Massage Research

The emergent scope of massage in healthcare

• Massage and bodywork practitioners routinely observe the influence massage has on a client’s state of mind. Many individuals receiving massage just drift off and relax deeply as a session progresses. Others discover a space from which to reflect and discuss their autobiography, and somato-emotional evoked experiences are not uncommon. It turns out, these unique attributes of massage hint at an underlying body-mind model capable of distinguishing the integral role of massage in health and healing. To gain perspective as to the significance of such a model to the massage discipline, let’s review a few consummate massage research efforts that illuminate the current state of massage in healthcare. 

The Efficacy Of Massage:

• In a massive undertaking, the Australian Association of Massage Therapy categorized and ranked 740 studies as to the evidence based effectiveness of massage therapy. The search criteria were broad as to the types of practitioner, massage technique and study design in order to capture a wide array of information. Strong evidence for recommending massage therapy was observed for low back pain, anxiety, stress, chronic disease management, delayed onset muscle soreness and pulmonary function. Additionally, massage or acupressure was effective against nausea and vomiting in various conditions. Limited evidence for recommending massage was found for more than 20 other conditions, while evidence in many other conditions was inconclusive or lacking. The authors note that the scattered nature of massage related studies makes it difficult to identify research evidence to inform best practice. (1) 

• In a compilation of studies measuring physiological indicators of massage post treatment, they cumulatively found either significant decreases in cortisol or consistent increases in dopamine and serotonin neurotransmitters in respective conditions. The combined category groupings included depression resulting from sexual abuse and eating disorders, pain syndromes ranging from burns to migraine headaches, immune and autoimmune conditions including asthma, chronic fatigue, HIV and breast cancer, and stress disorders related to physical activity, occupation, aging or pregnancy. (2) 

• Finally, a review of studies from various researchers measuring for the effects on cortisol, autonomic stress hormones, heart rate or blood pressure generally reported significant stress reducing benefits. The studies specifically selected for massage preformed by trained therapists; however, results varied by study design. In some instances, the measured effects were short lived but reproducible. We’ll revisit some important implications later in this series, but for our purposes here, the wide range of study populations responding positively to massage is noteworthy if not definitive. (3,4) 

A Defining Moment:

• Taken together, large meta-analyses, literature reviews and astute massage research validate the clinical benefits of massage therapy across a myriad of health conditions. Additionally, the potent effect of massage on stress hormones and neurotransmitters, as well as the central effect on autonomic function is observed in conditions where such changes are therapeutic. To now convey the efficacy of massage as an integral component in both private and public healthcare delivery, requires a model capable of edifying the mechanisms of action in a given class of conditions or disease processes. To decisively realize this goal, it is essential to view the attributes of massage from an inclusive and supportable vantage. 

The Body-Mind Nature:

• We can conceptualize and establish a body-mind model not as a metaphysical abstraction, but instead as a means to describe the tangible interfaces through which the central nervous system may be therapeutically influenced by massage. In this context, massage and bodywork are described in terms of a bottom-up healing discipline. Bottom-up refers to inputs that are provided through physical means to the body or senses. (5) 

• Given that these bottom-up massage inputs then communicate with and ascend within the central nervous system, the concept of a body-mind tiered model emerges. From this perspective, it becomes straightforward to understand why massage research documents beneficial effects of massage in afflictions well beyond the realm of musculoskeletal conditions. Specifically, when these somatic bottom-up inputs ultimately reach into the brain-based stress systems, they evoke powerful effects on the top-down regulation of stress drives back into the body. The inclusive big picture attributes of a body-mind model answers many questions, removes roadblocks and supports the efficacy of massage backed by the weight of scientific rigor. 

A Tiered Classification System:

• The benefits of massage cross all boundaries of conditions and yield considerable therapeutic effects on important stress hormones and neurotransmitter systems. Let’s now outline the principal levels at which massage influences both body and brain stress systems from the bottom up. This tiered classification then facilitates both the accurate placement of conditions amenable to massage and provides a distinction from which to discuss mechanisms of action. 

Musculoskeletal Primary Conditions:

• Forty percent of all body tissues consist of skeletal muscle and connective fascia that is highly innervated with sensory, motor and pain fibers. Additionally, neurovascular bundles and lymphatics course through myofascia and require a compliant system. It should not surprise anyone that massage is a principal treatment consideration in the preponderance of conditions involving myofascial pain, peripheral entrapments, referred pain and orthopedic stress considerations. This of course represents a broad field of study and training in its own right.

Autonomic Nervous System Dys-Regulation:

• Myofascia and other somatic tissues under physical and inflammatory stresses send pain signals into the spinal cord at the corresponding levels of innervation. It turns out that these abnormal input barrages are capable of producing too much sympathetic activation into organ systems with deleterious effects on cardiovascular, respiratory, gastrointestinal, urinary, integument as well as immune system responses. With an understanding of these relationships, massage can be directed to effectively decrease these aberrant autonomic inputs at the source. 

Neuroendocrine Chronic Stress Diseases:

• The scope and extent of this class of tissue breakdown diseases is fueled when bottom-up physical stressors co-activate brain- based hormonal stress responses. Fortunately, the research cited earlier clearly establishes that massage therapy is incredibly effective in evoking productive shifts in neurotransmitter systems, stress hormones and autonomic physiology from the bottom up. In this class of brain-based stress dys-regulation, the likelihood of top-down emotional and cognitive stress drives must also be a consideration, as we will discuss later in the series. 

The Timeline Of Autoimmune Disorders:

• The progression and transition from elevated stress responses to the eventual fatigue of stress systems is well documented. Here, it becomes increasingly important to encourage co-treatment strategies with professionals incorporating top-down specific skill sets. The role of massage therapy as a valuable co-treatment of choice remains steadfast. The greater the understanding of the processes at work, the greater the ability of the massage therapist to treat with confidence and competence. 

Massage As Primary Health Care:

• By incorporating a body-mind perspective, the seemingly scattered types of conditions responding to massage, as well as the elusive mechanisms of action can now coalesce into a cohesive model. The unambiguous role of massage can be expanded and confidently recommended for conditions as reflected in the tiered level of body-mind stress system dysfunction. In Part 2, we’ll consider specific examples as we continue to define the integral role of massage in health and healing. Increasingly, the massage profession has the potential to change the way massage is perceived and practiced from the bottom up. 

The Emergent Scope Of Massage, Part 2:

• In last month’s article, we summarized research illustrating that massage beneficially affects conditions that cut completely across the traditional boundaries of the health disciplines. We also defined the application of massage as a bottom-up healing discipline and the concept of a body-mind tiered stress system classification as a relevant new model. To understand these relationships in a meaningful way, let’s now create an awareness of the body-mind stress systems and the corresponding mechanisms from what begins as a bottom-up physical treatment applied to body tissues. 

• Imagine an established client presents with low-back pain not particularly attributable to any specific injury. We know that at some threshold, there exists abnormal physical stressors on tissues which initiate pain signals perceived by the client. We also know that a qualifiable level of massage care for such conditions is beneficial in remedying the musculoskeletal dysfunction in the absence of other pathology. 

• Following the session, taught and tender muscle fibers, trigger points, congested nodules, fascial expansions and postural asymmetries producing pain may be documented. The level of massage therapist training, time in practice and advanced skill sets are all reflected in reducing or correcting the underlying physicality of the stress system imbalance. At the somatic level, the physicality of massage treatment is at the core of the healing experience. 

• Let’s now think again about an individual experiencing a level of discomfort or pain. Pain receptors in the skin and other tissues are all free nerve endings. Signals interpreted as pain are elicited by mechanical, thermal or chemical stimuli. In cases where myofascial imbalance gains traction, mechanical distress is further compounded by chemical pain mediators. Tissue ischemia and metabolites resulting from hypertonic, contracted and adhesed tissues preferentially activate non-adapting repetitive slow pain c-fibers which may produce hyperalgesia. 

• Once reaching the spinal cord, both fast and slow pain fibers make connections in spinal lamina II & V/VII respectively. This includes pain and inflammation inputs arising from myofascial and joint-ligament tissues. The sympathetic division of the autonomic nervous system courses down through the thoracic and upper lumbar spinal levels sharing lamina V/VII with the incoming somatic pain signaling. It is at this point in the spinal cord itself that abnormal pain inputs can affect the physiological regulation of the sympathetic stress system. (1) Importantly, active or latent TP’s, pain and inflammatory barrages from peripheral body tissues drive excessive sympathetic activity from the bottom up. Where myofascial dysfunction contributes disproportionate drive to the sympathetic system an entire class of conditions of autonomic dysregulation is created. (2) 

• The conditions in this somato-visceral class capable of responding to massage therapy are as diverse as the systems under sympathetic regulation and include skin conditions; dizziness and postural orthostatic hypotension (POTs); vision abnormalities; tachycardia/bradycardia; cardiac arrhythmias; digestive disorders (dysphasia, diarrhea, constipation); urinary frequency, nocturea; hypothermia, heat intolerance; sexual dysfunction; as well as a special consideration for somato-sympathetic-immune connections which include allergic responses. 

• The seat of unconscious physiologic regulation is in the brainstem and hypothalamus sitting at the top of the brainstem. This region includes the principal brain-based stress system comprised of both autonomic and neuroendocrine components. The neuroendocrine component is referred to as the hypothalamus-pituitary-adrenal (HPA) axis. A cascade of releasing factors starting with corticotropin releasing factor (CRF) flows from the hypothalamus to the pituitary where adrenocorticotrophic hormone (ACTH) is then released to flow in blood to the adrenal cortex where cortisol is produced. Cortisol is the primary stress hormone in the body with additional effects in the brain. 

• The primary function of cortisol in the body is to produce glucose to meet the demands of a given stress response. When adequate stores of glucose in the liver and muscle are depleted, a metabolic shift occurs that allows glucose to be manufactured in the liver. This is called gluconeogenesis and requires a tissue substrate from the body to catabolize. Catabolic processes break down body tissues and the more chronic the stress demands for glucose, the greater the breakdown in tissues. Over time, this process can be devastating to essentially every body system starting with muscle. Skeletal muscle consists mostly of proteins which make it a prime candidate to catabolize as proteins are easily converted to glucose during gluconeogenesis. 

• The insidious progression of skeletal muscle tissue loss is known simply as skeletal muscle myopathy. (3) It is associated with increasing falls, injury and disability. Negative effects on both voluntary striated and smooth muscle in the GI tract, as well as mineral absorption include: muscle weakness, wasting and pain; muscle cramps/restless leg; bone calcium depletion and osteoporosis; stomach ulcers & GERD; Chrons Disease and Leaky Gut Syndrome (LGS). 

• Associated metabolic shifts and high blood sugars result in insulin resistance, diabetes and metabolic syndrome (METS) and reproductive disorders including dysmenorrhea, fibroids, infertility, prostate swelling (BPH) and prostatitis. Massage consistently decreases cortisol by approximately one third. The results are reproducible and when coupled with other mind-body and lifestyle changes become a best practice treatment of choice for conditions in this class. 

• The amygdala (AMY) is an emotional learning and memory system sitting deep in the brain that serves as a gatekeeper for both body and mind. As body signals including visual, auditory and touch ascend into the subconscious brain, AMY responds preferentially to signals conveying danger or threat. AMY makes decisions concerned with defense and protection and then orchestrates expanded stress responses capable of releasing an array of autonomic, neuroendocrine, sensori-motor and neurotransmitter system responses to meet the challenges of a given situation either real or perceived. AMY has a particularly interesting relationship with pain. As pain signals from the body are received, AMY is quite capable of both learning and remembering relevant associations and powerfully driving the expanded stress responses described above.

• As a result of AMY keying on dangerous or threatening stimuli, massage treatments that decrease pain barrages from the body into mind serve to calm AMY. Additionally, it turns out that AMY’s learned stress related activations can be effectively switched off by pleasant touch. (4) With AMY not driving the HPA axis and expanded stress response unnecessarily, dopamine reward is free to express and elevate with pleasant touch. With this understanding of mechanism alone, one may begin to glimpse the power of massage to update traumatic somato-emotional associations within the massive forty percent of body tissues which comprise myofascia. 

• The benefits of massage cut across the boundaries of health disciplines and are more accurately described in terms of body-mind stress system relationships. Understanding the relationships between stress system mechanisms and classes of conditions can greatly facilitate research designs by selecting for desired criteria to investigate. Importantly, massage therapists well versed in these principles open their practice and experience to patients and clients looking for answers that address the source of their given target condition. 

The Emergent Scope Of Massage, Part 3:

• In the second article, we moved well beyond the physicality of massage benefits for musculoskeletal primary conditions. Journeying into the realm of body-mind, we developed an understanding of the mechanisms involved at the spinal cord level class of autonomic dysregulation disorders. Massage at the somato-visceral level accounts in part for beneficial changes in the well known stress indicators of heart rate and blood pressure; however, the list of treatable disorders in this class includes essentially every organ system. Then, ascending into the body-mind interface of the hypothalamic-pituitary-adrenal (HPA) axis, we looked at the nature of the neuroendocrine chronic hyperactive stress response including major control coming from the amygdala subconscious learning and memory system. Here again, massage generates massive beneficial inputs to this level of circuitry to reduce cortisol and mitigate physiological stress responses as well as the myriad of diseases resulting from the catabolic breakdown of body tissues.

• Let’s now continue by adding the brain-based neuroendocrine conditions with high cortisol profiles where massage stands as an effective treatment component. We’ve already spoken of the amygdala (AMY) as a major player in driving expanded stress responses which includes producing high levels of cortisol. Additionally, the corticotropin releasing factor (CRF) at the top of the HPA axis has major effects in deep brain circuitry which becomes important now. Under the influence of excessive CRF and cortisol, AMY ramps up and is largely responsible for driving general anxiety disorders (GAD). GAD affects about 6.8 million American adults, with a 2 to 1 female ratio. (1) High cortisol and CRF profiles are also directly responsible for sabotaging the circuitry that results in major depressive disorders. Excessive CRF blocks dopamine release in the deep reward centers which may not recover for greater than 90 days. (2) 

• Elevations in cortisol resulting from chronic stress also dramatically increase the uptake of serotonin normally found in the synapses between neurons. (3) This explains why patients are often prescribed serotonin selective reuptake inhibitors (SSRI’s) to counter depression. Cortisol is too high while valuable dopamine and serotonin systems are effectively taken out. Massage has just the reverse effect; cortisol is lowered and dopamine and serotonin are elevated by approximately one third. (4) Massage is powerful medicine as there is no pharmacology or other modality known to have this immediate beneficial effect on all three of the major players in this class of conditions. 

• Individuals experiencing general anxiety or affective disorders ranging to major depression are also at increased risk for coronary artery and heart disease and by and large have elevated cortisol profiles. Coronary heart disease is the leading cause of morbidity and mortality of women in the United States and most developed countries, exceeding that of all cancers combined. (5) Massage assumes a valuable supportive role, and in conservative cases a combination of massage, therapeutic exercise and meditation training can be quite effective. 

• Prolonged exposure to stress and cortisol leads to loss of neurons which is initially observed in the hippocampus. (6) These processes may first be recognized as mild cognitive impairment (MCI) and may or may not advance to end stage dementia and Alzheimer’s disease. The message being that stress can rob us of our very self identity if we do not increase awareness and have effective counter measures in place with massage being a treatment of choice. 

• When stressors evoke sustained elevation in cortisol profiles, immuno-suppression predominates. Essentially, the stress hormone cortisol stops the inflammatory cascade and healing. Healing is considered a lower priority than meeting the perceived stress of the moment. When two individuals are exposed to the same virus, it’s the stressed individual who succumbs to illness as their immune system is suppressed. 

• The immunosuppressive property of glucocorticoids is used medically as cortisone injections to decrease inflammation by serving as a brake on immune inflammatory responses. We have seen how devastating high cortisol profiles can be, but it can get worse. At some point in time, the adrenal cortex is no longer capable of generating enough cortisol and adrenal fatigue sets in. 

• Chronic Fatigue Syndrome (CFS) is defined as fatigue for greater than six months (excluding other conditions), with four of the eight following symptoms: myalgia, arthralgia, sore throat, tender nodes, cognitive difficulty, headache, post-exertional malaise, or sleep disturbance. (7) The stress system profile includes hypoactivity of the HPA axis with sympathetic over-activity. In many cases the adrenal fatigue is attributed to the sympathetic cytokine storm competing for receptor cites on the adrenal cortex. (8) Subtypes of CFS involving top-down psychological trauma or bottom-up physical trauma are both common. Massage protocols designed to quell sympathetic drive while elevating dopamine and serotonin are strongly indicated along with guided mental training to improve coping skills. 

• Without adequate cortisol to hold the immune system in check, the immune system is now unleashed to attack the body’s own tissues. The autoimmune disorders do not occur by happenstance but instead represent a direct timeline effect of degenerative stress responses. The target tissues vary depending on hereditable and environmental traits, but the overall pattern is clear. 

• Multiple sclerosis (MS) is the most common autoimmune disease of the central nervous system, affecting 1 in 1000 people in western cultures. MS leads to chronic disability mostly in young adults ages 20 to 40. Multiple sclerosis patients benefit from massage therapy. Twenty-four adult MS patients served as medical controls or received 45- minute massages twice a week for five weeks. The massage group had lower anxiety and less depressed mood immediately following massage and at studies end had improved self-esteem, better body image, image of disease progression and enhanced social functional status. (9) 

• The benefits of massage in autoimmune disorders is common experience across conditions effecting different systems including atopic dermatitis; psoriasis; asthma; rheumatoid arthritis; systemic lupus erythematosus and Sjogrens. 

• It turns out the cortisol profile in fibromyalgia (FM) is typically elevated until end stage disease. The continued catabolic draw on muscle resembles a skeletal muscle myopathy as proteins are catabolized to fuel chronic stress needs. Additionally, a sympathetic nervous system gone wild creates a pro-inflammatory state. Over time, myofascia sourced pain signals into the central nervous system sensitize the pathways with the result of winding up pain perception. Almost 40% of FM patients describe either physical trauma in the six months prior to onset or emotional trauma overlays such as sexual abuse in childhood. Adrenal insufficiency is not uncommon in end stage FM. FM patients benefit from massage post treatment and at one month, however at six months only sleep ratings remained improved from massage alone. (10) 

• Massage as a bottom-up therapy integrates in the central nervous system to both positively influence brain-based systems and also powerfully reflect back to regulate stress physiology, health and healing. The therapeutic benefits of massage shine for conditions at every level in the tiered body-mind continuum based on documented mechanisms of stress system neurophysiology. The perspective as one ascends into conditions involving brain based stress dysfunction is one in which co-treatment alliances incorporating the benefits of massage are essential in facilitating improved long-term outcomes. 

1. Ng CW, Kenny, Cohen, M. (2008) The Effectiveness Of Massage Therapy, A Summary of Evidence-Based Research, Australian Association of Massage Therapy.

2. Fields, T., et.al., Cortisol Decreases and Serotonin and Dopamine Increase Following Massage Therapy,. Intern J. Neuroscience, 2005, 115: 1397-1413. 

3. Moraska, A., et. al., Physiological Adjustments to Stress Measures Following Massage Therapy: A Review Of The Literature. Evidence-Based Complementary and Alternative Medicine, 2008, 7(4), 409-418. 

4. Barberree, B., et. al., Massage And The Stress Response, Massage Today, 2015, Dec, Vol. 15. Issue 12. 

5. Taylor, A.G., et. al., Top-Down and Bottom-Up Mechanisms in Mind-Body Medicine: Development of an Integrative Framework for Psychophysiological Research, Explore (NY), 2010, January; 6(1): 29. 

1. Cabot, J.B., et.al., Spinal Cord Lamina V and Lamina VII Interneuronal Projections to Sympathetic Preganglionic Neurons, The Journal Of Comparative Neurology 347515-530 (1994). 

2. Mathias, J.C., Autonomic Diseases: Clinical Features and Laboratory Evaluation, Neurol Neurosurg Psychiatry 2003;74 (Suppl III): iii31–iii41. 

3. Pereira, R., Glucocorticoid-Induced Myopathy, Joint Bone Spine 78 (2011) 41–44. 

4. Rolls, E., et.al., Representations of Pleasant and Painful Touch in the Human Orbitofrontal and Cingulate Cortices, Cerebral Cortex Mar 2003;13:308–317; 1047–3211. 

1. Rose C. Mantella, et.al., Salivary cortisol is associated with diagnosis and severity of late- life generalized anxiety disorder, Psychoneuroendocrinology, Volume 33, Issue 6, July 2008, Pages 773-781. 

2. Lemos, J.C., et. al., Severe Or Chronic Stress Switches CRF Action In The Nucleus Accumbens From Appetitive To Aversive, Nature 2012 October 18; 490 (7420); 402-406 

3. Taffet, G.E., Correlation between cortisol level and serotonin uptake in patients with chronic stress and depression, Cognitive, Affective, & Behavioral Neuroscience 2001, 1 (4), 388-393 

4. Fields, T., et.al., Cortisol Decreases and Serotonin and Dopamine Increase Following Massage Therapy,. Intern J. Neuroscience, 2005, 115: 1397-1413. 

5. Shively, C.A, Stress, Depression & Coronary Artery Disease: Modeling Comorbidity In Female Primates., Neuroscience & Biobehavioral Reviews 33 (2009) 133-144 

6. McEwen B., Salpolsky, R., Stress and Cognitive Function, Current Opinion in Neurobiology 1995, 5: 205-216. 

7. Silverman, M.N., et.,al., Neuroendocrine & Immune Contributors To Fatigue, Physical Medicine & Rehabilitation, 2010, May ; 2(5); 338-346 (including Esther Sternberg, M.D.) 

8. Hai-ming, XIA, et.al., Tumor necrosis factor alpha affect hydrocortisone expression in mice adrenal cortex cells mainly through tumor necrosis factor alpha-receptor 1, Chin Med J 2011;124(17):2728-2732. 

9. Hernandez-Reif, M., et.,al., Multiple sclerosis patients benefit from massage therapy, Journal of Bodywork and Movement Therapies, Volume 2, Issue 3, July 1998, Pages 168- 174. 

10. Castro-Sanchez, A.M., et.al., Benefits Of Massage-Myofascial Release Therapy On Pain, Anxiety, Quality Of Sleep, Depression & Quality Of Life In Patients With Fibromyalgia, Evidence Based Complementary And Alternative Medicine, Vol. 2001, Article ID 561753, 9 pgs. 

För mig är det viktigt att mina massagebehandlingar vilar på en trygg och vetenskaplig grund. Därför ser jag det som en självklar del av mitt arbete att följa och sammanställa aktuell forskning inom manuell terapi.

Daniel Näsman
Medicinsk Massageterapeut @ Massageterapeuten Göteborg