Several studies have reported improved outcome following massage therapy for various health-related conditions in adults, including chronic pain (89). Massage therapy involves manipulation of the body by combining tactile and kinesthetic stimulation performed in purposeful sequential application. According to Ireland and Olson, although the precise mechanism of action in massage therapy is not known, increased parasympathetic activity (90) and a slowed physiological state appear to underpin the behavioral and physiological processes associated with massage.

The main theories regarding the ability of massage to reduce pain include gate theory, serotonin, and restorative sleep (91). According to gate theory (92), because pressure receptors are longer and more myelinated than pain fibers, pressure signals from massage are transmitted faster, closing the gate to pain signals. The serotonin hypothesis maintains that massage appears to increase levels of serotonin, a neurotransmitter that modulates the pain control system (93). The restorative sleep hypothesis holds that because substance P, a neuro-transmitter associated with pain, is released in the absence of deep sleep, the ability of massage to increase restorative sleep leads to reductions in substance P and consequent pain (94).

2.6.1. Chronic Pain

We identified only two published studies that examined the specific impact of massage on pediatric pain (95,96). In the first study (95), 20 children with juvenile rheumatoid arthritis aged 5-14 years had a 15-minute session with their parents every day for a 30-day period. The parents either gave a 15-minute massage, following a standardized procedure, or participated in a 15-minute relaxation session with the children. At posttreatment, both children and parents in the massage group reported less pain than their counterparts in the relaxation group. In addition, an independent physician blinded to group assignment rated both groups on pain and morning stiffness and found the massage group lower on both measures.

The standardized massage procedure and blinded physician assessment are strong points of this study design. However, these are offset by several weaknesses, including the small sample size, failure to randomize (or to describe randomization, if employed), and lack of a control group using a physical contact intervention. Sham massage (light touch) would have controlled more effectively than relaxation for the therapeutic benefits of physical contact, while permitting assessment of the specific massage intervention. Finally, although parent instruction in a standardized technique is feasible and cost-effective, the investigators did not report that they verified parents' adherence to the protocol; some parents may have extended the massage beyond the 15-minute period or deviated from the procedure.

2.6.2. Procedural Pain

The second controlled study of massage was a randomized trial in child burn victims undergoing dressing changes (96). In this study, 24 children (mean age, 2.5 years) were randomly assigned to a massage therapy group or an attention-control group. Before a scheduled dressing change, the first group was massaged for 15 minutes by a trained therapist, who touched only unburned skin and followed a standardized protocol. The children in the control group met with the same therapist for 15 minutes of informal conversation. Independent raters blinded to group assignment observed the children before and during the dressing change. Results indicated that massage patients increased torso movements during the procedure but otherwise showed minimal distress; the control group exhibited multiple behaviors indicative of distress, including increased facial grimaces, crying, torso movements, leg movements, and reaching out during the procedure. These results supported the notion that massage can reduce procedural pain in pediatric burn patients following a brief, single-session intervention.

Further studies with larger sample sizes and across repeated procedures would increase confidence in the findings. Again, as in the previous study (95), comparison with an appropriate control condition involving physical contact would strengthen the results.

In sum, existing studies point to the designation of massage therapy as a promising modality for the relief of pediatric pain. For massage to be designated as an EST, several larger-scale, randomized controlled trials using a sham massage or physical contact control group are required. The development and use of detailed treatment manuals, as well as monitoring and rating of adherence to treatment protocols, are also essential to advance research on this CAM therapy. The work of Field and colleagues (89,90,93,95) has shown that standardization of massage procedures is possible but is only the first step.

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