SPINE Volume 32, Number 3, pp 353–362
©2007, Lippincott Williams & Wilkins, Inc.
Massage for Mechanical Neck Disorders
A Systematic Review
Jeanette Ezzo, PhD, CMT,* Bodhi G. Haraldsson, RMT,† Anita R. Gross, MSc,‡
Cynthia D. Myers, PhD, LMT,§ Annie Morien, PhD, PA-C, LMT,㛳 Charlie H. Goldsmith, PhD,¶
Gert Bronfort, PhD, DC,# Paul M. Peloso, MD, MSc,** and the Cervical Overview Group
Study Design. Systematic review.
Objective. To assess the effects of massage on pain,
function, patient satisfaction, cost of care, and adverse
events in adults with neck pain.
Summary of Background Data. Neck pain is common,
disabling, and costly. Massage is a commonly used mo-
dality for the treatment of neck pain.
Methods. We searched several databases without lan-
guage restriction from their inception to September 2004.
We included randomized and quasirandomized trials. Two
reviewers independently identified studies, abstracted data,
and assessed quality. We calculated the relative risks and
standardized mean differences on primary outcomes. Trials
could not be statistically pooled because of heterogeneity in
treatment and control groups. Therefore, a levels-of-evi-
dence approach was used to synthesize results.
Results. Overall, 19 trials were included, with 12/19
receiving low-quality scores. Descriptions of the massage
intervention, massage professional’s credentials, or expe-
rience were frequently missing. Six trials examined mas-
sage as a stand-alone treatment. The results were incon-
clusive. Results were also inconclusive in 14 trials that
used massage as part of a multimodal intervention be-
cause none were designed such that the relative contri-
bution of massage could be ascertained.
Conclusions. No recommendations for practice can be
made at this time because the effectiveness of massage
for neck pain remains uncertain. Pilot studies are needed
to characterize massage treatment (frequency, duration,
number of sessions, and massage technique) and estab-
lish the optimal treatment to be used in subsequent larger
trials that examine the effect of massage as either a stand-
alone treatment or part of a multimodal intervention. For
multimodal interventions, factorial designs are needed to
determine the relative contribution of massage. Future
reports of trials should improve reporting of the conceal
From *JPS Enterprises, Baltimore, MD; †West Coast College of Mas-
sage Therapy, Massage Therapy Association of British Columbia, Van-
couver, British Columbia, Canada; ‡McMaster University, Hamilton,
Ontario, Canada; §Integrative Medicine Program, H. Lee Moffitt Can-
cer Center and Research Institute, Tampa, FL; 㛳Dermatology and Skin
Cancer Clinic, Gainesville, FL; ¶Department of Clinical Epidemiology
& Biostatistics, McMaster University, and Father Sean O’Sullivan Re-
search Centre, St. Joseph’s Healthcare, Hamilton, Ontario, Canada;
#Northwestern Health Sciences University, Bloomington, MN; and
**Product Benefit Risk Assessment and Management, Amgen Inc.,
Thousand Oaks, CA.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
Institutional and Professional Organizational funds were received in
support of this work. No benefits in any form have been or will be
received from a commercial party related directly or indirectly to the
subject of this manuscript.
Address correspondence and reprint requests to Jeanette Ezzo, PhD,
CMT, 1905 West Rogers Avenue, Baltimore, MD 21209; E-mail:
jeanetteezzo@prodigy.net
ment of allocation, blinding of outcome assessor, adverse
events, and massage characteristics. Standards of reporting
for massage interventions, similar to Consolidated Stan-
dards of Reporting Trials, are needed. Both short and
long-term follow-up are needed.
Key words: neck pain, cervical dysfunction, cervico-
genic headache, mechanical neck disorders, massage,
manual therapy, whiplash, chronic pain. Spine 2007;32:
353–362
Neck disorders are common, and can be severely dis-
abling and costly.1– 6 According to the 2003 US National
Health Interview Survey, 15% of adults age 18 years and
older reported that in the past 3 months, they had expe-
rienced neck pain that had lasted 1 day or more. Of
these, 15% experienced migraine or severe headache
lasting 1 day or more.7 Neck pain frequently becomes
chronic, and 10% of males and 17% of females have
reported neck pain that has lasted longer than 6
months.8 Motor vehicle crashes leave 24% to 50% of
subjects with persistent symptoms at 12 months.9 Mas-
sage is commonly used to treat persistent neck pain.
However, studies of its effectiveness on neck pain have
been inconclusive.10 –15
The objectives of this review were: (1) to assess the
efficacy and effectiveness of massage. either alone or in
combination with other treatments on pain, function/
disability, patient satisfaction, and global perceived ef-
fect in adults with mechanical neck disorders; (2) to as-
sess the secondary outcomes of adverse events and cost
of care; and (3) where appropriate, to conduct sensitivity
analysis to assess the influence of study methodological
quality, symptom duration, and subtypes of neck disor-
der on the magnitude of treatment effects.
Materials and Methods
Inclusion Criteria. Any published or unpublished random-
ized controlled trial (RCT) or quasi-RCT, either in full text or
abstract form, was included. The participants were adults who
suffered from acute (less than 30 days), subacute (30 –90 days),
or chronic (greater than 90 days) neck disorders. Neck disor-
ders were categorized as: (1) mechanical neck disorders, includ-
ing whiplash-associated disorders category I and II,16,17 myo-
fascial neck pain, and degenerative changes18; (2) neck disorder
with headache19 –21; and3 neck disorders with radicular find-
ings, including whiplash-associated disorders category III.16,17
Studies were excluded if they investigated neck disorders
with: (1) definite or possible long tract signs (e.g., myelopa-
thies); (2) neck pain caused by other pathologic entities (e.g.,
rheumatoid arthritis, ankylosing spondylitis, spasmodic torti-
collis, fractures, and dislocations)18; (3) headache not of cervi-
353
354 Spine • Volume 32 • Number 3 • 2007
cal origin but associated with the neck; or (4) coexisting head-
ache when either neck pain was not dominant or the headache
was not provoked by neck movements or sustained neck pos-
tures, or “mixed” headache.
Studies using massage alone or combined with other thera-
pies were included. Massage was defined as contact with or
manipulation of the soft tissues of the human body with the
hand, foot, arm, or elbow on the structures of the neck. Mas-
sage techniques included Swedish techniques, fascial or connec-
tive tissue release techniques, cross fiber friction, and myofas-
cial trigger point techniques. Techniques based on subtle
energy manipulation or noncontact (Reiki, Polarity) were ex-
cluded.
The comparison groups could either be a control or other
treatment. A control could be: (1) sham or placebo; (2) no
treatment control; (3) active treatment control (i.e., massage ⫹
ultrasound vs. ultrasound); and (4) inactive treatment control
(i.e., massage ⫹ sham ultrasound vs. sham ultrasound). Other
treatments could be: (1) one active treatment versus another
very different active treatment (i.e., massage vs. exercise); (2)
one type of treatment (i.e., Chinese massage) versus another
type of a similar treatment (i.e., Western massage); and (3) one
dosage of a treatment versus another dosage of the same treat-
ment (i.e., 3 weeks 9 sessions of Chinese massage vs. 3 weeks 3
sessions of Chinese massage).
The primary outcomes were pain relief, disability/function,
patient satisfaction, and global perceived effect. Secondary out-
comes were adverse events and cost. Follow-up definitions
were: (1) immediately posttreatment, less than or equal to 1
day; (2) short-term follow-up, greater than 1 day, but less than
3 months; (3) intermediate-term follow-up, 3 months to less
than a year; and (4) long-term follow-up, 1 year or longer.
Unless otherwise specified, the longest follow-up period is re-
ported in Table 1.
Search Strategy. A research librarian searched the following
databases without language restriction from root up to Septem-
ber 2004: MEDLINE (January 1966 to September 2004),
EMBASE (January 1980 to September 2004), Manual Alterna-
tive and Natural Therapy (1985 to September 2004), Cumula-
tive Index to Nursing and Allied Health Literature (January
1982 to March 2004), Index to Chiropractic Literature (1980
to September 2004), and CENTRAL (The Cochrane Library
September 2004). Terms were consistent with the Cochrane
Back Group and have been published elsewhere.41,42 We also
screened references, communicated with the Cochrane Back
Group and other experts, and searched our own personal files.
Pairs of independent reviewers identified citations and se-
lected studies. At least 2 independent reviewers abstracted data
using a standardized abstraction form. We contacted primary
authors if data were not reported on primary outcomes. When
the author could not be contacted or data were not available,
values were imputed using previously published imputation
rules.43,44 When data could not be retrieved from the author,
the author’s report of significance was reported in tabular
form. Two independent reviewers assessed methodological
quality using the 11-item Cochrane Back Pain scale with dis-
agreement resolved by consensus. A high-quality score was
greater than 5 criteria met (Table 2).42
Clinical applicability addresses whether the results are under-
standable and usable by clinicians applying the interventions. To
assess clinical applicability, we developed a 6-item checklist using
the criteria from a number of sources (Table 3).41,52–54 The check-
list included questions about completeness of reporting on impor-
tant clinical applicability items (items 1, 2, 3, and part of 5) as well
as on questions asking whether specific items had been satisfacto-
rily performed (items 4, 6, and part of 5). Pairs of independent
reviewers assessed each study, and discussion resolved disagree-
ments.
Data Analysis. For continuous data, standardized mean differ-
ences (95% confidence interval) were calculated using a random-
effects model. Relative risks were calculated for dichotomous out-
comes. The number needed to treat and treatment-advantage
calculations were calculated when a clear positive effect was seen.
Our calculations appear after the reported results in Table 1.
To reach final conclusions, we used the levels-of-evidence
approach.42,55 Strong evidence denoted consistent findings in
multiple high-quality RCTs. Moderate evidence denoted find-
ings in a single, high-quality RCT or consistent findings in
multiple low-quality trials. Limited evidence indicated a single
low-quality RCT. Conflicting evidence denoted inconsistent re-
sults in multiple RCT. No evidence meant no studies were
identified. Consistent was defined as at least two thirds of the
trials showing the same results.
Results
From 538 postings, 19 trials were selected.22– 40 Of these,
8 had more than 1 publication.34,46 – 49,56 –58 One ap-
peared only as an abstract.39 Four were in non-English
languages and required translation.22,25,35,40
Six trials assessed multiple disorders.23,25,30,33,38,40
Thirteen studied mechanical neck disorder.23,25–33,36,38,40
Seven studied headache of cervical origin.22,25,33,37–39
Three evaluated neck disorder with some radicular signs
and symptoms.23,35,45
Of the 19 trials, 12 received a low-quality score (Table
2). Few trials described or used appropriate concealment
of allocation (5/19) avoided or controlled for cointerven-
tions (6/19). Slightly more than half (10/19) reported
blinding the outcome assessor.
On the clinical applicability scale, the characteristics
of the study participants (i.e., gender, age) were well
reported. The characteristics of the massage were ade-
quately reported in less than half the trials (8/19), and
11/19 trials reported enough detail to determine who
delivered the intervention. Statistical results were seldom
reported according to Consolidated Standards of Re-
porting Trials (CONSORT)51 guidelines. The main out-
come was rated as being client centered in all trials (19/
19), and the timing of evaluation of outcome was rated
as sensible in most (17/19) trials. In all, 2/19 trials were
rated as having adequately balanced efficacy with safety,
primarily because few reported adverse events at all, and
few reported efficacy statistics adequately.
Trials were small, with a median of 20 per group
(mode ⫽ 15; minimum to maximum ⫽ 8 – 87). We were
not able to pool trials or conduct sensitivity analysis due
to substantial heterogeneity in the massage treatment,
the treatment combinations, and control groups.
Six studies24,27–29,31,37 examined massage alone as a
treatment group. Four of these compared massage to a

Table 1. Interventions and Outcomes
Author (y), Participants
Ammer and Rathkolb22 (1990)
n(A/R): 45/45
Acute/subacute/chronic NDH
Brodin23 (1985)
n(A/R): 63/71
Chronic MND (25% with radicular
findings or lower cervical
degenerative changes)
Cen et al 24 (2003)
n(A/R): 28/31
Chronic MND
Fialka et al 25 (1989)
n(A/R): 60/60
Acute MND, NDH
Gam et al 26 (1998)
n(A/R): 58/67
10% Chronic MND
Hanten et al 27 (1997)
n(A/R): 60/60
Pain duration: NR
Hanten et al 28 (2000)
n(A/R): 40/40
MND without radicular symptoms
Pain duration: NR
Hou et al 29 (2002)
Massage for Mechanical Neck Disorders • Ezzo et al 355
Intervention Outcome
G3: massage, munaripack Pain intensity (5-point scale):
G2: ultra, direct gal, ultraviolet light Reported results: NS
G1: manip, pulsed gal
Patient perceived effect (5-point scale):
Treatment schedule: 2 w, 10 s Reported results: NR
Duration of follow-up: immediate
Calculated results: data insufficient
G3: massage, heat, mob, trac, edu, analg G2: mock therapy Pain intensity (9-point scale transformed to
(massage, trac, es), edu, analg dichotomous outcomes)
G1: analg Reported results: sig favoring G3 vs. 1;
G3 vs. 2
Treatment schedule: 3 w, 9 s Calculated results:
Duration of follow-up: 1 w RR (G3 vs. 1): 0.44 (95% CI 0.16–1.24)
RR (G3 vs. 2): 0.42 (95% CI 0.15–1.21)
NNT (G3 vs. 1): 4
Adverse events: 10 patients from G1; mock
therapy (G2) reported slight discomfort
Group A: traditional Chinese massage group C: no
treatment
Group B: ex Function (Northwick Park Pain
Questionnaire; score 0–100):
Reported results: sig favoring A vs. B, A vs. C
Treatment schedule: group A ⫽ 6 w, 18 sessions; group
B ⫽ 1 initial visit, 5 telephone follow-ups
Duration of follow-up: immediate Calculated results:
SMD (A vs. C): ⫺1.75 (95% CI ⫺2.82
to ⫺0.68)*
SMD (A vs. B): ⫺0.55 (95% CI ⫺1.53 to 0.42)
Group 3: massage trac, ex Pain:
Group 1: stereodynamic interferential current Neck pain and headache (present
or absent)
Group 2: iontophoresis Reported results: not clear
Group 4: no treatment
Calculated results:
Treatment schedule: 2 times per w for 5 w RR (3 vs. 4): 0.33 (95% CI 0.11, 0.99)*
Duration of follow-up: immediate RR (3 vs. 1): 0.22 (95% CI 0.04–1.11)
RR (3 vs. 2): 0.17 (95% CI 0.03–0.85)*
Group A: massage, ultra, ex Pain at rest (VAS 10 cm):
Group B: massage, sham ultra, ex group C: no treatment Reported results: NS
Treatment schedule: 4 w, total 8 s Calculated results:
Duration of follow-up: 6 m SMD (Ga vs. Gc): ⫺0.75 (95% CI ⫺1.4
to ⫺0.10)*
SMD (Gb vs. Gc): ⫺0.27 (95% CI ⫺0.90,
to 0.35)
Pain on function (VAS 0–10 cm)
Reported results: NS
Calculated results:
SMD (Ga vs. Gc): ⫺0.07 (95% CI ⫺0.69
to 0.56)
SMD (Gb vs. Gc): ⫺0.00 (95% CI ⫺0.62
to 0.62)
Group 1: occipital release† Pain pressure threshold
Group 2: McKenzie neck exercises group 3: no treatment Reported results: NS
Treatment schedule: 1 s Calculated results:
Duration of follow-up: immediate SMD (1 vs. 3): ⫺0.07 (95% CI ⫺0.69 to 0.55)
SMD (1 vs. 2): ⫺0.24 (95% CI ⫺0.87 to 0.38)
Group 1: self-ischemic compressions† Pain (VAS 100 mm, mean over 24 hours)
Group 2: active neck movements Reported results: sig favoring group 1
(ANCOVA P ⫽ 0.043)
Treatment schedule: 5 d Calculated results:
Duration of follow-up: 3 d SMD: ⫺0.61 (95% CI ⫺1.24 to 0.03)
B2: ischemic compression† heat, rom Pain (VAS 100 mm)
B3: ischemic compression, TENS, heat, rom
(Continued)
356 Spine • Volume 32 • Number 3 • 2007

Table 1. Continued
Author (y), Participants Intervention Outcome

n(A/R): 19/19 B6: interferential current, myofascial release technique* Reported results: sig favoring B6 vs. B1, B3
heat, rom vs. B1, NS for B2 vs. B1
MND B1: heat, rom
Pain duration: NR Calculated results:
SMD (B2 vs.B1): ⫺0.54 (95% CI ⫺125 to 0.16)
Treatment schedule: 1 s SMD (B3 vs. B1): ⫺1.07 (95% CI ⫺1.91
to ⫺0.24)*
Duration of follow-up: immediate SMD (B6 vs. B1): ⫺1.20 (95% CI ⫺2.05
to ⫺0.36)*
Hoving et al 30 (2002) (PT): massage, ex, rom, trac, es, heat Pain (NRS, 0–10)
n(A/R): 178/183 (MT): mob, coordination and stabilization techniques; rom Reported results: sig favoring MT over PT
Acute, subacute, chronic MND (GP): general practitioner care
with and without radicular
findings, NDH
Calculated results:
Treatment schedule: 6 w, 6 s SMD (PT vs. MT): 0.41 (95% CI 0.04–0.78)‡
Duration of follow-up: 52 w SMD (PT vs. GP): 0.34 (95% CI ⫺0.02 to 0.70)
Function (Neck Disability Index, 0–50)
Reported results: sig favoring MT over PT
Calculated results:
SMD (PT vs. MT): 0.12 (95% CI ⫺0.25 to 0.48)
SMD (PT vs. GP): 0.28 (95% CI ⫺0.08 to 0.64)
Global perceived effect (perceived
recovery, %)
Reported results: sig favoring MT over PT
Calculated results:
RR (PT vs. MT): 1.32 (95% CI 0.78–2.22)
RR (PT vs. GP): 0.85 (95% CI 0.55–1.31)
Adverse events: benign and transient
Cost of care: favors MT
Total costs
Reported results: NS
Calculated results:
SMD (MT vs. PT): ⫺0.34 (95% CI ⫺0.70 to 0.02)
SMD (PT vs. GP): ⫺0.02 (95% CI ⫺0.38 to 0.33)
Total direct costs
Reported results: sig favoring MT vs. PT
Calculated results:
SMD (MT vs. PT): ⫺0.49 (95% CI ⫺0.85 to
⫺0.17)‡
SMD (PT vs. GP): 0.21 (95% CI ⫺0.15 to 0.56)
Total indirect costs
Reported results: NS PT vs. MT
Calculated results:
SMD (MT vs. PT): ⫺0.28 (95% CI ⫺0.64 to 0.08)
SMD (PT vs. GP): ⫺0.07 (95% CI ⫺0.43 to 0.28)
Duration off work
Reported results: NS PT vs. MT
Calculated results:
SMD (MT vs. PT): ⫺0.29 (95%vCI ⫺0.71 to 0.12)
SMD (PT vs. GP): ⫺0.10 (95% CI ⫺0.51 to 0.32)
Irnich et al 31 (2001) (M): conventional Western massage Pain (VAS 100 mm)
n(A/R): 165/177 (A): acupuncture Reported results: sig favoring A vs. M
(P ⬍ 0.0052) at 1 w; NS at 3 m
Subacute MND without radicular (S): sham laser
symptoms
Calculated results:
Treatment schedule: 3 times a w for total of 5 s SMD (M vs. S): ⫺0.01 (95% CI ⫺0.38 to 0.36)
Duration of follow-up: 3 m SMD (M vs. A): 6.49 (95% CI ⫺3.42 to 16.40)
Adverse events: slight pain or lowered
blood pressure reported by 4 patients in
massage group, 17 patients in the
acupuncture group, 12 patients in sham
acupuncture group
Jordan et al 32 (1998) (PT): massage, heat, ultra, mob, trac, pnf, ed Pain (3, 11-point box scales)
n(A/R): 102/119 (CH): manip, trac, soft tissues treatments, ed Reported results: NS
(Continued)
 Massage for Mechanical Neck Disorders • Ezzo et al 357

Table 1. Continued
Author (y), Participants Intervention Outcome

Chronic MND (INT): intensive training

Calculated results:
Treatment schedule: 6 w, 12 s SMD (PT vs. CH): 0.00 (95% CI ⫺0.48 to 0.48)
Duration of follow-up: 52 w SMD (PT vs. INT): 0.00 (95% CI ⫺0.47 to 0.47)
Function: (self-report disability index, 30-
point scale)
Reported results (PT vs. Int): NS
Calculated results:
SMD (PT vs. CH): 0.00 (95% CI ⫺0.48 to 0.48)
SMD (PT vs. INT): ⫺0.25 (95% CI ⫺0.73 to 0.22)
Patient perceived effect (6-point scale)
Reported results: NS
Adverse events: NR. One patient in the
manipulation group was excluded
because 1 chiropractic treatment
resulted in persistent acute pain
Karlberg et al 33 (1996) (G1): massage, mob, ex, relaxation, analg, ed Pain (VAS; 100 mm)
n(A/R): 17/17 (G2): wait list Reported results: sig favoring G1
MND, NDH
“recent onset,” suspect Follow-up: immediate Calculated results:
“subacute” SMD: ⫺1.47 (95% CI ⫺2.58 to ⫺0.36)*
NNT: 2
Treatment advantage: 40.8%

Koes34 (1992) (PT): massage, ex, heat, es Severity of main complaint (10-point scale)
n(A/R): 58/64 (GP) general practitioner Reported results: NS
Subacute and chronic MND (MT): manip, mob
(PL) placebo ultra Calculated results:
SMD (PT vs. PL): 0.79 (95% CI 0.04–1.53)‡
Treatment schedule: 9 w SMD (PT vs. GP): 0.00 (95% CI ⫺0.70 to 0.69)
Duration of follow-up: 3, 6, and 12 w months (were not SMD (PT vs. MT): 0.64 (95% CI ⫺0.08 to 1.35)
used due to significant loss of follow-up and cross over)
Function: (10-point scale)
Reported results: NS
Calculated results:
SMD (PT vs. PL): 0.73 (95% CI ⫺0.02 to 1.48)
SMD (PT vs. GP): ⫺0.16 (95% CI ⫺0.86 to
0.55)
SMD (PT vs. MT): 0.75 (95% CI 0.00–1.50)
Kogstad et al 35 (1978) (MT): massage, heat, manip Global perceived effect (objective and
subjective findings)
n(A/R): 50/50 (CT): massage, heat, isometric ex, trac (PL): placebo Reported results: sig at immediate follow-up
tablets favoring MT vs. PL, CT vs. PL. NS
at 18 m
MND with radicular symptoms
Pain duration: NR Treatment schedule: 5 w, 8 s for MT; 12 s for CT Calculated results:
RR (MT vs. PL) 0.77 (95% CI 0.16–3.61)
Duration of follow-up: 18 m RR (MT vs. CT) 0.33 (95% CI 0.08–1.32)
36
Levoska et al (1993) (PE): passive exercise: heat, massage, stretches, ex Pain (occurrence of pain symptoms in
head, neck, or shoulder)
n(A/R):44/47 (AE): active exercise Reported results: sig (P ⬍ 0.01) favoring
active exercise immediately
posttreatment; NS at 1 y
MND
Pain duration: NR Treatment schedule: 5 w, 3 times per w Calculated results:
RR: 0.50 (95% CI 0.18–1.42)
Duration of follow-up: 1 y
Nilsson et al 37 (1997) (ST): massage, sham laser Headache intensity per episode (VAS scale)
n(A/R): 53/54 (Manip): manipulation Reported results: sig favoring manip
Chronic NDH
Treatment schedule: 3 w Calculated results:
Follow-up: 1 w SMD: 0.45 (95% CI ⫺0.10 to 0.99)
Provinciali et al 38 (1996) Group A: massage, mob, ex, ed Pain (VAS: 0–10):
n(A/R): 60/60 Group B: ultra, TENS, es Reported results: NS at immediate follow-up;
sig favoring group A at 6 m
(Continued)
358 Spine • Volume 32 • Number 3 • 2007

Table 1. Continued
Author (y), Participants Intervention Outcome

Acute/subacute MND, WAD,

NDH, CES
Treatment schedule: 2 w, 10 1-h s Calculated results:
Duration of follow-up: 6 m SMD ⫺0.79 (95% CI ⫺1.32, ⫺0.26)*
NNT: 6 favoring group A
Treatment advantage: 36.9% favoring
group A
Function: return to work (d)
Reported results: sig favoring group A
Calculated results:
SMD: ⫺1.05 (95% CI ⫺1.59 to ⫺0.51)*
Self-assessment of outcome (ordinal scale:
⫺3 to ⫹ 3):
Reported results: NS
Reginiussen et al 39 (2000) (MT): massage, mob, manip, stretch (PT): ex, diathermy Pain (headache and neck pain intensity)
n(A/R): ?/63 Reported results: sig favoring MT at 1 w
and 3 m
NDH Treatment schedule: 3 w/6 s
Pain duration: NR Duration of follow-up: 12 w Function (Neck Disability Index, 0–50)
Reported results: sig favoring MT at 1 w;
NS at 3 m
Schnabel et al 40 (2002) (PT): massage, lymph drainage, heat, ex Pain intensity (NRS 0–10)
n(A/R): 124/168 (SC): soft collar Reported results
Acute WAD, NDH (ST): soft collar, analg
Calculated results:
Treatment schedule: 14 d SMD ⫺0.51 (95% CI ⫺0.84 to ⫺0.18)*
Duration of follow-up: 4 w
Function: (NRS 0–10)
Reported results: sig (P ⬍ 0.01) favoring PT
Calculated results:
SMD ⫺0.47 (95% CI ⫺0.79 to ⫺0.14)*
*Significant favoring massage treatment.
†Technique counted as massage treatment.
‡Significant favoring nonmassage treatment.
analg indicates analgesic medications; ANCOVA, analysis of covariance; CES, cephalgic; Cgal, galvanic current; CI, confidence interval; ed, education; es, electrical
stimulation; ex, exercise; f, frequency per week; manip, manipulation; m, month(s); MND, mechanical neck disorder; mob, mobilization; n(A/R), No. analyzed/
randomized; NDH, neck disorder with headache; NNT, No. needed to treat; NR, not reported; NRS, nominal rating scale; NS, not significant; pnf, proprioceptive
neuromuscular facilitation; rom, range of motion; RR, relative risk; s, sessions; sig, significant; SMD, standardized mean difference; trac, traction; ultra, ultrasound;
w, week(s); WAD, whiplash-associated disorder.

control group for pain. They showed limited evidence of
no benefit for pain relief when compared to various con-
trol conditions. One trial24 assessed function and re-
ported 18 sessions of traditional Chinese massage
(TuiNa) to be significantly better than no treatment for
chronic mechanical neck disorders. Three trials com-
pared massage to another active treatment: acupunc-
ture,31 exercise,27 or manipulation37 (Table 1). Results
were mixed.
Fourteen trials22,23,25,26,29,30,32,33,35,36,38 – 40,45 incor-
porated massage as 1 component of a multimodal inter-
vention (Table 1). However, none of the trials were de-
signed such that the relative contribution of massage
could be ascertained. Therefore, the evidence remains
unclear about the benefit of massage in multimodal in-
terventions.
Three studies reported adverse events.23,30,31Adverse
events, when reported, were rare, short lived, and be-
nign, mostly pertaining to transient discomfort after
treatment.
One study examined cost of care.30 This trial com-
pared physical therapy methods of massage, manual
traction, exercise, interferential, and heat (PT) to mobi-
lization and stabilization techniques (MT). There was no
significant difference between the PT and MT groups for
total costs or total indirect costs. However, there was a
significant difference favoring the MT group for total
direct costs (Table 1).
Discussion
Although there has been a marked increase in the num-
ber of publications that incorporate massage since the
last Cochrane systematic review a decade ago,11 the con-
tribution of massage to managing cervical pain remains
unclear. This review did not find a strong or moderate
level of evidence for massage alone relative to a control.
Six studies in our review were assessed as stand-alone
massage treatments; however, each study used a different
form of “massage” (e.g., 1-finger Chinese meditation
massage, ischemic compression, conventional Western
massage and occipital release). Of these, 2 gave 1 treat-
ment, and 1 gave self-administered massage, practices
that are uncommon and, perhaps, suboptimal in the clin-
ical setting. Furthermore, it is likely that the small sample
sizes and inability to pool data made it difficult to find
any statistically significant effect.
 Massage for Mechanical Neck Disorders • Ezzo et al 359

Table 2. Methodological Quality Assessment

Questions

Author (y) A B C D E F G H I J K Total/11 Low/High

Ammer and Rathkolb22 (1990) 0 1 0 0 0 1 0 1 0 0 1 4 L

Brodin23 (1985) 1 1 0 0 0 0 0 1 0 1 1 5 L
Cen et al 24 (2003) 0 1 1 0 0 0 0 1 1 0 1 5 L
Fialka et al 25 (1989) 0 1 0 0 0 1 0 1 1 0 1 5 L
Gam et al 26 (1998) 1 1 1 1 1 0 0 0 1 1 1 8 H
Hanten et al 27 (1997) 0 1 1 0 1 1 1 0 0 0 1 6 H
Hanten et al 28 (2000) 0 0 0 0 1 1 1 1 0 0 1 5 L
Hou et al 29 (2002) 0 1 0 0 0 1 0 1 0 0 1 4 L
Hoving et al 30 (2002) 1 1 1 0 1 1 1 1 0 1 1 9 H
Irnich et al 31 (2001) 0 1 1 0 1 1 0 1 0 0 1 6 H
Jordan et al 32 (1998) 1 1 1 0 0 0 1 1 0 1 1 7 H
Karlberg et al 33 (1996) 0 1 0 0 0 1 0 1 0 0 0 3 L
Koes et al 34,45–49 (1991–1992) 1 1 0 0 1 1 0 1 0 1 1 7 H
Kogstad et al 35 (1978) 0 0 0 0 0 0 0 0 0 0 0 0 L
Levoska et al 36 (1993) 0 1 0 0 0 0 0 1 0 0 1 3 L
Nilsson et al 37,50,51 (1995–1997) 0 1 0 0 0 1 0 1 0 0 1 5 L
Provinciali et al 38 (1996) 0 1 0 0 0 1 0 1 0 0 1 5 L
Reginiussen et al 39 (2000) 0 1 0 0 0 0 0 1 0 0 1 3 L
Schnabel et al 40 (2002) 0 1 0 1 1 1 1 1 0 0 1 7 H
Total/19 5 17 6 1 7 12 5 16 3 5 17
For all questions, 1 ⫽ yes.
Question: A, Was the treatment allocation concealed?; B, Was the drop-out rate described and acceptable?; C, Were cointerventions avoided or similar?; D, Was
the patient blinded to the intervention?; E, Was the outcome assessor blinded to the intervention?; F, Did the analysis include an intention-to-treat analysis?; G,
Was the compliance acceptable in all groups?; H, Were the groups similar at baseline regarding the most important prognostic indicators?; I, Was the care provider
blinded to the intervention?; J, Was the method of randomization adequate?; K, Was the timing of the outcome assessment in all groups similar?

Likewise, our review did not find a strong or moderate of massage to the overall effect. Primarily, the designs
level of evidence for or against massage in studies that were such that the relative contribution of massage could
combined massage with other methods. Several difficul- not be ascertained apart from other therapies with which
ties undermined our understanding of the contribution it was combined. Factorial designs would be needed to

Table 3. Clinical Applicability Assessment

Questions

Author (y) 1 2 3 4 5 6 Total/6

Ammer and Rathkolb22 (1990) 1 1 1 1 0 1 5

Brodin23 (1985) 1 0 1 1 0 1 4
Cen et al 24 (2003) 0 1 1 1 0 1 4
Fialka et al 25 (1989) 1 0 1 1 0 1 4
Gam et al 26 (1998) 1 0 1 1 0 1 4
Hanten et al 27 (1997) 0 1 1 1 0 1 4
Hanten et al 28 (2000) 0 1 1 1 0 1 4
Hou et al 29 (2002) 0 1 1 1 0 1 4
Hoving et al 30 (2002) 1 0 1 1 1 1 5
Irnich et al 31 (2001) 0 1 1 1 1 1 5
Jordan et al 32 (1998) 1 0 1 1 0 1 4
Karlberg et al 33 (1996) 1 1 1 1 0 1 5
Koes34 (1992) 1 0 1 1 0 1 4
Kogstad et al 35 (1978) 0 0 1 1 0 0 2
Levoska et al 36 (1993) 1 0 1 1 0 1 4
Nilsson et al 37 (1997) 1 1 1 1 0 1 5
Provinciali et al 38 (1996) 0 0 1 1 0 1 3
Reginiussen et al 39 (2000) 0 0 0 1 0 1 2
Schnabel et al 40 (2002) 1 0 1 1 0 1 4
Total/19 11 8 18 19 2 18
For all questions, 1 ⫽ yes and 0 ⫽ no.
Question: 1, For the index and control interventions, was enough detail given about who delivered the intervention? (a. professional, b. referral source, c. treatment
setting); 2, For the index and control interventions, was enough detail given about their method of delivery to permit replication? (a. dose, b. frequency, c. duration,
d. technique); 3, Was enough information provided about the characteristics of the study patients to permit us to relate them to the spectrum of patients with
this problem? (a. gender, b. age, c. comorbidities, d. disorder); 4, Was the main outcome(s) client centered? (a. pain, b. function, c. satisfaction/global perceived
effect); 5, Based on the presented evidence, do authors balance efficacy and safety? (a. compliant with CONSORT, b. intergroup difference significant, c. adverse
effects reported and minimal); and 6, Was the timing of evaluation of the intervention sensible, given the mechanisms of action of the effect?
Note: For a question to score a “yes,” all the lettered items after it had to be sufficiently reported and score a “yes” to meet applicability criteria.
360 Spine • Volume 32 • Number 3 • 2007
tease out the contribution of massage from other thera-
pies, and these were not done. In the absence of factorial
designs, we aimed to find a superior multimodal treat-
ment in general, but such a pattern did not emerge.
Several methodological or reporting problems were
noted related to the massage intervention. Most studies
lacked a definition, description, or rationale for massage,
or massage technique selected. There are numerous mas-
sage techniques, and these techniques can have different
physiologic effects. Massage research would benefit from
a massage taxonomy59 with standardized vocabulary,
definitions, and known mechanisms of action of various
massage techniques. Such a standardized reference
would greatly assist researchers in selecting appropriate
techniques and also assist in interpreting the results of
existing massage studies.
In most trials in this review, researchers did not justify
the other dosing parameters such as frequency (number
of MT sessions per week), duration (length of time of
each massage session), and depth/pressure and duration
of application of depth. Massage pilot studies are needed
that establish an optimal or at least adequate treatment
by exploring dosing variables. These studies should be
conducted before doing a larger trial. This would be sim-
ilar to the small dose-finding studies conducted in phar-
maceutical trials in order to establish a minimally effec-
tive or biologically active dose.
Observational data presented in a massage meta-
analysis60 suggest the total number of massage sessions
may influence the pain outcomes noting no pain reduc-
tion immediately after a single massage, but significant
pain reduction days to weeks after multiple massages.
Although they did not find a similar pattern for the time
duration of a session, they note that little is known about
the variables for massage for pain relief, including the
optimal frequency, optimal duration of session, and the
“decay” time in analgesic effect.
Furthermore, many of the trials in this review did not
report sufficient details on the massage characteristics to
permit replication. Reporting conventions such as those
proposed in the CONSORT statement52 for clinical tri-
als generally, or the STRICTA61 statement for clinical
trials of acupuncture specifically, are needed for massage
trials to report the massage parameters in a transparent
and standardized way.
The qualifications or experience of the persons per-
forming massage were also frequently missing from the
reports, and this may reflect researchers’ lack of consid-
eration given to this issue. Persons who do massage vary
from those with no formal training to those with doc-
toral degrees in massage therapy, and potential variabil-
ity in outcomes may be associated with the level of ex-
perience or training of the persons performing massage.
Future trials need to provide justification for the thera-
pist(s) selected to perform the intervention. To ensure the
competence of the massage professional(s) being used in
a trial, investigators may wish to require specific creden-
tials, experience, and even a working interview, which
includes receiving a massage from the massage thera-
pist.62
From the trials reporting adverse effects, adverse ef-
fects of massage appear to be minimal and transient.
However, the majority of trials did not mention adverse
events. It was not clear from those reports whether ad-
verse effects had not been measured or had been mea-
sured, but none occurred. To achieve a balanced discus-
sion between efficacy and harm, trials need to document
all adverse events, measure and report side effects in a
standardized format, and, equally important, to docu-
ment if none occur.
In our review, no trials met the criteria of double
blinding (blinded patients and care providers). This is
because in massage studies, blinding patients can be dif-
ficult, and blinding care providers is impossible. Other
design features, therefore, must attempt to compensate
for the lack of blinding. For example, it is important to
ensure that treatments are equally credible and accept-
able to patients to minimize placebo effects and high
dropout rates. It is also important to collect and report
information on patients’ previous experience with mas-
sage, or their expectations of massage, to assess the im-
pact of expectations. Finally, although it is difficult to
blind the patients and therapists, the outcomes assessor
and statistician can and should always be blinded.
The outcome measures in the studies described in our
review were diverse, and several were not validated. The
use of reliable and valid outcome measures is essential to
reduce bias, provide standardized and precise measures,
and allow for comparisons across trials. Disability ori-
ented outcomes such as “return to work,” “activities of
daily living,” and “function” were rarely reported. We
suggest that these be included in future studies as these
capture a dimension of patients’ experiences that are not
necessarily captured by pain outcomes.
Our approach to summarizing the literature has sev-
eral strengths. We conducted a comprehensive, librarian-
assisted search of multiple databases. A minimum of 2
people extracted data, and the principal investigator
(A.R.G.) verified data entry. In addition, we used a group
consensus approach coupled with the Sackett55 and van
Tulder42 hierarchy on the strength of the evidence to
minimize bias.
The weakness of this paper rests with limitations of
the primary studies. We were unable to make any firm
statements about the strength of the evidence due to 4
major limitations of the studies: (1) the majority of stud-
ies were of low methodological quality; (2) the majority
of studies used massage as 1 component in a multimodal
treatment but did not use a research design such as a
factorial design that could ascertain the relative contri-
bution of massage; (3) no study provided pilot data jus-
tifying the minimal effective “amount” of massage (fre-
quency, duration, dose, technique), thus we could not
assess whether adequate doses of massage had been
given; and (4) many studies were underpowered but
could not be pooled due to heterogeneous populations,

massage techniques, treatment combinations, and con-
trol groups.
Conclusions
Implications for Practice
No firm statement can be made about the efficacy of
massage for neck pain due to the limitations of existing
studies.
Implications for Research
For trials using massage as a stand-alone treatment or a
multimodal intervention, pilot studies of various mas-
sage treatments are needed to ascertain an optimal mas-
sage treatment (frequency, duration, number of sessions,
and massage technique) that can then be used in a sub-
sequent larger trial. For multimodal interventions, facto-
rial designs are needed to determine the relative contri-
bution of massage. Adverse effects in massage trials
should be assessed and reported consistently. Addition-
ally, future trials should improve reporting of the con-
cealment of allocation, blinding of outcome assessor and
subject, and massage characteristics. Standards of re-
porting for massage interventions, similar to CONSORT
are needed. Both short and long-term follow-up are
needed. Future metaanalyses need to consider prognostic
factors (e.g., psychological factors, central sensitization)
during sensitivity analysis. For this to occur, trials need
to assess these items during the conduct of the trial.
Key Points
● This review examined 19 trials for neck pain and
dysfunction; 12/19 received low-quality scores.
● Six trials examined massage as a stand-alone
treatment; 14 examined massage as part of a mul-
timodal intervention.
● Results are inconclusive due to methodological
limitations of the studies.
● Future research should ascertain an optimal mas-
sage treatment (frequency, duration, number of
sessions, and massage technique) ahead of doing a
large trial.
● When using multimodal interventions, future re-
search should use factorial designs so that the rel-
ative contribution of massage can be determined.
Acknowledgments
This review was adapted from Haraldsson BG, Gross
AR, Myers CD, Ezzo JM, Morien A, Goldsmith C, Pe-
loso PM, Bronfort G, Cervical Overview Group. Mas-
sage for mechanical neck disorders. The Cochrane Data-
base of Systematic Reviews Submitted for publication in
Issue 3, 2006. Copyright Cochrane Library, reproduced
with permission.
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