The report is a product of the VA/HSR Evidence Synthesis Program.

Massage for Pain: An Evidence Map

Results from the 2012 National Health Interview Survey (representative sample of U.S. adults) estimate that approximately 15.4 million adults (7%) used massage therapy in the past 12 months. Moreover, many Veterans desire complementary and integrative health or alternative medicine modalities, both for treatment and for the promotion of wellness. Given this – and the widespread use of various massage therapies for pain, investigators with VA's Evidence-based Synthesis Program Center located in West Los Angeles, CA developed an evidence map project to:

• Determine the distribution of evidence on massage therapy for pain,
• Identify gaps in the evidence, and
• Inform future research priorities.

This mapping project provides a visual overview of the distribution of evidence for massage therapy for indications of pain, as well as an accompanying narrative that will help stakeholders interpret the state of the evidence to inform policy and clinical decision-making.

Investigators searched PubMed, Embase, and Cochrane from database inception through February 17, 2016 for systematic reviews reporting pain outcomes for massage therapy, and identified 31 systematic reviews, of which 21 were considered high-quality. Some common massage types included Swedish massage, myofascial therapies, Shiatsu, Chinese traditional massage, Thai massage, slow stroke massage, and more general descriptions of massage. The most common types of pain included in systematic reviews were neck pain (n=6), followed by low back pain, headache, or shoulder pain. Also included in some studies were labor pain, fibromyalgia, cancer pain, and musculoskeletal pain.

Summary of Review
There are a number of indications where a potential benefit of massage was found. Findings from higher-quality systematic reviews describe potential benefits of massage for pain indications including labor, shoulder, neck, back, cancer, fibromyalgia, and temporomandibular disorder. However, no findings were rated as moderate- or high-strength due to limitations of the literature. Further research is necessary to define the role of massage in pain management.

Below is the evidence map of systematic reviews describing the effects of massage for pain. The evidence map displays each of the 31 included systematic reviews as bubbles.

• The bubble label represents the pain indication described in that review.
• Bubble size denotes the number of primary studies included in that review specifically related to massage for pain.
• Each bubble is plotted according to the strength of the findings for massage for pain (y-axis), as well as by the effect massage was found to have for pain when compared to a heterogeneous mix of comparators (x-axis).
• Primary studies may be included in multiple systematic reviews.

This evidence mapping project aims to help provide guidance to VA leadership about the distribution of evidence on massage therapy for pain to inform policy and clinical decision-making.

Future Research
More research is needed to establish confidence in the effect of massage for pain. Primary studies often do not provide adequate details of the massage therapy provided, especially in the descriptions of provider type. Few primary studies of large samples with rigorous methods have been conducted, as noted by many of the systematic review authors included in this evidence map. When multiple systematic reviews within the evidence map overlap in pain indications, cross-checking of these reviews may be necessary to determine if the same primary studies are being described, the extent of the overlap, and the applicability of some or all findings in a review for a particular research or policy question. The topics with multiple bubbles, especially with differing findings, may be areas that are ripe for an updated systematic review. Other areas where future synthesis efforts would be beneficial include updating pain indications for which existing reviews are outdated (i.e., critical care).

Reference
Miake-Lye IM, Lee JF, Luger T, Taylor S, Shanman R, Beroes JM, Shekelle PG. Massage for Pain: An Evidence Map. VA ESP Project #05-226; 2016

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This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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