DOES MASSAGE THERAPY HAVE A PLACE IN THE MANAGEMENT OF ARTHRITIS?

‘If it hurts, rub it better’ is a course of action that has felt natural for probably as long as humans have existed. However, in these days of evidence-based therapy, we have to have clinical proof that a treatment works. If you are a regular reader of Co-Kinetic’s Journal Watch, you will know how difficult it is to find a good-quality study of massage, and massage seems to have fallen off the list of therapies for arthritis largely because of this. But we all know that absence of evidence is not evidence of absence. Reading this article, combined with knowing your arthritis patients, will help you to decide whether massage can be part of a treatment plan for those individuals. Read this article online http://bit.ly/3mtcrbw

Osteoarthritis

Of the different types of arthritis, osteoarthritis (OA) is the most common form affecting more than 300 million people worldwide. OA is the leading cause of disability in older adults, with the knee, hip and hands being the most commonly affected joints. Pathology may involve the whole joint, including cartilage degradation, bone remodelling, osteophyte formation and synovial inflammation. This leads to pain, stiffness, swelling and loss of normal joint function.

OA may span decades of a patient's life. During this time patients are likely to be treated with a range of pharmaceutical and nonpharmaceutical interventions, often in combination. Finding the right treatment for a patient may depend on the individual, the extent of their OA, and their socioeconomic situation. Some treatment recommendations are specific to a particular joint, whereas others are particular to a patient population (eg. those with erosive OA). Therapies recommended for the management of OA are shown in 'Figure 1. Recommended therapies for the management of osteoarthritis (OA)'

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(https://bit.ly/3ZmMMQw) in Kolasinski et al. and are based on the strength of scientific evidence from randomised controlled clinical trials (1*).

Recommendations for OA treatment assume the appropriate application of physical, psychological, and/or pharmacologic therapies by an appropriate provider. For some patients at some time points, a single intervention may be adequate to control their symptoms; for others, multiple interventions may be used in sequence or in combination. These treatment options are listed in Figure 1 mentioned above and in 'Table 1. Recommendations for physical, psychosocial, and mind-body approaches for the management of osteoarthritis of the hand, knee, and hip' (https://bit.ly/3ZmMMQw), both in Kolasinski et al. (1*). What is evident is that massage therapy does not feature as a recommended treatment option in managing OA. In fact, in certain cases, the advice may be against the use of it in the management of OA.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is also common, affecting joints – especially of

By Kathryn Thomas BSc MPhil

All references marked with an asterisk are open access and links are provided in the reference list the upper limbs (hands, wrist, elbow and shoulder). RA is defined as a systemic, idiopathic, inflammatory and autoimmune disease. It is three times more common in women than in men, most often affecting the 40–50-year age bracket. Symptoms of RA include chronic pain, swelling in the joints, loss of joint function, stiffness and often deformity. The joint inflammation, which leads to the symptoms listed above, can result in disability, psychosocial issues, mobility problems and a poor quality of life or poor sense of wellbeing.

Pharmacological interventions for RA include anti-inflammatory medications, anti-rheumatic medications, and analgesics. Longterm, frequent use of pharmaceutical medication and other invasive procedures (for example injections and joint replacements) for managing chronic pain can lead to further complications and stress. Complementary therapies have been reported to be useful, these may include (but not be limited to) exercise therapy, manual therapy, devices, hydrotherapy, acupuncture, education and massage. Evidence indicates that massage is a frequent complementary therapy used in the management of chronic conditions, especially chronic pain conditions (2,3*).

Likewise, the most recent guidelines published by Peter et al. for physical therapy management of RA stated that “the cornerstones of physical therapist treatment for people with RA are active exercise therapy in combination with education, whereas passive interventions play a subordinate role” (4*). They state that, based on systematic literature searches, the following non-active exercise interventions are not recommended: electrotherapy (including transcutaneous electrical nerve stimulation), low-level laser therapy, ultrasound, massage (evidence absent), thermotherapy (evidence absent), medical taping (evidence absent), and dry needling (evidence absent). These recommendations align with the use of treatment modalities in the Choose Wisely campaign of the American Physical Therapy Association (4*,5*).

Studying the Effect of Massage

Massage therapy encompasses a number of techniques aimed at affecting muscle and other soft tissue. Clinical trials assessing massage efficacy have suffered from a high risk of bias, small sample sizes, and have not demonstrated significant benefits for arthritis outcomes. Massage may be more effective than non-active management but has not been shown to be superior to other recommended treatments (6). Studies often use massage in combination with other modalities which ‘muddies the water’ on its efficacy. It should be noted, however, that some studies have shown positive outcomes and minimal risk and the authors felt strongly that massage therapy was beneficial for symptom management (7*). However, based on the available evidence regarding OA and RA, there remains a conditional recommendation against the use of massage for the reduction of arthritis symptoms because of lowor moderate-quality evidence.

So Where Does that Leave Massage Therapy?

Therapeutic massage is a treatment that can be performed in a number of ways, with contrasting techniques. The modality can be offered to patients almost anywhere, requires no special equipment and has a low likelihood of any serious harm – making it easily accessible and affordable. Massage therapy itself can encompass many techniques, the type, pressure and time may depend on the patient’s needs or tolerance (3*).

As stated above, massage therapy has been the subject of hundreds of clinical trials and dozens of systematic reviews, with varying results. Some outcomes show treatment efficacy in managing certain conditions or alleviating pain, whereas others have found massage not to be effective, or with unclear benefit to the patient. It can be difficult to interpret the breadth and depth of evidence, as various painful conditions may respond differently to therapeutic massage, and distinct types of massage involve unique approaches to manipulating muscles and soft tissue with varying results. There is a general bias in massage-based clinical trials, as providing a ‘placebo’ is challenging. Massage is often compared to other treatments or no treatment/ intervention or combined with other therapies, making it challenging to identify its relative efficacy.

When treating any patient, particularly one with a chronic condition (such as arthritis) where the relationship will be ongoing, the personal beliefs and preferences of the patient need to be considered, not to mention their socioeconomic situation. The choice of treatment will impact their physical, psychological, and mind–body response. In addition to pain and functional limitations arising from arthritis and/or comorbidities, symptoms including mood disorders, such as depression and anxiety, altered sleep, chronic widespread pain, and impaired coping skills may manifest (1*).

Thus, a multimodal treatment option, rather than a single modality (eg. medication or exercise or bracing or heat therapy), should be chosen to best address the patient’s needs. Measures aimed at improving mood, reducing stress, addressing insomnia, managing weight, and enhancing fitness may improve the patient's overall well-being. Indeed, interventions that have proven beneficial in the management of chronic pain may prove useful in managing arthritis (1*).

‘Figure 2. Evidence map of systematic reviews describing the effect of massage for pain’ (https://bit.ly/3JgfwER) in Miake-Lye et al. displays 49 systematic reviews of massage therapy (3*). The bubble label represents the pain indication in that review, and the bubble size denotes the number of primary studies included in the review specifically related to massage for pain. Each bubble was plotted according to the strength of the findings for massage for pain (y-axis,) and the effect massage had on pain (x-axis) (3*).

Although the map highlights gaps in the evidence as well as the lack of moderate- to high-strength clinical findings, a number of highquality systematic reviews reached low-strength findings that massage offers potential benefits for pain indications, and that massage can be beneficial across multiple conditions (3*). The effect of simple human touch, particularly in the alleviation of pain, is one of the oldest approaches to healing known to humankind (8*).

A pilot study of massage therapy for OA of the knee found that biweekly (two sessions per week for 4 weeks) rather than weekly (one session per week for 4 weeks) Swedish massage sessions of 1-hour resulted in significant improvements in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), for assessing pain, stiffness, and physical functional disability outcomes, compared to usual care (9*). Notably, the benefits persisted for up to 8 weeks following the cessation of massage. Despite these promising results, there were no data to determine whether the dose used in the pilot study was optimal (9*). As in so many clinical trials, the treatment protocol for massage is often one of 20–30 minutes once or twice weekly. Could the treatment dose be impacting the perceived ‘poor’ outcomes? Operationally, finding the optimal dose may be one of balancing the optimal and the practical – ie. producing the greatest ratio of desired effect compared to costs (in time, labour, and convenience) (7*).

Thus, the first formal dosefinding study of massage therapy was implemented (7*). The study investigated four different doses of tailored Swedish massage, varying both the time (30 versus 60 minutes per treatment) and frequency (once a week versus twice a week for the first month) to determine an optimal, practical

Co-Kinetic.com dose. Subjects receiving the 60-minute doses improved with highly clinically significant changes (44–50% change from baseline) in WOMAC scores. A dose-response curve based on WOMAC Global scores indicated an increasing improvement with a greater total dose (minutes) of massage, with a threshold effect at the 480-minute dose. Thus, patients in the groups receiving massage therapy treatment sessions of 60 minutes showed greater benefit and magnitude of change from baseline compared to usual care and the 30-minute massage treatment groups. The durability of the response in the improvement of OA symptoms and functions to massage treatment was also supported by treatment duration. The magnitude of the effect was greatest after 8 weeks of treatment. The persistence of improvement at 2 months and 4 months after treatment cessation indicated that the effects of massage go beyond immediate changes. This may involve longer-term shifts globally and/or locally at the joint. The mechanism for persistent benefit is not fully understood; however, it highlights an opportunity for periodic maintenance doses of massage to sustain the effects over time. It was recommended that 60-minute massage sessions should be advised over a 30-minute session because of the superiority in the results; however, a once-weekly session may suffice. This is a result of the time and cost constraints of a biweekly massage protocol (7*).

Massage therapy should be considered as a routine complementary, not alternative, part of an individualised, multimodal painmanagement plan (10). It may not remove the need for medication and may not be appropriate for everyone; however, massage may reduce the dependence on analgesic or opioid medication, which has negative long-term side effects on other bodily systems, as well as being addictive in nature (11*). A study has shown that Swedish massage can reduce the severity of arthritic joint pain immediately after each session and for 1 month after the intervention. In addition to pain reduction,

Swedish massage also reduced the consumption of painkiller medication (2).

Conclusion

Regardless of its origin or underlying disease manifestation, pain is an experience that is multidimensional. It may impact an individual physically, socially, mentally, emotionally and spiritually. As is often the case with arthritis, pain persists and worsens; it can interfere with daily activities, and significantly impair the performance of social responsibilities, sports, work and family life, thus negatively affecting the individual’s psychological health and quality of life.

Despite the many options available, some patients may continue to experience inadequate symptom control; others will experience adverse effects from the available interventions. Clinicians treating patients in these circumstances should choose alternative complementary interventions with a low risk of harm. Effective pain management thus requires therapies that treat the biomechanical pathophysiological component of the joint, the pain and its related sequela by addressing the whole patient through a holistic biopsychosocial model (12*). There are controversies in the interpretation of the evidence, particularly regarding ‘alternative’ treatments such as acupuncture and massage therapy. The ambiguity in treatment protocol, definitions, methodology and sample size has resulted in massage therapy falling away from the published guidelines for the management of arthritis. The process of updating treatment guidelines permits scrutiny of the state of the literature and identification of critical gaps in our knowledge about best practices. Future research may see massage being re-instated in the guidelines as we learn more about the complexity of humans and pain. Optimal management requires a comprehensive, multimodal approach to treating patients with arthritis. The ultimate goal is to share decisionmaking with patients to choose the safest and most effective treatment for that individual.

References

1. Kolasinski SL, Neogi T, Hochberg MC et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis & Rheumatology 2020;72:220–233 Open access https://bit.ly/3ZmMMQw

2. Sahraei F, Rahemi Z, Sadat Z et al. The effect of Swedish massage on pain in rheumatoid arthritis patients: a randomized controlled trial. Complementary Therapies in Clinical Practice 2022;46:101524

3. Miake-Lye IM, Mak S, Lee J et al. Massage for pain: an evidence map. Journal of Alternative and Complementary Medicine 2019;25:475–502 Open access https://bit.ly/3JgfwER

4. Peter WF, Swart NM, Meerhoff GA et al. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 Open access https://bit.ly/3SMI5Nt

5. 'Choosing Wisely' app now available [website]. American Physical Therapy Association 2017 http://bit.ly/3YkjWPj

6. Nelson NL, Churilla JR. Massage therapy

Key Points

for pain and function in patients with arthritis: a systematic review of randomized controlled trials. American Journal of Physical Medicine & Rehabilitation 2017;96:665–672

7. Perlman AI, Ali A, Njike VY et al. Massage therapy for osteoarthritis of the knee: a randomized dose-finding trial. PLoS One 2012;7:e30248 Open access http://bit.ly/3ZFCWsD

8. Jonas W, Schoomaker E, Berry K et al. A time for massage. Pain Medicine 2016;17:1389–1390 Open access https://bit.ly/3ZpTCV9

9. Perlman AI, Sabina A, Williams AL et al. Massage Therapy for Osteoarthritis of the Knee: A Randomized Controlled Trial. Archives of Internal Medicine

2006;166:2533 Open access http://bit.ly/3ZnjgKn

10. Wu Q, Zhao J, Guo W. Efficacy of massage therapy in improving outcomes in knee osteoarthritis: a systematic review and meta-analysis. Complementary Therapies in Clinical Practice 2022;46:101522

11. Buckenmaier C, Cambron J, Werner R et al. Massage therapy for pain—call to action. Pain Medicine 2016;17(7):1211– l Finding the right treatment for a patient may depend on the individual, the extent of their arthritis, and their socioeconomic situation. l Based on the strength of scientific evidence from randomised controlled clinical trials, non-pharmacological treatments highly recommended for managing osteoarthritis include exercise, weight loss, self-efficacy and selfmanagement, orthotics and bracing. l The cornerstone of non-pharmacological physical therapy treatment for patients with rheumatoid arthritis includes exercise therapy, education and self-management strategies. l Guidelines suggest against using passive modalities (including massage therapy) owing to a lack of or low-quality evidence relative to arthritis management. l Clinical trials assessing massage efficacy have suffered from a high risk of bias, small sample sizes, ambiguity in methodology and have not demonstrated significant benefits for arthritis outcomes. l Emerging evidence suggests that longer massage sessions (1 hour) offered biweekly significantly improve arthritis outcomes of pain, stiffness and function. l It is suggested a ‘higher’ massage dose may provide more optimal outcomes in arthritis patients. l Across a number of systematic reviews, massage therapy has been shown to be effective in managing pain. l In addition to pain and functional limitations arising from arthritis and/or comorbidities, symptoms including mood disorders, such as depression and anxiety, altered sleep, chronic widespread pain, and impaired coping skills are often present. l It can be argued that a multimodal treatment option should be considered for long-term holistic management, including complimentary therapies such as massage therapy. l The ultimate goal may be shared decision-making with patients to choose an individualised treatment plan that is safe, effective and affordable to them.

1214 Open access https://bit.ly/3L1raom

12. Crawford C, Boyd C, Paat CF et al. The impact of massage therapy on function in pain populations—a systematic review and meta-analysis of randomized controlled trials: part I, patients experiencing pain in the general population. Pain Medicine 2016;17(7):1353–

1375 Open access https://bit.ly/3ycjsAf

Discussions

l Have you found benefits in using massage therapy when managing patients with arthritis?

l Do you believe that using passive treatment modalities, such as massage, hinders the progression of patients towards self-efficacy and self-management of their chronic disease?

l Would you agree that there may be a dose-response to massage therapy potentially affecting its perceived long-term efficacy?

RELATED CONTENT l Osteoarthritis of the Knee: A Practical Treatment Approach [Article] https://bit.ly/3hCalDF l Efficacy of Manual Therapy for Chronic Musculoskeletal Pain [Article] http://bit.ly/3lh94nI l Pain Does Not Always Indicate Injury [Article] https://bit.ly/3pweyZI

The Author

Kathryn Thomas BSc Physio, MPhil Sports Physiotherapy is a physiotherapist with a Master’s degree in Sports Physiotherapy from the Institute of Sports Science and University of Cape Town, South Africa. She graduated both her honours and Master’s degrees Cum Laude, and with Deans awards. After graduating in 2000 Kathryn worked in sports practices focusing on musculoskeletal injuries and rehabilitation. She was contracted to work with the Dolphins Cricket team (county/provincial team) and The Sharks rugby teams (Super rugby). Kathryn has also worked and supervised physios at the annual Comrades Marathon and Amashova cycle races for many years. She has worked with elite athletes from different sporting disciplines such as hockey, athletics, swimming and tennis. She was a competitive athlete holding national and provincial colours for swimming, biathlon, athletics, and surf lifesaving, and has a passion for sports and exercise physiology. She has presented research at the annual American College of Sports Medicine congress in Baltimore, and at South African Sports Medicine Association in 2000 and 2011. She is Co-Kinetic’s technical editor and has taken on responsibility for writing our new clinical review updates for practitioners.

Email: kittyjoythomas@gmail.com