MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Fibromyalgia (FM) is a chronic condition which ruins the quality of life of many patients. It is also a domain of alternative medicine: dozens of different treatments are on offer – this is clearly a paradise for charlatans and bogus claims. So is there a treatment that is demonstrably effective? The purpose of this systematic review is to evaluate the evidence of massage therapy FM.

Electronic databases were searched to identify relevant studies. The main outcome measures were pain, anxiety, depression, and sleep disturbance. Two reviewers independently abstracted data and appraised risk of bias. The risk of bias of eligible studies was assessed based on Cochrane tools.

Nine randomized controlled trials involving 404 patients met the inclusion criteria. A meta-analyses showed that massage therapy with a duration of at least 5 weeks significantly improved pain , anxiety, and depression. Sleep disturbance was not improved by massage therapy.

The authors conclude that massage therapy with duration ≥5 weeks had beneficial immediate effects on improving pain, anxiety, and depression in patients with FM. Massage therapy should be one of the viable complementary and alternative treatments for FM. However, given fewer eligible studies in subgroup meta-analyses and no evidence on follow-up effects, large-scale randomized controlled trials with long follow-up are warrant to confirm the current findings.

To put these results into context, we need to consider the often poor methodological quality of the primary studies. It is, of course, not easy to test massage therapy in rigorous trials. For instance, there is no obvious placebo, and we can therefore not be sure whether the treatment benefits patients through a specific effect or whether non-specific effects are the cause of the improvement.

We also should be aware of the facts that for most other alternative therapies the evidence is not encouraging, and that massage therapy is relatively safe. Therefore the conclusion for those who suffer from FM might well be that massage therapy is worth a try.

34 Responses to Is massage therapy effective for fibromyalgia?

  • Edzard – You say “Nine randomized controlled trials involving 404 patients met the inclusion criteria. A meta-analyses showed that massage therapy with a duration of at least 5 weeks significantly improved pain , anxiety, and depression. Sleep disturbance was not improved by massage therapy.”

    Massage therapy is a pretty broad term – do you know any specifics? What kind of massage, how many treatments per week, duration of treatments, things like that. In my experience, FM patients require very individualized treatment – so I’m curious as to how any meaningful results were gathered.

    • the nine trials were different in many respects, including the type of massage employed. a meta-analysis usually has to lump fairly divers studies together and therefore will not give you the type of specific answer that you are looking for.

      • Pardon my ignorance of how to read these things. As an example, one of the studies cited:

        “Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.

        Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.”

        To the uninitiated…this reads as spinal manipulation/mobilization (chiropractics, yes?) effective for LBP, migrane, cervogenic HA/dizziness, extremity joint conditions, neck pain. I’ll have to go back and read the chiro posts on here, as the evidence seems to suggest that chiropractics is quite useful.

        Both chiro & massage seem inconclusive for FM.

        Am I reading that right?

        And, the all caps thing is not necessary. I’m not attacking you in any way, just trying to understand the logic here.

        • jm said:

          Pardon my ignorance of how to read these things. As an example, one of the studies cited:

          “Spinal manipulation/mobilization is effective in adults for…Am I reading that right?

          Yes and no. Yes, you correctly copied and probably read it correctly; no, because it was not an independent, unbiased, thorough or systematic review. That would probably explain why the systematic review and meta analysis (which, of course, only considered actual trials) that Prof Ernst is writing about didn’t include it.

          Your quote comes from Effectiveness of manual therapies: the UK evidence report. It was produced at the request of the UK’s General Chiropractic Council so that they could see what evidence there was for what their registrants were doing to their customers.

          The answer – despite all the spin – was “not a lot”.

          For an idea of how bad it was, see: Evidence-based chiropractic is an oxymoron:

          Bronfort’s overview was commissioned by the General Chiropractic Council, it was hastily compiled by ardent believers of chiropractic, published in a journal that non-chiropractors would not touch with a barge pole, and crucially it lacks some of the most important qualities of an unbiased systematic review. In my view, it is nothing short of a white-wash and not worth the paper it was printed on. Conclusions, such as the evidence regarding pneumonia, bed-wetting and otitis is inconclusive are just embarrassing; the correct conclusion is that the evidence fails to be positive for these and most other indications.

    • So basically…the entire exercise was totally useless, in terms of research. Hopefully no money was spent on this.

      • useless? I don’t think so, neither in terms of research or in terms of clinical care for FM-patients.
        before you jump to such strange conclusions you might bother to read the original paper.

      • jm said:

        Massage therapy is a pretty broad term – do you know any specifics? What kind of massage, how many treatments per week, duration of treatments, things like that.

        Since the systematic review gives full details of all the studies it looked at (as it should), you could always read them for yourself and find out!

        So basically…the entire exercise was totally useless, in terms of research. Hopefully no money was spent on this.

        Why would you think that?

      • If this (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3930706/) is the paper you’re talking about, I did bother to read it. This is what I mean by useless:

        “Massage therapy, as one of complementary and alternative treatments, has been widely used for FM. It may improve pain, anxiety, depression, and sleep disturbance by complex interplay of both physical and mental modes of action [16]. However, the conclusions of massage therapy for FM are inconsistent. Some reviews maintained that the effects of massage therapy for FM still kept inconclusive [17], [18] or negative [19]. The others suggested that the studies had provided beneficial evidence of use of massage therapy in treating FM [10], [20], [21], but most of them were only qualitative researches without a quantitative meta-analysis [10], [21]. In addition, traditional Chinese massage is one of the most ancient massage therapies, but most prior reviews did not include Chinese studies of massage therapy for FM due to language barrier or limited retrieving resources.”

        And this: “At the end of 24 follow-up weeks, no statistically significant differences were observed for all the tested parameters compared with the baseline in the study conducted by Brattberg [24]. In Castro-Sánchez study [30], the experimental group showed significant improvements on pain, anxiety and sleep duration versus baseline after the 4 follow-up weeks. But at the end of 24 follow-up weeks, the experimental group only showed a significant improvement on sleep duration versus baseline.”

        If I’m reading this right, the summary could be: various types of massage by various practitioners, sometimes get results beneficial to FM patients when treatments times range somewhere between 25 to 90 minutes. Patients sleep better.

        And they go on to say that massage affects fluids and soft tissue. No kidding. Again, I hope no money was spent on this.

        In glancing through other posts on your site, this type of research is considered useless – or considered as “alternative” practitioners not understanding research, or trying to justify certain practices/therapies, or something along those lines. Hence my confusion as to why this one is different. But, I don’t regularly read papers like this – I would like to know what you find useful here, and why you think my conclusions are strange.

        • yes this is the paper, and I linked to it in my post.
          it is useful to:
          FM-SUFFERERS BECAUSE THEY LEARN THAT IT MIGHT HELP THEM TO TRY MASSAGE
          RESEARCHERS BECAUSE THEY LEARN THAT THIS IS A PROMISING AREA WHERE MORE RESEARCH MIGHT BE NEEDED
          INSURERS BECAUSE THEY MIGHT CONSIDER PAYING FOR MASSAGE
          MASSAGE THERAPISTS BECAUSE THEY CAN STUDY THE PRIMARY DATA AND FIND OUT WHICH APPROACH IS THE MOST PROMISING
          GPs BECAUSE THEY LEARN THAT IT MIGHT BE HELPFUL TO SEND FM-PATIENTS TO MASSAGE THERAPISTS
          ETC. ETC.

          • Doing a nice thing leading to patients reporting how they feel more positively isn’t the best basis for recommending that nice thing as a medical treatment though. I worry that we can end up wrongly medicalising people’s lives by presenting certain sorts of nice activities as ‘evidence based treatments’ when the evidence for their value over any other nice activity is rather tenuous. Unless there is really clear evidence to support a medical suggestion I think we should try harder to leave people to decide for themselves how they want to live their lives, providing them with the resources to choose their own nice activities.

            I’ve not read the individual studies, but these results just don’t look to me like reason to suggest FMS patients spend their money on massage over whatever else they happen to enjoy.

  • How is massage “alternative” to begin with? It is simply something that feels good. Studying it seems pointless beyond “do you feel better after the massage”?

    It’s fine to get a massage and I would love insurance to pay for them (and regulate the claims for them), but it’s not fine for “therapists” to advertise that massage “treats” or “cures” any condition beyond making the person “feel better”.

    • “Treat” and “cure” are different. Massage treats pretty much anything – there aren’t a lot of reasons not to use massage.

      As far as “alternative” goes – in many parts of the world things like massage, scraping, cupping, etc aren’t considered alternative. They are considered common sense, in that they deal with things before they become a big problem.

  • Wait…Even massage therapists rub EE the wrong way!?

  • @jm

    I’m sure there are a lot of things in other parts of the world that are considered “common sense”, but that is no reason that thinking people should accept those practices. Child marriage and very early childbearing come to mind. Why not bring back foot-binding along with cupping, et al, as well?

    massage doesn’t TREAT anything. It simply makes aches and pains from sore muscles feel better. If you want to call that “treatment”, well, okay, but it wouldn’t be so in any clinical sense.

  • @ Irene – because foot binding wont get rid of a cold, or deal with minor pains/injuries before they become chronic. Cupping will.

    Yes, that would fall under “treatment”, not “cure”.

    • jm
      This is getting tiresome.
      Once again you come up with a false and unproven statement of an unbelievable health-fantasy.

      The truth:
      Cupping is a “leftover” from the days when bloodletting was both a western and eastern way of outdated, mistaken medicine. It has not been banned because it is relatively benign. Cupping was used to increase the yield of blood from bloodletting wounds. Cupping is today a way of scamming ignorant people under false pretexts of healing.
      Cupping has no biological, anatomic, physiologic or in other way reasonable way of healing or aiding in the improvement of any ailment. Certainly not “cure” a cold or lessen the effect of minor injury. This is a fact!
      There exist no evidence whatsoever of its efficacy other than the usual anecdotes that ignorant people produce because they do not realize that common cold and minor injuries and many other ailments HEAL BY THEMSELVES.

      Now “jm”, I dare you to prove me wrong! If you cannot, then keep your fantasies to yourself from now on.

      You can spare us stories about an hitherto undetected, magical life force or other fantasies and please do not test our patience with arguments to antiquity, popularity, authority etc. References to credible sources and adherence to reality and laws of nature please.

      • That’s a fascinating take on cupping – and one piece of it is actually true! Cupping really is used in conjunction with bloodletting. And now, with the most modern form of cupping (negative pressure wound therapy) there’s a focus on increasing drainage from wounds.

        But that’s not the point of Edzard’s post. And neither is your bizarre fascination with magical life forces. That certainly is tiresome, as you say.

        The subject of the post is the effectiveness of massage for fibromyalgia. Since the majority of my clients have been diagnosed with FM, I’m curious about the studies…although I’m relying on others here (like Alan, for instance) to interpret the results. Massage is a broad field – and different types of massage are based in different sciences, and therefore use different technical language and treatment strategies.

        Swedish massage focuses on fluid. But practitioners will use Swedish massage to work superficial fascia, deep fascia, muscle tissue, etc. So just saying something like “Swedish massage helps FM” doesn’t really give massage practitioners any useful info. Thai, Chinese, Japanese, Russian, Greek – they all look at the body in different ways, and have different approaches. While it’s not an apples to apples comparison, a researcher literate in traditional and modern ways of looking at the body might be able to determine, even in a broad way, what is actually beneficial to FM patients.

        If, as was suggested, the various studies delve into these details – then the research might be quite useful. But I wouldn’t know where to begin in terms of assessing the research. Alan pointed out the bias of the study mentioned above – which I would not have known.

        • @ jm
          Are you sober? You are not making any coherent sense with your ramblings about different massage nationalities.

          Modern suction therapy for open wounds, with which I am very familiar as a surgeon, has absolutely no relation or similarity with cupping. Why don’t you try to keep to what you know something about.

          It was you who went off topic with a false statement that cupping can cure colds and minor injuries. I dared you to prove it. Please do.

  • – I never said cupping could cure colds. Go back and read the comments before going with your grade school “Are you sober” crap.

    – I’m not going to explain the differences in massage modalities to you. Look it up. If you can’t understand why it would matter, leave this thread.

    – Modern suction therapy is, in fact, cupping. “Cupping” is the common term for negative pressure used therapeutically. It became the common term when drinking cups were the most common vessel used. Previous to that, it was called “horn therapy” because animal horns were used. Before that, people used their mouths. Negative pressure wound therapy most resembles someone performing negative pressure therapy (cupping) with the mouth. Look that up, too. Talk to some docs that practice NPWT. I have. It’s very obviously cupping.

    – I’m quite familiar with cupping, which is how I know that you aren’t. As you say, why don’t you try to keep to what you know something about.

    – Your attitude is getting really, really old. I dare you to be civil. Please do.

  • @jm
    Your words:

    because foot binding wont get rid of a cold, or deal with minor pains/injuries before they become chronic. Cupping will.

    As I said before, NPWT is not cupping. You have no idea what you are talking about.
    Please read this: https://en.wikipedia.org/wiki/Negative-pressure_wound_therapy

  • If you think “get rid of” in terms of dealing with cold is equivalent to “cure”…I don’t know what to tell you. Would you say that a tight aching muscle was “cured” by massage? I’ve never heard anyone use that term. I’ve also never heard anyone use “cure” in relation to a cold. In my experience, cupping gets rid of colds most of the time, in about 24 hours. A little longer if it’s the flu. H1N1 seems to take 2 treatments. For most people.

    This is from the page you sent: “NPWT promotes wound healing by applying a vacuum…”. Cupping is the common term for applying vacuum to the body. So even Wikipedia can see that NPWT is cupping.

    Send me a link that supports your claim that “Cupping (application of negative pressure) has no biological, anatomic, physiologic or in other way reasonable way of healing or aiding in the improvement of any ailment.”.

    After reading your comment, I googled “npwt cupping”. Top five results:
    http://www.hpisum.com/17%20Dirckx,%20Wound%20Therapy.pdf
    http://www.awma.com.au/publications/2011_sa-08_haydon_tnpt.pdf
    http://aspsn.org/convention/program/2012/files/440_Winn_Placek.pdf
    -http://www.huzr.hr/index_htm_files/Thesis_Ann-Mari_Fagerdahl.pdf
    -http://www.devonmedicalproducts.com/therapeutic-devices/extricare-npwt-system/what-is-negative-pressure-wound-therapy-npwt/

    A simple search for the term “cupping” in all of these documents should take you less than a minute.

    If you want to do some additional research, watch what people do after they cut their finger, get a splinter, bang their hand into something hard. They suck on it. That’s negative pressure. Or cupping. Or the horn method. Different terms for the same therapy. NPWT most resembles sucking on a finger cut, because the mouth can form a seal over an irregular surface – a glass, bronze, or bamboo cupping vessel can’t.

    The brilliance of NPWT is:
    – the application over irregular surface
    – the ability to sustain vacuum for extended periods of time
    – the mobile units that allow you to move around while being cupped
    – the dressing that moves fluid (historically you would use an herbal plaster)

    Send me a link that supports your claim that “Cupping (application of negative pressure) has no biological, anatomic, physiologic or in other way reasonable way of healing or aiding in the improvement of any ailment.”.

  • jm,,, your perseverance is admirable but you are totally in the dark. Are you saying that because you can find writings and presentations where nurses decorate their thesis or power-points about NPWT with silly, irrelevant and meaningless tales about ancient useless applications of suction cups, that this proves that Jennifer Aniston bought a useful therapy from some charlatan. The only improvement from her suction marks was the bank balance of the fraudster who pretended to treat her.
    I know I should not be even bothering to partake in this dialogue but I will do one last effort to feed the truth to you with a spoon: The practice of cupping to the skin of worried well and sick victims of charlatans has only one thing in common with the practice of using negative pressure dressings for difficult wounds: the application of negative pressure. Am I not making myself clear?

    And by the way. Thank you for the second reference. THer is a good picture in that slide presentation, which illustrates how idiotic the practice of cupping can get. I am stealing it for my own presentation of useless pseudotherapies 🙂

    • Based on the evidence, you do seem to be an expert on pseudoscience. You post on many topics here, claiming “facts” and “truths”…quite emphatically…about things you know nothing about. You even back up your claims with medical qualifications.

      Most of the topics on this blog I don’t really know anything about (chiro, homeopathy, osteopathy, etc.). But, I do know cupping and gua sha – I’ve had pretty extensive training in the theory, practice, and application of both. And I know that what you’re claiming as fact in regards to cupping and gua sha is not true. The closest you get is inaccurate.

      Based on that evidence, it would be silly to think that your comments on other topics hold any weight either. Evidence would suggest that, either intentionally or out of ignorance, claim knowledge and understanding that you don’t have.

      Since you brought up the terms ‘charlatan’ and ‘quack’ (like healthquakery and other terms like that)…I thought I’d look them up.

      Charlatan: a person falsely claiming to have a special knowledge or skill; a fraud.
      Quack: a person who pretends, professionally or publicly, to have skill, knowledge, or qualifications he or she does not possess

      Since you claim authority on cupping and gua sha, but don’t know (literally) the first thing about either…you fit the definition of quack. Or charlatan. Take your pick.

  • Incredible!

    “jm” is not even gathering points for effort.
    If anyone cares they can copy my (real!) name up there and Google it.
    One of the top results will lead you to my LinkedIn profile which you can compare to jm’s sputtering.
    If anyone has good reason to doubt anything that is listed in my LinkedIn profile, then by all means complain to them.

    “jm” has given us an incredible insight into the muddled mind of an incognito connoisseur of suck-marks and blemishes.
    This dialog is finished as far as I am concerned. It seemed like fun for a while… but no longer.

    • I don’t doubt what’s listed in linkedin. You may very well know what you’re talking about on other subjects. I have no way of knowing. All I have to go on is the evidence that I mentioned above.

      Before you finish, send me a link that supports your claim that “Cupping (application of negative pressure) has no biological, anatomic, physiologic or in other way reasonable way of healing or aiding in the improvement of any ailment.”.

      • The burden of proof lies upon the salesmen of suckmarks. one cannot “prove” the negative. I cannot even “prove” that Santa Claus does not exist for real.
        Real doctors use negative pressure for certain kinds of wound treatments. We do not offer false hope and fraudulent services by producing meaningless, unproven bruises and blemishes on the backs of the worried well. That is for charlatans.

        • You say that negative pressure is used for certain kinds of wound treatments, and you say that negative pressure has no biological, anatomic, physiologic or in other way reasonable way of healing or aiding in the improvement of any ailment.

          People have been using negative pressure for therapy since there have been people. Including but not limited to treating wounds. Again, you are speaking with authority while proving you know nothing about the subject. And again bring up the terms false and fraudulent while doing so. I provided you with definitions of quack and charlatan.

          Methinks you protest a bit much.

  • FB sufferers are all individuals who need bespoke massage treatment. Therapists need to have multiple massage THERAPY skills, using deep tissue and sports massage styles amongst others. They can not be beauty or spa massage therapists as those simply are for asthetics and have no real remedial benefits.
    Heat is something that can help FB, hot stone massage can be used along with deep tissue, neuromuscular technique and stretching of the fascia.
    FB does improve with continued massage. The regularity depends on the subject and their environmental stimulus, such as work, posture and levels of exercise undertaken.

    I see that the usual attention has been paid to running down something that works and helps! I see this is because modern western medicine though very useful and benifial can not find reason for FB or treat it.
    Complimentary medicine and therapies are labeled such because neither us nor you have the single ability to solve all problems. The important thing is helping the client! But your attitude and claims show your true qualities. The evidence and study you hide behind were undertaken as a mass of FB sufferers, who are all individual in their experience. Treated by different massage (therapists?) we hope or you will not have done much for them.
    Modern medicine hopes to solve on mass and maximise profit.
    Professional therapists seek to help individually, knowing that everyone is different.
    My advice Dr, is drop the ego, plain and simple. True and honest help can not contain it. I have as many letters after my name as you! However I do not need to show them all. I need to focus my energy on helping others.

    I can post testimonials from genuine sufferers.

    • Ross Workman said:

      FB does improve with continued massage. The regularity depends on the subject and their environmental stimulus, such as work, posture and levels of exercise undertaken.

      [Citation required.]

      I see that the usual attention has been paid to running down something that works and helps!

      You say that, but provide no evidence…

      I see this is because modern western medicine though very useful and benifial [sic] can not find reason for FB or treat it.

      Non sequitur.

      Complimentary [sic] medicine and therapies are labeled such because neither us nor you have the single ability to solve all problems.

      No. They are labelled as such because their proponents have not been able to provide good evidence of their efficacy.

      The important thing is helping the client!

      The important thing is not to mislead the client by making claims that are not based on good evidence.

      But your attitude and claims show your true qualities.

      Ad hominem.

      The evidence and study you hide behind were undertaken as a mass of FB sufferers, who are all individual in their experience. Treated by different massage (therapists?) we hope or you will not have done much for them.

      Not sure what your point is here.

      Modern medicine hopes to solve on mass and maximise profit.

      Red herring.

      Professional therapists seek to help individually, knowing that everyone is different.

      Irrelevant.

      My advice Dr, is drop the ego, plain and simple. True and honest help can not contain it. I have as many letters after my name as you! However I do not need to show them all.

      Another ad hominem.

      I need to focus my energy on helping others.

      Based on what? Your ‘expertise’ or what the best evidence says?

      I can post testimonials from genuine sufferers.

      And what do you believe that will prove?

    • @Ross – you say “The evidence and study you hide behind…” – were you actually able to determine what modalities and/or treatment strategies were used in the studies?

      FM has an incredibly broad presentation. “Massage” is an incredibly broad term. There seem to be folks on this site that have the skills to ferret out the details, and I am certainly not one of them. But without the specifics, “massage therapy is effective for FM” is about as practically useful as saying “modern western drugs might be helpful for headaches”.

      If you (or anyone else) has dug any deeper, I’d love to know what you found.

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