MASSAGE: RESEARCH

Parkinsons disease symptoms are dierentially aected by massage therapy vs. progressive muscle relaxation: a pilot study
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Maria Hernandez-Reif, Tiany Field, Shay Largie, Christy Cullen, Julia Beutler, Chris Sanders, William Weiner, Dinorah Rodriguez-Bateman, Lisette Zelaya, Saul Schanberg, Cynthia Kuhn
Abstract Sixteen adults diagnosed with idiopathic Parkinsons disease (M age=58) received 30-min massage therapy or progressive muscle relaxation exercise sessions twice a week for 5 weeks (10 sessions total). Physicians rated participants in the massage therapy group as improved in daily living activities by the end of the study. The massaged group also rated themselves as improved in daily functioning, and having more eective and less disturbed sleep. Urine samples revealed that at the end of the 10 sessions, the massage therapy group had lower norepinephrine and epinephrine (stress hormone) levels, suggesting they were less stressed. The progressive muscle relaxation group had higher dopamine levels, which is interesting in that Parkinsons is associated with a decrease in dopamine. The relaxation group also showed higher epinephrine levels, suggesting that although the relaxation exercises might have been benecial, some Parkinsons participants might have found the relaxation technique stressful. r 2002 Elsevier Science Ltd. All rights reserved.
Maria Hernandez-Reif, Tiany Field, Shay Largie, Christy Cullen, Julia Beutler, Chris Sanders Touch Research Institutes, USA William Weiner, Dinorah Rodriguez-Bateman, Lisette Zelaya Department of Neurology, University of Miami School of Medicine, USA Saul Schanberg and Cynthia Kuhn Department of Pharmacology, Duke University, USA
........................................... Journal of Bodywork and Movement Therapies (2002) 6(3),177^182 r 2002 Elsevier Science Ltd. All rights reserved. doi: 10.1054/jbmt.2002.0282, available online at http://www.idealibrary.com on

Parkinsons Symptoms are Reduced by Massage Therapy

Idiopathic Parkinsons disease (PD), a progressive central nervous system disorder, aects approximately 50,000 Americans every year, or one in every 100 Americans over the age of 60 (The National Institute of Neurological Disorders and Stroke of the National Institutes of Health
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2000). Characteristic symptoms of PD include tremors, rigidity, bradykinesia (or slowness in executing movements) and dopamine deciency (Lien & Mutch 1997). Other symptoms that impact quality of life include diculty concentrating, impaired daily living activities, fatigue and diculty sleeping (Herndon et al. 2000; Pal et al. 2001; Tom & Cummings 1998).

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Hernandez-Reif et al.

Standard medical care for individuals with PD includes oral Levodopa (L-dopa), which acts like a neurotransmitter and leads to an increase in brain dopamine (Chase 1998; Jenner & Brin 1998). Dopamine is essential in modulating motor functioning and substance P (that causes pain) in the basal ganglia pathways (Contreras et al. 1998). However, L-dopa therapy may rapidly advance symptoms in a mild-to-moderate PD patient (Chase 1998; Fariello 1998). Other aversive eects of L-dopa include motor uctuations and dyskinesias (involuntary limb and facial movements) (Chase 1998; Jenner & Brin 1998; Koller, 1998) and possible cell degeneration (Jenner & Brin 1998, Contreras et al. 1998). Moreover, the ecacy of the drug diminishes with prolonged use (Chase 1998). Other medications (e.g., Selegiline) used to reduce PD symptoms also feature side eects including dizziness, insomnia, nausea and headache (Rinne et al. 1998). Alternative therapies may attenuate side eects of PD without some of the adverse eects of drug therapy. For example, lowfrequency muscle stimulation, or electroconvulsive therapy, and magnetic stimulation/pulse therapy have been shown to reduce rigidity (Henneberg 1998; Wengel et al. 1998), and music therapy has been shown to attenuate emotional distress and improve motor functions and quality of life in patients with Parkinsons disease (Pacchetti et al. 1998). Massage therapy may also reduce symptoms associated with PD based on previous research. For example, massage therapy decreased fatigue, improved sleep, and led to changes in urinary biochemical levels, including increased urinary dopamine and/or serotonin levels for patients with eating disorders (e.g., anorexia and bulimia nervosa)

(Field et al. 1998; Hart et al. 2001), chronic fatigue syndrome (Field et al. 1997), chronic lower back pain (Hernandez-Reif et al. 2000), migraine headaches (HernandezReif et al. 1998a), bromyalgia (Sunshine et al. 1996), and for pregnant women (Field et al. 2000). In addition, massage therapy enhanced activities of daily living (self-care and household activities) in individuals with multiple sclerosis (Hernandez-Reif et al. 1998b). The purpose of the present study was to examine massage therapy as compared to progressive muscle relaxation eects on disease-related symptoms and biochemical levels in individuals with Parkinsons disease. Specically, massage therapy was expected to stabilize disease progression, improve sleep and daily living activities in individuals with Parkinsons. A progressive muscle exercise group was included as an attention control comparison group.

severe) and (3) medication stability for the month prior to admission into the study. Exclusion criteria included: (1) initiation of levodopa (L-dopa) therapy, (2) severe resting tremor with the UPDRS tremor score in one location X3, (3) signs of dementia (score of 2, 3, or 4 on item 1 of UPDRS), (4) psychiatric disorders, (5) drug or alcohol dependence, (6) participation in any other clinical study within 30 days prior to screening, and (7) any other concomitant diseases. Following stratication for disease severity and dyskinesias, assessed via the UPDRS, 16 participants (n=8 females) were randomly assigned to a massage therapy or progressive muscle relaxation group. The participants were from middle socioeconomic class as rated on the Hollingshead Two Factor Index (M=2.4) and were ethnically distributed, 69% Caucasian and 31% Hispanic. Demographic data did not dier between groups (all ps40.10). Procedures Massage therapy Participants in this group received two 30-min sessions a week for 5 weeks by a trained massage therapist. The massage therapy included the following steps with the patient in the prone position for the rst 15 min: Back: (1) long gliding strokes to the back (2 min); (2) kneading and friction of the shoulder area and upper arms and then general kneading to the back muscles (3 min) ; Buttocks: (1) kneading and pressure to the gluteal muscle area, including application of pressure to specic points where muscle tightness or tender points are noted until the muscles relax, (2 min); (2) friction to tight tendons (1 min); Ribs: stretching small muscles between the ribs (1 min) ; Thigh: kneading, friction and tendon stretches to the

Method
Participants Sixteen adults (M=58 years, SD=12.5) in the early stages of PD (M=1.84, SD=0.30 on the Hoehn Yahr scale 1967) were recruited at a PD treatment center. The Severity Stage Classication Scale (HoehnYahr, 1967) grades Parkinsons disease severity in the individual from 0 (asymptomatic) to 3 (mildto-moderate bilateral involvement) to 5 (wheelchair bound or bedridden). This scale was administered in conjunction with the Unied Parkinsons Disease Rating Scale (UPDRS) (Martinez-Martin et al. 1991) and Schwabb and England scale (1958) to screen for inclusion/ exclusion criteria. Inclusion criteria included: (1) Idiopathic PD age between 50- and 70-years old, (2) r stage 2.5 on the HoehnYahr scale (a disease severity scale from 1 to 5, with 1 being mild and 5 being
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hamstrings (2 min); Calf: kneading and friction to the back of the calf with emphasis on the Achilles tendon, attending to tight areas or tender points found (2 min); Feet: (1) general kneading of the feet; (2) with the knee slightly bent, exing the foot toward the back of the calf (2 min). With participant in the supine position for the nal 15 min: Thigh: (1) friction and pressure to the front, upper thigh area, including applying pressure to specic points where muscle tightness or tender points are noted until muscles relax (2 min), (2) friction to the small muscles focused just above the knee (1 min); Lower leg: stretching (longitudinal and transverse) and small nger kneading of the underside of the leg (2 min); Feet: kneading the foot followed by exing the foot to stretch the Achilles tendon (1 min); Range of motion: taking each joint (hips, knees, ankles and toes) into exion and lightly into other ranges of motion (2 min); Hands: kneading the hands and ngers (1 min); Forearms: kneading and friction to tendons and muscles (1 min); Upper arms: kneading and friction to biceps and triceps (2 min); Neck: gentle squeezing of muscle immediately inferior to the hairline with moderate pressure, using caution to avoid the major blood vessels (1 min); Face: circular ngertip kneading to the face, especially the forehead, under the eyes (all around the eyes) and around the jaw (1 min); Head: scalp kneading (i.e., shampooing) (1 min). Progressive muscle relaxation The attention control group received progressive muscle relaxation therapy that consisted of the participants lying on their back while listening to a cassette tape leading them through the exercise steps. These 30-min sessions involved the participant tightening and then relaxing the same large

muscle groups that were massaged in the massage group starting at the feet and progressing to the face. The muscle groups that were exercised included the feet, calves, thighs, back, arms (including hands), and face. Assessments First day/last day measures (longterm eects) On the rst and last days of the study, participants (1) were rated by their physicians, (2) completed selfreports on functioning, sleep and fatigue and (3) provided a urine sample to assay biochemical levels. Physicians diagnostic assessments The following scale was completed by the participants physician who was unaware of their patients group assignment. Although having one physician rate all participants would have been optimal, this was not feasible. It is also possible that more accurate ratings were made because the participants physician was more familiar with the participants clinical condition. Physicians treatment assessment Activities of daily life scale (Schwab & England1958) This scale rated at 10% increments measures the amount of daily living activities a PD patient can perform. For example, a score of 100% reects complete independence and normal performance of chores and a score of 40% identies a patient who is very dependent, can conduct few chores alone but can assist with all chores. Reliability for this scale is acceptable (0.81) (Schwab & England 1958). High concurrent validity (p o0.001) has been established between the UPDRS and the Schwabb and England
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Activities of Daily Life Scale (Martinez-Martin et al. 1991; Shwab & England, 1958).

Self-reports Activities of Daily Life Scale (Schwab & England1958). Same as the physicians scale. Sleep Scale (Verran & SnyderHalperin1988) Questions on this 15-item scale are rated on a visual analogue anchored at one end with eective sleep responses (e.g., Did not awaken, Had no trouble sleeping) and at the opposite end with ineective responses (e.g., Was awake 10 hours, Had a lot of trouble falling asleep). Participants marked the line at the point that best reected their last nights sleep. The scale yields subcategories of sleep disturbance (I had a lot of trouble with disrupted sleep), sleep eectiveness (Awoke refreshed) and supplementary sleep (After morning awakening, stayed awake). A reliability coecient of 0.82 has been reported for this scale (Verran & Snyder-Halperin 1988). Urine samples These were collected early in the morning on the rst and last days of the study to assess treatment eects on biochemistry levels. An aliquot of each sample was frozen and sent to Duke University. The aliquot of urine using a Biorex-70 column was extracted and analyzed by highpressure liquid chromatography with electrochemical detection (HPLC-ECD). Based on previous massage therapy studies, participants in the massage group were expected to show decreased cortisol, norepinephrine and epinephrine and increased dopamine and serotonin levels by the end of the 5-week period.

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Results
Physicians diagnostic assessments An analysis of variance (ANOVA) revealed no baseline dierences between the two groups on the Unied Parkinsons disease rating Scale (Massage M=38.4, SD=18.6; Exercise M=37.0, SD=13.7) or the Severity Stage Classication Scale (HoehnYahr) , (Massage M=1.9, SD=0.4; Exercise M=1.8, SD =0.3), suggesting that the stratication procedure was successful. First vs. last day measures Because of the small sample size, non-parametric Wilcoxon Signed Ranks paired t-tests were conducted for the massage therapy and progressive muscle relaxation exercise group separately for the following measures.

Table 1 Means (and standard deviations in parentheses) for the Physicians Diagnostic Scale for the MassageTherapy and Progressive Muscle Relaxation Exercise groups Massage Variables First day Last day p-value Relaxation exercise First day Last day p-value r 89(8.6)a 89(8.9)
a

Activities of Daily Life Scale (Schwab & England) Physician rating (%) Subject rating (%) 87(7.1)a 87(7.1)
a

91(8.2)b 91(8.2)
b

0.05 0.05

87(6.8)a 89(5.5)a

NS NS

Note: Dierent letter superscripts denote dierences in means (within group) for that variable.

Urinary measures Wilcoxon Signed Ranks tests revealed (1) reduced norepinephrine (stress hormone) levels, Z=2.10, p o 0.05, and reduced epinephrine (stress hormone) levels, Z=1.96, p r 0.05, for the massage therapy group, and (2) increased dopamine values, Z=2.52, p o 0.05 and epinephrine (stress hormone) values, Z=2.52, p o0.05 for the exercise group.

Discussion
Physicians assessments The physicians rated the participants in the massage therapy group as improved on the Activities of Daily Life Scale, Z=1.90, p o0.05 (one-tailed), and the massage therapy participants also reported improved scores for this measure, Z=1.73, p o 0.05 (one-tailed), suggesting greater independence and more normal functioning on chores (see Table 1). Self-reports Sleep scale. Less sleep disturbance was reported by the massage therapy group for the last day of the study, Z=2.52, p o 0.01. Both the massage therapy group, Z=1.90, p o 0.05, and the progressive muscle relaxation group, Z=2.0, p o 0.05, reported more eective sleep by the end of the study (see Table 2). Following a 5-week massage therapy program, ratings of physician and self-ratings improved for the massage therapy group on the Activities of Daily Life Scale, suggesting slight improvement in increased independence and functioning on chores. These data are consistent with previous research showing improvement on activities of daily living following massage therapy, for example, for patients with multiple sclerosis (HernandezReif et al. 1998b) and spinal cord injuries (Diego et al. 2002). Taken together, these ndings suggest that massage therapy may enhance some level of functioning in progressive or degenerative central nervous system disorders or conditions. The lack of improvement for the progressive muscle relaxation group may relate to the possibility that the participants had little or no relaxation exercises prior to the
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study and/or found the progressive muscle relaxation exercises fatiguing. Both groups reported more eective sleep for the last day of the study and the massage therapy group reported less sleep disturbance as well. Improved sleep following massage therapy has been reported in other studies for individuals with Chronic Fatigue Syndrome (Field et al. 1997), Fibromyalgia Syndrome (Sunshine et al. 1996) and Migraine headaches (Hernandez-Reif et al. 1998a). The report of less sleep disturbance by the massage therapy group might have reected their more relaxed state as evidenced by their decreased urinary norepinephrine and epinephrine (stress hormone) levels at the end of the study. Of additional interest were the ndings of increased dopamine levels and epinephrine (stress hormone) for the progressive muscle relaxation group. That progressive muscle relaxation exercises were associated with increased dopamine levels is encouraging in that Parkinsons disease is characterized by the progressive death of dopaminergic neurons, which leads to decrease in the overall dopamine content (Tekumalla et al. 2001). Why massage therapy was not associated with increased dopamine levels in this study is unclear, as it has been shown to increase in other groups (see Field et al. 1998).

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Table 2 Means (and standard deviations in parentheses) for the Self-Report and Biochemistry measures for the MassageTherapy and Progressive Muscle Relaxation Exercise groups Massage Variables Sleep Scale Disturbance* Eective Supplementary Biochemistry Creatinine 5-HIAA Cortisol Norepinephrine Epinephrine Dopamine 0.99(.79)a 3953(942) 245(94)a 48(30)a 7(9) a 208 (146)a
a

Relaxation Exercise p-value First day Last day p-value r

First day

Last day

42.4(10.9)a 47.1(12.8) 7.9(9.6)a

a

22.4(14.3)b 61.8(12.0)
b

0.01 0.05 NS

33.8(25.0)a 43.8(11.5)
a

28.5(14.7)a 60.9(20.9)b 19.6(23.9)a

NS 0.05 NS

19.5(23.2)a

18.3(19.2)a

0.68(.28)a 3498(772) 218(36)a 25(18)b 12(9)b 174 (110)a

a

NS NS NS 0.05 0.05 NS

1.1(.74)a 4791(2575) 257(144)a 25(18)a 8 (6)a 153 (97)a

a

1.2(.69)a 4596(3778) 254(132)a 33(14)a 14 (8)b 280(131) b

a

NS NS NS NS 0.05 0.05

Note:* Lower score is optimal. Dierent letter superscripts denote dierences in means (within group) for that variable.

Perhaps, initial level eects were operating in that the massage therapy group level was higher than the relaxation group level at the start of the study, and the groups dopamine levels moved in the opposite direction. The increased epinephrine values in the exercise group suggest that the progressive muscle relaxation exercise might have also stressed the Parkinsons disease participants. Future research might also consider including a standard care control group and larger sample sizes, as the small sample size for the current study warrants caution in interpreting the ndings. Additional measures might include massage and movement therapies eect for reducing tremors, dyskinesias, rigidity (hypertonicity), and bradykinesia (or slowness in executing movements). In at least one study, massage therapy reduced hypertonicity (in young children with cerebral palsy), and spasticity (Hernandez-Reif et al. 2001). In sum, the preliminary ndings from this pilot study support the use of massage therapy for central nervous system disorders like Parkinsons

disease to ameliorate symptoms associated with the disease and to improve sleep and activities of daily living. Acknowledgements
We would like to thank the participants and the massage therapist volunteers in this study. Special thanks are extended to Iris Burman from Educating Hands and Diana Grin from SutherlandChan School of Massage in Toronto for designing the massage routine. This research was supported by an NIMH Senior Research Scientist Award (#MH00331) to Tiany Field and funding from Johnson & Johnson to the Touch Research Institutes. Correspondence and requests for reprints should be sent to Maria Hernandez-Reif, Ph.D., Touch Research Institutes, University of Miami School of Medicine, PO Box 016820(D-820), Miami, FL 33101. E-mail:mhernan4@med.miami.edu

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