H.O.P.E. | Massage Therapy for Fibromyalgia

Massage Therapy for Fibromyalgia
Treatment options for fibromyalgia include the latest drug therapies, exercise, and alternative therapies like acupuncture, manual/manipulative therapies, and mind/body therapies (Friedburg & Jason, 2001). Research suggests that moderate/high intensity exercise is effective (Gowans et al., 1999; Hadhazy et al., 2000). Fibromyalgia patients may benefit from massage therapy because it enhances immunologic and neuroendocrine function. For example, massage therapy decreases the level of the hormones cortisol and norepinephrine (Field et al, 1992). It also decreases natural killer-cell activity (Ironson et al, 1996). The low serotonin levels in fibromyalgia patients have been blamed for their nonrestorative sleep, low mood, and, increased pain sensitivity. In at least one study, massage therapy increased serotonin levels (Ironson et al, 1996). In another, sleep patterns improved (Field et al, 1992). Although these data are suggestive, they are based on studies with other disease groups.

Our First Study
The purpose of our first study was to determine the effects of massage therapy on the pain, depression, and anxiety associated with fibromyalgia (Sundhine et al, 1996). We compared massage therapy with microcurrent transcutaneous electrical stimulation (TENS) therapy. This was a double-blind study using sham (disabled) TENS as a control (placebo).

Method
We recruited 30 female adult fibromyalgia patients from local rheumatology practices. They had been diagnosed with fibromyalgia according to the criteria established by the American College of Rheumatology. They weren't receiving any other treatment at the time. We assigned these women randomly to one of three groups: a massage therapy group, a TENS group, and a sham TENS group.

Measures
We began by measuring each patient's sensitivity to pain at the 18 tender points outlined in the American College of Rheumatology classification criteria. At the end of the study we repeated these measurements to see if they changed. Point-pressure threshold was measured with the use of a dolorimeter by exerting a force of 1 kilogram per second.

We measured the immediate effects of the therapies by:

We assessed the end-of-study effects by repeating the dolorimeter test, by interviewing each patient about her pain, sleep, and daily functioning, and by the Center for Epidemiologic Studies-Depression Scale (CES-D), which measures depressive symptoms over the previous week.

Massage Therapy
Massage therapy sessions consisted of Swedish massage stroking of the head, neck, shoulders, back, arms, hands, legs, and feet for 30 minutes.

TENS and Sham TENS
The TENS and Sham TENS groups received tactile stimulation with the TENS roller, with no current for the Sham TENS group. Neither the therapist nor the subject knew whether electrical stimulation was being delivered.

Results and Discussion
During the first and last sessions of therapy, we conducted t-tests (statistical tests to determine whether the scores of two groups differ on a single variable) on the data on the pretherapy and posttherapy session measures.

Pretherapy and Posttherapy Immediate Effects Measures
In both the first and last sessions, the group that received massage therapy had less anxiety, less depression, and lower salivary cortisol levels after therapy than before. The group that received TENS therapy had the same result, but only in the last session. We saw no changes in either session for the group that received sham TENS.

First Session Versus Last Session Measures
In the massage therapy group, both the dolorimeter readings and the rheumatologist's rating of clinical condition improved. These subjects reported fewer symptoms at the end of the study, including less pain over the past week, less stiffness, less fatigue, and fewer nights of difficult sleeping. The TENS group improved only on the physician's assessment of clinical condition. The sham TENS group likewise improved on the physician's assessment but less than the other two groups.

The study therefore suggests that massage therapy is better than TENS therapy. These findings are consistent with those reported by Yunus and Masi (Yunus & Masi, 1985), who studied the effects of massage therapy on adolescents with fibromyalgia.

Our Second Study
The purpose of our second study (Field et al, 2002) was to explore the possible mechanisms for the massage therapy effects reported in our earlier study (Sunshine et al, 1996). We expected massage therapy to increase restorative sleep, decrease levels of Substance P, and reduce pain.

Method
We recruited 20 adult patients from a university-and-bookstore fibromyalgia discussion group. In each, a rheumatologist confirmed the diagnosis of fibromyalgia according to the criteria established by the American College of Rheumatology. We then randomly assigned these patients to either a massage therapy group or a relaxation therapy group.

Massage Therapy
Participants received a massage twice a week for 5 weeks by a volunteer professional massage therapist. The massage consisted of moderate-pressure stroking of the head, neck, shoulders, back, arms, hands, legs, and feet for 30 minutes. First, with hands positioned under the head and neck, the therapist stretched the neck and spine. This was followed by stroking the forehead and face. Pressure was applied to the tender points, and the shoulders were gently depressed. The arms and legs were stretched, and the arms were lifted and moved in a circular motion. Finger pressure was applied to the palms of the hands and the soles of the feet with extra pressure given to the tender points. Stroking was then continued from the top to the bottom of the limbs. Medium-pressure squeezing was applied to the upper shoulder and neck area, while light, brisk rubbing movements were performed along the spine. The massage was concluded in each position with gentle rocking and more stroking from head to toe.

Progressive Muscle Relaxation Therapy
We assessed the relaxation group to control for any placebo effect in the mere attention given the massage therapy group. Receiving the same amount of attention on a massage table, in 30-minute sessions twice a week for 5 weeks, the relaxation-therapy patients were given instructions coaching them through progressively relaxing their muscles. These sessions involved tensing and relaxing large muscle groups, starting with the head, neck, shoulders, back, arms, hands, legs, and feet.

Measures
On the first and last days of the study, we measured the intermediate effects of the therapy through a questionnaire and an assessment given both before and after the session. The questionnaire (administered first) was the State of Anxiety Inventory (STAI), and the assessment was the Profile of Mood States.

Before treatment on the first and last days of the study, we measured the long-term effects of the therapy through an assessment -- the Center for Epidemiological Studies Depression Scale. During the previous week, sleep disturbance was measured by a motion recorder -- a Timex watch (Timex, Waterbury, CT, U.S.A.) with the time mechanism removed so that each limb movement advanced the time hand. The patient recorded the watch's reading at bedtime and upon arising. Participants also kept a daily sleep log. In addition, the patients rated their pain, fatigue, and stiffness on a 10 point Likert Scale. The assessing physician was a rheumatologist blind to the participants' group assignment. This assessment weighed the participant's illness, medication usage, and tender-points pain as assessed by a dolorimeter (Wagner Force Dial FDK 20) with the ACR 1990 Criteria for Fibromyalgia (Wolfe et al, 1990). The dolorimeter test was performed at the beginning and end of the study. In it we measured the point-pressure threshold by exerting increasing force for 1kilogram per second over the 18 tender-point sites. Saliva samples collected before the first and last sessions were assayed for Substance P.

Results and Discussion
We conducted t-tests to compare the two groups' self-reports of anxiety and depression through questionnaires administered both before and after treatment sessions. Both groups showed decreased anxiety and depression after the first and last sessions.

Over the course of the study, the massage therapy group as compared to the relaxation therapy group experienced decreased depression, improved sleep (a greater number of hours sleeping and fewer sleep movements), decreased symptoms (including pain, fatigue, and stiffness), improved assessments by the physician (on course of disease and pain), a decrease in the number of tender points, and a reduced Substance P level.

We weren't surprised by the decrease in anxiety and depression following massage therapy and relaxation therapy, because we noted these changes in our previous study on fibromyalgia (Sunshine et al, 1996). Using a motion recorder this time, however, we objectively measured sleep activity in this study, confirming our previous finding of less difficulty sleeping (Sunshine et al, 1996). Less difficulty sleeping and less sleep activity may have contributed to the decrease in Substance P (Sunshine et al, 1996). The physicians' assessment of improved clinical condition and their dolorimeter assessment of less pain replicated our previous findings, highlighting the clinical benefits of massage therapy as a complementary treatment.

Our Third Study
In our third study (Field et al, 2003), we combined exercise movements with massage therapy to determine whether the combination gave greater benefit. Also, this time the therapy was self-administered through Eutonic techniques.

Eutony is becoming increasingly popular in Europe (especially in Germany and France) as a combination of movement exercises and self-administered massage. The movement part of the Eutony sessions involves yoga-like stretching movements on the floor and through space in an upright position. The self-administered massage involves rolling wooden dowels and balls (e.g., tennis balls) over the limbs. We know that applying pressure diminishes pain, as, for example, when you squeeze your elbow after bumping it. So, we hypothesized that the self-administered pressure applied in the movement and massage techniques of Eutony might be effective in treating fibromyalgia.

Method
We recruited 40 fibromyalgia patients from community pain clinics and randomly assigned each to either a movement/massage therapy group or to a relaxation control group.

Movement/Massage Therapy
Participants performed yoga-like stretching movements in lying, seated, and standing positions. During these exercises they stimulated the pressure receptors of their nerve endings by rubbing their limbs against the floor and against other limbs. They also massaged themselves with 2-foot-long, 1-inch-diameter wooden dowels and tennis balls. We asked them to rub their upper and lower limbs with a dowel and to rub their face, shoulders, arms and hands (in a circular motion) with a tennis ball. The sessions lasted 50 minutes and were held twice a week for 3 weeks.

Progressive Muscle Relaxation Therapy
We assessed the relaxation group to control for any placebo effect in the mere attention given the massage therapy group. So, as in our second study, this group received the same amount of therapy (for 50 minutes twice a week for 3 weeks) in the same environment (while lying quietly on a carpeted floor) as the other group. But instead of receiving movement/massage therapy, participants received instructions coaching them through progressively relaxing their muscles. The muscle relaxation involved tensing and relaxing large muscle groups, starting with the head and moving to the neck, shoulders, back, arms, hands, legs, and feet.

Measures
On the first and last days of the study, we measured the intermediate effects of the therapy through two questionnaires and an assessment, each given both before and after the session. They were administered in the following order:

The Regional Pain Scale is a drawing of 21 regions on the front and back of the body where pain is to be rated. The participant rates the pain in each region on a scale ranging from 0 for no pain to 5 for unbearable pain, for a total possible score of 105.

Results and Discussion
We conducted t-tests to compare the two groups' self-reports in the questionnaires. For both the first and last session, both groups showed less anxiety and pain at the end than at the beginning. However, only the movement/ massage therapy group showed improved mood, lower anxiety, and less pain across at the end of the study than at the beginning.

We weren't surprised by the decrease in anxiety and depression following movement/massage therapy and relaxation therapy, because we noted these changes in our previous studies on fibromyalgia (Field et al., 2002; Sunshine et al., 1996). The movement/massage therapy patients' reports of long-term mood, anxiety, and pain benefits (as determined by measurements taken at the beginning and end of the study) were also consistent with our previous findings on massage therapy's effects on fibromyalgia (Sunshine et al., 1996). The data from the current study, however, suggest that massage and massage-like movements or stimulation of pressure receptors can be self-administered and still reduce pain.

Tiffany Field, Ph.D.
Touch Research Institutes
University of Miami School of Medicine