question: is MT an effective therapy for neck and shoulder pain? Inactive therapies included standard care, waiting list, and sham treatment control in our review. Sham treatment control has advantages with regard to the blinding of patients, evaluators, or both to the treatment compared with other inactive therapies. The meta-analyses showed that MT is an effective therapy on relieving neck and shoulder pain. And the meta-analyses results from active therapy controlled RCTs address the question of whether MT is more effective than other active therapies for neck and should pain. No evidence suggested that MT was better than active therapies. In addition, we also paid attention to the immediate and followup effects of MT for neck and shoulder pain.
Our positive results concur with those from systematic reviews. Ottawa panel evidence-based clinical practice guidelines [
Our results differ from those of Ezzo and colleagues’ systematic review [
There are several limitations in our review. First, the distorting effects of publication and location bias on systematic reviews and meta-analyses are well documented [
Assuming that MT was beneficial on relieving pain related to the neck and shoulder, the complex interplay of both physical and mental modes may provide a possible rationale. MT delivered to soft and connective tissues may induce local biochemical changes that modulate local blood circulation, improve muscle flexibility, intensify the movement of lymph, and loosen adherent connective tissue, which may alternately improve reuptake of local nociceptive and inflammatory mediators [
MT is an effective intervention that may provide immediate effects for neck and shoulder pain. However, MT does not show better effects than other active therapies on pain relief. Additionally, MT only showed short-term effects for shoulder pain in followup. No evidence suggests that MT was effective in improving functional status related to neck and shoulder pain.
Future studies of MT for neck and shoulder pain should adhere to large-scale and high-quality RCTs with long followup for better quantitative meta-analysis. Even though it is difficult to blind subjects and therapists for treatments, employing assessor blinding and allocation concealment are important for reducing bias. The RCT should adopt validated primary outcome measures, adequate statistical tests, applicable comparison groups, and standard MT. This comprehensive review of MT for neck and shoulder pain acts to provide guidelines for future researches.
This work is supported by the Key Discipline of Tuina of the State Administration of Traditional Chinese Medicine of the People’s Republic of China; the National Science Foundation for Distinguished Young Scholars of China (81025022); the National Natural Science Foundation of China (81273869, 81072891, and 81202707); and Innovation Team of College of Shanghai Municipal Education Commission (2009-26).