research articles on massage therapy

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Massage Therapy for Health : What the Science Says

Clinical Guidelines, Scientific Literature, Info for Patients:  Massage Therapy for Health

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Several reviews of research have found weak evidence that massage may be helpful for low-back pain. Clinical guidelines issued by the American College of Physicians in 2017 included massage as an option for treating acute/subacute low-back pain but did not include massage therapy among the options for treating chronic low-back pain.

What Does the Research Show?

• The Agency for Healthcare Research and Quality, in a 2016 evaluation of nondrug therapies for low-back pain, examined 20 studies that compared massage to usual care or other interventions and found that there was evidence that massage was helpful for chronic low-back pain but that the strength of evidence was low. The agency also looked at 6 studies that compared different types of massage but found that the evidence was insufficient to show whether any types were more effective than others.
• A 2015 Cochrane review found evidence that massage may provide short-term relief from low-back pain, but the evidence is not of high quality. The long-term effects of massage for low-back pain have not been established.
• Clinical practice guidelines issued by the American College of Physicians in 2017 included massage therapy as an option for treating acute/subacute low-back pain but did not include massage therapy among the options for treating chronic low-back pain.

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Massage therapy may provide short-term benefits for neck or shoulder pain.

• A 2016 review of four randomized controlled trials found that massage therapy may provide short-term benefits from neck pain. However, a 2012 Cochrane review of 15 trials on massage therapy for neck pain concluded that no recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.
• A 2013 review of 12 studies of massage for neck pain (757 total participants) found that massage therapy was more helpful for both neck and shoulder pain than inactive therapies but was not more effective than other active therapies. For shoulder pain, massage therapy had short-term benefits only.
• A 2014 randomized controlled trial involving 228 participants with chronic nonspecific neck pain found that 60-minute massages given multiple times per week was more effective than fewer or shorter sessions. The participants were randomized to 5 groups receiving various doses of massage (a 4-week course consisting of 30-minute visits 2 or 3 times weekly or 60-minute visits 1, 2, or 3 times weekly) or to a single control group (a 4-week period on a wait list).

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Only a few studies have examined massage therapy for osteoarthritis, but results of some of these studies suggest that massage may have short-term benefits in relieving knee pain.

• A 2017 systematic review of seven randomized controlled trials involving 352 participants with arthritis found low- to moderate-quality evidence that massage therapy is superior to nonactive therapies in reducing pain and improving functional outcomes. A 2013 review of two randomized controlled trials found positive short-term (less than 6 months) effects in the form of reduced pain and improved self-reported physical functioning. Results of a 2006 randomized controlled trial of 68 adults with OA of the knee who received standard Swedish massage over 8 weeks demonstrated statistically significant improvements in pain and physical function.

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Only a small number of studies have looked at massage for headache, and results have not been consistent.

• Limited evidence from two small studies suggests massage therapy is possibly helpful for migraines, but clear conclusions cannot be drawn. A 2011 systematic review of these two studies concluded that massage therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine.
• A 2016 randomized controlled trial with 64 participants evaluated 2 types of massage (lymphatic drainage and traditional massage), once a week for 8 weeks, in patients with migraine. The frequency of migraines decreased in both groups, compared with people on a waiting list.
• In a 2015 randomized controlled trial , 56 people with tension headaches were assigned to receive massage at myofascial trigger points or an inactive treatment (detuned ultrasound) twice a week for 6 weeks or to be on a waiting list. People who received either massage or the inactive treatment had a decrease in the frequency of headaches, but there was no difference between the two groups.

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With appropriate precautions, massage therapy can be part of supportive care for cancer patients who would like to try it; however, the evidence that it can relieve pain and anxiety is not strong. 2014 clinical practice guidelines for the care of breast cancer patients include massage as one of several approaches that may be helpful for stress reduction, anxiety, depression, fatigue, and quality of life.

• Clinical practice guidelines issued in 2009 by the Society for Integrative Oncology recommends considering massage therapy delivered by an oncology-trained massage therapist as part of a multimodality treatment approach in patients experiencing anxiety or pain.
• In 2017 the Society for Integrative Oncology issued guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment, recommending the use of massage therapy to improve mood disturbance in breast cancer survivors after active treatment (grade B). This recommendation is based on results from six trials.
• In clinical practice guidelines issued by the American College of Chest Physicians in 2013, massage therapy is suggested as part of a multi-modality cancer supportive care program for lung cancer patients whose anxiety or pain is not adequately controlled by usual care.
• A 2016 Cochrane review of 19 small studies involving 1,274 participants found some studies suggesting that massage with or without aromatherapy may help relieve pain and anxiety in people with cancer; however, the quality of the evidence was very low and results were not consistent.
• Another 2016 systematic review and meta-analysis of 16 studies concluded that based on the available evidence, weak recommendations are suggested for massage therapy, compared to an active comparator, for the treatment of pain, fatigue, and anxiety.

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Results of research suggest that massage therapy may be helpful for some fibromyalgia symptoms.

• A 2014 systematic review and meta-analysis of 9 studies (404 total participants) concluded that massage therapy, if continued for at least 5 weeks, improved pain, anxiety, and depression in people with fibromyalgia but did not have an effect on sleep disturbance.
• A 2015 systematic review and meta-analysis of 10 studies (478 total participants) compared the effects of different kinds of massage therapy and found that most styles of massage had beneficial effects on the quality of life in fibromyalgia. Swedish massage may be an exception; 2 studies of this type of massage (56 total participants) did not show benefits.

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There is some evidence that massage therapy may have benefits for anxiety, depression, and quality of life in people with HIV/AIDS, but the amount of research and number of people studied are small.

• A 2010 review of four studies involving a total of 178 participants concluded that massage therapy may help improve the quality of life for people with HIV or AIDS. A 2013 randomized controlled trial of 54 people suggested that massage may be helpful for depression in people with HIV; and a 2017 study of 29 people with HIV found that massage may be helpful for anxiety.

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There is some evidence that premature infants who are massaged may have improved weight gain. No benefits of massage for healthy full-term infants have been clearly demonstrated.

• In a 2017 review of 34 randomized controlled trials of massage therapy for premature infants, 20 of the studies (1,250 total infants) evaluated the effect of massage on weight gain, with most showing an improvement. The mechanism by which massage therapy might increase weight gain is not well understood. Some studies suggested other possible benefits of massage but because the amount of evidence is small, no conclusions can be reached about effects other than weight gain.
• A 2013 Cochrane review of 34 studies of healthy full-term infants didn’t find clear evidence of beneficial effects of massage in these low-risk infants.

The risk of harmful effects from massage therapy appears to be low. However, there have been rare reports of serious side effects, such as blood clot, nerve injury, or bone fracture. Some of the reported cases have involved vigorous types of massage, such as deep tissue massage, or patients who might be at increased risk of injury.

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• Published: 08 April 2024

A systematic review and multivariate meta-analysis of the physical and mental health benefits of touch interventions

• Julian Packheiser   ORCID: orcid.org/0000-0001-9805-6755 2   na1   nAff1 ,
• Helena Hartmann 2 , 3 , 4   na1 ,
• Kelly Fredriksen 2 ,
• Valeria Gazzola   ORCID: orcid.org/0000-0003-0324-0619 2 ,
• Christian Keysers   ORCID: orcid.org/0000-0002-2845-5467 2 &
• Frédéric Michon   ORCID: orcid.org/0000-0003-1289-2133 2  

Nature Human Behaviour ( 2024 ) Cite this article

Metrics details

• Human behaviour
• Paediatric research
• Randomized controlled trials

Receiving touch is of critical importance, as many studies have shown that touch promotes mental and physical well-being. We conducted a pre-registered (PROSPERO: CRD42022304281) systematic review and multilevel meta-analysis encompassing 137 studies in the meta-analysis and 75 additional studies in the systematic review ( n  = 12,966 individuals, search via Google Scholar, PubMed and Web of Science until 1 October 2022) to identify critical factors moderating touch intervention efficacy. Included studies always featured a touch versus no touch control intervention with diverse health outcomes as dependent variables. Risk of bias was assessed via small study, randomization, sequencing, performance and attrition bias. Touch interventions were especially effective in regulating cortisol levels (Hedges’ g  = 0.78, 95% confidence interval (CI) 0.24 to 1.31) and increasing weight (0.65, 95% CI 0.37 to 0.94) in newborns as well as in reducing pain (0.69, 95% CI 0.48 to 0.89), feelings of depression (0.59, 95% CI 0.40 to 0.78) and state (0.64, 95% CI 0.44 to 0.84) or trait anxiety (0.59, 95% CI 0.40 to 0.77) for adults. Comparing touch interventions involving objects or robots resulted in similar physical (0.56, 95% CI 0.24 to 0.88 versus 0.51, 95% CI 0.38 to 0.64) but lower mental health benefits (0.34, 95% CI 0.19 to 0.49 versus 0.58, 95% CI 0.43 to 0.73). Adult clinical cohorts profited more strongly in mental health domains compared with healthy individuals (0.63, 95% CI 0.46 to 0.80 versus 0.37, 95% CI 0.20 to 0.55). We found no difference in health benefits in adults when comparing touch applied by a familiar person or a health care professional (0.51, 95% CI 0.29 to 0.73 versus 0.50, 95% CI 0.38 to 0.61), but parental touch was more beneficial in newborns (0.69, 95% CI 0.50 to 0.88 versus 0.39, 95% CI 0.18 to 0.61). Small but significant small study bias and the impossibility to blind experimental conditions need to be considered. Leveraging factors that influence touch intervention efficacy will help maximize the benefits of future interventions and focus research in this field.

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The sense of touch has immense importance for many aspects of our life. It is the first of all the senses to develop in newborns 1 and the most direct experience of contact with our physical and social environment 2 . Complementing our own touch experience, we also regularly receive touch from others around us, for example, through consensual hugs, kisses or massages 3 .

The recent coronavirus pandemic has raised awareness regarding the need to better understand the effects that touch—and its reduction during social distancing—can have on our mental and physical well-being. The most common touch interventions, for example, massage for adults or kangaroo care for newborns, have been shown to have a wide range of both mental and physical health benefits, from facilitating growth and development to buffering against anxiety and stress, over the lifespan of humans and animals alike 4 . Despite the substantial weight this literature gives to support the benefits of touch, it is also characterized by a large variability in, for example, studied cohorts (adults, children, newborns and animals), type and duration of applied touch (for example, one-time hug versus repeated 60-min massages), measured health outcomes (ranging from physical health outcomes such as sleep and blood pressure to mental health outcomes such as depression or mood) and who actually applies the touch (for example, partner versus stranger).

A meaningful tool to make sense of this vast amount of research is through meta-analysis. While previous meta-analyses on this topic exist, they were limited in scope, focusing only on particular types of touch, cohorts or specific health outcomes (for example, refs. 5 , 6 ). Furthermore, despite best efforts, meaningful variables that moderate the efficacy of touch interventions could not yet be identified. However, understanding these variables is critical to tailor touch interventions and guide future research to navigate this diverse field with the ultimate aim of promoting well-being in the population.

In this Article, we describe a pre-registered, large-scale systematic review and multilevel, multivariate meta-analysis to address this need with quantitative evidence for (1) the effect of touch interventions on physical and mental health and (2) which moderators influence the efficacy of the intervention. In particular, we ask whether and how strongly health outcomes depend on the dynamics of the touching dyad (for example, humans or robots/objects, familiarity and touch directionality), demographics (for example, clinical status, age or sex), delivery means (for example, type of touch intervention or touched body part) and procedure (for example, duration or number of sessions). We did so separately for newborns and for children and adults, as the health outcomes in newborns differed substantially from those in the other age groups. Despite the focus of the analysis being on humans, it is widely known that many animal species benefit from touch interactions and that engaging in touch promotes their well-being as well 7 . Since animal models are essential for the investigation of the mechanisms underlying biological processes and for the development of therapeutic approaches, we accordingly included health benefits of touch interventions in non-human animals as part of our systematic review. However, this search yielded only a small number of studies, suggesting a lack of research in this domain, and as such, was insufficient to be included in the meta-analysis. We evaluate the identified animal studies and their findings in the discussion.

Touch interventions have a medium-sized effect

The pre-registration can be found at ref. 8 . The flowchart for data collection and extraction is depicted in Fig. 1 .

Animal outcomes refer to outcomes measured in non-human species that were solely considered as part of a systematic review. Included languages were French, Dutch, German and English, but our search did not identify any articles in French, Dutch or German. MA, meta-analysis.

For adults, a total of n  = 2,841 and n  = 2,556 individuals in the touch and control groups, respectively, across 85 studies and 103 cohorts were included. The effect of touch overall was medium-sized ( t (102) = 9.74, P  < 0.001, Hedges’ g  = 0.52, 95% confidence interval (CI) 0.42 to 0.63; Fig. 2a ). For newborns, we could include 63 cohorts across 52 studies comprising a total of n  = 2,134 and n  = 2,086 newborns in the touch and control groups, respectively, with an overall effect almost identical to the older age group ( t (62) = 7.53, P  < 0.001, Hedges’ g  = 0.56, 95% CI 0.41 to 0.71; Fig. 2b ), suggesting that, despite distinct health outcomes, touch interventions show comparable effects across newborns and adults. Using these overall effect estimates, we conducted a power sensitivity analysis of all the included primary studies to investigate whether such effects could be reliably detected 9 . Sufficient power to detect such effect sizes was rare in individual studies, as investigated by firepower plots 10 (Supplementary Figs. 1 and 2 ). No individual effect size from either meta-analysis was overly influential (Cook’s D  < 0.06). The benefits were similar for mental and physical outcomes (mental versus physical; adults: t (101) = 0.79, P  = 0.432, Hedges’ g difference of −0.05, 95% CI −0.16 to 0.07, Fig. 2c ; newborns: t (61) = 1.08, P  = 0.284, Hedges’ g difference of −0.19, 95% CI −0.53 to 0.16, Fig. 2d ).

a , Orchard plot illustrating the overall benefits across all health outcomes for adults/children across 469 in part dependent effect sizes from 85 studies and 103 cohorts. b , The same as a but for newborns across 174 in part dependent effect sizes from 52 studies and 63 cohorts. c , The same as a but separating the results for physical versus mental health benefits across 469 in part dependent effect sizes from 85 studies and 103 cohorts. d , The same as b but separating the results for physical versus mental health benefits across 172 in part dependent effect sizes from 52 studies and 63 cohorts. Each dot reflects a measured effect, and the number of effects ( k ) included in the analysis is depicted in the bottom left. Mean effects and 95% CIs are presented in the bottom right and are indicated by the central black dot (mean effect) and its error bars (95% CI). The heterogeneity Q statistic is presented in the top left. Overall effects of moderator impact were assessed via an F test, and post hoc comparisons were done using t tests (two-sided test). Note that the P values above the mean effects indicate whether an effect differed significantly from a zero effect. P values were not corrected for multiple comparisons. The dot size reflects the precision of each individual effect (larger indicates higher precision). Small-study bias for the overall effect was significant ( F test, two-sided test) in the adult meta-analysis ( F (1, 101) = 21.24, P  < 0.001; Supplementary Fig. 3 ) as well as in the newborn meta-analysis ( F (1, 61) = 5.25, P  = 0.025; Supplementary Fig. 4 ).

Source data

On the basis of the overall effect of both meta-analyses as well as their median sample sizes, the minimum number of studies necessary for subgroup analyses to achieve 80% power was k  = 9 effects for adults and k  = 8 effects for newborns (Supplementary Figs. 5 and 6 ). Assessing specific health outcomes with sufficient power in more detail in adults (Fig. 3a ) revealed smaller benefits to sleep and heart rate parameters, moderate benefits to positive and negative affect, diastolic blood and systolic blood pressure, mobility and reductions of the stress hormone cortisol and larger benefits to trait and state anxiety, depression, fatigue and pain. Post hoc tests revealed stronger benefits for pain, state anxiety, depression and trait anxiety compared with respiratory, sleep and heart rate parameters (see Fig. 3 for all post hoc comparisons). Reductions in pain and state anxiety were increased compared with reductions in negative affect ( t (83) = 2.54, P  = 0.013, Hedges’ g difference of 0.31, 95% CI 0.07 to 0.55; t (83) = 2.31, P  = 0.024, Hedges’ g difference of 0.27, 95% CI 0.03 to 0.51). Benefits to pain symptoms were higher compared with benefits to positive affect ( t (83) = 2.22, P  = 0.030, Hedges’ g difference of 0.29, 95% CI 0.04 to 0.54). Finally, touch resulted in larger benefits to cortisol release compared with heart rate parameters ( t (83) = 2.30, P  = 0.024, Hedges’ g difference of 0.26, 95% CI 0.04–0.48).

a , b , Health outcomes in adults analysed across 405 in part dependent effect sizes from 79 studies and 97 cohorts ( a ) and in newborns analysed across 105 in part dependent effect sizes from 46 studies and 56 cohorts ( b ). The type of health outcomes measured differed between adults and newborns and were thus analysed separately. Numbers on the right represent the mean effect with its 95% CI in square brackets and the significance level estimating the likelihood that the effect is equal to zero. Overall effects of moderator impact were assessed via an F test, and post hoc comparisons were done using t tests (two-sided test). The F value in the top right represents a test of the hypothesis that all effects within the subpanel are equal. The Q statistic represents the heterogeneity. P values of post hoc tests are depicted whenever significant. P values above the horizontal whiskers indicate whether an effect differed significantly from a zero effect. Vertical lines indicate significant post hoc tests between moderator levels. P values were not corrected for multiple comparisons. Physical outcomes are marked in red. Mental outcomes are marked in blue.

In newborns, only physical health effects offered sufficient data for further analysis. We found no benefits for digestion and heart rate parameters. All other health outcomes (cortisol, liver enzymes, respiration, temperature regulation and weight gain) showed medium to large effects (Fig. 3b ). We found no significant differences among any specific health outcomes.

Non-human touch and skin-to-skin contact

In some situations, a fellow human is not readily available to provide affective touch, raising the question of the efficacy of touch delivered by objects and robots 11 . Overall, we found humans engaging in touch with other humans or objects to have medium-sized health benefits in adults, without significant differences ( t (99) = 1.05, P  = 0.295, Hedges’ g difference of 0.12, 95% CI −0.11 to 0.35; Fig. 4a ). However, differentiating physical versus mental health benefits revealed similar benefits for human and object touch on physical health outcomes, but larger benefits on mental outcomes when humans were touched by humans ( t (97) = 2.32, P  = 0.022, Hedges’ g difference of 0.24, 95% CI 0.04 to 0.44; Fig. 4b ). It must be noted that touching with an object still showed a significant effect (see Supplementary Fig. 7 for the corresponding orchard plot).

a , Forest plot comparing humans versus objects touching a human on health outcomes overall across 467 in part dependent effect sizes from 85 studies and 101 cohorts. b , The same as a but separately for mental versus physical health outcomes across 467 in part dependent effect sizes from 85 studies and 101 cohorts. c , Results with the removal of all object studies, leaving 406 in part dependent effect sizes from 71 studies and 88 cohorts to identify whether missing skin-to-skin contact is the relevant mediator of higher mental health effects in human–human interactions. Numbers on the right represent the mean effect with its 95% CI in square brackets and the significance level estimating the likelihood that the effect is equal to zero. Overall effects of moderator impact were assessed via an F test, and post hoc comparisons were done using t tests (two-sided test). The F value in the top right represents a test of the hypothesis that all effects within the subpanel are equal. The Q statistic represents the heterogeneity. P values of post hoc tests are depicted whenever significant. P values above the horizontal whiskers indicate whether an effect differed significantly from a zero effect. Vertical lines indicate significant post hoc tests between moderator levels. P values were not corrected for multiple comparisons. Physical outcomes are marked in red. Mental outcomes are marked in blue.

We considered the possibility that this effect was due to missing skin-to-skin contact in human–object interactions. Thus, we investigated human–human interactions with and without skin-to-skin contact (Fig. 4c ). In line with the hypothesis that skin-to-skin contact is highly relevant, we again found stronger mental health benefits in the presence of skin-to-skin contact that however did not achieve nominal significance ( t (69) = 1.95, P  = 0.055, Hedges’ g difference of 0.41, 95% CI −0.00 to 0.82), possibly because skin-to-skin contact was rarely absent in human–human interactions, leading to a decrease in power of this analysis. Results for skin-to-skin contact as an overall moderator can be found in Supplementary Fig. 8 .

Influences of type of touch

The large majority of touch interventions comprised massage therapy in adults and kangaroo care in newborns (see Supplementary Table 1 for a complete list of interventions across studies). However, comparing the different types of touch explored across studies did not reveal significant differences in effect sizes based on touch type, be it on overall health benefits (adults: t (101) = 0.11, P  = 0.916, Hedges’ g difference of 0.02, 95% CI −0.32 to 0.29; Fig. 5a ) or comparing different forms of touch separately for physical (massage therapy versus other forms: t (99) = 0.99, P  = 0.325, Hedges’ g difference 0.16, 95% CI −0.15 to 0.47) or for mental health benefits (massage therapy versus other forms: t (99) = 0.75, P  = 0.458, Hedges’ g difference of 0.13, 95% CI −0.22 to 0.48) in adults (Fig. 5c ; see Supplementary Fig. 9 for the corresponding orchard plot). A similar picture emerged for physical health effects in newborns (massage therapy versus kangaroo care: t (58) = 0.94, P  = 0.353, Hedges’ g difference of 0.15, 95% CI −0.17 to 0.47; massage therapy versus other forms: t (58) = 0.56, P  = 0.577, Hedges’ g difference of 0.13, 95% CI −0.34 to 0.60; kangaroo care versus other forms: t (58) = 0.07, P  = 0.947, Hedges’ g difference of 0.02, 95% CI −0.46 to 0.50; Fig. 5d ; see also Supplementary Fig. 10 for the corresponding orchard plot). This suggests that touch types may be flexibly adapted to the setting of every touch intervention.

a , Forest plot of health benefits comparing massage therapy versus other forms of touch in adult cohorts across 469 in part dependent effect sizes from 85 studies and 103 cohorts. b , Forest plot of health benefits comparing massage therapy, kangaroo care and other forms of touch for newborns across 174 in part dependent effect sizes from 52 studies and 63 cohorts. c , The same as a but separating mental and physical health benefits across 469 in part dependent effect sizes from 85 studies and 103 cohorts. d , The same as b but separating mental and physical health outcomes where possible across 164 in part dependent effect sizes from 51 studies and 62 cohorts. Note that an insufficient number of studies assessed mental health benefits of massage therapy or other forms of touch to be included. Numbers on the right represent the mean effect with its 95% CI in square brackets and the significance level estimating the likelihood that the effect is equal to zero. Overall effects of moderator impact were assessed via an F test, and post hoc comparisons were done using t tests (two-sided test). The F value in the top right represents a test of the hypothesis that all effects within the subpanel are equal. The Q statistic represents heterogeneity. P values of post hoc tests are depicted whenever significant. P values above the horizontal whiskers indicate whether an effect differed significantly from a zero effect. Vertical lines indicate significant post hoc tests between moderator levels. P values were not corrected for multiple comparisons. Physical outcomes are marked in red. Mental outcomes are marked in blue.

The role of clinical status

Most research on touch interventions has focused on clinical samples, but are benefits restricted to clinical cohorts? We found health benefits to be significant in clinical and healthy populations (Fig. 6 ), whether all outcomes are considered (Fig. 6a,b ) or physical and mental health outcomes are separated (Fig. 6c,d , see Supplementary Figs. 11 and 12 for the corresponding orchard plots). In adults, however, we found higher mental health benefits for clinical populations compared with healthy ones (Fig. 6c ; t (99) = 2.11, P  = 0.037, Hedges’ g difference of 0.25, 95% CI 0.01 to 0.49).

a , Health benefits for clinical cohorts of adults versus healthy cohorts of adults across 469 in part dependent effect sizes from 85 studies and 103 cohorts. b , The same as a but for newborn cohorts across 174 in part dependent effect sizes from 52 studies and 63 cohorts. c , The same as a but separating mental versus physical health benefits across 469 in part dependent effect sizes from 85 studies and 103 cohorts. d , The same as b but separating mental versus physical health benefits across 172 in part dependent effect sizes from 52 studies and 63 cohorts. Numbers on the right represent the mean effect with its 95% CI in square brackets and the significance level estimating the likelihood that the effect is equal to zero. Overall effects of moderator impact were assessed via an F test, and post hoc comparisons were done using t tests (two-sided test).The F value in the top right represents a test of the hypothesis that all effects within the subpanel are equal. The Q statistic represents the heterogeneity. P values of post hoc tests are depicted whenever significant. P values above the horizontal whiskers indicate whether an effect differed significantly from a zero effect. Vertical lines indicate significant post hoc tests between moderator levels. P values were not corrected for multiple comparisons. Physical outcomes are marked in red. Mental outcomes are marked in blue.

A more detailed analysis of specific clinical conditions in adults revealed positive mental and physical health benefits for almost all assessed clinical disorders. Differences between disorders were not found, with the exception of increased effectiveness of touch interventions in neurological disorders (Supplementary Fig. 13 ).

Familiarity in the touching dyad and intervention location

Touch interventions can be performed either by familiar touchers (partners, family members or friends) or by unfamiliar touchers (health care professionals). In adults, we did not find an impact of familiarity of the toucher ( t (99) = 0.12, P  = 0.905, Hedges’ g difference of 0.02, 95% CI −0.27 to 0.24; Fig. 7a ; see Supplementary Fig. 14 for the corresponding orchard plot). Similarly, investigating the impact on mental and physical health benefits specifically, no significant differences could be detected, suggesting that familiarity is irrelevant in adults. In contrast, touch applied to newborns by their parents (almost all studies only included touch by the mother) was significantly more beneficial compared with unfamiliar touch ( t (60) = 2.09, P  = 0.041, Hedges’ g difference of 0.30, 95% CI 0.01 to 0.59) (Fig. 7b ; see Supplementary Fig. 15 for the corresponding orchard plot). Investigating mental and physical health benefits specifically revealed no significant differences. Familiarity with the location in which the touch was applied (familiar being, for example, the participants’ home) did not influence the efficacy of touch interventions (Supplementary Fig. 16 ).

a , Health benefits for being touched by a familiar (for example, partner, family member or friend) versus unfamiliar toucher (health care professional) across 463 in part dependent effect sizes from 83 studies and 101 cohorts. b , The same as a but for newborn cohorts across 171 in part dependent effect sizes from 51 studies and 62 cohorts. c , The same as a but separating mental versus physical health benefits across 463 in part dependent effect sizes from 83 studies and 101 cohorts. d , The same as b but separating mental versus physical health benefits across 169 in part dependent effect sizes from 51 studies and 62 cohorts. Numbers on the right represent the mean effect with its 95% CI in square brackets and the significance level estimating the likelihood that the effect is equal to zero. Overall effects of moderator impact were assessed via an F test, and post hoc comparisons were done using t tests (two-sided test). The F value in the top right represents a test of the hypothesis that all effects within the subpanel are equal. The Q statistic represents the heterogeneity. P values of post hoc tests are depicted whenever significant. P values above the horizontal whiskers indicate whether an effect differed significantly from a zero effect. Vertical lines indicate significant post hoc tests between moderator levels. P values were not corrected for multiple comparisons. Physical outcomes are marked in red. Mental outcomes are marked in blue.

Frequency and duration of touch interventions

How often and for how long should touch be delivered? For adults, the median touch duration across studies was 20 min and the median number of touch interventions was four sessions with an average time interval of 2.3 days between each session. For newborns, the median touch duration across studies was 17.5 min and the median number of touch interventions was seven sessions with an average time interval of 1.3 days between each session.

Delivering more touch sessions increased benefits in adults, whether overall ( t (101) = 4.90, P  < 0.001, Hedges’ g  = 0.02, 95% CI 0.01 to 0.03), physical ( t (81) = 3.07, P  = 0.003, Hedges’ g  = 0.02, 95% CI 0.01–0.03) or mental benefits ( t (72) = 5.43, P  < 0.001, Hedges’ g  = 0.02, 95% CI 0.01–0.03) were measured (Fig. 8a ). A closer look at specific outcomes for which sufficient data were available revealed that positive associations between the number of sessions and outcomes were found for trait anxiety ( t (12) = 7.90, P  < 0.001, Hedges’ g  = 0.03, 95% CI 0.02–0.04), depression ( t (20) = 10.69, P  < 0.001, Hedges’ g  = 0.03, 95% CI 0.03–0.04) and pain ( t (37) = 3.65, P  < 0.001, Hedges’ g  = 0.03, 95% CI 0.02–0.05), indicating a need for repeated sessions to improve these adverse health outcomes. Neither increasing the number of sessions for newborns nor increasing the duration of touch per session in adults or newborns increased health benefits, be they physical or mental (Fig. 8b–d ). For continuous moderators in adults, we also looked at specific health outcomes as sufficient data were generally available for further analysis. Surprisingly, we found significant negative associations between touch duration and reductions of cortisol ( t (24) = 2.71, P  = 0.012, Hedges’ g  = −0.01, 95% CI −0.01 to −0.00) and heart rate parameters ( t (21) = 2.35, P  = 0.029, Hedges’ g  = −0.01, 95% CI −0.02 to −0.00).

a , Meta-regression analysis examining the association between the number of sessions applied and the effect size in adults, either on overall health benefits (left, 469 in part dependent effect sizes from 85 studies and 103 cohorts) or for physical (middle, 245 in part dependent effect sizes from 69 studies and 83 cohorts) or mental benefits (right, 224 in part dependent effect sizes from 60 studies and 74 cohorts) separately. b , The same as a for newborns (overall: 150 in part dependent effect sizes from 46 studies and 53 cohorts; physical health: 127 in part dependent effect sizes from 44 studies and 51 cohorts; mental health: 21 in part dependent effect sizes from 11 studies and 12 cohorts). c , d the same as a ( c ) and b ( d ) but for the duration of the individual sessions. For adults, 449 in part dependent effect sizes across 80 studies and 96 cohorts were included in the overall analysis. The analysis of physical health benefits included 240 in part dependent effect sizes across 67 studies and 80 cohorts, and the analysis of mental health benefits included 209 in part dependent effect sizes from 56 studies and 69 cohorts. For newborns, 145 in part dependent effect sizes across 45 studies and 52 cohorts were included in the overall analysis. The analysis of physical health benefits included 122 in part dependent effect sizes across 43 studies and 50 cohorts, and the analysis of mental health benefits included 21 in part dependent effect sizes from 11 studies and 12 cohorts. Each dot represents an effect size. Its size indicates the precision of the study (larger indicates better). Overall effects of moderator impact were assessed via an F test (two-sided test). The P values in each panel represent the result of a regression analysis testing the hypothesis that the slope of the relationship is equal to zero. P values are not corrected for multiple testing. The shaded area around the regression line represents the 95% CI.

Demographic influences of sex and age

We used the ratio between women and men in the single-study samples as a proxy for sex-specific effects. Sex ratios were heavily skewed towards larger numbers of women in each cohort (median 83% women), and we could not find significant associations between sex ratio and overall ( t (62) = 0.08, P  = 0.935, Hedges’ g  = 0.00, 95% CI −0.00 to 0.01), mental ( t (43) = 0.55, P  = 0.588, Hedges’ g  = 0.00, 95% CI −0.00 to 0.01) or physical health benefits ( t (51) = 0.15, P  = 0.882, Hedges’ g  = −0.00, 95% CI −0.01 to 0.01). For specific outcomes that could be further analysed, we found a significant positive association of sex ratio with reductions in cortisol secretion ( t (18) = 2.31, P  = 0.033, Hedges’ g  = 0.01, 95% CI 0.00 to 0.01) suggesting stronger benefits in women. In contrast to adults, sex ratios were balanced in samples of newborns (median 53% girls). For newborns, there was no significant association with overall ( t (36) = 0.77, P  = 0.447, Hedges’ g  = −0.01, 95% CI −0.02 to 0.01) and physical health benefits of touch ( t (35) = 0.93, P  = 0.359, Hedges’ g  = −0.01, 95% CI −0.02 to 0.01). Mental health benefits did not provide sufficient data for further analysis.

The median age in the adult meta-analysis was 42.6 years (s.d. 21.16 years, range 4.5–88.4 years). There was no association between age and the overall ( t (73) = 0.35, P  = 0.727, Hedges’ g = 0.00, 95% CI −0.01 to 0.01), mental ( t (53) = 0.94, P  = 0.353, Hedges’ g  = 0.01, 95% CI −0.01 to 0.02) and physical health benefits of touch ( t (60) = 0.16, P  = 0.870, Hedges’ g  = 0.00, 95% CI −0.01 to 0.01). Looking at specific health outcomes, we found significant positive associations between mean age and improved positive affect ( t (10) = 2.54, P  = 0.030, Hedges’ g  = 0.01, 95% CI 0.00 to 0.02) as well as systolic blood pressure ( t (11) = 2.39, P  = 0.036, Hedges’ g  = 0.02, 95% CI 0.00 to 0.04).

A list of touched body parts can be found in Supplementary Table 1 . For the touched body part, we found significantly higher health benefits for head touch compared with arm touch ( t (40) = 2.14, P  = 0.039, Hedges’ g difference of 0.78, 95% CI 0.07 to 1.49) and torso touch ( t (40) = 2.23, P  = 0.031; Hedges’ g difference of 0.84, 95% CI 0.10 to 1.58; Supplementary Fig. 17 ). Touching the arm resulted in lower mental health compared with physical health benefits ( t (37) = 2.29, P  = 0.028, Hedges’ g difference of −0.35, 95% CI −0.65 to −0.05). Furthermore, we found a significantly increased physical health benefit when the head was touched as opposed to the torso ( t (37) = 2.10, P  = 0.043, Hedges’ g difference of 0.96, 95% CI 0.06 to 1.86). Thus, head touch such as a face or scalp massage could be especially beneficial.

Directionality

In adults, we tested whether a uni- or bidirectional application of touch mattered. The large majority of touch was applied unidirectionally ( k  = 442 of 469 effects). Unidirectional touch had higher health benefits ( t (101) = 2.17, P  = 0.032, Hedges’ g difference of 0.30, 95% CI 0.03 to 0.58) than bidirectional touch. Specifically, mental health benefits were higher in unidirectional touch ( t (99) = 2.33, P  = 0.022, Hedges’ g difference of 0.46, 95% CI 0.06 to 0.66).

Study location

For adults, we found significantly stronger health benefits of touch in South American compared with North American cohorts ( t (95) = 2.03, P  = 0.046, Hedges’ g difference of 0.37, 95% CI 0.01 to 0.73) and European cohorts ( t (95) = 2.22, P  = 0.029, Hedges’ g difference of 0.36, 95% CI 0.04 to 0.68). For newborns, we found weaker effects in North American cohorts compared to Asian ( t (55) = 2.28, P  = 0.026, Hedges’ g difference of −0.37, 95% CI −0.69 to −0.05) and European cohorts ( t (55) = 2.36, P  = 0.022, Hedges’ g difference of −0.40, 95% CI −0.74 to −0.06). Investigating the interaction with mental and physical health benefits did not reveal any effects of study location in both meta-analyses (Supplementary Fig. 18 ).

Systematic review of studies without effect sizes

All studies where effect size data could not be obtained or that did not meet the meta-analysis inclusion criteria can be found on the OSF project 12 in the file ‘Study_lists_final_revised.xlsx’ (sheet ‘Studies_without_effect_sizes’). Specific reasons for exclusion are furthermore documented in Supplementary Table 2 . For human health outcomes assessed across 56 studies and n  = 2,438 individuals, interventions mostly comprised massage therapy ( k  = 86 health outcomes) and kangaroo care ( k  = 33 health outcomes). For datasets where no effect size could be computed, 90.0% of mental health and 84.3% of physical health parameters were positively impacted by touch. Positive impact of touch did not differ between types of touch interventions. These results match well with the observations of the meta-analysis of a highly positive benefit of touch overall, irrespective of whether a massage or any other intervention is applied.

We also assessed health outcomes in animals across 19 studies and n  = 911 subjects. Most research was conducted in rodents. Animals that received touch were rats (ten studies, k  = 16 health outcomes), mice (four studies, k  = 7 health outcomes), macaques (two studies, k  = 3 health outcomes), cats (one study, k  = 3 health outcomes), lambs (one study, k  = 2 health outcomes) and coral reef fish (one study, k  = 1 health outcome). Touch interventions mostly comprised stroking ( k  = 13 health outcomes) and tickling ( k  = 10 health outcomes). For animal studies, 71.4% of effects showed benefits to mental health-like parameters and 81.8% showed positive physical health effects. We thus found strong evidence that touch interventions, which were mostly conducted by humans (16 studies with human touch versus 3 studies with object touch), had positive health effects in animal species as well.

The key aim of the present study was twofold: (1) to provide an estimate of the effect size of touch interventions and (2) to disambiguate moderating factors to potentially tailor future interventions more precisely. Overall, touch interventions were beneficial for both physical and mental health, with a medium effect size. Our work illustrates that touch interventions are best suited for reducing pain, depression and anxiety in adults and children as well as for increasing weight gain in newborns. These findings are in line with previous meta-analyses on this topic, supporting their conclusions and their robustness to the addition of more datasets. One limitation of previous meta-analyses is that they focused on specific health outcomes or populations, despite primary studies often reporting effects on multiple health parameters simultaneously (for example, ref. 13 focusing on neck and shoulder pain and ref. 14 focusing on massage therapy in preterms). To our knowledge, only ref. 5 provides a multivariate picture for a large number of dependent variables. However, this study analysed their data in separate random effects models that did not account for multivariate reporting nor for the multilevel structure of the data, as such approaches have only become available recently. Thus, in addition to adding a substantial amount of new data, our statistical approach provides a more accurate depiction of effect size estimates. Additionally, our study investigated a variety of moderating effects that did not reach significance (for example, sex ratio, mean age or intervention duration) or were not considered (for example, the benefits of robot or object touch) in previous meta-analyses in relation to touch intervention efficacy 5 , probably because of the small number of studies with information on these moderators in the past. Owing to our large-scale approach, we reached high statistical power for many moderator analyses. Finally, previous meta-analyses on this topic exclusively focused on massage therapy in adults or kangaroo care in newborns 15 , leaving out a large number of interventions that are being carried out in research as well as in everyday life to improve well-being. Incorporating these studies into our study, we found that, in general, both massages and other types of touch, such as gentle touch, stroking or kangaroo care, showed similar health benefits.

While it seems to be less critical which touch intervention is applied, the frequency of interventions seems to matter. More sessions were positively associated with the improvement of trait outcomes such as depression and anxiety but also pain reductions in adults. In contrast to session number, increasing the duration of individual sessions did not improve health effects. In fact, we found some indications of negative relationships in adults for cortisol and blood pressure. This could be due to habituating effects of touch on the sympathetic nervous system and hypothalamic–pituitary–adrenal axis, ultimately resulting in diminished effects with longer exposure, or decreased pleasantness ratings of affective touch with increasing duration 16 . For newborns, we could not support previous notions that the duration of the touch intervention is linked to benefits in weight gain 17 . Thus, an ideal intervention protocol does not seem to have to be excessively long. It should be noted that very few interventions lasted less than 5 min, and it therefore remains unclear whether very short interventions have the same effect.

A critical issue highlighted in the pandemic was the lack of touch due to social restrictions 18 . To accommodate the need for touch in individuals with small social networks (for example, institutionalized or isolated individuals), touch interventions using objects/robots have been explored in the past (for a review, see ref. 11 ). We show here that touch interactions outside of the human–human domain are beneficial for mental and physical health outcomes. Importantly, object/robot touch was not as effective in improving mental health as human-applied touch. A sub-analysis of missing skin-to-skin contact among humans indicated that mental health effects of touch might be mediated by the presence of skin-to-skin contact. Thus, it seems profitable to include skin-to-skin contact in future touch interventions, in line with previous findings in newborns 19 . In robots, recent advancements in synthetic skin 20 should be investigated further in this regard. It should be noted that, although we did not observe significant differences in physical health benefits between human–human and human–object touch, the variability of effect sizes was higher in human–object touch. The conditions enabling object or robot interactions to improve well-being should therefore be explored in more detail in the future.

Touch was beneficial for both healthy and clinical cohorts. These data are critical as most previous meta-analytic research has focused on individuals diagnosed with clinical disorders (for example, ref. 6 ). For mental health outcomes, we found larger effects in clinical cohorts. A possible reason could relate to increased touch wanting 21 in patients. For example, loneliness often co-occurs with chronic illnesses 22 , which are linked to depressed mood and feelings of anxiety 23 . Touch can be used to counteract this negative development 24 , 25 . In adults and children, knowing the toucher did not influence health benefits. In contrast, familiarity affected overall health benefits in newborns, with parental touch being more beneficial than touch applied by medical staff. Previous studies have suggested that early skin-to-skin contact and exposure to maternal odour is critical for a newborn’s ability to adapt to a new environment 26 , supporting the notion that parental care is difficult to substitute in this time period.

With respect to age-related effects, our data further suggest that increasing age was associated with a higher benefit through touch for systolic blood pressure. These findings could potentially be attributed to higher basal blood pressure 27 with increasing age, allowing for a stronger modulation of this parameter. For sex differences, our study provides some evidence that there are differences between women and men with respect to health benefits of touch. Overall, research on sex differences in touch processing is relatively sparse (but see refs. 28 , 29 ). Our results suggest that buffering effects against physiological stress are stronger in women. This is in line with increased buffering effects of hugs in women compared with men 30 . The female-biased primary research in adults, however, begs for more research in men or non-binary individuals. Unfortunately, our study could not dive deeper into this topic as health benefits broken down by sex or gender were almost never provided. Recent research has demonstrated that sensory pleasantness is affected by sex and that this also interacts with the familiarity of the other person in the touching dyad 29 , 31 . In general, contextual factors such as sex and gender or the relationship of the touching dyad, differences in cultural background or internal states such as stress have been demonstrated to be highly influential in the perception of affective touch and are thus relevant to maximizing the pleasantness and ultimately the health benefits of touch interactions 32 , 33 , 34 . As a positive personal relationship within the touching dyad is paramount to induce positive health effects, future research applying robot touch to promote well-being should therefore not only explore synthetic skin options but also focus on improving robots as social agents that form a close relationship with the person receiving the touch 35 .

As part of the systematic review, we also assessed the effects of touch interventions in non-human animals. Mimicking the results of the meta-analysis in humans, beneficial effects of touch in animals were comparably strong for mental health-like and physical health outcomes. This may inform interventions to promote animal welfare in the context of animal experiments 36 , farming 37 and pets 38 . While most studies investigated effects in rodents, which are mostly used as laboratory animals, these results probably transfer to livestock and common pets as well. Indeed, touch was beneficial in lambs, fish and cats 39 , 40 , 41 . The positive impact of human touch in rodents also allows for future mechanistic studies in animal models to investigate how interventions such as tickling or stroking modulate hormonal and neuronal responses to touch in the brain. Furthermore, the commonly proposed oxytocin hypothesis can be causally investigated in these animal models through, for example, optogenetic or chemogenetic techniques 42 . We believe that such translational approaches will further help in optimizing future interventions in humans by uncovering the underlying mechanisms and brain circuits involved in touch.

Our results offer many promising avenues to improve future touch interventions, but they also need to be discussed in light of their limitations. While the majority of findings showed robust health benefits of touch interventions across moderators when compared with a null effect, post hoc tests of, for example, familiarity effects in newborns or mental health benefit differences between human and object touch only barely reached significance. Since we computed a large number of statistical tests in the present study, there is a risk that these results are false positives. We hope that researchers in this field are stimulated by these intriguing results and target these questions by primary research through controlled experimental designs within a well-powered study. Furthermore, the presence of small-study bias in both meta-analyses is indicative that the effect size estimates presented here might be overestimated as null results are often unpublished. We want to stress however that this bias is probably reduced by the multivariate reporting of primary studies. Most studies that reported on multiple health outcomes only showed significant findings for one or two among many. Thus, the multivariate nature of primary research in this field allowed us to include many non-significant findings in the present study. Another limitation pertains to the fact that we only included articles in languages mostly spoken in Western countries. As a large body of evidence comes from Asian countries, it could be that primary research was published in languages other than specified in the inclusion criteria. Thus, despite the large and inclusive nature of our study, some studies could have been missed regardless. Another factor that could not be accounted for in our meta-analysis was that an important prerequisite for touch to be beneficial is its perceived pleasantness. The level of pleasantness associated with being touched is modulated by several parameters 34 including cultural acceptability 43 , perceived humanness 44 or a need for touch 45 , which could explain the observed differences for certain moderators, such as human–human versus robot–human interaction. Moreover, the fact that secondary categorical moderators could not be investigated with respect to specific health outcomes, owing to the lack of data points, limits the specificity of our conclusions in this regard. It thus remains unclear whether, for example, a decreased mental health benefit in the absence of skin-to-skin contact is linked mostly to decreased anxiolytic effects, changes in positive/negative affect or something else. Since these health outcomes are however highly correlated 46 , it is likely that such effects are driven by multiple health outcomes. Similarly, it is important to note that our conclusions mainly refer to outcomes measured close to the touch intervention as we did not include long-term outcomes. Finally, it needs to be noted that blinding towards the experimental condition is essentially impossible in touch interventions. Although we compared the touch intervention with other interventions, such as relaxation therapy, as control whenever possible, contributions of placebo effects cannot be ruled out.

In conclusion, we show clear evidence that touch interventions are beneficial across a large number of both physical and mental health outcomes, for both healthy and clinical cohorts, and for all ages. These benefits, while influenced in their magnitude by study cohorts and intervention characteristics, were robustly present, promoting the conclusion that touch interventions can be systematically employed across the population to preserve and improve our health.

Open science practices

All data and code are accessible in the corresponding OSF project 12 . The systematic review was registered on PROSPERO (CRD42022304281) before the start of data collection. We deviated from the pre-registered plan as follows:

Deviation 1: During our initial screening for the systematic review, we were confronted with a large number of potential health outcomes to look at. This observation of multivariate outcomes led us to register an amendment during data collection (but before any effect size or moderator screening). In doing so, we aimed to additionally extract meta-analytic effects for a more quantitative assessment of our review question that can account for multivariate data reporting and dependencies of effects within the same study. Furthermore, as we noted a severe lack of studies with respect to health outcomes for animals during the inclusion assessment for the systematic review, we decided that the meta-analysis would only focus on outcomes that could be meaningfully analysed on the meta-analytic level and therefore only included health outcomes of human participants.

Deviation 2: In the pre-registration, we did not explicitly exclude non-randomized trials. Since an explicit use of non-randomization for group allocation significantly increases the risk of bias, we decided to exclude them a posteriori from data analysis.

Deviation 3: In the pre-registration, we outlined a tertiary moderator level, namely benefits of touch application versus touch reception. This level was ignored since no included study specifically investigated the benefits of touch application by itself.

Deviation 4: In the pre-registration, we suggested using the RoBMA function 47 to provide a Bayesian framework that allows for a more accurate assessment of publication bias beyond small-study bias. Unfortunately, neither multilevel nor multivariate data structures are supported by the RoBMA function, to our knowledge. For this reason, we did not further pursue this analysis, as the hierarchical nature of the data would not be accounted for.

Deviation 5: Beyond the pre-registered inclusion and exclusion criteria, we also excluded dissertations owing to their lack of peer review.

Deviation 6: In the pre-registration, we stated to investigate the impact of sex of the person applying the touch. This moderator was not further analysed, as this information was rarely given and the individuals applying the touch were almost exclusively women (7 males, 24 mixed and 85 females in studies on adults/children; 3 males, 17 mixed and 80 females in studied on newborns).

Deviation 7: The time span of the touch intervention as assessed by subtracting the final day of the intervention from the first day was not investigated further owing to its very high correlation with the number of sessions ( r (461) = 0.81 in the adult meta-analysis, r (145) = 0.84 in the newborn meta-analysis).

Inclusion and exclusion criteria

To be included in the systematic review, studies had to investigate the relationship between at least one health outcome (physical and/or mental) in humans or animals and a touch intervention, include explicit physical touch by another human, animal or object as part of an intervention and include an experimental and control condition/group that are differentiated by touch alone. Of note, as a result of this selection process, no animal-to-animal touch intervention study was included, as they never featured a proper no-touch control. Human touch was always explicit touch by a human (that is, no brushes or other tools), either with or without skin-to-skin contact. Regarding the included health outcomes, we aimed to be as broad as possible but excluded parameters such as neurophysiological responses or pleasantness ratings after touch application as they do not reflect health outcomes. All included studies in the meta-analysis and systematic review 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 , 160 , 161 , 162 , 163 , 164 , 165 , 166 , 167 , 168 , 169 , 170 , 171 , 172 , 173 , 174 , 175 , 176 , 177 , 178 , 179 , 180 , 181 , 182 , 183 , 184 , 185 , 186 , 187 , 188 , 189 , 190 , 191 , 192 , 193 , 194 , 195 , 196 , 197 , 198 , 199 , 200 , 201 , 202 , 203 , 204 , 205 , 206 , 207 , 208 , 209 , 210 , 211 , 212 , 213 , 214 , 215 , 216 , 217 , 218 , 219 , 220 , 221 , 222 , 223 , 224 , 225 , 226 , 227 , 228 , 229 , 230 , 231 , 232 , 233 , 234 , 235 , 236 , 237 , 238 , 239 , 240 , 241 , 242 , 243 , 244 , 245 , 246 , 247 , 248 , 249 , 250 , 251 , 252 , 253 , 254 , 255 , 256 , 257 , 258 , 259 , 260 , 261 , 262 , 263 are listed in Supplementary Table 2 . All excluded studies are listed in Supplementary Table 3 , together with a reason for exclusion. We then applied a two-step process: First, we identified all potential health outcomes and extracted qualitative information on those outcomes (for example, direction of effect). Second, we extracted quantitative information from all possible outcomes (for example, effect sizes). The meta-analysis additionally required a between-subjects design (to clearly distinguish touch from no-touch effects and owing to missing information about the correlation between repeated measurements 264 ). Studies that explicitly did not apply a randomized protocol were excluded before further analysis to reduce risk of bias. The full study lists for excluded and included studies can be found in the OSF project 12 in the file ‘Study_lists_final_revised.xlsx’. In terms of the time frame, we conducted an open-start search of studies until 2022 and identified studies conducted between 1965 and 2022.

Data collection

We used Google Scholar, PubMed and Web of Science for our literature search, with no limitations regarding the publication date and using pre-specified search queries (see Supplementary Information for the exact keywords used). All procedures were in accordance with the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines 265 . Articles were assessed in French, Dutch, German or English. The above databases were searched from 2 December 2021 until 1 October 2022. Two independent coders evaluated each paper against the inclusion and exclusion criteria. Inconsistencies between coders were checked and resolved by J.P. and H.H. Studies excluded/included for the review and meta-analysis can be found on the OSF project.

Search queries

We used the following keywords to search the chosen databases. Agents (human versus animal versus object versus robot) and touch outcome (physical versus mental) were searched separately together with keywords searching for touch.

TOUCH: Touch OR Social OR Affective OR Contact OR Tactile interaction OR Hug OR Massage OR Embrace OR Kiss OR Cradling OR Stroking OR Haptic interaction OR tickling

AGENT: Object OR Robot OR human OR animal OR rodent OR primate

MENTAL OUTCOME: Health OR mood OR Depression OR Loneliness OR happiness OR life satisfaction OR Mental Disorder OR well-being OR welfare OR dementia OR psychological OR psychiatric OR anxiety OR Distress

PHYSICAL OUTCOME: Health OR Stress OR Pain OR cardiovascular health OR infection risk OR immune response OR blood pressure OR heart rate

Data extraction and preparation

Data extraction began on 10 October 2022 and was concluded on 25 February 2023. J.P. and H.H. oversaw the data collection process, and checked and resolved all inconsistencies between coders.

Health benefits of touch were always coded by positive summary effects, whereas adverse health effects of touch were represented by negative summary effects. If multiple time points were measured for the same outcome on the same day after a single touch intervention, we extracted the peak effect size (in either the positive or negative direction). If the touch intervention occurred multiple times and health outcomes were assessed for each time point, we extracted data points separately. However, we only extracted immediate effects, as long-term effects not controlled through the experimental conditions could be due to influences other than the initial touch intervention. Measurements assessing long-term effects without explicit touch sessions in the breaks were excluded for the same reason. Common control groups for touch interventions comprised active (for example, relaxation therapy) as well as passive control groups (for example, standard medical care). In the case of multiple control groups, we always contrasted the touch group to the group that most closely matched the touch condition (for example, relaxation therapy was preferred over standard medical care). We extracted information from all moderators listed in the pre-registration (Supplementary Table 4 ). A list of included and excluded health outcomes is presented in Supplementary Table 5 . Authors of studies with possible effects but missing information to calculate those effects were contacted via email and asked to provide the missing data (response rate 35.7%).

After finalizing the list of included studies for the systematic review, we added columns for moderators and the coding schema for our meta-analysis per our updated registration. Then, each study was assessed for its eligibility in the meta-analysis by two independent coders (J.P., H.H., K.F. or F.M.). To this end, all coders followed an a priori specified procedure: First, the PDF was skimmed for possible effects to extract, and the study was excluded if no PDF was available or the study was in a language different from the ones specified in ‘ Data collection ’. Effects from studies that met the inclusion criteria were extracted from all studies listing descriptive values or statistical parameters to calculate effect sizes. A website 266 was used to convert descriptive and statistical values available in the included studies (means and standard deviations/standard errors/confidence intervals, sample sizes, F values, t values, t test P values or frequencies) into Cohen’s d , which were then converted in Hedges’ g . If only P value thresholds were reported (for example, P  < 0.01), we used this, most conservative, value as the P value to calculate the effect size (for example, P  = 0.01). If only the total sample size was given but that number was even and the participants were randomly assigned to each group, we assumed equal sample sizes for each group. If delta change scores (for example, pre- to post-touch intervention) were reported, we used those over post-touch only scores. In case frequencies were 0 when frequency tables were used to determine effect sizes, we used a value of 0.5 as a substitute to calculate the effect (the default setting in the ‘metafor’ function 267 ). From these data, Hedges’ g and its variance could be derived. Effect sizes were always computed between the experimental and the control group.

Statistical analysis and risk of bias assessment

Owing to the lack of identified studies, health benefits to animals were not included as part of the statistical analysis. One meta-analysis was performed for adults, adolescents and children, as outcomes were highly comparable. We refer to this meta-analysis as the adult meta-analysis, as children/adolescent cohorts were only targeted in a minority of studies. A separate meta-analysis was performed for newborns, as their health outcomes differed substantially from any other age group.

Data were analysed using R (version 4.2.2) with the ‘rma.mv’ function from the ‘metafor’ package 267 in a multistep, multivariate and multilevel fashion.

We calculated an overall effect of touch interventions across all studies, cohorts and health outcomes. To account for the hierarchical structure of the data, we used a multilevel structure with random effects at the study, cohort and effects level. Furthermore, we calculated the variance–covariance matrix of all data points to account for the dependencies of measured effects within each individual cohort and study. The variance–covariance matrix was calculated by default with an assumed correlation of effect sizes within each cohort of ρ  = 0.6. As ρ needed to be assumed, sensitivity analyses for all computed effect estimates were conducted using correlations between effects of 0, 0.2, 0.4 and 0.8. The results of these sensitivity analyses can be found in ref. 12 . No conclusion drawn in the present manuscript was altered by changing the level of ρ . The sensitivity analyses, however, showed that higher assumed correlations lead to more conservative effect size estimates (see Supplementary Figs. 19 and 20 for the adult and newborn meta-analyses, respectively), reducing the type I error risk in general 268 . In addition to these procedures, we used robust variance estimation with cluster-robust inference at the cohort level. This step is recommended to more accurately determine the confidence intervals in complex multivariate models 269 . The data distribution was assumed to be normal, but this was not formally tested.

To determine whether individual effects had a strong influence on our results, we calculated Cook’s distance D . Here, a threshold of D  > 0.5 was used to qualify a study as influential 270 . Heterogeneity in the present study was assessed using Cochran’s Q , which determines whether the extracted effect sizes estimate a common population effect size. Although the Q statistic in the ‘rma.mv’ function accounts for the hierarchical nature of the data, we also quantified the heterogeneity estimator σ ² for each random-effects level to provide a comprehensive overview of heterogeneity indicators. These indicators for all models can be found on the OSF project 12 in the Table ‘Model estimates’. To assess small study bias, we visually inspected the funnel plot and used the standard error as a moderator in the overarching meta-analyses.

Before any sub-group analysis, the overall effect size was used as input for power calculations. While such post hoc power calculations might be limited, we believe that a minimum number of effects to be included in subgroup analyses was necessary to allow for meaningful conclusions. Such medium effect sizes would also probably be the minimum effect sizes of interest for researchers as well as clinical practitioners. Power calculation for random-effects models further requires a sample size for each individual effect as well as an approximation of the expected heterogeneity between studies. For the sample size input, we used the median sample size in each of our studies. For heterogeneity, we assumed a value between medium and high levels of heterogeneity ( I ² = 62.5% 271 ), as moderator analyses typically aim at reducing heterogeneity overall. Subgroups were only further investigated if the number of observed effects achieved ~80% power under these circumstances, to allow for a more robust interpretation of the observed effects (see Supplementary Figs. 5 and 6 for the adult and newborn meta-analysis, respectively). In a next step, we investigated all pre-registered moderators for which sufficient power was detected. We first looked at our primary moderators (mental versus physical health) and how the effect sizes systematically varied as a function of our secondary moderators (for example, human–human or human–object touch, duration, skin-to-skin presence, etc.). We always included random slopes to allow for our moderators to vary with the random effects at our clustering variable, which is recommended in multilevel models to reduce false positives 272 . All statistical tests were performed two-sided. Significance of moderators was determined using omnibus F tests. Effect size differences between moderator levels and their confidence intervals were assessed via t tests.

Post hoc t tests were performed comparing mental and physical health benefits within each interacting moderator (for example, mental versus physical health benefits in cancer patients) and mental or physical health benefits across levels of the interacting moderator (for example, mental health benefits in cancer versus pain patients). The post hoc tests were not pre-registered. Data were visualized using forest plots and orchard plots 273 for categorical moderators and scatter plots for continuous moderators.

For a broad overview of prior work and their biases, risk of bias was assessed for all studies included in both meta-analyses and the systematic review. We assessed the risk of bias for the following parameters:

Bias from randomization, including whether a randomization procedure was performed, whether it was a between- or within-participant design and whether there were any baseline differences for demographic or dependent variables.

Sequence bias resulting from a lack of counterbalancing in within-subject designs.

Performance bias resulting from the participants or experiments not being blinded to the experimental conditions.

Attrition bias resulting from different dropout rates between experimental groups.

Note that four studies in the adult meta-analysis did not explicitly mention randomization as part of their protocol. However, since these studies never showed any baseline differences in all relevant variables (see ‘Risk of Bias’ table on the OSF project ) , we assumed that randomization was performed but not mentioned. Sequence bias was of no concern for studies for the meta-analysis since cross-over designs were excluded. It was, however, assessed for studies within the scope of the systematic review. Importantly, performance bias was always high in the adult/children meta-analysis, as blinding of the participants and experimenters to the experimental conditions was not possible owing to the nature of the intervention (touch versus no touch). For studies with newborns and animals, we assessed the performance bias as medium since neither newborns or animals are likely to be aware of being part of an experiment or specific group. An overview of the results is presented in Supplementary Fig. 21 , and the precise assessment for each study can be found on the OSF project 12 in the ‘Risk of Bias’ table.

Reporting summary

Further information on research design is available in the Nature Portfolio Reporting Summary linked to this article.

Data availability

All data are available via Open Science Framework at https://doi.org/10.17605/OSF.IO/C8RVW (ref. 12 ). Source data are provided with this paper.

Code availability

All code is available via Open Science Framework at https://doi.org/10.17605/OSF.IO/C8RVW (ref. 12 ).

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Acknowledgements

We thank A. Frick and E. Chris for supporting the initial literature search and coding. We also thank A. Dreisoerner, T. Field, S. Koole, C. Kuhn, M. Henricson, L. Frey Law, J. Fraser, M. Cumella Reddan, and J. Stringer, who kindly responded to our data requests and provided additional information or data with respect to single studies. J.P. was supported by the German National Academy of Sciences Leopoldina (LPDS 2021-05). H.H. was supported by the Marietta-Blau scholarship of the Austrian Agency for Education and Internationalisation (OeAD) and the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation, project ID 422744262 – TRR 289). C.K. received funding from OCENW.XL21.XL21.069 and V.G. from the European Research Council (ERC) under European Union’s Horizon 2020 research and innovation programme, grant ‘HelpUS’ (758703) and from the Dutch Research Council (NWO) grant OCENW.XL21.XL21.069. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

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Julian Packheiser

Present address: Social Neuroscience, Faculty of Medicine, Ruhr University Bochum, Bochum, Germany

These authors contributed equally: Julian Packheiser, Helena Hartmann.

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Social Brain Lab, Netherlands Institute for Neuroscience, Royal Netherlands Academy of Art and Sciences, Amsterdam, the Netherlands

Julian Packheiser, Helena Hartmann, Kelly Fredriksen, Valeria Gazzola, Christian Keysers & Frédéric Michon

Center for Translational and Behavioral Neuroscience, University Hospital Essen, Essen, Germany

Helena Hartmann

Clinical Neurosciences, Department for Neurology, University Hospital Essen, Essen, Germany

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J.P. contributed to conceptualization, methodology, formal analysis, investigation, data curation, writing the original draft, review and editing, visualization, supervision and project administration. HH contributed to conceptualization, methodology, formal analysis, investigation, data curation, writing the original draft, review and editing, visualization, supervision and project administration. K.F. contributed to investigation, data curation, and review and editing. C.K. and V.G. contributed to conceptualization, and review and editing. F.M. contributed to conceptualization, methodology, formal analysis, investigation, writing the original draft, and review and editing.

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List of studies included in and excluded from the meta-analyses/review.

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Source Data Fig. 2

Effect size/error (columns ‘Hedges_g’ and ‘variance’) information for each study/cohort/effect included in the analysis. Source Data Fig. 3 Effect size/error (columns ‘Hedges_g’ and ‘variance’) together with moderator data (column ‘Outcome’) for each study/cohort/effect included in the analysis. Source Data Fig. 4 Effect size/error (columns ‘Hedges_g’ and ‘variance’) together with moderator data (columns ‘dyad_type’ and ‘skin_to_skin’) for each study/cohort/effect included in the analysis. Source Data Fig. 5 Effect size/error (columns ‘Hedges_g’ and ‘variance’) together with moderator data (column ‘touch_type’) for each study/cohort/effect included in the analysis. Source Data Fig. 6 Effect size/error (columns ‘Hedges_g’ and ‘variance’) together with moderator data (column ‘clin_sample’) for each study/cohort/effect included in the analysis. Source Data Fig. 7 Effect size/error (columns ‘Hedges_g’ and ‘variance’) together with moderator data (column ‘familiarity’) for each study/cohort/effect included in the analysis. Source Data Fig. 7 Effect size/error (columns ‘Hedges_g’ and ‘variance’) together with moderator data (columns ‘touch_duration’ and ‘sessions’) for each study/cohort/effect included in the analysis.

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Packheiser, J., Hartmann, H., Fredriksen, K. et al. A systematic review and multivariate meta-analysis of the physical and mental health benefits of touch interventions. Nat Hum Behav (2024). https://doi.org/10.1038/s41562-024-01841-8

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Massage therapy for the treatment of attention deficit/hyperactivity disorder (ADHD) in children and adolescents: A systematic review and meta-analysis

Affiliations.

• 1 School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, China.
• 2 Pediatric Tuina Health Care Clinic, Shandong University of Traditional Chinese Medicine Affiliated Hospital, China.
• 3 Department of Psychology, The Chinese University of Hong Kong, China.
• 4 School of Chinese Medicine, Hong Kong Baptist University, China.
• 5 School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, China. Electronic address: [email protected].
• PMID: 30670272
• DOI: 10.1016/j.ctim.2018.12.011

Objective: To summarize the current evidence on the effects and safety of massage therapy for the treatment of ADHD in children and adolescents.

Method: A systematic review of 8 randomized controlled trials (RCTs) and 3 case series studies was conducted with a meta-analysis of 4 of the RCTs.

Results: Pooled analysis showed that massage produced more improvement in ADHD symptoms in terms of effective rate compared to Ritalin (risk ratio: 1.39, 95%CI: 1.16 - 1.66; P = 0.0004). Individual RCTs suggested that massage was differed significantly from waitlist control in improving the conditions of anxious-passive (mean difference: -11.7; 95%CI [-17.84, -5.56]; P = 0.0002), and asocial behavior (mean difference = - 8.60; 95%CI [-15.87, -1.33]; P = 0.02).

Conclusion: Evidence suggests that massage therapy is beneficial for treating ADHD in children and adolescents.

Keywords: ADHD; Massage; Meta-analysis; Systematic review.

Copyright © 2018 Elsevier Ltd. All rights reserved.

Publication types

• Meta-Analysis
• Systematic Review
• Adolescent Behavior
• Attention Deficit Disorder with Hyperactivity / complications
• Attention Deficit Disorder with Hyperactivity / therapy*
• Child Behavior
• Child, Preschool
• Methylphenidate
• Waiting Lists

Research Literacy: Massage & Sleep

Does massage therapy improve sleep in infants and their mothers?

By Martha Brown Menard, Ph.D., LMT, February 1, 2020

The Study Question

Sleep issues are common among infants and toddlers, and are estimated to occur in 20 to 30 percent of children under 3 years of age. When children experience poor sleep, mothers are also affected. While implementing a bedtime routine is often recommended, there is little research on its efficacy separate from other treatments, or on which components of a bedtime routine help to improve infant sleep. Previous research has shown that massage can have a positive effect on sleep for preterm infants, infants and young children. This study examined the impact of a massage-based bedtime routine on infant sleep, maternal sleep and maternal mood.

The Study Methods

Participants were recruited through an independent clinical research organization and offered a financial incentive for completing the study. Inclusion criteria were that children had an identified sleep problem as noted by the mother, with all mothers endorsing that their child had a sleep problem that ranged from “small” to “severe.” Families were excluded if the child was reported to wake more than three times a night, stayed awake more than 60 minutes per night and had a total daily sleep duration of less than nine hours. Additional exclusion criteria were non-English speaking, current acute or chronic illness, and if the child was routinely bathed or had lotion applied in the hour before bedtime four or more times per week.

There were 123 families recruited and randomly assigned to continue their child’s usual bedtime practices during the study period (the control condition) or to implement a new nightly two-step bedtime routine: following a one-week baseline period during which mothers followed their child’s usual bedtime practices, for the next two weeks mothers included a massage (using a provided massage product in a blinded container and instructional materials including possible massage techniques), and quiet activities such as cuddling and singing a lullaby.

Instructions were given for massaging the baby’s chest, arms and hands, stomach, back, and legs and feet. Mothers continued to put their child to bed as they normally did, whether they put their child to bed awake or stayed with their child until asleep, and had lights out within 30 minutes of completing the massage, so that the only change was the new bedtime routine.

The massage intervention included 64 families, and 59 families participated in the control condition. Mothers were aged 18–45 years, with a mean age of 30.6 years; infants were aged 3–18 months with a mean age of 8.96 months, and 46 percent were male.

Outcomes measures included the Brief Infant Sleep Questionnaire (BISQ), completed on a weekly basis, and the Pittsburgh Sleep Quality Index (PSQ J), Epworth Sleepiness Scale, Edinburgh Postnatal Depression Scale, Brief Mood Introspection Scale, Parenting Stress Index and State-Trait Anxiety Inventory, completed at baseline and at the end of the study. All questionnaires were completed online.

Independent samples t-tests and chi-square tests were conducted to determine any pre-existing demographic or sleep differences between the control group and the intervention group; none were found. No differences were found across demographic variables, or baseline maternal or child sleep variables between the two groups.

The Results

Analyses showed a significant reduction in the number of nighttime wakings for children and mothers in the intervention group, but not for those in the control group. Overall, mothers perceived improvements in their child’s sleep for all variables measured for the intervention group, with no changes reported in the control group. Mothers reported improvements in bedtime difficulty, how well their child slept, child morning mood and their confidence in managing child sleep issues.

Mothers in the intervention group reported improved sleep quality as measured by the PSQI. There was also a decreased perception by mothers of sleep as a problem. The percent of mothers who reported their child had a sleep problem decreased from 78.1 percent at baseline to 60.9 percent after the first week of intervention, and to 46.9 percent at the end of the two-week intervention period. No significant differences were found for those in the control group. Mothers in the intervention group were also more likely to report feeling “somewhat” or “very confident” in managing their child’s sleep compared to the control group, and were highly likely to continue to use the prescribed routine.

There were no changes for the majority of mood and behavior scales for the mothers. No differences were found for depressive symptomatology (EPDS), daytime sleepiness (ESS), parenting stress (PSI) or state anxiety (STAI).

Limitations of the Study

This study has several limitations. The massage instructions are not described. Many of the outcomes are selfreported, and there were no objective measures of infant and toddler sleep, such as actigraphy.

Results may have been due to participant expectations that sleep would improve, although not all self-reported outcomes showed improvement. While participants reported being satisfied with the bedtime intervention and likely to continue it, there was no longer term follow-up of reported massage effects or whether participants actually did continue the intervention.

Implications for Evidence-Informed Practice

In this study, massage therapy as part of a consistent bedtime routine appears to offer benefits to both infants and mothers related to improved sleep quality. Practitioners who have clients with young children and who report sleep difficulties may want to offer to teach the parents how to give a simple massage to their child as part of a bedtime routine.

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Evaluation of Serum Reaction to Low-Intensity Laser Exposure by Its Solid Phase Structure

• Published: 25 October 2016
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The effects of various modes of low-intensity laser exposure on the sera of healthy subjects and patients are studied. It is shown by the cuneiform dehydration method that the serum structure is liable to change in response to certain modes of low-intensity laser exposure. The structure of patients’ sera is more sensitive to low-intensity laser exposure.

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Translated from Byulleten’ Eksperimental’noi Biologii i Meditsiny , Vol. 161, No. 6, pp. 803-806, June, 2016

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Shabalin, V.V., Shatokhina, S.N. Evaluation of Serum Reaction to Low-Intensity Laser Exposure by Its Solid Phase Structure. Bull Exp Biol Med 161 , 841–844 (2016). https://doi.org/10.1007/s10517-016-3525-9

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• Winter 2024 | VOL. 22, NO. 1 Reproductive Psychiatry: Postpartum Depression is Only the Tip of the Iceberg CURRENT ISSUE pp.1-142

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Massage Therapy for Psychiatric Disorders

• Mark Hyman Rapaport , M.D. ,
• Pamela J. Schettler , Ph.D. ,
• Erika R. Larson , M.S., L.M.T. ,
• Dedric Carroll , L.M.T. ,
• Margaret Sharenko , L.M.T., C.P.T. ,
• James Nettles , Ph.D., L.M.T. ,
• Becky Kinkead , Ph.D.

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This article reviews the current state of knowledge of the role of massage therapy in the treatment of common psychiatric disorders and symptoms. It briefly discusses the prevalence of psychiatric disorders and the popularity of complementary and integrative treatments in the general population. The authors touch on the growing literature describing the biology and neurobiology of massage therapy. The impact of massage as both a therapy for major psychiatric disorders and a treatment for psychiatric symptoms is reviewed, and how massage therapists conceptualize and treat their patients with psychiatric complaints is discussed. If psychiatrists are going to partner with massage therapists, they need to understand how massage therapists’ perspectives differ from those of traditional practitioners of allopathic medicine. A model of how psychiatrists and other mental health professionals can work with massage therapists to care for patients is proposed, followed by a summary of the article’s key points.

Of the top 25 disorders associated with years lost because of disability, seven are major psychiatric disorders ( 1 ). Major depression is the second leading cause of years living with disability in the world, anxiety disorders are the ninth leading cause, and schizophrenia is the 11th leading cause. Thus, major psychiatric syndromes are clearly associated with a major cost to society. Major psychiatric syndromes are also remarkably prevalent. One in four individuals will have a major psychiatric syndrome at some point in their lifetime ( 2 ). This means that everyone knows someone with a major psychiatric disorder, and every family is touched by the presence of these diseases. Despite significant advances toward both understanding the neuroscience of and developing new psychotherapies and pharmacotherapies to treat these disorders, a great unmet treatment need still exists. Using major depressive disorder as an example, we know from the National Institute of Mental Health–funded Sequenced Treatment Alternatives to Relieve Depression study that only one-third of individuals go into remission with initial treatment for depression ( 3 ). Furthermore, although close to two-thirds may enter remission with multiple successive treatments, the majority of these individuals will relapse within one year of reaching remission status ( 3 ). Thus, there is clearly a need for additional options to treat people with depression. It is reasonable to extrapolate from depression to other psychiatric disorders for which there are even fewer available treatment options. We contend that approaches to identifying potential treatment interventions for patients need to be broadened.

Systematic investigation into the popularity of complementary and alternative medicine (CAM) for treatment in the United States began in 1990 with the survey spearheaded by Eisenberg and colleagues ( 4 ). In this initial report in the New England Journal of Medicine, they documented that 33.8% of the adults surveyed had used some type of alternative or complementary medical service in the past 12 months. These findings were a revelation to most individuals in traditional Western or allopathic medical communities. Eisenberg and colleagues followed this report with a paper that compared and contrasted their 1990 data with those from a survey conducted in 1997 ( 5 ). This later publication documented an increase in the use of alternative therapies from 33.8% to 42.0%, with herbal medicine, massage, megavitamins, self-help groups, folk remedies, homeopathy, and energy healing increasing the most. They reported that some of the most frequent reasons for using complementary and alternative therapies included back pain, anxiety, depression, and headaches. In the 1997 paper, they estimated that the cost for services provided was $21.2 billion, with at least $12.2 billion being paid out of pocket. These initial findings by Eisenberg and colleagues were updated in the 2002 and 2007 Centers for Disease Control and Prevention–sponsored CAM surveys. In both of these surveys ( 6 , 7 ), approximately 40% of adults reported having used some type of complementary and alternative therapy in the past 12 months. Also, both of these surveys indicated that approximately 5% of the U.S. adult population had used massage therapy. Purohit and colleagues ( 8 ) performed a reanalysis of the 2007 National Health Interview data of 23,393 adults that focused on the presence of neuropsychiatric symptoms and their impact on CAM usage. The prevalence of the use of CAM therapies was 43.78% for individuals with self-reported symptoms of depression, insomnia, headaches, memory deficits, attention deficits, and sleep problems versus 29.7% for individuals who did not report any of these symptoms. Of those individuals with at least one neuropsychiatric symptom who used CAM therapies, 20% used CAM therapy because they felt that standard treatments were either too expensive or ineffective, and 25% used CAM therapies because they were recommended by their traditional medical provider.

In conclusion, there is an interface between psychiatric disorders and complementary and alternative therapies such as massage. Accordingly, validated alternative therapies are now being integrated within the medical mainstream under the rubric “complementary and integrative medicine” (CIM). Consistent with this, and reflecting an emphasis on well-being and treatment of disease, the National Institutes of Health have renamed the center addressing CAM therapies the National Center for Complementary and Integrative Health. Psychiatric disorders are common and disabling, and current treatment methods, although helpful for many, are not the treatment of choice for many patients and are insufficient to alleviate disability and suffering for many others. This suggests that allopathic practitioners should think about two questions: What is the body of evidence supporting CIM interventions, and what is the best way for a psychiatrist or other mental health service provider and a CIM practitioner to interact with each other in the care of a patient? We address these two important issues.

Biology of Massage

Rigorous study of the biology of therapeutic massage is still in a relatively nascent phase. Although studies have attempted to understand the impact of various forms of massage on the body since the early 1990s, the research has been fraught with problems, in particular a lack of consistent funding for investigation of the biological effects of massage. Another challenge faced by the field is that there are many different types of massage and great variation in research study designs. As a result, current knowledge of the biology of massage rests mainly on a number of small studies investigating very different interventions that have been done for different lengths of time and at different frequencies. Despite these limitations, certain biological patterns seem to have emerged from recent studies.

Human Studies of the Neurobiology of Massage

A few EEG and imaging studies have investigated the impact of massage on brain circuitry or brain regions. One of the first studies was performed by the Touch Institute. In this study, 26 adults were given chair massage for 15 minutes twice weekly for five weeks, and 24 adults were asked to sit quietly in the massage chair twice weekly for five weeks ( 9 ). Field and colleagues found that twice-weekly massage was associated with an increase in frontal delta power in the EEG and a decrease in frontal alpha and beta power. This pattern is consistent with increased relaxation yet enhanced alertness, which was supported by the massage group’s having increased speed and accuracy on mathematical computations and decreased levels of anxiety. Salivary cortisol levels were also lower in the massage condition but not in the control condition. In a study of an aromatherapy massage intervention versus no treatment, Wu and colleagues ( 10 ) were able to replicate an increase in alpha wave activity in their aromatherapy massage sample, but they found a reduction in delta wave activity. However, they reported decreases in state anxiety and depression and an increase in psychological well-being as well as a reduction in salivary cortisol levels and an increase in plasma brain-derived neurotrophic factor in the aromatherapy group.

Neuroimaging studies investigating the impact of massage on the brain have been limited. In a small positron emission tomography study in 2006, Ouchi and colleagues ( 11 ) reported that being placed in the scanner in a prone position versus a supine position caused increased activation in the precuneus. This activation was further enhanced by both four minutes and 20 minutes of palm pressure massage applied to participants’ backs. The 20 minutes of massage also caused a greater increase in parasympathetic tone as well as activation of the parieto-occipital region. Ouchi and colleagues also reported activation in the cerebellum associated with massage. The authors concluded that this pattern of activation of the precuneus with back massage might reflect augmentation of arousal in consciousness functions associated with positive affect and that their findings of increased activity in the forebrain-amygdala system might be responsible for an increase in parasympathetic tone in the brain. The latter would also be consistent with a cerebellar increase in blood flow, which again would help regulate parasympathetic tone. These findings were partially replicated and extended by Sliz and colleagues ( 12 ), who looked at the neurocorrelates of a single session of massage versus those of a resting control condition, reflexology and massage with an object. They found that Swedish massage of the right foot while the participant performed a cognitive task in the scanner was associated with increased activation of the subgenual anterior and retrosplenial-posterior cingulate cortices. This increased activation of the retrosplenial-posterior cingulate cortex was sustained even without activation by the task.

If one integrates these findings investigating the impact of massage with those of a series of elegant studies that have been performed to attempt to understand the basic neurobiology of touch, one can come up with unifying theory of the impact of massage on the brain. An MRI study by Golaszewski and colleagues ( 13 ) demonstrated that vibrating tactile stimulation of the plantar surface of the foot increased activity in the inferior and posterior cingulate gyri along with the somatosensory cortex, insula, thalamus, caudate, and cerebellum. These brain regions integrate tactile and sensory information from mechanoreceptors, the myelinated A-beta and A-alpha afferents, and the unmyelinated sensory nerve fibers called c-tactile afferents that are thought to be associated with positive affect. The c-tactile afferents are stimulated by gentle stroking of hairy skin surfaces. They project to the limbic cortex, including the orbital frontal cortex and posterior insulate bilaterally.

In summary, although the data on the impact of massage on EEG and neuroimaging changes in the brain are limited, when these data are combined with the emerging data on somatic sensory pleasure circuitry, it is reasonable to postulate that massage’s beneficial effects on affiliation and feelings of well-being may be due to stimulation of specific brain circuits involved in pleasure and reward ( 14 ).

Impact of Massage on the Hypothalamic-Pituitary-Adrenal Axis and Neurohormones

A myriad of small studies of massage have measured either salivary or plasma cortisol levels. Many of these studies investigated only single time-point measures of cortisol before and after a series of massage interventions. The consensus of existing meta-analyses as well as of this review is that massage tends to decrease measures of plasma and salivary cortisol versus either a wait-list or a no-treatment condition ( 15 ). However, in general these studies have not looked at the sustained impact of massage after cessation of treatment. Rapaport and colleagues ( 16 ) have compared and contrasted the impact of a single 45-minute session of manualized Swedish massage with that of a manualized light-touch control condition in adults with no psychiatric disorder. They sampled cortisol, oxytocin, vasopressin, and adrenocorticotropic hormone after a 30-minute accommodation period at two points before initiation of massage or touch and then at several time points during the hour after the intervention. These authors found that a single session of either massage or touch was associated with a small effect-size decrease in cortisol levels in healthy young participants as well as a large effect-size increase in oxytocin in both groups. However, compared with changes found in cortisol and oxytocin, the massage group showed a profound significant decrease in vasopressin compared with the touch control group.

In a subsequent study, Rapaport and colleagues investigated the impact of weekly massage versus weekly touch for five weeks, as well as the impact of twice-weekly massage or twice-weekly touch for five weeks ( 17 ). Weekly massage versus weekly touch was associated with a pattern of results similar to that observed with a single session of massage. However, twice-weekly massage caused a significantly greater cumulative increase in oxytocin and decrease in vasopressin than twice-weekly touch. Although these data are of interest and consistent with previous studies reporting a decrease in cortisol levels and an increase in sense of affiliation associated with massage, these small studies require replication with larger cohorts of participants.

In summary, data suggest that massage may be associated with a decrease in hypothalamic-pituitary-adrenal activation and possibly with an increase in oxytocin levels. However, larger rigorous studies are needed.

Impact of Massage on the Immune System

A great deal of the pioneering work investigating the relationship between massage and the immune system occurred at the University of Miami. This group investigated the impact of massage on immune function in a variety of different patient populations including depressed individuals, HIV-positive young women, and HIV-positive adolescents ( 18 – 20 ). In general, this group reported an increase in natural killer (NK) cells and an increase in NK cell activity associated with massage compared with control conditions such as muscle relaxation. Rapaport and colleagues reported that a single session of Swedish massage versus a touch control condition caused a leukocytosis with a moderate effect-size increase in CD56+ NK cells and an increase in activated T cells ( 16 ). They have also reported that massage was associated with a significant decrease in Type 2 T helper (TH2) mitogen-stimulated cytokines compared with both baseline levels and the touch control condition ( 16 ). Massage was also associated with a decrease in mitogen-stimulated proinflammatory cytokine production when contrasted with the touch control condition. In 2012, Rapaport and colleagues reported that these effects were sustained for at least one week and that they were specific to individuals who received one massage per week in contrast to the groups receiving two massages per week ( 17 ). These findings are consistent with a report by Donoyama and Ohkoshi ( 21 ), who reported that two healthy female participants had an increase in gene expressions associated with immune response in the immune system compared with a 40-minute resting control condition. These findings are also consistent with work that has been done to investigate the local impact of massage on muscles that have been injured during exercise ( 22 ). Consistent with reports of both a single session of massage and repeated massage on TH2 cytokine production is a paper by Loft and colleagues that reports that massage decreased antibody responses after hepatitis B vaccination ( 23 ). In summary, although these findings require replication, they suggest that massage may affect the immune system in a way that enhances immune surveillance and NK cell activity while decreasing inflammation and TH2-type responses.

Summary of the Biology of Massage

In summary, although much more extensive investigation of the neurobiology of massage is needed, the data suggest that there is a parsimonious way of conceptualizing the mechanisms underlying its beneficial effects. The brain circuitry stimulated by c fibers is associated with feelings of positive affect and well-being. Massage also stimulates brain circuits involved in the control of sympathetic and parasympathetic activity, with an enhancement of parasympathetic tone. These effects could in turn lead to a decrease in stress response as well as modulation of certain aspects of immune function, such as a decrease in inflammatory response. Thus, it is possible to synthesize the existing data regarding the biology of massage into a cogent working hypothesis about its benefits for certain psychiatric disorders.

Massage, Depression, and Depressive Symptoms

As previously discussed, the use of CAM to treat depressive symptoms and major depression is common ( 5 , 24 ). A reanalysis of a national survey by Kronenberg and colleagues ( 25 , 26 ) that focused on 220 women with depression who were part of a national telephone survey of 3,060 women indicated that 54% of the depressed women reported using CAM in the past year and that half of those respondents indicated that they used some form of manual therapy. Despite the clear data suggesting that many patients with major depression or depressive symptoms are interested in CIM therapies and, in particular, manual therapies, the data have significant limitations. A meta-analysis by Coelho and colleagues ( 27 ) reviewed 595 articles and excluded all but four from their meta-analysis of massage therapy for treatment of major depression or depressive symptoms. A more recent meta-analysis of massage therapy for depressed people by Hou and colleagues ( 28 ) used less stringent criteria and identified 17 studies with 786 participants from among 246 references. This meta-analysis included many studies whose participants were recruited because of a primary disorder other than depression, including insomnia, breast cancer, fibromyalgia, HIV infection, and low back pain. They concluded that these clinical trials were of moderate quality and that the pooled standardized mean differences from fixed and random effects models were .76 and .73, respectively. However, they cautioned that these 17 studies had considerable heterogeneity and that standardized protocols for massage therapy are needed, using validated depression scales with larger and more homogeneous participant populations.

In a comprehensive review of the use of CAM for perinatal depression, Deligiannidis and Freeman ( 29 ) suggested that a growing body of literature supports the use of antenatal massage therapy either in combination with psychotherapy or as a monotherapy to treat pregnant women with mild depressive symptomatology. Poland and colleagues ( 30 ) published results of a randomized, parallel-group, open-label controlled trial of massage versus light touch and wait-list control for the treatment of major depressive disorder in individuals infected with HIV. They reported that twice-weekly massage therapy was effective in decreasing depressive symptoms as measured by both the Hamilton Depression Rating Scale and the Beck Depression Inventory, beginning at week 4 and continuing throughout the eight-week trial period.

When the data presented here are synthesized with those of previous meta-analyses investigating the biology and efficacy of massage therapy across multiple disorders, they suggest that massage may be beneficial, at least as an adjuvant treatment, for depressed patients interested in a manual alternative therapy ( 15 , 31 , 32 ).

Massage and Anxiety Symptoms and Disorders

Not surprisingly, similar to the findings about the use of complementary and alternative therapies for the treatment of depressive symptoms, massage and other complementary and alternative therapies are frequently used to treat symptoms of anxiety by the general population as well as by individuals with a host of different medical conditions ( 4 – 7 ). In fact, 43% of people who were treated in the National Institutes of Health–funded Coordinated Anxiety and Learning Management study reported using some type of complementary and alternative treatment for their anxiety disorder ( 33 ). These individuals met the DSM-IV criteria for generalized anxiety disorder, panic disorder, social anxiety disorder, or posttraumatic stress disorder. However, despite the high rate of use of complementary and alternative treatments for anxiety disorders as well as for symptoms of anxiety, very little systematic research has investigated massage therapy as a treatment for the anxiety disorders. Four published studies have investigated the use of massage for patients with generalized anxiety disorder. Billhult and Määttä ( 34 ) reported that eight women with generalized anxiety disorder who were treated twice weekly with one-hour massages had decreased feelings of anxiety and increased feelings of self-confidence associated with this open-label pilot treatment.

In contrast, Sherman and colleagues ( 35 ) compared and contrasted therapeutic massage with thermal therapy and relaxing room therapy for 10 sessions over a 12-week period. They reported that all three treatments were equally as effective in decreasing symptoms of anxiety. The patients in this study were allowed to be medicated and the treatment protocols were flexible in terms of the 10 intervention sessions. McPherson and McGraw ( 36 ) reported results of a multimodule intervention with 25 individuals with generalized anxiety disorder and comorbid disorders. In this multimodule therapy that included partner-assisted massage, they found significant reductions on the GAD-7, decreased anxiolytic medication use, and decreased pain scale ratings. In a randomized, single blind comparison of massage and light touch for patients with generalized anxiety disorder, Rapaport and colleagues found that the group randomized to twice-weekly Swedish massage therapy had significant improvements in both clinician and self-report ratings of anxiety ( 37 ). They further observed significant improvement in both clinician and self-report ratings of depression. There currently are no published studies evaluating massage as a treatment for posttraumatic stress disorder, social anxiety disorder, or panic disorder.

In conclusion, a growing body of evidence has suggested that massage may be a beneficial intervention either as an adjuvant or as a monotherapy for decreasing anxiety symptoms. The data demonstrating the efficacy of massage in specific psychiatric disorders are quite limited, and more rigorous studies are needed.

Evidence Supporting the Use of Massage for Other Psychiatric Symptom Clusters

A growing number of studies have suggested that a variety of massage interventions may facilitate greater sleep quality and sleep length for patients with primary and postpartum insomnia, insomnia and fatigue secondary to renal failure and hemodialysis, post–coronary bypass graft surgery sleep disturbance, and insomnia secondary to perimenopausal and postmenopausal symptoms ( 38 – 42 ). Massage therapy has also been linked to both improvement in sleep and improvement in behavior for patients with dementia ( 43 , 44 ). Other studies have also suggested that massage interventions may decrease anxiety and enhance mood in nursing home residents with cognitive impairment ( 45 , 46 ). The data on the use of massage therapy to decrease symptoms of autism are relatively limited ( 47 ), but one recently published trial of Qigong massage delivered by the parents of preschool children with autism reported improvement on measures of autism as well as in sensory and self-regulation responses ( 48 ). Although a comprehensive review of the complex literature investigating the relationship of decreasing pain and massage is beyond the scope of this review, data suggesting that massage may be useful in decreasing a variety of forms of musculoskeletal pain are increasing ( 49 – 51 ).

In summary, the extant, albeit limited, data on the relationships between the treatment of sleep, agitation, climacteric symptoms associated with menopause, and pain have suggested that massage may be helpful for at least some patients. Clearly, more rigorous study is needed before definitive conclusions can be reached about the value of massage therapy, especially in light of the marked variety of massage interventions and the cultural and societal factors influencing their use.

How Massage Therapists Conceptualize and Treat Clients With Psychiatric Complaints

Therapeutic massage is an intentionally holistic treatment approach that can complement the traditional practice of medicine. Massage therapy is not a substitute for traditional medical care, and the massage therapist cannot diagnose. The community practice of therapeutic massage has three basic themes: It is client centered, its practice has a formal structure, and factors influence practice ( 52 ). Establishing trust is the basis for a therapeutic relationship forged between practitioner and client. The emphasis on shared decision making in CIM empowers clients to take an active role in their health ( 53 ). A typical outline of activities involved in the practice of massage therapy includes ongoing assessment and evaluation, development of a treatment plan, treatment, health messages, documentation, and closure ( 52 ). Assessment starts when a client enters the treatment space; basic massage therapy education includes postural analysis and instruction in observing other cues such as breathing patterns. Massage therapists are trained to conceptualize health as a natural relaxed and aware state and any disease as an imbalance in that state. Accordingly, therapeutic massage assessment and treatment focuses on promoting interoceptive awareness (of both individuals in the therapeutic dyad), allowing the individual to feel more relaxed and comfortable in his or her body. The massage therapist may use special orthopedic assessment tests before continuing with a tactile assessment (often using broad holistic strokes to palpate the underlying tissues). An individualized treatment plan—including type of massage, session frequency, and session length—is developed on the basis of a combination of the client’s health history and current health status, balancing client goals with reality, referencing the best available evidence (research and resources such as pharmacology textbooks) and the massage therapist’s clinical expertise ( 52 , 54 ). Assessment of the client through conversation and nonverbal clues is continuous both during the session and after the session is completed.

The literature has no consensus regarding the optimal type of massage therapy, frequency of treatment, or length of the sessions. All modalities of massage therapy are performed with intention and presence, providing an opportunity for the client to interact with another human being (the massage therapist) in a safe environment. Initial contact with the patient during treatment allows the massage therapist to gauge surface tension or ease before systematically progressing deeper or working a larger area. Most massage therapists are trained in a variety of modalities, allowing them to choose the tools best suited to the client’s current needs. In a treatment session, the client is in control of his or her experience ( 54 ).

Few studies have reported attempts to identify clinically relevant massage therapy frequency and dose ( 17 , 55 , 56 ). In practice, considerations of budget, schedule, accessibility, and acuity of symptoms are considered in determining the individualized treatment plan. Massage therapists on our team who have a community practice generally recommend that sessions occur every 10–14 days. In follow-up interviews for a recent study on massage for cancer-related fatigue, several participants indicated that the positive effects of the sessions lasted for days beyond completion of treatment. This is consistent with Rapaport and colleagues’ findings that the biological effects of massage were sustained for at least a week after the last session ( 17 ), as well as with those of the study by Perlman and colleagues ( 55 ), who reported that the positive effects of a massage intervention were sustained throughout the follow-up period for their study of osteoarthritis of the knee.

Along with the aforementioned factors, session length depends on techniques used and could vary in length from 15 to 90 minutes. Relaxing and revitalizing techniques are used at the end of a treatment session and establish closure. Finally, an exit interview is conducted, which may include home care suggestions relevant to the massage experience. All sessions should be formally documented, typically using SOAP (subjective, objective, assessment, and plan) note format.

Two factors influence the practice of massage therapy in the community: scope of practice and professional standards and ethics ( 52 ). Massage therapy is often thought of as a treatment for soft tissue dysfunction (i.e., muscle aches, tightness, and pain). However, an individual massage therapist’s scope of practice depends on his or her training, education, and location of practice. Basic educational requirements for massage therapy vary from state to state, as do regulatory laws (which can also vary by municipality). A massage therapist may choose to specialize in a certain type of treatment or work with a particular population. The practice of therapeutic massage is not static but continues to evolve as parameters change ( 57 ). Participation in continuing education classes, professional meetings, and experience continually shapes and refines a massage therapist’s practice and potentially expands the scope of practice.

Professional massage therapy organizations maintain and refine a repository of professional standards and ethics statements to guide the practice of massage therapy ( https://www.amtamassage.org/articles/3/MTJ/detail/2493 ). In the case of a client currently in the care of a psychiatrist, collaboration between the psychiatrist and the massage therapist may be beneficial in establishing boundaries to preserve safety of the client and the massage therapist.

How Psychiatrists and Massage Therapists Can Work Together

Many individuals with psychiatric disorders are already using CIM. A mail survey of adults with serious mental illness found that 31% of respondents reported using massage therapy ( 58 ). A starting point may be to begin by asking which of your existing clients uses massage therapy, which massage therapist they frequent, and what the massage therapist’s intake process entails. This query may lead the psychiatrist to seek out massage therapy to better understand available treatment options, but it may also prove helpful in identifying characteristics of individuals who may benefit most from referrals to therapeutic massage.

Communication is key to facilitating collaboration and ensuring that the patient is given consistent messages. Collaboration between psychiatrists and massage therapists can yield an integrated approach that capitalizes on the benefits of both forms of treatment while incorporating patient preferences and priorities. In addition, collaboration can expand treatment options, potentially allowing patients to have a more active role in their health care. Therapeutic massage invites a patient to actively engage in optimizing his or her mind-body awareness. The massage therapist serves as a witness to changes the patient undergoes through treatment, both conventional and complementary or integrative. Massage therapy is best viewed as an adjunct therapy rather than as an alternative to conventional treatment.

Identification of a well-suited massage therapist to add to your professional network can be accomplished through word of mouth or professional associations. For a successful partnership, the massage therapist will have a treatment philosophy that aligns with the physician’s treatment philosophy and a basic understanding of psychiatric disorders. Professional massage therapy organizations offer massage therapist locator services, and these services only list members in good standing ( https://www.amtamassage.org/findamassage/index.html )

In closing, patients accept and commonly use complementary and integrative therapies. They frequently seek out massage therapy to treat symptoms of depression and anxiety. Although data have suggested that massage may help decrease problems with depressed mood or acute anxiety, less information is available regarding the use of massage as a therapy for depression or anxiety disorders. Current data do suggest that massage may have some benefit as at least an adjuvant to conventional therapies. Although the data are limited, some findings have suggested that massage may acutely decrease hypothalamic-pituitary-adrenal activity, have a positive effect on immune function, enhance parasympathetic tone, and modulate brain circuitry. The approach and philosophy of well-trained massage therapists is complementary to conventional psychiatric training and can thus be an important additional resource in treating patients. A respectful and collaborative approach to care may truly help patients.

Dr. Schettler reports being a statistical analysis consultant to LivaNova. Dr. Nettles reports participation in the Novartis Employees Retirement Fund, being a consultant to Wolf Greenfield—Boston Drug Discovery IP, and serving as an expert witness. Dr. Rapaport, Ms. Larson, Mr. Carroll, Ms. Sharenko, and Dr. Kinkead report no financial relationships with commercial interests.

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• The skin‐brain connection and pleasant touch as supportive care for psychocutaneous disorders 1 December 2023 | Skin Health and Disease, Vol. 4, No. 1
• Effect of massage on blood pressure in patients with hypertension: A meta-analysis Journal of Bodywork and Movement Therapies, Vol. 37
• Patient Attitudes and Perceived Barriers Toward Mental Health Treatment Options in a Rural Student-Run Clinic Cureus, Vol. 4
• Utilization of massage chairs for promoting overall health and wellness: A rapid scoping review EXPLORE, Vol. 31
• Effects of aromatherapy on depression: A meta-analysis of randomized controlled trials General Hospital Psychiatry, Vol. 84
• Effects of Massages and Other Touch Interventions on Various Diseases 28 October 2023
• AIM in Alternative Medicine 1 January 2022
• Berührung ein Lebensmittel: Einfluss auf die körperliche und geistige Gesundheit 12 May 2022
• The Effect of Foot Reflexology on Amnesia in Patients Undergoing Electroconvulsive Therapy: A Randomized Clinical Trial 28 February 2021 | Journal of Caring Sciences, Vol. 10, No. 1
• Touch Research–Quo Vadis? A Plea for High-Quality Clinical Trials 28 December 2020 | Brain Sciences, Vol. 11, No. 1
• AIM in Alternative Medicine 11 August 2021
• A reformulated contextual model of psychotherapy for treating anxiety and depression Clinical Psychology Review, Vol. 80
• Model structure for protocol adherence utilizing a manualized therapeutic massage intervention 12 October 2018 | Journal of Complementary and Integrative Medicine, Vol. 16, No. 2
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• complementary and integrative medicine

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Massage Therapy for Psychiatric Disorders

This article reviews the role of massage therapy in the treatment of common psychiatric disorders and briefly discusses the prevalence and popularity of complementary and integrative treatments in the general population and touches on the literature on the biology and neurobiology of massage therapy.

This article reviews the current state of knowledge of the role of massage therapy in the treatment of common psychiatric disorders and symptoms. It briefly discusses the prevalence of psychiatric disorders and the popularity of complementary and integrative treatments in the general population. The authors touch on the growing literature describing the biology and neurobiology of massage therapy. The impact of massage as both a therapy for major psychiatric disorders and a treatment for psychiatric symptoms is reviewed, and how massage therapists conceptualize and treat their patients with psychiatric complaints is discussed. If psychiatrists are going to partner with massage therapists, they need to understand how massage therapists’ perspectives differ from those of traditional practitioners of allopathic medicine. A model of how psychiatrists and other mental health professionals can work with massage therapists to care for patients is proposed, followed by a summary of the article’s key points.

Of the top 25 disorders associated with years lost because of disability, seven are major psychiatric disorders ( 1 ). Major depression is the second leading cause of years living with disability in the world, anxiety disorders are the ninth leading cause, and schizophrenia is the 11th leading cause. Thus, major psychiatric syndromes are clearly associated with a major cost to society. Major psychiatric syndromes are also remarkably prevalent. One in four individuals will have a major psychiatric syndrome at some point in their lifetime ( 2 ). This means that everyone knows someone with a major psychiatric disorder, and every family is touched by the presence of these diseases. Despite significant advances toward both understanding the neuroscience of and developing new psychotherapies and pharmacotherapies to treat these disorders, a great unmet treatment need still exists. Using major depressive disorder as an example, we know from the National Institute of Mental Health–funded Sequenced Treatment Alternatives to Relieve Depression study that only one-third of individuals go into remission with initial treatment for depression ( 3 ). Furthermore, although close to two-thirds may enter remission with multiple successive treatments, the majority of these individuals will relapse within one year of reaching remission status ( 3 ). Thus, there is clearly a need for additional options to treat people with depression. It is reasonable to extrapolate from depression to other psychiatric disorders for which there are even fewer available treatment options. We contend that approaches to identifying potential treatment interventions for patients need to be broadened.

Systematic investigation into the popularity of complementary and alternative medicine (CAM) for treatment in the United States began in 1990 with the survey spearheaded by Eisenberg and colleagues ( 4 ). In this initial report in the New England Journal of Medicine, they documented that 33.8% of the adults surveyed had used some type of alternative or complementary medical service in the past 12 months. These findings were a revelation to most individuals in traditional Western or allopathic medical communities. Eisenberg and colleagues followed this report with a paper that compared and contrasted their 1990 data with those from a survey conducted in 1997 ( 5 ). This later publication documented an increase in the use of alternative therapies from 33.8% to 42.0%, with herbal medicine, massage, megavitamins, self-help groups, folk remedies, homeopathy, and energy healing increasing the most. They reported that some of the most frequent reasons for using complementary and alternative therapies included back pain, anxiety, depression, and headaches. In the 1997 paper, they estimated that the cost for services provided was $21.2 billion, with at least $12.2 billion being paid out of pocket. These initial findings by Eisenberg and colleagues were updated in the 2002 and 2007 Centers for Disease Control and Prevention–sponsored CAM surveys. In both of these surveys ( 6 , 7 ), approximately 40% of adults reported having used some type of complementary and alternative therapy in the past 12 months. Also, both of these surveys indicated that approximately 5% of the U.S. adult population had used massage therapy. Purohit and colleagues ( 8 ) performed a reanalysis of the 2007 National Health Interview data of 23,393 adults that focused on the presence of neuropsychiatric symptoms and their impact on CAM usage. The prevalence of the use of CAM therapies was 43.78% for individuals with self-reported symptoms of depression, insomnia, headaches, memory deficits, attention deficits, and sleep problems versus 29.7% for individuals who did not report any of these symptoms. Of those individuals with at least one neuropsychiatric symptom who used CAM therapies, 20% used CAM therapy because they felt that standard treatments were either too expensive or ineffective, and 25% used CAM therapies because they were recommended by their traditional medical provider.

In conclusion, there is an interface between psychiatric disorders and complementary and alternative therapies such as massage. Accordingly, validated alternative therapies are now being integrated within the medical mainstream under the rubric “complementary and integrative medicine” (CIM). Consistent with this, and reflecting an emphasis on well-being and treatment of disease, the National Institutes of Health have renamed the center addressing CAM therapies the National Center for Complementary and Integrative Health. Psychiatric disorders are common and disabling, and current treatment methods, although helpful for many, are not the treatment of choice for many patients and are insufficient to alleviate disability and suffering for many others. This suggests that allopathic practitioners should think about two questions: What is the body of evidence supporting CIM interventions, and what is the best way for a psychiatrist or other mental health service provider and a CIM practitioner to interact with each other in the care of a patient? We address these two important issues.

Biology of Massage

Rigorous study of the biology of therapeutic massage is still in a relatively nascent phase. Although studies have attempted to understand the impact of various forms of massage on the body since the early 1990s, the research has been fraught with problems, in particular a lack of consistent funding for investigation of the biological effects of massage. Another challenge faced by the field is that there are many different types of massage and great variation in research study designs. As a result, current knowledge of the biology of massage rests mainly on a number of small studies investigating very different interventions that have been done for different lengths of time and at different frequencies. Despite these limitations, certain biological patterns seem to have emerged from recent studies.

Human Studies of the Neurobiology of Massage

A few EEG and imaging studies have investigated the impact of massage on brain circuitry or brain regions. One of the first studies was performed by the Touch Institute. In this study, 26 adults were given chair massage for 15 minutes twice weekly for five weeks, and 24 adults were asked to sit quietly in the massage chair twice weekly for five weeks ( 9 ). Field and colleagues found that twice-weekly massage was associated with an increase in frontal delta power in the EEG and a decrease in frontal alpha and beta power. This pattern is consistent with increased relaxation yet enhanced alertness, which was supported by the massage group’s having increased speed and accuracy on mathematical computations and decreased levels of anxiety. Salivary cortisol levels were also lower in the massage condition but not in the control condition. In a study of an aromatherapy massage intervention versus no treatment, Wu and colleagues ( 10 ) were able to replicate an increase in alpha wave activity in their aromatherapy massage sample, but they found a reduction in delta wave activity. However, they reported decreases in state anxiety and depression and an increase in psychological well-being as well as a reduction in salivary cortisol levels and an increase in plasma brain-derived neurotrophic factor in the aromatherapy group.

Neuroimaging studies investigating the impact of massage on the brain have been limited. In a small positron emission tomography study in 2006, Ouchi and colleagues ( 11 ) reported that being placed in the scanner in a prone position versus a supine position caused increased activation in the precuneus. This activation was further enhanced by both four minutes and 20 minutes of palm pressure massage applied to participants’ backs. The 20 minutes of massage also caused a greater increase in parasympathetic tone as well as activation of the parieto-occipital region. Ouchi and colleagues also reported activation in the cerebellum associated with massage. The authors concluded that this pattern of activation of the precuneus with back massage might reflect augmentation of arousal in consciousness functions associated with positive affect and that their findings of increased activity in the forebrain-amygdala system might be responsible for an increase in parasympathetic tone in the brain. The latter would also be consistent with a cerebellar increase in blood flow, which again would help regulate parasympathetic tone. These findings were partially replicated and extended by Sliz and colleagues ( 12 ), who looked at the neurocorrelates of a single session of massage versus those of a resting control condition, reflexology and massage with an object. They found that Swedish massage of the right foot while the participant performed a cognitive task in the scanner was associated with increased activation of the subgenual anterior and retrosplenial-posterior cingulate cortices. This increased activation of the retrosplenial-posterior cingulate cortex was sustained even without activation by the task.

If one integrates these findings investigating the impact of massage with those of a series of elegant studies that have been performed to attempt to understand the basic neurobiology of touch, one can come up with unifying theory of the impact of massage on the brain. An MRI study by Golaszewski and colleagues ( 13 ) demonstrated that vibrating tactile stimulation of the plantar surface of the foot increased activity in the inferior and posterior cingulate gyri along with the somatosensory cortex, insula, thalamus, caudate, and cerebellum. These brain regions integrate tactile and sensory information from mechanoreceptors, the myelinated A-beta and A-alpha afferents, and the unmyelinated sensory nerve fibers called c-tactile afferents that are thought to be associated with positive affect. The c-tactile afferents are stimulated by gentle stroking of hairy skin surfaces. They project to the limbic cortex, including the orbital frontal cortex and posterior insulate bilaterally.

In summary, although the data on the impact of massage on EEG and neuroimaging changes in the brain are limited, when these data are combined with the emerging data on somatic sensory pleasure circuitry, it is reasonable to postulate that massage’s beneficial effects on affiliation and feelings of well-being may be due to stimulation of specific brain circuits involved in pleasure and reward ( 14 ).

Impact of Massage on the Hypothalamic-Pituitary-Adrenal Axis and Neurohormones

A myriad of small studies of massage have measured either salivary or plasma cortisol levels. Many of these studies investigated only single time-point measures of cortisol before and after a series of massage interventions. The consensus of existing meta-analyses as well as of this review is that massage tends to decrease measures of plasma and salivary cortisol versus either a wait-list or a no-treatment condition ( 15 ). However, in general these studies have not looked at the sustained impact of massage after cessation of treatment. Rapaport and colleagues ( 16 ) have compared and contrasted the impact of a single 45-minute session of manualized Swedish massage with that of a manualized light-touch control condition in adults with no psychiatric disorder. They sampled cortisol, oxytocin, vasopressin, and adrenocorticotropic hormone after a 30-minute accommodation period at two points before initiation of massage or touch and then at several time points during the hour after the intervention. These authors found that a single session of either massage or touch was associated with a small effect-size decrease in cortisol levels in healthy young participants as well as a large effect-size increase in oxytocin in both groups. However, compared with changes found in cortisol and oxytocin, the massage group showed a profound significant decrease in vasopressin compared with the touch control group.

In a subsequent study, Rapaport and colleagues investigated the impact of weekly massage versus weekly touch for five weeks, as well as the impact of twice-weekly massage or twice-weekly touch for five weeks ( 17 ). Weekly massage versus weekly touch was associated with a pattern of results similar to that observed with a single session of massage. However, twice-weekly massage caused a significantly greater cumulative increase in oxytocin and decrease in vasopressin than twice-weekly touch. Although these data are of interest and consistent with previous studies reporting a decrease in cortisol levels and an increase in sense of affiliation associated with massage, these small studies require replication with larger cohorts of participants.

In summary, data suggest that massage may be associated with a decrease in hypothalamic-pituitary-adrenal activation and possibly with an increase in oxytocin levels. However, larger rigorous studies are needed.

Impact of Massage on the Immune System

A great deal of the pioneering work investigating the relationship between massage and the immune system occurred at the University of Miami. This group investigated the impact of massage on immune function in a variety of different patient populations including depressed individuals, HIV-positive young women, and HIV-positive adolescents ( 18 – 20 ). In general, this group reported an increase in natural killer (NK) cells and an increase in NK cell activity associated with massage compared with control conditions such as muscle relaxation. Rapaport and colleagues reported that a single session of Swedish massage versus a touch control condition caused a leukocytosis with a moderate effect-size increase in CD56+ NK cells and an increase in activated T cells ( 16 ). They have also reported that massage was associated with a significant decrease in Type 2 T helper (TH2) mitogen-stimulated cytokines compared with both baseline levels and the touch control condition ( 16 ). Massage was also associated with a decrease in mitogen-stimulated proinflammatory cytokine production when contrasted with the touch control condition. In 2012, Rapaport and colleagues reported that these effects were sustained for at least one week and that they were specific to individuals who received one massage per week in contrast to the groups receiving two massages per week ( 17 ). These findings are consistent with a report by Donoyama and Ohkoshi ( 21 ), who reported that two healthy female participants had an increase in gene expressions associated with immune response in the immune system compared with a 40-minute resting control condition. These findings are also consistent with work that has been done to investigate the local impact of massage on muscles that have been injured during exercise ( 22 ). Consistent with reports of both a single session of massage and repeated massage on TH2 cytokine production is a paper by Loft and colleagues that reports that massage decreased antibody responses after hepatitis B vaccination ( 23 ). In summary, although these findings require replication, they suggest that massage may affect the immune system in a way that enhances immune surveillance and NK cell activity while decreasing inflammation and TH2-type responses.

Summary of the Biology of Massage

In summary, although much more extensive investigation of the neurobiology of massage is needed, the data suggest that there is a parsimonious way of conceptualizing the mechanisms underlying its beneficial effects. The brain circuitry stimulated by c fibers is associated with feelings of positive affect and well-being. Massage also stimulates brain circuits involved in the control of sympathetic and parasympathetic activity, with an enhancement of parasympathetic tone. These effects could in turn lead to a decrease in stress response as well as modulation of certain aspects of immune function, such as a decrease in inflammatory response. Thus, it is possible to synthesize the existing data regarding the biology of massage into a cogent working hypothesis about its benefits for certain psychiatric disorders.

Massage, Depression, and Depressive Symptoms

As previously discussed, the use of CAM to treat depressive symptoms and major depression is common ( 5 , 24 ). A reanalysis of a national survey by Kronenberg and colleagues ( 25 , 26 ) that focused on 220 women with depression who were part of a national telephone survey of 3,060 women indicated that 54% of the depressed women reported using CAM in the past year and that half of those respondents indicated that they used some form of manual therapy. Despite the clear data suggesting that many patients with major depression or depressive symptoms are interested in CIM therapies and, in particular, manual therapies, the data have significant limitations. A meta-analysis by Coelho and colleagues ( 27 ) reviewed 595 articles and excluded all but four from their meta-analysis of massage therapy for treatment of major depression or depressive symptoms. A more recent meta-analysis of massage therapy for depressed people by Hou and colleagues ( 28 ) used less stringent criteria and identified 17 studies with 786 participants from among 246 references. This meta-analysis included many studies whose participants were recruited because of a primary disorder other than depression, including insomnia, breast cancer, fibromyalgia, HIV infection, and low back pain. They concluded that these clinical trials were of moderate quality and that the pooled standardized mean differences from fixed and random effects models were .76 and .73, respectively. However, they cautioned that these 17 studies had considerable heterogeneity and that standardized protocols for massage therapy are needed, using validated depression scales with larger and more homogeneous participant populations.

In a comprehensive review of the use of CAM for perinatal depression, Deligiannidis and Freeman ( 29 ) suggested that a growing body of literature supports the use of antenatal massage therapy either in combination with psychotherapy or as a monotherapy to treat pregnant women with mild depressive symptomatology. Poland and colleagues ( 30 ) published results of a randomized, parallel-group, open-label controlled trial of massage versus light touch and wait-list control for the treatment of major depressive disorder in individuals infected with HIV. They reported that twice-weekly massage therapy was effective in decreasing depressive symptoms as measured by both the Hamilton Depression Rating Scale and the Beck Depression Inventory, beginning at week 4 and continuing throughout the eight-week trial period.

When the data presented here are synthesized with those of previous meta-analyses investigating the biology and efficacy of massage therapy across multiple disorders, they suggest that massage may be beneficial, at least as an adjuvant treatment, for depressed patients interested in a manual alternative therapy ( 15 , 31 , 32 ).

Massage and Anxiety Symptoms and Disorders

Not surprisingly, similar to the findings about the use of complementary and alternative therapies for the treatment of depressive symptoms, massage and other complementary and alternative therapies are frequently used to treat symptoms of anxiety by the general population as well as by individuals with a host of different medical conditions ( 4 – 7 ). In fact, 43% of people who were treated in the National Institutes of Health–funded Coordinated Anxiety and Learning Management study reported using some type of complementary and alternative treatment for their anxiety disorder ( 33 ). These individuals met the DSM-IV criteria for generalized anxiety disorder, panic disorder, social anxiety disorder, or posttraumatic stress disorder. However, despite the high rate of use of complementary and alternative treatments for anxiety disorders as well as for symptoms of anxiety, very little systematic research has investigated massage therapy as a treatment for the anxiety disorders. Four published studies have investigated the use of massage for patients with generalized anxiety disorder. Billhult and Määttä ( 34 ) reported that eight women with generalized anxiety disorder who were treated twice weekly with one-hour massages had decreased feelings of anxiety and increased feelings of self-confidence associated with this open-label pilot treatment.

In contrast, Sherman and colleagues ( 35 ) compared and contrasted therapeutic massage with thermal therapy and relaxing room therapy for 10 sessions over a 12-week period. They reported that all three treatments were equally as effective in decreasing symptoms of anxiety. The patients in this study were allowed to be medicated and the treatment protocols were flexible in terms of the 10 intervention sessions. McPherson and McGraw ( 36 ) reported results of a multimodule intervention with 25 individuals with generalized anxiety disorder and comorbid disorders. In this multimodule therapy that included partner-assisted massage, they found significant reductions on the GAD-7, decreased anxiolytic medication use, and decreased pain scale ratings. In a randomized, single blind comparison of massage and light touch for patients with generalized anxiety disorder, Rapaport and colleagues found that the group randomized to twice-weekly Swedish massage therapy had significant improvements in both clinician and self-report ratings of anxiety ( 37 ). They further observed significant improvement in both clinician and self-report ratings of depression. There currently are no published studies evaluating massage as a treatment for posttraumatic stress disorder, social anxiety disorder, or panic disorder.

In conclusion, a growing body of evidence has suggested that massage may be a beneficial intervention either as an adjuvant or as a monotherapy for decreasing anxiety symptoms. The data demonstrating the efficacy of massage in specific psychiatric disorders are quite limited, and more rigorous studies are needed.

Evidence Supporting the Use of Massage for Other Psychiatric Symptom Clusters

A growing number of studies have suggested that a variety of massage interventions may facilitate greater sleep quality and sleep length for patients with primary and postpartum insomnia, insomnia and fatigue secondary to renal failure and hemodialysis, post–coronary bypass graft surgery sleep disturbance, and insomnia secondary to perimenopausal and postmenopausal symptoms ( 38 – 42 ). Massage therapy has also been linked to both improvement in sleep and improvement in behavior for patients with dementia ( 43 , 44 ). Other studies have also suggested that massage interventions may decrease anxiety and enhance mood in nursing home residents with cognitive impairment ( 45 , 46 ). The data on the use of massage therapy to decrease symptoms of autism are relatively limited ( 47 ), but one recently published trial of Qigong massage delivered by the parents of preschool children with autism reported improvement on measures of autism as well as in sensory and self-regulation responses ( 48 ). Although a comprehensive review of the complex literature investigating the relationship of decreasing pain and massage is beyond the scope of this review, data suggesting that massage may be useful in decreasing a variety of forms of musculoskeletal pain are increasing ( 49 – 51 ).

In summary, the extant, albeit limited, data on the relationships between the treatment of sleep, agitation, climacteric symptoms associated with menopause, and pain have suggested that massage may be helpful for at least some patients. Clearly, more rigorous study is needed before definitive conclusions can be reached about the value of massage therapy, especially in light of the marked variety of massage interventions and the cultural and societal factors influencing their use.

How Massage Therapists Conceptualize and Treat Clients With Psychiatric Complaints

Therapeutic massage is an intentionally holistic treatment approach that can complement the traditional practice of medicine. Massage therapy is not a substitute for traditional medical care, and the massage therapist cannot diagnose. The community practice of therapeutic massage has three basic themes: It is client centered, its practice has a formal structure, and factors influence practice ( 52 ). Establishing trust is the basis for a therapeutic relationship forged between practitioner and client. The emphasis on shared decision making in CIM empowers clients to take an active role in their health ( 53 ). A typical outline of activities involved in the practice of massage therapy includes ongoing assessment and evaluation, development of a treatment plan, treatment, health messages, documentation, and closure ( 52 ). Assessment starts when a client enters the treatment space; basic massage therapy education includes postural analysis and instruction in observing other cues such as breathing patterns. Massage therapists are trained to conceptualize health as a natural relaxed and aware state and any disease as an imbalance in that state. Accordingly, therapeutic massage assessment and treatment focuses on promoting interoceptive awareness (of both individuals in the therapeutic dyad), allowing the individual to feel more relaxed and comfortable in his or her body. The massage therapist may use special orthopedic assessment tests before continuing with a tactile assessment (often using broad holistic strokes to palpate the underlying tissues). An individualized treatment plan—including type of massage, session frequency, and session length—is developed on the basis of a combination of the client’s health history and current health status, balancing client goals with reality, referencing the best available evidence (research and resources such as pharmacology textbooks) and the massage therapist’s clinical expertise ( 52 , 54 ). Assessment of the client through conversation and nonverbal clues is continuous both during the session and after the session is completed.

The literature has no consensus regarding the optimal type of massage therapy, frequency of treatment, or length of the sessions. All modalities of massage therapy are performed with intention and presence, providing an opportunity for the client to interact with another human being (the massage therapist) in a safe environment. Initial contact with the patient during treatment allows the massage therapist to gauge surface tension or ease before systematically progressing deeper or working a larger area. Most massage therapists are trained in a variety of modalities, allowing them to choose the tools best suited to the client’s current needs. In a treatment session, the client is in control of his or her experience ( 54 ).

Few studies have reported attempts to identify clinically relevant massage therapy frequency and dose ( 17 , 55 , 56 ). In practice, considerations of budget, schedule, accessibility, and acuity of symptoms are considered in determining the individualized treatment plan. Massage therapists on our team who have a community practice generally recommend that sessions occur every 10–14 days. In follow-up interviews for a recent study on massage for cancer-related fatigue, several participants indicated that the positive effects of the sessions lasted for days beyond completion of treatment. This is consistent with Rapaport and colleagues’ findings that the biological effects of massage were sustained for at least a week after the last session ( 17 ), as well as with those of the study by Perlman and colleagues ( 55 ), who reported that the positive effects of a massage intervention were sustained throughout the follow-up period for their study of osteoarthritis of the knee.

Along with the aforementioned factors, session length depends on techniques used and could vary in length from 15 to 90 minutes. Relaxing and revitalizing techniques are used at the end of a treatment session and establish closure. Finally, an exit interview is conducted, which may include home care suggestions relevant to the massage experience. All sessions should be formally documented, typically using SOAP (subjective, objective, assessment, and plan) note format.

Two factors influence the practice of massage therapy in the community: scope of practice and professional standards and ethics ( 52 ). Massage therapy is often thought of as a treatment for soft tissue dysfunction (i.e., muscle aches, tightness, and pain). However, an individual massage therapist’s scope of practice depends on his or her training, education, and location of practice. Basic educational requirements for massage therapy vary from state to state, as do regulatory laws (which can also vary by municipality). A massage therapist may choose to specialize in a certain type of treatment or work with a particular population. The practice of therapeutic massage is not static but continues to evolve as parameters change ( 57 ). Participation in continuing education classes, professional meetings, and experience continually shapes and refines a massage therapist’s practice and potentially expands the scope of practice.

Professional massage therapy organizations maintain and refine a repository of professional standards and ethics statements to guide the practice of massage therapy ( https://www.amtamassage.org/articles/3/MTJ/detail/2493 ). In the case of a client currently in the care of a psychiatrist, collaboration between the psychiatrist and the massage therapist may be beneficial in establishing boundaries to preserve safety of the client and the massage therapist.

How Psychiatrists and Massage Therapists Can Work Together

Many individuals with psychiatric disorders are already using CIM. A mail survey of adults with serious mental illness found that 31% of respondents reported using massage therapy ( 58 ). A starting point may be to begin by asking which of your existing clients uses massage therapy, which massage therapist they frequent, and what the massage therapist’s intake process entails. This query may lead the psychiatrist to seek out massage therapy to better understand available treatment options, but it may also prove helpful in identifying characteristics of individuals who may benefit most from referrals to therapeutic massage.

Communication is key to facilitating collaboration and ensuring that the patient is given consistent messages. Collaboration between psychiatrists and massage therapists can yield an integrated approach that capitalizes on the benefits of both forms of treatment while incorporating patient preferences and priorities. In addition, collaboration can expand treatment options, potentially allowing patients to have a more active role in their health care. Therapeutic massage invites a patient to actively engage in optimizing his or her mind-body awareness. The massage therapist serves as a witness to changes the patient undergoes through treatment, both conventional and complementary or integrative. Massage therapy is best viewed as an adjunct therapy rather than as an alternative to conventional treatment.

Identification of a well-suited massage therapist to add to your professional network can be accomplished through word of mouth or professional associations. For a successful partnership, the massage therapist will have a treatment philosophy that aligns with the physician’s treatment philosophy and a basic understanding of psychiatric disorders. Professional massage therapy organizations offer massage therapist locator services, and these services only list members in good standing ( https://www.amtamassage.org/findamassage/index.html )

In closing, patients accept and commonly use complementary and integrative therapies. They frequently seek out massage therapy to treat symptoms of depression and anxiety. Although data have suggested that massage may help decrease problems with depressed mood or acute anxiety, less information is available regarding the use of massage as a therapy for depression or anxiety disorders. Current data do suggest that massage may have some benefit as at least an adjuvant to conventional therapies. Although the data are limited, some findings have suggested that massage may acutely decrease hypothalamic-pituitary-adrenal activity, have a positive effect on immune function, enhance parasympathetic tone, and modulate brain circuitry. The approach and philosophy of well-trained massage therapists is complementary to conventional psychiatric training and can thus be an important additional resource in treating patients. A respectful and collaborative approach to care may truly help patients.

Dr. Schettler reports being a statistical analysis consultant to LivaNova. Dr. Nettles reports participation in the Novartis Employees Retirement Fund, being a consultant to Wolf Greenfield—Boston Drug Discovery IP, and serving as an expert witness. Dr. Rapaport, Ms. Larson, Mr. Carroll, Ms. Sharenko, and Dr. Kinkead report no financial relationships with commercial interests.