M OV E M E N T/ MA S S AG E T H E R A PY

Movement and massage therapy

reduce fibromyalgia pain
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tiffany Field*, Jesse Delage, Maria Hernandez-Reif

Abstract Forty patients with fibromyalgia were randomly assigned to a movement/

massage therapy group or a relaxation control group. The movement/massage therapy
group attended a 50-min session twice per week for 3 weeks and the relaxation group
simply relaxed in a lying down position on the same schedule. The movement/massage
therapy group in contrast to the relaxation control group showed decreases in
depressed mood, state anxiety and regional pain immediately after the first and last
sessions of the study and a decrease in depressed mood, state anxiety and regional pain
at baseline from the first to the last session. Both the movement and the massage
portions of the session involved self-administered stimulation of pressure receptors.
The positive effects on pain relief in particular suggest that self-administered pressure
stimulation may reduce pain.
r 2002 Elsevier Science Ltd. All rights reserved.

Fibromyalgia syndrome is a chronic 2001). Research on exercise

Tiffany Field, Jesse Delage,
Maria Hernandez-Reif
Touch Research Institutes, University of Miami
School of Medicine, P.O. Box 016820, Miami,
FL 33101, USA
Correspondence to: Dr T. Field
Received June 2002
Revised July 2002
Accepted 10 August 2002
...........................................
Journal of Bodywork and Movement Therapies (2003)
7(1), 49^52
r 2003 Elsevier Science Ltd. All rights reserved.
doi:10.1016/S1360-8592(02)00078-5
S1360-8592/03/$ - see front matter
medical condition characterized by
symptoms of widespread body pain
(musculoskeletal aching and
stiffness) and soft tissue tender
points. The syndrome is frequently
accompanied by fatigue and sleep
disturbances (Maurizio & Rogers
1997, Reiffenberger & Amundson
1996). Diagnostic criteria include
tender point locations and other
symptoms already mentioned.
Fibromyalgia syndrome has been
identified as one of the most
economically burdensome
syndromes (Berman & Swyers,
1997). Treatment options have
included the latest drug therapies
(including tricyclic antidepressants),
exercise and alternative therapies
including acupuncture, manual/
manipulative therapies and mind/
body therapies (Friedburg & Jason
suggests that moderate/high
intensity exercise has been effective
(Gowans et al. 1999, Hadhazy et al.
2000). Antidepressants have been
useful for increasing serotonin
levels and, in turn, decreasing
fibromyalgia symptoms (Russell
et al. 1992). Chiropractic
management (Blunz et al. 1997)
and acupuncture (Berman et al.
2000) have also proven
effective.
We have successfully
used massage therapy to reduce
pain, stiffness, fatigue and
sleeping difficulties in patients
with fibromyalgia (Sunshine et al.
1996). In that study fibromyalgia
patients were randomly assigned
to a massage therapy or a
transcutaneous electrical
stimulation and a no-current

49
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S JANUARY 20 0 3

transcutaneous electrical stimulation
group for 30-min treatment
sessions twice weekly for 5 weeks.
The massage therapy group showed
lower anxiety and depression, and
their cortisol levels were lower
immediately after the therapy
sessions on both the first and the last
days of the study. The
transcutaneous electrical stimulation
group showed similar changes
in depressed mood, anxiety
and cortisol. The massage therapy
group, however, also improved
on the dolorimeter measure
of pain and, by the end
of the study, they reported less
pain, stiffness and fatigue
and fewer nights having difficulty
sleeping. That both the massage
therapy and transcutaneous
electrical stimulation groups
had reduced cortisol levels might
relate to the participants’ self-report
of reduced anxiety. However,
current data also suggest
that individuals with
fibromyalgia have lower overall
production of cortisol (Demitrack &
Crofford 1998), or impaired
activation of the hypothalamic–
pituitary–adrenal (HPA) axis
(Adler et al. 1999). Cortisol
deficiency has also been associated
with symptoms similar to
those of fibromyalgia, including
fatigue, pain and mood disturbance
(Adler et al. 1999). In that in
our study, massage therapy was
associated with an attenuation
of these symptoms suggests
that the reduction in cortisol,
at least for the massage therapy
group, might have been related to
something other than a cortisol
deficiency. Clearly, more research is
necessary to understand that
relationship between cortisol
reduction in response to therapies
like massage for fibromyalgia
patients.
In a second study by our group,
sleep was recorded with a more
objective measure (an activity
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S JANUARY 20 0 3
Field, Delage and Hernandez-Reif
bracelet that recorded limb
movements) (Field et al. 2002). In
that study, following 30-min
treatments twice weekly for 5 weeks,
both groups (a massage therapy and
a relaxation therapy control group)
showed a decrease in anxiety and
depressed mood immediately after
the first and last therapy sessions.
However, across the course of the
study, only the massage therapy
group reported an increase in the
number of sleep hours and a
decrease in their sleep movements as
measured by activity bracelets. In
addition, the substance-P levels of
the massage group decreased, and
the patients’ physicians assigned
lower disease and pain ratings and
rated fewer tender points using the
dolorimeter.
In the current study, an attempt
was made to combine exercise
movements with massage therapy
to determine whether the
combination resulted in greater
effects. In addition, the therapy
was self-administered. A new field
called Eutony, which has been
increasingly popular in Europe
(most particularly in Germany
and France), combines movement
and massage therapy techniques
that are basically self-administered.
The movement part of the
Eutony sessions involves stretching
movements on the floor and
stretching movements through
space in an upright position. The
self-administered massage involves
the rolling of wooden dowels
across limbs and the use of balls
(e.g. tennis balls) that are again
rolled across the surface of the
limbs. Pain is noted to diminish
following the application of pressure
as, for example, in squeezing one’s
elbow after bumping it and reducing
pain. Thus, we hypothesized that the
self-administered pressure
stimulation involved in the
movement and massage aspects of
Eutony might be effective in
fibromyalgia.
50
Method
Participants
Forty patients with fibromyalgia
were recruited from community
pain clinics and were randomly
assigned to a movement/massage
therapy group or a relaxation
control group. The participants
on average spent 8.4 years in
treatment, were 53.1 years of
age and were of middle-
socioeconomic status (M=2.1 on
the Hollingshead Index). They
were distributed 91% white and 9%
Hispanic. The two groups did not
differ based on age, socioeconomic
status or ethnicity.
Procedure
Prior to random assignment, a
rheumatologist confirmed the
diagnosis of fibromyalgia in the
participants according to the criteria
established by the American College
of Rheumatology in 1990 (Wolfe
et al. 1990). During the study period
all participants continued their
standard medical care.
Movement/massage therapy
Participants engaged in movements
in lying, seated and standing
positions (much as in yoga
stretching classes). During these
stretching exercises they received
self-stimulation of pressure
receptors by rubbing limbs against
the floor and against other limbs.
Self-massage was administered
using 2-ft-long, 1-inch-diameter
wooden dowels and tennis balls.
The participants were asked to rub
their upper and lower limbs with
the wooden dowels, and to rub a
tennis ball in a circular fashion
on the face, shoulders, arms and
hands. The sessions lasted 50 min
and were held twice per week for 3
weeks.

Table 1 Means for immediate effects of movement/massage therapy and relaxation therapy
Variables Relaxation (n=20)
First session
Pre Post
POMS (mood) 13.4(14.5) 11.2(12.7)
STAI (anxiety) 54.6(10.2) 48.0(13.8)*
Regional pain score 49.6(15.1) 46.4(17.2)
Note: Superscripts (P*o0.05) in column 2 of each group indicate significant pre–post differences and in column 3 superscripts indicate significant
first/last session differences. Lower scores are optimal.
Progressive muscle relaxation
therapy
A relaxation group was assessed
to control for potential placebo
effects or improvement related to
the increased attention given to
the massage therapy group
participants. The relaxation therapy
group was given instructions on
how to conduct progressive muscle
relaxation sessions for 50 min
while laying quietly on a carpeted
floor (similar floor as the movement/
massage therapy group used).
The muscle relaxation included
tensing and relaxing large muscle
groups starting with the head
and moving to the neck, shoulders,
back, arms, hands, legs, and
feet. The therapist conducted
these sessions twice a week for
3 weeks.
Assessments of effects
(pre--post treatment sessions
on first and last days)
The questionnaires and assessments
were given pre- and post-sessions on
the first and last days of the study to
measure the effects of the therapy in
the following order: (a) The State
Anxiety Inventory (STAI)
(Spielberger et al. 1970) is an anxiety
scale consisting of 20 items on
how the participant feels at that
moment in terms of severity from
(1) ‘not at all’ to (4) ‘very much so’.
Typical items include ‘I feel nervous’
and ‘I feel calm’. The STAI has
adequate concurrent validity and
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S JANUARY 20 0 3
Movement and massage therapy
Movement/massage (n=20)
Last session First session
Pre Post Pre
14.8(12.6) 12.6(13.1) 15.2(12.5)
49.2(11.8) 49.2(5.9) 51.4(15.3)
45.8(16.6) 38.2(15.8)* 42.6(8.4)
internal consistency (r=0.83):
(b) The Profile of Mood States
(POMS) (McNair et al. 1971) is
a 5-point adjective rating scale on
how well an adjective describes
the participants’ feelings including
helpless or gloomy feelings,
depression and anxiety. The
scale has adequate internal
consistency (r=0.95) and is an
adequate measure of intervention
effectiveness (Pugtach et al. 1969).
(c) The Regional Pain Scale is a
drawing of 21 regions on the front
and back of the body where pain is
to be rated. The participant rates the
pain in each region on a scale
ranging from 0 for no pain to 5 for
unbearable pain for a total possible
score of 105.
Results
Analyses of variance and post hoc
Bonferroni t-tests were conducted to
compare the two groups on the self-
report anxiety and depressed mood
questionnaires and the pain rating
scale, with the before and after
treatment sessions being the
repeated measures. As can be seen
from Table 1, both groups showed
decreased anxiety and pain after the
first and/or last sessions. However,
only the movement massage therapy
group experienced improved mood,
lower anxiety and lower pain across
the course of the study.
51
Last session
Post Pre Post
*
7.6(10.9) 15.2(12.5) 4.2(1.4)*
32.2(8.6)* 35.0(14.1)* 28.4(14.9)*
31.8(7.9)* 24.6(7.3)* 18.8(4.0)*
Discussion
The decrease in anxiety and
depressed mood after movement/
massage therapy and relaxation
therapy sessions was not surprising
given that these changes were
noted in our previous studies on
fibromyalgia (Field et al. 2002,
Sunshine et al. 1996), and in our
other massage and relaxation
therapy studies (see Field 1998
for a review). The movement/
massage therapy patients’ reports of
less depressed mood, anxiety
and pain across the study were also
consistent with our previous
findings on massage therapy
effects with fibromyalgia (Sunshine
et al. 1996) and with other
chronic pain conditions including
migraine headaches, premenstrual
syndrome, lower back pain, and
chronic fatigue syndrome (Field
1998). The data from the current
study, however, suggest that
massage and massage-like
movements or stimulation of
pressure receptors can be self-
administered and still result in
reduced pain.
ACKNOWLEDGEMENTS
We would like to thank the men and
women who participated in this study
and the massage therapists who assisted
with this study. This research was
supported by an NIMH Senior Research
Scientist Award (#MH00331) to Tiffany
Field and a grant from Johnson &

Johnson to the Touch Research
Institutes.
REFERENCES
Adler G, Kinsley B, Hurwitz S, Mossey C,
Goldenberg D 1999. Reduced
hypothalamic–pituitary and
sympathoadrenal responses to
hypoglycemia in women with
fibromylagia syndrome. American
Journal of Medicine, 106: 534–543
Berman BM, Swyers JP 1997 Establishing a
research agenda for investigating
alternative interventions for chronic pain.
Primary Care 24: 743–758
Berman BM, Swyers JP, Ezzo J 2000 The
evidence for acupuncture as a treatment
for rheumatological conditions.
Rheumatic Disease and Clinics of North
America 26: 103–115
Blunz KL, Rajwani MR, Guerriero RC 1997
The effectiveness of chiropractic
management of fibromyalgia patients:
a pilot study. Journal of Manipulative
Physical Therapy 20: 389–399
Demitrack M, Crofford L 1998 Evidence for
and pathophysiologic implications of
hypothalamic–pituitary–adrenal axis
dysregulation in fibromyalgia and
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S JANUARY 20 0 3
Field, Delage and Hernandez-Reif
chronic fatigue syndrome. Annuals of
New York Academy of Sciences 840:
684–697
Field T 1998 Massage therapy effects.
American Psychologist 53:
1270–1281
Field T, Diego M, Cullen, C, Hernandez-Reif
M, Sunshine W, Douglas S 2002.
Fibromyalgia pain and substance P
decrease and sleep improves after
massage therapy. Journal of Clinical
Rheumatology 8: 72–76
Friedburg F, Jason LA 2001 Chronic
fatigue syndrome and fibromyalgia:
clinical assessment and treatment.
Journal of Clinical Psychology 57:
433–455
Hadhazy VA, Ezzo J, Creamer P, Berman
BM 2000 Mind–body therapies for the
treatment of fibromyalgia: a systematic
review. Journal of Rheumatology 27:
2911–2918
Maurizio SJ, Rogers JL 1997 Recognizing
and treating fibromyalgia. Nurse
Practitioner 22: 18–26
McNair DM, Lorr M, Droppelman LF 1971
POMS – Profile of Mood States.
Educational and Industrial Testing
Service, San Diego
Pugtach D, Haskell D, McNair D 1969
Predictors and patterns of change
52
associated with the course of
time-limited psychotherapy. Mimeo
report
Reiffenberger DH, Amundson LH 1996
Fibromylagia syndrome: a review.
American Family Physician 53:
1698–1712
Russell IJ, Michalek J, Vipraio J et al.
1992 Platelet 3H-imipramine uptake
receptor density and serum
serotonin levels in patients
with fibromyalgia/fibrositis symptoms.
Journal of Rheumatology 19:
104–119
Spielberger CD, Gorsuch RC, Lushene RE
1970 The State Trait Anxiety Inventory.
Consulting Psychologists Press,
Palo Alto
Sunshine W, Field TM, Quintino O et al.
1996 Fibromyalgia benefits from
massage therapy and transcutaneous
electrical stimulation. Journal
of Clinical Rheumatology 2:
18–22
Wolfe F, Smythe HA, Yunus MB et al.
1990 The American College of
Rheumatology 1990 criteria for the
classification of fibromyalgia. Report
of the Multicenter Criteria Committee.
Arthritis Rheumatology 33:
160–172