Massage therapy (MT) is an ancient form of treatment that is now gaining popularity as part of the complementary and alternative medical therapy movement. A meta-analysis was conducted of studies that used random assignment to test the effectiveness of MT. Mean effect sizes were calculated from 37 studies for 9 dependent variables. Single applications of MT reduced state anxiety, blood pressure, and heart rate but not negative mood, immediate assessment of pain, and cortisol level. Multiple applications reduced delayed assessment of pain. Reductions of trait anxiety and depression were MT’s largest effects, with a course of treatment providing benefits similar in magnitude to those of psychotherapy. No moderators were statistically significant, though continued testing is needed. The limitations of a medical model of MT are discussed, and it is proposed that new MT theories and research use a psychotherapy perspective. Massage therapy (MT), the manual manipulation of soft tissue intended to promote health and well-being, has a history extending back several thousand years. Recorded in writing as far back as 2000 B.C. (Fritz, 2000, p. 13), massage was a part of many ancient cultures including that of the Chinese, Egyptians, Greeks, Hindus,

Background: Exercise therapy encompasses a heterogeneous group of interventions. There continues to be uncertainty about the most effective exercise approach in chronic low back pain. Purpose: To identify particular exercise intervention characteris-tics that decrease pain and improve function in adults with non-specific chronic low back pain.

F rom its origins as an unconventional therapyin the late 19th century through decades of marginalization dur-ing the 20th century, chiropractic has acquired legitimacy and prominence (Meeker and Haldeman 2002). Signs of its success abound. They include a broadening of the laws and regulations affecting its licen-sure, scope of practice, and reimbursement; greater acceptance by both physicians and health plans; and a sustained demand for its services. Chi-ropractic’s political base is strong, and it enjoys a high degree of patient satisfaction. Moreover, it is at the vanguard of complementary and alter-native medicine (CAM), which receives ever greater proportions of health expenditures (Eisenberg et al. 1993, 1998) and which is being increas-ingly integrated into conventional medicine (Macy Foundation 2001). Even so, chiropractic’s future seems uncertain. Recent expansions of chiropractic colleges are swelling the ranks of practitioners while man-aged care is restricting payment for what chiropractors do and evidence-based medicine is demanding that what they do must have demonstrable value. At the same time, chiropractors are experiencing greater com-petition from acupuncturists and massage therapists, whose ranks also are growing. In response, the profession is expanding beyond its tra-ditional forms of chiropractic treatment by reaching deeper into both

BACKGROUND: Mindfulness-based stress reduction (MBSR) and mas-sage may be useful adjunctive therapies for chronic musculoskeletal pain. OBJECTIVE: To evaluate the feasibility of studying MBSR and mas-sage for the management of chronic pain and estimate their effects on pain and mood. DESIGN: Randomized trial comparing MBSR or massage with stand-ard care. PARTICIPANTS: Thirty patients with chronic musculoskeletal pain. MEASUREMENTS: Pain was assessed with 0 to 10 numeric rating scales. Physical and mental health status was measured with the SF-12. RESULTS: The study completion rate was 76.7%. At week 8, the mas-sage group had average difference scores for pain unpleasantness of 2.9 and mental health status of 13.6 compared with 0.13 (Po.05) and 3.9 (Po.04), respectively, for the standard care group. These differenc-es were no longer significant at week 12. There were no significant dif-ferences in the pain outcomes for the MBSR group. At week 12, the mean change in mental health status for the MBSR group was 10.2 compared with 1.7 in the standard care group (Po.04). CONCLUSIONS: It is feasible to study MBSR and massage in patients with chronic musculoskeletal pain. Mindfulness-based stress reduc-tion may be more effective and longer-lasting for mood improvement while massage may be more effective for reducing pain. KEY WORDS: mindfulness-based stress reduction; massage; chronic pain; mental health; integrative medicine.

Chronic low back pain KCE reports vol. 48 C Federaal Kenniscentrum voor de gezondheidszorg

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Is massage therapy genuinely e ff e c t i v e? Michele Preyde has provided an in-teresting addition to the litera-ture on massage therapy.1 One question that needs to be answered is whether perceived benefits from less expensive nonspecific massage would be equiva-lent to those achieved by registered massage therapists (manual therapy in this study cost $50 per session). In this study, patients receiving soft-tissue manipulation scored better on self-rated scales of pain, anxiety and function than controls. However, there is no way to know whether this was due to the nonspecific effects of being touched by a caregiver or to particular aspects of the intervention that were unique to massage therapy. Sham massage may have been a more appropriate control. Another issue that weakens the con-clusions of this paper is that of patient recruitment. Patients volunteering for a study of massage therapy may be predis-posed to have faith in its tenets or have pre-existing expectations of its benefits. This is especially problematic in a study in which patients were not blinded to the type of treatment administered. Preyde states that massage improved patient function. It would be more accu-rate to say that those receiving massage perceived their function to be improved. Unfortunately, this is a perception very prone to nonspecific provider influences. For the reasons noted above, the self-rating scales used in this trial pro-vide less than robust information. This concern is highlighted by the finding that lumbar range of motion was not different between groups. This was the only objective measure and the only one for which blinded evaluators were used. As such, this paper’s most power-ful findings indicate a lack of effect for massage therapy when compared with nonmassage controls.

The aim of this study was to verify the clinical responses to Thai massage (TM) and Thai herbal compression (THC) for treating osteoarthritis (OA) of the knee in comparison to oral ibuprofen. This study was a randomized, evaluator-blind, controlled trial. Sixty patients with OA of the knee were randomly assigned to receive either a one-hour session of TM or THC (three times weekly) or oral ibuprofen (three times daily). The duration of treatment was three weeks. The clinical assessments included visual analog scale assessing pain and stiffness, Lequesne's functional index, time for climbing up ten steps, and physician's and patient's overall opinions on improvement. In a within-group comparison, each treatment modality caused a significant improvement of all variables determined for outcome assessments. In an among group comparison, all modalities provided nearly comparable clinical efficacy after a three-week symptomatic treatment of OA of the knee, in which a trend toward greatest improvement was likely to be found in THC group. In conclusion, TM and THC generally provided comparable clinical efficacy to oral ibuprofen after three weeks of treatment and could be considered as complementary and alternative treatments for OA of the knee.

T ension-type headache (TTH) is a dull aching headache that a ects a large percentage of the population to varying degrees; it frequently resolves with time or over-the-counter analgesics. However, for some individuals, the regularity of headache persists to a clinical condition that is recognized as either episodic or chronic, the di erence based primarily on the frequency of attack with the episodic form occurring fewer than 15 days per month and the chronic form 15 or more days per month 1 . e episodic form of TTH a ects between 20-42% of the population while the chronic form a ects 2.5-3% e personal burden associated with these clinical forms of TTH can be substantial as it encompasses physical su ering alongside the personal economic e ect from lost work days, which in turn perpetuate psychological symptoms such as stress, anxiety, and depression. Yet while TTH is the most prevalent form of headache and has a considerable impact on quality of life, treatment avenues have been under-investigated 5 . Moreover, due to the pervasive nature of TTH, pain measures alone that are typically used in the current literature provide incomplete information about the impact of headache on these associated psychological aspects. On average, perceived stress is higher in individuals who report chronic daily headache than in a healthy population 6 . Although recurrent TTH su erers have similar physiological responses to laboratory stressors, they report a greater number of everyday stresses or daily "hassles" than do matched non-headache control subjects

With over 1.7 million people in the United States seeking medical attention for head injury each year, emergency clinicians are challenged daily to screen quickly for the small subset of patients who harbor a potentially lethal intracranial lesion while minimizing excessive cost, unnecessary diagnostic testing, radiation exposure, and admissions. Whether working at a small, rural hospital or a large inner-city public hospital, emergency clinicians play a critical role in the diagnosis and management of mild traumatic brain injury. This review assesses the burgeoning research in the field and reviews current clinical guidelines and decision rules on mild traumatic brain injury, addressing the concept of serial examinations to identify clinically significant intracranial injury, the approach to pediatric and elderly patients, and the management of patients who are on anticoagulants or antiplatelet agents or have bleeding disorders. The evidence on sports-related concussion and postconcussive syndrome is reviewed, and tools for assessments and discharge are included. Author