Massage in Clinical Practice Guidelines

By Virginia Cowen , LMT, PhD

Massage in Clinical Practice Guidelines

By Virginia Cowen , LMT, PhD

Recently, two very important things happened in the evidence-based practice world for massage. Clinical practice guideline recommendations from conventional health care organizations included massage as a complementary treatment. The American College of Physicians recommended treatment with massage alone or as part of a multidisciplinary approach for acute, subacute, or chronic low back pain.1

The American Society of Clinical Oncology recommended treatment with massage for mood disturbance and anxiety during breast cancer treatment and survivorship.2 While this may not be surprising news for massage therapists, it presents an opportunity for the massage profession.

Clinical Practice Guidelines

Systematic reviews are part of the clinical practice guideline development process. The inclusion criteria for these reviews affect the relevance of the studies to massage therapists. Three important things to note are the publication dates, research designs for the included studies, and the outcomes.

Both of the systematic reviews identified a specific date range for eligible studies. This date range was not arbitrarily set for studies 5 or 7 years old. The included back pain studies were published between 2008 and 20163 and the included breast cancer studies were published between 1990 and 2015.4 Since each review was an update for previously published reviews, the date ranges encompassed all potentially relevant articles from the prior review forward while referencing older studies.

The very first systematic review on a topic generally encompasses all studies regardless of date of publication. Subsequent reviews pick up where the prior review left off. This ensures the ability to look back and link together a series of systematic reviews for stronger evidence. Because research does not expire like bottled milk, when a study is relevant to a topic it should never be excluded based solely upon publication date. These systematic reviews provide an excellent example of methodology.

Understanding the Research

For both reviews, the research question was whether or not to refer patients (i.e. efficacy massage.) That type of question is explored using research designs involving a comparison group receiving no treatment at all, standard of care, or a different treatment. What these designs do not explore is comparative effectiveness of different massage treatments.

For a physician who may refer a patient with back pain or cancer for massage, the research evidence must only suggest that there may be some effect of massage. Yet a massage therapist needs evidence of a different type to support the type, intensity, duration, and frequency of massage treatment for the patient. That type of research evidence requires comparative effectiveness research exploring different treatment approaches. These guidelines do not provide those answers.

The guidelines indicated that there was adequate evidence to suggest that conventional health care providers could refer patients for massage for specific outcomes.1-2 For breast cancer—even though the strength of evidence was considered weak—there were favorable effects found for anxiety, mood disturbance, and lymphatic drainage.4

Research Design

Research evidence suggested massage was effective over the short term for subacute to chronic back pain and more effective when used in combination with another treatment.3 Despite the inclusion of 12 studies for breast cancer patients4 and 26 for back pain patients3, neither review rated massage as highly effective. The reasons for this have more to do with research designs than the potential for massage as an integrative treatment.

For massage therapists clinical practice guidelines like these are an overture: an invitation to massage therapy profession to take the next step in evidence-based practice. That means examining our best practices in treatment designs, our body of comparative effectiveness research, and the outcomes we use to measure effects of treatment to develop our own clinical practice guidelines. This can help us to understand differences that may occur with variations in designs of massage treatment. It also means considering how to incorporate outcomes that are used by conventional health care providers to meet them on common ground.

Clinical practice guidelines are our chance as a profession to let the health care industry, insurance reimbursement decision makers, policy makers, and patients know what we do, how we do it, and how we assess the effects of our work with patients/clients. Hopefully our professional associations will accept these overtures. We have the ability to leverage our best practices and body of knowledge to be a stronger presence in the integrative health arena.


  1. Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med, 2017; 166(7): p. 514-530.
  2. Lyman GH, et al. Integrative Therapies During and After Breast Cancer Treatment: ASCO Endorsement of the SIO Clinical Practice Guideline. J Clin Oncol, 2018; p JCO2018792721.
  3. Chou R, et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med, 2017; 166(7): p. 1-14.
  4. Greenlee H, et al. Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment. CA Cancer J Clin, 2017; 67(3): p. 194-232.