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Department of Veterans Affairs

Health Services Research & Development Service Evidence-based Synthesis Program

Massage for Pain:

An Evidence Map

September 2016

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Quality Enhancement Research Initiative

Health Services Research & Development Service

Washington, DC 20420 

Prepared by:

Evidence-based Synthesis Program (ESP) Center

West Los Angeles VA Medical Center

Los Angeles, CA 

Paul G. Shekelle, MD, PhD, Director 

Investigators:

Principal Investigator: 

Isomi Miake-Lye, PhDc

Co-Investigators: 

Jason Lee, MD, MPH

Tana Lugar, PhD, MPH

Stephanie Taylor, PhD, MPH

Paul Shekelle, MD, PhD

Research Associates: 

Roberta Shanman, MLS

Jessica Beroes, BS

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Massage for Pain Evidence Map Evidence-based Synthesis Program

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PREFACE

The VA Evidence-based Synthesis Program (ESP) was established in 2007 to provide timely and 

accurate syntheses of targeted healthcare topics of particular importance to clinicians, managers, and 

policymakers as they work to improve the health and healthcare of Veterans. QUERI provides funding 

for 4 ESP Centers, and each Center has an active University affiliation. Center Directors are recognized 

leaders in the field of evidence synthesis with close ties to the AHRQ Evidence-based Practice Centers. 

The ESP is governed by a Steering Committee comprised of participants from VHA Policy, Program, 

and Operations Offices, VISN leadership, field-based investigators, and others as designated appropriate 

by QUERI/HSR&D.

The ESP Centers generate evidence syntheses on important clinical practice topics. These reports help: 

Develop clinical policies informed by evidence;

Implement effective services to improve patient outcomes and to support VA clinical practice

guidelines and performance measures; and

Set the direction for future research to address gaps in clinical knowledge.

The ESP disseminates these reports throughout VA and in the published literature; some evidence 

syntheses have informed the clinical guidelines of large professional organizations. 

The ESP Coordinating Center (ESP CC), located in Portland, Oregon, was created in 2009 to expand the 

capacity of QUERI/HSR&D and is charged with oversight of national ESP program operations, program 

development and evaluation, and dissemination efforts. The ESP CC establishes standard operating 

procedures for the production of evidence synthesis reports; facilitates a national topic nomination, 

prioritization, and selection process; manages the research portfolio of each Center; facilitates editorial 

review processes; ensures methodological consistency and quality of products; produces “rapid response 

evidence briefs” at the request of VHA senior leadership; collaborates with HSR&D Center for 

Information Dissemination and Education Resources (CIDER) to develop a national dissemination 

strategy for all ESP products; and interfaces with stakeholders to effectively engage the program. 

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP CC Program 

Manager, at Nicole.Floyd@va.gov. 

Recommended citation: Miake-Lye IM, Lee JF, Luger T, Taylor S, Shanman R, Beroes JM, Shekelle 

PG. Massage for Pain: An Evidence Map. VA ESP Project #05-226; 2016

This report is based on research conducted by the Evidence-based Synthesis Program (ESP) Center located at 

the West Los Angeles VA Medical Center, Los Angeles, CA, funded by the Department of Veterans Affairs, 

Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. 

The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the 

findings and conclusions do not necessarily represent the views of the Department of Veterans Affairs or the 

United States government. Therefore, no statement in this article should be construed as an official position of the 

Department of Veterans Affairs. No investigators have any affiliations or financial involvement (eg, employment, 

consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or 

royalties) that conflict with material presented in the report.
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TABLE OF CONTENTS 

ABSTRACT ................................................................................................................................... 2

Introduction ................................................................................................................................. 2

Methods ...................................................................................................................................... 2

Results ......................................................................................................................................... 2

Discussion ................................................................................................................................... 2

INTRODUCTION......................................................................................................................... 3

METHODS .................................................................................................................................... 4

Topic Development ..................................................................................................................... 4

Search Strategy ........................................................................................................................... 4

Study Selection ........................................................................................................................... 4

Data Abstraction ......................................................................................................................... 4

Quality Assessment ..................................................................................................................... 5

Data Synthesis ............................................................................................................................. 5

Evidence Map ......................................................................................................................... 5

Narrative Synthesis ................................................................................................................. 6

Technical Expert Panel ............................................................................................................... 6

Peer Review ................................................................................................................................ 7

RESULTS ...................................................................................................................................... 8

Literature Flow ........................................................................................................................... 8

Quality of Included Systematic Reviews .................................................................................. 10

Evidence Map ........................................................................................................................... 12

Findings from Systematic Reviews in the Evidence Map ........................................................ 14

Findings from High Quality Systematic Reviews ................................................................ 14

Findings from Low Quality Systematic Reviews ................................................................. 16

Features of Massage Described in Included Systematic Reviews ............................................ 16

Types of Pain in Included Systematic Reviews ........................................................................ 18

SUMMARY AND DISCUSSION .............................................................................................. 20

Future Work .............................................................................................................................. 20

REFERENCES ............................................................................................................................ 21

TABLES

Table 1. AMSTAR Scoring for Included Systematic Reviews .................................................... 10

Table 2. Features of Massage Described in Included Systematic Reviews .................................. 17

FIGURES

Figure 1. Literature Flow Chart ...................................................................................................... 9

Figure 2. Evidence Map of Systematic Reviews Describing Massage for Pain ........................... 13

Figure 3. Types of Pain in Included Systematic Reviews ............................................................ 19

APPENDICES

Appendix A. Search Strategies ..................................................................................................... 25
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Appendix B. Criteria Used in Quality Assessment ....................................................................... 27

Appendix C. Peer Review Comments/Author Responses ............................................................ 30

Appendix D. Evidence Tables for Included Systematic Reviews ................................................ 32
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ABSTRACT

INTRODUCTION

Given the widespread use of various massage therapies for pain, we conducted an evidence 

mapping process to determine the distribution of evidence available for various pain indications 

as well as different forms of massage therapy, identify gaps in evidence, and inform future 

research priorities. This mapping project provides a visual overview of the distribution of 

evidence for massage therapy for indications of pain, as well as an accompanying narrative that 

will help stakeholders interpret the state of evidence to inform policy and clinical decisionmaking.

METHODS

We searched PubMed, Embase, and Cochrane for systematic reviews reporting pain outcomes 

for massage therapy. Abstracted data included: number of studies included in the review that 

report massage as the intervention and pain as an outcome; total number of studies included in 

the review; descriptions of the massage style, provider, co-interventions, duration, and 

comparators; pain type; main findings relevant to massage for pain; and whether the systematic 

review focused solely on massage as the intervention or included a variety of interventions, of 

which massage was one. Quality of each systematic review was assessed using the Assessing the 

Methodological Quality of Systematic Reviews (AMSTAR) criteria. We used a bubble plot to 

visually depict the number of included articles, pain indication, effect of massage for pain, and 

strength of findings for each included systematic review.

RESULTS

We identified 31 systematic reviews, of which 21 were considered high-quality. Systematic 

reviews varied in the amount of detail they collected in describing the massage therapy. Some 

common massage types included Swedish massage, myofascial therapies, Shiatsu, Chinese 

traditional massage, Thai massage, slow stroke massage, and more general descriptions of 

massage. The most common type of pain included in systematic reviews was neck pain (n=6). 

Findings from high-quality systematic reviews describe potential benefits of massage for pain 

indications including labor, shoulder, neck, back, cancer, fibromyalgia, and temporomandibular 

disorder. However, no findings were rated as moderate- or high-strength.

DISCUSSION

More research is needed to establish confidence in the effect of massage for pain. Primary 

studies often do not provide adequate details of the massage therapy provided, especially in the 

descriptions of provider type. Few primary studies of large samples with rigorous methods have 

been conducted, as noted by many of the systematic review authors included in this evidence 

map.
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EVIDENCE REPORT

INTRODUCTION

Many Veterans desire complementary and integrative health or alternative medicine modalities, 

both for treatment and for the promotion of wellness. Given VA’s desire to promote evidencebased practice, this evidence mapping project aims to help provide guidance to VA leadership 

about the distribution of evidence on massage therapy for pain to inform policy and clinical 

decision making.

The term “massage therapy” encompasses many techniques, and the type varies by a patient’s 

needs and physical conditions.1 Common types include Swedish massage, deep tissue massage, 

sports massage, and chair massage.2,3 In general, massage therapists treat patients by using touch 

to manipulate the muscles and other soft tissues of the body. Massage therapies aim to relieve 

pain, help heal injuries, improve circulation, relieve stress, increase relaxation, and aid in the 

general wellness of patients.4 Preliminary evidence suggests that massage may help with back 

pain and may improve the quality of life for people with cancer, depression, or HIV/AIDS.5-9

Massage therapy appears to have few risks if used appropriately and provided by a trained 

massage professional.10,11 Results from the 2012 National Health Interview Survey – a national 

survey conducted on a representative sample of adults in the United States – estimates that 

approximately 15.4 million adults (6.9%) used massage therapy in the past 12 months.12 In the 

United States, 44 states and the District of Columbia regulate massage therapists or provide 

voluntary state certification. In states that do not regulate massage therapy, cities, counties, or 

other local governments also may regulate massage therapists. However, training standards and 

licensure requirements for massage therapists vary greatly by state and locality.13

While massage is thought to be an effective treatment for various types of pain, to date an 

evidence synthesis surveying the evidence for massage therapy across a broad spectrum of pain 

types has not been conducted. Given the widespread use of various massage therapies for pain, 

we conducted an evidence mapping process to determine the distribution of evidence available 

for various pain indications as well as different forms of massage therapy, identify different gaps 

in evidence, and inform future research priorities. An evidence map is an overview of a broad 

research field that describes the volume, nature, and characteristics of research in a particular 

field.14 The objective of this mapping project was to provide a visual overview of the distribution 

of evidence for massage therapy for indications of pain, as well as an accompanying narrative

that will help stakeholders interpret the state of evidence to inform policy and clinical decisionmaking.
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METHODS

TOPIC DEVELOPMENT

This topic was developed in response to a nomination by Stephen Ezeji-Okoye, MD, VA 

Integrative Health Coordinator, Patient Care Services and Laura Krejci, MSW, Associate 

Director, Office of Patient Centered Care and Cultural Transformation. The scope was further 

developed with input from the topic nominators, the ESP Coordinating Center, the review team, 

and the technical expert panel (TEP).

The scope of this report includes the following:

An evidence map that provides a visual overview of the distribution of evidence (both 

what is known and where there is little or no evidence base) for massage therapy for 

indications of pain; and

An accompanying narrative that helps stakeholders interpret the state of the evidence to 

inform policy and clinical decision making.

SEARCH STRATEGY

The searches for this study consisted of broad searches from database inception through 

February 17, 2016 using terms related to pain and massage in 3 databases: PubMed, Embase, and 

Cochrane (see Appendix A for full strategy). Searches were also conducted in the same time 

range in PubMed related to 3 key publications which identified articles similar to the key 

publications.

15-17 We restricted our searches to English language publications.

STUDY SELECTION

Each title was screened independently by 2 authors for relevance; any article chosen by either 

reviewer was included in the abstract screen. When citations were ambiguous they were included 

for further review. Abstracts were then reviewed in duplicate with any discrepancies resolved by 

a third reviewer. In order to be included, abstracts or titles needed to be relevant to massage, 

mention pain or a pain-related condition (eg, headache), and discuss a systematic review.

For inclusion in the evidence map, each reference must have represented a unique systematic 

review that reported pain outcomes for at least one massage intervention. Reports and journal 

articles from the same study or updates to the same review were included but data were extracted 

and counted once in these instances. Systematic reviews were still eligible if they covered 

additional outcomes or other interventions if results for massage for pain were reported 

separately.

DATA ABSTRACTION

Each included systematic review had data abstracted by one reviewer and verified by a second 

reviewer. Abstracted data included: number of studies included in the review that had massage as 

the intervention and pain as an outcome; total number of studies included in the review; 

descriptions of the massage style, provider, co-interventions, duration, and comparators; pain 

type; main findings relevant to massage for pain; and whether the systematic review focused 
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solely on massage as the intervention or included a variety of interventions, of which massage is 

one.

QUALITY ASSESSMENT

Each systematic review was assessed using a modified version of the Assessing the 

Methodological Quality of Systematic Reviews (AMSTAR) criteria.18 This 11-item tool was 

designed to assess the methodological quality of systematic reviews (see full modified tool in 

Appendix B). Four criteria were relaxed for the quality assessment in this project: (1) the search 

strategy was not required to have supplemental searches beyond the 2 or more sources being 

searched; (2) reviews were not required to provide a list of their excluded studies; (3) narrative 

publication bias discussions were acceptable for systematic reviews not using quantitative 

methods; and (4) documented sources of support were not required for the included individual 

studies.

While there is no agreed-upon threshold for AMSTAR criteria above which a systematic review 

would be considered “high quality,” we used a score of 9 or higher for our purposes. Thus, 

studies could miss a maximum of 2 criteria and still be considered “high quality.”

DATA SYNTHESIS

Our evidence mapping process resulted in a visual depiction of the evidence for massage for 

pain, as well as an accompanying narrative with ancillary figures and tables.

Evidence Map

The visual depiction uses a bubble plot format to display information on 4 dimensions: bubble 

size, bubble label, x-axis, and y-axis. This allowed us to provide 4 types of information about 

each included systematic review, as follows:

Number of articles in systematic review (bubble size): Each systematic review bubble’s size is 

directly proportional to the number of primary research studies included in that systematic 

review related to the effect of massage for pain. 

Pain type (bubble label): Each bubble is labelled with the pain indication(s) discussed by that 

systematic review. 

Effect of massage for pain (x-axis): We grouped systematic reviews into 5 categories of

findings they reported on for massage for pain. Reviews that reported massage as more 

beneficial than the comparator were included in the “potentially better” group, those that 

reported massage as less beneficial than the comparator were included in the “potentially worse” 

group, those that suggested insufficient evidence to draw clear conclusions about the 

effectiveness of massage for pain were included in the “unclear” group, those that had findings 

that varied within the systematic review were included in the “mixed results” group, and those 

that were unable to detect differences between massage and the comparator for pain were 

included in the “no difference” group. Each systematic review had one overall finding included 

in the bubble plot; if a systematic review had multiple consistent findings it was added to that 

appropriate group, whereas reviews with multiple conflicting findings were included in the 

“mixed results” group.
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Strength of findings (y-axis): Systematic reviews were grouped into 5 categories based on the

strength of their findings, which fall along the y-axis. The first 4 categories came from the 

GRADE approach,

19 which takes into account study design limitations, inconsistency, 

indirectness, and imprecision in primary study results to assess the body of evidence contributing 

to a particular finding. Findings from systematic reviews that received high quality scores (scores 

of 9 or higher) were categorized using the GRADE levels. In most cases, these findings were 

already described with levels of evidence in the original systematic reviews, but in the cases 

where this was not provided, our group assessed the GRADE score based on the description of 

findings provided in the systematic review. 

Findings from systematic reviews with scores of 8 or lower were not classified using the 

GRADE criteria, and comprise the fifth and final group along the y-axis: “unable to determine.” 

The methodological issues with these systematic reviews makes interpretation of the reported 

findings difficult, as sources of bias may be affecting the results and conclusions drawn. 

The findings from high-quality systematic reviews were classified as having one of the following 

levels for quality of evidence:

High: We are very confident that the true effect lies close to that of the estimate of the 

effect. Further research is unlikely to change our confidence in the estimate of effect.

Moderate: We are moderately confident in the effect estimate. The true effect is likely to 

be close to the estimate of the effect, but there is a possibility that it is substantially 

different. Further research is likely to have an important impact on our confidence in the 

estimate of effect and may change the estimate.

Low: Our confidence in the effect estimate is limited. The true effect may be 

substantially different from the estimate of the effect. Further research is very likely to 

have an important impact on our confidence in the estimate of effect and is likely to 

change the estimate.

Very low: We have very little confidence in the effect estimate. The true effect is likely 

to be substantially different from the estimate of effect. Any estimate of effect is very 

uncertain.

The evidence map figure also allows the reader to visualize gaps in the literature base, where 

there is no or little evidence for particular pain indications.

Narrative Synthesis

The narrative synthesis expands upon the visual evidence map to provide more details from the 

included systematic reviews. These include descriptions of the findings, the features of massage 

therapy, and the types of pain.

TECHNICAL EXPERT PANEL

The technical expert panel (TEP) for the project included: Allison Mitchinson, MPH, Certified 

Massage Therapist, VA Ann Arbor Healthcare System; Baron Tang, PT, Physical Therapist, 

Postdoctoral Fellow in Training, Evidence In Motion, White River Junction VA Medical Center; 
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Stephen Ezeji-Okoye, MD, VA Integrative Health Coordinator, Patient Care Services, VA Palo 

Alto Health Care System; and Laura Krejci, MSW, Associate Director, Office of Patient 

Centered Care and Cultural Transformation, Department of Veterans Affairs, Washington, DC.

PEER REVIEW

A draft version of the report was reviewed by technical experts and clinical leadership. Reviewer 

comments and our response are documented in Appendix C.
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RESULTS

LITERATURE FLOW

Our searches identified 4,568 titles as potentially relevant for this evidence map. From these 

titles, 246 references were included for abstract review. Our screen of abstracts excluded 196 

abstracts because they did not mention pain as an outcome, did not mention massage as an 

intervention, used a study design other than systematic review, or some combination of these 

factors. When reviewing full texts, there were 13 references that did not meet inclusion criteria 

upon further inspection. In 3 publications, the results for massage were not reported separately 

from other interventions, 3 publications were only available in abstract form, 2 were systematic 

reviews of systematic reviews, 2 were non-systematic reviews, 2 were not retrievable, and one 

was a duplicate of another included publication. See the Literature Flow in Figure 1.

From the 50 references included in the full-text review, we included 37 references that discuss 31

systematic reviews. Six references discussed systematic reviews that were duplicative of 

included systematic reviews.20-25 This includes older iterations of Cochrane systematic reviews, 

the updates for which had been included,20,21 as well as instances where multiple publications 

were produced from the same systematic review effort.22-25
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Figure 1. Literature Flow Chart

Search results: 

4,568 references*

Eligible for full text review: 

50 references

Included publications:

37 references of

31 systematic reviews**

Excluded = 4,322

Excluded = 13 references

Results not reported for massage: 3

Only abstract available: 3

Systematic review of systematic reviews: 2

Not systematic review: 2

Unable to retrieve: 2

Duplicate of included publication: 1

* Results from searches described in Appendix A

** Manuscript reference list includes additional references cited for background and methods.

Reviewed abstracts: 246 

references Excluded = 196 references
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QUALITY OF INCLUDED SYSTEMATIC REVIEWS 

Of the 31 systematic reviews included, 6 reviews met all 11 modified AMSTAR criteria (see 

Table 1). Seven reviews met 10 of the criteria, and 8 reviews met 9 of the criteria. These 21 

systematic reviews were considered high quality and account for 67.7 percent of the included 

reviews. The other 10 systematic reviews were of lower quality, receiving credit for 8 criteria 

(n=3), 7 criteria (n=2), 6 criteria (n=3), 5 criteria (n=1), or 3 criteria (n=1) in the AMSTAR 

quality assessment. All 31 systematic reviews provided the characteristics of their included 

studies, which was the only criterion met by all included systematic reviews in this evidence 

map. The least often-met criterion was to provide an a priori design, with 11 systematic reviews 

meeting this criterion.

Table 1. Modified AMSTAR Scoring for Included Systematic Reviews A priori design provided Duplicate review Comprehensive search Status of publication used List of studies included Included study characteristics Assessed quality of includes Quality used in conclusions

Synthesis methods appropriatePublication bias assessedInclude conflict of interestTotal Score

Anthonissen 2016 ? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 10

Piper 2016 Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10

Furlan 2015 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11

Bervoets 2015 ? Yes Yes Yes Yes Yes Yes Yes Yes No Yes 9

Calixtre 2015 ? Yes Yes Yes Yes Yes Yes No Yes Yes Yes 9

Keeratitanont 2015 No ? Yes No Yes Yes Yes Yes N/A No Yes 6

Yuan 2015 Yes Yes Yes No Yes Yes Yes Yes Yes No No 8

Loew 2014 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11

Chaibi 2014 No No Yes Yes Yes Yes Yes Yes ? ? Yes 7

Cheng 2014 No Yes Yes Yes Yes Yes Yes Yes Yes ? No 8

Li 2014 ? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 10

Kong 2013 ? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 10

Patel 2012 Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes 10

van den Dolder 2014 Yes Yes Yes Yes Yes Yes Yes Yes No ? Yes 9

Smith 2012 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11

Terhorst 2011 No Yes Yes Yes Yes Yes Yes Yes Yes ? Yes 9

Furlan 2010 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11
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Ernst 2009 No ? Yes Yes Yes Yes Yes Yes Yes ? No 7

Wilkinson 2008 ? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 10

Ezzo 2007 ? Yes Yes ? Yes Yes Yes Yes Yes ? Yes 8

Bardia 2006 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11

Smith 2006 Yes Yes Yes Yes Yes Yes Yes Yes No ? Yes 9

Haraldsson 2006 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11

Huntley 2004 ? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 10

Cherkin 2003 ? Yes Yes Yes Yes Yes Yes ? Yes Yes Yes 9

Simkin 2002 ? Yes Yes Yes Yes Yes Yes Yes Yes Yes No 9

Pan 2000 ? Yes Yes Yes Yes Yes ? ? ? ? Yes 6

Richards 2000 No ? Yes Yes Yes Yes Yes ? ? ? No 5

Ernst 1999 ? ? Yes Yes Yes Yes ? No Yes Yes No 6

Kong 2011 No ? ? ? No Yes Yes Yes ? ? No 3

Lewis 2006 ? Yes Yes Yes Yes Yes Yes Yes Yes ? Yes 9

? = cannot determine based on description provided; N/A = not applicable in this publication; full criteria are 

described in Appendix B. 
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EVIDENCE MAP

The results of the evidence mapping process are depicted visually in the evidence map (Figure 

2), as well as described narratively. The evidence map displays each of the 31 included 

systematic reviews as bubbles. The bubble label represents the pain indication described in that 

review. The bubble size denotes the number of primary studies included in that review 

specifically related to massage for pain. Primary studies may be included in multiple systematic 

reviews. Each of these bubbles is plotted according to the strength of the findings for massage 

for pain (y-axis), as well as by the effect massage was found to have for pain (x-axis). The 

evidence tables provide details of included systematic reviews (Appendix D).
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Figure 2. Evidence Map of Systematic Reviews Describing the Effect of Massage for Pain 

LBP = low back pain, TMJ = temporomandibular disorder; Multi = multiple conditions described
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FINDINGS FROM SYSTEMATIC REVIEWS IN THE EVIDENCE MAP

Findings from High-quality Systematic Reviews

The findings from the 21 high-quality systematic reviews were categorized according to strength 

of findings, with no systematic reviews describing moderate- or high- strength findings. No 

systematic reviews found massage to be worse than the comparator.

Of the 6 systematic reviews describing low-strength findings, 3 reviews found that massage was 

potentially better than the comparator. The first systematic review included 6 trials, all of which 

were describing the use of massage for pain during labor. This Cochrane review found that 

compared to usual care, massage during the first stage of labor was associated with less pain in 

the pooled results from 4 trials of 225 women (standardized mean difference -0.82, 95% CI: -

1.17, -0.47). Overall, the authors found that massage may reduce pain during labor, but none of 

the included trials were completely at a low risk of bias for all quality domains and data were 

available for 326 women total, so our research team assigned their finding at low strength of 

evidence. The next systematic review aimed to determine the effectiveness of exercise and softtissue massage, either individually or in combination, when used to treat shoulder pain, and 7 of 

the 23 included publications were relevant to massage for pain. Their findings included studies 

using massage alone, as well as with combinations of treatments. They concluded that there is 

low-quality evidence supporting the effectiveness of massage for shoulder pain, when compared 

to no treatment or active controls like hot packs or short wave diathermy. All included studies 

had small sample sizes. The final systematic review with low-strength findings suggested that

massage may be beneficial described the effectiveness of soft-tissue therapies for multiple 

conditions, including carpal tunnel syndrome, lateral epicondylitis, subacromial impingement 

syndrome, and plantar fasciitis. They found 6 studies with low risk of bias that suggested that 

overall, various types of massage may be effective for the musculoskeletal disorders and injuries 

of the lower extremities, however for each comparison identified, a single randomized controlled 

trial served as the source of information.

Three high-quality systematic reviews found mixed results, when massage sometimes performed

better than the comparator, with low-strength findings. Two reviews were authored by Furlan 

and colleagues, with one focused on massage for low back pain and the other looking more 

broadly at complementary and alternative medicine for back and neck pain. These were the 2 of 

the 3 largest systematic reviews included in this evidence map, with 25 RCTs and 35 studies 

included, respectively. Both met all AMSTAR criteria, and described a number of detailed 

findings relevant to massage for pain for different pain types (eg, acute, subacute, chronic), 

follow-up periods, and comparators. Both grouped the comparison groups into 2 types: inactive 

controls that are not expected to improve outcomes (eg, sham therapy, waiting list, or no 

treatment), and active controls that are intended to improve outcomes (eg, manipulation, 

mobilization, acupuncture, traction, relaxation, physical therapy, exercises, pain medication, or 

self-care education). Massage for low back pain performed better than both active and inactive 

comparators in the short-term follow-up, but only compared to active comparators in the longterm follow-up. No difference was found between massage and inactive controls for long-term 

follow-up. Furlan and colleagues rated the strength of this evidence as low or very low due to the 

small sample sizes and methodological issues of the RCTs included in this Cochrane review. In 

their other review, massage was found to be superior to inactive comparators for acute and subacute low back pain, superior to active comparators for back pain, and superior to both active and 
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inactive comparators for neck pain. For patients with nonspecific chronic low back pain, 

massage did not differ from inactive comparators but compared to active controls it performed 

significantly better in 2 meta-analyses. Massage for neck pain performed better than inactive 

comparators. These findings were ranked by their authors as mostly low strength. The final 

review in this group examined a range of conservative treatments, of which massage was one, for 

burn scars. Two of the 22 studies included in this systematic review were relevant to massage for 

pain, and both reported reductions in pain in the massage groups. These studies were small, and 

there were variations in massage techniques and populations, so we ranked this finding as low 

strength.

Five systematic reviews found very low-strength findings suggesting that massage may be better 

than the comparator for a variety of conditions. According to the GRADE approach, very low 

strength means there is “very little confidence in the effect estimate. The true effect is likely to 

be substantially different from the estimate of effect. Any estimate of effect is very uncertain.”

19

So while these 5 reviews had positive findings, there is very little confidence in these positive 

effects. All 5 systematic reviews reported positive findings, but our research team assigned a 

very low strength, using the GRADE approach to all of them. 

For fibromyalgia pain, massage therapy was reported in all 9 RCTs identified by Li and 

colleagues. Six of these were included in a meta-analysis that found nonsignificant reductions in 

pain, but the 3 RCTs reporting on massage with a duration 5 weeks or longer did show 

significant reductions in a subgroup analysis (SMD: 0.62; 95% CI: 0.05, 0.1.2; p=0.03). We 

rated this finding as very low strength. The second systematic review found very low strength of 

evidence from 8 small studies that manual therapies, including massage, improve pain in subjects 

with temporomandibular disorder. The third systematic review focused solely on massage for 

neck and shoulder pain and found 12 studies, 10 of which were RCTs that were included in the 

meta-analyses. Pooled outcomes showed significant immediate effects compared to inactive 

therapies (ie, waiting list control, standard care, and sham therapies) for both shoulder and neck 

pain (SMD: 1.79; 95% CI: 1.01, 2.57 and SMD: 1.5; 95% CI: 0.55, 2.45 respectively), and 

nonsignificant positive effects compared to active therapies (eg, acupuncture, traction, physical 

therapy, exercise, and activator trigger point therapy) for both shoulder and neck pain. The fourth 

systematic review assessed the evidence for massage for cancer symptom relief, with 4 of the 10 

included studies reporting pain outcomes. These 4 studies suggested that pain improved with 

massage for patients with cancer, however the authors note that despite statistically significant 

findings in individual studies, the poor methodological quality and small sample sizes necessitate 

cautious interpretation of the findings. The final systematic review in this group summarized the 

evidence for complementary and alternative medicine for back pain, with 8 of the 17 included 

studies relevant to massage for back pain. Overall, the authors concluded that massage was 

effective for persistent back pain, but described the need for further research in the area.

One systematic review included 60 RCTs on complementary and alternative medicine for 

fibromyalgia pain and found 6 small RCTs relevant to massage. The individual studies varied in 

whether they favored massage or the control, with most demonstrating no statistical significance. 

The pooled result reflects this ambivalence, with a nonsignificant positive outcome.

In broad review of massage for musculoskeletal pain, 26 studies contributed to findings 

supporting the use of massage for shoulder pain and osteoarthritis of the knee, while no benefits 

or reductions in pain were found for low back pain, neck pain, fibromyalgia, and general 
Massage for Pain Evidence Map Evidence-based Synthesis Program

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musculoskeletal pain. These studies had different follow-up periods and comparators, 

contributing to the very low strength and heterogeneous nature of the evidence from this 

systematic review. The other systematic review with very low strength of evidence for mixed 

results examined the use of complementary and alternative medicine for cancer pain in 14 

studies, 4 of which included massage. The studies were split between showing no difference and 

improvements in pain with massage, with the small sample sizes and other methodological 

considerations creating additional uncertainty.

Seven high-quality systematic reviews found very low strength of evidence demonstrating

unclear findings for massage.15,33,45-48,53 These reviews all described the need for more research 

before any conclusions could be drawn for topics including tendinitis, labor, neck pain, 

headache, and other musculoskeletal conditions.

Findings from Low Quality Systematic Reviews

Ten systematic reviews were scored as having not met 3 or more quality criteria using 

AMSTAR. This indicates that there were flaws in the reporting or methodology of these 

systematic reviews that make it difficult to determine how their findings should be interpreted. 

As such, these findings were not able to be categorized by strength, and the conclusions drawn in 

these systematic reviews should be interpreted with caution. To the extent that higher quality 

systematic reviews have covered the same topics, these findings may be interpreted with more 

confidence than the findings in this group of lower quality reviews. For instance, neck pain, 

fibromyalgia, low back pain, cancer, and headache have all been the subject of higher quality 

systematic reviews.

FEATURES OF MASSAGE DESCRIBED IN INCLUDED SYSTEMATIC 

REVIEWS

Systematic reviews varied in the amount of detail they collected in describing the massage 

performed in primary studies, as well as how they reported this information (see Table 2). 

Twenty of the systematic reviews focused solely on interventions they categorized as massage, 

while the other 11 systematic reviews included other types of similar interventions in their 

systematic reviews. This latter group of systematic reviews covered a variety of intervention 

types, the most common group being types of complementary and alternative medicine.16,40

Other examples of interventions included in broad systematic reviews include manual 

therapies,34 exercise,38 nonpharmacologic strategies, and conservative treatments,26 which 

included silicone gel application, ultrasound, pressure therapy, hydration, and combinations of 

therapy in addition to massage.

All 31 systematic reviews included descriptions of the other interventions against which massage 

was compared, as well as the duration or timing of massage treatment. Twenty-eight systematic 

reviews included descriptions of co-interventions, or reported that they excluded studies with cointerventions. These 3 features of massage were most often reported for each primary study 

included in the review, with variability between these primary studies. Some reviews, like the 

one by Furlan and colleagues,16 parsed out findings for different comparators, while many did 

not. 
Massage for Pain Evidence Map Evidence-based Synthesis Program

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Some type of description of massage style was included in all but 2 of the systematic reviews.

Two systematic reviews limited included studies to particular types of massage – traditional Thai 

massage31 and deep transverse friction massage33 – but these reviews were small, with 6 and 2 

included studies respectively. Another 2 systematic reviews included studies of therapeutic 

massage, however they included a different range of therapies within this categorization, with 

one including chiropractic management in their review,52 while the other explicitly excluded 

manipulation techniques.53 Other systematic reviews had general inclusion criteria for massage 

interventions, and there was variation in whether related interventions like reflexology or 

manipulation techniques were included. Some common massage types included Swedish 

massage, myofascial therapies, Shiatsu, Chinese traditional massage, Thai massage, slow stroke 

massage, and more general descriptions of massage. As noted in one high-quality systematic 

review that focused on massage as the sole intervention, most of the primary research studies 

“lacked a clear definition, description, or rationale for massage, the massage technique, or both.” 

There is considerable variability both within individual systematic reviews as well as between 

reviews in what is considered to be massage. Abridged descriptions for each systematic review 

are provided in the evidence tables (Appendix D).

The feature of massage least often described in the systematic reviews was the provider of the 

massage therapy. Thirteen systematic reviews did not provide descriptions of the massage 

provider. Multiple reviews mentioned that primary research study descriptions often did not 

provide this information, which affected the reviewers’ abilities to abstract and report on 

provider information systematically.

Table 2. Features of Massage Described in Included Systematic Reviews

Author, year

Focused on massageStyleProviderCo-interventions

DurationComparators

Anthonissen 2016 ○ ● ○ ● ● ●

Piper 2016 ● ● ● ● ● ●

Furlan 2015 ● ● ● ● ● ●

Bervoets 2015 ● ● ● ● ● ●

Calixtre 2015 ● ● ● ● ● ●

Keeratitanont 2015 ● ● ○ ● ● ●

Yuan 2015 ● ● ● ● ● ●

Loew 2014 ● ● ● ● ● ●

Chaibi 2014 ○ ● ● ● ● ●

Cheng 2014 ● ● ○ ● ● ●

Li 2014 ● ● ○ ● ● ●
Massage for Pain Evidence Map Evidence-based Synthesis Program

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Kong 2013 ● ● ○ ● ● ●

Patel 2012 ● ● ● ● ● ●

van den Dolder 2014 ○ ○ ○ ● ● ●

Smith 2012 ● ● ● ● ● ●

Terhorst 2011 ○ ● ○ ● ● ●

Furlan 2010 ○ ● ● ● ● ●

Ernst 2009 ● ● ● ● ● ●

Wilkinson 2008 ● ● ● ○ ● ●

Ezzo 2007 ● ● ○ ● ● ●

Bardia 2006 ○ ○ ○ ○ ● ●

Smith 2006 ○ ● ● ● ● ●

Haraldsson 2006 ● ● ● ● ● ●

Huntley 2004 ○ ● ○ ● ● ●

Cherkin 2003 ○ ● ○ ● ● ●

Simkin 2002 ○ ● ● ● ● ●

Pan 2000 ○ ● ● ● ● ●

Richards 2000 ● ● ● ● ● ●

Ernst 1999 ● ● ○ ● ● ●

Kong 2011 ● ● ○ ○ ● ●

Lewis 2006 ● ● ● ● ● ●

●= yes; ○= no

TYPES OF PAIN IN INCLUDED SYSTEMATIC REVIEWS

Types of pain described by the 31 included systematic reviews are visualized in the word cloud 

depicted in Figure 3. The size of each pain descriptor is proportional to the number of systematic 

reviews focused on that pain type, with some reviews covering multiple pain types (eg, neck and 

low back pain). The most common type of pain included in systematic reviews was neck pain 

(n=6), with 3 systematic reviews focused exclusively on neck pain, and the others also including 

low back pain, headache, or shoulder pain. Labor pain and fibromyalgia each had 4 systematic 

reviews dedicated to that particular pain type, while cancer pain and low back pain each were the 

subject of 3 systematic reviews. Four pain types were included in 2 systematic reviews: shoulder 

pain, headache, musculoskeletal pain, and pain treatment in palliation. Tendinitis,

temporomandibular disorder, scar pain, back pain, pain in a critical care setting, chronic pain (ie, 

chronic myofascial pain syndrome, chronic low back pain, and scapulocostal syndrome), and 

multiple conditions (ie, carpal tunnel syndrome, lateral epicondylitis, subacromial impingement 

syndrome, and plantar fasciitis) were each the subject of a systematic review. Some of these 

groupings are overlapping or contain multiple types of pain, and are described in this report as 

they are described in the original systematic reviews in order to preserve the classifications of the 
Massage for Pain Evidence Map Evidence-based Synthesis Program

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systematic review authors. The 2 reviews of musculoskeletal pain in particular subsumed many 

of the other pain types, including low back pain, neck pain, and shoulder pain.29,53 More detailed 

descriptions are provided for each review in the evidence tables (Appendix D). 

Figure 3. Types of Pain in Included Systematic Reviews

LBP = low back pain; TMJ = temporomandibular disorder
Massage for Pain Evidence Map Evidence-based Synthesis Program

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SUMMARY AND DISCUSSION

Findings from high-quality systematic reviews describe potential benefits of massage for pain 

indications including labor, shoulder, neck, back, cancer, fibromyalgia, and temporomandibular 

disorder. However, no findings were rated as moderate- or high-strength, indicating that more 

research is needed to establish confidence in the effect of massage for pain. A third of included 

reviews did not meet our threshold for high quality. While some of these reviews overlapped in 

scope with higher quality reviews, others did not, and these topics need to be revisited with 

strong synthesis methodology before conclusions can be drawn from the findings.

Systematic review authors found that primary studies often do not provide adequate details of the 

massage therapy provided, especially in the descriptions of provider type. In addition, 

terminology is unclear, with no standardized definition of massage types or what specific 

therapies are included under the umbrella term “massage.”

FUTURE WORK

This evidence mapping process was intended to describe the range of evidence on massage for 

pain. When multiple systematic reviews within the evidence map overlap in pain indications,

cross-checking of these reviews may be necessary to determine if the same primary studies are 

being described, the extent of the overlap, and applicability of some or all findings in a review 

for a particular research or policy question. In one such example, fibromyalgia systematic 

reviews had differing findings, with 2 of lower quality. A future synthesis would be needed to 

see which studies were included in all reviews, and which were included in some but not others 

to determine a new finding inclusive of all potential evidence. The topics with multiple bubbles, 

especially with differing findings, may be areas that are ripe for an update systematic review. 

Other areas where future synthesis efforts would be beneficial include updating pain indications 

for which existing reviews are outdated (eg, critical care).
Massage for Pain Evidence Map Evidence-based Synthesis Program

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REFERENCES

1. National Center for Complementary and Integrative Health (NCCIH). Massage Therapy 

for Health Purposes. 

7/19/2016:https://nccih.nih.gov/health/massage/massageintroduction.htm.

2. American Massage Therapy Association. Types of Massage. 

https://www.amtamassage.org/findamassage/massage_type.html Accessed 7/14/2016.

3. National Certification Board for Therapeutic Massage & Bodywork (NCBTMB). 

Glossary: Therapy and Techniques. http://www.ncbtmb.org/consumers/glossary-therapytechniques. Accessed 7/14/2016.

4. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, 

2016-17 Edition, Massage Therapists. 2016; http://www.bls.gov/ooh/healthcare/massagetherapists.htm. Accessed 7/14/2016.

5. Field T, Diego M, Solien-Wolfe L. Massage therapy plus topical analgesic is more 

effective than massage alone for hand arthritis pain. Journal of bodywork and movement 

therapies. Jul 2014;18(3):322-325.

6. Ye L, Kalichman L, Spittle A, Dobson F, Bennell K. Effects of rehabilitative 

interventions on pain, function and physical impairments in people with hand 

osteoarthritis: a systematic review. Arthritis research & therapy. 2011;13(1):R28.

7. Kalichman L. Massage therapy for fibromyalgia symptoms. Rheumatology international. 

Jul 2010;30(9):1151-1157.

8. Kalichman L. Perineal massage to prevent perineal trauma in childbirth. The Israel 

Medical Association journal : IMAJ. Jul 2008;10(7):531-533.

9. Shmushkevich Y, Kalichman L. Myofascial pain in lateral epicondylalgia: A review. 

Journal of bodywork and movement therapies. October 2013;17(4):434-439.

10. Vickers A, Zollman C. ABC of complementary medicine: Massage therapies. British 

Medical Journal. 1999;319(7219):1254-1257.

11. American Massage Therapy Association. Uncovering the Hidden Risks in Your Practice. 

https://www.amtamassage.org/articles/3/MTJ/detail/1687 Accessed 7/14/2016.

12. Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. Trends in the use of 

complementary health approaches among adults: United States, 2002–2012. National 

health statistics reports. 2015(79):1.

13. American Massage Therapy Association. Industry Fact Sheet. 

https://www.amtamassage.org/infocenter/economic_industry-fact-sheet.html. Accessed 

7/14/2016.

14. Miake-Lye IM, Hempel S, Shanman R, Shekelle PG. What is an evidence map? A 

systematic review of published evidence maps and their definitions, methods, and 

products. Systematic reviews. 2016;5(1):1.

15. Patel KC, Gross A, Graham N, et al. Massage for mechanical neck disorders. The 

Cochrane database of systematic reviews. 2012;9:Cd004871.
Massage for Pain Evidence Map Evidence-based Synthesis Program

22

16. Furlan AD, Yazdi F, Tsertsvadze A, et al. Complementary and alternative therapies for 

back pain II. Evidence report/technology assessment. Oct 2010(194):1-764.

17. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A review of the evidence for the 

effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation 

for back pain. Annals of internal medicine. Jun 3 2003;138(11):898-906.

18. Shea BJ, Grimshaw JM, Wells GA, et al. Development of AMSTAR: a measurement tool 

to assess the methodological quality of systematic reviews. BMC medical research 

methodology. 2007;7(1):1.

19. Balshem H, Helfand M, Schünemann HJ, et al. GRADE guidelines: 3. Rating the quality 

of evidence. Journal of clinical epidemiology. 2011;64(4):401-406.

20. Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back pain. The Cochrane 

database of systematic reviews. 2008(4):Cd001929.

21. Furlan AD, Brosseau L, Imamura M, Irvin E. Massage for low back pain. The Cochrane 

database of systematic reviews. 2002(2):Cd001929.

22. Furlan AD, Yazdi F, Tsertsvadze A, et al. A systematic review and meta-analysis of 

efficacy, cost-effectiveness, and safety of selected complementary and alternative 

medicine for neck and low-back pain. Evidence-based complementary and alternative 

medicine : eCAM. 2012;2012:953139.

23. Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low back pain: an updated 

systematic review within the framework of the Cochrane Back Review Group. Spine. Jul 

15 2009;34(16):1669-1684.

24. Furlan AD, Brosseau L, Imamura M, Irvin E. Massage for low-back pain: a systematic 

review within the framework of the Cochrane Collaboration Back Review Group. Spine. 

Sep 1 2002;27(17):1896-1910.

25. Terhorst L, Schneider M. Complementary and alternative medicine in the treatment of 

pain in fibromyalgia: A systematic review of randomized controlled trials. BMC 

complementary and alternative medicine. 2012;12(1):2012-2005.

26. Anthonissen M, Daly D, Janssens T, Van den Kerckhove E. The effects of conservative 

treatments on burn scars: A systematic review. Burns : journal of the International 

Society for Burn Injuries. Jan 14 2016.

27. Piper S, Shearer HM, Cote P, et al. The effectiveness of soft-tissue therapy for the 

management of musculoskeletal disorders and injuries of the upper and lower 

extremities: A systematic review by the Ontario Protocol for Traffic Injury management 

(OPTIMa) collaboration. Manual therapy. Feb 2016;21:18-34.

28. Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M. Massage for low-back pain. The 

Cochrane database of systematic reviews. 2015;9:Cd001929.

29. Bervoets DC, Luijsterburg PA, Alessie JJ, Buijs MJ, Verhagen AP. Massage therapy has 

short-term benefits for people with common musculoskeletal disorders compared to no 

treatment: a systematic review. Journal of physiotherapy. Jul 2015;61(3):106-116.

30. Calixtre LB, Moreira RF, Franchini GH, Alburquerque-Sendin F, Oliveira AB. Manual 

therapy for the management of pain and limited range of motion in subjects with signs 
Massage for Pain Evidence Map Evidence-based Synthesis Program

23

and symptoms of temporomandibular disorder: a systematic review of randomised 

controlled trials. Journal of oral rehabilitation. Nov 2015;42(11):847-861.

31. Keeratitanont K, Jensen MP, Chatchawan U, Auvichayapat P. The efficacy of traditional 

Thai massage for the treatment of chronic pain: A systematic review. Complementary 

therapies in clinical practice. Feb 2015;21(1):26-32.

32. Yuan SL, Matsutani LA, Marques AP. Effectiveness of different styles of massage 

therapy in fibromyalgia: a systematic review and meta-analysis. Manual therapy. Apr 

2015;20(2):257-264.

33. Loew LM, Brosseau L, Tugwell P, et al. Deep transverse friction massage for treating 

lateral elbow or lateral knee tendinitis. The Cochrane database of systematic reviews. 

2014;11:Cd003528.

34. Chaibi A, Russell MB. Manual therapies for primary chronic headaches: a systematic 

review of randomized controlled trials. The journal of headache and pain. 2014;15:67.

35. Cheng YH, Huang GC. Efficacy of massage therapy on pain and dysfunction in patients

with neck pain: a systematic review and meta-analysis. 2014;2014:204360.

36. Li YH, Wang FY, Feng CQ, Yang XF, Sun YH. Massage therapy for fibromyalgia: a 

systematic review and meta-analysis of randomized controlled trials. PloS one. 

2014;9(2):e89304.

37. Kong LJ, Zhan HS, Cheng YW, Yuan WA, Chen B, Fang M. Massage therapy for neck 

and shoulder pain: a systematic review and meta-analysis. Evidence-based 

complementary and alternative medicine : eCAM. 2013;2013:613279.

38. van den Dolder PA, Ferreira PH, Refshauge KM. Effectiveness of soft tissue massage 

and exercise for the treatment of non-specific shoulder pain: a systematic review with 

meta-analysis. British journal of sports medicine. Aug 2014;48(16):1216-1226.

39. Smith CA, Levett KM, Collins CT, Jones L. Massage, reflexology and other manual 

methods for pain management in labour. The Cochrane database of systematic reviews. 

2012;2:Cd009290.

40. Terhorst L, Schneider MJ, Kim KH, Goozdich LM, Stilley CS. Complementary and 

alternative medicine in the treatment of pain in fibromyalgia: a systematic review of 

randomized controlled trials. Journal of manipulative and physiological therapeutics. Sep 

2011;34(7):483-496.

41. Ernst E. Massage therapy for cancer palliation and supportive care: a systematic review 

of randomised clinical trials. Supportive care in cancer : official journal of the 

Multinational Association of Supportive Care in Cancer. Apr 2009;17(4):333-337.

42. Wilkinson S, Barnes K, Storey L. Massage for symptom relief in patients with cancer: 

systematic review. Journal of advanced nursing. Sep 2008;63(5):430-439.

43. Ezzo J, Haraldsson BG, Gross AR, et al. Massage for mechanical neck disorders: a 

systematic review. Spine. Feb 1 2007;32(3):353-362.

44. Bardia A, Barton DL, Prokop LJ, Bauer BA, Moynihan TJ. Efficacy of complementary 

and alternative medicine therapies in relieving cancer pain: a systematic review. Journal 
Massage for Pain Evidence Map Evidence-based Synthesis Program

24

of clinical oncology : official journal of the American Society of Clinical Oncology. Dec 

1 2006;24(34):5457-5464.

45. Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative 

therapies for pain management in labour. The Cochrane database of systematic reviews. 

2006(4):Cd003521.

46. Haraldsson BG, Gross AR, Myers CD, et al. Massage for mechanical neck disorders. The 

Cochrane database of systematic reviews. 2006(3):Cd004871.

47. Huntley AL, Coon JT, Ernst E. Complementary and alternative medicine for labor pain: a 

systematic review. American journal of obstetrics and gynecology. Jul 2004;191(1):36-

44.

48. Simkin PP, O'Hara M. Nonpharmacologic relief of pain during labor: systematic reviews 

of 5 methods. American journal of obstetrics and gynecology. May 2002;186(5 Suppl 

Nature):S131-159.

49. Pan CX, Morrison RS, Ness J, Fugh-Berman A, Leipzig RM. Complementary and 

alternative medicine in the management of pain, dyspnea, and nausea and vomiting near 

the end of life. A systematic review. Journal of pain and symptom management. Nov 

2000;20(5):374-387.

50. Richards KC, Gibson R, Overton-McCoy AL. Effects of massage in acute and critical 

care. AACN clinical issues. Feb 2000;11(1):77-96.

51. Ernst E. Massage therapy for low back pain: a systematic review. Journal of pain and 

symptom management. Jan 1999;17(1):65-69.

52. Kong L, Bannuru RR, Yuan W, et al. Therapeutic massage on pain relief for 

fibromyalgia: A systematic review and meta-analysis. Arthritis and rheumatism. 

2011;63(10):2011-2011.

53. Lewis M, Johnson MI. The clinical effectiveness of therapeutic massage for 

musculoskeletal pain: a systematic review. Physiotherapy. Sep 2006;92(3):146-158.
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APPENDIX A. SEARCH STRATEGIES 

DATABASE SEARCHED & TIME PERIOD COVERED:

PubMed – From inception to 2/17/2016 

SEARCH STRATEGY 1:

"Massage"[Mesh] OR massag*[tiab] OR massag*[ot] OR shiatsu 

AND

pain[mh] OR pain*[tiab] OR pain*[ot] OR pain management[mh] OR ache*[tiab] OR 

sore*[tiab] OR discomfort[tiab] OR backache* OR headache*

SEARCH STRATEGY 2:

“Similar Article” searches for the following 3 publications:

Patel, K. C., A. Gross, N. Graham, C. H. Goldsmith, J. Ezzo, A. Morien and P. M. Peloso 

(2012)."Massage for mechanical neck disorders." Cochrane Database Syst Rev 9: Cd004871. 

Furlan, A. D., F. Yazdi, A. Tsertsvadze, A. Gross, M. Van Tulder, L. Santaguida, D. Cherkin, J. 

Gagnier, C. Ammendolia, M. T. Ansari, T. Ostermann, T. Dryden, S. Doucette, B. Skidmore, R. 

Daniel, S. Tsouros, L. Weeks and J. Galipeau (2010)."Complementary and alternative therapies 

for back pain II." Evid Rep Technol Assess (Full Rep)(194): 1-764. Oct 

Cherkin, D. C., K. J. Sherman, R. A. Deyo and P. G. Shekelle (2003)."A review of the evidence 

for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation 

for back pain." Ann Intern Med 138(11): 898-906. Jun 3 

DATABASE SEARCHED & TIME PERIOD COVERED:

EMBASE - From inception to 2/17/2016 

LANGUAGE:

English

SEARCH STRATEGY:

'massage'/exp OR 'massage' OR massag* OR 'shiatsu'/exp OR shiatsu 

AND

pain* OR ache* OR sore* OR discomfort OR backache* OR headache* 

NOT
Massage for Pain Evidence Map Evidence-based Synthesis Program

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'case report'/de

AND

Human

DATABASE SEARCHED & TIME PERIOD COVERED:

Cochrane - From inception to 2/17/2016 

massag* or shiatsu:ti,ab,kw (Word variations have been searched) 

AND

pain* or ache* or sore* or discomfort or backache* or headache*:ti,ab,kw (Word variations have 

been searched)
Massage for Pain Evidence Map Evidence-based Synthesis Program

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APPENDIX B. CRITERIA USED IN QUALITY ASSESSMENT

MODIFIED AMSTAR – A MEASUREMENT TOOL TO ASSESS THE 

METHODOLOGICAL QUALITY OF SYSTEMATIC REVIEWS.

NOTE: where alterations were made to original AMSTAR criteria, language is bolded. Removal 

of original criteria are displayed with a strikethrough, and additions are displayed in italics.

1. Was an 'a priori' design provided?

The research question and inclusion criteria should be established before the conduct of the 

review.

Note: Need to refer to a protocol, ethics approval, or pre-determined/a priori published

research objectives to score a “yes.”

Yes/ No/ Can't answer/ Not applicable

2. Was there duplicate study selection and data extraction?

There should be at least 2 independent data extractors and a consensus procedure for

disagreements should be in place.

Note: 2 people do study selection, 2 people do data extraction, consensus process or one

person checks the other’s work.

Yes/ No/ Can't answer/ Not applicable

3. Was a comprehensive literature search performed?

At least 2 electronic sources should be searched. The report must include years and databases 

used (eg, Central, EMBASE, and MEDLINE). Key words and/or MESH terms must be 

stated and where feasible the search strategy should be provided. All searches should be 

supplemented by consulting current contents, reviews, textbooks, specialized registers, or 

experts in the particular field of study, and by reviewing the references in the studies found.

Note: If at least 2 sources + one supplementary strategy used, select “yes” (Cochrane

register/Central counts as 2 sources; a grey literature search counts as supplementary).

Yes/ No/ Can't answer/ Not applicable

4. Was the status of publication (ie grey literature) used as an inclusion criterion?

The authors should state that they searched for reports regardless of their publication type. 

The authors should state whether or not they excluded any reports (from the systematic 

review), based on their publication status, language etc.

Note: If review indicates that there was a search for “grey literature” or “unpublished

literature,” indicate “yes.” SIGLE database, dissertations, conference proceedings, and trial 
Massage for Pain Evidence Map Evidence-based Synthesis Program

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registries are all considered grey for this purpose. If searching a source that contains both 

grey and non-grey, must specify that they were searching for grey/unpublished lit.

Yes/ No/ Can't answer/ Not applicable

5. Was a list of studies (included and excluded) provided?

A list of included and excluded studies should be provided.

Note: Acceptable if the excluded studies are referenced. If there is an electronic link to the 

list but the link is dead, select “no.”

Yes/ No/ Can't answer/ Not applicable

6. Were the characteristics of the included studies provided?

In an aggregated form such as a table, data from the original studies should be provided on 

the participants, interventions and outcomes. The ranges of characteristics in all the studies 

analyzed eg, age, race, sex, relevant socioeconomic data, disease status, duration, severity, or 

other diseases should be reported.

Note: Acceptable if not in table format as long as they are described as above.

Yes/ No/ Can't answer/ Not applicable

7. Was the scientific quality of the included studies assessed and documented?

'A priori' methods of assessment should be provided (eg, for effectiveness studies if the

author(s) chose to include only randomized, double-blind, placebo controlled studies, or

allocation concealment as inclusion criteria); for other types of studies alternative items will 

be relevant.

Note: Can include use of a quality scoring tool or checklist, eg, Jadad scale, risk of bias,

sensitivity analysis, etc., or a description of quality items, with some kind of result for EACH 

study (“low” or “high” is fine, as long as it is clear which studies scored “low” and which 

scored “high”; a summary score/range for all studies is not acceptable).

Yes/ No/ Can't answer/ Not applicable

8. Was the scientific quality of the included studies used appropriately in formulating 

conclusions?

The results of the methodological rigor and scientific quality should be considered in the

analysis and the conclusions of the review, and explicitly stated in formulating

recommendations.

Note: Might say something such as “the results should be interpreted with caution due to

poor quality of included studies.” Cannot score “yes” for this question if scored “no” for

question 7.
Massage for Pain Evidence Map Evidence-based Synthesis Program

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Yes/ No/ Can't answer/ Not applicable

9. Were the methods used to combine the findings of studies appropriate?

For the pooled results, a test should be done to ensure the studies were combinable, to assess 

their homogeneity (ie, Chi-squared test for homogeneity, I2). If heterogeneity exists a 

random effects model should be used and/or the clinical appropriateness of combining should 

be taken into consideration (ie, is it sensible to combine?).

Note: Indicate “yes” if they mention or describe heterogeneity, ie, if they explain that they 

cannot pool because of heterogeneity/variability between interventions.

Yes/ No/ Can't answer/ Not applicable

10. Was the likelihood of publication bias assessed?

An assessment of publication bias should include a combination of graphical aids (eg, funnel 

plot, other available tests) and/or statistical tests (eg, Egger regression test, Hedges-Olken).

Note: If no test values or funnel plot included, score “no”. Score “yes” if mentions that

publication bias could not be assessed because there were fewer than 10 included studies.

For strictly narrative systematic reviews (ie, no quantitative methods employed), some 

narrative discussion of publication bias is required to score yes.

Yes/ No/ Can't answer/ Not applicable

11. Was the conflict of interest included?

Potential sources of support should be clearly acknowledged in both the systematic review and 

the included studies.

Note: To get a “yes,” must indicate source of funding or support for the systematic review AND 

for each of the included studies.

Yes/ No/ Can't answer/ Not applicable

Original source:

Shea et al. BMC Medical Research Methodology 2007 7:10 doi:10.1186/1471-2288-7-10
Massage for Pain Evidence Map Evidence-based Synthesis Program

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APPENDIX C. PEER REVIEW COMMENTS/AUTHOR RESPONSES

Comment Response

Pages 4 and 6 Steven Ezeji-Okoye should be Stephen and title should be 

Integrative Health Coordinator, Patient Care Services.

This has been corrected

A brief discussion of what an "active" or "inactive" comparators would be 

beneficial. Language is ambiguous in the literature regarding "active" or 

"inactive" comparators or controls and a discussion of these per study (if at 

all possible) may help with downstream decision making and may shed 

greater light on the actual comparative effectiveness of the intervention.

For all findings using the terms “active” or “inactive” we have now added examples 

or definitions from that particular review to provide more clarity for that finding. 

Because this report looks at systematic reviews, rather than individual studies, we 

are limited to reporting what the systematic reviews report, and could not collect 

these details from the included studies from each of the 31 systematic reviews.

Is it possible to add the date of publication to the evidence map? That would 

help the reader understand how old the review is.

The dates for each systematic review have been added to the bubble labels in the 

evidence map.

You might want to comment in your summary that some of these reviews 

are quite old and could be updated in the future. For example the review on 

massage in a critical care setting was done in 2000. There are other studies 

on massage that include patients in a critical care setting that have been 

published including the largest RCT of massage for postoperative pain 

which was funded by HSRD and published in 2007(I was a co-investigator 

on that study.

This has been included in the “Summary and Discussion” section.

I do not understand this sentence on page 14, line 38, "These 3 features of 

massage were most often reported for each primary studying including in

the review, with variability between these primary studies".

This sentence has been revised to fix the grammatical issues.

My one concern is that when one looks at the Evidence Map and sees 

"mixed results" for so many of the LBP reviews, it gives a bit of a different 

picture then when one reads the text. The fact is it seems to me that overall 

the evidence is fairly good for the utility of massage in LBP and neck pain--

and this does come through in the text--but visually when one sees that the 

bigger reviews of these conditions fall in the "mixed results" category the 

impression is that the evidence is really equivocal.

I realize this may be part of how the evidence map methodology works but 

for some readers who will only look at the graphic and not read the text I 

think it is a bit problematic.

Both larger reviews described by the peer reviewer (Furlan, 2010 and Furlan, 2015) 

are described in the text as finding a number of positive findings, but both also 

included findings of no difference between massage and the control in certain 

comparisons.

We have updated the evidence map to have these studies crossing the boundary 

between “mixed results” and “potentially better” in order to signal that both these 

important systematic reviews do lean positive, with many positive findings. 
Massage for Pain Evidence Map Evidence-based Synthesis Program

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In most evidence maps that I have reviewed, there is not a bubble 

representing each review, but rather a bubble representing the strength of 

evidence for a given condition. This article's representation, which has 

several bubbles for many conditions, will not be as helpful to decision 

making (ex: Fibromyalgia has studies in 4 categories). It does represent the 

wide array of findings, but is not as useful a presentation for the decision 

makers as a synthesis.

While single bubbles for each condition may be more useful for decision makers, 

this type of depiction would be less faithful to the evidence, since it would require the 

report authors to make judgements in synthesizing findings across systematic 

reviews. The current figure presents the findings of each included systematic review, 

but does not judge how these would be integrated with each other, which would 

require looking at all the primary studies within each of the systematic reviews for 

topics with multiple bubbles. 

In the example of Fibromyalgia, we would need to see which studies were included 

in all reviews, and which were included in some but not others to determine a new 

finding inclusive of all potential evidence. The topics with multiple bubbles, 

especially with differing findings, may be areas that are ripe for an update systematic 

review. This is now noted in the “Summary and Discussion” section.
Massage for Pain Evidence Map Evidence-based Synthesis Program

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APPENDIX D. EVIDENCE TABLES FOR INCLUDED SYSTEMATIC REVIEWS

Author, year Description of 

systematic review

Description of massage Description of 

pain

Excerpted findings relevant to massage

Anthonissen 

2016

includes a variety of 

interventions, of which 

massage is one

2/22 includes relevant to 

massage

Quality Score: 10

Style: Soft tissue mobilization, 

massage with cocoa butter, skin 

rehabilitation massage (detailed 

descriptions provided)

Provider: Not provided

Co-interventions: Provided

Duration: Provided

Comparators: Standard care, no 

treatment

Scar pain A reduction of pain was shown in 2 studies... 

these findings were based on subjective rating 

scales and mostly based on trials with small 

sample sizes.

Piper 2016 focused solely on 

massage as the 

intervention

6/6 includes relevant to 

massage

Quality Score: 10

Style: Soft-tissue therapy

Provider: Provided

Co-interventions: Provided

Duration: Provided

Comparators: Placebo/sham, 

waiting list (wait and see), or no 

intervention.

Carpal tunnel 

syndrome, lateral 

epicondylitis, 

subacromial 

impingement 

syndrome, plantar 

fasciitis

Myofascial release therapy was effective for 

treating lateral epicondylitis and plantar fasciitis. 

Localized relaxation massage combined with 

multimodal care may provide short-term benefit for 

treating carpal tunnel syndrome.

Furlan 2015 focused solely on 

massage as the 

intervention

25/25 includes relevant to 

massage

Quality Score: 11

Style: Soft-tissue manual 

manipulation

Provider: Provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Acute and chronic 

low-back pain

Massage was better than inactive controls for pain 

in the short-term, but not in the long-term followup. Massage was better than active controls for 

pain both in the short- and long-term follow-ups. 

There were no reports of serious adverse events 

in any of these trials. The most common adverse 

events were increased pain intensity in 1.5% to 

25% of the participants.
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Author, year Description of 

systematic review

Description of massage Description of 

pain

Excerpted findings relevant to massage

Bervoets 2015 focused solely on 

massage as the 

intervention

26/26 includes relevant to 

massage

Quality Score: 9 

Style: Swedish massage, Thai 

massage, self-massage, 

combination of techniques, not 

described

Provider: Provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Low back pain, 

shoulder pain, 

fibromyalgia, 

osteoarthritis of 

the knee, chronic 

musculoskeletal 

pain, neck pain, 

chronic patellar 

tendinopathy, 

carpal tunnel 

syndrome, hand 

pain, and hand 

osteoarthritis

Low- to moderate-level evidence indicated that: 

(1) massage reduces pain in the short term 

compared to no treatment in people with shoulder 

pain; (2) massage reduces pain in the short term 

compared to no treatment in people with 

osteoarthritis of the knee; (3) massage does not 

reduce pain in those with low back pain; (4)

massage does not reduce pain in those with neck 

pain.

Low- to very low-level evidence from single 

studies indicated no clear benefits of massage 

over active treatments in people with: (5) 

fibromyalgia, (6) low back pain, and (7) general 

musculoskeletal pain.

Calixtre 2015 focused solely on 

massage as the 

intervention

8/8 includes relevant to 

massage

Quality Score: 9

Style: Provided

Provider: Provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Acute and chronic 

temporomandibular 

disorder

Widely varying evidence that manual therapy 

improves pain and pressure pain threshold in 

subjects with temporomandibular disorder signs 

and symptoms, depending on the technique.

Keeratitanont

2015 

focused solely on 

massage as the 

intervention

6/6 includes relevant to 

massage

Quality Score: 6

Style: Traditional Thai massage

Provider: Not provided

Co-interventions: Provided

Duration: Provided

Comparators: Not provided

Chronic 

myofascial pain 

syndrome, chronic 

low back pain, 

scapulocostal 

syndrome

Traditional Thai massage benefits of pain 

reduction appear to maintain for up to 15 weeks.
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Author, year Description of 

systematic review

Description of massage Description of 

pain

Excerpted findings relevant to massage

Yuan 2015 focused solely on 

massage as the 

intervention

10/10 includes relevant to 

massage

Quality Score: 8 

Style: Swedish massage, 

connective tissue massage, 

manual lymphatic drainage, 

myofascial release, shiatsu, a 

combination of different massage 

styles

Provider: Provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Fibromyalgia There is moderate evidence that myofascial 

release has positive effects on multiple 

fibromyalgia symptoms, especially pain, anxiety, 

and depression, for which the effect sizes are 

clinically relevant. Shiatsu improves pain and 

Swedish massage does not improve outcomes.

Loew 2014 focused solely on 

massage as the 

intervention

2/2 includes relevant to 

massage

Quality Score: 11

Style: Deep transverse friction 

massage

Provider: Provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Lateral elbow or 

lateral knee 

tendinitis

We do not have sufficient evidence to determine 

the effects of deep transverse friction on pain, 

improvement in grip strength, and functional status 

for patients with lateral elbow tendinitis or knee 

tendinitis, as no evidence of clinically important 

benefits was found.

Chaibi 2014 includes a variety of 

interventions, of which 

massage is one

1/6 includes relevant to 

massage

Quality Score: 7

Style: Head and neck massage

Provider: Provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Chronic headache The massage therapy study included only 11 

participants, but the massage group had 

significantly more reduction in their headache 

intensity than detuned ultrasound group. 

Cheng 2014 focused solely on 

massage as the 

intervention

15/15 includes relevant to 

massage

Quality Score: 8 

Style: Chinese traditional 

massage, common Western 

massage, manual pressure 

release, strain/counterstrain 

technique, and myofascial band 

therapy

Provider: Not provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Chronic neck pain This systematic review found moderate evidence 

of manual therapy on improving pain in patients

with neck pain compared with inactive therapies 

and limited evidence compared with traditional 

Chinese medicine.
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Author, year Description of 

systematic review

Description of massage Description of 

pain

Excerpted findings relevant to massage

Li 2014 focused solely on 

massage as the 

intervention

9/9 includes relevant to 

massage

Quality Score: 10

Style: Swedish massage, 

connective tissue, Shiatsu, 

therapeutic touch, unspecified, 

Chinese traditional massage, 

myofascial therapy

Provider: Not provided

Co-interventions: None

Duration: Provided

Comparators: Provided

Fibromyalgia Massage therapy with duration ≥ 5 weeks had 

beneficial immediate effects on improving pain in 

patients with fibromyalgia. The meta-analyses 

showed that massage therapy with duration ≥ 5 

weeks significantly improved pain (SMD, 0.62; 

95% CI 0.05 to 1.20; p = .03)

Kong 2013 focused solely on 

massage as the 

intervention

12/12 includes relevant to 

massage

Quality Score: 10

Style: Massage therapy, Chinese 

traditional massage, soft tissue 

massage, slow-stroke back 

massage, manual pressure 

release, strain/counterstrain 

technique, myofascial band 

therapy, Thai massage

Provider: Not provided

Co-interventions: None

Duration: Provided

Comparators: Provided

Acute and chronic 

neck pain, acute 

and chronic 

shoulder pain

In immediate effects, the meta-analyses showed 

significant effect of MT for neck pain (standardised 

mean difference, SMD, 1.79; 95% confidence 

intervals, CI, 1.01 to 2.57) 

Patel 2012 focused solely on 

massage as the 

intervention

15/15 includes relevant to 

massage

Quality Score: 10

Style: Included Swedish 

techniques, fascial or connective 

tissue release techniques, cross 

fibre friction, and myofascial trigger 

point techniques

Provider: Provided

Co-interventions: Provided

Duration: Provided

Comparators: included no 

treatment, hot packs, active rangeof-movement exercises, 

acupuncture, exercises, sham 

laser, manual traction, mobilization, 

and education

Acute and chronic 

neck pain without 

radiculopathy, 

cervicogenic 

headache, neck 

disorders with 

radiculopathy

No firm conclusions could be drawn and the 

effectiveness of massage for improving neck pain 

and function remains unclear. There was very lowlevel evidence that massage may have been more 

beneficial than education in the short term for pain 

bothersomeness.
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Author, year Description of 

systematic review

Description of massage Description of 

pain

Excerpted findings relevant to massage

van den Dolder

2014

includes a variety of 

interventions, of which 

massage is one

7/23 includes relevant to 

massage

Quality Score: 9

Style: Not provided

Provider: Not provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Acute and chronic 

shoulder pain

There is low-quality evidence that soft tissue 

massage is effective for improving pain in patients 

with shoulder pain in the short term.

Smith 2012 focused solely on 

massage as the 

intervention

6/6 includes relevant to 

massage

Quality Score: 11

Style: Slow stroke, effleurage, 

variety of techniques, none 

specified

Provider: Partner, masseuse, not 

reported

Co-interventions: None

Duration: Provided

Comparators: Provided

Labor pain Massage may have a role in reducing pain, and 

improving women’s emotional experience of 

labour. 

Terhorst 2011

Terhorst 2012

includes a variety of 

interventions, of which 

massage is one

6/60 includes relevant to 

massage

Quality Score: 9

Style: Swedish massage, 

connective tissue massage, tui na 

and yoga, massage

Provider: Not provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Fibromyalgia Of the 5 pooled studies, 4 showed no effect; and 

the composite effect indicated that massage was 

not effective in reducing FM pain in this set of 

studies. All studies scored low- or very low-quality. 
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Author, year Description of 

systematic review

Description of massage Description of 

pain

Excerpted findings relevant to massage

Furlan 2010

Furlan 2012

includes a variety of 

interventions, of which 

massage is one

35/356 includes relevant 

to massage

Quality Score: 11

Style: Myofascial pressure release, 

transverse friction, connective 

tissue, traditional Chinese 

massage, soft tissue, Swedish, 

Thai, bone setting, reflexology, 

accupressure, underwater, 

roptrotherapy, undescribed styles

Provider: included: licensed or 

experienced massage therapists, 

physical therapists, reflexologists, 

acupressure therapists, folk 

healers, general practitioners, 

manual therapists, bone setter, 

chiropractic students, and not 

provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Acute and chronic 

low back pain, 

neck pain 

Massage was superior to placebo or no treatment

in reducing pain (grade: moderate) immediately 

post-treatment only in subjects with 

acute/subacute but not in subjects with chronic 

low back pain (grade: low). Massage was 

significantly better than relaxation (clinical 

importance of difference: medium degree) or 

physical therapy (clinical importance of difference: 

large degree) in reducing chronic nonspecific low 

back pain intensity immediately after the treatment 

(grade: low to moderate). Massage was better 

than no treatment in reducing immediate-term 

post-treatment pain intensity in subjects with 

chronic or unknown duration of nonspecific pain 

(grade: low). Massage was better than placebo in 

reducing neck pain intensity immediately after the 

treatment in subjects with acute/subacute or 

unknown duration of nonspecific pain (grade: low).

Ernst 2009 focused solely on 

massage as the 

intervention

8/14 includes relevant to 

massage

Quality Score: 7 

Style: Style not directly addressed 

aside from: “Classical massage 

was defined as a manual treatment 

using effleurage (long, slow 

strokes), friction (small circular 

strokes), percussion (chopping and 

drumming motions) and petrissage 

(kneading action on muscles).” 

Provider: excluded lay persons

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Cancer palliation Collectively, studies suggest that massage can 

alleviate pain, however the methodological quality 

was poor, preventing definitive conclusions
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Author, year Description of 

systematic review

Description of massage Description of 

pain

Excerpted findings relevant to massage

Wilkinson 2008 focused solely on 

massage as the 

intervention

4/10 includes relevant to 

massage

Quality Score: 10

Style: Soft tissue manual 

manipulation, including foot 

massage, Swedish, unspecified, 

aromatherapy/carrier oil massage.

Provider: A therapist with 

recognized qualification

Co-interventions: Not provided

Duration: Provided

Comparators: Provided

Cancer symptoms 

including pain

In the 4 studies using pain as an outcome 

measure, there was a nonstatistically significant 

trend towards improvement.

Ezzo 2007 focused solely on 

massage as the 

intervention

14/19 includes relevant to 

massage

Quality Score: 8 

Style: Soft tissue manual 

manipulation, including Swedish 

techniques, fascial or connective 

tissue release techniques, cross 

fiber friction, and myofascial trigger 

point techniques.

Provider: Not provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Acute and chronic 

neck pain

The contribution of massage to managing cervical 

pain remains unclear.

Bardia 2006 includes a variety of 

interventions, of which 

massage is one

4/18 includes relevant to 

massage

Quality Score: 11

Style: Not provided

Provider: Not provided

Co-interventions: Unclear

Duration: Provided

Comparators: Provided

Cancer pain Mix of results from methodologically weak studies

Smith 2006 includes a variety of 

interventions, of which 

massage is one

1/14 includes relevant to 

massage

Quality Score: 9

Style: Directional firm rhythmic 

massage comprised of effleurage, 

sacral pressure, and shoulder and 

back kneading.

Provider: Researcher and partner

Co-interventions: Standard care

Duration: Provided

Comparators: Standard care

Labor pain There was a significant reduction in women’s 

perception of pain for the massage group 

compared to the control group during all 3 phases 

of labour in the one included study. The efficacy of 

massage has not been established.
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Author, year Description of 

systematic review

Description of massage Description of 

pain

Excerpted findings relevant to massage

Haraldsson 

2006 

focused solely on 

massage as the

intervention

19/19 includes relevant to 

massage

Quality Score: 11

Style: Soft tissue manual 

manipulation including Swedish 

techniques, fascial or connective 

tissue release techniques, cross 

fiber friction, and

myofascial trigger point techniques

Provider: Provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Chronic neck pain No recommendations for practice can be made at 

this time because the effectiveness of massage 

for neck pain remains uncertain.

Huntley 2004 includes a variety of 

interventions, of which 

massage is one

2/12 includes relevant to 

massage

Quality Score: 10

Style: Provided

Provider: Not provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Labor pain Both of the massage trials showed positive effects 

for the relief of pain during labor. These trials did 

not rate highly on the Jadad scale because and it 

is impossible to make any definitive conclusions 

regarding effectiveness in labor pain control.

Cherkin 2003 includes a variety of 

interventions, of which 

massage is one

8/17 includes relevant to 

massage

Quality Score: 9

Style: Included to therapeutic 

massage, comprehensive 

massage, unspecified.

Provider: Not provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Back pain Two reviews, including 5 studies total, concluded 

that high-quality trials were needed before the 

value of massage for back pain could be 

determined. The 3 RCTs that evaluated massage 

reported that this therapy is effective for subacute 

and chronic back pain. Initial studies suggest that 

massage is effective for persistent back pain.

Simkin 2002 includes a variety of 

interventions, of which 

massage is one

1/38 includes relevant to 

massage

Quality Score: 9

Style: Desribed as for back, head, 

hands, feet

Provider: Partner

Co-interventions: Lamaze

Duration: Provided

Comparators: Usual care

Labor pain The randomized controlled trial of massage by 

partners in labor found that the massaged women 

had significant emotional and physical relief, as 

reported by the women themselves, and assessed 

by their partners and a blinded observer. The 

intervention of massage has not undergone 

sufficient scientific study to provide clear 

conclusions regarding benefits and risks.
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Author, year Description of 

systematic review

Description of massage Description of 

pain

Excerpted findings relevant to massage

Pan 2000 includes a variety of 

interventions, of which 

massage is one

3/21 includes relevant to 

massage

Quality Score: 6

Style: Swedish massage, 

unspecified

Provider: Not provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Palliative care 

patients’ pain

Massage with or without aromatherapy, might 

provide short-term relief for patients with 

intractable cancer pain. Evidence level 3.3 

(second lowest rating of 6). 

Richards 2000 focused solely on 

massage as the 

intervention

4/22 includes relevant to 

massage

Quality Score: 5

Style: Therapeutic massage, 

myofascial trigger point therapy, 

Swedish, unspecified

Provider: Provided

Co-interventions: Provided

Duration: Provided

Comparators: Provided

Pain in critical 

care setting

In studies in which the effect of massage on 

discomfort was investigated, it was found to be 

effective in reducing pain.

Ernst 1999 focused solely on 

massage as the 

intervention

4/4 includes relevant to 

massage

Quality Score: 6

Style: Gentle stroking back 

massage, light effleurage, soft 

tissue lumbosacral massage, 

underwater massage

Provider: Not provided

Co-interventions: None

Duration: Provided

Comparators: Provided

Low back pain It is concluded that too few trials of massage 

therapy exist for a reliable evaluation of its 

efficacy. Massage seems to have some potential 

as a therapy for LBP.

Kong 2011 focused solely on 

massage as the 

intervention

10/10 includes relevant to 

massage

Quality Score: 3 

Style: Swedish massage, tui na, 

other soft tissue manual 

manipulation

Provider: Not provided

Co-interventions: Not provided

Duration: Provided 

Comparators: Provided

Fibromyalgia All studies reported an association between the 

therapeutic massage and improved clinical 

symptom of pain. The meta-analysis results 

showed that 4 studies with 3 to 10 weeks of 

therapy had a decrease in pain versus either other 

therapies or no treatment controls. The pooled 

effect size was -0.92 (95% CI, -1.28 to -0.56) 

favoring therapeutic massage. The studies are

very heterogeneous, and there is insufficient 

evidence for a definitive conclusion.
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Author, year Description of 

systematic review

Description of massage Description of 

pain

Excerpted findings relevant to massage

Lewis 2006 focused solely on 

massage as the 

intervention

20/20 includes relevant to 

massage

Quality Score: 9

Style: Therapeutic massage, 

including Swedish

Provider: Provided

Co-interventions: None

Duration: Provided

Comparators: Provided

Musculoskeletal 

pain (low back, 

neck, various 

chronic, shoulder, 

diffuse, eccentric 

exercise limb, 

post-running 

soreness)

Research on the effectiveness of TM to relieve 

pain of musculoskeletal origin is inconclusive. TM 

was superior to no treatment in 5 out of 10 

comparisons, superior to sham laser treatment in 

one out of 2 comparisons, and superior to active 

treatment in 7 out of 22 comparisons.