The report is a product of the VA/HSR Evidence Synthesis Program.

Evidence Map of Massage Therapy: Update from 2018 to 2023

Takeaway: Investigators found conclusions of potential benefit for massage therapy with moderate certainty of evidence in six reviews published since July 2018. Since the previous evidence map only included conclusions of low and very low certainty of evidence, these six new reviews with moderate certainty of evidence suggest that conclusions of benefit regarding massage therapy have a stronger evidence base now. According to the new evidence, massage therapy is likely to be of benefit for conditions such as chronic low back pain, fibromyalgia, and myofascial pain.

Massage therapy is a popular and widely accepted complementary and integrative health (CIH) modality for individuals seeking relief from pain. VHA defines massage therapy as “the practice of manual assessment and manipulation of the superficial soft tissues of skin, muscle, tendon, ligament, fascia, and the structures that lie within the superficial tissues for therapeutic purpose.” Massage therapy encompasses a range of techniques (i.e., acupressure, myofascial release), styles, (e.g., deep tissue, Tui Na, shiatsu). Individuals may seek massage therapy to address pain where conventional treatments may not provide complete relief or may come with potential side effects. Massage therapy has seen a dramatic increase in the number of users and visits since 2016 across the VA healthcare system. However, despite its popularity and long history in practice, evidence of the beneficial effects of massage therapy remains limited.

HSR&D’s Evidence Synthesis Program (ESP) Center located within the VA Greater Los Angeles Healthcare System conducted a systematic review to present an evidence map offering a visual overview of the distribution of evidence for massage therapy for pain, in addition to a narrative to help stakeholders interpret the evidence to inform policy and clinical decision-making. Search strategies were based on those used for a previous ESP evidence map of massage therapy (2016) and subsequent journal article (Miake-Lye, et al., 2019), which included literature published through July 2018.

For the new evidence map (see Figure below), five databases were searched for relevant records published from July 2018 to April 2023 including: PubMed, Allied and Complementary Medicine Database (AMED), Cumulated Index to Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews (CDSR), and Web of Science. Eligible publications were systematic reviews of studies that examined the efficacy or effectiveness of therapist-delivered massage therapy for pain in adults. Publications also had to 1) state or cite the method used to formally assess the certainty (or strength or quality) of included evidence, and 2) report the certainty (or strength or quality) of evidence for the effect of massage therapy on pain.

Investigators identified 1,164 potentially relevant citations, and 38 publications were reviewed at full text. Of these, investigators included 15 reviews of massage therapy describing health conditions with pain as an outcome in the evidence map. Conditions included: back pain (i.e., chronic back pain, chronic low back pain, and low back pain), cancer-related pain, chronic neck pain, fibromyalgia, mechanical neck pain, myofascial pain, palliative care needs, post-breast cancer surgery, post-caesarean pain, post-partum pain, and post-operative pain.

Summary of Findings

Investigators found conclusions of potential benefit for massage therapy with moderate certainty of evidence in six reviews published since July 2018. Since the previous evidence map only included conclusions of low and very low certainty of evidence, these six new reviews with moderate certainty of evidence suggest that conclusions of benefit regarding massage therapy have a stronger evidence base now than in 2018.  These conditions include back pain (including chronic low back pain and chronic back pain), fibromyalgia, myofascial pain, and breast-cancer-related pain.

Bubble colors denote intervention type, shapes denote type of comparator, and the size of shapes indicates the number of studies included in the review.

Only 20% of reviews (3 of 15) included more than 10 primary studies; therefore, the majority of conclusions about the potential benefit for massage therapy for pain were drawn from a small number of primary studies. Evidence about adverse events was collected by about half of the included reviews and no serious adverse events were reported. While 9 of 15 reviews described adverse events, only two included certainty of evidence conclusions for adverse events.

Limitations

Limitations of the evidence include study design weaknesses of the primary studies included in the systematic reviews, which contributed to low or very low certainty of evidence ratings for the effectiveness of massage therapy for pain. Inconsistent reporting of details about the interventions (e.g., frequency, duration, follow-up) also made it difficult to provide further synthesis of the data regarding the delivery of massage therapy for pain. An implication of this ambiguity is that translating this research into practice is challenging, since the provider needs to know what type of massage therapy was used for which condition and at what frequency/duration to deliver it in a clinical setting.

Future Research

For painful conditions of importance to VA that currently do not have at least moderate-certainty evidence supporting use of massage therapy, new studies that address the limitations of existing research are needed. Further, instituting more consistent and standardized reporting of details about massage therapy, as well as adverse events in clinical trials, will provide additional insights regarding the application and appropriateness of massage therapy as a non-pharmacological treatment for pain.

Implications

The number of conclusions about the effectiveness of massage therapy that were judged to have at least moderate certainty of evidence is greater now than in 2018, yet it is still small relative to the need. More high-quality randomized controlled trials are needed to provide a stronger evidence base to assess the effect of massage therapy for pain.

Mak S, Allen J, Begashaw M, Miake, Lye I, Beroes, Severin J, Lawson E, Shekelle P. Evidence Map of Massage Therapy: Update from 2018-2023. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #05-226;2023.

To view the full report, go to: vaww.hsrd.research.va.gov/publications/esp/evidence-massage.cfm (Intranet only).

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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