MD, PhD, FMedSci, FSB, FRCP, FRCPEd

As I have mentioned before, I like positive news as much as the next person. Therefore, I am constantly on the look-out for recently published, sound evidence suggesting that  some form of alternative medicine is effective and safe for this or that condition. This new systematic review fits that description, I am pleased to report.

Its authors evaluated the effectiveness of massage therapy (MT) for neck and shoulder pain. Their extensive literature searches identified 12 high-quality studies. The meta-analyses showed significant effects of MT for neck pain and shoulder pain compared to inactive therapies. MT did not yield better effects for neck pain or shoulder pain than other active therapies administered to the control groups. Shoulder function was not significantly affected by MT. The authors concluded that “MT may provide immediate effects for neck and shoulder pain. However, MT does not show better effects on pain than other active therapies. No evidence suggests that MT is effective in functional status”.

Massage therapy is thus a promising treatment, particularly as this systematic review is by no means the only piece of encouraging evidence. It is not better than other effective treatments, but it is not associated with frequent or serious adverse effects. This means that the demonstrable benefits are likely to outweigh its risks; in other words, the risk benefit balance is positive. Regular readers of this blog will appreciate the importance of this point.

Massage is practiced by several professions: mostly, of course, by massage therapists, but occasionally also by nurses, osteopath, chiropractors etc. Chiropractors, in particular, have recently tried to make much - I think too much - of this fact. They tend to claim that, as they use treatments which are evidence-based, such as massage, chiropractic is an evidence-based profession. I think this is akin to surgeons claiming that all of surgery is evidence-based because surgeons use medications which effectively reduce post-operative pain. Chiropractors foremost employ spinal manipulation and surgeons foremost use surgery; if they want us to believe that their practice is evidence-based, they need to show us the evidence for their hall-mark interventions. In the case of surgery, the evidence is mostly established; in the case of chiropractic, it is mostly not.

Massage is backed by reasonably sound evidence not just for neck and shoulder pain but for a range of other conditions as well. WHAT DO WE CALL AN ALTERNATIVE MEDICINE THAT WORKS? WE CALL IT MEDICINE!

So why is massage not a mainstream therapy? The answer is simple: in many countries, massage therapy has long been considered to be entirely conventional. Twenty years ago, I was chair of rehabilitation medicine at the university of Vienna. Amongst my staff, there always were about 5-8 full time massage therapists and nobody thought this to be unusual in any way. Similarly, in Germany, massage is entirely conventional.

Perhaps it is time that the English-speaking countries catch up with Europe when it comes to massage therapy and the evidence that supports it?

37 Responses to Some alternative therapies are effective and safe!

  • fedup says:

    Nice to see you have done nothing more but show your own bias. Lets not forget your piece on pulse labelled, “even massage therapy is without its risks”

    You started with “It might be best to start this article with a declaration of conflict of interest: I am quite fond of massage therapy ” but now for some reason you have forgotten this bit, the very thing you accuse other therapies of doing.

    And, if we look for data, we soon realise that there is no reporting schemes for adverse events. This striking absence is a phenomenon we observe in many areas of alternative medicine. I find this worrying: if we do not look, we will not see.

    In such a situation, we have to rely on published case-reports for information. Having had a long-standing interest in massage therapy, I decided a decade ago to systematically review this type of evidence.

    “What I found was surprising and a little unsettling: there were reports of cerebrovascular accidents, stent displacements, embolisations of kidneys, haematomas, leg ulcers, nerve damage, pseudo-aneurisms, pulmonary embolisms, ruptured uterus, strangulation of the neck and pain syndromes all of which had occurred after massage therapy2. In most cases, there seemed to be little doubt about causality. Since then, many more adverse effects have come to light, and there is good reason to suspect that under-reporting is huge.”

    So which is it Mr Ernst? safe or not? you seem to tell us its both.

    • edzard says:

      “what we found is a LITTLE unsettling” …this is your clue! a little unsettling can still be relatively safe. adverse effects of massage exist but seem to be very, very scarce.
      what we find with other alt med is MORE THAN A LITTLE unsettling.
      but you are not really interested in an answer, are you?

  • fedup says:

    But Prof Ernst, would you not demand all massage therapists inform their patients/clients of the possible adverse effects? Even though they are only case reports and even though the adverse effects are very rare? And if these massage therapists are not informing their patients/clients about adverse effects would you class them as unethical? Did your massage therapists in Vienna evr discuss adverse effects?

    • Edzard says:

      thank you for your interest.
      i think, practitioners using massage – not just massage therapists! – would be wise to metion that in very rare instances, massage has caused problems; they then would have to mention that most adverse effects occured with non-massage therapists. because of the rarety of the problems and the fact that massage therapists are not really implicated, not providing this info would probably not be unethical.

  • Dr.Avijit Majumdar says:

    how funny!! MT is a therapy oriented treatment,here is no use of medicine,then how you called MT as an alternative medicine?!! Very sad. You should apologies for it and sd accept the efficacy of actual alternative medicine, i.e homeopathy. Thanx.

    • Edzard says:

      massage therapy is considered in most english speaking countries to be part of alt med. what is sad about that? what precisely do you want me to appologise for? why should i accept the “efficacy” of homeopathy?

  • fedup says:

    But Prof Ernst you have stated that “there were reports of cerebrovascular accidents, stent displacements, ” and that ” there seemed to be little doubt about causality.” How can you possibly come to that conclusion?

    • Edzard says:

      pehaps you care to read the article or at least the abstract http://www.ncbi.nlm.nih.gov/pubmed/12777645:
      OBJECTIVES:

      After many years out of the limelight, massage therapy is now experiencing a revival. The aim of this systematic review is to evaluate its potential for harm.

      METHODS:

      Computerized literature searches were carried out in four databases. All articles reporting adverse effects of any type of massage therapy were retrieved. Adverse effects relating to massage oil or ice were excluded. No language restrictions were applied. Data were extracted and evaluated according to predefined criteria.

      RESULTS:

      Sixteen case reports of adverse effects and four case series were found. The majority of adverse effects were associated with exotic types of manual massage or massage delivered by laymen, while massage therapists were rarely implicated. The reported adverse events include cerebrovascular accidents, displacement of a ureteral stent, embolization of a kidney, haematoma, leg ulcers, nerve damage, posterior interosseous syndrome, pseudoaneurism, pulmonary embolism, ruptured uterus, strangulation of neck, thyrotoxicosis and various pain syndromes. In the majority of these instances, there can be little doubt about a cause-effect relationship. Serious adverse effects were associated mostly with massage techniques other than ‘Swedish’ massage.

      CONCLUSION:

      Massage is not entirely risk free. However, serious adverse events are probably true rarities.

      perhaps then you can tell me what displeases you about my conclusion?

  • fedup says:

    “Some alternative therapies are effective and safe!” This is your title. But for some reason when looking at other therapies, rare adverse effects and lack of reporting schemes even when there is no evidence of “cause-effect relationship” put those therapies in your “unsafe” category.

    • Edzard says:

      “other therapies” like what? like chiropractic perhaps? ~50% of patients have mild to moderate adverse effects after chiro + several hundres vascular accidents are on record. i really don’t know what you are going on about. it is a question of how many adverse effects have been noted and how severe they are and who is implicated. massage therapists are very, very rarely implicated.
      but you probably know all of this and merely want to show me up; am i right?
      you might need to find another pretext.

  • fedup says:

    I have no wish to “show anybody up” I have only ever tried to understand your perceived bias. I don’t understand why you seem to differentiate between the different types of massage therapy but find it impossible to do with other therapies. Chiropractic for example. Why have you singled out Swedish massage to be so safe? Does the research show other techniques to be more likely to cause adverse effects? If you are able to do this for massage why not other therapies?

    • Edzard says:

      have you still not read the abstract? it says so! the answers to your questions are obvious and i have provided them.
      why not for other techniques?
      because you do not read my articles, perhaps?
      i have done a similar thing for chiro vs osteo, and for phytotherapy vs individualised herbalism; even on this blog you can find a lot on these and related subjects.

    • Gift says:

      “I have no wish to “show anybody up” I have only ever tried to understand your perceived bias.

      The former belies that latter.

      It’s rather obvious from Prof. Ernst’s publication record that he differentiates between therapies. Differentiating doesn’t preclude calling treatments out when they have things in common though… like say… not working?

      • fedup says:

        Sorry Gift but you are wrong. If you think you are correct then point me to the article done by Prof Ernst which indicates which type of chiropractic technique is more likely to cause an adverse effect. Which chiropractic technique is likely to cause vad?

    • Skepticat_UK says:

      “I have only ever tried to understand your perceived bias.”

      Interestingly, this bias you perceive is only perceptible to those with a vested interest in whatever therapy has been scrutinised and found wanting. The rest of us just see EE telling it like it is.

  • fedup says:

    Again Prof Ernst you have missed my point. Your blog states massage therapy is safe and effective, you also pay attention in your article to different types of massage therapy and the possible adverse outcomes. You then comment on different types of massage therapy being “safer” than others and also state that non qualified therapists are more likely to cause adverse effects. Why do you not throw all massage therapies in the same pot as you do chiropractic? Making a distinctions between types of a similar therapy is very different to comparing different therapies. ie chiro/ osteo

    I also don’t understand how you can say that massage therapists are rarely indicated when you have blogged that “there seemed to be little doubt about causality” by which I take to mean the massage caused it and you also blog that “we soon realise that there is no reporting schemes for adverse events.” So if that is the case is it any wonder the massage therapist is rarely indicated? That means you are left with case studies, the same as with chiropractic. For some reason here you class massage as safe and chiropractic as not???

  • edzard says:

    this is a message to “fedup”. as you noticed, i am not posting any more of your posts which go over issues that we have already dealt with. PLEASE READ THE “RULES” SET OUT FOR THIS BLOG.

  • fedup says:

    nice prof ernst, thanks for not publishing my comments then you decide to comment after!!! how very decent of you. Believe me I feel as irritated as you having to constantly deal with the odd person who decides to pipe in with something you have gone over a hundred times. Its very tedious. As you put it I shall go around in circles else where and let you continue to publish your biased, one sided blog without my daring to question your evidence, standards or motives.
    Cheers.

  • Adam Meakins says:

    Prof Ernst, I do like your clinical scientific and regardless if what others say an ‘unbiased’ review of the evidence

    Why you bother to ‘debate’ with these chiropractic zealots is beyond me, and it reminds me of a very good saying

    “He who argues with a fool, only makes himself look foolish”

    Your better than that, let them rage and moan but I wouldn’t even dignify them with an educated response

    Keep up the good work

    Cheers

    Adam

  • A N Other says:

    I do enjoy reading this blog and do understand the importance of evidence based medicine.
    Therefore I think it is important to add some important information to the above article.
    The most recent Cochrane Database of Systematic Reviews http://www.ncbi.nlm.nih.gov/pubmed/22972078 done in 2012 reach some different conclusions.
    MAIN RESULTS:
    Fifteen trials met the inclusion criteria. The overall methodology of all the trials assessed was either low or very low GRADE level. None of the trials were of strong to moderate GRADE level. The results showed very low level evidence that certain massage techniques (traditional Chinese massage, classical and modified strain/counter strain technique) may have been more effective than control or placebo treatment in improving function and tenderness. There was very low level evidence that massage may have been more beneficial than education in the short term for pain bothersomeness. Along with that, there was low level evidence that ischaemic compression and passive stretch may have been more effective in combination rather than individually for pain reduction. The clinical applicability assessment showed that only 4/15 trials adequately described the massage technique. The majority of the trials assessed outcomes at immediate post-treatment, which is not an adequate time to assess clinical change. Due to the limitations in the quality of existing studies, we were unable to make any firm statement to guide clinical practice. We noted that only four of the 15 studies reported side effects. All four studies reported post-treatment pain as a side effect and one study (Irnich 2001) showed that 22% of the participants experienced low blood pressure following treatment.
    AUTHORS’ CONCLUSIONS:
    No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain. As a stand-alone treatment, massage for MND was found to provide an immediate or short-term effectiveness or both in pain and tenderness. Additionally, future research is needed in order to assess the long-term effects of treatment and treatments provided on more than one occasion.
    I think the most important conclusion from the above systematic review is that no firm statement can be made to guide clinical practice i.e. I don’t think it is possible to recommend massage for neck pain.

    Also, this systematic review highlights that only 4 of the 15 studies reported side effects. So I think it could be difficult to say that the risk benefit balance is positive when it is not possible to state the prevalence of the risks.

    I personally feel that the severe adverse events are probably rare but mild to moderate adverse effect could be more common. A study (http://www.ncbi.nlm.nih.gov/pubmed/17983334) found that 10% of patients reported some minor discomfort after massage. However, Paul Ingraham, a massage therapist for 10 years and now an editor for science based medicine states on his website regarding the above study that “… I’m surprised only 10% reported it. The massage must have been quite gentle”. Therefore I think it could be a case of absence of evidence does not mean evidence of absence in relation to adverse effects.

    Finally, a review of the evidence base by the Australian Association of Massage Therapy (http://aamt.com.au/wp-content/uploads/2011/11/AAMT-Research-Report-10-Oct-11.pdf) states that the evidence for massage for constipation is “inconclusive due to mixed evidence and poor quality studies”. With regards low back pain they state “Although further research with improved power and methodological quality appears warranted current evidence was reportedly moderate in strength and fairly robust”. They had similar conclusions regarding the use of massage with patients who have cancer for example “moderate evidence in symptom management i.e. anxiety, pain, quality of life and potential for improved immunity”

    In conclusion, I think it could be too early to say “Massage is backed by reasonably sound evidence not just for neck and shoulder pain but for a range of other conditions as well.” If we a higher standard for the evidence base, we may fine that massage may be not that much better than all the other alternatives.

    • edzard says:

      i love the idea that i am sometimes too optimistic when it comes to judging the value of alt med. you are correct, however, the contradiction between the 2 reviews is odd and needs a closer look and explanation.
      the reason i often favour massage is that it is backed by some level of biological plausibility and that it is relatively safe, according to my review of reported adverse effects and common sense.

      • A N Other says:

        @ edzard

        We both know common sense doesn’t have a place in evidence based medicine and your review on adverse events seems to concentrate on severe adverse events, which i agree are rare, but mild to moderate adverse effects have not been covered. As i stated previously it seems only one study has looked into mild to moderate adverse effects, so i don’t think we have enough info to ascertain the risks regarding massage.

        I would also again state that there is not “reasonably sound evidence” to back massage in the treatment of constipation, especially when another review states the evidence is “inconclusive due to mixed evidence and poor quality studies”.

        Finally and most importantly, there was no mention within the above article that massage therapy is mired in quackery. A article on Quackwatch by Stephen Barrett (http://www.quackwatch.org/01QuackeryRelatedTopics/massage.html) describes in detail this issue. This could lead potential patients vulnerable to the “bait and switch” as described by David Colquhoun. I don’t think you have been too optimistic but maybe lost your way, considering previously you have written about massage on this blog stating that “… there is precious little evidence to demonstrate that it is effective”.

          • A N Other says:

            @ edzard

            Thanks for the reply. It is good to see that we do agree that you have lost “your way”. In fact, “your way” in previous, current, and with no doubt future cases, has been to thoroughly analyze the totality of the evidence before coming to a conclusion. However, in the above article you have seemed to have demonstrated the same actions as other people from professions such as acupuncture, chiropractic, homeopathy etc. and jumped to a positive conclusion, when there is strong evidence to the contrary.

            Regarding your assertion that there is “reasonably sound evidence” for massage in the treatment of constipation, this is plainly wrong, to the point where I would say that there is not a jot of evidence for massage to treat constipation. It seems that the respectable face of rigorous scientific scrutiny seems happy to promote a bogus treatment.

  • edzard says:

    your point does not get stronger by repeating it over and over again. not a jot of evidence? http://www.ncbi.nlm.nih.gov/pubmed/10460984.
    strong evidence to the contrary? no, my conclusions were based on systematic reviews as always; the confusion is merely that there are more than one systematic review and they arrive at different conclusions.
    despite your objections, i will continue to report on the few emerging papers which are sound and report positive results for alt med.

    • A N Other says:

      @ edzard

      Can i point you to the following website:

      http://www.medicine.ox.ac.uk/bandolier/booth/alternat/AT043.html

      Here is the article too:

      Abdominal massage for chronic constipation

      Clinical bottom line: There is insufficient evidence of effect of abdominal massage for chronic constipation. The trials were small and of poor methodological quality.

      Chronic constipation is common. Observational studies and case reports show that massage may be helpful.
      Systematic review:

      Ernst E. Abdominal massage for chronic constipation: A systematic review of controlled clinical trials. Forsch Komplementärmed 1999;6;149-151.

      Date review completed: June 1997

      Number of trials included: Four

      Number of patients: Total 54 patients

      Control groups: phase of no massage or treatment with laxatives.

      Main outcomes: total gastrointestinal/colonic transit time, stool frequency, number of days with bowel movements, episodes of faecal incontinence, number of enemas given, stool consistency, patient well-being.

      Inclusion criteria were: controlled clinical trial; active treatment phase (abdominal massage) compared with a control phase (no massage or treatment with laxatives); patients with chronic constipation.

      Medline, Embase, CISCOM and the Cochrane Library (all years to June 1997) and the reviewer’s own database of alternative therapies were searched to identify controlled trials of massage treatment for chronic constipation. A number of relevant search terms were used and experts were contacted for other published/unpublished information. Referenece lists of retrieved reports were checked for additional citations and no language restrictions were made. A controlled trial was defined as having a nonmassage treatment group. Study quality was assessed using a validated scale. Data were extracted in a standardised, predefined manner. A descriptive analysis was conducted.
      Findings:

      Four trials were included. The patient population was: chronic constipation, no further details (21 patients), 48 year old female with chronic constipation (1), disabled, institutionalised adults with severe chronic constipation (32). One study was randomised, none were blind. The randomised study (32 patients) found no significant difference in outcomes (gastrointestinal transit time, stool frequency & consistency, number of enemas given, patient well-being) between the different treatment phases (three weeks run-in, regular massage for seven weeks, one week wash-out, laxatives for seven weeks). Two trials (21 patients) found no significant difference between massage and control phases for total colonic transit time and stool frequency; one also reported massage therapy to cause significant improvement in the number of days with bowel movements, episodes of faecal incontinence and number of enemas given. One N-of-1 (one patient) trial reported improved stool frequency and consistency with massage compared with the control phase.
      Adverse effects

      Adverse effects were not mentioned.

      Comment
      As stated by the reviewer, these trials were of poor quality and were methodologically flawed. The studies were small (the largest had 32 patients), assessed different outcomes and durations of treatment, and provided no definition of constipation (other than transit time in one study) or abdominal massage. None of the included trials were blind and were open to observer bias. Only one study was randomised – this showed no effect of abdominal massage on constipation. Three studies were not randomised and were open to selection bias. The studies were likely to be of poor validity and incapable of producing a true result. No sound scientific evidence exists to determine whether massage is effective in patients with chronic constipation.

      MY COMMENTS ON THE ABOVE:

      I think the above article concludes that there is not a jot of evidence, to say that there is “reasonably sound evidence” for massage in the treatment of constipation.

      The reason why I am repeating this point over and over, is because you seem to be holding double standards. For example in an article on Gua Sha on this blog you state the following:
      “The truth, of course, is that neither this case (report) nor the two RCTs provide any good evidence at all. The case-report is, in fact, a classic example of drawing hilariously over-optimistic conclusions from data that are everything but conclusive. And the two RCTs just show how remarkable placebo-effects can be, particularly if the treatment is exotic, impressive, involves physical touch, is slightly painful and raises high expectations”.

      Now comparing this statement, to the one made on the trials for massage in the treatment of constipation shown above, they both seem equally damning.

      However, you conclude that there is “reasonably sound evidence” for massage in the treatment of constipation, whereas in Gua Sha your conclusion is negative!!

      Please explain how you can reach a positive conclusion for massage, and a negative conclusion for Gua Sha, when the level of evidence for both is poor?

  • edzard says:

    the post was not about massage for constipation. in fact, i do not even mention the term, i think. so what are you going on about?
    i explain that i am constantly on the look-out for new papers which report positive results, the systematic review of massage for neck/shoulder pain fits that bill, and i write about it. i merely linked to my old massage/constipation paper in support of the notion that massage is backed by evidence. i see nothing wrong with that.

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