COMPLEMENTARY AND ALTERNATIVE MEDICINE /02 $

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1 COMPLEMENTARY AND ALTERNATIVE MEDICINE /02 $ MASSAGE THERAPY Tiffany Field, PhD HISTORICAL BACKGROUND Massage therapy dates to prerecorded time and was epitomized by Hippocrates (the father of modern medicine) in 400 BC as medicine being the art of rubbing. Medicine was essentially touch therapies before the advent of drugs. The laying on of hands was the primary form of healing throughout history in places such as ancient Greece, where Hippocrates wrote that the physician must be experienced in many things, most especially in rubbing. 16 Eastern touch therapies, such as those in China and Ayurvedic medicine in India, have been practiced since before the beginning of recorded time. Touch therapies such as massage therapy have reached the Western world only relatively recently. The beginnings of Western massage date back to Lind, an athlete and educator from nineteenthcentury Sweden. His Swedish massage technique is one of the most popular touch therapies in Western countries. Massage therapy is considered a form of medical treatment in several countries where it is covered by national health insurance, including China, Japan, Russia, and West Germany. In the United States, massage therapy still is considered an alternative therapy. Nonetheless, its popularity seems to be growing. National and international massage therapy associations increased their membership by thousands of therapists during the 1990s. Supported by an NIMH Senior Research Scientist Award to Tiffany Field (#MH00331) and funds from Johnson & Johnson to the Touch Research Institutes. From the Touch Research Institutes, Department of Pediatrics, University of Miami School of Medicine, Miami, Florida MEDICAL CLINICS OF NORTH AMERICA VOLUME 86 NUMBER 1 JANUARY

2 164 FIELD TYPES OF MASSAGE Touch therapies can be classified into three groups: energy methods, manipulative therapies, and amalgams (combinations of both). All of these are considered alternative medical therapies that are becoming increasingly popular. Eisenberg et al 2 reported survey data suggesting that 42% of American people are paying (out of their own pockets because it is not covered by most health care plans) for alternative medicine. The most popular forms of alternative medicine in this survey were relaxation therapy, chiropractics, and massage therapy. Because there are so few data on the relative effectiveness of these therapies, most people tend to try a therapist who has been recommended and by trial and error find a preferred therapy. Massage therapy, in addition to feeling good, theoretically releases muscle tension, facilitates the removal of toxic metabolic waste products (resulting from exercise or inactivity), and allows more oxygen and nutrients to reach body cells and tissues. Massage therapy is accompanied by the release of natural pain killers (e.g., serotonin) and natural killer cells (enhancing immune function). Swedish massage is the most common form of massage in the United States, although it is not a pure form of therapy because most therapists integrate Swedish massage with other forms of touch therapy, such as pressure points. Swedish massage usually is given on a massage table, on the floor, or on a special massage chair and often with oil (baby, vegetable, or some aromatic oil). These oils are stroked and kneaded on all parts of the body. Movements called effleurage (smooth stroking) and petrissage (kneading-type movements) are done up and down the back and across the shoulder muscles and the neck muscles and the backs of the legs, feet, arms, and hands. Stroking on the front is done across the stomach, the front of the legs and arms, and the face and forehead. Among other claims made, Swedish massage reportedly boosts circulation, sending more blood to the muscles and facilitating oxygen consumption and waste elimination in the muscles. 3 The Trager method, similar to many other types of massage therapy, is named after its founder. It involves gentle holding and rocking of different body parts. The arms and legs are held individually in different positions suspended to the side or above the body, then gently rocked back and forth. This is a gentle form of body work, and for people with generalized pain, the Trager method may be the preferred method because no pressure is applied to the painful tissues. Reflexology typically is considered an energy method, although it also could be called a massage therapy because it involves kneading, stroking, rubbing, and other massage procedures. These procedures are centered on particular points of the feet, hands, or ears. According to reflexologists, energy from the point that is touched is transmitted across a network of nerves to other parts of the body, such as the back or the stomach. The feet and hands are considered connected to the rest of the body so that if a point, for example, the heel, is touched, the lower back

3 MASSAGE THERAPY 165 is affected. The middle of the foot is connected to the stomach area; the ball of the foot is connected to the heart and lungs; the toes are connected to the head, eyes, and mouth; and so on. Little is known about the origins of this therapy, and there are no empiric data on the use of this method. RESEARCH ON MASSAGE THERAPY Research in the field of massage therapy dates back many years. The first academic journal publications date occurred in the 1930s, when massage therapy research on humans and animals was fairly popular. Most of the more recent research on massage therapy has been conducted at the Touch Research Institutes. Areas of study have included growth in premature infants, depression and addictive problems, pain syndromes, and immune and autoimmune conditions. Examples of studies from these areas are reviewed briefly. Growth for Infants Tactile and kinesthetic stimulation was given to 20 preterm neonates (mean gestational age, 31 weeks; mean birth weight, 1280 g; mean time in neonatal intensive care unit, 20 days) during transitional (grower) nursery care, and their growth, sleep-wake behavior, and Brazelton scale performance were compared with a group of 20 control neonates. 8 The tactile and kinesthetic stimulation consisted of body stroking and passive movements of the limbs for three 15-minute periods per day for 10 days. The stimulated neonates averaged a 47% greater weight gain per day (mean, 25 g versus 17 g); were more active and alert during sleep-wake behavior observations; and showed more mature habituation, orientation, motor, and range of state behavior on the Brazelton scale than control infants. Their hospital stay was 6 days shorter, yielding a cost savings of approximately $3000 per infant. These data suggest that tactile and kinesthetic stimulation may be a cost-effective way of facilitating growth and behavioral organization in small preterm neonates. In a current study, the author s group added growth hormone (insulin-like growth factor I) and oxytocin measurements. These variables are considered important for growth and have been shown to increase with additional stimulation in the rat model. 17 In an earlier study it was speculated that the underlying mechanism for the weight gain in the preterm infants after massage was that their vagal activity (activity of the 10th cranial nerve, the vagus) was increased, and there were more hormones being released for more efficient food absorption because that is the function of the vegetative branch of the vagus nerve. Vagal activity was measured and shown to increase, and plasma samples of insulin increased (one of the more active growth hormones). This may be one of the underlying mechanisms, along with several others,

4 166 FIELD including the fact that gastric motility (which also is stimulated by the vegetative branch of the vagus) also may increase. Increased gastric motility could contribute to more efficient food absorption. Depression and Addictive Problems Depression in Children A 30-minute massage was given daily for 5 days to 52 hospitalized depressed and adjustment disorder children and adolescents. 7 Compared with a control group, who viewed relaxing videotapes, the massaged subjects were less depressed and anxious and had lower saliva cortisol levels after the massage. Nurses rated the subjects as being less anxious and more cooperative on the last day of the study, and nighttime sleep increased over this period. Urinary cortisol and norepinephrine levels decreased but only for the depressed subjects. Anorexia Nervosa Nineteen women (mean age, 25 years) diagnosed with anorexia nervosa were given standard treatment alone or standard treatment plus massage therapy twice weekly for 5 weeks. 9 The massage group reported lower stress and anxiety levels and had lower stress hormone cortisol levels after massage. During the 5-week treatment period, the subjects reported decreases in body dissatisfaction on the Eating Disorder Inventory and showed increased dopamine and norepinephrine levels. Smoking Smoking cessation attempts have been correlated with severe withdrawal symptoms, including intense cigarette cravings, anxiety, and depressed mood. Twenty adult smokers (mean age, 32.6 years) were assigned randomly to a self-massage treatment or a control group. 12 The treatment group was taught to conduct a hand or ear self-massage during three cravings a day for 1 month. Self-reports revealed lower anxiety scores, improved mood, and fewer withdrawal symptoms. The self-massage group smoked fewer cigarettes per day by the last week of the study. The present findings suggest that self-massage may be an effective adjunct treatment for adults attempting smoking cessation to alleviate smoking-related anxiety, reduce cravings and withdrawal symptoms, improve mood, and reduce the number of cigarettes smoked. Invariably in the studies on depression and addictive problems, a decrease in depression was noted after massage therapy. Associated with that decrease was a typical decrease in the stress hormone cortisol and an increase in serotonin levels. These biochemical changes may contribute to the improved clinical condition.

5 MASSAGE THERAPY 167 Pain Syndromes Fibromyalgia In a study on fibromyalgia, 30 adults with fibromyalgia syndrome were assigned randomly to massage therapy, transcutaneous electrical stimulation (TENS), or TENS no-current group for 30-minute treatment sessions two times per week for 5 weeks. 15 The massage therapy subjects reported lower anxiety and depression, and their cortisol levels were lower immediately after the therapy sessions on the first and last days of the study. The massage therapy group improved on the dolorimeter measure of pain. They also reported less pain the last week, less stiffness and fatigue, and fewer nights of difficult sleeping. Massage therapy was the most effective therapy with fibromyalgia patients. Migraine Headaches Twenty-six adults with migraine headaches were assigned randomly to a wait-list control group or to a massage therapy group, who received two 30-minute massages per week for 5 consecutive weeks. 11 The massage therapy subjects reported fewer distress symptoms, less pain, more headache-free days, and fewer sleep disturbances, and they showed an increase in serotonin levels. Origins of Pain Syndromes Because anxiety exacerbates pain syndromes, the author has used anxiety scales (State Trait Anxiety Inventory) to assess the pre and post massage therapy session anxiety levels. 3 Salivary cortisol has been used as the secondary index of anxiety and stress levels before and after massage therapy sessions. Because sleep is considered disturbed in most pain syndromes, either because of the pain or because lack of deep sleep is contributing to the pain (the direction of effects is not certain here), sleep recordings (typically sleep diaries) also have been used. More recently, because it was noticed that in all of the pain syndrome studies sleep improved after massage therapy and pain in turn was reduced, the author s group now are trying to get better measures of sleep, including actometer readings during sleep. One current theory about the origins of pain syndromes is that there is insufficient quiet or restorative sleep, and when that happens, there are increased levels of substance P, which causes pain. Because substance P can be measured in salivary samples, the author s group are assaying substance P at the beginning and end of the massage therapy treatment periods in a replication study. Preliminary analyses of the data suggest that deep sleep increases, and substance P decreases.

6 168 FIELD Immune Disorders Human Immunodeficency Virus In a study conducted on men with human immunodeficiency virus (HIV), 29 gay men (20 HIV-positive, 9 HIV-negative) received daily massages for 1 month. 14 A subset of 11 of the HIV-positive subjects served as a within-subjects control group (1 month with and 1 month without massage). Major immune findings for the effects of the month of massage included a significant increase in natural killer (NK) cell number and NK cell activity. There were no changes, however, in HIV disease progression markers (CD4 or CD4-to-CD8 ratio). Major neuroendocrine findings, measured by 24-hour urine samples, included a significant decrease in cortisol and nonsignificant trends toward decreased catecholamines. Decreased anxiety and increased relaxation were correlated significantly with increased NK cell number. The implication for HIV-positive men is that they are less likely to experience opportunistic infections such as pneumonia because NK cells kill viral cells. To determine whether HIV disease markers (CD4 cells or CD4-to- CD8 ratio) could be increased, less immune compromised HIV-positive adolescents were recruited for a similar study. 1 Adolescents were assigned randomly to receive massage therapy (n 12) or progressive muscle relaxation (n 12) two times per week for 12 weeks. The participants were assessed for depression, anxiety, and immune changes before and after the 12-week treatment period. Adolescents who received massage therapy versus those who received relaxation therapy reported feeling less anxious, and they were less depressed and showed enhanced immune function by the end of the 12-week study. Immune changes included increased NK cell number and increased disease markers (CD4 number and CD4-to-CD8 ratio). Breast Cancer Because NK cells had increased in two HIV studies and because NK cells also kill cancer cells, a study was conducted on massage therapy with women who had breast cancer. 13 Thirty-four women (mean age, 53 years) diagnosed with stage I or II breast cancer were assigned randomly after surgery to a massage therapy group (to receive 30- minute massages three times per week for 5 weeks) or a standard treatment control group. On the first and last day of the study, the women were assessed on (1) immediate effects measures of anxiety, depressed mood, and vigor and (2) longer term effects on depression, anxiety and hostility, functioning, body image, avoidant versus intrusive coping style, urinary catecholamines (norepinephrine, epinephrine, and dopamine) and serotonin levels, and immune measures. The immediate massage therapy effects included a decrease in anxiety, depressed mood, and anger. The longer term massage therapy effects included reduced depression and hostility, increased urinary dopamine and serotonin lev-

7 MASSAGE THERAPY 169 els, and increased NK cell number and lymphocytes. Avoidance coping was associated with greater NK cell number, and intrusive coping was associated with lower dopamine levels. The immune measure that seemed to be invariably improved after 1, 13, 14 massage therapy across all immune studies was the increased number of NK cells. NK cells not only are considered the front line of the immune system because they ward off viral and cancer cells, but also current theory suggests that they may substitute for the destroyed CD4 cells in HIV. These investigators invariably have assayed NK cell number and NK cell cytotoxicity (activity). In more immune-compromised conditions, such as the study on HIV-positive men, the CD4 cell number was so low that it was not possible to reverse those numbers, whereas in the less immune-compromised adolescent HIV study, not only were NK cells increased but also the CD4 cell number was reversed and the HIV disease markers (CD4 cells and CD4-to-CD8 ratio) were improved. Similar to all the other conditions studied, these immune conditions are highly affected by stress hormones, so cortisol levels (cortisol being known to kill immune cells) also were assayed. Autoimmune Conditions Asthma Thirty-two children with asthma (16, 4- to 8-year-olds and 16, 9- to 14-year-olds) were assigned randomly to receive either massage therapy or relaxation therapy. 6 The children s parents were taught to provide one therapy or the other for 20 minutes before bedtime each night for 30 days. The younger children who received massage therapy showed an immediate decrease in behavioral anxiety and cortisol levels after massage. Also, their attitude toward asthma and their peak air flow and other pulmonary functions improved over the course of the study. The older children who received massage therapy reported lower anxiety after the massage. Their attitude toward asthma also improved over the study, but only one measure of pulmonary function (forced expiratory flow 25% to 75%) improved. The reason for the smaller therapeutic benefit in the older children is unknown; however, it appears that daily massage improved airway caliber and control of asthma in both age groups. Diabetes In a similar study, 24 children with diabetes were assigned randomly to a massage therapy or relaxation therapy group. 5 Half the parents were asked to massage their children for 20 minutes before bedtime for 30 consecutive nights, and the other half were asked to conduct progressive muscle relaxation exercises for the same period. The immediate

8 170 FIELD effects of the massage therapy were decreased parental anxiety and depressed mood and decreased child anxiety, fidgeting, and depressed affect. Over the 30-day period, compliance with insulin and food regulation improved, and mean blood glucose levels decreased from a high of 159 mg/dl to within the normal range (118 mg/dl) for the massage group. Because stress and particularly stress hormones such as cortisol are known to interact and affect autoimmune and immune conditions, cortisol was measured in saliva before and after the massage therapy sessions and in urine at the beginning and end of the study period. In all of the autoimmune diseases studied to date (asthma, diabetes, and dermatitis), children were studied, and the parents were used as the massage therapists. The parents also are likely to benefit from the therapy; grandparent volunteer massage therapists who massaged infants became less depressed and had lower cortisol levels. 6 Parents stress levels affect children s stress levels and in turn may affect their autoimmune condition. Otherwise, the measures for the autoimmune diseases have been as different as the diseases themselves. SUMMARY The author and other investigators have documented improvement in several medical and psychiatric conditions after massage therapy, including growth in preterm infants, depression and addictive problems, pain syndromes, and immune and autoimmune conditions. Although some potential underlying mechanisms have been explored for the massage therapy improved clinical condition relationship, including decreased stress (and decreased cortisol), improved sleep patterns, and enhanced immune function, further research is needed in this area. ACKNOWLEDGMENT The author thanks the children and adults who participated in these studies and the researchers who assisted with data coding. References 1. Diego MA, Hernandez-Reif M, Field T, et al: Massage therapy effects on immune function in adolescents with HIV. Int J Neurosci 106:35 45, Eisenberg DM, Kessler RC, Foster C, et al: Unconventional medicine in the United States: Prevalence, costs, and patterns of use. N Engl J Med 82: , Field T: Massage therapy research methods. In Lewith G, Jones W (eds): Clinical Research in Complementary Therapies. Harcourt Publishers Limited, Field T, Henteleff T, Hernandez-Reif M, et al: Children with asthma have improved pulmonary functions after massage therapy. J Pediatr 132: , Field T, Hernandez-Reif M, LaGreca A, et al: Massage therapy lowers blood glucose levels in children with diabetes. Diabetes Spectrum 10: , 1997

9 MASSAGE THERAPY Field T, Hernandez-Reif M, Quintino O, et al: Elder retired volunteers benefit from giving massage therapy to infants. J Appl Gerontol 17: , Field T, Morrow C, Valdeon C, et al: Massage reduces anxiety in child and adolescent psychiatric patients. Am Acad Child Adolesc Psychiatry 31: , Field T, Schanberg SM, Scafidi F, et al: Tactile/kinesthetic stimulation effects on preterm neonates. Pediatrics 77: , Hart S, Field T, Hernandez-Reif M, et al: Anorexia nervosa symptoms are reduced by massage therapy. Eating Disorders The Journal of Treatment and Prevention 9: , Hartshorn K, Delage J, Field T, et al: Senior citizens benefit from movement therapy. Journal of Bodywork, Hernandez-Reif M, Dieter J, Field T, et al: Migraine headaches are reduced by massage therapy. Int J Neurosci 96:1 11, Hernandez-Reif M, Field T, Hart S: Smoking cravings are reduced by self-massage. Prev Med 28:28 32, Hernandez-Reif M, Ironson G, Field T, et al: Breast cancer patients have improved immune functions following massage therapy. CA Cancer J Clin (in review) 14. Ironson G, Field T, Scafidi F, et al: Massage therapy is associated with enhancement of the immune system s cytotoxic capacity. Int J Neurosci 84: , Sunshine W, Field T, Quintino O, et al: Fibromyalgia benefits from massage therapy and transcutaneous electrical stimulation. J Clin Rheumatol 2:18 22, Tse SK, Bailey DM: Tai chi and postural control in the well elderly. Am J Occup Ther 46: , Uvnas-Moberg K: Role of efferent and afferent vagal nerve activity during reproduction: Integrating function of oxytocin metabolism and behaviour. Psychoendocrinology 19: , 1994 Address reprint requests to Tiffany Field, PhD Touch Research Institutes University of Miami School of Medicine Department of Pediatrics PO Box Miami, FL tfield@med.miami.edu