Massage, loosely defined as the manipulation of soft tissues of the musculoskeletal system, has been practiced for centuries in nearly every culture around the world (Vickers and Zollman 1999). A holistic form of therapy, massage affects all body systems, especially the musculoskeletal, circulatory, lymphatic, and nervous systems. Thus, it may be particularly helpful in decreasing muscular tension or flaccidity, increasing blood and lymph circulation, enhancing tissue healing, and sedating or stimulating the nervous system (Greene 2000).

The use of massage for healing purposes was first documented in Chinese medical manuscripts dating back 4,000 years (Greene 2000), and it is still an important aspect of Traditional Chinese Medicine (TCM) (Vickers and Zollman 1999). Per Henrik Ling of Sweden (1776-1839) developed a contemporary form of massage known as Swedish massage. In the 1850s, George and Charles Taylor, two physicians who had studied in Sweden, introduced massage therapy to the United States. It was used in the late 1800s by a significant number of American physicians and at the nation's first massage therapy clinics, which opened after the Civil War. Massage became overshadowed as a therapeutic technique in the early 1900s as technology and pharmaceuticals gained the focus of medical practices. It remained largely dormant and was practiced by only a small number of massage therapists until the 1970s. At that point, the public and the medical profession began to take notice of alternative medicine and mind-body therapies, which thrust massage therapy into the limelight. Today, there are more than 125,000 massage therapists practicing in the United States. Their numbers are growing rapidly to keep up with the demand for nearly eighty million appointments each year (Greene 2000).

There are nearly 100 different massage techniques, each of which is used to achieve a specific goal. The most common types practiced in the United States include:

• Aromatherapy massage. This type of massage uses essential oils, which are derived from plants, to enhance the healing and relaxing effects of massage. Essential oils are said to have a powerful effect on mood via absorption through the skin as well as through olfactory stimulation (Vickers and Zollman 1999). (See the monograph on Aromatherapy for more details.)
• Craniosacral massage. This type of massage locates and realigns imbalances or blockages in the soft tissues, fluids, and membranes of the head, spine, and sacrum (Greene 2000).
• Manual lymph drainage. This technique uses light, rhythmic strokes to improve the flow of lymph and is generally used for cases of edema, inflammation, and neuropathy (Greene 2000).
• Myofascial release. Gentle traction, hands-on pressure, and body positioning are used to relax and stretch the muscles, fascia, and related structures (THOMAS Healthcare 2000). This technique is used frequently by physical therapists as well as massage therapists.
• On-site/chair massage. Popular in offices and other public places, on-site massage therapists use a portable chair to deliver brief upper-body massages to fully clothed patients (THOMAS Healthcare 2000).
• Polarity therapy. Using gentle massage, polarity therapists seek to rebalance the body's energy fields to enhance health and well-being (THOMAS Healthcare 2000).
• Reflexology. This form of massage is based on the idea that the hands and feet contain reflex points for the entire body; stimulating certain points on the hands and feet is believed to affect corresponding organs (THOMAS Healthcare 2000).
• Shiatsu. Intended to stimulate energy along channels known in TCM as meridians, Shiatsu applies pressure to specific points on the body to relieve pain and enhance the flow of energy (THOMAS Healthcare 2000).
• Sports massage. Often used on professional athletes and other active individuals, sports massage can enhance performance and prevent and treat sports-related injuries (THOMAS Healthcare 2000).
• Swedish massage. Primarily for general and musculoskeletal relaxation, Swedish massage uses a wide variety of strokes and pressure to enhance venous return to the heart; flush lactic acid, uric acid, and other metabolic waste products from the tissues; stretch the ligaments and tendons; and ease physical and emotional tension (THOMAS Healthcare 2000).
• Trigger point massage. This form of therapy is used to alleviate muscle spasms and pain by applying pressure to "trigger points." These are tender areas where the muscles have been damaged or have acquired recurring spasms that are maintained by a nervous system feedback cycle of pain-spasm-pain (THOMAS Healthcare 2000). Trigger points refer pain to other parts of the body (Greene 2000) and reduce blood and oxygen flow to those areas (THOMAS Healthcare 2000).

Mechanical stimulation of tissues is translated into electrical signals that are transmitted locally and throughout the body (Hamill and McBride 1995). The stimulation and transmission improve tissue healing in the musculoskeletal system, stimulate the circulatory and lymphatic systems, enhance the function of the immune system, and provoke a sedative or stimulating action on the nervous system. These signals may also increase the sense of well-being by stimulating the release of endorphins and reducing levels of cortisol (Greene 2000).

Massage relieves tension and enhances relaxation, as evidenced by decreased blood pressure and heart rate and increased skin temperature in test subjects. It also relieves pain, stimulates blood and lymph circulation, speeds the removal of waste products from the body, and alleviates restrictions in muscles, joints, and ligaments (Greene 2000).

An initial massage therapy session begins with the patient's medical history and description of the presenting complaint(s); a discussion about expectations for the session also generally takes place, particularly if this is the patient's first visit to a massage therapist. Typically, the practitioner leaves the room while the patient undresses and lies down on the massage table. A sheet is used as a drape during the session and is moved only to expose the part of the body being worked on at any given time. Massage oil or lotion is often used to decrease friction on the skin. The room is kept warm and free of distractions; the therapist may play soft music in the background and frequently asks for feedback on whether the pressure is too deep or too superficial (Greene 2000). The therapist massages the body in a specific sequence depending on the health condition. A massage session can last from 15 to 90 minutes and may include a schedule of follow-up visits, depending on the nature and extent of the problem (Vickers and Zollman 1999).

Studies indicate that massage relieves chronic back pain and improves function at a lower cost than other modalities (InfoTeam 2000). Studies on infant massage indicate that both the mothers and the newborns benefit from the therapy. Mothers trained to massage their newborns experience a reduction in postnatal depression and a better bond with their babies (Payne 1999). Newborns receiving massage therapy from their mothers cry less, are more sociable and easily soothed, are more active and alert, and have lower levels of cortisol in the saliva, reflecting a lower level of stress in the infant (Field et al. 1996a). In addition, studies of preterm infants show faster weight gain in those receiving massage compared to those who do not (Scafidi et al. 1993).

Numerous randomized, controlled clinical studies suggest that massage is also an effective modality for young children and adolescents with a range of health conditions. Trials from the University of Miami Touch Research Institute suggest the following:

• Autistic children, who usually dislike being touched, respond well to massage therapy from their parents, displaying less autistic behavior and more sociability, on-task behavior, and attentiveness (Field et al. 1997c).
• Massage helps regulate blood glucose levels, improves dietary compliance, and reduces anxiety and depression in children with diabetes (Field et al. 1997a).
• Children with atopic dermatitis experience improvement in redness, scaling, lichenification, excoriation, and pruritus (Schachner et al. 1998).
• Children with attention deficit hyperactivity disorder (ADHD) experience an improvement in mood and on-task behavior and a reduction in fidgeting and hyperactivity (Field et al. 1998b).
• Children with juvenile rheumatoid arthritis (JRA) experience less pain and morning stiffness as well as decreased anxiety and cortisol levels (Field et al. 1997b).
• Massage reduces anxiety and improves peak airflow in children with cystic fibrosis (Hernandez-Reif et al. 1999).
• Bulimic adolescents who receive massage therapy exhibit reduced levels of cortisol and higher levels of dopamine in conjunction with reduced anxiety and depression (Field et al. 1998a).
• Parents administering massages to their children also report feeling more relaxed and less anxious (Field et al. 1997c; Field et al. 1997a; Schachner et al. 1998).

A descriptive and qualitative evaluation of the use of massage therapy in the acute care setting suggests that it supports healing; enhances relaxation, mood, and general well-being; increases mobility, energy, and quality of life; and reduces time to recovery (Smith et al. 1999). In the workplace, massage can decrease work-related stress and enhance mental alertness (Field et al. 1996b).

Massage also seems to reverse depression in cases of chronic fatigue syndrome, decrease lymphedema following radical mastectomy (Greene 2000), relieve sleep disorders, and improve self-image (Vickers and Zollman 1999). Abdominal massage also seems to be effective for alleviating chronic constipation (Richards 1998). Perineal massage, taught by practitioners to women and their partners and performed in the last few weeks of pregnancy, seems to strengthen the tissues and reduces the risk of injury and tears during vaginal delivery (Labrecque et al. 1999).

In general, massage therapy is considered a safe modality. Very few adverse events are reported in the literature and generally relate to side effects of an extremely vigorous massage technique (Vickers and Zollman 1999). Caution should be exercised if massage is used during pregnancy and should only be performed by therapists specifically trained to work with pregnant women. Diabetics should have blood sugars followed carefully, with measurements checked following a massage session, as well as over time if receiving massage regularly (Greene 2000).

Contraindications to massage therapy include advanced heart disease, phlebitis, deep vein thrombosis, kidney failure, cancer in cases where massage could accelerate metastasis or damage fragile tissue, infectious diseases, contagious skin conditions, acute inflammation, infected injuries, conditions with increased risk of hemorrhage, and psychosis. Massage should be avoided in the case of acute flare-ups of rheumatoid arthritis, eczema, goiter, and skin lesions. Recent surgery and mental impairment are considered relative contraindications. Massage is not recommended in the case of high fevers; and, osteoporosis should be considered at least a relative contraindication with extreme caution taken, particularly in areas of known or suspected bone loss (Greene 2000).

In addition to the above conditions, massage therapy is thought to be beneficial for colitis, Crohn's disease, irritable bowel syndrome, menstrual cramps, osteoarthritis, repetitive stress injuries, sprains and strains, fibromyalgia, headaches, and insomnia. It may also be a valuable adjunctive therapy for AIDS, asthma, bronchitis, diarrhea, diverticulitis, gastritis, menorrhagia, premenstrual syndrome, sinusitis, temporomandibular joint disorder, and restless leg syndrome (Greene 2000).

More research is needed to evaluate the efficacy, outcomes, and cost-effectiveness of massage therapy (Greene 2000). Although usually offered in the community by private practitioners, massage therapy is slowly being integrated into a variety of health care settings, such as hospices and hospitals (Vickers and Zollman 1999).

The standard training involves at least 500 hours of education from an accredited massage program that includes supervised practice. Massage therapists are licensed in 29 states, most of which require that they pass a national exam administered by the National Certification Board for Therapeutic Massage and Bodywork (Greene 2000).

The American Massage Therapy Association in Evanston, Illinois, the largest nonprofit association for massage therapists, maintains referral information. Contact the organization at 847-864-0123 or on the web at www.amtamassage.org. The Touch Research Institute at the University of Miami School of Medicine in Coral Gables, Florida is the first center in the world for basic and applied research on the sense of touch. For information on the Institute's research and clinical trials, call 305-243-6781 or consult their web site at www.miami.edu/touch-research. Associated Bodywork and Massage Professionals in Evergreen, Colorado provides a referral service and publishes Massage & Bodywork Magazine. For more information, call 800-458-2267 or contact the association at www.abmp.com.

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Field T, Ironson G, Scafidi F, et al. Massage therapy reduces anxiety and enhances EEG pattern of alertness and math computations. Int J Neurosci. 1996;86(3-4):197-205.

Field T, Hernandez-Reif M, LaGreca A, Shaw K, Schanberg S, Kuhn C. Massage therapy lowers blood glucose levels in children with Diabetes Mellitus. Diabetes Spectrum. 1997;10:237-239.

Field T, Hernandez-Reif M, Seligman S, et al. Juvenile rheumatoid arthritis: benefits from massage therapy. J Pediatr Psychol. 1997;22(5):607-617.

Field T, Lasko D, Mundy P, et al. Brief report: autistic children's attentiveness and responsivity improve after touch therapy. J Autism Dev Disord. 1997;27(3):333-338.

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Hernandez-Reif M, Field T, Krasnegor J, Martinez E, Schwartzman M, Mavunda K. Children with cystic fibrosis benefit from massage therapy. J Pediatr Psychol. 1999;24(2):175-181.

InfoTeam Inc. Chronic low-back pain: comparison of acupuncture, therapeutic massage, and self-care education [abstract]. Life Sciences & Biotechnology Update. May 2000. Full text available as Report No. L20000521 from InfoTeam Inc., P.O. Box 15640, Plantation, FL 33318-5640, phone (954) 473-9560.

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